THE ART OF ONCOLOGY: WHEN THE TUMOR IS NOT THE TARGET Opioid R otation i n t he M anagement o f R efractory Cancer P ain

ERE’S THE CASE: A 59-year-old woman notes worsening bone pain caused by a non–small-cell lung cancer metastatic to the ribs and spine. She has been treated with radiation and chemotherapy. During the past 3 weeks, she developed worsening posterior thoracic pain at the site of a previously irradiated rib lesion. A recent computed tomography scan of the chest showed that the mass was increasing in volume and extending into the chest itself. A surgical option for local control of this lesion was considered, but it was rejected by the patient. Before her pain increased, it had been adequately controlled for 4 months with a combination of an extendedrelease morphine formulation (200 mg taken twice daily) supplemented with a short-acting morphine formulation (30 mg every 2 hours as needed) for episodes of breakthrough pain. Her use of the short-acting morphine, or rescue dose, had increased to three times per day during the past week, but her pain was still not controlled. Two days ago, the patient called and was told to increase the morphine dose and add ibuprofen. She is now taking 200 mg of morphine every 8 hours and still has required about three extra doses of the short-acting morphine per day. Despite the increase in her dose, her pain continues to be uncontrolled and she is experiencing sedation and nausea. The patient verbalizes her frustration and asks, “Doctor, isn’t there something you can give me for this pain that won’t make me feel so sick?”