What are your thoughts on her current pain regimen? Would you increase the methadone dose? Would you consider switching to another long-acting opioid such as buprenorphine? Or is there something else entirely that you'd recommend?

recommend?I think that there is certainly a lot to consider here.

The first thing that came to mind for me is that she may be suffering from opioid-induced hyperalgesia.

Some of the things that made me think that would be worsening pain without a clear cause, and then when she started reporting things like having pain all over, that also is somewhat of a clue.

And the premise of this is that when someone is on opioids over time, that they can kind of sensitize our opioid receptors and cause something that's normally painful to be more painful.

They also can have things like allodynia, where something that's not normally supposed to be painful becomes painful.

For example, someone has sheets touching them and it's painful or wearing clothing is painful.

So I think the non-pharm should, should be just as important, if not more important, than some of the pharmacologic therapies that we offer for these folks.