The pharmacological approach to management of pain in palliative care
BMJ 2001; 323 doi: https://doi.org/10.1136/sbmj.0112455 (Published 01 December 2001) Cite this as: BMJ 2001;323:0112455
- Oliver Jones, research fellow1
- 1department of pharmacology, University of Oxford
Pain is a common feature of terminal disease. As a preregistration house officer, managing this pain can be bewildering. This article presents some principles of management. It is important to remember that pain control is only one aspect of terminal care. Empathy and attentiveness are no less important than appropriate pharmacological intervention.
First line treatment
The nature of incurable disease results in pain being almost invariably chronic and often progressive. Analgesia should be prescribed as a regular medication to prevent the onset of pain. This is best achieved through a system that avoids the patient depending on a nurse or relative for regular drug administration. This is most easily achieved with oral treatments (or infusion pumps, as described later). If simple analgesics such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDS) are not effective then oral morphine regimens are the next line of treatment.
Oral aqueous morphine
Oral aqueous morphine is a powerful analgesic that allows patients to self administer their analgesia while avoiding the need for repeated injections. Pharmacists will make up aqueous solutions of varying strength, which usually requires the patient to take a volume of 5 or 10mls a dose, normally starting with a dose of 5-10mg of morphine every four hours. However, if the patient has previously been taking weak analgesics and is experiencing severe pain it is appropriate to start at a higher dose--for example, 20mg every four hours. The dose can be increased gradually if pain persists and occasionally doses of up to several hundred milligrams every four hours are required.
Oral morphine tablets
Some patients prefer to take oral tablets rather than aqueous solutions. Slow release tablets also allow doses to be spaced at 12 hourly intervals. A reasonable starting dose of slow release morphine is around 10-30mg every 12 hours. This dose may be …
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