Synopsis
Start a strong opioid only after mechanism and safety assessment, prescribe maintenance, breakthrough and adverse-effect prevention coherently, titrate to a functional goal, and detect toxicity or organ-clearance change before harm occurs.
- Confirm that pain is opioid responsive, moderate to severe and persistent enough to justify a strong opioid; address emergency and non-opioid mechanisms first.
- First-line in advanced progressive disease is usually oral morphine when the oral route is reliable and renal and hepatic function are suitable.
- NICE describes 20 to 30 mg total daily sustained-release oral morphine plus 5 mg immediate-release rescue during initial titration for a typical opioid-naive adult; use lower individual doses in frailty.
- Prescribe a stimulant or osmotic laxative from initiation and give clear nausea advice; tolerance develops poorly to constipation.
- Provide written scheduled dose, breakthrough dose, minimum interval, maximum action plan, storage, driving and toxicity instructions.
- Review within days, not weeks, and after every increase. Count effective rescue doses and assess function, alertness, bowel habit, nausea and respiration.
- If pain remains opioid responsive and adverse effects are acceptable, a common titration step is about 30 to 50 percent of the regular 24-hour dose, verified against local policy.
- Do not increase automatically for incident pain, delirium, opioid-induced hyperalgesia, disease emergency or metabolite toxicity.
- The gold standard is the lowest total dose that achieves the patient's functional goal with acceptable adverse effects, not a predetermined milligram target.
Key red flags
New severe pain with neurological deficit, fracture, sepsis or obstruction needs cause-specific emergency management before routine titration.
Respiratory slowing, profound sedation, myoclonus, hallucinations or pinpoint pupils requires immediate toxicity assessment and dose withholding.
eGFR below 30 mL/min/1.73 m², rapidly changing renal function or severe hepatic impairment requires specialist or pharmacy-supported opioid selection.
Concurrent benzodiazepines, gabapentinoids, alcohol or illicit sedatives materially increase respiratory and falls risk.
Rapid repeated rescue use without relief may indicate an emergency, wrong mechanism, incident pain or unsafe self-administration rather than simple underdosing.
Uncontrolled access, diversion concern, cognitive impairment or an overwhelmed caregiver requires a supervised supply and administration plan.
New hallucination, cognitive fluctuation, myoclonus, hyperalgesia or excessive somnolence signals accumulation or interaction and blocks routine titration.
Investigation priorities
Confirm mechanism, severity, goal, current opioid exposure, oral reliability, organ function, cognition, sedatives and administration support.
Management branches
Moderate-to-severe persistent pain is opioid responsive and oral morphine is suitable after assessment.
- Explain goals and risks, establish baseline cognition, breathing, bowel function and renal or hepatic status and remove duplicate opioid prescriptions.
- Use the NICE and local starting regimen adjusted for frailty, prescribe immediate-release rescue and laxative, and document nausea, driving, storage and emergency advice.
- Review pain, function, rescue response, alertness, respiration, nausea and bowel activity within a few days and sooner after concern.