Side effects of analgesia may significantly reduce quality of life in symptomatic multiple myeloma: a cross-sectional prevalence study

An evidence-based breathing exercise intervention for chronic pain management in breast cancer survivors: A phase II randomized controlled trial

OBJECTIVE

Explore the preliminary effects of a breathing exercise (BE) intervention on chronic pain among breast cancer survivors.

METHODS

This two-parallel-arm, open-label pilot randomized controlled trial recruited 72 breast cancer survivors who were randomly allocated to either the control or intervention group (n = 36 each). Both groups received usual care and a pain information booklet, while the intervention group received 4 weeks of additional BE. The primary clinical outcome was measured using the Brief Pain Inventory (BPI), with secondary clinical outcomes measured by the Hospital Anxiety and Depression Scale (HADS), Quality of Life Patient/Cancer Survivor Version in Chinese (QOLCSV-C), and Functional Assessment of Cancer Therapy- Breast (FACT-B) immediately post-intervention and at 4-week follow-up. Both adjusted and unadjusted Generalized Estimating Equation models were utilized to assess the BE's potential effects, with safety assessed through participant self-report.

RESULTS

Sixty-eight participants completed the study. Statistical significance was observed in BPI in both adjusted and unadjusted models at post-intervention and follow-up (p < 0.05). BE demonstrated positive effects on anxiety, depression and quality of life improvement across all measures and timepoints in both adjusted and unadjusted models (p < 0.05). The effect sizes were smaller in the adjusted model. Three mild transient discomforts were reported associated with BE practice including dizziness, tiredness and yawning, without requirement of medical treatment. No severe adverse events occurred.

CONCLUSION

This BE intervention appears effective in alleviating chronic pain, anxiety and depression, and improving quality of life for breast cancer survivors. Fully powered large-scale studies are required to confirm its effects.

Efficacy of acupuncture on cancer pain: A systematic review and meta-analysis

BACKGROUND

Pain associated with cancer is one of the greatest causes of reduced quality of life in patients. Acupuncture is one of the treatments used to address this issue, with the great advantage of having little or no side effects, especially when compared with pharmacological pain-killers.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the current evidence regarding the efficacy of acupuncture for cancer pain.

SEARCH STRATEGY

Six electronic databases (PubMed, EBSCO, Cochrane Library, Scielo, b-On and Scopus) were searched for relevant articles about pain relief in cancer patients from their beginning until 2022 using MeSH terms such as "acupuncture," "electroacupuncture," "ear acupuncture," "acupuncture analgesia," ''oncological pain," and "cancer pain."

INCLUSION CRITERIA

Studies included were randomized controlled trials (RCTs) where acupuncture was compared with no treatment, placebo acupuncture or usual care.

DATA EXTRACTION AND ANALYSIS

Three independent reviewers participated in data extraction and evaluation of risk of bias, and a meta-analysis was conducted. The primary outcome was pain intensity, measured with the visual analog scale, numeric rating scale, or brief pain inventory. Secondary outcomes also assessed were quality of life, functionality, xerostomia, pain interference, and analgesic consumption. Results were expressed as standardized mean difference (SMD) with 95% confidence interval (CI).

RESULTS

Sixteen RCTs with a total of 1124 participants were included in the meta-analysis, with the majority of the studies presenting a low or unclear risk of bias. Acupuncture was more effective in reducing pain than no treatment (SMD = -0.90, 95 % CI [-1.68, -0.12]), sham acupuncture (SMD = -1.10, 95 % CI [-1.59, -0.61]) or usual care (SMD = -1.16, 95 % CI [-1.38, -0.93]).

CONCLUSION

The results of this study suggest that acupuncture may be an effective intervention to reduce pain associated with cancer. Despite some limitations due to the low quality and small sample size of some included studies, as well as the different types and stages of cancer, acupuncture might provide an effective and safe treatment to reduce cancer pain. Please cite this article as: Faria M, Teixeira M, Pinto MJ, Sargento P. Efficacy of acupuncture on cancer pain: A systematic review and meta-analysis. J Integr Med. 2024; 22(3): 235-244.

