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AS8.1-5 | Pain and Its Management — Assignment

Instructions

1. Read the patient vignette below carefully. Note every clinically relevant detail — pain character, severity, functional impact, and current medications.

Patient Vignette:
Mr. Ramesh Kumar, 64 years old, has advanced carcinoma of the head of the pancreas with hepatic metastases. He was diagnosed 8 months ago and has received two cycles of gemcitabine-nab-paclitaxel, now discontinued due to progression. Current pain: (a) constant dull aching in the epigastrium and right hypochondrium — he rates it 7/10 at rest, 9/10 after meals; (b) burning, shooting pain radiating to the mid-back — he describes it as 'electric' and rates it 5–6/10. He also has mild jaundice, pruritus, and anorexia. He weighs 58 kg. Current medications: oral paracetamol 500 mg four-hourly (patient-initiated, not prescribed), omeprazole 20 mg daily, spironolactone 100 mg daily. He can still swallow tablets.

1. Characterise the pain: Identify the likely pain types present (nociceptive visceral, somatic, neuropathic) and the anatomical basis for each component. State the pain scores using NRS and characterise each component using the SOCRATES framework (Site, Onset, Character, Radiation, Associations, Time, Exacerbating/relieving factors, Severity).

1. Apply the WHO Analgesic Ladder: State his current analgesic step, identify the gap, and propose a stepwise escalation plan. Specify the exact drug, dose (mg/kg or mg), route, and frequency for each agent. Include a breakthrough dose calculation.

1. Address the neuropathic component: Identify the most appropriate adjuvant(s) and provide a rationale based on mechanism.

1. Anticipatory prescribing for the terminal phase: Given his prognosis (likely weeks to 2–3 months), write the anticipatory SC prescriptions he would need if he loses the ability to swallow — specify drugs, doses, routes, and indications.

1. Monitoring and review: State what you would monitor (analgesia efficacy, adverse effects, function) and at what intervals.

1. Reflect briefly (1 paragraph) on the ethical dimension of opioid escalation in this patient, referencing the doctrine of double effect.

Length: 700–1000 words (excluding the prescription drug tables, which should be formatted as a structured table and do not count toward the word limit)

Grading Rubric — Pain and Its Management Assignment Rubric

Criterion	Points	Full-marks descriptor
Pain Assessment and Characterisation: Accurately identifies both pain components (visceral nociceptive + neuropathic), provides SOCRATES framework for each, assigns NRS scores, and identifies the anatomical basis (coeliac plexus invasion for neuropathic back pain, hepatic capsule stretch for RHC pain).	25 pts	Both components correctly identified and characterised with full SOCRATES, accurate anatomical basis, and correct NRS integration. Neuropathic features (burning, electric, radiation) distinguished from nociceptive (aching, position-related).
Analgesic Prescribing: Correct WHO ladder step identified; appropriate strong opioid prescribed at correct starting dose (mg/kg or mg) for opioid-naive patient; breakthrough dose calculated correctly (1/6 of background); laxative co-prescribed; paracetamol rationalised (dose and frequency); NSAID considered with explanation of contraindication given hepatic disease.	30 pts	WHO Step 3 correctly identified; morphine or oxycodone started at evidence-based dose (morphine 5–10 mg q4h or 0.1–0.2 mg/kg); breakthrough correctly = 1/6 of 24h dose; laxative co-prescribed from day one; paracetamol rationalised at 1g q6h maximum; NSAID avoided with correct reasoning (jaundice/hepatic involvement).
Neuropathic Component Management: Identifies the neuropathic pain component (coeliac plexus involvement, burning radiating to back); selects an appropriate first-line adjuvant (pregabalin or gabapentin) with mechanistic rationale (α2δ calcium channel modulation in dorsal horn); considers corticosteroid (dexamethasone) for nerve compression component; notes that pure opioid escalation is inadequate for neuropathic pain.	20 pts	Neuropathic component explicitly identified; pregabalin or gabapentin prescribed with starting dose and titration plan; mechanism (α2δ subunit, reduced calcium influx, dorsal horn) stated; dexamethasone mentioned for nerve compression; opioid limitation for neuropathic pain acknowledged.
Anticipatory Prescribing for the Terminal Phase: Provides complete SC anticipatory prescriptions (SC morphine equivalent from oral dose ÷ 2; SC midazolam for agitation/dyspnoea; SC hyoscine for secretions) with doses, routes, indications, and frequency. Demonstrates understanding that anticipatory prescribing prevents crisis management.	15 pts	Full anticipatory prescription set: SC morphine (correct dose = current oral dose ÷ 2, q4h or syringe driver); SC midazolam (2.5–5 mg SC q4h prn for agitation); SC hyoscine hydrobromide (400 mcg SC q4h prn for secretions). Each with correct indication. Anticipatory rationale explicitly stated.
Ethical Reflection: Accurately invokes the doctrine of double effect; states the four conditions (good act, good intent, harm not the means, proportionality); applies correctly to opioid escalation; notes that evidence does not support the claim that appropriately titrated opioids shorten life.	10 pts	Doctrine of double effect correctly named and all four conditions applied to the clinical scenario; notes evidence-based point that appropriately titrated opioids do not shorten life; balanced and clinically grounded.