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Analgesic Prescription  
 

WHO Analgesic Ladder: Sample Prescriptions

Step 1 

T Diclofenac 50 mg tid * 
C Omeprazole 20 mg od
(Cap proxyvon 1 prn)

*If worried about gastroduodenal toxicity
T Meloxicam 15 mg od
T Paracetamol 1 Gram qid

Step 2

T Diclofenac 50 mg tid
C Omeprazole 20 mg od
C Proxyvon** 1 qid and prn ( max 8 per day) 
T Bisacodyl (Dulcolax) 2 hs 

**Alternative- T Tramadol 50- 100 mg q6h (expensive)

Step 3

T Diclofenac 50 mg tid
C Omeprazole 20 mg od
T Morphine 5 to 10 mg q4h and prn ***
T Metoclopramide 10 mg prn


*** Sustained release morphine or fentanyl transderml patches can be used after dose titration with morphine

Also consider adding one or more of the following in steps 1 to 3
T Paracetamol 1 G qid
T Dexamethsone 8 mg od for nerve compression pain
Adjuvant analgesics such as amitryptiline for other types of pain

Oral Morphine : Prescribing Guidelines
Morphine should generally be given with a non opioid.
Start with 5 mg q 4h (unless patient is already on opioids * see below)
Prescribe q4h with double dose at bed time
For break through pain, give an extra dose (same strength as the 4 hourly dose)
Such prn doses can be given upto 1-2 hourly
Do not omit the next regular dose, if a prn dose has been taken.

Always
Prescribe a stimulant laxative prophylactically 
e.g. T. Dulcolax 2 at night. Do not use bulk laxatives such as Naturolax.
Prescribe an antiemetic prophylactically for the first few days.
Morphine when patient is on opioids :
* If a patient is already on regular Buprenorphine or taking more than 4 capsules of Proxyvon the starting dose would be at least Morphine 10 mg q 4h.

Increasing Morphine dosage :
If pain is not controlled or > 2 prn doses are needed per day
Increase by approximately 50% of the starting dose 5 10 mg, 10 - 15 mg, 15 - 20 mg, 20 mg
OR
Recalculate q4h dose based on total used in previous 24h (regular time)

If the oral route is no longer practical 
Give half the dose by subcutaneous injection (10 mg per oral = 5 mg subcutaneous)

Patients on a Fentanyl patch, having breakthrough pain need.

15 mg Morphine prn if on a 25 g patch
30 mg Morphine prn if on a 50 g patch

WHO Analgesic Ladder

Principles 

  • By the mouth
  • By the clock
  • By the ladder
  • Anticipate and treat side effects#
  • Monitor response- 
Step 1 Non opioid +/- adjuvant
Step 2 Non opioid + weak opioid +/- adjuvant
Step 3 Non Opioid + strong opioid +/- adjuvant

If pain is non responsive 
  • Check compliance
  • Is the patient taking drugs prn only?
  • Have you got the cause right?
  • Does the opioid dose need to be increased?
  • Is there a neuropathic element?
  • Are psychosocial aspects being neglected?
  • Will treatment of side effects permit more of analgesics?#
  • Will an alternate route of administration help?
  • Consider physical/invasive measures.

#Adverse effects
In the event of nausea/vomiting on opioids, use

  • oral metoclopramide 10 mg q8h X 3 days.

If patient is constipated on opioids even with bisacodyl,

  • Consider bisacodyl tid, along with
  • a softener (eg: cremaffin 15-30 ml tid)
  • If problem persists, intervene early with rectal measures:
  • rectal examination to rule out impaction
  • bisacodyl suppository
  • high glycerine enema , or
  • digital rectal evacuation 

Dose Titration With IV Morphine

Prerequisites 

Pain, i.e. 5/10 on a numerical scale.
Likelihood of a partial or complete response to morphine.

Method 
Obtain venous access with a butterfly cannula.
Give metoclopramide 10 mg IV routinely.
Dilute the contents of 15 mg morphine ampoule in a 10 ml syringe.
Inject 1.5 mg every 10 min until the patient is pain - free or complains of sedation.

If patients experience nausea, give additional metoclopramide 5 mg IV.

Results 
Dose required (with approximate percentages) :
1.5 - 4.5 mg (40%) 10.5 - 15 mg (15%)
6-9 mg (40%) > 15 mg (5%)

Ongoing treatment
Prescribe a dose of PO mrophine q4h which is similar to the IV requirement, rounded to the nearest 5 mg, i.e. relief with morphine 3-6mg IV 5 mg PO etc; the minimum dose is 5mg q4th.
Instruct patients to take p.r.n. doses and to adjust the dose the next day if necessary.

Use of Oral Morphine in advanced cancer

A monograph on the use of oral morphine in advanced cancer: Download as a word file.

 

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Online since 1st October '05
Published by Wolters Kluwer - Medknow