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Ovid: Oxford Handbook of Palliative Care

Editors: Watson, Max S.; Lucas, Caroline F.; Hoy, Andrew M.; Back, Ian N. Title: Oxford Handbook of Palliative Care, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Symptom Management > Chapter 6a – The management of pain > Step 3: Strong opioid ± non opioid ± adjuvants Step 3: Strong opioid ± non opioid ± adjuvants Two tablets of co-codamol contain 60mg of codeine which is already approximately equi-analgesic to oral morphine 5mg every 4h. (See conversion table). If changing to morphine, it will therefore be necessary to use a minimum of morphine 5mg but 10mg may be needed. Caution should be exercised in patients who are elderly or in renal failure, since active morphine metabolites are excreted by the kidney. The formulation of morphine may be immediate release (i/r) tablets or solution, depending on patient preference. If the pain seems responsive to opioids and there are no undue side-effects, continue to titrate the dose upwards by no more than 30–50 per cent every 24 h until pain is controlled. It is not necessary to wake the patient at night to give medication, but if pain during the night or first thing in the morning is a problem, it may be helpful to increase the last evening dose by 50 per cent.

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