Opioid Poorly Responsive Pain

Mr. Jones is a 66 y/o man with colon cancer with metastases to his bones and liver. His bone
pain was well controlled on morphine ER and oxycodone IR. Over the next two weeks he
noted increasing pain. Upward titration of the opioids had no effect. What is the first step in
responding to pain that is poorly responsive to opioids?

a) Conduct a substance abuse assessment
b) Conduct a thorough pain assessment
c) Begin an opioid parenteral infusion
d) Start gabapentin

Correct answer is b.

There is a broad differential for why the pain may not be responding to opioids such as changes in the cancer, pharmacological issues related to drug metabolism and delivery, new psychological/spiritual issues or non-cancer related issues. Performing a thorough pain history and assessment that evaluates the quantitative and qualitative aspects of his pain along with a review of drug therapy and spiritual and psychological factors is indicated. Conducing a substance abuse history may be appropriate, but not as the first step. Changing to a parenteral opioid infusion or starting an adjuvant analgesic should be considered but only after a completed pain assessment indicates that those interventions are appropriate

FAST FACTS AND CONCEPTS #215: Opioid Poorly-Responsive Cancer Pain