SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Pain, but no gain (Apr 2013)

A few weeks ago I was handed a prescription request for a man in his late 30's asking for soluble tramadol to be put on his record as a repeat prescription for back pain. Looking at his notes, I saw he had three previous prescriptions for this medication since joining our practice at the end of last year. I decided to see Tom before making this a repeat and asked the receptionist to pass the message on to him that he needed to arrange an appointment.

The next day I was the on call doctor and there was an urgent slot booked to request I call this patient, as he had told the receptionist that he quite simply must have the tablets as he was addicted to them. I made the requested call and spoke to Tom and arranged for him to have enough tablets to last him until he could get to an appointment with me.

Three years earlier he had injured his back at work and been given tramadol by his GP at the time. He told me that after a few days of nausea he had started to look forward to each dose and felt less stressed after taking them. He had gone back to work after a week but, having tablets left over from the initial consultation he had used these after a stressful day when he came in from work. Before too long he had been back to the GP complaining of a recurrence of his back pain, which led to a further prescription. By now he was using the tablets every day and his usage went up even more after he lost his job.

Towards the end of last year he had seen a new GP who had challenged him about his medication use and that had triggered him to change practices and he had registered with us. However, something about being challenged by the previous doctor had struck a chord with him and by the time I saw him, having accepted that he had a problem, he was open to the idea of trying to change.

We discussed the available options and he decided to start an incremental reduction in his daily dose, with regular reviews. We also discussed a switch to Buprenorphine and then withdrawing from that, so we had a "Plan B" as well! He readily accepted a referral to our local IAPT (Improving Access to Psychological Therapies) service and although at present he doesn't feel he wants to engage with a mutual aid group, we have raised this as a possibility too.

Addiction to medicines is increasingly being recognised as a growing problem and whilst it may be more obvious in the case of those who are also using illicit drugs or repeat benzodiazepines there are a lot of patients who move almost imperceptibly from mild to moderate to strong prescribed opioids. Our practice has now brought in a system whereas any patient who is about to have strong opioid analgesia added as a repeat, should be discussed with a colleague and this documented so we can audit the concordance.

Most patients don't present - as Tom did - with the words "I'm addicted to them" on their appointment note but as these are prescription only medicines, there are opportunities to ask questions and monitor usage, however it is important that practices develop consistent policies addressing this.

- Dr Steve Brinksman
Birmingham GP, SMMGP Clinical Director, RCGP Regional Lead in Substance Misuse for the West Midlands