4.7.2 Opioid analgesics

Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain

Specific dosage instructions should be written on the prescription, i.e. "X to be taken x hourly when required for pain", rather than simply "PRN". This ensures a maximum dose is stated and will prevent dose escalation without prescriber approval.

NPSA Rapid response July 2008: reducing dosing errors with opioid medicines (link) When opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the healthcare practitioner concerned, or their clinical supervisor, should:

  • Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done for example through discussion with the patient or their representative (exercise care in accepting self-report from patients with dependence or suspected drug dependence), the prescriber or through medication records
  • Ensure where a dose increase is intended, that the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than 50% higher than the previous dose)

For guidance on prescribing using opioid analgesics please see Treating Pain Using Opioids

Choice of opioid

The correct dose of opiate should be found with careful titration of a short acting opiate prior to converting to a slow release formulation of morphine or patch.

All slow release opioids should be prescribed by brand name.

Diamorphine hydrochloride
  • Injection 5mg, 10mg, 30mg, 100mg, 500mg (£12.65 = 30mg x 5 ampoules)

Indications

Dose

  • Acute pain, by subcutaneous or intramuscular injection, 5mg repeated every 4 hours if necessary (up to 10mg for heavier well-muscled patients); by slow intravenous injection, quarter to half corresponding intramuscular dose
  • Chronic pain, by subcutaneous or intramuscular injection
    • Adult not currently treated with a strong opioid analgesic, initially 2.5–5mg every 4 hours, adjusted according to response
    • Adult, by subcutaneous infusion, not currently treated with a strong opioid analgesic, initially 5–10mg over 24 hours, adjusted according to response
    • Adult currently treated with a strong opioid analgesic, see below for a table of approximate equivalent dosages of opioids
Morphine sulphate
  • Oral solution 10mg/5ml (£5.45 = 300ml)
  • Concentrated oral solution 100mg/5ml (£4.98 = 30ml)
  • Tablets 10mg, 20mg, 50mg (£10.61 = 20mg x 56 tablets)
  • Injection 10mg/1ml, 30mg/1ml (£8.84 = 30mg/1ml x 10 ampoules)
  • Injection 1mg/1ml, 40mg/1ml preservative free (unlicensed preparation)
  • MST® m/r tablets 5mg

Indications

  • Acute and chronic pain
  • Palliative care guidance
  • Oxycodone or fentanyl patches should be used as second line therapies (under specialist advice) if patients cannot tolerate morphine in the treatment of pain

Dose

  • Acute pain (adult doses, for children refer to current cBNF)
    • By subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection, initially 10mg (elderly or frail 5mg) every 4 hours or more frequently during titration), adjusted according to response
    • By slow intravenous injection, initially 5mg (reduce dose in elderly or frail) every 4 hours (or more frequently during titration), adjusted according to response
  • Chronic pain, by mouth initially 5–10mg every 4 hours, adjusted according to response

Morphine sulphate modified-release 12 hourly oral preparations

Zomorph®
  • m/r capsules 10mg, 30mg, 60mg, 100mg, 200mg (£8.30 = 30mg x 60 capsules)

Indications

  • Modified release opioids (M/R) should only be used for constant, persistent, moderate to severe pain lasting several weeks and unlikely to resolve suddenly
  • Palliative care guidance
  • Licensed for use via gastric or gastronomy tubes (diameter greater than 16FG)

Dose

  • Every 12 hours, dose adjusted according to daily morphine requirements
  • For breakthrough, doses of 1/6 of the total daily dose of M/R opioid given 4-hourly when required. During titration any increase in total daily opioid dosage should not be more than 50% of the previous total daily dosage

