Pain Management

Question 1

How might someone describe neuropathic pain?

Answer 1

Stabbing
Shooting
Stinging
Burning

Question 2

How might someone describe nociceptive somatic Pain?

Answer 2

Sharp
Throbbing
Well localised

Question 3

How might someone describe nociceptive visceral pain?

Answer 3

Diffuse ache, difficult to localis

Question 4

Outline the WHO pain ladder

Answer 4

Step 1: non-opioid e.g. aspirin, paracetamol +/- adjuvant
Step 2: weak opioid e.g. codeine, dihydrocodeine, tramadol +/- non-opioid +/- adjuvant
Step 3: strong opioid e.g. morphine, diamorphine, oxycodone, fentanyl, alfentanil +/- non-opioid +/- adjuvant

Question 5

What is the standard adult dosing regime for paracetamol?

Answer 5

1g TDS

Question 6

When should you consider reducing paracetamol dose to 500mg TDS?

Answer 6

Poor nutrition status
Weight < 50kg
Hepatic impairment
Chronic alcohol abuse

Question 7

What is celecoxib and why would you prescribe it?

Answer 7

COX-2 selective inhibitor

To avoid ADRs - mainly GI (stomach pain, nausea, heartburn, ulcers) in patients at risk of these side effects

Question 8

What cautions do you need to think about when prescribing NSAIDs?

Answer 8

GI ADRs - prescribe PPI
Renal Disease - NSAIDs reduce prostaglandins causing reduced GFR
Hepatic Disease
Heart failure

Question 9

What is the maximum daily dose of codeine?

Answer 9

60mg QDS or 240mg/24hrs

Question 10

What is the conversion ratio for codeine:morphine?

Answer 10

10:1

Question 11

How much morphine is equivalent to 240mg of codeine?

Answer 11

24mg morphine

Question 12

What would you generally prescribe to step up to rung 3 of the opioid ladder?

Answer 12

Morphine SR 15mg BD

Morphine IR 5mg PRN for breakthrough pain

Question 13

Why should paracetamol be continued at steps 2 and 3?

Answer 13

It may have an opiate sparing effect

Question 14

When might you consider starting with lower doses?

Answer 14

Frail, elderly

Renal impairment

Question 15

What types of pain responds poorly or partially to opioids?

Answer 15

Neuropathic

Bone

Question 16

What should prescribe alongside strong opiates?

Answer 16

Regular anti-emetic e.g. metoclopramide or haloperidol

Regular laxative e.g. Senna, Macrogol

Question 17

What are the side effects of morphine?

Answer 17

Constipation
Morphine
Drowsiness 
Dry mouth
Renal impairment
Respiratory depression

Question 18

How do you work out new doses of Zomorph and oromorph from TDD?

Answer 18

TDD / 2 = Zomorph BD

TDD / 6 = Oromorph PRN

Question 19

What are the second line opioids?

Answer 19

Oxycodone

Fentanyl

Question 20

What is the dose ratio of morphine:oxycodone?

Answer 20

2:1
So oral morphine 60mg = oral oxycodone 30mg = SC oxycodone 15mg
SC morphine 30mg = SC oxycodone 15mg

Question 21

What is fentanyl?

Answer 21

A potential opioid analgesic in a topical patch that lasts 72 hours

Question 22

How long does a fentanyl patch take to have an effect?

Answer 22

12-24 hours

Question 23

What is the smallest fentanyl patch available?

Answer 23

12 mcg

Question 24

What dose of oral morphine is a 12mcg fentanyl patch equivalent to?

Answer 24

45mg/24hr

Question 25

For what patients is alfentanil particularly suitable?

Answer 25

In stage 4-5 CKS or severe renal impairment

Question 26

What is an ‘adjuvant’ pain medication?

Answer 26

A drug whose primary indication is for something else other than pain.

Question 27

List some common adjuvants and the type of pain they can be used for.

Answer 27

NSAIDs - bone pain, liver pain, inflammatory pain
Antidepressants e.g. amitriptyline- neuropathic pain, helps sleep
Anticonvulsants e.g. gabapentin - neuropathic pain
Benzodiazepines
Steroids- liver capsule pain, neuropathic pain
Bisphosphonates - bone pain

Question 28

How do you convert oral morphine to SC morphine?

Answer 28

Half the dose

Oral morphine 30mg = SC morphine 15mg