Module 5v2

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@@.whitetext; !!!VA_Pain training_5: Management of opioid-tolerant patients Welcome to the one in a series of interactive scenarios to support learning during Pain training. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@

/* <<countdownTimer>> Widget - Start */ <<widget "countdownTimer">> <<set _seconds = $args[0]>> <<set _minutes = Math.floor(_seconds / 60)>> <<set _replacementPassage = $args[1]>> <div id="timer" class="timergreen">Time remaining _minutes:<<= (_seconds - (_minutes * 60)).toString().padStart(2, '0')>></div><<script>> if (!recall("countdown", undefined)) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } else { setup.countdown = recall("countdown"); if (setup.countdown.passage !== passage()) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } } setup.countdown.intervalID = setInterval(function () { if (setup.countdown.passage !== passage()) { clearInterval(setup.countdown.intervalID); forget("countdown"); setup.countdown.passage = ""; } else { var curtime = new Date(), str, seconds = State.temporary.seconds; var diff = Math.floor(seconds - ((curtime - setup.countdown.startTime) / 1000)), min = Math.floor(diff / 60); if ((diff >= 0) && (diff < seconds)) { if ($("#timer").length) { str = "Time remaining " + min + ":" + (diff - (min * 60)).toString().padStart(2, '0'); if (str != setup.countdown.lastStr) { $("#timer").empty().wiki(str); setup.countdown.lastStr = str; } if (diff <= 10) { if (!$("#timer").hasClass("timerred")) { $("#timer").removeClass("timeramber").addClass("timerred"); } } else if (diff <= 20) { if (!$("#timer").hasClass("timeramber")) { $("#timer").removeClass("timergreen").addClass("timeramber"); } } } } if (diff < 0) { clearInterval(setup.countdown.intervalID); forget("countdown"); $("#passages div.passage").empty().wiki('<<include "' + State.temporary.replacementPassage + '">>'); delete setup.countdown.passage; } } }, 200); <</script>> <</widget>> /* <<countdownTimer>> Widget - End */

@@.whitetext; !!!VA_Pain training_5: Exam day Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>>

<<cacheaudio "ed" "audio/ed.mp3">> <<cacheaudio "text" "audio/text.mp3">> <<cacheaudio "bell" "audio/bell.mp3">> <<cacheaudio "bell2" "audio/bell2.mp3">> <<set $history to []>> <<set $started to 0>>

!!@@.greentext;2021 Curriculum learning syllabus@@ !!!@@.greentext;Stage 1 Pain learning outcomes@@ @@.greentext; ''//Recognises, assesses and treats acute pain independently Differentiates between acute and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Can recognise, examine, assess and manage acute pain in the surgical and non-surgical patient * Is able to safely and appropriately prescribe medication for pain management * Demonstrates effective communication skills regarding pain management with patients, relatives and carers * Demonstrates the basic assessment and management of acute on chronic and chronic pain in adults * Describes the concept of biopsychosocial multi-disciplinary pain management * Describes the special circumstances in assessing and managing perioperative pain in specific patient groups including children, pregnancy and breast feeding, the elderly and frail, those with learning and communication difficulties, autism, dementia, renal and hepatic impairment and substance abuse * Demonstrates the safe use of equipment used in pain management !!!@@.greentext;Stage 2 learning outcome:@@ @@.greentext;''//Understands the aetiology and management of acute, acute on chronic and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Utilises a multi-disciplinary approach to the management of complex pain within a biopsychosocial model of care * Can confidently manage acute pain in the whole perioperative pathway in a timely manner * Is able to assess patients, interpret investigations and initiate management of chronic malignant and non-malignant pain in a timely manner under distant supervision * Can assess and manage acute on chronic and chronic inpatient pain in adults and recognise when referral to specialist pain services is appropriate * Identify barriers to effective pain management including those related to patient beliefs, society, culture, and healthcare provision * Explains the risk factors for persistent post-surgical pain including measures to minimise its occurrence !!!@@.greentext;Stage 3 learning outcome:@@ @@.greentext;''//Able to initiate complex pain management for in-patients and to sign-post to appropriate pain management services//''@@ !!!@@.greentext;Key capabilities@@ * Applies knowledge and understanding of assessment and management of pain in a multiprofessional context * Demonstrates safe effective pharmacological management of acute and procedure pain in all age groups * Acts as an effective member of the inpatient pain team * Effectively engages with multi-disciplinary primary and secondary pain services and palliative care when necessary * Recognises the need for and complications of interventional pain procedures * Prescribes appropriately in the perioperative period and recognises the long term implications of not reviewing patient analgesia in the post–operative period following discharge * Plans the perioperative management of patients for surgery who are taking high dose opioids and other drugs of potential addiction [[Next->Core clinical learning objectives]]

The exams officer looks at your passport and then up at your face. She nods slightly before handing it back to you and moving on to the next pale candidate in the waiting area. You rub the palm of your hand over the sticky label on your right lapel 'Dr $firstname $surname' and wonder if you're having an SVT. "Right everyone." She says to the room. "Has everyone put their phones and electronic devices away? No phones allowed on the exam floor." A few nods from the candidates. "Excellent. We will call each of you through to the SOE stations in turn. Good luck everyone." She finishes brightly. The exams officer is collecting the first twenty candidates to go up to the exams floor. She's looking at your badge. "Dr $surname? If you'd all like to follow me?" You take a deep breath, [[and follow her out of the room...->exam1b]]

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio ed play>> [[Transcript->transcript1]]   [[Next->audiopost1a]] <img src="images/methadone.jpg" style="max-width: 100%;"/> </center> <<set $ivdu to true>>

<p style="text-align:justify"> @@.typing; I need to get my phone working, I need to tell my ex I can’t make it to see my kid, she’ll think I’m flaking on him again. I wasn’t going to come, I knew it would be like this, people always treat me like dirt, like I’m just here to score or steal. You think that too don’t you? That’s what everyone recons. I’m clean and I still get treated like some scum junky who doesn’t deserve respect. I don’t need your judgment, I need help. I’m in agony and they won’t give me anything, I just get a hard time. Even if I was using, which I'm not, it doesn't stop me getting sick same as anyone else. You recon I wanted drugs in my life? I didn’t choose this. My whole life I never fit in, like constant anxiety. I’d drink and smoke to be part of the crowd and it went from there. Drugs was part of the scene, weed, speed, coke, pills, then anything I could get my hands on and someone’s giving me smack. At the start I did it to get high, I’d feel good, chill. I’d nod out, be relaxed, like for the first time in my life the anxiety was quiet, I could always stop, anytime? But I got trapped like everyone does. I thought I could control it, but by then using was more important than having a roof over my head, more important than my kid, I just needed the hit again, more and more. Coming down...I can’t even describe it...I was like dying...shaking...sweating...sneezing...nose pouring...puking...pain...I was strung out. I’d do anything to not feel like that. I did crazy stuff to not feel like that. Lie, steel, I'd manipulate anyone. People like you, people who were trying to help me. In the end I had nothing left. I was going to die. I’ve seen that, I watched people OD, I’ve OD’d. When you jack up you don’t know if this is the one that’s going to kill you, you don’t care. I was spending my whole life wasted. I’d hit bottom. I had to get out, get away from that life. That’s when I got with the programme, like that’s what got me clean. When I started on Methadone I had to not use the day before then stick around in the clinic to get these like tiny doses, I was like “man I’ve been on £60 a day minimum are you having a laugh”. I wasn’t even allowed to have a drink, but I stuck with it and after a couple of weeks they had me on a dose where I wasn’t out of my head trying to score. Some people cheat, but not me, I haven't used in nearly a year, I’ve got a decent key worker, who gets me, and the pharmacy, they treat me the same as any other problem, like I’m getting my treatment. We talked about changing to Subutex but I would have had to do five days off the methadone to get it out of my system, so I just stuck with what I know works for me. All my random checks have been clean, they know I’m not using. The methadone makes me feel normal, not constantly craving my next fix and stressing about how I’m going to get hold of it, not feel like I’m dying. I can do a normal life. I can see my kid again. I’m doing an access to work course. When I got this pain in my belly, I got sick, I couldn’t take my methadone, I started to crave again, that freaked me out, because I’m out of my mind with pain and I’m getting sick and that’s what made me come today. I don’t want to go back there; I knew I needed help. I really want you to hear what I’m saying. I never want to go back to that life, but man I’m out of my head with pain and I need you to do something. If I was using I wouldn’t be here, I’d be off my face in some squat and I wouldn’t need your help. I’m scared. That other guy said I might need an operation? To stay in? I don’t have time for any of this, I need that charger for my phone, my ex will be doing her nut if I don’t call and if I don’t show for my dose today the pharmacy will tell the programme and I’ll get kicked off, they warned me if I missed doses I’d lose tolerance or something, have to start again with the stupid little doses or I’d OD. Seriously this is so messed up. @@ </p> <center> [[Play audio->audio1]]    [[Next->audiopost1a]] </center> <<audio ed pause>>

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our actors: Richard Pierce Our module 5 advisory support: Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Sonia Pierce and Richard Wassall Our creative director and lead programmer: Kate Wainwright !!!Well done for completing VA_Pain training_5 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

As Ed finishes speaking what's running through your thoughts about what he says? You may have considered some of these [[points:->audiopost1b]] <<audio ed pause>>

There are two examiners already sat at the desk when you enter. You take a seat across from them. "Hello, I'm Dr Adams and this is Dr East we are your examiners today." Dr East gives a curt nod but doesn't look up from filling out, what you assume to be your name on the top of a mark sheet clipped to a black clip board. There's a pile of blank A4 and a pencil in front of you. Somewhere a bell rings. "Ah, time to get started" says Dr Adams. [[Next->exam3]] <<audio "bell" play>>

