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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
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  • 10. Common Symptoms
  • 11. Withholding Treatment
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    Back to Module 4: Pain Management
    Resources

    Recommended Literature
    Morphine Dosing
    Pain Assessment
    Downloadable Documents and Worksheets

    Recommended Literature

    Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline Number 9. Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service; March 1994. AHCPR Publication No. 94-0592.

    Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Adults Quick Reference Guide. Number 9. Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service; March 1994. AHCPR Publication No. 94-0593.

    Levy MH. Pharmacologic treatment of cancer pain. N Engl J Med. 1996;335:1124-1132.

    Management of pain. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. Oxford, England: Oxford University Press; 1998:299-487.

    Portenoy RK. Contemporary Diagnosis and Management of Pain in Oncologic and AIDS Patients. Newton, PA: Handbooks in Health Care Co; 1997.

    World Health Organization. Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee. 3rd ed. Geneva: World Health Organization; 1996.

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    Morphine Dosing

    1. Initial Dosing for Constant Pain

    For a patient with significant previous opioid exposure, calculate the starting dose for an immediate-release opioid using the equianalgesic table (to begin the new opioid you will cut back on this dose as appropriate) and dose q 4h, or

    For a patient who is relatively opioid naive and in significant pain, start dosing with 10 to 30 mg of immediate-release oral morphine liquid concentrate or tablet q 4h, or

    For a patient with stable pain that is not severe, start extended-release oral morphine at a dose of 15 or 30 mg twice daily or 30 to 60 mg once daily (depending on formulation).

    Then, prescribe a "breakthrough" or rescue dose that is 5% to 15% of the total dose in use every 24 hours and offer it q 1h po prn. Ask the patient and family to record in a diary all medication taken.

    To convert to an extended-release preparation, calculate the total morphine dose required to achieve comfort during a 24-hour period. Either divide by 2 to get the q 12h dose of extended-release morphine to prescribe routinely, or give the total dose once daily (depending on the product).

    Always prescribe a breakthrough dose of immediate release morphine using liquid concentrate or tablet. Offer 5% to 15% of the 24-hour dose q 1h po prn.

    Monitor closely and titrate as needed

    2. Increasing the Dose

    If a patient requires more than 2 to 4 breakthrough doses in a 24-hour period on a routine basis, consider increasing the dose of the extended-release preparation.

    Determine the total amount of morphine used (routine + breakthrough) and administer the total in divided doses q 12h or q 24h (depending on the product).

    Recalculate the breakthrough so that it is always 5% to 15% of the total daily dose and offer it q 1h po.

        NB: In the patient with cancer, the most common reason for an increased
        dose is worsened pathology, not pharmacological tolerance.

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    Pain Assessment

    • form.pdf    Brief Pain Inventory Form
    • scale.pdf    Memorial Symptom Assessment Scale

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    Downloadable Documents and Worksheets

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