1. How do I manage pain and agitation?
Kate Warburton
June 08

2. Pain

3. Pain ladder Paracetamol +/- NSAID +/- other Adjuvant
Weak Opioid + Paracetamol +/- NSAID +/- other Adjuvant
Strong Opioid + Paracetamol +/- NSAID +/- other Adjuvant
Remember laxative +/- anti-emetic

4. Pain ‘rules’ Breakthrough dose 1/6th total dose
Breakthrough pain different from incident pain
Increasing analgesia
Increase by 30% or as per prn dose

5. Adjuvant analgesia NSAID: bone/ liver/ soft tissue pain.
Amitriptyline/ Gabapentin: nerve pain.
Steroid: nerve pain/ raised intracranial pressure/ liver capsule pain.
TENS
Radiotherapy
Bisphosphonate

6. Pain Assessment Severe and overwhelming? What is it like?
What is cause of pain?
Specific type of pain?
Other contributing factors?

7. Approximate conversions
Codeine/ Dihydrocodeine 60mg
Morphine 6mg (oral)
Tramadol 50mg
Morphine 10mg (oral)
Morphine 5mg (subcut)
Morphine 20mg (oral)
Oxycodone 10mg (oral)
Morphine 60-90mg (oral)
Fentanyl 25mcg (patch)
Morphine 30mg (oral)
Alfentanil 1mg (subcut)
Oxycodone 5mg (subcut)
Fentanyl 12mcg (patch)

8. When to use naloxone?
Life threatening respiratory distress caused by opiate.
Not to be used if someone actively dying or for opiate induced drowsiness/ delerium.
If less severe opiate toxicity omit next dose and review dose- Usually reduce dose by 30%. Ensure adequate hydration.
Try adjuvants if still sore but opiate toxic or consider change to different preparation.

9. When to use oxycodone?
If pain opioid-responsive but unable to tolerate morphine in adequate dose because of side effects.
If drug sensitivity to morphine.
Some indication for nerve pain.
?Renal failure- but will also accumulate but to a lesser extent.

10. When to use alfentanil?
CKD 4 & 5: subcut alfentanil mcg hourly.
Very good for incident pain- Give 5minutes prior to event which will cause pain.
When on stable subcut infusion can convert to fentanyl.

11. Terminal pain
Subcut prn
Syringe driver
Don’t stop fentanyl patch

12. Ketamine
Lidocaine
Methadone
Local anaesthesia

13. Agitation

14. Assessment Cause Is it reversible Prognosis
Is investigation appropriate

15. Cause
Opiate toxicity
Physical causes (Eg.Pain, Urine retention, Constipation)
Infection
Hypoxia
Hypercalcaemia/ Abnormal glucose/ Uraemia
Psychological distress
Alcohol/ Nicotine withdrawal

16. Management Maintain hydration
Quiet room, reorientation, similar staff.
Minimal sedation, oral if possible- Haloperidol

17. Terminal agitation Midazolam 20- 30mg/ 24hrs in driver Prn 5mg
Levomepromazine 12.5mg prn subcut

18. Thanks