Subcutaneous opioids for moderate, acute nociceptive pain in adults

If oral administration of an opioid is not appropriate (eg prompt analgesia is required, or the patient cannot take oral medications or has impaired gastrointestinal absorption), consider subcutaneous opioid administration for moderate, acute nociceptive pain¹. A subcutaneous opioid is an alternative to methoxyflurane if a longer duration of analgesia is required. A single subcutaneous dose may be administered in the community, but repeat doses should only be administered in hospital; see Approach to managing moderate, acute nociceptive pain.

A subcutaneous opioid should be used in addition to paracetamol and an NSAID. If oral paracetamol or an NSAID is not appropriate, see Alternative routes of administration if oral paracetamol or NSAIDs cannot be used.

Subcutaneous tramadol may be preferred to other opioids for moderate, acute nociceptive pain because it is less likely to cause excessive sedation and opioid-induced ventilatory impairment. For further information on commonly used opioids, see Overview of opioids commonly used in pain management.

Oral opioid administration should be used for ongoing analgesia. If the oral route is not appropriate, opioids may be administered subcutaneously via a subcutaneous cannula, or via patient-controlled analgesia (PCA) (seek expert advice).

If subcutaneous doses of opioids are indicated for adults with moderate, acute nociceptive pain due to an acute illness (eg uncomplicated appendicitis), or following surgery or trauma, use:

1 paracetamol immediate-release 1 g orally, 4- to 6-hourly. Maximum dose 4 g in 24 hours acute pain, moderate (adults receiving subcutaneous opioids) paracetamol

OR

1 paracetamol modified-release 1.33 g orally, 8-hourly. Maximum dose 4 g in 24 hours paracetamol

PLUS ONE OF THE FOLLOWING NSAIDS

1 celecoxib 100 to 200 mg orally, twice daily acute pain, moderate (adults receiving subcutaneous opioids) celecoxib

OR

1 ibuprofen 200 to 400 mg orally, 3 times daily² acute pain, moderate (adults receiving subcutaneous opioids) ibuprofen

OR

1 naproxen 250 to 500 mg orally, twice daily³ acute pain, moderate (adults receiving subcutaneous opioids) naproxen

PLUS (if pain is not expected to be relieved with paracetamol plus an NSAID) ONE OF THE FOLLOWING OPIOIDS

1 tramadol ⁴ acute pain, moderate, subcutaneous dosing (adults) tramadol

adults 75 years or younger: 50 mg subcutaneously, 4-to 6-hourly as required. If adequate pain relief is not achieved with a 50 mg dose, increase the dose to 100 mg subcutaneously, 4-to 6-hourly if required

adults older than 75 years: 25 to 50 mg subcutaneously, 4-to 6-hourly if required. Use the lower end of the dose range for cachectic or frail patients

OR

2 fentanyl acute pain, moderate, subcutaneous dosing (adults) fentanyl

adults 39 years or younger: 50 to 100 micrograms subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 40 to 59 years: 37.5 to 75 micrograms subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 60 to 69 years: 20 to 50 micrograms subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 70 to 85 years: 20 to 37.5 micrograms subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults older than 85 years: 15 to 25 micrograms subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

after each dose, wait 1 hour then assess the patient for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate)⁵ and determine whether pain relief is adequate. Subsequent management depends on whether the patient is treated in the community or in hospital

OR

2 morphine acute pain, moderate, subcutaneous dosing (adults) morphine

adults 39 years or younger: 5 to 10 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 40 to 59 years: 2.5 to 5 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 60 to 69 years: 1.25 to 4 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 70 to 85 years: 1.25 to 2.5 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults older than 85 years: 1 to 1.5 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

after each dose, wait 1 hour then assess the patient for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate)⁶ and determine whether pain relief is adequate. Subsequent management depends on whether the patient is treated in the community or in hospital

OR

2 oxycodone acute pain, moderate, subcutaneous dosing (adults) oxycodone

adults 39 years or younger: 5 to 10 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 40 to 59 years: 2.5 to 5 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 60 to 69 years: 1.25 to 4 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults 70 to 85 years: 1.25 to 2.5 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

adults older than 85 years: 1 to 1.5 mg subcutaneously, 4-hourly if required. Use the lower end of the dose range for cachectic or frail patients

after each dose, wait 1 hour then assess the patient for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate)⁷ and determine whether pain relief is adequate. Subsequent management depends on whether the patient is treated in the community or in hospital.

¹ There is no universal definition of moderate acute pain. The definition used in these guidelines may differ to definitions used by other organisations (including the Therapeutic Goods Administration) and literature. Return

² Avoid ibuprofen in patients at increased risk of bleeding or gastrointestinal toxicity. In these patients, celecoxib is preferred. See Nonsteroidal anti-inflammatory drugs (NSAIDs) in pain management for further advice on adverse effects and contraindications.Return

³ Avoid naproxen in patients at increased risk of bleeding or gastrointestinal toxicity. In these patients, celecoxib is preferred. See Nonsteroidal anti-inflammatory drugs (NSAIDs) in pain management for further advice on adverse effects and contraindications.Return

⁴ Concurrent use of tramadol with other serotonergic drugs increases the risk of serotonin toxicity (see Drugs most commonly associated with serotonergic toxidrome for drugs associated with serotonin toxicity).Return

⁵ If the patient cannot be monitored (eg is being treated with oral opioids at home), they should be educated about opioid-induced ventilatory impairment and how to safely use an opioid for acute pain at home; see How to use an opioid for acute pain at home.Return

⁶ If the patient cannot be monitored (eg is being treated with oral opioids at home), they should be educated about opioid-induced ventilatory impairment and how to safely use an opioid for acute pain at home; see How to use an opioid for acute pain at home Return

⁷ If the patient cannot be monitored (eg is being treated with oral opioids at home), they should be educated about opioid-induced ventilatory impairment and how to safely use an opioid for acute pain at home; see How to use an opioid for acute pain at home Return