She breezed in saying those words I dread, “I just need a script”.
I had never seen her before.
I looked at her prescription record. She was on mirtazapine 15 mg nocte and sertraline 100 mg mane. That’s ok, I thought. Then I saw the Panadeine Forte.
So I printed off the antidepressants and smiled sweetly at her.
“Is everything going well?”
“yes, she said, apart from my dental pain. I have just been told I need dental surgery, and the waiting list is nine months. So I need my Panadeine Forte as well.”
My heart sank.
“It’s the only thing that works for me, I have tried everything else, and Dr… always gives me some.”
“Have you tried anti-inflammatories in combination with regular Panadol?”
“Yes, of course, I have. Nothing else works for my pain except Panadeine Forte, I have tried Nurofen, and that upsets my tummy.”
What started as a “quick script” consult turned into a twenty-minute discussion during which I told her the following.
The efficacy of codeine is dependent on its conversion to morphine.
The RACGP does not recommend the use of codeine for non-traumatic dental pain.
Opioids, including codeine, have no evidence of benefit beyond three months.
Opioids, including codeine, have plenty of evidence of harms in the long term, including dependency.
Her history of depression and her personal circumstances were risk factors for aberrant behaviour and ware relative contra-indications to long-term opioid use.
If an upset stomach was the only thing preventing her from using anti-inflammatories, then concomitant use of Nexium would protect her stomach and facilitate the use of an NSAID.
I ended the consultation by suggesting that she might benefit from a powerful NSAID. I suggested meloxicam; I told her that the vet had given my dog meloxicam for her post-operative hysterectomy pain. It had worked for Millicent; perhaps it might work for chronic dental pain in humans.
She left clutching her scripts for antidepressants and a new script for meloxicam 15 mg daily and Nexium 20 mg daily.
I wonder if she will see Dr… soon for a refill of her Panadeine Forte. It will be interesting to see what will happen when Safescript becomes mandatory in my area.
Author: Ferghal Armstrong
Ferghal is an experienced medical educator and teaches the subject of pharmacotherapy to other doctors.