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The painkiller conundrum

‘You have reached your destination,’ the sat-nav confidently announced.

I looked up at a towering crowd of pylons, transformers and stacks of glass insulators looped with cables looming over the hedge. Their disturbing hum almost drowned out the nearby motorway and certainly made ‘DANGER’a superfluous warning.

I had put in the post code of the address for an urgent house call - a woman was drifting in and out of consciousness and the caller didn’t like the look of her. As I reached for my phone to speak to the practice for more details a small boy tapped on the car window.

‘Are you t’doctor, sir? Would you follow me, please? Me mam’s over dere,’ he said politely, pointing to a gap in the hedge opposite sci-fi city. I followed him in to a neat and tidy travellers’ camp with alternating Transit vans with tow bars and top of the range caravans with satellite dishes.  A young girl in an immaculate white rodeo outfit was berating some older boys about their ‘disgustin’ language’ and they looked appropriately sheepish particularly when threatened with ‘Ma’.

My patient, in a double bed in a nearby caravan, was vomiting noisily into a washing-up bowl with a supportive crowd of relatives to hand. I squeezed past them and took a history from the nearest.

She was more awake now, they said, but had been out cold for hours. Terrible problem with the diabetes, damaged the nerves in her feet, it had. She had to take so many pills for the pain, and a morphine patch, and then the gabapentin. Did I think it was the gabapentin makin’ her bad? Blood sugar’s fine, though, we’ve checked it a few times. How much insulin tonight, normally fifty, wid her bein’ sick ‘n’ that I thought t’irty?

I looked at the printout in my hand with her medication list on it; we hadn’t mentioned her amitriptyline or carbamazepine yet. I asked how she managed to remember her medication and not get muddled with it.

Well now, was the answer, the pharmacy put them in those special boxes, so many for each time of the day. Ah, yes, dosettes, a great compliance aid. But she doesn’t like them, see? So she pops them all all out in this bowl here. Large bowl exhibited containing, mainly, white tablets, albeit of different sizes. But how does she know what to take, I asked, feeling a little foolish. She can tell by the feel of them what they are and she knows what she needs. Of course. But this morning she was a little confused and took them all twice; isn’t that right, Vertina?

Vertina confirmed this was so and berated my patient appropriately but promised to keep an eye on her through the night. Her obs. were all fine and she was clearly settling so I left her in the somewhat acerbic bosom of her family and drove back to the surgery reflecting on the day. She was fine but elsewhere in the Western world we are killing more people with prescription pain killers than are dying on the roads in RTAs.