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Palliative cancer care - pain - Management
Which strong opioid drug should I prescribe?

  • Use the oral route of administration where possible.
  • Morphine is recommended:
  • If the person's compliance with oral morphine is good, but pain is inadequately controlled:
  • If compliance with oral morphine is good, but the person cannot tolerate an adequate dose, consider using an alternative oral opioid — seek specialist advice.
  • If the oral route is not appropriate (for example, the person has nausea and vomiting, or cannot swallow, or has poor compliance with oral analgesia), consider:
    • Switching to a subcutaneous diamorphine or morphine infusion. For more information, see Switching from morphine to another strong opioid.
    • Switching to transdermal fentanyl if the person has stable analgesic requirements and has previously tolerated opioids — seek specialist advice.
  • When prescribing a strong opioid:
    • Prescribe an anti-emetic (such as metoclopramide for gastric stasis, otherwise low-dose haloperidol):
      • If the person has experienced nausea with a previous opioid, give regularly for the first week, to prevent opioid-induced nausea and vomiting and then reassess, or
      • If the person experiences nausea with morphine but has not experienced nausea with a previous opioid, prescribe for use on an as-required basis for 1 week.
    • To prevent constipation, prescribe a stimulant (such as senna or bisacodyl) and a softening laxative (such as docusate):
      • A laxative with both properties (for example, co-danthramer or co-danthrusate) is also an option.
      • Avoid dantron-containing laxatives in people who are incontinent as these drugs can cause a chemical burn (reddening) of the perianal area.
      • Dantron can also colour the urine red and alarm the person.
  • Seek specialist palliative care advice if:
    • There is doubt about how to manage a person's pain.
    • Adverse effects limit treatment and cannot be adequately managed.
    • An unfamiliar opioid or route of administration is being considered.
    • The pain is still at 50% or more of its starting level after 2 weeks.

In depth

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