Starting an opioid for pain in palliative care

The preferred approach to starting opioid therapy for pain in patients with palliative care needs is to start an immediate-release opioid, to be taken as required for intermittent pain. This approach tests patient tolerability to the opioid and informs the ongoing optimal dose and regimen. However, it should not be used as an initial strategy in settings where timely administration of as-required opioids may be challenging (eg residential aged-care facilities).

An alternative approach is to start regular opioid therapy (either with an oral opioid or transdermal buprenorphine—see Choice of opioid for pain in palliative care), together with an immediate-release opioid to be taken as required.

Starting opioid therapy is a signal to review the effectiveness and burden of other analgesics, particularly paracetamol—follow the principles of medication rationalisation.

Starting an opioid requires cautious adjustment and frequent review because individuals vary markedly in their response. Best practice is to start with a low dose and slowly adjust the dose until pain is controlled.

For further details, including additional considerations when starting an opioid, factors that guide opioid choice and dose, and prevention and management strategies for opioid-related adverse effects, see Principles of opioid use in palliative care.