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5. Rectal administration of single doses of paracetamol results in highly variable plasma
concentrations that often remain subtherapeutic (N) (Level II).
6. Intermittent subcutaneous morphine injections are as effective as intramuscular injections
and have better patient acceptance (U) (Level II).
7. Intranasal opioids, in particular the more lipid‐soluble drugs such as fentanyl, are effective
for the management of acute pain (N) (Level II).
8. Continuous intravenous infusion of opioids in the general ward setting is associated with
an increased risk of respiratory depression compared with other methods of parenteral
opioid administration (U) (Level IV).
9. Transdermal fentanyl should not be used in the management of acute pain because of
safety concerns and difficulties in short‐term dose adjustments needed for titration;
furthermore, in most countries, it lacks regulatory approval for use in other than opioid‐
tolerant patients (S) (Level IV).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Other than in the treatment of severe acute pain, and providing there are no
contraindications to its use, the oral route is the route of choice for the administration of
most analgesic drugs (U).
Titration of opioids for severe acute pain is best achieved using intermittent intravenous
bolus doses as it allows more rapid titration of effect and avoids the uncertainty of drug
absorption by other routes (U).
CHAPTER 6 Controlled‐release opioid preparations should only be given at set time intervals (U).
Immediate‐release opioids should be used for breakthrough pain and for titration of
controlled‐release opioids (U).
The use of controlled‐release opioid preparations as the sole agents for the early
management of acute pain is discouraged because of difficulties in short‐term dose
adjustments needed for titration (U).
Neither oral transmucosal fentanyl citrate nor fentanyl buccal tablets should be used in the
management of acute pain because of safety concerns and, in most countries, lack of
regulatory approval for use in other than opioid‐tolerant patients (N).
REFERENCES
Abboud TK, Zhu J, Gangolly J et al (1991) Transnasal butorphanol: a new method for pain relief in post‐
cesarean section pain. Acta Anaesthesiol Scand 35(1): 14–8.
Anderson B, Kanagasundarum S & Woollard G (1996) Analgesic efficacy of paracetamol in children using
tonsillectomy as a pain model. Anaesth Intensive Care 24(6): 669–73.
Anderson BJ, Holford NH, Woollard GA et al (1999) Perioperative pharmacodynamics of acetaminophen
analgesia in children. Anesthesiology 90(2): 411–21.
Ashburn MA, Lind GH, Gillie MH et al (1993) Oral transmucosal fentanyl citrate (OTFC) for the treatment
of postoperative pain. Anesth Analg 76(2): 377–81.
Aubrun F, Monsel S, Langeron O et al (2001) Postoperative titration of intravenous morphine. Eur J
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164 Acute Pain Management: Scientific Evidence
