Clinical Guideline. Guidelines for the use of opioid analgesics in the management of acute pain in adults
|
|
- Nickolas Lewis
- 5 years ago
- Views:
Transcription
1 Clinical Guideline Guidelines for the use of opioid analgesics in the management of acute pain in adults Document detail Document location West Kent and MTW Formulary Version 1.0 Effective from July 2017 Review date July 2020 Owner Directorate of Critical Care Author Consultant in Anaesthesia & Pain Medicine Approved by Pain Management Steering Group Date June 2017 MTW Medicines Management Committee May 2017 West Kent Medicines Optimisation Group April 2017 Ratified by Trust Clinical Governance Committee Date 14 th September 2017 Superseded documents Prescribing Guidelines > Central nervous system Guidelines Opioid analgesics in the management of acute pain 2014 Related documents Neuropathic Pain Guidelines Chronic Pain Guidelines Palliative Care Pain Guidelines Change history Date Change details Approved by Version no.: 1.0 Page 1 of 14
2 Contents Page Abbreviations 2 Aim of guidelines 3 References 3 Oral analgesia flowchart 4 Paracetamol 5 NSAIDs 5 Opioids 5 Alternative opioids (oxycodone, codeine, tramadol, buprenorphine) 6 Patient factors 7 Opioid equivalences 7 Parenteral analgesia flowchart 8 Intravenous (IV) paracetamol 9 Parenteral opioids 9 Opioid patches 9 Naloxone 9 Appendix 1: Additional drug information 11 PRN IV IM SC NSAID PPI SSRI SNRI AKI CKD Abbreviations Pro re nata (as required) Intravenous Intramuscular Subcutaneous Non-Steroidal Anti-inflammatory Drug Proton Pump Inhibitor Selective Serotonin Reuptake Inhibitor Selective Noradrenaline Reuptake Inhibitor Acute Kidney Injury Chronic Kidney Disease Version no.: 1.0 Page 2 of 14
3 Aim of guideline To provide a general framework that should be widely applicable when prescribing opioid analgesia for the management of acute pain in adults To standardise clinical practice as far as possible - safe and effective practice is likely to be achieved by familiarity Not to undermine the autonomy or freedom of clinicians to make their own decisions regarding the clinical management of patients in their care. References: Core Standards for Pain Management Service in the UK (2015) Faculty of Pain Medication Opioid Aware: A resource for Patients and Healthcare professional to support prescribing of Opioid Medication for pain. Opioids for persistent pain: Good Practice. (2010). Long-term opioid management for chronic non cancer pain.noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM. Cochrane Database of Systematic Reviews 2010, Issue 1. Version no.: 1.0 Page 3 of 14
4 Oral analgesic flowchart Analgesia should be prescribed orally unless this route is unavailable (e.g. nil by mouth, ileus) Co-prescribe baseline analgesia for all patients unless contraindicated; this will minimise the amount of opioid required to effectively manage pain. Figure 1: Oral analgesia flowchart for acute pain Mild Pain Regular paracetamol +/- regular or PRN NSAID add in Moderate Pain or or Morphine immediate release PRN (1 st line) Codeine phosphate PRN (2 nd line) Tramadol PRN (3 rd line) switch to Regular morphine modified release + morphine immediate release PRN 1 st line Severe Pain or or or Regular oxycodone modified release + oxycodone immediate release PRN 2 nd line (but 1 st line in renal impairment or true morphine allergy) Buprenorphine tablets sublingually PRN 3rd line Fentanyl seek advice from pain team 4 th line Parenteral route should be used for speed of onset of action for chest pain/trauma. Version no.: 1.0 Page 4 of 14
5 Paracetamol Reduces opioid consumption, good safety profile when taken at therapeutic doses Few contraindications to its use Avoid co-codamol (medication cannot be optimised as easily, risk that paracetamol is prescribed concurrently, codeine is not 1 st line option if an opioid is required). NSAIDs Paracetamol 1g QDS PO Use in addition to paracetamol to further reduce opioid consumption Prescribe at meal times Ibuprofen 400mg TDS PO 1 st line lowest gastrointestinal and cardiovascular risk Naproxen 500mg BD 2 nd line higher gastrointestinal risk than ibuprofen Consider gastric protection for patients prescribed a regular NSAID. e.g. omeprazole 20mg OD Risk factors include: over 65s, concurrent irritant drugs (e.g. aspirin, prednisolone, rivaroxiban), alcoholic liver disease, history of heart burn/ulceration) Contraindications and cautions to NSAIDs include: Ischaemic heart disease, cerebrovascular disease, poorly controlled hypertension, heart failure, renal impairment, hepatic impairment, hypovolaemia and dehydration, unstable asthma, gastritis, coagulopathy or haemorrhage, drug allergy and they should be used with caution in the elderly, patients co-prescribed lithium, methotrexate and warfarin. Opioids First line PRN opioid analgesia in patients with moderate to severe pain should be morphine immediate release. Morphine has a more predictable dose response curve than codeine (see note 1). Morphine immediate release 10-20mg 2-4 hourly PRN Consider 5-10mg 2-4houry PRN in elderly/frail patients Morphine has active metabolites and can therefore accumulate in renal impairment; consider oxycodone/increase dosing interval Opioid use should be reviewed regularly Increase morphine dose in small increments until pain is controlled. Patients requiring significant amounts of PRN opiates should be switched to a regular modified release preparation. This reduces the potential for undue pain and delays in administering PRN medication. Version no.: 1.0 Page 5 of 14
