Quality prescribing for chronic pain 2026-2029: consultation

12. Case studies

12.1 Case study: Opioids in chronic pain

Case summary

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. 240mg morphine equivalent daily (MED) dose)

Current medical history and relevant comorbidities

• 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:
• Two years ago 34.1kg, with dietetic input started
• Now on sip feeds and carers add in full cream milk, biscuits etc

Three years ago 38kg

“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 resources “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

Steps

1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Ask patient to complete PROMs (questions to prepare for my review) before their review

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

Steps

2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• Essential – none

Steps

3.

Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see drug efficacy and applicability (NNT) table)

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

Steps

4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

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

Steps

5. Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

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 240mg 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
• Reassess BP after medicines are deprescribed with potential to reduce ramipril

Medication Sick Day Guidance given for ramipril

Steps

6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

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

Steps

7. Person-centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask patient to complete the post-review PROMs questions after their review

Person specific issues to address

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
• 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 (90 MED). Pain still 9/10, but now going out with carer one day a week and visiting shops

Key concepts in this case

• Reducing medicine related harm compared to person-centredness
• A person-centred approach is required as individuals often feel medicines are necessary and report no side effects. However, a lack of efficacy and risk of adverse effects must be considered and ensure safety in prescribing.
• There is a need to build a therapeutic relationship with trust to support and influence change, and to deprescribe medicines
• The need for subsequent and ongoing reviews to address a stepped and supported approach to trials of reduction and deprescribing, ensuring shared decision-making at every stage

12.2 Case study: Anticonvulsants in chronic pain

Case summary

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 comorbidities

• 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 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

Steps

1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems.
• Prevention of future health issues, including lifestyle advice

Ask patient to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address

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

Steps

2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• Essential - none

Steps

3. Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see drug efficacy and applicability (NNT) table)

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

Steps

4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address

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

Steps

5. Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

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

Steps

6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

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

Steps

7. Person-centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask patient to complete the post-review PROMs questions after their review

Person specific issues to address

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

Key concepts in this case

• Pain improved, therefore same level of medication no longer required
• Side effects:
  • drowsiness
  • weight gain
  • dependency (evidenced by withdrawal)
• High risk medicine combinations
• Deprescribing – supporting the individual to safely reduce or stop medicines

12.3 Case study: Antidepressants in chronic pain

Case summary

Background (age, sex, occupation, baseline function)

• 54-year-old male
• Works as a painter and decorator

History of presentation/reason for review

• Attends appointment due to uncontrolled pain

Current medical history and relevant comorbidities

• Diabetic peripheral neuropathic pain - two years ago
• Type 2 diabetes mellitus - four years ago
• Gout - seven years ago

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

Allergies or adverse drug reactions (ADRs): nil

Currently prescribed:

• Allopurinol 100mg tablets: one tablet daily
• Amitriptyline 50mg tablets: one tablet at night
• Atorvastatin 10mg tablets: one tablet daily
• Duloxetine 60mg capsules: one capsule daily (started three months prior to review)
• Metformin 500mg tablets: two tablets twice daily
• Tramadol 50mg capsules: two capsules when required for pain (no recent change – average use two to three times daily)

Over the counter medicines: nil

Occasional cannabis use for neuropathic pain

Lifestyle and current function

• Keeps active with regular walking
• Does not smoke
• Drinks eight units of alcohol a week (on his days off work)
• Has significantly changed diet over past two years since diabetes worsened

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

• Wants pain to stop, especially during the day. He is particularly struggling when working

Observations, examinations and results

Note: local laboratory reference ranges may vary

• Weight 70kg, Height 174cm, BMI 23kg/m² (with changes to diet and lifestyle he has managed to significantly reduce weight over past two years – nothing sinister suspected)
• BP 128/67mmHg
• Urea and Electrolytes in normal range, eGFR greater than 60ml/min/1.73m²
• HbA1c 50mmol/mol (6.7%)
• Thyroid function tests (TFTs) in normal range
• Bone profile in normal range
• Lipids in normal range

Most recent relevant consultations

• Duloxetine started for neuropathic pain three months prior to review

Steps

1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Ask patient to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address

• Assess pain control and function as states struggling with pain during the day and at work
• Biopsychosocial assessment to determine if other factors worsening pain
• Diabetes well controlled

Steps

2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• Essential - none

Steps

3. Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see drug efficacy and applicability (NNT) table)

