Related guidance:

Osteoarthritis: care and management in adults (CG177 February 2014)

Rheumatoid arthritis in adults: management (NG100 July 2018)

Headaches in over 12s: diagnosis and management (CG150 November 2015)

Neuropathic pain in adults: pharmacological management on non-specialist settings (CG173 Updated July 2019)

Low back pain and sciatica in over 16s: assessment and management (NG59 September 2020)Nice has reviewed the evidence and made new recommendations on the pharmacological management for people with sciatica, including not to offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines; it also recommends against opioids for chronic sciatica.

Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain (NG193 April 2021)

Use this decision aid to help you and your healthcare professional decide which tablets you may like to take for long-term and flare-up pain of the muscles, ligaments, or soft tissue
Avoid soluble formulations of Paracetamol and Co-Codamol because of high sodium content (the equivalent of up to 9g of salt per day at full dose) which may contribute to or exacerbate hypertension or heart failure. These products are also more expensive, for example paracetamol soluble tablets 500mg are £9.21 for 100, and for patients with swallowing difficulties a suspension is a more cost effective and often more palatable option.
Medication Overuse Headache All medications for treating headache can cause MOH in patients with a pre-existing primary headache disorder, even if taking medicines for pain other than headache. Mean onset 1.7 years (triptans) to 4.8 years (analgesics)
Prescribing duration of Controlled Drugs. Maximum duration per prescription should be no longer than thirty days
Oral dosage forms in the main, particularly morphine MR which, at bd dose, should not exceed 60 tablets/capsules.
Patch quantities are a particular problem.
Fentanyl- 72 hour (three day) patches so 10 patches (2×5) per month limit
Buprenorphine 5, 10 and 20mg -7 day patches so one pack of 4 per month limit
Buprenorphine 35, 52.5 and 70mg-change twice a week so 8 patches (2×4) per month limit
Click here for resources to support reducing opiate prescribing

See NHS Somerset  pain management webpage for useful information and resources

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Non-opioid analgesics
First-line
Paracetamol
as Mandanol®

suitable for self-care
Green cross

Paracetamol oral suspension 250mg/5ml S/F
500mg tablets: £0.76 (32)








£2.15 (200mls)
First choice drug in acute and chronic pain. If treatment is not effective check that adequate dose is being used (i.e. 1g QDS) before adding other options. Available OTC.
Paracetamol may be considered an option for treating agitation in people with dementia where pain may be a factor. Husebo et al. (2011) Br Med J 343: d4065; Husebo, Ballard, & Aarsland (2011) Int J Ger Psych 26: 1012-1018.


Avoid 500mg/5ml solution or susp as very expensive (£18 or £30 per 200mls)
Weak opioid analgesicsIt is strongly recommended that prescribers discuss the risk of addiction when initiating new patients on any opioid containing medication and also on review. This discussion should be recorded in the patient notes. Just three days of codeine or dihydrocodeine medicines can lead to addiction.
Co-codamol 8/500, 15/500 and co-dydramol are non-formulary. It is recommended that standard paracetamol treatment be topped up with codeine 15mg tablets at breakthrough.
The Faculty of Pain at The Royal College of Anaethestists states some important principles around opiate prescribing:
* Opioids are very good an analgesic for ACUTE PAIN AT THE END OF LIFE but there is little evidence that they are helpful for long term pain.
* A small proportion of people may obtain good pain relief with opioids in the long term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation)
* The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit.
* If a patient is using opiods but is still in pain, the opioids are not effective and should be discontinued, even if no other treatment is available.
* Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.
For more information see Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain

The BNF updated its opioid dose equivalences in August 2020, this is reflected in the FPM tables
Codeine 30mg x 8/day provides 240mg codeine equivalent to Morphine 30mgCodeine15mg tablets: £0.87 (28)
30mg tablets: £0.98 (28)
60mg tablets: £1.67 (28)
Note that around 10% of White people lack the enzyme to metabolize Codeine so derive little benefit from it, but still suffer the side effects
Prescribing Paracetamol and Codeine separately enables more appropriate dose titration and enables patients to take more control of their own pain management, e.g. taking Paracetamol regularly and adding Codeine as required. Codeine alone is not considered a particularly effective analgesic.
Tramadol
First-line:
Immediate release capsules
50mg capsules: £0.82 (30)Tramadol may be considered as an alternative to codeine where its efficacy or tolerability is poor. MHRA advise short-term or intermittent treatment; caution where history of addiction or seizure

Tramadol may be most effective when given with full therapeutic doses of Paracetamol (i.e.Do NOT prescribe as Tramacet® as it only contains 375mg paracetamol).
Tramadol is associated with Serotonin syndrome when taken in conjunction with other serotonergic medications such as fentanyl, SSRIs, SNRIs, TCAs, MAOIs
Second-line:
Modified release

(twice-daily dosing)

50mg tablet: £4.60 (60)
50mg capsule: £7.24 (60)
100mg capsule: £14.47
150mg capsule: £21.71
200mg capsule: £28.93



For patients with long term chronic pain responsive to tramadol but who suffer significant side effects from the immediate release capsules a modified release product may be prescribed.





