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Nottinghamshire Area Prescribing Committee
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 Formulary Chapter 4: Central nervous system - Full Chapter
04.07.02  Expand sub section  Opioid analgesics
Controlled Drug Alfentanyl Sublingual Spray 5 mg in 5mL
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Restricted Drug Restricted
Red
  • Unlicensed medicine - named patient use only
  • For palliative care use only 
  • Link  Link to reviews
       
    Controlled Drug Buprenorphine (Bupeaze® patch)
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    Restricted Drug Restricted
    Amber 3
    Patch (Twice weekly patch)
  • Not for first line use.
  • Prescribe by brand in primary care.
  • GPs may initiate in line with Notts APC Opioids for persistent non-cancer pain - APC guideline
  • For chronic non-cancer pain, doses greater than 70 micrograms / hour by specialist recommendation or advice only. See Opioids for persistent non-cancer pain - APC guidelines. This does not apply to cancer related pain.
  • May be considered for patients with swallowing difficulties on stable dose of opiates or patients in whom morphine isn't tolerated. 
  • Link  Equivalent doses of opioids
    Link  Minimising errors with buprenorphine patches UKMI Q&A
    Link  Relative prices of opioids
    Link  NUH: brand switch information - Jan 2017
    Link  SFH: brand switch information - Jan 2017
    Link  SFH: buprenorphine preparations information
       
    Controlled Drug Buprenorphine (Butec® patch)
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    Restricted Drug Restricted
    Amber 3
    Patch (Weekly patch)
  • Not for first line use.
  • Prescribe by brand in primary care.
  • GPs may initiate in line with Notts APC Opioids for persistent non-cancer pain guideline
  • Considered to have a low place in therapy. Only for patients where other options eg codeine, tramadol or low dose morphine have been exhausted. Morphine preferred if a strong opioid needed.
  • When compared to other opiates Butec® patches are relatively weak and expensive 
  • Link  Buprenorphine patches QIPP aid
    Link  Buprenorphine patches QIPP aid supporting document
    Link  Equivalent doses of opioids
    Link  Independent drug reviews
    Link  Minimising errors with buprenorphine patches UKMI Q&A
    Link  Opioids for persistent non-cancer pain - APC guidelines
    Link  NUH: brand switch information - Jan 2017
    Link  SFH: brand switch information - Jan 2017
    Link  SFH: buprenorphine preparations information
       
    Controlled Drug Buprenorphine (Temgesic®)
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    Formulary
    Amber 2
    Tablet sublingual
     
    Link  SFH: buprenorphine preparations information
       
    Codeine
    (analgesia)
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    Formulary
    Green

    Tablet, Syrup (25mg/5mL), Injection (not recommended as no advantages over morphine and is a CD)

    • Very poor analgesic when used alone. Only use in addition to paracetamol. Works by small amounts (~10%) being converted to morphine (some people do not convert!).
    • New restrictions on use of codeine in children and breastfeeding mothers - see MHRA advice below.
    • Further information about use of codeine in breastfeeding here (UKMI Q&A).
    • Restricted Item NUH Medicines Matters Bulletin regarding Codeine
     
    Link  Equivalent doses of opioids
    Link  MHRA: Children restrictions for codeine (June 2013)
    Link  MHRA: Children restrictions for codeine (July 2013)
    Link  Relative strengths graph of analgesics
    Link  SFH: Analgesia one side guide
    Link  SFH: Basic opioid advice
       
    Controlled Drug Diamorphine
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    Restricted Drug Restricted
    Green

    Injection

     
    Link  Derbyshire anticipatory medicines guidelines
    Link  Link to reviews
    Link  SFH advice for managing drug misusers maintained on IV diamorphine
    Link  SFH opioid misusers guideline
       
    Dihydrocodeine
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    Formulary
    Green
    Tablet, Tablet MR, Oral solution.
  • Poor analgesic when used alone, probably similar to or theoretically slightly better than codeine, but based on minimal evidence. Only use in addition to paracetamol. 
    Controlled Drug Injection Only
  •    
    Controlled Drug Fentanyl
    (Patch)
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    Restricted Drug Restricted
    Green
    Patch
  • For patients with swallowing difficulties on stable doses of opiates or on pain team specialist advice when morphine isn't suitable.
  • For chronic non-cancer pain, doses greater than 50 micrograms / hour by specialist recommendation or advice only. See Opioids for persistent non-cancer pain - APC guidelines.
  • Relatively expensive compared to Zomorph®
  • Same side effect profile as morphine, but there is a small chance patients may tolerate one better than the other (but this is likely to be due to giving a relatively smaller dose.)
  • May have a slightly lower constipation effect compared to morphine. See Notts APC laxative guideline (appendix 2).
  • When prescribed specifically as "Matrifen®" in primary care and on hospital outpatient prescriptions, it is significantly cheaper than Durogesic.
  • Fentanyl patch QIPP detail aid and supporting info.
  • For practical information on changing to and from fentanyl patches see Palliative Adult Network Guidelines on the SFH intranet. 
  • Link  Equivalent doses of opioids
    Link  MHRA warning regarding accidental exposure
    Link  Moderate to severe acute post-operative pain: fentanyl transdermal patch
    Link  NUH Medicines Matter: Fentanyl patches
    Link  Opioids for persistent non-cancer pain - APC guidelines
    Link  Relative prices of long acting opioids
    Link  SFH dose equivalence tables (via opioids links page)
    Link  UKMI Q &A: switching from morphine to fentanyl patches
       
