Pain Ladder (non-cancer) Guidance on analgesic choice for adults in primary care Acute pain Chronic pain Adjuvant therapies (consider for inclusion at any stage of treatment) Short-term pain <3 months Continuous, long-term pain >3 months Gentle exercise programmes Transcutaneous electrical nerve stimulation (TENS)—consider Paracetamol [1g QDS oral/rectal] seeking physiotherapist advice +/- Anticholinergics to relieve smooth muscle spasms (e.g. hyoscine PAIN MILD MILD Ibuprofen [400mg TDS oral/5% gel TDS topical] OR Naproxen [250-500mg BD oral] butylbromide for intestinal colic; oxybutynin for bladder spasms) Consider a proton pump inhibitor in patients at increased risk of gastrointestinal adverse effects with an NSAID** Muscle relaxants (e.g. baclofen, diazepam) to relieve painful As for Mild pain muscle spasms + Corticosteroids to alleviate pain due to CNS involvement, plexus or Consider possibility of neuropathic/mixed pain; treat with neuropathic agent as appropriate (see overleaf) peripheral nerve compression and visceral organ infiltration +/- Morphine sulphate * *Alternatives to morphine/oxycodone in moderate pain Oral solution/immediate-release tablets Codeine is metabolised to morphine. Due to the risk of unpredictable and [moderate pain: initially 2.5–5mg 4-hourly; severe pain: initially 5–10mg 4-hourly] variable metabolism of codeine to morphine, morphine itself is the preferred For up to 5 days or for occasional use <3 days/week opioid in the management of moderate and severe pain. In patients intolerant of morphine consider: Codeine phosphate [oral, 30-60mg QDS] In the management of chronic pain, oxycodone Contra-indicated in all patients of any age known to be Oxycodone hydrochloride* to SEVERE should only be initiated by the specialist pain Oral solution/immediate-release capsules ultra-rapid metabolisers of the CYP2D6 enzyme PAIN service (due to the increased risk of addiction) [moderate pain: initially 1.5–3mg 4–6 hourly; Metabolism to morphine can vary significantly & ultra- If larger severe pain: initially 3–5mg 4–6 hourly] rapid metabolisers have a marked increase in toxicity opioid dose Abrupt withdrawal precipitates a withdrawal syndrome required, For up to 5 days or for occasional use <3 days/week MODERATE (especially if used at high doses for >2 weeks) switch to If regular opioid required, convert to equivalent modified-release 12-hourly preparation morphine Meptazinol [oral, 200mg every 3–6 hours as required] If pain remains poorly controlled, or if opioid dose increases >60mg/24hours morphine equivalent, review diagnosis and treatment plan and seek advice if necessary; opioid dose >120mg/24hours Tramadol hydrochloride [oral, 50-100mg TDS-QDS] morphine equivalent should only be prescribed on the advice of the specialist pain service Risk of serotonin syndrome with concomitant use of Diclofenac sodium suppositories Buprenorphine transdermal patches SSRIs (serious & potentially fatal if undetected); [75-150mg daily in divided doses] Only for severe chronic pain in patients with severe symptoms include neuromuscular and autonomic Consider for short-term use as an alternative to dysphagia or on advice of specialist pain service; not hyperactivity and altered mental state ibuprofen or naproxen for severe acute pain suitable for rapid dose titration or acute pain Pain should respond to an opioid within 48 hours, & to other treatments within 6 weeks; ineffective medicines should be stopped, diagnosis reviewed & alternative treatment sought During long-term treatment, review patient at least monthly for the first six months after stable dosing achieved Seek advice on dose adjustment before prescribing to patients with renal or hepatic impairment, and on dose equivalence if switching opioids Fentanyl preparations are not recommended for initiation in primary care & should generally be reserved for palliative care (risk of serious adverse effects & inappropriate use of transdermal preparations has caused fatalities) Cost-effective preparations should be prescribed **Increased risk of gastrointestinal (GI) adverse effects if: on the maximum recommended dose of an NSAID, aged ≥ 65 years, history of GI bleeding/ulcer/perforation, on concomitant medicines with a risk of GI effects (e.g. anticoagulants, aspirin, corticosteroids, antidepressants), cardiovascular disease, hepatic/renal impairment, dehydration, diabetes, hypertension, prolonged NSAID use (e.g. for arthritis or chronic lower back pain in those aged over 45 years), H. pylori infection, excessive alcohol intake, or heavy smoker. Neuropathic