Chronic Pain, Codeine, and Diazepam: A Prescribing Boundary
Mr Ng, 45, a construction worker, has chronic low back pain after a fall two years ago. He is on codeine/paracetamol 30/500 mg, two tablets four times a day, and diazepam 10 mg at night, both from your clinic. He now asks for 'something stronger' and says the tablets 'don't work anymore'. He admits to buying extra codeine from a friend and to drinking six cans of beer most nights. He has missed two appointments and has been seen at two other clinics asking for the same drugs. He becomes irritable when you mention reducing the diazepam and says, 'If you cut me off, I'll just get them elsewhere.' He has a history of depression and once took an overdose. On examination he is drowsy but rousable; there are no focal neurological signs.
1. What are the key risks in this consultation, and what would you do first?
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The key risks are opioid and benzodiazepine dependence, tolerance, overdose, alcohol-related harm, doctor-shopping, and possible suicide risk. His drowsiness may reflect codeine, diazepam, alcohol, or a combination, and must be assessed before any dose increase. First, take a focused history: pain severity and function, exact doses and sources of all medicines, alcohol intake, previous withdrawal symptoms, mental state, and suicidal ideation. Examine for sedation, respiratory rate, and neurological signs. Check the electronic patient record and, with his consent, contact the other clinics to confirm what has been prescribed. Do not escalate the codeine or diazepam. Explain your concerns directly but non-judgementally, and agree a safety plan. If he is acutely sedated or suicidal, arrange urgent assessment and do not send him home alone. Document the consultation carefully.
2. How would you manage his medications safely?
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Avoid abrupt withdrawal, which can cause benzodiazepine withdrawal seizures and opioid withdrawal. Continue the current dose in the very short term to prevent withdrawal, but make it clear that this is not an escalation and that you will not replace the codeine he buys illegally. Agree a written tapering plan: for diazepam, reduce by about 10–25% every two weeks, slower if withdrawal symptoms occur; for codeine, reduce gradually and consider switching to a structured pain plan. Treat the underlying pain with non-opioid measures, physiotherapy, and attention to sleep and mood. Refer him to a pain clinic and, if he agrees, to substance misuse or mental health services. Assess and treat his depression, and review suicide risk at each visit. Warn him not to drive or operate machinery while drowsy, and not to drink alcohol with these medicines. Provide clear written instructions and a follow-up appointment.
3. What if he becomes threatening or demands drugs under pressure?
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Your safety and that of staff come first. Stay calm, keep the door open, and use a chaperone or security if needed. Do not prescribe under threat or coercion; explain that you want to help but that the decision must be clinically appropriate. Set clear boundaries: you will not increase the doses today, you will not replace illegally obtained drugs, and you will not tolerate threats. Offer an alternative, such as a same-day senior review, a pain clinic referral, or a crisis line. If he makes a specific threat, end the consultation and follow the clinic's incident-reporting policy. Document his words and your actions. If he leaves angrily, ensure he has safety advice and a follow-up route. Prescribing controlled drugs requires a therapeutic relationship based on trust and clear limits, not compliance with demands.