A Qualitative Study of the Pain Experience of Black Individuals With Cancer Taking Long-Acting Opioids

BACKGROUND

Little is known about the experience of Black individuals with cancer taking long-acting opioids for cancer pain.

OBJECTIVE

This study aimed to describe the day-to-day experience of living with pain and the experiences of taking opioids for pain management among Black individuals with cancer prescribed with long-acting opioids.

METHODS

This qualitative descriptive study was part of a larger investigation focused on opioid adherence. Participants (N = 14) were interviewed using a semistructured interview guide. Analysis followed conventional content analysis and constant comparison approaches. Sociodemographics, clinical information, and the Brief Pain Inventory form were collected.

RESULTS

The majority of the subsample was female (64.3%), not married (78.6%), and with a median age of 52.5 years. Participants were taking either MS Contin (85.7%) or OxyContin (14.3%). The Brief Pain Inventory median "average" pain severity scores and pain interference scores were 5.1/10 (interquartile range [IQR] = 6.1) and 3.5/10 (IQR = 6.7), respectively. Three themes are reported from the analyses: desire for control, barriers to pain relief, and isolation versus connectedness.

CONCLUSION

Our findings highlight the persistent nature of moderate to severe cancer pain and how pain and its treatment interfere with patients' lives. The findings describe ways that patients learn to manage and exert control over pain despite conflicting attitudes and dealing with opioid stigma.

IMPLICATION FOR PRACTICE

Clinicians should partner with patients with cancer, especially people of color, who may experience intersecting stigmas related to their cancer pain and opioid use, to best provide an individualized and culturally sensitive pain treatment plan.

Virtual Reality for Pain and Anxiety Management in Cardiac Surgery and Interventional Cardiology

Pain and anxiety are common in patients undergoing cardiac surgery and percutaneous cardiac interventions. Virtual reality (VR) is an emerging non-pharmacological tool for pain and anxiety management. However, its application around cardiac procedures remains relatively unexplored. In this review, we perform a targeted non-systematic literature review to assess the current state-of-the-art of VR for pain and anxiety management in patients undergoing cardiac procedures. Contexts of interest were preprocedural, periprocedural, and postprocedural applications. Existing trials show inconsistent results. The majority of studies in the preprocedural (7 studies, n = 302), periprocedural (1 study, n = 99), and postprocedural stage (4 studies, n = 214) demonstrate significant reduction of pain and anxiety through VR distraction therapy or VR patient education. However, larger-scale trials (2 preprocedural studies [n = 233], 1 periprocedural study [n = 32], 2 postprocedural studies [n = 300]) report no effect. Current literature on effectiveness of VR for pain and anxiety management in cardiac surgery and interventional cardiology remains inconclusive.

The role of surgery in relieving calcified shunt site-related pain in patients with functioning VP shunt

PURPOSE

Shunt calcification is a known late sequela of ventriculoperitoneal (VP) shunt insertion and is associated with shunt malfunction. However, in some patients, while shunt functionality is preserved despite calcification of the catheters, they experience nociceptive symptoms. In this paper, the authors present their surgical experience in managing patients with a functional VP shunt and experiencing pain secondary to shunt calcification.

METHODS

We analysed outcomes of patients presenting with pain at the level of a calcified shunt who underwent surgical untethering of the calcified catheter from the soft tissues. This procedure was commenced by the senior author in 2015. Patients were collected prospectively from the databases of two institutions. Evidence of shunt calcification was confirmed on neuroimaging.

RESULTS

Seven patients, two male and five female, were included. The mean age at untethering was 13.5 years. The mean time interval between primary shunt surgery and symptom onset was 12 years (range 6-16 years). The commonest site of tethering was the neck (50%) followed by abdomen and chest (both 25%). Six patients underwent untethering of the catheter from soft tissues. One patient had removal of a redundant segment of calcified shunt left in situ during a previous revision. All patients experienced pain relief following shunt untethering.

