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COUNSELLING IN PRACTICE
1. Which of the following statements
about tolerance to opioids is TRUE?
a) Tolerance is characterised by
symptoms such as tremors and
b) Tolerance to opioids is linked with an
increased likelihood of addiction.
c) Opioid tolerance early in treatment
will discount the use of this class of
d) Increasing the dose of opioid is a
valid strategy to regaining symptom
2. Which of the following statements
about morphine in renal impairment
a) Chronic use of morphine should be
avoided in patients with any level of
b) Chronic use of morphine is appropriate
for all patients regardless of their renal
c) Morphine is contraindicated in
patients with a calculated creatinine
clearance of less than 50 mL/minute.
d) Morphine is contraindicated in
patients with a calculated creatinine
clearance of less than 10 mL/minute.
3. Which of the following side effects
should be anticipated with long-
term use of morphine?
a) Mental clouding.
d) Respiratory depression.
4. If Margaret is stabilised on a
dose of 15 mg controlled-release
morphine twice a day, what would
be a reasonable breakthrough dose
of immediate-release morphine to
a) 2.5 mg every 4 hours as required
b) 25 mg every 4 hours as required
c) 1 mg every 4 hours as required
d) 10 mg every 4 hours as required
5. Which of the following statements
about pain is CORRECT?
a) Pain is described as an objective
b) Therapies for pain need to be tailored
to the individual needs of the patient.
c) The intensity of the pain is unaltered in
the presence of anxiety.
d) The treatment of cancer pain is limited
Take home messages
• Uncontrolled pain can negatively
impact on a person’s quality of life.
• Opioids provide the mainstay of
therapy for moderate to severe
cancer pain and may present
concerns such as addiction,
tolerance, side effects and fears that
treatment implies the final stages
• The carer can be a valuable ally
in supporting and monitoring
appropriate pain control. If their
concerns are unmet, carers can also
have a negative impact on outcomes
for the person living with pain.
Where should the medicine
All medicines should be stored in a cool,
dry, clean location securely away from other
people (including children) and animals.
As there is a strong potential for opioid
abuse (including diversion by others
in the household), they may require
more rigorous storage conditions than
other medicines. Storage of opioids
and accompanying prescriptions in a
locked cabinet should be considered.
Prescription opioids are appealing due to
their high street value.2
In Margaret’s case
The dose of morphine prescribed is clearly
a starting dose and is based on Margaret’s
age and expected poor kidney function.
Sarah presents a second sheet of paper,
provided by the doctor, listing a plan for
progressive dose adjustments as well as a
follow-up appointment to review progress.
The use of aperients is discussed and an
appropriate over-the-counter medicine is
selected to commence with the morphine.
Sarah explains that she will stay with her
mother to observe for compliance as well as
A pamphlet produced by the Cancer Council
responding to common questions about
pain and its management is provided to
reinforce these messages.
1. Angell M. The quality of mercy. NEJM 1982;306:98–9 .
2. Opioid prescription in chronic pain conditions. Drug and
Alcohol Services South Australia. 2008. At: www.dassa.sa .gov.
3. Dy SM. Evidence-based approaches to pain in advanced
cancer. Cancer J 2010;16(5):500–6 .
4. Adult cancer pain. National Comprehensive Cancer Network.
5. Klepstad P, Kaasa S, Borchgrevink PC. Starting step III opioids
for moderate to severe pain in cancer patients: dose titration: a
systematic review. Palliat Med 2011;25:424–30 .
6. Caraceni A, Hanks G, Kaasa S, Bennett MI, et al. Use of opioid
analgesics in the treatment of cancer pain: evidence-
based recommendations from the EAPC. Lancet Oncol
7. Palliative Care Expert Group. Terminal care. In: Therapeutic
guidelines: Palliative care. Version 3. Melbourne: Therapeutic
Guidelines; 2010. p. 357–61.
8. Portenoy RK, Sibirceva U, Smout R, et al. Opioid use and survival
at the end of life. J Pain Symp Man 2006;32(6):532–40.
9. Analgesic Expert Group. Therapeutic guidelines: Analgesic.
Version 6. Melbourne: Therapeutic Guidelines; 2012.
10. Rossi S, ed. Australian Medicines Handbook. Adelaide: AMH; 2013.
11. Clary PL, Lawson P. Pharmacologic pearls for end-of-Life care.
Am Fam Physician 2009;79(12):1059–65.
12. ISMP list of high-alert medications in community/ambulatory
healthcare. Institute for Safe Medication Practices. At: www.
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