Chronic Malignant Pain
Goal of Malignant Pain Management
29. A.J., a 68-year-old man, was diagnosed with metastatic prostate cancer 6 months ago. Now he is admitted for excessive sedation and respiratory rate of eight breaths per minute. A.J.'s admitting diagnosis is possible opioid overdose. A.J. was started on a fentanyl patch 100 mcg/hour 24 hours ago by his physician because of spinal pain not adequately relieved by oral acetaminophen 325 mg and oxycodone 5 mg every 3 hours. The fentanyl patch was removed 86 hours ago, and A.J. is again complaining of his spinal pain radiating to his buttocks and left leg. A.J. is currently awake and alert and relates that his pain level is at 9 of 10 on the pain scale. What is the goal in managing A.J.'s pain?
The goal in treating pain of terminal illness is comfort and an acceptable (to the patient) level of consciousness. Opioids should not be withheld for fear of addiction or that the dose may be too high. Instead, the dose should be titrated based on the patient's clinical response. Ideally, the patient should be comfortable and voice no complaints when questioned about his or her level of activity and alertness. Under these conditions, any dosage reductions or changes in therapy serve no purpose, even if the patient is receiving doses several times those typically used to treat acute pain. To emphasize, clinicians should focus attention on their patients' clinical response rather than on an arbitrary list of doses or ideal number of medications. The immediate goal for A.J. is to break the cycle of pain and to rapidly achieve the greatest degree of comfort possible.
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