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BNSSG Adult Joint Formulary

16.1 Pain due to cancer in adults- Palliative Care

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Last edited: 19-06-2025

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

The WHO analgesic ladder

Step 1 - Mild

Non-opioid + / - adjuvant

Paracetamol

and NSAIDs

Step 2 - Moderate

Opioid for mild to moderate pain + paracetamol + / - adjuvant

Codeine

(as co-codamol 30/500)

Step 3 - Severe

Opioid for moderate to severe pain + / - non-opioid + / - adjuvant

Morphine for oral use

Morphine/Diamorphine for parenteral use

Analgesia should be titrated in each patient according to response and side effects
Analgesia for breakthrough pain (i.e. prn doses) should alwaysbe available
Non-opioids can be continued and combined with step 2 and step 3 analgesics if they are beneficial and tolerated
Check renal function before starting NSAID and/or opioid and continue to monitor
Patients with significant renal or hepatic impairment require special consideration with regard to choice and dose of opioid
Consider the type of pain being treated e.g. bone pain may be NSAID sensitive. Prescribers may move from step 1 - step 3 in these patients if benefits outweigh risks.
When using opioids, consider if eGFR<30mL/min/1.73 m², seek specialist palliative care advice

Non-opioid

Paracetamol - oral preparations (TLS Green)

Ibuprofen (TLS Green)

Naproxen (TLS Green)

Diclofenac (TLS Blue)

For other non-steroidal anti-inflammatory drug options, see Chapter 10.4 for formulary options.

Duloxetine (TLS Blue)

As per formulary on chapter 4.5

Paracetamol (intravenous & rectal) (TLS Blue)

Ketorolac subcutaneous injection (TLS Amber specialist recommended)

Opioids for mild to moderate pain

Codeine – ideally as co-codamol 30/500 (TLS Green)

If not tolerated in this formulation, or to allow individual drug dose changes, can be prescribed as separate paracetamol and codeine

Tramadol (TLS Blue)

Opioids for moderate to severe pain

NICE CG140 Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults

Morphine (oral) (TLS Green)

For information on formulations, see chapter 4.5

Morphine sulphate (parenteral) (TLS Green)

Oxycodone (TLS Blue)

For information on formulations, see chapter 4.5
Oxyact^® brand - non-formulary

Diamorphine injection (TLS Amber Specialist Recommended)

Transdermal patches

For guidance on using transdermal patches safely in healthcare settings, see SPS

Fentanyl transdermal patches (TLS Blue)

Buprenorphine transdermal patches (TLS Blue)

Generic patches	Dosage Frequency	Recommended brand for prescribing
Buprenorphine 5, 10 and 20micrograms/hr	Apply ONCE a WEEK	Butec^®
Buprenorphine 15micrograms/hr	Apply ONCE a WEEK	Butrans^®
Buprenorphine 35, 52.5, 70micrograms/hr	Apply EVERY FOUR DAYS	Bupeaze^® or Transtec^®
Buprenorphine 35, 52.5, 70micrograms/hr	Apply EVERY THREE DAYS	Hapoctasin^®

Fentanyl subcutaneous injection (TLS Blue)

Hydromorphone (TLS Blue)

For breakthrough/incident pain

Fentanyl sublingual tablets (Abstral^®) (TLS Amber Specialist Recommended)

Alfentanil injection 500micrograms/mL, 5mg/mL (TLS Amber Specialist Recommended)

For subcutaneous use with patients with severe renal impairment or morphine intolerance
The high strength product should only be used, with caution, if volume restriction prevents use of the lower strength

Oxycodone injection 50mg/mL for subcutaneous use (TLS Blue)

Hydromorphone injection (TLS Amber Specialist Recommended)

Available on a named patient basis
For complex pain

Methadone (TLS Amber Specialist Recommended)

Adjuvant Medication for Treating Neuropathic Pain

NICE CG173 Neuropathic pain – pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings

Amitriptyline (TLS Green)

Gabapentin (capsules) (TLS Green)

Pregabalin (TLS Blue)

Caution – Use Pregabalin with caution in women of childbearing age. Effective contraception should be used during treatment and avoid use in pregnancy unless clearly necessary – see MHRA Guidance (April 2022)

Clonazepam tablets / injection for subcutaneous use (TLS Blue)

Note: Clonazepam injection is unlicensed

Dexamethasone (TLS Blue)

Ketamine (TLS Red)

Lidocaine patches (TLS Amber Specialist Recommended)

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