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BNSSG Adult Joint Formulary
16.1 Pain due to cancer in adults- Palliative Care
Last edited: 22-05-2025
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)
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 nasal / buccal / sublingual spray (TLS Amber Specialist Recommended)
- Made on named patient basis by Torbay pharmaceuticals in patients with severe renal impairment or morphine intolerance
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)
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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