Greetings:
I wanted to pick SDN pain community's brain on this case I am managing.
53 y/r old male, advanced laryngeal SCC (history of chewing tobacco), s/p radiation, partial laryngeal resection, tongue resection at a university center in Philadelphia. Patient now has a PEG tube, has lost a ton of weight also. Has recurrence of cancer after excision of tumor (I am not sure the details of the procedure - didnt get reports yet), but was told by his ENT surgeon that he's not a surgical candidate anymore and possibly radiation and immunotherapy are options.
The first ENT surgeon who referred the patient to me is community based and was managing his pain and referred him to me back in August. The patient came to me on methadone 20 q6h + oxycodone 30 q3 hours. He's max'd out on gabapentin already at 3600 mg/day. I did start tylenol 1g po q8hr.
His surgeons did not want an intrathecal pump at that time because he was frequently traveling from here to Philly and he was also on Abx here and there.
Im seeing him q2-3 weeks.
At the time of discharge from hospital after his recent 10 day admission, the hospice doctor who managed his pain while inpatient called me to transition his opioids. He is now on:
1) Tylenol 1g liquid q8h via PEG
2) Gabapentin liquid 2700-3600 mg/day
3) Methadone increased to 120 mg/ day (30 q6)
4) Oxycodone increased to 45 mg q3 hours.
5) xanax 0.5-1 mg qpm to sleep.
I just wrote him a script of oxycodone 15mg # 720 for the month. I was not comfortable with it, but no one else in the community will touch him and thats why his first ENT doctor was writing his meds to begin with. He is the one who diagnosed him.
I called the pharmacist myself and re-assured that this is his new titrated regimen. I got so worried today that I called the DEA office in Philadelphia and spoke to the agent to give them a heads up re: this dose and the circumstances.
Of note, I did do two UDS with GC/ MS on him when I was getting to know him initially - both were normal and expected.
Now that he is likely palliative care, I want to plan intrathecal pump trial for him.
My question is:
1) How effective is intrathecal analgesia for head and neck cancers? I know the evidence is there for visceral cancers, but will it work effectively for his condition? or will it be a waste of resources?
He is OK on this current oral regimen.
Majority of the pain is left side of the neck - The ENT docs left the incision open because there is drainage - hence on and off abx - thinking its infection/ abscess vs. increasing tumor size. It looks red and angry. There is always this concern about doing invasive procedures like spinal analgesia with questionable systemic infection. Is the risk worth taking for supposed benefits?
2) Are there any other options for him?
Thank you for your help.
I wanted to pick SDN pain community's brain on this case I am managing.
53 y/r old male, advanced laryngeal SCC (history of chewing tobacco), s/p radiation, partial laryngeal resection, tongue resection at a university center in Philadelphia. Patient now has a PEG tube, has lost a ton of weight also. Has recurrence of cancer after excision of tumor (I am not sure the details of the procedure - didnt get reports yet), but was told by his ENT surgeon that he's not a surgical candidate anymore and possibly radiation and immunotherapy are options.
The first ENT surgeon who referred the patient to me is community based and was managing his pain and referred him to me back in August. The patient came to me on methadone 20 q6h + oxycodone 30 q3 hours. He's max'd out on gabapentin already at 3600 mg/day. I did start tylenol 1g po q8hr.
His surgeons did not want an intrathecal pump at that time because he was frequently traveling from here to Philly and he was also on Abx here and there.
Im seeing him q2-3 weeks.
At the time of discharge from hospital after his recent 10 day admission, the hospice doctor who managed his pain while inpatient called me to transition his opioids. He is now on:
1) Tylenol 1g liquid q8h via PEG
2) Gabapentin liquid 2700-3600 mg/day
3) Methadone increased to 120 mg/ day (30 q6)
4) Oxycodone increased to 45 mg q3 hours.
5) xanax 0.5-1 mg qpm to sleep.
I just wrote him a script of oxycodone 15mg # 720 for the month. I was not comfortable with it, but no one else in the community will touch him and thats why his first ENT doctor was writing his meds to begin with. He is the one who diagnosed him.
I called the pharmacist myself and re-assured that this is his new titrated regimen. I got so worried today that I called the DEA office in Philadelphia and spoke to the agent to give them a heads up re: this dose and the circumstances.
Of note, I did do two UDS with GC/ MS on him when I was getting to know him initially - both were normal and expected.
Now that he is likely palliative care, I want to plan intrathecal pump trial for him.
My question is:
1) How effective is intrathecal analgesia for head and neck cancers? I know the evidence is there for visceral cancers, but will it work effectively for his condition? or will it be a waste of resources?
He is OK on this current oral regimen.
Majority of the pain is left side of the neck - The ENT docs left the incision open because there is drainage - hence on and off abx - thinking its infection/ abscess vs. increasing tumor size. It looks red and angry. There is always this concern about doing invasive procedures like spinal analgesia with questionable systemic infection. Is the risk worth taking for supposed benefits?
2) Are there any other options for him?
Thank you for your help.
