Best given by mouth PRN at first then by the clock . Monitor response . Step 1 - paracetamol/nsaid and adjuvants as needed ( gabapentine , amitryptilline,nsaids )

Step 2 weak opiod lole cocadomol/coproxamol , adjuvants , steroids

Step 3 strong opiod lole morphine plus voltarol plus paracetamol plus steroids . - oramorph or mst tablets by mouth Opioids

Morphine , diamorphine (equivalent to 3x morphine eg 30mg morphine=10mg diamorphine) , oxycodone(morphine 20,g=10mg oxycodone) , buprenorphine (transtec) or fentany patch( 25mcg/hr= morphine 75mg=diamorphine 25mg. Morphine 10,g=tramadol 5mg orally. fentanyl is not effecive if pain is not relived by morphine . Useful if there is renal faliure or intolerant of side effects of morphine.

Laxatives

Codanthramer is licensed only in terminal care , is a stimulatn and a softer , can case griping pain , and is in capsule and syrup form . Increase dose when opiod dose is increased. Give antiemetic for nausea

Steroids very useful but have long term effects after two months -suhingoid , diabetes mellitus etc.. Very good in anorexia and lethargy, give a two week trial .

Spinal cord compression with back pain , upgoing plantars , urine and feces retention .

Hypercalacemia can manifest as confusion , drowsniness and needs iv fluids ,bisphosphonates .