## Opioid Dose Titration in Cancer Pain **Key Point:** Inadequate analgesia on a stable opioid dose in opioid-naive patients warrants dose escalation, not switching agents or adding adjuvants as first-line. **High-Yield:** The WHO analgesic ladder and standard cancer pain management guidelines recommend: 1. Start low (10 mg morphine 4-hourly in this case) 2. Titrate by 25–50% increments every 2–3 days until pain control is achieved 3. Switch opioids only if intolerable side effects develop (e.g., excessive sedation, constipation, hallucinations) **Clinical Pearl:** This patient is opioid-naive with no signs of respiratory depression or over-sedation (RR 16, alert). His pain is undertreated, not the opioid excessive. Increasing the dose is safe and evidence-based. **Mnemonic: TITRATE** — **T**itrate dose first, **I**ncrement by 25–50%, **T**est for tolerance/side effects, **R**eassess pain, **A**djuvants later if needed, **T**ry switching only for toxicity, **E**scalate to IV/SC only if swallowing impaired. ### Why Dose Escalation Is Correct - Patient is opioid-naive; tolerance has not developed - No respiratory depression or excessive CNS depression - Pain remains inadequately controlled (7/10 vs. target <3/10) - Morphine is the gold standard first-line opioid in cancer pain ### When to Consider Alternatives - **Opioid switching:** indicated for intolerable adverse effects (e.g., morphine-induced hallucinations, severe constipation despite laxatives) - **Adjuvants:** added to opioids for neuropathic pain (gabapentin, pregabalin), bone pain (NSAIDs, bisphosphonates), or visceral pain (anticholinergics) - **Route change:** IV/SC considered only if oral intake is compromised [cite:KD Tripathi 8e Ch 31]
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