UK pain meds - what's available stronger than codeine (exc tramadol)

[monkeygone2heaven]

swim wants to bring up again the issue of UK... swim moved here after being a chronic pain patint in the US for many years. she takes Tramadol for chronic pain regularly. for breakthrough pain, in the US swim took Vicodin or Oxycodone. these don't exist in the UK.

swim had a real upsurge in pain and was just given co-codamol 30/500 - which has 30 mg of codeine phosphate and is similar to Tylenol with codeine in the US. swim does not get any serious pain relief with this whereas she did get better relief from the US painkillers.

swim's doctor is allright and wants to help (after a bad experience with one who freaked out about having to treat a pain patient and tried to giveher OTC codeine for several year persisting chronic pain...). the doctor saud to try the co-codamol and contact him and tell him how it went. as i said above, it was not all that successful.

the question now is, what should swim ask for for breakthrough pain? what is available in the UK stronger than codeine. and remember swim already take tramadol (plus topiramate) daily just to maintain.

thanks!

[Jatelka]

Oxycodone is available in the UK, but is generally used for cancer pain.

The "analgesic-ladder" suggests that if pain is unresponsive to regular paracetamol and a SINGLE regular weak opiate then a strong opiate should be considered.

The most common strong opiate in the UK is morphine sulphate. This is available in CR (most common are MST continus or Zomorph) and fast acting preparations (commonly Oromorph or Sevredol), which would be used for breakthrough

Consideration should also be taken as to whether an NSAID (non-steroidal anti-inflammatory) like diclofenc (Voltarol) would be beneficial

SWIY states that they are already on topiramnate. Some pain specialists would consider adding in or substituting a small dose of amitryptiline.

Depending on the cause of pain, then referral to a chronic pain specialist for consideration of other techniques, such as trigger-point or facet joint injections, TENS machine etc. would be appropriate

[monkeygone2heaven]

thanks Jatelka! this helps a lot.

do you have any links for the 'analgesic ladder' as practiced in the UK?

it's neuropathic pain so NSAIDs do not help very often. neither did TENS or nerve blocks of various sorts. you're right amytriptyline would be something to try. swim's old pain doctor was hesitant to add it to the mix because swim gets too much sedation as it is from topiramate and needs to be alert for work. swim tried other antidepressants which are not considered as effective but in combination with the rest, were helpful (and way better side-effects-wise).

it appears swim needs a high dose of codeine. maybe tolerance even though don't use opiates regularly. swim got some decent pain relief after taking more but concerned about the paracetamol. swim might have to do CWE. but the more sensible thing is to find something stronger.on the other hand, swim is not sure she wants to go up to morphine yet. do you know comparison of potency between morphine pills and say hydrocodone?

[stoneinfocus]

Swims taking diclofenac injections 75mg which are great for pain relief, even better sometimes than tramadol, but he does it on his own bill (quote "today we use opiates for chronic pain -"can I get some" -"No" ), tens is only good for building muscles and some electrco massage... and swims tens is like a spaceship compared to a radio, when he´s looking the tens of his medics from the 70ies *lol*

Isn´t the UK prescribing Heroin in to be taken at the doc´s reception?

Sorry for being off-topic, swim was crawling the last few years from time ot time over the floor for hours because the pain was so immens, he felt breakthrough pain by yearning, or breathing too quichly, he didn´t know opiates might stop breakthrough pain, and he never heard of it being discussed or asked by a doc or specialist here, notr whether swim´s experciencing such pain.

[monkeygone2heaven]

glad diclofenac helps swiy's pain. it's an NSAID and swim doesnt get relief from those as her pain is neuropathic in origin.

swim used to have very severe pain but it's under control most of the time through various meds and meditation. but if swim hurts herself or sometimes randomly then there are periods of intense pain and swim takes opiates.

swim did not have trouble getting opiates for pain in the USA -- in fact she didn't have to ask for them, many times the opposite. (this was in CA and pain clinic but my GP also would give them to me).

swim's pretty sure you can't get heroin from the doctor, at least not a GP and for pain. maybe substance abuse centres or clinics?

the UK thing is confusing swim but she's finding out more as she deals with the system and here at the forums. but clearly it is much less common to use opiates here than in the US.

[Jatelka]

Here SWIY goes:

Analgesic Ladder

The World Health Organization (WHO) has produced an analgesic ladder to be used as a guide for prescribing analgesics. If a patient does not experience pain relief on one step of the analgesic ladder, they should progress to the next step.

