New clinical-practice guidelines for the management of pain in patients with cancer

Nociceptive transmission to rat primary somatosensory cortex--comparison of sedative and analgesic effects

CO(2)-laser C-fibre evoked cortical potentials (LCEPs) is a potentially useful animal model for studies of pain mechanisms. A potential confounding factor when assessing analgesic effects of systemically administered drugs using LCEP is sedation. This study aims to clarify: 1) the relation between level of anaesthesia and magnitude of LCEP, 2) the effects of a sedative and an analgesic on LCEP and dominant EEG frequency 3) the effects of a sedative and analgesic on LCEP when dominant EEG frequency is kept stable. LCEP and EEG were recorded in isoflurane/nitrous-oxide anaesthetized rats. Increasing isoflurane level gradually reduced LCEPs and lowered dominant EEG frequencies. Systemic midazolam (10 μmol/kg) profoundly reduced LCEP (19% of control) and lowered dominant EEG frequency. Similarly, morphine 1 and 3 mg/kg reduced LCEP (39%, 12% of control, respectively) and decreased EEG frequency. When keeping the dominant EEG frequency stable, midazolam caused no significant change of LCEP. Under these premises, morphine at 3 mg/kg, but not 1 mg/kg, caused a significant LCEP reduction (26% of control). In conclusion, the present data indicate that the sedative effects should be accounted for when assessing the analgesic effects of drug. Furthermore, it is suggested that LCEP, given that changes in EEG induced by sedation are compensated for, can provide information about the analgesic properties of systemically administrated drugs.

Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial

BACKGROUND

This study sought to describe the results of a single-arm multicenter clinical trial using image-guided percutaneous cryoablation for the palliation of painful metastatic tumors involving bone.

METHODS

Over a 44-month period, 61 adult patients with 1 or 2 painful bone metastases with a score of 4 or more on a scale of 0 to 10 (≥4/10) worst pain in a 24-hour period who had failed or refused conventional treatment were treated with percutaneous image-guided cryoablation. Patient pain and quality of life was measured using the Brief Pain Inventory prior to treatment, 1 and 4 days after the procedure, weekly for 4 weeks, and every 2 weeks thereafter for a total of 6 months. Patient analgesic use was also recorded at these same follow-up intervals. Complications were monitored. Analysis of the primary endpoint was undertaken via paired comparison procedures.

RESULTS

A total of 69 treated tumors ranged in size from 1 to 11 cm. Prior to cryoablation, the mean score for worst pain in a 24-hour period was 7.1/10 with a range of 4/10 to 10/10. At 1, 4, 8, and 24 weeks after treatment, the mean score for worst pain in a 24-hour period decreased to 5.1/10 (P < .0001), 4.0/10 (P < .0001), 3.6/10 (P < .0001), and 1.4/10 (P < .0001), respectively. One of 61 (2%) patients had a major complication with osteomyelitis at the site of ablation.

CONCLUSIONS

Percutaneous cryoablation is a safe, effective, and durable method for palliation of pain due to metastatic disease involving bone.

Opioid rotation in clinical practice

INTRODUCTION

Although chronic opioid therapy is usually initiated using short-acting opioids, many patients with chronic pain are subsequently converted to long-acting and extended-release preparations. In clinical practice, optimal management requires careful individualization of dosage in order to achieve an appropriate balance of efficacy and adverse effects. After successful initiation and stabilization of opioid treatment, subsequent changes in regimen may still be required to maintain efficacy with an acceptable adverse effect profile.

METHODS

This is a qualitative review of the available literature from June 2012 or earlier on opioid rotation for the management of chronic pain in the clinical setting. The PubMed database was searched using various search terms, and additional articles were identified through manual search of the bibliographies of articles identified through the PubMed search. Papers were selected based on relevance to the topic.

RESULTS

When considering opioid rotation, clinicians must take into account not only the significant differences in potency among opioid drugs but also the considerable interpatient variability in response to opioids. The estimate of relative potency used in calculating an appropriate starting dose when switching from one opioid to another has been codified on equianalgesic dose tables. To reduce the risk of unintentional overdose, a two-step calculation has been proposed, which incorporates an initial reduction (typically 25-50%) in the equianalgesic dose followed by a second evaluation based on the severity of pain at the time of rotation along with other medical or psychosocial factors that might alter the effectiveness and tolerability of the new drug. Given the uncertainty of accurately predicting a patient's response to treatment, each initial exposure to a new opioid should be considered a discrete clinical trial to assess the degree of response. Systematic reviews of opioid rotation have documented the re-establishment of adequate pain control or reduced adverse effects in 50-80% of patients.

CONCLUSIONS

Although continued research is needed to refine equianalgesic doses further, opioid rotation is an important and necessary practice in patients with chronic cancer or noncancer pain that is refractory to the initially used opioid.

Revision and Validation of a Medication Assessment Tool for Chronic Cancer Pain Management

The medication assessment tool for cancer pain management (MAT-CP) measures the quality of medication use in relation to guidelines. The original MAT-CP was reviewed, modified and tested at a comprehensive cancer center in Jordan. The tool comprised 30 criteria covering six different aspects of pain management. Seventy patients were included, males 41 (59%), females 29 (41%), mean age 49 (range, 20-79) years. The overall level of adherence to guidelines was 78% with good inter-rater reliability (κ= 0.899). The tool's implementation showed opportunities for improvement in pain management at our institution. The MAT-CP was revised and validated for the first time outside Europe. This tool can be routinely used to assess and compare the quality of pain management in different institutions.