6 Calculate the total quantity of immediate release opioid administered over the last 24-hour period and divide by 2 to obtain the modified release dose. Remember to add and/or adjust breakthrough pain relief (1/6 th 1/10 th of total daily dose). Example calculation 8 x 10mg doses administered over the previous 24 hours can be switched to: Morphine modified release 40mg BD + Morphine immediate release 10-20mg 2-4 hourly PRN Likewise, patients requiring few PRN opioid doses should be reviewed with the view of weaning pain relief where appropriate. Modified release preparations Prescribe at 12 hourly intervals e.g. 08: :00 in order to provide 24 hour cover. Morphine modified release should be 1 st line if a regular modified release opioid is required. Prescribe regular laxatives and PRN anti-emetics for all patients on regular opioids. Alternative opioid preparations Senna 15mg ON Lactulose 10mL BD Cyclizine 50mg TDS PRN Oxycodone A strong opioid Approximately twice as potent as morphine (therefore halve dose if converting from morphine to oxycodone) 5-10mg 2-4hourly PRN Codeine A weak opioid Codeine is metabolised to morphine in order to relieve pain; individuals can vary from poor metabolisers (little or no pain relief) to ultra-rapid metabolisers (excessive amounts of morphine in the blood) mg 4-6 hourly PRN (max 240mg/hours for pain) Tramadol Weak opioid + modulates serotonin/noradrenaline pathways Caution in patients prescribed other medicines which can inhibit serotonin reuptake potential risk of serotonin syndrome (SSRIs, SNRIs, mirtazapine, MAOs, tricyclic antidepressants) Caution in patients with epilepsy and in patients with other seizure threshold lowering drugs (SSRI, SNRIs, antipsychotics) Tramadol mg QDS PRN Version no.: 1.0 Page 6 of 14
7 Buprenorphine A partial opioid agonist Do not prescribe concurrently with other high dose opioids (can potentially precipitate withdrawal) 200micrograms buprenorphine is equivalent to 15mg oral morphine micrograms sublingually TDS PRN Patient factors In true morphine allergy consider oxycodone as an alternative opioid. Nausea and vomiting are side effects; consider prescribing antiemetics and laxatives to counteract these. Morphine has active metabolites and can therefore accumulate in severe CKD or AKI. Consider alternative opioid to manage pain and increase dosing interval. o 1 st line - Oxycodone immediate release PRN 4-6 hourly o 2 nd line - Buprenorphine o 3 rd line - Fentanyl (contact pain team for advice) Liver impairment consider dosage of opioid Opioid equivalences Table 1: Oral Opioid Equivalences (RCoA Opioid Aware Project) Drug Potency Ratio with Equivalent Dose to 10mg Oral Morphine oral morphine Morphine 1 10mg Codeine Phosphate 0.1 but variable 100mg Tramadol 0.15 but variable 67mg Oxycodone 2 5mg Drug Table 2: Patch preparation opioid equivalences Patch Size (micrograms/hour) Buprenorphine 5 12mg 10 24mg 20 48mg Fentanyl 12 45mg 25 90mg mg Oral Morphine equivalent/ 24 hours Version no.: 1.0 Page 7 of 14
8 Parenteral therapy flowchart Parenteral analgesia should be considered only when the practicality and appropriateness of other routes of administration have been excluded. Parenteral opioids should be administered by staff, who have received appropriate training. Figure 2: Parenteral medication flowchart for acute pain Mild Pain Regular paracetamol add in Severe Pain First Line- Second Line- IV morphine immediate release injection 2mg aliquots titrated up to 10mg 2mg every 5 mins with more given as needed Baseline observations pre-dose Further observations every 5 mins for 30 mins Oxygen saturations, respiratory rate and blood pressure See Note 1 IV oxycodone immediate release injection 2mg aliquots titrated up to 10mg 2mg every 5 mins with more given as needed Baseline observations pre-dose Further observations every 5 mins for 30 mins Oxygen saturations, respiratory rate and blood pressure See Note 4 Consider whether a PCA (patient controlled analgesia) may be suitable contact pain team. Palliative care patients refer to Palliative care team. Version no.: 1.0 Page 8 of 14
9 IV Paracetamol Weight >50kg 1g IV QDS Weight <50kg 15mg/kg QDS Weight >50kg with additional risk factors for toxicity 3g/day max (hepatocellular insufficiency, severe renal insufficiency, chronic alcoholism, chronic malnutrition, dehydration) Strong IV opioids Do not prescribe PO/IV. The bioavailability of oral and parenteral opioids are not equivalent; this should be considered and different doses prescribed depending upon the drug (see appendix 1 for additional information). Prescribe PRN anti-emetic s for all patients prescribed regular IV opioids. Transdermal patches Buprenorphine and Fentanyl exist as a transdermal preparation Patches take up to 48hours to reach steady state and also after removal up to 30hours for drug levels to drop 50%. Therefore there is a slow onset and slow offset of analgesia and side effects and are therefore generally unsuitable for the management of acute pain. Fentanyl patches should only be initiated following assessment by the pain team. Heat can increase drug absorption from opioid patches. Monitor for toxicity in febrile patients dose adjustment may be required. Avoid exposing the application site to heat, e.g. a heat pad or hot bath as this can have the same effect. Naloxone All patients prescribed strong opioids (IV and oral) should have when required naloxone prescribed. If respiratory rate is persistently 8 or less and sedation score is 3 or less call the pain team, primary medical team or on-call anaesthetist. Version no.: 1.0 Page 9 of 14
10 To prepare: Add 1mL of naloxone 400micrograms/mL to 9mL sodium chloride 0.9%. This produces a concentration of 40micrograms/mL. Naloxone should be given titrated 40micrograms (1mL) at a time in approximately 5 minute intervals. Be aware that naloxone will not only reverse opioid side-effects but analgesic effect also. In addition naloxone has a very short half-life and respiratory depression may recur therefore, close monitoring must continue. Naloxone should be given in carefully as side effects include: nausea, vomiting, hypotension, hypertension, tachycardia, headache, dizziness; less commonly diarrhoea, dry mouth, bradycardia, arrhythmia, hyperventilation, tremor, sweating; rarely seizures; very rarely ventricular fibrillation, cardiac arrest, pulmonary oedema, erythema multiforme, and hypersensitivity reactions including anaphylaxis; also reported agitation. Version no.: 1.0 Page 10 of 14
