Pain
Regular review to ensure adequate pain control is key in managing pain.
SIGN 136: Chronic pain British Pain Society website
Prescribing Notes:
Acute Pain
- Acute pain relates to pain occurring during tissue damage and repair, for example surgery, trauma or burns. The pain typically improves with tissue healing.
- Long term treatment of acute pain should not be necessary – a step down approach should be used, with regular reassessment of pain so that analgesics are not continued for any longer than is required.
Chronic Pain
- Chronic pain is continuous long-term pain of more than 12 weeks that persists beyond the time of expected healing and recovery after surgery or traumatic injury, or the cause of pain may relate to a chronic condition. The cause can be unclear and less responsive to analgesia, as well as being complicated by psychological distress. The approach to management of chronic pain requires a different management strategy from acute pain:
- Selection of treatment options most likely to be effective is informed by careful assessment of pain including type of pain, severity and functional impact.
- Supported self-management and non-pharmacological approaches should be encouraged either alone or in combination with medicines for all patients with pain.
- Healthcare professionals should work with patients to develop their understanding of chronic pain, set realistic expectations (some chronic pain does not respond to analgesics) and agree a plan of treatment.
- Explain risk versus benefit of treatment and make clear that treatment will be reviewed regularly and stopped if not effective.
- The WHO ladder was designed to aid cancer pain and is useful in acute pain. It was not designed for chronic pain but may give guidance to aid patients to manage symptoms whilst trying to implement self-help strategies. Refer to Lothian Chronic Pain Service ‘Strong Opioids for Chronic Pain: Good Practice Guide for Clinicians’ for advice when considering use of strong opioids and the British Pain Society’s Guidance on Good Practice. The objective of treatment in all types of pain, irrespective of origin, is to achieve symptom control, and improve the patient’s quality of life. At any stage in the ladder, the addition of an appropriate Formulary NSAID can be considered for the treatment of short-term exacerbation of pain or where there is an inflammatory component.
- If any underlying cause of pain has no definitive treatment then pain control should be established as far as that may be possible using regular, rather than as required analgesia.
- Short acting and parenteral preparations are NOT appropriate for treating chronic pain.
- There is occasionally a role for strong opioids in intractable chronic pain. Morphine is the drug of choice.
- Analgesia for “acute on chronic” pain should be reviewed and stepped down when appropriate.
- Inpatients commenced on new opioid analgesia should have a treatment plan clearly discussed and documented and include in discharge letter at hospital discharge.
History Notes
27/10/2022
East Region Formulary content agreed.
Supported self-management and non-pharmacological approaches should be encouraged either alone or in combination with medicines for all patients with pain.
Prescribing Notes:
- Explain how pain manifests itself and provide information (Tame the Beast video) which helps patients understand why pain persists.
- Movement is an important part of managing chronic pain, and patients should be encouraged to find ways to pace their tasks, activity or exercise to avoid over activity / rest cycles. There are adapted exercise and movement videos on the NHS Fife Pain Management service website.
- Pain may also affect mood and vice-versa. Relaxation, mindfulness and pleasurable activity can help counter distress. NHS inform or Breathing Space.
- The NHS Lothian Pain Management service has a website with a number of helpful resources, including videos and audio tracks. The Pain Toolkit, Reconnect2Life and Live Well With Pain are also useful patient guides to living with pain.
- TENS therapy is known to provide short term relief in chronic pain.
History Notes
27/10/2022
East Region Formulary content agreed.
Paracetamol with or without ibuprofen.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Maintenance 200-400mg 3 times a day, may be adequate.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Maintenance 200-400mg 3 times a day, may be adequate.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Maintenance 200-400mg 3 times a day, may be adequate.
Apply up to three times a day.
Paracetamol with or without naproxen.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
500mg-1g daily in 1-2 divided doses.
500mg-1g daily in 1-2 divided doses.
Paracetamol with or without diclofenac sodium.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Orally 75-150mg daily in 2-3 divided doses.
Orally 75-150mg daily in 2-3 divided doses.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight adults.
For older patients and other patients at high risk of gastro-intestinal adverse events:
- Prescribe a NSAID (as shown in this pathway) + omeprazole or lansoprazole (see the ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary). Risk factors for GI adverse effects include previous peptic ulcer, previous GI bleed, alcohol excess, systemic corticosteroids, anticoagulants, SSRIs, age>65 years, high dose NSAIDS.
Additional prescribing notes:
- Refer to the ‘Treatment of musculoskeletal pain’ pathway for prescribing information relating to NSAIDs.
- Patients that require NSAIDs should be prescribed them at the lowest effective dose for the shortest time possible and long term use should be avoided if possible.
- Diclofenac is contraindicated in those with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease or established heart failure. The arterial thrombosis risk with diclofenac is similar to that of the COX-2 inhibitors.
- The MHRA has issued information on the cardiovascular risk with NSAIDs and in particular diclofenac.
- Low dose ibuprofen is considered to have the most favourable thrombotic cardiovascular safety profile.
- Ibuprofen is commonly used at doses of 1.2g daily or less to minimise side-effects. At this dose ibuprofen has little anti-inflammatory effect. A full anti-inflammatory effect for ibuprofen is achieved with maximum doses (i.e. 2.4g daily).
- For patients with cardiovascular and cerebrovascular disease, current evidence suggests that the risk of heart failure is increased with all NSAIDs. The risk of myocardial infarction is also increased with most NSAIDs, with the possible exception of naproxen. The risk of stroke is increased with most NSAIDs.
- Contra-indications to NSAIDS include proven hypersensitivity to aspirin or any NSAID, severe heart failure and active gastrointestinal bleeding. Refer to BNF for contraindications and cautions.
- NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
- Long-term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
- During long term use of NSAIDs ensure appropriate monitoring and regular re-evaluation of clinical need.
- Patients should be advised against excessive exposure to sunlight of areas treated with topical NSAIDs in order to avoid the possibility of photosensitivity.
- Avoid oral NSAIDs if possible in mild/moderate renal impairment, avoid in severe renal impairment.
History Notes
27/10/2022
East Region Formulary content agreed.
30-60mg every 4-6 hours if required; maximum 240mg per day.
30-60mg every 4-6 hours if required; maximum 240mg per day.
1-2 tablets every 4-6 hours; max 8 tablets daily. Dose reduction required in adults weighing less than 50kg.
