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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 Zomorph MST Morphogesic @ 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 http://www.necn.nhs.uk/wp-content/uploads/2016/09/NECNXPALLIATIVEXCAREX2016.pdf