Subcutaneous morphine therapy is effective and safe and particularly useful if parenteral therapy is required in the home setting. Subcutaneous morphine is indicated for patients unable to take or retain oral medication; in all other circumstances the oral route is to be preferred. Morphine can be given either by 4-hourly injection or by continuous infusion, via a subcutaneous butterfly needle. Infusions are given by a portable battery-operated syringe driver and, if one is available, continuous infusion is the preferred method as it avoids fluctuating blood levels and requires drug preparation only once a day. The frequency with which the needle site needs to be changed depends on how quickly local inflammation develops and varies from daily to 2 or 3 weeks.

Initial dose-Guidelines for the calculation of the initial 24 hour dose of SC morphine. These conversion factors are approximate and do not account for individual patient variation. Unrelieved or increased pain at the time of starting SC morphine will necessitate an increase in the calculated dose. A loading dose (IM or SC) equivalent to the

4-hour requirement (1/6 of 24h dose) should be given at the time of starting the infusion.

Patients who have not previously received any opioid analgesics are best treated by intermittent 4-hourly injections for 12 or 24 hours to establish the approximate dose required, rather than guessing a 24 hour dose which may either not relieve their pain or cause significant toxicity.

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Pain Relief/Muscle Relaxers