1-2 tablets every 4-6 hours as required; maximum 8 tablets per day. Dose reduction required in adults weighing less than 50kg.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight adults.
- Some people do not respond to codeine; approximately 10% of patients are unable to convert it to morphine. Consider dihydrocodeine (co-dydramol) as an alternative.
- Consider interval prescribing of analgesics in those with history of self-harm.
- There is no evidence that of low strength compound analgesics, e.g. co-codamol 8/500 and co-dydramol 10/500 are more effective than paracetamol in relieving acute pain, they produce more side-effects and can complicate treatment of overdosage.
- Combining paracetamol +/- opioid +/- NSAID may be considered in mild to moderate pain. Consider prescribing opioid and paracetamol separately rather than the combined products.
- Consider the risk versus the benefits of prescribing more than one opioid.
- Frail, elderly patients are at higher risk on constipation when taking opioids.
- Initiate anti-emetic treatment (metoclopramide, preferred) and laxative treatment, when prescribing regular opioid therapy. Laxatives should be continued, and anti-emetics reviewed after 1-2 weeks.
History Notes
27/10/2022
East Region Formulary content agreed.
Patient safety concerns are due to the risk of serious adverse effects, dependence, diversion, abuse and overdose.
Initially 5-10mg every 4-6 hours (5mg in elderly patients), adjusted according to response.
Initially 5-10mg every 4-6 hours (5mg in elderly patients), adjusted according to response.
Initially 5-10mg every 4-6 hours (5mg in elderly patients), adjusted according to response.
Initially 5-10mg every 4-6 hours (5mg in elderly patients), adjusted according to response.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Patient safety concerns are due to the risk of serious adverse effects, dependence, diversion, abuse and overdose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Consult BNF for dose.
Consult BNF for dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours, dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
For in-patient use only - opioid of choice for patients with significant renal impairment.
Specialist use.
Prescribing Notes:
- In acute pain management, it will often be appropriate to initiate treatment with potent opioids plus non-opiates and then gradually wean these as the symptoms improve.
- Prescribers should reconsider the individual risks and benefits when increasing the dose above 50mg Oral Morphine Equivalent Dose (OMED) daily and should avoid increasing dosage to above 90 OMED daily or carefully justify a decision to titrate dosage to over 90 OMED daily and should discuss these with the patient. Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm. The risk of harm significantly increases at doses above 120mg OMED daily with no increase in benefit.
- Avoid concomitant use of two or more opioids.
- Opioid equivalent dose information can be found here – Scottish Palliative Care Guidelines - Choosing and Changing Opioids.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Patients prescribed a strong opioid should have access to regular prophylactic laxatives. A macrogol laxative is recommended as first line.
- Elderly patients are particularly susceptible to side effects of opioids e.g. respiratory depression and constipation.
History Notes
20/11/2023
Addition of MST continus 5mg, 10mg,15mg, 30mg and 60mg tablet formulations, ERWG November 23.
11/05/2023
Shortec liquid 1mg/ml oral solution removed as discontinued.
27/10/2022
East Region Formulary content agreed.
Paracetamol with or without ibuprofen.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Maintenance 200-400mg 3 times a day, may be adequate.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Maintenance 200-400mg 3 times a day, may be adequate.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Maintenance 200-400mg 3 times a day, may be adequate.
Apply up to three times a day.
Paracetamol with or without naproxen.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
500mg-1g daily in 1-2 divided doses.
500mg-1g daily in 1-2 divided doses.
Paracetamol with or without diclofenac sodium.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Orally 75-150mg daily in 2-3 divided doses.
Orally 75-150mg daily in 2-3 divided doses.
Orally 75mg twice daily.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight adults.
For older patients and other patients at high risk of gastro-intestinal adverse events:
- Prescribe a NSAID (as shown in this pathway) + omeprazole or lansoprazole (see the ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary). Risk factors for GI adverse effects include previous peptic ulcer, previous GI bleed, alcohol excess, systemic corticosteroids, anticoagulants, SSRIs, age>65 years, high dose NSAIDS.
Additional prescribing notes:
- Refer to the ‘Treatment of musculoskeletal pain’ pathway for prescribing information relating to NSAIDs.
- Patients that require NSAIDs should be prescribed them at the lowest effective dose and long term use should be avoided if possible.
- Diclofenac is contraindicated in those with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease or established heart failure. The arterial thrombosis risk with diclofenac is similar to that of the COX-2 inhibitors.
- The MHRA has issued information on the cardiovascular risk with NSAIDs and in particular diclofenac.
- Low dose ibuprofen is considered to have the most favourable thrombotic cardiovascular safety profile.
- Ibuprofen is commonly used at doses of 1.2g daily or less to minimise side-effects. At this dose ibuprofen has little anti-inflammatory effect. A full anti-inflammatory effect for ibuprofen is achieved with maximum doses (i.e. 2.4g daily).
- For patients with cardiovascular and cerebrovascular disease, current evidence suggests that the risk of heart failure is increased with all NSAIDs. The risk of myocardial infarction is also increased with most NSAIDs, with the possible exception of naproxen. The risk of stroke is increased with most NSAIDs with the possible exception of low dose (<200mg daily) celecoxib.
- Contra-indications to NSAIDS include proven hypersensitivity to aspirin or any NSAID, severe heart failure and active gastrointestinal bleeding. Refer to BNF for contraindications and cautions.
- NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
- Long-term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
- During long term use of NSAIDs ensure appropriate monitoring and regular re-evaluation of clinical need.
- Patients should be advised against excessive exposure to sunlight of areas treated with topical NSAIDs in order to avoid the possibility of photosensitivity.
- Avoid oral NSAIDs if possible in mild/moderate renal impairment, avoid in severe renal impairment.
History Notes
27/10/2022
East Region Formulary content agreed.
30-60mg every 4-6 hours if required; maximum 240mg per day.
30-60mg every 4-6 hours if required; maximum 240mg per day.
1-2 tablets every 4-6 hours; max 8 tablets daily. Dose reduction required in adults weighing less than 50kg.
1-2 tablets every 4-6 hours as required; maximum 8 tablets per day. Dose reduction required in adults weighing less than 50kg.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight adults.
- Some people do not respond to codeine; approximately 10% of patients are unable to convert it to morphine. Consider dihydrocodeine (co-dydramol) as an alternative.
- Consider interval prescribing of analgesics in those with history of self-harm.
