• Immediately relieve pain, using a subcutaneous or slow intravenous dose of a strong opioid.
• The dose depends on the person's comorbidities and their existing analgesia:
• If the person is opioid naive, consider a subcutaneous or slow intravenous dose of 2.5 mg of diamorphine (1–2 mg if the person is elderly or frail).
• If the person is already taking a regular opioid, calculate the 4-hourly dose by taking the total dose given over the previous 24 hours (including doses required for breakthrough pain but excluding those for incident pain) and dividing it by six, and then give the equivalent subcutaneous dose of diamorphine or morphine:
• The subcutaneous dose of diamorphine is one third of the 4-hourly oral morphine dose.
• The subcutaneous dose of morphine is approximately half of the 4-hourly oral morphine dose.
• For more detailed information on converting oral morphine to a subcutaneous dose, see the conversion table in Switching from morphine to another strong opioid.
• Following this, seek immediate specialist palliative care advice regarding further management and try to determine the cause of the pain.
• Always take into account the person's circumstances and wishes:
• If the person wishes to stay at home and is near the end of life, then control of symptoms should be attempted in this setting; if this is not possible, transfer to a hospice or hospital may be needed.

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