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Case 0003 – Beyond opiates in Chronic pain

63 yo man with advanced oesophageal cancer, diagnosed 18 months ago.  Now has extensive liver mets, retroperitoneal tumour and fungating open tumour in lower abdomen.

Presents to ED Saturday morning with intractable visceral-sounding pain – “not responding to his usual pain tablets”.  So what is he taking for this pain :

2 x 80 mg OxyContin tabs every 3 hours, plus 10 or 11 Oxynorm tabs for breakthrough each day – yes, thats right a total of 1500 mg of oxycodone/day.  He is NOT taking any other pain medications – does use some oral Movicol for constipation and prn PR Microlax enemas.

So, how can we get control of this pain?  What other options are available to us?  He is keen to stay at home and is relatively active, not keen on parenteral meds…. he reluctantly agrees to stay in for a day or so in order for us to titrate some new meds for the pain – what are you going to write up??

Here is my cocktail, trying to avoid parenteral drugs for discharge. Any comments:

  1. Maintain baseline opiate load – 240 mg SR Oxycontin tds (roughly 1 g background) – don’t let him withdraw!
  2. Breakthrough opiates : oxycodone 40 – 60 mg prn  – in case the next few additions don’t cut it…
  3. Paracetamol: 1g regularly
  4. Consider a trial of NSAID – if tolerated – celocoxib 200 mg
  5. Nocte pregabalin – start with 150 mg – I have had good results with this, especially for the sleep / nocte pain control
  6. Backup plan – try some prn tramadol , either it helps or it doesn’t
  7. If all else fails – rotate opiates, the dose of morphine is huge, too much for standard patches, consider Hydomorph pump?
  8. What about ketamine – if you are struggling to get over the opiate wind-up – “try to reset the clock” with a 48 hour infusion.

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