1. A 79-year-old man with a history of metastatic prostate cancer is admitted to the hospital with an exacerbation of COPD. He also notes that his back pain has been worsening over the past 3 weeks. There have been no recent accidents or injuries. The pain is limiting his ability to bathe himself and participate in therapy. He has been having trouble getting comfortable at night, and has not slept well. PE is normal, except for tenderness to palpation over his lower spine. Previous Bone scan reveals metastatic disease in the lumbar spine and pelvis.
    Which of the following is the most appropriate initial management strategy for this pt’s pain?


    1. immediate-release oxycodone with acetaminophen

    2. Sustained-release oxycodone

    3. Propoxyphene-acetaminophen

    4. Transdermal fentanyl

    5. None of the Above


    Answer: a
    This patient has moderate pain that is affecting functional status and quality of life. He should have scheduled dosing of an opioid. His pain would best be managed with initiation of a fast-acting opioid, such as immediate-release oxycodone. This medication should be given around the clock and the dose adjusted as needed to achieve adequate pain control. Once the pain is under control, the amount of immediate-release oxycodone required in 24 hours should be calculated. The regimen can then be converted to an equianalgesic dose of a long-acting opioid, such as sustained-release oxycodone or transdermal fentanyl. These agents should not be initiated until the amount of opioid required for optimal pain management has been determined. Please note, however, that Fentanyl has incomplete cross-tolerance with other opioids and should be started at the lowest dose. Propoxyphene has efficacy similar to acetaminophen, but a much more severe side-effect profile, including dizziness, ataxia, and cardiac issues. For these reasons, it is now no longer available in the US market.

  2. A 56-year-old woman is admitted to the hospital for a small bowel obstruction. Surgery is planned for the following morning, and an NG tube is placed. In the Emergency department she initially received 1 mg of Dilaudid (hydromorphone) IV, which is followed 2 hours later with an additional dose of 2 mg. After the first dose of Dilaudid, she stated to the ER nurse that her pain decreased from an “8” to a “5”. After the second dose, her pain decreased to a “3”, she was resting comfortably, however she developed intense itching. Her respiratory rate and vitals remain stable. Two more hours have elapsed, and she is now rating her pain at a “6/10”. She is worried about an additional dose of Dilaudid due to the previous itching and would like to try a different medication. The patient’s nurse calls you for orders. The most appropriate next step is:


    1. DC the dilaudid and change to meperidine (Demerol) 10mg IV q 3h PRN.

    2. DC the dilaudid and change to a 50mcg transdermal fentanyl patch.

    3. Continue the Dilaudid at a dose of 2mg IV q 3h PRN and add PRN. ranitidine 50mg IV q 6h and diphenhydramine 25mg IV q6h

    4. DC the dilaudid and change to morphine 2-4mg IV q4h PRN.

    5. DC the dilaudid and change to morphine 6-10mg IV q3h PRN.

    6. None of the Above


    Answer: e
    Meperidine is metabolized into a relatively toxic compound that easily accumulates when given frequently and causes tremulousness, seizures, and delirium. It should not be used for recurring and ongoing pain needs. Transdermal fentanyl is used for chronic, rather than acute, pain control. It takes 3-6 days to achieve steady-state in most patients. It is also not appropriate due to the risk of unintended release of fentanyl that could occur with heating blankets used commonly in the OR. Hydromorphone produces active metabolites at relatively low concentrations and is unlikely to produce unanticipated effects such as itching. In this situation, because an unlikely effect has caused distress to the patient, the most appropriate next step is to change to different medication. Morphine is a good choice, and given that the patient was experiencing good pain relief with 1-2mg of hydromorphone IV, an appropriate morphine dose would be 6-10mg IV q3h PRN.

