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Milton Keynes Formulary
Milton Keynes University Hospital NHS Foundation Trust
Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group
Milton Keynes Community Health Services
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 Formulary Chapter 4: Central nervous system - Full Chapter
04.07.02  Expand sub section  Opioid analgesics
 note 

 

Opioid Resource Pack January 2020 Final.docx

Dose equivalents and changing opiods

Important Notes:

  • The dosage equivalencies shown in the guide above are only approximate because comprehensive data are lacking and there is significant inter-individual variation. This variation is demonstrated, for example, with 100mg oral tramadol being quoted as approximately equivalent to between 10mg and 20mg of oral morphine.
  • These dosage equivalencies are based on data in Palliative Care medicine. No data could be found that would indicate different equivalencies for treating other patient groups.
  • When converting between opioids consider the total dosage per 24 hours being taken, including both regular and additional PRN doses. If the patient is on multiple opioids, it helps to convert them all to oral morphine equivalents.
  • When converting, particularly to a "stronger" opioid, consider an initial dose reduction of 25-50% from the calculated equi-analgesic dosage (or choose a dosage at the lower end of the equivalent dosage range of the new opioid), and ensure that 4-hourly doses of PRN short-acting doses of opioid (eg Oramorph®) are prescribed for breakthrough pain.
  • However, a dosage reduction may not be appropriate if the original opioid taken at the prescribed dosage has failed to control the pain.
  • Once conversion has occurred, the dosage of the new opioid should be titrated carefully according to individual response and the patient monitored closely for the first 7-14 days for side effects and efficacy especially when switching at high doses. 
Controlled Drug Alfentanil (Rapifen)
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Formulary
Red
  • Injection 500 microgram per 1mL (2mL, 10mL amps)
  • Injection 5mg per 1mL (1mL amps)
  • 1mg in 2mL amp
  • 5mg in 1mL amp intensive care injection

 Note:

    • Intravenous use by anaesthetists and intensive care physicians only due to rapid and profound respiratory depression.
    • Although not included in the original safety alert, the use of 5mg in 1mL amps is subject to the same restrictions as high strength morphine and diamorphine as per NPSA/2006/12.
 
   
Controlled Drug Buprenorphine (Patch)
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Formulary
Amber 2
  • Patches (BuTrans®) (Amber 2) releasing 5 micrograms/hour for 7 days, 10 micrograms/hour for 7 days, 20 micrograms/hour for 7 days
  • Patches (Transtec®) (Amber 2) releasing 35 micrograms/hour for 96 hours, 52.5 micrograms/hour for 96 hours, 70 micrograms/hour for 96 hours

 

Notes:

  • Buprenorphine patches are not suitable, or licensed, for use in the management of acute or intermittent pain.
  • Prescribers should ensure that patients and/or their careers are aware that Butrans® patches need to be applied at appropriate seven-day intervals to ensure that patients are not left in pain (because of too long an interval) and that the patches are not used wastefully (because of too short an interval).
  • Remember to remove the old patch before application of new patch.
  • To increase the dose, a higher strength patch should replace the patch that is currently being worn, rather than multiple patches being used.
 
Link  Minimising errors with buprenorphine patches UKMI Q&A
   
Controlled Drug Buprenorphine (Temgesic)
(Sublingual tablet)
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Formulary
Green

Sublingual tablet 200 micrograms

 
   
Codeine Phosphate
(analgesia)
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Formulary
Green
  • Tablet 15mg, 30mg
  • Oral solution 25mg in 5mL
  • Injection 60mg in 1mL - CD (Hospital only)

 

Note:

  • Codeine is effective for the relief of mild to moderate pain but is too constipating for long-term use.
  • Codeine is contraindicated in all patients of any age known to be CYP2D6 ultra-rapid metabolisers.
 
Link  MHRA: Children restrictions for codeine (June 2013)
Link  MHRA: Children restrictions for codeine (July 2013)
   
Controlled Drug Diamorphine
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Formulary
Green
  • Injection 5mg, 10mg, 30mg, 100mg, 500mg

Note: All Ayendi® Nasal Sprays have been discontinued by the manufacturer.

