Perioperative dilemma: Challenges of the management of a patient on mega doses of morphine and methadone

Alan David Kaye, MD, PhD, DABA, DABPM, DABIPP; Aymen A. Alian, MD; Nalini Vadivelu, MD; Keun Sam Chung, MD

doi:10.5055/jom.2014.0194

Authors

Alan David Kaye, MD, PhD, DABA, DABPM, DABIPP
Aymen A. Alian, MD
Nalini Vadivelu, MD
Keun Sam Chung, MD

DOI:

https://doi.org/10.5055/jom.2014.0194

Keywords:

opioids, methadone, NMDA receptors, ketamine, opioid-induced hyperalgesia, cancer pain

Abstract

High doses of opioids are often needed in the management of cancer-related pain. A discussion of a patient’s perioperative opioid management and mechanisms contributing to opioid-induced hyperalgesia (OIH) are presented. In the present case report, a patient on high doses of opioids, including morphine and methadone, with severe worsening back pain and a history of increasing opioid requirements for the last 2 months due to metastatic leiomyosarcoma to the femur, spine, and neck is described. Use of high dose opioids is associated with numerous challenges, including tolerance. The successful management of this patient was multimodal and included the use of potent analgesics, N-methyl-D-aspartatereceptor antagonists, and the α-2 agonist clonidine.

Author Biographies

Alan David Kaye, MD, PhD, DABA, DABPM, DABIPP

Professor and Chairman, Department of Anesthesiology, Louisiana State University Health Science Center, New Orleans, Louisiana; Professor, Department of Pharmacology, Louisiana State University Health Science Center, New Orleans, Louisiana

Aymen A. Alian, MD

Assistant Professor, Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut.

Nalini Vadivelu, MD

Associate Professor, Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut.

Keun Sam Chung, MD

Associate Clinical Professor, Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut.

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