4.7 Analgesics

For non-steroidal analgesics see Section 10.1.1

Treatment of acute and chronic pain:

Mild pain: Paracetamol amd/or NSAID (see section 10.1.1)

Mild to moderate pain: Dihydrocodeine or codeine, plus paracetamol and/or NSAID

Moderate to severe pain: Morphine oral

Acute pain Guidance

Chronic Pain Guidelines

Complex Regional Pain Syndrome (CRPS) - DMSO (dimethyl sulphoxide) 50% cream & Acetylcysteine 600mg tablets (unlicensed) Pain clinic dispensing only.

Pain Ladder

4.7.1 Non opoid and compound analgesics (mild-moderate pain)

1st     PARACETAMOL (IV formulation)    
2nd     CO-CODAMOL 30/500    
        Paracetamol i.v formulation is restricted for patients if the oral or rectal route are unavailable or inappropriate. Change to oral formulation as soon as possible

4.7.2 Opoid analgesics (moderate-severe pain)

Opiates are used in anaesthesia - see Anaesthesia Section 15

NICE TA354 Naloxegol for treating opioid-induced constipation Jul 15

1st      TRAMADOL (IV formulation)     Caution using tramadol with SSRI's, serotonin syndrome can develop 
2nd     CODEINE    
3rd     MORPHINE MR     
3rd      BUPRENORPHINE (BuTrans Patches)   for patients intolerant to tramadol or codeine/DHC
4th     TAPENTADOL MR (Yellow)   for Specialist Chronic Pain team initiation only

Do not combine weak and strong opiates. For severe pain, usually a strong opiate is required and should replace any weak opiate, e.g do not combine tramadol or codeine with morphine or fentanyl

Slow release preparations are not appropriate for the treatment of acute pain

Immediate release preparations are not appropriate for treatment of chronic pain

Acute and breakthrough pain

1st     ORAMORPH    Oramorph should be used in acute pain for up to one week due to risk of addiction

Chronic pain

1st      ZOMORPH      
        Very few patients are unable to tolerate oral morphine
        If Zomorph is not tolerated, refer to the Pain Clinic where the following options will be considered:
2nd     FENTANYL PATCH (Yellow)
        Fentanyl should be used for specific patients where morphine is not tolerated, consider cost
        Buprenorphine patches should be used for patients requiring a low dose opioid, or in the elderly* (*where there has either been no response to Zomorph or where Zomorph has not been tolerated.) This should not be initiated in primary care and must be prescribed initially with an antiemetic
3rd     OXYCODONE MR (Yellow) 
4th     METHADONE (Yellow) 

Specific uses for Opiates

      DIAMORPHINE     Palliative care, CCU and spinal block
      FENTANYL   (Cassette use only in renal failure)
      FENTANYL buccal tablet (Effentora)   Epidurals used for post operative anaesthesia, for specific patients and in maternity only. Lozenges are non-formulary
      OXYCODONE (Yellow)   Palliative care and for very few patients where morphine is not tolerated, consider cost
      PETHIDINE   Used in Maternity and for patients who cannot tolerate morphine
        METHADONE (Yellow)   For established patients, IDAS patients and palliative care

4.7.3 Neuropathic pain

These medicines are often used in combination, see link to guidelines:

NICE CG173 - Neuropathic pain: The pharmacological management of neuropathic pain in adults in non-specialist settings Nov 13

Trust Neuropathic pain pathway

NICE Drugs

      AMITRIPTYLINE    Amitriptyline may be used as an adjunctive analgesic for chronic pain and for neuropathic pain (unlicensed indication). It may take 4-6 weeks before the full analgesic effect is achieved
      GABAPENTIN   Gabapentin should be used if amitriptyline is contra-indicated or if lancinating pain "shocks" are present. Reduce opiate usage by optimising gabapentin use. If gabapentin is not tolerated, carbamazepine should be considered. Gabapentin may be used for neuropathic pain or phantom limb pain
      CARBAMAZEPINE   Carbamazepine is licensed for the treatment of trigeminal neuralgia, gabapentin although unlicensed has also been used for this condition

2nd line

      If satisfactory pain reduction is obtained with amitriptyline, but the patient cannot tolerate the adverse effects, consider switching to nortriptyline       
      If amitriptyline provides pain reduction, but patient needs more, add gabapentin      
      If amitriptyline does not provide pain reduction, switch to gabapentin      
      A patient should only be referred to secondary care once all of the above options have been exhausted.      

3rd line

      Refer to pain clinic     
      While waiting for referral:   Consider tramadol instead or in combination with 2nd line treatment
Consider:   LIDOCAINE 5% plaster (Yellow)   for touch sensitive pain (allodymia) only (neuropathic pain pathway)

In secondary care the following options will be considered:

      Opioid treatment     
      Neuropathic block    
      Investigating the route cause    

Painful diabetic neuropathy

1st      AMITRIPTYLINE    
2nd       If 1st treatment was with duloxetine, switch to amitriptyline or pregabalin/gabapentin, or combine with pregabalin/gabapentin    
        If 1st treatment was with amitriptyline, switch to or combine with pregabalin/gabapentin.    
3rd       As for neuropathic pain (see above)    

4.7.4 Antimigraine Drugs

NICE CG150 Headaches: Diagnosis and management of headaches in young people and adults Sep 12

NICE TA260 Migraine (chronic) - botulinum toxin type A Jun 12 Treatment of acute migraine

        Low cost generic triptans:    
      ZOLMITRIPTAN (orodispersible)    
      SUMATRIPTAN nasal    (if patient vomiting) 
      ZOLMITRIPTAN nasal   (if patient vomiting)
      FROVATRIPTAN   Prolonged effect Prophylaxis of migraine

      TOPIRAMATE (Yellow) Cluster headache

        SUMATRIPTAN Injection      
      VERAPAMIL (Yellow)    

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