CONCLUSION

Untethering of calcified VP shunt catheters from soft tissue can be considered an effective treatment of shunt site pain and offered to patients presenting with a functional VP shunt.

Characterizing the Patient Journey in Multiple Myeloma: A Patient Perspective (Preprint)

Background

The patient experience of multiple myeloma (MM) is multifaceted and varies substantially between individuals. Current published information on the patient perspective and treatment of MM is limited, making it difficult to gain insights into patient needs regarding the condition.

Objective

In this review, a combined research method approach (ie, the review of published literature and social media posts) was undertaken to provide insight into patients’ perspectives on the burden and treatment of MM, the impact of the COVID-19 pandemic, and the impact of MM on caregivers of patients with MM.

Methods

Targeted searches of PubMed and PsycINFO were conducted from November 16, 2010, to November 16, 2020; in parallel, patient-reported information derived from social media posts from 6 patient advocacy websites and YouTube were searched. The review of patient advocacy websites and YouTube targeted patient-reported information from patients with a self-reported diagnosis of MM who discussed their experience of MM and its treatments.

Results

A total of 27 articles and 138 posts were included (patient-reported information included data from 76 individuals), and results from both sources showed that patients experienced a variety of symptoms and treatment side effects, including neuropathy, fatigue, nausea, and back pain. These can affect areas of health-related quality of life (HRQOL), including physical functioning; emotional, psychological, and social well-being; the ability to work; and relationships. Patients valued involvement in treatment decision-making, and both the patient-reported information and the literature indicated that efficacy and tolerability strongly influence treatment decision-making. For patients, caregivers, and physicians, the preference for treatments was strongest when associated with increased survival. Caregivers can struggle to balance care responsibilities and jobs, and their HRQOL is affected in several areas, including emotional-, role-, social-, and work-related aspects of life. The COVID-19 pandemic has challenged patients’ ability to manage MM because of limited hospital access and restrictions that negatively affected their lives, psychological well-being, and HRQOL. Unmet patient needs identified in the literature and patient-reported information were for more productive appointments with health care professionals, better-tolerated therapies, and more support for themselves and their caregivers.

Conclusions

The combination of published literature and patient-reported information provides valuable and rich details on patient experiences and perceptions of MM and its treatment. The data highlighted that patients’ HRQOL is impeded not only by the disease but also by treatment-related side effects. Patients in the literature and patient-reported information showed a strong preference for treatments that prolong life, and patients appeared to value participation in treatment decisions. However, there remain unmet needs and areas for further research, including treatment, caregiver burden, and how to conduct appointments with health care professionals. This may help improve the understanding of the journey of patients with MM.

Plain Language Summary

Multiple Myeloma (MM) is the second most common cancer that affects blood cells. In this study, researchers wanted to know patients’ views on the effects of MM and the treatments they received. Researchers also looked at the impact of the COVID-19 pandemic on patients’ treatment and the impact of MM on caregivers. To this end, the researchers reviewed information from 27 published studies and 138 social media posts by 76 patients with MM. Patients commonly reported nerve pain, tiredness, feeling sick, and back pain caused by MM and the treatments they received. The effects of MM and treatments affected patients’ physical function; emotional, psychological, and social well-being; ability to work; and relationships. The researchers found that patients wanted to be involved in decisions related to their treatment. The effectiveness against MM and known negative effects strongly influenced the choice of treatments for patients. Increased survival was the strongest factor in the choice of treatment for patients, caregivers, and doctors. Researchers found that the emotional-, role-, social-, and work-related aspects of caregivers’ lives were affected by caring for patients with MM. The COVID-19 pandemic also affected the ability of patients to manage their MM because of limited hospital access and the effects of restrictions that impacted their lives and psychological well-being. Finally, the researchers identified some areas requiring improvement, including unproductive appointments with health care professionals, the need for treatments with fewer negative effects, and more support for patients with MM and their caregivers. This information may be useful to improve and understand the experience of patients with MM.

