4.7 Analgesics

When an analgesic strategy is being formulated, reference should be made to a patient's previous experience of pain, analgesics used, any adverse effects and preferences. Renal function and age must also be considered. The concept of a balanced or multi model approach to pain management should be employed. Using analgesics with different modes of action improves analgesia and decrease the risk of adverse effects.

Analgesia Ladder

The choice of analgesia should be guided by the principles outlined below.

Analgesia should be prescribed appropriate to the pain intensity.

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DO NOT GIVE MORE THAN ONE OPIOID DRUG SIMULTANEOUSLY UNLESS DIRECTED BY A PAIN SPECIALIST

4.7.1 Non-opioid analgesics

For mild to moderate pain relief. Suitable for pain in musculoskeletal conditions.

GREEN Paracetamol

tablets 500mg, soluble tablets 500mg

suspension 120mg/5m, 250mg/5mL

suspension SF 500mg/5mL (Rosemont)

suppositories 125mg, 250mg, 500mg

For short term use as advised by acute pain team or anaesthetists only

RED Paracetamol intravenous infusion 10mg/mL 100mL vial

Non-steroidal Anti-inflammatory Drugs

Ibuprofen, Naproxen, Diclofenac

for preparations see section 10.1.1

Compound analgesic preparations (containing opioids)

These preparations should not be used routinely.

Patients should be given the individual components where possible to allow titration of dose.

Where these preparations are used, they should be for short term use only, for relief of moderate pain.

GREEN Co-codamol 8/500 (codeine 8mg + paracetamol 500mg)

tablets 8/500, tablets dispersible 8/500

GREEN Co-codamol 30/500 (codeine 30mg + paracetamol 500mg)

tablets 30/500, tablets effervescent 30/500

GREEN Co-dydramol (dihydrocodeine 10mg + paracetamol 500mg)

tablets 10/500

BLACK Nefopam tablets - link to ELHE Position Statement

4.7.2 Opioid analgesics

Used for relief of moderate to severe pain. Suitable for pain of visceral origin.

GREEN Codeine phosphate

tablets 15mg, 30mg, 60mg

syrup 25mg/5mL

GREEN Dihydrocodeine

tablets 30mg

elixir 10mg/5mL

GREEN Tramadol

capsules 50mg

capsules m/r 100mg, 150mg, 200mg

(M/R preparations should be prescribed in favour of standard release if there is a risk of abuse or diversion)

RED Tramadol injection 100mg/2mL (Theatre Recovery only)

GREEN Morphine

tablets 10mg, 20mg

oral solution 10mg/5mL, 100mg/5mL

injection 10mg/mL, 15mg/mL, 30mg/mL

capsules m/r 10mg, 30mg, 60mg, 100mg

tablets m/r 5mg, 10mg, 15mg, 30mg, 60mg, 200mg

(Modified release tablets and capsules should be prescribed by brand name due to variations in release profiles – RPSGB advice 06)

N.B. This formulary does not specify which brand to prescribe because procurement costs are frequently changing. The current preferred product is MST tablets June 2017

The onus is on the prescriber to take adequate steps to assure safe and cost effective choices.

RED Morphine syringe 100mg/50mL

GREEN Diamorphine (ongoing supply problems contact pharmacist for advice)

injection 5mg, 10mg, 30mg, 100mg, 500mg

GREEN Pethidine

injection 50mg/mL, 100mg/2mL

GREEN Fentanyl matrix patches 12, 25, 50, 75,100 micrograms/hr

Matrifen®, Mezolar®, Fencino®, Opiodur®

(Fentanyl matrix patches should be prescribed by brand name to minimise the risk of reservoir patches being accidentally supplied)

N.B. This formulary does not specify which brand to prescribe because procurement costs are frequently changing.

The onus is on the prescriber to take adequate steps to assure safe and cost effective choices.

For guidance on the use of fentanyl patches in care homes - click here

AMBER Oxycodone

capsules 5mg, 10mg, 20mg (Lynlor®, Shortec®)

tablets m/r 5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg (Reltebon®, Longtec®)

AMBER Oxycodone Liquid 5mg/5mL - 2nd line to capsules

AMBER Oxycodone Concentrated oral solution 10mg/mL - Palliative Care Use Only

AMBER Oxycodone Injection 10mg/mL - Palliative Care Use Only when morphine is unsuitable

RED Methadone (see section 4.10 for use in opiate addiction)

mixture 1mg/mL (some brands are unlicensed for use in analgesia)

tablets 5mg

injection 10mg/mL

GREEN Buprenorphine

sublingual tablets 200microgram, 400microgram
(see section 4.10 for use in opiate addiction)

