Starting treatment

• when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
• if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
• oral modified-release morphine should be used in preference to transdermal patches
• laxatives should be prescribed for all patients initiating strong opioids
• patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
• drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered

SIGN guidelines

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points

• the breakthrough dose of morphine is one-sixth the daily dose of morphine
• all patients who receive opioids should be prescribed a laxative
• opioids should be used with caution in patients with chronic kidney disease
  • oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
  • if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred
• metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy

Other points

When increasing the dose of opioids the next dose should be increased by 30-50%.

In addition to strong opioids, bisphosphonates and radiotherapy, denosumab may be used to treat metastatic bone pain.

Opioid side-effects

Conversion between opioids