Starting Oral Morphine

If pain is uncontrolled on WHO step 2 analgesics at full dose(e.g. codeine 60mg qds )

Either Or

Titration with i/r morphine 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 drugStart 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)

Stop WHO step 2 drugStart 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 hoursIf 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 hoursIf 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 30-50% of total MST dose). Adjust prn does appropriately- appropriate prn dose Oramorph/Sevredol =total daily dose of MST divided by 6e.g. MST 60mg bd, Oramorph dose = (60x2)/6= 20mg

Review after 24 hours as aboveWhen 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.

Review after 24 hours as aboveWhen 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