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  5. Pain medicines / analgesics
  6. Fentanyl sublingual (Abstral)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Fentanyl sublingual (Abstral)

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Contains fentanyl, a potent opioid analgesic with a rapid onset of action.

Do not confuse with Alfentanil

Third line opioid: only for use with specialist advice

  • This guideline is for the use of Abstral – a dispersible, sublingual fentanyl tablet (available as 100, 200, 300, 400, 600, 800 micrograms).
  • Most NHS boards have only approved one or two rapid acting fentanyl products for use in their area. Refer to your local Formulary (see Effentora and PecFent medicine information sheets).
  • Rapid acting fentanyl products have different absorption and elimination characteristics and are not interchangeable. Start with the lowest dose and titrate very carefully if the patient is changed to a different product.
  • The brand name should always be included in the prescription.

 

  • Rapid acting fentanyl preparations are SMC approved for restricted use in NHS Scotland; for the management of opioid responsive, breakthrough pain in adults requiring regular opioid therapy for chronic cancer pain.
  • Use is restricted to patients where other oral opioids (immediate release morphine or immediate-release oxycodone) are unsuitable, ineffective or not tolerated.
  • Patients must have been on a stable dose of a regular opioid for at least 7 days equivalent to at least 60mg of oral morphine or 30mg of oral oxycodone in 24 hours or a 25 micrograms/hour fentanyl patch before rapid acting fentanyl is used.
  • Opioids with a rapid onset of action can be effective in breakthrough pain where background cancer pain is well controlled but the patient has:
    • pain related to a particular event (for example movement, dressing changes).
    • pain that occurs spontaneously, is sudden in onset, is moderate to severe, but may not last long.

 

  • Hepatic metabolism to an inactive metabolite is slower when higher doses of fentanyl are used.
  • Rapid acting fentanyl products can have a variable and unpredictable half life which in some products can be up to 22 hours.
  • Liver impairment: lower doses and slower titration are needed in severe liver disease.
  • Renal impairment: no initial dose reduction. May accumulate gradually over time in patients with Grade 4 to 5 chronic kidney disease. Fentanyl is not removed by dialysis.
  • Monitor patients with liver or renal impairment and reduce the dose if side effects develop.
  • Avoid in patients with severe chronic obstructive pulmonary disease or respiratory depression.
  • Mouth ulcers or mucositis can affect absorption.

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.
  • Manufacturers warn of a risk of serotonin toxicity when fentanyl is used in combination with other serotoninergic drugs.

Side effects

Similar to other opioids: nausea, dizziness, sedation, delirium.

  • Rapid acting fentanyl preparations can accumulate if repeated doses are given.
  • Monitor the patient closely for opioid side effects; review the dose and dosing interval.

Titrated naloxone is only indicated in life-threatening, opioid induced respiratory depression (refer to Naloxone guideline).

 

  • Rapid acting fentanyl preparations must be individually titrated to an effective dose; patients should be monitored closely during the initial dose titration period.
  • The effective dose of rapid acting fentanyl cannot be predicted from the dose of regular opioid being used to manage background pain.
  • The licensed titration regimen may be too complex for some care settings and too rapid for some patients. In specialist palliative care there is little consensus on the most appropriate way to titrate the rapid acting fentanyl preparations – refer to local specialist advice. The regimen below is used by some specialists but is unlicensed (patients under specialist palliative care may have the dose escalated more quickly):
  • Start with the lowest dose of the sublingual fentanyl tablet (Abstral 100 micrograms):
    • one dose of Abstral can be given to treat an episode of pain or 5 to 10 minutes before an event anticipated to cause pain
    • if the patient can be monitored and is not at risk of opioid toxicity, a second tablet of 100 micrograms can be given after 15 to 30 minutes, if required
    • if the patient is still in pain after taking one or two tablets of Abstral as above, a dose of their usual immediate release oral opioid can be given
    • wait for 2 hours before treating another episode of breakthrough pain with Abstral – see table below.

Tables are best viewed in landscape mode on mobile devices

Strength of FIRST sublingual tablet per episode of breakthrough pain Strength of SECOND sublingual tablet to be taken 15 to 30 minutes after first tablet, if required
100 micrograms 100 micrograms
200 micrograms 100 micrograms
300 micrograms 100 micrograms
400 micrograms 200 micrograms
600 micrograms 200 micrograms
800 micrograms NONE – efficacy and safety of doses > 800 micrograms have not been evaluated.
  • A maximum of 4 episodes of breakthrough pain in 24 hours should be treated with sublingual fentanyl tablets.
  • The dose of Abstral can be increased in a stepwise manner if it is showing some effect and is well tolerated, usually after 24 to 48 hours. Palliative care specialists may recommend an individualised titration regimen.
    • Continue to monitor the patient carefully.
  • Make sure background pain is well controlled with regular opioids and other analgesics.
  • If pain remains poorly controlled, review the patient, reassess the background analgesia, and consider other approaches to pain management.
  • Rapid acting fentanyl should be discontinued if it is ineffective or no longer needed.

 

  • Seek advice from a specialist about use of rapid acting fentanyl products.
  • Fentanyl is 100 to 150 times more potent than oral morphine; titrate and monitor carefully.
  • Even the lowest strength preparations can accumulate and cause opioid toxicity.
  • Different rapid acting fentanyl products should not be used at the same time.
  • The GP, community nurse and community pharmacist should be informed.
  • The unscheduled care service should be informed that the patient is receiving a third-line opioid under specialist supervision.
  • Fentanyl sublingual tablets (Abstral®) can be prescribed by the patient’s GP in liaison with local palliative care specialists.
  • The patient should have information about who to contact if there are any queries or problems relating to use of Abstral® in the community. 

 

Summary of product characteristics for Abstral from the electronic medicines compendium

 

Davies A. The management of cancer related breakthrough pain: recommendations of a task group of the Association for Palliative Medicine. European Journal of Pain; 2009, 13 (4): 331-338.