As part of my role as Medical Director at Swanswell I was recently involved in delivering some training to the shared care GPs in Worcestershire. When asked about the topics we should cover they were almost unanimous in asking me to cover addiction to medicines. By chance, I had recently seen a young man at our practice with a dependency on over the counter painkillers, which made for a good discussion.
Craig is 32, he has a stressful job in IT and also has inflammatory bowel disease, which has been difficult to control and has fairly frequent flare-ups. He had been to the practice on 3 occasions in the past 2 months complaining of low mood and stress and had been started on antidepressants. I was reviewing him about this and he told me he didn’t think they were working and his bowel disease was much worse. As we started to explore this, he broke down and told me he had been buying painkillers from the pharmacy and over the Internet and was taking many times more than the recommended dose.
He hadn’t told anyone this, not even his wife, and he felt it had become a significant factor in his low mood and anxiety. He had started buying Nurofen Plus to deal with the pain from his bowels, but had soon found they helped him feel less stressed and so he carried on taking them even after his bowels settled and at the time I saw him he was taking 24 a day. He felt unwell if he stopped them and was very keen to try and do a managed withdrawal. After discussing the options he decided he wanted to use codeine [the opioid in Nurofen Plus] to gradually reduce as he felt the use of methadone or buprenorphine would stigmatise him as a drug user to the pharmacist.
Things went well for the first few weeks and we managed to reduce his dose by about a third. However at that point he told me he had started buying additional medication again. Acknowledging his perhaps understandable desire not to feel stigmatised, I explained how it can be difficult to reduce using the drug which causes the dependency, as he had already developed a response to stress by using more. He agreed we should try and stabilise him on OST and then look to do a managed withdrawal from that. A buprenorphine prescription was initiated and he stabilised on a 6mg dose. During this time he agreed to contact our local IAPT [Improving Access to Psychological Treatment] service and then over a period of 3 months we were able to reduce and then finally stop his medication.
Craig is doing well, however his bowel disease still causes flare-ups and he remains concerned that he could relapse. I have told him that we can review him regularly and if he does have a further problem, we want to engage with him as soon as possible.
As I discussed with the Worcestershire GPs, our job is to facilitate treatment not impose it and by offering information and working with people as individuals we can build the effective therapeutic relationships necessary to engender long term change.
Steve Brinksman is a GP in Birmingham and Medical Director at Swanswell.
SMMGP supports the Opioid Painkiller Dependency Alliance: www.opdalliance.org.uk/
This article first appeared in DDN Magazine, June edition in the "Post It from Practice" column.