1. Pain Ladder and Opiate Conversion Christopher Haigh Medicines Optimisation Pharmacist Bolton CCG

2. Pain Ladder Step 1 Mild Pain FULL DOSE REGULAR PARACETAMOL (1G QDS) +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 1 Mild Pain FULL DOSE REGULAR PARACETAMOL (1G QDS) +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 2 Moderate Pain Full Dose Regular Paracetamol + Weak Opiate e.g. Codeine 15-60mg PRN or Regular +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 2 Moderate Pain Full Dose Regular Paracetamol + Weak Opiate e.g. Codeine 15-60mg PRN or Regular +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 3 Severe Pain Full Dose Regular Paracetamol + Strong Opiate STOP WEAK OPIATE +/- NSAID +/- Adjuvant – see separate table for neuropathic pain Step 3 Severe Pain Full Dose Regular Paracetamol + Strong Opiate STOP WEAK OPIATE +/- NSAID +/- Adjuvant – see separate table for neuropathic pain Chronic Pain Acute Pain

3. How to Use Pain Ladder Start at the appropriate level for the patients current pain level Regularly review treatment to step up or down Long term opiate treatment should be used only if absolutely necessary Full dose paracetamol should be used at all stages as it reduces the need for opiate and adjuvant medicines Consider adjuvants and NSAIDs at all levels

4. NSAID Main benefit in musculoskeletal pain Can be used at any stage of pain ladder Try to avoid long term use if possible Ibuprofen or Naproxen Renal risk Cardiovascular risk – lowest with naproxen GI risk – lowest with ibuprofen Co-prescribe PPI for regular use Avoid diclofenac and cox-II agents – increased CV risk

5. Adjuvants  Neuropathic pain – amitriptyline or gabapentin 1 st line agents  Adequate trial – 6-8 weeks  Adequate titration  Pregabalin 3 rd line agent  Consider duloxetine in diabetic neuropathy, carbamazepine for trigeminal neuralgia

6. Weak Opiates Step 1 Mild Pain FULL DOSE REGULAR PARACETAMOL (1G QDS) +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 1 Mild Pain FULL DOSE REGULAR PARACETAMOL (1G QDS) +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 2 Moderate Pain Full Dose Regular Paracetamol + Weak Opiate e.g. Codeine 15-60mg PRN or Regular +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 2 Moderate Pain Full Dose Regular Paracetamol + Weak Opiate e.g. Codeine 15-60mg PRN or Regular +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain

7. Weak Opiates  Codeine, Dihydrocodeine and Tramadol  Codeine 1 st line  Consider tramadol if neuropathic element – BUT interactions with SSRIs, epilepsy, serotonin syndrome  Low dose combinations such as co-codamol 8/500mg do not offer significant advantages over full dose paracetamol and cause significant constipation.  Consider separate components to reduce constipation  Prescribe laxatives if taking regular or bowels a concern.

8. Pain Ladder Step 1 Mild Pain FULL DOSE REGULAR PARACETAMOL (1G QDS) +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 1 Mild Pain FULL DOSE REGULAR PARACETAMOL (1G QDS) +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 2 Moderate Pain Full Dose Regular Paracetamol + Weak Opiate e.g. Codeine 15-60mg PRN or Regular +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 2 Moderate Pain Full Dose Regular Paracetamol + Weak Opiate e.g. Codeine 15-60mg PRN or Regular +/- NSAID PRN or Regular – Ibuprofen or Naproxen (Consider PPI) +/- Adjuvant – see separate table for neuropathic pain Step 3 Severe Pain Full Dose Regular Paracetamol + Strong Opiate STOP WEAK OPIATE +/- NSAID +/- Adjuvant – see separate table for neuropathic pain Step 3 Severe Pain Full Dose Regular Paracetamol + Strong Opiate STOP WEAK OPIATE +/- NSAID +/- Adjuvant – see separate table for neuropathic pain Chronic Pain Acute Pain

9. Strong Opiates  Morphine 1 st line  When stepping up from full dose codeine: Start with 5-10mg PRN QDS and establish need 24 requirement OR consider 5-10mg MR bd.  PRN most suitable for acute pain that is likely to reduce.  Always co-prescribe appropriate laxatives  Morphine can be used in stable mild renal impairment with dosage adjustment – use cautiously  Don’t mix opiates unless no practical immediate release preparation for breakthrough pain e.g. fentanyl patch.  Oxycodone is more constipating than morphine but has less renally cleared active metabolites. It is also significantly more expensive £100-200 per month vs £10-20 for morphine.  Fentanyl patches should only be considered for chronic pain and if the transdermal route is advantageous. Also have advantages in renal impairment

