1

Medicines Management Team NHS Wiltshire CCG Written March 2013, updated July 2014

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 2

Brief Pain Inventory (short form) assessment tool:

http://prc.coh.org/pdf/BPI%20Short%20Version.pdf Use to quantify level of pain & provide a baseline.

DN4 Neuropathic pain screening tool:

http://staging.aafplearninglink.org/Resources/Upload/File/AAFPLL-Act%202-DL%20Resource%20DN4-

11-13-11(1).pdf

LANSS neuropathic pain scale (will ask for a password but just press cancel):

http://www.palliativecareswo.ca/Regional/LondonMiddlesex/The%20Leeds%20Assessment%20of%20

Neuropathic%20Symptoms%20and%20Signs.pdf

Weight loss services/referrals:

Wiltshire: http://www.intelligencenetwork.org.uk/health/obesity-resources/

BaNES: Passport to Health programme, Health Improvement Services, The Bungalow, 11 Park

Road, Keynsham. Tel 01225 831852

Patient Health Questionnnaire (PHQ9) score: http://www.patient.co.uk/doctor/Patient-Health-

Questionnaire-(PHQ-9).htm

General Pain management tools: www.britishpainsociety.org

www.kirklees.nhs.uk/fileadmin/documents/your_health/Long_term_pain/practitioner_decision_aid_-

_opioid_use_OUPA.pdf

STarT back screening tool (Keele University): http://www.keele.ac.uk/sbst/ - a brief validated tool (Hill

et al 2008), designed to screen primary care patients with low back pain for prognostic indicators that

are relevant to initial decision making.

Lancet abstract about this tool: http://www.thelancet.com/journals/lancet/article/PIIS0140-

6736(11)60937-9/fulltext#article_upsell

CKS: http://cks.nice.org.uk/back-pain-low-without-radiculopathy

http://cks.nice.org.uk/osteoarthritis

NICE CG88- Low back pain (May 2009) http://www.nice.org.uk/CG88

NICE CG177- Osteoarthritis (Feb 2014) http://www.nice.org.uk/guidance/cg177

NICE CG173- Neuropathic pain- pharmacological management (Nov 2013)

http://guidance.nice.org.uk/CG173/Guidance/pdf/English

www.paintoolkit.org

http://lift.awp.nhs.uk/all-courses/browse/

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 3

If p

ain

se

ttle

s at

an

y st

ep

, co

nsi

der

a s

tep

-wis

e tr

ial o

f re

du

ctio

n o

f an

alge

sia.

Ch

eck

com

plia

nce

at

ever

y st

ep b

efo

re m

ovi

ng

up

.

R e

g u

l a

r P

a r

a c

e t

a m

o l

1 g

Q D

S t

h r

o u

g h

o u

t

No

n-o

pio

id A

nal

gesi

c

Op

ioid

fo

r M

od

era

te t

o S

eve

re P

ain

Op

ioid

fo

r Se

vere

Pai

n

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 4

DRUG NAME DRUG DOSE EQUIVALENT ORAL MORPHINE DOSE

Codeine 30mg 4.5mg

Dihydrocodeine 10mg 1mg

Tramadol* 50mg 5-10mg

*Tramadol: is now a schedule 3 controlled drug

DRUG NAME DRUG DOSE EQUIVALENT ORAL MORPHINE DOSE

Diamorphine (sub-cut) 10mg 30mg

Oxycodone MR (Oral, LONGTEC®) 10mg 20mg

Pethidine (oral) 50mg 5-6.25mg

Pethidine (injected) 12.5mg 3mg

Oral Morphine equivalent (mg/24hrs)

10 15 30 40 45 60 90 120 180 270 360

Oral Codeine (mg/24hrs)

60-90

120 240

ONLY WITH ADVICE FROM PAIN SPECIALIST

Oral Dihydrocodeine (mg/24hrs)

80

Oral Tramadol (mg/24hrs)

100 150 300 400

Oral Oxycodone (mg/24hrs) Longtec

5 7.5† 15 20 22.5† 30 45 60 90 135 180

Transdermal Buprenorphine (µg/hr)

