Opioid Analgesics (pain control)

Tramadol is a weak opioid which is no more effective than co-codamol. It is not as effective in severe pain as other opioids. It may cause nausea and dizziness particularly in the elderly. Psychiatric reactions (eg hallucinations) have been reported and there is an increased risk of convulsions in epilepsy. There is also a risk of developing serotonin syndrome when co-prescribed with other serotonergic drugs eg SSRIs. It may also interact with warfarin.

Buprenorphine is a partial agonist at opioid receptors (it has opioid agonist and antagonist properties). In overdose it's effects are only partly reversed by naloxone. Buprenorphine sublingual tablets are for acute pain, and the patches are only for chronic pain.

Oxycodone is for use on the advice of the acute pain team or in palliative care

MTW: Fentanyl injection (100micrograms/2ml) has been approved for use intranasally (unlicensed route) for moderate to severe pain in children > 1 year presenting to A&E with fractures, dislocations, burns or major lacerations. It should be used according to the approved MTW SOP for this found on the intranet.

Tapentadol IR and oral solution are non-formulary and restricted for use where morphine and/or oxycodone have failed to provide adequate pain control or have been tried and not tolerated. 

Diamorphine is used for acute pain, in acute pulmonary oedema and myocardial infarction. It is widely used in palliative care for subcutaneous continuous infusion via a syringe driver. Hospital only, unless under specialist palliative care advice.

Hospital only, unless under specialist palliative care advice. 

Pethidine has occasionally been used off-licence for pyrexia and reactions associated with antibody therapy. There is no robust evidence base in the literature for this usage. In practice it would not just be used for any pyrexia, but for difficult to manage patients with Grade 2 or 3 infusion-related syndrome at a single dose of 25mg IV. It should be a third line option, not used routinely or as a standard. Those requiring it would need to be monitored closely every 15 minutes. If there is a reaction the patient would remain on higher monitoring. Prescription of this should be by a haematology registrar on the haematology wards only. It is not to be prescribed by Junior doctors on general wards.