Pain control

Question 1

Describe the steps of the analgesia ladder

Answer 1

(Step 1) Non-opioids +/- adjuvants: paracetamol 1g/4 hrs (max. dose of 4g per day)

(Step 2) Weak-opioids + non opioids +/- adjuvants: Combined paracetamol with codeine OR dihydrocodeine

(Step 3) Strong opioid + non opioid +/- adjuvants: minimum of morphine 5mg starting dose. Titrate dose upwards 30%-50% percent every 24 hours

(Adjuvant drugs) Corticosteroid: oedema pain; antidepressant: neuropathic pain; anticonvulsant: neuropathic pain; muscle relaxant: muscle cramp pain; antispasmodic: bowel colic; NSAID: inflammatory; antibiotic: infection pain; night sedative: low sleep leading to lower pain threshold;

Question 2

Define breakthrough pain

Answer 2

Acute flare of pain, may be precipitated by activity or spontaneously

Question 3

Briefly describe the management of background pain

Answer 3

Immedicate release oral morphine at 50%-100% equivalent background 4 hour dose

Oral transmucosal fentanyl citrate lozenges (OTFC)

Midazolam SC 2.5mg to 5mg OR lorazempam SC 0.5mg sublingually (for anxiety)

NSAIDs SC

Question 4

What are the types fo opioid resistant cancer pain

Answer 4

(Pseudo-resistant) Underdosing; poor absorption; poor intake (i.e. vomiting); untreated psychological aspects

(Semi-resistant) Bone pain; increased intracranial pressure; nerve trunk compression; neuropathic pain; activity related pain

(Resistant) Muscle spasm; abdominal cramp; spiritual pain