Fortnightly Review: Morphine in cancer pain: modes of administration

doi:10.1136/bmj.312.7034.823

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Expert Working Group of the European Association for Palliative Care

Department of Palliative Medicine, Bristol Oncology Centre, Bristol BS2 8ED G W Hanks, Macmillan professor of palliative medicine. Istituto Nazionale dei Tumori, Milano, Italy F de Conno, director of pain therapy and palliative care division C Ripamonti, vice director of pain therapy nd palliative care division V Ventafridda, scientific director, Floriani Foundation. Kings College School of Medicine and Dentistry, University of London M Hanna, director, pain relief research unit. Oxford Pain Relief Unit, University of Oxford, Oxford HJ McQuay, clinical reader in pain relief. Societa per L'Assistenza al Malato Oncologico Terminale, Palermo, Italy S Mercadante, chief of pain relief and palliative care. Centre Oscar Lambret, Lille, France J Meynadier, chief of department of anaesthesiology, intensive care, and pain relief. Institut Gustave-Roussy, Villejuif, France P Poulain, assistant professor, pain clinic. Hospital de la Santa Creu, Barcelona, Spain J Roca i Casas, director of hospital and palliative care unit.

Correspondence to: Professor Hanks. Huddinge University Hospital, Huddinge, Sweden J Sawe, associate professor of clinical pharmacology. Sir Michael Sobell House, University of Oxford, Oxford R G Twycross, Macmillan clinical reader in palliative medicine. Helsinki University Central Hospital, Helsinki, Finland A Vainio, consultant, department of anaesthesia. Universitatsklinik fur Anaesthesiolgie, Cologne, Germany D Zech, consultant in anaesthesia and pain management *Dr Zech died on 5 August 1995.

Most cancer pain responds to pharmacological measures, and successful treatment is based on simple principles that have been promoted by the World Health Organisation1 and extensively validated.2 3 Oral administration of analgesic drugs is preferred, and analgesics are given regularly to prevent recurrence of pain, often for months or even years. A step by step approach to the choice of drug is recommended, based on the “analgesic ladder” (fig 1). The first step is a non-opioid analgesic such as aspirin, paracetamol, or a non-steroidal anti-inflammatory drug. At the second step a weak opioid such as codeine is added, and when this proves inadequate a strong opioid is substituted for the weak opioid.

Fig 1

Analgesic ladder for control of pain

Morphine is the preferred strong opioid analgesic. The dose is titrated up to achieve adequate relief of pain. There is no upper limit. Dose requirements may vary 1000-fold, but few patients need daily doses above 200-300 mg.4 Adjuvant analgesics such as antidepressant or anticonvulsant drugs, used alone or in conjunction with a conventional analgesic, have an important role in some patients.5

Unfounded fears associated with morphine

Morphine has long been feared by both the general public and doctors.6 Underlying the fear is a mistaken belief that the problems associated with abuse of opioids are inextricably linked with their therapeutic use. Concerns about addiction, excessive sedation, and respiratory depression have resulted in widespread avoidance or underdosing. Yet extensive, carefully documented clinical experience has shown that these fears are unfounded.7 Regular doses of morphine may be indicated and safely instituted early in the course of a patient's illness and continued for many months. Alternatively, some patients may be treated with morphine for short periods and, when their pain ameliorates, can reduce the dose and discontinue it without difficulty.

Daytime drowsiness, dizziness, or mental …