This page was printed from the South & West Devon Formulary and Referral site at
Please ensure you are using the current version of this document
Careful assessment of the most likely cause of the pain is important as this will help in deciding the most effective management. Pain may be related to the underlying disease process (e.g. cancer), treatment related (e.g. radiotherapy) or due to a coincidental condition (e.g. osteoarthritis).
Cancer-related pain may be divided into three main types:
Many factors influence the perception of pain e.g. fear, loneliness, depression.
A guide to equivalent doses of opioids often used in palliative care has been developed by local specialists across the region. Please note that this is not a definitive set of equivalences. Local specialist advice should be sought if considering an opioid switch. The guide is hosted on the Rowcroft Hospice website and can be accessed here.
By the clock
By the mouth
By the ladder (see below)
Pain persisting or increasing: Add in weak opioid as a combination drug if NSAID/paracetamol not sufficient
Pain persisting or increasing: Prescribe one drug at a time in step 2 to achieve effective analgesia, stepping up as necessary
It may be appropriate to move straight from step 1 to step 3 of the ladder in some cases. Please seek advice if unsure.
Also recognised are:
This may present with visual hallucinations, vivid dreams or excessive drowsiness. Myoclonic jerks may also be noticed. Reduction of opioid dose or changing to an alternative opioid may resolve these effects.
When used appropriately opioids very rarely cause respiratory depression.
Escalating doses of opioids occasionally induce escalation of pain, particularly at high doses. This phenomenon is known as opioid-induced hyperalgesia. Seek specialist advice if you are concerned about this.
Generally, switching from morphine to another strong opioid is considered in an attempt to improve analgesia and/or reduce unwanted side-effects.
A guide to equivalent doses of opioids often used in palliative care has been developed by local specialists across the region. Please note that this is not a definitive set of equivalences. The guide is hosted on the Rowcroft Hospice website and can be accessed here.
Before opioid switching consider other options e.g. using an adjuvant analgesic or treating side-effects.
Seek specialist advice if considering opioid switch.
See Management of opioids - Rotating/switching opioids for further guidance.
Morphine, diamorphine and oxycodone and their active metabolites accumulate in renal failure, causing sedation, myoclonic jerks, hallucinations and respiratory depression.
It may be necessary to:
If in doubt, consult the specialist palliative care team for advice.
Many centrally acting drugs have the potential to influence driving performance. Doctors have a duty of care to inform patients of this risk and advise them accordingly.
Driving performance does not appear to be affected by stable doses of appropriately titrated strong opioids.
Advise the patient not to drive after initiating opioids or after titration of opioids until they have been on a settled dose for about a week and have no undue side-effects.
They should not drive after taking a when required dose of strong opioid.
It is the patient's responsibility that they are in a fit state to drive whilst talking prescribed opioids
Patient information leaflet on Drugs and driving
Breakthrough pains are transitory flare ups of pain against a background of otherwise well controlled pain.
Ensure patients have access to immediate release opioid (e.g. Morphine sulphate oral solution) for episodes of breakthrough pain. Prescribe a dose up to 1/6 of total 24 hour oral morphine dose.
If more than 3 doses of breakthrough pain relief are regularly needed over 24 hours it may suggest poorly controlled pain and a review of the maintenance analgesic regime may be required. Dose increases should not exceed 1/3-1/2 of total daily dose.
When the dose of m/r morphine is increased, the breakthrough dose of immediate release morphine should be increased proportionately.
For most patients morphine is the opioid of choice.
Initiation and titration
Most patients will require less than 180mg morphine per 24 hours to achieve pain control.
A patient should not normally be prescribed more than one modified release opioid at a time.
Relative doses of opioids:
3mg oral morphine = 1 mg of subcutaneous (SC) diamorphine
|Oral morphine (mg/24hrs)||90||180||240|
|Subcutaneous morphine (mg/24hrs)||45||90||120|
|Dose of subcutaneous morphine for breakthrough pain (mg)||5-7.5||7.5-15||10-20|
|Subcutaneous diamorphine (mg/24hrs)||30||60||80|
|Dose of subcutaneous diamorphine for breakthrough pain (mg)||2.5-5||5-10||7.5-15|
Prescribers are reminded to prescribe transdermal fentanyl by brand (Matrifen® / Mezolar®) to ensure continuity and avoid confusion.
There are two different conversions for oral morphine to transdermal fentanyl depending on the nature of the change and the individual patient:
The decision regarding which conversion to use should be based on patient specific factors, the level of patient monitoring which can be offered and the clinical setting.
