Successful Multidimensional Intervention in a Patient with Intractable Neuropathic Cancer Pain

At this point she was transferred from her community hospital to the palliative care unit. Medications consisted of morphine 1 mg/hour, clonidine 0.4 mg/hour, and bupivacaine 0.075 mg/hour, all administered epidurally; amitriptyline 50 mg orally twice a day, lorazepam 4 mg orally every night, ibuprofen as needed, ketorolac as needed, and oxycodone as needed. On physical examination, the patient was drowsy with a Folstein's Mini-Mental State Examination (2) score of 18/30. There were no masses or tenderness in the buttocks or hips. Although strength testing was normal, the patient was unsteady on her feet and dependent upon a wheelchair for mobility. Urinary catheterization was required. Blood work was unremarkable. Methadone was initiated on Day 0 at a dosage of 10 mg orally every 8 hours and then titrated to achieve pain control. Concurrently the epidural medications, amitriptyline, and lorazepam were tapered and discontinued by Day 9. On Day 5 the patient developed a fever and elevated white blood cell count. Antibiotics were administered and the epidural, central venous, and urinary catheters removed, with the subsequent resolution of infective signs. Transient agitation and hallucinations were treated with haloperidol. As the patient became more alert and less confused, she was able to verbalize her fears related to the illness. It became apparent that her complaints of severe pain reflected major psychological distress. She was also found to have a history of alcoholism, scoring 3/4 on the CAGE questionnaire (3). Supportive counseling was provided by the multidisciplinary team, and rehabilitation became a major focus of her care. Although she did not fully gain insight in the nature of her distress and continued to report CASE REPORT