  3. A 54-year-old man with prostate cancer that is metastatic to his skull and thoracic spine is admitted for pain control from home. He is currently taking morphine sulfate ER (Kadian) 100mg Q12h. There has been no recent trauma. Repeat imaging shows stable bony lesions without new fractures. Other than mild pain, he is without complaints. In addition to ordering his home dose of pain medications, a reasonable order for breakthrough pain would be:


    1. morphine sulfate 15-30mg po q2h prn pain

    2. morphine sulfate ER 30mg po q4h prn pain

    3. morphine sulfate 15-30mg po q6h prn pain

    4. Dilaudid (hydromorphone) 2mg IV q2h prn pain

    5. morphine sulfate 4mg IV q4h prn pain

    6. None of the Above


    Answer: a
    This patient is already receiving pain control with long-acting morphine, and every attempt should be made to continue to control his pain with this medication. It is not stated that the patient is not tolerating po medications, and so po morphine is the best choice. To find the needed breakthrough dose of medications for a patient on a stable regimen of chronic long-acting opioids, two different calculations can be used. Either give the patient 10-20% of their total daily dose of long-acting opioid every 2-3 hours, OR give the patient 25% of one of the doses. In this case, the patient is taking 200mg of morphine daily, and 10-20% of that is 20-40mg. Thus 15-30mg po q2h prn is the best answer. Alternatively, 25% of 100mg (one dose) is 25mg, and again answer a is the best answer. Long acting medications should not be used for breakthrough pain. Hydromorphone is a very potent opioid, and 2mg would potentially be too much, based on the above discussion and the conversion factors. It is important to use calculators (such as those found in MedCalc or MediEquations) for opioid conversions. It is also preferable to treat a patient with the same long-acting and short-acting opioid (in this case long- and short-acting morphine). Using MedCalc, it is apparent that answer e would be an insufficient amount of morphine to likely cover breakthrough pain.

  4. The patient from the case above, following a prolonged hospital stay, is ready to be discharged home form the hospital. His wife will be assisting him in his IADLS, and he is otherwise independent. He has declined Hospice and palliative care services at this point. For the past three days he has been stable on a regimen of morphine sulfate ER 100mg po q12h and 15-30mg po q2h prn “breakthrough pain”. A review of the MAR shows that he is receiving this prn medication as follows:
      Three days ago: 30mg(0200), 15mg (0600), 30mg(0900), 30mg (1500), 15mg(2100)
      Two days ago: 30mg(0500), 30mg(0900), 15mg(1500), 15mg(1700), 15mg(1900), 15mg(2300)
      Yesterday: 30mg(0200), 30mg(0600), 15mg(1100), 30mg(1700), 15mg(2200)

    The most appropriate discharge pain regimen would be:


    1. morphine sulfate ER 260mg po q12h and 60mg po q2h prn

    2. morphine sulfate ER 220 mg po q12h and 60mg po q2h prn

    3. morphine sulfate ER 130mg po q12h and 30mg po q2h prn

    4. transdermal fentanyl 75mcg/h q72h and morphine sulfate30mg po q2h prn

    5. methadone 80mg po q12h and morphine sulfate30mg po q2h prn

    6. None of the Above


    Answer: c
    To increase a patients long-acting opioid, first ensure that the previous dose adjustment has had long enough to take effect (2-3 days for long-acting po formulations and 5-6 days for transdermal systems). Following that, total the daily amount of breakthrough opioid needed in the past 2-3 days, and average this (in this case, 120mg of prn morphine was given daily). Depending on the adequacy of pain control that this has achieved over the past 2-3 days, add 30-50% of this total to the long-acting total opioid dose. In this case 30-50% of 120mg is 40-60mg, added to 200mg = 240-260mg. A good new dose would be 130mg q12h of extended-release morphine. To calculate the new prn dose: 10-20% of 260mg total long-acting opioid is 26-52mg, and so 30mg po prn q2h is reasonable. There is not a good justification in the case to switch to transdermal fentanyl at this point (note: transdermal fentanyl may be less constipating at equi-analgesic doses to po odioids). Methadone has a unique pharmacology that make it surprisingly effective in some settings, but also gives it potential for unexpected and unanticipated toxicity. Methadone’s half life ranges from 12 hours to one week. Unintended accumulation due to this effect can easily lead to unintentional overdose, and its use should be considered second or third tier. Titration above a total daily dose of 40mg should only be performed by an experienced clinician.