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

• The Liverpool Care Pathway: treatment for the dying patient
• Oxycodone use still increasing
• Vitamin D supplementation: navigating the debate

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 www.bpac.org.nz.

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.

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: www.lcpnz.org.nz

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.

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 1/6^th 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.

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.

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.

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.

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.

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.

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.