5* 10* 20* 35 52.5 70

Transdermal Fentanyl (µg/hr)

12 25 50 75 100

*BuTrans patches should only be used as per the patch advice on page 7. †Round to nearest whole dose equivalent

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 5

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 6

Dose titration (for step by step approach overleaf)

Patient leaflets available here: https://prescribing.wiltshireccg.nhs.uk/prescribing-guidance-by-bnf-chapter/cns

Amitriptyline (Off-label for this indication) Week 1 Week 2 Week 3 Week 4 Week 5

10mg ON 20mg ON 30mg ON 40mg ON 50mg ON

CNS side-effects are common with amitriptyline particularly in the elderly, therefore low doses should be used for initial treatment in this group. If contra-indicated try gabapentin instead:

Gabapentin Week 1 Week 2 Week 3 Week 4

Morning 300mg 300mg 300mg

Midday 300mg 300mg

Night 300mg 300mg 300mg 600mg

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 7

Slower titration may be required in the elderly, starting at 100mg and increasing by 100mg increments. Somnolence, peripheral oedema and asthenia may be more frequent in elderly patients.

Medication management of Neuropathic Pain

Reassess patients every two weeks until pain is well controlled.

Refer if there is no significant improvement and to clarify the diagnosis.

Other Possible Options:

Pregabalin (Lyrica®) – step 3 alternative if steps 1 and 2 and gabapentin have failed/not been tolerated/ contra-indicated. Start at 75mg per day and increase in 75mg weekly steps aiming for 300mg bd. Slow titration in elderly patients and those susceptible to side-effects. Pregabalin is “flat priced” across the dose ranges, therefore increase the strength of the capsule rather than simply increasing the number taken, twice daily dosage regimens are most cost effective. Review use at 6-8 weeks, taper and stop if no benefit. Refer patient to specialist pain service if there is no response or it is ineffective. Slower titrations may be required if it is not tolerated very well or in elderly patients.

Duloxetine (Cymbalta®) –consider in painful diabetic neuropathy (this is the only pain indication it is licensed for), where Amitriptyline and Gabapentin have either failed or are contraindicated. Discuss with patient‟s mental health team before initiation if already on antidepressants. Start at 30mg nocte, increasing to 60mg nocte after 1 week. Maximum 60mg BD. Discontinue if no response after 2 months.

Tramadol – Only for use if acute rescue therapy is needed while the patient is waiting for a referral appointment, NOT for long-term use. Start at 50mg qds and increase to a maximum of 400mg/day. Do not start other opioids. The combination of Tramadol with Amitriptyline, Nortriptyline, Imipramine or Duloxetine is associated with only a low risk of serotonin syndrome.

Opioids - Only to be used on recommendation from a specialist pain service.

Capsaicin: Localized areas of neuropathic pain may respond to topical capsaicin (e.g. 0.075% cream 3-4 times a day), especially for those who cannot tolerate oral treatments. This is licensed for treatment of post-herpetic neuralgia, after lesions have healed. Capsaicin patches require exceptions approval before prescribing – pain clinic ONLY.

Although NICE CG173 http://guidance.nice.org.uk/CG173/Guidance/pdf/English - Neuropathic pain - pharmacological

management (Nov 2013) recommends that for “all neuropathic pain (except trigeminal neuralgia) that patients should be

offered a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment”, our local consensus that suggests

that amitriptyline and gabapentin should be used as the first-line treatment options.

