Chronic pain – opioids

Background (age, sex, occupation, baseline function)

• 74-year-old female
• Lives in ground floor flat
• Mobilises with walking aid but currently housebound 

History of presentation/reason for review

• Identified for review by a search in her GP practice (using Scottish Therapeutics Utility (STU)), as she is prescribed a high dose opioid (>50mg morphine equivalent)
• Currently taking Longtec® 90mg daily plus Shortec® 30mg daily (i.e. 180mg morphine equivalent daily (MED) dose)

Current medical history and relevant co-morbidities

• Lower back pain episode - six years ago
• Transient diplopia - cause uncertain – 10 years ago
• Essential hypertension – 14 years ago
• Barrett’s oesophagus with hiatus hernia – 14 years ago
• Chronic lower back pain - 24 years ago
• Cerebrovascular disease – 25 years ago
• Seronegative polyarthropathy – 25 years ago
• Osteoporosis – 26 years ago
• Anxiety – 31 years ago

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

Allergies or adverse drug reactions (ADRs)

• Adverse reaction to aspirin previously - GI upset

Current medication

• Amlodipine 5mg tablets: one tablet daily
• Clopidogrel 75mg tablets: one tablet daily
• Diazepam 2mg tablets: one tablet daily in the morning
• Longtec® 40mg tablets: one tablet twice daily
• Longtec® 5mg tablets: one tablet twice daily
• Mirtazapine 15mg tablets: one tablet at night
• Nitrofurantoin 50mg capsules: one capsule at night
• Omeprazole 20mg capsules: one capsule twice daily
• Oxybutynin 2.5mg tablets: one tablet twice daily
• Paracetamol 500mg tablets: two tablets three times daily
• Quinine sulphate 200mg tablets: one tablet at night
• Ramipril 10mg capsules: one capsule daily
• Senna 7.5mg tablets: two tablets at night
• Shortec® 10mg capsules: one capsule six hourly, as required
• Vitamin D3 1000IU capsules: one capsule daily
• Zopiclone 3.75mg tablets: one tablet at night

Over the counter medicines: nil

Lifestyle and current function

• Clinical Frailty Score (Rockwood) 6 (moderately frail)
• Medication in compliance aid
• No difficulty swallowing medicines
• Carers four times a day for personal care/medication prompt/meals/shopping
• Appears a bit confused at times but lucid and normally perceptive (MMSE score 26/30 on testing three months ago)
• Smokes 15 cigarettes a day
• Reports no alcohol or recreational/over the counter drug use
• Reports poor appetite and diet but weight stable at 32kg:
  • Three years ago 38kg
  • Two years ago 34.1kg, with dietetic input started
  • Now on sip feeds and carers add in full cream milk, biscuits etc

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

• Very fixed mindset on requirement for all medicines. Denies any side effects
• Would like to reduce pain levels - widespread pain in back, joints, and stomach. She rates her pain as 10/10
• Would like to go to bingo but has lost confidence to leave the flat
• Keeps herself happy by feeding birds/foxes - misses her dog who died last year

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• Weight 32kg (stable for last six months), Height 140cm, BMI 16.3kg/m²
• Urea and electrolytes– within range three months ago, eGFR greater than 60ml/min/1.73m², calculated creatinine clearance 33mL/min
• BP average over three readings 145/85mmHg, no postural drop
• Serum cholesterol 4.4mmol/l (<5.0mmol/L), HDL/LDL ratio 3.8 (for women <2.5)
• DXA six years ago after being on bisphosphonate for five years. T= -2.7 Advised to stop bisphosphonate for two years and then re DXA - GP to refer again

Most recent relevant consultations

• Pain and polypharmacy review during a home visit three months ago. Brief Pain Inventory score average is 9/10 (unable to score interference questions, analgesic effectiveness 0-10%) 
• GAD score 9/21
• Weekly phone calls to practice over last six months for a variety of complaints: urinary tract infection (UTI), upper respiratory tract infection (URTI), stomach pains

Follow-up:

• Regular contact with community link worker and follow-up with pharmacist to implement pain and polypharmacy medication review changes. Medication changes discussed, but reluctant to try some of them. Signposted to the patient resources on “My Live Well with Pain” website
• Follow up every four to six weeks to review medication changes - slow, gradual changes with regular reassessment and individual choice over which medications to deprescribe and when

Person specific issues to address

• Does not want to stop any medication, reports all are effective despite pain 10/10. “If it’s not broke, don’t fix it”
• Wants to go out to bingo/shops
• Challenge of matching her expectations of remaining on all medicines versus reducing risks of ADR/side effects. Suspicious of reviews due to past experiences
• Discuss realistic expectations of pain management
• Discuss non-pharmacological ways of managing pain
• Develop a therapeutic relationship

 

Person specific issues to address

• Essential – none

 

Person specific issues to address

• Nitrofurantoin: complains of UTI despite continuous nitrofurantoin. CrCl 33ml/min, so should be avoided and no evidence to support prophylactic use beyond six months. Trial without
• Mirtazapine, zopiclone and diazepam: contributing to anticholinergic burden (ACB). Review and rationalise if possible after opioid reduction. Reassess GAD. Not keen to engage with mental health teams currently, has tried before, with no benefit
• Zopiclone: trial reduction after opioids have been reduced
• Amlodipine: BP adequately controlled, with no postural drop 

 

Person specific issues to address

• Bone protection: awaiting DXA, receives vitamin D but no calcium, however her diet is calcium rich with full fat milk, cream and cheese
• Previous cerebrovascular disease – no statin prescribed. Discuss if this has been stopped previously, reasons for discontinuation and if appropriate to restart?

 

Person specific issues to address

• Quinine sulfate: still reports leg cramps, therefore trial without  
• Oxybutynin: high ACB. She reports previous catheterisation because of urinary retention. Trial discontinuation to reduce ACB, then assess urinary frequency
• Opioids: she reports 10/10 for pain despite 180mg MED dose.Discuss ADR and potential harm, increasing risk of falls, hyperalgesia, impact on cognition, sedation, immune suppression, query a factor in recurrent UTIs
• Plan: reduce oxycodone by 7-10% every two to four weeks to achieve lowest possible dose
• Paracetamol: Reduce dose to one tablet as weight less than 50kg
• Omeprazole may reduce efficacy of clopidogrel – change to lansoprazole
• Reassess BP after medicines are deprescribed with potential to reduce ramipril

Medication Sick Day Guidance given for ramipril

 

Person specific issues to address

• Check local formulary choices for sustained-release oxycodone and if necessary, switch to a more cost-effective preparation when a stable dose is reached 
• Advised to dispose of medicines through the community pharmacy 
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Unwilling to change pain medicines at first but willing to ‘trial’ reduction of therapy at subsequent consultations  
• Gradual changes in medicines discussed and agreed
• Stop: nitrofurantoin, oxybutynin, quinine sulfate
• Reduce: opioids, then zopiclone
• Reduce: paracetamol dose
• Change: omeprazole to lansoprazole
• Option to include functional assessment scores before and after medication changes, along with the pain score 
• Refer to community link worker for social prescribing and community support options
• Attitude to smoking explored and reports reducing her cigarette smoking to less than eight a day

After four months follow-up, she had reduced to 45mg oxycodone (67.5mg MED). Pain still 9/10, but now going out with carer one day a week and visiting shops