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4.7.2 Opioid analgesics

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  
                           Opiodur® £ Matrifen® ££, Mezolar® ££, Fencino® ££, 
         (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
                           Oxyact® £ tablets 5mg, 10mg, 20mg  [PRESCRIBE BY BRAND] £
                            capsules 5mg, 10mg, 20mg (Lynlor®, Shortec®) ££
         AMBER     Oxycodone Hcl modified-release tablets*   
                           *Oxylan® Prolonged Release £ tablets 5mg, 10mg, 20mg, 40mg, 80mg [PRESCRIBE BY BRAND] £
                            tablets m/r 5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg (Oxypro® MR tablets, Longtec®) ££
                           *[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
         AMBER     Alfentanil solution for injection 1mg/2mL
                                             solution for injection 5mg/1mL
                            Only for use as a continuous subcutaneous infusion and on the advice of Specialist Palliative Care
                            See below and Syringe Pump Policy ELHT

         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
                            Rebrikel® 5mcg/hour, 10mcg/hour, 20mcg/hour patch [PRESCRIBE BY BRAND] £
                            Butec® 5, 10, 15, 20 micrograms/hour, Sevodyne® 5,10, 20micrograms/hr ££
         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. Rebirkel®, Butec® and Sevodyne® require changing 
         every seven days whilst Bupeaze® is 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.   
         Back to Main chapter
         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
         For 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 
         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 [fentanyl patches]
         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. 
         Patients should be counselled on safe use, correct administration, disposal, strict adherence to dosage instructions, and the
         symptoms and signs of opioid over dosage.
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