Notes

  1. Specify dosing interval on prescriptions to avoid confusion e.g. 4 hourly
  2. Following titration (except for stat doses e.g. for dressing changes) immediate release morphine should be given regularly every four hours. If pain recurs because of when required dosing it is likely that increased dose or frequency of analgesia may be needed to regain pain control
  3. Morphine remains the most valuable opioid analgesic for severe pain although it frequently causes nausea and vomiting in early use, although tolerance does develop. In addition to pain relief, morphine also confers a state of euphoria and mental detachment
  4. Zomorph® is the morphine sulphate MR preparation of choice because it is a capsule formulation that may be opened and the contents administered in semi-solid food for patients with swallowing difficulties. MST® lacks these advantages and is more expensive than Zomorph® in the community and hospital and so its use is not recommended
  5. In hospital only, immediate release morphine is first line and should normally be given every two to four hours.
Buprenorphine

Indications

  • Moderate, non-malignant pain unresponsive to non-opioid analgesics
  • Buprenorphine patches should only be used in patients with cognitive deficit or swallowing difficulties, after a trial of soluble/liquid medication. Remember that Zomorph® capsules can be opened up for ease of swallowing

Dose

  • Initially one '5 micrograms/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)

Notes

  1. Prescribe buprenorphine patches by brand (Butec®) to ensure continuity. High strength buprenorphine patches (Transtec®) are not approved for use.
  2. Buprenorphine patches are not suitable, or licensed, for use in the management of acute or intermittent pain
  3. Prescribers should ensure that patients and/or their careers are aware that Butec® patches need to be applied at appropriate seven-day intervals to ensure that patients are not left in pain (because of too long an interval) and that the patches are not used wastefully (because of too short an interval). Remember to remove the old patch before application of new patch. To increase the dose, a larger patch should replace the patch that is currently being worn, rather than multiple patches being used
Codeine phosphate
  • Tablet 15mg, 30mg, 60mg (£1.10 = 30mg x 28 tablets)
  • Oral solution 25mg in 5ml (£6.46 = 500ml)
  • Injection 60mg in 1ml (for use in hospital manufacturing only)

Indications

Dose

  • Adult over 18 years, 30–60mg every 4 hours when necessary, to a maximum of 240mg daily

Notes

  1. Codeine is useful for the relief of mild to moderate pain but is too constipating for long-term use.
Tramadol
  • Capsules 50mg (£2.87 = 100 capsules)
  • Soluble tablets 50mg (£13.33 = 100 tablets)
  • Injection 50mg/ml (£0.98 = 2ml ampoule)

Indications

  • Moderate to severe pain

Dose

  • Oral, 50–100mg not more often than every 4 hours; total of more than 400mg daily not usually required
  • By intramuscular injection or by intravenous injection (over 2–3 minutes) or by intravenous infusion, 50–100mg every 4–6 hours
  • Postoperative pain, 100mg initially then 50mg every 10–20 minutes if necessary during first hour to total maximum 250mg (including initial dose) in first hour, then 50–100mg every 4–6 hours; maximum 600mg daily

Notes

  1. Modified-release preparations of tramadol are non-formulary. However, if there is a defined clinical need for a modified-release preparation, prescribe as 12-hourly brand product Marol® to ensure lowest acquisition cost.
  2. Caution: Tramadol increases CNS serotonin levels and may cause increased serotogenic effects when given with other drugs that increase serotonin levels e.g. SSRIs, SNRIs and some TCAs.
  3. The CSM have cautioned the use of Tramadol in patients with a history of epilepsy, as there may be an increased risk of convulsions.
Fentanyl

Indications

  • Fentanyl patches are only licensed for chronic intractable pain and are mainly used in palliative care and rarely by consultants for treatment of chronic pain. They are expensive but there is a small group of patients in whom their use is justifiable and appropriate
  • Fentanyl patches are not suitable, or licensed, for use in the management of acute or intermittent pain as life-threatening respiratory depression may occur
  • Single low dose patches are used in some centres for step down analgesia from post-operative epidural prescriptions. In the post-operative period, patients should be closely monitored for adequate pain relief as well as for signs of possible side-effects especially respiratory depression.
  • Fentanyl patches should only be used in patients who are opioid tolerant and have already tried a strong opioid such as morphine

