Chronic pain – anticonvulsants

Background (age, sex, occupation, baseline function)

• 47-year-old female
• Police officer

History of presentation/reason for review

• She self-presents concerned about the impact of medicines and side effects on her ability to do her job. Recently she had tried to stop them all completely and felt awful, like she had the flu. She is concerned that she is addicted 

Current medical history and relevant co-morbidities

• Chronic low back pain and neuropathic leg pain following accident at work - two years ago
• Menopause - three years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions: nil

• Femoston-conti® 1mg/5mg tablets: one tablet daily
• Gabapentin 300mg capsules: three capsules three times daily
• Paracetamol 500mg caplets: two tablets up to four times daily when required
• Tramadol 50mg capsules: two capsules four times daily

Over the counter medicines: nil

Lifestyle and current function

• Lives with husband and two teenage sons
• After accident was moved from being on the beat to a desk job as was overly sedated on medication
• Not as active due to back and leg pain, and sedentary job
• Avoids driving due to drowsiness
• Concerned she is putting on weight despite a healthy diet
• Non-smoker
• Alcohol less than seven units/week

“What matters to me” (ideas, concerns and expectations of treatment)

• “Pain has been improving so I tried to stop the medicines because they made me so tired. Burning and shooting feeling had gone”
• “One day I decided enough was enough, and just stopped taking the gabapentin and the tramadol. I don’t really use the paracetamol very often”
• “I felt so bad, my pain was worse, it was as though I had flu and I ended up taking them again - I’m scared to try stopping them now”

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• Weight 74.3kg, Height 168cm, BMI 26kg/m²
• Serum creatinine 84micromol/L (60-120micromol/L)
• FBC in normal range
• MRI - nothing abnormal

Most recent relevant consultations

• Gabapentin dose was increased eight months ago following a fall which had flared up her pain

Person specific issues to address

• Concerned regarding side effects and possible ‘addiction’ 
• She feels original pain improved  
• Gaining weight despite healthy diet 

 

Person specific issues to address

• Essential - none

 

Person specific issues to address

• Pain improved. May not need higher dose gabapentin or full dose tramadol, both would need slowly reduced to avoid adverse effects of withdrawal. Reduce one at a time

 

Person specific issues to address

• Pain improved overall 
• Consider therapeutic paracetamol, if evidence of benefit. May need tramadol as required

 

Person specific issues to address

• Gabapentinoid and opioid both central nervous system depressant with risk of dependency 
• Weight gain: gabapentin adverse effect includes abnormal appetite, therefore although diet is healthy may be consuming more. Previous pain and sedation could result in less physical activity. Increased weight can lead to joint pain
• Counsel and agreed shared decision to gradually reduce to lowest effective dose or stop

 

Person specific issues to address

• Consider non-pharmacological ways to manage pain
• Advised to dispose of medicines through the community pharmacy 
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Discuss reduction plan advising that it may take several weeks or months to gradually reduce  
• Discuss likely side effects of withdrawal and how to mitigate 
• Explain the need to monitor pain, and stop at lowest effective dose if needed  
• Could consider when required NSAID to help manage any flare up  
• Additional steps: signpost to supported self-management and other allied team members to support activity management and pacing