 
   
Dihydrocodeine
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Formulary
Green

 Tablets 30mg     

 
   
Controlled Drug Fentanyl
(Actiq lozenges)
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Formulary
Red

Immediate release fentanyl 100mcg, 200mcg, 300mcg, 400mcg, 600mcg, 800 mcg sublingual tablets.

 

Secondary care use only.

 
   
Controlled Drug Fentanyl
(Patch)
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Formulary
Amber 1
  • Patch 12 microgram/hour, for 3 days
  • Patch 25 microgram/hour, for 3 days
  • Patch 50 microgram/hour, for 3 days
  • Patch 75 microgram/hour, for 3 days
  • Patch 100 microgram/hour, for 3 days

In primary care, fentanyl patches should be prescribed as Fencino brand.

 
Link  MHRA Warning: Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children
Link  UKMI Q &A: switching from morphine to fentanyl patches
   
Controlled Drug Fentanyl (Effentora buccal tablets)
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Formulary
Amber 3

Buccal tablets 100micrograms, 200micrograms, 400micrograms 

Prescribing on the recommendation of Palliative Care only. 

Must be initiated and stabilised by the specialist in Palliative Care prior to passing prescribing responsibility to the GP.

 

Fentanyl, Immediate Release Commissioning Statement

The statement below applies to prescribing outside NICE CG140 Opioids in Palliative Care.

Prescribers should not initiate immediate release fentanyl for any new patient other than in line with NICE CG140 Opioids in Palliative Care.

If necessary, immediate release fentanyl should be discontinued from primary care prescribing (deprescribed) with support from specialist services.

Patient Information Leaflet can be found here.

 
   
Meptazinol (Meptid)
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Formulary
Amber 1
  • Meptid® Tablet 200mg
  • Meptid® Injection 100mg in 1mL (Hospital only) 
 
   
Controlled Drug Morphine
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Formulary
Green

(Controlled Drug except for oral solution 10mg in 5mL) 

4 hourly dosing preparations:

  • Oral solution 10mg in 5mL, 100mg in 5mL
  • Tablet 10mg, 20mg, 50mg
  • Injection 10mg in 1mL, 30mg in 1mL, 60mg in 2mL

 

12 hourly dosing preparations:

  • Zomorph® Modified Release capsule 10mg, 30mg, 60mg, 100mg, 200mg
  • MST® Modified Release tablet 5mg

 

Infusion (red)

  • PCA (Accufusor) 100mg in 5mL

 

Notes:

  • Morphine remains the most valuable opioid analgesic for severe pain although it frequently causes nausea and vomiting. In addition to pain relief, morphine also confers a state of euphoria and mental detachment.
  • Zomorph® is the morphine sulphate MR preparation of choice because it is a capsule formulation that may be opened and the contents administered in semi solid food for patients with swallowing difficulties. Zomorph® is also licensed for use via gastric or gastronomy tubes (diameter >16 F.G.). MST® lacks these advantages and is more expensive than Zomorph® in the community and hospital and so its use is NOT recommended.
  • Following titration, except for stat doses, for example for dressing changes, morphine should be given regularly every four hours (unless m/r preparations). If additional PRN doses are required the regular doasage should be reviewed and increased as appropriate.
  • M/R preparations should be prescribed by brand name. ‘As required’ doses of immediate release product should be prescribed in case of breakthrough pain. 
 
   
Controlled Drug Pethidine
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Formulary
Green
  • Tablet 50mg
  • Injection 50mg in 1mL, 100mg in 2mL 
 
   
Controlled Drug Tapentadol (Palexia)
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Formulary
Amber SCG

Palexia SR® Modified Release Tablets 50mg, 100mg, 150mg, 200mg, 250mg

Note:

For specialist initiation and prescribing of first month's supply in line with Pain Guidelines and Shared Care Protocol.