Dose

  • Apply to dry, non-irritated, non-irradiated, non-hairy skin on torso or upper arm, removing after 72 hours and siting replacement patch on a different area (avoid using the same area for several days)
  • Adult and child over 2 years currently treated with a strong opioid analgesic, initial dose based on previous 24-hour opioid requirement
  • Fentanyl patches should only be used in patients who require the equivalent dose of at least 60mg morphine daily
  • Once titrated to an effective dose, patients should not be changed to other forms (matrix or reservoir) of transdermal fentanyl patches

Notes

  1. Prescribers are reminded to prescribe fentanyl by brand to ensure continuity and avoid confusion.
  2. Fentanyl is available both as a reservoir patch and a matrix patch. The difference between the reservoir patch and matrix patch is the size. This size difference could lead to confusion on dosing if the patient is switched between reservoir and matrix patches. Neither matrix nor reservoir patches are recommended to be cut
  3. Fentanyl patches are only licensed to be changed every 72 hours. Use for shorter periods eg. 48 hours is unlicensed and significantly increases costs. If patient is still experiencing pain in 72 hour change interval, review analgesia options. Do not suggest the patches are changed more frequently
  4. Prescribers should ensure that patients and/or their carers are aware that fentanyl patches need to be applied at appropriate 72-hour (three-day) intervals to ensure that patients are not left in pain (because of too long an interval) and that the patches are not used wastefully (because of too short an interval). Remember to remove the old patch before application of new patch
  5. Fentanyl patches are implicated in a high level of patient harms and the CQC Annual Report for 2012 again highlights the care that must be taken to ensure the safe use of these patches. Fentanyl patches should be restricted to patients that are already receiving regular doses of opioids
  6. Do not use for acute pain
  7. Do not use in opiate naïve patients
Abstral®
  • Fentanyl sublingual tablets 100 micrograms, 200 micrograms, 300 micrograms, 400 micrograms, 600 micrograms, 800 micrograms (£5.00 = per tablet)

Indications

Dose

  • Abstral® requires dose titration to determine optimal dosage- consult product literature for further details.
  • If more than 4 episodes of breakthrough pain each day, adjust background analgesia
  • The dose of Abstral® is not interchangeable with Effentora®.

Notes

  1. Please refer to Guidelines for prescribing transmucosal fentanyl preparations for breakthrough pain
  2. Patients must be assessed by the palliative care or pain team before commencing treatment with Abstral® tablets. They should be used in the minority of patients with breakthrough pain that fail immediate release morphine or oxycodone. Patients must be reviewed weekly.
Effentora®
  • Fentanyl buccal tablets 100 micrograms, 200 micrograms, 400 micrograms, 600 micrograms, 800 micrograms (£4.99 = per tablet)

Indications

Dose

  • Initially 100 micrograms repeated if necessary 30 minutes after first dose (no more than 2 dose units for each pain episode); adjust dose according to response, see titration guidance; maximum 800 micrograms per episode of breakthrough pain; leave at least 4 hours between treatment of episodes of breakthrough pain during titration
  • The dose of Effentora® is not interchangeable with Abstral®

Notes

  1. Please refer to Guidelines for prescribing transmucosal fentanyl preparations for breakthrough pain
  2. Patients must be assessed by the palliative care or pain team before commencing treatment with Effentora® buccal tablets. They should be used in the minority of patients with breakthrough pain that fail immediate release morphine or oxycodone. Patients must be reviewed weekly.
Oxycodone
  • Shortec® capsules 5mg, 10mg, 20mg (£20.58 = 30mg daily)
  • Injection 10mg/ml, 50mg/1ml (£3.20 = 2ml 10mg ampoule)
  • Oral solutionSF 5mg/5ml (£9.71 = 250ml)
  • Oral solution concentrate 10mg/1ml (£46.63 = 120ml)
  • Modified release 12 hourly dosing
    • Longtec® M/R tablet 5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg, 120mg (£25.05 = 40mg daily)

