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.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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