    Controlled Drug Fentanyl Nasal Spray (PecFent®)
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    Restricted Drug Restricted
    Red

    Nasal spray:
    - 100 micrograms / spray (~£36 per 8 sprays)
    - 400 micrograms / spray (~£36 per 8 sprays)

    • Restriction: Specialist initiation only for the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain, when other short-acting opioids are unsuitable
    • Grey Non-formulary for use in non-cancer related pain.
    • On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.
     
    Link  Price graph for breakthrough opioids
    Link  see independent reviews
       
    Controlled Drug Fentanyl sublingual tablets (Abstral®)
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    Restricted Drug Restricted
    Red

    Sublingual tablets. £5 each tablet.

    • Restriction: Specialist initiation only for the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain, when other short-acting opioids are unsuitable
    • Grey Non-formulary for use in non-cancer related pain.
    • On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.
     
    Link  Price graph of breakthrough opioids
    Link  See independent drug reviews
       
    Controlled Drug Methadone
    (Analgesic)
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    Restricted Drug Restricted
    Amber 2
    Tablet, Liquid
  • For initiation by pain team only when used as an analgesic 
  • Link  SFH: Methadone for analgesia guidelines (see tab 'PMH Text'))
       
    Controlled Drug Morphine
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    Formulary
    Green

    - Normal release (~4 hours effect): Tablet (Sevredol®), Oral solution (e.g. Oramorph®), NUH only: Low strength concentration of oral solution (100micrograms/mL - unlicensed)
    - Slow release (~12hr effect): Zomorph® Capsule MR 10mg, 30mg, 60mg, 100mg, 200mg, (MST® Tablet MR 5mg and 15mg ONLY, 15mg not available at NUH), Injection.

    • First line strong opioid
    • For chronic non-cancer pain, doses greater than 60mg every 12 hours by specialist recommendation or advice only. See Opioids for persistent non-cancer pain APC guidelines.
    • Low strength concentration of oral solution (100micrograms/mL) for use as per Nottingham Children's Hospital: Oral Analgesia Guideline.
    • If needed Zomorph capsules can be opened and beads mixed with semi solid food (puree, jam, yoghurt). Do not crush the beads. More Info on opening capsules
    • The beads can also go down via NG or PEG tubes of a diameter of more than 16Fr with an open distal end or lateral pores. Flush the tube with 30ml to 50ml of water.
    • Always give prophylactic laxatives with regular opioids.
     
    Link  Converting from parenteral morphine to Zomorph
    Link  End of life guideline available on Nottinghamshire APC site
    Link  Equivalent doses of opioids
    Link  Guide to different morphine preparations
    Link  Nottingham Children’s Hospital: Oral Analgesia Guideline
    Link  NUH Zomorph FAQs
    Link  Opioids for persistent non-cancer pain - APC guidelines
    Link  SFH basic opioid advice
    Link  SFH Opioids further information page
    Link  Standard anticipatory medicines for end of life care
       
    Controlled Drug Oxycodone
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    Restricted Drug Restricted
    Green
    -Normal release: Capsule (Shortec®). Liquid, Concentrate liquid and Injection (Oxynorm®)
    -Slow release: Tablet (Longtec®)
  • Not first line strong opioid
  • Prescribe by brand. Longtec®/ Shortec® preferred in Nottinghamshire for new patients. Longtec costs 20% and Shortec 30% less than Oxycontin®/ Oxynorm® (Jan 2015).
  • For chronic non-cancer pain, doses greater than 30mg every 12 hours by specialist recommendation or advice only . See Opioids for persistent non-cancer pain - APC guidelines.
  • In secondary care restricted for pain management service use and palliative care use only.
  • More expensive, and not superior to morphine. Only for patients unable to tolerate idiosyncratic side effects with morphine.
  • Always give prophylactic laxatives
  • Oxycodone injection 10mg/ml and 50mg/ml are available, but 50mg/ml comparatively more expensive and so only for use where high doses will not fit into syringe. Using a 30ml syringe you have approx 17ml volume available to measure 48mm. So doses of over 170mg using 10mg/ml oxycodone will not fit, and high strength oxycodone will be required. If other drugs are included this amount will be less. Seek advice from hospice if required. 
  • Link  Opioids for persistent non-cancer pain - APC guidelines
    Link  End of life guideline available on Nottinghamshire APC site
    Link  Equivalent doses of opioids
    Link  NUH: Change of Oxycodone Preparations FAQs
    Link  NUH: Change of Oxycodone Preparations Poster
    Link  NUH: Change of Oxycodone Preparations Discharge Letter
    Link  SFH: Oxycontin/ Oxynorm switching to Longtec/ Shortec MEMO
       
