4.5 Pain

Controlled drugs incidents should now be reported to the NHS England Controlled Drugs Accountable Officer via their online reporting system www.cdreporting.co.uk. This NHS website is the preferred method to report controlled drug related incidents. You need to set up an account before you use it but you can register on the site. The CD team can always be contacted at england.southwestcontrolleddrugs@nhs.net or by telephone (0113 825 0168) for advice, but for incident reports please use www.cdreporting.co.uk

Analgesics

For NSAIDs see Chapter 10

Also refer to Chapter 16 - Palliative Care

Please see the Central Nervous System Guidelines page for:

• BNSSG Treatment of Adult Chronic Pain
• Chronic Pain Self Help Resources Summary
• Opioid Conversion Table
• BNSSG Reducing and Stopping Opioids, Information for Patients leaflet
• Top Tips for Prescribing Opioids In Older People Living With Frailty

The Faculty of Pain Medicine has produced patient information leaflets on medications and interventions commonly used to treat persistent pain. Click here for patient information leaflets currently available - Faculty of Pain Medicine Patient Information Leaflets

Recommended:

Paracetamol (TLS Green)

• Paracetamol is available as an IV formulation for the urgent treatment of moderate pain or fever and / or where other routes are not available on initiation by an anaesthetist. Treatment should revert to oral as soon as clinically appropriate

BNSSG Paracetamol Dosing Guidelines In Adult Patients

Opioids

In general, the use of concomitant opioids should be avoided.

When opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the healthcare practitioner concerned, or their clinical supervisor, should:

• Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done for example through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records
• Ensure where a dose increase is intended, that the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than 50% higher than the previous dose).
• Ensure they are familiar with the following characteristics of that medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side effects

The Health Innovation West of England have created a resource library to provide support materials in one location for people living with pain and professionals supporting people living with pain.

for Healthcare Professionals:

https://www.healthinnowest.net/improving-chronic-pain-management-by-reducing-harm-from-opioids-resources/#Professionals

for patients:

https://www.healthinnowest.net/improving-chronic-pain-management-by-reducing-harm-from-opioids-resources/#People

Recommended:

Codeine (TLS Green)

• Click here for the MHRA advice for codeine for cough and cold restricted use in children.

Morphine (Parenteral or oral):

Morphine sulfate (oral solution) (TLS Green)

Morphine sulfate (parenteral) (TLS Green)

Sevredol^® tablets (TLS Blue)

Actimorph^® orodispersible tablets (TLS Blue)

• As an alternative for patients not able to tolerate oral morphine sulfate solution, or if this is not suitable due to safety concerns.

When switching between brands, patients should be counselled that they may experience changes in symptom control and it is recommended the patient contacts the prescriber if this happens.

Zomorph^® Morphine modified release capsules (TLS Green)

For use of morphine modified release tablets in refractory chronic cough see 3.4 cough and congestion

Alternatives: 

Diamorphine (TLS Blue)

Dihydrocodeine (TLS Blue)

Tramadol (TLS Blue)

• May be considered if full dose simple analgesia has proven ineffective

Oxycodone (oral) (TLS Blue)

• Modified release - use tablets
• Immediate release - use capsules or oral solution
• Oxyact brand - non-formulary

Oxycodone (PCA) (TLS Red)

• Patients intolerant of morphine only

Pethidine (TLS Blue)

• Parenteral only and in secondary care only

Specific indications:

Fentanyl injection (TLS Blue)

• Renal impairment / intolerable side-effects from other opioids

Fentanyl patches (TLS Blue)

• Renal impairment / pain team / palliative care

Fentanyl lozenges (TLS Blue)

• Specialist advice

Fentanyl sublingual tablets (TLS Blue)

• Breakthrough pain in patients receiving opioid therapy for chronic cancer pain
• Within the adult burns unit at NBT, in-procedure analgesia in patients who will have already received their usual analgesia (usually Oramorph^® or oxycodone) prior to the procedure

Alfentanil injection (TLS Red)

• Renal impairment / intolerable side-effects from other opioids

Alfentanil intranasal (TLS Red)

• Palliative care renal patients (Southmead hospital only)

