• Always prescribe breakthrough dose (total dose/24h divided by 10) in addition to regular dose
• If pain not controlled increase dose according to amount of breakthrough used in previous 24 hours
• Use 4hrly dosing until pain well controlled, then convert to modified release preparation and prescribe12hrly (total dose/24hr divided by 2).
• Keep required dose under constant review and adjust to give optimum pain control.

The parenteral dose is 30-50% of the oral dose if converting from oral morphine. Caution in renal and liver impairment. Pruritus and urinary retention are seen in the paediatric setting in addition to constipation and nausea and vomiting.

Licence: Sevredol® licensed in children >3yr. Oral solution licensed in children >1yr. MST® licensed for children with severe cancer pain. Suppositories are not licensed.

Diamorphine Hydrochloride

Form

Injection: 5mg, 10mg, 30mg, 100mg, 500mg
Nasal spray: 720µg/actuation and 1600µg/actuation

Diamorphine is metabolized to morphine but is more water-soluble and therefore considered more convenient for SC and i/v injection. Though Morphine is increasing the first line in all common routes of administration. Normally convert using oral morphine equivalent (OME) from previous analgesia. OME (24hr dose) is divided by 3 to give a Diamorphine subcutaneous 24hr infusion dose. Use the following start doses in opioid naïve patient. The max dose stated applies to starting dose only.

Dose: (continuous SC or IV infusion)

Neonate: 2.5µg/kg/hr (max: 7µg/kg/hr)
1 month-18yr: 7-25µg/kg/hr (initial max 10mg/24hr)

Dose (Single SC or IV injection)

Neonate: 15µg/kg every 6 hours as necessary, adjusted according to response,
Child 1-3 month: 20µg/kg every 6 hours as necessary, adjusted according to response,
Child 3-6 months: 25-50µg/kg every 6 hours as necessary, adjusted according to response,
Child 6-12 months: 75µg/kg every 4 hours as necessary, adjusted according to response,
Child 1-12 years: 75-100µg/kg every 4 hours as necessary, adjusted according to response.

Suggested initial maximum dose of 2.5mg, Child 12-18 years: 75-100µg/kg every 4 hours as necessary, adjusted according to response. Suggested initial maximum dose of 2.5-5mg.

Dose (buccal or intranasal route)

Child over 10kg: 50-100µg/kg; maximum single dose 10 mg.

Injection solution can be used by intranasal or buccal routes or Nasal spray (Ayendi®) now available and licensed for use in children aged 2 years and over (weight 12kg upwards) for the management of severe acute pain.

720µg/actuation
12-18kg: 2 sprays as a single dose
18-24kg: 3 sprays as a single dose
24-30kg: 4 sprays as a single dose

1600µg/actuation
30-40kg: 2 sprays as a single dose
40-50kg: 3 sprays as a single dose

Breakthrough

By buccal, subcutaneous or IV routes

For breakthrough pain use 5-10% of total daily diamorphine dose every 1- hours as needed.

Contraindications: In severe renal impairment, dosage interval may be lengthened or opioids given as required and titrated against symptoms. Consider converting to Fentanyl.

Licence: injection form licensed for children with terminal illness. Nasal spray licensed from 2 yrs for severe acute pain

Fentanyl Citrate

Form

Patches: for transdermal absorption over 72 hours: 12µg/hr,
25µg/hr, 50µg/hr, 75µg/hr, 100µg/hr.
Lozenge: for buccal use: 200µg, 400µg, 600µg, 800µg, 1200µg, 1600µg.
Sublingual tablets: 100, 200, 300, 400, 600, 800, 1200µg
Intranasal spray: 50, 100, 200 and 400µg/metered spray
Injection form available for use in CSCI under specialist supervision.

Useful for incident and breakthrough pain.

Dose (buccal)

2-18yrs and greater than 10kg: 15µg/kg as a single dose.

Dose (intranasal)

Neonate- 2yr: 1µg/kg as a single dose
2-18yrs: 1-2µg/kg as a single dose (initial max: 50µg)

Dose (Single intravenous injection)

Neonate - 2yr: 1-2µg/kg/dose slowly over 3-5mins every 2-4hr as required
2-18yrs: 1-2µg/kg/dose repeated every 30-60mins as required.

Dose (continuous IV infusion)

All ages: initial IV bolus 1-2µg/kg followed by 0.5-1µg/kg/hr

Dose (transdermal)

Fentanyl patches can be used as the long acting (background) opioid. See table below to convert from OME (Oral morphine Equivalent) to Fentanyl patches.

Oral morphine (mg/24h)	30mg	60mg	120mg	180mg	240mg
Fentanyl patch (µg/hr)	12	25	50	75	100

Note: With the Matrix Fentanyl patches some centers cut the patches in half to allow for starting doses at less than 12µg/hr, but this is not recommended by the manufacturers.

Converting from oral morphine sulphate to transdermal fentanyl:

• Continue oral preparation for up to 12h after starting first fentanyl patch as fentanyl patch will take 6-12h to reach therapeutic levels. Wait 24-48h before evaluating analgesic effect or changing dose
• Always provide PRN doses of oral morphine for breakthrough pain: calculate 1/10th of Oral morphine equivalent / 24hr. For a 25µg/hr patch, this would be 1/10th 60mg oral morphine, which is 6mg oral morphine 4hrly PRN
• Use new area of skin with each patch change
• Avoid exposure of patch to excessive heat (sun bathing, fever, hot water bottle, hot baths.) as heat will increase absorption

Licence: Lozenges and nasal sprays are unlicensed in children.

Injection is not licensed for use in under 2yrs of age.

Oxycodone

Alternative opioid for severe pain

Form

Capsules: OxyNorm® (immediate release) 5mg,10mg,20mg
Liquid: 5mg in 5ml
Concentrate: 10mg in 1 ml
Tablets, OxyContin® modified release: 5mg, 10mg, 20mg, 40mg, 80mg, 120mg
Injections: 10mg in 1mL, 50mg in 1mL

Doses are start doses for opiate naïve patients.

Dose (oral)

1-12 months: 50-125µg/kg every 4-6hr
1-12yr: 125-200µg/kg (max initial dose: 5mg) every 4-6hr
12-18yr: 5mg every 4-6hr

Dose (SC or IV)

Oral to IV or SC Oxycodone dose single bolus injection dose: divide Oxycodone by 1.5.
Oral to IV or SC continuous infusion Oxycodone over 24hr: divide the total daily oral Oxycodone by 1.5

Conversion

Oral Morphine 1.5: Oral oxycodone 1 i.e. Morphine 15mg to 10mg Oxycodone.

Caution: in renal and hepatic impairment

Licence: not licensed for use in children.

Buprenorphine

Form

BuTrans patch: for transdermal absorption over 7 days: 5µg/hr, 10 µg/hr, 20 µg/hr
Transtec patch: for transdermal absorption over 72hrs: 35µg/hr, 52.5 µg/hr, 70 µg/hr
Tablets (sublingual): 200µg, 400µg
Injection: 300µg/mL

Dose (Sublingual): for >6yrs only

Body weight 16–25 kg, 100µg 6-8hrly
Body weight 25–37.5 kg, 100–200µg 6-8hrly
Body weight 37.5–50 kg, 200–300µg 6-8hrly
Body weight over 50kg: 200-400µg 6-8hrly