Prescribing of Strong Opioids for Pain in Palliative Care of Adults (NICE Guideline)

Summary of NICE guidance on prescribing opioid analgesics.

This guidance relates to adults with advanced and progressive disease who require strong opioids (Step 3 of WHO pain ladder).

Prescribing of Strong Opioids for Pain in Palliative Care of Adults
  • Discuss concerns about addiction, tolerance, side-effects and fears that treatment implies the final stages of life
  • Provide verbal and written information to patient and carer on the use of strong opioids for background and breakthrough pain, including:
    • When and why these agents are used
    • How effective they are likely to be
    • How, when and how often to take them
    • How long pain relief is expected to last
    • Side-effects (see box below) and signs of toxicity
    • Safe storage
    • Follow-up and further prescribing
    • Out-of-hours contacts
Initiation/Dose Titration
  • Offer regular oral sust-release or immediate-release morphine (depending on patient preference), plus rescue doses of oral immediate-release morphine for breakthrough pain
  • Typical starting dose: 20–30mg oral morphine daily (eg, 10–15mg oral sust-release morphine twice daily), plus 5mg rescue doses of oral immediate-release morphine for breakthrough pain
  • Review patient frequently and adjust dose to balance pain control and side-effects; seek specialist advice if good balance not achieved after a few dose adjustments
  • Seek specialist advice in moderate to severe renal or hepatic impairment

Patients able to tolerate oral opioids

First-line maintenance:

  • Offer oral sust-release morphine
  • Do not routinely offer transdermal patch formulations

First-line rescue medication for breakthrough pain:

  • Offer oral immediate-release morphine
  • Do not offer fast-acting fentanyl

Patients unable to tolerate oral opioids

Consider seeking specialist support when initiating treatment.

If analgesic requirement stable:

  • Consider initiating transdermal patch with lowest acquisition cost
  • Caution required when calculating opioid equivalence for transdermal patches

If analgesic requirement unstable:

  • Consider initiating subcutaneous opioid with lowest acquisition cost
Management of side-effects


  • Advise patient that constipation affects nearly all patients receiving strong opioids
  • Prescribe regular laxative treatment when initiating strong opioids
  • Advise patient that laxatives take time to work and about the importance
    of adherence
  • Optimise laxative therapy before considering switching opioids


  • Advise patient that nausea may occur at initiation or after dose increases, but is often transient
  • If persistent, prescribe and optimise antiemetics before considering
    switching opioids

Drowsiness/impaired concentration

  • Advise patient that mild drowsiness or impaired concentration may occur at initiation or after dose increases, but is often transient. If present, it may affect ability to undertake manual tasks, including driving
  • For persistent or moderate to severe CNS side-effects:
    • – If pain controlled, consider dose reduction
    • – If pain uncontrolled, consider switching opioids


  • If pain or side-effects remain uncontrolled despite optimising first-line maintenance treatment, review analgesic strategy and consider seeking specialist advice
  • Review pain control and side-effects frequently

Adapted from: NICE Clinical Guideline 140 (May 2012; updated August 2016) - Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults.

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