PAIN MANAGEMENT
WHO PAIN LADDER
Step 1
Non - Opioid Analgesics
E.g. Aspirin 300mg & Paracetamol 500mg
Paracetamol 500mg tablets are the drug of choice.
Always prescribe in tablet rather than capsule form:
Paracetamol tablets
100
£1.62
Paracetamol capsules
32
£1.17
Paracetamol soluble tablets 60
£4.88 – beware high sodium content
If using a liquid formulation is a necessity use paracetamol 250mg/5ml suspension (500ml £3.66)
20ml dose
Do not use paracetamol 500mg/5ml (other than when specified as Christie formula) which is
an unlicensed special and can cost upwards of £100 per bottle.
Step 2
Weak Opioid Analgesics for mild to moderate pain
E.g. Codeine
When stepping up to opioid therapy consider current or past history of depression or anxiety and
substance misuse including alcohol as these may be risk factors for problematic opioid use.
However the need for increased dose of opioid is not always indicative of problem drug use. Dose
escalation may result because of disease progression, opioid tolerance and opioid induced
hyperalgesia.
Compound analgesic preparations containing opioids should not be used routinely. Patients
should be given the individual components where possible to allow titration of dose. When these
preparations are used, they should be for short term use only, for relief of moderate pain and the
soluble preparations avoided due to their high sodium content. Tablets are cheaper than capsules.
Please avoid the use of the 15/500mg strength of co-codamol due to its disproportionate cost:
Co-codamol 8/500mg tabs 32
£1.26
Co-codamol 8/500mg cap
32
£2.69
Co-codamol 8/500 eff. tabs 100
£5.40
Co-codamol 15/500mg tabs 100
£8.25
Co-codamol 30/500mg tabs 100
£4.33 ZAPAIN is one of the more cost -effective brands
Co-codamol 30/500mg caps 100
£6.86
Co-codamol 30/500mg eff tabs100
£9.64
If Tramadol is to be prescribed please refrain from using modified release preparations and use the
50mg capsules. The use of Tramacet is not recommended as it contains sub therapeutic doses of
both paracetamol and tramadol and is not cost effective.
Step 3
Strong Opioid analgesics for moderate to severe pain
E.g. Morphine, Fentanyl patches
If patients do not achieve useful relief of pain symptoms at doses between 120-180mg
morphine equivalent in 24 hours referral to a specialist in pain management is strongly
recommended.
Morphine sulphate MR capsules are the preferred option preferably prescribed as the Zomorph
brand – 12 hourly dosing. Always prescribe short-acting morphine in addition to other opioids for
break-through pain. Start with lowest dose.
Neuropathic pain
Amitriptyline is recommended for first line use due to the strength of existing evidence for its use
for this indication despite the fact it is unlicensed. Pregabalin is an alternative but much more
expensive. Please refer to recent NICE guidance for additional information.
Migraine
Use simple analgesics (plus anti-emetics if needed) for first line treatment reserving triptans for
second line. Aspirin has been shown to be as effective as Sumatriptan.
Sumatriptan is the most cost effective triptan and is now available as a generic. Almotriptan or
Rizatriptan can be tried if the patient is non responsive.
Beware over use of opioids which can lead to chronic daily headache syndrome. Do not prescribe
Migraleve yellow which is a costly OTC version of co-codamol 8/500mg.
Action Plan
Suggested
process
Within regular
reviews
Identify
patients on
capsule
formulations
Review all
patients on
Soluble
formulations
Review all
patients on
Tramacet
Identify
patients on
Pregabalin/
Gabapentin
Identify pts on
Migraleve
yellow
Actions required and Rationale
Assess patient’s requirement for pain relief. Is the
current level appropriate and effective
Weigh the need for regular vs prn use
Is the choice of agent still appropriate
Is there a clear need for a capsule?
Where possible switch to tablet formulation or caplets
where they are available
Is this formulation indicated? Switch to tablets where
possible.
Ensure the sodium load is safe for each individual
patient
Review need and switch to separate agents at
therapeutic doses
Is this indicated?
Has the dose been titrated to an effective level and is
the dose optimised.
NB all strengths of Pregabalin cost the same amount
Switch to Co-codamol 8/500 tablets
Agreement
By
When
whom