10. Conversion and Breakthrough Breakthrough generally 1/6 th to 10-20% total daily dose For palliative care, may not always be suitable for other long term pain conditions Fentanyl – use morphine or oxycodone Pragmatic approach to dosing requirement Convertion calculation ‘via’ morphine Conversion charts available in palliative care guidelines: http://gp.boltonmlz.co.uk/navigations/view/clinical- guidelines http://gp.boltonmlz.co.uk/navigations/view/clinical- guidelines Opiate conversion and breakthrough calculator shortly to go on GP systems

11. Conversion Tables Drug To obtain equivalent oral morphine dose, multiply by: For example if the patient is having: Dose in 24h Approximate oral morphine equivalent in 24h Dihydrocodeine1/1030mg QDS120mg12mg Codeine1/1230mg QDS120mg10mg Tramadol1/10100mg QDS400mg40mg Buprenorphine (sublingual) 80 200microgram TDS 600microgram50mg Buprenorphine (transdermal patch e.g. Transtec ®, BuTrans ® ) 10035microgram/h840microgram84mg

12. Conversion Tables Morphine mg Diamorphine mg Oxycodone † mg Hydromorphone mg RouteOralSC * OralSC *Oral 24h total q4h 4 hrly CSCI 24h q4hCSCI 24h q4h24h total q4hCSCI 24h q4h24h totalq4h Dose305152.5102.5152.5102.541.3 601030520530520581.3 9015457.5305457.5305122.6 1202060104056010405162.6 150257512.5507.57512.5507.5203.9 180309015601090156010243.9 24040120208015120208015325.2 3606018030120201803012020487.8 4808024040160252404016025†6410.4 60010030050200303005020030†8013 80013040065260404006526040†10616.9 100016050080†330605008033060†13222.1 1200200600100†4007060010040070†16026

13. Conversion Tables Buprenorphine patch strength (microgram/h) Equivalent codeine dose Equivalent oral morphine dose (mg/24 h) PRN dose of oral morphine (mg) * BuTrans ® 5**30mg QDS122 10**60mg QDS245 20-4810 Transtec ® 35-8415 52.5-12620 70-16830

14. Conversion Tables – Fentanyl 24-hrly morphine dose (mg) Fentanyl Transdermal (microgram/h) Oral short-acting morphine breakthrough dose 60 - 902515 90 - 1343720 135 - 1895030 190 - 2246235 225 - 3147545 315 - 40410060 405 - 49412575 495 - 58415090 585 - 674175105 675 - 764200120 765 - 854225135 855 - 944250150 945 - 1034275165 1035 - 1124300180

15. Conversion Calculator Currently in draft stage Will be available on vision and EMIS web GP systems via DXS Also to be available as a standalone for System 1 practices

16. Conversion and Titration Conversion calculator and charts are only a tool – do not account for cross tolerance, renal/hepatic impairment, altered physical states Use clinical judgement to assess patient and response Increase in doses generally 30-50% in palliative care, can be more gradual in other chronic pain conditions Establish PRN usage to control pain and calculate this into slow release preparations Patients should be closely monitored after dosage change/conversion for toxicity and poor control

17. Case Studies On sheet in packs 5 mins for each Volunteers to Feedback

18. Case Study 1 Answers Swallowing assessment Liquid or soluble meds where possible – paracetamol, senna. ramipril caps can be opened. Daily requirement of morphine = 80mg Consider transdermal route – fentanyl Patient stable Already on strong opiate and tolerating Oral route comprimised Conversion = 25mcg/h patch Attach patch with last dose of MR morphine Breakthrough dose – stay with morphine, good renal function 7.5- 15mg. Currently 10mg, can advise on dosage range Ensure adequate follow up and monitoring during transition

19. Case Study 2 Answers Issues Fentanyl patch unsuitable Variable pain, can swallow, told to use acutely, No current need for strong opiate Mixed opiates – rationalise as per pain ladder Combination paracetamol and opiate preparation No laxatives Diclofenac – CV risk and renal risk and no cover PPI Poor diabetic control + BMI Actions Stop patch Change to co-codamol to paracetamol 1g qds Stop diclofenac, if required offer naproxen + PPI and monitor GFR Counsell on pain management Follow up appointment

20. Bolton Draft Pain Pathways Draft form for comment Lower back Pain Chronic Pain Neuropathic Pain Currently out to consultation Comments to Paul Juson: paul.juson@bolton.nhs.uk