Researchers removed 5,519 excess completely identical rows before analysis. They retained non-identical rows recorded for the same patient at the same time and disclosed this decision. American Society of Anesthesiologists physical status was linked only when both the patient and exact encounter or start time matched. The primary cohort comprised 120,680 assessments from 45,177 patients and 15 assessors. Logistic mixed models from M0 through M4 were used to account for repeated patients and to incorporate year, ward and available case-mix information.

Corrected assessor-specific rates ranged from 0.14% to 13.19% for a nausea or vomiting code of at least 1, from 0.10% to 16.43% for a dizziness code of at least 1, and from 0% to 7.78% for a documented sedation score of at least 1. Assessor-only variance partition coefficients were 28.1% for nausea or vomiting, 42.5% for dizziness and 67.6% for sedation. These figures describe variation in the corrected recorded rates, rather than causal effects of assessor behavior or differences in patients’ clinical risk.

The adjusted analysis was incompletely estimable. Of 14 primary-cohort models with numeric result records, nine met the prespecified numerical acceptance criteria and five were not estimable; three accepted fits were singular. For M3, two models produced median odds ratios of 1.00 and 1.02 but were singular, while the third was not estimable. Sedation M4 remained not estimable after the prespecified fallback attempts. A post hoc amendment approved by the corresponding author preceded the remaining restricted-cohort models, but those six models were not run; the restricted cohorts were instead summarized descriptively with Wilson 95% confidence intervals. The authors concluded that prospective validation is required before these routinely recorded fields are used for benchmarking.

Subject of Research: Variability in routinely recorded postoperative symptom fields among nursing assessors

Article Title: Between-assessor and temporal heterogeneity in routinely recorded postoperative symptom fields: a five-year retrospective observational study of 121,755 nursing assessments

Article References: Ge, J., Chen, S., Xie, F., Zhang, Q., Cao, N., Zhang, S., Wang, T., Ding, R., Li, Z., Cao, X., & Kong, Q. (2026). Between-assessor and temporal heterogeneity in routinely recorded postoperative symptom fields: a five-year retrospective observational study of 121,755 nursing assessments. BMC Nursing. https://doi.org/10.1186/s12912-026-05380-7

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05380-7

Keywords: postoperative symptoms, patient-controlled analgesia, nursing assessments, assessor variability, nausea and vomiting, dizziness, sedation, retrospective cohort study, mixed-effects models, benchmarking, Between-assessor, temporal

Cancer pain is extraordinarily common. According to a 2023 systematic review and meta-analysis cited in the report, the overall prevalence of pain among cancer patients is 44.5 percent, with roughly 30.6 percent experiencing moderate to severe pain. Among patients with advanced, metastatic, or end-stage disease, the prevalence climbs to 54.6 percent. Most of these patients achieve reasonable relief through oral or topical medications organized along the World Health Organization analgesic ladder. But an estimated 10 to 20 percent of those with moderate-to-severe cancer pain never obtain effective relief, or they abandon treatment because of intolerable side effects. These cases are defined as refractory cancer pain, and they represent a vicious physiological cycle in which persistent severe pain triggers central sensitization, placing the nervous system in a state of abnormally heightened and sustained sensitivity. Pain not only causes direct suffering but also amplifies its own signals through emotional and physiological mechanisms, elevating stress hormones, increasing cardiovascular demand, and impairing immune function, which may in turn accelerate disease progression.

The central technical argument of the new report is that traditional assessment tools are simply too narrow to capture this complexity. Clinicians have long relied on unidimensional instruments such as the numeric rating scale and the visual analogue scale, which reduce the entire pain experience to a single number, as well as on multidimensional questionnaires like the Brief Pain Inventory and neuropathic pain screening scales. All of these depend on patient subjectivity, which inherently biases the scores and can push treatment regimens away from optimal protocols. Neurophysiological testing offers objective data, but high equipment costs and technical complexity have limited its widespread clinical utility. The 6D BTS system was designed to fill this gap by combining multidimensional depth with objectivity and ease of use through a digital interface.

