Skip to main content
  1. Right Decisions
  2. Scottish Palliative Care Guidelines
  3. Pain
  4. Back
  5. Pain medicines / analgesics
  6. Alfentanil
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Alfentanil

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Potent opioid, rapid onset and short duration of action.

Third-line opioid: only for use with specialist advice.

Caution: Do not confuse with Fentanyl. Fentanyl is four times more potent than alfentanil. 

Preparations

Tables are best viewed in landscape mode on mobile devices

Injection 1mg in 2ml
5mg in 10ml (not routinely used) 5mg in 1ml (high strength)		 Ampoules
  • Used as a subcutaneous infusion or sublingually. (The ampoules can be opened and administered sublingually ⴕ).
  • A high concentration preparation (5mg in 1ml) can be ordered.
Caution with high strength preparation; refer to local policy for its use.
Sublingual/
buccal spray		 5mg/5ml (1 metered dose = 140 micrograms) 5ml spray Pharmacist can order spray on a named patient basis if advised by a palliative care specialist (check local NHS board for availability).

 

Indications

  • Third-line injectable opioid for moderate to severe opioid responsive pain in patients unable to tolerate morphine, diamorphine or oxycodone due to persistent side effects (for example sedation, confusion, hallucinations, itch). Refer to Pain management, Choosing and changing opioids guidelines.
  • Injectable analgesic for moderate to severe, opioid responsive pain in patients with Stage 4 to 5 chronic kidney disease (eGFR less than 20ml/min) although specialists may recommend earlier, or severe acute renal impairment.
  • Episodic/incident pain:
    • pain often related to a particular event (for example movement, dressing changes); sudden in onset, can be severe, but may not last long
    • different from breakthrough pain occurring when the dose of regular analgesic has worn off
    • assessed and treated independently of the regimen used to manage any continuous/background pain. 

 

Cautions

  • Liver impairment: reduced clearance.
    Dose reduction of 30 to 50% may be necessary.
  • Renal impairment: no dose reduction needed.
    Not removed by dialysis.

Drug interactions

  • Hepatic metabolism is reduced by grapefruit juice and a number of medications, for example fluconazole, QTclarithromycin, QTerythromycin: refer to British National Formulary (BNF).
  • Alcohol and central nervous system depressants increase side effects
  • Anticonvulsants may reduce its effect. Refer to BNF.

Side effects

Similar to other opioids: nausea, dizziness, sedation, delirium, rarely respiratory depression.

 

Dose and administration

  1. Alfentanil for moderate to severe opioid responsive pain
    • Continuous subcutaneous infusion in a CME T34 syringe pump over 24 hours.
    • Stability and compatibility – refer to CME T34 syringe pump compatibility tables.
    • Titrate on the advice of a specialist.
    • Prescribe doses of over 1000micrograms in milligrams (mg).
    • Prescribe 1/6th to 1/10th of the 24 hour dose hourly for breakthrough pain as alfentanil has a very short duration of action. The same dose can be given subcutaneously or sublingually. Sometimes other opioids with a longer duration of action are used for breakthrough pain.  If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review.  If more than 6 doses are required in 24 hours seek advice or review.

  2. Alfentanil for episodic/ incident pain
    • Starting dose: 100micrograms.
    • Give a dose five minutes before an event likely to cause pain, for example, a painful dressing change; repeat if needed.
    • Increase dose according to response.  This dose is titrated independently of the background dose.
    • Give by subcutaneous injection or sublingually at the same dose.
    • Consider an alfentanil spray if the patient is being discharged home (check local health board for availability).

 

Dose conversions

Alfentanil is approximately (≈) 30 times more potent than oral morphine.

Tables are best viewed in landscape mode on mobile devices

Oral morphine 30mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Subcutaneous morphine 15mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Subcutaneous diamorphine 10mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Oral oxycodone 15mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Subcutaneous oxycodone 7.5mg ≈ subcutaneous alfentanil 1mg (1000micrograms)

 

A patient whose pain is controlled on a subcutaneous alfentanil infusion can be converted to a fentanyl patch. Apply the patch and stop the infusion 12 hours later. Seek advice for dose conversions as cross titration may be necessary.

  • Dose conversions should be conservative and doses rounded down.
  • Monitor the patient carefully so that the dose can be adjusted if necessary.
  • If the patient has opioid toxicity, reduce dose by approximately 1/3rd when changing opioid (refer to Choosing and changing opioids guideline).

 

Practice points

  • The community pharmacist, GP and community nurse should be informed as preparations may not be readily available.
  • The unscheduled care service should be informed that the patient is receiving this third-line opioid.
  • Alfentanil can be prescribed by the patient’s GP for the indications listed in liaison with local palliative care specialists.

 

Resources

Professional
Royal Pharmaceutical Society. Palliative Drugs. 2018 [cited 2018 Oct 02]; Available from: http://www.palliativedrugs.com/.

 

References

Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504.

Urch CE, Carr S, Minton O. A retrospective review of the use of alfentanil in a hospital palliative care setting. Palliat Med. 2004;18(6):516-9.