The prescribing of analgesia for chronic cancer or non-cancer pain is widely recognised as a significant public health issue, particularly in respect of the challenges of medication-related harm (British Medical Association (BMA), 2018). The BMA estimate that there has been a substantial increase in opioid prescribing for chronic pain since 2015, with considerable associated cost implications for the NHS and an increase in opioid-related deaths. It therefore suggests that prescribers should be diligent, rigorously trained in pain management and ensure that medications are prescribed only to those who derive benefit from them.
However, the Royal Pharmaceutical Society (RPS) (2016) acknowledges that the prescribing of medicines, including analgesia, can significantly improve the quality of life and outcomes for patients, but realises that there are key improvements to consider when prescribing and supporting patients who require treatment. This includes the wide promotion of the existing evidence-base with regard to pharmacological and non-pharmacological pain management. Chronic cancer pain should be managed on an individual basis using the World Health Organization's (2019) Analgesia Ladder (Table 1). When prescribing for patients who are experiencing chronic cancer-related or non-cancer pain, it may be worthwhile to remember McCaffery (1968: 95) who stated that, ‘pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does’. This said, within the ‘consultation domain’ of A Competency Framework for all Prescribers (RPS, 2016: 10), prescribers are expected to ‘consider all pharmacological treatment options, including optimising doses as well as stopping treatment’ (ie ensuring that polypharmacy is appropriate and de-prescribing is considered where necessary). Furthermore, the National Institute for Health and Care Excellence (2017) reminds prescribers that chronic pain is multi-faceted with a biological, social and psychological inter-relationship in the patients' lived experiences of pain. Consideration of these factors should therefore be adopted as the standard approach to chronic pain management. Try to observe this while carrying out the following calculations:
Table 1. Analgesia ladder
| Step 1 | Mild pain |
| Non-opioid analgesics (eg paracetamol) to which an adjuvant can be added if necessary | |
| When a non-opioid no longer adequately controls the pain, an opioid analgesic should be added | |
| Step 2 | Mild-to-moderate pain |
| Weak-acting opioid analgesics, to which non-opioid analgesics and adjuvants can be added if necessary | |
| If the pain is still persisting or increasing | |
| Step 3 | Moderate-to-severe pain |
| Strong-acting opioids, to which non-opioid analgesics and adjuvants can be added if necessary | |
QUESTION 1
Ben, aged 52, has type 2 diabetes mellitus and has been commenced on gabapentin capsules for neuropathic pain. The British National Formulary (Joint Formulary Committee, 2019) states that he should be prescribed the following regimen:
- Day 1 – gabapentin 300 mg capsule once daily
- Day 2 – gabapentin 300 mg capsules twice daily
- Day 3 onwards – gabapentin 300 mg capsules three times a day
- How many capsules will Ben take in the first 7 days?
- How many capsules will you prescribe for 1 month's supply from the day of commencement (28 days)?
- Ben tolerates this dose and you prescribe a further 1-month supply at his review. The pack size of gabapentin 300 mg capsules = 100 capsules/pack. How many full packs will you request in order to supply Ben with an adequate amount of tablets for 28 days' treatment and how many capsules will remain?
QUESTION 2
Janet, aged 45, was prescribed buprenorphine transdermal patch 10 micrograms per hour/one patch weekly. After 3 months' use, her pain is not adequately controlled and you decide to increase the strength of the patch by 50%.
- What is the new strength of the buprenorphine transdermal patch?
- If there are 4 patches in a pack, how many packs will she use in 12 months? Assume a calendar month is 28 days.
- The cost of one pack of 4 patches is £49.15. What is the total cost for 6 months' supply?
QUESTION 3
Morphine sulfate 2 mg/ml oral solution (Oramorph) is prescribed for Ian who is in chronic pain at the end of life. The recommended dose for Ian is 10 mg every 4 hours.
- How many ml of morphine sulfate should Ian take per dose?
- How many ml of morphine sulfate will Ian require in 24 hours?
- Ian is supplied with a bottle containing 300 ml. Assuming Ian takes the full-recommended dose, calculate how many days his oral solution will last.
QUESTION 4
Charlotte has chronic back pain due to previous orthopaedic surgery. Tramadol hydrochloride (modified-release) was prescribed and she has been taking one 200 mg tablet every 12 hours for 6 months. Charlotte has decided she wants to reduce this medication. As a prescriber, you agree to reduce the strength by 25% every 2 weeks.
- What is the strength of tramadol that you will prescribe first?
- How many tablets will you prescribe for the first 2 weeks' treatment?
- After 6 weeks, what strength of tramadol will Charlotte be prescribed?
‘Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does’
