4.7.2 Chronic non-malignant pain

General Prescribing Notes

  • See Opioid Prescribing for Chronic Pain Resource Pack.
  • 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
ChoiceDrugDosage
1st choiceParacetamol tablets 500mgDose:
0.5-1g every 4-6 hours; max 4g daily
2nd choice

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)

 

+/- NSAID

Dose:
Co-codamol 8/500, 1-2 tablets every 4-6 hours; max 8 tablets daily
Co-codamol 15/500, 1-2 tablets every 4-6 hours; max 8 tablets daily
Co-codamol 30/500, 1-2 tablets every 4-6 hours; max 8 tablets daily

See 10.1

If pain not resolved in 6 weeks consider modified release preparations
1st choices

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 a sole agent)

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)

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). Titrate to lowest effective dose that achieves agreed goals of treatment.

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)

See guidelines on morphine equivalence

1st choice

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.
2nd choice

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

Prescribing Notes

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.
  • 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.
  • 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).