Palliative Care

Question 1

What is pain?

Answer 1

An unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Subjective phenomena with physiological, social and spiritual dimensions

Question 2

Nociceptive somatic pain is the stimulation of:

Treatment?

Answer 2

peripheral receptors in skin bone joints and muscle.
It is a LOCALISED ache, throbbing, gnawing.

Good response from non-opioids and opioids

Question 3

Nociceptive visceral pain is the stimulation of:

Treatment?

Answer 3

receptors in internal organs.
It is a poorly localised, deep ache

Good response from non-opioids and opioids

Question 4

What is neuropathic pain?

What are the features/ types? e.g. shooting pain, etc?

What is the treatment?

Answer 4

Usually pain that arises from damage to peripheral nervous system.

Features: burning, sharp, itching, stabbing, shooting

More complex pain to treat. May need specialist advice. Adjuvant drugs are usually needed.

Question 5

What is in Step 1 of the WHO ladder?

Answer 5

Non opioids

Question 6

What is in Step 2 of the WHO ladder?

Answer 6

Weak opioids

Question 7

What is in Step 3 of the WHO ladder?

Answer 7

Strong opioids

Question 8

Give examples of non opioids

Answer 8

paracetamol

NSAIDS

Question 9

Give examples of WEAK opioids

Answer 9

Codiene
DHC
Tramadol
Buprenorphine
\+ paracetamol

Question 10

Give examples of STRONG opioids

Answer 10

Morphine
Oxycodone
Fentanyl
Methadone
Alfetanil
\+Paracetamol

Question 11

What can you give with weak/strong opioids?

Answer 11

+/- adjuvants, laxatives and anti-emetics (prevent vomiting)

Question 12

What COX does Paracetamol inhibit in the CNS?

Answer 12

3

Question 13

What is the safest NSAID?

Answer 13

Naproxen

Question 14

How do NSAIDs work?

Answer 14

Inhibit prostaglandin synthesis. Inhibits the pain & inflammatory response

Question 15

Mild to moderate pain treated with?

Give examples

Answer 15

Step 2 - Weak opioid + non opioid

e. g.
- Tramadol (combines weak opioid with SSRI effect)
- Paracetamol 500mg + Codeine 30mg combination
- Buprenorphine (usually transdermal)

Question 16

Mild pain treated with?

Answer 16

Step 1 - Non opioid
e.g. NSAIDS.
naproxen is the safest - evidence based

Question 17

Moderate to severe pain treated with?
1st line

2nd line

3rd line

Answer 17

Strong opioids

Morphine

Oxycodone, Fentanyl transdermal, Alfentanil. Diamorphine used occassionaly when need large dose of analgesia in small volume.

Methadone

Question 18

If morphine is contraindicated e.g. due to intolerance, what do you give?

Answer 18

Switch to Oxycodone

Question 19

What is breakthrough pain?

Answer 19

Sudden sharp / severe pain despite adequate background

analgesia. Can be due to incident e.g. movement, or spontaneous.

Question 20

What is the onset of breakthrough pain?

What is the duration of breakthrough pain?

Answer 20

3 minutes

30 minutes

Question 21

How do you treat breakthrough pain?

Answer 21

IR opioids e.g. oral morphine/ oxycodone liquid

Faster acting Fentanyls (FAFs) now available.

Question 22

What is the dose for breakthrough pain?

Answer 22

1/6 total daily dose, given initial.

Question 23

What is an alternative opioid analgesic for moderate-severe pain?

Benefits of Fentanyl Transdermal Patch over Morphine/ Oxycodone

Answer 23

Fentanyl transdermal patch

Less constipating
Reduces pill count, so increase compliance
Useful for patients with renal impairment.

Question 24

Methadone is a 3rd/4th line opioid analgesic, useful for patients with:

Answer 24

• neuropathic pain
• renal impairment
• poor responders/ side effects to other opioids

Question 25

Alfentanil is a 2nd line opioid sc injection, useful for patients with:

Answer 25

• renal impairment

- morphine/oxycodone intolerance

Question 26

What is neuropathic pain caused by?

Answer 26

Damage caused by:
- compression
- chronic local inflammation 
- invasion by tumours.
USUALLY REQUIRES ADJUVANT ANALGESIA.

NERVE BLOCKS MAY BE NECESSARY

Question 27

When are TCAs such as amitriptyline used?

Answer 27

Useful if depression or insomnia is associated with pain

Question 28

TCA’s are contradicted in patients with?

Answer 28

• Cardiac problems
• Prostate problems (OK if catheterised)
• Glaucoma
• Confusion/ fits

Question 29

Which anticonvulsant interacts with oxycodone to cause increased drowsiness?

Answer 29

Pregabalin

Question 30

Name two anticonvulsants used for neuropathic pain:

Answer 30

Gabapentin

Pregabalin

Question 31

Which anticonvulsant should you avoid due to interaction profile with other drugs?

Answer 31

Carbamazepine

Question 32

What is an alternative anti convulsant if 1st/ 2nd line choices are not effective?

Answer 32

Sodium valporate

Question 33

Which anticonvulsant is useful if patient has: anxiety, muscle spasm, and sleep problems that coexist with the neuropathic pain?

Answer 33

Clonazepam

Question 34

Name a corticosteroid used for pain?

Answer 34

Dexamethasone

Question 35

How does Dexamethasone help in pain?

Answer 35

Reduces tumour mass/ pain due to compression

Reduce headache due to cerebral oedema

Question 36

What drug helps reduce the rate of bone turnover and reduce cancer-related bone pain?

Answer 36

Biphosphonates