Loss of control of pain
There is no upper limit for strong opiates in palliative care but if the pain is not controlled despite rapidly escalating doses consider:
- fracture or impending fracture
- hypercalcaemia, a common cause of worsening bone pain
- urinary retention
- constipation
- compliance: patients may dislike opiate owing to nausea, sedation, confusion, groundless fears or uncertainty as to the dose
- failure to absorb eg vomiting
- neuropathic origin of pain
- new or other pathology, related or unrelated to cancer such as angina
- depression or psychological distress
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