Medication management in patients with chronic non-malignant pain. A review of the use of a drug withdrawal protocol.

One hundred and twenty-four (71%) of 173 patients, admitted consecutively to the Inpatient Service of the University of Washington Multidisciplinary Pain Center, were consuming narcotic/sedative drugs and 49 (29%) were not. We describe the use of a drug withdrawal protocol entailing outpatient drug consumption diaries; a 48 h inpatient drug profile; the use of drug equivalence tables to convert drugs consumed to a methadone/phenobarbital pain cocktail and the subsequent tapering of the active contents of the pain cocktail. Diaries reliably revealed the types of drug consumed but not extent of consumption. Narcotic consumption in particular tends to be underreported. For patients with a history of a drug problem and those who consume narcotics heavily during the first day of profile, a 48 h profile is appropriate. In others a 24 h profile is safe. Objective signs of excessive consumption or a withdrawal syndrome were noted in 2 patients during the profile period and in 4 patients during the taper from pain cocktail. Published tables appear to give a reasonable estimate of drug equivalence. The importance of monitoring patients during the protocol is emphasized.