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Rob comes to see you. Life is hard for him. He is 40, lives alone, has chronic pain from multiple previous fractures and associated nerve damage. He has a past history of drug and alcohol misuse, but he says this is now under control. He is requesting a repeat prescription of pregabalin for his chronic pain. He is also on long-term tramadol. So, how do you manage this request? This is an example of a seemingly simple prescription request which in reality is incredibly complex and difficult to manage, especially within the confines of a 10 minute GP appointment. And yet it is a scenario that most GPs face on a daily basis. How you manage it of course depends on the time of day, how late you are running and how 'resilient' you feel but one thing we should all consider now is the undoubted misuse potential of these drugs and the potential danger to the patient especially if they are also taking opioids.
I must say I was very suspicious of pregabalin when it first came along. A drug claimed to help chronic pain AND anxiety just seems too good to be true, and too seductive to prescribe to unhappy patients with seemingly insoluble problems. In my experience it is an example of a drug that has hugely over promised and under delivered (as has duloxetine...who wouldn't want a treatment for chronic pain, depression and urinary incontinence??) and side effects seem common. Yet, in the last 5 years the prescribing of pregabalin and gabapentin has increased by 350% and 150% respectively.
A recent report from the Advisory Council on the Misuse of Drugs has highlighted the increasing concerns over the abuse, misuse and addictive potential of gabapentinoids and recommended that their status is changed to that of controlled drugs. They are described as having a significant risk of addiction and high misuse potential. This is particularly a problem in patients with polydrug use, especially opioids, and has for some time to be known to be a major problem in prisons. Gabapentoids increase the risk of respiratory depression and fatal overdose and recent research Addiction 2017 reveals that the number of deaths associated with gabapentoids in the UK has increased from 1 in 2009 to 137 in 2015 (which is likely to be an under estimate) and 80% of deaths also involve opioids. Heroin users report that they potentiate the effect of heroin and that they are easy to obtain.
So, what do we do with Rob's prescription request? As always yes is easy, and no is hard....sometimes we just have to take the path of least resistance to get through the day and often this can be justified 'for the greater good'. After all, we have a lot of people to try to help every day. But one of the beauties of General Practice is that it is not static, it is not limited to a 10 minute snapshot. It is highly dynamic, we offer continuity and over time relationships, management plans, values and attitudes evolve. 10 minutes doesn't sound very long, but we probably see Rob 12 times a year. That gives us a couple of hours to try to change things over the next year, starting today with 'planting the seed' ('Do you know Rob about the risks of this drug?', 'It doesn't seem to be helping your pain Rob?' etc). From this seed a tree may grow and over the year maybe we could wean him off and introduce a more holistic, rehabilitative approach to his pain management. Or, at least a safer prescription. Who knows, it may even save Rob's (or someone else's) life...
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