- Combining paracetamol +/- opioid +/- NSAID may be considered in mild to moderate pain. Consider prescribing opioid and paracetamol separately rather than the combined products.
- Consider the risk versus the benefits of prescribing more than one opioid.
- Frail, elderly patients are at higher risk on constipation when taking opioids.
- Initiate anti-emetic treatment (metoclopramide, preferred) and laxative treatment, when prescribing regular opioid therapy. Laxatives should be continued, and anti-emetics reviewed after 1-2 weeks.
History Notes
27/10/2022
East Region Formulary content agreed.
There is a lack of evidence for efficacy of opioids in the long-term treatment of chronic pain. Patient safety concerns are due to the risk of serious adverse effects, dependence, diversion, abuse and overdose.
Initially 5-10mg every 4 hours (5mg in elderly patients), adjusted according to response.
Initially 5-10mg every 4 hours (5mg in elderly patients), adjusted according to response.
Initially 5-10mg every 4 hours (5mg in elderly patients), adjusted according to response.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
Every 12 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.
There is a lack of evidence for efficacy of opioids in the long-term treatment of chronic pain. Patient safety concerns are due to the risk of serious adverse effects, dependence, diversion, abuse and overdose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 2.5-5mg every 4-6 hours, dose to be increased if necessary according to severity of pain, some patients may require higher doses than the maximum daily dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Initially 10mg every 12 hours dose to be increased if necessary according to severity of pain, some patients might require higher doses than the maximum daily dose, use 12-hourly modified-release preparations for this dose.
Suitable only for stable, chronic pain where an opioid is indicated. Matrix patches such as Matrifen are preferred and can be cut in half if required.
Consult BNF.
Matrix patches such as Matrifen are preferred.
Consult BNF.
Matrix patches such as Matrifen are preferred.
Prescribing Notes:
- Refer to Lothian Chronic Pain Service ‘Strong Opioids for Chronic Pain: Good Practice Guide for Clinicians’ for advice when considering use of strong opioids. Extensive guidance is also given in the NHS Fife Chronic Non-Malignant Pain Strong Opioid Prescribing Guideline and British Pain Society's Opioids Aware.
- Prescribers should reconsider the individual risks and benefits when increasing the dose above 50mg Oral Morphine Equivalent Dose (OMED) daily and should avoid increasing dosage to above 90 OMED daily or carefully justify a decision to titrate dosage to over 90 OMED daily and should discuss these with the patient. Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm. The risk of harm significantly increases at doses above 120mg OMED daily with no increase in benefit.
- Avoid concomitant use of two or more opioids.
- Opioid equivalent dose information can be found here – Scottish Palliative Care Guidelines - Choosing and Changing Opioids.
- Analgesia for ‘breakthrough pain’ is not recommended in chronic pain because it may increase the risk of tolerance, dependence and dose escalation.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Patients prescribed a strong opioid should have access to regular prophylactic laxatives. A macrogol laxative is recommended.
- Elderly patients are particularly susceptible to side effects of opioids e.g. respiratory depression and constipation.
History Notes
20/11/2023
Addition of MST continus 10mg, 30mg and 60mg tablet formulations, ERWG November 23.
11/05/2023
Shortec liquid 1mg/ml oral solution removed as discontinued.
27/10/2022
East Region Formulary content agreed.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice.
In-patient use only. Tramadol or oral liquid morphine, with or without a NSAID.
Initially 50-100mg, then 50-100mg every 4-6 hours; Usual maximum 400mg/24 hours.
Limit to 3-5 days. Maximum 7 days at discharge.
Initially 5-10mg every 4-6 hours (5mg in elderly patients), adjusted according to response.
Limit supply to 3-5 days only at discharge.
NSAID choices – Ibuprofen, diclofenac sodium or etoricoxib.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Rectally, 75–150 mg daily in divided doses.
Rectally, 75–150 mg daily in divided doses.
Rectally, 75–150 mg daily in divided doses.
Rectally, 75–150 mg daily in divided doses.
120mg daily for 2 days, followed by 90mg daily for 5 days; or 90mg daily for 7 days.
120mg daily for 2 days, followed by 90mg daily for 5 days; or 90mg daily for 7 days.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight adults.
- In acute pain management, it will often be appropriate to initiate treatment with potent opioids plus non-opiates and then gradually wean these as the symptoms improve.
- Avoid concomitant use of two or more opioids.
- Tramadol is considered to be a strong opioid (approximately twice as potent as codeine) and is associated with important safety considerations.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Patients prescribed a strong opioid should have access to regular prophylactic laxatives. Combination of a stimulant and softening laxative is recommended.
- Elderly patients are particularly susceptible to side effects of opioids e.g. respiratory depression and constipation.
History Notes
27/10/2022
East Region Formulary content agreed.
Non-pharmacological measures e.g. reassurance, rest, stress management, ice, massage.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight adults.
- Where possible, non-pharmacological measures (e.g. reassurance, rest, stress management, ice, massage) should be tried before drug therapy.
- If pain persists despite taking paracetamol, then codeine may be added. Codeine is a pro-drug and some patients are poor responders.
- All non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in the first trimester and after the 32nd week of pregnancy. If an NSAID is required in the 2nd trimester, then ibuprofen is preferred.
- Acute pain requires regular treatment with analgesics. There is little data on the safety of tramadol in pregnancy or breastfeeding. For severe acute pain regular paracetamol and dihydrocodeine is used for inpatients.
- Refer to the Bumps (Best Use of Medicines in Pregnancy) website for additional medicines information in pregnancy.
History Notes
27/10/2022
East Region Formulary content agreed.
Any ineffective medicines should be stopped before trying alternative options. Liquid medicine options are only for patients who cannot take solid doses.
Initially 10-25mg daily, a single dose to be taken in the evening, then increased, if tolerated, in steps of 10mg every 3-7 days; usual dose 25-75mg daily, doses above 100mg should be used with caution (doses above 75mg should be used with caution in the elderly and in patients with cardiovascular disease); generally a maximum dose of 50mg would be a clinically appropriate dose.
Initially 10-25mg daily, a single dose to be taken in the evening, then increased, if tolerated, in steps of 10mg every 3-7 days; usual dose 25-75mg daily, doses above 100mg should be used with caution (doses above 75mg should be used with caution in the elderly and in patients with cardiovascular disease); generally a maximum dose of 50mg would be a clinically appropriate dose.
