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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.07.02  Expand sub section  Opioid analgesics
 note 

BNF: Equivalent doses of opioid analgesics:

This is only an approximate guide (doses may not correspond with those given in clinical practice); patients should be carefully monitored after any change in medication and dose titration may be required.

Analgesic Route Dose
Codeine PO 100 mg
Diamorphine IM, IV, SC 3 mg
Dihydrocodeine PO 100 mg
Hydromorphone PO 2 mg
Morphine PO 10 mg
Morphine IM, IV, SC 5 mg
Oxycodone PO 6.6 mg
Tramadol PO 100 mg
PO = by mouth; IM = intramuscular, IV = intravenous, SC = subcutaneous
Controlled Drug Buprenorphine (Bunov® 7-day patch)
(5mcg/hr, 10mcg/hr, 20mcg/hr)
View adult BNF View SPC online View childrens BNF
First Choice
Brown

First choice brand of buprenorphine patches (replacing Butec). To be used on specialist recommendation only, in line with Opioid Prescribing Guidelines for Non Cancer Pain.

Only for patients with stable persistent pain who have swallowing difficulties or cannot tolerate other options. Not to be used for any other patient group.

APCO March 2019. 

 
Controlled Drug Buprenorphine (Hapoctasin® 72-hourly patch)
(35mcg/hr, 52.5mcg/hr, 70mcg/hr)
View adult BNF View SPC online View childrens BNF
Formulary
Amber Continuation

Suitable for prescribing in primary care following specialist recommendation as per Opioid Prescribing Guidelines for Non Cancer Pain.

Only for patients with stable persistent pain who have swallowing difficulties or cannot tolerate other options. Not to be used for any other patient group.

APCO September 2015. 

 
Link  UKMI Q&A: Minimising errors with buprenorphine patches
   
Controlled Drug Buprenorphine (Transtec® 96-hourly patch)
(35mcg/hr, 52.5mcg/hr, 70mcg/hr)
View adult BNF View SPC online View childrens BNF
Formulary
Amber Continuation

Suitable for prescribing in primary care following specialist recommendation as per Opioid Prescribing Guidelines for Non Cancer Pain.

Only for patients with stable persistent pain who have swallowing difficulties or cannot tolerate other options. Not to be used for any other patient group.

APCO September 2015. 

 
Link  UKMI Q&A: Minimising errors with buprenorphine patches
   
Codeine
(Analgesia)
View adult BNF View SPC online View childrens BNF
Formulary
Green

In line with Opioid Prescribing Guidelines for Non Cancer Pain.

APCO September 2015. 

 
Link  MHRA: Children restrictions for codeine (July 2013)
Link  MHRA: Children restrictions for codeine (June 2013)
   
Controlled Drug Diamorphine
(5mg, 10mg, 30mg, 100mg)
View adult BNF View SPC online View childrens BNF
Formulary

Green Traffic Light  For acute or severe pain.

Red Traffic Light  For substance misuse.

APCO July 2011.

 
   
Controlled Drug Diamorphine
(500mg)
View adult BNF View SPC online View childrens BNF
Formulary
Red

Secondary care use only. 

APCO July 2011.

 
   
Dihydrocodeine
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Brown

NB: Not included in Opioid Prescribing Guidelines for Non Cancer Pain.

 
Controlled Drug Injection Only
   
Controlled Drug Fentanyl
(Nasal spray)
View adult BNF View SPC online View childrens BNF
Formulary
Red

For acute severe pain in adolescents at Helen House (End of Life). 

APCO May 2018. 

 

 
   
Controlled Drug Fentanyl (Fencino®)
(Patch)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Brown

Restricted for patients who have stable pain and are unable to take medication orally. In line with Opioid Prescribing Guidelines for Non Cancer Pain.

NB. Fentanyl is a very strong opioid, e.g. 50mcg/hr patch = 120mg morphine daily (Fentanyl conversion ratio table is available in the guideline).

See Good Practice Guidance: Use of Transdermal Fentanyl Patches and record sheet.

APCO September 2015. 

 
Link  NICE Evidence Summary: Moderate to severe acute post-operative pain - fentanyl transdermal patch
Link  MHRA: Fentanyl - warning regarding accidental exposure
Link  MHRA: 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
   
Fentanyl  (Ionsys®)
(Transdermal system)
View adult BNF View SPC online View childrens BNF
Formulary
Red

For moderate to severe acute post-operative pain.

APCO May 2008.

 
Link  NICE Evidence Summary: Moderate to severe acute post-operative pain - fentanyl transdermal patch
Link  MHRA: Fentanyl - warning regarding accidental exposure
Link  MHRA: 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 Methadone
(Analgesic)
View adult BNF View SPC online View childrens BNF
Formulary
Amber Continuation

Suitable for continuation in primary care following specialist initiation.

 
   
Controlled Drug Morphine
View adult BNF View SPC online View childrens BNF
Formulary
Green

In line with Opioid Prescribing Guidelines for Non Cancer Pain.

APCO September 2015. 

 
   
Controlled Drug Morphine suppositories
View adult BNF View SPC online View childrens BNF
Formulary
Amber Continuation

Suitable for continuation in primary care following specialist initiation.