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 8

2013-14 Data Wiltshire BaNES Swindon

All Opioid Analgesics - items 177,122 68,250 85,184

All Opioid Analgesics - cost £2,219,155 £697,212 £1,155,960

Opioid Patches – items 27,968 16% 13,933 20% 10,844 13%

Opioid Patches - cost £931,801 42% £363,293 52% £389,129 34%

Low Strength Buprenorphine – items 17,545 10% 10,807 16% 6,652 8%

Low Strength Buprenorphine - cost £516,086 23% £247,180 35% £198,639 17%

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 9

Morphine capsules (as Zomorph)

Oxycodone MR generic (i.e. Oxycontin)

Oxycodone MR as Longtec

Annual Saving by prescribing

Zomorph vs Longtec total daily dose

annual cost total daily

dose annual

cost annual cost

20mg £ 42 10mg £ 326 £ 260 £ 218

40mg £ 84 20mg £ 326 £ 260 £ 176

80mg £ 143 40mg £ 651 £ 520 £ 377

160mg £ 239 80mg £ 1,302 £ 1,040 £ 801

320mg £ 461 160mg £ 2,605 £ 2,080 £ 1619 N.B. Not all strengths that are available are shown here

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 10

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 11

Red flags are clinical indicators of possible serious underlying conditions requiring further medical intervention. Red flags were designed for use in acute low back pain, but the underlying concept can be applied more broadly in the search for serious underlying pathology in any pain presentation.

Differential diagnosis

Red Flags from patient history

Red Flags from examination

Possible fracture

Major trauma

Minor trauma in elderly or osteoporotic

Evidence of neurological deficit (in legs or perineum in the case of low back pain)

Possible tumour or infection

Age < 20 or > 50 years old

History of cancer

Constitutional symptoms (fever, chills, weight loss)

Recent bacterial infection

Intravenous drug use

Immunosuppression

Pain worsening at night or when supine

Possible significant neurological deficit

Severe or progressive sensory alteration or weakness

Bladder or bowel dysfunction

The presence of red flags in acute low back pain suggests the need for further investigation and possible specialist

referral as part of the overall strategy. If there are no red flags present in this situation it is safe to reassure the patient

and move ahead with a multimodal management approach.

Yellow flags are psychosocial indicators suggesting increased risk of progression to long-term distress, disability and pain. Yellow flags were designed for use in acute low back pain. In principle they can be applied more broadly to assess likelihood of development of persistent problems from any acute pain presentation.

Attitudes and Beliefs

Pain is harmful or severely disabling

Expectation that passive treatment rather than active participation will help

Feeling that „no-one believes the pain is real‟ – may relate to previous encounters with health professionals

Emotions and Behaviour

Fear-avoidance behaviour (avoiding activity due to fear of pain)

Low mood and social withdrawal

Other psychosocial factors

Poor family relationships or history of abusive relationships

Financial concerns particularly related to ill- health or ongoing pain

Work related factors e.g. conflict over sick-leave, ability to perform current job tasks

Ongoing litigation related to persistent pain condition

The presence of multiple biopsychosocial factors may highlight the need for a multi-disciplinary approach to care.

Medicines Management Team NHS Wiltshire CCG July 2014 Review date July 2016 12

DRUG NAME DRUG DOSE EQUIVALENT ORAL MORPHINE DOSE

Codeine 30mg 4.5mg

Dihydrocodeine 10mg 1mg

Tramadol* 50mg 5-10mg

*Tramadol: is now a schedule 3 controlled drug

DRUG NAME DRUG DOSE EQUIVALENT ORAL MORPHINE DOSE

Diamorphine (sub-cut) 10mg 30mg

Oxycodone MR (Oral, LONGTEC®) 10mg 20mg

Pethidine (oral) 50mg 5-6.25mg

Pethidine (injected) 12.5mg 3mg

Oral Morphine equivalent (mg/24hrs)

10 15 30 40 45 60 90 120 180 270 360

Oral Codeine (mg/24hrs)

60-90

120 240

ONLY WITH ADVICE FROM PAIN SPECIALIST

Oral Dihydrocodeine (mg/24hrs)

80

Oral Tramadol (mg/24hrs)

100 150 300 400

Oral Oxycodone (mg/24hrs) Longtec

5 7.5† 15 20 22.5† 30 45 60 90 135 180

Transdermal Buprenorphine (µg/hr)

5* 10* 20* 35 52.5 70

Transdermal Fentanyl (µg/hr)

12 25 50 75 100

*BuTrans patches should only be used as per the patch advice on page 7. †Round to nearest whole dose

equivalent.