Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Cancer (NCC-C) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the Availability of Companion Documents field for the full version of this guidance.
When offering pain treatment with strong opioids to a patient with advanced and progressive disease, ask them about concerns such as:
- Side effects
- Fears that treatment implies the final stages of life
Provide verbal and written information on strong opioid treatment to patients and carers, including the following:
- When and why strong opioids are used to treat pain
- How effective they are likely to be
- Taking strong opioids for background and breakthrough pain, addressing:
- How, when, and how often to take strong opioids
- How long pain relief should last
- Side effects and signs of toxicity
- Safe storage
- Follow-up and further prescribing
- Information on who to contact out of hours, particularly during initiation of treatment
Offer patients access to frequent review of pain control and side effects.
Starting Strong Opioids – Titrating the Dose
When starting treatment with strong opioids, offer patients with advanced and progressive disease regular oral sustained-release or oral immediate-release morphine (depending on patient preference), with rescue doses of oral immediate-release morphine for breakthrough pain.
For patients with no renal or hepatic comorbidities, offer a typical total daily starting dose schedule of 20–30 mg of oral morphine (for example, 10–15 mg oral sustained-release morphine twice daily), plus 5 mg oral immediate-release morphine for rescue doses during the titration phase.
Adjust the dose until a good balance exists between acceptable pain control and side effects. If this balance is not reached after a few dose adjustments, seek specialist advice. Offer patients frequent review, particularly in the titration phase.
Seek specialist advice before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.
First-line Maintenance Treatment
Offer oral sustained-release morphine as first-line maintenance treatment to patients with advanced and progressive disease who require strong opioids.
Do not routinely offer transdermal patch formulations as first-line maintenance treatment to patients in whom oral opioids are suitable.
If pain remains inadequately controlled despite optimising first-line maintenance treatment, review analgesic strategy and consider seeking specialist advice.
First-line Treatment if Oral Opioids Are Not Suitable – Transdermal Patches
Consider initiating transdermal patches with the lowest acquisition cost for patients in whom oral opioids are not suitable and analgesic requirements are stable, supported by specialist advice where needed.
Use caution when calculating opioid equivalence for transdermal patches:
- A transdermal fentanyl 12 microgram patch equates to approximately 45 mg oral morphine daily.
- A transdermal buprenorphine 20 microgram patch equates to approximately 30 mg oral morphine daily.
First-line Treatment if Oral opioids Are Not Suitable – Subcutaneous Delivery
Consider initiating subcutaneous opioids with the lowest acquisition cost for patients in whom oral opioids are not suitable and analgesic requirements are unstable, supported by specialist advice where needed.
First-line Treatment for Breakthrough Pain in Patients Who Can Take Oral Opioids
Offer oral immediate-release morphine for the first-line rescue medication of breakthrough pain in patients on maintenance oral morphine treatment.
Do not offer fast-acting fentanyl as first-line rescue medication.
If pain remains inadequately controlled despite optimising treatment, consider seeking specialist advice.
Management of Constipation
Inform patients that constipation affects nearly all patients receiving strong opioid treatment.
Prescribe laxative treatment (to be taken regularly at an effective dose) for all patients initiating strong opioids.
Inform patients that treatment for constipation takes time to work and adherence is important.
Optimise laxative treatment for managing constipation before considering switching strong opioids.
Management of Nausea
Advise patients that nausea may occur when starting strong opioid treatment or at dose increase, but that it is likely to be transient.
If nausea persists, prescribe and optimise anti-emetic treatment before considering switching strong opioids.
Management of Drowsiness
Advise patients that mild drowsiness or impaired concentration may occur when starting strong opioid treatment or at dose increase, but that it is often transient. Warn patients that impaired concentration may affect their ability to drive and undertake other manual tasks.
In patients with either persistent or moderate-to-severe central nervous system side effects:
- Consider dose reduction if pain is controlled or
- Consider switching opioids if pain is not controlled
If side effects remain uncontrolled despite optimising treatment, consider seeking specialist advice.