Second-line opioids

(refer to oxycodone information sheet)

• For moderate to severe pain if morphine/diamorphine are not tolerated.
• Immediate and modified release oral preparations (ensure correct preparation is prescribed); SC injection; syringe pump (CSCI).
• Lower concentration preparation limits dose for SC injection to 20mg (2ml). (In some NHS boards, a 50mg/ml injection is available – check local guidance.)
• Avoid in moderate to severe liver impairment, where clearance is much reduced.
• Mild to moderate renal impairment: reduced clearance so titrate slowly and monitor carefully.
• Avoid modified release preparations in stage 4 and 5 Chronic Kidney Disease. Immediate release preparations may be used with caution for breakthrough pain.
• Avoid use of Oxylan and Oxyact in people with soya and peanut allergy. 

(refer to fentanyl patches information sheet and consider seeking specialist advice)

• Transdermal patch lasting 72 hours; use if oral and SC routes are unsuitable.
• Consider only if tolerant to opioids as this is a very potent opioid. A 12 microgram/hour fentanyl patch is equivalent to about 30mg to 60mg of oral morphine in 24 hours. Inappropriate use can cause fatal overdose.
• For stable pain if morphine not tolerated; dose cannot be changed quickly.
• No initial dose reduction in renal impairment but may accumulate over time as it is cleared through the kidneys. Consider changing every 96 hours if eGFR<30ml/min, pain is well controlled but the patient has shown signs of mild toxicity. Consider seeking specialist advice in this situation.
• Liver impairment; dose reduction may be needed in severe liver disease.
• Do not initiate in the last days of life when the oral route is no longer available (can take too long to reach steady state) – refer to fentanyl patches information sheet. If a patient is already on a fentanyl patch and in the last days of life, refer to fentanyl patches information sheet.