Person specific issues to address

• Duloxetine and amitriptyline: review effectiveness of these, determining which has been the most beneficial. Optimise the dose and gradually reduce the other
• Tramadol not recommended as treatment for neuropathic pain, consider stopping

Steps

4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address

• Diabetes well controlled, continue with treatment and lifestyle measures
• Pain poorly controlled, optimise medicines and encourage use of self-management strategies

Steps

5. Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• · monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

Person specific issues to address

• Duloxetine, tramadol and amitriptyline: all serotonergic, review for signs and symptoms of serotonin syndrome and rationalise therapy
• On several psychoactive substances including cannabis. Educate on cannabis use in pain, and use health behaviour change techniques to encourage stopping
• Assess for other ADR
• Counsel on potential long-term issues with regular opioids. Advise gradual dose reduction of tramadol with aim to stop

Steps

6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

Person specific issues to address

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

Steps

7. Person-centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask patient to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address

Agreed plan

• He is happy to take less medication and does not want to take medicines that are “doing more harm than good”
• Stop: agreed to reduce amitriptyline and then stop
• Increase: duloxetine could be increased up to a maximum of 120mg daily
• Review: tramadol could be reduced and stopped once other pain management strategies are in place
• Signposted to NHS Inform and pain management websites for information on self-management

Key concepts in this case

• Optimisation of medication to maximise benefit and minimise risk to the individual
• Acceptance of, and education, around chronic pain conditions. Use of self-management strategies will support chronic pain management in conjunction with pharmacological options

12.4 Case study: Drug dependency and requests for medication out of hours in chronic pain

Case summary

Background (age, sex, occupation, baseline function)

• 38-year-old female
• Part-time shop assistant

History of presentation/reason for review

• Contact to out of hours (via NHS 24) on Friday evening. Reports increasing pain, described as ‘tingling and shooting pain down my legs which comes and goes.’ Pain is chronic, more than three years, has not changed in nature, just intensity. No other symptoms which might suggest cord compression or other red flags
• Requesting more gabapentin and tramadol as states that pain is not controlled with current doses, so takes more than prescribed and has run out of medication

Current medical history and relevant comorbidities

• Depression – seven years ago
• Chronic pain: hip and back – nine years ago
• Drug dependency – 18 years ago

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

Allergies or adverse drug reactions: nil

Currently prescribed:

• Amitriptyline 50mg tablets: two tablets daily
• Bisacodyl 5mg tablets: one or two at night as required
• Co-codamol 30/500mg tablets: two tablets four times daily
• Gabapentin 300mg capsules: one capsule three times daily
• Methadone 1mg/ml oral solution: 30ml daily, twice weekly pick-up
• Pregabalin 150mg capsules: one capsule twice daily
• Sertraline 100mg tablets: one tablet daily
• Tramadol 50mg capsules: one capsule three times daily

Over the counter medicines: nil

Lifestyle and current function

• Single, two grown up daughters who live away from home
• Moved to the area ten months ago due to violent break-up with previous partner
• Alcohol: one bottle of wine most evenings
• Smoker: 30g tobacco weekly
• Occasional street drug use: cannabis at the weekend
• Usually little physical activity. Currently unable to drive, as licence confiscated due to drink-driving, so walking to and from work

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

• Wants to get pain under control
• Frustrated at time taken to get through on phone to have query dealt with by out of hours (OOH)

Observations, examinations and results

Note: local laboratory reference ranges may vary

• Urea and electrolytes normal
• Weight 79kg, Height 168cm, BMI 28kg/m²
• No change to bladder or bowel function, no loss of sensation
• Normal MRI scan within the last six months
• No additional information on Emergency Care Summary (ECS)

Most recent relevant consultations

Has frequent contacts with GP practice and out of hours as runs out of medication, which is dispensed weekly, often due to hip and low back pain.

Steps

1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Person specific issues to address

• Wishes to manage her pain
• Wishes to reduce her need for out of hours contacts and find ways to better manage her condition

Steps

2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• Methadone maintenance is essential as substance dependence therapy and should not be stopped abruptly. Methadone is normally initiated by specialist services and the risks of prescribing in OOH services is high. Individuals presenting with opioid withdrawal symptoms during the OOH period should be signposted to the emergency department for assessment and management of their symptoms. Consider elimination half-life of medication requested (see below) and risk of harm from prescribing without access to daytime medical records
• If prescribing, prescribe the smallest quantity needed to allow follow up in daytime GP services and clearly document in case records the strength and quantity supplied

Steps

3.

Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see drug efficacy and applicability (NNT) table)

Person specific issues to address

• Multiple medications prescribed for pain, all associated with a risk of dependency and which would require support to withdraw safely in daytime practice:
• Amitriptyline
• Co-codamol
• Gabapentin
• Pregabalin
• Tramadol

Steps

4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address

• Be aware of any local or national policies around prescribing of medicines with risk of dependency during the OOH period
• Take a person-centred approach to management and prescription request in OOH services. Review any management advice on case records/ ECS from daytime GP and discuss the benefits, risks and alternatives to prescribing. Where prescribing in the OOH period, use the smallest quantity to allow daytime GP practice follow up and document clearly in records
• During daytime follow up discuss effective pain management options for chronic pain considering physical function, mental health, social and emotional factors. Record clear instructions on patients ECS with indication for use and management of prescription requests during the OOH period
• Tolerance to opioids occurs therefore higher doses are required to maintain the same level of pain relief
• Good practice not to combine opioids
• During daytime follow up target tramadol first for gradual reduction
• Work with individual to develop a plan to gradually deprescribe gabapentinoids (gabapentin and pregabalin separately) and opioids (tramadol first, then codeine in co-codamol). Agree a plan to communicate to OOH services using ECS
• Explain potential for withdrawal symptoms and that the tapering may take months. Leave clear instructions for OOH management and prescription requests during this time ensuring safety across transitions of care

Steps

5. Safety

Does the individual have or is at risk of ADR/ side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• · drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

Person specific issues to address

• Constipation possibly a side effect of opioid use
• Increased risk of adverse effects such as drowsiness, respiratory depression and interactions with multiple opioids and gabapentinoids (see MHRA alert)
• Ensure awareness of need for contraception to reduce teratogenic effects with gabapentin
• Potentially increased risk of drug-related death due to use of multiple opioids, gabapentinoids and street drugs

Steps

6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

Person specific issues to address

• During daytime practice review, consider reducing ineffective pain medication and introducing non-pharmacological therapy such as physiotherapy, yoga, CBT. Support may be available from a community link worker to identify the best plan for the individual

Steps

7. Person- centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific issues to address

Agreed plan

• In OOH establish what pain medication is requested and take a person-centred, risk/ benefit approach to management, in line with local and national policies, until reopening of daytime GP services
• Recommend follow up with regular GP practice in a suitable time frame
• In daytime practice recommend stepwise reduction plan for any ineffective medicines in agreement with the individual. Record indication for medicine, any reduction plans and management options for prescription requests during the OOH period on the individual’s ECS
• Consider option of physiotherapist and community link worker support
• Signpost to National Wellbeing Hub
• Alcohol: discussed the effects of alcohol and potential to worsen symptoms related to pain and depression and signpost to local support if available
• Smoking: recommend smoking cessation services and reduction/cessation of cannabis

Key concepts in this case

• Managing regular requests (including out of hours) for pain medication which has potential for problematic substance use
• Special notes around indication for prescribing, planned reduction regimes or suggested management options for early prescription requests can be recorded within the ECS to aid decision making in OOH services
• In daytime GP practice recommend a plan for reducing inappropriate polypharmacy in pain and depression associated with drug dependency and substance use. This is preferable in daytime GP services due to access to full medical records and relational continuity, as this process can be complex and take time. With a clear plan documented on ECS, this will aid other healthcare providers such as out of hours or community pharmacies
• Referral to community link workers and third sector agencies may be helpful to assist a holistic approach to the management of pain and depression with a background of substance use. Gaining acceptance and motivation for this pathway may be challenging
• Varied half-lives for medication (and therefore elimination rates) (see Table 16 below) can be used to help determine if withdrawal effects are likely to be present during the out of hours period

Table 16: Half-life of selected analgesics

Medication	Half-life (T1/2)(hours, unless specified)	Time to almost complete elimination (five half-lives) (hours, unless specified)
Amitriptyline	25	125 (five days)
Tramadol	6	30
Morphine	1.5-4.5	7.5-22.5
Gabapentin	5-7	25-35
Pregabalin	6.3	31.5