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, “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 percent of patients undergoing active antineoplastic therapy.

Jack is concerned that Rocky might be in withdrawal and needs to see one of the providers today. Rocky’s plan for pain management should adhere to the Centers for Disease Control and Prevention guideline for safe opioid prescribing, including:

  • Use nonopioid medications and other therapies such as physical therapy instead of or in combination with opioids.
  • Prescribe the lowest effective dosage of opioids to reduce risks of opioid use disorder and overdose.
  • Discuss potential benefits and harms of opioids with patients.
  • Assess improvements in pain and function regularly.
  • Use tools such as urine drug tests and prescription drug monitoring programs to inform yourself about patients’ other medications that increase risk.
  • Monitor patients for signs of whether opioid use disorder might be developing, and arrange treatment if needed.

The provider understands that Rocky no longer fits the patients profiled in the guideline because of his ongoing cancer treatment, but he also understands that back pain would limit Rocky’s ability to do his job and sit while driving. He 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.


Posted by Bonnie (not verified) 1 week 2 days ago

I agree, control the pain, and refer to a specialist, but we need to remember - is it safe for him to drive truck over -the-road? Federal guidelines have changed in the past few years, and unfortuately, this gentleman most likely should not be driving.

Posted by Ellen Wardlaw, RN (not verified) 1 week 2 days ago

It would be ideal for oncology patients to have pain management teams to consult with. Exceedingly difficult to find providers taking new pain mgmt pts, or taking the pt's insurance, or taking non-insured pts, or willing to see cancer pts. Definitely more challenging in some organ sites than others. Also, need to address oncology psychiatric care, which can also exacerbate pain and has even fewer available providers.

Posted by Lori Johnson (not verified) 1 week ago

This is a nice case study, but the CDC guidelines on opioid therapy should. It be cited here without a knowledging that they are specifically written for patient populations OUTSIDE OF ACTIVE CANCER TREATMENT. The way the article is written it appears to be promoting these guidelines for cancer patients on active treatment. Let's try not to set the clock back three decades, please.

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