Guidelines

• Ensure that pain is likely to be opioid-sensitive.

• Give morphine orally (if possible) either by mixture or tablets.

• Starting doses are usually in the range of 5-20 mg (average 10 mg).

• If analgesia is inadequate, the next dose should be increased by 50% until pain control is achieved.

• Give it regularly, usually 4 hourly, before the return of the pain (see Fig. 7.2).

• Many patients find a mixture easier to swallow than tablets, e.g. 10 mg/10 mL solution.

• Constipation is a problem, so treat prophylactically with regular laxatives and carefully monitor bowel function.

• Order a 'rescue dose' (usually 5 mg) for breakthrough pain or anticipated pain (e.g. going to toilet).

• Order antiemetics, e.g. haloperidol prn at first (usually can discontinue in 1 to 2 weeks as tolerance develops).

• Reassure the patient and family about the safety and efficacy of morphine (see Table 7.3). (Beware of opiophobia.)

• Using morphine as a mixture with other substances, e.g. Brompton's cocktail, has no particular advantage.

• Pethidine is not recommended (short half-life, toxic metabolites) and codeine and IM morphine should be avoided.

• Other opioids are sometimes used instead of morphine (Table 7.4).

• Fentanyl is a potent synthetic opioid which is available as a transdermal system.

Fig. 7.2 Appropriate scheduling of analgesia to achieve optimal pain control Parenteral morphine

This is generally given subcutaneously (not IV or IM). Indications are: 6

inappropriate pain control Appropriate

- inadequate dosage medication

- Infrequent doses schedule

Fig. 7.2 Appropriate scheduling of analgesia to achieve optimal pain control Parenteral morphine

This is generally given subcutaneously (not IV or IM). Indications are: 6

1. Unable to swallow, e.g. severe oral mucositis; dysphagia; oesophageal obstruction

2. Bowel obstruction

3. Severe nausea and vomiting

4. At high oral dose, i.e. above 100-200 mg dose, there appears to be no additional benefit from further dose increments.

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