You are viewing an older, archived article. There may be more up to date articles on this subject, try a new search

Quiz feedback: Liverpool Care Pathway / Oxycodone / Vitamin D

Issue 36 Essentials:
Upfront: In the aftermath of a catastrophe: the Christchurch earthquake
Short articles: 
News in brief
Quiz feedback:  Liverpool Care Pathway / Oxycodone / Vitamin D
Issue 36 Contents

This quiz feedback provides an opportunity to revisit BPJ 36 (June, 2011), with a focus on the following articles:

All general practitioners who participated in this quiz will receive personalised online feedback and be allocated one hour of CQI activity. There are now in excess of 25 interactive quizzes available which provide an ongoing opportunity for accumulating CME points. These are available from

1. The Liverpool Care Pathway is: Your peers Answer
A guide for palliative care in general practice only 1%
A guide for palliative care in a hospice only 1%
A guide to manage the last days and hours of a person’s life 100%
A guide for cardiovascular risk assessment <1%
 Question 1 comments

The Liverpool Care Pathway (LCP) begins once a multidisciplinary team agrees that a patient’s condition has deteriorated to the point where they are in the last days or hours of their life. The purpose of the LCP is to manage patient care during this time. The LCP requires all stages of the care process to be documented and provides symptom control guidelines for the management of pain, restlessness, respiratory tract secretions, nausea and dyspnoea.

The term palliative care refers to treatment aimed at relieving and preventing suffering and can be applied to any disease, including curable illnesses.

2. Which of the following statements about the Liverpool Care Pathway (LCP) are true? Your peers Answer
General practices can only register to use LCP as stand-alone providers 4%
Clinicians can be trained to use the LCP in under one hour 84%
Patients can be placed on the LCP shortly after being diagnosed with a terminal illness 14%
Any dying patient can be placed on the LCP, irrespective of whether they are in a hospital, hospice, residential care facility or their home 92%
 Question 2 comments

Statistics from the United Kingdom show that most deaths occur in hospitals and residential care facilities (57%) - rather than in hospices. A fundamental aim of the LCP is to provide hospice standards of care for people who are dying, irrespective of setting. Diagnosis of a terminal illness alone is not a sufficient reason to place a patient on the LCP. A multidisciplinary team must be convinced that a patient is in the last hours or days of their life before placing a patient on the LCP.

Although it is possible for general practices to be registered as stand-alone LCP providers, most practices choose to register under the umbrella of an existing project as this option requires less time and training overheads. Clinicians who wish to use the LCP can easily be trained to do so - in under an hour - by a LCP facilitator from an existing project. For further information on training and enrolment, visit the National LCP Office website at:

3. Oxycodone is: Your peers Answer
Another name for codeine <1%
An opioid for mild pain, similar to codeine <1%
An opioid for severe pain, similar to morphine 100%
Not an opioid <1%
 Question 3 comments

Due to its name being similar to codeine, oxycodone is sometimes – erroneously – thought to be a weak opioid for mild to moderate pain. However, oxycodone is a strong opioid for severe pain and sits at the top (step three) of the WHO analgesic ladder along with morphine, fentanyl and methadone.

4. Which of the following statements about prescribing oxycodone are true? Your peers Answer
In an opioid naive patient, start with the lowest dose (e.g. 5 mg) and increase as required until pain is controlled 96%
In an opioid naive patient, start with a high dose (e.g. 40 mg) in order to adequately treat pain 1%
When changing from morphine to oxycodone due to intolerable adverse effects, use the same dose, as morphine and oxycodone are equivalent 10%
Once established on a regular oxycodone dose, also prescribe short-acting oxycodone at 1/6th of the 24 hour dose for breakthrough pain if necessary 90%
 Question 4 comments

Based on the WHO analgesic ladder, strong opioids should only be prescribed once the analgesia provided by weak opioids (e.g. codeine, tramadol or dihydrocodeine) has proved to be ineffective. In opioid-naive patients, the starting dose for oxycodone should be 5 mg (OxyNorm immediate release is currently funded) every four to six hours, which can be increased as necessary. For long-term treatment, patients should be switched to controlled release tablets (OxyContin controlled release is currently funded), taken every 12 hours, once the 24 hour requirement has been established.

Breakthrough pain can be controlled with an additional dose of short-acting oxycodone. Breakthrough doses should be taken at 1/6th of the 24 hour dose. For example, if the 24 hour opioid requirement is 60 mg (30 mg OxyContin twice daily), then OxyNorm 10 mg can be prescribed as a maximum dose every two to four hours.

Oxycodone is 1.5 to two times more potent than morphine. For instance, 10 mg Oxycodone is equivalent to 15 to 20 mg oral morphine.

5. Long-term use of oxycodone and other opioids is associated with which of the following? Your peers Answer
Constipation 93%
Nausea 61%
Hyperalgesia 50%
Immunosuppression 46%
 Question 5 comments

There appeared to be some confusion between the long and short term effects of opioid use. Although up to 60% of patients taking any strong opioid will experience nausea and vomiting, tolerance to these adverse effects usually occurs within the first week of treatment. Constipation is associated with the long term use of all opiods. Where constipation cannot be managed by increasing fluids or fibre, prescribe a combination stimulant plus softener laxative. Hyperalgesia may develop after long-term use of an opioid and immunosuppression is associated with long term, high-dose opioid use. The mechanism of immunosuppression is unknown, however, there are suggestions that this may be related to the underlying condition causing the pain.

