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

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Pain management for AKT NICE guidelines
Neuropathic pain Opioid conversion Controlled
drugs
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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 lt3/12 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
• Dont change Rx if its working (esp trigeminal
  neuralgia - no good evidence)

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Neuropathic pain

• 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

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First-line treatment

• 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

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First-line treatmentdiabetic neuropathy

• 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

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Second-line treatment

• If maximum tolerated dose of first-line treatment
  doesnt 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

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Third-line treatment

• 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)
• dont start opioids other than tramadol without
  specialist assessment (poor evidence, increased
  dependence)

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Opioid conversion
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
1/10th the potency of alfentanil Breakthrough
dose is 1/6th of 24hr background dose (except
alfentanil)
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Opioid conversion


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Controlled drugs
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