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Ok. So my name is Dr Jane mcauley, one of the palliative care consultants. And today, we're going to look at the principles of managing cancer pain. It's a learning objectives for today's session. You should be able to assess pain using a structured approach. Uh have a better understanding of the key characteristics of nociceptive and neuropathic pain. We'll look at the principles of the World Health Organization Analgesic Ladder and how it can be used in managing cancer pain and then look at some of the common opioid calculations that you will be doing in a not that many months time, uh particularly when you're switching somebody from their oral medication when they're no longer able to swallow, either due to nausea, bowel obstruction or end of life. So that's what we'll be covering today. So how common is pain? And in patients with advanced cancer, 75% will have significant pain and also in patients with non malignant disease, they will have very similar uh incidence of usually 70 even higher, sometimes, uh maybe not quite as severe pain, but certainly a significant incidence of pain. So it is a common problem in palliative care patients what do we say? The definition is very much simplistic approach is if the patient amount of pair of patient has their store, we take that as uh that they are and then we have to try and work out what is going on. Other definition that can be useful is bringing in that holistic approach that it's an unpleasant sensory but emotional experience. So it's not just a pure physical experience. Um if you're in bad mood yourself, or if you, you, you've you have a pain that is associated with a pleasant experience. It's a completely different experience to someone who's maybe worried that their headache is due to a metastatic cancer. So you can see how the psychological and emotional can play into the experience of pain. It also can be from actual or potential tissue damage. So a lot of the times in neuropathic pain, it can be warning of potential damage, but there's actually not damage there at the, at that time. And it actually becomes a pathological process in itself so affected by mood morale and by the meaning, it was da sorry, it was Dame Sly Saunders that very much uh popularized this concept of the total pain. And that then led to really focusing on the holistic assessment of patients or palliative care patients. So really realizing that treating physical pain with analgesics was never really going to solve patients pain of 100%. We really needed the multidisciplinary team to be focusing on the social concerns, the psychological, emotional anxiety, depression, uh and also dealing with the spiritual side of things. So that's why you need that multidisciplinary team to achieve the best pain relief uh that you can looking at types of pain, we can classify it to do with time. And you will see services are very much set up that way, you'll have acute pain teams, you have chronic pain teams. Um but also causation can be a useful way of thinking of, of, of how of dealing with pain because it will guide you towards uh the different medications that we might think of using. So, nociceptive pain is the pain caused by actual damage to the body tissues. While neuropathic pain is more often caused by a lesion or disease, uh actually affecting the nervous system itself. Most of the pains that I would see in my palliative care, patients would tend to have a mixed component, they would have actual tissue damage, but also the nerves are being affected as well. So you can see why we end up with quite a concoction of medication. S seems quite a busy slide, but we'll work our way through it slowly cos it's quite useful just in a way of getting the concept of pain and how you know what the patient may describe in the history, what sort of things you should be thinking and what sort of analgesics we should be looking at. So it's, it's a helpful thing to look through. So we, we're dividing it into nociceptive neuropathic pain. Let's a simplistic approach. And if you're reading into the literature, you'll realize that there's much more complexity and there are other, more neuroplastic pains out there. But we'll just stick to the basics at the moment. You can learn those key principles and then if you all go and become chronic pain physicians, you can, you can delve into the, to the, the wider the wider literature. So the nociceptive pain can again also be divided into somatic pain and visceral pain. Somatic pain is coming from the musculoskeletal system while the visceral pain is coming from the visceral organs. So, your somatic pain is the typical pain that we're all very familiar with. Uh you stub your toe, you pull a muscle, those types of pains. So you can localize them very specifically to, to, to where the pain is it. When a patient is describing them, they'll say it's an ache. It can actually be tender. If you're touching, it might be worth on movement, dull, localized pain. And there's usually a very good response to conventional analgesia and the patient doesn't have a difficulty in describing it. It's something they've experienced before. So they have language for it. Uh and you have language for it. So you're, you're, you're able to, to, to understand what they're describing visceral pain, as I said, came from the visceral organs and it's more of a diffuse pain, you know, it will be experienced off sight, I suppose. A classical is where you see the appendix and when they, where they're initially having problems, they're having a grumbling pain around their, their tummy button or the belly button. And it's only really when the parietal uh, lining of the, the, the part names becomes inflamed, they suddenly they localize it down to the, to the right