pain Pain arising from a primary lesion or dysfunction in the peripheral or central nervous system Trigeminal neuralgia Diabetic peripheral neuropathy All other neuropathic pain Carbamazepine Duloxetine Amitriptyline hydrochloride (unlicensed indication) [oral, 100mg OD-BD, [oral, 60mg once daily; max. 60mg BD] [oral, 10mg nocte, increased gradually if required to 50mg nocte] increased gradually according Max. 75mg nocte only if patient awaiting referral to the specialist pain service to response; usual dose If satisfactory pain relief achieved but intolerable adverse effects, 200mg TDS-QDS, up to 1.6g consider imipramine or nortriptyline as alternatives daily] If not tolerated or if contraindicated, switch to amitriptyline If not tolerated or if contraindicated, switch to gabapentin If ineffective, not tolerated or If ineffective switch to, or combine with, gabapentin If ineffective switch to, or combine with, gabapentin contraindicated, consider Gabapentin treating as for ‘All other [oral, initially 100mg nocte, increased if necessary after 5-7 days by 100mg to max. 1.8g daily, in 3 divided doses]† neuropathic pain’ (opposite) Higher doses only under supervision of the specialist pain service and refer to the specialist If gabapentin not tolerated, contraindicated or ineffective, switch gabapentin to pregabalin pain service or a condition- Pregabalin specific service [oral, initially 50-75mg nocte, increased if necessary after 5-7 days by 50-75mg to max. 150-300mg BD]† Alternatives Tramadol [oral, 50-100mg 4-hourly] only if acute rescue therapy required (& not on other opioid); long-term use only on specialist pain service advice Capsaicin 0.075% cream [sparingly up to 3–4 times daily, not more often than every 4 hours] for localised pain if oral treatments unsuitable Lidocaine 5% medicated plasters for highly localised pain with a significant neuropathic component only on advice of specialist pain service Taper the regimen when switching or withdrawing treatment Pain should respond to an opioid within 48 hours, & to other treatments within 6 weeks; ineffective medicines should be stopped, diagnosis reviewed & alternative treatment sought During long-term treatment, review patient at least monthly for the first six months after stable dosing achieved If pain remains poorly controlled, review diagnosis & treatment plan, seek advice & refer to the specialist pain service if necessary Seek advice on dose adjustment before prescribing to patients with renal or hepatic impairment, or if switching medicines Cost-effective preparations should be prescribed † This is a low dose initiation regime which is recommended in primary care References BNF Online (January, February, May 2014) http://www.medicinescomplete.com/mc/bnf/current/ British Pain Society http://www.britishpainsociety.org/ Clinical Knowledge Summaries http://cks.nice.org.uk/: Analgesia - mild-to-moderate pain (August 2010) ; Trigeminal neuralgia (February 3013) Codeine Phosphate 30mg Tablets Summary of Product Characteristics, Actavis Ltd (DOR 07.10.13) http://www.medicines.org.uk/emc/medicine/23910/SPC/Codeine+Phosphate+Tablets+30mg/ College of Emergency Medicine Clinical Effectiveness Committee: Guideline for the management of pain in adults (June 2010) http://www.collemergencymed.ac.uk/code/document.asp?ID=4681 MHRA Drug Safety Update Vol 6, Issue 12, July 2013 http://www.mhra.gov.uk/home/groups/dsu/documents/publication/con296410.pdf NICE Clinical Guideline 140: Opioids in palliative care (May 2012) http://guidance.nice.org.uk/CG140/NICEGuidance/pdf/English NICE Clinical Guideline 173: Neuropathic pain – pharmacological management (November 2013) http://guidance.nice.org.uk/CG173/NICEGuidance/pdf/English & Clinical Guideline 96 (March 2010) http://publications.nice.org.uk/neuropathic-pain-the-pharmacological-management-of-neuropathic-pain-in-adults-in-non-specialist-cg96 PrescQIPP Bulletin 50 (January 2014, v2.0) Neuropathic pain: Pregabalin & gabapentin prescribing http://www.prescqipp.info/prescqipp-bulletin-downloads/viewcategory/5 UKMi Q&A 94.4 Risk of developing Serotonin Syndrome following concomitant use of tramadol with selective serotonin reuptake inhibitors (SSRIs) (21.12.11; minor revision 5.3.12) www.ukmi.nhs.uk/activities/medicinesQAs/default.asp This information is intended as a guide; patients currently well-controlled should continue with their existing pain management treatment. Produced by the Medicines Management Team, West Suffolk Clinical Commissioning Group, in conjunction with the West Suffolk NHS Foundation Trust. V1: May 2014. .