Indications

Dose

  • Oral, initially 5mg every 4–6 hours, increased if necessary according to severity of pain, usual maximum 400mg daily, but some patients may require higher doses
  • Slow intravenous injection, 1–10mg every 4 hours when necessary
  • Intravenous infusion, initially 2mg/hour, adjusted according to response
  • Subcutaneous injection, initially 5mg every 4 hours when necessary
  • Subcutaneous infusion, initially 7.5mg/24 hours adjusted according to response
  • Modified release, initially 10mg every 12 hours, increased if necessary according to severity of pain, usual maximum 200mg every 12 hours, but some patients may require higher doses;

Notes

  1. Oxycodone preparations and fentanyl patches should be used as second line therapies (under specialist advice) if patients cannot tolerate morphine
  2. In primary care there is a significant cost reduction though prescribing standard release oxycodone capsules as branded Shortec® capsules and M/R oxycodone tablets (12 hourly) as branded Longtec® tablets.
  3. In secondary care only, generic prescribing is advised. Please specify formulation- capsules or liquid for immediate (standard) release or modified release (MR) tablets (12 hourly dosing)."
Oxycodone with naloxone
Targinact®
  • m/r tablet oxycodone/ naloxone 5mg/ 2.5mg, 10mg/ 5mg, 20mg/ 10mg, 40/ 20mg (£84.62 = 20mg/ 10mg x 56 tablets)

Indications

  • Severe pain requiring opioid analgesia
  • Only be used in palliative care patients, chronic pain and gastroenterology where laxative treatment has failed. Not recommended for pre-operative use or within the first 12-24 hours post-operatively.

Dose

  • Adult over 18 years not currently treated with opioid analgesics, initially 10mg/5 mg every 12 hours, increased according to response
  • Patients already receiving opioid analgesics can start with a higher dose
  • The maximum daily dose of Targinact® is 80mg/40mg in 24 hours

Notes

  1. For patients requiring higher doses for pain relief, administration of supplemental oxycodone prolonged-release at the same time intervals should be considered, taking into account the maximum daily dose of 400mg prolonged-release oxycodone hydrochloride.
  2. In the case of supplemental oxycodone dosing, the beneficial effect of naloxone on bowel function may be impaired. Ensure patients are on full dose of appropriate bowel care prescription before initiating Targinact®. If no clear objective improvement in bowel function is noted do not continue (measure improvement on Bristol stool Chart)
Tapentadol
  • Tablets MR 50mg, 100mg, 150mg, 200mg, 250mg (£99.64 = 200mg x 56 tablets)

Indications

Dose

  • Initially 50mg every 12 hours, adjusted according to response; maximum 500mg daily
Alfentanil
  • Injection 500 micrograms/ml, 2ml, 10ml ampoules
  • Injection 5mg/ml, 1ml ampoule

Notes

  1. Intravenous use by anaesthetists and intensive care physicians only due to rapid and profound respiratory depression.
  2. Although not included in the original safety alert, the use of 5mg in 1ml amps is subject to the same restrictions as high strength morphine and diamorphine as per NPSA/2006/12
Dihydrocodeine
  • Tablets 30mg
  • Tablets m/r 60mg, 90mg, 120mg

Indications

  • Dihydrocodeine is included for the treatment of opioid dependence. Used as second line under specialist initiation and monitoring ONLY if other interventions have failed.
  • For use in Plymouth Community Healthcare, please refer to Prescribing Policy for the Management of Substance Misuse.
Fentanyl
  • Injection 50 micrograms/ml, 2ml, 10ml ampoules
  • Injection 2.5mg in 50ml vials

Notes

  1. Intravenous use by anaesthetists and intensive care physicians only due to rapid and profound respiratory depression. Intravenous fentanyl Patient Controlled Analgesia (PCA) may only be prescribed on the advice of an anaesthetist or the Acute Pain Team.
  2. South Devon only: Consult hospital epidural protocol (intranet guideline 0202), Epidural analgesia via continuous infusions.

 

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