Mr. Twain is a 46 year-old man with hidradenitis suppurativa that has not been active for the last year. At his last follow-up 3 months ago, he reported groin pain in spite of a benign physical exam. Today his chief concern is again pain: “Doctor, I have been aching in my armpits a lot recently. I haven’t seen any boils and bumps in these areas, but I keep feeling the pain. It’s worse at night when I try to go to sleep.”

The physical exam is, as it was noted last time, unremarkable. You perform a thorough review of Mr. Twain’s medical chart, paying close attention to his problem list and history of medication use. It appears that he has had a long history of chronic back and shoulder pain unresponsive to high doses of non-steroidal anti-inflammatory drugs, gabapentin, and morphine analogs. After you finish reviewing the chart, he states, “As you can see, I have tried many pain killers in the past, so I know which ones work for me. I want you to give me some hydromorphone to get rid of the pain in my armpits.”