If Patient is older, frail and/or has renal, hepatic or respiratory function impaired, seek senior advice.

Long-acting opioids should not be used routinely for acute post-operative pain.

Older people and/or those with frailty require significantly less opioid to achieve the same level of analgesia, initial doses should be reduced to 25-50% of the doses used in young healthy people.

• Draw up 10mg morphine sulfate in a 10 ml syringe and add 9mls 0.9% sodium chloride to a total volume of 10mls (1mg morphine per ml).

• Consider need for antiemetic, ensure naloxone is to hand.

• Record observations: RR, SaO₂, Pulse, BP, pain score, sedation score.

• If RR>10/min, BP>100mmHg systolic, sedation score < 1: Administer 2mg morphine IV push over 30 seconds and flush cannula with 5mls 0.9% sodium chloride or suitable IV clear fluid.

• Wait 3 - 5 minutes then, if patient’s condition unchanged, give another 1 or 2mg morphine IV.

• Check and record observations every 5 minutes.

• Continue titration every 3 to 5 minutes until patient comfortable or until side effects prevent further
  administration. The peak effect of IV morphine boluses may be 15 to 20 minutes after injection.

• If more than 20mg IV morphine required in a single episode consult senior doctor.

• Give naloxone 0.1 to 0.4mg IV or IM if RR<8/min (2222: NEWS call for all patients given naloxone, titrate dose of naloxone to response). Use of Naloxone in management of opioid induced respiratory depression in palliative care patients

• Once morphine titration complete, document amount given on drug chart in ‘once only’ section and sign.

• Make and prescribe onward plan for patient’s analgesia (consult senior doctor, Pain Team or on-call anaesthetist if necessary). Document titration and plan in medical notes.

• Ensure ward nurses are able to continue to observe patient and record observations every 30 minutes
  for 1 hour after titration. They should also action onward plan.

(see Symptom Control in Palliative Care guidelines for palliative care patients)

IN PATIENTS WITH eGFR < 90 ml/min seek senior advice and consider reducing regular morphine dose or switching opioid. (remember codeine is broken down into morphine.)

• Regular paracetamol improves pain relief. Caution: reduce dose of paracetamol in adults <50kg.

• Patients on opioids usually require concurrent laxatives; antiemetics should also be available.

• Breakthrough dose analgesia of normal release analgesia should be 1/6th of daily long-acting opioid available 4 hourly (on PRN side of Epic MAR).

What is equal to what dose of oral morphine? Reference table

Transdermal opioids: Approximate equivalence with oral morphine

N.B. Transdermal opioids take 12 to 24 hours to come to peak efficacy, are difficult to titrate to pain, and are not licensed for acute pain.

FPH Pain Team bleep 5252 or X134571, on-call anaesthetist bleep 5002.

WPH Pain Team bleep 4820 or X154435, on-call anaesthetist 07768463877

HWD – 07776633562 or as for WPH