 
   
Controlled Drug Oxycodone
(Oral)
View adult BNF View SPC online View childrens BNF
Formulary
Green

NB. Modified-release tablets: Longtec® is bioequivalent to oxycontin®. Longtec® is the first line oxycodone long acting preparation for Oxfordshire (APCO November 2013).

See Opioid Prescribing Guidelines for Non Cancer Pain.

APCO September 2015. 

 
   
Controlled Drug Oxycodone 10mg/ml
(Injection)
View adult BNF View SPC online View childrens BNF
Formulary
Green
For palliative care use only. 
   
Controlled Drug Oxycodone 50mg/ml
(Injection)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Brown

Restricted for use in a syringe driver where volume is an issue.

APCO May 2011.

 
   
Controlled Drug Pentazocine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Continuation

Suitable for continuation in primary care following specialist initiation.

 
   
Controlled Drug Pethidine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Continuation

Suitable for continuation in primary care following specialist initiation.

 
   
Controlled Drug Tramadol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Use if codeine ineffective, in line with Opioid Prescribing Guidelines for Non Cancer Pain.

APCO September 2015. 

For neuropathic pain see Guideline for the Management of Neuropathic Pain in Primary Care.

APCO March 2017.

 
   
 ....
 Non Formulary Items
Controlled Drug  Alfentanyl Sublingual Spray 5 mg in 5mL

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Buprenorphine
(Sublingual tablets - Pain)

View adult BNF View SPC online View childrens BNF
Non Formulary

See Opioid Prescribing Guidelines for Non Cancer Pain.

 
Controlled Drug  Buprenorphine  (Butrans® patch)
(5mcg/hr, 10mcg/hr, 15mcg/hr, 20mcg/hr)

View adult BNF View SPC online View childrens BNF
Non Formulary

Prescribe Butec® for new patients when recommended by a specialist only. Consider switching existing patients using buprenorphine 7 days patches to Butec®.

See Opioid Prescribing Guidelines for Non Cancer Pain.

 
Controlled Drug  Dextromoramide

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Dihydrocodeine Tartrate  (DF 118 Forte®)

View adult BNF View SPC online View childrens BNF
Non Formulary

Controlled Drug Injection Only
 
Dihydrocodeine Tartrate  (DHC Continus®)

View adult BNF View SPC online View childrens BNF
Non Formulary

Controlled Drug Injection Only
 
Controlled Drug  Dipipanone  (Diconal®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

For substance misuse.

APCO July 2011.

 
Controlled Drug  Fentanyl
(Buccal/ Sublingual Tablets)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

Previously ‘non-formulary’. Updating in line with NHS England Items which should not routinely be prescribed in primary care guidance.

APCO September 2019.

 
Controlled Drug  Fentanyl  (Actiq®)
(Lozenges)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

For breakthrough pain. Limited information available regarding place in therapy.

APCO November 2008.

 
Controlled Drug  Fentanyl Buccal Film  (Breakyl®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

Previously ‘non-formulary’. Updating in line with NHS England Items which should not routinely be prescribed in primary care guidance.

APCO September 2019.

 
Controlled Drug  Fentanyl sublingual tablets  (Abstral®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

Previously ‘non-formulary’. Updating in line with NHS England Items which should not routinely be prescribed in primary care guidance.

APCO September 2019.

 
Controlled Drug  Hydromorphone  (Palladone®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Hydromorphone Hydrochloride  (Palladone® SR)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Meptazinol  (Meptid®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Morphine and cyclizine  (Cyclimorph®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Oxycodone and Naloxone  (Targinact®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

Not recommended for:

  • Pain management (APCO July 2009).
  • Restless legs syndrome (APCO March 2016).

 
Controlled Drug  Papaveretum

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Papaveretum and Hyoscine
(Injection)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Pethidine Hydrochloride and promethazine  (Pamergan® P100)

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

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Tapentadol  (Palexia®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

Not recommended due to lack of evidence of clinical efficacy compared to standard treatment.

APCO July 2011.

 
Controlled Drug  Tramadol Hydrochloride and Paracetamol  (Tramacet®)

View adult BNF View SPC online View childrens BNF
Non Formulary
Black

Not recommended for prescribing due to sub-therapeutic doses.

APCO March 2006.

 
Controlled Drug  Tramadol oral drops

View adult BNF View SPC online View childrens BNF
Non Formulary

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

Red

Red: Medicines which should only be prescribed in secondary care by a specialist.  

Amber Continuation

Amber Continuation: Medicines which should be initiated or recommended by a specialist for continuation in primary care. The specialist must notify the GP that the prescribing responsibility has been transferred.   

Amber Shared Care Protocol

Amber Shared Care Protocol: Medicines which are appropriate to be initiated and stabilised by a specialist, once stabilised the medicine may be appropriate for responsibility to be transferred from secondary to primary care with the agreement of a GP and a formal ‘shared care’ agreement. The shared care protocol must be approved by the Area Prescribing Committee Oxfordshire (APCO).   

Green

Green: Medicines which are suitable for initiation and ongoing prescribing within primary care.   

Brown

Brown: Medicines which should only be prescribed in restricted circumstances.  

Black

Black: Medicines which are not recommended for use because of lack of evidence of clinical effectiveness, cost effectiveness or safety.  

OCCG Green

not used  

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