Pain not relieved by morphine (1024/1700)

48yo pt after surgical removal of mandibular ca presents with perioral paresthesia and severe
pain which is not relieved by oral morphine. What is the next step in treating this pt?
a. Oral amitryptiline
b. Oral oxycodone
c. PCA
d. IV morphine
e. Fentanyl patch
f. Gabapentine



































The answer should be B.... Cancer pain not relieved by morphine= oxydcodone next.

Gabapentin and TCA are equally recommended for neuropathic pain, there is no first line and I think that is a big clue that the answer is Oxycodone. First we will try all the standard forms of analgesia for mixed pain and then add TCA or gabapentin.

From NICE :

• Consider whether there is a treatable underlying cause (for example, nerve compression from bone metastases or soft-tissue disease) and seek specialist advice regarding further treatment of the cause (for example, surgical stabilization for bone metastases or radiotherapy for soft-tissue disease).
• If pain is purely neuropathic and reversible conditions (for example, vitamin B₁₂ deficiency) have been excluded:
• Consider offering amitriptyline (off-label use) or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin).
• Titrate the dosage according to response and tolerability.
• For further information, on contraindications, cautions, managing adverse effects, and second-line options if amitriptyline or pregabalin are not effective, see the CKS topic on Neuropathic pain - drug treatment.
• If pain is of mixed origin, use standard analgesics in addition to a tricyclic antidepressant or pregabalin (or gabapentin) if pain is not adequately controlled with standard analgesia alone.

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