B149. Non-neuropathic drugs inastepwise approach. The WHO analgesic ladder advisesoral administration of should not usually beusedasfirst linetherapy for pain. reducing disability andimproving quality of life. only aspartof a wider management planaimed at Pharmacological management for painshouldbeused Background Recommendations aged 18 years andover suffering from . This document doesnot cover thespecificmanagement of painassociated withcancer. These resources are aimedat reviewing painpathways and facilitating theappropriate primary care management of paininallpatients Non-neuropathic pain • • • • • • down anddiscontinued. If ineffective, the opioidshouldbeslowly tapered been achieved. monthly inthefirst sixmonths after stabledosinghas term. During longterm treatment, review at least There islittle evidence that opioidsare helpful long with medicalco-morbidity). Use with cautioninolder people (particularly those improvements (includingsleep). pain intensity andability to achieve specificfunctional pain) to establishif thepatient achieves a reduction in effect of opioids on two or three episodes of increased two week opioidtrial(or longenoughto observe the When initiating prescribing, always consider aone to non cancer paininadults. therapy. +/-NSAIDs andnon-pharmacological) before Consider nonopioidinterventions (paracetamol relief. analgesia may only offer a30-50% reduction inpain that complete painrelief may not bepossibleand improving quality of life. Patients should beinformed management planaimedat reducing disability and Use medication for painonly aspart of a wider 1,2

1-3 See attachment 1: Treatment pathway for 1,2 2 This document is for use inthe NHS 1,2 1,2 a reasonable outcome. 80%of patients takingopioids will experience at leastoneadverse becoming ableto dotasksthat thepaincurrently prevents. Improved sleep would alsobe in somecasesof persistent pain. Treatment success isdemonstrated by thepatient The safety andefficacy of long termopioiduseisuncertain althoughuse may beappropriate Wales isover £10.4 million. should bereviewed, The current annual cost of theseformulations across England and sublingual administration are inappropriate for the management of persistent painand Use of opioidformulations witha rapid onset, suchas fentanyl for transmucosal or equates to £179,494per 100,000patients. this would leadto over £109million worth of savings across England andWales. This prescribing and discontinuing treatment nolonger needed resulted ina20% reduction, The annualcost of analgesics across England and Wales isover £546million.If reviewing Cost savings (ePACT April to June 2016) equivalence or anequianalgesic effect.) Table 1:Cost comparison for strong oral opiates for 30days (NB.Doses donot imply trying analternative opioidif the first drugishelpful butcauses intolerable side effects. more effective or show improved tolerability. However, there isatheoretical rationale for morphine. There isnoconsistent evidence to suggest that non-morphineopioidsare any as fentanyl, buprenorphine andoxycodone are significantly more expensive thanoral effects thananother. Oral morphineisthepreferred choice. Non-morphine opioids,such There islittle evidence that oneopioidismore effective andassociated with fewer side doses above oral morphineequivalent to 120mg/day, butthere isnoincreased benefit. opioid therapy shouldbeplanned. The riskof harm with opioidsincreases substantially at that opioidtherapy may play arole infurther management of thepatient’s pain,atrial of effect, e.g. constipation, nausea, itchinganddizziness. Ifthe prescriber and patient agree release tablets Tapentadol prolonged Oxycodone MR Morphine SR(Zomorph) Tramadol SRcapsules and isnot to be used for commercial or marketing purposes 100-250mg bd 20mg-40mg bd 30mg-60mg bd 100-200mg bd Doses 4,5 £49.82 -£124.55 £53.66 -£107.35 £8.30 -£16.20 £14.47 -£28.93 Drug Tariffcost 4 £49.82 –£124.55(Palexia SR) Reltebon) £26.83 -£53.66(Longtec, £8.30 -£16.20(Zomorph) £6.94 -£14.19(Marol) Most cost effective brand

1,2 1,2 5 B149. Non-neuropathic pain 5. 4. 3. 2. 1. References across England andWales of over £19.4million. This equates to £31,887per 100,000patients. If areview of prescribing ledto a50%reduction infentanyl, nefopam or pethidine formulations thenthis would leadto annualsavings of nefopam across England and Wales isover £24.4million. Review existing patients on nefopam. If ineffective and patients cannot tolerate side effects, reduce slowly and discontinue. The currentannual cost team) should not beprescribed. The current annualcost of pethidine across England and Wales isover £1.9million. Opioid injections,or pethidine inany form, for themanagement of persistent noncancer pain (unless ontheadvice of aspecialistpainmanagement Additional resources available: MIMS. Haymarket Publishing, . March 2016. Accessed via 21/03/16. Prescription Pricing Division (PPD). NHS Business Services Authority. Drug Tariff March 2016. Accessed via www.bpac.org.nz/BPJ/2008/December/ladder2.aspx Best Practice Advocacy Centre New Zealand (BPAC) WHO Analgesic Ladder: whichopioid to use at step two. BPJ 2008:18 Accessed via prescribing of opioidmedicinesfor pain. Accessed via Faculty of Pain . Supported by Public Health England. Opioids Aware: A resource for patients andhealthcare professionals to support Accessed via of theRoyal College of Anaesthetists, Royal College of General Practitioners andthe Faculty of Addictions ofthe Royal College of Psychiatrists. The British Pain Society. Opioids for persistent pain. A consensus statement prepared onbehalf of the British Pain Society, Faculty of Pain Medicine Bulletin

http://www.rcoa.ac.uk/news-and-bulletin/rcoa-news-and-statements/opioids-persistent-pain-good-practice This document is for use inthe NHS Datapack https://www.prescqipp.info/resources/category/349-non-neuropathic-pain Audit, patient letter, pathway on21/03/16. http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware and isnot to be used for commercial or marketing purposes www.mims.co.uk on 21/03/16. Community InterestCompany http://www.drugtariff.nhsbsa.nhs.uk on09/12/16 http:// on on