Hydromorphone (TLS Blue)

• Renal impairment / palliative care

Methadone (TLS Blue)

• Pain team / palliative care

Buprenorphine patches (TLS Blue)

• On the advice of the pain team/palliative care when a parenteral drug is indicated, but syringe driver may not be appropriate and lowest strength fentanyl patch is too potent or for short-term use in renal impairment

Tapentadol modified-release (TLS amber 3 months) (SCP click here)

• Should be reserved for the management of severe chronic pain in adults who cannot tolerate other strong opioids e.g. morphine sulphate or oxycodone, on recommendation of the pain team or palliative care

Tapentadol immediate-release (TLS Red)

• Should be reserved for the management of severe chronic pain in adults who cannot tolerate other strong opioids e.g. morphine sulphate or oxycodone, on recommendation of the pain team or palliative care. Off label use
• For the management of moderate to severe acute pain (including severe acute on chronic pain) in adults where conventional opioids are unsuitable, under the acute pain service for a five day duration

4.5.1 Migraine

NICE guideline 150. Headaches: Diagnosis and management of headaches in young people and adults

Migraine Clinical Knowledge Summary May 2014

Migraine Treatment

Antihistamines

Pizotifen (TLS Blue)

5HT₁ Receptor Agonists

If simple analgesia fails:

Recommended: (TLS Green)

Sumatriptan

Alternatives: (TLS Blue)

Almotriptan

Naratriptan

Rizatriptan

Calcitonin gene-related peptide receptor antagonist

Rimegepant (TLS Blue)

• NICE TA919 Rimegepant for treating migraine

Migraine Prophylaxis

NICE CG 150 Headaches in over 12s

Migraine Clinical Knowledge Summary May 2014

Recommended:

Propranolol (TLS Green)

Alternatives:

Candesartan (TLS Blue)

Amitriptyline (TLS Blue)

Topiramate (TLS Blue)

• Topiramate should not be used:

  • in pregnancy for prophylaxis of migraine

  • in pregnancy for epilepsy unless there is no other suitable treatment

  • in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled.

  The use of topiramate during pregnancy is associated with significant harm to the unborn child. Harms included a higher risk of congenital malformation, low birth weight and a potential increased risk of intellectual disability, autistic spectrum disorder and attention deficit hyperactivity disorder in children of mothers taking topiramate during pregnancy - see MHRA Drug Safety Update for information (June 2024).

Lamotrigine (TLS Blue)

Sodium valproate (TLS Amber 3 months)

• Do not use valproate for migraine prophylaxis for new patients. 
• Joint Formulary decision on 29th August 2023 to make sodium valproate non-formulary for migraine prophylaxis - use for migraine is no longer recommended. This recommendation is not intended to affect treatment that was started prior to this date. Patients currently prescribed valproate for migraine may continue without change until they and their NHS clinician consider it appropriate to stop. Clinicians must review use of valproate at the next routine review to explore alternative treatment options.
• Not for use for migraine in women of childbearing potential - see MHRA Drug Safety Update
• SCP

Methysergide - Consultant Neurologist only (TLS Red)

Atogepant (TLS Amber Specialist Initiated)

• NICE TA973 Atogepant for preventing migraine
• See BNSSG Migraine Prevention Pathway

Botulinum toxin type A (TLS Red)

• Only for use in accordance with the NICE guidance TA260 for the prevention of headaches in adults with chronic migraine

Eptinezumab (TLS Red)

• NICE TA871 Eptinezumab for preventing migraine

Erenumab (TLS Red)

• NICE TA682 Erenumab for preventing migraine

Fremanezumab (TLS Red)

• NICE TA764 Fremanezumab for preventing migraine

Galcanezumab (TLS Red)

• NICE TA659 Galcanezumab for preventing migraine

Rimegepant (TLS Amber Specialist Initiated)

• NICE TA906 Rimegepant for preventing migraine
• See BNSSG Migraine Prevention Pathway

4.5.2 Cluster Headache

Sumatriptan (subcutaneous injection) (TLS Green)

• For the treatment of cluster headache

Verapamil (immediate release tablets) (TLS Amber 3 months)

• Cluster headache for patients <75 years old without a history of hypertension. See shared care protocol

Verapamil (immediate release tablets) (TLS Red)

• Cluster headache for patients ≥75 years old or have longstanding hypertension
• ECG monitoring required for this higher risk cohort of patients i.e. repeat ECG 10 days after each dose titration. Repeat ECGs required on completing a course and on restarting subsequent courses of verapamil immediate release.