11 Appendix 1: Additional drug information Morphine First line oral opioid analgesic Metabolised to two metabolites - M3 & M6 glucuronides M6G has analgesic properties as a mu opioid receptor agonist. It crosses the blood/brain barrier more slowly than morphine M3G has no analgesic activity but is primarily responsible for neurotoxic side effects of morphine including hyperalgesia, allodynia & myoclonus Morphine and its metabolites are renally excreted so accumulate in renal failure leading to toxicity. Oral dose is 1-3 times higher than intravenous dose due to low bioavailability Pharmacokinetics: Bioavailability 35% PO Onset of action min IM 5-90 min SC Time to peak plasma conc min PO min IM/SC Plasma half life hrs PO 1.5 hrs IV Duration of action 3-6 hours Codeine Weak opioid Weak mu agonist Primary action is by metabolism by CYP2D6 by de-methylation - approximately 10% is metabolised to morphine Large variability in metabolism so hypermetabolisers (~5%) get excessive effects and are at risk of narcosis Hypometabolisers (~7.5%) get little benefit from drug but may still get side effects As a result of this highly varied metabolism leading to potential toxicity or lack of effect codeine is no longer recommended for breast feeding mothers or for children as per NPSA warnings. We would recommend that it is not used as first line analgesia for in hospital acute pain. Dose = 30-60mg qds Pharmacokinetics: Bioavailability 40% po Onset of action min Time to peak plasma conc. 1-2 hours Plasma half life hours Duration of action 4-6 hours Version no.: 1.0 Page 11 of 14
12 Tramadol Synthetic centrally-acting analgesic with opioid and non-opioid properties Opioid agonist, serotonin and NA reuptake inhibitor Can be effective treatment for neuropathic pain Can potentiate serotonin syndrome - theoretical risk of precipitating serotonin syndrome if used with other drugs which increase serotonin levels, (SSRIs, TCAs, Pethidine). Presents with tachycardia, mycoclonus, dilated pupils, sweating, shivering & hyper-reflexia. Pro-convulsant: caution with epilepsy, particularly with tramadol IV Can led to hyponatraemia Dose = mg up to QDS Pharmacokinetics: Bioavailability 65-75% po Onset of action 30 min - 1 hour Time to peak plasma conc. 2 hours Plasma half life 6 hours (doubles in cirrhosis & severe renal failure) Duration of action 4-9 hours Oxycodone Potent opioid agonist By mouth, oxycodone is approximately twice as potent as morphine, (so dose needs to be halved when converting from morphine to oxycodone) Consider switch from morphine to oxycodone if neurotoxic side effects of morphine occur. Oxycodone is renally excreted but has no active metabolites. The dose is unchanged in renal impairment until GFR is <10ml/min Pharmacokinetics: Bioavailability 75% po Onset of action min po Time to peak plasma conc hours Plasma half life 3.5 hours (4.5 hrs in renal failure) Duration of action 4-6 hours Version no.: 1.0 Page 12 of 14
13 Buprenorphine Partial mu agonist and kappa antagonist Consider use where oral route to be avoided or for patients in renal failure (second line after oxycodone) No analgesic ceiling effect but respiratory depression ceiling effect 2/3 excreted unchanged, 1/3 hepatically metabolised Not renally excreted so safe to use in renal failure In severe renal impairment (creatinine clearance <10 reduce dose by 25%) Strong receptor affinity so increased doses of naloxone needed to reverse effect Highly lipid soluble making it suitable for transdermal delivery in the form of BuTrans and Transtec patches. These take >48 hours to reach steady state so are unsuitable for use in acute pain It may take 30 hours for levels to drop by 50% after patch removal Sub lingual tablet dose: micrograms 6-8 hourly Pharmacokinetics (Sublingual): Bioavailability 30-50% Onset of action min Time to peak plasma conc. 30 min hours Plasma half life hours Duration of action 6-8 hours Fentanyl Highly potent semi-synthetic opioid Minimally renally excreted (<7%) so safe to use in renal failure Lipid soluble making it suitable for transdermal delivery in form of patches Highly lipid soluble making it suitable for transdermal delivery in form of patches These take >48 hours to reach steady state so are unsuitable for use in acute pain It may take 30 hours for levels to drop by 50% after patch removal Fentanyl can precipitate Serotonin syndrome - theoretical risk of precipitating serotonin syndrome if used with other drugs which increase serotonin levels, (SSRIs, TCAs, Pethidine). Presents with tachycardia, mycoclonus, dilated pupils, sweating, shivering & hyper-reflexia. Version no.: 1.0 Page 13 of 14
14 Sublingual preparations: Abstral - sublingual fentanyl tablet Can be used when oral route is to be avoided or for patients in renal failure Very rarely required except in palliative care Please seek advice before use from either palliative care or acute pain team Licensed for breakthrough pain (predominantly cancer) for patients on 60mg morphine equivalent/day Dosage needs to be titrated to individual, independently of other opioid analgesia (see flow chart below Figure 3: Sub-Lingual Fentanyl Tablet flowchart Starting dose 100 micrograms Adequate pain relief within minutes? Yes No Take a second tablet* Use this dose for further breakthrough episodes * Dose of second tablet if first tablet unsuccessful Increase first tablet to next higher strength for next breakthrough pain episode. 2 tablets total per pain episode First Tablet Second Tablet 100 micrograms 100 micrograms 200 micrograms 100 micrograms 300 micrograms 100 micrograms 400 micrograms 200 micrograms 600 micrograms 200 micrograms 800 micrograms - Version no.: 1.0 Page 14 of 14
Mid Essex Locality Guideline for Management of Adult Acute and Chronic Non-Cancer Pain in Primary care
Guideline for Management of Adult Acute and Chronic Non-Cancer Pain in Primary care If possible patients should be assessed using a simple visual analogue scale VAS to determine the most appropriate stage
More informationBJF Acute Pain Team Formulary Group
Title Analgesia Guidelines for Acute Pain Management (Adults) in BGH Document Type Issue no Clinical guideline Clinical Governance Support Team Use Issue date April 2013 Review date April 2015 Distribution
More informationBerkshire West Area Prescribing Committee Guidance
Guideline Name Berkshire West Area Prescribing Committee Guidance Date of Issue: September 2015 Review Date: September 2017 Date taken to APC: 2 nd September 2015 Date Ratified by GP MOC: Guidelines for
More informationGUIDELINES ON THE MANAGEMENT OF PAIN DUE TO CANCER IN ADULTS
GUIDELINES ON THE MANAGEMENT OF PAIN DUE TO CANCER IN ADULTS Bristol Palliative Care Collaborative Contact Numbers: Hospital Specialist Palliative Care Teams: North Bristol 0117 4146392 UH Bristol 0117
More informationGuidelines for the Management of Chronic Non-Malignant Pain (CNMP) in Primary Care (not including neuropathic pain (NeP).