Oral analgesic drugs are usually the first line treatment for treating pain. The choice of analgesic should be based on the severity of the pain rather than the stage of the patient's disease. Analgesics should be taken regularly and the dose gradually increased, as necessary.
Step One

The first step of the analgesic ladder is to use a non-opioid analgesic, for example paracetamol. Adjuvant drugs to enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and provide independent analgesic activity for specific types of pain may be used at any step (eg NSAIDS)
.
Step Two
If the pain is persisting or worsening despite step one then a mild opioid such as codeine should be added (not substituted). Examples are combination preparations including co-proxamol and co-codamol.

Step Three
When higher doses of opioid are necessary, the third step is used. At this step an opioid for moderate to severe pain is used, eg morphine. The dose of the stronger opioid can then be titrated upwards, according to the patient's pain as there is no ceiling dose for morphine.

Medications for persistent pain should be prescribed on a regular basis and patient should always have extra medication available to take in between doses if they experience break-through pain

[monkeygone2heaven]

thanks much. cheers!

[Fantasian]

SWIF's friend had neuropathic pain and he found that amitriptyline did wonders, also one might look at gabapentin or pregablin. SWIF has had some experience with them being very effective again with neuropathic

[monkeygone2heaven]

thanks Fantasian. indeed those things help. i coudn't tolerate side effects of amytryptyline but use a different combination of antidepressants i could tolerate. plus topiramate (again gabapentin was too bad side effects). these things got my pain under control but i still have days when i need some extra help and take opiates.

Originally Posted by Fantasian

SWIF's friend had neuropathic pain and he found that amitriptyline did wonders, also one might look at gabapentin or pregablin. SWIF has had some experience with them being very effective again with neuropathic

[monkeygone2heaven]

thanks everyone this helps a lot!

i have not been as badly in pain as i used to be so lately i have not needed too much extra opiates on top of my meds. but last month i needed some extra pain relief. the doctor tried co-codamol (prescription/max strength). it was really not very effective plus bad nausea. this time i will try dihydrocodeine. will see what happens. but in the US i used to take hydrocodone or oxycodone. these helped the pain a lot more than this co-codamol. i heard some people don't get relief from codeine though... maybe that's something to consider.

cz-one i agree that they're much more stringent than in the USA pain clinics (who are way too liberal with pain meds if you ask me and i am someone who needs the pain relief!) but i have only been to GPs and not pain specialists so i dont' know about UK system's "limits".

AceovArts, thanks much for your input. hope your wife is doing well now.

raw edge: the issue wth OTC codeine is for it to have effect, i'd have to take a lot and then get too much paracetamol and in the long term there is liver issues.

[Raw edge]

SWIY should consider nurofen plus. Each tablet contains 200mg ibuprofen and 12.8mg codeine phosphate. Normal dosage is two tablets at a time.
Maximum recomendation is 6 tablets a day. This equals 1200mg of ibuprofen.

Dosages of 3200mg is the maximum daily dosages recommended. This equates to 16 tablets. i.e 4 tablets four times a day equating to 800mg ibuprofen and 51.2mg codeine.

Only take this kind of dosage under guidance of your doctor.

Another option would be is Panamol which contains paracetemol (acap) 500mg and dihydrocodeine titrate 7.48mg. In this case your dihydrocodeine dosage is limited severly by the maximum recommended paracetemol (acap) dosage.

[AceOvArts]

just as a small note of my wifes experience with chronic back pain (ultimately resulting in an operation to fuse 2 discs) She was never prescribed morphine (only administered this in hospital). The strongest drug used was 50mg (I think) df118 (dihydrocodeine), more commenly she was ghiven co-proximol which has since been discontinued in the UK. She has used used co-codemol, co-dydromol, diclofenac as an anti inflamitory, when things were at thier worst she was given a cortizone injection to her spine.
So as you see morphine is not prescribed flippantly, if youre still suffering chronically Im sure your doctor will help, otherwise ask for another opinion, speak to another GP or your consultant.

[cz-one]

Here in the UK,ive found that DR's are loathed to prescribe strong opiates for
chronic pain syndromes and prefer to mix medium strength opiates with NSAIDS etc. When they do finally decide to prescribe strong opiates they go
for fentanyl patches,hydromorphone,oxycontin etc.,as for prescribing diamorphine,the only patients who get that,tend to be terminal cancer patients,and in very,very limited amounts to chronic extreme addicts in
specialist drug units,to qualify for it,you have to have long.long histories of
jails/hospitals/infectious diseases and multiple failed attempts at detoxes and
rehabs,its basically used as a last ditch attempt at stopping the addict killing themselves.