A 66-year-old man comes to the office to follow up on his prostate cancer treatment. The patient has painful, bony metastasis in the pelvis and is being treated with hormonal therapy and radiotherapy. He has been receiving long-acting and as-needed short-acting morphine, but he continues to have significant pain. In the past 2 weeks, the patient has also experienced insomnia due to the pain, leading to worsening fatigue. He has no nausea, constipation, drowsiness, or suicidal ideation. Urine drug screen is positive for opioids and negative for other substances. A review of the state prescription drug monitoring program database reveals no irregularities. In addition to titration of opioid therapy to improve pain control, which of the following responses is the most appropriate recommendation for this patient?

Question

A 66-year-old man comes to the office to follow up on his prostate cancer treatment.  The patient has painful, bony metastasis in the pelvis and is being treated with hormonal therapy and radiotherapy.  He has been receiving long-acting and as-needed short-acting morphine, but he continues to have significant pain.  In the past 2 weeks, the patient has also experienced insomnia due to the pain, leading to worsening fatigue.  He has no nausea, constipation, drowsiness, or suicidal ideation.  Urine drug screen is positive for opioids and negative for other substances.  A review of the state prescription drug monitoring program database reveals no irregularities.  In addition to titration of opioid therapy to improve pain control, which of the following responses is the most appropriate recommendation for this patient?

Quizplus · Accepted Answer

Explanation: Patients receiving chronic opioid therapy are at risk for opioid overdose, including those with cancer. In general, patients with prostate cancer and isolated bony metastasis can live for many years; therefore, balancing adequate pain control versus avoiding opioid overdose is crucial. Because overdose leads to fatal respiratory depression, naloxone, an opioid receptor antagonist, should be offered to every patient receiving chronic opioid therapy, especially those at high risk for overdose; family members should be trained on its use. Naloxone reverses the effects of opioid toxicity and can be administered intranasally or intramuscularly by bystanders pending arrival of emergency medical services. Patients at high risk for overdose include those with the following characteristics: Escalating or high-dose opioid therapy, such as this patient Concurrent benzodiazepine use History of substance use disorder or overdose Close contacts (eg, children) who may accidentally ingest the drug (Choice A) Calcitonin is often used as adjunctive therapy for patients with painful acute osteoporotic vertebral fracture but is generally not used to treat metastatic bone pain due to lack of evidence regarding its efficacy. (Choice B) Concurrent use of a benzodiazepine (eg, clonazepam) with an opioid is highly discouraged due to the increased risk for fatal respiratory depression. Appropriate pain control might help with insomnia. (Choice D) Naltrexone, an opioid antagonist, is used to treat opioid use disorder; it blocks the euphoric effects of opioids and suppresses cravings. Naltrexone is typically initiated after the patient has stopped taking opioids for 1-2 weeks and is not used with an opioid. Educational objective: Opioid overdose causes fatal respiratory depression. Naloxone should be offered to every patient who receives chronic opioid therapy, especially those at high risk for overdose (eg, high or escalating opioid dosage, concurrent benzodiazepine use). References: Coprescription of opioid and naloxone in office-based practice and emergency department settings in the United States. (http://www.ncbi.nlm.nih.gov/pubmed/31864155)

A 66-Year-Old Man Comes to the Office to Follow Up