Surrey (East Surrey CCG, Guildford & Waverley CCG, North West Surrey CCG, Surrey Downs CCG & Surrey Heath CCG) North East Hampshire & Farnham CCG and Crawley, Horsham & Mid-Sussex CCG Guidelines for the
More informationTRAPADOL INJECTION FOR I.V./I.M. USE ONLY
TRAPADOL INJECTION FOR I.V./I.M. USE ONLY Composition : Each 2ml. contains : Tramadol Hydrochloride I.P. Water for injection I.P. 100mg. q.s. CLINICAL PHARMACOLOGY : Pharmacodynamics Tramadol is a centrally
More informationAnalgesia. This is widely used in palliative care. It has antipyretic and analgesic effects but no anti-
Page 1 of 8 Analgesia The World Health Organisation (WHO, 1990) has devised a model to assist health care professionals in the management of cancer pain. The recommendations include managing pain, by the
More informationPalliative Prescribing - Pain
Palliative Prescribing - Pain LAURA BARNFIELD 21/2/17 Aims To understand the classes of painkillers available in palliative care To gain confidence in counselling regarding opiates To gain confidence prescribing
More informationBACKGROUND Measuring renal function :
A GUIDE TO USE OF COMMON PALLIATIVE CARE DRUGS IN RENAL IMPAIRMENT These guidelines bring together information and recommendations from the Palliative Care formulary (PCF5 ) BACKGROUND Measuring renal
More informationAgonists: morphine, fentanyl Agonists-Antagonists: nalbuphine Antagonists: naloxone
Opioid Definition All drugs, natural or synthetic, that bind to opiate receptors Agonists: morphine, fentanyl Agonists-Antagonists: nalbuphine Antagonists: naloxone Opioid agonists increase pain threshold
More informationPRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT A collaboration between: St. Rocco s Hospice, Bridgewater Community Healthcare NHS Trust, NHS Warrington Clinical Commissioning Group,
More informationOP01 [Mar96] With regards to pethidine s physical properties: A. It has an octanol coefficient of 10 B. It has a pka of 8.4
Opioid MCQ OP01 [Mar96] With regards to pethidine s physical properties: A. It has an octanol coefficient of 10 B. It has a pka of 8.4 OP02 [Mar96] Which factor does NOT predispose to bradycardia with
More informationAnalgesia in patients with impaired renal function Formulary Guidance
Analgesia in patients with impaired renal function Formulary Guidance Approved by Trust D&TC: January 2010 Revised March 2017 Contents Paragraph Page 1 Aim 4 2 Introduction 4 3 Assessment of renal function
More informationPAEDIATRIC DOSAGE GUIDELINES For management of post-operative acute pain
Index No: MMG43 PAEDIATRIC DOSAGE GUIDELINES For management of post-operative acute pain Version: 3.1 (Includes anti-emetics and naloxone) Date ratified: July 2013 Ratified by: (Name of Committee) Name
More informationSupporting Last Days of Life Symptom Control Medication Guidance: Algorithm. Agitation & Anxiety
Agitation & Anxiety (Exclude or treat REVERSIBLE causes*) Patient is anxious / frightened, but lucid Patient is confused, agitated and / or hallucinating MIDAZOLAM 2.5-5mg s/c (Max total 24 hour dose of
More informationQ&A: Opioid Prescribing for Chronic Non-Malignant Pain
NHS Hastings and Rother Clinical Commissioning Group Chair Dr David Warden Chief Officer Amanda Philpott NHS Eastbourne, Hailsham and Seaford Clinical Commissioning Group Chair Dr Martin Writer Chief Officer
More informationAdult Opioid Prescribing Guidelines for Acute or Persistent Pain
Adult Opioid Prescribing Guidelines for Acute or Persistent Pain Author: Sponsor/Executive: Responsible committee: Consultation & Approval: (Committee/Groups which signed off the policy, including date)
More informationGUIDELINES AND AUDIT IMPLEMENTATION NETWORK
GUIDELINES AND AUDIT IMPLEMENTATION NETWORK General Palliative Care Guidelines The Management of Pain at the End Of Life November 2010 Aim To provide a user friendly, evidence based guide for the management
More informationPAIN PODCAST SHOW NOTES:
PAIN PODCAST SHOW NOTES: Dallas Holladay, DO Ultrasound Fellow Cook County Hospital Rush University Medical Center Jonathan D. Alterie, DO PGY-2, Emergency Medicine Midwestern University An overview of
More informationSYMPTOM MANAGEMENT GUIDANCE FOR PATIENTS RECEIVING PALLIATIVE CARE AT ROYAL DERBY HOSPITAL
SYMPTOM MANAGEMENT GUIDANCE FOR PATIENTS RECEIVING PALLIATIVE CARE AT ROYAL DERBY HOSPITAL If a patient is believed to be approaching the end of their life, medication should be prescribed in anticipation
More informationPrescribing and Administration of Analgesia within Maternity
Prescribing and Administration of Analgesia within Maternity CONTENTS Introduction and Who The Guideline Applies To... 2 UHL Paracetamol Prescribing Guideline... 2 Oral dosing... 2 Intravenous dosing...
