4.7.2 Chronic non-malignant pain
General Prescribing Notes
- See HSCB Opioid Prescribing in Chronic Pain Implementation Support Tool
- The psychological aspects of pain must not be overlooked in the management of chronic pain. Coping strategies can be found within The Pain Toolkit.
- If analgesics are commenced regular review to gauge the efficacy is essential.
- Consider specialist referral:
- to access additional services e.g. pain clinic
- if the patient does not respond to <160mg morphine equivalent
|1st choice||Paracetamol tablets 500mg||Dose:|
0.5-1g every 4-6 hours; max 4g daily
Co-codamol 8/500 tablets (codeine 8mg with paracetamol 500mg) Co-codamol 15/500 tablets (codeine 15mg with paracetamol 500mg) Co-codamol 30/500 tablets (codeine 30mg with paracetamol 500mg)
|If pain not resolved in 6 weeks consider modified release preparations|
Tramadol MR +/- NSAID / Paracetamol
Maxitram® is the recommended cost-effective choice (prescribe by brand)
Dose of Tramadol MR:
Buprenorphine patch (as a sole agent)
Butec® patches are the recommended cost-effective choice (prescribe by brand)
Dose of Butec®:
If pain still not adequately controlled consider morphine MR. A “worthwhile benefit” could be an improvement in pain, function. quality of life or a decrease in sleep disturbance (rather than 100% pain resolution)
Morphine MR 12-hourly tablets, capsules (see BNF)
Morphine preparations should be prescribed by brand name
|Dose: Chronic pain, initially 5-10mg (if opioid naïve) or 10-20mg (if opioid tolerant) every 12 hours, adjusted according to response. Titrate to lowest effective dose that achieves agreed goals of treatment.|
Reserve for patients experiencing s/e with oral opioids
Fentanyl patches, ‘12’ patch (releasing approx. 12 micrograms/hour for 72 hours), ‘25’ patch ‘37.5’ patch
Mezolar® is the recommended cost-effective choice (prescribe by brand)
Dose: See BNF for full prescribing details
- In chronic non-malignant pain the long-term use of opioids has many implications. Guidance is given on the Faculty of Pain Medicine website.
- 100% pain relief is rarely achievable in chronic pain. Pain reduction of at least 30% is generally accepted to be a clinically meaningful result.
- See GAIN: general palliative care guidelines for the management of pain at the end of life in adult patients.
- NICE CG 140 discusses the use of opioids in palliative care.
- Oral morphine /codeine equivalence should be considered to ensure the dosage is safe and appropriate e.g. Butec® 10 is equivalent to ~240mg of oral codeine daily. See caution below re incomplete cross tolerance if switching between opioids.
- Buprenorphine patches should be prescribed by brand name.
- Butec® patches are replaced every 7 days.
- Fentanyl patches should not be used in opioid naïve patients. They should be reserved for patients experiencing side-effects with oral opioids. Fentanyl patches are replaced every 3 days.
- 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.
- The use of opioids should be reviewed regularly, preferably face to face and by 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. The Faculty of Pain Medication has a useful section on information for patients taking opioids. See also the pain section of patient zone.
- Older patients are particularly susceptible to respiratory depression and constipation secondary to opioids.
- The MHRA Drug Safety Update March 2020 detailed the risk of potentially fatal respiratory depression, when benzodiazepines and opioids are prescribed together: only prescribe together if there is no alternative and closely monitor patients for signs of respitatory depression
- Refer to NPSA Alert for advice on reducing dosing errors with opioid medicines.
- Incomplete cross-tolerance is where tolerance exists 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. See MHRA for further information on fentanyl patches.
- In severe opioid toxicity consider reversal of respiratory depression using naloxone (refer to the BNF).