<br> "Right we can start with a nice simple one to kick off. Tell me what's the definition of pain?" He asks you. You have a brief flash-back of Dr Jones asking you exactly the same question while your brain tries to track down the definition you //know// that you know. You reply "Pain is... [[...something that happens following injury and is either acute or chronic|exam3b][$three = "incorrect"]]." [[...an adverse sensory and emotional experience typically caused by, or resembiling that caused by, actual or potential tissue injury|exam3a][$three = "correct"]]." [[...an unpleasant sensory and emotional experience associated with potential or actual tissue damage, or described in terms of such damage|exam3a][$three = "correct"]]." [[...caused by the action of neurotransmitters and cytokines on peripheral neurons|exam3b][$three = "incorrect"]]." [[...a term that is synonymous with nociception and indicates a pathophysiological cause|exam3b][$three = "incorrect"]]." <<timed 59s>> <<goto exam3b>> <</timed>> <<countdownTimer 60 "exam3b">> <<set $result to 0>> <<audio "bell" pause>>

<br> Dr Adams keeps his poker face on. "Can you tell me where the more commonly used definition of pain is from?" You think for a moment "That definition is from... [[...the Royal College of Anaesthetists|exam4b][$threeb = "incorrect"]]." [[...the Faculty of Pain Medicine|exam4b][$threeb = "incorrect"]]." [[...the World Health Organization|exam4b][$threeb = "incorrect"]]." [[...the International Association for the Study of Pain|exam4a][$threeb = "correct"]]." <<timed 59s>> <<goto exam4b>> <</timed>> <<countdownTimer 60 "exam4b">>

<br> Dr Adams keeps his poker face on but you think you see Dr East make a tick on the mark sheet. "And can you tell me where that definition is from?" You think for a moment "That definition is from... [[...the Royal College of Anaesthetists|exam4b][$threeb = "incorrect"]]." [[...the Faculty of Pain Medicine|exam4b][$threeb = "incorrect"]]." [[...the World Health Organization|exam4b][$threeb = "incorrect"]]." [[...the International Association for the Study of Pain|exam4a][$threeb = "correct"]]." <<timed 59s>> <<goto exam4b>> <</timed>> <<countdownTimer 60 "exam4b">> <<set $result to $result + 1>>

<br> You don't feel confident in that answer and try and look enthusiastic for what comes next. "How would you distinguish between acute and chronic pain?" "Acute pain is... [[...due to an underlying pathological process whereas there is no identifiable pathology in chronic pain|exam4c][$four = "incorrect"]]." [[...sudden in onset and associated with a definite cause, whereas chronic pain persists longer than the expected time of healing and usually longer than three months|exam4d][$four = "correct"]]." [[...easily abolished with standard analgesics whereas chronic pain needs much higher doses for a longer period|exam4c][$four = "incorrect"]]." [[...independent from chronic pain and doesn't co-exist|exam4c][$four = "incorrect"]]." [[...is pain lasting less than three months whereas chronic pain is any pain lasting more than three months|exam4c][$four = "incorrect"]]." <<timed 59s>> <<goto exam4c>> <</timed>> <<countdownTimer 60 "exam4c">>

<br> You feel confident in that answer and try and look enthusiastic for what comes next. "How would you distinguish between acute and chronic pain?" "Acute pain is... [[...due to an underlying pathological process whereas there is no identifiable pathology in chronic pain|exam4c][$four = "incorrect"]]." [[...sudden in onset and associated with a definite cause, whereas chronic pain persists longer than the expected time of healing and usually longer than three months|exam4d][$four = "correct"]]." [[...easily abolished with standard analgesics whereas chronic pain needs much higher doses for a longer period|exam4c][$four = "incorrect"]]." [[...independent from chronic pain and doesn't co-exist|exam4c][$four = "incorrect"]]." [[...is pain lasting less than three months whereas chronic pain is any pain lasting more than three months|exam4c][$four = "incorrect"]]." <<timed 59s>> <<goto exam4c>> <</timed>> <<countdownTimer 60 "exam4c">> <<set $result to $result + 1>>

<br> Dr Adams places a diagram down on the desk between you… <center> <img src="images/spine.jpg" style="max-width: 50%;"/> </center> "We shall use this diagram for the next part of the exam." You feel slightly offended, your diagram isn't //that// bad. "In relation to pain pathways tell me about the neurone marked A." "The neurone marked A on the diagram is... [[...a first order neuron which is either a fast myelinated Aδ or slow unmyelinated C fibre with it's cell body in the dorsal root ganglion and it's synapse in the dorsal horn|exam6a][$five = "correct"]]." [[..a first order neuron which is either a slow unmyelinated Aδ or fast myelinated C fibre with it's cell body in the dorsal root ganglion and it's synapse in the dorsal horn|exam6b][$five = "incorrect"]]." [[...a first order neuron which is either a fast myelinated Aβ or slow unmyelinated C fibre with it's cell body in the dorsal root ganglion and it's synapse in the dorsal horn|exam6b][$five = "incorrect"]]." [[...a first order neuron which is either a slow unmyelinated Aβ or fast myelinated C fibre with it's cell body in the dorsal root ganglion and it's synapse in the dorsal horn|exam6b][$five = "incorrect"]]." [[...blue|exam6b][$five = "incorrect"]]." <<timed 89s>> <<goto exam6b>> <</timed>> <<countdownTimer 90 "exam6b">>

<br> The diagram isn't going anywhere, you know what's coming next. <center> <img src="images/spine.jpg" style="max-width: 50%;"/> </center> "And which tract is marked at B? "The tract marked at B is the... [[...anterior spinothalamic|exam7b][$six = "incorrect"]]." [[...anterior spinocerebellar|exam7b][$six = "incorrect"]]." [[...lateral spinothalamic|exam7a][$six = "correct"]]." [[...posterior spinocerebellar|exam7b][$six = "incorrect"]]." [[...red one|exam7b][$six = "incorrect"]]." <<timed 59s>> <<goto exam&b>> <</timed>> <<countdownTimer 60 "exam7b">> <<set $result to $result + 1>>

<br> Ok, you think it's going alright. Dr Adams pauses for a moment "Tell me about where the red neurone goes." Ouch. You rack your brains for the neuroanatomy you know you've covered, probably. "The red neurone has it's main synapse in... [[...the periaqueductal grey matter of the midbrain and then on to the somatosensory cortex. There are also fibres to the thalamus, hypothalamus and the reticular formation of the medulla|exam8b][$seven = "incorrect"]]." [[...the somatosensory cortex. There are also fibres to the thalamus, hypothalamus, periaqueductal grey matter of the midbrain and the reticular formation of the medulla|exam8b][$seven = "incorrect"]]." [[...the hypothalamus and then on to the somatosensory cortex. There are also fibres to the thalamus, periaqueductal grey matter of the midbrain, and the reticular formation of the medulla|exam8b][$seven = "incorrect"]]." [[...the reticular formation of the medulla and then on to the somatosensory cortex. There are also fibres to the thalamus, hypothalamus, and periaqueductal grey matter of the midbrain|exam8b][$seven = "incorrect"]]." [[...the thalamus and then on to the somatosensory cortex. There are also fibres to the periaqueductal grey matter of the midbrain, reticular formation of the medulla, and hypothalamus|exam8a][$seven = "correct"]]." <<timed 59s>> <<goto exam8b>> <</timed>> <<countdownTimer 60 "exam8b">>

<br> Ok, you think it's going alright. Dr Adams pauses for a moment "Tell me about where the red neurone goes." Ouch. You rack your brains for the neuroanatomy you know you've covered, probably. "The red neurone has it's main synapse in... [[...the periaqueductal grey matter of the midbrain and then on to the somatosensory cortex. There are also fibres to the thalamus, hypothalamus and the reticular formation of the medulla|exam8b][$seven = "incorrect"]]." [[...the somatosensory cortex. There are also fibres to the thalamus, hypothalamus, periaqueductal grey matter of the midbrain and the reticular formation of the medulla|exam8b][$seven = "incorrect"]]." [[...the hypothalamus and then on to the somatosensory cortex. There are also fibres to the thalamus, periaqueductal grey matter of the midbrain, and the reticular formation of the medulla|exam8b][$seven = "incorrect"]]." [[...the reticular formation of the medulla and then on to the somatosensory cortex. There are also fibres to the thalamus, hypothalamus, and periaqueductal grey matter of the midbrain|exam8b][$seven = "incorrect"]]." [[...the thalamus and then on to the somatosensory cortex. There are also fibres to the periaqueductal grey matter of the midbrain, reticular formation of the medulla, and hypothalamus|exam8a][$seven = "correct"]]." <<timed 89s>> <<goto exam8b>> <</timed>> <<countdownTimer 90 "exam8b">> <<set $result to $result + 1>>

<br> "Can you tell me about the descending pain inhibitory system?" You take a sharp inhalation of breath. Cramming the coagulation casade last night isn't doing you any favours today it seems, but you know you know this. "The descending pain inhibitory includes inputs from... [[...periaqueductal grey matter, nucleus raphe magnus and the gamma efferent system|exam9b][$eight = "incorrect"]]." [[...periaqueductal grey matter, nucleus raphe magnus and locus coeruleus|exam9a][$eight = "correct"]]." [[...periaqueductal grey matter, nucleus raphe magnus and nucleus tractus solitarius|exam9b][$eight = "incorrect"]]." <<timed 59s>> <<goto exam9b>> <</timed>> <<countdownTimer 60 "exam8b">>

