title: Perioperative dilemma: challenges of the management of a patient on mega doses of morphine and methadone.
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.
authors.affiliation: 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.
authors.forename: Alan David
authors.initials: AD
authors.lastname: Kaye
authors.affiliation: Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Aymen A
authors.initials: AA
authors.lastname: Alian
authors.affiliation: Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Nalini
authors.initials: N
authors.lastname: Vadivelu
authors.affiliation: Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Keun Sam
authors.initials: KS
authors.lastname: Chung
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008691:Methadone / Q000008:administration & dosage*; D009020:Morphine / Q000008:administration & dosage*; D016202:N-Methylaspartate / Q000037:antagonists & inhibitors; D009369:Neoplasms / Q000503:physiopathology* / Q000601:surgery; D010148:Intractable Pain / Q000188:drug therapy*; D010149:Postoperative Pain / Q000188:drug therapy
chemical_list: D016202:N-Methylaspartate; D009020:Morphine; D008691:Methadone