GS Palliative care opioid calculations

Question 1

Two main first line opioids?

Answer 1

Codeine + tramadol (weak)
Morphine (strong)
-Orally
- Immediate and modified release formulations

Question 2

Second line opioids?

Answer 2

Oxycodone (Strong, if morphine is contraindicated.)
-Oral/SC/IV

Fentanyl

• Topical use (or inj for ops and intensive care)
• Strong
• Contraindication to oral meds
• Acute pain only

Question 3

3rd and 4th line opioids?

Answer 3

Alfentanil
Methadone
Intranasal
Buccal fentanyl

Question 4

Doses or oral and injectable opioids are…

Answer 4

not equivalent (i.e. adjustments to be made)

Question 5

When switching and converting opioids it is sometimes easier to work out equivalent doses by converting back to …

Answer 5

oral morphine and working from there.

Question 6

The standard dose of a strong opioid for breakthrough pain is ROUGHLY?

Answer 6

1/6 to 1/10 of the regular 24-hour dose, repeated every 2–4 hours as required – this is subject to inter-patient variability so should be tailored to the individual.

Question 7

Oral morphine 10mg =
SC morphhine ? mg
SC diamorphine ? mg
SC oxycodone ? mg

Answer 7

Oral morphine 10mg =
SC morphhine 5 mg
SC diamorphine 3 mg
SC oxycodone 5 mg

Question 8

Oral morphine 5-10mg = Oral hydromorphone ?mg

Answer 8

Oral morphine 5-10mg = Oral hydromorphone 1.3mg

Question 9

What is the conversion factor for immediate release oxycodone oral to SC?

Answer 9

Divide by 2
Oral =5mg
SC= 2/3mg

Question 10

palliative care nurse specialist. He is complaining of abdominal pain for which he is taking 5mg of immediate release oral morphine only – this helps at the time but wears off quickly. He has used six of his 5mg doses in the past 24 hours. He is not getting good background pain relief and in discussion with his GP, the nurse specialist advises starting 12-hourly modified release morphine.

What total dose of morphine is he using in 24 hours?
What dose of modified release (M/R) morphine might the GP prescribe?

Answer 10

1. What total dose of morphine is he using in 24 hours?
   Answer - 6 doses of 5mg = 30mg
2. What dose of modified release (M/R) morphine might the GP prescribe?
   The patient needs to get better background analgesia as the immediate release (I/R) version is not lasting long enough.
   Total daily requirement (30mg) can be given as two 12-hourly modified-release doses = 15mg in the morning and 15mg at night.
   This is prescribed as modified release (M/R) morphine and each dose should last 12 hours.  Prescription would look like this: Morphine M/R 15mg orally twice daily.

Question 11

A patient is taking oral morphine modified release (Zomorph) 30mg twice daily and requires some breakthrough analgesia, for example when they are transferring from the bed to have a shower. What dose of oral “immediate release” (I/R) morphine should be prescribed?

Answer 11

From the guided study we read that breakthrough dose should be between 1/6 to 1/10th of the 24 hour dose, with careful monitoring of patient’s response.

 If we choose 1/6 of dose (60mg) = 10mg.
 If we choose 1/10 of dose (60mg) = 6mg. (round to multiple of 5, so 5mg)

The prescription would look like this:
Morphine I/R 5/10mg orally if required for breakthrough pain

Out of interest the brands of Morphine I/R commonly used include Oramorph and Sevredol.

Question 12

Out of interest the commonest brands which are 12-hourly M/R (modified release) include _____ and MST Continus and the GP prescription would usually include the brand name.

Answer 12

Out of interest the commonest brands which are 12-hourly M/R include Zomorph and MST Continus and the GP prescription would usually include the brand name.

Question 13

Out of interest the brands of Morphine I/R (immediate release) commonly used include ____ and ____.

Answer 13

Out of interest the brands of Morphine I/R commonly used include Oramorph and Sevredol.

Question 14

A patient has been taking morphine modified release (MR) (Zomorph) 60mg 12-hourly plus a total dose of 40mg of oral immediate release (IR) morphine tablets (Sevredol) in 24 hours for breakthrough pain. They are now unable to swallow and reaching the end of their life. To make the patient comfortable the patient is to be switched to a subcutaneous morphine infusion over 24 hours, via a syringe driver.

 How much morphine should be added to syringe?
 What dose of injectable SC morphine should be used as breakthrough?

Answer 14

 How much morphine should be added to syringe?
60 x 2 = 120mg of modified release orally in 24hrs
+
40 immediate release orally in 24hrs
= 160mg total

Oral morphine /2 = SC
160/2- 80mg SC by syringe

 What dose of injectable SC morphine should be used as breakthrough?
1/6 or 1/10 of 80mg
So..
13mg or 8mg is the breakthrough dose