• Oral diclofenac is restricted to short-term use for post operative pain.
• If long-term use is required diclofenac is only approved for 4th line treatment (see below):
  
  • Ibuprofen low dose – first line treatment.
  • Naproxen low dose – second line treatment.
  • Naproxen high dose – third line treatment.
  • Diclofenac – fourth line treatment.

First line

• 15mg tablets

Second line

• 30mg tablets

The following codeine preparations are unlicensed and approved for use:

• 30 mg suppositories.
• codeine 2mg, 3mg, 6mg, 15mg;
• codeine 30mg in 1ml injection 

Modified release

• 10mg, 30mg, 60mg, 100mg, 200mg MR capsules(Zomorph^®) - 1st choice modified release preparation
• 5mg, 10mg, 15mg, 30mg, 60mg, 100mg, 200mg MR tablets (MST^®) - 2nd choice modified release preparation

Immediate release

• 1mg, 2.5mg, 5mg, 10mg, 20mg & 30mg oro-dispersible tablets (Actimorph^®) 
• 10mg in 5ml oral solution. There are safety concerns associated with the use of oral morphine sulfate solution in primary care. It is a high-risk medication with increased risk of overdose and death. Coroners have raised concerns about its safety.

Injection

• 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml injection

Other approved formulations

• 100 micrograms/1 ml oral solution. For use in neonates  unlicensed
• morphine 5mg in 1ml injection  unlicensed 
• 10mg in 1ml preservative free injection  unlicensed
• 2mg in 5ml epidural  unlicensed
• 50mg in 50ml PCA injection 

• Palliative care use  
• 500micrograms in 1ml [ST&S], 1mg in 2ml, 5mg in 10ml & 5mg in 1ml injection ampoules - approved for initiation by specialists in palliative care  
• All non-palliative care indications 

•  Unlicensed intranasal diamorphine is approved for use in children for the relief of severe pain due to clinically suspected limb fractures, burns and significant fingertip injuries. Appropriate risk assessments are to be conducted by each organisation in order to determine formulation of choice (e.g. ampoules or intranasal spray).

• Note: intranasal diamorphine   

• 30 microgram sublingual tablets
• Approved for use during dressing changes in burns patients.
• Trusts that use this product should review its use after 6 months and submit the results to the FWG.

• 50mg capsules, 50mg dispersible tablets & 100mg/2ml injection
• Only approved for use as a second-line weak opioid analgesic for use in patients where treatment with possible alternatives such as paracetamol, NSAIDs, and codeine is insufficiently effective, not tolerated or considered unsuitable for other reasons.
• Note: modified release tramadol is not approved or recommended. 
• Note: tramadol and paracetamol combination products are classified as BLACK - not approved for use

• 200microgram sublingual tablets
• 300microgram in 1ml injection
• Buprenorphine patches (Preferred brand - Butec®) are approved for use in palliative care when fentanyl 12 microgram/hr transdermal patches exceed the patient’s analgesic requirements.

• 12, 25, 37.5, 50, 75 & 100 microgram/hour transdermal patches
  • Prescribe by brand. Mezolar® has replaced Matrifen® as the first choice brand. Patients who currently use Matrifen® can continue to do so if managing well.
• Fentanyl sublingual tablets (Abstral®)   restricted to use for breakthrough / rescue pain relief in palliative care on recommendation of a pain specialist or palliative care team.
• nasal spray 
  • approved for use in children during diamorphine shortage with appropriate local governance arrangements

The following preparations are approved:

• 5mg tablets;
• 5mg in 5ml mixture DTF & 5mg in 5ml sugar free solution
• 20mg in 1ml concentrated oral solution (unlicensed)
• 10mg in 1ml injection

• Approved only for use in patients who are intolerant of morphine. 

• Note: Oxycodone 50mg in 1ml injection  is also approved for use, but is restricted to controlled circumstances in palliative patients following risk assessment by individual organisations.

• Approved for use as part of Enhanced Recovery After Surgery (ERAS) as part of multi-modal enhanced recovery pathway following hip and knee surgery 

• The OxyPro® branded generic is preferred (most cost effective option). 

• The oral solution should be used instead of immediate release tablets. 

• Approved for use by chronic pain specialist in adults with severe pain who have been screened for a neuropathic element to their pain and are uncontrolled or experiencing GI side effects on existing therapy.

• Note: the use of dihydrocodeine 30mg tablets & 10mg in 5ml oral solution is no longer recommended for regular use. Codeine is the preferred weak opioid analgesic.
• Dihydrocodeine is only approved for use in antenatal from 36 weeks and postnatal patients immediately postdelivery / c-section where adequate pain relief has not been achieved using paracetamol and NSAIDs. Commencing during in-patient admission with up to 14 days prescribed and dispensed on discharge as a take home medication.

