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Chapter 54: Pain Management

JG is a 56-year-old woman with a chief complaint of left arm, shoulder, and axillary pain. Patient underwent a left subtotal mastectomy and chemotherapy for breast cancer 1 year ago and received radiation therapy and bone marrow transplant at that time. Patient is currently free of cancer, but complains of burning and stinging pain down her left arm and nothing has worked well for her. She is also complaining of severe constipation. Her current medications are Bupropion (Wellbutrin) 150 mg po bid, Ibuprofen 600 mg po one tablet tid, morphine sulfate extended release (ER) 30 mg bid, atenolol 50 mg po every morning, and Tamoxifen 10 mg po bid.

What is best therapeutic plan of this patient's analgesic regimen?

a. Analgesic regimen should be discontinued, because long-acting opiate is not appropriate for this patient's pain.

b. Increase morphine ER to 30 mg po every 4 hours since it is not providing adequate analgesia.

c. Increase morphine ER to 60 mg po tid since it is not optimally controlling patient’s pain.

d. Add pain medication to focus on neuropathic symptoms.

Answer d is correct. Adding a medication to focus on the neuropathic pain would be appropriate (eg, tricyclic antidepressant, carbamazepine, gabapentin).

Answer a is incorrect. Based upon the patient’s history, her pain is most likely moderate to severe; therefore, use of opioids would be appropriate. However, since the pain is neuropathic, adjunctive pain medications like antidepressants or antiepileptics should be considered.

Answer b is incorrect. Large increases in dose or interval of opioids should be avoided to minimize risk of side effects (eg, respiratory depression).

Answer c is incorrect. The patient’s pain is neuropathic, therefore, adding adjunctive therapy would be appropriate.

JG is a 56-year-old woman with a chief complaint of left arm, shoulder, and axillary pain. Patient underwent a left subtotal mastectomy and chemotherapy for breast cancer 1 year ago and received radiation therapy and bone marrow transplant at that time. Patient is currently free of cancer, but complains of burning and stinging pain down her left arm and nothing has worked well for her. She is also complaining of severe constipation. Her current medications are Bupropion (Wellbutrin) 150 mg po bid, Ibuprofen 600 mg po one tablet tid, morphine sulfate extended release (ER) 30 mg bid, atenolol 50 mg po every morning, and Tamoxifen 10 mg po bid.

What is the best approach for the burning pain in this patient?

a. Add amitriptyline 50 mg po at bedtime.

b. Add duloxetine ...

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