Opioids in Palliative Care – NICE Guidance on a Page

Diagnosis

When offering pain treatment with strong opioids to a patient with advanced and progressive disease, ask them about concerns such as:
- Addiction
- Tolerance
- Side effects
- Fears that treatment implies the final stages of life
Provide verbal and written information on strong opioid treatment to patients and carers including:
- When and why strong opioids are used to treat pain
- How effective they are likely to be
- Taking strong opioids for background and breakthrough pain, addressing: how, when and how often to take strong opioids & how long pain relief should last
- Side effects and signs of toxicity
- Safe storage
- Follow-up and further prescribing

Regular oral sustained-release or oral immediate-release morphine (patient preference) with rescue doses of oral immediate-release morphine for breakthrough pain
Renal or hepatic comorbidities, offer a total daily starting dose of 20–30 mg of oral morphine (i.e. 10-15 mg sustained release BD) + 5 mg immediate release PRN
Adjust the dose until a good balance exists between acceptable pain control and side effects

Oral sustained-release morphine
If oral opioids are not suitable (consider with specialist advice):
- Transdermal patch formulations but not routinely
- Subcutaneous morphine

Oral immediate-release morphine
Do not offer fast-acting fentanyl, if pain remains inadequately controlled despite optimising treatment, consider seeking specialist advice

Prescribe laxative treatment regularly at an effective dose, advise takes time to work and adherence important

advise likely transient, if persists prescribe and optimise anti-emetic treatment before considering switching strong opioids

consider dose reduction if pain is controlled or consider switching opioids if pain, specialist advice if continues