Antinociceptive effects of a hydroethanolic stem bark extract of Burkea africana

Introduction

Pain is a major symptom of many clinical disorders and its relief has long been a concern for individuals across the globe. There is therefore an unmet need to search for new efficacious agents for the effective management of pain. The stem bark of the savanna tree Burkea africana (Hook) (Family: Leguminosae) is used in the Ghanaian traditional medicine for the treatment and management of various pain-related diseases.

Method

An acute oral toxicity study in mice was conducted by administering BAE (50–5000 mg kg⁻¹p.o.). Antinociceptive effect of BAE (50–1000 mg kg⁻¹p.o.) was evaluated using the acetic acid-induced abdominal constriction, acidic saline-induced muscle pain and formalin-induced pain models. The antinociceptive mechanism of BAE was also assessed using the formalin-induced pain model.

Results

The LD₅₀ of BAE was thus estimated to be above 5000 mg kg⁻¹ since none of the animals died in the acute toxicity study. Pretreatment with BAE (50–1000 mg kg⁻¹p.o.) significantly reduced the number of writhes after acetic-acid administration compared to the vehicle treated group. BAE also produced a significant and dose-dependent reversal of mechanical hyperalgesia induced by the injection of the acidic saline. Administration of BAE was able to significantly suppress both phases of the formalin test. This effect of the extract was however reversed by pretreatment with naloxone and granisetron.

Conclusions

BAE exhibits antinociceptive effects in rodent pain models with a possible involvement of 5-HT₃ receptors and opioidergic pathways.

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Burkea africana stem bark extract.

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Acetic acid-induced abdominal constriction.

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Acidic saline-induced muscle pain.

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Formalin-induced pain.

Characterizing Pain Experiences: African American Patients With Multiple Myeloma Taking Around-the-Clock Opioids

BACKGROUND

Despite known disparities by race, studies to date have not focused on pain characterization among African American patients with multiple myeloma.

OBJECTIVES

This study aimed to characterize the pain experience, beliefs about pain and pain control, and additional symptoms among African American patients with multiple myeloma taking around-the-clock opioids.

METHODS

This study employed secondary analysis of baseline data from a completed longitudinal study of opioid adherence. Descriptive statistics were used to characterize the sample, pain experience, beliefs regarding pain and pain control, and related symptoms.

FINDINGS

Participants (N = 34) experienced everyday pain and additional symptoms, and half experienced depression. Pain management barriers included dislike of pills, fear of addiction, and bothersome side effects from pain and medication. Additional larger studies can incorporate multilevel factors contributing to high symptom burden.

Patients' experiences of living with multiple myeloma

BACKGROUND

Multiple myeloma is a B-cell haematological malignancy characterised by uncontrolled plasma cell proliferation. Patients with the disease often undergo periods of remission followed by multiple relapses. Understanding patients' experience of living with this chronic condition is key to providing effective patient-centred care.

AIMS

This qualitative descriptive study explored the experiences of patients living with multiple myeloma.

METHODS

A purposive sample of 6 patients was used. Data were collected using in-depth unstructured interviews and analysed using Colaizzi's (1978) thematic framework.

FINDINGS

The emergent themes included: information and communication; treatment and symptom burden; the importance of support from family/friends and professional help; psychosocial elements of survivorship.

CONCLUSION

The complex symptoms of multiple myeloma need to be treated holistically to manage the unpredictable nature of this disease.

Utilization of pain medications and its effect on quality of life, health care utilization and associated costs in individuals with chronic back pain

Purpose

Pain medications are widely prescribed to treat chronic back pain (CBP). However, the effect of using pain medications on individuals with CBP has received very little attention.

Objective

The aim of this study was to determine the patterns of pharmacological treatment in the population with CBP and assess its impact on quality of life, health care utilization and associated costs in USA.

Patients and methods

Retrospective, cross-sectional data obtained from the Medical Expenditure Panel Survey (MEPS), from 2011 to 2015, were utilized for this study. Pharmacological treatment for CBP was categorized into three mutually exclusive categories: 1) opioids only, 2) nonsteroidal anti-inflammatory drugs (NSAIDs) only, 3) opioids and NSAIDs (combination). The effect of the use of these treatments was also evaluated.