Combination analgesics


Co-codamol 30/500 x 8/day provides 240mg codeine equivalent to Morphine 30mg
Combination formulations that include tramadol as one of the ingredients (e.g. Tramacet®) are non-formulary.
The CCG strongly recommends that prescribers discuss the risk of addiction when initiating new patients on any opioid containing medication and also on review. This discussion should be recorded in the patient notes. Just three days of codeine or dihydrocodeine medicines can lead to addiction.
as Zapain® tablets


as Zapain® capsules
30/500mg tablets: £3.11 (100)


30/500mg capsules £3.85 (100)
Co-Codamol 30/500 is a potent analgesic carrying the full range of opioid side effects e.g. constipation and sedation, requiring particular care in the elderly – see BNF warning.
Prescribe as separate components if possible.
Management of opioid overdosage may require use of Naloxone: refer to Chapter 15 of the BNF
Strong opioid analgesicsFor non-cancer pain, strong opioids should be considered only when they are used as part of a programme of supported rehabilitation, with the goal of helping patients to manage pain-related disability. Further information and resources are available on our Pain management webpage

There is no evidence of superior clinical analgesic effect of other opioids over morphine

MHRA Drug Safety Update

Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression. (March 2020)

New recommendations following a review of the risks of dependence and addiction associated with prolonged use of opioid medicines (opioids) for non-cancer pain. Before prescribing opioids, discuss with the patient the risks and features of tolerance, dependence, and addiction, and agree together a treatment strategy and plan for end of treatment. (September 2020)
First-line:Immediate release
Morphine
Orodispersible tablets as
Actimorph®
1mg tablets: £2.00 (56)
2.5mg tablets: £2.50 (56)
5mg tablets: £3.50 (56)
10mg tablets: £4.75 (56)
20mg tablets: £9.50 (56)
30mg tablets: £13.00 (56)
Use for initial dose titration and breakthrough pain every 4-6 hours. Can be taken with or without food. The tablet disperses rapidly in the mouth and is then swallowed. Alternatively, for special population such as children or patients with difficulties in swallowing, the tablet may be placed in a spoon with the addition of a small quantity of water until sufficient dispersion to allow ingestion.
Actimorph is a CD schedule 2.
Tablets as
Sevredol®
10mg tablets: £5.31 (56)
20mg tablets: £10.61 (56)
50mg tablets: £28.02 (56)
Use for initial dose titration and breakthrough pain every 4 hours.
Sevredol is a CD schedule 2.
Solution
10mg/5ml solution: £4.42 (300ml)Use for initial dose titration and breakthrough pain every 4 hours.
Morphine solution 10mg/5ml is a CD schedule 5, unlike its equivalent strength of tablets or capsules which are schedule 2. It is therefore not subject to the same rules of prescribing, recording and storage as the solid dose forms. Do not confuse with Oramorph Concentrated oral solution which is 100mg/5ml (120ml) and is designed to be measured with the accompanying dropper.

There are safety concerns associated with the use of oral morphine sulfate solution. It is a high-risk medication with increased risk of overdose and death.
Coroners have raised concerns about its safety.
Please note that oral morphine sulfate solution contains alcohol and sugar. We recommend it is limited to palliative care prescribing in primary care. Actimorph OR Sevredol may be preferable alternatives if a short acting oral morphine formulation is required.




Modified release capsules as Zomorph®10mg capsules: £3.47 (60)
30mg capsules: £8.30 (60)
60mg capsules: £16.20 (60)
100mg capsules: £21.80 (60)
200mg capsules: £43.60 (60)
Zomorph® is the recommended modified-release morphine formulation.
Prescribe 12-hourly.
Subject to CD regulations.
Capsules can be opened and sprinkled on semi-solid food (e.g. yoghurt) or given in water via NG tube.
Modified release tablets as Morphgesic SR®10mg tablets: £3.85 (60)
30mg tablets: £9.24 (60)
60mg tablets: £18.04 (60)
100mg tablets: £28.54 (60)
Morphgesic SR® is the recommended modified-release morphine tablet formulation.
Prescribe 12-hourly.
Subject to CD regulations.
Second-line:FentanylFentanyl is only included for patients where morphine is contra-indicated or not tolerated or where there is specific need for a non-oral route. For non-cancer pain, 75mcg/hour should be the maximum dose, if ineffective other causes for lack of response should be considered (eg. Primary anxiety or unrealistic expectations of analgesia from patch).
Fentanyl is associated with Serotonin syndrome when taken in conjunction with other serotonergic medications such as tramadol, SSRIs, SNRIs, TCAs, MAOIs
Patches
as Matrifen®
12mcg / hour: £7.52 (5)
25mcg / hour: £10.76 (5)
50mcg / hour: £20.12 (5)
75mcg / hour: £28.06 (5)
100mcg / hour: £34.59 (5)
See MHRA DSU Vol.2 Issue 2 (Sep-08): Fentanyl patches: serious and fatal overdose from dosing errors, accidental exposure, and inappropriate use.

