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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of various etiologies of pain

  • Identify the goals of therapy for chronic pain management

  • Identify actual and potential side effects of drugs utilized in pain management

  • Develop an appropriate treatment regimen and monitoring plan for chronic pain based on individual patient characteristics

  • Select an appropriate drug regimen for chronic pain, including scheduled, as-needed, and adjunctive therapy

  • Select appropriate therapy for prevention and treatment of opioid side effects

  • Properly educate a patient on pain management therapies

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PATIENT PRESENTATION

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Chief Complaint

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"This back pain is unbearable. What other pain pills are available that won't cause constipation?"

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History of Present Illness

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Jean Walter is a 58-year-old woman with stage IV ductal breast carcinoma who presents anxiously to the cancer clinic after having run out of her previous prescription for oxycodone/acetaminophen 1 week prior. Three weeks ago, she was prescribed oxycodone SR 10 mg twice daily and oxycodone 5 mg/acetaminophen 325 mg as needed (#120 tablets); however, she decided to only fill her oxycodone/acetaminophen prescription since she didn't think she needed two different pills to control her pain. After taking all of the oxycodone/acetaminophen over the course of 2 weeks, she began to supplement her pain regimen with OTC acetaminophen (averaging 12 tablets per day) for her worsening lower back pain. She describes the back pain as throbbing and constant and rates the severity as a 9 on a scale of 1 to 10, but also notes a "pins and needles" sensation that radiates from her lower back down her left leg to her knee and some weakness in her left leg. JW was initially diagnosed with breast cancer in 2006 after which she underwent a lumpectomy, radiation therapy, and adjuvant chemotherapy. During the past year, a CT scan showed recurrence of a breast tumor and spinal metastases in the L4–S2 region, which is consistent with her complaints of increasing back pain and immobility.

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Past Medical History

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Stage IV ductal breast carcinoma (diagnosed 2006) s/p chemotherapy and radiation

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DM type 2 × 12 y

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HTN × 17 y

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Past Surgical History

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Left breast lumpectomy (2008)

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Hysterectomy (2002)

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Cholecystectomy (1989)

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Family History

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Father had DM type 2 and CAD and died of MI at the age of 70. Mother had breast cancer and died at the age of 62 secondary to metastatic disease. She has two brothers who are alive with hypertension and DM type 2.

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Social History

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Married and lives with her husband of 34 years; has three adult children. She previously worked as a social worker, but had to retire secondary to her disease progression.

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Tobacco/Alcohol/Substance ...

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