The Case of the Omitted Opioid
Rocky is a 56-year-old man with stage III oropharyngeal cancer. He is undergoing concurrent chemotherapy and radiation. Rocky is a long-haul truck driver, has had sporadic medical care in the past, has no primary care provider, and usually visits the emergency department in whatever town he is in when he gets sick. He was diagnosed during one of those visits after an episode of hematemesis.
He is staying with his sister while undergoing treatment and has attended all of his appointments. Today, when he comes in for his weekly weight check, he seems shaky and reports having nausea but no vomiting. His infusion room nurse, Jack, asks him what is going on. Rocky admits that he has been taking 30–40 mg of hydrocodone per day, but he recently ran out.
Jack learns that Rocky has been taking hydrocodone for back pain for the past year, but he took extra doses over the past few days because of throat pain. He had not disclosed this use during previous appointments.
What Would You Do?
According to van den Beuken-van, de Rijke, Kessels, et al (https://www.ncbi.nlm.nih.gov/pubmed/17916403)., “Pain is highly prevalent in the cancer population. Virtually all patients with malignant disease experience recurrent episodes of acute pain, which may accompany surgery, invasive procedures, or complications, such as a pathological fracture. In addition, chronic pain that is severe enough to warrant opioid therapy is experienced by 30 to 50 percent of patients undergoing active antineoplastic therapy and by 75 to 90 percent of those with advanced disease.”
Chronic pain that is severe enough to warrant opioid therapy is experienced by 30% to 50% of patients undergoing active antineoplastic therapy.
Jack realizes that Rocky needs to see one of the providers today. Because Rocky is in active treatment for cancer, the Centers for Disease Control and Prevention (CDC) guideline (https://www.cdc.gov/drugoverdose/prescribing/guideline.html) for safe opioid prescribing do not apply. Instead, the CDC recommends that providers follow palliative care protocols. "For this guideline, palliative care is defined in a manner consistent with that of the Institute of Medicine as care that provides relief from pain and other symptoms, supports quality of life, and is focused on patients with serious advanced illness. Palliative care can begin early in the course of treatment for any serious illness that requires excellent management of pain or other distressing symptoms."
The provider asks Rocky if he would be willing to have a pain specialist consult on his case. Rocky gratefully agrees.
It is important to fully assess and identify the cause of pain and then implement a plan that best manages or eliminates the cause of pain. Interventions differ for neuropathic, bone, and tissue pain. A diagnostic work-up should also include assessment for chemical coping.