Intended for healthcare professionals

Practice Guidelines

Prescribing strong opioids for pain in adult palliative care: summary of NICE guidance

BMJ 2012; 344 doi: (Published 23 May 2012) Cite this as: BMJ 2012;344:e2806
  1. Michael I Bennett, professor of palliative medicine1,
  2. John Graham, director and consultant in clinical oncology2,
  3. Mia Schmidt-Hansen, researcher2,
  4. Matthew Prettyjohns, health economist2,
  5. Stephanie Arnold, information specialist2
  6. On behalf of the Guideline Development Group
  1. 1Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
  2. 2National Collaborating Centre for Cancer, Cardiff CF10 3AF, UK
  1. Correspondence to: M I Bennett m.i.bennett{at}

Pain is common in advanced cancer but also in the late stages of other incurable non-malignant diseases, such as heart failure and neurological conditions.1 2 Almost half of patients with advanced cancer are undertreated for their pain, largely because clinicians are reluctant to use strong opioids for effective analgesia.3 4 Strong opioids such as morphine are indicated for moderate to severe pain and should be prescribed only after a full assessment of the analgesic needs of the patient.

This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the care of people with advanced and progressive disease who require strong opioids for pain control.5 These patients are defined as those in moderate to severe pain who may never have used strong opioids, or those whose pain has been inadequately controlled by weak opioids such as codeine or tramadol. The guideline does not cover all aspects of pain management (including second line approaches) or pain control during the last days of life (for example, for patients who are being managed by the Liverpool care pathway, a care pathway that integrates the best aspects of care for dying patients that can be used in any clinical setting).


NICE recommendations are based on systematic reviews of the best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Communication and provision of information

When offering strong opioids as pain treatment to a patient with advanced and progressive disease:

  • Ask about concerns such as addiction, tolerance, side effects, or fears that treatment implies the final stages of life. Reassure patients that addiction is very rare and that tolerance does not significantly affect pain …

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