Guidelines for Pain
Management
Paula Wilkinson
Chief Pharmacist
NHS Mid-Essex
Drivers
• Increasing spend on Opioid Analgesics
– Over £1million spend YTD
– 8% (£75K) more than SHA average
• Increasing range of Fentanyl products
– Rational use
– Expensive
– Risk
• Cost of Oxycodone
– Oxycodone is 7x as expensive per item as Morphine
Opioid Prescribing
Act Cost
Per
Den Act Cost
omin
Per
ator
Item Total Act Cost
Variance Act
Cost
Ratio
Act
Cost
Fentanyl
£64,946.67
123.86%
£668.22
£77.85
£337,179.44
Buprenorphine
£56,951.60
136.82%
£419.40
£28.30
£211,625.94
Tramadol
Hydrochloride
£30,678.95
118.56%
£388.37
£8.55
£195,966.79
Oxycodone
Hydrochloride
£10,513.99
107.02%
£317.69
£50.30
£160,305.27
Morphine Sulphate
-£20,306.76
74.15%
£115.45
£7.85
£58,253.32
BNF Name
Morphine v Oxycodone
Items of morphine and oxycodone prescribed
15,000
Cost of morphine and oxycodone prescribing
£250,000.00
£200,000.00
£150,000.00
£100,000.00
£50,000.00
£0.00
10,000
5,000
0
2006-7
2007-8
2008-9
oxycodone morphine
2009-10
2006-7
2007-8
2008-9
oxycodone morphine
2009-10
Mild Pain
•
Gastrointestinal protection is required for patients at increased risk of GI
bleeding. A PPI (omeprazole or lansoprazole capsules), should be
prescribed for the following patients: aged > 65 years; taking steroids or
anticoagulant therapy; requiring long-term NSAID; co-morbidity.
Moderate Pain
•
•
•
Targinact (oxycodone/naloxone) due to a lack of good evidence remains NONFORMULARY and should not be prescribed.
Tramadol prescribe with caution in elderly [aged 75+ (consider 50mg tds)]; palliative care
patients; renal failure (CKD levels 3 – 5); history of seizures/epilepsy; pregnancy; on
warfarin therapy; taking SSRIs.
BuTrans patch dose adjustment: When starting, analgesic effect should not be evaluated
until the patch has been worn for 72 hours (to allow for gradual increase in plasmabuprenorphine concentration) – if necessary, dose should be adjusted at 3-day intervals
using a patch of the next strength or two patches of the same strength (applied at same
time to avoid confusion). Max. two patches can be used at any one time. Wait 24 hours
before initiating a slow release opioid.
Severe Pain
•
•
The NPSA (2006) recommends caution in the use of strong opioids in opioid naïve
patients. Before prescribing strong opioids, it is important to first establish if
patients are opioid naïve to minimise risk of adverse events of administering strong
opioids by titrating immediate release opioids up, starting with a low dose.
The prescribing of opioids will often be prescribed in a sustained-release oral or
patch formulation and there is potential for prescribing and dispensing errors
involving confusion with names, formulations and dosage calculations when
prescribed generically. These products should therefore be prescribed by brand.
Refer to the Mid Essex Guideline for Prescribing of Strong Opiates for more
detailed information.
Use of Oxycodone
• Patients should only be prescribed oxycodone where morphine is
not appropriate for the following reasons:
– They develop side-effects with morphine such as confusion,
hallucinations, myoclonic jerks;
– They have excessive sickness DESPITE taking anti-emetics
(including a trial of the buccal route of administration);
– They develop an associated rash;
• Oxycodone should be prescribed by BRAND name.
• Oxycodone is approximately twice as potent as morphine.
• Dose conversions should be conservative and doses rounded down.
Use of Fentanyl
•
•
•
•
Use Third Line
Prescribe by brand
Buccal, sublingual, intranasal as well as patches
Concern regarding the suitability of such products for
wider use outside of specialist care where observation
may not be as intense and where prescribers will be less
familiar with these products.
• Fentanyl is associated with a relatively high incidence of
adverse effects and treatment complications.
• Cost between £5 or £6 per dose compared with less
than £1 per dose for morphine.
Cost comparison
Mid-Essex Guidelines
•http://www.midessex.nhs.uk/key_documents/Medicines-Management/