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Opioids in palliative care - NICE guideline CG140

Longson, Damian, Stannard, Catherine, Bennett, Mike, Piggin, Catherine, Smith, Lindsay, Ross, Joy, Taubert, Mark, Gibbs, Margaret, Stevens, Anna-Marie, Laine, Natalie and Pipe, Vivien 2012. Opioids in palliative care - NICE guideline CG140. vol. CG140. NICE. Available at:

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Pain is common in advanced and progressive disease. Up to two-thirds of people with cancer experience pain that needs a strong opioid. This proportion is similar or higher in many other advanced and progressive conditions. Despite the increased availability of strong opioids, published evidence suggests that pain which results from advanced disease, especially cancer, remains under-treated. Each year 300,000 people are diagnosed with cancer in the UK and it is estimated that there are 900,000 people living with heart failure. Others live with chronic illness such as kidney, liver and respiratory disease, and with neurodegenerative conditions. Many people with these conditions will develop pain for which a strong opioid may be needed. The 2008 World Cancer Declaration included a target to make effective pain control more accessible. Several key documents highlight the importance of effective pain control, including ‘Improving supportive and palliative care for adults with cancer’ (NICE cancer service guidance 2004), ‘Control of pain in adults with cancer’ (Scottish Intercollegiate Guidelines Network guideline 106), ‘A strategic direction for palliative care services in Wales’ (Welsh Assembly Government 2005) and ‘End of life care strategy’ (Department of Health 2008). Strong opioids, especially morphine, are the principal treatments for pain related to advanced and progressive disease, and their use has increased significantly in the primary care setting. However, the pharmacokinetics of the various opioids are very different and there are marked differences in bioavailability, metabolism and response among patients. A suitable opioid must be selected for each patient and, because drug doses cannot be estimated or calculated in advance, the dose must be individually titrated. Effective and safe titration of opioids has a major impact on patient comfort. The World Health Organization has produced a pain ladder1 for the relief of cancer pain; strong opioids are represented on the third level of the three-step ladder. The guideline will address first-line treatment with strong opioids for patients who have been assessed as requiring pain relief at the third level of the WHO pain ladder. It will not cover second-line treatment with strong opioids where a change in strong opioid treatment is required because of inadequate pain control or significant toxicity.

Item Type: Monograph (UNSPECIFIED)
Date Type: Publication
Status: Published
Schools: Medicine
Additional Information: Last updated 03 August 2016
Publisher: NICE
Related URLs:
Last Modified: 12 Jun 2020 15:00

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