| Formulary Chapter 4: Central nervous system - Full Chapter
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| Notes: |
This chapter of the formulary is under continual development, please let the team know if you have any comments about the contents: mlcsu.lscformulary@nhs.net.
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| Details... |
| 04.07.02 |
Opioid analgesics |
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For relief of moderate to severe pain |
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Buprenorphine
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Formulary
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SEVEN day patches only to be prescribed (brands are interchangeable)
Hospital prescriber to prescribe generically and contract patches to be supplied
(To be prescribed as Sevodyne patches in Primary Care - 5,10,15 and 20mcg/hr)
Only for use in patients who are unable to take or tolerate oral medicine (including soluble tablets and liquids) OR where use of the low-dose buprenorphine patches may prevent administration problems for frail, elderly patients in the Community.
Transdermal preparations lack the flexibility required when treating patients with fluctuating or uncontrolled pain. Use should be reserved for patients with stable pain who are unable to take or tolerate oral medicines. Buprenorphine patches are several times more expensive than equivalent doses of oral analgesics, and inappropriate use of transdermal preparations has cost implications for commissioners. It is recommended that the reason for using a patch is documented on initiation and, if appropriate, patients are switched to oral formulations at the earliest opportunity.
**Under review**
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Buprenorphine (Temgesic®)
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Formulary
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s/l tablets 200micrograms
See section 4.10 for products used in opioid dependence
**under review**
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Codeine Phosphate
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Formulary
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Tablets 15mg, 30mg
Injection 60mg/1mL
Syrup 25mg/5mL
Linctus, BP 15mg/5mL
Injection Only
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Diamorphine
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Formulary
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Injection 5mg, 10mg, 30mg, 100mg, 500mg
**under review**
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Dihydrocodeine
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Formulary
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Tablets 30mg
For use only in patients who are breastfeeding or after initiation by the pain team. For short term use only.
**under review**
Injection Only
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Fentanyl
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Formulary
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Matrix patches 12, 25, 50, 75, 100micrograms/hour for 72hours
Sublingual tablets (Abstral®) 100microgram, 300 microgram, 400microgram, 600microgram, 800 microgram
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 MHRA: Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children
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Methadone
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Formulary
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Tablets 5mg
Injection 10mg/1mL
Methadone, when used as an analgesic, should be initiated by specialists in palliative care only
see section 4.10 for products used in opioid dependence
**under review**
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Morphine
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Formulary
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Check local guidance
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Oxycodone
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Formulary
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Check local guidance
Oxycodone should be initiated by consultant physicians or specialists in palliative care only, it is indicated only for patients who do not tolerate morphine
**under review**
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Pethidine
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Formulary
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Injection 50mg/1mL
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Tapentadol (Palexia®)
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Formulary
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M/R tablets 50mg, 100mg, 150mg, 200mg, 250mg
for palliative care
In Morecambe Bay for other indications
**under review**
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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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Tramadol
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Formulary
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Capsules 50mg
Dispersible tablets 50mg
m/r tablets 100mg, 200mg
Injection 100mg/2mL
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MHRA: Warfarin: be alert to the risk of drug interactions with tramadol
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance and local commissioning arrangements |
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