Severe Abdominal Pain

Vignette

A 71 year old man with metastatic colon cancer describes his abdominal pain as a sensation of hot and cold for the last several months. He has such discomfort that he stabbed himself in the chest with a knife in an attempt to alleviate the sensation. He is currently being treated with a fentanyl patch that was recently increased from 25 mcg to 50 mcg. He had previously received gabapentin but it caused him to be confused and was discontinued. What else can be done to treat this man's pain?

Discussion:

This patient has neuropathic pain. His primary physician found the diagnosis challenging because the patient spoke of uncomfortable sensations instead of using the word pain. This is a common feature of neuropathic pain. Recommended removal of fentanyl patch and initiating morphine, in order to facilitate rapid titration and dose finding. Rapid titration of morphine will often provide relief within 24-48 hours. Conversion to methadone after a stable dose of morphine has been established may be an effective long-term treatment plan for the likely mixed neuropathic/nociceptive pain. Dexamethasone would also be an option beginning with 20mg daily for 3 days as an adjuvant analgesic. If effective in pain management, dexamethasone can be tapered to lowest dose necessary to control pain. A trial of pregabalin in combination with the other drugs as an adjuvant analgesic could also be considered.

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