Initially 10-25mg daily, a single dose to be taken in the evening, then increased, if tolerated, in steps of 10mg every 3-7 days; usual dose 25-75mg daily, doses above 100mg should be used with caution (doses above 75mg should be used with caution in the elderly and in patients with cardiovascular disease); generally a maximum dose of 50mg would be a clinically appropriate dose.
Initially 10-25mg daily, a single dose to be taken in the evening, then increased, if tolerated, in steps of 10mg every 3-7 days; usual dose 25-75mg daily, doses above 100mg should be used with caution (doses above 75mg should be used with caution in the elderly and in patients with cardiovascular disease); generally a maximum dose of 50mg would be a clinically appropriate dose.
Initially 10-25mg daily, a single dose to be taken in the evening, then increased, if tolerated, in steps of 10mg every 3-7 days; usual dose 25-75mg daily, doses above 100mg should be used with caution (doses above 75mg should be used with caution in the elderly and in patients with cardiovascular disease); generally a maximum dose of 50mg would be a clinically appropriate dose.
Any ineffective medicines should be stopped before trying alternative options. Liquid medicine options are only for patients who cannot take solid doses.
Starting dose 300mg (reduce to 100mg in elderly / frail adults), titrate dose slowly over a few weeks to an initial target dose of 600mg 3 times a day or as per BNF; reduced maximum dose in renal impairment.
Starting dose 300mg (reduce to 100mg in elderly / frail adults), titrate dose slowly over a few weeks to an initial target dose of 600mg 3 times a day or as per BNF; reduced maximum dose in renal impairment.
Starting dose 300mg (reduce to 100mg in elderly / frail adults), titrate dose slowly over a few weeks to an initial target dose of 600mg 3 times a day or as per BNF; reduced maximum dose in renal impairment.
Any ineffective medicines should be stopped before trying alternative options. Duloxetine is licensed for diabetic peripheral neuropathic pain.
Initiate at 10mg and titrate up to 50mg as a maximum dose.
Initiate at 10mg and titrate up to 50mg as a maximum dose.
Initiate at 30mg and titrate up to 60mg as a maximum dose.
Initiate at 30mg and titrate up to 60mg as a maximum dose.
For post-herpetic neuralgia or diabetic peripheral polyneuropathy. Axsain cream is discontinued choices are under review Sept 2024.
Apply up to 4 times daily, sparingly, not more often than every 4 hours.
Specialist use.
The symptomatic relief of neuropathic pain associated with post-herpetic neuralgia. Any ineffective medicines should be stopped before trying alternative options.
Apply once daily for up to 12 hours, followed by a 12-hour plaster-free period; discontinue if no response after 4 weeks, up to 3 plasters may be used to cover large areas; plasters may be cut.
Prescribing Notes:
- Neuropathic symptoms are characterised by a description of tingling, burning or shooting pains, there may also be allodynia (pain elicited by light touch) and hyperalgesia.
- Patients should be warned of likely side effects and that medication may have to be taken regularly for 4-6 weeks before the full analgesic effect is appreciated. Discontinue treatment if there is no therapeutic benefit after 8 weeks.
- Topical application of menthol and aqueous cream may be helpful (unlicensed use).
Amitriptyline
- In the older patient, amitriptyline is particularly likely to cause postural hypotension, urinary retention, memory problems and constipation.
- Amitriptyline should be titrated, side effects allowing, up to a minimum of 50mg before a drug failure is declared.
- The analgesic effect of amitriptyline is attained at a lower dose (<75mg) than that required to treat depression.
- Amitriptyline should be used with caution in the elderly and be avoided in patients with cognitive impairment. It should also be avoided in patients with cardiac disease, glaucoma or prostatic hypertrophy.
- Laxatives should be considered for patients receiving regular amitriptyline.
Tricyclic antidepressants (TCAs)
- There is evidence that tricyclic antidepressants have analgesic efficacy in a variety of chronic pain syndromes and their use should be considered where conventional analgesics are proving of limited benefit in the chronic situation.
- Tricyclic antidepressants appear to be more effective than other classes of antidepressants. Amitriptyline has been the most studied, but imipramine has similar benefits and may be chosen if amitriptyline is not tolerated.
- Patients should be warned of likely side-effects with TCAs and that unlike conventional analgesics, the TCAs may have to be taken regularly for 4-6 weeks before the full analgesic effect may be apparent.
Gabapentin
- Gabapentin should be titrated, side-effects allowing, up to 1800mg for patients with normal renal function before a drug failure is declared.
- Gabapentin tablets are substantially more expensive than the capsules. When prescribing use the most cost-effective strength and formulation.
- Patients should be warned that, unlike conventional analgesics, gabapentin may have to be taken regularly for 4-6 weeks before the full analgesic effect is appreciated.
- Prescribers should be alert to the abuse potential of gabapentin.
Capsaicin
- Capsaicin is a counterirritant which may cause a transient burning sensation when applied. It should be applied four times daily in all patients. Less burning is reported at this frequency of application.
- Capsaicin works by depleting Substance P in nerve ends. The process can take about 4 weeks. Benefits to patients and need for continuing treatment should be assessed after 6-8 weeks.
- Capsaicin cream is also available as a lower strength – 0.025% which is only licensed for osteoarthritis. This can be found in the Osteoarthritis recommendations in the Musculoskeletal and joint diseases chapter of the formulary.
Lidocaine
- Lidocaine 5% medicated plaster may be used in the treatment of post-herpetic neuralgia where first line therapies are ineffective. Ensure appropriate patient counselling and regular review of efficacy with a plaster-free day each month.
- Different brands of lidocaine patches are available. The most cost-effective brand should be used. There are no clinical differences between the brands. If initiated for inpatient a plan for trial of lidocaine plasters should be documented in the notes and indication and plan included in discharge letter.
- Lidocaine patches may be considered where there is evidence of localised neuropathic pain (particularly for patients who are unable to tolerate adequate oral analgesia) i.e. small area of allodynia or hyperalgesia or pain with burning, shooting qualities.
- Prescription of lidocaine plasters should be on a trial basis (4 weeks and then reviewed) with treatment continuing if there is a response. Ensure appropriate patient counselling and regular review of efficacy with a plaster-free day each month.
- After a minimum trial period of 6-8 weeks at maximum tolerated dose the patient should be reviewed to ascertain benefits produced. Treatment should be withdrawn gradually if ineffective.
History Notes
27/10/2022
East Region Formulary content agreed.