Due to its slow onset (approximately 24 hours) and long period of action (72 hours), transdermal fentanyl is not suitable for acute pain where rapid dose titration is required.
It is also inappropriate for use in patients whose pain is unstable because of inflexibility in terms of rapid titration up or down of opioid dose.
Fentanyl can be considered as an alternative to morphine for patients:
Refer to prescribing notes in section 4.7.2 Opioid analgesics for further prescribing notes and MHRA Drug Safety Updates.
Patients converting from:
Warn the patient that they might experience more breakthrough pain than usual in the first 1 to 3 days. An immediate release opioid preparation should always be available for breakthrough pain (up to 1/6 of the equivalent 24 hour oral morphine dose).
The dose of the fentanyl patch should not be changed within the first 2 days of the first application
Titrate the dose up in 12 or 25 microgram/hour steps if needed when the next patch change is due, according to use of breakthrough medication.
Apply the patch to dry, non-irritated, non-irradiated, non-hairy skin on the torso or upper arm, removing after 72 hours and positioning replacement patch on a different area, avoid using the same area for 7 days. Replace patches at the same time of day, every 3 days.
Laxatives may need to be reduced.
Remember, on removal a depot remains in the skin for 24 hours, falling by 50% by 17 hours.
Therefore, in a patient whose pain is controlled either…..
See 4.7.2 Opioid analgesics for list of preparations.
Effentora® buccal tablets and Abstral® sublingual tablets are the formulary choice products for transmucosal fentanyl. These products require careful titration and are relatively expensive compared with alternatives. The doses of Effentora® and Abstral® are not interchangeable.
Following national guidance from NHS England, Effentora® and Abstral® should only be used in patients undergoing palliative care treatment and where the recommendation to use immediate release fentanyl in line with NICE guidance, has been made by a multi-disciplinary team and/or other healthcare professional with a recognised specialism in palliative care. Do not prescribe for patients with non-cancer pain.
Effentora® and Abstral® are indicated for the treatment of breakthrough pain in adults receiving maintenance opioid therapy for chronic cancer pain. Breakthrough pain is a transient exacerbation of otherwise controlled chronic background pain. Patients receiving maintenance opioid therapy are those who are taking at least 60 mg of oral morphine daily, at least 25 micrograms of transdermal fentanyl per hour, at least 30 mg of oxycodone daily, or an equianalgesic dose of another opioid for a week or longer.
Transmucosal fentanyl preparations have a faster onset of action and shorter duration of effect compared to other opioid analgesic preparations and may be useful for the management of incident pain, in the following situations:
Seek specialist palliative care advice before initiating transmucosal fentanyl to ensure full assessment of pain.
Effective control of chronic pain with around the clock opioids should be achieved prior to commencing treatment with transmucosal fentanyl. Do not use in opioid non-tolerant/opioid naive patients – all patients must be on background opioid treatment.
Constant reassessment is needed for accurate symptom control. All patients receiving transmucosal fentanyl prescriptions should be reviewed weekly.
All prescriptions must be written by brand as Effentora® or Abstral® and not as generic fentanyl. This will enable the correct formulation to be dispensed.
Patients experiencing xerostomia are advised to drink water to moisten the buccal mucosa and cavity prior to administration of Effentora® or Abstral®.
Effentora® and Abstral® require dose titration to determine the optimal dose. This is outlined in brief below; consult manufacturer's summary of product characteristics (SPC) for further details. There is no direct conversion from other opioids and the correct dose must be established by titration. The doses of Effentora® and Abstral® are not interchangeable. If a patient has previously used another transmucosal fentanyl preparation the correct dose must be re-titrated - stop current transmucosal fentanyl and start replacement transmucosal fentanyl at next breakthrough pain episode.