4.5.3 Neuropathic Pain

See NICE clinical guideline 173

Recommended: (TLS Green)

Amitriptyline

Gabapentin

Alternatives: (TLS Blue)

Pregabalin

• 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 Drug Safety Update (April 2022)

Nortriptyline

Carbamazepine

Sodium valproate (TLS Amber 3 months)

• Do not use valproate for neuropathic pain for new patients. 
• Joint Formulary decision on 27th March 2024 to make sodium valproate non-formulary for neuropathic pain - use is no longer recommended. This recommendation is not intended to affect treatment that was started prior to this date. Patients currently prescribed valproate for neuropathic pain may continue without change until they and their NHS clinician consider it appropriate to stop. Clinicians must review use of valproate at the next routine review to explore alternative treatment options.
• Not for use for neuropathic pain in women of childbearing potential - see MHRA Drug Safety Update
• SCP

Tramadol

Duloxetine

• For treatment resistant neuropathic pain as per BNSSG treatment pathway or as first line option for patients with neuropathic pain who are also prescribed methadone or buprenorphine

Specific indications:

Duloxetine (TLS Blue)

• Diabetic neuropathy

Corticosteroids (TLS Blue)

• Compression neuropathy

Axsain^® cream (TLS Blue)

• Diabetic neuropathy

Dosulepin (TLS Blue)

• Non-formulary from April 2018. This recommendation is not intended to affect treatment with dosulepin that was started prior to this date. People having treatment with dosulepin may continue without change until they and their NHS clinician consider it appropriate to stop
• Specialist initiation only
• Low value medicine that should not routinely prescribed in primary care as per NHS guidelines

Clonazepam (TLS Blue)

• Palliative care only

Ketamine  (TLS Red)

• Palliative care and pain team only

Lacosamide (TLS Amber 3 months)  (SCP click here)

• UHB only. Diabetic neuropathic pain where other treatments have failed (unlicensed)

Botulinum toxin type A (TLS Red)

• For use in trigeminal neuralgia where pharmacological treatments have failed. See Botulinum Toxin A Pathways page for more information
• For use in bruxism where pharmacological treatments have failed. See Botulinum Toxin A Pathways page for more information

Lidocaine patch (TLS Red)

• For new patients only- for the treatment of localised, neuropathic pain after other treatments have been tried. Existing patients prescribed lidocaine patches for this indication by Primary Care are to remain Primary Care responsibility
• TLS Red status to be reviewed in 12 months' time pending evaluation and development of treatment pathway (April 2021)
• Lidocaine 5% plasters are low value medicines that should not be routinely prescribed in primary care as per NHSE guidelines

 Lidocaine patch (TLS Red)

• For patients with isolated rib fractures under the care of the pain team

Lidocaine patch (TLS blue)

• For post herpetic neuralgia

Lidocaine patch (TLS Amber Specialist Recommended)

• For palliative care, on recommendation of palliative care specialist team only, see Chapter 16.1 Palliative Care

Capsaicin

Capsaicin cream (TLS Green)

Capsaicin patch (Qutenza^®)

Specific Indication: (TLS Red)

• For the treatment of peripheral neuropathic pain in non-diabetic patients
• For pain relief in diabetic neuropathy for use in pain clinic only

Doxepin 5% cream (TLS Amber Specialist Recommended)

• For use in localised neuropathic pain, specifically notalgia paraesthetica, brachioradial pruritus, and post-herpetic neuralgia. 
• Use in diabetic neuropathy is not recommended due to lack of an evidence base
• For use in pruritis see 13.6 for traffic light status and further information. 

4.5.4 Neuropathy

Polyneuropathy

Vutrisiran (TLS Red)

• NICE TA868 Vutrisiran for treating hereditary transthyretin-related amyloidosis

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