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Providing help that is needed but not wanted


Thileepan Naren


17/08/2021 4:47:14 PM

Dr Thileepan Naren’s choice to persevere with a patient during their recovery from opioid addiction led to triumphant outcomes.

Packs of opioid medication.
GPs already have many of the baseline skills needed to manage ‘difficult’ patients.

Sometimes in medical practice, we can get bogged down with labels, how we perceive a patient, and what the ‘right thing to do’ is.
 
In these situations, we can lose sight of the person behind the label, the person who is coming to us for help. It is important not to lose our humanity and not to be afraid to seek out assistance with more complicated patients rather than just refusing to see a patient or refusing to prescribe.
 
Currently, in most of the Western world, we appear to be grappling with an opioid epidemic. By now, most medical practitioners have received voluminous information about the harms and risks of opioid medications, including the risks of dependence, addiction, respiratory depression, polypharmacy overdose and death.
 
The risks listed are all true, and being a responsible prescriber and providing appropriate opioid stewardship is the role of every medical practitioner. But sometimes I fear we take things too far − we may refuse to provide help and assistance for patients who are seeking it and for patients who are unaware of the help that they are seeking.
 
We are concerned about labels like ‘addiction’ and ‘dependence’ and so worried about doing the ‘wrong thing’. This ‘paralysis of action’ prevents us from providing any assistance for a patient.
 
Jane* is a 69-year-old who came to see me several months after her previous prescriber had some conditions placed on his medical registration and was no longer allowed to prescribe her opioid medications.
 
Many decades ago, Jane was involved in a devastating motor vehicle accident and had a prolonged hospitalisation. As a result, she had chronic left-leg pain and was no longer able to walk or weight bear on her left leg and required a wheelchair to mobilise.
 
Over the years she had required increasing doses of pain medications, and at the time I met her was on 80 mg of Physeptone and 200 mg of Palexia with an oral morphine equivalent dose of 320 mg. She was also taking 350 mg of Lyrica per day. Her previous prescriber was in the habit of prescribing and dispensing 240 tablets at a time of 10 mg of Physeptone.
 
Jane also had several health issues including obesity, sleep apnoea and ischaemic heart disease. She was concerned about worsening shortness of breath, a worsening tremor (which her previous prescriber had diagnosed as essential tremor and prescribed propranolol with no significant effect) and a skin lesion on her right forearm which she felt had been increasing in size over the past couple of years.
 
In our first consultation, Jane appeared quite drowsy and was slurring her words slightly. She appeared mildly narcotised though her partner reported that ‘this is how she’s been for the last few years’.
 
She was petrified that I would stop her medications and that she would be in unbearable pain.
 
‘I need these tablets or I won’t be able to function,’ she implored. ‘I only take what I’m prescribed and I don’t take any extra and I only come when I’ve run out − you can check my records.’
 
I reviewed Jane’s prescribing on the Victorian Safescript real-time prescribing database and this confirmed what she stated.
 
Naturally, I was concerned by the dilemma I now faced. I could refuse to see this patient and ask her to find another doctor who could help her.
 
I could continue prescribing high-dose opioid medications for chronic non-cancer-related pain, with defiance of current best practice guidelines and the known harms associated with high-dose opioid medications. Or I could choose a third option − I could try to engage with the patient, try to address her concerns and make her medication regimen safer.
 
The first steps 
My practice is in regional Victoria and there is no local addiction medicine service. I contacted an addiction medicine specialist in Melbourne who was concerned about the risks of harm with this patient on high-dose opioid medications, her pre-existing medical conditions, and that she already appeared narcotised. They recommended weaning her Physeptone by 10 mg per fortnight.
 
I had a frank discussion with Jane about the harms associated with her current medication dosages and that I would be happy to work with and support her transition to a safer medication regimen.
 
She was understandably anxious and worried about her pain recurring but was agreeable towards weaning her medications. I also instructed her pharmacist to collect her loose tablets and to give her a weekly staged supply of her medications via a Webster pack, and I prescribed her some take-home naloxone for her partner to administer in the event of opioid toxicity or overdose.
 
Jane and her partner came and saw me every fortnight and we slowly weaned her Physeptone dosage. She started complaining of some increased pain and I referred her to the local pain management clinic in town for some allied health input and strategies to actively manage her pain symptoms without resorting to medications.
 
She saw a rehabilitation physician who felt that the tapering and weaning of opioids could go at a slower rate and whether aiming for opioid cessation was viable. The rehabilitation physician was concerned about Jane’s quality of life after being weaned off opioid medications. Jane wanted a break from her opioid weaning and when she got down to 40 mg daily of Physeptone (half her original dose) we paused here for some months and commenced weaning and ultimately ceasing her Lyrica.
 
Through all of this, Jane was anxious and concerned but ready to listen and understand the rationale for decreasing her medications. She became more alert and stopped slurring her words and her husband noticed a change in her behaviour and that she was more willing to try things and engage with people.
 
This process required significant communication and involvement of both Jane, her partner, and our practice staff to elicit any concerns they might have and provide appropriate and detailed responses. This took time, but over this period a good rapport was established and trust between us increased.
 
I also reviewed her tremor and stopped her propranolol and undertook a punch biopsy of the large skin lesion on her forearm. Jane was exceptionally grateful that I was addressing her medical concerns and ‘not just seeing me as a lot of tablets’.
 
Over the next few weeks, Jane’s tremor remained unchanged but her breathing and shortness of breath resolved post-cessation of the propranolol.
 
