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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.07.02  Expand sub section  Opioid analgesics
 note 

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
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Formulary
Green

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
 
Controlled Drug Morphine
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Formulary
Green
  • 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  
 
 
Alfentanil
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Formulary
Red
  • 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
 
 
Controlled Drug Diamorphine
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Formulary
Red

 

    • 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  

 

 
 
Ketamine
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Formulary
Red
 
 
Controlled Drug Tramadol
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Alternatives
Green
  • 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 Buprenorphine
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Alternatives
Green
  • 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 Fentanyl
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Alternatives
  • 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 Hydromorphone
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Alternatives
Green plus
 
 
Controlled Drug Methadone
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Alternatives
Green plus

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 Oxycodone
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Alternatives
  • 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 Pethidine
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Alternatives
Red
 
 
Controlled Drug Tapentadol
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Alternatives
Green plus
  • 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 Dihydrocodeine
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Alternatives
Red
  • 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).
 
 
04.07.02  Expand sub section  Weak opioids
04.07.02  Expand sub section  Strong opioids
04.07.02  Expand sub section  Breakthrough pain
04.07.02  Expand sub section  Injectable to top
04.07.02  Expand sub section  Other
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
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Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Red

Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing.  

Amber

Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber. If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care.  

Green plus

Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs.  

Green

Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care.  

Black

NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria.   

Brown

UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.  

Not Recomended

NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status.  

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