MTW NHS Trust West Kent CCG

Drug Status Key

  • Preferred
  • Second Line
  • Third Line
  • Specialist Initiation
  • Hospital Only
  • Not Approved for Formulary

Opioid Analgesics (pain control)

Drug Safety Update

 September 2008: Serious and fatal overdose with fentanyl patches

 July 2013: Codeine for analgesia: restricted use in children due to morphine toxicity.

 July 2014: Transdermal fentanyl patches reminder of potential for life-threatening harm from accidental exposure particularly in children

 October 2018: Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children

 Safety warning letter there is a risk of serotonin syndrome developing if fentanyl patches are used concurrently with serotonergic drugs. Please note the letter refers only to the brand Durogesic Dtrans®.

 Drugs and driving: blood concentration limits to be set for certain controlled drugs in a new legal offence, July 2014. See also the drugs and driving: the law government webpage for more details

March 2020: Benzodiazepines and opioids: reminder of the risk of potentially fatal respiratory depression

September 2020: Opioids: risk of dependence and addiction

September 2020: Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients

NICE guidelines

 CG 140 Palliative care for adults: strong opioids for pain relief, updated August 2016

 NG 59 Low back pain and sciatica in the over 16s: assessment and management, November 2016

 NG 46: Controlled drugs: safe use and management, April 2016

Local Guidelines

See here for local Trust pain guidelines

See here for the following K&M ICB guidelines & resources:-

  • Guidance to Support the Safe and Effective, Initiation and Review of Opioids
  • Opioid Tapering Resource Pack
  • Opioid Prescribing Position Statement
  • Information Leaflet - Ten Opioid Safety Messages
  • Position Statement on Prescribing Liquid Morphine Sulfate in Kent & Medway
  • Morphine Sulfate 10mg in 5ml Oral Solution Appropriate Use Guidance
  • Patient Information Leaflet for Actimorph (morphine) orodispersible tablets

See here for K&M ICB Controlled Drugs / Benzodiazepine Prescribing Patient Treatment Agreement

See Q-pulse for local MTW SOPs for Controlled Drug management

See local guidance above for choice of opioid and recommended dosing.

Remember to co-prescribe both an antiemetic and a laxative for use when necessary - see local guidance above.

Note: If a patient is having PCA (patient controlled analgesia), ensure that additional opioids including codeine are NOT prescribed as there is an additive effect with increased likelihood of side effects.

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.

Morphine sulphate (Actimorph) orodispersible tablets (immediate release)

For primary care: Actimorph is on formulary as green for primary care as an alternative choice to morphine sulphate 10mg/5ml oral solution. See above position statement and appropriate use guidance for morphine sulphate oral solution.

In hospital, the following has been agreed:-

  • Morphine orodispersible immediate release (IR) tablets (Actimorph) can be prescribed as second choice of morphine preparation for moderate or severe pain in place of Sevredol or Oramorph (first line choice)
  • It is unlikely that orodispersible morphine (Actimorph) will be required for patients with acute pain in hospital unless it is used in preparation for discharge.
  • It is recommended that patients admitted on orodispersible morphine tablets are changed to Oramorph whilst an inpatient.
Pack Price
100 tablet £2.68
28 tablet £0.75
30 tablet
500 tablet
Pack Price
100 tablet £4.14
28 tablet £1.16
30 tablet
500 tablet
Pack Price
100 tablet
28 tablet £1.99
30 tablet
Pack Price
500 ml £6.64
Pack Price
10 ampoule

See here for the following K&M ICB guidance:

  • Position Statement on Prescribing Liquid Morphine Sulfate in Kent & Medway
  • Morphine Sulfate 10mg in 5ml Oral Solution Appropriate Use Guidance
Pack Price
100 ml £2.41
300 ml £7.22
500 ml £12.03
Pack Price
56 tablet (8 x 7 tablets) £2.00
Pack Price
56 tablet (8 x 7 tablets) £2.50
Pack Price
56 tablet (8 x 7 tablets) £3.50
Pack Price
56 tablet (8 x 7 tablets) £4.75
Pack Price
56 tablet (8 x 7 tablets) £9.50
Pack Price
56 tablet (8 x 7 tablets) £13.00
Pack Price
56 tablet (4 x 14 tablets) £5.31
Pack Price
56 tablet (4 x 14 tablets) £10.61
Pack Price
56 tablet (4 x 14 tablets) £28.02
Pack Price
60 tablet (2 x 30 tablets) £3.29
Pack Price
60 capsule (6 x 10 capsules) £3.47
Pack Price
60 capsule (6 x 10 capsules) £8.30
Pack Price
60 capsule (6 x 10 capsules) £16.20
Pack Price
60 capsule (6 x 10 capsules) £21.80
Pack Price
60 capsule (6 x 10 capsules) £43.60

Hospital only, unless under specialist palliative care advice

Pack Price
10 ampoule £7.52
Pack Price
1 vial £5.07
10 vial £50.70
Pack Price
100 tablet £7.89
28 tablet £2.21
30 tablet
500 tablet
Pack Price
56 tablet £5.20
Pack Price
56 tablet £8.66

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.

Pack Price
100 capsule £2.37
105 capsule
140 capsule
30 capsule £0.71
Pack Price
100 tablet (10 x 10 tablets) £13.33
20 tablet (2 x 10 tablets) £2.79
Pack Price
60 tablet (6 x 10 tablets) £6.98
Pack Price
60 tablet (6 x 10 tablets) £14.28
Pack Price
10 ampoule
5 ampoule £4.00

Safety information

Do not confuse the formulations of transdermal patches which are available as 72 hourly, 96 hourly and 7 day patches . Check carefully which brand is required and the appropriate dosage interval.

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.

Pack Price
50 tablet £5.04
Pack Price
2 patch
4 patch £17.60
Pack Price
4 patch £31.55
Pack Price
4 patch £57.46
Pack Price
3 patch
4 patch £15.80
5 patch
6 patch
Pack Price
3 patch
4 patch £23.71
5 patch
6 patch
Pack Price
3 patch
4 patch £31.60
5 patch
6 patch

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

Pack Price
250 ml £8.76
Pack Price
56 capsule £11.43
Pack Price
56 capsule £22.86
Pack Price
56 capsule £45.71
Pack Price
28 tablet
56 tablet £25.04
Pack Price
28 tablet
56 tablet £50.08
Pack Price
28 tablet
56 tablet £100.19
Pack Price
28 tablet
56 tablet £200.39

Hospital only, unless under specialist palliative care advice

Pack Price
10 ampoule
5 ampoule £3.61

There is a risk of serotonin syndrome developing if fentanyl patches are used concurrently with serotonergic drugs. For more details see the safety warning letter  please note the letter refers only to the brand Durogesic Dtrans®.

Fentanyl is a potent opioid – a 12 microgram (µg) per hour fentanyl patch equates to daily doses of oral morphine of up to 45mg a day.

Fentanyl patches are used for severe chronic pain and palliative care only. Do not use fentanyl patches in opioid-naive patient. It should only to be used on the advice of the pain team/palliative care team. Sublingual tablets are used for breakthrough pain in palliative care. 

Pack Price
5 patch £17.99
Pack Price
5 patch £33.66
Pack Price
5 patch £46.99
Pack Price
5 patch £57.86
Pack Price
10 tablet £49.99
30 tablet
Pack Price
10 tablet £49.99
30 tablet
Pack Price
10 tablet £49.99
30 tablet

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.

Pack Price
5 ampoule £12.80
Pack Price
5 ampoule £16.56
Pack Price
5 ampoule £16.52
Pack Price
5 ampoule £42.39