This is the seventh in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
JY, a 28 year old woman with advanced cystic fibrosis and Burkholderia cenocepacia colonization is hospitalized for a cystic fibrosis exacerbation. She has chronic chest wall pain from coughing and pleurisy, and recently broke 2 ribs from coughing. She is on IV glucocorticoids, IV ketorolac, IV ketamine prior to vest treatments, and lorazepam.
Prior to her hospitalization, she took oxycodone ER 30mg q12h. Currently she is on a hydromorphone IV PCA at 2mg/hour, with 2mg q30 minute boluses. She used 72mg of IV dilaudid in the last 24h. Despite this she is becoming drowsy, and reports her pain is minimally improved and still severe for most of the day: 7-8/10, and ‘nearly intolerable’ during vest therapy
The best next step is to:
a) Increase her PCA basal and ‘bolus’ doses by 50% and monitor for 24 hours.
b) Add a 5% lidocaine patch to her chest wall over her rib fractures
c) Discontinue hydromorphone and switch the patient to another opioid
d) Advise the primary team to stop vest therapies
Correct answer is (c)
a) Indications for opioid rotation are 1) dose-limiting side effects such as sedation, nausea, pruritus, myoclonus from the patient’s current opioid, 2) need for a new dosing route (patient cannot swallow), 3) costs/insurance changes, 4) inadequate analgesia despite ‘adequate’ dose-escalation of the current opioid. There is no consensus on what 4 actually means, however rapidly escalating someone by an order of magnitude (as in this case) without good response, is generally a scenario in which you’d consider rotation (if not long before). Is not best next step given the above discussion
b) No data at all suggesting the lidocaine patch is effective for pain from fractures
c) Is the correct answer: Morphine, methadone, or fentanyl are all reasonable options. Some prefer methadone in these sorts of settings, but no actual data to support that and probably not tested on the boards. Another reasonable approach in this situation would be to consult a pain interventionalist for regional options.
d) Opioid rotation is reasonable first, before advising this, as it will likely affect the patient’s ability to recover.
(For email readers - click here for the answer and discussion)