Like many modern GP group practices, ours has GPs with specialist interests. One of mine is rheumatology and it was in this role that I met Maria. She was 43 and had been diagnosed with rheumatoid arthritis four years ago. She had a lot of joint pain and was started on co-codamol 30/500 (30mg codeine and 500mg paracetamol in each tablet) She was taking these regularly, so slow release dihydrocodeine was added in and titrated up to 120mg twice a day with Oramorph (liquid morphine) for breakthrough pain.
After seeing a consultant rheumatologist she was started on methotrexate, a disease modifying anti rheumatoid drug (DMARD), and was being seen in our clinic so that this could be monitored.
On examination I could find no signs of active joint inflammation and noted this had been the same the last couple of times she had been seen. When the possibility of reducing her analgesia had been suggested before, she said she still needed it. When I asked her about this, she told me that she felt much better in herself when she took her medication and worried that she would be ‘bad’ if she didn’t. She explained that she had previously had bouts of low mood and panic attacks, which had eased since starting her painkillers, and that the Oramorph was now mainly used when she was anxious.
There wasn’t time to explore this further, but she agreed that I could book her another appointment to follow this up. A week later she told me about growing up in a home where her father had been very controlling and frequently demeaned and verbally abused her mother, and to a lesser extent her. Her panic attacks had significantly worsened after the death of her mother eight years ago and she agreed that the opioids were not really being used for her RA pain now but to deal with her mental health issues.
A referral for CBT was arranged and we discussed how best to deal with her medication. She felt it would be difficult to slowly reduce what she was currently taking as she felt out of control with the Oramorph, and the decision was made to start her on buprenorphine. This has been titrated and she has stabilised on 6mg, which we are going to start slowly reducing while continuing her CBT.
Maria is a reminder that opioids are not only good painkillers but have psychological effects as well, and life events that can increase the risk of illicit drug use can also make dependence on prescribed medication more likely. The key is assessing these at the outset and using ongoing monitoring to try to avoid strong opioids from readily ending up on repeat prescriptions.
Steve Brinksman is a GP in Birmingham, clinical lead of SMMGP, and a member of the Opioid Painkiller Dependence Alliance, www.opdalliance.org