pain and breakthrough pain

[Nik]

What is interesting though is that stockleys does say they can have additive beneficial effect so I don't know if she was trying to use this agaisnt me?

"Concurrent use of two opioid agonists..."

If you're ever in doubt you can't make the final decision because you are the pre-reg not the qualified ward pharmacist. Let the jr doc argue it with someone senior. Perhaps when pts under her care develop signs of opioid toxicity she will accept our advice more readily.

[Asterix]

I was told once at uni you could see the combination in palliative care and in which case you wouldn't challenge

[Nik]

Palliative care formulary do mention concurrent use of these at certain strengths, however palliative care is a specialism in it's own right and extending the principles of drug use here isn't always appropriate. I don't think there will ever be a time when you won't have to question decisions or provide advice in a palliative patient. Otherwise we wouldn't have palliative care pharmacists...

[hibernia]

Additive effects CAN be beneficial.
The questions you must ask are 'are they beneficial to THIS patient at THIS time and do those benefits exceed the risks?'

The doctor is looking at the patient and you are looking at the drugs. Both of you need to look at BOTH the patient and the drugs to get the right answers and that is why you can't find them in a book. In some cases the use may be justified, in others it won't be.

[Asterix]

I think pain ladder is the gold standard to pain management and in all honesty in an elderly patient with potential risk of resp depression?

[Asterix]

codeine and morphine together??? is that always a no no as codeiine is metabolised to morphine?

[Shwampa]

can't remember seeing other pain killers co-prescribed alongside morphine..

[hibernia]

can't remember seeing other pain killers co-prescribed alongside morphine..

Some patients on MST prefer souble co-codamol to morphine for breakthrough pain, saying that it acts quicker. Pain relief is very subjective and if a patient believes a soluble prep is 'better' or 'faster' then it may be for them. Others use it in an effort to reduce the morphine dose and its sedative side-effects.

The human mind and body are so complex that blanket rules like 'never use codeine and morphine together' may not be appropriate even if they are perfectly logical.

[Shwampa]

Thanks hibernia. Doses needed for breakthrough pain should be used to adjust the initial dose of controlled release morphine. The aim is to find the right dose that will stop or limit breakthrough pain.

link for opiates conversion: Narcotic Equivalence Converter

[Asterix]

what is the point of codeiene and morphine though? codeieine breaks down into morphine