Palliative Care Prescribing

Question 1

How do you start opiod treatment in palliative care?

Answer 1

1. Offer Zomorph (Slow release morphine) or Fentanyl if preferred.
2. Breakthrough pain - 1/6 of daily dose of morphine.
   
   1. 20-30mg/day of Zomorph 15mg BD) + 5mg Oramorph
3. Always prescribe Laxatives
4. Antiemetics only if nausea
5. If CKD, use opiods with caution - consider alfentanil, buprenorphine or fentanyl.

Question 2

How high should opiods be increased if they need increasing?

Answer 2

30-50%

Question 3

When converting codeine or tramadol to oral morphine, what do you divide the dose by to get the equivalence?

Answer 3

Divide by 10

50mg of codeine = 5mg Oramorphine.

Question 4

When converting from oral morphine to oxycodone, what do you divide by to get the equivalence?

Answer 4

Divide by 2.

10mg of Morphine = 5mg Oxycodone.

(NOTE Recent BNF says more like divide by 1.5 but 2 is easier to remember)

Question 5

What is the difference between oxynorm/oxycodone and morphin?

Answer 5

Oxycodone is less sedative. It causes less vomiting and pruritis than morphine.

But it is more constipating.

Question 6

30mg of Oramorph in a day equates to what fentanyl patch?

Answer 6

12 micrograms fentanyl patch

Therefore conversion factor of 2.5

Question 7

24mg of Oramorph in a day equates to what Buprenorphine patch?

Answer 7

10mg Buprenorphine patch

Question 8

Theory

To convert from oral morphine to diamorphine, what do you divide by?

Answer 8

3

9mg of morphine = 3mg diamorphine

Question 9

To convert from oral oxycodone to diamorphine, what do you divide by?

Answer 9

1.5

10mg oxycodone = 6.66 mg of diamorphine

Question 10

What are some causes of confusion in palliative care patients?

Answer 10

1. Hypercalcaemia
2. Infection
3. Urinary retention
4. Medication

Question 11

How can you treat agitation and confusion if there is no specific cause?

Answer 11

1. First choice: haloperidol
2. Other options: chlorpromazine, levomepromazine
3. Terminal phase: midazolam

Question 12

What is the management of hiccups in palliative care?

Answer 12

1. Chlorpromazine is licensed for the treatment of intractable hiccups
2. Haloperidol, gabapentin are also used

Question 13

Reality

Patient is on 20mg of MST BD but you want to switch to a syringe driver. What dose of subcut diamorphine should they be placed on?

Answer 13

The oral to subcutaneous potency ratio of morphine is between 1:2 and 1:3 (that is, the subcutaneous dose is one third to one half of the oral dose).

In practice, most centres divide the oral dose by two and re-titrate as necessary.

Therefore 20mg of diamorphine over 24 hours

Question 14

How do you treat someone with metastatic bone pain?

Answer 14

Bone pain: NSAIDs, Bisphosophonates or radiotherapy.

Question 15

Is drowsiness from opiods permanent or transient?

Answer 15

Drowsiness from opiods is transient -if persists reduce dose of morphine.

Question 16

Which side effects are usually transient?

Answer 16

Nausea and drowsiness

Question 17

Which side effects are usually persistent?

Answer 17

Constipation

Question 18

Oxycodone causes less A and B but more C than morphine

Answer 18

A = Sedation (less)

B = Vomiting (less)

C = Constipation (more)