I referred Jane to a neurologist who diagnosed her with Parkinson’s disease and commenced definitive treatment for this condition. The punch biopsy revealed a superficial basal cell carcinoma and after discussing this diagnosis with Jane, she felt she would like definitive surgical management for this lesion. As per her request, a referral to a local surgeon for removal of this lesion was made.
 
Jane remained very grateful that I was addressing all of her concerns and I think that this aided me in continuing to wean and adjust her medications.
 
Ceasing opioids 
Having limited engagement with the pain management clinic, Jane was not keen to engage in group classes or trial non-pharmacological measures to manage her pain symptoms. She remained quite focused on medications as a cure for her pain symptoms.
 
It was during this period that Jane saw a local pain specialist who felt that her opioid usage was not justified and could not be supported. She felt that Jane was in fact addicted to her opioid medication. She recommended either cessation of opioid medication or commencement on opioid substitution therapy, preferably Suboxone.
 
Jane was on 40 mg Physeptone and 200 mg Palexia at this time and I discussed an admission in Melbourne for supervised withdrawal management, or at the very least, admission at the local withdrawal management unit for semi-supervised management. Jane found the suggestion of this abhorrent and did not ‘want to be around those people’.
 
She was adamant about coming off her opioid medication as an outpatient, despite extensive explanations on my behalf about the very long half-life of Physeptone, how unpleasant such a withdrawal could be, the risks to her health − especially with her pre-existing medical conditions − and the risks of a precipitated withdrawal with Suboxone. Jane was adamant about not attending or being admitted to a withdrawal management service.
 
Jane was quite anxious about her Physeptone being stopped and quite resistant to this overall, but again with significant explanation that I would assist her throughout this process, she was agreeable to try to transition to opioid substitution therapy.
 
Ultimately, in discussion with Jane and her husband I decided to try and transition from Physeptone to Suboxone in the community. I had done this with some success in our regional town where I have had patients on 50−60 mg of liquid methadone, and post-withholding a dose for around two days and the patient being in withdrawal, Suboxone was commenced without triggering a precipitated withdrawal.
 
With Jane, I withheld her Physeptone for three days. When she was in withdrawal and complaining of severe pains she went to the local pharmacy and had a small test dose of Suboxone.
 
Unfortunately, this triggered a precipitated withdrawal and Jane presented to the clinic very distressed, shaking, groaning, yawning with piloerection, dilated pupils, and a runny nose. She scored 25 (moderately severe) on the Clinical Opiate Withdrawal Scale.
 
I explained to Jane and her frantic partner what had happened and that I would do all I could to assist her. I rang an addiction medicine specialist colleague who suggested restarting Jane on Physeptone at 30 mg daily and also starting her on a 10 mcg/hr Norspan patch (buprenorphine) and slowly titrating the Norspan patch every week until she reached 60 mcg/hr dosage.
 
Once Jane was at this dosage, we would recommence Suboxone at 2 mg (whilst the Physeptone continued) and then to slowly increase the dosage of Suboxone until she was at 12 mg daily, then stop the Physeptone and up-titrate the Suboxone until it was tolerated by the patient. This is known as the ‘Bernese method’ and something that I had no experience in prescribing.
 
Furthermore, I was concerned about how Jane and her partner would react. Her main fears were being in pain and her medications changing − and they had been realised.
 
I had another discussion with Jane and her partner about the proposed management plan and I spent significant time discussing how this would be implemented, how the clinic and I would manage and follow her up, and how we would assist her on this journey.
 
In a lot of patients once they have experienced precipitated withdrawal it is very difficult to re-engage and establish a therapeutic relationship. However, Jane was agreeable to trial the proposed management.
 
The outcome
My practice staff and I followed up with Jane daily for the first week to see how she was progressing and to provide reassurance.
 
Over the next few weeks, Jane presented to the clinic initially every 2−3 days and then weekly as her Norspan patches were slowly up-titrated, and then when she was ultimately upgraded to Suboxone. She tolerated this well. She hated going to the pharmacy every day for the Suboxone but surprisingly found she was pain-free on a dose of 32 mg.
 
I discussed transitioning to the long-acting injectable buprenorphine. She has tolerated this well since it was commenced, and now presents to the clinic every four weeks for her injection.
 
Jane is very happy about her progress. She and her partner report that she is much more alert, her pain is well-controlled and she is more able to engage and enjoy her life.
 
I decided to write about Jane and her story to show what we as GPs can do with some specialist support and the impacts and improvement we can make on people’s lives and wellbeing.
 
There are plenty of Janes in our community who need our help and support and often they are deemed to be ‘too hard’ and denied the help that they need.
 
As GPs, we see our patients holistically and already have many of the baseline skills needed to manage ‘difficult’ patients.
 
In medicine, the help that we have to offer is not always what the patient wants initially, but it can be what they need and lead to long-term and sustained positive outcomes.
 
*Jane is not this patient’s real name. The patient has however, given consent for her story to be told.
 
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addiction medicine doctor–patient relationship opioid dependence opioid substitution therapy pain management


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Dr Simon Holliday   18/08/2021 3:04:51 PM

Well done Dr Naren. Patients on high dose opioid usually have complex multimorbidities. Opioid withdrawal is more than the classical physical features and includes emotional and other disturbing psychological features. The microdose transition ("Bernese") system is quite experimental in Australia and there are trials looking at doing this for patients during a one week hospital stay. I presented my first 10 cases in out-patients at this years International Medicine in Addiction Conference.
Helping people off full agonist opioids and onto the safe and stable depot buprenorphine will revolutionise the management of opioid dependence and assist reducing the harms from opioid-based pain care.


Dr Omar Muwafak Mohamad Wafek   18/08/2021 7:46:24 PM

Well done