Station 73
Edward Brown
Age: 74 years old male
Full Case
Patient’s Data
Patient’s Name: Edward Brown
Age: 74-year-old male
Past Medical History:
- Hypertension
- Hyperlipidaemia
- Chronic Kidney Disease (CKD, Stage 3B)
- Metastatic Prostate Cancer –for palliative
- Has DNACPR in place
Drug and Allergy History:
- Ramipril 5 mg OD
- Atorvastatin 20 mg OD
- Butec (Buprenorphine) 10 µg/hour Transdermal Patch: Apply one patch every 7 days
- Paracetamol 1g QDS PRN
- No known drug allergies
QOF and alerts!!: Has no advance care plan in place
Recent Notes/Consultation
Recent notes from oncology
Subject: Discharge Summary for Mr. Edward Brown
Dear GP,
As you may know, Mr. Edward Brown, aged 74, has been under our care for metastatic prostate cancer with bone involvement. He suffers significant chronic pain, particularly in his lower back and hips. He has been started on a Butec 10 µg/hour transdermal patch, to apply one patch every 7 days. Additionally, he remains on paracetamol as needed. If issues arise with the patch not adhering to the skin, we have advised the use of micropore tape to help secure it
Mr. Brown has been counselled regarding the advanced nature of his disease and his prognosis, including the limited time he has remaining.
He is aware of the focus on symptom management and maintaining quality of life. He has now been discharged to the community for palliative management.
Yours sincerely,
Dr Arjun Narayanan MBBS, MRCP (UK), FRCR (Clin Onc), PhD
Consultant Oncologist
District Nurse Review (2 weeks ago)
Routine bloods taken to monitor renal function
| Test | Result | Reference Range |
|---|---|---|
| Serum Creatinine | 200 µmol/L | 64–104 µmol/L (male) |
| eGFR | 30 mL/min/1.73m² | >90 mL/min/1.73m² |
| Urea | 12 mmol/L | 2.5–7.8 mmol/L |
| Potassium | 4.8 mmol/L | 3.5–5.1 mmol/L |
| Sodium | 138 mmol/L | 135–145 mmol/L |
| Albumin | 35 g/L | 35–50 g/L |
| Calcium (Corrected) | 2.25 mmol/L | 2.2–2.6 mmol/L |
| Phosphate | 1.4 mmol/L | 0.8–1.5 mmol/L |
Note: Patient booked routine telephone consultation to discuss his current concerns.
Patient's Story (Role player’s brief)
Opening statement: Hi doctor, I just don’t think my pain is properly controlled at the moment, and my patch keeps falling off after a couple of days. I really need something that works better to help manage it.
You are Edward Brown, a 74-year-old man living with metastatic prostate cancer, which has spread to your bones and causes persistent pain, especially in your lower back and hips.
The pain hasn’t worsened, but it can be disruptive at night and occasionally interferes with your sleep. You are still able to mobilise, and your bladder and bowels are functioning normally.
You’ve been prescribed a Butec (buprenorphine) pain patch, which is meant to last for seven days, but you’ve noticed that it often starts to peel off after just two days. This seems to be due to the fact that you sweat quite a lot, which has always been normal for you and hasn’t been a problem in the past. However, the patch not staying in place has become frustrating, and it’s making you feel uncertain about whether your pain will ever be properly managed.
You’ve tried using the micropore tape provided by the hospital to help the patch stay in place, but unfortunately, it hasn’t made much of a difference. You also use paracetamol when needed, but it’s not strong enough to control the level of pain you’re experiencing.
You’re also aware that you can’t take ibuprofen because of your kidney function, which was explained to you during your hospital care, so you haven’t tried buying any over-the-counter alternatives.
Social History: You live with your wife, who is your main caregiver. You’re retired, but you enjoy reading and watching nature documentaries. You’ve been less active due to the pain. You don’t smoke or drink alcohol. You’re generally in good spirits but feel tired from coping with the pain.
Ideas: You believe the patch may not be staying in place because of your excessive sweating, and that this could be the reason your pain isn’t being well controlled.
Concerns: You’re particularly worried because the pain is starting to affect your sleep and daily routine, making it harder to cope.
Expectations: You would like to discuss alternative pain relief options and get practical advice on how to manage your symptoms more effectively moving forward.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Question for the doctor: If the doctor offers you a new tablet for pain, ask whether you should start taking it straight away or wait, since you still have the patch on. If they do not suggest a new tablet, do not ask this question.
A good example of how to ask: “Should I start the tablets straight away once you prescribe them, or do I need to wait since I still have the patch on at the moment?”
Marking Scheme
Data Gathering and Diagnosis
- Ask about the pain – nature (burning, dull, throbbing), whether it radiates, and any relieving or aggravating factors
- Ask if the pain is getting better, worse, or staying the same
- Ask about red flag symptoms for spinal cord compression – leg weakness, difficulty walking, numbness or tingling in the legs, inability to control bladder or bowel (urinary or faecal incontinence), or numbness around the back passage
- Ask how the pain is affecting his quality of life
- Ask if he is using the Butec patch as prescribed and confirm correct application (dry, non-irritated, hairless skin, rotating sites)
- Ask whether the excessive sweating is a new symptom or something that has been ongoing for a long time — to help determine whether it may need further investigation now, or if it’s a chronic, non-concerning feature that could be addressed later if it becomes bothersome.
- Ask if micropore tape has been tried as advised by oncology- for example, you can say: “I can see from your notes that the cancer doctor (oncologist) suggested using micropore tape to help the patch stay in place, have you had a chance to try that?”
