Leeds Analgesia Pathway for Chronic Pain
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.
Approved Feb 2013 by Leeds APC
Updated and approved October 2014 Leeds APC
Review date 28.2.2016
Review Jun 2019
Faculty of Pain Medicine Patient Resources:
Types of pain: Faculty of Pain Medicine Patient Information Leaflet
What is chronic pain? Patient Information Video & leaflet links: https://www.leedsth.nhs.uk/a-z-of-services/pain-management/living-with-pain/
British Pain Society ‘Understanding and Managing Long-term Pain’ - Full Length Patient Information PDF – Suitable for emailing to patient on request (44 page in-depth patient resource) https://www.britishpainsociety.org/static/uploads/resources/LeedsPathways/files/Understanding_and_Managing_Long-term_Pain_Final2015.pdf
Leeds Social Prescribing Links>
Linking Leeds is the new citywide social prescribing service for the people of Leeds Monday to Friday (8am until 6pm) including weekend availability.
Telephone: (0113) 336 7612. Download the introductions form from the website https://www.commlinks.co.uk/wp-content/uploads/2016/07/Linking-Leeds-Introduction-Form.docx
Email the completed form to the Linking Leeds secure email address: email@example.com
Ten top tips for GPs managing pain summary
By Dr Tim Williams. www.paintoolkit.org
Video Link: Ten Top Tips for Self-Management of Persistent Pain https://youtu.be/XFhBRVACrMo
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.
Assess patient to establish type of pain, either nociceptive, neuropathic or mixed.
Faculty of Pain Medicine: Types of pain Patient Information Leaflet
Types of Pain
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. Consider whether to prescribe analgesia regularly, rather than just when required. If pain present constantly regular analgesia likely to be more effective
If a patient is unable to self-administer, review frequency of analgesia.
When choosing an appropriate analgesic it is worth considering the below factors plus any compelling indications:
- What has been tried already - what dose and for how long? Was it a proper therapeutic trial?
- Success with current medication
- Side effects with medications e.g.
- nausea / vomiting
- drowsiness and light-headedness
- Drug interactions
- Past medical history
- Co-existing mental health issues
- Any prescription drug dependence
- Any street drug misuse
- Does patient understand how to use medication appropriately
- Sleep disturbances
- Prepare them for side-effects of analgesic options and likely delay before they see any benefits from treatment
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 (caution in low body weight individuals <50kg).
Mild Opioids may be appropriate for some patients with nociceptive chronic pain.
Patients should be educated on risk of dependency and high rate of side effects e.g. Constipation
Do not use combinations of weak opioids together, although different weak opioids maybe tried sequentially as response varies between individuals.
Review responsiveness early and manage side effects, particularly constipation.
Codeine phosphate 30-60mg tablets four times a day,to a maximum of 240mg daily in divided doses.
Dihydrocodeine can be used as an alternative to codeine,to a maximum of 240mg daily in divided doses.
Alternative Mild Opioids –NOT first line:
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.
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. If combination preparations are prescribed - state strength clearly. Co-codamol 30/500mg can be prescribed once patients are stabilised.
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.
Black Listed Mild Opioids –Not to be prescribed:
Tramacet (tramadol / paracetamol), significantly more expensive than the individual products and contains sub therapeutic doses of tramadol and paracetamol.
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.
Start low and go slow
Amitriptyline is an appropriate first line agent where tolerated for chronic neuropathic pain.
Start low and go slow, advise patient of high chance of side effects immediately but pain relief benefits may be delayed until optimum dose reached.
Elderly patients are particularly susceptible to many of the side effects of Amitriptyline, so caution should be used.
Patient Information Leaflet
Imipramine and nortriptyline were recommended in the previous NICE guideline on the pharmacological management of neuropathic pain but due to a lack of good quality evidence to support their use, they are no longer recommended for the management of neuropathic pain.
Gabapentin and Pregabalin are appropriate first line agents where tolerated for chronic neuropathic pain.
Advise patient of high chance of side effects immediately but pain relief benefits may be delayed until optimum dose reached.
Advise patient that some people respond to one and not the other, and some people tolerate one better than the other – it may be required to try both.
Elderly patients are particularly susceptible to many of the side effects, so caution should be used.
Patient Information Leaflet
Please see attached patient information leaflets on:
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.Maximum of 2 month’s supply before treatment response review to confirm if to continue.
Grey Listed Drugs –Should only be initiated by a pain specialist for specific indications
Lidocaine plasters, do not initiate. Classified as grey drug for post herpetic neuralgia where alternative treatments have proved ineffective or contraindicated. NICE do not recommend this treatment in primary care due to a lack of consistent evidence.
Tapentadol MR, do not initiate. Leeds grey list medication. Should only be initiated by a pain specialist for severe chronic pain as a third line option.
Consider referral to community chronic pain service before initiation of strong opioids – link to chronic pain pathway
“Thinking about Opioid Treatment for Pain” patient information leaflet - Royal College of Anaesthetists
Discuss the potential harms of opioid treatment including: -
- Effects on hormones
- Effects on the immune system
- Potential for the drugs to worsen pain
- Potential for problematic drug use and addiction
- Effect on cognitive function - how brain takes in, processes and stores information
ALL patients should read and agree to opioid initiation contract before being issued with opioid prescription
“Taking Opioids for Pain” patient information leaflet - Royal College of Anaesthetists
RCGP Top Ten Tips: Dependence Forming Medications:
The OPIOID TRIAL
If deemed necessary to commence strong opioids – initiate Opioid Trial – see details below and on SystmOne & Emis Chronic Pain Template
Starting the Trial
Duration of the Opioid trial
Choice of Opioid Formulation and Dose
Assessing whether the Opioid Trial is a Success
If the opioid trial demonstrates some benefit from opioids, further exploration of opioid treatment may be helpful. A successful short-term opioid trial does not predict long-term efficacy. Click here for guidance on long-term prescribing of opioids
Strong Opioids 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 opioid naïve patients) due to the high risk of side effects in both the short and longer term, and the risk of dependency.
Further Resources For Healthcare Professionals – Opioids Aware Materials HERE: https://fpm.ac.uk/opioids-aware/structured-approach-opioid-prescribing
Provide patient with information about the harmful effects of using opioids incorrectly and ensure you ask patient to read and sign opioid agreement
Morphine slow release orally would be the strong opioid 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 opioid-based immediate release formulations can lead to rapid opioid dose escalation. Breakthrough analgesia is not recommended for patients with chronic pain; it can encourage dependence on medication as the way to manage 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.
Monitoring Guidance – the 4 A’s
Perform regular clinical reviews to assess and monitor effectiveness of chosen treatments. Include assessment of:
Patient Information Leaflet
The Leeds Opioid Conversion Guide for Adult Palliative Care Patients available on Leeds Health pathway: http://nww.lhp.leedsth.nhs.uk/common/guidelines/other_versions/4654LeedsOpioidConversionChart-3.pdf
Long Term Prescribing with Opioids: https://fpm.ac.uk/opioids-aware-structured-approach-opioid-prescribing/long-term-prescribing
Tapering & Stopping Opioid Guidance: https://fpm.ac.uk/opioids-aware-structured-approach-opioid-prescribing/tapering-and-stopping