fossa. So you, you, it's really, it's hard for them to localize. They describe it as diffuse and actually they could be things in my shoulder and it's actually their liver that's causing the pain, but the irritation of the diaphragm could be referring it. So you can see where you could might miss or, or, or misdiagnose quite often if it's in hollow viscera, uh you might have this cramping pain, say in bowel or bladder, it might also be a deep pain. You might describe it as a dull or aching, doesn't relate as much to movement. Um but still quite a good response to conventional analgesics and the patient usually has quite good language to describe it because they've had urinary tract infections or they've been constipated. So they, they can, they can give you language for that neuropathic pain. Again, as we talked about injury, it's actually the central or peripheral nervous system or potential injury and it tends to follow the nerve path. So you might find these radicular pains around the side of the chest wall or down into the leg. Or it might actually be a poor diffuse pain depending on the, the dermato that's being affected. They may describe as burning, stabbing, electric shooting. Um not always movement related. Sometimes you might have a maybe an unstable spine and you might find that the pain may be related to movement, but there will usually be a sensory deficit or uh allodynia or hyperalgesia, sort of other things that you're picking up uh in the assessment to make you think that this is to do with this the nervous system that there's uh an impairment of sensation. There's quite often a poor to moderate response to conventional analgesics. So they, it's not that they won't respond at all, but that they might um not have a complete response. And you're quite often having to think about adjuvants like antidepressants, anticonvulsants to try and get achieve better pain control and this pain does tend to be a newer stranger sensation. So, quite often patients will say so, you know, it's really not quite a pain and yet it's obviously bothering them, it's obviously unpleasant, but it's not quite, it's not really a pain they may say or they just maybe don't have the language for it. Um especially in the first uh period of experiencing it because it's new to them, but they can't compare it to something they've had in the past. Um So that sometimes gives you the clue that you're dealing with neuropathic pain. We're gonna integrate this into a case. You're an fy one doctor um attending Ed or working in Ed and Barbara has attended Ed. She's a 74 year old lady with breast cancer and she's presenting with leg pain. Now, assing you're all in the room and if you can turn your cameras on or at least turn your uh microphones on. How are you going to assess this lady's pain? What's the, what are the things that you need to do? Go back to the ABC be? What do you think? And so I wanna take a history from her, kinda get a bit of information about the pain where exactly it is and what type of pain it is very much so because you could go on with breast cancer pain. You actually need to look at this pain. You need to take a history. So you're thinking you're gon you're doing your, your Socrates, you know, when did it start? And all of the things that you're gonna ask and what anything else on that you might think of doing? Um an examination? Yes. And what are you thinking? What could, what potentially could be going on? What would you be wanting to assess with examination? Um I suppose in this lady, uh there's leg pain you sort of want to rule out sort of any sort of um neurological impairment. Yeah, very key. You're gonna be thinking um, neurological impairments. You're gonna do a full neurological assessment of this lady. Um Any other potential diagnoses in your head with, with breast cancer like a spinal cord compression or something like, well, maybe that's maybe. So you're gonna be thinking of back pain. You're gonna be assessing for that as well, but don't get phone in. You always, that's always in your mind. That's the big one you do not want to miss, but you could be thinking it could be a DVT or it could be a cellulitis or she could just be arthritis in the hip or, you know, so there are other diagnoses there. But the one you, the one that's on top is the one you're worrying about. Could this be a spinal cord compression? I need to check for back pain. I need to see about what symptoms, other symptoms she's complaining of and I want to really do a good neurological assessment. So that's great. Thank you. So, the principles of pain management, it is basically the ABCD of good quality care. So good pain history. When did the pain come on, how would you describe it? Is it, does it radiate anywhere? Does anything help? Does anything make it worse? Have you ever had it before you're getting into all of that? And then you're going to do the appropriate examination and that might be examining other areas like this like the, the back. Uh It could be uh and then thinking of your different investigations, that's gonna be your bloods and your x rays. You're gonna explain as you're going along. The patient's anxious. They're worried the family are concerned. You're, you know, it can be hard because you're thinking, I'm thinking it spinal cord compression. I don't wanna make them worried, but also they want to know that you're taking things seriously and quite often they're equally as worried and concerned. So you, you, you, you make sure you're not using jargon and you are gonna explain to them, you're concerned about the nerve function. You just want to check out that it's the, that, that, that the, the big nerves that go down through the back aren't affected. And that, that's why we're, we're doing all of these tests and