The Botong score comprises six dimensions. The first is the numeric rating scale itself, ranging from 0 for no pain to 10 for the worst pain imaginable, with scores of 1 to 3 reflecting mild pain, 4 to 6 moderate pain, and 7 to 10 severe pain. The second dimension assesses the impact of pain on physical function, with separate regional queries covering cervical spine, upper limb, lower back, and lower limb function, each scored from 0 for no impact to 10 for the most serious impact. The third and fourth dimensions measure the impact of pain on emotions and on sleep, using the same 0 to 10 range. The fifth dimension screens for neuropathic pain using the LANSS scale, in which affirmative responses to questions about needling stabbing pain, burning pain, tingling sensations, electric-shock-like pain, and pain exacerbated by touching clothes or sheets each add one point, while an affirmative response to a sixth question subtracts one point; scores of 2 to 3 suggest neuropathic pain and scores of 4 to 5 strongly suggest it. The sixth dimension assesses breakthrough pain, asking whether sudden, brief, unbearable severe pain occurs even when analgesics are otherwise controlling the baseline pain, including when body position changes.

Psychometric testing supports the instrument. Reliability analysis yielded a Cronbach’s alpha coefficient of 0.78 for the BTS, and validity analysis produced a KMO value of 0.80, indicating good reliability and construct validity. A randomized crossover trial published in Pain Therapeutics in 2023 compared the digital multidimensional Botong score with the Brief Pain Inventory for evaluating cancer-related pain and found the BTS could compensate for some of the BPI’s deficiencies. Notably, the BPI requires complex color-coding on body maps, a task frequently too difficult for elderly patients, whereas the BTS system employs voice-activated control and simplified queries to ensure accessibility. In the new case report, a robot equipped with the BTS 6D system visited the patient’s bedside, administered the questionnaire, and organized the results, remaining unaffected by healthcare staff and delivering standardized, objective scoring with a high detection rate.

The patient’s history illustrates why such comprehensive assessment matters. He had undergone laparoscopic cholecystectomy with extended radical resection and partial hepatectomy for gallbladder carcinoma in February 2022 at another hospital, where histopathology revealed moderately to well-differentiated adenocarcinoma invading the serosal layer with perineural invasion and metastases in both lymph nodes at the porta hepatis, staged T3N1Mx. Four cycles of oral capecitabine followed. In October 2022, clavicular metastasis was detected and treated with 25 sessions of localized radiotherapy. In May 2023, chest pain prompted imaging that suggested sternal metastasis, leading to another 25 radiotherapy sessions targeting the sternum plus two cycles of a GP chemotherapy regimen. Severe myelosuppression after each cycle forced discontinuation of further chemotherapy. Over the preceding year, his intermittent stabbing chest pain had escalated from self-managed codeine and ibuprofen to oxycodone extended-release tablets at 50 mg every 12 hours combined with pregabalin and celecoxib, with morphine suppositories for breakthrough episodes. In the five days before presentation, pain intensity surged, destroying his sleep and appetite.

On admission, the patient was cachectic with a Karnofsky Performance Status score of 60, confined to a forced supine position, with post-radiation hyperpigmentation across his chest, two firm palpable subcutaneous nodules roughly 2 cm in diameter, an enlarged tender lymph node in the right supraclavicular fossa, fine crackles in the right lung fields, and pitting edema in the lower extremities. His diagnoses included gallbladder carcinoma at stage IVB with multiple secondary bone, hepatic, pulmonary, and left adrenal malignancies, plus chronic refractory chest and back pain. The robot-assisted BTS evaluation localized his primary pain to the chest and back, characterized by stabbing and burning sensations, and quantified regional impact scores of 4 for the cervical spine, 3 for the upper limbs, 6 for the lumbar and dorsal regions, and 7 for the lower limbs. Sleep impact registered 9 and emotional impact 10. Screening identified a neuropathic pain component with a score of 3, and he reported six daily breakthrough episodes, significantly exacerbated by postural changes. In accordance with the 2017 Expert Consensus on Refractory Cancer Pain, the team designed a tailored multimodal analgesic regimen addressing this complex profile.

