1. Safe Opioid Prescribing MedicinesDoseFrequencyRouteQuantity Morphine Sulphate MR 10mg tablets10mgBD OralSupply 28 tablets (Twenty eight tablets) Morphine Sulphate Solution 10mg / 5ml 10mg2 to 4 hourly PRN OralSupply 100ml (One Hundred millilitres) Fentanyl patch 25micrograms / hour1 patch72 hourly TopicalSupply 4 (four) patches For further information on pain management, look on the Intranet: Documents – Local Clinical Guidance – Pain Management Prepared by: Lynn Grigg (Senior Nurse Specialist for Pain Management), Julie Phillips, Karen Scott and Bernadette Fultang (Pharmacy) March 2009 (To be reviewed – March 2011)  Information needed on the prescription: Medicine name Strength Form (e.g. tablet / SR tablet / capsule / patch / solution)Dose Total quantity (in words and figures)  If still unsure - please contact Ward Pharmacist or Technician BEFORE sending the TTA letter to the dispensary (otherwise the discharge process will be DELAYED) Need help prescribing a Controlled Drug on a TTA? The National Patient Safety Agency (NPSA) has recommended that the guidance below should be applied when the following opioid medicines are prescribed: buprenorphine, diamorphine, fentanyl, meptazinol, methadone, morphine and pethidine (these are all in the L&D Formulary). (The NPSA guidance also applies to the following non-formulary opioid medicines: dipipanone, hydromorphone, oxycodone and papaveretum). In anything other than acute emergencies, the healthcare practitioner concerned or their clinical supervisor should: Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient This can be done through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records Ensure where a dose increase is intended, that the calculated dose is safe for the patient (E.g. for oral morphine in adult patients – not normally more than 50% higher than the previous dose) Ensure patients are familiar with the following characteristics and formulations of their medicines: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side effects While dose increments should be in line with this guidance, it is recognised that in palliative care higher than normal doses may be required. In these cases, please contact: Mon to Fri, 8am to 4pm, extn 7522 or bleep 269 / 492. Out-of-hours: 0808 1807788 The Pain Team will also, on occasion, manage a patient outside of these parameters. Their recommendations will be documented in the medical notes for the specific individual. To contact the Pain Team for advice or involvement – bleep 288 Analgesic Ladder Please prescribe by pain score and not by weight * Use morphine first line. If not tolerated – oxycodone can be used second line Adjuvants NSAIDs- add these if not contra-indicated (i.e. in patients with duodenal ulcers, renal failure, aspirin sensitive asthmatics). Laxatives- prescribe regularly with all opioids (not with anastomosis patients): senna is the drug of choice – 2 tablets at night. Anti-emetic - cyclizine 50mg 8 hourly prn is first line; ondansetron 4 to 8mg 8 hourly prn is second line. (prescribe regularly if ongoing problem) Anticonvulsant- for neuropathic pain (described as ‘shooting’, ‘pins and needles’). Gabapentin is first line, pregabalin is second line. Antidepressant - for neuropathic pain. (eg. amitriptyline 10mg at night) Regular paracetamol + Regular strong opioid: Tramadol 100mg qds or Morphine Sulphate tablets MR (MST) * Plus PRN: Oramorph 10mg / 5ml Plus or minus: adjuvants Regular paracetamol + Regular weak opioid: Codeine phosphate 60mg qds or Meptazinol 200mg qds or Tramadol 50mg qds Plus PRN: Oramorph 10mg / 5ml Plus or minus: adjuvants Regular non opioid: such as paracetamol Plus or minus: adjuvants Step 3 Pain scores 7-10 Step 2 Pain scores 4-6 Step 1 Pain scores 1-3 Approximate single dose equivalence of oral opioid analgesics Oral Opioid analgesic Dose approx equivalent to 10mg morphine Dose and maximum 24hr dose Formulation Codeine phosphate100mg30 to 60mg 4 hourly Max 240mg Tablets (30mg) Linctus (15mg in 5ml) Tramadol50mg50 to 100mg 4 hourlyCapsules (50mg) Morphine sulphate modified release (MR) tablets (eg. MST ® ) Morphine sulphate immediate release solution / tablets (eg. Oramorph ® solution or Sevredol ® tablets) 10mg Always 12 hourly regularly No maximum dose Usually PRN – calculated to the nearest one 6 th of total MST per day given 2 to 4 hourly No maximum dose Tablets (5mg, 10mg, 15mg, 30mg, 60mg and 100mg) Solution (10mg in 5ml) Concentrated solution (100mg in 5ml) Tablets (10mg and 20mg) Oxycodone modified release (MR) tablets (eg. Oxycontin® tablets) Oxycodone immediate release capsules / liquid (eg. Oxynorm ® capsules or liquid) 5mg Always 12 hourly regularly No maximum dose Usually PRN – calculated to the nearest one 6 th of total Oxycontin per day No maximum dose Tablets (5mg, 10mg, 20mg, 40mg, 80mg) Capsules (5mg, 10mg, 20mg) Liquid (5mg in 5ml) Buprenorphine100mcg200 to 400mcg 6-8 hourly Max 1600mcg daily Sublingual tablets (200mcg and 400mcg) Topical Fentanyl transdermal patch (Durogesic ® ) 25mcg / hr = 90mg morphine daily Replace every 72 hoursSelf adhesive patches (12mcg, 25mcg, 50mcg, 75mcg and 100mcg / hour for 72 hours) NB. Please use the oral route whenever possible These equivalences are intended only as an approximate guide: patients should be carefully monitored after any change in medication and dose titration may be required