We agreed to disagree

We agreed to disagree
A patient who normally saw Dr…came to me. She needed more of her fentanyl patch.
She needed high dose opioids for her right elbow pain. These drugs were the only thing that kept the pain away, and she worked as a hairdresser, so she needed these patches and her other meds to stay in work.
According to the clinical record, she was on the following interesting medications.

Fentanyl 50 mcg/hr patch
Tramadol 50 mg prn
Temazepam 10 mg nocte


I looked up Safescript.
Her record was full of red alarm bells suggesting that she was at a higher risk of death, not only because of her high dose of opioids but also because of her concomitant use of benzodiazepines.

I told her that I was unable to sanction her use of these medications.

The summary points were as follows:

Her OME was > 100 mg of morphine (fentanyl 25 = OME 100) This alone put her at an increased risk of death

Her use of additional short-acting tramadol was inappropriate and possibly indicated a dependency syndrome.

Her use of temazepam at night put her at an even higher risk of death.

The RACGP explicitly states that there is no role for Fentanyl for chronic non-cancer pain in GP-land.

She had non-cancer pain, probably osteoarthritis of the right elbow, which needed a proper assessment and a decent management plan.

I had no choice but to deny her current prescription request. I told her to stop the tramadol and immediately and I advised her to wean off the high dose fentanyl.

The next step was a 25 patch and a 12 patch in combination. This would be a step forward towards the goal of weaning her off fentanyl completely.

She was somewhat shocked and angry at this but seemed to accept what I said finally.
We agreed on a review in a fortnight.

In a fortnight she cancelled her appointment to see me. Instead, she saw Dr…, her regular doctor.

I looked at his medical record for the consultation. He had restarted her on fentanyl 50 mcg patches. I spoke to him later in the evening to ask his opinion of what was going on with the patient.

He told me that she was in severe pain and could not work because of her left elbow and that I had contributed to her increased suffering. She could not afford to buy two patches at the same time, so he had advised her to use a full 50 mcg patch again.

I asked him if he had read her safe script record. He said he had. We agreed to disagree.
Author: Ferghal Armstrong
Ferghal is an experienced medical educator and teaches the subject of pharmacotherapy to other doctors.
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