Oncologists’ perceptions of cancer pain management in Spain: The real and the ideal

AIM

Studies in some countries suggest that cancer pain is often not adequately controlled, but little is known about the situation in Spain. The objective of this study was to identify medical oncologists' perceptions about pain management in their patients.

METHODS

Two-round Delphi survey of 24 medical oncologists from 22 large, geographically diverse hospitals in Spain. Physicians rated each of 150 statements on a Likert scale (1=strongly disagree; 5=strongly agree). The mean, standard deviation and frequency of replies in three agreement categories were calculated for each item. Statements allowing comparison of oncologists' perceptions of how pain is managed in routine clinical practice with how it should be managed were grouped together and analyzed.

RESULTS

The most notable discrepancies between the real and the ideal occurred in the failure to provide written information or to confirm that patients understand what they are told, the lack of comprehensive and systematic evaluation of pain, and the lack of use of non-pharmacological treatments (NPTs) for cancer pain.

CONCLUSIONS

Medical oncologists need to improve their communication skills, providing patients with both written and verbal information about their disease and the plan for pain management. Pain should be evaluated at each patient visit using validated scales, and greater attention should be paid to the possible use of NPTs.

Evaluation of the comparative analgesic effectiveness of transdermal and oral opioids in cancer patients: a propensity score analysis

BACKGROUND

Transdermal delivery systems containing fentanyl or buprenorphine, despite the relatively lack of comparative studies, have reached an impressive share of the market in several countries. In the context of a wider observational study, we applied the propensity score to test the comparative effectiveness of the two routes of administration (oral vs. transdermal).

METHODS

We applied the propensity score in a subgroup of patients (starting the World Health Organization third step therapy during the scheduled follow-up of 28 days) using pre-planned primary (pain intensity change) and secondary endpoints, such as increase in doses, need for switching and safety profile. Univariate and multivariate analyses were carried out.

RESULTS

Three-hundred sixty-six eligible cases were analysed. We found a difference among the two groups in terms of variables potentially associated with therapy choice and outcomes. After adjusting for propensity score, results were in favour of transdermal delivery systems for the primary endpoint (odds ratio 1.68; p = 0.04). A similar trend was also present for the other secondary endpoints. Only in the case of nausea and vomiting, patients receiving transdermal delivery systems reported a higher frequency of events.

CONCLUSION

The application of the propensity score has helped understand better the actual effectiveness of transdermal delivery systems that are at least equivalent to the oral opioids, and even more effective for pain intensity reduction.

Rationale, design, and implementation protocol of the Dutch clinical practice guideline pain in patients with cancer: a cluster randomised controlled trial with Short Message Service (SMS) and Interactive Voice Response (IVR)

Background

One-half of patients with cancer have pain. In nearly one out of two cancer patients with pain, this was undertreated. Inadequate pain control still remains an important problem in this group of patients. Therefore, in 2008 a national, evidence-based multidisciplinary clinical practice guideline 'pain in patients with cancer' has been developed. Yet, publishing a guideline is not enough. Implementation is needed to improve pain management. An innovative implementation strategy, Short Message Service with Interactive Voice Response (SVS-IVR), has been developed and pilot tested. This study aims to evaluate on effectiveness of this strategy to improve pain reporting, pain measurement and adequate pain therapy. In addition, whether the active role of the patient and involvement of caregivers in pain management may change.

Methods/design

A cluster randomised controlled trial with two arms will be performed in six oncology outpatient clinics of hospitals in the Southeastern region of the Netherlands, with three hospitals in the intervention and three in the control condition. Follow-up measurements will be conducted in all hospitals to study the long-term effect of the intervention. The intervention includes training of professionals (medical oncologists, nurses, and general practitioners) and SMS-IVR to report pain in patients with cancer to improve pain reporting by patients, pain management by medical oncologists, nurses, and general practitioners, and decrease pain intensity.

Discussion

This innovative implementation strategy with technical tools and the involvement of patients, may enhance the use of the guideline 'pain in patients with cancer' for pain management. Short Message Service alerts may serve as a tool to support self-management of patients. Therefore, the SMS-IVR intervention may increase the feeling of having control over one's life.

Trail registration

Netherlands Trial Register (NTR): NTR2739

Controlled-release oxycodone tablets after transdermal-based opioid therapy in patients with cancer and non-cancer pain

BACKGROUND AND AIMS

Several publications and guidelines stress the efficacy and safety of opioid-based therapy for cancer and non-cancer pain management. The first point of the World Health Organization (WHO) guidelines recommends that, if possible, analgesics should be given by mouth. This advice fully matches the European Society for Medical Oncology (ESMO) guidelines, which advise that opioids should be titrated to take effect as rapidly as possible. The European Association for Palliative Care (EAPC) guidelines specify that transdermal fentanyl should be administered only in patients with stable analgesic requirements. The aim of this study was to assess the efficacy and influence on the quality of life of controlled- release (CR) oxycodone in patients who had obtained no or only partial pain relief after transdermal (TTD)-based opioid therapy.

METHODS

Forty-one consecutive patients experiencing persistent cancer and non-cancer related pain and in treatment with transdermal- based opioid therapy for at least 5 days were enrolled in this open-label, multicenter observational study. All patients were switched from transdermal to oral opioid therapy with oxycodone CR for 21 days. Pain intensity was rated on a numeric rating scale (NRS) from 0 to 10 (0=no pain, 10=maximum severity). Patients were asked to rate their perceptions on efficacy and pain interference on the quality of life on an NRS from 0 to 10 (0=no interference, 10=maximum interference).

