Palliative care prescribing: pain

Question 1

Summarise the wHO pain ladder.

Answer 1

Question 2

What types of oral morphine are available for advanced and chronic disease?

Answer 2

Modified-release morphine
Immediate-release morphine

Based on patient preference

Question 3

How much oral morphine is usually used for palliative pain with no comorbidities?

Answer 3

20-30mg oral MR morphine/day and 5mg morphine for breakthrough pain

e.g. 15mg MR BD + 5mg PRN

Question 4

What else should be prescribed for all patients on strong opioids?

Answer 4

Laxatives

Question 5

What advice is given to those with nausea on morphine?

Answer 5

Nausea usually transient - but antiemetic may be given
Drowsiness is also usually transient, but if persists then adjust dose.

Question 6

What do the SIGN guidelines suggest in terms of breakthrough pain?

Answer 6

Breakthrough dose should be one sixth the daily dose of morphine

Question 7

Which opioids are preferred in mild/mod renal impairment vs severe renal impariment?

Answer 7

No renal impairment: morphine
Mild-moderate renal impairment: oxycodone
Severe renal impairment: alfentanil, buprenorphine, fentanyl

Question 8

What treatment options are available for pain in metastatic bone pain?

Answer 8

Strong opioids
Bisphosphonates
Radiotherapy
Denosumab

NSAIDs have not been shown to be good for this.

Question 9

When increasing opioid doses, what % increase should be used?

Answer 9

By 30-50%

Question 10

Which side effects of opioids are transient vs persistent?

Answer 10

Transient: nausea and drowsiness
Persistent: constipation

Question 11

How do you convert from oral codeine to oral morphine?

Answer 11

Divide dose by 10

Question 12

How do you convert from oral tramadol to oral morphine?

Answer 12

Divide by 10

NB: previously divided by 5 but now BNF says 10

Question 13

How do you convert from oral morphine to oral oxycodone? Why would this conversion be done?

Answer 13

Divide by 1.5 or 2

Oxycodone causes less sedation, vomiting and pruritus than morphine but more constipation.

Oxycodone is twice as strong as oral morphine

Question 14

How do you convert from oral morphine to subcutaneous morphine/diamorphine?

Answer 14

Oral morphine –> SC morphine - divide by 2
Oral morphine –> SC diamorphine - divide by 3

Question 15

How do you convert oral oxycodone to SC diamorphine?

Answer 15

Divide by 1.5