Just over 24 hours later you are in CEPOD theatres anaesthetic room taking the on-call bleep from an outgoing colleague. “Anything to handover?” “Oh hi $firstname. Recovery is majorly busy. Theatre J and M both overran and have only just finished. The surgical F2 bleeped about a case for CEPOD about an hour ago but never turned up with a booking form so I don’t know what’s going on with that. Otherwise that’s it, nothing else on the list so you should have a q...” You butt in “Don't say it! Do you know who the boss is tonight?” “Haha, sorry. I think it’s Dr Franklin?” You take the bleep and… [[wander down to recovery->marj1]]

<p style="text-align:left"><img src="images/examlogo.jpg" style="max-width: 175px;"/></p> <p style="text-align:right">Virtual Anaesthetics The internet St Elsewhere HE11 0U <<set $CurDate = new Date(Date.now())>> <<= $CurDate.toLocaleString("en-UK", { day: "numeric", month: "numeric", year: "numeric" } )>></p> Dear Dr $firstname $surname <u> ''EXAMINATION <<set $CurDate = new Date(Date.now())>> <<= $CurDate.toLocaleString("en-US", { month: "long", year: "numeric" } )>>'' </u> Following your recent structured oral examination please find your results as follows: ''SOE 1:''<<if $result > 7>> ''PASS'' <<else>> ''FAIL'' <</if>> ''SOE 2:''<<if $result2 >7>> ''PASS'' <<else>> ''FAIL'' <</if>> Please refer to the enclosed report for the correct answers for individual questions. We wish you every success in your future endeavours. Yours sincerely !!!@@.writing; //S Boyle//@@ Exams department [[Exam Report]] [[Next|finally]]

You head down to recovery to see what’s happening. When you arrive several of the spaces are occupied with patients at varying stages of consciousness. The nurse in charge spots you and makes a beeline over. “Hi $firstname. I was about to bleep you. I’ve got a lady just out from K who’s in an awful lot of pain after her shoulder replacement and we’ve given everything she has on her chart. The ortho reg has been round and is happy there's nothing surgically wrong but we aren't winning with getting on top of things." You go over to the bedside where an older lady is lying, clearly in pain. [[Next->marj2]] <<set $block to false>> <<set $patch to false>>

You bleep the surgical reg. “Hi, this is the surgical reg on-call, you just bleeped me?” “Hi its $firstname, on for anaesthetics, the day team said you had something?” “You’re keen. Yes...er...might be easier if you came down actually. Majors bed 8. I’m already down here.” [[Ok see you in two minutes->ed2]]

You find the surgical reg writing at central nurses station in majors. They look up as you approach. "Oh Hi $firstname, thanks for coming down." "What’s up?" You ask The reg gestures towards the notes in front of them as though it illustrates the problem. "Ed Walls, 27 year old IVDU who won’t even sit down and won’t let me examine him properly but may have appendicitis or some other intra-abdominal pathology." You frown, your mind immediately jumping to the assumption of a horible untreated peritonitis. "Is he systemically well?" "Maybe. He won’t let the nurses do obs either. And no joy for bloods." "What does he want if he won't let us assess him?" "I have no idea." You go and [[see him->ed3]]

You quickly scan the notes and the anaesthetic chart to see what’s been happening. It look's like Marjorie, is 82 years old, weighing 64kg, has had her shoulder arthroplasty done under general anaesthesia with local anaesthetic infiltration with bupivicaine by the surgeons. She's had paracetamol IV and a total of 300 micrograms of fentanyl, 100 at the start, 100 during and a further 100 in recovery. She can't take NSAIDs as she's had an ulcer in the past and uses Butrans 15 microgram/hour patches. She's got hypertension and is on ramipril which she paused as instructed before surgery. "You normally have patches you take for pain?" You ask. "Yes, for my arthritis, I put it on the calendar so I remember to change them on the right day." She speaks clearly and is obviously alert. "Did they tell you to do anything different with your patches when you came in?" "No doctor, I’ve got it on here." She ineffectually gestures towards her right axilla and grimaces. [[leave it on?->marj3a]] [[take it off?->marj3b]]

The exams officer leads you up a flight of stairs to the exam floor where a room has been divided off into several smaller areas with partitions. She gestures to you to enter the first. [[Next->exam2]] <<audio "bell" pause>> <<set $three = "no answer given">> <<set $threeb = "no answer given">> <<set $four = "no answer given">> <<set $five = "no answer given">> <<set $six = "no answer given">> <<set $seven = "no answer given">> <<set $eight = "no answer given">> <<set $nine = "no answer given">> <<set $ten = "no answer given">> <<set $eleven = "no answer given">> <<set $twelve = "no answer given">> <<set $thirteen = "no answer given">> <<set $fourteen = "no answer given">> <<set $fifteen = "no answer given">> <<set $sixteen = "no answer given">> <<set $seventeen = "no answer given">> <<set $eighteen = "no answer given">> <<set $nineteen = "no answer given">> <<set $twenty = "no answer given">> <<set $twentyone = "no answer given">> <<set $twentytwo = "no answer given">> <<set $twentythree = "no answer given">>

<center> !!!@@.whitetext;You need paper and something to write with for the first part of this module. Once you have them please click @@ [[here|exam1]] <img src="images/paper.jpg" style="max-width: 100%;"/> </center>

<br> You realise the gentle introduction to the SOE is over when Dr Adams gestures casually towards the paper in front of you “Could you draw me a cross section through the spinal cord showing a simple pain pathway? You have one minute to use your paper to do so.” Time's getting on. Better get drawing... Once you are done click [[Next->exam5]] <<timed 119s>> <<goto exam5>> <</timed>> <<countdownTimer 120 "exam5">>

<br> You realise the gentle introduction to the SOE is over when Dr Adams gestures casually towards the paper in front of you “Could you draw me a cross section through the spinal cord showing a simple pain pathway? You have two minutes to use your paper to do so.” Time's getting on. Better get drawing... Once you are done click [[Next->exam5]] <<timed 119s>> <<goto exam5>> <</timed>> <<countdownTimer 120 "exam5">> <<set $result to $result + 1>>

<br> "and which proinflammatory cytokines are involved in pain?" "Proinflammatory cytokines are produced predominantly by activated macrophages and are involved in the up-regulation of inflammatory reactions. Those most involved in pain are... [[...IL-1, IL10 and TNFβ|exam10b][$nine = "incorrect"]]." [[...IL-4, IL-6 and TNFβ|exam10b][$nine = "incorrect"]]." [[...IL-2, IL-4 and TNFα|exam10b][$nine = "incorrect"]]." [[...IL-2, IL-10 and TNFβ|exam10b][$nine = "incorrect"]]." [[...IL-1, IL-6, and TNFα|exam10a][$nine = "correct"]]." <<timed 59s>> <<goto exam10b>> <</timed>> <<countdownTimer 60 "exam10b">>

<br> "Can you tell me any other of the local mediators that classically act on the primary pain neurone to cause nociception?" "Some of the other mediators involved in pain include... [[...histamine, thyroid hormones, prostaglandins, and substance P|exam10d][$ten = "incorrect"]]." [[...histamine, bradykinin, prostaglandins and substance P|exam10c][$ten = "correct"]]." [[...PDGF, thyroid hormones, prostaglandins, and substance P|exam10d][$ten = "incorrect"]]." [[...IGF-1, histamine, prostaglandins, and substance P|exam10d][$ten = "incorrect"]]." [[...histamine, VEGF, prostaglandins, and substance P|exam10d][$ten = "incorrect"]]." <<timed 59s>> <<goto exam10d>> <</timed>> <<countdownTimer 60 "exam10d">>

Dr Adams raises his hand slightly just as you finish your sentence. "That is the examination over." You try to read his expression, but he's giving you nothing. Nor is Dr East. They politely and efficiently kick you out of the cubical. The exams officer escorts you and the other candidates off the exam floor. Now there's a couple of hours before the clinical SOE this afternoon. You decide to… [[…do some last-minute revision->exam12][$revise to true]] [[…unpick the exam you’ve just done with the other candidates->exam12][$unpick to true]] [[…find some food->exam12][$food to true]] [[…not sit the clinical SOE and go home->gohome]] <<set $result to $result + 1>> <<audio text pause>>

<<if $revise is true>> You feel better about this afternoon’s exam after a couple of hours going over your notes. <</if>> <<if $unpick is true>> You feel better after unpicking the mornings exam with the other candidates. Seems like no-one found it a walk in the park so maybe you did ok? <</if>> <<if $food is true>> You have a hearty lunch and now an afternoon nap feels like a much more attractive proposition than another round with the examiners. <</if>> [[Next->exam13]]

The first thing you do when you get off the exam floor is retrieve your bag and turn your phone back on. There’s 47 unread emails and a [[text|text2]]. <<audio text play>>

<center><img src="images/matt.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 13:08@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> how did it go????</p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; i'm bailing, not up for the second half @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> pub?? </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; nights tomorrow, need an early night, sorry @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> <img src="images/sademoji.jpg" style="max-width: 25%;"/> </p> </div> </div> </p> [[time to get going->home]] <<audio text pause>>

You have an eerie sense of déjà vu as you wait in the same room as this morning for the clinical SOE and the exams officer says the exact same thing about phones. You check yours is off for the second time. She takes you through to a different room on the exam floor. [[Next|exam14]]

Two different examiners greet you as you enter. “Hello, I’m Dr Smith and this is Dr Hurst. We will be taking you through your examination this afternoon.” [[Next->exam14b]] <<audio "bell2" pause>> <<set $result2 to 0>>