RESULTS

After 3 days with oxycodone CR, pain intensity decreased by 38.83% (p<0.001) and maintained a significant decrease throughout the period (T0-T7: -59.71%, p<0.001; T0-T21: -65.75%, p<0.001). The average daily dose of oxycodone CR increased from 68.75 mg at baseline to 72.39 mg after 7 days and was maintained stable until the study ended. At T0, 56.10% of patients suffered from severe pain (NRS 7- 10); this percentage had decreased to 2.56% at the end of the study. About 7% of patients considered transdermal therapy effective at baseline; after 21 days, 72.22% and 19.44% of patients considered it effective and very effective, respectively. Quality of life improved significantly during the 21 days with the oral treatment (p<0.001).

CONCLUSIONS

Switching from transdermal opioid to oxycodone CR treatment is effective and leads to patients' improved satisfaction and quality of life.

Palliation of painful metastatic disease involving bone with imaging-guided treatment: comparison of patients' immediate response to radiofrequency ablation and cryoablation

OBJECTIVE

The purpose of this article was to compare periprocedural analgesic requirements and hospital length of stay for treatment of patients with painful metastatic tumors involving bone using either percutaneous radiofrequency ablation (RFA) or cryoablation.

MATERIALS AND METHODS

A retrospective review was conducted of patients who underwent either imaging-guided cryoablation or imaging-guided RFA for painful metastatic tumors involving bone. The total analgesic usage for 24 hours after the procedure was expressed as a standard morphine-equivalent dose. Analgesic usage at admission served as a baseline for comparison. Total hospital stay was used as an additional measurement of procedure-related morbidity.

RESULTS

Fifty-eight patients underwent either cryoablation (n = 36) or RFA (n = 22) for painful metastatic tumors involving bone. Twenty-two primary tumors were treated. The most common treatment site was the pelvis (n = 31). There was no significant difference between the two groups with regard to tumor histologic type (p = 0.52) and location (p = 0.72). The median tumor diameter was 4.4 cm for the cryoablation group and 5.0 cm for the RFA group (p = 0.63). Pretreatment pain scores, measured on a scale of 0 to 10, were not significantly different between the two groups: 6.5 for cryoablation and 6.0 for RFA (p = 0.78). Analgesic use in the 24 hours immediately after the procedure decreased significantly by 24 morphine-equivalent doses after cryoablation, whereas it increased by a median of 22 morphine-equivalent doses after RFA (p = 0.03). Total hospital length of stay for patients undergoing cryoablation was a median of 2.5 days less than that for patients receiving RFA (p = 0.003).

CONCLUSION

The use of cryoablation compared with RFA is associated with a greater reduction in analgesic dose and shorter hospital stays after the procedure in the perioperative time frame.

[Anesthesiology and palliative medicine. Structured results of a prospective questionnaire-based survey in German hospitals]

BACKGROUND

Anesthesiology departments were often integrated into the primary formation of palliative activities in Germany. The aim of this study was to present the current integration of anesthesiology departments into palliative care activities in Germany.

METHODS

The objective was to determine current activities of anesthesiology departments in in-hospital palliative care. A quantitative study was carried out based on a self-administered structured questionnaire used during telephone interviews.

RESULTS

A total of 168 out of 244 hospitals consented to participate in the study and the response rate was 69%. In-hospital palliative care activities were reported for most of the surveyed hospitals. Only two hospitals in the maximum level of care reported no activities. Participation in these activities by anesthesiology departments was described in up to 92%. Historically, most activities are due to the commitment of individuals, whereas the development of palliative care of cancer pain services and hospital support teams took place in the university hospitals by 2005.

CONCLUSIONS

Until 2005 many university palliative care activities had their origins in cancer pain services. These were often integrated into anesthesiology departments. Currently, anesthesiology departments work as an integrative part of palliative medicine. However, it appears from the present results that there is a domination of internal medicine (especially hematology and oncology) in palliative activities in German hospitals. This allows the focus of palliative activities to be formed by subjective specialist interests. Such a state seems to be reduced by the integration of anesthesiology departments because of their neutrality with respect to faculty-specific medical interests. Advantages or disadvantages of these circumstances are not considered by the present investigation.

The prevalence of pain in patients attending sarcoma outpatient clinics

The prevalence of pain in patients with sarcoma is not well documented. We investigated this in outpatients at a tertiary cancer referral centre, assessing the adequacy of pain control and for risk factors leading to higher prevalence and severity of pain. 149 patients were surveyed. Patients with pain within the previous 7 days completed pain assessment tools (BPI, S-LANSS, PMI). 53% of patients had pain within the previous 7 days, and 25% had significant pain. Of those with pain, 63% was inadequately controlled and neuropathic pain was identified in 36%. Age, gender, tumour type, and the type of cancer treatment were not significant predictors of the prevalence or severity of the pain. Based on our results, patients with sarcoma should be actively screened for pain and have regular reviews of their analgesic requirements.

Trajectories of pain and analgesics in oncology outpatients with metastatic bone pain

A large proportion of oncology outpatients with bone metastasis report unrelieved pain that significantly interferes with daily functioning and quality of life. However, little is known about the longitudinal pattern of pain intensity and analgesic prescriptions or use. Moreover, despite considerable advantages, the use of sophisticated statistical techniques, such as hierarchical linear modeling (HLM) has not been applied to the study of pain and analgesic outcomes. In a prospective longitudinal study, HLM was used to explore predictors of pain intensity and analgesic prescription and intake at the time of enrollment into the study (intercept) and over the course of 6 weeks (trajectory) in a sample of oncology outpatients with bone metastasis who received standard care for pain. In addition to corroborating known predictors of pain intensity, previously unrecognized variables were found that appear to affect both pain and analgesic outcomes. Importantly, some of the predictors of the trajectories of pain intensity and analgesic use (ie, pain-related distress and Pain Management Index (PMI) scores) are particularly amenable to interventions. Findings from this study suggest that sophisticated statistical modeling can be used in pain research to identify individual risk factors and propose novel targets that can be used to improve pain management in oncology outpatients with bone metastasis.

