Angela (51) is a regular visitor to your pharmacy. You have noticed she seems paler than usual, and rather withdrawn.
For the past two years Angela has been collecting her prescription for Tramadol from you (https://pubmed.ncbi.nlm.nih.gov/15509185/; https://bnf.nice.org.uk/treatment-summaries/low-back-pain-and-sciatica/).
You recall overhearing a conversation Angela had with a fellow customer. They were sympathising with each other about their chronic lower back pain. You remember her saying something like ‘I’m not sure what I’d do without my pain tablets.’
Clinically, in patients with chronic low back pain who have had an inadequate response to non-drug treatment, NSAIDs should be considered as first-line therapy. Opioids should be the last treatment option considered and should be contemplated only in patients for whom other therapies have failed, and only if the potential benefits outweigh the risks. If indicated, opioids should be prescribed only for a limited period. Long term opioid therapy should be avoided. However, it is possible to be on opioids like Tramadol for several years, if needed.
For the last three months or so Angela has not been bringing in a prescription for Tramadol. A couple of weeks ago you politely asked her why. She told you her GP had called her in for a medication review and declared that after two years she was no longer sure Tramadol was helping Angela much, if at all, and tapered off her medication. She said the doctor explained that Tramadol can get less effective over time and in some patients it can become a habit. As an alternative, the GP prescribed Naproxen for a 10-day trial and in addition suggested adding in co-codamol OTC 8/500mg tablets for breakthrough pain; 2 tabs four times daily if needed. The GP also recommended more physiotherapy and an exercise programme she could do at home.
As she was relating this decision Angela appeared disgruntled. She’s now buying low strength co-codamol from you over the counter. You observe that she seems quite lethargic. She has lost weight in her face but is otherwise rather bloated, and her lips are unusually pale. She tells you, “To be honest the pain is no better this way either, in fact it’s worse. I feel full all the time and it’s not easy to go to the toilet.”
You have asked staff to monitor her use since you suspect she may be using more than the recommended dose. You are of course aware that there is nothing to stop Angela buying co-codamol and similar drugs from other pharmacies in the area, or via the internet.”
As a pharmacist, what if anything should you do for Angela?