Leeds Analgesia Pathway for Chronic Pain

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1. Background information / scope of pathway

Quick info:
This guidance is intended to aid high quality, cost-effective care and improve clarity of understanding between primary and secondary care. It is recommended for use in primary care for Leeds patients age 18 years and over.

Recommendations assume the absence of established contraindications or cautions and that  other established interventions are also considered. Refer to the BNF, relevant NICE guidance and summaries of product characteristics for more information.  Legal and clinical responsibility lies with the prescriber.

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2.  Information Resources for Patients and Carers

Quick info:
Patient Information
Please see attached patient information leaflet on Opioids for persistent pain.

Pregabalin Titration Chart
Gabapentin Titration Chart
Amitryptilline Titration Chart

Kirklees Persistent Pain Patient Information:

Please see attached patient information leaflet on Opioids for persistent pain.
Please see attached patient information leaflet on Amitriptyline
Gabapentin (Slow dose increase)
Gabapentin (Fast dose increase)
Nortriptyline Patient Information Leaflet

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3. Development and updates to this pathway

Quick info:
Approved Feb 2013 by Leeds APC
Review date 28.2.2016 Written by Sally Bower
Commented on by David Abbott, Steve Brennan, Dudley Bush, Heather Edmonds, Lis Farqhaur, Tony Jamieson, Helen Liddell, Kathryn Marczewski, Jane Otter, Elizabeth Scott, Carey Tebby.
Updated and approved October 2014 Leeds APC

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4.  Further Resources

Quick info:
Dose Equivalence Table
Opioids for Persistent Pain - Summary of guidance on good practice from the British Pain Society
Opioids for Persistent Pain: Good practice (full guidance)
High dose morphine and diamorphine injections - patient safety resource
National Patient Safety Agency - Reducing dosing errors with opioid medicines

RCGP Substance Misuse and Associated Health - Fact sheets for Primary and Community care practitioners:
Fact sheet 1 - The Problem
Fact sheet 2 - Prevention
Fact sheet 3 - Misuse Identification
Fact sheet 4 - Treatment

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5. Review of Medication Following Patient Completed Pain Assessment

Quick info:
Persistent (chronic) Pain is described as pain persisting more than six months or persistent pain irrespective of the number of sites/s
Persistent pain is different to short acting 'acute' pain and often doesn't respond to usual treatments.
This is because the problem is with the pain system itself, rather than being related to a specific problem in the body.

Ensure steps in the persistent (chronic) pain pathway have been followed. Check OTC medicine use and from any other sources.
Only add analgesics to repeat prescription when pain control is stabilised and need is long term.  Prescribe analgesia regularly, not when required.
If a patient is unable to self administer, review frequency of analgesia.

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6.  Assessment of Type of Pain

Quick info:
Assess patient to establish type of pain, either nociceptive or neuropathic.
Neuropathic pain is described as tingling, pricking, cold, burning, numb, stabbing, shooting or abnormal sensation.
Validated assessment tools are available such as the LANSS Pain Scale  (Leeds assessment of neuropathic symptoms and signs).
Please see attached the original paper by Michael Bennett from Pain92 (2001) 147-157.

This paper has been attached for interest, and because the final pages contain the scale which can be utilised with patients to determine a likelihood of whether or not a pain is neuropathic in origin.
LANSS Paper (Bennett 2001)
Another shorter assessment tool is the DN4 tool

Nociceptive pain by contrast is usually caused by tissue damage or injury.

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7. Consider Analgesic Options with Patient

Quick info:
Factors include:

  • What has been tried already
  • Success with current medication
  • Side effects with medications e.g.
    • constipation
    • nausea / vomiting
    • drowsiness and light-headedness
  • Drug interactions
  • Past medical history
  • Contraindications
  • Co-existing mental health issues
  • Any prescription drug dependence
  • Any street drug misuse
  • Does patient understand how to use medication appropriately
  • Activity
  • Sleep disturbances

When choosing an appropriate analgesic it is worth considering the above factors plus any compelling indications.