PERSPECTIVE

Findings from this study suggest that a large amount of inter-individual variability exists in patients' experiences with cancer pain and analgesic use. Future studies need to elucidate the mechanisms that underlie these differences.

Review article: palliative care in gynecologic oncology

Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.

Psychological treatment of chronic pain

Psychological treatment has emerged as a common component of a multidimensional and interdisciplinary plan of pain care for many persons with persistent pain. Treatments are informed by a biopsychosocial model of pain and a long history of psychological research that has identified the central role of behavioral, cognitive, and emotional factors that are believed to contribute to the perpetuation, if not the development, of chronic pain and pain-related disability and emotional distress. Empirically supported self-regulatory, behavioral, cognitive-behavioral, and acceptance and commitment interventions are reviewed, and current and future interventions are highlighted. Important issues related to individual differences and disparities in the experience of pain and pain treatment are discussed. In particular, race and ethnicity are considered, and special considerations for the management of pain in children and older adults are discussed.

Problems of quality and equity in pain management: exploring the role of biomedical culture

OBJECTIVES

To explore how social scientific analyses of the culture of biomedicine may contribute to advancing our understanding of ongoing issues of quality and equity in pain management.

DESIGN

Drawing upon the rich body of social scientific literature on the culture of biomedicine, we identify key features of biomedical culture with particular salience for pain management. We then examine how these cultural features of biomedicine may shape key phases of the pain management process in ways that have implications not just for quality, but for equity in pain management as well.

SETTING AND PATIENTS

We bring together a range of literatures in developing our analysis, including literatures on the culture of biomedicine, pain management and health care disparities.

MEASURES

We surveyed the relevant literatures to identify and inter-relate key features of biomedical culture, key phases of the pain management process, and key dimensions of identified problems with suboptimal and inequitable treatment of pain.

RESULTS

We identified three key features of biomedical culture with critical implications for pain management: 1) mind-body dualism; 2) a focus on disease vs illness; and 3) a bias toward cure vs care. Each of these cultural features play a role in the key phases of pain management, specifically pain-related communication, assessment and treatment decision-making, in ways that may hinder successful treatment of pain in general -- and of pain patients from disadvantaged groups in particular.

CONCLUSIONS

Deepening our understanding of the role of biomedical culture in pain management has implications for education, policy and research as part of ongoing efforts to ameliorate problems in both quality and equity in managing pain. In particular, we suggest that building upon the existing the cultural competence movement in medicine to include fostering a deeper understanding of biomedical culture and its impact on physicians may be useful. From a policy perspective, we identify pain management as an area where the need for a shift to a more biopsychosocial model of health care is particularly pressing, and suggest prioritization of inter-disciplinary, multimodal approaches to pain as one key strategy in realizing this shift. Finally, in terms of research, we identify the need for empirical research to assess aspects of biomedical culture that may influence physician's attitudes and behaviors related to pain management, as well as to explore how these cultural values and their effects may vary across different settings within the practice of medicine.

Managing severe cancer pain: the role of transdermal buprenorphine: a systematic review

Pain is a frequent and important symptom in cancer patients. Among the available strong opioids, transdermal buprenorphine has been licensed in Europe since 2002, and results from a few clinical studies suggest that it may be a good alternative to the other oral or transdermal opioids. To assess the best available evidence on its efficacy and safety, we carried out a systematic literature review with the aim of pooling relevant studies. We identified 19 eligible papers describing 12 clinical studies (6 randomized controlled trials and 6 observational prospective studies), including a total of about 5000 cancer patients. Given the poor quality of reports and the heterogeneity of methods and outcomes, pooling was not feasible as the type of data was not appropriate for combining the results statistically. A meta-analysis based on individual data is ongoing in the context of the Cochrane Collaboration. In conclusion, although the narrative appraisal of each study suggests a positive risk benefit profile, well designed and statistically powered controlled clinical trials are needed to confirm this preliminary evidence.

[Palliative medicine. Fifth pillar of anaesthesia departments]

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.

Adherence to medication guideline criteria in cancer pain management

The medication-assessment tool for cancer pain management (MAT-CP) is a novel tool for measuring the quality of drug use in chronic pain management in relation to guideline standards. MAT-CP has recently been revised and validated for use in the U.K. clinical setting. This article presents a measure of the adherence of current practice to specific cancer pain guideline criteria in two palliative care settings. Adult patients with malignant disease experiencing pain and/or receiving analgesics were identified by clinical pharmacists at two hospitals and five hospices in Scotland, United Kingdom. The MAT-CP was applied to data extracted from case notes. Results were quantified in terms of applicability and adherence to guideline criteria and the presence of insufficient data. MAT-CP was applied to 192 cancer patients experiencing pain; 103 (54%) were males and the mean (standard deviation) age was 68.5 (13.0) years. Overall guideline adherence was 75% (confidence interval [CI]: 74%, 77%; n=3460 applicable criteria). Low adherence (<50%) was seen for nine criteria, whereas 21 criteria were considered high-adherence criteria (>75%). Overall adherences for 56 (29%) hospitalized patients and 136 (71%) hospice patients were 65% (CI: 62%, 68%) and 79% (CI: 78%, 81%), respectively. Although good overall guideline adherence was found, there were gaps in both the hospice and hospital palliative care settings in the implementation of certain treatment recommendations, particularly in relation to pain assessment. The application of the tool has highlighted issues for feedback to health care providers and for further study.