AMBER Buprenorphine transdermal weekly patches

(Butec®) 5, 10, 20 micrograms/hour / (Sevodyne®) 10, 20micrograms/hr

Preferred brands for all patients

AMBER Buprenorphine transdermal 96 hourly patches

(Bupeaze®) 35, 52.5, 70 micrograms/hour - preferred brand for all patients

Please note the difference in duration of action between the patches. Butec® and Sevodyne® require changing every seven days whilst Transtec® and Bupeaze® are a 96 hour patch which will require changing twice weekly. Ensure that the dosage interval prescribed is appropriate for the product prescribed in order to prevent either unnecessary changing of patches or potentially leaving patients unmedicated.

Strong Opioids: Treatments of choice

Chronic Pain

Morphine is the first line strong opioid in management of severe chronic pain, in combination with non-opioid and adjuvant therapies. Oxycodone and topical agents (Fentanyl / Buprenorphine patches) should be considered as second line agents, for patients intolerant or contraindicated of morphine.

Post Operative Pain

Various agents and regimens are used according to treatment pathway and prescribing is restricted to secondary care, although patients may be discharged on limited course of high potency opioid. Choices are in accordance with the Acute Post Operative Analgesic Prescribing Guidelines and Oxycodone Guideline for Orthopaedic Patients. For prescribing after discharge from hospital, patients should be stepped down to lower potency analgesics or pre admission regimens should be reinstated after careful consideration of the new analgesic requirement.

Palliative Care

Morphine is the first line strong opioid in palliative care, by oral or parenteral route.

Oxycodone and topical agents (Fentanyl / Buprenorphine patches) should be considered as second line agents, for patients intolerant or contraindicated of morphine.

Actions recommended in NPSA/2008/RRR05

Reducing Dosing Errors with Opioid Medicines

This guidance applies when the following opioid medicines are prescribed, dispensed or administered: buprenorphine,

diamorphine, dipipanone, fentanyl, hydromorphone, meptazinol, methadone, morphine, oxycodone, papaveretum and pethidine.

When opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the healthcare practitioner concerned, or their clinical supervisor, should:

> Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done for example

through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records.

> Ensure where a dose increase is intended, that the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone in adult patients, not normally more

than 50% higher than the previous dose).

> Ensure they are familiar with the following characteristics of that medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side effects.

Healthcare organisations should ensure local medicines and prescribing policies, including Standard Operating Procedures, are reviewed to reflect this guidance.

Prescribing Fentanyl Patches

Fentanyl patches may differ between brands depending on the type of patch used (matrix or reservoir) and it may not be suitable to switch patients from one type to the other.

For this reason we recommend that only matrix patches are used across the health economy for all patients. Matrix transdermal patches consist of a protective film

(to be removed prior to application of the patch) and two functional layers: one self-adhesive matrix layer containing fentanyl and a carrier film impermeable to water.

Matrix patches differ from reservoir patches by the way that the drug is carried. Reservoir patches have a reservoir filled with the fentanyl in a gel or solution form which is released

into the body through a membrane. Matrix patches hold the drug in an adhesive layer which is distributed evenly throughout the patch and so are considered to be a more

safe delivery method as there is no chance of the fentanyl leaking.

Method of administration

The patches should be applied to non-irritated and non-irradiated skin on a flat surface of the torso or upper arm (in young children, the upper back is the preferred location to apply

the patch, this is to minimize the potential of the child removing the patch).

Hair at the application site (hairless area is preferred) should be clipped (not shaved) prior to system application. If the site requires cleansing prior to application of the patch, this should be done with water. Soaps, oils, lotions, alcohol or any other agent that might irritate the skin or alter its characteristics should not be used. The skin should be

completely dry before application of the patch. Since the transdermal patch is protected outwardly by a waterproof covering foil, it may also be worn when taking a shower.

The patch should be attached as soon as the pack has been opened. Following removal of the protective layer, the transdermal patch should be pressed firmly in place with the palm of the hand for approximately 30 seconds, making sure that the contact is complete, especially around the edges. The patches should be worn continuously for 72 hours

after which it should be replaced with a new patch. A new transdermal patch should always be applied to a different site from the previous one. The same application site may be re-used only after an interval of at least 7 days. If residues remain on the skin after removal of the patch, these can be cleaned off with soap and plenty of water. In no case should alcohol or other solvents be used for cleansing as these could penetrate the skin due

to the effect of the patch. The transdermal patch should not be divided, as no data are available with regard to this.

Safe use and disposal of used patches

Patients with fever should be regularly monitored for increased side effects as increased absorption is possible.

