Starting morphine: Information for clinicians

This advice is sourced from NICE and  Dr Ros Taylor a senior palliative physician

Q.  How do I decide when it is appropriate to start a patient on a strong opioid and what is best practice?

The WHO ladder recommends regular analgesia by mouth for severe cancer pain. The steps are:

  1. Non-opioids (e.g. Paracetamol and NSAIDs)
  2. Weak opioids (e. g. Codeine and Tramadol) Both are a tenth as strong as Morphine ie 60mg Codeine = 6mg Morphine
  3. Strong opioids (e. g. Morphine, Fentanyl, Oxycodone, Methadone, Buprenorphine) until the patient is free of pain

At each step adjuvants should be considered e.g. medicines for neuropathic pain, bone pain, or pain caused by spasm, rather than simply escalating the opioid.

Some pains are not opioid sensitive - increasing the dose may lead to toxicity rather than improved pain control.

Stepping up from a weak to a strong opioid (step 2 to 3 above)

If a full dose of a weak opioid (step 2) is not giving 24 hour pain relief, then consider stepping up to a strong opioid.

The gold standard is Morphine oral solution (10mgs/5 mls) used regularly e.g. 2mg - 5mg mgs 4 hourly and titrate as needed.

Once a steady dose is reached then convert to 12 hourly modified release e.g. MST or Zomorph. E.g. if a patient is needing 5mgs six times a day (30mgs total daily dose), then can convert to Morphine Modified Release Tablets 15mgs twice daily.

A PRN dose will be needed to manage breakthrough pain - prescribe 1/6 of the 24 hour Morphine dose.

Renal Failure

As renal function worsens it is safer to use low doses of short-acting liquid options such as low dose Oxycodone, which evidence suggests may be slightly safer than Morphine in advanced renal failure (eGFR<30)

See Opioid Conversion table

Fentanyl patches

Fentanyl patches are also a good option if patients are not safely swallowing, poorly compliant with oral medications or are vomiting. 

Fentanyl patches are changed every 72 hours and the lowest dose is 12mcg per hour which is equivalent to approximately 30mg - 40mg of Morphine per 24 hours.

Ideally, the pain should be stable before switching to Fentanyl.

Remember to prescribe a laxative and possibly an antiemetic.

It is always good to explore a patient's concerns and beliefs when starting a medicine such as Morphine.

Recommended Resources

NICE GUIDANCE Palliative care for adults: Opioids for strong pain relief

Published 3rd August 2016

Share

Related Services

Audley Mills Pharmacy
Close

Audley Mills Pharmacy

T. 01268 776479

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 55-57 Eastwood Road, Rayleigh, SS6 7JE

Opening hours: Monday to Friday 8.00am to 9.00pm. Saturday 9.00am to 5.00pm. Sunday 10.00am to 5.00pm.

Basildon and Wickford Integrated Care Team
Close

The team deliver specialist care for palliative and end of life care at home, complex care at home e.g. chemotherapy management of Hickman/PICC lines and support to those who are housebound within their own home including residential homes.

Blackwater Pharmacy
Close

Blackwater Pharmacy

T. 01621 855118

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: Blackwater Medical Centre, Princes Rd, Maldon, CM9 5GP

Opening hours: Monday to Saturday 7.00am to 10.00pm. Sunday 10.00am to 6.00pm

Brentwood and Billericay Integrated Care Team
Close

The team deliver specialist care for palliative and end of life care at home, complex care at home e.g. chemotherapy management of Hickman/PICC lines and support to those who are housebound within their own home including residential homes.

Chemist@Southend
Close

Chemist@Southend

T. 01702 612003

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: Queensway Surgery, 75 Queensway, Southend On Sea, SS1 2AB

Opening hours: Monday to Saturday 8.00am to 11.00pm. Sunday 10.00am to 8.00pm.

Christchurch Pharmacy
Close

Christchurch Pharmacy

T. 01376 328157

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: Mace Avenue, Off Rayne Road, Braintree, CM7 2AE

Opening hours: Monday to Friday 8.30am to 7.00pm. Saturday 9.30am to 1.00pm.

Community Matrons
Close

Community Matrons

T. 0300 300 1712

Community Matrons support patients with complex health needs. 

Derix
Close

Derix

T. 01702 715558

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 1065 London Road, Leigh-on-Sea, SS9 3JP

Opening hours: Monday to Friday 8.00am to 11.00pm. Saturday 8.00am to 9.00pm. Sunday 8.00am to 11.00pm.

Hassengate Pharmacy
Close

Hassengate Pharmacy

T. 01375 641569

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: Hassengate Medical Centre, Southend Road, Stanford-le-Hope, SS17 0PH

Opening hours: Monday 8.00am to 10.30pm. Tuesday 7.00am to 10.30pm. Wednesday to Saturday 8.00am to 10.30pm. Sunday 9.00am to 10.00pm.

PharmChoice
Close

PharmChoice

T. 01277 215809

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 9 Ingrave Road, Brentwood, CM15 8AP

Opening hours: Monday to Saturday 7.30am to 10.00pm. Saturday 9.00am to 10.00pm.

Tesco In-Store Pharmacy
Close

Tesco In-Store Pharmacy

T. 01245 772368

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: Princes Road, Chelmsford, CM2 9XW

Opening hours: Monday 8.00am to 10.30pm. Tuesday to Friday 6.30am to 10.30pm. Saturday 6.30am to 10.00pm. Sunday 10.00am to 4.00pm.

Well Pharmacy
Close

Well Pharmacy

T. 01787 479 793

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: Solar Superstore, 12 Weavers Court, Halstead, CO9 2JN

Opening hours: Monday to Friday 9.00am to 5.30pm. Saturday 9.00am to 1.30pm.

Related Articles

9th November 2023

Opioid conversion

4th July 2024

Starting a Syringe Pump: Information for clinicians

Feedback