Mak et al.: OPIOID THERAPY IN AN ACTIVE POLICEMAN
577
patient was first seen at our clinic in 1995.
Subsequently, in 1996, the Medical Council of Hong
Kong published general guidelines for medical practi-
tioners prescribing opioid, benzodiazepine and psy-
madol. One also has to be careful when introducing
tramadol to a patient already receiving high doses of
potent opioids as this combination can cause acute
opioid withdrawn symptoms. A detailed and informa-
tive discussion with our patient showed that he had a
good understanding of these drugs before initiation of
therapy. At this stage however, it is still too early to
recommend the ideal drug, its formulation and the
starting and maintenance dosages in this highly het-
13
chotropic drugs. However, these simple guidelines
were not specifically targeted for patients with chron-
ic non-malignant pain. The Australian Pain Society
and the College of Physicians and Surgeons of Ontario
14
in Canada published their guidelines in 1997 and
00015 respectively. These require a detailed history
erogeneous group of patients.
21
2
and physical examination, regular assessment, precise
treatment plan and objectives, informed consent
As opioids may also cause psychomotor distur-
bance, we believed that it was essential to receive reg-
ular assessment and work reports from his supervisors
to allow the patient to return to work. Monthly
reports from the marine police headquarters were
required during his first year of opioid treatment and
quarterly thereafter. This was arranged in advance
with informed consent from the patient. One can be
more precise in these work reports by including a
scoring chart for routine tasks. Such scoring charts can
then be used to evaluate patient progress. The police
department suspended our patient's use of firearms
while on opioid treatment. However, a high degree of
physical activity was required from the patient as a
training officer and a high level of vigilance and cog-
nitive function for communication duties. Despite the
chronic use of methadone at doses of up to 80 mg
(including a written agreement with patients), means
to consult other expertise if problems arise and metic-
ulous record keeping. Single prescriber and pharmacy
as well as monitoring of compliance e.g., urine and
serum drug level testing were also stressed. Overall
management of this patient concurred remarkably well
with guidelines subsequently published worldwide.
The Australian guidelines suggest that sustained
release morphine preparations are the drugs of choice
for patients with non-malignant pain. Our patient
however, disliked the idea for the fear of being addict-
ed to a ‘street-drug’. Literature on the use of
methadone is scant. We chose to use it for several rea-
sons. It is a potent opioid with high bioavailability and
therefore suitable for oral administration. It has no
known metabolites, is relatively inexpensive and has
long administration intervals.16 As well as its mu and
delta receptor agonist activity, it is also known to pos-
sess some N-methyl-D-aspartate (NMDA) receptor
inhibition.17 It has been suggested that the combina-
tion of an opioid and a drug with NMDA receptor
antagonist properties may improve the level of analge-
–1
day , his performance was judged as excellent by his
colleagues and supervisors. Close communication
between all parties involved is highly recommended.
Existing guidelines do not address the issue of ‘moni-
tored return to work’ and it may be useful to incor-
porate this facet into future recommendations. This is
especially important when return to full time work is
crucial for the patient, financially or otherwise. Overall
functional improvement can also be assessed by scor-
18
sia and minimize adverse effects. However, its long
half-life with unpredictable pharmacokinetics between
individuals may cause delayed toxicity such as excessive
sedation and respiratory depression.19 Careful titration
and observation must be carried out to avoid these.
Tramadol was started while the patient was on
vacation abroad. As well as being a centrally acting
opioid, tramadol also affects the descending inhibito-
ry pathways and modulates nociception through its
inhibition on the reuptake of monoamines such as
norepinephrine and selective serotonin receptors
22
ing systems such as the Sickness Impact Profile and
23
the Multidimentional Pain Inventory. Together with
pain scores, categories like work, ambulation, recre-
ation, sleep pattern, perceived life control and pain
behaviour can be examined more objectively.
This case is unique because of the patient's working
environment. Police officers (including marine offi-
cers) in Hong Kong are constantly involved in drug
related crime. We warned our patient that occasional
measurement of serum opioid levels would be
required if concerns arose about drug compliance.
Dose escalation in this group of patients can be rela-
(
SSRI).20 Although a weaker analgesic, its use
decreased the consumption of methadone. Fluoxetine
is an antidepressant with SSRI activity. Its combina-
tion with tramadol, which has serotonergic activity,
can therefore precipitate serotonin syndrome with
hyperstimulation and seizures. Fortunately, the use of
fluoxetine was no longer required and had been dis-
continued 18 months prior to the introduction of tra-
4
tively common, up to 78% in one study. Although
pharmacological tolerance may be the reason for pro-
gressive increases in dosage, drug abuse remains a pos-
sibility. Fortunately, our patient reduced his drug
requirement voluntarily.
Hueckel