6. Your peers Answer
Oxycodone has the greatest addiction potential of all the opioids 10%
A person with no previous history of addictive or risk-taking behaviour is unlikely to become addicted to oxycodone prescribed appropriately for pain 85%
Physical signs of addiction to oxycodone include constricted pupils, pruritus and dry mouth 81%
Physical and psychological dependence to opioids may develop after six to eight months of continuous use 15%
 Question 6 comments

Oxycodone has a similar addiction and misuse potential as morphine. However, only a small subset of patients prescribed opioids appear to display misuse tendencies. One study found that approximately 3% of people who take opioids for chronic pain develop problems of misuse and 11% develop “aberrant drug-related behaviours”. However, when patients with a history of drug addiction, or drug misuse were removed, these numbers fell to 0.2% and 0.6% respectively. People who are susceptible to physical and psychological dependence to opioids appear to become so in the relatively short time frame of two to ten days. Patients continuously taking opioids for long periods, who have not developed issues of dependence in the first few weeks of treatment, are unlikely to do so in the following months.

The physical signs of addiction to opiods include; constricted pupils, itching, dry mouth and difficulty concentrating. The physical signs of withdrawal include; dilated pupils, tachycardia, hypertension, diarrhoea, muscle cramps, frequent yawning, rhinorrhoea and lacrimation.

7. Your peers Answer
Osteomalacia 98%
Decreased muscle strength 63%
Exacerbation of epileptic seizures 5%
Hypocalcaemic seizures in infants 73%
 Question 7 comments

The body requires vitamin D to maintain good calcium balance. The major symptoms of vitamin D deficiency relate to the effects of reduced calcium on the musculoskeletal system. Sub-optimal levels of calcium absorption, due to vitamin D deficiency, may cause bones to soften due to defective mineralisation (osteomalacia). Muscle fibre contraction also relies on the actions of calcium at both post and pre-synaptic sites of the neuromuscular junction. Deficiencies in vitamin D can lead to reduced muscle strength.

Infants have high rates of skeletal growth and are particularly susceptible to calcium deficiency. Vitamin D deficiency can, in severe cases, present as hypocalcaemic seizures in infants of breastfeeding mothers who are deficient in vitamin D.

There is no evidence that vitamin D exacerbates seizures in epilepsy.

8. Your peers Answer
Vitamin D is unable to be derived from food 2%
Oily fish is a dietary source of vitamin D 90%
Approximately 90% of the body’s vitamin D requirements can be synthesised with adequate sunlight exposure to the skin 98%
If adequate sunlight exposure is not possible, use of a sunbed is recommended <1%
 Question 8 comments

Vitamin D is produced in the skin through the conversion of 7-dehydrocholesterol by ultraviolet B light. Given adequate exposure to direct sunlight, the body will synthesise approximately 90% of its vitamin D requirements endogenously. Oily fish (e.g. cod liver oil, salmon, mackerel, tuna) is the richest dietary source of vitamin D. Patients who do not receive sufficient sunlight and cannot increase their dietary intake of vitamin D, may benefit from supplementation. Sunbed use is not a recommended method of increasing vitamin D levels due to the increased risk of skin cancer.

9. Your peers Answer
Adolescents during periods of bone growth 1%
Women who are veiled 93%
Elderly people who are house-bound 100%
People with darkly pigmented skin 81%
 Question 9 comments

Vitamin D supplementation can be considered for any person considered to be at risk of deficiency. In general, elderly people are considered an at risk group because they often spend less time outside, obtain less vitamin D from their diet due to reduced calorific intake and may synthesise vitamin D at a slower rate due to decreased skin thickness and renal function. Women who are veiled are also an at risk group due to the small amount of their skin that is exposed to direct sunlight. People with dark skin pigmentation produce vitamin D at rates up to six times slower than people with lightly pigmented skin and may also be at risk of vitamin D deficiency.

Adequate exposure to sunlight through regular exercise and a healthy diet will ensure that adolescents receive sufficient vitamin D.

10. Your peers Answer
All exclusively breastfed infants should receive vitamin D supplementation 3%
Infants who are exclusively breastfed by mothers who are at risk of vitamin D deficiency should receive vitamin D supplementation 97%
All infants who are formula fed require vitamin D supplementation 1%
Vitadol C is an appropriate vitamin D supplement for an infant 86%
 Question 10 comments

It is important that women who are pregnant, or breast feeding, have adequate levels of vitamin D to ensure their infants are not at risk of deficiency. Breast milk from healthy mothers does provide infants with sufficient vitamin D. However, mothers who are exclusively breast feeding their infant, and who are themselves at risk of deficiency, should be prescribed vitamin D supplementation. Infant milk formula is fortified with 5 µg/L of vitamin D, therefore, deficiency is unlikely to be a problem for infants fed milk formula.

Vitadol C liquid is fully funded and contains 10 µg of vitamin D per ten drops. Vitadol C also contains vitamins A and C. Infants who require vitamin D supplementation should be given ten drops a day of vitadol C with feeds.