More informationB. Long-acting/Extended-release Opioids
4 Opioid tolerance is assumed in patients already taking fentanyl 25 mcg/hr OR daily doses of the following oral agents for 1 week: 60 mg oral morphine, 30 mg oxycodone, 8 mg hydromorphone, 25 mg of oxymorphone
More informationFor patients and their carers this means smoother symptom control, better support in a crisis, and avoidance of admission if that is their choice.
Bedfordshire Palliative Care Palliative Care Medicines Guidance This folder has been produced to support professionals providing palliative care in any setting. Its aim is to make best practice in palliative
More informationSupportive Care. End of Life Phase
Supportive Care End of Life Phase Guidelines for Health Care Professionals In the care of patients with established renal failure who are in the last days of life References: Chambers E J (2004) End of
More information5 MUSCULOSKELETAL SYSTEM
5 MUSCULOSKELETAL SYSTEM 5.01 NON-STEROIDAL ANTIILAMMATORY DRUGS (NSAIDS) *Acetylsalicylic Acid (Aspirin) Tab Soluble 300mg Diclofenac Sodium Tab 25mg, Supp 25mg, 50mg & 100mg (Voltaren) 300-900mg every
More informationRenal Prescribing at End of Life Guidance for Anticipatory prescribing for patients in renal failure (egfr<30) at the end of life
Guidance for Anticipatory prescribing for patients in renal failure (egfr
More information21 st June BDS BASHD Therapeutics Pain and Analgesia. BASHD Therapeutics Analgesics and Pain Management. Links to other BASHD content
Volume of Prescribing by Dentists 2011 ( a reminder) BASHD Therapeutics Analgesics and Pain Management Analgesics account for 1 in 80 dental prescriptions made A lot more analgesics will be suggested for
More informationAcute painful crisis in patients with sickle cell disease: Clinical Guidelines (HN-506a)
Acute painful crisis in patients with sickle cell disease: Clinical Guidelines (HN-506a) Introduction The majority of acute painful crises in patients with sickle cell disease will be managed independently
More informationOpioid rotation or switching may be considered if a patient obtains pain relief with one opioid and is suffering severe adverse effects.
Dose equivalence and switching between opioids Key Messages Switching from one opioid to another should only be recommended or supervised by a healthcare practitioner with adequate competence and sufficient
More informationPostoperative Pain Management. Nimmaanrat S, MD, FRCAT, MMed (Pain Mgt)
Postoperative Pain Management Nimmaanrat S, MD, FRCAT, MMed (Pain Mgt) Topics to be Covered Definition Neurobiology Classification Multimodal analgesia Preventive analgesia Step down approach Measurement
More informationRenal Palliative Care Last Days of Life
Renal Palliative Care Last Days of Life Introduction This guideline is an aid to clinical decision-making and good practice for patients with stage 4-5 chronic kidney disease (egfr
More informationPAIN AND SYMPTOM MANAGEMENT GUIDANCE IN THE LAST DAYS OF LIFE
PAIN AND SYMPTOM MANAGEMENT GUIDANCE IN THE LAST DAYS OF LIFE Reference: DCM029 Version: 1.1 This version issued: 07/06/18 Result of last review: Minor changes Date approved by owner (if applicable): N/A
More informationAppendix D: Drug Tables
Appendix D: Drug Tables A. Short-acting, Orally Administered Opioids Table D-1: Use of Short-acting, Orally Administered Opioids in Adults [198] Additional Maximum APAP dose: 4000 mg/d (2000 mg/d in chronic
More informationDBL NALOXONE HYDROCHLORIDE INJECTION USP
Name of medicine Naloxone hydrochloride Data Sheet New Zealand DBL NALXNE HYDRCHLRIDE INJECTIN USP Presentation DBL Naloxone Hydrochloride Injection USP is a sterile, clear, colourless solution, free from
More informationOpioid Pharmacology. Dr Ian Paterson, MA (Pharmacology), MB BS, FRCA, MAcadMEd. Consultant Anaesthetist Sheffield Teaching Hospitals
Opioid Pharmacology Dr Ian Paterson, MA (Pharmacology), MB BS, FRCA, MAcadMEd Consultant Anaesthetist Sheffield Teaching Hospitals Introduction The available opioids and routes of administration - oral
More informationPAIN MANAGEMENT Patient established on oral morphine or opioid naive.
