• Oral diclofenac is restricted to short-term use for post operative pain.
• If long-term use is required diclofenac is only approved for 4th line treatment (see below):
  
  • Ibuprofen low dose – first line treatment.
  • Naproxen low dose – second line treatment.
  • Naproxen high dose – third line treatment.
  • Diclofenac – fourth line treatment.

First line

• 15mg tablets

Second line

• 30mg tablets

The following codeine preparations are unlicensed and approved for use:

• 30 mg suppositories.
• codeine 2mg, 3mg, 6mg, 15mg;
• codeine 30mg in 1ml injection 

• Tablets - 10mg, 20mg, 50mg (Sevredol^®)
• MR capsules - 10mg, 30mg, 60mg, 100mg, 200mg (Zomorph^®)
• MR tablets -  5mg, 10mg, 15mg, 30mg, 60mg, 100mg, 200mg (MST^®)
• Oral solution - 10mg in 5ml
• Injection - 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml
• Zomorph^® is the preferred M/R formulation. 
•  Note: the following preparations are also approved for use:
  
  • morphine 5mg in 1ml injection   unlicensed 
  • 10mg in 1ml preservative free injection   unlicensed 
  • 2mg in 5ml epidural   unlicensed 
  • 100 micrograms/1 ml oral solution. For use in neonates.   unlicensed 
  • 50mg in 50ml PCA injection  

• Palliative care use  
• 500micrograms in 1ml [ST&S], 1mg in 2ml, 5mg in 10ml & 5mg in 1ml injection ampouless - approved for initiation by specialists in palliative care  
• All non-palliative care indications 

•  Unlicensed intranasal diamorphine is approved for use in children for the relief of severe pain due to clinically suspected limb fractures, burns and significant fingertip injuries. Appropriate risk assessments are to be conducted by each organisation in order to determine formulation of choice (e.g. ampoules or intranasal spray).

• Note: intranasal diamorhine   

• 50mg capsules, 50mg dispersible tablets & 100mg/2ml injection
• Only approved for use as a second-line weak opioid analgesic for use in patients where treatment with possible alternatives such as paracetamol, NSAIDs, and codeine is insufficiently effective, not tolerated or considered unsuitable for other reasons.
• Note: modified release tramadol is not approved or recommended. 

• 200microgram sublingual tablets
• 300microgram in 1ml injection
• Buprenorphine patches (Preferred brand - Butec®) are approved for use in palliative care when fentanyl 12 microgram/hr transdermal patches exceed the patient’s analgesic requirements.

• 12, 25, 50, 75 & 100 microgram/hour transdermal patches
  • Prescribe by brand. Mezolar® has replaced Matrifen® as the first choice brand. Patients who currently use Matrifen® can continue to do so if managing well.
• Fentanyl sublingual tablets (Abstral®) NoTGhdNC  only for patients experiencing incident pain during radiotherapy, restricted to palliative care use only 
• Fentanyl sublingual tablets (Abstral®) CD&TV  for breakthrough / rescue pain relief in palliative care
• nasal spray 
  • approved for use in children during diamorphine shortage with appropriate local governance arrangements

The following preparations are approved:

• 5mg tablets;
• 5mg in 5ml mixture DTF & 5mg in 5ml sugar free solution
• 20mg in 1ml concentrated oral solution (unlicensed)
• 10mg in 1ml injection

• Approved only for use in patients who are intolerant of morphine. 

• Note: Oxycodone 50mg in 1ml injection  is also approved for use, but is restricted to controlled circumstances in palliative patients following risk assessment by individual organisations.

• Approved for use as part of Enhanced Recovery After Surgery (ERAS) as part of multi-modal enhanced recovery pathway following hip and knee surgery 

• The OxyPro® branded generic is preferred (most cost effective option). 

• The oral solution should be used instead of immediate release tablets. 

• Approved for use by chronic pain specialist in adults with severe pain who have been screened for a neuropathic element to their pain and are uncontrolled or experiencing GI side effects on existing therapy.

• Note: the use of dihydrocodeine 30mg tablets & 10mg in 5ml oral solution is no longer recommended for regular use. Codeine is the preferred weak opioid analgesic.
• Dihydrocodeine is only approved for use in breast feeding mothers immediately postdelivery/ c-section where adequate pain relief has not been achieved using paracetamol and NSAIDs. Patients requiring contunation of dihydrocodeine following discharge (post delivery/c-section) can have dihydrocodeine prescribed in primary care (for short-term use only).

• For use in the treatment of neuropathic pain
• Gabapentin is also approved for hospital use  as an adjunct to other treatment in the management of peri/post-operative pain.  unlicensed
• GPs should not be asked to prescribe gabapentin for this unlicensed indication.
• Approved for intractable itch with severe burns 

• Pregabalin is restricted to use in the management neuropathic pain as a second choice where treatment with gabapentin has been unsuccessful or not tolerated.

• Restricted use in treatment of trigeminal neuralgia only.

• For third-line use (after drugs such as the tricyclic antidepressants and gabapentin) in the treatment of neuropathic pain on the advice of pain specialists.

• Qutenza® cutaneous patch approved for the treatment of neuropathic pain as fourth line agent for neuropathic pain and in line with the attached regionally agreed pathway. 


• 0.075% cream (Axsain®) approved for post hepatic neuralgia and peripheral diabetic neuropathy 

• For use in the treatment of post-herpetic neuralgia only, on the advice of pain specialists and subject to an appropriate trial of efficacy in each individual patient.

• Please refer to Chapter 04.07.01

• Used to help promote absorption of analgesics.

• MHRA Drug Safety Update (July 2022): Topiramate (Topamax): start of safety review triggered by a study reporting an increased risk of neurodevelopmental disabilities in children with prenatal exposure

• Clonidine is not generally recommended for migraine prophylaxis; may aggravate depression/cause insomnia.

• 100mg/1ml concentrate for solution for infusion
  • Approved for the prevention of chronic migraine in adults in line with NICE only if
    • they have 4 or more migraine days a month
    • at least 3 preventative drug treatments have failed

• 70mg/1ml and 140mg/1ml solution for injection (pre-filled pens)
  • Approved for the prevention of chronic migraine in adults in line with NICE only if
    • they have 4 or more migraine days a month
    • at least 3 preventative drug treatments have failed

• 225mg/1.5ml solution for injection (Pre-filled pens/syringes)
  • Approved for the prevention of chronic migraine in adults in line with NICE only if
    • they have 4 or more migraine days a month
    • at least 3 preventative drug treatments have failed
    
    
    

• 120mg/1ml injection
  
  • Approved for the prevention of chronic migraine in adults in line with NICE only if
    • they have 4 or more migraine days a month
    • at least 3 preventative drug treatments have failed

• 75mg oral lyophilisates
• Approved for preventing migraine in line with NICE
  • First three month's supply from secondary care followed by 12 week review and then transfer to primary care with a 4 week prescription to allow for handover
• Approved for treating migraine in line with NICE 

• Only approved for use in accordance with NICE guidance. 

• Note: sodium valproate 500mg & 1000mg MR granules (Episenta®) are also approved for use in those who have difficulty swallowing sodium valproate tablets. MR granules may be more convenient to use than large volumes of liquid formulations.

Black Triangle in Females

Valproate must no longer be prescribed to women and girls of
childbearing potential unless there is no alternative and they are on the
Pregnancy Prevention Programme (PPP)  

For information relating to alerts regarding valproate, including Drug Safety Updates and links to PPP materials, please use the following link:

MHRA Drug Safety Updates (valproate)

• Lithium should be prescribed by brand name.

• Lithium should be prescribed by brand name.