George was a fiery gentleman residing in the nursing home. He had come to the nursing home after his last hospital admission where he had a recent setback from his end stage lung cancer. You see, George was a veteran, pretty stoic and had stopped his cancer treatment a while ago when electing hospice care.

George had ongoing pain issues and had been treated with various different regimens over the year and they all left him feeling his pain wasn’t controlled. While he was in the hospital this last time, they started him on a morphine continuous infusion of 0.5mg/hr basal and 0.5mg every 2 hours as needed for breakthrough pain, which seemed to provide a lot of relief.

Fast forward a couple of weeks, George’s nurse reports he’s just mad. Not like disease progression agitated, more like I’m mad at the world agitated. The nurse reported she had been discussing with George the idea of moving off the morphine continuous infusion and back to oral medications. George wasn’t hearing that. After so many trials and failures that’s the last thing he wanted to hear. In addition, he was extremely upset with the IV pole he had to roll around the nursing home.

I asked George if he would talk to me. Yes, he was afraid to make a change to his pain medications. Yes, being tethered to the IV pole caused extreme frustration. I think George saw that IV pole as a constant reminder to him and everyone else he was sick. But I saw something interesting, his total morphine dose was pretty small in the grand scheme of things. So, was it that the IV morphine was magic or were his previous failed regimens maybe just not optimized very well?

Upon some digging and talking with George, it was clear that his previous pain regimens were not consistent. Lots of PRNs, chasing the pain, max number of pills and worry about acetaminophen max doses and do this, but not that. His goals were to be as alert as possible and his words were: “if I have to be in this damn nursing home, I sure want to be able to do stuff… Not half asleep and tethered to this pole!”

I suggested we discuss with his physician making a change to methadone. He was reluctant, but agreed to the trial. I explained that the methadone would be twice a day and would cause less drowsiness than other medications. I also knew George was going to have difficulty swallowing soon, his decline was showing and he already had some bouts with dysphagia, so methadone gave us that flexibility to crush and/or use a liquid and still be long acting.

About a week after George’s conversion to methadone my phone rang. I answered and the nurse on the other end was laughing. I said, well I’ve clearly missed the joke, but what’s going on? She just says he, (George), wants to talk to you. He gets on the phone and says: “hey medicine man, I’m not sure what games you’re playing, but this is the best I’ve felt in a long time! That dumb IV pole is gone, I can dance around this nursing home. I’m not sure why no one suggested this months ago, just know in my eyes, you’re alright.” I chuckled; we conversed and ended the call.

After hanging up, I sat there for a minute and laughed at what he said…. ‘you’re alright’- I’ll take it!