JS is a 48-year -old woman who comes to see you for the first time. She has been treated with modified release oral morphine 60mg 5 times a day for the last 10 years. She is unwilling to consider changing her medication and becomes angry and tearful when you suggest that you are concerned about her current medication regime. She doesn’t take any other medications and doesn’t consider that her medication is a problem. She lives with her 12 year old son, husband and mother in law, who manages the household as JS is too unwell to do very much around the house. She spends most days resting on the sofa watching TV.
She has tried non opioid pharmacotherapies, counselling, and manual therapies and found no benefit. She claims that the multidisciplinary pain clinic has suggested in the past that her current treatment is appropriate. She hasn’t escalated her dose in the last 5 years. Pain scores suggest that her pain is being poorly managed with her current treatment regime.
She tearfully says that you are treating her like ‘a junkie’ and she has a legitimate pain condition and needs her medication to function. You explain that you are only able to assist her with ongoing multidisciplinary pain clinic support and suggest a case conference with the local pain clinic and are only able to prescribe for her if she re-attends the pain clinic, visits the pharmacy weekly to collect a week’s medication, and begin a slow reduction in her dose at a time to be negotiated, with supported adoption of self-management strategies.
She reluctantly agrees to this. You note the plan in her file. She then cancels her next appointment. The pharmacy rings to let you know that she has presented to the pharmacy with a script from another doctor. She has transferred to another doctor. You note the transfer to another doctor and practice in her file.
Note: patients who are unwilling to engage in active self-management can be difficult to manage. Bear in mind that you need to make an assessment whether you consider it safe to prescribe, and if you are concerned about this, you’re under no obligation to do so. It is however important to offer the patient other reasonable options. Get support and help from your specialist pain and or drug and alcohol teams. It is anticipated that the introduction of an Electronic Real Time Reporting and Monitoring system will provide a framework for improved management of such patients.