Increases in body temperature and external heat sources may lead to potentially fatal rises in serum fentanyl levels.
as Fencino®12mcg / hour: £8.46(5)
25mcg / hour: £12.10 (5)
50mcg / hour: £22.62 (5)
75mcg / hour: £31.54 (5)
100mcg / hour: £38.88 (5)
as Mezolar®12mcg / hour: £7.53(5)
25mcg / hour: £10.77 (5)
37.5mcg / hour: £15.46 (5)
50mcg / hour: £20.13 (5)
75mcg / hour: £28.07
100mcg / hour: £34.60
Buprenorphine patchesLike other transdermal products, increases in body temperature (eg after bathing) and external heat sources may lead to increased serum levels of active drug.
as Bunov®5mcg/hr: £5.54 (4)
10mcg/hr: £9.94 (4)
20mcg/hr: £18.10 (4)
20mcg is bioequivalent to Butrans. 5mcg and 10mcg strengths were subject to biowaiver.
as Reletrans®5mcg/hr : £6.34(4)
10mcg/hr: £11.36 (4)
15mcg/hr: £17.70 (4)
20mcg/hr: £20.06(4)
Equivalent to Butrans® but considerably cheaper.
as Butec®5mcg/hr : £7.92 (4)
10mcg/hr: £14.20 (4)
15mcg/hr: £22.12 (4)
20mcg/hr: £25.86(4)
Equivalent to Butrans® but cheaper.
as Hapoctasin®35mcg/hr : £9.48 (4)
52.5mcg/hr: £14.23 (4)
70mcg/hr: £18.96 (4)
As an option for patients with moderate to severe cancer pain for whom fentanyl may be too potent.
Note: Hapoctasin® are 72 hour patches the same as fentanyl. Transtec® have the same rate of drug delivery as Hapoctasin® but are 96 hour patches. Table of approximate dose equivalents from the British Pain Society
(see below)
as Relevtec®35mcg/hr : £11.06 (4)
52.5mcg/hr: £16.60 (4)
70mcg/hr: £22.12 (4)
Relevtec should be replaced after 96 hours (4 days) at latest. For convenience of use the transdermal patch can be changed twice a week at regular intervals e.g Monday morning and Thursday evening
Third-line:OxycodoneOxycodone is included only for patients where morphine is contra-indicated or not tolerated. Available data does not provide any evidence of oxycodone‟s superiority to morphine.
The CQC have issued guidance on prescribing, supply and administration:
Safer Use of Controlled Drugs – Preventing Harm From Oral Oxycodone Medicines
Immediate release
as Oxyact®
5mg capsules £5.15 (56)
10mg capsules £10.29 (56)
20mg capsules £20.57 (56)
4-6 hourly dose
Immediate release
as Shortec®
5mg capsules £6.86 (56)
10mg capsules £13.72 (56)
20mg capsules £27.43 (56)

5mg/5ml oral solution: £8.25. (250ml)
10mg/ml oral solution, £39.64(120ml) (CONCENTRATE-note strength)
4-6 hourly dose
Modified release
as Oxeltra®
5mg tablets: £3.13 (28)
10mg tablets: £6.26 (56)
15mg tablets: £9.53 (56)
20mg tablets: £12.52 (56)
30mg tablets: £19.06 (56)
40mg tablets: £25.05 (56)
60mg tablets: £38.12 (56)
80mg tablets: £50.10 (56)
12 hourly dose
Modified release
as Oxypro®
5mg tablets: £3.13 (28)
10mg tablets: £6.26 (56)
15mg tablets: £9.53 (56)
20mg tablets: £12.52 (56)
30mg tablets: £19.06 (56)
40mg tablets: £25.05 (56)
60mg tablets: £38.12 (56)
80mg tablets: £50.10 (56)
12 hourly dose
Fourth-line:TapentadolFourth-line strong opioid analgesic: Approved for relief of moderate to severe pain in adults as an alternative to oxycodonePlease be aware of MHRA alert January 2019 warning of increased risk of seizures and of serotonin syndrome. Tapentadol can induce convulsions and increase the potential for selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, antipsychotics and other medicinal products that lower the seizure threshold to cause convulsions.
AVOID IF PATIENT HAS A HISTORY OF SEIZURES
Immediate release50mg tablets: £12.46 (28)
75mg tablets: £18.68 (28)
Note: Immediate release product only licensed for acute pain
Modified release50mg tablets: £12.46 (28)
100mg tablets: £49.82 (56)
150mg tablets: £74.73 (56)
200mg tablets: £99.64 (56)
250mg tablets: £124.55 (56)
Note: slow release preparation is only licensed for chronic pain.

Procedures should be in place to prevent inadvertent prescribing errors