Efficacy and safety profile of a single dose of hydromorphone compared with morphine in older adults with acute, severe pain: a prospective, randomized, double-blind clinical trial

BACKGROUND

Older adults (ie, those aged > or =65 years) are the fastest growing segment of the US population, with an estimated approximately 71 million expected by 2030. Over the past 10 years, there has been an 11% increase in the number of emergency department (ED) visits by older adults, and pain is their most common chief complaint.

OBJECTIVE

The goal of this study was to compare weight-based IV hydromorphone and IV morphine in adults aged > or =65 years presenting to the ED with acute, severe pain.

METHODS

This was a prospective, randomized, double-blind clinical trial of older adults with acute, severe pain at an adult, urban academic ED. Patients were randomly allocated to receive a single dose of 0.0075-mg/kg IV hydromorphone or 0.05-mg/kg IV morphine. The primary outcome was the between-group difference in decrease in pain from baseline to 30 minutes after the medications were infused. Patients' degree of pain was measured on a numerical rating scale (NRS) where "0" was defined as "no pain" and "10" was defined as "the worst pain possible." Adverse effects, pain reduction at 10 minutes and 2 hours postbaseline, patient evaluations of satisfaction and pain relief at 30 minutes postbaseline, and use of additional analgesics and antiemetics were tracked as secondary outcomes.

RESULTS

A total of 194 patients were randomized to treatment; 183 patients (hydromorphone group, n = 93; morphine group, n = 90 [overall mean (SD) age, 75 (8) years]) had sufficient data for analysis at the primary end point of 30 minutes postbaseline. The mean decrease in pain from baseline to 30 minutes in patients allocated to IV hydromorphone was 3.8 versus 3.3 NRS units in patients allocated to IV morphine. This difference of 0.5 NRS unit (95% CI, -0.2 to 1.3) was neither clinically nor statistically significant. A majority of patients in both groups (57.0% randomized to hydromorphone and 58.9% randomized to morphine) failed to achieve a > or =50% reduction in pain within 30 minutes of treatment. The incidence of adverse effects from baseline to 30 minutes was not statistically different in the 2 groups.

CONCLUSIONS

A single dose of IV hydromorphone at 0.0075 mg/kg was neither clinically nor statistically different from IV morphine at 0.05 mg/kg for the treatment of acute, severe pain at 30 minutes postbaseline in these older adults in the ED. The incidence of adverse effects was not statistically different. Our data suggest that hydromorphone and morphine in the doses given had similar efficacy and safety profiles in these older adults. Neither regimen provided > or =50% pain relief for the majority of patients. Future investigations of acute pain management in older adults should examine the efficacy and safety of higher initial (loading) doses of opioids titrated at frequent intervals until adequate analgesia is achieved.

Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group

Most patients with advanced or metastatic cancer experience pain and despite several guidelines, undertreatment is well documented. A multicenter, open-label, prospective, non-randomised study was launched in Italy in 2006 to evaluate the epidemiology, patterns and quality of pain care of cancer patients. To assess the adequacy of analgesic care, we used a standardised measure, the pain management index (PMI), that compares the most potent analgesic prescribed for a patient with the reported level of the worst pain of that patient together with a selected list of clinical indicators. A total of 110 centres recruited 1801 valid cases. 61% of cases were received a WHO-level III opioid; 25.3% were classified as potentially undertreated, with wide variation (9.8–55.3%) according to the variables describing patients, centres and pattern of care. After adjustment with a multivariable logistic regression model, type of recruiting centre, receiving adjuvant therapy or not and type of patient recruited (new or already on follow-up) had a significant association with undertreatment. Non-compliance with the predefined set of clinical indicators was generally high, ranging from 41 to 76%. Despite intrinsic limitations of the PMI that may be considered as an indicator of the poor quality of cancer pain care, results suggest that the recourse to WHO third-level drugs still seems delayed in a substantial percentage of patients. This delay is probably related to several factors affecting practice in participating centres and suggests that the quality of cancer pain management in Italy deserves specific attention and interventions aimed at improving patients’ outcomes.

Comparison of Two Brief Parent-Training Interventions for Child Distress During Parent-Administered Needle Procedures

This randomized clinical trial employed a 2-group (general child behavior management training vs. distraction for pain management training) design across repeated parent-administered needle procedures. Forty-seven children with a chronic illness requiring recurrent injections were observed at baseline and 2 intervention sessions. Videotaped observations of parent-child interactions were coded for child behavioral distress and parents' use of behavior management strategies. Across groups, many children displayed minimal to no distress at baseline. Among participants with significant distress, neither intervention group displayed consistently decreased procedural distress or increased use of child behavior management strategies.

