1. CH 20: PAIN NATIONAL DEPARTMENT OF HEALTH PRIMARY HEALTHCARE 2014
11/30/2018
CH 20: PAIN
NATIONAL DEPARTMENT OF HEALTH
AFFORDABLE MEDICINES
ESSENTIAL MEDICINES PROGRAMME
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published STG. This information does not supersede or replace the STG itself.
PRIMARY HEALTHCARE 2014
Updates to the 2008 PHC STG & EML

2. PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN
20.1 PAIN CONTROL
MODERATE PAIN
Children:
Ibuprofen: added
Aligned with Paediatric Hospital level STG, 2013.
Tramadol: not added
Not pragmatic for primary level of care for management of moderate pain in children.
Level of Evidence: III Guidelines
Paediatric Hospital level STG, 2013.
Ref 1
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN

3. PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN
20.1 PAIN CONTROL
ACUTE SEVERE PAIN
Morphine injection: retained
Metocloperamide: not added
Paracetamol, IV: not added
Tramadol, IV: not added
Impractical to use syringe drivers for subcutaneous administration of morphine for primary level of care.
Not pragmatic to include paracetamol IV and tramadol IV to the PHC EML.
Metocloperamide is included in the STG for concomitant significant nausea and vomiting in chronic cancer pain.
Level of Evidence: III Expert opinion
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN

4. 20.2 CHRONIC NON-CANCER PAIN
Oxycodone slow release tablets/capsules: not added
Morphine slow release tablets/capsules: added
(Refer to the medicine review for oxycodone)
Paucity of robust head-to-head comparative trials of oxycodone vs. morphine.
Morphine more nausea; oxycodone more hallucinations.
Oxycodone is hepatically metabolised potential drug-drug interactions.
Most oxycodone studies done in patients with chronic non cancer pain.
SIGN stated:
Bioequivalence studies of (generic) modified release opioid
preparations in the UK are unsatisfactory (e.g. comparator
not available in the UK; comparator product , immediate release formulation).
Studies on switching between opioids are of poor quality & often anecdotal.
Management of chronic non-cancer pain for adults was delineated from children medicinal therapy.
Scottish Intercollegiate Guidelines Network. [Internet] 106: Control of pain in adults with cancer. A national clinical guideline. [November 2008; cited February 2014]. Available at:
National Department of Health, Affordable medicines, Essential Drugs Programme: Oxycodone medicine review.
Adult Hospital level STG, 2012.
Level of Evidence: III Guidelines
Ref 2
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN

5. 20.2 CHRONIC NON-CANCER PAIN
CHILDREN
Mist morphine: retained
Tilidine: not added
Mist morphine is required for breakthrough pain (adults) & pain management (children).
PHC STG recommends administration of morphine, prior to referral to secondary level & inclusion of an
additional pain medicine (tilidine) to the
EML not considered pragmatic.
Level of Evidence: III Expert opinion
Algorithm added indicating 2-step pain ladder regimen
World Health Organisation. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses
Ref 3
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN

6. 20.2 CHRONIC NON-CANCER PAIN
ADJUVANT THERAPY
ADULTS:
Amitriptyline: retained
Tramadolol: retained
Methadone: not added
Restricting prescribing of amitriptyline to specialists only, due to irrational medicine use was not considered pragmatic for primary level of care – the STG restricts the medicine as doctor initiated.
Concerns about the rising incidence of death from opioid overdose (report from North America) was noted. Pain requiring strong opioids require referral to secondary level of care. Tramadolol, a weak opioid, was retained in the STG.
An external comment to include methadone (based on the National Cancer Institute guidelines) in the primary level EML for neuropathic pain was not pragmatic for primary level of care.
Level of Evidence: III Expert opinion
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN

7. 20.2 CHRONIC NON-CANCER PAIN
CHILDREN
Non-opioid
Ibuprofen: amended
The weight-band dosing table for ibuprofen was amended for correctness.
For anxiety
Diazepam, oral: retained for a maximum of 2 weeks.
Lorazepam, sublingual: not added
Lorazepam sublingual is not included in the PHC EML.
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: PAIN

8. CASE STUDY
A 55 year old male patient with chronic cancer pain complains of pain between his morphine dosing. Patient indicated that there are 2 periods in the day when the morphine does not seem to be working.
The patient’s current prescription includes:
Morphine, oral, 20mg 4 hourly
Ibuprofen 400mg 6 hourly
Paracetamol 1g 6 hourly
What adjustments would you make to the prescription? 8

9. CASE STUDY: SOLUTION
A doctor must adjust the dose of morphine according to the number of episodes of break through pain episodes per day. Remember there is no maximum morphine dose threshold for this indication.
Adjust Morphine dose as follows:
Patient gets 30 mg morphine every four hours.
The patient has 2 episodes of breakthrough pain:
2x 30 mg = 60 mg
60 mg ÷ 6 = 10 mg
The regular 4 hourly dose of 30 mg must be increased by 10 mg
i.e. 30 mg + 10 mg = 40 mg.
The increased morphine dose will be 40 mg 4 hourly.
Dose of Ibuprofen can also be adjusted to a maximum dose of 2400mg (doses must be administered with food) – must be doctor initiated. 9

10. 10 Slide Ref # Reference 20.1 PAIN CONTROL 2 1 IBUPROFEN
Paediatric Hospital level STG, 2013.
20.2 CHRONIC NON-CANCER PAIN 4
OXYCODONE SLOW RELEASE TABLETS/CAPSULES
Scottish Intercollegiate Guidelines Network. [Internet] 106: Control of pain in adults with cancer. A national clinical guideline. [November 2008; cited February 2014]. Available at:
National Department of Health, Affordable medicines, Essential Drugs Programme: Oxycodone medicine review.
Adult Hospital level STG, 2012.
MORPHINE SLOW RELEASE TABLETS/CAPSULES 5 3
MIST MORPHINE
World Health Organisation. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses.
TILIDINE 10