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 of management on the pain ladder. This can also be used at review to gauge response to treatment- see appendix 1 Pain other than lower back pain Lower back pain STEP ONE Mild Pain (2-3 on VAS) Paracetamol 1g QDS Maximum 4g/24 hours +/- Non Steroidal Anti- Inflammatory Drug (NSAID) 1 Ibuprofen 400mg tds or Naproxen 500mg bd. Diclofenac should not be routinely used due to increased cardiac risk (appropriately risk assessed and concomitant PPI where indicated) +/- Non Steroidal Anti- Inflammatory Drug (NSAID) 1 Ibuprofen 400mg tds or Naproxen 500mg bd. Diclofenac should not be routinely used due to increased cardiac risk (appropriately risk assessed and concomitant PPI where indicated) Adjuvants such as Tricyclic antidepressants, and anticonvulsants may also be added at this stage) Paracetamol 1g QDS Maximum 4g/24 hours Patient: Young and/or Good renal function STEP TWO Moderate Pain (4-5 on VAS) Continue with STEP ONE plus Codeine phosphate 30 60mg QDS (Plus laxative as per formulary). This can be prescribed as co-codamol if taken with paracetamol If poor response or not tolerated; Tramadol HCl 50 100mg QDS Patient: Elderly Osteoarthritic Musculo-skeletal pain Acute back pain (not for routine initiation) Elderly Buprenorphine patch; Prescribed by brand Initiated at 5mcg/hour (Consideration should be given to the previous opioid history of the patient as well as to the current general condition and medical status of the patient-see equivalence charts below) and titrated as appropriate but not before 3 days when the maximum effect of a given dose is established. Oramorph oral solution; (morphine sulphate 10mg/5mL) 2.5mg 5mg every 4 hours PainManagementAdultsGUI201707v2.0final 1
STEP THREE Severe Pain (6-7 on VAS) Continue with STEP ONE plus Regular use of a potent opioid may be appropriate for certain cases of chronic non-malignant pain but should not be offered for the management of chronic low back pain; treatment should be supervised by a specialist and the patient should be assessed at regular intervals. N.B. Seek specialist advice before prescribing strong opioids for patients with CKD 3,4, and 5 First line; Oral Morphine sulphate; Prescribed by brand as per local policy. Either immediate or sustained release depending on patient preference. For breakthrough pain (this should be 1/6 th of total daily dose) during the titration phase consider oral immediate release doses of Morphine either as solution or tablets. PLUS Laxatives as per local formulary Anti-emetic- Domperidone 10mg TDS for short term use as required (up to maximum 7 days). If nausea persists optimise anti-emetic regimen before considering alternative analgesia. Second line (unresolved pain) Third line; Fourth line; Oxycodone 8; Prescribed by brand (e.g. Longtec (modified release) or Shortec (immediate release)). Second line opioid only use if morphine unsuitable or not tolerated. See equivalence charts below Tapentadol SR; Specialist initiation only Fentanyl patch Prescribed by brand; Only use if oral opioids are not suitable and analgesic requirements are stable. See dose equivalence chart below. Do not use for acute pain or opiate naïve patients. Record the anatomical position of currently applied patch to inform future decisions and actions Approximate Equivalent doses of Opioid (BNF online accessed 10/2/17) Analgesic Route Dose ORAL; Morphine Oral 10mg Codeine Oral 100mg Dihydrocodeine Oral 100mg Oxycodone Oral 6.6mg Tramadol Oral 100mg INJECTION; Morphine IM,IV,SC 5mg Diamorphine IM,IV,SC 3mg PainManagementAdultsGUI201707v2.0final 2
Approximate Equivalent doses of Patches to 24 hr doses of oral Morphine (BNF online accessed 10/2/17) Morphine Salt daily Buprenophine Patch Morphine Salt daily Fentanyl Patch 12mg BuTec 5 (7 day patch) 30mg Fentanyl 12 Patch 24mg BuTec 10 (7 day patch) 60mg Fentanyl 25 Patch 48mg BuTec 20 (7 day patch) 120mg Fentanyl 50 Patch 84mg Transtec 35 (4 day 180mg Fentanyl 75 Patch patch) 126mg Transtec 52.5 (4 day 240mg Fentanyl 100 patch) Patch 168mg Transtec 70 (4 day patch) Guideline for Pain Management in Adults To maintain freedom from pain, drugs should be given by the clock, that is every 3 6 hours, rather than on-demand. An exception is in renal failure (CKD levels 4-5) where opioids must be given on-demand in an immediate release form to avoid drug accumulation. Treatment should be initiated at the step most relevant to the presenting degree of pain. Medication will be stepped up or down accordingly in line with persistence or easing of pain and also in respect of signs of toxicity or severe side effects. Opioid medication should be reviewed as appropriate and the dose titrated accordingly. Initially, an immediate release preparation should be prescribed four hourly and when required. The total dose of opioid used within a 24 hour period can then be calculated and used to determine an appropriate regime using a 12 hourly (slow release) preparation, with a breakthrough dose 1/6 th of the total daily dose. NOTES: 1. Regarding NSAIDs at STEP ONE, gastrointestinal protection is required for patients at increased risk of GI bleeding. A Proton Pump Inhibitor, PPI (omeprazole or lansoprazole capsules), should be prescribed for the following patients: aged > 65 years; taking drugs known to increase bleeding risk such as steroids, anticoagulant therapy or antidepressants (SSRI and SNRI); requiring long-term NSAID; co-morbidity. NSAIDs should be avoided in asthmatic patients who are known to get worsening bronchospasm with NSAIDs. NSAIDs should be used with caution in the elderly and women who are experiencing fertility issues. They should also be avoided in pregnancy, particularly during the third trimester. 2. Codeine and stronger opioids cause constipation. A laxative should be prescribed and the patient advised to start taking it at the same time as the opioid. NB. Targinact (oxycodone/naloxone) has been reviewed by the Area Prescribing Committee but due to a lack of good evidence remains NON-FORMULARY and should not be prescribed. 3. At STEP TWO, Tramadol is to be prescribed with caution in the following patients: elderlyelimination may be prolonged [aged 75+ (consider 50mg tds)]; palliative care patients; renal failure (CKD levels 3 5); hepatic impairment; history of seizures/epilepsy (risk of convulsions may increase, contraindicated in uncontrolled epilepsy); pregnancy; on warfarin therapy; or PainManagementAdultsGUI201707v2.0final 3