PAIN MANAGEMENT Patient established on oral morphine or opioid naive. Important; It is the responsibility of the prescriber to ensure that guidelines are followed when prescribing opioids. Every member
More informationCare in the Last Days of Life
Care in the Last Days of Life Introduction This guideline is an aid to clinical decision making and good practice in person-centred care for patients who are deteriorating and at risk of dying. The patient
More informationEnd of life prescribing guidance
End of life prescribing guidance Introduction This guidance has been prepared to ASSIST IN DECISION MAKING for the prescribing and monitoring of medicines useful in the management of symptoms commonly
More informationANNEX I SUMMARY OF PRODUCT CHARACTERISTICS
ANNEX I SUMMARY OF PRODUCT CHARACTERISTICS 1 1. NAME OF THE VETERINARY MEDICINAL PRODUCT Tralieve 50 mg/ml solution for injection for dogs (AT, BE, BG, CY, CZ, DE, EL, ES, HR, HU, IE, IT, LU, NL, PT, RO,
More informationSubstitution Therapy for Opioid Use Disorder The Role of Suboxone
Substitution Therapy for Opioid Use Disorder The Role of Suboxone Methadone/Buprenorphine 101 Workshop, December 10, 2016 Leslie Lappalainen, MD, CCFP, dip ABAM Prepared by Mandy Manak, MD, ABAM, CCSAM
More informationPOLICY and PROCEDURE
Misericordia Community Hospital Administration of Intravenous FentaNYL During Labour POLICY and PROCEDURE Labour and Delivery Manual Original Date Revised Date Approved by: Director, Women s Health, Covenant
More informationBuprenorphine pharmacology
Buprenorphine pharmacology Victorian Opioid Management ECHO Department of Addiction Medicine St Vincent s Hospital Melbourne 2018 Page 1 Opioids full, partial, antagonist Full Agonists - bind completely
More informationOverview of Essentials of Pain Management. Updated 11/2016
0 Overview of Essentials of Pain Management Updated 11/2016 1 Overview of Essentials of Pain Management 1. Assess pain intensity on a 0 10 scale in which 0 = no pain at all and 10 = the worst pain imaginable.
More informationGateshead Pain Guidelines for Chronic Conditions
Gateshead Pain Guidelines for Chronic Conditions Effective Date: 13.2.2013 Review Date: 13.2.2015 Gateshead Pain Guidelines: Contents PAIN GUIDELINES Chronic Non-Malignant Pain 5 Musculoskeletal Pain 6
More informationGUIDELINES FOR PRESCRIBING AT THE END OF LIFE FOR PATIENTS WITH RENAL IMPAIRMENT (estimated glomerular filtration rate<30)
GUIDELINES FOR PRESCRIBING AT THE END OF LIFE FOR PATIENTS WITH RENAL IMPAIRMENT These guidelines have been produced in collaboration with Dr Lucy Smyth, Consultant in Renal Medicine, Royal Devon and Exeter
More information6/6/2018. Nalbuphine: Analgesic with a Niche. Mellar P Davis MD FCCP FAAHPM. Summary of Advantages. Summary of Advantages
Nalbuphine: Analgesic with a Niche Mellar P Davis MD FCCP FAAHPM 1 Summary of Advantages Safe in renal failure- fecal excretion Analgesia equal to morphine with fewer side effects Reduced constipation
More informationAssociate Professor Supranee Niruthisard Department of Anesthesiology Faculty of Medicine Chulalongkorn University January 21, 2008
Associate Professor Supranee Niruthisard Department of Anesthesiology Faculty of Medicine Chulalongkorn University January 21, 2008 PAIN MECHANISMS Somatic Nociceptive Visceral Inflammatory response sensitizes
More informationPART 1.B SPC, LABELLING AND PACKAGE LEAFLET
TRAMADOG, solution for injection Decentralised Procedure D195 February 2018 V3 Tramadol HCl 50 mg/ml Part 1.B SPC, Labelling and Package Leaflet PART 1.B SPC, LABELLING AND PACKAGE LEAFLET 1B- 1 ANNEX
More informationPrimary care review of Tramadol Prescribing
Primary care review of Tramadol Prescribing Aim of the Audit To ensure the prescribing of tramadol is safe, appropriate and regularly reviewed, in line with local chronic pain guidelines 1 Background Tramadol
More informationPain management in palliative care. Dr. Stepanie Lippett and Sister Karen Davies-Linihan
Pain management in palliative care Dr. Stepanie Lippett and Sister Karen Davies-Linihan contents Concept of total pain Steps in pain management Recognising neuropathic pain WHO analgesic ladder Common
More informationPain Management Management in Hepatic Hepatic and and Renal Dysfunction
Pain Management in Hepatic and Renal Dysfunction Review the pharmacologic basis for medications used in pain management Identify pain medications which hshould ldbe avoided in patients with hepatic dysfunction
More informationANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL IMPAIRMENT
ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL Doses of opiates must be proptional to current analgesic medication Please refer ALL patients on Methadone Ketamine to SPCT f advice. Patients
More informationLong Term Care Formulary HCD - 08
1 of 5 PREAMBLE Opioids are an important component of the pharmaceutical armamentarium for management of chronic pain. The superiority of analgesic effect of one narcotic over another is not generally
More informationTrust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Patient Controlled Analgesia (PCA) in Adults A clinical guideline recommended for use For Use in: In all Clinical Areas By: Anaesthetists, Ward Nurses, Recovery Staff Acute Pain Service Staff For: Adult
More informationDoncaster & Bassetlaw Cancer Locality. Palliative Care Core Formulary
Doncaster & Bassetlaw Cancer Locality Palliative Core Formulary Approved by Doncaster & Bassetlaw Hospitals NHS Foundation Trust Drugs and Therapeutics Committee. DJ14/2155 Oct 2014 Review date: Oct 2017
More informationPAIN MANAGEMENT Person established taking oral morphine or opioid naive.