A new transmucosal drug delivery system for patients with breakthrough cancer pain: the fentanyl effervescent buccal tablet

Breakthrough pain, a transitory severe pain with the background of otherwise controlled persistent pain has a prevalence between 52% and 67% in outpatients with cancer. Medications for such sudden-onset pain require non-invasive delivery of a potent and short-acting opioid for rapid pain relief. Although oral transmucosal delivery of fentanyl citrate (OTFC) has been shown to provide better pain relief than a typical oral opioid administration such as morphine sulfate immediate release (MSIR) in the management of breakthrough pain in patients with cancer-related pain, newer delivery systems offer a potential for further enhancement of pain relief. The fentanyl effervescent buccal tablet (FBT) formulation employs a novel drug delivery system that relies on an effervescence reaction to improve buccal fentanyl absorption. Using the effervescence reaction results in the production and dissipation of carbon dioxide with a dynamic shift in pH as the tablet dissolves. The induced low pH favors dissolution of fentanyl citrate in saliva (higher water solubility). The subsequent increase in pH thereafter favors the buccal absorption of non-ionized fentanyl across the buccal mucosa. Such a pH “pumping” mechanism increases the permeation of fentanyl into and through the buccal to the vascular system from where the agent is transported to the specific opioid receptor sites in the CNS. Compared with OTFC, data in healthy volunteers show that the effervescence reaction employed in FBT increases the total amount and the speed of absorption of fentanyl being absorbed. Compared with OTFC there is an increase in peak fentanyl blood concentrations, and an enhancement of the amount of buccal delivery of fentanyl. Such favorable data are underlined by the results of clinical studies where the FBT technology was studied in patients with breakthrough pain in chronic malignant pathologies.

Cancer pain and analgesia

Pain ranges in prevalence from 14-100% among cancer patients and occurs in 50-70% of those in active treatment. Cancer pain may result from direct invasion of tumor into nerves, bones, soft tissue, ligaments, and fascia, and may induce visceral pain through distension and obstruction. Cancer pain is multifaceted. Clinicians may describe cancer pain as acute, chronic, nociceptive (somatic), visceral, or neuropathic. Despite implementation of the WHO guidelines, reports of undertreatment of cancer pain persist in various clinical settings and in spite of decades of work to reduce unnecessary discomfort. Substantial obstacles to adequate pain relief with opioids include specific concerns of patients themselves, their family members, physicians, nurses, and the healthcare system. The WHO analgesic ladder serves as the mainstay of treatment for the relief of cancer pain in concert with tumoricidal, surgical, interventional, radiotherapeutic, psychological, and rehabilitative modalities. This multidimensional approach offers the greatest potential for maximizing analgesia and minimizing adverse effects. Primary therapies are directed at the source of the cancer pain and may enhance a patient's function, longevity, and comfort. Adjuvant therapies include nonopioids that confer analgesic effects in certain medical conditions but primarily treat conditions that do not involve pain. Nonopioid medications (over-the-counter agents) are useful in the management of mild to moderate pain, and their continuation through step 3 of the WHO ladder is an option after weighing a drug's risks and benefits in individual patients. Symptomatic treatment of severe cancer pain should begin with an opioid, regardless of the mechanism of the pain. They are very effective analgesics, titrate easily, and offer a favorable risk/benefit ratio. Cancer pain remains inadequately controlled despite the diagnostic and therapeutic means of ensuring that patients feel comfortable during their illness. Therefore, all practitioners need to make control of cancer pain a professional duty, even if they can only use the most basic and least expensive analgesic medications, such as morphine, codeine, and acetaminophen, to reduce human suffering.

No relief in sight: postgraduate training in pain management

This study investigated training in pain management in postgraduate medical education programs. A mail survey of program directors was conducted, evaluating the format of training in pain management and the self-assessed adequacy of the training. The response rate was 70%, with 188 total respondents. It included all programs in a large Midwestern state, representing most specialties. Just over half of all programs offered any formal training in pain management, and even fewer required it. Less than one quarter required a clinical component to such training. Nonetheless, an overwhelming majority of program directors (85%) rated their training as adequate or excellent. Improvements are clearly needed in postgraduate training in pain management, and external incentives, such as requirements in the accreditation process, will be needed.

End-of-life care for the hospitalized patient

The majority of Americans die in hospitals where shortcomings in end-of-life care are endemic. Patients often die alone, in pain, their wishes unheeded by physicians. Hospitalists can improve end-of-life care in hospitals dramatically. Hospitalists must relieve symptoms, such as pain, dyspnea, nausea, vomiting, delirium, and depression; communicate clearly; and provide support to patients and families. Hospitalists can increase the number and the timeliness of hospice referrals, allowing more patients to die at home. Finally, physicians must attend to their own sense of grief and loss to avoid burnout and to continue to reap the rewards end-of-life care provides.

Pain attitudes and knowledge among RNs, pharmacists, and physicians on an inpatient oncology service

Patients with cancer often experience pain, yet studies continue to document inadequate and inappropriate assessment and management of cancer-related pain. This study aimed to evaluate the attitudes and knowledge of inpatient oncology healthcare providers toward pain management by surveying nurses, pharmacists, and physicians working on the inpatient oncology units at an academic medical center. Healthcare providers generally reported positive attitudes toward pain management but were deficient in their knowledge of pain management. The authors suggest that pharmacists become more integral members of palliative care teams and actively participate in rounds. A need exists for educational programs in pain management for healthcare providers, especially for those who do not routinely care for patients with cancer.

Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure

BACKGROUND

Symptoms are a central component of health status; however, little is known about the full range and trajectory of symptoms experienced by persons with chronic diseases other than cancer.

METHODS

Observational cohort study with interviews performed at least every 4 months for up to 2 years among community-dwelling persons 60 years or older with chronic obstructive pulmonary disease (COPD) or heart failure (HF). Seven symptoms rated as absent, mild, moderate, or severe were assessed at each interview.

