Morphine is the major opioid of choice unless there is a specific reason not to use it.  Use of an immediate release preparation (Oramorph liquid or Sevradol tablets) allows rapid titration and dose adjustment.  This formulation can then be changed to slow release Morphine with additional breakthrough doses given as required.

• The starting dose of Morphine in opioid naïve patients is 1mg/kg in 24hrs (TDD (total daily dose) of morphine).
• Prescribe 1/6th of the TDD to be given every 4 hours.
• Prescribe the same 4hrly dose to be given for breakthrough pain.
• For a child already receiving opioids (minor or major) – use dose of opioids already required as a guide (see table).  The onset of analgesia occurs in approx 20 - 30 minutes with peak activity at 60-90 minutes.
• The average half life is 3 hours so steady state plasma concentration is achieved in 15 hours.