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Chapter 55. Pain Management

KK is a 65-year-old woman with a chief complaint of left arm, shoulder, and axillary pain. She underwent a left subtotal mastectomy, radiation, and chemotherapy for breast cancer. KK has currently no evidence of cancer, but complains of two types of pain. The first in her chest is a dull achy pain; the second is a burning and stinging pain down her left arm and nothing has worked well for this pain. She is also complaining of severe constipation. Her current medications are bupropion 150 mg bid, ibuprofen 600 mg one tablet tid, morphine sulfate extended release (ER) 30 mg bid, atenolol 50 mg every morning, and tamoxifen 10 mg bid. All medications are taken by mouth.

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, TCA, 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—especially for the nociceptive pain in her chest. However, since the second 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). Also ineffective for the neuropathic pain.

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

KK is a 65-year-old woman with a chief complaint of left arm, shoulder, and axillary pain. She underwent a left subtotal mastectomy, radiation, and chemotherapy for breast cancer. KK has currently no evidence of cancer, but complains of two types of pain. The first in her chest is a dull achy pain; the second is a burning and stinging pain down her left arm and nothing has worked well for this pain. She is also complaining of severe constipation. Her current medications are bupropion 150 mg bid, ibuprofen 600 mg one tablet tid, morphine sulfate extended release (ER) 30 mg bid, atenolol 50 mg every morning, and tamoxifen 10 mg bid. All medications are taken by mouth.

What is the best approach for the burning pain in ...

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