PAIN MANAGEMENT Person established taking oral morphine or opioid naive. Important; it is the responsibility of the prescriber to ensure that guidelines are followed when prescribing opioids. Every member
More informationDrug Information Common to the Class of Extended-Release and Long-Acting Opioid Analgesics (ER/LA opioid analgesics) Avinza Butrans
FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics 7/9/2012 Drug Information Common to the Class of Extended-Release and Long-Acting Opioid Analgesics (ER/LA
More informationAlgorithms for Symptom Management. In End of Life Care
Algorithms for Symptom Management In End of Life Care The Use of Drugs Beyond Licence (off label) -The Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK regulates the activity of the
More informationpatient group direction
CYCLIZINE v01 1/7 CYCLIZINE PGD Details Version 1.0 Legal category Staff grades Approved by POM Paramedic (Non-ECP) Nurse (Non-ECP) Emergency Care Practitioner (Paramedic) Emergency Care Practitioner (Nurse)
More informationANNEX III LABELLING AND PACKAGE LEAFLET
ANNEX III LABELLING AND PACKAGE LEAFLET 1 A. LABELLING 2 PARTICULARS TO APPEAR ON THE OUTER PACKAGE AND THE IMMEDIATE PACKAGE Outer carton Multi-pack 1. NAME OF THE VETERINARY MEDICINAL PRODUCT Tralieve
More informationRegional Renal Training
Regional Renal Training Palliative and End of Life Care Dr Clare Kendall North Bristol NHS Trust Advanced Kidney Disease Dialysis/Transplant Conservative Management Deteriorating despite dialysis/failing
More informationNEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES
NEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES GENERAL PRINCIPLES Neuropathic pain may be relieved in the majority of patients by multimodal management A careful history and examination are essential.
More informationSTARSHIP WITHDRAWAL OF ANALGESIA AND SEDATION
STARSHIP WITHDRAWAL OF ANALGESIA AND SEDATION Patients receiving analgesia and/or sedation for longer than 5-7 days may suffer withdrawal if these drugs are suddenly stopped. To prevent this happening
More informationPain Management Strategies Webinar/Teleconference
Pain Management Strategies Webinar/Teleconference Barry K. Baines, MD April 16, 2009 Objectives Describe the principles of pain management. Identify considerations in the use of opioids. Describe the benefits
More informationAcute Pain Management in the Hospital Setting. Alexandra Phan, PharmD PGY-1 Pharmacy Practice Resident Medical Center Hospital Odessa, TX
Acute Pain Management in the Hospital Setting Alexandra Phan, PharmD PGY-1 Pharmacy Practice Resident Medical Center Hospital Odessa, TX 2 What is Pain? An unpleasant sensory and emotional experience associated
More informationOpioid Pearls and Acute Pain Management
Opioid Pearls and Acute Pain Management Jeanie Youngwerth, MD University of Colorado Denver Assistant Professor of Medicine, Hospitalist Associate Director, Colorado Palliative Medicine Fellowship Program
More informationADULT (>16) ACUTE SICKLE PAIN GUIDELINE
ADULT (>16) ACUTE SICKLE PAIN GUIDELINE ID 2013 065 Author s Name Dr Anna Wood Author s Job Title Consultant Haematologist Division Consultant Haematologist Department Haematology Version number 3 Ratifying
More informationEnhanced Community Palliative Support Services. Lynne Ghasemi St Luke s Hospice
Enhanced Community Palliative Support Services Lynne Ghasemi St Luke s Hospice Learning Outcomes Define the different types of pain Describe the process of pain assessment Discuss pharmacological management
More informationMethadone Maintenance
Methadone Maintenance A Practical Guide to Pharmacotherapy Methadone/Buprenorphine 101 Workshop, April 1, 2017 Ron Joe, MD, DABAM Objectives I. Pharmacology Of Methadone II. Practical Application of Pharmacology
More informationXTRAM. Composition Xtram 50 mg capsule Each capsule contains Tramadol HCl 50 mg
XTRAM Composition Xtram 50 mg capsule Each capsule contains Tramadol HCl 50 mg Capsules Action Tramadol is a centrally acting synthetic analgesic of the aminocyclohexanol group with opioid-like effects.
More informationAnnex C. (variation to nationally authorised medicinal products)
Annex C (variation to nationally authorised medicinal products) Annex I Scientific conclusions and grounds for variation to the terms of the marketing authorisations Scientific conclusions Taking into
More informationLACIPIL QUALITATIVE AND QUANTITATIVE COMPOSITION
LACIPIL lacidipine QUALITATIVE AND QUANTITATIVE COMPOSITION Lacidipine, 2 mg - round shaped white engraved on one face. Lacidipine, 4 mg - oval white with break line on both faces. Lacidipine, 6 mg - oval
More informationAnalgesia for Patients with Substance Abuse Disorders. Lisa Jennings CN November 2015
Analgesia for Patients with Substance Abuse Disorders Lisa Jennings CN November 2015 Definitions n Addiction: A pattern of drug use characterised by aberrant drug-taking behaviours & the compulsive use
More informationNARCAN Injection. 4,5 α Epoxy-3,14 dihydroxy 17 (prop-2-enyl)morphinan-6-one hydrochloride
NAME OF MEDICINE Naloxone hydrochloride The molecular weight of naloxone hydrochloride is 363.84 and the CAS registry number for the drug substance (naloxone hydrochloride) is 357-08-4. The molecular formula
More informationCare of the Dying. For dosing in severe renal impairment see separate guidance for care of the dying in severe renal failure.
Care of the Dying Early diagnosis of the dying process allows for adequate preparation of the patient, the family and the carers. This clinical guidance covers the prescribing and management of patients
More informationOpioid Conversion Guidelines
Opioid Conversion Guidelines March 2015 Gippsland Region Palliative Care Consortium Clinical Practice Group Title Keywords Ratified Opioid, Conversion, Drug, Therapy, Palliative, Guideline, Palliative,
More informationGuideline for the use of Clonidine for Sedation in Adult Intensive Care
Guideline for the use of Clonidine for Sedation in Adult Intensive Care This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the
More informationPharmacokinetics of strong opioids. Susan Addie Specialist palliative care pharmacist
Pharmacokinetics of strong opioids Susan Addie Specialist palliative care pharmacist What is the difference between pharmacokinetics and pharmacodynamics? Definitions Pharmacokinetics = what the body does
More informationNEW ZEALAND DATA SHEET ACUPAN TM. 3. PHARMACEUTICAL FORM White, round, biconvex, film-coated tablets (7 mm diameter) engraved APN on one face.
