Intranasal opioids for severe, acute nociceptive pain in adults

The intranasal 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. Intranasal fentanyl should only be administered in hospitals or ambulance services with staffing and resources that allow immediate resuscitation of a patient with opioid-induced ventilatory impairment, see Using opioids in hospital. Intranasal fentanyl should rarely be used outside critical care areas (eg emergency departments). Always refer to local protocols when they are available.

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

Intranasal fentanyl 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.

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

If intranasal fentanyl is indicated for initial analgesia in adults with severe, acute nociceptive pain due to an acute illness or following 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 intranasal 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 intranasal opioids) celecoxib

OR

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

OR

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

PLUS

fentanyl 50 micrograms/mL solution³ acute pain, severe, intranasal dosing (adults) fentanyl

adults 49 years or younger: 75 to 100 micrograms intranasally, via atomiser attached to a small syringe. Spray up to 0.3 mL (15 micrograms) into each nostril, alternating between nostrils up to the required dose⁴.Use the lower end of the dose range for cachectic or frail patients

adults 50 to 75 years: 50 to 75 micrograms intranasally, via atomiser attached to a small syringe. Spray up to 0.3 mL (15 micrograms) into each nostril, alternating between nostrils up to the required dose⁵.Use the lower end of the dose range for cachectic or frail patients

adults older than 75 years: 25 to 50 micrograms intranasally, via atomiser attached to a small syringe. Spray up to 0.3 mL (15 micrograms) into each nostril, alternating between nostrils up to the required dose⁶. Use the lower end of the dose range for cachectic or frail patients

after each 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. If the patient does not have signs of opioid-induced ventilatory impairment and pain relief is inadequate, a repeat dose can be given while establishing an alternative route of administration.

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

³ A 300 micrograms/mL solution is available in some hospitals; due to the smaller volume required, dividing the dose between nostrils may not be necessary.Return

⁴ The dose is divided into actuations because volumes over 0.3 mL are unlikely to be absorbed from the nasal mucosa; excess solution runs down the back of the throat limiting the effect due to poor gastrointestinal absorption of the swallowed portion.Return

⁵ The dose is divided into actuations because volumes over 0.3 mL are unlikely to be absorbed from the nasal mucosa; excess solution runs down the back of the throat limiting the effect due to poor gastrointestinal absorption of the swallowed portion.Return

⁶ The dose is divided into actuations because volumes over 0.3 mL are unlikely to be absorbed from the nasal mucosa; excess solution runs down the back of the throat limiting the effect due to poor gastrointestinal absorption of the swallowed portion.Return