On January 3, 2024, the team initiated intravenous hydromorphone patient-controlled analgesia at a concentration of 0.6 mg/mL, with a basal rate of 1.3 mL/h, a 3.2 mL bolus, a 15-minute lockout interval, and an hourly limit of 10.9 mL. Baseline control was initially adequate, but three breakthrough episodes occurred within the first 12 hours. Titration on January 5 to a 1.5 mL/h basal rate and 3.6 mL bolus brought the NRS to 3 with three daily breakthrough episodes. By January 7, pain had rebounded to NRS 6 with six daily episodes occurring predominantly at night. The team added pregabalin and olanzapine and adjusted the PCA to a 2.5 mL/h basal rate and 4.5 mL bolus, achieving stable control at NRS 3 with only one daily episode. Critically, the BTS data identified the pain as classic incident pain triggered by movement or postural changes, so the patient was instructed to self-administer pre-emptive PCA boluses before physical activity. Laxatives and dietary modifications prevented opioid-induced constipation. By January 13, when he transferred to a local hospital continuing intravenous PCA, his NRS was 1 with no breakthrough episodes, and remote monitoring through the BTS digital health system confirmed stable analgesia at NRS 2 by January 20, with regional impact scores collapsing toward zero and the neuropathic component down to 1.

The patient’s own words capture what the numbers mean. Before treatment, he reported that his pain destroyed his will to live, and stated that his greatest fear was not death but dying in agony. After achieving adequate analgesia, he told the nursing staff that he could now say goodbye to his children without screaming in pain. The authors emphasize that the real harm of cancer pain lies not only in physical suffering but in the erosion of dignity and meaningful connection at the end of life. They also acknowledge important limitations: as the BTS is an assessment instrument, the observed analgesic benefit is attributable to the therapeutic regimen it informed rather than to the tool itself, and this single case cannot isolate the incremental contribution of multidimensional assessment over standard titration. The patient succumbed to disease progression one month after discharge, precluding long-term follow-up data.

Even so, the case demonstrates that multidimensional digital assessment proved feasible and provided clinically relevant information that may offer a foundation for hypothesis testing in subsequent controlled trials. The authors argue that investigations should now focus on full-cycle management and real-time surveillance of refractory pain, maximizing quality of life for cancer patients. If the 6D BTS system and its robotic interface can be validated at scale, the integration of artificial intelligence, standardized digital scoring, and remote dynamic monitoring could transform refractory cancer pain from an unmeasurable ordeal into a precisely quantified, continuously tracked, and effectively treated condition, offering patients the chance to spend their final months in comfort and connection rather than in agony.

Subject of Research: Digital pain assessment technology for refractory cancer pain management

Article Title: Case Report: Application of the 6D BTS digital assessment system in the comprehensive management of refractory cancer pain in a patient with gallbladder carcinoma

Article References: Ren, J., Li, Y., Zhou, K., Wang, Y., Wang, Q., Hu, D., Song, T., Dong, H., Cheng, Z., Hu, C., Huang, K., Zhang, Y., & Zhuang, L. (2026). Case Report: Application of the 6D BTS digital assessment system in the comprehensive management of refractory cancer pain in a patient with gallbladder carcinoma. Frontiers in Pain Research, 7, Article 1808441. https://doi.org/10.3389/fpain.2026.1808441

Image Credits: AI Generated

DOI: 10.3389/fpain.2026.1808441

Keywords: cancer pain, refractory cancer pain, digital health, pain assessment, gallbladder carcinoma, robotics, patient-controlled analgesia, palliative care, artificial intelligence, oncology, Case, Report

The clinical stakes are laid bare in the opening case. Mr. Warren, hospitalized with bacteremia caused by resistant gram-negative bacteria, repeatedly requested discharge because standard withdrawal treatments were not controlling his symptoms. His care team started with methadone, his preferred medication for opioid use disorder, along with clonidine and symptomatic adjuncts. When those measures failed and he again moved to leave, the team turned to high doses of intravenous hydromorphone, delivered through a patient-controlled analgesia pump that allowed smaller, more frequent doses with lockout periods. The objective signs of withdrawal, including elevated heart rate, dilated pupils, yawning, tremors, goosebumps, vomiting, diarrhea, and sweating, all ceased. What remained were cravings, which the author identifies as a cornerstone symptom of withdrawal and the predominant driver of the patient’s urge to leave.

The central argument of the viewpoint is that opioid withdrawal, including uncontrolled cravings, should be treated as an acute, life-threatening illness requiring prompt management, just as sepsis or diabetic ketoacidosis would be. Rose contends that the historical framing of withdrawal as uncomfortable but benign has bred complacency. In reality, untreated or undertreated withdrawal is a common cause of premature hospital discharge and a rapid return to fentanyl use, which acutely raises mortality both through overdose and through complications of foregone medical care. Avoidance of withdrawal, he notes, is also a major reason patients with opioid use disorder continue to use opioids in the first place.