examination. What's the big problem with them going to say you're going to organize an MRI scan? What's the big problem with that? Nathan? It's on the slide anything. Um, well, I was just thinking like, well, they're elderly, like they might have had hip replacements or, you know, they might be able to go for an MRI scan. Yes. You're concerned to give the pacemakers or any contraindications. Quite most hips, most metal work that's gone in. They'll want to know about it, but most is compatible now. Definitely compatible. Um, but yes, they'll want to know about that. What it can do if there's a lot of metal work in or especially around the spine or wherever you're looking, it can distort and make it harder to see um, what's going on. But usually if it's there for a good while, it's not stopping you doing the scan, but you want to make sure they're aware of it. Pacemaker obviously is something a completely different thing. You're not gonna do one in that scenario, but I'm more thinking this lady's come in so you're sent her for the MRI, you've got the precious slot on the MRI scanner. Is she gonna be able to underlie on that hard table for 40 minutes? 45 minutes. No. What first? There's a, oh, ok. Sorry. My signal keeps dropping out. So I had to come into work because I went no electricity. No wifi and no phone signal. So that's, that's why we're recording, we're recording today. So if you drop out, you can, you can pick it up later. So what, what's the big thing making sure that you've given her, uh, like appropriate analgesia before you give her a scan? We have had a lot of patients and it's hard but, but you, you can't have them through drowsy so they can't comply with the scan. But also they have to lie 40 45 minutes in a very tight space and a very hard table and they came in because they were so too sore to be at home. So you're gonna have to get them well enough pain control so they can lie on the table. For you to get a good scan. And then it's reviewing titr all of those things. So your findings, she has left upper leg pain, it's not radiating anywhere. She describes it as a deep nagging pain, as worse on movement. Paracetamol is, that's all she has at home that, that seem to be helping, but she hasn't been sleeping well with the pain and she's concerned, she said I can't drive to visit grandchildren. This has an impact on her life. Uh And she's worried that it's related to her cancer. What are we thinking? What's gonna be on the plan? I think we've talked a wee bit about it. We're going to be thinking about scans, aren't we? We're concerned about spinal cord compression. Uh but we need to get the pain relief on board. So World Health Organization Ladder has been there for II think it was 1986. Possibly. So, it really is due an update. But if you're managing to use this and use this appropriately, we should be able to have 80 to 90% of patients with a really, really good pain relief and the, the extra sort of 10% having pain that they can. It's not completely controlled, but it's a lot better than it was. So it's worth using even though it is relatively simple. Do we go step 123. What do you think Ella? Are we gonna go? One? She's on paracetamol. Are we gonna go 23 or what do you think? What are our K FL is not hearing us? Um, you maybe like her pain seems quite severe. So you might start a little bit higher up the bladder. That is, you know, because a ladder sometimes makes you feel that you're going step one, step two, step three. It really, as you go in at the, it's probably not a helpful term because you really start on the step that's appropriate to the pain. So if somebody's got moderate to severe pain, you're gonna go in at step three with your strong opioid. But it's to encourage you to think that not all patients just because they've got cancer need a strong opioid. They may be ok on paracetamol or they may be ok on a weak opioid. But obviously this lady's coming in very sore and she's going to have to go through quite painful investigations. So we really are thinking step three and also that will always key thinking of the holistic assessment involving the multidisciplinary team and thinking of the psychosocial and the spiritual issues. Quite often. We're also thinking about the adjuvant analgesics trying to sort of limit the amount of opioids. We're using somebody's elderly frail. If we can limit the the the amount there's no ceiling that we're not going to go above. It's what they will tolerate. But you may find that using the adjuvants allows them to, to tolerate things a little bit better. Particularly if um there's a particular pain that, that uh adjuvant analgesia might address. So, in this situation, we may have concern of neuropathic pain. This is drifting over the top of it, go up, it's gone up. You've got your tricyclic antidepressants, like amitriptyline, 10 mgs at night. Anticonvulsants like pregabalin or gabapentin and steroids, taking the, the pressure, the swelling out of the normal tissues, um will allow the nerves to be less compressed, less i it uh and may actually help the neuropathic pain, bone pain quite often can be helped with nonsteroidals. But again, you're having to think of any contraindications or any other comorbidities. That may mean that nonsteroidals are not a good idea. And you might just use IV paracetamol instead while you're trying to, to get on top of the pain, liver capsule pain because of the stretch of the membrane over the liver, uh steroids or nonsteroidals can be helpful in that situation. And if it sounds like a muscle spasm pain, particularly the strong muscles in the back thinking of baclofen and or benzodiazepines for a short period of time. Uh while that spasm is, is worked out and then thinking of maybe abdominal cramp or bladder spasm, something like a butyl