Prescribing Notes:
- The National Palliative Care Guidelines have been developed by a multidisciplinary group of professionals working in the community, hospital and specialist palliative care services throughout Scotland and are used in all Scottish Health Boards.
- The guidelines reflect a consensus of opinion about good practice in the management of adult patients with a life limiting illness.
- Guidelines on individual symptoms are available. Each page has some introductory information, links to related guidelines and web resources. The individual guidelines are in PDF format and can be downloaded or printed off.
History Notes
27/10/2022
East Region Formulary content agreed.
Prescribing Notes:
Acute Pain
- Acute pain relates to pain occurring during tissue damage and repair, for example surgery, trauma or burns. The pain typically improves with tissue healing.
- Long term treatment of acute pain should not be necessary – a step down approach should be used, with regular reassessment of pain so that analgesics are not continued for any longer than is required.
Chronic pain
- Chronic pain is continuous long-term pain of more than 12 weeks that persists beyond the time of expected healing and recovery after surgery or traumatic injury, or the cause of pain may relate to a chronic condition. The cause can be unclear and less responsive to analgesia, as well as being complicated by psychological distress. The approach to management of chronic pain requires a different management strategy from acute pain:
- Selection of treatment options most likely to be effective is informed by careful assessment of pain including type of pain, severity and functional impact.
- Supported self-management and non-pharmacological approaches should be encouraged either alone or in combination with medicines for all patients with pain.
- Healthcare professionals should work with patients to develop their understanding of chronic pain, set realistic expectations (some chronic pain does not respond to analgesics) and agree a plan of treatment.
- Explain risk versus benefit of treatment and make clear that treatment will be reviewed regularly and stopped if not effective.
- See the NHS Lothian intranet leaflet on Persistent Pain: Information for children, young people, their families and carers.
- The WHO ladder was designed to aid cancer pain and is useful in acute pain. It was not designed for chronic pain but may give guidance to aid patients to manage symptoms whilst trying to implement self-help strategies. Refer to Lothian Chronic Pain Service ‘Strong Opioids for Chronic Pain: Good Practice Guide for Clinicians‘ for advice when considering use of strong opioids and the British Pain Society’s Guidance on Good Practice. The objective of treatment in all types of pain, irrespective of origin, is to achieve symptom control, and improve the patient’s quality of life.
- The MHRA advice (July 2013) advises restricted use of codeine for analgesia in children due to reports of morphine toxicity. The Royal College of Paediatrics and Child Health (RCPCH) have issued guidance for the administration of codeine and alternative opioid analgesics in children.
- If any underlying cause of pain has no definitive treatment, then pain control should be established as far as that may be possible using regular, rather than as required analgesia.
- Short acting and parenteral preparations are NOT appropriate for treating chronic pain.
- There is occasionally a role for strong opioids in intractable chronic pain. Morphine is the drug of choice.
- Analgesia for “acute on chronic” pain should be reviewed and stepped down when appropriate.
- Inpatients commenced on new opioid analgesia should have a treatment plan clearly discussed and documented and include in discharge letter at hospital discharge.
Tips on selecting an appropriate analgesic dose for the individual child
- Using a child’s weight is generally the most accurate way of dosing medicines in children. The following table shows age and expected weight ranges. This should be used to ensure the appropriate dose is selected.
- It is advisable to check that the child’s weight is within the expected age range:
- If the patient is underweight use the dose corresponding to the age range for their actual body weight.
- If the patient is overweight use the dose corresponding to the age range for their ideal body weight.
- Examples are given in the NHS Lothian intranet guideline for discharge analgesia and anti-pyrexia management (currently under review 18/08/2023). When approved the document will be available on the Children’s Services Medicine Prescribing and Administration resources on the NHS Lothian intranet.
- Age ranges and expected weights:
- 3-12 months: 5-10kg
- 1-3 years: 10-16kg
- 4-6 years: 17-22kg
- 7-9 years: 23-29kg
- 10-12 years: 30-39kg
- 13-14 years: 40-50kg
- Over 15 years: Above 50kg
History Notes
09/11/2023
East Region Formulary content agreed.
Supported self-management and non-pharmacological approaches should be encouraged either alone or in combination with medicines for all patients with pain.
Prescribing Notes:
- Explain how pain manifests itself and provide information (Tame the Beast video) which helps patients understand why pain persists.
- Movement is an important part of managing chronic pain, and patients should be encouraged to find ways to pace their tasks, activity or exercise to avoid over activity / rest cycles. There are adapted exercise and movement videos on the NHS Fife Pain Management service website.
- Pain may also affect mood and vice-versa. Relaxation, mindfulness and pleasurable activity can help counter distress. See the NHS inform or Breathing Space websites.
- The NHS Lothian Pain Management service has a website with a number of helpful resources, including videos and audio tracks. The Pain Toolkit, Reconnect2Life and Live Well With Pain are also useful patient guides to living with pain.
- TENS therapy is known to provide short term relief in chronic pain.
History Notes
09/11/2023
East Region Formulary content agreed.
Paracetamol with or without ibuprofen.
Intravenous paracetamol is restricted to use for the short-term treatment of moderate pain, when administration by the intravenous route is clinically justified.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Paracetamol with or without diclofenac sodium.
Intravenous paracetamol is restricted to use for the short-term treatment of moderate pain, when administration by the intravenous route is clinically justified.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight children.
Additional prescribing notes
- Patients that require NSAIDs should be prescribed them at the lowest effective dose for the shortest time possible and long term use should be avoided if possible.
- Contra-indications to NSAIDS include proven hypersensitivity to aspirin or any NSAID, severe heart failure and active gastrointestinal bleeding. Refer to BNF for contraindications and cautions.
- NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
- Long-term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
- During long term use of NSAIDs ensure appropriate monitoring and regular re-evaluation of clinical need.
- Avoid oral NSAIDs if possible in mild/moderate renal impairment, avoid in severe renal impairment.
- NSAIDs should be avoided in children suffering from varicella due to a suggested link between NSAIDs and skin and soft tissue complications of varicella.
- Aspirin should not be given to children under 16 years, unless specifically indicated because of the risk of Reye’s syndrome.
History Notes
09/07/2024
Paracetamol 60mg suppositories discontinued
09/11/2023
East Region Formulary content agreed.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- MHRA/CHM advice (July 2013) – Codeine for analgesia: restricted use in children due to reports of morphine toxicity. Codeine should only be used to relieve acute moderate pain in children older than 12 years and only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone.