Initiating Effentora® fentanyl buccal tablets (100 micrograms, 200 micrograms, 400 micrograms, 600 micrograms, 800 micrograms):
Local specialists have indicated that the licensed titration regimen above may be too rapid for some patients. The regimen below is unlicensed and a combination of strengths may need to be prescribed. Specialist advice should be sought; the following guidance may be appropriate (taken from Scottish Palliative Care Guidelines):
|Strength of first Effentora® tablet per episode of breakthrough pain||Strength of second Effentora® tablet to be taken 30 minutes after first tablet, if required|
|100 micrograms||100 micrograms|
|200 micrograms||200 micrograms|
|400 micrograms||200 micrograms|
|600 micrograms||200 micrograms|
NONE - efficacy and safety of doses > 800 micrograms have not been evaluated
Initiating Abstral® fentanyl sublingual tablets (100 micrograms, 200 micrograms, 300 micrograms, 400 micrograms, 600 micrograms, 800 micrograms):
|Strength of first Abstral® sublingual tablet per episode of breakthrough pain||Strength of second Abstral® sublingual tablet to be taken 15-30 minutes after first tablet, if required|
|100 micrograms||100 micrograms|
|200 micrograms||100 micrograms|
|300 micrograms||100 micrograms|
|400 micrograms||200 micrograms|
|600 micrograms||200 micrograms|
When patients require more than one dose for several consecutive episodes, having been previously stable:
Buprenorphine may occasionally be useful for patients who would benefit from a transdermal analgesic but whose opioid dose requirements are too low to consider a fentanyl patch.
The indications are otherwise similar to those for fentanyl, including the recommendation for use in stable pain only.
Buprenorphine is generally safe to use in renal impairment. It is approximately 100 times more potent than morphine. We recommend seeking specialist advice regarding which dose to use.
To avoid confusion, please be aware that transdermal buprenorphine patches are available in two formulations and note the different patch change intervals for each:
The maximum authorised dose is two 70 microgram/hour patches.
The oral dose conversion ratio for morphine and oxycodone is approximately 1.5:1 but safe practice is to recommend a clinical ratio of 2:1.
When converting a patient to oxycodone, the dose of morphine (either orally or parenterally) should be halved for an equivalent dose via the same route:
Relative doses of opioids:
Parenteral oxycodone is equivalent to half the dose of oral oxycodone
Like morphine, oxycodone is available in both m/r and immediate release formulations.
Targinact® is seldom used in Specialist Palliative Care. It may be useful in some palliative care patients with severe pain requiring opioid analgesia but experiencing constipation where laxative treatment has failed.
It should not to be used in patients with liver failure or those at risk of liver failure e.g. patients with liver metastases because of the need for 1st pass metabolism of naloxone.
Its use is currently best restricted to patients who fail to get satisfactory analgesia from conventional strong opioids +/- adjuvant medications.
Please seek specialist advice.
An adjuvant analgesic is a drug primarily used for other indications but which can provide pain relief in certain situations. They have also been called co-analgesics and can be used in combination with drugs at all steps of the analgesic ladder.
The information provided in the sections below is not all-inclusive and further specialist advice should be sought if necessary.
Patients at risk of NSAID induced gastro duodenal ulceration, and those taking both steroids and NSAIDs together, should be considered for gastro-protection. Please refer to section 10.1 Drugs used in rheumatic diseases and gout and Prescribing non-steroidal anti-inflammatory drugs
For some palliative care patients, it may be appropriate to consider celicoxib as an alternative to a traditional NSAID
See Neuropathic pain
In palliative care, the starting doses for gabapentin and pregabalin will generally be lower and dose titration more cautious:
A dose reduction for gabapentin and pregabalin is required in patients with renal impairment, if in doubt,
seek specialist advice.
Dose adjustments for gabapentin in renal impairment
|Creatinine clearance (ml/minute)||Starting dose||Maximum dose|
200mg 8 hourly
||600mg 8 hourly|
|30-49||100mg 8 hourly||300mg 8 hourly|
|15-29||300mg alternate days||300mg 12 hourly|
|Less than 15||300mg alternate days||300mg at bedtime|
|After every 4 hours of haemodialysis||Supplementary single dose of 200-300m|
Dose adjustment for pregabalin in renal impairment
|Creatinine clearance (ml/minute)||Starting Dose||Maximum dose|
|Greater than 60||75mg 12 hourly||300mg 12 hourly|
|31-60||25mg 8 hourly*||150mg 12 hourly|
|15-30||25-50mg once daily||150mg once daily|
|Less than 15||25mg once daily||75mg once daily|
*37.5mg capsules are not available, necessitating 8 hourly regimen. Please revert to usual 12 hourly dose when titrating dose upwards
Stopping gabapentin and pregabalin
Lidocaine 700mg (5% w/w) medicated plasters (Ralvo®) may be helpful in patients with focal allodynia.
Transcutaneous nerve stimulation (TENS)
Nerve block/interventional approach (involve the Chronic Pain Team)
Please refer to: Malignant gastro-intestinal obstruction