Pain Management

Question 1

What is Step 1 in the WHO pain ladder?

Answer 1

Non-opioid analgesia ± adjuvants

Question 2

What is Step 2 in the WHO pain ladder?

Answer 2

Weak opioid analgesia + non-opioid analgesia ± adjuvants

Question 3

What is Step 3 in the WHO pain ladder?

Answer 3

Strong opioid analgesia + non-opioid analgesia ± adjuvants

Question 4

Give an example of a non-opioid analgesic agent and an appropriate dose

Answer 4

Paracetamol 1g QDS po

Question 5

Give 3 examples of weak opioid analgesic agents used for the management of pain

Answer 5

Co-codamol 30/500
Co-dydramol
Tramadol

Question 6

What are the components of co-codamol 30/500?

Answer 6

Codeine 30mg

Paracetamol 500mg

Question 7

What are the components of co-dydramol?

Answer 7

Dihydrocodeine

Paracetamol

Question 8

Give examples of strong opioid analgesic agents

Answer 8

Morphine
Oxycodone
Fentanyl
Diamorphine
Buprenorphine

Question 9

List some adjuvant analgesics which can be used alongside the steps of the WHO pain ladder

Answer 9

NSAIDs e.g. ibuprofen
Tricyclics e.g. amitriptyline
Gabapentin
Bisphosphonates
Steroids
Radiotherapy

Question 10

What are the names (drug name and trade name) of the short-acting and the long-acting preparations for morphine?

Answer 10

Short-acting = Oral morphine sulphate solution (Oramorph)
Long-acting = Morphine sulphate slow release tablets (MST Continus)

Question 11

True / False: It is acceptable to use the trade name for morphine when prescribing

Answer 11

True - You can write ‘Oramorph’ on the prescription

Question 12

How long does Oramorph last for?

Answer 12

4 hours

Question 13

How many doses of long-acting morphine (morphine sulphate slow release tablets) are given daily?

Answer 13

2 doses - one in the morning and one in the evening

Question 14

What is the trade name for the short-acting morphine TABLETS which are available?

Answer 14

Sevredol

Question 15

What dose of Oramorph would you start someone on?

Answer 15

Usually 10mg - If they have been on regular Step 2 analgesia they have already shown they can cope with opioids so this is appropriate. Consider lower dose in people with risk factors.

Question 16

How frequently would you prescribe Oramorph?

Answer 16

Every 4 hours

Question 17

How do you work out the dose of long-acting morphine (MST Continus) to give?

Answer 17

Add up the total dose of short-acting Oramorph the patient is taking in one day and divide this into 2 equal doses. For example, if patient is on 10mg of Oramorph 4hrly (6 times per day) they take 60mg of morphine. 60/2 = 30 so the dose of MST Continus is 30mg twice a day (one in the morning and one in the evening)

Question 18

What might you consider prescribing alongside morphine to reduce the effects of a particular side effect?

Answer 18

Anti-emetic - Morphine commonly causes nausea and vomiting

Metoclopromide 10mg TDS po or s/c

Question 19

Can you give ‘breakthrough’ morphine to a patient already on long-acting MST Continus?

Answer 19

Yes

Question 20

What would be your choice of breakthrough analgesia for a patient who is already on long-acting MST Continus?

Answer 20

Oramorph (a short-acting morphine preparation)

Question 21

How would you work out the dose of breakthrough morphine required for a patient who is daily long-acting MST Continus if they needed extra analgesia for acute pain?

Answer 21

Total daily dose of morphine divided by 6 e.g. if patient is on 60mg of MST Continus daily (split into 2x 30mg doses), then you can prescribe 60/6 = 10mg of Oramorph as breakthrough medication

Question 22

What is the dosing instruction for PRN ‘breakthrough’ morphine?

Answer 22

Max. 2 doses every 4 hours or 6 doses per 24 hours

Question 23

What does of codeine is in the standard dose of co-codamol which is prescribed?

Answer 23

30mg (Co-codamol is usually 30/500)

Question 24

How long does it take for the effects of a morphine patch to wear off?

Answer 24

12-18 hours

Question 25

If switching from MST Continus BD to Fentanyl patches, how much overlap should there be between the 2 medications?

Answer 25

Take the final tablet of MST Continus at the same time as applying the Fentanyl patch

Question 26

Tramadol 100mg is equivalent to what dose of oral morphine sulphate?

Answer 26

20mg (conversion is 5:1)

Question 27

What must be included on a prescription for a controlled drug?

Answer 27

• Prescriber details: Signature, date, prescriber address
• Patient full name, DOB and address
• The name and form of the drug e.g. morphine sulphate tablets
• The dose (e.g. 40mg) or strength (e.g. 10mg/5mL) of the drug
• The total quantity or total number of units written in words and figures

Question 28

How would you write an outpatient prescription of Morphine Sulphate Tablets (MST) 40mg PO BD?

Answer 28

Morphine sulphate tablets (MST) 40mg PO BD
Supply 20 (twenty) 10mg tablets and 20 (twenty) 30mg tablets

Question 29

What dose of MST Continus is NOT available?

Answer 29

Tablets don’t come in 20mg

Question 30

List some side effects of NSAIDs

Answer 30

Fluid retention, hypertension
Heart failure
Bleeding
GI disturbance - Ulcers, dyspepsia, nausea and vomiting
Nephrotoxocity and renal failure
Bronchospasm