Post-its from Practice:
The need to manage pain in people who use drugs (Jan 2007)
Nicky is 42 year old and has been registered with the practice for a couple of years. Until recently she received her drug treatment from the local specialist drug service and was on 200mg injectable methadone. She used to be a national cross-country runner and also suffered from anorexia as a teenager. She started opiates in her late 20s for severe knee pain. For pain relief, she first bought heroin but quickly transferred to methadone, firstly from a private prescriber and more recently from the drug service. She uses no illicit drugs and does not drink alcohol.
She came to see me to explain that her knee pain was getting worse and that the methadone was no longer helping. About a year ago her orthopaedic surgeon had decided the best solution was bilateral knee replacements. The first one was done about 8 months ago and had failed, causing more pain. Over the years she has seen a number of pain teams who have prescribed a number of medications, most recently gabapentin and amitriptyline, but never opioids and none of the drugs tried have helped.
She requested an increase in methadone and/or alternative analgesia from the drug team but they said they had reached their maximum dose and that she should discuss pain relief with her GP.
It was a difficult problem for me to address. However, it felt the first thing to do was take over her methadone and ask her to try splitting the dose four times a day. Dose splitting can be more effective as pain relief, and this did help a little, but she continued to experience severe pain. Her sleeping and mobility decreased and she began to get depressed.
Having tried most analgesia's other than opioids, we decided together that we needed a new approach to try and get the pain under control. We started with a small dose of long-acting morphine, which required increases until the pain was more under control. The only remaining problem was break through pain, especially after any mobility and sometimes at night, so we added quick acting morphine which she takes very occasionally.
Nicky is now on 200mg of methadone, which she splits into two, as she feels this works the most effectively for her, 100mg long-acting morphine twice daily and 50mg of short acting morphine as required and she is almost pain-free. Her mood has improved, as has her mobility and sleeping. She does not feel chemically affected by these doses and she feels that she is "living again" (her words). She is thinking about returning to college and has recently started as a volunteer in a charity shop.
Nicky's pain management proved difficult and daunting for me as this was the first time prescribing these doses and this combination, but seeing the excellent results for her has made the risk worthwhile. In my experience (and the evidence supports this) people on long-term substitution therapy often need higher doses of pain relief - don't forget they also do feel pain!