bromide orally, it doesn't get well absorbed, it's not terribly beneficial. So, quite often it is that you're going with that. There is nice guidance for the control of pain, uh palliative care uh for adults, strong opioids pain relief. They're a relatively um simple guideline, very much just as MST is the first opioid of choice. Use laxatives when you start it and use PN antiemetics. And that pretty much summarizes it. Um So very much still telling us that the first line stronger opioid for most patients with normal renal function should, should be morphine, sulfate two methods of administration. So if you're starting, you would need to be thinking of using the modified release capsules, something like Zor, which is a capsule or MST, which is a tablet, the duration of action of about 12 hours. And when you're starting that regular pain relief for someone that's got regular cancer pain, you also need to be thinking of what they can take when they're sore in between. So the immediate release preparations like morphine, sulfate oral solution or several, several all tablets. Again, the duration of action is about four hours. So it will be in their system. But at the half hour maximum action about two hours and out of their system in four hours. But they can use that for um and in between and you can be guided then uh by their use to let you know what you need to titrate uh your modified release preparations with other strong opioids. You may see used um oxyCODONE Long Te or Short Tech or something that we would say see fairly frequently in the hospital. It does come in an injectable form of ox oxyCODONE too, alfentanyl is injectable form only and we tend to use that with people with very severe renal impairment. Egfr under 20. Um because oxyCODONE and morphine are both, um they're got out of the body through the kidneys. So if they've got really severe renal impairment, they're running toxicity. Diamorphine is also an injectable morphine and then transdermal patches. Uh we tend to avoid if the pain is unstable. Given the fact that if you put a patch on someone, it has to get through the skin, it has to get into the fat, it will not achieve steady state for maybe well worth 24 36 hours even longer. Um But you may see them usually see patients coming in on them maybe being treated for chronic pain. Um not the acute pain uh or the cancer pain, but something like Butrans, which is changed every seven days or trans ec which is changed every 96 hours or fentaNYL, which is a strong opioid. Um 25 mcg patch of fentaNYL would be around the equivalent of about 75 mg of morphine. So orally, so quite a a decent enough dose and that's changed every three, every 7 to 2 hours, every three days. And the buprenorphine and fentaNYL are significantly more potent than morphine. You see, that's why there's such a crisis if fentaNYL obviously ends up in uh in the wrong hands in the wrong preparations. A lot of deaths over in America with, with it being misused. And um but from the prescribed point of view, it's, it's really only in patches or in um little sublingual uh preparations where you're using the, the buckle uh mucosa. So thinking about the relative potency, this isn't really for you to memorize, but you have that as you have the slides as a resource or the, the, the lecture as a resource. Um It's just a reminder that codeine that oxyCODONE is twice as strong as morphine. Sometimes we don't think we don't remember that. So you're looking at long type 10 and in your head, you haven't really thought that long. It's still the same as MST 20. So it's important to remember that it is a lot stronger codeine when someone's taking codeine uh say in a preparation with paracetamol or they're taking maybe Cocodamol, say 3500 that the codeine will go to the liver. And in about eight out of 10 people be converted to morphine and that, that uh would be 10%. Um So say you were on Cocodamol, 3502 tablets four times a day. That would be eight tablets, 30 mg, it'd be 240 mg of codeine. The body would be receiving the equivalent of about 24 mg of morphine. So even though it's really a step two analgesic, it's still giving somebody a significant, they're not opiate naive, they're having significant amounts of morphine. If you were if we were in the room as we'd expect, I would give you the little cards. Hopefully, you may have had the little cards if not come to me and II can sort, yeah, somebody come up and I can give you enough for everybody. Um, but I know a lot of you have had them from different, different things, the little green cards with the QR codes. Uh, also we, when you go on to aas the app, um you can get these conversion tables within the end of life care guidance as well. So this is just a useful resources also on the sharepoint as well. And so you can get it on the app, you can get it on sharepoint. I, we have hard copies uh and it's on the E QR codes as well. So it lets you know if, if you're changing from oral morphine to subcut, you're dividing by two oxyCODONE orally to subcut, you're dividing by two. Also lets you know if you're going to a fentaNYL, then that's not something that you would be doing yourself, but it might be something uh whenever your f ones that you'll see um senior folk or the palliative care team doing when the renal team is when the renal function is, is very bad. Also very useful because patches can be tricky. And you're thinking what is this patch? What strength is it? So it's a useful want to know um what strength of your but patches are and what strength your fentaNYL patches are. So not for you to be memorizing, but just to know where those resources are when you need them, it's also something key for you to know what, when you're using these painkillers to know what adverse effects they are. Part of that is so