Thu11November0627PM 5

Mrs Samson is a 74-year-old lady with renal cell carcinoma with liver and bone metastases. She is on regular morphine for her pain but has recently developed severe pain in her left upper arm which does not completely respond to PRN doses of morphine.

Her daughter reports that she has become increasingly agitated and confused over the past 24 hours, and is experiencing visual hallucinations, yet remains in significant pain.

Which of the following would be the most appropriate initial management?

(Please select 1 option)

Stop the morphine

Increase her regular morphine dose

Amitriptyline should be added to her analgesic regime

Urgent referral to specialist palliative care team Correct

Start an oral bisphosphonate for bone pain

Explanation

The patient has uncontrolled pain and yet is exhibiting symptoms suggestive of opioid side effects. These can occur due to non-opioid-responsive pain; for example, bone pain tends to be less responsive to opioids. Specialist advice regarding rotation to an alternative opioid should be urgently sought.

Whilst amitriptyline is used for neuropathic pain, it is unlikely to be helpful for bone pain and would not be in the initial management.

Although her pain is not controlled, increasing the morphine is likely to worsen her side effects but stopping the morphine completely may well lead to escalating pain and withdrawal symptoms.

IV bisphosphonates are used for bone pain in metastatic cancer but should not be used acutely without assessing renal function, calcium and dental health.

Answer Statistics

1

13%

2

3%

3

8%

4

52%

5

26%

Times answered: 257