A 58-year-old woman with advanced abdominal malignancy has diffuse visceral pain requiring escalating opioid doses that cause intolerable sedation and vomiting. She is expected to survive more than six months. Oral opioid titration has been optimised. The MOST appropriate next step is:

• A Continuous deep sedation
• B Anterolateral cordotomy
• C Conversion to high-dose transdermal buprenorphine
• D Implantable intrathecal drug delivery system with morphine or ziconotide ✓

Explanation

An implanted intrathecal pump delivering morphine or ziconotide is indicated when systemic opioids fail through inefficacy or intolerable side effects, in patients with a life expectancy beyond about three months. It achieves superior analgesia at a fraction of the systemic dose, avoiding the sedation and vomiting seen here. Cordotomy suits unilateral nociceptive pain below the shoulder, buprenorphine will reproduce the same systemic side effects, and palliative sedation is a last resort reserved for refractory symptoms at end of life.

Reference: Benzon's Essentials of Pain Medicine, 5th ed.

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Written and medically reviewed by the StethoPrep medical team.