Results

A total of 5,203 individuals with CBP were identified. Of these, 2,568 (49.4%) utilized opioids only, 1,448 (27.8%) utilized NSAIDs only and 1,187 (22.8%) utilized both pain medications. Lower health-related quality-of-life scores on both the Short Form Health Survey-12 version 2 (SF-12v2) components (mental component summary score: 44.42 vs 46.67, P<0.001; physical component summary score: 35.34 vs 40.11, P<0.001) were observed for the opioid-only group compared to the NSAID-only group. In addition, individuals utilizing opioids only had greater utilization of inpatient services, office-based services, outpatient services and emergency room visits along with higher related health care costs.

Conclusion

Future researchers need to investigate the long-term risks and benefits of opioids, and policy makers should evaluate the prescribing guidelines to aim for a more patient-centered care.

Standards for the management of cancer-related pain across Europe-A position paper from the EFIC Task Force on Cancer Pain

BACKGROUND AND OBJECTIVE

Pain is a common symptom in patients who survive cancer and in those who live with progressive advanced disease. Evidence from meta-analyses suggests that pain remains poorly controlled for a large proportion of patients; barriers to good management include poor assessment of pain, inadequate support for patient self-management and late or inadequate access to strong opioid analgesia in those with advanced disease.

METHODS

The European Pain Federation (EFIC) established a Task Force in 2017 which convened a European group of experts, drawn from a diverse range of relevant clinical disciplines, to prepare a position paper on appropriate standards for the management of cancer-related pain. The expert panel reviewed the available literature and made recommendations using the GRADE system to combine quality of evidence with strength of recommendation. The panel took into account the desirable and undesirable effects of the management recommendation, including the cost and inconvenience of each when deciding the recommendation.

RESULTS AND CONCLUSIONS

The 10 standards presented are aimed to improve cancer pain management and reduce variation in practice across Europe. The Task Force believes that adoption of these standards by all 37 countries will promote the quality of care of patients with cancer-related pain and reduce unnecessary suffering.

SIGNIFICANCE

Pain affects up to 40% of cancer survivors and affects at least 66% of patients with advanced progressive disease, many of whom experience poor pain control. These 10 standards are aimed to improve cancer pain management, promote the quality of care of patients and reduce variation across Europe.

'It is a journey of discovery': living with myeloma

PURPOSE

Although multiple myeloma (MM) is incurable, many people live with the disease for a number of years. Thus, understanding the effect of the disease and its therapies on the lives of those with MM is important. This qualitative study explores the impact of MM and its treatments on patients.

METHODS

People with newly diagnosed or relapsed MM were recruited from a tertiary institution. Participants were interviewed using a semi-structured approach. The questions were designed to obtain insight into how participants viewed their diagnosis, treatment, and symptoms and how these had impacted on their lives. Data were analysed using a phenomenological approach.

RESULTS

Fifteen people with MM with a mean age of 62 were recruited. Participants' mean time since diagnosis was 2.7 years and they had received a mean of 1.7 lines of therapy. The first major theme to emerge was lifestyle changes. Interviewees described MM as causing changes to all aspects of their lives, including substantial functional changes, as well as changes to employment, relationships, and their sense of self. The second major theme was 'adjust, adjust, adjust'. Alongside challenging life changes, participants described a range of practical, psychological, and relational approaches to adjusting to living with MM.

CONCLUSION

This study highlights the importance of and the need for improved supportive care in patients with MM, ideally with a multidisciplinary approach. It also identifies the potential for further investigation of patient approaches to adjusting to MM and development of support strategies.

The Effect of Acupressure on Pain in Cancer Patients With Bone Metastasis: A Nonrandomized Controlled Trial

BACKGROUND

Pain is a serious and common problem in bone metastases. For this purpose, complementary and supportive practices are also applied along with medical treatment. This study was conducted for the purpose of evaluating the effect of acupressure on pain in cancer patients with bone metastasis.

