[Use of oral morphine in incurable pain]

Oral morphine sulphate is the strong narcotic of choice at most hospices. Administered in simple aqueous solution (e.g. 10 mg in 10 ml). No advantage in giving as "Brompton Cocktail." Usual starting dose 10 mg every 4 h. If patient has previously only had a weak narcotic analgesic, 5 mg may be adequate. If changing to morphine from alternative strong narcotic, such as dextromoramide, levorphanol, methadone, a considerably higher dose may be needed. With frail elderly patients, it may be wise to start on sub-optimal dose in order to reduce likelihood of initial drowsiness and unsteadiness. Adjust upwards after first dose if not more effective than previous medication. Adjust after 24 h "if pain not 90% controlled." Most patients are satisfactorily controlled on dose of between 5 and 30 mg 4 hourly; however, some patients need higher doses, occasionally up to 500 mg. Giving a larger dose at bedtime (1,5 or 2 x daytime dose) may enable a patient to go through the night without waking in pain. Use co-analgesic medication as appropriate. Eigher prescribe an antiemetic concurrently or supply (in anticipation) for regular use should nausea or vomiting develop. Prescribe laxative. Adjust dose according to response. Suppositories may be necessary. Unless carefully monitored, constipation may be more difficult to control than the pain. Write out regimen in detail with times to be taken, names of drugs and amounts to be taken. Warn patient of possibility of initial drowsiness. Arrange for close liaison and follow up.