RESULTS

Among the 79 participants with COPD, at least 50% reported shortness of breath, physical discomfort, fatigue, and problems with appetite and anxiety. Among the 59 participants with HF, at least 50% reported physical discomfort, fatigue, and problems with appetite at both their initial and final interviews. Both disease-specific and non-disease-specific symptoms increased in severity over time. The prevalence of individual symptoms did not differ according to whether the participants lived or died.

CONCLUSIONS

As a potentially modifiable contributor to poor health status, the high symptom burden among older persons with COPD and HF represents a large unmet need for improved symptom assessment and treatment. This need may not be met by current disease management guidelines, which focus on a small number of symptoms except for patients at the end of life.

Palliative care in orthopaedic surgical oncology

Hundreds of thousands of Americans are affected every year by skeletal complications of oncologic disease. Recent developments in medical oncology, radiation oncology and radiology, particularly with respect to the use of bisphosphonate medication and radiofrequency techniques, have served to greatly lessen the morbidity associated with metastatic skeletal disease. Similarly, there has been significant advancement in the field of orthopaedic oncology in the areas of internal fixation, endoprosthetic implant design, and minimally invasive kyphoplasty technology. Given the palliative intent of intervention in this patient population, the goal of treatment of skeletal metastases must be optimization of limb function and ultimately, quality of life.

Assessment tools for the evaluation of pain in the oncology patient

The control of cancer pain is an essential goal in the care of patients with cancer. Inadequate pain assessment by health care providers is a major risk factor for undertreatment of pain. Repeated and accurate pain assessment is required for optimal pain management. Pain assessment tools such as simple rating scales and short pain questionnaires can facilitate routine measurement of cancer-related pain in clinical and research settings. In addition to measuring pain intensity, it is important to determine the impact of pain on patients' function, mood, and quality of life. Developmental issues must be considered when assessing the pain of children and elderly individuals with cancer. Novel technologies may be used to improve accurate and timely pain measurement.

Medications of abuse in pain management

PURPOSE OF REVIEW

Chronic pain leads to a reduction in the quality of life for those who suffer it. Due also to high medical costs and lost productivity, chronic pain is a significant burden on society. One contributor to the burden of pain is the fear that medications used in pain management produce dependency, leading to diversion and addiction. Certain medications used in practice, although not abused by the patient, seem to be favored and these are frequently reported to be used recreationally by the nonpatient population. This report identifies medications that most frequently present a problem in pain practices, why they are a problem, and possible alternatives to their use.

RECENT FINDINGS

Problem medications used in analgesic regimens tend to be those that have rapid onset due to their lipophilic nature or route of administration, short duration, and a sedating or energizing effect. These medications are generally more affordable than alternatives with less abuse potential. These medications are more often covered by insurance and more frequently prescribed. Changes in prescribing habits have resulted in predictable shifts in abuse.

SUMMARY

Addiction and diversion of prescription medications is a multidimensional problem. Its multifactorial solution will require efforts at many regulatory levels.

Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer

The growing interest in the psychological morbidity of patients with cancer has been the major reason for conducting this study. The measurements used were the Beck Depression Inventory, the Beck Hopelessness Scale, the Mini Mental State Examination, the Greek Brief Pain Inventory, and the Spiritual Involvement and Beliefs Scale. The analysis was conducted in 82 patients with advanced cancer. Significant associations were found between pain interference in "mood" and in "enjoyment of life" and hopelessness, as well as between worse pain and pain interference items with depression and cognitive status. Significant correlations were found between hopelessness, depression, and cognitive condition. These findings demonstrate the physical, psychological, and cognitive aspects of patients with cancer.

Pain management in hospitalized cancer patients: a systematic review

PURPOSE

To assist cancer centers in improving pain management, we conducted a systematic review of institutional interventions designed to improve the assessment and treatment of pain in hospitalized cancer patients.

METHODS

We performed a MEDLINE search for all English-language articles published from January 1966 through February 2006 using the medical subject headings terms of pain or pain measurement and outcome assessment (health care) or quality assurance (health care). Selected bibliographies were also searched. Studies were reviewed if they included clinical interventions directed at improving the treatment of cancer pain across an institution or nursing unit. Meta-analyses and randomized controlled trials or other controlled studies were included where possible. If no such trials were identified, then the best evidence available from studies with other designs was included.

RESULTS

Five interventions were identified. These interventions included professional and patient education, instituting regular pain assessment (pain as a vital sign), audit of pain results and feedback to clinical staff, computerized decisional support systems, and specialist-level pain consultation services. Most studies were small in size and used quasiexperimental pre-post test designs. Successes were reported in increasing patient satisfaction, increasing documentation of pain intensity, and improving nurses' knowledge and attitudes. No study reported successful interventions that consistently improved patients' pain severity.

CONCLUSION

Although professional knowledge and attitudes about pain and nursing pain assessment rates have been shown to be improvable, no systematic, hospital-wide intervention has yet to be associated with improvement in pain severity. Future research on the development of new interventions, perhaps targeted specifically at physicians, is urgently needed.

