Can morphine and MS contain be ineffective? Also vascular question!

SamJB · Sep 24, 2011

Hi,

I'm doing an assignment for a pain management subject (an elective for my FINAL semester of uni) and I chose to do a case study Q for one of the assignments... The case study is below but first I will give you my questions/thoughts...

1. Is it possible that a patient can be essentially 'immune' to morphine i.e. it's ineffective... I can't find any research articles to back up my theory however it is difficult to come up with key words that give me what I want... If you could either suggest some articles or key words to use in my search that would be great?

2. Do you think the IV morphine is working? I'm highly doubtful as he has had a reasonably high dose and it hasn't done much to his pain score overnight (although it's possible he is tolerant to it now as a result of long term use of MS contin)?

3. Regarding his slender legs... could I argue that he has a peripheral vascular disorder secondary to diabetes mellitus...?? I'm a bit confused about whether the pain is vascular or as a result of neuropathy... although if it was neuropathy heat would make it worse as a result of vasodilation... If it is a vascular disorder can you recommend any treatments over others? I know exercise, elevating legs etc helps... My instructor also told us that we can refer to other health professionals where appropriate so long as we state why... I would look at a diabetic educator/endocrinologist... Dr re. ineffective pain regime for his chronic pain... perhaps a physic or OT? What do you guys think? also could I suggest non-pharmocological treatments as a nurse and if so to what extent?

If you have any extra points you think I should consider PLEASE let me know :) Don't want to fail this semester and also would love to know if morphine is really ineffective for some people!

Analyse the 'Mr. Alexander' scenario and identify how you would respond in his situation supporting your ideas with arguments that incorporate relevant theoretical concepts/principles and evidence from the literature.

Mr A. is a 63 years old gentleman admitted to hospital for a femoro‐ popliteal graft to the L. leg. The procedure was completed without complication, and it is now the second day following surgery.

Postoperatively Mr A. has been prescribed PCA Morphine and his usual MS Contin for pain management (see Pain History below). During Day 1 'post‐ op' he used 90mg Morphine Sulphate via the PCA. He remained alert and oriented, and reported no nausea or itching. When asked about his pain he reported 8/10 pain in both legs from the knee down. He also reported pain at 6/10 in his thigh wound. It was noted in the report that he 'did not sleep well'. Today, on Day 2, he has used 96mg Morphine Sulphate via the PCA. He is alert and orientated, and reports no Morphine‐ related side effects. He tells you that the pain in both legs is an '8/10' and that his thigh wound pain is '4/10'. He wants to know if something else can be done to help relieve his pain.

Excerpts from Mr Alexander's Patient Record

Past history

Mr. A. had bilateral Total Knee replacements 5 years ago. He also has a past history of Type 2 diabetes that is being treated with Metformin. He has been on MS Contin for the past 6 months for pain in both legs from the knees down. His dose escalated from 30 mg to 100mg BD during this time. He states that 'it hasn't really made too much difference' as 'it always burns from my knees down'. He also tells you that he has pain in his joints which is often worse at night but improves with mobilisation and heat.

Physical Assessment

As part of Mr. Alexander's physical assessment it was noted that:

*his legs appear somewhat 'skinny' from the knee down with many visible varicose veins

*no ulcers are observed

*his feet appear well cared for

*he reports decreased sensation on the soles and toes of both feet.

Pain History

Mr. A. has been on MS Contin for 6 months. His dose has escalated from 30 mg to 100mg BD during this time. He states that 'it hasn't really made too much difference' as 'it always burns from my knees down'. He also tells you that he has pain in his joints, which is often worse at night but improves with mobilisation and heat.