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Palliative cancer care - pain - Management
How should oral morphine be initiated?

  • Either immediate-release or modified-release formulations are recommended for the initiation of morphine:
    • Immediate-release oral morphine has a rapid onset of action (about 20 minutes) that makes it suitable for initiating treatment of severe pain and for treating breakthrough pain, but it requires administration every 4 hours to maintain a continuous analgesic effect [SIGN, 2008]. Consequently, it is difficult to cover pain throughout 24 hours, unless the person is being closely monitored. Immediate-release morphine is useful for titration if the person's pain is severe and rapid titration is required, usually on an inpatient basis. Oramorph® solution and Sevredol® tablets are both immediate-release morphine products.
    • Modified-release morphine preparations have a slower onset of action (1–2 hours) and later peak levels (4 hours) than immediate-release preparations. Consequently, they cannot be rapidly titrated for people in severe pain [McQuay and Moore, 1997; SIGN, 2008]. However, in many people, they provide continuous analgesia that is ideal for titration, especially for those at home.
  • Take care to avoid prescribing errors:
    • Prescribe by mass (for example, 2 mg) rather than by volume (for example, 2 mL).
    • Avoid decimal points in doses if possible (for example, 2.5 mg) to minimize the risk of dose errors, and try to avoid prescribing awkward doses.
    • If using morphine 10 mg/5 mL solution, doses without a decimal point are easier to measure (for example, 2 mg [1 mL of solution]).
  • Final doses of morphine cannot be predicted from age, body weight, or body surface area. The starting dose of oral morphine should take into account previous exposure to opioids.
  • Starting regimens of oral morphine are listed below as a guide and are based on suggested doses in UK and European guidelines [Hanks et al, 2001; SIGN, 2008] and the Palliative Care Formulary [Twycross and Wilcock, 2007]. However, some experts advocate a more cautious approach with lower starting doses. Clinical judgement is therefore required.
  • For people not currently taking an opioid:
    • In elderly or frail people, start with morphine 2–5 mg every 4 hours plus as required (up to 2-hourly) for breakthrough pain. Cautious dose titration can help to reduce initial drowsiness, confusion, and unsteadiness.
    • In young and middle-aged people, start with morphine 5–10 mg every 4 hours plus as required (up to 2-hourly) for breakthrough pain.
  • For people previously on a weak opioid (such as codeine) at a full therapeutic dose, start with:
    • Immediate-release morphine 10 mg every 4 hours plus as required (up to 2-hourly) for breakthrough pain, or
    • Modified-release morphine 20–30 mg every 12 hours plus breakthrough doses of immediate-release morphine as required (up to 2-hourly).
    • Consider starting at a lower dose and titrating carefully if the person is elderly or frail.
  • For people previously on an alternative strong opioid:
    • CKS recommends seeking specialist advice because of the differences in opinion regarding conversion ratios.
  • Seek specialist palliative care advice for people with renal impairment, people with increased intracranial pressure, or people at risk of respiratory depression. For people with renal impairment, a lower or less frequent regular dose of morphine may be preferable [ABPI Medicines Compendium, 2009], or a different opioid may be more appropriate [SIGN, 2008].

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