serotonergic drugs (SSRI, SNRI, MAOI, Tricyclics and Mirtazapine may all cause serotonin toxicity). 4. BuTec patch dose adjustment: When starting, analgesic effect should not be evaluated until the patch has been worn for 72 hours (to allow for gradual increase in plasma-buprenorphine concentration) if necessary, dose should be adjusted at 3-day intervals using a patch of the next strength or two patches of the same strength (applied at same time to avoid confusion). Max. two patches can be used at any one time. Wait 24 hours before initiating a slow release opioid. 5. At STEP THREE: Caution is recommended in the use of strong opioids in opioid naïve patients. Before prescribing strong opioids, it is important to first establish if patients are opioid naïve to minimise risk of adverse events of administering strong opioids by titrating immediate release opioids up, starting with a low dose. 6. The prescribing of opioids will often be as sustained-release oral or patch formulation and there is potential for prescribing and dispensing errors involving confusion with names, formulations and dosage calculations when prescribed generically. These products should therefore be prescribed by brand. If Pharmacists receive scripts written generically the brand required should be confirmed and this information should be recorded on the patient s PMR. 7. Oxycodone; Prescribe by brand; This should ONLY be used where Morphine is not appropriate due to side effects (such as confusion, hallucinations, myoclonic jerks), excessive sickness despite adequate dosages of anti-emetics (including a trial of a buccal anti-emetic) or rash. PainManagementAdultsGUI201707v2.0final 4
Appendix I Mid Essex Locality Oxycodone Prescribing Information Patients should only be prescribed oxycodone where morphine is not appropriate for the following reasons: They develop side-effects with morphine such as confusion, hallucinations, myoclonic jerks; They have excessive sickness DESPITE taking anti-emetics (including a trial of the buccal anti-emetics); They develop an associated rash; Oxycodone should be prescribed by BRAND name. Prescribers must be aware of the high potential for confusion and errors due to the different release characteristics of these products and therefore to avoid confusion and allow continuity of supply, should prescribe oxycodone by brand name. Such practice should reduce the potential for dosing, dispensing and administration errors and reduce confusion for patients. There are significant risks of overdose when a fast acting product of short duration is used in error for the slow acting, longer duration products. Preparations Oral Injection Immediate release oxycodone Shortec capsules Shortec liquid Modified release (long acting) oxycodone Oxycontin tablets Longtec tablets Oxycodone injection Oxynorm injection 5mg, 10mg, 20mg 1mg/1ml, 10mg/ml 5mg, 10mg, 20mg, 40mg, 80mg 10mg/ml. 50mg/ml Dosage & Administration Immediate release oral oxycodone: Prescribe 4 hourly regularly and use the same dose as required for breakthrough pain. Modified release (long acting) oral oxycodone: o Prescribe 12 hourly, with 1/6 th of the 24 hour dose as immediate release oral oxycodone for breakthrough pain. o Biphasic action; a rapid release is followed by a controlled release phase. If the patient has pain when the dose of modified release (long acting) oxycodone is given, wait an hour before giving a breakthrough dose of immediate release oxycodone. Oxycodone injection: o Continuous subcutaneous infusion in a syringe driver or pump over 24 hours. o In addition, prescribe 1/6 th of the 24 hour infusion dose subcutaneously, 1-2 hourly as required for breakthrough pain. o If the infusion dose is greater than 60mg/24 hours, use another opioid for breakthrough injections; prescriptions should have clear guidance on the frequency that doses can be administered (low concentration of oxycodone preparation limits dose for sc injection to 10mg in 1ml). o Diluent: water for injection PainManagementAdultsGUI201707v2.0final 5
Laxatives: Regular opioids cause constipation. Prescribe a laxative as per local formulary at the same time as initiation of the opioid. DO NOT prescribe Targinact (oxycodone/naloxone) which is NON-FORMULARY Title Adult Acute and Chronic Pain Guidelines Document reference PainManagementAdultsGUI201707v2.0final Author Medicines Management Team MECCG Consulted with Dr Ahmed Mayet, Clinical Lead for Planned Care Mid Essex CCG Approved by Medicines Management Committee Date approved June 2017 Next review date June 2020 Previous version Key changes PainManagementAdultsGUI201011v01final Document management added Include lower back pain as a separate treatment plan for Step One Amendment of BuTrans reference to BuTec Updated to reflect NICE NG59:low back pain and sciatica in over 16s PainManagementAdultsGUI201707v2.0final 6