An early request for medication
S.J. is a 44-year-old patient who has requested a prescription for her usual diazepam and dihydrocodeine but was asked to see the doctor as the request was a week early. Her summary tells you she suffers from chronic anxiety and low back pain. She is prescribed diazepam 5mg twice a day and dihydrocodeine 30mg two tablets four times a day in quantities of 150 per month. Her medication screen reveals eight prescriptions over the last six months.
Dr Richard Stokell discusses.
Why is this likely to be a difficult consultation?
Any consultation that starts with a patient wanting one thing and you another is likely to be challenging.
It can feel frustrating to deal with issues, which perhaps should have been tackled earlier by colleagues.
You may wonder how this prescription was arrived at to begin with and the origins of the prescription can be hard to track down if
it has been going on a long time. These feelings become even worse if you are already running late.
How can we approach this in a positive way?
Not knowing the patient may provide you with opportunities for a fresh approach. Offer a patient-centred consultation focused on the psychological symptoms for which diazepam is taken and the painful condition for which dihydrocodeine is being prescribed.
Explore how effective the medication is, how it is taken and how this relates to activities and stresses in daily life. Examine carefully to assess the underlying physical condition and to show the patient you are taking them seriously.
Why do we need to try to change this patient's behaviour?
Benzodiazepine dependence has been shown to cause memory impairment, emotional changes, hangover effects and falls in the elderly1.
They have also been shown to lose their therapeutic effect after about four months of treatment, after that merely preventing rebound anxiety. The dihydrocodeine is a bit more complicated. Again it is a drug of dependence which leads to dosage
escalation but it does nevertheless sometimes provide analgesia to painful long-term conditions.
However, it has also been shown to delay rehabilitation due to excessive tiredness and loss of motivation2.
In this case it is likely to be being used as an anxiolytic and its short action makes psychological dependence very likely.
The dosage of both drugs is showing signs of increasing and there is a clear need to look at the underlying problems.
Motivating the patient to change
Exploring the problems in this patient's life offers the best hope of achieving change. Establish that the medications are taken in different quantities on different days then ask what happened on the last day when higher doses were needed.
Ask a question like 'Talk me through your last difficult day', then discuss the situations and relationships that made that day difficult. Relating this to tension and changes in pain threshold may be useful.
A symptom diary noting medication taken, symptoms suffered and situations in which they occurred is an option.
Education about why these drugs may not be ideal is also useful. Also considering alternative strategies such as simple problem solving, physical therapies for her back pain and antidepressants for depression and agrophobia are of value.
Telling the patient off, continuing the prescription unaltered and issuing warnings of what will happen if this occurs again has the effect of establishing a parent-child relationship and we all know how children respond to attempts to discipline them. Try to avoid turning it into your problem by taking control in this way.
Closing the consultation
All this is not possible in one consultation but it does provide a framework to work within. Today our options are:
· Continue present prescription, issuing it early but stressing the need for compliance.
· Add antidepressant medication if this is indicated and the patient is keen to try this.
· Rethink her analgesia, perhaps by substituting controlled-release
dihydrocodeine, to reduce the short-term anxiolytic effects while preventing any withdrawal effects.
However, our primary aim should be to establish a good working relationship with the patient.
Comments like 'I'm only going to change these medications when you are ready to' and 'It may take a little while to see the benefits of what we are doing' may help to gain the patient's trust.
Sow the seeds of change at the first consultation and challenge their behaviour more at your follow-up, which you should arrange for about a fortnight so the issue of overusing medication is not the only reason for re-attending.
It may be time to consider a practice policy for prescribing of opiates and benzodiazepines.
· Take a fresh look at the patient's problems
· Try to establish a trusting relationship before challenging established behaviour and attitudes
· Long-term benzodiazepines and opiates are likely to adversely influence the patient's life
1 Heather Ashton, emeritus professor of clinical pharmacology at the University of Newcastle upon Tyne, Pulse, 3.8.04
2 Chronic opioid therapy another reappraisal, R.Norman Harden. American Pain Society Bulletin, January 2002 Vol 12, no.1 www.ampainsoc.org
Richard Stokell is a GP in Merseyside