Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Pain with neurological, skeletal or opioid danger
New weakness or sphincter change, an unstable pathological fracture, acute abdomen, sepsis, compartment compromise or reduced respiratory rate and consciousness during opioid use requires diagnosis and rescue rather than routine dose escalation.
Action: Use ABCDE care, check glucose, respiratory rate, oxygenation, pupils and recent medicines, protect a potentially unstable spine or limb and activate the relevant acute-oncology pathway. For clinically important opioid respiratory depression, support airway and ventilation and give carefully titrated naloxone with repeated monitoring because its effect may end before the opioid.
Synopsis
Identify the biological and psychosocial drivers of cancer pain, exclude time-critical complications, combine tumour-directed, pharmacological and non-drug treatment and initiate, titrate, switch and stop opioids with explicit safety, bowel and monitoring plans.
Assess pain by site, onset, quality, radiation, severity at rest and movement, breakthrough pattern, sleep and function; examination and investigation must explain a new pattern.
First exclude emergencies: cord compression, fracture, intracranial pressure, obstruction, infection, thrombosis and serious treatment toxicity need anatomical or cause-specific rescue.
Classify somatic, visceral, neuropathic and incident pain because opioids, anti-inflammatory treatment, adjuvants, radiotherapy, surgery and procedures address different mechanisms.
Key red flags
Back pain with weakness, gait change, sensory loss or bladder or bowel dysfunction requires immediate metastatic-spinal-cord-compression assessment and whole-spine MRI.
Opioid toxicity
Increasing drowsiness, respiratory slowing, hallucination, delirium, myoclonus or pinpoint pupils after dose, organ or interaction change requires urgent medicine review.
Investigation priorities
01
First-line multidimensional pain assessmentFirst stepFirst line
Define each pain’s mechanism, severity, breakthrough pattern, functional effect, current exposure, understanding and psychosocial context.
Management branches
New or changed painDiagnose the generator before escalating
Pain appears, changes character or becomes difficult to control.
Assess each site, mechanism, rest and movement severity, function, neurological and skeletal signs, bowel pattern, current medicines and psychosocial distress.
Activate emergency imaging and specialist pathways for cord, brain, fracture, obstruction, infection or treatment toxicity and protect unsafe movement while anatomy is clarified.
Key medicines
Oral morphine for opioid-naive cancer painWhen suitable, start a total of 20 to 30 mg oral morphine over 24 hours, for example 5 mg immediate release every 4 hours or 10 to 15 mg modified release every 12 hours, plus 5 mg immediate-release rescue.
Transdermal fentanylUse the product-specific patch strength derived from the current stable 24-hour oral-morphine equivalent, commonly changed every 72 hours, with specialist verification and an immediate-release rescue opioid.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.