Equivalent doses of opioid analgesicsThis table is only anapproximateguide (doses may not
correspond with those given in clinical practice); children
should be carefully monitored after any change in
medication and dose titration may be required.Analgesic/Route Dose
Codeine: PO 100 mg
Diamorphine: IM, IV, SC 3 mg
Dihydrocodeine: PO 100 mg
Hydromorphone: PO 2 mg
Morphine: PO 10 mg
Morphine: IM, IV, SC 5 mg
Oxycodone: PO 6. 6 mg
Tramadol: PO 100 mg
PO = by mouth; IM = intramuscular; IV = intravenous;
SC = subcutaneousParenteral routeDiamorphine hydrochloride p. 277 is
preferred for injection because, being more soluble, it can be
given in a smaller volume. The equivalent subcutaneous
dose is approximately a third of the oral dose of morphine
p. 282. Subcutaneous infusion of diamorphine hydrochloride
via a continuous infusion device can be useful (for details,
see Continuous Subcutaneous Infusions).
If the child can resume taking medicines by mouth, then oral
morphine may be substituted for subcutaneous infusion of
diamorphine hydrochloride. See the tableApproximate
Equivalent doses of Morphine and Diamorphine.
Rectal routeMorphine is also available for rectal
administration as suppositories.
Transdermal routeTransdermal preparations of fentanyl
p. 279 and buprenorphine p. 274 [not licensed for use in
children] are available; they are not suitable for acute pain or
in those children whose analgesic requirements are changing
rapidly because the long time to steady state prevents rapid
titration of the dose. Prescribers should ensure that they are
familiar with the correct use of transdermal preparations
(see under fentanyl p. 279 ) because inappropriate use has
caused fatalities.
The following 24 -hour oral doses of morphine are considered
to beapproximatelyequivalent to the buprenorphine and
fentanyl patches shown, however when switching due to
possible opioid-induced hyperalgesia, reduce the calculated
equivalent dose of the new opioid by one-quarter to one-
half.
Buprenorphine patches areapproximately
equivalent to the following 24 -hour doses of oral
morphinemorphine salt 12 mg daily :buprenorphine’ 5 ’patch
morphine salt 24 mg daily :buprenorphine’ 10 ’patch
morphine salt 36 mg daily :buprenorphine’ 15 ’patch
morphine salt 48 mg daily :buprenorphine’ 20 ’patch
morphine salt 84 mg daily :buprenorphine’ 35 ’patch
morphine salt 126 mg daily :buprenorphine’ 52. 5 ’patch
morphine salt 168 mg daily :buprenorphine’ 70 ’patch
Formulations of transdermal patches are available as 72 -hourly,
96 -hourly and 7 -day patches, for further information see
buprenorphine in BNF. Conversion ratios vary and these figures
are a guide only. Morphine equivalences for transdermal opioid
preparations have been approximated to allow comparison with
available preparations of oral morphine.72 -hour Fentanyl patches areapproximately
equivalent to the following 24 -hour doses of oral
morphinemorphine salt 30 mg daily :fentanyl’ 12 ’patch
morphine salt 60 mg daily :fentanyl’ 25 ’patch
morphine salt 120 mg daily :fentanyl’ 50 ’patch
morphine salt 180 mg daily :fentanyl’ 75 ’patch
morphine salt 240 mg daily :fentanyl’ 100 ’patch
Fentanyl equivalences in this table are for children on well-
tolerated opioid therapy for long periods; fentanyl patches should
not be used in opioid naive children. Conversion ratios vary and
these figures are a guide only. Morphine equivalences for
transdermal opioid preparations have been approximated to allow
comparison with available preparations of oral morphine.Symptom control
Unlicensed indications or routesSeveral recommendations
in this section involve unlicensed indications or routes.
AnorexiaAnorexia may be helped by prednisolone p. 442 or
dexamethasone p. 439.
AnxietyAnxiety can be treated with a long-acting
benzodiazepine such as diazepam p. 220 , or by continuous
infusion of the short-acting benzodiazepine midazolam
p. 223. Interventions for more acute episodes of anxiety
(such as panic attacks) include short-acting benzodiazepines
such as lorazepam p. 222 given sublingually or midazolam
given subcutaneously. Temazepam p. 821 provides useful
night-time sedation in some children.
Capillary bleedingCapillary bleeding can be treated with
tranexamic acid p. 82 by mouth; treatment is usually
continued for one week after the bleeding has stopped but it
can be continued at a reduced dose if bleeding persists.
Alternatively, gauze soaked in tranexamic acid 100 mg/mL or
adrenaline/epinephrine solution 1 mg/mL ( 1 in 1000 )p. 136
can be applied to the affected area.
Vitamin K may be useful for the treatment and prevention of
bleeding associated with prolonged clotting in liver disease.
In severe chronic cholestasis, absorption of vitamin K may be
impaired; either parenteral or water-soluble oral vitamin K
should be considered.ConstipationConstipation is a common cause of distress
and is almost invariable after administration of an opioid
analgesic. It should be prevented if possible by the regular
administration of laxatives. Suitable laxatives include
osmotic laxatives (such as lactulose p. 41 or macrogols),
stimulant laxatives (such as co-danthramer p. 45 and senna
p. 46 ) or the combination of lactulose and a senna
preparation. Naloxone hydrochloride p. 842 given by mouth
may help relieve opioid-induced constipation; it is poorly
absorbed but opioid withdrawal reactions have been
reported.
ConvulsionsIntractable seizures are relatively common in
children dying from non-malignant conditions.
Phenobarbital p. 216 by mouth or as a continuous
subcutaneous infusion may be beneficial; continuous
infusion of midazolam p. 223 is an alternative. Both cause
drowsiness, but this is rarely a concern in the context of
intractable seizures. For breakthrough convulsions diazepam
p. 220 given rectally (as a solution), buccal midazolam, or
paraldehyde p. 221 as an enema may be appropriate.
SeeContinuous subcutaneous infusions, below, for the use of
midazolam by subcutaneous infusion using a continuous
infusion device.Dry mouthDry mouth may be caused by certain
medications including opioid analgesics, antimuscarinic
drugs (e.g. hyoscine), antidepressants and some antiemetics;BNFC 2018 – 2019 Prescribing in palliative care 21
Prescribing in palliative care