Using opioids in hospital

All hospitals should have local protocols to ensure safe opioid administration, including paediatric protocols if the hospital treats children. Local protocols should include advice on:

  • opioid dose titration
  • monitoring for and managing adverse effects (in particular opioid-induced ventilatory impairment)
  • escalating care
  • resuscitation
  • staff training requirements relevant to the clinical setting (including age-appropriate pain assessment).

Some ambulance services may meet the requirements for safe opioid administration in hospital.

At a minimum, staff should be available to monitor the patient at the time the peak effect of the opioid dose is expected (eg 1 hour after oral or subcutaneous dosing) and before administering a repeat dose. Staff must be able to recognise and respond to the signs of opioid-induced ventilatory impairment. If administering opioids to an infant or child, staff involved must be experienced in assessing and resuscitating paediatric patients.

Maximum doses are difficult to pre-emptively define for an individual patient when opioids are prescribed ‘as required’ to a patient. In hospital, a maximum sedation score (eg sedation score less than 2) may be specified on a patient’s medication chart instead of a maximum dose per 24 hours. If a maximum sedation score is specified, the hospital’s protocol must specify a standard sedation scoring system and process for recording the scores; see here for suggested sedation scores.

Opioid doses should be conservative (using the dose regimens for moderate, acute nociceptive pain) when there are inadequate staff and resources to immediately identify and resuscitate a patient who develops opioid-induced ventilatory impairment. For example, in a hospital without medical staff on site at all times, conservative opioid doses should be used because immediate response to a patient who deteriorates is not assured. However, a hospital with critical care and medical staff on site at all times to immediately identify and respond to opioid-induced ventilatory impairment can use the higher opioid doses and shorter dosing intervals recommended for severe, acute nociceptive pain.

Intravenous and intranasal opioids are associated with a high risk of opioid-induced ventilatory impairment and should rarely be used outside critical care areas (eg emergency departments, intensive care units, postoperative recovery units).