Multimodal control of nociceptive, neuropathic and incident pain in advanced malignancy.
Management
- • WHO ladder: non-opioid → weak opioid → strong opioid, plus adjuvants at every step
- • Regular modified-release opioid plus PRN breakthrough at 1/6 of the 24 h dose
- • Neuropathic pain: amitriptyline, gabapentin, pregabalin or duloxetine
- • Bone pain: NSAID, radiotherapy, bisphosphonate
- • Always co-prescribe a stimulant laxative
Complications
- • Opioid toxicity — myoclonus, pinpoint pupils, hallucinations, drowsiness
- • Constipation
- • Opioid-induced hyperalgesia
Clinical pearls
- • Renal impairment: switch morphine to oxycodone or alfentanil
- • Escalating dose with worsening confusion suggests toxicity, not undertreatment
Related in WardRound
Educational — verify locally.
