Opiates -Safe Prescribing

Question 1

What is this?

Answer 1

Analgesic Ladder

Question 2

What is the analgesic ladder?

Answer 2

• Work up the ladder in medication for increasing pain

Question 3

When should alternative routes to oral be considered?

Answer 3

Considere in cases of:

• Dysphagia
• Gastric stasis
• Intractable vomiting
• Impaired consciousness dictate

Question 4

What is on step 1 on the analgesic ladder? Appropriate for what level of pain?

Answer 4

• Low level pain
• Non-opioids analgesics: Paracetamol
• Adjuvant drugs considered i.e. may consider NSAID

Question 5

If pain is persisting or increasing what is step 2 of the analgesic ladder?

Answer 5

• Consider weak opioid e.g. codeine
• Plus paracetamol
• e.g. co-codamol (codeine and paracetamol)
• Adjuvant drugs can be considered

Question 6

What is on step 3 of the analgesic ladder?

Answer 6

• Strong opioids considered e.g. Morphine or diamorpine
• Adjuvant medication can be added in

Question 7

What adjuvant medication can be added to the analgesic ladder? When can they be addded?

Answer 7

Adjuvant medication:

• NSAIDs =can be used at any step on the analgesic ladder
• Antiepileptics
• Antidepressants
• Corticosteoids
• Rest of adjuvant medication added when clinically appropriate

Question 8

What are the different strenght that co-codamol can be prescribed in? In elderly or frail patients what is appropriate?

Answer 8

• Weak
  
  • 8mg Codeine and 500mg paracetamol
• Strong:
  
  • 15mg Codeine and 500mg paracetamol
  • 30mg Codeine and 500mg paracetamol
• In elderly or frail patients a lower strength is more appropriate for pain

Question 9

What are the side effects of strong opioids? How can they be treated?

Answer 9

• Constipation (universal)
  
  • treat by prescribing a laxative e.g. co-danthramer
• Nausea and vomiting (1/3 patients)
  
  • prescribe p.r.n antiemetic
  • considere regular antiemtic if patient already nauseated or has had sickness in past
• Drowsiness may occur when starting or changing dose of opioid, usually improves within 48 hours
  
  • nb. excessive sedation may indicate excessive dosing or co-morbidity e.g. renal impairment
• Confusion and visual hallucinations (rare if correct dose given)
  
  • check dose and renal functions
  • consider alternative opioid if confusion persisits
• Respiratory depression
• Psychological dependence and addication

Question 10

What are the signs and symptoms of opioid toxicity?

Answer 10

• Spectrum from mild to severe
• Persistent nausea or vomiting
• Persistent drowsiness
• Confusion
• Visual hallucinations
• Myoclonic jerks
• Respiratory depression
• Pinpoint pupils (not useful sign in patient on long term opioids)

Question 11

What 2 forms are oral morphine available in? Consider:

• when does it become effectives
• lasts how long
• example names

Answer 11

• Normal / immediate release tablets and liquid
  
  • would be expected to be effective after 20-30minutes
  • lasts up to 4 hours
  • e.g. oramorph liquid or sevredol tablets
• Modified / slow release tablets, granules or capsules
  
  • expected to last up to 12 hours
  • e.g. Morphine sulphate tablets (MST)
  • Zomorph capsules

Question 12

In which patients should you start on a lower starting dose than normal patients?

Answer 12

• Elderly or frail patients
• Patients with renal failure
  
  • as will accumulate morphine metabolites

Question 13

How should the dose of morphine be titrated up?

Answer 13

• Titrate dose upwards by 30-50% increments to relieve pain or until unacceptable adverse effects occur
• Always check pain is opioid sensitive

Question 14

All patients on modified release morphine should have what available? Why?

Answer 14

• Should also have normal release morphine available p.r.n for breakthrough pain
• i.e. 1/6trh of total 24hour morphine dose e.g. patient on MST 20mg bd should have oramorph 5-10mg p.r.n

Question 15

Features of morphine injections. Consider:

• Names
• How can it be given
• Features of different ways given
• Features compared to oral morphine
• Dose comparied to oral morphine

Answer 15

• Names: diamorphine and morphine sulphate injection
• Given:
  
  • subcutaneously (p.r.n duration of action 4hours)
  • continous SC infusion via syringe driver
• Parenteral diamorphine 3x more potent than oral morphine
• Parenteral morphine sulphate 2 times more potent that oral morphine
• Total dose: SC continuous infusions diamorphine 1/3 of total 24hr oral morphine dose

Question 16

Transdermal morphine. Consider:

• Name
• How it is given
• Duration of action
• Who are they suitable for

Answer 16

• Name: Fentanyl transdermal
• Given: Patches
• Duration of action: 72 hours
• Suitable for: Patients with severe chronic pain already stabilise don other opioids

Question 17

What are other strong opioids available is morphine is not tolerated?

Answer 17

• Oxycodone
• Alfentanil
• Methadone
• Different preparations of fentanyl

Question 18

How much stronger is oramorph than paracetamol?

Answer 18

x10 stronger

Question 19

How much stronger is oral oxycodone vs oral oramorph?

Answer 19

x2 stronger than morphine

Question 20

How much stronger is SC morphine vs oramorph?

Answer 20

x2 stronger

Question 21

How much stronger is SC diamorphine than oramorph?

Answer 21

x3 stronger

Question 22

How much stronger is SC oxycodone vs oral oxycodone?

Answer 22

x2 stronger

Question 23

What is the equivalent oramorph dose in 24hrs to a fentanyl patch 72hrs?

Answer 23

• Fentanyl patch =25microgram patch/72hours
• Equals
• Oramorph 60-90ml/24hrs

Question 24

How much stronger is a buprenorphine patch than oramorph? Weak and strong patch doses?

Answer 24

x2 stronger

• Weak patch is 5,10,20micrograms and lasts 7/7
• Strong patch is 52, 75 micrograms and lasts 4/7