Formulary
Strong Opioids: Treatments of choice
Chronic Pain
Morphine is the first line strong opioid in management of severe chronic pain, in combination with non-opioid and adjuvant therapies. Oxycodone and topical agents (Fentanyl / Buprenorphine patches) should be considered as second line agents, for
patients intolerant or contraindicated of morphine.
| Buprenorphine sublingual |
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Formulary
|
Sublingual tablets 200micrograms |
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| Codeine Phosphate |
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Formulary
|
Tablets 15mg, 30mg |
 MHRA: Codeine for analgesia: restricted use in children because of reports of morphine toxicity MHRA: Codeine for cough and cold: restricted use in children |
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| Dihydrocodeine |
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Formulary
|
Tablets 30mg For short term use only.
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in MBHT For use only in patients who are breastfeeding or after initiation by the pain team. For short term use only.| Fentanyl patches |
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Formulary
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Matrix patches 12, 25, 50, 75, 100micrograms/hour for 72hours Fentanyl matrix patches should be prescribed by brand name to minimise the risk of reservoir patches being accidentally supplied. |
|
MHRA: Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients MHRA: Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children |
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| Meptazinol Meptid |
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Formulary
|
Tablets 200mg MBHT use only: For those women who may need pain relief whilst they await transfer to either RLI or FGH. |
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| Morphine |
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Formulary
|
Modified-release tablets
Modified-release capsules
Immediate-release tablets
Oral solution
Injection
Orodispersible tablets
Do not confuse modified-release 12-hourly preparations with 24-hourly preparations. Modified-release tablets and capsules should be prescribed by brand. Care should be taken to ensure that the correct strength of oral solution is prescribed and dispensed, and the dose stated as both quantity and volume. |
|
HSIB: Unintentional overdose of morphine sulfate oral solution |
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| Tramadol (oral) |
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Formulary
|
Capsules 50mg Do not confuse modified-release 12-hourly preparations with 24-hourly preparations, prescribers and dispensers must ensure that the correct formulation is prescribed and dispensed. Modified-release formulations should be prescribed by brand. |
|
MHRA: Warfarin: be alert to the risk of drug interactions with tramadol |
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| Tramadol injection |
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Formulary
|
Injection 100mg/2mL |
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MHRA: Warfarin: be alert to the risk of drug interactions with tramadol |
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| Tapentadol modified release |
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Formulary
|
M/R tablets 50mg, 100mg, 150mg, 200mg, 250mg Chronic severe pain in adults. |
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MHRA: Tapentadol (Palexia): risk of seizures and reports of serotonin syndrome when co-administered with other medicines |
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Links
- HSIB: Unintentional overdose of morphine sulfate oral solution
- Independent reviews
LSCMMG: Assessing Suitability for Strong Opioid Use- LSCMMG: Chronic Pain Patient Resources: Managing Opioid Medication
- LSCMMG: Chronic Pain Prescriber Resources
- LSCMMG: Neuropathic Pain: Primary Care Management
- LSCMMG: POSITION STATEMENT High dose morphine prescribing for chronic non-cancer pain
- LSCMMG: Primary Care Adult Headache Management Pathway
- MHRA Drug Safety Update Jan 2019: Tapentadol (Palexia): risk of seizures and reports of serotonin syndrome when co-administered with other medicines
- MHRA Drug Safety Update March 2020: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression
- MHRA Drug Safety Update Oct 2018:Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children
- MHRA patient information: Changes to drug driving law
- MHRA warning regarding accidental exposure
- MHRA warning regarding serotonin syndrome July 2013
- MHRA: Children restrictions for codeine (July 2013)
- MHRA: Children restrictions for codeine (June 2013)
- MHRA: Codeine for analgesia: restricted use in children because of reports of morphine toxicity
- MHRA: Codeine for cough and cold: restricted use in children
- MHRA: Drugs and driving: blood concentration limits to be set for certain controlled drugs in a new legal offence
- MHRA: Opioids: risk of dependence and addiction
- MHRA: Tapentadol (Palexia): risk of seizures and reports of serotonin syndrome when co-administered with other medicines
- MHRA: Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients
- MHRA: Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children
- MHRA: Warfarin: be alert to the risk of drug interactions with tramadol
- MHRA: Warfarin: be alert to the risk of drug interactions with tramadol
- NICE CG140: Palliative care for adults: strong opioids for pain relief
- NICE CG150: Headaches in over 12s: diagnosis and management
- NICE CG173: Neuropathic pain in adults: pharmacological management in non-specialist settings
- NICE CG59: Low back pain and sciatica in over 16s: assessment and management
- NICE NG180: Perioperative care in adults
- NICE NG193: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain
- Relative prices of long acting opioids
- SFH: Methadone for analgesia guidelines (see tab 'PMH Text'))
- UHMB Tramadol prescription form
UKMI Q&A: risk of developing Serotonin Syndrome following concomitant use of tramadol with selective serotonin reuptake inhibitors (SSRIs)