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A 69-year-old man is evaluated for low back discomfort. He has a history of metastatic prostate cancer to the spine without evidence of spinal cord compression. He is ambulatory and functional in all activities of daily living. He recently received palliative radiation therapy to treat metastatic disease in L1 and L3. The treatment improved but did not eliminate his discomfort. He rates his discomfort as 5 on a scale of 1 to 10. He denies any radiation of the pain, fever, motor weakness, or difficulties with bowel or bladder control. The patient takes at least two naproxen 250-mg tablets daily. The pain medication reduces but does not eliminate his back discomfort.
On physical examination, temperature is normal, blood pressure is 150/88 mm Hg, pulse rate is 88/min, and respiration rate is 16/min. BMI is 28. Neurologic and mental status examinations are normal. There is no point tenderness over the lumbar vertebrae.
Which of the following is the most appropriate strategy for pain management in this patient?
A. Add an extended-release opioid
B. Add fentanyl patch
C. Add a short-acting opioid
D. Discontinue naproxen and substitute ibuprofen
Answer: C, Add a short-acting opioid.
Educational Objective: Manage narcotic medications in a terminally ill patient with mild to moderate pain.
Critique: Patients with advanced malignancy often exceed the ability of non-narcotic analgesics to control their pain. In cancer patients with mild to moderate pain such as this one, an effective strategy is moving to step 2 on the World Health Organization three-step pain relief ladder by prescribing an intermittent low-dose narcotic in addition to adjuvant, non-narcotic pain medicine. The most appropriate management for this patient is adding a short-acting opioid medication such as immediate-release formulations of oxycodone, morphine, or oxymorphone.
Initiating a long-acting narcotic such as a fentanyl transdermal patch or extended-release oxycodone is not indicated until the patientís pain is adequately controlled with short-acting narcotics, which can be rapidly titrated to achieve adequate pain control. Once pain control is established, the cumulative dose of the short-acting opioid can be used to calculate an effective dose of a long-acting opioid, remembering to reduce the dose by 30% to 50% and maintaining access to a short-acting opioid for break-through pain. If the short-acting opioid is needed more than three times daily, the amount of long-acting opioid is increased. Long-acting opioids should not be used as initial therapy for moderate to severe pain because their long-half lives makes it impossible to quickly titrate the dose and control the patientís pain.
Changing the NSAID is much less likely to control this patientís pain than is adding a short-acting opioid analgesic.
Key Point: Low-dose narcotic pain medications combined with non-narcotic analgesics are often an effective treatment strategy for mild to moderate cancer-associated pain.
Bruera E, Kim HN. Cancer Pain. JAMA. 2003;290(18):2476-2479. [PMID:14612485]Table of Contents
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