North East and North Cumbria
ICS Formulary
 
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4 Central nervous system
04-07-02 Opioid analgesics

North East North Cumbria (NENC) ICB Medicines Committee Position Statement on Prescribing in Persistent Pain

NENC ICB DOES NOT support the routine long-term prescribing (greater than 3 months) of opioids or the use of high dose opioids (higher than 120 mg/day of oral morphine equivalent) for non-cancer, persistent pain in adults.


Codeine
Formulary

First line

  • 15mg tablets

Second line

  • 30mg tablets

The following codeine preparations are unlicensedunlicensed and approved for use:

  • 30 mg suppositories.
  • codeine 2mg, 3mg, 6mg, 15mg;
  • codeine 30mg in 1ml injection CD
Link  MHRA Drug Safety Update (Dec 2014): Codeine for analgesia: restricted use in children because of reports of morphine toxicity
Link  MHRA Drug Safety Update (Dec 2014): Codeine: very rare risk of side-effects in breastfed babies

Green View adult BNF  View SPC online  View childrens BNF
Morphine
Formulary
  • 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. 
  • Red Note: the following preparations are also approved for use:
    • morphine 5mg in 1ml injection   unlicensedunlicensed 
    • 10mg in 1ml preservative free injection   unlicensedunlicensed 
    • 2mg in 5ml epidural   unlicensedunlicensed 
    • 100 micrograms/1 ml oral solution. For use in neonates.   unlicensedunlicensed 
    • 50mg in 50ml PCA injection  

Controlled Drug  Green View adult BNF  View SPC online  View childrens BNF
Alfentanil
Formulary
  • Palliative care use Green plus 
  • 500micrograms in 1ml [ST&S], 1mg in 2ml, 5mg in 10ml & 5mg in 1ml injection ampouless - approved for initiation by specialists in palliative care Green plus 
  • All non-palliative care indications Red

Red View adult BNF  View SPC online  View childrens BNF
Diamorphine
Formulary

 

    • unlicensed 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 Red Traffic Light  

 


Controlled Drug  Red View adult BNF  View SPC online  View childrens BNF
Ketamine
Formulary

Red View adult BNF  View SPC online  View childrens BNF
Tramadol
Formulary
  • 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. 

Controlled Drug  Green View adult BNF  View SPC online  View childrens BNF
Buprenorphine
Formulary
  • 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.

Controlled Drug  Green View adult BNF  View SPC online  View childrens BNF
Fentanyl
Formulary
  • 12, 25, 50, 75 & 100 microgram/hour transdermal patches Green Traffic Light
    • 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 Red only for patients experiencing incident pain during radiotherapy, restricted to palliative care use only 
  • Fentanyl sublingual tablets (Abstral®) CD&TV Green plus for breakthrough / rescue pain relief in palliative care
  • nasal spray Red
    • approved for use in children during diamorphine shortage with appropriate local governance arrangements
Link  MHRA Drug Safety Update (Oct 2018): Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children
Link  MHRA Drug Safety Update (Sep 2020): Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients
Link  Transdermal fentanyl – MHRA Drug Safety Update (July 2014): Transdermal fentanyl “patches”: reminder of potential life threatening harm from accidental exposure, especially in children

Controlled Drug  View adult BNF  View SPC online  View childrens BNF
Hydromorphone
Formulary

Controlled Drug  Green plus View adult BNF  View SPC online  View childrens BNF
Methadone
Formulary

The following preparations are approved:

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




Controlled Drug  Green plus View adult BNF  View SPC online  View childrens BNF
Oxycodone
Formulary
  • Approved only for use in patients who are intolerant of morphine. Green
    • 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.Green Traffic Light
  • Approved for use as part of Enhanced Recovery After Surgery (ERAS) as part of multi-modal enhanced recovery pathway following hip and knee surgery Red
    • The OxyPro® branded generic is preferred (most cost effective option). 
    • The oral solution should be used instead of immediate release tablets. 

Controlled Drug  View adult BNF  View SPC online  View childrens BNF
Pethidine
Formulary

Controlled Drug  Red View adult BNF  View SPC online  View childrens BNF
Tapentadol
Formulary
  • 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.
Link  MHRA Drug Safety Update (Jan 2019): Tapentadol (Palexia): risk of seizures and reports of serotonin syndrome when co-administered with other medicines

Controlled Drug  Green plus View adult BNF  View SPC online  View childrens BNF
Dihydrocodeine
Formulary
  • 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).

Controlled Drug  Red View adult BNF  View SPC online  View childrens BNF