Best Evidence Topics
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Intranasal diamorphine in adults with severe pain.

Three Part Question

Is [intranasal diamorphine a suitable alternative] to [IV diamorphine in adults] presenting with [severe pain (>= 7/10) in ED].

Clinical Scenario

A 68 yrs old female presents with Fracture neck of femur in ED after a fall and now in severe pain 10/10 and we couldn't get a line so IV morphine can be given, so would intranasal diamorphine be a suitable alternative?

Search Strategy

Medline 1950- May 2011
embase 1980- May 2011
intranasal diamorphine and adults

Search Outcome

We found 4 papers and 2 to be relevant to answer our 3 part question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Ward et al,
52 patients after total hip or knee replacement were randomly given IV or intra nasal diamorphine unblinded.Randomized, non blinded, comparative studyComparison of Intravenous diamorphine versus Intranasal diamorphine in pain control..Intranasal diamorphine resulted in higher pain score 35.5 vs 20 for Intravenous diamorphine (p=0.30)and on movement (Intransal median 64 vs Intravenous median 50 p=0.016)Small number, single center, difference in the groups, selection bias, no power calculation.
Dooris et al,
57 yrs old female known chronic renal failure with deformed elbow.Case reportTo see if Intransal diamorphine was an effective alternative to Intravenous diamorphine in pain management.With 0.1mg/kg intransal diamorphine they achieved immediate pain relief.Case report, no statistical significance, weak level of evidence.


There isn't enough evidence available in the literature to answer our question.

Clinical Bottom Line

There isn't enough evidence to prove or disprove usage. A large randomized, double blinded multicenter trial will give the answer. The other reason for Intranasal diamorphine not being used for adults in UK is that it is not licensed for use in adults.


  1. Ward M, Minto G, Alexander-Williams JM. A comparison of patient controlled analgesia administered by the intravenous or intranasal route during the early post operative period. Anaesthesia 2002;57: 49-52.
  2. Dooris B, Reid C, Gaunt D. Intranasal Diamorphine in Adults. Emerg Med J 2001;18:412-415.