| Vignette | Question | Answer | Dosage | Explanation |
| Patient D is an 86-year-old [race] [gender] with history of multiple myeloma who presents with 6 months of progressive neck pain and limb weakness. Patient D states that [possessive] pain is triggered by flexion or extension of [possessive] neck. The pain has become severe and [subject] is worried that it prevents [possessive] participation in daily activities. Patient D is also requiring more assistance to ambulate, citing that [subject] is feeling weakness of [possessive] arms and legs. NSAIDs have not provided any pain relief. Through physical examination, you detect diffuse numbness and weakness in all [possessive] extremities. You also identify Hoffmann signs and hyperreflexia in both of [possessive] arms and legs. You obtain MRI and CT scans of [possessive] cervical spine, and discover a large tumor involving C4-C5 with epidural extension resulting in severe stenosis and kyphotic deformity. There are also innumerable osteolytic lesions throughout the visible spine segments. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D likely has myelopathy secondary to relapse of [possessive] multiple myeloma, with a new lesion that would likely require surgical intervention. While determining long term treatment options, pain control with opioids may be beneficial. |
| Patient D is a 77-year-old [race] [gender] with history of lung cancer who presents with 3 months of diffuse back pain and progressive, unintentional weight loss. Patient D describes the pain as constant and exacerbated by bending and twisting movements of [possessive] spine. In addition to increasing pain, [subject] endorses progressive diffuse weakness, and [subject] now to requires a front-wheel-walker to ambulate. Upon examining Patient D, you find that [subject] is cachetic and diffusely deconditioned. You palpate the full length of [possessive] spine and note that [subject] is diffusely tender. You review the MRI of [possessive] full spine and identify innumerable lesions in all spine segments and multiple pathologic fractures. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D likely has bone pain from progression of [possessive] lung cancer. Management will depend on overall prognosis, and will likely be multimodal and potentially palliative. Providing pain relief with opioids is reasonable, pending long term treatment planning. |
| Patient D is a 65-year-old [race] [gender] with 5 months of mid back pain. Patient D states that the pain has gradually reached peak intensity and now interrupts [possessive] sleep. No medications have helped with [possessive] pain. When you perform a physical exam, you find that [subject] has diminished sensation in [possessive] mid thoracic dermatomes, and [possessive] back is not tender to palpation. You also note that [possessive] eyes and mucous membranes were more pale than normal. Concerned for this constellation of signs/symptoms, you order for MRI of [possessive] thoracic spine, which reveals a large mass involving the gastric body and extending posteriorly into the spinal column. You also note multiple additional lesions in several distant regions of the thorax. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has a neoplastic process involving the stomach, spine and other tissues. Pending full oncologic workup and prognostication, offering pain relief with opioids is reasonable. |
| Patient D is a 59-year-old [race] [gender] with neurofibromatosis with 8 months of progressive pain from thoracic spinal neurofibromas and a new diagnosis of glioblastoma after a recent seizure. Patient D explains that [subject] previously has managed [possessive] pain with NSAIDs and neuropathic medications, however [subject] noticed that it has progressed to the point that [possessive] regimen is no longer effective. When asked to describe the pain, [subject] says that it is sharp and radiates from [possessive] back to [possessive] sternum. On your physical examination, you find that Patient D has no focal neurological deficits. You decide to obtain a thoracic MRI for surveillance of [possessive] neurofibromas, and find that they have increased in size. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has signs of progressive growth of [possessive] spinal neurofibromas and a new diagnosis of glioblastoma. Pending a comprehensive surgical and oncologic plan, it is reasonable to offer opioids for pain control. |
| Patient D is a 75-year-old [race] [gender] with history of lung cancer and 4 months of progressive low-back and right leg pain. Patient D describes the pain as a dull ache that shoots down [possessive] right leg in no particular pattern or frequency. Recently, [subject] started experiencing intermittent numbness throughout [possessive] right leg. Overall, [subject] believes the pain is becoming more frequent and intolerable, as it now interrupts [possessive] sleep nightly and acetaminophen and ibuprofen have not helped. On your physical examination, you find that Patient D has diffusely diminished sensation in [possessive] leg, but [possessive] strength and reflexes are normal. Upon reviewing [possessive] lumbar spine MRI, you identify diffuse leptomeningeal disease. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has leptomeningeal disease, which suggests recurrence and progression of malignancy. They will need an oncologic workup and treatment plan, and in the meantime it is reasonable to palliate [possessive] pain with opioids. |
| Patient D is a 48-year-old [race] [gender] with history of colorectal cancer that has progressed despite aggressive therapy. Patient D began to experience diffuse back and pelvic pain 2 months ago but declined a visit to [possessive] oncologist. Instead, [subject] tried to manage [possessive] pain with NSAIDs. Patient D now presents to you with intolerable pain, and [subject] says it has not responded to [possessive] efforts. On your. physical examination, you incidentally discover a left foot drop and diminished sensation in [possessive] left foot. MRI of [possessive] lumbar spine shows diffuse bony metastases, with a metastatic lesion involving the left L5-S1 neuroforamen. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has progressive back pain likely related to diffuse metastatic disease to the bone. While the lesion at L5-S1 may be surgical, a full discussion weighing the goals [possessive] goals of care in context of oncologic prognosis is warranted. Pain control with opioids until such planning is completed is reasonable. |
