1. Guidelines for Pain Management Paula Wilkinson Chief Pharmacist NHS Mid-Essex

2. Drivers Increasing spend on Opioid Analgesics –Over £1million spend YTD –8% (£75K) more than SHA average Increasing range of Fentanyl products –Rational use –Expensive –Risk Cost of Oxycodone –Oxycodone is 7x as expensive per item as Morphine

3. Opioid Prescribing BNF Name Variance Act Cost Ratio Act Cost Act Cost Per Den omin ator Act Cost Per ItemTotal Act Cost Fentanyl£64,946.67123.86%£668.22£77.85£337,179.44 Buprenorphine£56,951.60136.82%£419.40£28.30£211,625.94 Tramadol Hydrochloride£30,678.95118.56%£388.37£8.55£195,966.79 Oxycodone Hydrochloride£10,513.99107.02%£317.69£50.30£160,305.27 Morphine Sulphate-£20,306.7674.15%£115.45£7.85£58,253.32

5. Morphine v Oxycodone

7. Mild Pain Gastrointestinal protection is required for patients at increased risk of GI bleeding. A PPI (omeprazole or lansoprazole capsules), should be prescribed for the following patients: aged > 65 years; taking steroids or anticoagulant therapy; requiring long-term NSAID; co-morbidity.

8. Moderate Pain Targinact (oxycodone/naloxone) due to a lack of good evidence remains NON- FORMULARY and should not be prescribed. Tramadol prescribe with caution in elderly [aged 75+ (consider 50mg tds)]; palliative care patients; renal failure (CKD levels 3 – 5); history of seizures/epilepsy; pregnancy; on warfarin therapy; taking SSRIs. BuTrans patch dose adjustment: When starting, analgesic effect should not be evaluated until the patch has been worn for 72 hours (to allow for gradual increase in plasma- buprenorphine concentration) – if necessary, dose should be adjusted at 3-day intervals using a patch of the next strength or two patches of the same strength (applied at same time to avoid confusion). Max. two patches can be used at any one time. Wait 24 hours before initiating a slow release opioid.

9. Severe Pain The NPSA (2006) recommends caution in the use of strong opioids in opioid naïve patients. Before prescribing strong opioids, it is important to first establish if patients are opioid naïve to minimise risk of adverse events of administering strong opioids by titrating immediate release opioids up, starting with a low dose. The prescribing of opioids will often be prescribed in a sustained-release oral or patch formulation and there is potential for prescribing and dispensing errors involving confusion with names, formulations and dosage calculations when prescribed generically. These products should therefore be prescribed by brand. Refer to the Mid Essex Guideline for Prescribing of Strong Opiates for more detailed information.Mid Essex Guideline for Prescribing of Strong Opiates

10. Use of Oxycodone Patients should only be prescribed oxycodone where morphine is not appropriate for the following reasons: –They develop side-effects with morphine such as confusion, hallucinations, myoclonic jerks; –They have excessive sickness DESPITE taking anti-emetics (including a trial of the buccal route of administration); –They develop an associated rash; Oxycodone should be prescribed by BRAND name. Oxycodone is approximately twice as potent as morphine. Dose conversions should be conservative and doses rounded down.

11. Use of Fentanyl Use Third Line Prescribe by brand Buccal, sublingual, intranasal as well as patches Concern regarding the suitability of such products for wider use outside of specialist care where observation may not be as intense and where prescribers will be less familiar with these products. Fentanyl is associated with a relatively high incidence of adverse effects and treatment complications. Cost between £5 or £6 per dose compared with less than £1 per dose for morphine.

12. Cost comparison

13. Mid-Essex Guidelines http://www.midessex.nhs.uk/key_documents/Medicines-Management/