Pain Management

Question 1

Define each step on the WHO pain ladder

Answer 1

Step 1: Non-opioid treatment

Step 2: Weak opioid +/- non-opioid

Step 3: Strong opioid +/- non-opioid

Question 2

Which conditions are contraindications for NSAIDs?

Answer 2

Severe heart failure

History of or active GI bleeding, ulceration or perforation

Question 3

When should an IV paracetamol dose be altered? (2)

What would the alterations be?

Answer 3

If bodyweight is less than 50kg - altered dose 15mg/kg

If CrCL <30ml/min - Dosage interval should be increased to 6 hourly instead of 4-6 hourly

Question 4

When is dihydrocodeine preferable to codeine? (2)

Answer 4

Patient with liver impairment

Patients who are breastfeeding

Question 5

What should be a consideration when moving a patient to step 3 of the pain ladder from step 2?

Why?

Answer 5

The dose of the weak opioid due to relative opioid potencies

If the starting dose of a strong opioid is lower than the equivalent of a weak opioid, the patient’s pain will still not be managed

Question 6

When should a lower dose of ibuprofen be used for pain management?

Answer 6

In elderly patients

Question 7

In which patients would morphine be switched to oxycodone?

Answer 7

Renally impaired patients with a CrCL of <30ml/min?

Question 8

When can fentanyl patches be used to manage chronic pain?

Answer 8

Once the patient’s pain has been controlled on shorter acting formulation of an opioid

Question 9

How should a dose of an immediate-release preparation be decided for breakthrough pain?

Answer 9

This should be 1/6th to 1/10th of the TOTAL daily dose of a prolonged-release formulation

Question 10

What is the equivalent dose of oral oxycodone for 10mg oral morphine?

Answer 10

6.6mg

Question 11

What is the relative potency of IV/IM/SC morphine compared to oral morphine?

Answer 11

Oral morphine is half as potent as injectable morphine, so the dose of oral morphine should be double

Question 12

What are the equivalent doses of codeine, dihydrocodeine and tramadol for 10mg morphine?

Answer 12

All are 100mg

Question 13

Which 72-hourly fentanyl patch is equivalent to 60mg of morphine daily?

Answer 13

25mcg/hour patch

Question 14

What is the best type of laxative to combat the constipating effects of opioids and why?

When should this type not be used?

Answer 14

Stimulant laxatives (e.g. senna) - Opioids slow peristalsis of the gut so stimulant laxatives reverse the action of opioids

Stimulant laxatives should not be used if there are signs of an obstruction as this can perforate the bowel