What are the equivalent doses of opioid analgesics?
- Codeine PO 100mg
- Diamorphine IM, IV, SC 3mg
- Dihydrocodeine PO 100mg
- Hydromorphine PO 10mg
- Morphine PO 10mg
- Morphine IM, IV, SC 5mg
- Oxycodone PO 6.6mg
- Tramadol PO 100mg
What are some conversions for painkillers?
- Morphine breakthrough doses (total daily divided by 6)
- Oramorph > SC or IV morphine (divide by 2)
- Codeine > oromorph (divide by 10)
What is the medication used to control GI problems in palliative care?
- Anorexia: prednisolone, dexamethsone
- Bowel colic and excessive resp secretions: hyoscine hydrobromide, hyoscine butylbromide or glycopyronium bromide
- Constipation: faecal softner with a peristaltic stimulant e.g. co-danthramer, lactulose solution with a senna preparation
- GI pain: loperamide hydrochloride
- N+V: haloperidol, cyclizine
- Dysphagia: dexamethasone
- Dry mouth: good mouth care, sugar free gum
- Hiccup: metoclopramide hydrochloride
What are the medications used to control symptoms of: convulsions, dyspnoea, insomnia, muscle spasm, pruritis, restlessness/confusion?
- Convulsions: phenytoin, carbamazepine
- Dyspnoea: morphine
- Insomnia: temazepam
- Muscle spasm: diazepam, baclofen
- Pruritis: colestyramine
- Restlessness/confusion: haloperidol, levomepromazine, midazolam
When are people approaching end of life care?
When they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hrs/days) and those with:
- Advanced, progressive, incurable conditions
- General frailty and co-existing conditions that mean they are expected to die within 12 months
- Existing conditions if they are at risk of dying from a sudden acute crisis in their condition
- Life-threatening acute conditions caused by sudden catastrophic events
Describe ReSPECT forms
Forms are indefinite unless the patient revokes the decision, a fixed review date is not recommended but it may be appropriate to review decision as clinical circumstances change.
What is the management of pain in palliative care?
- Start off with non-opioids for mild pain - paracetamol/NSAIDs (ibuprofen)
- Move to weak opioids next for moderate pain - codeine phosphate or tramadol hydrochloride
- Strong opioids for even worse pain - morphine, transdermal buprenorphine, transdermal fentanyl, methadone, hydrochloride, oxycodone hydrochloride
- Oxycodone is used when patients cannot tolerate morphine or have renal impairment
- Remember to give laxatives to patients on opioids
What is given for bone metastases pain?
Radiotherapy, bisphosphonates and radioactive isotopes of strontium chloride (Metastron)
What is the pain control for neuropathic pain?
- Tricyclic antidepressants - anti-epileptics may be added or substituted; gabapentin or pregabalin
- Ketamine can be used under specialist supervision if opioid analgesics not treating neuropathic pain
- Pain due to nerve compression - corticosteroid like dexamethasone (reduces oedema around tumour, reduces compression)
- Nerve blocks/regional anaesthesia techniques (including epidural and intrathecal catheter use) can be considered when pain is localised to a specific area
What is used for breakthrough pain?
- Standard dose of a strong opioid breakthrough pain usually 1/10th to 1/16th of regular 24hr dose, repeated every 2-4hrs as required
- Breakthrough pain - sudden and brief flare up of pain from a chronic condition like arthritis or cancer. The flare-up pain becomes severe enough to break through the pain medication you are taking.
How do you convert 24hr oral dose of morphine to fentanyl patches?
- Morphine salt 30mg daily = fentanyl 12 patch
- Morphine salt 60mg daily = fentanyl 25 patch
- Morphine salt 120mg daily = fentanyl 50 patch
- Morphine salt 180mg daily = fentanyl 75 patch
- Morphine salt 240mg daily = fentanyl 100 patch
MST (Morphine slow release tablet) must be phased out of the body before the patch is given.
How do you confirm a death?
- Confirm identity of the patient
- Inspection for any signs of life, any sign of respiration and any response to verbal stimuli
- Pressure on fingernail - response to pain
- Check pupils to ensure fixed and dilated
- Feel carotid pulse for at least 2 mins
- Listen to heart for at least 2 mins
- Listen to respiratory sounds for at least 3 mins
- Document findings and time of death
How do you phase out MST and introduce fentanyl?
MST is sub-therapeutic after approx 12hrs and fentanyl takes 12-13hrs to reach therapeutic levels in the body. Take on final dose of morphine and apply the patch at the same time.