 
Link  MHRA: risk of seizures and serotonin syndrome with tapentadol
Link  Shared care prescribing guideline Tapentadol
   
Controlled Drug Tramadol
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Formulary
Green
  • Capsule 50mg 
  • Injection 50mg in 1mL 

 

Caution: 

  • Tramadol increases CNS serotonin levels and may cause increased serotogenic effects when given with antidepressants.
  • The CSM have cautioned the use of tramadol in patients with a history of epilepsy, as there may be an increased risk of convulsions. 
 
Link  UKMI Q&A: Serotonin Syndrome risk with tramadol and SSRIs
   
Controlled Drug Oxycodone
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Restricted Drug Restricted
Amber 1

(Specialist recommendation only and restricted use)

Oxycodone is restricted to use in:

  1. Palliative Care patients intolerant of morphine
  2. Inpatient use for pain relief following THR/TKR protocol
  3. Chronic Pain consultant initiation according to criteria agreed in the Chronic Pain Guideline

 

  • Capsules 5mg, 10mg, 20mg
  • Injection 10mg in 1mL, 50mg in 1mL
  • Oral solution Sugar Free 5mg in 5mL
  • Oral solution Sugar Free Concentrate  10mg in 1mL

 

 12 hourly dosing preparations:

  • Modified Release Tablets 5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg, 120mg 
  • In primary care, oxycodone modified release preparations should be prescribed by brand as advised through OptimiseRx.
 
   
 ....
 Non Formulary Items
Controlled Drug  Alfentanyl Sublingual Spray 5 mg in 5mL

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Non Formulary
 
Controlled Drug  Dextromoramide

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Non Formulary
 
Controlled Drug  Dipipanone  (Diconal)

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Non Formulary
 
Controlled Drug  Fentanyl  (Instanyl nasal spray)

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Non Formulary
 
Controlled Drug  Fentanyl Buccal Film  (Breakyl)

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Non Formulary
 
Controlled Drug  Fentanyl Nasal Spray  (PecFent)

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Non Formulary
 
Controlled Drug  Fentanyl sublingual tablets  (Abstral)

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Non Formulary
 
Controlled Drug  Hydromorphone  (Palladone)

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Non Formulary
 
Controlled Drug  Methadone
(Analgesic)

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Non Formulary
 
Controlled Drug  Morphine and cyclizine  (Cyclimorph)

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Non Formulary
 
Controlled Drug  Morphine suppositories

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Non Formulary
 
Controlled Drug  Oxycodone MR  (Onexila XL)

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Non Formulary
 
Controlled Drug  Papaveretum

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Non Formulary
 
Controlled Drug  Papaveretum
(Papaveretum with hyoscine injection)

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Non Formulary
 
Controlled Drug  Pentazocine

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Non Formulary
 
Controlled Drug  Pethidine Hydrochloride and promethazine  (Pamergan P100)

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Non Formulary
 
Sufentanil  (Zalviso)

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Non Formulary
 
Controlled Drug  Targinact (Oxycodone/Naloxone)  (Targinact)
(Restless legs)

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Non Formulary
 
Controlled Drug  Targinact (Oxycodone/Naloxone)  (Targinact)
(Pain)

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Non Formulary
 
Controlled Drug  Tramadol and dexketoprofen  (Skudexa)

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Non Formulary
 
Controlled Drug  Tramadol Hydrochloride and paracetamol  (Tramacet)

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Non Formulary
Link  PrescQIPP: Tramacet review
 
Controlled Drug  Tramadol MR

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Non Formulary
 
Controlled Drug  Tramadol oral drops

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Non Formulary
 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Routine prescribing within licensed indication  

Amber 1

Specialist recommendation followed by GP initiation and continuation  

Amber 2

Specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation   

Amber 3

Specialist initiation and stabilisation followed by GP continuation  

Amber SCG

Specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline  

Red

Hospital or specialist prescribing only  

Red Red

These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost effectiveness or safety.  

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