Transcript Using this template

Pain management for AKT
NICE guidelines: Neuropathic pain
Opioid conversion
Controlled drugs
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 <3/12 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
• Don’t change Rx if it’s working (esp trigeminal
neuralgia - no good evidence)
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
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
First-line treatment:
diabetic 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
Second-line treatment
If maximum tolerated dose of first-line treatment doesn’t 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
Third-line treatment
If satisfactory pain reduction is not achieved with secondline treatment:
•refer to a specialist pain service and/or a conditionspecific service
and
•consider additional or alternative treatment options while
waiting for referral (e.g. tramadol, topical lidocaine)
•don’t start opioids other than tramadol without specialist
assessment (poor evidence, increased dependence)
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)
Opioid conversion
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