Monday, January 5, 2009

Pain management success

One of the things that I LOVE about my job is the impact I can have on people with pain. Consider this woman: 46 years old, ovarian cancer, metastasis to the bone, pain in her right shoulder, lower back, and right hip. When I first met her she was on very high doses of methadone (good drug but not working for her), and was still doubled up in pain. She had not slept in days, except for naps disturbed by dreams. She had lost 25 pounds in 2 months because she was unable to eat due to the pain. I put her on a Dilaudid infusion at 5 mg per hour with a 3 mg bolus every 10 minutes. She used the bolus very little, because the basal rate turned out to be spot on. The next day after starting this, she told me she had slept all night. She was able to walk standing straight up. She was eating. The next day after that, she was smiling. She had again slept all night, but was not sleepy during the day. She was functional. She is still on her infusion at this dose, but we discussed the probability that at some point her illness will worsen and she may need more. It will be simple to increase the dose, just by adjusting the pump. Her hospice nurse is visiting her frequently and checking for any side effects, changing the tubing and bags as needed, and will let me know of any issues. Seeing her move about, eat normally, and function normally is such a rush for me. I don't know how long this will last, but if she gets even a week (although I think it will be much longer) of pain relief, it will be worth it.


  1. I really like to hear stories like this to demonstrate the effectiveness of good pain control to improve functionality.

    Just as a side note, I presume she was pretty opioid tolerant before starting a dilaudid infusion at 5mg/hr? Since you did not mention it in your post I thought it might be prudent for others to know that is not a usual starting dose for opioid naive patients.

  2. Hello Dr Sinclair. Yes. She had been on 240 mg daily of Methadone and 720 mg of oxycodone, and was still having 10/10 pain. It's not easy figuring the equianalgesic dosing at that level, and I really thought I was going to have to do some adjustment based on bolus use. As it turned out, she only used the bolus 3-4 times every 12 hours.

    Thanks for bringing this up. This would have been a MASSIVE dose for an opioid naive patient. Considering that parenteral Dilaudid is 10 times more potent than Morphine, you have to be very careful.