Fentanyl has magnified these dangers. As the dominant non-prescribed opioid across the United States, it carries a markedly higher overdose risk than heroin or prescription opioids. Its brief duration of action increases injection frequency, compounding risks of infectious complications such as endocarditis and viral hepatitis. Its potency also raises patient tolerance, and its accumulation in tissues prolongs withdrawal, often making traditional methadone titrations unbearable and increasing the risk of precipitated withdrawal when buprenorphine is initiated. Clinicians are therefore increasingly confronting hospitalized patients with severe illness whose withdrawal and cravings cannot be controlled by conventional protocols alone.

The pharmacological rationale for intravenous therapy follows established practice in other acute conditions. For pathologies ranging from sepsis to heart failure to diabetic ketoacidosis, intravenous medications are initially required to achieve faster clinical improvement and offer superior titratability. The same logic applies to other withdrawal syndromes, such as alcohol withdrawal, and to opioid use for acute pain. Intravenous opioids produce a rapid rise in drug concentrations that facilitates swift symptomatic relief, while their short half-lives reduce the risk of accumulation. Patient-controlled analgesia pumps, which require active patient participation and enforce lockout intervals, can safely deliver the large morphine-equivalent doses demanded by patients with especially high fentanyl-driven tolerances while granting them a measure of autonomy over their own treatment.

Short-acting opioids, whether intravenous or oral, already have a recognized adjunctive role in the literature. They can fill residual opioid agonism deficits during methadone titrations. During buprenorphine initiation, they can be used for symptom control while fentanyl clears from the body, alongside buprenorphine during low-dose initiations, or to treat precipitated withdrawal if it occurs. This adjunctive use is described as an increasingly accepted harm reduction practice. What remains undefined, and what the viewpoint seeks to address, is the specific role of the intravenous route, whose absence from formal guidance has produced uncertain and inconsistent use across hospitals.

A crucial element of the argument is the assessment of risk. Clinicians rightly worry that the association between receiving opioids and relief from distress or cravings could reinforce, rather than reverse, the learned behavior that opioids are a solution to stressors. Faster time to peak effect, a hallmark of intravenous administration, is known to increase this reinforcing potential. However, Rose argues that for hospitalized patients with severe opioid use disorder, fentanyl use, and uncontrolled withdrawal, the risk of worsening the disorder is low while the benefit of controlling symptoms, thereby facilitating ongoing medical care including addiction treatment, is high. As time and treatment suppress withdrawal and cravings and the acute medical illness improves, the risk-benefit calculus reverses, and short-acting opioids should be discontinued.

The viewpoint is emphatic that intravenous opioids are never a substitute for evidence-based treatment. Medications for opioid use disorder should be recommended to all patients and serve as the backbone of withdrawal management, with buprenorphine or methadone identified as the most effective treatments even for patients uninterested in continuing them after discharge. Alpha-2 agonists such as clonidine or lofexidine should be first-line adjunctive therapies unless contraindicated. Symptomatic treatment with anxiolytics like hydroxyzine, antiemetics like ondansetron, antispasmodics like dicyclomine, antidiarrheals like loperamide, and non-opioid pain medications such as NSAIDs should also be deployed as needed. Short-acting opioids enter the picture only for patients with residual symptoms despite these measures, or in rare instances where patients decline buprenorphine and methadone entirely and the medications are used to facilitate hospital-based care.

Route selection and expectation setting form the practical core of the proposed guidance. Because the reinforcing risk of rapid-onset opioids is amplified with prolonged use, oral opioids should be prioritized once initial withdrawal symptoms have improved and effective doses have been identified. This transition also smooths drug exposures, offering more consistent symptom control throughout the day. Plans to move from intravenous to oral therapy and eventually to discontinue short-acting opioids altogether should be established with patients early. Once patients reach therapeutic buprenorphine doses, typically 16 to 24 milligrams daily, short-acting opioids should no longer be required. Methadone initiation is typically slower, and patients should understand that short-acting opioids will be tapered as methadone is increased, a process that growing evidence suggests can be expedited through more rapid titration schedules.

