NHS Dudley Health Economy Medicines Formulary
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4.7.2 Opioid analgesics

General guidance

  • Opioid analgesics are usually used to relieve moderate to severe pain particularly of visceral origin.
  • Repeated administration may cause dependence and tolerance, but this is no deterrent in the control of pain in terminal illness.
  • Opioid analgesics share many side-effects although the frequency and severity differs between individual drugs.
  • Morphine remains the most valuable opioid analgesic for severe pain although it frequently causes nausea and vomiting. In addition to analgesic properties, morphine also confers a state of euphoria and mental detachment. Morphine is the opioid of choice for the oral treatment of severe pain in palliative care.
  • Buprenorphine has both opioid agonist and antagonist properties and may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids. This agent is also noted for its emetogenic potential. Its use should therefore be discouraged. Note BuTrans patch was NOT approved for inclusion on the Dudley Formulary (Dec 2009).
  • Fentanyl is available in transdermal patches; these are designed to release the drug at a steady rate over three days and so should not be replaced more frequently than this. However, the dosage can be difficult to titrate to achieve a balance between efficacy and side-effects and it is important that analgesic control is achieved before considering therapy with fentanyl patches. Fentanyl patches provide a useful alternative for those unable to take oral medication (including liquid forms) or for situations were a sub-cutaneous syringe driver is considered unsuitable.
  • Fentanyl transdermal patches - Prescribing Guidelines can be accessed by clicking here
  • Fentanyl buccal tablets (Effentora) for patients requiring submucosal preparations for break through pain relief due to inability to take oral formulations (who are already recieving opioid therapy for chronic cancer pain). To be used under specialist recommendation only.
  • Fentanyl nasal spray (Instanyl) for patients requiring nasal preparations for break through pain relief due to inability to take oral/buccal formulations. To be used under specialist recommendation only.

Recommended drugs

Codeine £

Morphine ££

Fentanyl patches £££

Oxycodone hydrochloride prolonged-release tablets: Oxypro PR (1st line);  Oxeltra PR (2nd line) 

Marol (Tramadol) prolonged release tablets 100mg, 150mg, 200mg  

Fentanyl lozenges £££

Fentanyl buccal tablets (Effentora) £££

Fentanyl nasal spray (Instanyl) ££££


ACE non- approved drugs

Targinact (oxycodone with naloxone)

Butec transdermal patch

Longtec prolonged release tablets


Drug Traffic Light Key:

Green – On Formulary

Amber – Restricted use, see local guidelines      

Purple – Specialist use/initiation

Red – Non Formulary


Relative Costs Key (where indicated):

£££££ - high

£££ - moderate

£ - low

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