<br> "What can you tell me about how opioids work?" Is that fair? That’s a pharmacology question surely? "Opioids work via… [[...mu, kappa, delta and nociceptin opioid receptors, which are all mainly inhibitory G-protein coupled receptors|exam10e][$eleven = "correct"]]." [[...mu, kappa, delta and nociceptin opioid receptors, which are all mainly excitatory G-protein coupled receptors|exam10f][$eleven = "incorrect"]]." [[...mu, kappa, delta and nociceptin opioid receptors, of which mu, kappa, delta are all mainly inhibitory G-protein coupled receptors and nociceptin is an excitatory G-protein coupled receptor|exam10f][$eleven = "incorrect"]]." [[...mu, kappa, delta and nociceptin receptors, which are mainly kinase linked receptors|exam10f][$eleven = "incorrect"]]." [[...mu, kappa, delta and nociceptin opioid receptors on ligand-gated ion channels in most circumstances|exam10f][$eleven = "incorrect"]]." [[...mu, kappa, delta and nociceptin receptors, which are kinase linked receptors|exam10f][$eleven = "incorrect"]]." <<timed 59s>> <<goto exam10f>> <</timed>> <<countdownTimer 60 "exam10f">>

<br> You take a seat. There's that bell again. Dr Smith continues “So this is the clinical short case. You are asked to anaesthetise a 24 year old man who has an axillary abscess. The individual has a history of IV heroin use. Describe how you would approach this case?” You pause for a moment to consider your answer. “I would firstly… [[…make sure he has had a full set of bloods|exam15b][$thirteen = "incorrect"]]." [[…ask him if he has used IV drugs in the last 8 hours|exam15b][$thirteen = "incorrect"]]." [[…take a thorough anaesthetic history|exam15a][$thirteen = "correct"]]." [[…order a chest x-ray as TB is common in this population|exam15b][$thirteen = "incorrect"]]." <<timed 59s>> <<goto exam15b>> <</timed>> <<countdownTimer 60 "exam15b">> <<audio "bell2" play>>

<br> Dr Smith is nodding "So you start by taking a thorough anaesthetic history. What specific questions will influence how you manage this patient?" “I would want to ask about... [[...relevant medical history|exam16b][$fourteen = "incorrect"]]." [[...recent opioid use including signs and symptoms of tolerance or withdrawal|exam16b][$fourteen = "incorrect"]]." [[...the current presentation because they may be systemically unwell due to the infection|exam16b][$fourteen = "incorrect"]]." [[...drug history including prescribed and illicit drug use and whether they are taking any prescribed substitution therapy such as methadone or buprenorphine|exam16b][$fourteen = "incorrect"]]." [[...any blood born viruses including HIV and Hepatitis B and C|exam16b][$fourteen = "incorrect"]]." [[...I would ask all of the above|exam16a][$fourteen = "correct"]]." <<timed 59s>> <<goto exam16b>> <</timed>> <<countdownTimer 60 "exam16b">> <<set $result2 to 0>> <<audio "bell2" pause>>

<br> Dr Adams follows with "So how do they work at a spinal level when you give intrathecal opioids?" Surely the time must be up now? "Intrathecal opioids mainly decrease pain transmission via... [[...circulation of the CSF centrally where opioids act on mu receptors in the sensory cortex|exam11b][$twelve = "incorrect"]]." [[...G-protein coupled opioid receptors on the anterior root spinal nerves with the release of inhibitory cellular messengers such as cAMP and activation of inhibitory interneurons|exam11b][$twelve = "incorrect"]]." [[...circulation of the CSF centrally where opioids act on mu receptors in the periaqueductal-periventricular grey matter|exam11b][$twelve = "incorrect"]]." [[...G-protein coupled opioid receptors in laminae I and II of the dorsal horn with the inhibition of cAMP production and activation of inhibitory interneurons|exam11a][$twelve = "correct"]]." <<timed 59s>> <<goto exam11b>> <</timed>> <<countdownTimer 60 "exam11b">> <<set $result to $result + 1>>

<br> "What concerns would you have relating to anaesthesia for this patient?" asks Dr Smith You consider for a moment. "For this patient my concern would be... [[...opioid tolerance which needs to be considered when planning the anaesthetic induction and maintenance as well as post-operative analgesia|exam17a][$fifteen = "correct"]]." [[...they are likely to be less responsive to induction agents due to upregulation of hepatic enzymes|exam17b][$fifteen = "incorrect"]]." [[...that opioids should not be used perioperatively with a history of substance misuse disorder due to the risk of relapse|exam17b][$fifteen = "incorrect"]]." [[...that this patient is likely to be ‘manipulative’ and ‘non-cooperative’ and therefore difficult to manage|exam17b][$fifteen = "incorrect"]]." <<timed 59s>> <<goto exam17b>> <</timed>> <<countdownTimer 60 "exam17b">>

<br> Dr Smith glances at the mark sheet. "How easy do you think assessing this patient’s pain will be?" "Assessing this person’s pain is likely to be... [[...challenging however pain scores are a reliable guide to therapy|exam17d][$sixteen = "incorrect"]]." [[...challenging with pain scores are higher to those of patients not tolerant to opioids|exam17c][$sixteen = "correct"]]." [[...no different to that of a patient who is opioid naïve|exam17d][$sixteen = "incorrect"]]." [[...of no-benefit if they are still using heroin or are on methadone|exam17d][$sixteen = "incorrect"]]." <<timed 59s>> <<goto exam17d>> <</timed>> <<countdownTimer 60 "exam17d">> <<set $result2 to $result2 + 1>>

<br> "Lets assume all the relevant parties are involved what would you prescribe?" “I would prescribe a... [[...standard morphine PCA to prevent withdrawal|exam19b][$eighteen = "incorrect"]]." [[...suitable morphine dose over 24h to prevent withdrawal either as a PCA or divided IV doses|exam19a][$eighteen = "correct"]]." [[...a 25 mcg/h fentanyl patch as a sufficient dose to prevent withdrawal|exam19b][$eighteen = "incorrect"]]." [[...benzodiazepine IV to treat withdrawal symptoms and incremental doses of fentanyl for acute pain|exam19b][$eighteen = "incorrect"]]." [[...morphine PCA with a standard bolus and a lockout reduced to 1 minute to prevent withdrawal|exam19b][$eighteen = "incorrect"]]." <<timed 59s>> <<goto exam19b>> <</timed>> <<countdownTimer 60 "exam19b">>

<br> Dr Smith follows up with "And would your management change if this patient was on prescribed substitution therapy with buprenorphine?" You are sure you reviesed this, either that or it was in a teaching session. "Buprenorphine has a... [[...low affinity for mμ receptors with low intrinsic activity and slow dissociation while being a full antagonist at κappa and delta receptors|exam20b][$nineteen = "incorrect"]]." [[...high affinity for mμ receptors with high intrinsic activity and rapid dissociation while being a full antagonist at κappa and delta receptors|exam20b][$nineteen = "incorrect"]]." [[...high affinity for mμ receptors with low intrinsic activity and slow dissociation while being a full antagonist at κappa and delta receptors-|exam20a][$nineteen = "correct"]]." [[...low affinity for mμ receptors with low intrinsic activity and slow dissociation while being a partial antagonist at κappa and delta receptors|exam20b][$nineteen = "incorrect"]]." [[...high affinity for mμ receptors with high intrinsic activity and rapid dissociation while being a partial antagonist at κappa and delta receptors|exam20b][$nineteen = "incorrect"]]." <<timed 59s>> <<goto exam20b>> <</timed>> <<countdownTimer 60 "exam20b">>

<br> "If this patient normally takes 100mg of oral methadone a day but is systemically unwell and vomiting how would you manage their opioid requirements?" Are they expecting actual mental arithmetic in an exam? Hopefully not. "This patient has complex analgesic requirements so... [[...I would prescribe a replacement opioid to avoid the risk of sudden withdrawal|exam18b][$seventeen = "incorrect"]]." [[...I would discuss the case with my supervising consultant, and the acute pain service if available while minimising any delay to prescribing a replacement opioid|exam18a][$seventeen = "correct"]]." [[...if they have recently taken opioids they require no further doses and adjunct analgesia should be provided with paracetamol and a NSAID|exam18b][$seventeen = "incorrect"]]." <<timed 59s>> <<goto exam18b>> <</timed>> <<countdownTimer 60 "exam18b">>

<br> "What would the clinical implications of that be?" "Theoretically the clinical implications would be... [[...the additive action of additional traditional mμ receptor agonists such as morphine would inevitably cause respiratory depression|exam21b][$twenty = "incorrect"]]." [[...patients on once daily substitution therapy do not need further analgesia|exam21b][$twenty = "incorrect"]]." [[...additional traditional mμ receptor agonists such as morphine would be blocked and analgesia could be inadequate|exam21a][$twenty = "correct"]]." [[...you could increase the buprenorphine dose without any risk of side effects|exam21b][$twenty = "incorrect"]]." <<timed 59s>> <<goto exam21b>> <</timed>> <<countdownTimer 60 "exam21b">>

<br> "Theoretically? Can you tell me what you would do in practice to manage this patients opioid requirements?" Dr Smith wants more for that answer. "There are several ways you could manage this patients opioid requirements. I would... [[...take advice from the prescribing clinician in the substance misuse service if possible|exam22b][$twentyone = "incorrect"]]." [[...discuss the case with my supervising consultant and the acute pain team if available|exam22b][$twentyone = "incorrect"]]." [[...consider either splitting the daily buprenorphine dose and administering twice or three times daily or discontinuing and providing an alternative if appropriate|exam22b][$twentyone = "incorrect"]]." [[...titrate additional opioid analgesia as required|exam22b][$twentyone = "incorrect"]]." [[...all of the above|exam22a][$twentyone = "correct"]]." <<timed 59s>> <<goto exam22b>> <</timed>> <<countdownTimer 60 "exam22b">>

