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Blog articles are provided as informational purposes only and are not intended to constitute medical advice. Medication protocols are subject to patient’s medical provider’s authorization.

 

History: 

The patient was on a high dose morphine, patient-controlled analgesia (PCA) pump and had severe cancer pain. He reported to have "pain all over" even when not being touched. He developed a myoclonic twitch several days prior. He wanted to die early and was suicidal due to the pain and discomfort. Goals of care were to manage his pain with oral medications so he could be more mobile and spend time with family. But since his pain could not be controlled with IV morphine via PCA pump, the team was hesitant to remove or reduce the pump for fear of increasing his pain. They were stuck, and so was the patient.

As a result, ProCare PharmacyCare clinical pharmacy was consulted.

Intervention:

Upon review of the case, the patient seemed to be suffering from opioid (morphine) toxicity: "pain all over" suggested allodynia and hyperalgesia, and myoclonic twitching is another sign/symptom of morphine neurotoxicity. The pharmacy determined the patient was a good candidate for oral methadone, which can help reduce opioid toxicity and tolerance. A 5-day cross-taper was constructed off the morphine PCA and onto oral methadone. 

Results:

The patient was successfully transferred onto oral methadone and off the PCA and needed methadone 45mg/day in divided doses to control his pain. Hyperalgia, allodynia, and twitching resolved. He also rallied: he lived longer than expected. He was found playing cards with his daughter one night. He was able to attend a grandson's basketball game, another grandson's concert recital, and dine out with family. He died happily and in minimal to no pain.

 

 

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