Subcutaneous opioids for severe, 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), or intranasal or intravenous administration is not available (eg the patient is being treated in a non–critical care area), consider subcutaneous opioid administration for severe, acute nociceptive pain. For advice on choosing an opioid or the route of administration for severe, acute nociceptive pain, see Approach to managing severe, 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.
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 severe, acute nociceptive pain due to an acute illness (eg biliary colic), or following surgery or trauma, as a three-drug regimen, use:
1 paracetamol immediate-release 1 g orally, 4- to 6-hourly. Maximum 4 g in 24 hours acute pain, severe (adults receiving subcutaneous opioids) paracetamol
OR
1 paracetamol modified-release 1.33 g orally, 8-hourly. Maximum 4 g in 24 hours paracetamol
PLUS ONE OF THE FOLLOWING NSAIDS
1 celecoxib 100 to 200 mg orally, twice daily acute pain, severe (adults receiving subcutaneous opioids) celecoxib
OR
1 ibuprofen 200 to 400 mg orally, 3 times daily1 acute pain, severe (adults receiving subcutaneous opioids) ibuprofen
OR
1 naproxen 250 to 500 mg orally, twice daily2 acute pain, severe (adults receiving subcutaneous opioids) naproxen
PLUS ONE OF THE FOLLOWING OPIOIDS
1 fentanyl acute pain, severe, subcutaneous dosing (adults) fentanyl
adults 39 years or younger: 100 to 200 micrograms subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 40 to 59 years: 75 to 150 micrograms subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 60 to 69 years: 40 to 100 micrograms subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 70 to 85 years: 40 to 75 micrograms subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults older than 85 years: 30 to 50 micrograms subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses 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) and determine whether pain relief is adequate. See Opioid dose titration in hospital for subsequent management, including top-up doses
OR
1 morphine acute pain, severe, subcutaneous dosing (adults) morphine
adults 39 years or younger: 7.5 to 12.5 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 40 to 59 years: 5 to 10 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 60 to 69 years: 2.5 to 7.5 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 70 to 85 years: 2.5 to 5 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults older than 85 years: 2 to 3 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses 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) and determine whether pain relief is adequate. See Opioid dose titration in hospital for subsequent management, including top-up doses
OR
1 oxycodone acute pain, severe, subcutaneous dosing (adults) oxycodone
adults 39 years or younger: 7.5 to 12.5 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 40 to 59 years: 5 to 10 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 60 to 69 years: 2.5 to 7.5 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 70 to 85 years: 2.5 to 5 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults older than 85 years: 2 to 3 mg subcutaneously, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses 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) and determine whether pain relief is adequate. See Opioid dose titration in hospital for subsequent management, including top-up doses.