that you can advise patient, you can counsel them about what um and have you get informed consent to start the medication. So you need to be able to know about the medication to do that appropriately. Also means you can watch for side effects and you can also watch for the key, usually relatively unusual but more concerning toxicity. Uh So common side effects, a third to half of patients will feel some nausea and vomiting in the first couple of days of starting it should settle. But that's why the nice guidance if you remember advised going with P RN Antiemetics. So writing up something like cyclizine, 50 mg, eight hourly P RN only ever used if the patient's sick and you can say that you might experience some nausea, but that usually will settle. I've written you up for something to take if that happens, but it should settle drowsiness again. Somebody's starting into strong opioid, they might feel a bit hazy for a day or two. That's not settling. That's not, that's something we need to address and change. The it's not, they shouldn't be permanently drowsy on, on it. It's not doing its job. Again, you're watching for delirium confusion again, that might signpost to the fact that they're having toxicity. Some patients will describe itch does tend to be patients that are getting the intrathecal, the spinal uh opioids that would tend to be more the ones with itch. We see it occasionally and if it does occur, it's worth um changing maybe from say it's with morphine, you can change oxyCODONE and it usually settles things that would point you towards thinking that a person is getting mildly or moderately or severely toxic would be say the visual hallucinations, the myotonic jerks, those sorts of things very common uh would be constipation. And that's why you're, when you're starving your strong opioid, you're always starting your laxative at the same time. They shouldn't, you shouldn't be waiting for them to tell you they're constipated. Otherwise you're in real bother. They, it's going to be difficult constipation to treat and they're usually quite sick and sometimes coming into hospital with it. So, starting your morphine, starting your laxative at the same time. And it's always the thing that people are very concerned about, which is relatively rare if opioids are prescribed appropriately. Uh the respiratory depression and psychological dependence. So key thing, regular laxative and P RM antiemetic. This is just a reminder about prescribing um when you're prescribing controlled drugs, even with encompass uh coming, you will these legal requirements will still stand and with the help of your, our pharmacist uh on the ward, we're going to have to still meet those. So if somebody's being discharged on a uh on an opioid, you're having to, to meet these legal requirements because of the class of drug it is, it's a controlled drug. Uh and very, very specific requirements. The specific requirements are that you're writing it and that it's handwritten uh and legible in capitals, indelible ink can't be altered by someone. Patient details, prescriber details are all very clear. And then the things that you might not think about or something like the formulation. So you're actually writing capsules about Zor and tablets at its MST. So if you write Zor tablets that goes down to pharmacy, they can't issue it because it's not a tablet, it's a capsule. So you're needing to know what it is, the strength. So you need to know. So quite often what strength the pharmacy has otherwise, it might come back up to you going, I don't have 20 mg tablets. I have 10 mg tablets. So again, it's very useful to involve uh the pharmacist to actually get an idea of what is down there. Um particularly um if, if you're trying to get a discharge, so the dose and the frequency and then the total quantity being supplied in words and figures needs to be written and then making sure it's, it's, it's as safe as possible from somebody all trained. So that's something that's, that's useful to know because it's a, it's a legal requirement. Talk about regular review if you remember those uh um the little slide that had the, the, the examination, the and the, the review and all and starting Algesia if you remember that slide. So this is the regular review. So we've started somebody on pain relief. It's unlikely to be perfect. So you're having to review and what are, why are you reviewing, you're reviewing to see if you need titrated up because they're still sore with that caveat. You're not titr up unless you see that, that they don't have side effects and they are, are still finding the pain relief. Helpful theory are saying to them, it's not making you too drowsy, too sleepy or not having hallucinations. And does it help when you take the extra ones if they're saying? Yeah, I'm not having any of those horrible side effects and I'm finding the uh morphine really helpful then you're going up. But it's usually by a third, normally, not more than a half. So you're usually going up to that sort of safe margin. You're much more cautious with this medication as with any medication, when you're dealing with somebody who's very elderly, kick, kick and very frail. So you're gonna be going up more gently, uh, and watching more first toxicity much more carefully if uh you're switching. So if it's a situation where they develop itch or they develop drowsiness, hallucinations, you're thinking actually opioids seem to help, but this opioid doesn't seem to work for them. Well, they're having too many side effects. You might switch, switch them from one to the other because we start with more MST. Usually the commonest one we'll switch to then is long. That doesn't mean that long takes better if we had started with long. There's a very good study which shows that we'd gone with