Supportive and Palliative Care (Pain)

Question 1

What are the pain managements according to WHO Pain ladder?

Answer 1

Step 1: non-opioid +/- adjuvant
Step 2: opioid for mild to mod pain +/- non-opioid +/- adjuvant
Step 3: opioid for mod to sev pain +/- non-opioid +/- adjuvant

Question 2

Is morphine a controlled drug in SG?

Answer 2

No, hence it is conveniently used

Question 3

What is the active metabolite of morphine?

Answer 3

Morphine-6-glucuronide

Question 4

Is morphine renally or hepatically cleared

Answer 4

Renal -> must be careful in cancer pts who often have end organ failure i.e kidney failure

Question 5

SE of opioids

Answer 5

Somnolence
Respiratory depression
Constipation

Question 6

How to determine the prn dose to give from the chronic dose

Answer 6

Add 50% to 100% of prn usage to around the clock scheduled doses
Rescue prn doses = 10% - 20% daily opioid requirements

Question 7

Is fentanyl stronger than heroin and morphine?

Answer 7

Yes, up to 50x stronger than heroin and 100x stronger than morphine

Question 8

Fentanyl PK (half life, onset, ss)

Answer 8

IV: Very short half life, fast onset, often used in ICU

For patch:
Slow onset: 8-12hr
Steady state slower: Q72hrs for full effect

Question 9

When is fentanyl patches recommended over other opioids?

Answer 9

When pt is opioid tolerant
Pt cannot swallow

Question 10

What does opioid tolerant mean?

Answer 10

Can tolerate 60mg morphine PO per day or equivalent

Question 11

What are some counselling points for fentanyl patch?

Answer 11

Do not put on broken skin/rashes
Do not rub on the patch or expose it to the sun
Do not use it when pt has a fever

Question 12

When is methadone given?

Answer 12

For opioid withdrawals and to reverse some opioid tolerance

Question 13

Methadone or fentanyl take longer for full effect?

Answer 13

Methadone (5-7days)

Question 14

Is ketamine an opioid?

Answer 14

No, it is an anesthetic with some interesting properties in patients with opioid hyperalgesia

Question 15

What is opioid hyperalgesia?

Answer 15

end of life pts on 80-100mcg/hr fentanyl patch and pain still not controlled.

Question 16

How does ketamine work?

Answer 16

Ketamine itself has analgesic effect but not potent. It works with opioid to make the opioid “supercharged” so reduces baseline opioid dose.

Question 17

How much to reduce baseline opioid when initiating ketamine?

Answer 17

> =50%

Question 18

2 Side effects of ketamine

Answer 18

Nightmares and hallucinations

Question 19

Difference btw opioid tolerance vs dependence vs addiction

Answer 19

Tolerance: reduced response to medication to require more opioids or higher doses to exp same effect

Dependence: body adjusts normal functioning ard regular opioid use. Unpleasant physical smx occur when medication is stopped

Addiction: Opioid use disorder (OUD) when reducing dose or control use are unsuccessful or when it results in social problems and failre to fulfill obligations at work/sch/home. Often comes after tolerance and dependence.

Question 20

CDC clinical practice guidelines are not applicable for __?

Answer 20

• management of pain related to sickle cell disease,
• management of cancer-related pain, or
• Palliative care or end-of-life care

…but still has useful principles we can learn from for all situations

Question 21

What are some considerations when prescribing opioids for pain according to CDC guidelines

Answer 21

• When initiating, prescribe immediate-release opioids
• Prescribe the lowest effective dosage, avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks
• Exercise care when changing opioid dosage:
  Optimize nonopioid therapies while continuing opioid therapy
  If benefits do not outweigh risk, gradually taper
• Prescribe no greater quantity than needed
• Evaluate benefits and risks early and regularly
• Evaluate and discuss if needed opioid-related harms and mitigation steps
• Drug monitoring program (PDMP)?
• Consider the benefits and risks of toxicology testing
• Use caution when combining opioids with benzodiazepines and other CNS depressants
• Use evidence based medicine to treat opioid use disorder (OUD)

Question 22

What are some adjuvants that can be given for pain

Answer 22

• Gaba acting anticonvulsants (more common)
  Gabapentin
  Pregabalin
• SNRIs
• Tramadol
• Lidocaine patches (not common)

Question 23

End of life syndromes: How to treat dyspnea?

Answer 23

• Non-pharmacologic approaches should be considered
• Oxygen therapy may be helpful in some cases, remember to consider if had previous bleomycin chemotherapy
• Morphine prn is routinely seen prescribed at NUH, titrated to respiratory rate eg. when RR>15-20 PRN

Question 24

End of life syndromes: How to treat secretions?

Answer 24

Glycopyrrolate (but exempt in SG)
Anticholinergics (but weight toxicities and pt preference)

Question 25

End of life syndromes: How to treat agitation/delirium?

Answer 25

• Pharmacists should always look for medication related causes or contributors to delirium and look for alternatives or consider deprescribing
• Antipsychotics seen as an option of last resort due to questionable efficacy and undesirable AEs, although anecdotally atypical antipsychotics are increasingly being used to perhaps safer effect

Question 26

What are other common ailments for end or life syndromes?

Answer 26

• Anorexia/cachexia: supplements, milk feeds
• Persistent nausea
• Chronic diarrhea/constipation
• Insomnia/over-sedation
• Wound care/pressure ulcers: barrier creams, bed turning