<br> "and what would you need to consider if switching this patient from one opioid to another?" You think for a second, you are sure know this and time is running out. "In most cases when switching from one opioid to another the calculated equivalent analgesic dose should be... [[...reduced by 25-50% to ensure safety as cross-tolerance may only be partial|exam23a][$twentytwo = "correct"]]." [[...increased by 25-50% to ensure adequate analgesia|exam23b][$twentytwo = "incorrect"]]." [[...reduced by 10% to ensure safety as cross-tolerance may only be partial|exam23b][$twentytwo = "incorrect"]]." [[...increased by 10% to ensure adequate analgesia|exam23b][$twentytwo = "incorrect"]]." <<timed 59s>> <<goto exam23b>> <</timed>> <<countdownTimer 60 "exam23b">>

<br> "Finally what would you want to communicate to the patient?" "I would reassure them that... [[...we will not give opioids and risk a recurrence of previous substance misuse behaviours|exam24b][$twentythree = "incorrect"]]." [[...their pain will be assessed and managed appropriately|exam24a][$twentythree = "correct"]]." [[...their pain will be easy to control using standard analgesic regimens|exam24b][$twentythree = "incorrect"]]." [[...they are unlikely to suffer significant pain while on substitution therapy|exam24b][$twentythree = "incorrect"]]." <<timed 59s>> <<goto exam24b>> <</timed>> <<countdownTimer 60 "exam24b">> <<set $result2 to $result2 + 1>>

And there's the bell. Times up. You thank Dr Smith and Dr Hurst. The relief that the exam is over is almost palpable. [[Time to escape->finished]] <<audio text pause>>

And there's the bell. Times up. You thank Dr Smith and Dr Hurst. The relief that the exam is over is almost palpable. [[Time to escape->finished]] <<set $result2 to $result2 + 1>> <<audio text pause>>

The first thing you do when you get off the exam floor is retrieve your bag and turn your phone back on. There’s 47 unread emails and a [[text->text3]]. <<audio text play>>

<center><img src="images/matt.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 18:08@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> how did it go????</p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; find out when I get the results @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> pub?? </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; nights tomorrow, need an early night, sorry @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> <img src="images/sademoji.jpg" style="max-width: 25%;"/> </p> </div> </div> </p> [[time to get going->home]] <<audio text pause>>

Finally you get a seat on the train heading for home. You get your phone out again, this time to plough through a days worth of emails. Half way down is one about [[next weeks journal club]].

@@.typing;''From:'' Sally Fenton ''Sent:'' Today ''To:'' $firstname $surname and 18 others ''Subject:'' next week's journal club Hi Everyone I've attached the summary for next week's journal club. It's a BJA Ed article about chronic opioid use. I dug around a few other papers for a bit of context. See you all next week. Cheers Sally @@ <a data-passage="next weeks journal club 2" class="link-internal link-image"> <img src="images/bja.jpg" style="max-height: 175px"> </a> Sent from my iPad [[I'll skip that thanks->night1]]

<p style="text-align:justify">Notes from: Simpson GK, Jackson M. ''Perioperative management of opioid-tolerant patients''. //BJA Ed//. 2017; 17(4):124-128</p><center> !!@@.typing; Managing the opioid tolerant patient @@ </center> <div class="notes">''Scale of the issue''</div> * Over 23 million opioid analgesic prescriptions were dispensed in 2018 up from 15 million in 2008^^1^^ * 8-12% of long-term prescribed opioid users meet criteria for a current or past opioid use disorder^^2^^ * 300,000 people in England are dependent on illicit opioids or crack^^3^^ * 9.4% people aged 16-59 used an illicit drug in the last year^^4^^ Vs opioid naïve patients, opioid-tolerant patients: * Have higher dynamic and at rest pain scores * Have 2-3 x greater use of patient controlled analgesia * Are at risk of tolerance, dependence and withdrawal * Are at higher risk of adverse effects and overdose <div class="notes">''Key definitions''</div> @@.greentext;''Tolerance = ''@@ predictable physiological state where an increased dose is required for same effect @@.greentext;''Dependence = ''@@ predictable physiological state where abrupt cessation brings about withdrawal @@.greentext;''Withdrawal = ICD-10 = ''@@ a group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a substance after repeated, and usually prolonged and/or high-dose, use of that substance @@.greentext;''Addiction, substance (mis)use disorder, dependence syndrome = '' @@ complex condition of uncontrolled use of a substance despite harmful consequences (extensive diagnostic criteria in <<link [[ICD-10->next weeks journal club 2]]>> <<set Dialog.setup("Dependence syndrome diagnostic criteria")>> <<set Dialog.wiki("Three or more of the following have been present together at some time during the previous year: ''(a)'' a strong desire or sense of compulsion to take the substance; ''(b)'' difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use; ''(c)'' a physiological withdrawal state when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms; ''(d)'' evidence of tolerance, such that increased doses of the psychoactive substances are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill nontolerant users); ''(e)'' progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects; ''(f)'' persisting with substance use despite clear evidence of overtly harmful consequences.")>> <<set Dialog.open ()>> <</link>>) @@.greentext;''Opioid Substitution therapy (OST) = ''@@ Provision of prescription opioid to reduce harmful behaviour, risk of blood borne infections and uncontrolled withdrawal associated with illicit drug use <div class="notes">''Opioid sparing techniques''</div> * Regular paracetamol and NSAID unless contraindicated * Local, regional or neuraxial local anaesthetic techniques * Ketamine infusions (dosing regimes vary so follow local policy) * Gabapentinoids also carry a risk of misuse but can have a role where other options have been exhausted and there is a clear plan for review and cessation * IV lidocaine infusions in some situations (follow local policy) <div class="notes">''Avoid withdrawal''</div> <p style="text-align:justify">In general, @@.greentext;''continue baseline prescribed opioids including transdermal patches''@@. Patches should be located where they won’t be warmed causing excess drug administration, cooled or where perfusion may be unreliable causing under administration such as bellow a tourniquet. Parenteral replacement is necessary in patients unable to tolerate PO. For example the 24h PO dose can be used to calculate an IV dose equivalent using appropriate conversion ratios (see FPM opioids aware^^2^^) and then given as a background infusion + bolus regimen via PCA. These patients should have pain team involvement and local protocols should be followed.</p> <div class="notes">''Switching from one opioid to another''</div><center> !!@@.typing; Caution! Incomplete cross tolerance! @@ </center><p style="text-align:justify">Opioid conversion tables are based on data from single doses in healthy opioid naïve volunteers. When changing from one opioid to another reduce the calculated equianalgesic dose by 30-50% as a starting dose. In frail or elderly patients or those taking > 500 mg oral morphine or equivalent per 24h reduce the calculated equianalgesic dose by more than 50%. </p> <div class="notes">''Opioid-induced hyperalgesia''</div> <p style="text-align:justify">Is a complex phenomenon following exposure to opioids which may involve glial cell activation, NMDA receptor activation, glutaminergic activation, and alterations in opioid intracellular signalling. This leads to nociceptive sensitization and frequently more diffuse and widespread patterns of pain.</p> <div class="notes">''Substitution therapy''</div> * Prescribed by specialist substance misuse services * Reduces harm from problem drug use and prevents withdrawal * Oral methadone or SL buprenorphine * Titrated to maintenance dose <div class="notes">''Methadone''</div> <center> <img src="images/bottle.jpg" style="max-width: 30%;"/> </center> * mu opioid receptor agonist, NMDA receptor antagonist and MAOI * Initial analgesic action 4-6 h, increasing to 8-12h with accumulation of repeated doses * Prevention of withdrawal 24-48 h * Long QT with high doses * Risk of respiratory depression, hypotension and sedation with other opioids, phenothiazines, sedatives, hypnotics or other CNS depressants (including alcohol) ''Acute pain management:'' * Continue perioperatively if possible * Split the dose and administer twice or three times daily * Titrate additional analgesia to effect * Provide alternative parentral opioid if no oral intake to include maintenance requirement * Formulate and communicate a plan for onward-care and return to baseline dose <div class="notes">''Buprenorphine''</div> <img src="images/box.jpg" style="max-width: 100%;"/> * Patches, PO or SL * Some brands: Butrans or Transtec (Patch), Subutex (SL), or Suboxone (SL combination buprenorphine/naloxone) * Partial mu agonist, antagonist at kappa and delta * High affinity for opioid receptors and slow dissociation * Analgesic action 4-6 h * Prevention of withdrawal 24-48 h * Risk of respiratory depression, hypotension and sedation with other opioids, phenothiazines, sedatives, hypnotics or other CNS depressants (including alcohol) ''Acute pain management:'' * If oral substitution therapy split the dose and administer twice or three times daily * Titrate additional analgesia or * Discontinue and provide alternative analgesia * Formulate and communicate a plan for onward-care and return to baseline dose <div class="notes">''Naltrexone''</div> * Competitive mu and delta opioid receptor antagonist * Duration 48-72 h * Causes increased brain opioid receptor density * Current use or within the last 72 h = opioid resistant * Recent use greater than 72 h after last dose = opioid sensitive !!!<p style="text-align:justify"> @@.typing;The bottom line: Be safe, avoid withdrawal, aim to control acute pain and communicate that to the patient. These are complex patients to manage so involve the MDT. As always if in doubt get help.@@</p> [[Next->night1]] [[Show me the evidence->ref1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

