| Formulary Chapter 4: Central nervous system - Full Chapter
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| 04.07.02 |
Opioid analgesics |
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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. |
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Buprenorphine (sublingual)
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Formulary
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Sublingual tablets 200micrograms
See section 4.10 for products used in opioid dependence.
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Buprenorphine (Transdermal)
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Formulary
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Preparations that should be applied every 3 days (72 hours) include Hapoctasin®.
Preparations that should be applied every 4 days (96 hours) include Bupeaze®, Carlosafine®, Relevtec®, and Transtec®.
Preparations that should be applied every 7 days include Bunov®, Bupramyl®, Butec®, BuTrans®, Panitaz®, Rebrikel®, Reletrans®, and Sevodyne®.
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.
Do not confuse the formulations of transdermal patches which are available in various strengths as 7-day, 4-day and 3-day patches; prescription by brand name is recommended.
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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
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 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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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 short term use only.
in MBHT For use only in patients who are breastfeeding or after initiation by the pain team. For short term use only.
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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.
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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
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Tablets 200mg
Injection 100mg/1mL
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
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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.
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HSIB: Unintentional overdose of morphine sulfate oral solution
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Oxycodone oral
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Formulary
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Modified-release tablets
Immediate-release tablets
Immediate-release capsules
Oral solution
Refer to Trust guidance and protocols for specific prescribing information.
Do not confuse modified-release 12-hourly preparations with 24-hourly preparations.
Modified-release tablets and capsules should be prescribed by brand.
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Pethidine hydrochloride
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Formulary
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Injection 50mg/mL, 100mg/2mL
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Tramadol (oral)
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Formulary
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Capsules 50mg
Dispersible tablets 50mg
Modified-release tablets 100mg, 200mg
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.
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MHRA: Warfarin: be alert to the risk of drug interactions with tramadol
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Tramadol injection
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Formulary
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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
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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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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. |
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