METHODS

The study was conducted in a nonrandomized controlled trial with patients who applied to the radiotherapy unit of an oncology hospital. The data of the study were collected by using a questionnaire and the Visual Analog Scale. A total of 8 acupressure sessions, which lasted for approximately 10 minutes each (with warming and acupressure periods), was applied to the intervention group. The data were analyzed by using χ2 test, paired t test, and Pearson's correlation coefficient.

RESULTS

It was determined that the pain mean score of the intervention group was 7.6 ± 1.9 before the acupressure and decreased to 6.8 ± 1.9 after the acupressure and this result was statistically significant. On the other hand, no significant difference was determined in the pain mean score of the control group.

CONCLUSIONS

Acupressure is applicable for cancer patients with bone metastasis by nursing staff after receiving brief training and may make a difference in relieving pain of the patients. Further well-designed trials should be conducted.

Defining a set of standardised outcome measures for newly diagnosed patients with multiple myeloma using the Delphi consensus method: the IMPORTA project

OBJECTIVE

To define a standard set of outcomes and the most appropriate instruments to measure them for managing newly diagnosed patients with multiple myeloma (MM).

METHODS

A literature review and five discussion groups facilitated the design of two-round Delphi questionnaire. Delphi panellists (haematologists, hospital pharmacists and patients) were identified by the scientific committee, the Spanish Program of Haematology Treatments Foundation, the Spanish Society of Hospital Pharmacies and the Spanish Community of Patients with MM. Panellist's perception about outcomes' suitability and feasibility of use was assessed on a seven-point Likert scale. Consensus was reached when at least 75% of the respondents reached agreement or disagreement. A scientific committee led the project.

RESULTS

Fifty-one and 45 panellists participated in the first and second Delphi rounds, respectively. Consensus was reached to use overall survival, progression-free survival, minimal residual disease and treatment response to assess survival and disease control. Panellists agreed to measure health-related quality of life, pain, performance status, fatigue, psychosocial status, symptoms, self-perception on body image, sexuality and preferences/satisfaction. However, panellist did not reach consensus about the feasibility of assessing in routine practice psychosocial status, symptoms, self-perception on body image and sexuality. Consensus was reached to collect patient-reported outcomes through the European Organisation for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) Core questionnaire 30 (C30), three items from EORTC-QLQ-Multiple Myeloma (MY20) and EORTC-QLQ-Breast Cancer (BR23), pain Visual Analogue Scale, Morisky-Green and ad hoc questions about patients' preferences/satisfaction.

CONCLUSIONS

A consensual standard set of outcomes for managing newly diagnosed patients with MM has been defined. The feasibility of its implementation in routine practice will be assessed in a future pilot study.

Guidelines for screening and management of late and long-term consequences of myeloma and its treatment

A growing population of long-term survivors of myeloma is now accumulating the 'late effects' not only of myeloma itself, but also of several lines of treatment given throughout the course of the disease. It is thus important to recognise the cumulative burden of the disease and treatment-related toxicity in both the stable and active phases of myeloma, some of which is unlikely to be detected by routine monitoring. We summarise here the evidence for the key late effects in long-term survivors of myeloma, including physical and psychosocial consequences (in Parts 1 and 2 respectively), and recommend the use of late-effects screening protocols in detection and intervention. The early recognition of late effects and effective management strategies should lead to an improvement in the management of myeloma patients, although evidence in this area is currently limited and further research is warranted.

Surgical management of spinal fractures and neurological involvement in patients with myeloma

INTRODUCTION

Multiple Myeloma (MM) typically involves the spine and causes bone pain, pathological fractures and spinal cord compression with possible consequent neurological deficits. This retrospective study reports the results of surgery on a selected population of patients who underwent surgery for symptomatic spinal myeloma.

MATERIALS AND METHODS

A total of 26 patients who underwent surgery for spinal myeloma with neurological involvement were studied retrospectively. Neurological evaluation was performed according to the Frankel grade. Characteristics of this population, reconstructive techniques and surgery-related complications were reviewed.