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14. Other agents

Quick info:
Pregabalin is now second line after gabapentin due to a less favourable cost and side effect profile. Substitute gabapentin with pregabalin titrated slowly up to 600mg per day if necessary.

See dose increase chart. Pregabalin Titration Chart

Capsaicin cream 0.075% is licensed for neuropathic pain but the intense burning sensation during initial treatment may limit use. Capsaicin 0.025% is licensed for osteoarthritis only.

Duloxetine is licensed for diabetic neuropathy. The initial dose is 60mg daily up to a maximum of 120mg per day in divided doses.

Lidocaine plasters only to be prescribed for post herpetic neuralgia (licensed), neuropathic pain (unlicensed), diabetic neuropathy (unlicensed) for those patients unable to take oral medication.  Do not initiate, Leeds Grey list medicine.

Targinact (oxycodone / naloxone) no evidence for use of oxycodone in neuropathic pain - do not initiate, Leeds Black Light list medication.

Transtec (high dose buprenorphine, 96hr patch) only prescribe when swallowing difficulties.

Tapentadol MR should only be initiated by a pain specialist for severe chronic pain as a third line option. Do not initiate, Leeds Grey list medication. Tapentadol immediate release, do not initiate, Leeds black Light list medication.

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15. Indications / Side Effects / Contraindications

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Paracetamol is an appropriate first line analgesic for nociceptive milder chronic pain, for example mild osteoarthritis. Encourage patients to take 1g four times a day regularly.

Paracetamol has a favourable safety and side effect profile.

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16. Indications / Side Effects / Contraindications

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Mild opiates may be appropriate for some patients with nociceptive chronic pain, however great caution should be exercised due to the risk of dependency and high rate of side effects e.g. constipation.

First line would be codeine phosphate 30-60mg tablets four times a day, to a maximum of 240mg daily in divided doses. Review responsiveness early and manage side effects, particularly constipation.

Tramadol is generally no more effective or better tolerated than other weak opioid analgesics.  Consider where significant codeine intolerance or codeine not giving adequate pain relief (10% of the population are non/partial responders to codeine).  Only prescribe generic capsules 50mg 1-2 four times a day.

Only consider slow release tramadol when four times a day dosage provides a short duration of response.

Dihydrocodeine can be used as an alternative to codeine.  Co-codamol 8/500mg and 15/500mg and co-dydramol 10/500mg are no more effective than paracetamol and can cause side effects particularly constipation.  Do not initiate unless sub therapeutic dose previously found to be effective for an individual patient. Co-codamol 30/500mg can be prescribed once patients are stabilised.

Do not use combinations of weak opioids together, although different weak opioids maybe tried sequentially as response varies between individuals.

Tramacet (tramadol / paracetamol), is significantly more expensive than the individual products and contains sub therapeutic doses of tramadol and paracetamol. Do not initiate, Leeds Black Light list medicine.

Butrans (buprenorphine low dose, 7 day patch), reserve only for patients who cannot take large, oral, regular doses of weak opioids or non-opioid and opioid combination analgesics and patients who are unable to comply with a frequent analgesia regimen.  May be considered for patients with renal impairment and opioid non/partial responders.

Buprenorphine Equivalence Chart

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17. Indications / Side Effects / Contraindications

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NSAIDs may be appropriate for some patients with chronic pain who may have an inflammatory component.
First line is ibuprofen tablets 400mg to 600mg three times a day, increased to a maximum of 2.4g daily in divided doses.

Use the lowest dose possible for the shortest possible time, review responsiveness regularly.  Advise to take with food.  Naproxen 500mg tablets twice a day can be used as an alternative when ibuprofen partially effective.  Consider gastro-protection if appropriate, lansoprazole 15mg daily / omeprazole 20mg daily / pantoprazole 20mg daily.  If a PPI is not suitable then ranitidine 300mg twice a day, (unlicensed) can be considered as an alternative.

