Hydromorphone and Verapamil Infusion in Severe Cancer Pain

This report is on synergy based approach to manage a clinical challenging situation in increased opiate use due to both progression of tumour growth and pharmacological tolerance in a patient suffering very severe cancer pain. CM was a 52 year-old man who 12 months before was diagnosed with rectal cancer and metastatic disease to the liver and L3 to S1 vertebrae. Antineoplastic treatments included an abdominal-perineal resection, multiple chemotherapy protocols and radiotherapy cycles on lumbar spine disease. CM was well informed on the diagnosis and he partially coped with his prognosis. He had been undergoing palliativ e care for 6 months due to severe, incidental lumbar pain and left radiculopathy interpreted as somatic-neuropathic pain, secondary to bony metastasis and lumbar plexus involvement. Initial treatment with hydromorphone 7.5 mg/PO/da y and carbamazepine 300 mg/PO/da y, achieved satisfactory pain relief with no relevant side effects during 10 days; but because of uncontrollable pain in the left dorso-lumbar region (intensity 10/10) in spite of repeated dose adjustments, he was admitted into hospital. At that moment the degree of sedation was a major limiting factor (Ramsay scale 3-4). Examination findings on admission revealed a normal mini mental state examination, hypoesthesia in left lower limb from L1-4, muscular atrophy, 3/5 proximal muscle strength. Magnetic resonance imaging confirmed infiltr ation of left psoas and lumbosacral plexus, increase in L1-L5 bony lesions. Electrolytes, kidney function tests, glycaemia and A.M/P.M serum cortisol levels were within normal limits.