- Codeine is contra-indicated in all children (under 18 years) who undergo the removal of tonsils or adenoids for the treatment of obstructive sleep apnoea.
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight children.
- Some people do not respond to codeine; approximately 10% of patients are unable to convert it to morphine. Consider dihydrocodeine (co-dydramol) as an alternative.
- Consider interval prescribing of analgesics in those with history of self-harm.
- There is no evidence that of low strength compound analgesics, e.g. co-codamol 8/500 and co-dydramol 10/500 are more effective than paracetamol in relieving acute pain, they produce more side-effects and can complicate treatment of overdosage.
- Combining paracetamol +/- opioid +/- NSAID may be considered in mild to moderate pain. Consider prescribing opioid and paracetamol separately rather than the combined products.
- Consider the risk versus the benefits of prescribing more than one opioid.
- Initiate anti-emetic treatment and laxative treatment, when prescribing regular opioid therapy. Laxatives should be continued, and anti-emetics reviewed after 1-2 weeks.
History Notes
09/11/2023
East Region Formulary content agreed.
Patient safety concerns are due to the risk of serious adverse effects, dependence, diversion, abuse and overdose.
Morphine (dose for severe pain) and paracetamol, with or without NSAID (ibuprofen or diclofenac sodium).
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Intranasal diamorphine for use in emergency department for acute severe nociceptive pain, hospital use only.
For dose follow local emergency department guidelines.
Restricted to use under the management of the paediatric pain team in oncology patients. Used in combination with paracetamol, with or without NSAID (ibuprofen or diclofenac sodium). Refer to individual product information for licence status.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
Prescribing Notes:
- Use the lowest effective dose of morphine for the shortest possible time, review pain management regularly and titrate to effect.
- Seek specialist advice for the management of pain in children and young people if required from the Royal Hospital for Children and Young People multidisciplinary pain service.
- Information should be given to parents and caregivers on recognizing the signs of opioid toxicity with advice to stop giving morphine to the child and seek immediate medical attention if the child shows these signs or symptoms.
- Signs and symptoms of toxicity include: reduced levels of consciousness; somnolence, respiratory depression, ‘pin-point’ pupils, lack of appetite, constipation, nausea and vomiting.
- Laxatives should be co-prescribed with opioids and consideration given to the use of anti-emetics.
- Post-operative patients may be discharged with an appropriate short-term course of morphine, as detailed in the NHS Lothian intranet guideline for discharge analgesia. This should not routinely be continued beyond this period.
- See the NHS Lothian intranet guideline for discharge analgesia and anti-pyrexia management (currently under review 18/08/2023). When approved the document will be available on the Children’s Services Medicine Prescribing and Administration resources on the NHS Lothian intranet.
- Morphine should be given parenterally when possible for acute severe pain. The first dose of intravenous morphine should be given slowly over 5-10minutes, titrated to effect, and respiratory rate monitored.
- In acute pain management, it will often be appropriate to initiate treatment with potent opioids plus non-opiates and then gradually wean these as the symptoms improve.
- Prescribers should reconsider the individual risks and benefits when increasing the opioid dose and should discuss these with the patient. Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm. The risk of harm significantly increases at ceiling doses for age/weight with no increase in benefit.
- Avoid concomitant use of two or more opioids.
- Opioid equivalent dose information can be found here – Scottish Palliative Care Guidelines - Choosing and Changing Opioids.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Zomorph morphine modified release capsules should not be chewed and should normally be swallowed whole. The administration of broken, chewed or crushed capsules or granules may lead to a rapid release and absorption of a potentially fatal dose of morphine.
- For patients who cannot swallow the capsules, their contents can be administered directly in semi-solid food (puree, jam, yoghurt) or via gastric or gastrostomy tubes of a diameter of more than 16 F.G. with an open distal end or lateral pores. It is sufficient to rinse the tube with 30ml to 50ml of water.
History Notes
09/11/2023
East Region Formulary content agreed.
Paracetamol with or without ibuprofen.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Paracetamol with or without diclofenac sodium.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- In chronic non-malignant pain, appropriate patient selection is particularly important due to the risk of dependence and ‘leakage’ of drugs in the community. Specialist referral is essential before commencing opiates for non-malignant pain.
- Chronic pain is not simply a physical problem. It is associated with severe and extensive psychological, social and economic factors. Non-pharmacological treatments are often worthwhile. Consider specialist referral for additional services, e.g. Pain Clinic.
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight children.
Additional prescribing notes:
- Refer to the ‘Treatment of musculoskeletal pain’ pathway for prescribing information relating to NSAIDs.
- Patients that require NSAIDs should be prescribed them at the lowest effective dose for the shortest time possible and long term use should be avoided if possible.
- Contra-indications to NSAIDS include proven hypersensitivity to aspirin or any NSAID, severe heart failure and active gastrointestinal bleeding. Refer to BNF for contraindications and cautions.
- NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
- Long-term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
- During long term use of NSAIDs ensure appropriate monitoring and regular re-evaluation of clinical need.
- Avoid oral NSAIDs if possible in mild/moderate renal impairment, avoid in severe renal impairment.
- NSAIDs should be avoided in children suffering from varicella due to a suggested link between NSAIDs and skin and soft tissue complications of varicella.
Aspirin should not be given to children under 16 years, unless specifically indicated because of the risk of Reye’s syndrome.
History Notes
09/11/2023
East Region Formulary content agreed.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- MHRA/CHM advice (July 2013) – Codeine for analgesia: restricted use in children due to reports of morphine toxicity. Codeine should only be used to relieve acute moderate pain in children older than 12 years and only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone.
- Codeine is contra-indicated in all children (under 18 years) who undergo the removal of tonsils or adenoids for the treatment of obstructive sleep apnoea.
- In chronic non-malignant pain, appropriate patient selection is particularly important due to the risk of dependence and ‘leakage’ of drugs in the community. Specialist referral is essential before commencing opiates for non-malignant pain.
- Chronic pain is not simply a physical problem. It is associated with severe and extensive psychological, social and economic factors. Non-pharmacological treatments are often worthwhile. Consider specialist referral for additional services, e.g. Pain Clinic.
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight children.
- Some people do not respond to codeine; approximately 10% of patients are unable to convert it to morphine. Consider dihydrocodeine (co-dydramol) as an alternative.
- Consider interval prescribing of analgesics in those with history of self-harm.