Main source: Simpson GK, Jackson M. Perioperative management of opioid-tolerant patients. BJA Ed. 2017, 17(4):124-128 Other cited refs: # https://digital.nhs.uk/data-and-information/publications/statistical/prescription-cost-analysis/2018 # Faculty of Pain Medicine. Opioids Aware. A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain. Available at: https://fpm.ac.uk/opioids-aware # Hay G. Anderson R. Swithenbank Z. Estimates of the prevalence of opiate use and/or crack cocaine use, 2014/15: Sweep 11 report. 2017 Liverpool John Moores University # Public Health England, Public Health Scotland, Public Health Wales and Public Health Agency Northern Ireland. Shooting Up: Infections among people who inject drugs in the UK, 2019. London: Public Health England, December 2020. available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/953983/Shooting_Up_2020_report.pdf [[Back->next weeks journal club 2]]

!!Structured oral examination 1: Basic science @@.pinktext;''Q1 What is the definition of pain?''@@ ''Your answer:'' <<print $three>> ''Correct answer:'' Pain is an adverse sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury. ''and'' Pain is an unpleasant sensory and emotional experience associated with potential or actual tissue damage, or described in terms of such damage. @@.pinktext;''Q2 Where is the definition in Q1 from?''@@ ''Your answer:'' <<print $threeb>> ''Correct answer:'' The International Association for the Study of Pain. @@.pinktext;''Q3 How would you distinguish between acute and chronic pain?''@@ ''Your answer:'' <<print $four>> ''Correct answer:'' Acute pain is sudden in onset and associated with a definite cause, whereas chronic pain persists longer than the expected time of healing and usually longer than three months @@.pinktext;''The following three questions relate to this diagram of a cross section through the spinal cord at L1:''@@ <center> <img src="images/spine.jpg" style="max-width: 65%;"/> </center> @@.pinktext;'' Q4 In relation to pain pathways the neurone marked A is what type of neuron?''@@ ''Your answer:'' <<print $five>> ''Correct answer:'' The neurone marked A on the diagram is a first order neuron which is either a fast myelinated Aδ or slow unmyelinated C fiber with it's cell body in the dorsal root ganglion and it's synapse in the dorsal horn. @@.pinktext;''Q5 In the above diagram the tract marked at B is the...''@@ ''Your answer:'' <<print $six>> ''Correct answer:'' ...lateral spinothalamic @@.pinktext;''Q6 In the above diagram the red neurone goes to the...''@@ ''Your answer:'' <<print $seven>> ''Correct answer:'' ...the thalamus and then on to the somatosensory cortex. There are also fibres to the periaqueductal grey matter of the midbrain, reticular formation of the medulla, and hypothalamus. @@.pinktext;''Q7 The descending pain inhibitory has inputs from?''@@ ''Your answer:'' <<print $eight>> ''Correct answer:'' The periaqueductal grey matter, nucleus raphe magnus and locus coeruleus. @@.pinktext;''Q8 Which proinflammatory cytokines are involved in pain?''@@ ''Your answer:'' <<print $nine>> ''Correct answer:'' IL-1, IL-6, and TNFα. @@.pinktext;''Q9 Other mediators involved in pain include?''@@ ''Your answer:'' <<print $ten>> ''Correct answers:'' Histamine, bradykinin, prostaglandins and substance P. @@.pinktext;''Q10 How do opioids work?''@@ ''Your answer:'' <<print $eleven>> ''Correct answer:'' Opioid act via mu, kappa, delta and nociceptin opioid receptors, which are mainly inhibitory G-protein coupled receptors. @@.pinktext;''Q11 At a spinal level how do intrathecal opioids work?''@@ ''Your answer:'' <<print $twelve>> ''Correct answer:'' Intrathecal opioids decrease pain transmission via G-protein coupled opioid receptors in laminae I and II of the dorsal horn with the inhibition of cAMP production and activation of inhibitory interneurons. !!Structured oral examination 2: Clinical short case @@.pinktext;''Q1 You are asked to anaesthetise a 24 year old man who has an axillary abscess. The individual has a history of IV heroin use. Describe how you would approach this case?''@@ ''Your answer:'' <<print $thirteen>> ''Correct answer:'' Firstly, take a thorough anaesthetic history. @@.pinktext;''Q2 When taking a thorough anaesthetic history what specific questions will influence how you manage this patient?''@@ ''Your answer:'' <<print $fourteen>> ''Correct answer:'' All of the following are pertinent to the case - * Relevant medical history * Recent opioid use including signs and symptoms of tolerance or withdrawal * Current presentation because they may be systemically unwell due to the infection * Drug history including prescribed and illicit drug use and whether they are taking any prescribed substitution therapy such as methadone or buprenorphine * Any blood born viruses including HIV and Hepatitis B and C @@.pinktext;''Q3 What concerns would you have relating to anaesthesia for this patient?''@@ ''Your answer:'' <<print $fifteen>> ''Correct answer:'' For this patient major concern would be opioid tolerance which needs to be considered when planning the anaesthetic induction and maintenance as well as post-operative analgesia. @@.pinktext;''Q4 How easy will assessing this patient’s pain be?''@@ ''Your answer:'' <<print $sixteen>> ''Correct answer:'' Assessing this persons pain score is likely to challenging with pain scores are higher to those of patients not tolerant to opioids. @@.pinktext;''Q5 This patient takes 100mg of oral methadone a day but is systemically unwell and vomiting how would you manage their opioid requirements?''@@ ''Your answer:'' <<print $seventeen>> ''Correct answer:'' This patient has complex analgesic requirements so should be discussed with the supervising consultant, and the acute pain service if available while minimising any delay to prescribing a replacement opioid. @@.pinktext;''Q6 All the relevant parties are involved. What would you prescribe?''@@ ''Your answer:'' <<print $eighteen>> ''Correct answer:'' Suitable morphine dose over 24h to prevent withdrawal either as a PCA or divided IV doses. @@.pinktext;''Q7 How would management change if this patient was on prescribed substitution therapy with buprenorphine?''@@ ''Your answer:'' <<print $nineteen>> ''Correct answer:'' Buprenorphine has a high affinity for mμ receptors with low intrinsic activity and slow dissociation while being a full antagonist at κappa and delta receptors. @@.pinktext;''Q8 What would the clinical implications of that be?''@@ ''Your answer:'' <<print $twenty>> ''Correct answer:'' Theoretically the clinical implications would be additional traditional mμ receptor agonists such as morphine would be blocked and analgesia could be inadequate. @@.pinktext;''Q9 If the theoretical implications of buprenorphine are as above, what could be done in practice to manage this patients opioid requirements.''@@ ''Your answer:'' <<print $twentyone>> ''Correct answer:'' All of the following: * Take advice from the prescribing clinician in the substance misuse service if possible. * Discuss the case with my supervising consultant and the acute pain team if available. * Consider either splitting the daily buprenorphine dose and administering twice or three times daily or discontinuing and providing an alternative if appropriate. * Titrate additional opioid analgesia as required. @@.pinktext;''Q10 What would you need to consider if switching this patient from one opioid to another?''@@ ''Your answer:'' <<print $twentytwo>> ''Correct answer:'' In most cases when switching from one opioid to another the calculated equivalent analgesic dose should be reduced by 25-50% to ensure safety as cross-tolerance may only be partial. @@.pinktext;''Q11 What would you want to communicate to the patient?''@@ ''Your answer:'' <<print $twentythree>> ''Correct answer:'' Their pain will be assessed and managed appropriately. [[Back->resultletter]]

<<if $result > 7 & $result2 > 7>> Well done you! Time to treat yourself to a takeway and open a bottle of fizz to celebrate. <<elseif $result < 8 & $result2 < 8>> Bad luck. That's just how it goes on the day sometimes. Time to order that takeaway you promised yourself and plan when to tackle it again. <<else>> It could be worse, you could have failed the lot. Time to order that takeaway you promised yourself and plan when to tackle it again. <</if>> [[End|exit2]] <<set $result1 to $result>>

When you head into the bay Ed is standing by the head of the bed looking intently at the blank screen of a mobile phone. Even from a couple of metres away you can see he's flushed and sweating. Before you get a chance to speak he looks up. "You got a charger for this?" "No. Sorry. It’s Mr Walls? I’m Dr $firstname $surname, one of the anaesthetic doctors, I’m here to see if we can get you a bit more sorted, can I ask you a few questions?" He nods but is back to trying to get some life out of the dead phone. This is going nowhere until you take that phone out of the equation. "I tell you what, once you’ve told me a bit about what’s been going on, I’ll ask around and see if there’s a spare charger anywhere, OK?" He nods, drags his attention away from the phone and starts to [[talk->audio1]]. Alternatively read a [[transcript->transcript1]] of what Ed said. <<audio ed pause>>

You follow up with the usual questions of an anaesthetic history and nothing untoward comes up. After you've finished talking to Ed you head back to the nurses station. Fortunately when you ask the various staff one of the ED staff turns out a charger cable from the bottom of a random draw and they offer to take it to Ed. The surgical reg comes out from behind the curtains of another bay. "You’ve seen him? Ed Walls? He says he’s not had methadone for 48h what do we give him?" You reply… [[This is complex stuff, I'd confirm his dose and speak to the boss->ed5a]] [[Don’t give him anything it's drug seeking behaviour->ed5b]] [[You do the conversion of 100mg methadone to morphine and prescribe it as an IV infusion->ed5c]]

It’s late so the dispensing pharmacy isn’t open and there won’t be anyone in the substance misuse service till nine am tomorrow to confirm the dose with the prescriber. Fortunately, when you check available online letters there’s a recent one that confirms how much methadone he’s been on. Your priority over night is to avoid withdrawal, treat his acute pain and be safe. You speak to the on-call consultant who works you through converting the methadone dose to morphine and then you write up that as a background infusion in addition to a bolus lock out regimen and confirm with the ED staff that the patient is going to a sufficiently high care area to watch for signs of sedation or respiratory depression. [[SEE YOUR CALCULATION]] You leg it back up to theatres to let CEPOD know about the case and see what's going on with recovery. [[Next->ed6a]]

