Page 167 Guide to Pain Management in Low-Resource Settings

Chapter 20

Lung Cancer with Plexopathy

Rainer Sabatowski and HansJ. Gerbershagen

Case study such as surgery, radiotherapy, or even chemotherapy.
Th erefore, they started morphine therapy with a start-
Ruben Perez is a 52-year-old farmer living in the prov- ing dose of 2.5 mg immediate-release morphine every
ince of Yucatan in Mexico. He had lost his job at a farm 4 hours. Th ey instructed Mr. Perez to use 2.5 mg addi-
some years before and has worked as a laborer ever tionally in case of pain recurrence, such as breakthrough
since. He and his wife, his children, and two grandchil- pain episodes. He was advised to increase his daily fl uid
dren live in a small hut in the village of Yaxcopil. Mr. intake to a minimum of 1.5 L of water a day to prevent
Perez has smoked cigarettes his whole life. During the opioid-induced constipation. Additionally, the physi-
last year, he noticed some health problems, feeling ex- cians prescribed gabapentin to improve morphine effi -
haustion and noticing his cough getting worse. When he cacy in the presence of neuropathic pain. Mr. Perez was
experienced lancinating pain in his left arm associated told to start with a dose of 100 mg and to increase the
with continuous weakness of his arm, he and his family dose at day 4 to 100 mg t.i.d. If pain was still not ad-
decided to visit the doctor at a large municipal hospital equately alleviated, he was asked to consult his local
in Mérida. At the initial presentation, Mr. Perez reported physician again.
his lancinating pain, involving predominantly the lower In the following weeks, the pain was alleviated
segments of the brachial plexus. Weakness and sensory suffi ciently, even though it was not absent. But with this
loss as well as Horner’s syndrome could be confi rmed. improvement and the support of his family, Mr. Perez
Th e pain was severe, and pretreatment with acetamino- could cope with his situation. Several weeks later, he had
phen, as needed, and codeine, which had been prescribed to go back to the hospital in Mérida because his pain in-
by a local doctor, was not able to relieve the pain. Mr. creased dramatically. Even though the morphine dose
Perez also reported dramatic weight loss, severe coughing was increased to a daily dose of 120 mg and gabapentin
with red spots in the sputum, as well as breathlessness. had been increased to 900 mg, the pain intensity wors-
An initial CT scan, which could be performed ened, and Mr. Perez reported a new pain sensation. Light
at the hospital, showed a tumorous mass in the apical touch on his left arm led to severe pain. Dr. Rodriguez
region of the left lung. Invasion and partial destruction decided to switch from morphine to methadone. Mor-
of the upper thoracic and lower cervical vertebral bod- phine treatment was stopped immediately, and metha-
ies could be confi rmed. Due to the progress of the disease done was started with a dose of 5 mg every 4 hours. For
and the comorbidity, the physicians at the hospital did breakthrough pain episodes or inadequate pain relief
not see an indication for further palliative treatment or both, 5 mg methadone could be administered within
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 155
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
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