Page 96 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

Domains and considerations

Quality of evidence A1
The panel based its recommendation against the intramuscular route on the value judgement that
pain should not be inflicted in the administration of a medicine. There is inadequate evidence to
support a preference for routes of administration other than the oral (Annex 4. Evidence retrieval
and appraisal, GRADE tables 11–15 and other studies on strong opioids reported on in Annex 4,
Section A4.3). The available studies dealt with management of acute or post-operative pain and did
not provide conclusive evidence to guide recommendations.
Uncertainty: yes.
A2 A2

Risks/benefits
Benefits
The oral route of administration is usually the least expensive and most convenient. The
subcutaneous route (via continuous infusion or intermittent bolus through an indwelling catheter) is
widely used.
Risks A3
The intramuscular route causes unnecessary pain.
Uncertainty: none.

Values and acceptability
In favour
The panel recognizes that some patients may not be able to take oral medication, and other routes
are required. A4
Against
Intramuscular administration is considered unacceptable, as alternatives exist.
Uncertainty: none.

Cost
Oral medications are normally less expensive than other routes of administration. Patient-controlled A5
analgesia techniques sometimes require access to expensive equipment.
Uncertainty: none.

Feasibility
The feasibility of employing different routes of administration depends on the setting.
Uncertainty: yes.
A6

Research agenda
Trials on the safety and efficacy of different routes of administration of opioids are needed.

A2.2.8 Breakthrough pain
Clinical question A7
In children with persisting pain due to medical illnesses, what is the evidence for the benefit of using
immediate-release morphine (in addition to regular background analgesia), in preference to other
strong opioids and routes of administration for breakthrough pain?

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