- There is no evidence that of low strength compound analgesics, e.g. co-codamol 8/500 and co-dydramol 10/500 are more effective than paracetamol in relieving acute pain, they produce more side-effects and can complicate treatment of overdosage.
- Combining paracetamol +/- opioid +/- NSAID may be considered in mild to moderate pain. Consider prescribing opioid and paracetamol separately rather than the combined products.
- Consider the risk versus the benefits of prescribing more than one opioid.
- Initiate anti-emetic treatment and laxative treatment, when prescribing regular opioid therapy. Laxatives should be continued, and anti-emetics reviewed after 1-2 weeks.
History Notes
09/11/2023
East Region Formulary content agreed.
There is a lack of evidence for efficacy of opioids in the long-term treatment of chronic pain. Patient safety concerns are due to the risk of serious adverse effects, dependence, diversion, abuse and overdose.
Morphine (dose for severe pain) and paracetamol, with or without NSAID (ibuprofen or diclofenac sodium).
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- In chronic non-malignant pain, appropriate patient selection is particularly important due to the risk of dependence and ‘leakage’ of drugs in the community. Specialist referral is essential before commencing opiates for non-malignant pain.
- Chronic pain is not simply a physical problem. It is associated with severe and extensive psychological, social and economic factors. Non-pharmacological treatments are often worthwhile. Consider specialist referral for additional services, e.g. Pain Clinic.
- In the management of chronic pain a balance has to be found between the lowest dose of morphine required to improve function versus higher doses required to abolish symptoms. Treatment dose and the risk of dependence should be discussed with the child and carer. The initial dose is determined by the age of the child.
- Refer to Lothian Chronic Pain Service ‘Strong Opioids for Chronic Pain: Good Practice Guide for Clinicians’ for advice when considering use of strong opioids. Extensive guidance is also given in the NHS Fife Chronic Non-Malignant Pain Strong Opioid Prescribing Guideline and British Pain Society's Opioids Aware.
- Use the lowest effective dose of morphine for the shortest possible time, review pain management regularly and titrate to effect.
- Seek specialist advice for the management of pain in children and young people if required from the Royal Hospital for Children and Young People multidisciplinary pain service.
- Information should be given to parents and caregivers on recognizing the signs of opioid toxicity with advice to stop giving morphine to the child and seek immediate medical attention if the child shows these signs or symptoms.
- Signs and symptoms of toxicity include: reduced levels of consciousness; somnolence, respiratory depression, ‘pin-point’ pupils, lack of appetite, constipation, nausea and vomiting.
- Laxatives should be co-prescribed with opioids and consideration given to the use of anti-emetics.
- Prescribers should reconsider the individual risks and benefits when increasing the opioid dose and should discuss these with the patient. Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm. The risk of harm significantly increases at ceiling doses for age/weight with no increase in benefit.
- Avoid concomitant use of two or more opioids.
- Opioid equivalent dose information can be found here – Scottish Palliative Care Guidelines - Choosing and Changing Opioids.
- Analgesia for ‘breakthrough pain’ is not recommended in chronic pain because it may increase the risk of tolerance, dependence and dose escalation.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Zomorph morphine modified release capsules should not be chewed and should normally be swallowed whole. The administration of broken, chewed or crushed capsules or granules may lead to a rapid release and absorption of a potentially fatal dose of morphine.
- For patients who cannot swallow the capsules, their contents can be administered directly in semi-solid food (puree, jam, yoghurt) or via gastric or gastrostomy tubes of a diameter of more than 16 F.G. with an open distal end or lateral pores. It is sufficient to rinse the tube with 30ml to 50ml of water.
History Notes
09/11/2023
East Region Formulary content agreed.
Intravenous paracetamol is restricted to use for the short-term treatment of moderate pain, when administration by the intravenous route is clinically justified.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
In-patient use only. Tramadol or oral liquid morphine, with or without a NSAID.
Limit supply at discharge.
For dose, refer to BNF for Children.
Limit supply at discharge.
For dose, refer to BNF for Children.
NSAID choices – Ibuprofen or diclofenac sodium.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Restricted to use in the acute post operative setting in RHCYP under the management of the paediatric pain team. Used in combination with paracetamol, with or without NSAID (ibuprofen or diclofenac sodium).
As per specialist.
Restricted to use under the management of the paediatric pain team in the acute post operative setting (RHCYP). Used in combination with paracetamol, with or without NSAID (ibuprofen or diclofenac sodium). Refer to individual product information for licence status.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight children.
- In acute pain management, it will often be appropriate to initiate treatment with potent opioids plus non-opiates and then gradually wean these as the symptoms improve.
- Post-operative patients may be discharged with an appropriate short term course of morphine, as detailed in the NHS Lothian intranet guideline for discharge analgesia. This should not routinely be continued beyond this period.
- See the NHS Lothian intranet guideline for discharge analgesia and anti-pyrexia management (currently under review 18/08/2023). When approved the document will be available on the Children’s Services Medicine Prescribing and Administration resources on the NHS Lothian intranet.
- Avoid concomitant use of two or more opioids.
- Tramadol is considered to be a strong opioid (approximately twice as potent as codeine) and is associated with important safety considerations.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Patients prescribed a strong opioid should have access to regular prophylactic laxatives. Combination of a stimulant and softening laxative is recommended.
History Notes
09/07/2024
Paracetamol 60mg suppositories discontinued
09/11/2023
East Region Formulary content agreed.
Individual patient factors and side-effect profile should be considered when selecting a treatment for neuropathic pain. Topical application of menthol and aqueous cream may be helpful.
Apply 1-2 times a day.
Any ineffective medicines should be stopped before trying alternative options. Liquid medicine options are only for patients who cannot take solid doses.
It is advisable to obtain an ECG prior to commencing amitriptyline.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Any ineffective medicines should be stopped before trying alternative options. Liquid medicine options are only for patients who cannot take solid doses.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
Any ineffective medicines should be stopped before trying alternative options.
As per specialist for chronic pain, to be worn for 12 hours, then removed for 12 hours.
Prescribing Notes:
- Arrangements should be made for early review of side-effects and efficacy. Patients should be warned of likely side-effects and that, unlike conventional analgesics, medication may have to be taken regularly for 4-6 weeks before the full analgesic effect is appreciated.
- In patients who are sensitive to sedative side-effects gabapentin doses may be titrated in smaller increments as appropriate and/or at longer time intervals e.g. weekly rather than daily.
