Opioids in Cancer pain

Steps for controlling cancer pain with morphine: 

1. Follow the WHO analgesic ladder
• Use morphine (or alternative) early for severe pain
2. Control severe pain quickly with immediate release (short-acting) oral morphine.
3. If the patient is opioid naive - "start low, go slow"
• 2.5-5mg PO immediate release morphine 1 -2 hourly PRN
4. Sustained release (slow release/long-acting) morphine can be charted regularly BD PO after titration with PRN doses
5. Patients should have both regular sustained release opioids charted and an appropriate PRN dose of immediate release opioid for 'breakthrough pain' and 'incident pain'
• Breakthrough pain is pain that occurs as a regular dose of sustained release opioid wears off - it suggests that the regular dose should be increased
• Incident pain is different - it is pain that is related to a specific activity, e.g. movement - and it does not necessarily suggest that the regular sustained release dose needs to be increased
• The PRN dose should be ≈ one sixth of the total daily opioid dose
6. If the patient requires a number of PRN doses to cover breakthrough pain, the regular dose of sustained release opioid may need to be increased 
• Increase slowly to ensure the patient does not develop side-effects
• Caution if the patient has a fluctuating level of pain
7. Remember to chart laxatives and anti-emetics
8. If a patient is vomiting or can not take oral medication - the subcutaneous (SC) route should be used
• Larger doses can be administered safely using the SC route rather than the IV (intra-venous) route
• Medication given SC lasts longer than medication given IV
• The oral morphine dose is approximately twice the SC dose
• e.g. Morphine PO 10mg = morphine SC 5mg

The Niki T syringe driver is usually used to deliver medication as a continuous subcutaneous infusion (CSCI) 

Indications for use of CSCI:

Basically .... used if patient not able to use oral route

1. Oral medication not being absorbed
• e.g. vomiting, bowel obstruction, poor or unreliable absorption for any reason 
2. Not able to swallow tablets
• End of life care, decreased GCS, pathology preventing swallowing
3. No IV access or IV access not appropriate
4. Not all 'palliative patients' need a syringe driver
5. Severe pain does not necessarily require the use of a syringe driver if the patient is eating and drinking
6. Subcutaneous doses are around half of the total daily oral dose of opioids