| Patient D is a 51-year-old [race] [gender] with renal cell carcinoma status-post T4-T7 corpectomy and fusion for spine metastases 6 months ago who presents with progressive leg pain. Patient D states that the pain [subject] had prior to [possessive] last surgery is returning and in a worse form. Specifically, [subject] endorses that in addition to mid-back pain, [subject] is experiencing shooting pains down both legs. The pain is worse with any ambulatory movement, and is not alleviated by ibuprofen or acetaminophen. When you examine Patient D, you identify tenderness to palpation of [possessive] lumbar spine and diminished sensation in [possessive] anterior thighs. You obtain MRI scans of [possessive] entire spine and discover that in addition to new metastatic lesions in the lumbar spine causing multilevel severe stenosis, there is evidence of adjacent level disease near [possessive] prior construct. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has progression of disease with multiple new metastases and signs of impending spinal deterioration on MRI. A discussion regarding prognosis is warranted with the care team. It is reasonable to initiate opioid pain management while planning proceeds. |
| Patient D is a 29-year-old [race] [gender] metastatic medulloblastoma status-post multiple rounds of chemotherapy and radiation therapy, presenting with several months of progressive leg pain. Patient D describes the pain as sometimes crampy and other times sharp, involving different regions of both [possessive] legs at different times. In addition to [possessive] deconditioning, [subject] is now unable to sleep due to constant pain. On physical examination, you detect diffuse bilateral lower extremity weakness with intact sensation. You obtain a surveillance MRI of [possessive] entire spine and discover drop metastases seeding extensive regions of [possessive] spinal cord and thecal sac, with multiple lower nerve roots engorged by tumor. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has extensive drop metastases that have begun to involve [possessive] nerve roots. Surgery may be an option for some of these, but will likely need to be deferred until a prognostic discussion is initiated with Patient D's care team. Temporizing the pain with opioids is reasonable while plans are being made. |
| Patient D is a 38-year-old [race] [gender] with a known cervical chordoma status-post multiple resections presenting with 2 months of progressive neck pain accompanied with thoracic and abdominal pain. Patient D describes the pain as the worst it has ever been, as it feels like [possessive] neck, chest and abdomen are constantly on fire. Acetaminophen and ibuprofen provide no relief, and [subject] is now unable to sleep. On physical exam, you note dysesthesia to palpation of [possessive] neck and pain to deep palpation of [possessive] abdomen. CT and MRI of [possessive] cervical spine, chest and abdomen reveal florid recurrence of disease with new lesions in [possessive] lungs and liver. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has recurrence of a very aggressive malignancy that may no longer be resectable. Pending a discussion with [possessive] care team, palliation of [possessive] pain with opioids is appropriate. |
| Patient D is a 45-year-old [race] [gender] with hepatocellular carcinoma status-post C4-C5 corpectomy and fusion 8 months ago who presents with new arm and leg pain. Of note, Patient D endorses unintentional weight loss over the last 2 months which coincided with increased severity of [possessive] pain. When describing the pain, [subject] says that [subject] feels intermittent shocks down both arms and legs, and also notes a diffuse ache in [possessive] neck and lower back. Tylenol and ibuprofen have not been effective, and Patient D is due to revisit [possessive] oncologist since completing [possessive] last radiation treatment. Physical examination reveals some numbness in [possessive] hands and thighs, as well as diffuse spine tenderness. MRI of scans of [possessive] entire spine show increased tumor burden in [possessive] lumbar and cervical spine causing multiple areas of severe stenosis. You are also able to identify new lesions seeding [possessive] peritoneum. | Would you offer morphine to Patient D? Yes or No? If yes, how much supply would you give – Low (1 week), or High (4 weeks) supply? Explain. | Yes | Low (1 week) | Patient D has developed significant progression of disease that may require surgical intervention if within goals of care and prognostic implications. It is reasonable to offer pain relief with opioids until a plan is finalized. |
| Patient B is a 50 year old with bladder cancer status-post treatment with cisplatin chemotherapy. For several months, they have had progressive pain, numbness and paresthesias in both hands and feet. Patient B has tried ibuprofen with limited relief. On physical examination, you note that they have symmetrically diminished sensation in a stocking-glove distribution. You also note that they have difficulty maintaining balance and that they have a positive Romberg sign. Patient B recalls that their oncologist warned that cisplatin could cause neuropathy, but had hoped it would improve over time. Patient B would like help with managing their pain. | Would you offer Patient B hydrocodone for pain control? Yes or no? If yes, what dose – Low (1 week), or High (4 week) supply? Explain. | No | N/A | Patient B has signs and symptoms of chronic neuropathy secondary to chemotherapy. Neuropathic pain agents would be more appropriate for management. |