pain management

Question 1

cancer pain assessment?

Answer 1

Taking full pain history •Past medical, family and drug history •Examination of patient •Review of relevant pathology and radiology •Effect of previous treatments •Effect on patient and carer’s life •Patient’s hopes and expectations

Question 2

types of cancer pain?

Answer 2

Nociceptive Pain; 1. Visceral Pain •tumour presses or invades viscera •usually dull aching constant pain which may be ill defined and radiate •Such as liver capsule pain or chest wall pain from bronchial tumour invading pleura 2. Somatic Pain •involving bones, muscles, joints and tendons •Pain is usually easily localised and often exacerbated by movement •such as bony metastases, myofascial pain and cramps 3.Neuropathic Pain •due to compression or invasion of a nerve •Usually paroxysmal, severe, shooting or burning pain often associated with allodynia and parasthesia •Such as lumbosacral plexopathy or peripheral neuropathy associated with chemotherapy

Question 3

oramorph?

Answer 3

on full strength Step 2 analgesics start; 10mg oral morphine 4hrly not qds (Oramorph liquid 10mg/5ml or Sevredol tabs) •Prescribe a breakthrough dose of 10mg oral morphine hourly between regular doses if needed. •Review after 24hrs or sooner if pain not improved •Start laxative and ? Antiemetic •If no step 2 agent or in the very elderly/frail start 5mg 4hrly

Question 4

after oramorph?

Answer 4

Increase the oral morphine dose according to the breakthrough doses needed eg- If pt on oramorph 10mg 4hrly + 3 extra 10mg doses of oramorph in 24hrs- increase oramorph to 15mg 4hrly with 15mg prn dose. •Once pain is controlled change to sustained release morphine (MST/Morphogesic/Zomorph) Total 24hr morphine ÷ 2 =MST dose bd ie 90mg morphine in 24hrs equats with MST 45mg bd

Question 5

side effects of opioids?

Answer 5

Respiratory depression is extremely rare when pain is properly assessed and WHO guidelines followed •Early signs of toxicity; sleepiness hallucinations myoclonic jerks confusion/ mental clouding

Question 6

responsiveness to opioids?

Answer 6

Fully responsive; visceral pain some somatic pain •Semi responsive; bony and muscular pain, neuropathic pain, raised ICP, •Unresponsive some neuropathic pain, spasm, spiritual and psychological pain

Question 7

adjuvents for opioids ise?

Answer 7

Antidepressant(amitryptyline 10-25mg nocte) –Anticonvulsant(gabapentin 300-1800mg/day) –Steroids(dexamethasone 4-8mg/day) –Membrane stabilisers (flecanide 100-400mg/day) –NMDA receptor antagonists (ketamine oral/subcut)

Question 8

other drugs for neuathos pain ?

Answer 8

Anti cancer treatments •Nerve blocks •Epidural/intrathecal infusions •TENS, Acupuncture •Cordotomy