You glance at Ed's drug chart. He's had some NSAID and paracetamol. You hand it back to the surgical reg. "He’s going to be in theatre shortly, he doesn’t need anything else now." [[You head back to theatres->ed6b]]

You convert the methadone dose to morphine. [[SEE YOUR CALCULATION->SEE YOUR CALCULATION 3]] You write it up as a background infusion in addition to a bolus lock out regimen and confirm with the ED staff that the patient is going to a sufficiently high care area to watch for signs of sedation or respiratory depression. Once that's done you dash back upstairs to get theatres ready for the case. [[Next->ed6c]]

@@.writing; '' Patient on 100 mg methadone The conversion factor methadone to morphine varies widely depending on dose and duration of treatment and should be done with specialist advice. For this example we will use... <u>1 : 2</u> to <u>1 : 3</u> Using <u>1 : 3</u> 100 mg methadone = 300 mg oral morphpine 300 mg oral morphine = 100 mg IV morphine Incomplete cross-tolerance so 50% reduction in equianalgesic dose = 50 mg IV morphine'' ''Give as PCA <u>either</u>:'' >>''Background infusion of 2 mg.h^^-1^^ and standard PCA bolus of 1 mg'' <center>''<u>or</u>''</center> >>''No background infusion with increased bolus dose of 1.5 to 2 mg'' @@ This is an example only. The faculty of pain medicine has useful resources for assisting in this sort of calculation available here [[here->https://fpm.ac.uk/opioids-aware-structured-approach-opioid-prescribing/dose-equivalents-and-changing-opioids]]. Always ensure that these patients are cared for in an area where side effects, including respiratory depression, can be quickly identified and appropriately managed. [[Back->ed5a]]

<center> <img src="images/letter.jpg" style="max-width: 50%;"/> </center> @@.whitetext; When you finally get home there's three different takeaway menus, a flyer for coach tours, and an official looking envelope waiting for you on the doormat. Better [[open it|resultletter]]

<center> <img src="images/exit.jpg" style="max-width: 50%;"/> </center> You check the machine, draw up the usual induction drugs and go through the plan with the ODP. After a lengthy wait the theatre co-ordinator comes into the anaesthetic room with a deep frown. "What’s up?" You ask. "It’s the patient we’re meant to be getting up, Ed Walls, he’s left the ED, they thought he’d gone out to smoke but they went out to get him and he’s gone." Damn. The ODP meets your eye and shrugs. The rest of the nightshift is pretty uneventful. [[Next->ed7b]]

A week later you are doing a plastics list, the second case is under local so you take the opportunity to go back to the anaesthetics department to do some admin. Your educational supervisor collars you in the corridor. "Ah, $firstname, that's good timing, I was going to email you. Do you have a minute?" They steer you into an empty office. [[Next->ed8b]]

<p style="text-align:justify">You both sit. "It's about a patient you saw last week, Ed Walls, apparently left the ED without treatment after you saw him? Well he re-presented a couple of days ago." He's not dead is he? Your educational supervisor must see the rising panic in your face. "He's fine, now, but he presented with acute opioid withdrawal and took quiet a bit of sorting out I understand. They were able to confirm his methadone dose with the dispensing pharmacy and that he hadn't turned up for the two days prior to when you saw him. Anyway he had his appendix out in the end. But it was flagged up that he wasn't treated for withdrawal or acute pain when he presented last time and we need to discuss that really." "He was about to come to theatre and I would have given him opioids then." "Why don't you have a think about how you could have managed his opioid requirements. Write a reflective entry on your portfolio and we can discuss this again after you've done that." Your ES leaves you to it in the empty office. You scribble the calculations for converting Ed's methadone to morphine [[SEE YOUR CALCULATION->SEE YOUR CALCULATION 2]] After you fill out a reflective entry in your portfolio you head back to the rest of the plastics list. If only you could go back and [[make those decisions again->ed4]]. </p> [[Next->exit1]]

You check the machine, draw up the usual induction drugs and go through the plan with the ODP. After a lengthy wait the theatre co-ordinator comes into the anaesthetic room with a deep frown. "What’s up?" You ask. "Change of plan. The patient from majors will have to wait. There's a patient with a suspected testicular torsion." She offers you the booking form. “The urology reg is just on their way to discuss it with you.” “Ok, thanks.” [[Next->ed9c]]

A week later you are doing a plastics list, the second case is under local so you take the opportunity to go back to the anaesthetics department to do some admin. Your educational supervisor collars you in the corridor. "Ah, $firstname, that's good timing, I got your email about that case while you were on nights. Do you have a minute?" They steer you into an empty office. [[Next->ed8c]]

<p style="text-align:justify">You both sit. "I understand you wanted to discuss what happened with Ed Walls, apparently you prescribed him a PCA and his case was delayed overnight? There was a respiratory arrest? A DATEX was filled out?" Your shoulders drop, you know Ed responded to the naloxone, went to high care for observation and was stable when you left him at the end of that night shift. You can't escape the feeling you could have done something different. "They were able to confirm his methadone dose with the dispensing pharmacy. The dose he told you was correct but he had been vomiting for several days and then hadn't collected his prescription for more than 48 hours so his tolerance to opioids had waned. Anyway, he had his appendix out in the end. But it was flagged up that you'd prescribed a non-standard PCA in the first instance without taking any steps to confirm the correct dose, or check with someone more experienced and we need to discuss that really." "I thought it was just a stop gap until we could get him to theatre, then it was delayed, and..." you struggle to finish the sentence. "You need to always use your best endeavours to make sure people are taking what they say they are, even with my many years experience, I wouldn't hesitate to involve a colleague in managing this, it's complex stuff. Write a reflective entry on your portfolio and we can discuss this again after you've done that." Your ES leaves you to it in the empty office. After you fill out a reflective entry in your portfolio and drop your ES an email to arrange a follow-up you head back to the rest of the plastics list. If only you could go back and [[make those decisions again->ed4]]. </p> [[Next->exit1]]

Two hours later you're on your way back from dropping the urology patient in recovery. Just then there’s an medical emergency bleep, you dash to SAU to see what’s going on. [[Next->ed10c]]

<center> <img src="images/eye.jpg" style="max-width: 100%;"/> </center> When you stick your head round the curtain the space is packed by other members of the response team. You can still see the face of the patient in the bed. It’s Ed, and he’s grey. The ICU Reg, Sally, is already at the head of the bed, she glances up at you and nods in greeting as she bags the patient. “Respiratory arrest. The nurse looking after him has just gone to get some naloxone." You are closer to the head of the bed. Sally gently rases one of Ed's eyelids. A blank pinpoint pupil stares back at you. Damn. [[Next->ed7c]]

Ok, so you leave it on. Now what? [[We need some non-opioid adjucts here, pass me the clonidine->marj5]] [[Nothing that more fentanyl can’t sort out->marj6]] [[Be done with it and set up an opioid PCA->marj7]] <<if $patch is true>> <<else>>[[Can we get hold of a higher dose patch this time of night?->marj8]] <</if>> <<if $block is true>> <<else>> [[There’s a block for this->marj4]] <</if>>

Ok, so you take it off. Now what? [[We need some non-opioid adjucts here, pass me the clonidine->marj5]] [[Nothing that more fentanyl can’t sort out->marj6]] [[Be done with it and set up an opioid PCA->marj7]] [[Can we get hold of a higher dose patch this time of night?->marj8]] <<if $block is true>> <<else>> [[There’s a block for this->marj4]] <</if>>

Ok so she could do with an interscalene brachial plexus block. This rings a bell, you recall that NICE has a guideline on anaesthesia for Joint replacement. You do a quick search on your phone, there it is, NG157, June 2020. That's interesting, the NICE says in 2 RCT looking at mean pain scores demonstrated regional + GA had less pain at 8 hours but this was reversed at 24 hours, with local infiltration + GA having lower scores, probably because they had a different analgesic regimens prescribed. Interesting, but that doesn't help Marjorie now, you need to get on top of her pain. Interscalene, can you do it? [[No problem->marj4a]] [[The boss is going to have to come in for this one->marj4b]] [[I've changed my mind about the block->marj4c]] [[Show me that NICE guidline->marj4d]]

Given her history of hypertension and age you are wary of the hypotensive effect of clonidine so you start her with a small dose IV and ask the recovery staff to keep her here where she can be monitored for that and excessive sedation. As a fan of multimodal analgesia, you may have experience in using the non-opioid based adjuvant analgesics? This is a night shift and you’ve just done an exam, so we won’t go into it too much here but... @@.typing; ''The obvious:'' paracetamol, NSAIDs (where not contraindicated), LA via local infiltration, nerve blocks, neuraxial ''More specialist:'' ketamine, gabapentinoids, membrane stabilizers (e.g. IV lidocaine) and α~~2~~ agonists (e.g. clonidine) Use of these agents perioperatively has been shown to decrease the intensity of acute post-operative pain, reduce opioid consumption, and opioid related side effects. But there is the risk of the known side effects of these drugs. If you want to read more see the BJA ref at the bottom of the page.@@ Good news is that Marjorie is much more comfortable and her blood pressure is fine. Better crack on, work to do. [[Next->ed1]] @@.typing; Ramaswamy S, Wilson J, Colvin L. Non-opioid-based adjuvant analgesia in perioprative care. //Continuing Education in Anaesthesia Critical Care & Pain//. 2013; 13(5):152-175 Available [[here->https://academic.oup.com/bjaed/article/13/5/152/273387]] @@

