Third-line opioids (seek specialist advice)

(refer to alfentanil information sheet)

• Alfentanil is a potent opioid: 1mg of alfentanil is roughly equivalent to 30mg oral morphine.
• Short-acting, injectable opioid for SC injection and in a syringe pump (CSCI).
• In episodic/incident pain, it can be given sublingually (an unlicensed †spray is available) or subcutaneously.
• Dose does not need to be reduced in renal disease including stage 4 and 5 Chronic Kidney Disease.
• Clearance may be reduced in liver impairment; reduce dose and titrate.
• Drug of choice if eGFR<20ml/hr, although may be recommended  earlier by specialists and syringe pump required
• Useful if severe pain and toxicity.
• Please seek specialist advice when switching from a CSCI of alfentanil to an alternative opioid.

sublingual/buccal/intranasal

• These are potent preparations. Before rapid acting fentanyl is used, patients must have been on a stable dose of a regular opioid for approximately 7 days equivalent to a minimum of 60mg oral morphine or 30mg of oral oxycodone in 24 hours or a
  25 micrograms/hour fentanyl patch.
• In episodic/incident pain, fentanyl can be given sublingually (Abstral®, Effentora®), buccal (Effentora®) or intranasally (PecFent® – check local guidance for preferred preparation and refer to Abstral®, Effentora® or PecFent® guidelines. These products are not interchangeable due to different absorption profiles.
• The effective dose of transmucosal fentanyl cannot be predicted from the background dose of opioid. Start at the lowest dose and titrate upwards to determine the effective dose.
• 100microgram fentanyl is approximately equivalent to 15mg of oral morphine.