The case concludes with hard-won but partial success. Mr. Warren’s symptoms improved on the patient-controlled pump, which was transitioned to oral therapy over subsequent days. As methadone was uptitrated, the short-acting opioids were tapered and eventually discontinued. He remained hospitalized for fourteen days of intravenous antibiotics, his first full treatment course in years. On the eve of transfer to rehabilitation, he again packed his bag and requested discharge, and this time no argument could dissuade him. He left with naloxone, a month’s supply of his medications, and a handshake. His infection was cured and he was alive, but not yet ready for recovery. That outcome, the viewpoint suggests, is precisely the point: intravenous opioids did not cure addiction, but they kept a critically ill patient in the hospital long enough to cure the infection that would otherwise have killed him, and they bought time that conventional withdrawal management alone could not.

Subject of Research: Use of intravenous opioids to manage opioid withdrawal in hospitalized patients with opioid use disorder

Article Title: The Role of IV Opioids for Opioid Withdrawal in Hospitalized Patients

Article References: Rose, M. R. (2026). The Role of IV Opioids for Opioid Withdrawal in Hospitalized Patients. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10856-y

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10856-y

Keywords: opioid withdrawal, intravenous opioids, opioid use disorder, fentanyl, methadone, buprenorphine, hospitalized patients, harm reduction, patient-controlled analgesia, medications for opioid use disorder, withdrawal management, internal medicine

The scale of the problem the guideline addresses is striking. According to a 2022 systematic review cited in the document, the overall prevalence of pain among cancer patients reaches 44.5 percent, with 30.6 percent experiencing moderate to severe pain. The incidence climbs to roughly 50.3 percent during active treatment, 35.8 percent after effective treatment, and 54.6 percent in advanced, metastatic, or end-stage disease. Under the International Classification of Diseases, 11th Revision, chronic cancer-related pain is formally defined as chronic pain caused by the primary tumor itself or by metastasis, encompassing both chronic cancer pain and chronic post-cancer treatment pain. Because pain profoundly affects physical, psychological, and social functioning, the guideline’s authors argue that its management is an integral component of comprehensive cancer treatment and can even influence survival outcomes.

At the heart of the guideline is the principle of holistic integrative medicine, a philosophy that transforms traditional multidisciplinary team approaches, known as MDT, into a fully integrated care model the authors call MDT-to-HIM. Rather than treating pain as an isolated symptom, this model assembles oncologists, palliative care specialists, pain physicians, surgeons, pharmacists, rehabilitation experts, nutritionists, traditional Chinese medicine practitioners, psychologists, and nurses into a dynamic, patient-centered team. The guideline recommends this collaborative model for patients whose pain is poorly controlled by drug therapy alone, those with intolerable adverse drug reactions, patients with bone metastasis-related pain, and those whose pain coexists with tumor-related complications such as malnutrition, gastrointestinal obstruction, or malignant intracranial hypertension.

Accurate assessment is positioned as the mandatory first step. The guideline prescribes ‘holistic’ and ‘routine, quantitative, and dynamic’ evaluation, recommending the Numerical Rating Scale and the Faces Pain Rating Scale for universal screening, while offering the Behavioral Pain Scale and the Critical Care Pain Observation Tool for patients who cannot self-report, such as those with cognitive impairment or at the end of life. Diagnosis should follow the ICD-11 hierarchical classification, distinguishing nociceptive pain, which affects roughly 59 percent of cancer patients, from neuropathic pain at about 19 percent, and mixed pain at about 20 percent. Nociceptive pain is further divided into somatic and visceral subtypes, each with distinct treatment implications. The guideline also formally defines the concept of a ‘pain crisis’ as new-onset or severe pain arising on a background of stable control, requiring immediate intervention.

Pharmacotherapy remains the backbone of cancer pain management, and the guideline notes that more than 80 percent of patients can achieve good relief through drugs alone. First-line regimens center on opioids, nonsteroidal anti-inflammatory drugs, and adjuvant analgesics such as calcium channel modulators and antidepressants. Notably, the document endorses pharmacogenomic testing, particularly CYP2D6 genotyping, to individualize prodrug therapy like codeine and avoid both poor efficacy and serious adverse reactions. For moderate pain, the guideline suggests that low-dose strong opioids may actually be preferable to weak opioids, given their lower nausea rates, lower cost, and comparable efficacy, though weak opioids carry a well-known ceiling effect. Acetaminophen in combination preparations should not exceed 2 grams daily because of hepatotoxicity risk.

