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4.7 Analgesics

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. 


4.7.1 Non-opioid analgesics

For mild to moderate pain relief. Suitable for pain in musculoskeletal conditions.
GREEN         Paracetamol [Consider OTC/Self care]                
                      tablets 500mg,  soluble tablets 500mg 
                      suspension 120mg/5mL, 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) [Consider OTC/Self care]   
                   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
                   tablets prolonged release* 100mg, 150mg, 200mg 
                   *prescribe as Marol® MR tablets - more cost effective than capsules MR
                    capsules m/r 100mg, 150mg, 200mg (prescribe as Marol® Tablets MR as above) 
(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 sulfate
                   capsules m/r  10mg, 30mg, 60mg, 100mg, 200mg {Zomorph®]
                   tablets 10mg, 20mg, 50mg [Sevredol®]
                   oral solution 10mg/5mL, 100mg/5mL [Oramorph®]
                   injection 10mg/mL, 15mg/mL, 30mg/mL
                   tablets m/r  5mg, 10mg, 15mg, 30mg, 60mg, 200mg [MST®]
                   (Modified release tablets and capsules should be prescribed by brand) 
               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 Hcl
                  capsules 5mg, 10mg, 20mg (Lynlor®, Shortec®) 
AMBER     Oxycodone Hcl modified-release tablets*                
                  tablets m/r 5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg (Oxypro®MR tablets, Longtec®) 
                  * Oxypro®MR tablets is the cost-effective branded generic to options for prolonged-release oxycodone.
                  [East Lancashire Hospital Trust use 'Oxylan®'' MR - please note this is similar in name to Oxypro®MR
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    
                   Please note: Buprenorphine oral lyophilisate (Espranor®) is RED traffic Light and  should only be prescribed by The 
                   Specialist Substance Misuse Service .(see section 4.10 for use in opiate addiction) 
AMBER      Buprenorphine transdermal  weekly patches
                   (Butec®) 5, 10, 15, 20 micrograms/hour / (Sevodyne®) 5,10, 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. Foprescribing 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.
 Use of Alfentanil
 Pain in patients with renal failure or intolerable side effects from other opioids. It is an alternative to other opioids such as     morphine, oxycodone and diamorphine, particularly in patients with renal failure. It should only be used as a continuous   subcutaneous infusion and on the advice of Specialist Palliative Care. 
 AMBER  Alfentanil solution for injection 1mg/2mL
                                  solution for injection 5mg/1mL
 See Syringe Pump Policy ELHT
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 o 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 should be counselled on safe use, correct administration, disposal, strict adherence to dosage instructions, and the 
symptoms and signs of opioid over dosage.

4.7.3 Neuropathic pain

See Neuropathic Pain Treatment Pathway
Duloxetine (Cymbalta®) – see section  4.3.4
Gabapentin – see section 4.8.1
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. 
[For prescribing in Generalised Anxiety Disorder, AMBER specialist initiation with criteria, see section 4.3]
GREEN     Pregabalin
                 capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg
BLACK     Pregabalin Liquid
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     * [currently out of stock - advise to purchase alternative product from pharmacy 
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.
administration is less than 3–4 times daily.  
GREEN         *Capsaicin cream 0.025% [Zacin®] (for osteoarthritis of the hand and knee only- NOT for back pain)  
                      For general musculoskeletal pain advise to purchase a rubefacient product]  [Consider OTC/Self care]  
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  have been used.)
AMBER       Lidocaine patches 5%  as a final option in palliative care.    
RED             Lidocaine patches 5% for all indications other than postherpetic neuralgia. 
Lidocaine plasters for Allondynia and/or hyperalgesia and dysesthesia 
Lidocaine patches are recommended 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. 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 spray10mg/ 0.1mL unit dose 
                  nasal spray 20mg/0.1mL unit dose
GREEN     Sumatriptan 3 mg/0.5 ml solution for injection in pre-filled pen
                  Sumatriptan 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. 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
GREEN     Topiramate capsules NICE CG150 (see section 4.8 for use in epilepsy [AMBER])
RED           Flunarizine tablets 5mg, 10mg (Sibelium®) Specialist use only
RED    Galcanezumab [Emgality 120mg/1mL solution for injection p/f pens]
NICE TA659  Galcanezumab is recommended as an option for preventing migraine in adults, only if:
                         >  they have 4 or more migraine days a month
                         >  at least 3 preventive drug treatments have failed and
                         >  the company provides it according to the commercial arrangement
                                                                                                                                                       CCG Commissioned Blueteq form required
RED    Erenumab [Aimovig]
NICE TA682  Erenumab is recommended as an option for preventing migraine in adults, only if:
     > they have 4 or more migraine days a month
     > at least 3 preventive drug treatments have failed
     > the 140mg dose of erenumab is used and
     > the company provides it according to the commercial arrangement
 Stop erenumab after 12 weeks of treatment if:
     > in episodic migraine  [less than 15 headache days a month] the frequency does not reduce by at least 50%
     > in chronic migraine [15 headache days a month or more with at least 8 of those having features of migraine] the frequency 
        does not reduce by at least 30%
Treatment of chronic migraine  
RED           Botulinum Toxin A (use of brand with lowest acquisition cost) injection             CCG Commissioned  
NICE TA260  Recommended as an option for the prophylaxis of headaches in adults with chronic migraine )defined as headaches 
                       on at least 15 days per month of which at least 8 days are with migraine):
                          ° that has not responded to at least three prior pharmacological prophylaxis therapies and 
                          ° whose condition is appropriately managed for medication overuse.
RED           Fremanezumab solution for injection [Ajovy® 225mg/1.5ml]                              CCG Commissioned BlueTeq form required
NICE TA631  Recommended as an option for preventing migraine in adults, only if:
                          º the migraine is chronic, that is, 15 or more headache days a month for more than 3 months with at least of those 
                            having features of migraine
                          ° at least 3 preventative drug treatments have failed and 
                          ° the company provides it according to the commercial arrangement



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