    Controlled Drug Pethidine
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    Formulary
    Green
    Tablet, Injection
  • Morphine usually preferred (except in obstetrics) 
  •    
    Controlled Drug Tapentadol (Palexia®)
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    Formulary
    Amber 2
    Modified release: Palexia SR
    Standard release (tablets, oral solution 20mg/ml): Palexia
  • Amber 2 - specialist initiation by pain teams only - for chronic pain in patients either unresponsive or unable to tolerate morphine, fentanyl, oxycodone and buprenorphine (i.e. fifth line strong opioid). Tapentadol can be used 3rd line only if the patient has not responded to morphine and buprenorphine and was showing symptoms of neuropathic pain. See Opioids for persisent noncancer pain - APC guidance for details
  • Pain teams are to provide the first 28 days treatment and evaluate patient response. Only responders may be referred to primary care for further prescriptions. 
  • Link  Click here for Prescribing Information (APC)
    Link  Link to reviews
    Link  Opioids for persisent noncancer pain - APC guidance
    Link  Relative prices of long acting opioids
       
    Controlled Drug Tramadol
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    Formulary
    Green
    Soluble tablet, Capsule, Injection
  • 400mg/day oral tramadol = approx 40mg oral morphine
  • Became a Sch 3 Controlled Drug on 10th June 2014.
  • Prescriptions now need to comply with CD requirements, with the total quantity to be supplied given in both words and figures and limits to validity of prescriptions and length of supply that can be provided. However tramadol is not subject to storage in a CD cupboard. 
  • Link  Equivalent doses of opioids
    Link  Opioid choice guide (SFH)
    Link  Relative strengths graph of analgesics
    Link  Tramadol controlled drug FAQ’s (June 2014)
    Link  UKMI Q&A: Serotonin Syndrome risk with tramadol and SSRIs
       
    Controlled Drug Tramadol MR
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    Formulary
    Green
    MR tablets
  • Prescribe by brand. For advice on the most cost-effective brand contact your local Medicines Management Team. 
  •    
     ....
     Non Formulary Items
    Controlled Drug  Dextromoramide

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    Non Formulary
    Grey
    Tablet
     
    Controlled Drug  Dipipanone  (Diconal®)

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    Non Formulary
    Grey
    Tablet
     
    Controlled Drug  Fentanyl
    (Actiq lozenges)

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    Non Formulary
    Red
  • NUH only
  • Very expensive (~£6 per dose)
  •  
    Controlled Drug  Fentanyl  (Effentora® buccal tablets)

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    Non Formulary
    Grey
  • Reviewed and rejected- Abstral is preferred tablet formulation (see above)
  • Link  Link to reviews
     
    Controlled Drug  Fentanyl  (Instanyl® nasal spray)

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    Non Formulary
    Grey
    Reviewed and rejected- PecFent is preferred intranasal formulation (see above)
    Link  Link to reviews
     
    Controlled Drug  Fentanyl Buccal Film  (Breakyl)

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    Non Formulary
    Grey
    • No formal submission
    Link  Link to reviews
     
    Controlled Drug  Hydromorphone  (Palladone®)

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    Non Formulary
    Grey
     
    Meptazinol  (Meptid®)

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    Non Formulary
    Grey
    Tablet
     
    Controlled Drug  Morphine and cyclizine  (Cyclimorph®)

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    Non Formulary
    Grey
     
    Controlled Drug  Morphine suppositories

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    Non Formulary
    Grey
    Unlicensed ’special’
  • No formal assessment
  •  
    Controlled Drug  Oxycodone MR  (Onexila XL®)

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    Non Formulary
    Grey

    No formal assesment.

    • Once daily MR oxycodone
     
    Controlled Drug  Papaveretum

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    Non Formulary
    Grey
    Injection
     
    Controlled Drug  Papaveretum
    (Papaveretum with hyoscine injection)

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    Non Formulary
    Grey
     
    Controlled Drug  Pentazocine

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

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Sufentanil  (Zalviso®)

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    Non Formulary
    Grey
    No formal assessment
     
    Controlled Drug  Targinact (Oxycodone/Naloxone)  (Targinact®)
    (Restless legs)

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    Non Formulary
    Grey
    No formal submission
     
    Controlled Drug  Targinact (Oxycodone/Naloxone)  (Targinact®)
    (Pain)

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    Non Formulary
    Grey

    Non formulary - APC July 2018 as per NHS England advice.

    Link  APC: Opioids for persistent noncancer pain guideline
    Link  NottsAPC: Laxative treatment guideline (see appendix 2)
     
    Controlled Drug  Tramadol and dexketoprofen  (Skudexa®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Link to reviews
     
    Controlled Drug  Tramadol Hydrochloride and paracetamol  (Tramacet®)

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    Non Formulary
    Grey
    Link  PrescQIPP: Tramacet review
     
    Controlled Drug  Tramadol oral drops

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    Non Formulary
    Grey
    100mg/ml oral dops.
    Use dispersible tablets if liquid preparation required.
     
      
    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

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

    netFormulary