An understanding of the relationship between the type of analgesic prescription and the prevalence and severity of side effects is crucial in making appropriate treatment decisions. The purposes of this study were: to determine if there were differences in the prevalence of side effects among four different types of analgesic prescriptions (i.e., no opioid, only an as needed (PRN) opioid, only an around-the-clock (ATC) opioid, or an ATC + PRN opioid); to determine if there were differences in the severity of side effects among the four prescriptions groups; and to determine the relationships between the total dose of opioid analgesic medication prescribed and taken and the severity of side effects. As part of a larger study, 174 cancer patients with bone metastasis reported their analgesic use and the prevalence and severity of eleven side effects. Significant differences (P < 0.05) were found in prevalence rates for seven of the side effects among the four prescription groups. The highest prevalence rates were found in the only ATC and ATC + PRN groups. Significant differences were found in the severity scores for five of the side effects, with the highest severity scores reported by patients in the only ATC and ATC + PRN groups. Significant positive correlations were found between the severity of six of the side effects and the total dose of opioid prescribed and taken. Risk factors for analgesic-induced side effects are ATC and ATC + PRN prescription types and higher doses of opioid analgesics.

This paper describes a case of a hospice patient that a hospice and palliative care team struggled to palliate. We review a case of a 63-year-old man with anal squamous cell carcinoma who was transferred from an inpatient hospice unit to an intensive care setting in an ill-fated attempt to alleviate his pain and suffering. This paper also describes the frustration and desperation on the part of his medical and interdisciplinary team to provide him adequate relief. In retrospect, there were likely many system factors that may have contributed to this patient's ongoing suffering, including restrictions on the use of certain medications by location (i.e., hospice unit versus intensive care setting) as well as medication and ordering misunderstandings. Opiate neurotoxicity, existential and spiritual angst, and social isolation also contributed substantially to this patient's suffering. Furthermore, we describe not only the importance of exhausting all medical resources to relieve patients' pain and suffering, but also of learning to sit with patients in their suffering.

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