Gastroprophylaxis:
People are at high risk of serious non-steroidal anti-inflammatory drug (NSAID)-induced gastrointestinal (GI) adverse events if they have one or more of the following risk factors:

  • Age 65 years or older
  • History of gastroduodenal ulcer, GI bleeding, or gastroduodenal perforation
  • Concomitant use of medications that are known to increase the likelihood of upper GI adverse events (e.g. anticoagulants, aspirin (even low-dose), corticosteroids, and selective serotonin reuptake inhibitors (SSRIs), venlafaxine, or duloxetine)
  • Serious co-morbidity, such as cardiovascular disease, hepatic or renal impairment (including dehydration), diabetes, or hypertension
  • Requirement for prolonged NSAID use, including people with:
    • Osteoarthritis or rheumatoid arthritis of any age
    • Chronic low back pain and 45 years of age or older
  • Use of the maximum recommended dose of an NSAID.

Additional risk factors for NSAID-induced GI adverse events have also been identified including:

  • The NSAID used
  • The presence of Helicobacter pylori infection
  • Excessive alcohol use
  • Heavy smoking

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18. Indications / Side Effects / Contraindications

Quick info:
Strong opiates will only be appropriate for a very small number of patients with chronic pain. They should be used with extreme care and caution, (particularly in opiate naive patients) due to the high risk of side effects in both the short and longer term, and the risk of dependency.

Morphine slow release orally would be the strong opiate of first choice.
Zomorph capsules are the most cost effective option.  10mg capsules twice a day, increased to a maximum of 180mg in 24 hours. Take care when selecting from the drug list - double check the strength!

Zomorph is not available in 5mg or 15mg strengths.
Oramorph, morphine sulphate 10mg/5ml, and other opiate-based immediate release formulations can lead to rapid opioid dose escalation, not recommended for break through pain in patients with chronic pain.

Fentanyl patches are reserved for patients who cannot take oral morphine or do not respond.

MHRA Guidance - Transdermal fentanyl patches: reminder of the potential risk of life-threatening harm from accidental exposure

Oxycodone orally can be used in renal impairment. Manage side effects particularly constipation and nausea.

Patient Information
Please see attached patient information leaflet on Opioids for persistent pain.

Further Resources
Opioids for Persistent Pain - Summary of guidance on good practice from the British Pain Society
Opioids for Persistent Pain: Good practice (full guidance)
High dose morphine and diamorphine injections - patient safety resource
National Patient Safety Agency - Reducing dosing errors with opioid medicines

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19. Indications / Side Effects / Contraindications

Quick info:
Amitryptiline is the most appropriate first line agent where tolerated for chronic neuropathic pain.
It is unlicensed, however, widely used.
Start low and go slow, side effects immediately but not pain relief.
See dose increase chart.
Amitryptiline Titration Chart
Nortriptyline can be used if amitriptyline is too sedating.

Patient Information
Please see attached patient information leaflet on Amitriptyline
Please see attached Patient Information Leaflet on Nortriptyline

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20. Indications / Side Effects / Contraindications

Quick info:
If amitryptiline is contraindicated or not tolerated, then gabapentin can be considered for chronic neuropathic pain.
See dose increase chart.
Gabapentin Titration Chart

Patient Information
Please see attached patient information leaflets on:
Gabapentin (Slow dose increase)
Gabapentin (Fast dose increase)

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21. Early Clinical Review

Quick info:
After starting or changing a treatment, perform an early clinical review of dosage titration, tolerability and adverse effects to assess suitability of chosen treatment. Following trial stop treatment and reassess if not effective.

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22. Regular Clinical Review

Quick info:
Perform regular clinical reviews to assess and monitor effectiveness of chosen treatments. Include assessment of:

  • Pain reduction
  • Adverse effects
  • Daily activities and participation (such as ability to work and drive)
  • Mood (in particular, possible depression and/or anxiety)
  • Quality of sleep
  • Overall improvement as reported by the person.

Key Dates
Published: 16-Feb-2015,  by Leeds
Valid until: 01-Feb-2017

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