Management of predictable pain using fentanyl pectin nasal spray in patients undergoing radiotherapy
A 69-year-old man with multiple skeletal metastases from a previously treated high-grade urothelial carcinoma was referred for palliative external beam radiotherapy as pain relief for an upper arm lesion (1,000 cGy over 10 fractions). Despite taking hydrocodone/acetaminophen (7.5/500 mg, two tablets every 6 hours), the patient reported left upper arm and shoulder pain (9/10) as well as bilateral hip pain (5/10) associated with walking and prolonged sitting. Morphine sulfate (15 mg every 4 hours) was added one hour before radiation during which he experienced significant difficulty related to restlessness and pain (6/10 during the entire 40 minutes of simulation, with occasional spikes to 8/10). Fentanyl transdermal patches were added (25 μg every 72 hours) and the morphine was replaced by FPNS (100 μg 20 minutes before radiation). The patient reported grade II nausea and visual hallucinations that resolved when the fentanyl patches were discontinued. Taking hydrocodone/acetaminophen (7.5/500 mg every 6–8 hours) plus FPNS (100 μg 20 minutes before each session) reduced his pain to 2/10. On this regimen, the patient remained alert and had enough energy to complete all ten sessions without interruption. One week after completion of radiotherapy, the patient discontinued FPNS and remained on hydrocodone/acetaminophen.