4.5 Pain

4.5 Pain

• Analgesics see paediatric pain service acute pain management guidelines

Non-opioid Analgesics

Recommended:

Paracetamol (TLS Green)

• Paracetamol has no demonstrable anti-inflammatory effect. If the pain has an inflammatory component then a "non-steroidal" should be considered
• 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
• Effervescent analgesics are not generally recommended because they are expensive and contain large amounts of sodium. Use is restricted to patients unable to swallow tablets or in the treatment of migraine attacks

Opioid

• Caution - opioids accumulate in renal impairment resulting in increased and prolonged effect.When opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the healthcare practitioner concerned, or their clinical supervisor, should:
• In general, the use of concomitant opioids should be avoided
• 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

Morphine (TLS Amber Specialist Recommended)*

• Parenteral, oral as immediate release preparation i.e. morphine liquid, Actimorph® (morphine sulfate orodispersible tablets) or Sevredol^® tablet, or modified release i.e. Morphine modified-release capsules Zomorph^®
• *Primary care prescribers may initiate morphine preparations where there is an urgent clinical need and provide a short supply whilst awaiting specialist advice / investigation.

Tramadol (TLS Amber Specialist Recommended) Age 12-17

• Tramadol should be recommended as the preferred analgesic if an opiate is required, and junior medical staff will not be permitted to prescribe codeine for patients aged 12 years or younger
• For use in other age groups see local guidance

Alternatives:

Codeine (TLS Blue)

• 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. Codeine is contraindicated in all children younger than 18 years who undergo procedures for obstructive sleep apnoea
• MHRA warning Codeine for analgesia: restricted use in children because of reports of morphine toxicity

Dihydrocodeine (oral) (TLS Blue)

Oxycodone (oral) (TLS Blue)

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

Tapentadol (20mg/mL oral solution) (TLS Red)

• For the treatment of acute pain now adequately managed by simple analgesia, only to be used in the inpatient

Pethidine (TLS Red)

• Parental only and in secondary care only (TLS Red)
• Pethidine is unsuitable for chronic pain due to short duration of action. The toxic metabolite nor-pethidine accumulates with repeated use and in renal impairment

Oxycodone (PCA) (TLS Red)

• Patients intolerant of morphine only

Diamorphine (TLS Red)

• Intranasal use as per internal UHBW policy

Fentanyl injection (TLS Blue)

Specific indications:

Fentanyl sublingual tablets (TLS Blue)

• Breakthrough pain in patients receiving opioid therapy for chronic cancer pain

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
• N.B. there are three different brands of patches Butrans^® (changed weekly), Hapoctasin^® (changed no later than every 72 hours) and Transtec^® (changed no later than every 96 hours)

4.5.1 Migraine

Simple analgesia (e.g. paracetamol) is often effective.

Dispersible or effervescent preparations are preferred because peristalsis is often reduced during migraine attacks.

Concomitant anti-emetics may be required see Antihistamines 

5HT₁ Receptor Agonists

• If one 5HT₁ agonist is ineffective patients may respond to another
• 5HT₁ agonists should not be used for prophylaxis and they are contraindicated in ischaemic heart disease, previous MI, coronary vasospasm (including Prinzmetal's angina), and uncontrolled hypertension
• Use of 5HT₁ agonists with ergotamine should be avoided. Refer to BNF for guidance on switching from 5HT₁ agonists to ergotamine (and vice versa)

Sumatriptan (TLS Green)

• For children >6 years

Sumatriptan (subcutaneous injection) (TLS Amber)

Zolmitriptan (TLS Amber)

Prophylaxis of Migraine

• Acute treatments are still required
• Prophylaxis only reduces the severity and frequency of attacks

Pizotifen (TLS Green)

Propranolol (TLS Amber)

Lamotrigine (TLS Amber)

Topiramate (TLS Amber 3 months)

• Click here for Topiramate shared care protocol

• 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).

Botulinum toxin type A (Botox^®) (TLS Red)

Alternatives:

Amitriptyline (TLS Amber)

Flunarizine (TLS Red)

4.5.2 Neuropathic pain

Gabapentin (TLS Amber)

Alternatives:

Nortriptyline (TLS Amber)

Corticosteroids (TLS Blue)

• Compression neuropathy

Ketamine (TLS Red)

• Palliative care and pain team only

Clonazepam (TLS Blue)

• Palliative care only

Specific indications:

Tramadol (TLS Amber)

Carbamazepine (TLS Amber)

Pregabalin (TLS Amber)

Amitriptyline (TLS Amber)

• See NICE CG173