Detailed dosing protocols form a major strength of the document. For opioid-naive patients, titration typically begins with 5 to 15 milligrams of oral morphine or an equivalent short-acting opioid, while opioid-tolerant patients start at 10 to 20 percent of their previous 24-hour total dose. Once stable control is achieved, patients convert to long-acting formulations with a rescue dose of short-acting opioid set at 10 to 20 percent of the daily total for breakthrough pain. Dose increases during maintenance follow pain intensity, ranging from 25 to 50 percent for mild pain up to 75 to 100 percent for severe pain measured on the numerical scale. The guideline also provides granular instructions for opioid rotation, noting that 20 to 44 percent of patients require a switch and that 40 to 80 percent improve analgesia afterward, with methadone conversions demanding reductions of 75 to 90 percent and, ideally, in-hospital supervision.

Safety receives extensive attention. The guideline catalogs management strategies for opioid-induced constipation, nausea and vomiting, pruritus, delirium, urinary retention, sedation, and respiratory depression, including precise naloxone dosing of 1 to 2 milliliters of a 0.4 milligram per 10 milliliter solution when respiratory rates fall below 8 breaths per minute. It also confronts the growing challenge of opioid misuse: prevalence estimates among long-term users range from 21 to 29 percent, and 8 to 12 percent of cancer patients on long-term opioids develop opioid use disorder. The document recommends validated screening tools such as the SOAPP-R and Opioid Risk Tool before initiating therapy, real-time monitoring with the Current Opioid Misuse Measure during treatment, urine drug testing, and prescription drug monitoring programs as pillars of risk mitigation.

When drugs fall short, the guideline opens the door to an arsenal of minimally invasive techniques that can be deployed before, during, or after standard three-step drug therapy. Patient-controlled analgesia via intravenous or subcutaneous routes offers rapid, individualized titration and can even be managed safely at home. Nerve blocks and neurolysis, particularly celiac plexus neurolysis with 75 to 100 percent ethanol, provide durable relief for refractory visceral pain. Percutaneous vertebroplasty stabilizes painful vertebral metastases, while spinal cord and peripheral nerve stimulation offer reversible neuromodulation for stable-tumor neuropathic pain. Perhaps most remarkable is intrathecal drug delivery, in which morphine infused directly into the cerebrospinal fluid is roughly 100 times more potent than the intravenous route and 300 times more potent than oral administration, dramatically reducing systemic doses and their side effects.

The guideline also integrates palliative antitumor therapies as analgesic tools, noting that a single 8-gray dose of radiotherapy relieves bone metastasis pain in about 40 percent of patients, while microwave and radiofrequency ablation can inactivate tumor tissue and reduce pain indirectly. Adjunctive approaches including traditional Chinese medicine, physical therapy, and structured psychological support such as mindfulness-based cognitive therapy and pain neuroscience education round out the multimodal framework. Ultimately, the authors identify the chief barriers to better care as outdated clinical concepts, restricted opioid access, nonstandard treatment, and weak multidisciplinary collaboration, and they express confidence that disseminating this guideline will extend both the quality of life and the survival of patients with cancer pain across China and beyond.

Subject of Research: Clinical practice guideline for the multidisciplinary management of adult cancer pain developed by the China Anti-Cancer Association

Article Title: CACA guidelines for the management of adult cancer pain

Article References: Jin, Y., Zhang, J., Suo, J., Yu, H., Song, L., Chen, F., Cheng, W., Cui, W., Fan, B., Feng, Z., Gong, L., Gu, N., Guo, L., Jia, Y., Li, S., Lin, F., Lin, R., Liu, B., Lu, G., … Xie, G. (2026). CACA guidelines for the management of adult cancer pain. Holistic Integrative Oncology, 5(1), Article 66. https://doi.org/10.1007/s44178-026-00286-5

Image Credits: AI Generated

DOI: 10.1007/s44178-026-00286-5

Keywords: cancer pain, CACA guideline, opioid therapy, palliative care, intrathecal drug delivery, multidisciplinary team, holistic integrative medicine, breakthrough pain, bone metastasis, neuropathic pain, opioid rotation, patient-controlled analgesia