Publication - Advice and guidance

Quality prescribing for chronic pain: guide for improvement 2026-2029

Published: 24 March 2026
From: Chief Medical Officer, +2 more … Cabinet Secretary for Health and Social Care, Minister for Public Health and Women's Health
Directorate: Chief Medical Officer Directorate
Topic: Health and social care
ISBN: 9781806439331

Chronic pain, defined as persistent pain lasting beyond three months, can significantly impact quality of life, affecting physical and mental wellbeing. This guide supports clinicians and people living with chronic pain, using a person-centred approach to pain management.

Supporting documents

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. 180mg 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	Process	Person specific issues to address
1. Aims What matters to the individual about their condition(s)?	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	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
2. Need Identify essential drug therapy	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)	· Essential – none
3. Does the individual take unnecessary drug therapy?	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)	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
4. Effectiveness Are therapeutic objectives being achieved?	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?	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?
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?	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	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
6. Sustainability Is drug therapy cost-effective and environmentally sustainable?	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	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
7. Person-centredness Is the person willing and able to take drug therapy as intended?	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	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
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

Steps

Process

Person specific issues to address

Aims

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

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

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

Need

Identify essential drug therapy

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)

· Essential – none

Does the individual take unnecessary drug therapy?

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)

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

Effectiveness

Are therapeutic objectives being achieved?

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?

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?

Safety

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

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

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

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

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

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

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

Person-centredness

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

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

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

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	Process	Person specific issues to address
1. Aims What matters to the individual about their condition(s)?	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	Concerned regarding side effects and possible ‘addiction’ She feels original pain improved Gaining weight despite healthy diet
2. Need Identify essential drug therapy	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)	Essential - none
3. Does the individual take unnecessary drug therapy?	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)	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
4. Effectiveness Are therapeutic objectives being achieved?	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?	Pain improved overall Consider therapeutic paracetamol, if evidence of benefit. May need tramadol as required
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?	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	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
6. Sustainability Is drug therapy cost-effective and environmentally sustainable?	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	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
7. Person-centredness Is the person willing and able to take drug therapy as intended?	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	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

Steps

Process

Person specific issues to address

Aims

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

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

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

Need

Identify essential drug therapy

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)

Essential - none

Does the individual take unnecessary drug therapy?

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)

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

Effectiveness

Are therapeutic objectives being achieved?

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?

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

Safety

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

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

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

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

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

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

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

Person-centredness

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

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

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	Process	Person specific issues to address
1. Aims What matters to the individual about their condition(s)?	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	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
2. Need Identify essential drug therapy	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)	Essential - none
3. Does the individual take unnecessary drug therapy?	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)	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
4. Effectiveness Are therapeutic objectives being achieved?	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?	Diabetes well controlled, continue with treatment and lifestyle measures Pain poorly controlled, optimise medicines and encourage use of self-management strategies
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?	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	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
6. Sustainability Is drug therapy cost-effective and environmentally sustainable?	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	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
7. Person-centredness Is the person willing and able to take drug therapy as intended?	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	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

Steps

Process

Person specific issues to address

Aims

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

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

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

Need

Identify essential drug therapy

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)

Essential - none

Does the individual take unnecessary drug therapy?

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)

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

Effectiveness

Are therapeutic objectives being achieved?

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?

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

Safety

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

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

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

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

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

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

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

Person-centredness

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

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

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	Process	Person specific issues to address
1. Aims What matters to the individual about their condition(s)?	Review diagnoses and consider: Therapeutic objectives of drug therapy Management of existing health problems Prevention of future health issues, including lifestyle advice	Wishes to manage her pain Wishes to reduce her need for out of hours contacts and find ways to better manage her condition
2. Need Identify essential drug therapy	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)	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
3. Does the individual take unnecessary drug therapy?	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)	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
4. Effectiveness Are therapeutic objectives being achieved?	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?	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
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?	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	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
6. Sustainability Is drug therapy cost-effective and environmentally sustainable?	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	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
7. Person- centredness Is the person willing and able to take drug therapy as intended?	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	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

Steps

Process

Person specific issues to address

Aims

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

Review diagnoses and consider:

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

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

Need

Identify essential drug therapy

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)

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

Does the individual take unnecessary drug therapy?

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)

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

Effectiveness

Are therapeutic objectives being achieved?

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?

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

Safety

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

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

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

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

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

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

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

Person- centredness

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

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

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 (T_1/2) (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

Contact

Email: EPandT@gov.scot

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Information

12. Case studies

12.1 Case study: Opioids in chronic pain

Case summary

12.2 Case study: Anticonvulsants in chronic pain

Case summary

12.3 Case study: Antidepressants in chronic pain

Case summary

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

Case summary

Contact