- There is a possible increased risk of suicidal ideation and behaviour in patients treated with gabapentin, therefore patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.
- It is common practice to round the gabapentin dose to the nearest capsule strength.
- Gabapentin capsules may be opened and mixed with a strong-tasting liquid to mask the bitter taste i.e. blackcurrant, immediately before administration.
- Gabapentin oral solution and tablets are considerably more expensive than the capsules, select the most cost-effective strength and formulation.
- Note that the levels of some excipients may exceed the recommended WHO daily intake limits if high doses of gabapentin oral solution (Rosemont brand) are given to adolescents with low body-weight - consult product literature.
- There is a significant abuse potential and street value for gabapentin, and it may be at risk of diversion.
- The following Medicines for Children leaflets provide useful information for patients and carers on the use of amitryptiline or gabapentin for neuropathic pain.
- Neuropathic symptoms are characterised by a description of tingling, burning or shooting pains, there may also be allodynia (pain elicited by light touch) and hyperalgesia.
- Patients should be warned of likely side effects and that medication may have to be taken regularly for 4-6 weeks before the full analgesic effect is appreciated. Discontinue treatment if there is no therapeutic benefit after 8 weeks.
- Topical application of menthol and aqueous cream may be helpful (unlicensed use).
Amitriptyline
- Amitriptyline should be titrated, side effects allowing, up to the recommended dose for neuropathic pain before a drug failure is declared.
- The analgesic effect of amitriptyline is attained at a lower dose than that required to treat depression.
- Laxatives should be considered for patients receiving regular amitriptyline.
Tricyclic antidepressants (TCAs)
- There is evidence that tricyclic antidepressants have analgesic efficacy in a variety of chronic pain syndromes and their use should be considered where conventional analgesics are proving of limited benefit in the chronic situation.
- Tricyclic antidepressants appear to be more effective than other classes of antidepressants.
- Patients should be warned of likely side-effects with TCAs and that unlike conventional analgesics, the TCAs may have to be taken regularly for 4-6 weeks before the full analgesic effect may be apparent.
Gabapentin
- Gabapentin should be titrated, side-effects allowing, up to the recommended dose for neuropathic pain for patients with normal renal function before a drug failure is declared.
- Gabapentin tablets are substantially more expensive than the capsules. When prescribing use the most cost-effective strength and formulation.
- Patients should be warned that, unlike conventional analgesics, gabapentin may have to be taken regularly for 4-6 weeks before the full analgesic effect is appreciated.
- Prescribers should be alert to the abuse potential of gabapentin.
Capsaicin
- Capsaicin is a counterirritant which may cause a transient burning sensation when applied. It should be applied four times daily in all patients. Less burning is reported at this frequency of application.
- Capsaicin works by depleting Substance P in nerve ends. The process can take about 4 weeks. Benefits to patients and need for continuing treatment should be assessed after 6-8 weeks.
Lidocaine
- Ensure appropriate patient counselling and regular review of efficacy with a plaster-free day each month.
- Different brands of lidocaine patches are available. The most cost-effective brand should be used. There are no clinical differences between the brands. If initiated for inpatient a plan for trial of lidocaine plasters should be documented in the notes and indication and plan included in discharge letter.
- Lidocaine patches may be considered where there is evidence of localised neuropathic pain (particularly for patients who are unable to tolerate adequate oral analgesia) i.e. small area of allodynia or hyperalgesia or pain with burning, shooting qualities.
- Prescription of lidocaine plasters should be on a trial basis (4 weeks and then reviewed) with treatment continuing if there is a response. Ensure appropriate patient counselling and regular review of efficacy with a plaster-free day each month.
- After a minimum trial period of 6-8 weeks at maximum tolerated dose, the patient should be reviewed to ascertain benefits produced. Treatment should be withdrawn gradually if ineffective.
History Notes
09/11/2023
East Region Formulary content agreed.
Sugar-free paracetamol suspension products are preferred, the sugar-containing product may be supplied as an alternative during supply shortage
Dose according to age and product licence.
Dose according to age and product licence.
Dose according to age and product licence.
Dose according to age and product licence.
Dose according to age and product licence.
Dose according to age and product licence.
Dose according to age and product licence.
Dose according to age and product licence.
Prescribing Notes:
- Children under 6 months should not be given paracetamol and ibuprofen concomitantly, without prior medical assessment.
- If symptoms suggest fever in a child refer to NICE Guideline NG143 which contains a traffic light system for symptoms and referral guidance.
- Aspirin should not be given to children under 16 because of the risk of Reye's syndrome.
- Paracetamol is generally regarded as being safe for use in pregnancy.
- There is significant potential for accidental overdose. Prescribers should be aware that patients may be taking other analgesic preparations (prescribed, OTC or ‘borrowed‘).
- Paracetamol is preferable to ibuprofen in the elderly.
- Paracetamol soluble tablets are available for patients who cannot swallow standard tablets. Ensure salt intake is considered when using soluble preparation.
- Paracetamol or ibuprofen suspension are only licensed for use in post-immunisation pyrexia in infants 2 months and older.
- Paracetamol or ibuprofen should not be given pre-immunisation. Post-immunisation only if the infant develops pyrexia and seems distressed.
- Avoid NSAIDs including ibuprofen in patients with chickenpox or shingles.
Examples of Counselling Points
Rest is essential to allow the injury to recover.
For sprains and strains, cold packs should be applied to reduce swelling and bruising for the first 72 hours. After this heat therapy should be applied to improve healing.
The area should be elevated if possible to remove fluid from area of injury.
When to advise patient to contact GP
Child under 6 months not improving on paracetamol alone.
Headache in children under 12 years old.
Headache associated with injury/trauma.
Severe headache of more than 4 hours duration.
Severe occipital headache (across the back of the head).
Headache which is worse in the morning then improves.
Suspected adverse drug reaction.
Associated drowsiness, visual disturbances or vomiting.
Neck stiffness.
History Notes
28/09/2023
Paracetamol 120mg/5ml oral suspension paediatric added.
07/01/2022
Added prescribing note to avoid NSAIDs in patients with chickenpox or shingles.
17/12/2021
Paracetamol 500mg soluble tablets added and ibuprofen added as second line to align to 01/10/2021 NHS Pharmacy First Scotland - Approved List of Products.
27/10/2020
Content migrated from ‘East Region Formulary: Pharmacy First - supporting minor ailments’ document.