Palliation and supportive care in radiation medicine

The treatment of bone metastases represents a paradigm for evaluating palliative care in terms of symptom relief, toxicities of therapy, and the financial burden to the patient, caregivers, and society. Despite enormous expenditures to treat metastases, patients continue to sustain symptoms of the disease, and uninterrupted aggressive therapies are pursued until death that incur toxicity in approximately 25% of patients. This approach is inconsistent with the goals of palliative care, which should efficiently provide comfort using antineoplastic therapies or supportive care approaches to the patient with the fewest treatment-related side effects, recognizing that the patient will die of the disease.The development of therapies such as bisphosphonates is important in advancing options for palliative care; however, clinical trials demonstrating the efficacy of bisphosphonates have not addressed important issues for clinical practice. The primary study endpoints should primarily address pertinent patient outcomes such as pain relief rather than asymptomatic radiographic findings. These studies should define clear indications of when to start and stop the therapy, the appropriate patient populations to receive the therapy, and the cost effectiveness of the treatment relative to other available therapies such as radiation. Cost-utility analyses, which account for a broader domain of cost effectiveness, need to be performed as part of clinical trials, especially for palliative care endpoints. Clinical trials that include these criteria are critical to future practice guideline development. As health care resources continue to become more limited, the criteria for care must be better defined to avoid administration of therapy with limited benefit. Leadership must come from the specialty as clinical trials and clinical practice increasingly interface with health care policy. Goals of therapy must remain clear for the benefit of the individual and all patients.

Colorado Revised Statutes in Support of Palliative Care Limiting Criminal Liability

Colorado's manslaughter law classifies assisted suicide as a felony. Because terminal patients are close to life's end, death while being treated is inevitable, therefore, there was concern among physicians that the fear of prosecution continued to prevent adequate pain relief for terminal patients. A group of physicians and concerned citizens set out to amend Colorado Revised Statutes to reassure doctors and others prescribing or administering palliative care for terminal patients that they would not be indicted under the law prohibiting assisted suicide. The 2006 Assembly passed the amendment (quoted in the text) with virtually no opposition in either house and it was signed into law by the governor, effective July 6, 2006. Note that in addition to allowing appropriate pain management, it specifically emphasizes that it does not permit assisted suicide.

Psychological distress of patients with advanced cancer: influence and contribution of pain severity and pain interference

The growing interest in the psychological distress and the multidimensionality of pain in patients with cancer has been the major reason for the conduction of this study. The aims were to evaluate psychological distress and pain in patients with advanced cancer and the impact of pain severity and pain interference dimensions on the anxiety and depression. One hundred twenty patients with advanced cancer were surveyed at a palliative care unit in Athens, Greece. Greek versions of the Hospital Anxiety and Depression (G-HAD) scale and the Brief Pain Inventory were administered. Information concerning patients' treatment received was acquired from the medical records, whereas physicians recorded their clinical condition. The analysis showed that significant associations were found between pain interference to "mood" and HAD-A (anxiety) (r = 0.252, P = .005) and between pain interference to "relations with other people" and HAD-A (r = 0.474, P < .0005). Multiple regression analyses showed that "average pain" (P < .05), pain interference to "walking ability" (P < .05), "normal work" (P < .05, and "relations with other people" are significant predictors of HAD-anxiety (HAD-A) (P < .0005), explaining 46.2% of total variance. For depression (HAD-D), the Greek version of the Brief Pain Inventory dimension that serve as predictor is "enjoyment of life," as well as the demographic variables of "age," and "gender" (P < .05), explaining 22.2% of variance. Moreover, a further analysis of the pain severity and pain interference scales showed that they differentiate the anxiety of the patients with cancer. In this patient sample, pain interference and, to a lesser extent, pain severity was significantly associated with psychological distress (anxiety and pain), whereas pain interference to "walking ability," "normal work," and "relations with other people" was found to be more prominent and troublesome to patients' anxiety than that to patients' depression.

Multidisciplinary management of cancer pain: a longitudinal retrospective study on a cohort of end-stage cancer patients

The epidemiology of cancer pain and the outcomes associated with pain treatments were investigated through a retrospective survey of 772 patients with advanced cancer. The cumulative prevalence of pain was 87%, including all types of cancer. Mean duration of pain was 6.9+/-8.1 months. The prevalence of pain was 28%, 46%, 67%, 75%, and 79% at 6 months, 3 months, 1 month, 1 week, and 1 day before the time of death, respectively. The so-called "strong" opioids had been used in 85% of the 669 patients with pain. Seventy-nine percent of patients with pain received nonsurgical antineoplastic treatment for pain control. No more than 11% of patients ultimately experienced substantial pain in the last 6 months of life (defined as pain score 5-10 on a 0-10 numeric rating scale). We conclude that the application of a multidisciplinary approach to pain management offers effective pain control for most patients with advanced cancer.

Brief cognitive-behavioral audiotape interventions for cancer-related pain: Immediate but not long-term effectiveness

BACKGROUND

Few studies have evaluated cognitive-behavioral interventions as an adjunct treatment for chronic cancer-related pain. A randomized clinical trial was performed evaluating the efficacy of 3 brief cognitive-behavioral techniques: relaxation, distraction, and positive mood interventions.

METHODS

Fifty-seven patients with chronic cancer-related pain taking opioid medications were randomly assigned to either the relaxation, distraction, positive mood, or waiting-list control group. The patients in the 3 intervention groups received audiotapes of the cognitive-behavioral technique and were asked to practice regularly at home. The tapes were supplemented with written instructions and follow-up telephone calls.

RESULTS

Patients in the relaxation and distraction groups reported significantly reduced pain intensity immediately after listening to the tapes. The pain reduction was not maintained, however. At the 2-week follow-up assessment, no significant differences in pain intensity or interference were found among the treatment groups. The groups also did not differ with regard to secondary outcome measures assessing quality of life, mood, self-efficacy, and other symptoms. The results of qualitative interviews indicated that patients often had difficulty focusing on the audiotapes and preferred their own methods of pain reduction.

CONCLUSIONS

Brief relaxation and distraction audiotape interventions produced immediate pain reductions but not longer-term pain relief. Additional research with a more individualized intervention is needed to evaluate cognitive-behavioral interventions for cancer pain control.