BNF for Children 2011-2012

204 4.7.2 Opioid analgesics BNFC 2011–20124 Central nervous systemOpioids are also given epidurally [unlicensed route] inthe postoperative period but are associated with sideeffectssuch as pruritus, urinary retention, nausea andvomiting; respiratory depression can be delayed, particularlywith morphine.For details of patient-controlled analgesia (PCA) andnurse-controlled analgesia (NCA) to relieve postoperativepain, consult hospital protocols. Formulationsspecifically designed for PCA are available (Pharma-Ject c Morphine Sulphate).Dental and orofacial pain Opioid analgesics arerelatively ineffective in dental pain. Like other opioids,dihydrocodeine often causes nausea and vomitingwhich limits its value in dental pain; if taken for morethan a few doses it is also liable to cause constipation.Dihydrocodeine is not very effective in postoperativedental pain.For the management of dental and orofacial pain, seep. 199.Pain management and opioid dependenceAlthough caution is necessary, patients who are dependenton opioids or have a history of drug dependencemay be treated with opioid analgesics when there is aclinical need. Treatment with opioid analgesics in thispatient group should normally be carried out with theadvice of specialists. However, doctors do not require aspecial license to prescribe opioid analgesics to patientswith opioid dependence for relief of pain due to organicdisease or injury.Dependence and withdrawal Psychological dependencerarely occurs when opioids are used for painrelief but tolerance can develop during long-term treatment;they should be withdrawn gradually to avoidabstinence symptoms. For information on the treatmentof neonatal abstinence syndrome, see section 4.10.BUPRENORPHINECautions see notes above; also impaired consciousness;effects only partially reversed by naloxoneContra-indications see notes above; also myastheniagravisHepatic impairment see notes aboveRenal impairment see notes abovePregnancy see notes aboveBreast-feeding present in low levels in breast milk—monitor neonate for drowsiness, adequate weightgain, and developmental milestonesSide-effects see notes above; can induce mild withdrawalsymptoms in children dependent on opioids;also diarrhoea, abdominal pain, anorexia, dyspepsia;vasodilatation; dyspnoea; paraesthesia, asthenia, fatigue,agitation, anxiety; less commonly flatulence,taste disturbance, hypertension, syncope, hypoxia,wheezing, cough, restlessness, depersonalisation,dysarthria, impaired memory, hypoaesthesia, tremor,influenza-like symptoms, pyrexia, rhinitis, rigors,muscle cramp, myalgia, tinnitus, dry eye, and dry skin;rarely paralytic ileus, dysphagia, diverticulitis,impaired concentration, and psychosis; very rarelyretching, hyperventilation, hiccups, and muscle fasciculationLicensed use sublingual tablets not licensed for usein children under 6 years; injection not licensed foruse in children under 6 monthsIndication and doseModerate to severe pain. By sublingual administrationChild body-weight 16–25 kg 100 microgramsevery 6–8 hoursChild body-weight 25–37.5 kg 100–200 microgramsevery 6–8 hoursChild body-weight 37.5–50 kg 200–300 microgramsevery 6–8 hoursChild body-weight over 50 kg 200–400 microgramsevery 6–8 hours. By intramuscular or by slow intravenous injectionChild 6 months–12 years 3–6 micrograms/kgevery 6–8 hours, max. 9 micrograms/kgChild 12–18 years 300–600 micrograms every 6–8 hoursAdministration for administration by mouth, tabletsmay be halvedTemgesic c (Reckitt Benckiser) 3Tablets (sublingual), buprenorphine (as hydrochloride),200 micrograms, net price 50-tab pack =£5.13; 400 micrograms, 50-tab pack = £10.26. Label: 2,26Injection, buprenorphine (as hydrochloride)300 micrograms/mL, net price 1-mL amp = 48pCODEINE PHOSPHATECautions see notes above; also cardiac arrhythmias;myasthenia gravis; acute abdomen; gallstonesVariation in metabolism The capacity to metabolise codeinecan vary considerably between individuals and lead toeither reduced therapeutic effect or marked increase in sideeffectsContra-indications see notes aboveHepatic impairment see notes aboveRenal impairment see notes abovePregnancy see notes aboveBreast-feeding amount usually too small to beharmful; however, mothers vary considerably in theircapacity to metabolise codeine—risk of morphineoverdose in infantSide-effects see notes above; also abdominal pain,anorexia, seizures, malaise, hypothermia, antidiureticeffect, and muscle fasciculation; pancreatitis alsoreportedLicensed use tablets not licensed for use in children;injection not licensed for use in children under 1yearIndication and doseMild to moderate pain. By mouth or by rectum or by subcutaneousinjection or by intramuscular injectionNeonate 0.5–1 mg/kg every 4–6 hoursChild 1 month–12 years 0.5–1 mg/kg every 4–6hours, max. 240 mg dailyChild 12–18 years 30–60 mg every 4–6 hours,max. 240 mg daily