Marie worked as a chef until she retired at the age of 61. She is now 84 years old and has had poor health for many years. She has experienced a gradual onset of pain from osteoarthritis since the mid-1970s, particularly affecting her lower back, shoulders, neck, right knee and right hip.

Marie’s medical history includes:

• Ischaemic heart disease
• CABG, performed in 1997, with secondary infection of the donor sites on the left leg leading to ulceration, MRSA infection, and very slow healing. She now has anteroseptal and apical ischaemia with poor left ventricular function
• Postural hypotension and falls, secondary to her cardiac status and the effect of sedative drugs
• Cerebrovascular ischaemic episodes with recovery
• Peripheral vascular disease
• Thyroid disease
• Partial gastrectomy
• Bilateral carotid surgery
• Weight loss

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Marie had a right total hip replacement in 1993; the acetabular component has now failed and the hip has migrated proximally, giving her intense pain on movement of the joint. Further surgery has been considered but after discussion between the specialist team, Marie and her daughter (her full-time caregiver), the decision has been made that it would be too risky.

Marie is taking many medications, including paracetamol 4g daily, tramadol 100mg daily, frusemide, lansoprazole, simvastatin, losartan, aspirin, dipyridamole, lercanidipine and temazepam. Her pain is worst in the lower back and right hip and thigh, rated six to eight out of 10 and described as aching, debilitating and severe.

The pain interferes with Marie’s movement and limits all daily activities. She can walk only a few paces, but despite her many difficulties, Marie maintains an optimistic outlook. She returns scores within the normal range on psychological testing but maximum scores for interference with walking, normal ‘work’ and sleep on the Brief Pain Inventory.

Management options for symptomatic relief of pain are limited by her frail condition, her desire to stay alert and the other medications she is taking. She opts to take few strong analgesics because of drowsiness and constipation.

Marie has been offered a short course of acupuncture to the right knee to see if she gains any symptomatic relief. If so, an acupuncturist will provide a longer course of treatment. Marie is also considering the option of a single lumbar plexus block or hip block, with dilute local anaesthetic (0.1% bupivacaine 10mL) and long-acting steroid (methylprednisolone 80mg) for symptomatic relief of her hip pain.

The block is performed under X-ray guidance, with a single needle at L3. The technique is commonly used with a catheter for continuous infusion, or by a single injection at the time of anaesthesia, for postoperative pain relief after hip surgery. There are no recent studies describing the usefulness of this technique in osteoarthritic hip pain, but case reports suggest worthwhile symptomatic relief for three to six months with minimal side-effects. Again, the likely systemic disturbance caused by such a procedure needs to be weighed against the likely benefit and Marie is not keen on having the procedure.

The third management suggestion is a buprenorphine seven-day skin patch, starting at 5µg/hour. She is given a patient information leaflet about the patch and her daughter will apply and remove the patches. The transdermal route is often more acceptable to older patients who are already taking many medications for other conditions.

Marie is warned to remove the patch if she experiences any breathlessness. If she becomes nauseated or dizzy, this is likely to resolve spontaneously. However, it is advised that a prescription for an antiemetic is provided to patients, which can be filled if it becomes necessary.