Prudent Healthcare
Chronic pain pathway workshop
Opioid analgesics
1. Products
Opioid analgesics are listed in British National Formulary (BNF) section
4.7.2. They include:
1.1
Strong opioids
Oxycodone (Oxycontin®)
Buprenorphine (Temgesic®)
Fentanyl (Durogesic®)
Tramadol (Non-proprietary)
Morphine (Oramorph®)
Diamorphine (Non-proprietary)
Pethidine (Non-proprietary)
Tapentadol (Palexia®)
Dipipanone (Diconal®)
Pentazocine (Non-proprietary)
1
Methadone (Non-proprietary)
1.2
Weak opioids
Dihydrocodeine (non-proprietary)
Codeine (non-proprietary)
Meptazinol (Meptid®)
The symbol
is used to denote preparations that are considered by the BNF Joint
Formulary Committee to be less suitable for prescribing. Although such preparations may
not be considered as drugs of first choice, their use may be justifiable in certain
circumstances.
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1.3
Combination products
Combination products are also available. These include:
Codeine with paracetamol (co-codamol) (non-proprietary
Dihydrocodeine with paracetamol (co-dydramol) (non-proprietary)
Tramadol with paracetamol combination (Tramacet®)
Codeine with aspirin (co-codaprin) (non-proprietary)
(The hyperlink links to one manufacturer’s summary of product
characteristics (SPC) for one formulation/ strength of the drug. The SPCs
for alternative manufacturer’s/ formulations/ strengths can be searched
for at eMC)
2. Indications
Opioid analgesics are usually used to relieve moderate to severe pain
particularly of visceral origin. Indications vary between products and
according to dosage.
Opioids can also be used to treat neuropathic pain, but not all neuropathic
pain is opioid-responsive. The use of strong opioids for treating nonmalignant chronic pain conditions is controversial because of concerns
about the long-term side effect profile of the drugs.
Opioids can also be used for their cough-suppressant effect and to reduce
intestinal motility. Some opioids are used in the management of opioid
dependence.
This briefing focuses on the use of opioids as analgesics.
3. National Institute for Health and Care Excellence (NICE)
3.1
Clinical guidelines
Clinical guidelines in which the use of opioid analgesics is recommended
or may be considered for use where appropriate:
Opioids in palliative care (CG140)
Osteoarthritis (CG177)
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Low back pain (CG88)
Neuropathic pain - the pharmacological management of neuropathic pain
in adults in non-specialist settings (CG96)
Lower limb peripheral arterial disease (CG147)
3.2
Do not do recommendations
From CG 140 Opioids in palliative care (ID: 1073, 1074).

Do not routinely offer transdermal patch formulations as first-line
maintenance treatment to patients in whom oral opioids are suitable.


Do not offer fast-acting fentanyl as first-line rescue medication.
From CG 173 Neuropathic pain - pharmacological management (ID 1473,
ID 470).

Do not use morphine to treat neuropathic pain in non-specialist
settings, unless advised by a specialist to do so.

Do not use tramadol to treat neuropathic pain for long-term use in
non-specialist settings, unless advised by a specialist to do so. For
short-term use, see recommendation 1.1.10 in the guidance.
4. Medicines and healthcare products regulatory agency drug
safety updates
Codeine: very rare risk of side-effects in breastfed babies
Rarely, opioid effects can occur in a breast-fed baby of a mother being
treated with codeine. This is likely if the mother has especially active form
of CYP2D6 isoenzyme, leading to rapid conversion of codeine to
morphine.
[Drug Safety Update Vol 1, Issue 4. November 2007]
Intrathecal drug pumps
Opioids administered through an implantable intrathecal pump can induce
an inflammatory mass near the tip of the intrathecal catheter.
[Drug Safety Update Vol 1, Issue 10. May 2008]
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Fentanyl patches: serious and fatal overdose from dosing errors,
accidental exposure, and inappropriate use
Inappropriate use of fentanyl patches can be very dangerous. Patches
should be prescribed with care and instructions on their use should be
followed closely.
[Drug Safety Update Vol 2, Issue 2. September 2008]
Over-the-counter painkillers containing codeine or dihydrocodeine
Restriction on the sale of codeine and dihydrocodeine products to reduce
abuse; the products can no longer be sold for indications relating to colds,
flu, cough and sore throat. Over-the-counter supply is limited to shortterm use for pain not relieved by aspirin, ibuprofen or paracetamol.
Drug Safety Update Vol 3, Issue 2. September 2009]
Addiction to benzodiazepines and codeine: supporting safer use
Reminder to use benzodiazepines and over-the-counter codeine products
for the shortest possible time.
[Drug Safety Update Vol 4, Issue 12. July 2011]
Codeine-containing pain relief in children: safety review initiated following
post-surgical fatalities in ultra-rapid metabolisers
The ongoing review was triggered by recent concerns that there is an
increased risk of morphine toxicity when certain susceptible children are
given codeine for post-operative pain after surgery. The European review
will evaluate the impact of the new information on the balance of benefits
and risks of codeine-containing medicines when used for pain relief in
children. The outcome of the review will be communicated when available.
[Drug Safety Update Vol 6, issue 5. December 2012]
5. Additional health issues
The British Pain Society, in collaboration with the Faculty of Pain Medicine
of the Royal College of Anaesthetists, the Royal College of General
Practitioners and the Faculty of Addictions of the Royal College of
Psychiatrists produced good practice guidance on opioids for persistent
pain.2
The guidance recognises that complete relief of pain is often not achieved
with opioids and the aim should be to balance a reduction in pain intensity
against potential adverse effects.
The British Pain Society. Opioids for persistent pain: good practice. January 2010.
www.britishpainsociety.org
2
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
Opioids can provide useful analgesia in the short and medium-term.


