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Opioid Dose Escalation Review — FRCA Final MCQ

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ModeratePain MedicineOpioid Dose Escalation ReviewFRCA Final

A 65-year-old man (ASA III) has chronic non-cancer pain attributed to lumbar spinal stenosis. He has taken oxycodone modified-release 40 mg twice daily and pregabalin 300 mg twice daily for 3 years. Over the past 6 months, the analgesic benefit has diminished without improvement in mobility or daily function. There are no new red-flag symptoms or neurological signs, and reassessment has not identified progression requiring urgent spinal intervention. He requests an increase in analgesic medication. What is the most appropriate next step?

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Correct answer: D — Arrange a structured review of efficacy, function and harms, with specialist pain-service input

Explanation lettering: E = shown as B · D = shown as C · C = shown as D · B = shown as E

C is correct. Diminishing benefit after prolonged opioid treatment, without functional improvement or new remediable pathology, should prompt a structured, person-centred review rather than automatic escalation. This should reassess pain mechanisms, function, adverse effects, dependence, mood, opioid-induced hyperalgesia, non-pharmacological treatment and whether supported dose reduction is appropriate. Pregabalin 300 mg twice daily is already the licensed maximum dose and also requires benefit–harm review. Increasing oxycodone or adding fentanyl would increase opioid exposure and associated harms without addressing loss of efficacy. Opioid rotation may occasionally be specialist-led but is not an automatic substitute for review and requires cautious conversion. Oral ketamine is not a routine long-term adjunct for this presentation. Neither opioid nor pregabalin should be stopped abruptly.

Reference: National Institute for Health and Care Excellence. NG215, Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults, sections 1.3–1.5. 2022. https://www.nice.org.uk/guidance/ng215/chapter/Recommendations