Self Directed Learning Package - University of Queensland

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32 • The Palliative Approach ToolkitBy the ladderProceed from a non-opioid, to a weak opioid, and then to a strongopioid, with adjuvant medications added as needed at any stage.Thinking PointImagine Alfred presents with a new pain in his hipthat he rates as severe.Do you think it reasonable to start him on a simpleanalgesic first then move up to a stronger morepotent opioid over time?Key PointIt is not necessary to start at the bottom of theladder. Consider the presenting pain severityreported by the resident.Opioids• Start with low doses of short acting opioids and titrateup slowly after evaluating its effect on pain scores untilsatisfactory relief is achieved.• Only then should sustained/controlled release preparationsbe commenced e.g. oxycodone (Oxycontin), morphine (MSContin, Kapanol) or fentanyl (Durogesic).• Do not use sustained/controlled release preparations for acutepain or breakthrough dosing.Figure 1The World Health Organisation (WHO) analgesic ladder forpharmaceutical treatment of pain 16Pain under controlStrong pain - strong opioids formoderate to severe pain,non-opioid adjuvantIncrease in painModerate pain - weak opioids formild to moderate pain,non-opioid adjuvantIncrease in painMild pain - non-opioid adjuvantKey PointThe parenteral dose of morphine is approximatelyone-third of the oral dose. 12,13If a resident was taking 30mg oral morphine/24hrsbut now cannot swallow, they would only needapproximately 10mg parenteral/24hrs to have anequianalgesic effect.
33 • Self Directed Learning Package - Introductory Registered & Enrolled NurseSide effects of opioids can often be anticipated and treatedor avoidedChanging to another opioid or another route of administrationmay be necessary if still troublesome.Adjuvant analgesicsAlfred not only takes regular paracetamol and a weak opioid forhis pain, he is also prescribed a tricyclic antidepressant for hissciatic pain.This and other medications such as corticosteroids,anticonvulsants and benzodiazepines can supplement analgesicsor control symptoms that can exacerbate the perception of pain(e.g. inflammation, oedema, anxiety etc.)Myths about opioidsSpend time with the resident or family to dispel commonmyths about opioids. Sometimes residents, familymembers and even aged care staff may have concernsabout these medications.It is important to know that, when used correctly, opioidmedicines:Do not lead to addiction or dependenceOpioid medicines are not addictive when used for pain.Addiction only occurs when people have no pain andthey abuse opioid medicines.Do not hasten deathMorphine and other opioid medicines are for improvinglife — not hastening death. Some people fear that beingprescribed opioid medicines means that they’re closer tothe end. However, relieving pain changes the quality-oflife— not its length.Do not cause terrible side-effectsAll medicines can have side effects. The side effects ofopioid medicines (constipation, drowsiness, nausea, drymouth) are usually manageable.WriteKey PointThe type and cause of pain will determine which, ifany adjuvant medications are needed.Consult “Therapeutic Guidelines: Palliative Care”for additional and comprehensive prescribingrecommendations.Version 3 of these guidelines is included in thePA Toolkit.Document your actionsAvoid general statementsPOOR COMMUNICATIONGOOD COMMUNICATIONEvaluation of PRN analgesia‘Resident states pain has reduced to 2/10‘with effect’ or ‘effective’.score (was 5/10)’.Note to GP‘Alfred has a new pain in R) hip. Says‘Please review Alfred ASAP re pain in hip’. its severe, average 5/10, walking = 8/10.Wakens him at night if he rolls over in bed.Have tried hot packs, massage and regularsimple analgesia so far but no better’.ReviewEvaluate and reassess as necessaryThinking PointYou identified that Alfred has pain and conducted anassessment. You’ve updated his care plan to reinforceappropriate manual handling techniques and somemassage at night. This morning you discussed withAlfred’s GP about a regular analgesic order. Great job!Can you tick this off your list? Not quite yet.There is an important question to answer:Did your strategies work?A formal scheduled review using the Modified Resident’s VerbalBrief Pain Inventory (M-RVBPI) or Abbey Pain Scale may bemore valuable than frequent, brief impressions. 2
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