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DRUG INFORMATION Sometimes, an escalation of strong opiates leads to benefit for a few weeks followed by a return of pain to original levels. If this occurs, do not escalate doses further. Consider alternative groups of analgesia or early referral to the pain clinic. Consider a review within 4 weeks of an escalation of the opiate dose, with an expectation that the dose will be reduced if there is no clear improvement in pain or function. If the dose has reached 180mg morphine or equivalent, it is almost never helpful to escalate the dose further. Consider adding alternative medications and /or referral to the pain clinic. Codeine and Dihydrocodeine (DHC) 10% of Caucasians do not metabolise codeine; DHC can be used instead Adverse effects include constipation, drowsiness, addiction, tolerance Buprenorphine patch (Butrans) Consider use if patient is unable to tolerate side effects of codeine/DHC Can be useful when pain is stable Accumulates less than oral preparations in renal failure Tramadol Has mixed opioid/SNRI activity; consider used in mixed/neuropathic pain Generally not well tolerated in the elderly Can lower seizure threshold, so should be used with care in epileptics Oxycodone MR Consider if good analgesic effects with morphine but intolerant of side effects Reduced incidence of hallucinations and nausea compared to morphine Note that oxycodone is twice the potency of oral morphine. Ie 10mg oxycodone Is equivalent to 20mg oral morphine. (Opiate equivalence Tool) Fentanyl (Matrifen) patch Do not prescribe for opiate naïve patients May accumulate less in renal failure and cause less constipation than oral morphine Amitriptyline Titrate up slowly to reduce side effects Best taken in the evening to reduce “hang over effect” eg 6-8 pm Usual maintenance dose is 1-=30mg but up to 75mg can be used if benefits outweigh side effects Initial side effects often settle, so encouraging patients to persist can be worthwhile Nortriptyline is less sedating Contraindicated in some conditions eg closed angle glaucoma, severe cardiovascular disease, arrhythmia, prolonged QT, urinary retention Gabapentin Consider slow titration in elderly or those susceptible to side effects Max dose 900mg tds Taper and stop if no benefit Pregabalin At present must be prescribed as Lyrica in neuropathic pain Useful if anxiety co-exists Use bd preparation (cheaper than tds) Consider slow titration in elderly or those susceptible to side effects Taper and stop if no benefit Duloxetine Use first line in diabetic neuropathy Useful if depression co-exists Take with food; nausea may settle with continued treatment C/I: hepatic impairment or severe renal impairment Do not co-prescribe another antidepressant nor use with amitriptyline>25mg Response is usually seen in one week and is unlikely if not seen by eight weeks Taper over 2 weeks if stopping.