| 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 |
| 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. 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.
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| |
| 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 |
| 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 [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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| Back to Main chapter |
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