long, uh, or oxyCODONE first line, the same non proportion of patients would have to switch to MST with benefit. So it's just people are different, their DNA is different, their genome is different and they will react to different killers differently. So, if they don't find it, that MST is not a good one, it's certainly worth trying long tech and vice versa. You use the conversion table which gives you a good average um equivalency and then you tweak it down you. Um because there sometimes there's not a cross tolerance to the medication. So if you've been titrating up, they run into problems with side effects. You do the equivalence and, and tweak it down opioid choice as you've guessed. Uh We've talked, keep mentioning things like alfentanil and kidney function. It, your choice, your dose, your range will be effective. If the person has moderate severe renal or hepatic impairment, general principles that you're going to start lower doses, you're going to go with longer dosing intervals, you're going to be not that keen to use modified release. The take home message is you're going to seek specialist advice. You're going to be saying this person who has got end stage liver disease or end stage renal disease. I'd like to say the pelvic care team to see them because I'm concerned. But if you're left um controlling their pain for a period of time, say a weekend bank holiday going with um, one that is best um as a short acting. Um and certainly you can still involved telephone advice out of ours as well. So for the renal impairment with egfr maybe 20 to 60 you may see us go a bit lower, but I would say for yourselves 20 to 60. 1st line would be oxyCODONE over 60. It would be morphine if you're in the under 20 or definitely under 15 or likely to deteriorate to that. If you're thinking that's likely to be to be going down. You're thinking a fentaNYL, a syringe driver again, nobody's expecting you to start that, but you're needing to know that that's what needs to happen. So you phone for, for advice on that avoiding morphine because that's very much really excreted. Sometimes you may see in maybe some with um more stable pain, we may think of uh buprenorphine or fentaNYL patches and because a fentaNYL is very short acting, it's not appropriate for breakthrough pain. It would only last maybe 15 minutes. Uh as a subcu injection, we use the P RN. Low dose oxyCODONE, not ideal, but it's still uh it's a balance. Go back to Barbara Barba is currently taking Cocodamol 3502 tablets four times a day. It's been helping her pee in but she's not fully controlled. So what are we thinking? We're back up to that, are we, what do we think? And so I probably wanna work out that dose as like conversion to morphine cause things you probably need to switch to something stronger. So she's not OK at naive. Um you're presuming she's one of the eight out of 10 because she says she got benefit from it. Usually people convert the codeine to morphine will say, oh, it's not great. You know, it's, it's not, I don't know as much difference to it, paracetamol. So if she's saying it's helpful but not she's now needing something stronger, you could probably assume that she's getting about 24 mg of morphine from that dose of codeine. So what, what would you be thinking? What strong opioid would you be thinking of kidney function is? OK? Would be like or more you could go with Oramorph, but she's been taking this regularly. So you, you know, you're wanting to give her something regular that works because night time wasn't good. She wasn't sleeping well at night you give her or 10 o'clock at night as she's going to bed. When's that out of her system? About four hours? So how long is that actually gonna wake up sore like three or four in the morning? Yeah, that's not great. So you wanna get that she can, that will tide her over for the 12 hours that she's trying to sleep and then that she can take for the 12 hours during the day. So what would your modified preparation be that would go with, with or which drug are you talking about the long term? So, Oramorph Squash. Ok. Sorry. Morphine, sulfate, morphine sulfate. So if you're using morphine sulfate as an immediate release preparation, what type of modified release preparation would you want to use with morphine? Um like a morphine based? Yeah. So you're gonna go with a long acting morphine. Can you remember the spelling of the long acting morphine? I can't remember the name. So there was Zor or MST. So with her, you'd want to go with a long acting modified release one. Can you think what dose would you be thinking? She's taking already on 24 mg of morphine and s over the 24 hours. What might be suitable Dospan and operation time? 30 so 30 BD. Yeah. So either 20 or 30 BD, she looks elderly frail. I probably would do 20 BD. She was a five year old man. I would probably go 30. Um So again you tailor it but yes, you're thinking and then for your breakthrough. So say we went with a 30 BD. She's on 60 in total. So it's right jump. But it's probably what she needs. But I think I'd probably do it in two steps but say we went with a 30 BD just for the ease of the mouth. Um If you're in general practice, you can prescribe Oramorph. If you're in the hospital, you have to prescribe your uh immediate release as morphine, sulfate oral solution because they don't have or more anymore. Um with procurement, they don't have a bottle of or if you've read up, if you write or up and the nurse doesn't have a bottle that says or on it, she can't use the morphine sulfate solution. So you have to write on it oral, right? Morphine, sulfate oral solution when you're prescribing it as a an immediate release. Can you remember if she's taking 60 mg in total of morphine? What your breakthrough would be your four hour breakthrough of the morphine sulfate oral solution for a 10. Yes. So you're gonna write both those up. You're gonna write up MST 30 mg BD and the morphine sulfate oral solution. 