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When the game is hard, more complex weapons are needed
  1. Sebastiano Mercadante1,2,
  2. Claudio Adile1,
  3. Patrizia Ferrera1 and
  4. Fausto Giuliana2
  1. 1 Pain relief and supportive care, La Maddalena, Palermo, Italy
  2. 2 Palliative Care, La Maddalena Cancer Center, Palermo, Italy
  1. Correspondence to Dr Sebastiano Mercadante, Pain Relief and Supportive Care, La Maddalena, Palermo, 90145, Italy; terapiadeldolore{at}


Objectives The aim of this paper is to illustrate how to manage a very difficult pain condition.

Methods This is a clinical note of a complex approach using multiple analgesic regimens to effectively afford challenging pain situations.

Results A man underwent an opioid dose titration, followed by dose stabilisation for some months. Then he underwent two opioid substitutions, unsuccessfully. A spinal analgesia provided good analgesia for a prolonged period of time, necessitating variable interventions to counteract the evolving, challenging clinical situation.

Conclusions The description of this case illustrates the need of a high level of experience and knowledge to elaborate complex strategies step by step every time the pain syndrome was worsening. Recommendations are unlikely in these extreme circumstances, and treatment should be based on continuous clinical counteraction to the evolving clinical conditions.

  • pain
  • cancer
  • hospice care
  • pharmacology
  • supportive care
  • terminal care

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  • Contributors All the authors contributed to follow the case. SM was the writer, and the manuscript was approved by the other authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.