Intravenous opioids for severe, acute nociceptive pain in adults

The intravenous route of administration is preferred to oral or subcutaneous opioid administration for severe, acute nociceptive pain because the fast onset of effect provides prompt analgesia. Intravenous opioids should only be administered in hospitals with staffing and resources that allow immediate resuscitation of a patient with opioid-induced ventilatory impairment; see Using opioids in hospital. Intravenous opioids should rarely be used outside critical care areas (eg emergency departments, intensive care units, postoperative recovery units).

An intravenous opioid should be used in addition to paracetamol and an NSAID for severe, acute nociceptive pain. If oral paracetamol or an NSAID is not appropriate, see Alternative routes of administration if oral paracetamol or NSAIDs cannot be used. For advice on choosing an opioid or the route of administration for severe, acute nociceptive pain, see Approach to managing severe, acute nociceptive pain.

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).

The initial intravenous opioid dose for severe, acute nociceptive pain depends on whether the patient has already received an opioid (eg intraoperatively, before hospital admission) and the treatment setting:

loading doses should not be used for patients if they have already received an opioid or if they are being treated outside of a monitored acute care setting because the risk of opioid toxicity is increased
loading doses are used for patients if they have not already received an opioid and they are being treated in a monitored acute care setting.

Local protocols for critical care areas may set out an alternative approach to intravenous opioid dosing for severe, acute nociceptive pain. Always refer to local protocols when they are available.

Note: Always refer to local protocols when they are available.

If a patient has already received an opioid (eg intraoperatively, before hospital admission) or is not being treated in a monitored acute care setting, 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 intravenous 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 intravenous opioids) celecoxib

OR

1 ibuprofen 200 to 400 mg orally, 3 times daily¹ acute pain, severe (adults receiving intravenous opioids) ibuprofen

OR

1 naproxen 250 to 500 mg orally, twice daily² acute pain, severe (adults receiving intravenous opioids) naproxen

PLUS ONE OF THE FOLLOWING OPIOIDS

1 fentanyl acute pain, severe, intravenous dosing (adults) fentanyl

adults 69 years or younger who are not frail or cachectic: 15 to 30 micrograms intravenously, for the first dose

adults who are frail or cachectic, or who are older than 69 years: 7.5 to 15 micrograms intravenously, for the first dose

after the first dose, wait 5 minutes 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 Example of intravenous opioid dose titration in hospital for severe, acute nociceptive pain in adults and children for subsequent doses, including maximum doses

OR

1 morphine acute pain, severe, intravenous dosing (adults) morphine

adults 69 years or younger who are not frail or cachectic: 1 to 2 mg intravenously, for the first dose

adults who are frail or cachectic, or older than 69 years: 0.5 to 1 mg intravenously, for the first dose

after the first dose, wait 5 minutes 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 Example of intravenous opioid dose titration in hospital for severe, acute nociceptive pain in adults and children for subsequent doses, including maximum doses

OR

1 oxycodone acute pain, severe, intravenous dosing (adults) oxycodone

adults 69 years or younger who are not frail or cachectic: 1 to 2 mg intravenously, for the first dose

adults who are frail or cachectic, or older than 69 years: 0.5 to 1 mg intravenously, for the first dose

after the first dose, wait 5 minutes 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 Example of intravenous opioid dose titration in hospital for severe, acute nociceptive pain in adults and children for subsequent doses, including maximum doses.

If a patient has not already received an opioid (eg intraoperatively, before hospital admission) and is being treated in a monitored acute care setting, as a three-drug regimen, use:

1 paracetamol immediate-release 1 g orally, 4- to 6-hourly. Maximum 4 g in 24 hours 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 celecoxib

OR

1 ibuprofen 200 to 400 mg orally, 3 times daily¹ ibuprofen

OR

1 naproxen 250 to 500 mg orally, twice daily² naproxen

PLUS ONE OF THE FOLLOWING OPIOIDS

1 fentanyl fentanyl

adults 69 years or younger who are not frail or cachectic: 30 to 75 micrograms intravenously, for the first dose

adults who are frail or cachectic, or older than 69 years: 15 to 30 micrograms intravenously, for the first dose

after the first dose, wait 5 minutes 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 Example of intravenous opioid dose titration in hospital for severe, acute nociceptive pain in adults and children for subsequent doses, including maximum doses

OR

1 morphine morphine

adults 69 years or younger who are not frail or cachectic: 2 to 5 mg intravenously, for the first dose

adults who are frail or cachectic, or older than 69 years: 1 to 2 mg intravenously, for the first dose

after the first dose, wait 5 minutes 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 Example of intravenous opioid dose titration in hospital for severe, acute nociceptive pain in adults and children for subsequent doses, including maximum doses

OR

1 oxycodone oxycodone

adults 69 years or younger who are not frail or cachectic: 2 to 5 mg intravenously, for the first dose

adults who are frail or cachectic, or older than 69 years: 1 to 2 mg intravenously, for the first dose

after the first dose, wait 5 minutes 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 Example of intravenous opioid dose titration in hospital for severe, acute nociceptive pain in adults and children for subsequent doses, including maximum doses.

¹ 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

² 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