10 mg four. Now, when you read the textbooks, this is quite often what they try and do um the immediate release preparation regularly, they can do that at home. So if you were looking at a very keen daughter and the patient, I probably would do this and ask them to phone me tomorrow. If I was a GP, if I'm in a hospital, there's very difficult to get this uh done because you just can't get two nurses to give something for that regularly. So we will always go with the modified release and in the hospital at the minute, it's, it's MST procurement could change it. It could be zo more for the time. You're coming across the door and 2030 10, depending where you're thinking. Um and always remember this bit, the regular laxative and the P RN antiemetic, it's kinda stormy up here. I'm gonna be going away. So we've already gone through. We're very cautious on this one. We had 15 BD and she got her laxator sachets and her PRL. So again, it's if you're looking at somebody as frail as that, you might think caution. But if you're looking at somebody my age, you might definitely think 30 BG. OK? And we'd on the sixth dose. So this is just giving you the I worked example, if she was on the 15, you're on 30 divide by six, you get five with Beth's prescription. It was 30 BD, it was 60 divided by six, it was 10. So you see how when this changes, this needs to change and as you titrate this, this has to titrate as well. So two weeks later, she was admitted to the AM U, she was drowsy, confused, hallucinating. What's the differential? What are we thinking or what could be going on opiate to toxicity? Sure. I can't hear you. Uh opiate toxicity. That's your big concern. You always hit the big ones. Uh, what else could be going on though? Cos it's not always the opioids quite often. Yeah, you're gonna be concerned. But what a, if it was opiate toxicity, what might, what might be contributing to it? And it's not opiate toxicity, what it might else might, it might, it be. Um, so if it was a toxicity, maybe you'd be worried about migraine long term. Uh And then other differentials like some kind of like encephalopathy or something like that. Um I missed that first bit. What were you thinking? So, I'm saying if um if she is opiate toxic, then you'd be worried about renal impairment. Possibly. Yes, that's what I thought. I didn't quite actually. Yes, you're, it, it sounds like opiate toxicity. But you're also thinking, why, why are you opiate toxic? So it could be something very simple, like somebody's just titrated it too high. Um Or she's got mixed up with the medicines and taking too much. But you're also thinking, has she gone into renal impairment for some reason? Has she gone hypercalcemic for some reason, has she developed an infection? You know, uh quite often people are very stable on their opioids. If they get a chest infection, they go, they definitely go opiate toxics, you reduce everything down, they come out of their opiate toxic of their infection and the opioids go back up to the original dose. They were on it. It just, they just don't tolerate it. They're a bit dehydrated and uh, and unwell. So, yeah, opiate toxicity is the one that's top on the line at the, on the, the list. But your thing is there, infection, is there some renal impairment? Could the calcium be up? Brain mets? You're thinking encephalopathy, you know, there's something that's impairing the brain or she had a stroke. Um, has somebody added something else? Somebody's only giving her a lot of diazePAM and that's played into it. Um So you're thinking of the differential, what makes you think it's, it's opioids. What might point you towards opiate toxicity? Nathan. So chemical. So they're drowsy. Um they might have pinpoint pupils, um hallucinations, um myoclonic. Um I'm trying to think what else like reduced respiratory rate. Yeah. So that's your big concerns. So, drowsy, pinpoint pupils just level of conscious. The my jerks are quite classical. Uh they're agitated visual hallucinations. Usually they look like they're dreaming, they're, and then the respirate is obviously crucial. So how are we going to immediately manage? This really comes down to the severity because what we don't want to do is go opiate toxicity. There's one amp of, of, of naloxone and it goes in and there's no thought process to it because that give stops their pain relief and actually could cause significant morbidity and even mortality in chronic pain patients as well as cancer patients. So, uh you know, there's situations where you may need to use that naloxone, but you do not want to harm the patient with its use and you can harm the patient with its use because I certainly had learning alerts come out uh across the province across the UK about harm that was being done with using naloxone inappropriately. So you want to know is it mild if she's just mildly sleepy? A few hallucinations, a few jerks she's talking to you. You're not worried about her respiratory rate. You're not worried about her oxygen at all. You'll probably reduce the opioid and you'll make sure she's well hydrated. Uh You're just tweaking around the edges, you might think about changing the opioid. So you're gonna do something here, but there's no panic, moderate things are a bit more unstable, but the Respi rate is still good, which is still able to chat to you. Oxygen's grand. You're probably gonna stop the opioid. You're gonna consider converting or reducing once we're out of this, this period. Uh You're probably going to admit in case this deteriorates. Uh And you want to investigate what's going on, you want to know kidney function, you want to know chest X