4.7.2 Chronic non-malignant pain

General Prescribing Notes

  • Refer to NICE NG193 Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.
  • Chronic pain persists for more than 3 months.
  • There has been a move away from the use of medication to treat chronic pain. Its primary purpose should be to facilitate patients to improve functional activity and to engage in pain management strategies / programmes, not to relieve pain.
  • Managing the psychological and social aspects of pain is important. Coping strategies and other useful information can be found within the online resources highlighted below.
  • Consider signposting/referral to:
    • Physical Activity Referral Scheme (PARS). GP practices and other relevant HSC staff can refer using PARS specific protocols generated through CCG.
    • Relevant support groups e.g. Versus Arthritis (VA) NI provides face to face, telephone and virtual support and pain management courses.
    • Better Days Pain Support Programmes run by Healthy Living Centres (HLC). Some centres provide pain support programmes. Refer to the HLC website or contact your local HLC to find out about the services they offer.
    • Online resources such as My live well with Pain and Flippin Pain and MyNI pain management.
    • Access additional services, e.g. Specialist Pain Clinic.
    • Relevant specialist before increasing dose above 90mg morphine equivalent.

Note: all opioids recommended by specialists should be accompanied by a clear management plan including arrangements for review, which has also been discussed with the patient.

Management of Chronic Primary Pain

  • Chronic primary pain has no clear underlying condition or is out of proportion to any observable injury or illness e.g. fibromyalgia.
  • Recommended management options are mainly non-pharmacological – see NICE NG193.
  • Antidepressants (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) can be considered even in the absence of depression. Note this is off-label use.
  • Do not initiate opioids, NSAIDs, paracetamol, antiepileptic drugs (including gabapentinoids), antipsychotics, benzodiazepines, local anaesthetics, corticosteroid +/- local anaesthetic trigger point injections or ketamine.

Management of Chronic Secondary Pain

  • Chronic secondary pain is a symptom of an underlying condition and should be managed in line with the relevant NICE guideline for the underlying condition e.g. low back pain and sciatica  or osteoarthritis.
  • Chronic secondary pain and chronic primary pain can co-exist and clinical judgement should be used to determine if it would also be helpful to manage as chronic primary pain alongside the management of the disease itself.
  • In chronic secondary pain opioids have a very limited role. They should only be used where absolutely necessary and only where recommended as an option within the specific NICE guidance for the condition. In these circumstances only, please refer to formulary choices and prescribing notes below:
ChoiceDrugDosage
1st choiceNon-pharmacological management
Paracetamol tablets 500mgDose:
0.5-1g every 4-6 hours; max 4g daily
Plus/Or NSAID

see 10.1.1

2nd choiceConsider addition of codeine 15mg tablets prescribed separately to paracetamol

Dose:
15mg-60mg every 4-6 hours; up to four times daily

Lowest dose that achieves goals. Max duration of codeine treatment 8-12 weeks

2nd choice
(alternative option to prescribing codeine separately)
Co-codamol 8/500 tablets (codeine 8mg with paracetamol 500mg) Dose:
Co-codamol 8/500, 1-2 tablets every 4-6 hours; max 8 tablets daily
Co-codamol 15/500 tablets (codeine 15mg with paracetamol 500mg)Dose:
Co-codamol 15/500, 1-2 tablets every 4-6 hours; max 8 tablets daily

Co-codamol 30/500 tablets (codeine 30mg with paracetamol 500mg)

Co-codamol 30/500, 1-2 tablets every 4-6 hours; max 8 tablets daily

Lowest dose that achieves goals. Max duration of codeine treatment 8-12 weeks

 

Stop codeine and consider modified release preparations in table below:

  • if codeine not tolerated, there is no improvement or goals not achieved
  • to maintain goals beyond 8-12 weeks codeine treatment

Continue regular paracetamol +/or NSAID.