She's already had the front of the chart fentanyl prescribed for recovery but it occurs to you that she's probably pretty tolerant after all that buprenorphine and you prescribe another dose titrated to pain and leave her in the capable hands of the recovery staff. Not sure the Cochrane Database Systematic Review 2006, //Patient controlled opioid analgesia vs conventional opioid analgesia for postoperative pain//, would agree with that decision. In 55 studies PCA provided better pain control and greater patient satisfaction with a similar incidence of adverse effects apart from pruritis, with no difference on LOS vs 'as needed' opioid analgesia. But that's for patients not already on opioids, and you know from that journal article that she's at risk of side effects. You ask the recovery staff to keep her for another hour and then she needs to go to an area with an appropriate level of care to identify and manage complications and titrate further opioids to manage her pain. Right, crack on there's work to do. [[Next->ed1]]

You write up an opioid PCA as per your trust protocol for patients over 70 years old. And the Cochrane Database Systematic Review 2006, //Patient controlled opioid analgesia vs conventional opioid analgesia for postoperative pain//, would seem to support that as a decision. In 55 studies PCA provided better pain control and greater patient satisfaction with a similar inicidence of adverse effects apart from pruritis, with no difference on LOS vs 'as needed' opioid analgesia. But that's for patients not already on opioids, and you know from that journal article that she's at risk of side effects. You ask the recovery staff to keep her for another hour and then she needs to go to an area with an appropriate level of care to identify and manage complications. Right, crack on there's work to do. [[Next->ed1]]

You float the idea of getting a higher dose buprenorphine patch with the nurse in charge of recovery. "Not a chance, we'd have to get the on-call pharmacist in, and doesn’t the transdermal patch have a really slow onset of action? Something like 12 to 24 hours?” You kick yourself, she’s right, we need something faster than that to get on-top of Marjorie’s pain. Ok so now what? [[We need some non-opioid adjucts here, pass me the clonidine->marj5]] [[Nothing that more fentanyl can’t sort out->marj6]] [[Be done with it and set up a PCA->marj7]] <<if $block is true>> <<else>> [[There’s a block for this->marj4]] <</if>> <<set $patch to true>>

You discuss the option of a block with Marjorie to get on top of her pain. She listens as you go through the potential risks and benefits and readily agrees. You take her back to the CEPOD anaesthetic room and perform the block under ultrasound guidance without incident, just how a recent [[BJA education paper]] you’ve read described it. By the time she goes back to recovery Marjorie says she’s already noticing some relief from the block. Better crack on, work to do. [[Next->ed1]]

You discuss the option of a block with Marjorie to get on top of her pain. She listens as you go through the potential risks and benefits and readily agrees. It’s not even gone nine yet. You call Dr Franklin. He picks up immediately with a familiar gruff "Dr Franklin here, who’s calling?" You give him a quick lowdown, fortunately he’s still in his office and come’s round to supervise you doing an interscalene block. You take Marjorie back to the CEPOD anaesthetic room and perform the block under ultrasound guidance without incident, just how a recent [[BJA education paper->BJA education paper 2]] you’ve read described it. As Dr Franklin leaves to head home he call if you need him, otherwise he’ll check in around eleven. By the time she goes back to recovery Marjorie says she’s already noticing some relief from the block. Better crack on, work to do. [[Next->ed1]]

Ok, not a block then. Now what? [[We need some non-opioid adjucts here, pass me the clonidine->marj5]] [[Nothing that more fentanyl can’t sort out->marj6]] [[Be done with it and set up an opioid PCA->marj7]] <<if $patch is true>> <<else>> [[Can we get hold of a higher dose patch this time of night?->marj8]] <</if>> <<set $block to true>>

@@.typing; Joint replacement (primary): hip, knee and shoulder. NICE guideline [NG 157]. Published date: 04 June 2020. Available [[here->https://www.nice.org.uk/guidance/ng157]] @@ [[Back->marj4]]

@@.typing; Hewson DW, Oldman M, Bedforth NM. Regional anaesthesia for shoulder surgery. //BJA Ed//. 2019;19(4):98-104 Available [[here->https://bjaed.org/article/S2058-5349(19)30003-4/pdf]] @@ [[Back->marj4a]]

@@.typing2; <center> !!HEADS UP ''This scenario includes some difficult content surrounding addiction. We wanted to let you know about some [[sources of support]] because if you, or someone you know, is struggling with addiction there is help out there'' ''Take care'' !!Virtual Anaesthetics ''[[Next|paper]]'' </center>

@@.typing; !!!Sources of support We wanted you to be aware of some of the sources of support available to you if you or someone you know is struggling with addicition: * Think about reaching out to a trusted colleague, friend, or family member * Contact your family doctor or healthcare provider * If you are in education find out about support services they provide * In the UK [[Alcoholics Anonymous->https://www.alcoholics-anonymous.org.uk/]] and [[Narcotics Anonymous->https://ukna.org/]] provide support and help to those struggling with alcohol or drug use For medics in the UK: ''Sick Doctors Trust'' Support and help for doctors and medical students who are concerned about their use of drugs or alcohol. A confidential helpline 24/7 is available including for anonymous enquiries: http://sick-doctors-trust.co.uk/ Phone: ''0370 444 5163'' Email: ''help@sick-doctors-trust.co.uk'' ''Practitioner Health Service'' A free, confidential NHS service providing support for doctors and dentists in the UK with mental health difficulties or struggling with addiction. Includes Shout a 24/7 text service. https://www.practitionerhealth.nhs.uk/ Phone: ''0300 0303 300'' Text: ''NHSPH to 85258'' ''The British Medical Association'' Confidential 24/7 counselling service is available to all doctors and medical students including non-members: https://www.bma.org.uk/advice-and-support/your-wellbeing Phone: ''0330 123 1245'' Email: ''wellbeingsupport@bma.org.uk [[Next->paper]] Virtual anaesthetics is not responsible for the contents of any of the websites listed.

When you meet Ed again it’s a couple of hours later in the CEPOD theatre anaesthetic room. The opioids you prescribed have got on top of his pain and he’s not sweating or shaking anymore. He give's you a smile when he recognises a familiar face. "I got the charger and managed to get hold of my ex. She was alright about it when I told her what was going on. So cheers for helping me." You get the line in first time and safely give the GA. [[Next->ed7a]]

When you hear the surgical reg’s intake of breath five minutes into the laparoscopic appendectomy you quickly glance at the video display. You’ve seen enough of these now to recognise the oedematous, necrotic appendix sitting in a pool of turbid fluid. Fortunately Ed’s in good hands and the rest of the case, and the night, are uneventful. [[Next|ed8a]]

A week later you are doing a plastics list, the second case is under local so you take the opportunity to go back to the anaesthetics department to do some admin. Your educational supervisor collars you in the corridor. "Ah, $firstname, that's good timing, I was going to email you. Do you have a minute?" You nod. "The acute pain team flagged up you'd managed a couple of complex cases when you were on nights and I wanted to feedback that they'd picked up on the good work so well done!" [[Next->exit1]]

!!!@@.greentext;Scenario learning objectives:@@ * Define key terms surrounding opioid tolerance including: tolerance, dependence, withdrawal and addiction * Know the important basic science underpinning management of these patients * Understand some of the risks associated with managing acute pain in this population * Be able to identify some of the signs of opioid withdrawal and know how to avoid acute, unmanaged opioid withdrawal * Appreciate the value of non-opioid analgesic adjuncts and their application in managing acute pain * Realize the importance of involving the MDT and accessing sources of specialist knowledge when managing complex and high risk patient groups [[Next|credits]] no-history tag <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VApain5">> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

* Fear of stereotyping and discrimination based on previous experiences causing clinician distrust * Acute pain and fear that the pain will not be taken seriously * Fear of withdrawal, more obvious after long wait, leading to drug seeking behaviour * Use of methadone as a harm reduction strategy with lessening of the chaotic behaviours associated with illicit drug use * Acknowledgment that he has gone to extreme lengths in the past to source drugs including manipulative behaviour, lying and stealing * Fear of relapse due to uncontrolled pain, opioid use and environmental stress * Other contributory factors, consider the <<link [[biosychosocial model->audiopost1b]]>> <<set Dialog.setup("Biopsychosocial model")>> <<set Dialog.wiki("This model is used in chronic pain, mental health and addiction. ''Physiology:'' (Bio-) in this case an acute pathology as well as dependence on opioids and chronic poor health related to drug use. ''Psychology:'' (-psycho-) anxiety, stress and low self esteem. ''Societal:'' (-social) lack of social support, fragile relationships, lack of trust, stigmatisation.")>> <<set Dialog.open ()>> <</link>>, as it applies to mental health, addiction and pain * Loss of identity with use of negative labels (e.g. 'junky', 'addict') and low self esteem As the attending clinician what are your concerns surrounding the case? * How do you feel about patients like this? * Do you trust him? * Do you think there’s an element of exaggeration of his pain to acquire opioids? * Are you apprehensive he’s going to abscond or become aggressive? * Are you wary of overtreatment and iatrogenic harm? * Are you confident about managing what he needs? If you have the opportunity you could discuss the case with your Faculty Tutor (Pain) or Clinical Supervisor? [[Next->ed4]]

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Scenario_5@@

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

<<set _answer to "">> !!!@@.greentext; Welcome to the trainers area of this scenario@@ Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

<p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

<center> !!!BETA Virtual Anaesthetics_Pain training_5 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/module5.pdf]]'' [[Back|Introduction]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>