- Ask if he is eating and drinking well and whether he has any swallowing difficulties
- Ask if he is passing urine and opening his bowels regularly (check for constipation as a side effect of opioids)
- Ask how he is feeling generally, aside from the pain
- Ask about his home situation and whether he has support
- Ask about his mood, as anxiety and depression are common in people who have cancer or going through uncontrolled pain
- Make a working diagnosis of uncontrolled pain due to patch displacement caused by long-standing excessive sweating
Example of explanation to patient
Thank you for speaking with me today, Mr Brown. I can see from what you’ve described that the pain has been a real challenge, especially with your patch not staying on properly. It’s understandable that this has left you feeling frustrated and worried, especially when it’s affecting your sleep and your day-to-day life.
From what you’ve said and given your history of sweating, which I understand has always been the case for you, it seems likely that the patch isn’t sticking well enough to give you steady pain relief. This could well explain why things haven’t felt under control lately.
What I would suggest is that we move away from the patch and start you on a tablet called oxycodone, which is another type of pain relief. The reason I’m suggesting this particular tablet is because it’s kinder on the kidneys, which is important given your existing kidney condition. We’ll work out the right starting dose carefully, based on your current pain levels, and adjust it if needed.
If you still have the patch on, I recommend removing it first and then starting the tablets 24 hours later, just to avoid having too much pain relief in your system at once. Meanwhile, you can use paracetamol for pain. Does that sound okay to you?
Because these tablets can sometimes cause side effects like constipation or feeling sick, I’ll prescribe a laxative and an anti-sickness medication alongside them to help prevent that.
I know your main worry is about the impact this pain is having on your sleep and daily comfort, and I want to reassure you that we’ll work together to get that under control. We’ll also check in again in a couple of weeks to see how things are going and make any changes you need.
Lastly, as part of your overall care, it might be helpful for us to start talking about advance care planning, just to make sure your wishes are known and respected moving forward. There’s no pressure to decide anything today, but I wanted to introduce that so we can have those conversations when you’re ready.
Does that all make sense so far? Is there anything you’d like to ask or go over again?
Management
Management
- Advise to discontinue buprenorphine patch and offer oral oxycodone due to CKD (Stage 3B), as oxycodone is better tolerated than morphine in reduced renal function
Oxycodone can be prescribed in two ways:
- Option 1: Immediate-release oral oxycodone – Prescribe to be taken regularly every 4hours. Review the patient after 24hrs, then prescribe 1/6th to 1/10th of the total 24-hour dose as additional immediate-release oxycodone for breakthrough pain.
- Option 2: Modified-release (long-acting) oral oxycodone — Prescribe to be taken every 12 or 24 hours, depending on the preparation used. For breakthrough pain, prescribe 1/6th to 1/10th of the total 24-hour dose in the form of immediate-release oxycodone.
Note: For exam purposes, you are not expected to calculate the exact opioid conversion between buprenorphine and oxycodone. It is sufficient to explain to the patient that you will be starting him on oxycodone tablet that is safer for his kidneys, but that you will need to calculate and check the appropriate dose to ensure safe and effective pain control.
- Advise the patient to wait 24 hours after removing the patch before taking the first dose of oxycodone. Meanwhile, offer paracetamol for pain while waiting. If the patch was removed more than 24 hours ago, oxycodone can be started immediately.
- Inform the patient about common side effects of oxycodone such as drowsiness, nausea, and constipation
- Prescribe an anti-emetic, such as metoclopramide, to help prevent nausea and vomiting
- Prescribe a stimulant laxative, such as senna 7.5–15 mg once daily or bisacodyl 5–10 mg once daily and a softening laxative, such as docusate sodium 100 mg three times a day
- Other non-opioid adjuvants can be considered if the patient does not want opioids: For bone pain, consider agents such as bisphosphonates (e.g. zoledronic acid) or denosumab. For neuropathic pain, medications like gabapentin or pregabalin may be considered, but should be used with caution and appropriate dose adjustment in patients with chronic kidney disease (CKD). Discuss with the palliative care team before initiating these.
- Discuss advance care planning, including preferences for future care, resuscitation, and preferred place of care as appropriate
- Review in 2 weeks to assess symptom control and tolerance of the new medication
- Safety net: advise to seek urgent medical attention if symptoms suggestive of spinal cord compression develop, such as new or worsening back pain, leg weakness, numbness, or difficulty controlling bladder or bowel function
Learning point from this station:
This case highlights the practical challenges associated with transdermal opioid delivery, particularly in patients with excessive sweating. Poor patch adhesion can significantly impair drug absorption and symptom control.
If a patch fails to adhere properly, initial strategies include
- Applying Micropore tape around the edges
- Using a non-occlusive transparent dressing such as Tegaderm over the patch
- Replacing it with a new patch.
If these measures are unsuccessful, switching to an oral preparation should be considered where appropriate.
Note that buprenorphine patches are not ideal for patients who sweat heavily
Avoid using occlusive dressings to secure transdermal patches, as they can increase drug absorption and lead to unintended effects.
Patients should also be advised to avoid covering patches completely with opaque dressings or tape, as the patch must remain visible to allow safe identification in the event of an emergency.
Transdermal patches can cause skin reactions, most commonly irritant contact dermatitis. Allergic contact dermatitis can also occur and is usually triggered by the adhesive, though it may also result from the active drug or other ingredients in the patch.
To reduce the risk of skin reactions:
- Follow the manufacturer’s instructions carefully
- Rotate application sites to allow previous areas time to recover
- Apply moisturisers or emollients after removing a patch, but avoid applying them just before putting on a new one
- Use correct techniques when applying and removing patches
If skin irritation continues despite correct use and skincare, consider switching to a different brand, as the reaction may be related to the adhesive. If an allergic reaction to a specific adhesive (e.g. acrylate) is suspected, choose a patch that uses a different adhesive type.
If changing brands or formulations isn’t possible, consider switching to an oral preparation or seeking specialist advice.