Opiates -Safe Prescribing Flashcards
What is this?
Analgesic Ladder
What is the analgesic ladder?
- Work up the ladder in medication for increasing pain
When should alternative routes to oral be considered?
Considere in cases of:
- Dysphagia
- Gastric stasis
- Intractable vomiting
- Impaired consciousness dictate
What is on step 1 on the analgesic ladder? Appropriate for what level of pain?
- Low level pain
- Non-opioids analgesics: Paracetamol
- Adjuvant drugs considered i.e. may consider NSAID
If pain is persisting or increasing what is step 2 of the analgesic ladder?
- Consider weak opioid e.g. codeine
- Plus paracetamol
- e.g. co-codamol (codeine and paracetamol)
- Adjuvant drugs can be considered
What is on step 3 of the analgesic ladder?
- Strong opioids considered e.g. Morphine or diamorpine
- Adjuvant medication can be added in
What adjuvant medication can be added to the analgesic ladder? When can they be addded?
Adjuvant medication:
- NSAIDs =can be used at any step on the analgesic ladder
- Antiepileptics
- Antidepressants
- Corticosteoids
- Rest of adjuvant medication added when clinically appropriate
What are the different strenght that co-codamol can be prescribed in? In elderly or frail patients what is appropriate?
- 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
What are the side effects of strong opioids? How can they be treated?
- 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
What are the signs and symptoms of opioid toxicity?
- 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)
What 2 forms are oral morphine available in? Consider:
- when does it become effectives
- lasts how long
- example names
- 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
In which patients should you start on a lower starting dose than normal patients?
- Elderly or frail patients
- Patients with renal failure
- as will accumulate morphine metabolites
How should the dose of morphine be titrated up?
- Titrate dose upwards by 30-50% increments to relieve pain or until unacceptable adverse effects occur
- Always check pain is opioid sensitive
All patients on modified release morphine should have what available? Why?
- 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
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
- 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
