1. Pain management for AKT NICE guidelines: Neuropathic pain Opioid conversion Controlled drugs

2. Neuropathic pain Neuropathic pain: result of damage to, or dysfunction of the system that normally signals pain (e.g. trigeminal neuralgia, diabetic neuropathy, post-herpetic pain) Scope of guidelines: adults, not <3/12 after trauma surgery, not under a specialist pain service Consider referral if pain is severe or significantly limits daily activities or underlying health has deteriorated Don’t change Rx if it’s working (esp trigeminal neuralgia - no good evidence)

3. Address ICE regarding: benefits vs SEs, coping strategies, non-drug treatments (e.g. surg/psych) When selecting drugs, consider vulnerability to SEs, safety, patient preference, lifestyle, mental health problems, other medication Explain the need to titrate, taper withdrawl and possibly overlap medications Arrange an early review, along with regular reviews looking at pain, SEs, activities, mood, sleep etc Neuropathic pain

4. Offer amitriptyline or pregabalin Amitriptyline: start at 10 mg/day; gradually titrate to maximum of 75 mg/day (if good pain relief but bad SEs, consider imipramine or nortriptyline) Pregabalin: start at 150 mg/day (two doses; consider lower starting dose if appropriate); titrate to maximum of 600 mg/day First-line treatment

5. Offer oral duloxetine: start at 60 mg/day (a lower starting dose may be appropriate for some people); titrate to effective dose or maximum tolerated dose – maximum 120 mg/day If duloxetine is contraindicated, offer oral amitriptyline First-line treatment: diabetic neuropathy

6. If maximum tolerated dose of first-line treatment doesn’t give satisfactory pain reduction, then after informed discussion: offer another drug as an alternative or offer another drug in combination with the original Amitriptyline: switch to/add in pregabalin Pregabalin: switch to/add in amitriptyline Duloxetine: switch to amitriptline or switch to/add in pregabalin Second-line treatment

7. If satisfactory pain reduction is not achieved with second- line treatment: refer to a specialist pain service and/or a condition- specific service and consider additional or alternative treatment options while waiting for referral (e.g. tramadol, topical lidocaine) don’t start opioids other than tramadol without specialist assessment (poor evidence, increased dependence) Third-line treatment

9. Morphine has 1/2 the potency of oxycodone Oxycodone: oral has 1/2 the potency of s/c Morphine: oral has 1/2 the potency of s/c Oral morphine has 1/3 the potency of s/c diamorphine S/c diamorphine is 1.5x more potent than s/c morphine Injectable diamorphine is 1/10 th the potency of alfentanil Breakthrough dose is 1/6th of 24hr background dose (except alfentanil) Opioid conversion

11. Schedule 1: non-medicinal drugs (e.g. LSD) - need special licence Schedule 2: drugs subject to full CD controls (e.g. diamorphine, pethidine, cocaine) - written dispensing record, locked CD prescription Schedule 3: partial CD controls (e.g. buprenorphine, temazepam) - as above but no dispensing register needed (exc temazepam - no CD Px) Schedules 4 & 5: no need for CD prescription or safe custody (e.g. most benzos, codeine, growth hormone, HCG, anabolic/androgenic steroids) Prescribing schedule 2 & 3 drugs: Name, address, age, NHS number Name and form of drug Strength and dose to be taken Quantity/number of dose units in words and numbers Signature, date and address (+ GMC number is good practice) Cannot be on repeat dispensing/prescriptions An export licence may be needed for taking these abroad Controlled drugs