Evidence for sustained opioid analgesic efficacy in the long-term is
poor.
Improvements in quality of life are unlikely to be achieved unless
opioids are prescribed as part of a broader approach to improve
patient function.

Serious harms associated with opioids include:
 Falls leading to fractures.
 Respiratory depression which can be fatal but is rare with
long-term treatment.
 The increasing use of opioids for chronic non-cancer pain is
paralleled by rising numbers of deaths related to prescription
opioids.
 The potential for long-term adverse effects, particularly in
relation to endocrine and immune function.
 The potential for psychological and physical dependence or
misuse. The risk is uncertain and seems to depend on a
number of factors. This is no deterrent to the control of pain
in terminal illness.3
6. All Wales Prescribing Indicators
Each year from 2013-13 to the present there have been three national
prescribing indicators for opioid analgesics. Currently these are:



Total items per 1,000 PUs.4
Items of morphine as a percentage of strong opioid prescribing.
Tramadol DDDs per 1,000 patients.5
Further information on national prescribing indicators and their analysis
from 2011-12 to 2014-15 can be found in the online AWMSG library.
3
BNF edition 66, September 2013-March 2014, [page 274]
4
PU = prescribing unit
5
DDD = daily defined dosage
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7. Resources to support change
7.1
All Wales Medicines Strategy Group (AWMSG)
Educational resource materials were developed to support the appropriate
prescribing of tramadol in NHS Wales and to review the prescribing of
tramadol within the complex context of pain management.
The materials were developed with regard to promoting the appropriate
use of tramadol and raising awareness of the risks associated with the
misuse and diversion of supplies of tramadol.
A protocol for the supply and administration of intranasal fentanyl
protocol was produced to facilitate the self administration of intranasal
fentanyl preparations for patients admitted to non-specialist palliative inpatient settings within Aneurin Bevan Health Board.
Patient information manuals for opioids in palliative care settings
Morphagesic SR® version and MST® version represent a useful takehome supplement to consultations where opioids have been discussed,
considered and/or prescribed.
The patient information leaflet Medicines for mild to moderate pain relief
provides written information on the medicines that are available for mild
to moderate pain relief, both over the counter and on prescription.
7.2
Welsh Medicines Resource Centre (WeMeRec)
The management of chronic non-malignant pain in primary care bulletin
will be available soon via www.wemerec.org.
The management of acute low back pain bulletin discusses the
appropriate management of acute, uncomplicated or non-specific low
back pain in the primary care setting. It focuses on overall management
strategies including appropriate first-line medicines.
The palliative care pain control bulletin and the accompanying issue, on
symptom control in palliative care, focus on the care of cancer patients.
Stopping compound medications containing codeine e-notes discusses
how these medicines can potentially be discontinued safely and
beneficially.
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7.3
MHRA opioids learning module
The opioids learning module identifies the most important hazards of
opioids and informs on actions that health professionals can take in order
to anticipate, minimise and manage the risks.
7.4
NICE clinical audit tool
Opioids in palliative care: initiating drug treatment clinical audit tool
accompanies the clinical guideline Opioids in palliative care (CG140).
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