ray, you're, you're, you're, you're thinking what's going on. Uh And you're concerned that this might change, but you're not reaching for naloxone at this stage, you're stopping the opioid, you're making sure they've got breakthroughs written up and the plan will be to discuss with the specialist team. Do we need to convert, do we reduce to need to retitrate? But you're stopping the opioid uh the regular one. but leaving them something for pain, severe is the more difficult one where the respiratory rate is down. And you're concerned the oxygen saturation is poor. They are cyanosed, decreased level of consciousness. So there's an urgency to this, there's respiratory depression. So you're going to have to use the naloxone. So you have to use it safely and appropriately. So you dilute it. It's a tiny, tiny, little ampoule. If you draw that up and whack that in, you've reversed their pain relief, they wake up screaming, they are into opiate withdrawal as well. So their heart rate's up, they are in the full yawning agitation and this is a very ill frail person that has suddenly gone into a world of pain and a world of opiate withdrawal. So you don't want to do that. You definitely don't want to do that. What you do is dilute it in a 10 mL syringe and you, you have IV access and you gently titrate it. So you're aiming to bring the level of consciousness up, possibly, but it's mostly the respiratory rate. You're getting that respiratory rate up to 1213 while trying to not um totally reverse their pain relief. You're going to stop the opioid. Obviously, you're going to do all the checks to see what might have tipped them into this. And your concern, you're going to reach out to the specialist and, and, and get a bit of advice because your concern is how naloxone has got quite a short half life. A lot of these medications that are causing up too many patches, kind of half life over days. You might need a drip, um, something like MST half-life. You know, you're going to be in the system for 12 hours. So you might need to go with the naloxone for a couple of times over the, over the day. So you're needing to make sure that people are monitoring the respiratory rate and that there is a plan and most trusts you work in will have a policy that you can access usually with a, a good clinical flow chart um to help you with this process, but this is an unusual place to be. This isn't something that you're doing lots of times when you see somebody in ed, when you're an F two and they're drowsy and sleepy and their respiratory rate is 24. You do not give them naloxone. I see a lot of people come in and there's respiratory at 24. Uh and they're given naloxone and they got more alert and I'm thinking, well, if you hit them with a brick that it could become more alert and that's what you did. You know, the naloxone should only be coming out when the respirator grade is causing concern if they're sitting with a rip roid chest infection and have a delirium. That opiate toxicity is a part of, you. Reduce, you, stop, you, you, you, you, you sort, but you don't reverse their analgesia at a time and they're really ill and they can't afford the extra stress on their body. So, Barbara was treated for a chest infection around that time. She wasn't able to swallow her medications. She was really getting sore. Um, so what are we thinking? How can we give her her pain relief when she's not well enough to swallow Edie? What do you think? Um, you can give it to subcu you could but you're wanting something regular. So certainly she should get her P RN subcut and you're gonna have to write those up. How can you regularly? What are you gonna replace the MST with something that gives her pain relief around the 24 hours? So, um, like a s driver? Yes. So you're thinking of a syringe driver cause she needs, you know, regular and you're gonna go with Sub for your PRN. So it allows you to give the drugs over 24 hours. It's not just for end of life care and it shouldn't, you know, but it will be used. It will say, oh, I'm not at that stage and you say, well, like it's not only used for end of life care, but you're also open it up front and say, well, you do use it a lot for end of life care, but it could be intractable, nausea and vomiting, dysphagia, bile obstruction. Or if we think somebody's really not absorbing, well, can be a temporary measure sometimes if the nausea and vomiting settles or the obstruction wanes. Um, and it's not just morphine, you can use lots and lots of drugs in it. So if you remember back to the conversion table, oral to parenteral for both morphine and oxyCODONE, you're dividing by two. If it's something weird, we always tend to get used to morphine as the the common language. So for simplicity, we've gone down. So uh because she was not great. Uh On the 15, we'd gone to 10. So that will give you 20 orally. You're dividing by two, you put 10 in the syringe driver. Does that make sense? And still needing the PRN subcut? So it's gonna be 1/6 of that. So you should have 1 to 2. Um You always have to the point of view dividing. It has to be sensible. It's not, it's not for you're not gonna go 1.236 mg of morphine. You're gonna go with something sensible and you're gonna avoid points wherever you can cause points could give problems. You see if you're at 1.5 some nurse could come in and give them 15 because she just didn't see the point. Um So you could see where it could cause problems. So avoid points where you can decimal points where you can also important to think of the non pharmacological methods. You do use tens machines, acupuncture, massage, relaxation, mindfulness. Um, a lot of those things can be used and people do like that, that control um, any questions? Not too bad for time, any questions? No, that's grand. Well, I'll stop recording.