Prescribing and administration guideline for Alfentanil spray in a palliative care setting

Alfentanil is a strong lipophylic opioid with agonist activity at mu and kappa opiate receptors. When administered by the buccal or nasal route, it works quickly and the effects last 10-15 minutes. It may, therefore, be helpful for both incident and spontaneous pain:

• Incident (predictable pain): is related to movement or activity. This might be in association with personal care, dressing changes, or transfers, for example.
• Spontaneous (unpredictable pain): is unrelated to movement or activity. Alfentanil may be an alternative for patients who do not tolerate immediate release Morphine or Oxycodone. However, Alfentanil has a shorter duration of action.

Alfentanil is a third line opioid and should be used under specialist advice. For hospital in-patients, it is normally more cost effective to use the intravenous vials of Alfentanil and administer it sublingually. However, patients may bring their own sprays in to hospital, or may need to practice using the spray in preparation for discharge home.

Do not confuse Alfentanil with Fentanyl; Fentanyl is four times more potent than Alfentanil.

1. Assembling the spray

Alfentanil spray bottles come in 4 parts:

• A glass bottle containing 5mg in 5ml Alfentanil
• A plastic bag containing the other 3 parts:
  • The pump mechanism which screws into the glass bottle
  • A buccal spray head with a 4 inch long delivery tube
  • A nostril shaped spray head with a clear plastic cover

Alfentanil is usually administered buccally. To ensure clarity, if the spray is prescribed for use by the buccal route, please dispose of the nostril spray head. Conversely, if the spray is prescribed for use by the nasal route, please dispose of the buccal spray head. Open the glass bottle and screw the pump mechanism and spray head into it.

Before using the pump for the first time, it will need to be primed. This is achieved by fully depressing the spray button two or three times which fills the pump mechanism.
This only needs to be done when setting up the pump for the first time, not before each use.

2. Administering the spray

To administer the spray, place the delivery tube inside the mouth or nose as appropriate and spray the prescribed number of doses. For buccal use, spray onto the inside of the cheek.

1. Ward stock

Alfentanil is a Schedule 2 controlled drug and must be ordered and stored following the normal procedures for controlled drugs.

Order Alfentanil spray in a Controlled Drug (CD) order book, including the patient’s name and CHI number. Pharmacy will add a patient specific label to the bottle during dispensing – note, this will only contain patient name, CHI and ward, no dosing information will be attached. Once order received from Pharmacy, document supply in ward CD book and then transfer 1 bottle from ward stock to a new page in the CD register specific for that patient and record as “Alfentanil 5mg/5ml for xxx (patient’s name)". The spray should be kept in the CD cupboard.

Each time a dose is given, record the number of sprays administered. Do not forget to record the number of sprays needed to prime the bottle when a new bottle is started. Each bottle should deliver 35 sprays – including the 2 or 3 required to prime it. Use this number as the total in the number received column and reduce the total after each use by the number of sprays used. For example:

2. Discharge prescriptions

If a patient is discharged from the BGH using an Alfentanil spray, sufficient supply will be given to the patient on discharge. The use of the spray will be highlighted on the discharge letter and these instructions will accompany the letter.

Alfentanil spray is unlicensed. It is manufactured by Torbay hospital as a special order. Community pharmacies can order supplies of Alfentanil spray, however this can take a few days therefore patients should be discharged with sufficient stock.
Contact ward pharmacist if advice is required.

Issued by the Specialist Palliative Care Team, Margaret Kerr Unit, BGH.

Adapted from guidelines including the Scottish Palliative Care Guidelines, The Royal Bournemouth and Christchurch Hospitals NHS Trust, St Christopher’s Hospice and palliativedrugs.com.

For further advice or guidance please contact the Palliative Care Team by email (palliativecareteam@borders.scot.nhs.com) or duty bleep 6838, or Pharmacy on 01896 826610 or consult www.palliativecareguidelines.scot.nhs.uk