Cancer Pain Management Case Studies
Managing Cancer Pain: Male with Colon Cancer
This patient developed colon cancer at age 45. After surgery and radiation, the cancer continued to grow and became extremely painful for the now 50-year-old male.
As a result, the patient was taking high doses of oral and skin patch opioids as an outpatient, without pain relief. He was ultimately admitted to the hospital for high dose intravenous opioids which relieved his pain at the expense of putting him into a near-comatose state.
Each time the hospital doctors tried to reduce the doses of intravenous opioids, the patient become more alert, but the pain returned with a vengeance. Everyone was stuck – the patient, his family, and the doctors trying to take care of him.
Ultimately, the oncologist called Nura and we intervened as follows:
- The patient was transferred from hospital discharge directly to our pain clinic.
- On arrival at Nura, the patient received an epidural catheter dosed with a mixture of local anesthetic and opioid. The pain was relieved within minutes (think of a labor epidural – if an epidural can eliminate labor pain, it can control just about any type of pain).
- Since epidural injection of local anesthetic/opioid wears off within two to three hours, we taught the patient to self-inject the epidural catheter at home overnight and, as a temporary measure, provided him with syringes pre-filled with local anesthetic to do this.
- Our cancer pain team (physician, APP, implant RN, implant coordinator, medical device company rep) educated the patient on pain pump technology and we scheduled surgery to implant a pain pump the next day.
- After the pump implant, the patient was able to return home with a continuous infusion plus boluses from the pain pump. Our cancer pain team is continuing to support him as an outpatient.
The patient’s pain level has now been significantly reduced and he can self-administer pump doses with a hand-held remote-control device programmed to deliver pre-set doses of medication as needed. He continues to undergo chemotherapy directed by his oncologist.
Managing Cancer Pain: Female with Esophageal Cancer
A 50-year-old mother with young children developed esophageal cancer at age 48. The tumor was inoperable and was treated with chemotherapy and radiation.
Unfortunately, the cancer continued to grow and became extremely painful. The patient was started on high doses of oral and skin patch opioids as an outpatient with poor pain relief and mental impairment from the drugs. She was ultimately admitted to the hospital for high-dose intravenous opioids, which relieved pain but caused mental clouding and confusion.
Every time the hospital doctors reduced the doses of intravenous opioids, pain returned with a vengeance and the patient could not be discharged from the hospital. Everyone suffered — the patient, the family and the doctors trying to manage the extreme pain in this desperate patient.
The patient’s oncologist called Nura to provide interventional pain management:
- The patient was transferred directly from the hospital to our pain clinic.
- On arrival at Nura, we placed an epidural catheter which we dosed with a mixture of local anesthetic and opioid. The patient’s pain was relieved within the hour. Epidural analgesia is very powerful – it can control the pain of labor and create regional anesthesia for surgical operations.
- Since epidural injection of local anesthetic/opioid wears off within several hours, and requires high volumes of local anesthetic for continuous pain relief, it is not very practical for outpatient pain management. We kept the epidural going overnight in the patient’s home to keep her out of the hospital and scheduled surgery to place a fully-implantable pain pump system the next day.
- Our cancer pain team (physician, APP, implant RN, implant coordinator, medical device company rep) educated and supported the patient throughout this process and we maintained ongoing communication with the managing oncologist.
- The patient returned to our surgery center the next day and underwent a 30-minute outpatient surgery to implant an intrathecal catheter and pain pump.
- After the pump implant, the patient was able to return home with a continuous infusion of spinal opioid and local anesthetic. She uses boluses from the pain pump to manage breakthrough pain.
The patient continues to use oral opioids but at much lower dose with much better pain control. Our cancer pain team is supporting her as an outpatient. She continues to undergo chemotherapy directed by her oncologist.
Managing Cancer Pain: Male with Pancreatic Cancer
A 69-year-old male patient has pancreatic cancer and developed severe abdominal pain. He was treated with high dose oral opioids but was not achieving good pain relief and was experiencing side effects of constipation, mental clouding and somnolence. He was hospitalized for pain management.
The patient was transferred to Nura by his oncologist for interventional pain management.
- At Nura, we first performed an alcohol ablation of the celiac plexus which resulted in good pain relief but only for a few weeks.
- For the next step, we placed an epidural catheter for infusion of spinal opioid/local anesthetic solution. This intervention resulted in excellent pain relief and served as a trial for a fully implanted pain pump.
- Insurance authorization was obtained for a pain pump implant. Payers are usually supportive of pain pumps in cancer pain and approval was quick.
- Our cancer pain team (physician, APP, implant RN, implant coordinator, medical device company rep) educated the patient on pain pump technology and set up a direct communication link with the patient.
- The implant surgery was performed in Nura’s outpatient surgery center and took about 30 minutes.
- The pump infusion was started in the PACU immediately after implant. We also administered a bolus dose of spinal medication in PACU which was well tolerated and relieved pain completely.
- In the final step, we programmed pre-set bolus doses of medication into the pain pump system so that the patient could self-administer pump medication with a handheld remote-control device as needed to control pain at home.
The patient is now achieving good pain relief with minimal side effects and is much more awake and alert. Our cancer pain team is continuing to support him as an outpatient. He is very grateful to be out of the hospital and continues to work with his oncologist on tumor management.
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