• For use in the treatment of neuropathic pain
• Gabapentin is also approved for hospital use  as an adjunct to other treatment in the management of peri/post-operative pain.  unlicensed
• GPs should not be asked to prescribe gabapentin for this unlicensed indication.
• Approved for intractable itch with severe burns 

• Pregabalin is restricted to use in the management neuropathic pain as a second choice where treatment with gabapentin has been unsuccessful or not tolerated.

• 100 units injection
• Prescribe by brand name.
• Approved for the treatment of myalgia temporomandibular disorders (M-TMD) and orofacial neuropathic pain (OFNP).

• Restricted use in treatment of trigeminal neuralgia only.

• For third-line use (after drugs such as the tricyclic antidepressants and gabapentin) in the treatment of neuropathic pain on the advice of pain specialists.

• Qutenza® cutaneous patch approved for the treatment of neuropathic pain as fourth line agent for neuropathic pain and in line with the attached regionally agreed pathway. 


• 0.075% cream (Axsain®) approved for post hepatic neuralgia and peripheral diabetic neuropathy 

Only for use in the treatment of post-herpetic neuralgia only on the advice of specialists and subject to an appropriate trial of efficacy in each individual patient.

• Please refer to Chapter 04.07.01

2.5 mg orodispersible tablets

• Used to help promote absorption of analgesics.

Topiramate is now contraindicated in pregnancy and in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled. 

Therefore:

• people of child-bearing potential – , with PPP
• people of childbearing potential with compelling reasons why PPP does not apply, and other people in whom the PPP does not apply – .

10mg and 60mg tablets

Approved for preventing migraine in line with NICE:

• they have 4 or more migraine days a month
• at least 3 preventative drug treatments have failed
• First 3 months supply from secondary care with a review at 3 months. If effective, transfer to primary care with a further 1 month supply from secondary care to allow for handover.

Clonidine is not generally recommended for migraine prophylaxis; may aggravate depression/cause insomnia.

100mg/1ml concentrate for solution for infusion

Approved for the prevention of chronic migraine in adults in line with NICE only if

• they have 4 or more migraine days a month

• at least 3 preventative drug treatments have failed

70mg/1ml and 140mg/1ml solution for injection (pre-filled pens)

Approved for the prevention of chronic migraine in adults in line with NICE only if

• they have 4 or more migraine days a month

• at least 3 preventative drug treatments have failed

225mg/1.5ml solution for injection (Pre-filled pens/syringes)

Approved for the prevention of chronic migraine in adults in line with NICE only if

• they have 4 or more migraine days a month

• at least 3 preventative drug treatments have failed

120mg/1ml injection

Approved for the prevention of chronic migraine in adults in line with NICE only if

• they have 4 or more migraine days a month

• at least 3 preventative drug treatments have failed

75mg oral lyophilisates

 for treating migraine in line with NICE 

 for preventing migraine in line with NICE 

• First 3 months supply from secondary care with a review at 3 months. If effective, transfer to primary care with a further 1 month supply from secondary care to allow for handover.

Only approved for use in accordance with NICE guidance. 

Note: sodium valproate 500mg & 1000mg MR granules (Episenta®) are also approved for use in those who have difficulty swallowing sodium valproate tablets. MR granules may be more convenient to use than large volumes of liquid formulations.

Valproate must no longer be prescribed to women and girls of
childbearing potential unless there is no alternative and they are on the
Pregnancy Prevention Programme (PPP)  

For information relating to alerts regarding valproate, including Drug Safety Updates and links to PPP materials, please use the following link:

MHRA Drug Safety Updates (valproate)

Valproate (Belvo, Convulex, Depakote, Dyzantil, Epilim, Epilim Chrono or Chronosphere, Episenta, Epival, and Syonell▼): new safety and educational materials to support regulatory measures in men and women under 55 years of age (MHRA Drug Safety Update January 2024)

Valproate use in men: as a precaution, men and their partners should use effective contraception (MHRA Drug Safety Update September 2024)

Valproate (Belvo, Convulex, Depakote, Dyzantil, Epilim, Epilim Chrono or Chronosphere, Episenta, Epival, and Syonell▼): review by two specialists is required for initiating valproate but not for male patients already taking valproate. (MHRA Drug Safety Update February 2025)

• Lithium should be prescribed by brand name.

• Lithium should be prescribed by brand name.