ChoiceDrugDosage
3rd choice

Tramadol MR +/- NSAID / Paracetamol Maxitram® is the recommended cost-effective choice (prescribe by brand)

Dose of tramadol MR:
50mg twice daily, increased if necessary to 100mg twice daily, maximum 200mg twice daily.
Titrate to lowest effective dose that achieves agreed goals of treatment
Or

Buprenorphine patch (as sole opioid agent)

+/- NSAID/Paracetamol

Butec® patches are the recommended cost-effective choice (prescribe by brand)

Butec® patches, '5'patch (releasing 5 micrograms/hour), '10' patch (releasing 10 micrograms/hour), '15' patch (releasing 15 micrograms/hour), '20' patch (releasing 20 micrograms/hour)

Titrate to lowest effective dose that achieves agreed goals of treatment



Dose of Butec®:
Initially one ‘5micrograms/hour’ patch; apply to dry, non-irritated, non-hairy skin on upper torso, removing after 7 days and siting replacement patch on a different area (avoid same area for at least 3 weeks)

Prescribing Notes

  • Set goals with the patient before starting any medication. The primary aim of treatment should be to improve function and quality of life. Pain reduction of 30% and a positive impact on daily life is a realistic goal (not 100% pain relief).
  • In chronic non-malignant pain the long-term use of opioids has many implications. See Faculty of Pain Medicine website for resources to support patients and healthcare professionals and the NI Formulary Patient Zone.
  • Prescribers should exercise caution before increasing to an oral morphine equivalent (OME) >50mg per day (e.g. tramadol 400mg/day has an OME of 40mg/day) and document reasons for increasing above this dose (note conversion ratios vary and these are an approximate guide only).
  • Oral morphine /codeine equivalence should be considered to ensure the dosage is safe and appropriate e,g. Butec® 10 (buprenorphine 10micrograms/hr) is equivalent to ~240mg of oral codeine daily. Caution re incomplete cross tolerance if switching between opioids.
  • Buprenorphine patches should be prescribed by brand name.
  • Butec® patches are replaced every 7 days.
  • Opioids have the potential to impair driving and anyone who is adversely affected must not drive. If a patient has a condition or is undergoing treatment that could impair their fitness to drive, healthcare professionals should advise them on their legal requirement to notify the DVA.  Discuss with the patient and document – for further details see driving information in the Opioid Prescribing for Chronic Pain Resource Pack.

Cautions

  • Some patients may be at increased risk of experiencing toxicity at therapeutic doses of paracetamol, particularly those with a body-weight under 50 kg and those with risk factors for hepatotoxicity. Clinical judgement should be used to adjust the dose of oral and intravenous paracetamol in these patients.
  • Long term use of opioids in non-cancer pain (longer than 3 months) carries an increased risk of dependence and addiction. Risks should be discussed with patient before prescribing – see MHRA recommendations.
  • The use of opioids should be reviewed regularly, preferably face to face and with the same clinician; this should be at least monthly in the first six months after stable dosing has been achieved. Frequency of review thereafter can be clinically determined by the complexity of the case, but should be at least biannually.
  • Patients must be aware of the signs and symptoms of opioid sensitivity/toxicity – i.e. trouble breathing, tiredness, extreme sleepiness, inability to think, walk, or talk normally and feeling faint, dizzy, or confused. If toxicity is suspected advise patients to seek medical attention immediately.
  • Older patients are particularly susceptible to respiratory depression and constipation secondary to opioids.
  • Incomplete cross-tolerance is where there is tolerance to a currently administered opioid that does not extend completely to other opioids, if the patient’s medication is switched. It may mean that a lower dose of the new opioid is required. It is therefore recommended that a 25-50% reduction of the calculated dose of the new opioid should occur to allow for this. The new regimen should then be re-titrated according to patient response. The patient should be monitored closely, especially at higher doses.
  • Tramadol has been reclassified as a Schedule 3 CD following an increased number of reports involving tramadol and the significant harm when misused including death.
  • Patients/carers must be informed about the safe use of transdermal opioid preparations.
  • In severe opioid toxicity, consider reversal of respiratory depression using naloxone (see BNF).
  • Never prescribe more than one opioid long-term e.g. codeine and tramadol.
  • Where possible, avoid co-prescribing other CNS depressants e.g. benzodiazepines or gabapentinoids with opioids. If co-prescribing cannot be avoided, exercise extreme caution due to the increased risk of serious side effects e.g. respiratory depression.
  • Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression. See MHRA.
  • Patients taking enzyme inducing or inhibiting medicines may demonstrate an altered response to some opioid medications and doses may need to be adjusted – refer to BNF for information on specific drug combinations.