prescribing for pain in palliative care
TRANSCRIPT
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Pain in Palliative Care
Katie Dumble
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Definition of Pain
‘An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such
damage’ (International Association for the Study of Pain)
‘whatever the experiencing person says it is, existing whenever he says it does’ (Margo McCaffrey ,1968)
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WHO Pain Ladder
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Analgesic DrugsRoute of Admin Major Side Effects Other problems
Paracetamol Oral/IV Hepatotoxicity
NSAIDSe.g. Ibuprofen
Oral GI- bleeding, dyspepsia, abdo pain, diarrhoea.Renal impairment
Opiatese.g. MorphineCodeine
Oral, Rectal, SC (syringe driver), IM, IV, PCA,Epidural
ConstipationRespiratory DepressionSedationNausea
Physical dependence
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Opioid side effects
• Constipation• Nausea and vomiting• Sedation• Vivid dreams• Hallucinations• Confusion• Myoclonic jerks• Respiratory depression
Toxicity
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Drug Relative potency to Oral Morphine
Oramorph (4hourly) 1
MST (12hourly) 1
IM Morphine 2
Sc Morphine 2
Diamorphine 3
Oxycodone 2
Fentanyl 150
Hydromorphone 7.5
Tramadol 0.2
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Prescribing
• Starting dose for morphine 10mg 4 hourly (2.5-5mg in frail/elderly)
• The same dose (10mg) is PRN dose (1/6th of total daily dose)
• Increase incrementally over days until patient’s pain controlled
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Case 1
• Mrs K, a 50 year old lady with breast cancer and pain from bone metastases
• Currently on Cocodamol 30/500, 2 tablets, QDS.
• Pain not controlled• What should you do?
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Case 1 Answers
• Pain not controlled so need to go up WHO pain ladder
• Add in strong opiate.• Starting dose Oramorph 10mg 4hourly and
PRN Oramorph 10mg.• Consider antiemetics and laxatives• Titrate dose up gradually until pain controlled
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Prescribing
• When daily morphine requirements are stable can convert 4hourly morphine into modified release form
• Same total daily dose given but split into 2 doses rather than 6.
• I.e Oramorph 10mg 4hourly is equivalent to MST 30mg 12hourly.
• PRN dose remains the same (10mg Oramorph)
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Case 2
• Mrs K’s pain is finally controlled with Oramorph 30mg. She does not like taking so many tablets.
• What do you do?
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Case 2 answer
• Change to modified release morphine e.g. MST.
• Dose is total daily amount of oramorph split into 2 doses 12 hours apart
• MST 90mg 12hourly and PRN Oramorph 30mg
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Prescribing if patient unable/unwilling to swallow
• IM morphine – divide total daily dose of oral morphine by 2. Then split between 6 daily doses (4hourly).– E.g Oramorph 10mg 4hourly is equivalent to IM Morphine
sulphate 5mg 4hourly.
• IM Diamorphine- better for palliative care patients because more soluble so given in smaller volume than morphine sulphate.– Divide total daily dose by 3 and split into 6 daily doses.– E.g. Oramorph 15mg 4hourly becomes Diamorphine 5mg
4hourly. (Comes in 5, 10, 30,100 and 500mg ampules)
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Case 3
• Mrs K becomes more weak and unwell, she can no longer swallow, but she is distressed by her pain. She is still prescribed MST 90mg 12hourly and PRN Oramorph 30mg.
• What should you do?
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Case 3 Answer
• Needs parenteral route for pain relief• IM Morphine sulphate 15mg 4hourly (90x2/2
into 6 doses) and PRN IM Morphine sulphate 15mg
Or• IM Diamorphine 10mg 4hourly (90x2/3 into 6
daily doses) and PRN IM Diamorphine 10mg
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Syringe drivers
• Diamorphine can also be given sc so can be put in a syringe driver
• Divide total daily dose oral morphine by 3• E.g. Oramorph 10mg 4hourly is equivalent to
20mg Diamorphine over 24hours in syringe driver.
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Case 4
• Mrs K is cachetic and the regular IM injections are difficult to do. She is currently prescribed IM diamorphine 10mg 4hourly and PRN Diamorphine 10mg.
• What should you do?
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Case 4 answer
• Set up a syringe driver• Total daily dose of diamorphine put into
syringe driver and infused over 24hours.• Diamorphine 60mg over 24hours in syringe
driver (10x6)• PRN Diamorphine 10mg IM• Consider adding any other necessary drugs to
syringe driver e.g. Antiemetics.