1. PRODUCT NAME ACUPAN 30 mg tablets 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each tablet contains nefopam hydrochloride 30 mg. For a full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM
More informationPain. Christine Illingworth. Community Nurse St Luke s Hospice 17/5/17
Pain Christine Illingworth Community Nurse St Luke s Hospice 17/5/17 What is pain? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain is whatever
More informationPalliative care for heart failure patients. Susan Addie
Palliative care for heart failure patients Susan Addie Treatments The most common limiting and distressing complaint is of fatigue and breathlessness. Optimal treatment strategies relieve symptoms, improves
More informationGG&C Chronic Non Malignant Pain Opioid Prescribing Guideline
GG&C Chronic Non Malignant Pain Opioid Prescribing Guideline Background Persistent pain is common, affecting around five million people in the UK. For many sufferers, pain can be frustrating and disabling,
More informationPain Management for Adult sickle cell disease patients: Information for patients, relatives and carers
Pain Management for Adult sickle cell disease patients: Information for patients, relatives and carers Why you should read this leaflet This leaflet will give you the information necessary to manage your
More informationPharmacogenetics of Codeine. Lily Mulugeta, Pharm.D Office of Clinical Pharmacology Pediatric Group FDA
Pharmacogenetics of Codeine Lily Mulugeta, Pharm.D Office of Clinical Pharmacology Pediatric Group FDA 1 Codeine Overview Naturally occurring opium alkaloid Demethylated to morphine for analgesic effect
More informationSwitching Tramacet to paracetamol alone or paracetamol and codeine
Bulletin 62 February 2014 Community Interest Company Switching Tramacet to paracetamol alone or paracetamol and codeine This is one of a number of bulletins providing further information on medicines contained
More informationAcute pain management in opioid tolerant patients. Muhammad Laklouk
Acute pain management in opioid tolerant patients Muhammad Laklouk General principles An adequate review and assessment Provision of effective analgesia (including attenuation of tolerance and hyperalgesia)
More informationNausicalm solution for injection is a clear colourless solution, presented in 1 ml ampoules.
Nausicalm Cyclizine lactate 50 mg/ml solution for injection Presentation Nausicalm solution for injection is a clear colourless solution, presented in 1 ml ampoules. Uses Actions Cyclizine is a piperazine
More informationHOPE. Considerations. Considerations ISING. Safe Opioid Prescribing Guidelines for ACUTE Non-Malignant Pain
Due to the high level of prescription drug use and abuse in Lake County, these guidelines have been developed to standardize prescribing habits and limit risk of unintended harm when prescribing opioid
More information4.4 Special warnings and precautions for use
SUMMARY OF PRODUCT CHARACTERISTICS 4.3 Contraindications Durogesic is contraindicated in patients with known hypersensitivity to fentanyl or to the excipients present in the patch. Acute or postoperative
More informationADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments
ADENOSINE Paroxysmal SVT 1 st Dose 6 mg rapid IV 2 nd & 3 rd Doses 12 mg rapid IV push Follow each dose with rapid bolus of 20 ml NS May cause transient heart block or asystole. Side effects include chest
More informationSyringe driver in Palliative Care
Syringe driver in Palliative Care Introduction: Syringe drivers are portable, battery operated devices widely used in palliative care to deliver medication as a continuous subcutaneous infusion over 24
More informationPALLIATIVE TREATMENT BY DR. KHRONGKAMOL SIHABAN MEDICAL ONCOLOGIST
PALLIATIVE TREATMENT BY DR. KHRONGKAMOL SIHABAN MEDICAL ONCOLOGIST TREATMENT IN ONCOLOGY Main treatment : surgery Neoadjuvant treatment : RT, CMT Adjuvant treatment : Tx micrometastatic disease -CMT,Targeted
More informationGUIDELINES FOR THE USE OF NALOXONE INJECTION FEBRUARY 2018
GUIDELINES FOR THE USE OF NALOXONE INJECTION FEBRUARY 2018 Guidelines for the use of naloxone injection in acute services Policy title Policy reference PHA58 Policy category Clinical Relevant to All medical,
More informationAcute Pain NETP: SEPTEMBER 2013 COHORT
Acute Pain NETP: SEPTEMBER 2013 COHORT Pain & Suffering an unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage International
More informationOpioid Conversion Ratios - Guide to Practice 2010
Opioid Conversion Ratios - Guide to Practice 2010 Released December 2010. 2010. The EMR PCC grants permission to reproduce parts of this publication for clinical and educational use only, provided that
More informationNeuropathic Pain Treatment Guidelines
Neuropathic Pain Treatment Guidelines Background Pain is an unpleasant sensory and emotional experience that can have a significant impact on a person s quality of life, general health, psychological health,
More informationChronic Non Malignant Pain Opioid Guideline
CLINICAL GUIDELINE Chronic Non Malignant Pain Opioid Guideline A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments. Clinical judgement should be exercised
More informationPolicy on Pharmacological Therapies Practice Guidance Note Reducing Dosing Errors with Opioid Medicines V04
Policy on Pharmacological Therapies Practice Guidance Note Reducing Dosing Errors with Opioid Medicines V04 Date issued Issue 1 Nov 2018 Planned review Nov 2021 PPT-PGN 18 part of NTW(C)38 Pharmaceutical
More informationCHAMP: Bedside Teaching TREATING PAIN. Stacie Levine MD. What is the approach to treating pain in the aging adult patient?
CHAMP: Bedside Teaching TREATING PAIN Stacie Levine MD Teaching Trigger: An older adult patient is identified as having pain. Clinical Question: What is the approach to treating pain in the aging adult
More informationMulti Modal Analgesia
Analgesic Drugs and Pharmacology Richard Craig R.N. B.N. M. Sci. Med (Pain Mgmt) Nurse Consultant Acute Pain Management Service Christchurch Hospital Multi Modal Analgesia Patients benefit from multi modal
More information