NAME: PAKO RAMAPHANE

ID NO: 202001368
PHA 422
Pain, case 2

Dr Jones, one of the local doctor, contacts you for advice regarding his patient Mr X, a 70 year-
old male. Mr X has been diagnosed with oesophageal cancer, and recently deteriorated after
his first course of chemotherapy.

DHx:
Oxycodone MR 40mg tablets BD

He is not taking morphine due hallucinations following treatment

His pain has been well controlled, but he is now struggling to swallow tablets, though can
manage liquids. Dr Jones would like to prescribe a transdermal analgesic and a suitable as
needed formulation for breakthrough pain.

Lab
Urine drug screen (UDS) result are positive for oxycodone and oxymorphone

In your presentation consider the following.

Q1. Start by stating the objective of this session.

 To Assess and address Mr. X's current pain management needs.
 To Transition Mr. X to a pain relief regimen that accommodates his difficulty swallowing
tablets.
 To Optimize Mr. X's pain control while minimizing adverse effects.
 To Address concerns raised by the urine drug screen (UDS) results, specifically the
presence of oxycodone and oxymorphone.

Q2. Complete the prescription as if you were Dr Jones and justify your decision
 Transdermal Analgesic: Fentanyl patch 25 mcg/hour, to be applied every 72 hours.
Justification: Fentanyl is a potent opioid analgesic that can provide continuous pain
relief over 72 hours, which can be particularly beneficial for patients like Mr. X who have
difficulty swallowing tablets. The transdermal route offers convenience and consistent
drug delivery, making it suitable for patients with compromised oral intake. The initial
 dose of 25 mcg/hour is selected to provide effective pain relief while minimizing the risk
of adverse effects, considering Mr. X's age and opioid tolerance. Starting with a low dose
of Fentanyl patch mitigates the risk of opioid-related adverse effects, particularly in
elderly patients.

 As Needed Formulation for Breakthrough Pain: Sublingual fentanyl 100 mcg, to be taken
every 30 minutes as needed for breakthrough pain. Justification: Sublingual fentanyl
provides rapid-onset analgesia, making them effective for managing breakthrough pain
episodes.
 Starting with a low dose of Fentanyl patch mitigates the risk of opioid-related adverse
effects, particularly in elderly patients.

Q3. Is a UDS result showing oxycodone and oxymorphone in a patient taking only oxycodone
appropriate? Is there potential for drug abuse in this patient?

A urine drug screen (UDS) result showing positive for oxycodone and oxymorphone in a patient
taking only oxycodone raises concerns for potential drug abuse or non-prescribed opioid use.
Oxycodone metabolizes into oxymorphone in the body, but in therapeutic doses of oxycodone,
the presence of oxymorphone in the urine is usually minimal. Therefore, the presence of
oxymorphone suggests additional opioid intake beyond the prescribed oxycodone.

Considering Mr. X's current medical condition and pain management regimen, the presence of
oxymorphone in the urine raises suspicion for non-prescribed opioid use, which could indicate
misuse, diversion, or inadequate pain control prompting self-medication