Patients should be advised to avoid exposing application site to external heat, for example a hot bath or a sauna.

The manufacturers recommend use only in opioid tolerant patients due to risk of respiratory depression in strong opioid naive patients.

Patients should be counselled on safe use, correct administration, disposal, strict adherence to dosage instructions, and the symptoms and signs of opioid overdosage.

4.7.3 Neuropathic pain

Duloxetine (Cymbalta®) – see section 4.3.4

Gabapentin – see section 4.8.1

Pregabalin

Pregabalin should only be used in patients who are unresponsive, unsuitable or intolerant of therapy with tricyclic anti-depressants, gabapentin and first line analgesics. Pregabalin should always be prescribed as a twice daily dose as this is the most cost effective regimen. Response to therapy should be regularly assessed, and therapy stopped in patients who are unresponsive.

GREEN Pregabalin

capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg

GREEN Alzain® (cost effective option)

capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg
GREEN Axalid ® (cost effective option)
capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg
Note: Licensed indications may vary. Check SPCs to inform decisions made with individual patients.

Capsaicin

Cautions

Avoid contact with eyes, and inflamed or broken skin. Hands should be washed immediately after use. Not for use under tight bandages. Avoid taking a hot shower or bath

just before or after applying capsaicin -burning sensation enhanced

Side-effects

Transient burning sensation can occur during initial treatment, particularly if too much cream is used, or if the frequency of administration is less than 3–4 times daily.

GREEN Capsaicin cream 0.025% [Zacin®] (for osteoarthritis)

AMBER Capsaicin cream 0.075% [Axsain®] (for post herpetic neuralgia & painful diabetic neuropathy)

Lidocaine Plasters

Lidocaine patches should only be initiated by specialists in the management of postherpetic neuralgia. These are chronic pain consultants and consultant neurologists. They should only be used for the management of post herpetic neuralgia where other available treatments (e.g. TCA’s, gabapentin/pregabalin, capsaicin cream) have been used, are inappropriate or not tolerated. Lidocaine patches have not demonstrated sufficient benefits in terms of efficacy or comparative effectiveness to warrant wider use at this stage. If no benefit has been seen after 2-4 weeks, treatment should be stopped. Assess possibility of reducing number of plasters, or increasing time between plasters on a regular basis.

AMBER Lidocaine patches 5% for postherpetic neuralgia

2nd line only after other options including capsaicin cream have been used.

RED Lidocaine patches 5% for all indications other than postherpetic neuralgia and as a final option in palliative care.

Lidocaine plasters for Allondynia and/or hyperalgesia and dysesthesia

Lidocaine patches are recommmended only if unresponsive to or intolerant of other neuropathic agents in NICE/ELMMB guidelines , and treatment is prescribed by clinicians

who specialise in control of pain. Prescribing should not be transferred to Primary Care

RED Lidocaine patches 5% for Allondynia and/or hyperalgesia and dysesthia (unlicensed use)

4.7.4 Antimigraine drugs

Guidelines for the management of migraine - see Appendix 1.

4.7.4.1 Treatment of the acute migraine attack

Analgesics - for preparations see section 4.7.1

Nausea - domperidone (section 4.6) may be helpful.

First Line Options

GREEN Sumatriptan

tablets 50mg

nasal spray 20mg/0.1mL unit dose

injection (subcutaneous) 6mg/0.5mL syringe

GREEN Zolmitriptan

Orodispersable tablets 2.5mg

Second Line options

Patients often warrant a trial of different oral triptans due to individual variability in response, and prescribers should choose a second line product with their patient based on efficacy, tolerability, formulation and cost.

4.7.4.2 Prophylaxis of migraine

Factors which trigger attacks should be sought. Therapy should be reviewed at 6 monthly intervals as long term prophylaxis with these drugs is undesirable.

Amitriptyline is unlicensed for migraine but may be usefully prescribed at a dose of 10mg at night, increasing to a maintenance dose of 50-150mg at night.

Sodium valproate (unlicensed) is no longer recommended. This is due to the availability of licensed anti-convulsants (e.g. topiramate) and also the teratogenic risk associated with its use in pregnancy (e.g. unplanned pregnancy).

GREEN Amitriptyline (unlicensed) tablets 10mg, 25mg, 50mg

GREEN Pizotifen

tablets 500 micrograms, 1.5mg

elixir 250 micrograms/5mL

GREEN Propranolol capsules m/r 80mg

AMBER Topiramate capsules (see section 4.8)

Treatment of chronic migraine (as defined by NICE TA260)

RED Botulinum Toxin A (use of brand with lowest acquisition cost) injection

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