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Opioid titration using Morphine

Pain uncontrolled on maximum dose WHO step 2 opioid for mild to moderate pain
 ( eg Codeine 60 mg qds or Tramadol 100 mg qds )

If using immediate release Morphine-Start Immediate release Morphine for eg
Oramorph liquid or
Sevredol tablets

@ 5mg regularly 4 hrly
 Omit dose during night if sleeping
 Also prescribe sane dose 1-2 hrly as required for breakthrough pain

-If sedated / signs of toxicity –> reduce dose
 If pain controlled cont same dose and review in further 24 hrs
 If pain uncontrolled add up previous 24 hr Morphine
use ( regular and prn ) to recalculate new 4 hrly dose
 Roundup to prescribe nearest practical dose
When pain is better controlled , convert to 12 hrly MR Morphine

If using modified release Morphine-Start MR Morphine eg

@ 10 mg 12 hrly
 Also prescribe IR Morphine eg
Oramorph liquid or Sevredol tablets
@ 5mg 1-2 hrly as required for breakthrough pain. If pain controlled continue same doses and review in further 24 hrs
 If pain uncontrolled , encourage use of breakthrough medication and review in further 24 hrs-If pain still uncontrolled , recalculate the MR Morphine 
dose by adding the value of breakthrough doses given in last 24 hrs

 Do not exceed a 50 % increase

Prescribe nearest practical dose
Adjust the breakthrough dose

Breakthrough pain-Breakthrough pain is treated with an immediate release formulation of the same opioid where possible

 Breakthrough dose is 1/6th to 1/10th of the total daily opioid dose

 A common starting point is to prescribe 1/6th of the total 24 hrs dose to be given 2 hrly as required and adjusted according to benefit and tolerability
 If pain severe and recurring – advice not to repeat dose within 1 hr as delayed absorption may result in rapid accumulation.
Seek advice about pain control

Setting a daily max
 of breakthrough doses 
for eg 6 /24 hrs – should
 prompt review of 
patient whose pain is 
out of control

 Acknowledgment -NHS Northern England Clinical Networks : Palliative and End of the Life Care guidelines Fourth Edition 2016 . Guideline available at


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