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Starting Oral Morphine
If pain is uncontrolled on WHO step 2 analgesics at full dose
(e.g. codeine 60mg qds )
Either
Titration with i/r morphine
Or
Titration with m/r morphine
NB: Use lower starting doses in elderly, frail or renal impairment
(e.g. 2.5mg prn/4 hourly or 5-10mg MST bd)
Stop WHO step 2 drug
Start morphine (Oramorph liquid or
Sevredol tablets) 5mg 4 hourly (aim
for 5 doses/24 hours; omit dose in
night). Also prescribe same dose
(5mg) prn for breakthrough pain; prn
dose may be given as often as
required (up to hourly)
Review after 24 hours
If sedated/toxic, reduce dose.
If pain controlled, continue same
doses and review in further 24 hours.
If pain uncontrolled, adjust regular
dose according to number of prn
doses taken (dose escalation usually
30-50% of total MST dose)
Adjust prn does appropriately
Review after 24 hours as above
When pain is controlled, convert to
m/r formulation. Add up total
morphine use in 24 hours, divide by 2
and prescribe the nearest sensible
dose as MST.
Prescribe appropriate prn dose
Oramorph/Sevredol (total daily dose
of MST divided by 6)
Arrange ongoing review.
Stop WHO step 2 drug
Start MST 15mg bd.
Also prescribe Oramorph liquid or
Sevredol tablets 5mg prn for
breakthrough pain; prn dose may be
given as often as required (up to
hourly)
Review after 24 hours
If sedated/toxic, reduce dose.
If pain controlled, continue same
doses and review in further 24
hours.
If pain uncontrolled, adjust regular
dose according to number of prn
doses taken in previous 24 hour
period (dose escalation usually 3050% of total MST dose).
Adjust prn does appropriatelyappropriate prn dose
Oramorph/Sevredol =total daily
dose of MST divided by 6
e.g. MST 60mg bd, Oramorph dose =
(60x2)/6= 20mg
Review after 24 hours as above
When pain is controlled, continue
same doses. Arrange ongoing review
Adapted from Cancer Care Alliance of Teeside, Durham and North Yorkshire Network Supportive and Palliative Care Guidelines, 2006