RESULTS

The tumours involved the thoracic spine in 13 patients, the lumbar spine in 10 patients, and the cervical spine in three patients. The most common approach was a posterior-only approach (70%), followed by a staged, combined approach (20%), and an anterior-only approach (10%). The mean postoperative survival time was 43 months (range: 8-60 months). A significant improvement in neurological function was observed in the study population after surgery (p=0.001). There were seven early postoperative complications, two late complications and five surgery-related complications.

DISCUSSION

Surgery in selected patients affected by spinal myeloma with neurological involvement is associated with good clinical outcomes and neurological recovery and an acceptable rate of complications. Neurological deficit and segmental instability can be treated sufficiently in most cases by the implementation of a posterior-only approach; however, the final treatment should, when possible, include adjuvant chemotherapy and radiotherapy and rigorous bracing.

Prevalence of symptoms in patients with multiple myeloma: a systematic review and meta-analysis

OBJECTIVES

Multiple myeloma (MM) is an incurable haematological disease. Due to novel agents, overall survival has improved in this group, yet there are no systematic reviews to understand the symptom profiles resulting from disease and treatment-related toxicities. We aimed to synthesise data on the prevalence of symptoms in patients with MM.

METHODS

A systematic database and grey literature search were conducted in six databases. Random-effects meta-analysis with inverse variance weighting to pool prevalence data was performed.

RESULTS

Thirty-six studies were included of which 34 studies (N = 3023) provided data for meta-analysis. Twenty-seven distinct symptoms were reported, with the majority of studies focusing on pain (n = 27), fatigue (n = 19) and problems with functioning (n = 15). The most prevalent symptoms were fatigue (98.8%, 95% CI 98.1-99.2%), pain (73%, 39.9-91.7), constipation (65.2%, 22.9-92.2) and tingling in the hands/feet with 53.4% (0.4-99.7). The most common problems were decreased physical functioning (98.9%, 98.2-99.3), decreased cognitive functioning (80.2%, 40-96.1) and financial difficulties (78.4%, 39.1-95.4). These problems were present in newly diagnosed to advanced disease stage.

CONCLUSIONS

Optimal quality of life and good symptom management in this incurable disease can only be achieved by routinely assessing symptoms throughout the disease trajectory.

Opioidergic effects on enteric and sensory nerves in the lower GI tract: basic mechanisms and clinical implications

Opioids are one of the most prescribed drug classes for treating acute pain. However, chronic use is often associated with tolerance as well as debilitating side effects, including nausea and dependence, which are mediated by the central nervous system, as well as constipation emerging from effects on the enteric nervous system. These gastrointestinal (GI) side effects limit the usefulness of opioids in treating pain in many patients. Understanding the mechanism(s) of action of opioids on the nervous system that shows clinical benefit as well as those that have unwanted effects is critical for the improvement of opioid drugs. The opioidergic system comprises three classical receptors (μ, δ, κ) and a nonclassical receptor (nociceptin), and each of these receptors is expressed to varying extents by the enteric and intestinal extrinsic sensory afferent nerves. The purpose of this review is to discuss the role that the opioidergic system has on enteric and extrinsic afferent nerves in the lower GI tract in health and diseases of the lower GI tract, particularly inflammatory bowel disease and irritable bowel syndrome, and the implications of opioid treatment on clinical outcomes. Consideration is also given to emerging developments in our understanding of the immune system as a novel source of endogenous opioids and the mechanisms underlying opioid tolerance, including the potential influence of opioid receptor splice variants and heteromeric complexes.

Reporting of adverse events for marketed drugs: Need for strengthening safety database

Pharmacovigilance is an evolving discipline in the Indian context. However, there is limited regulatory guidance for adverse event reporting outside the purview of clinical trials. There are number of deficiencies in the framework for adverse event reporting from the perspective of pharma industry, health-care professional and general public due to which adverse events for marketed drugs are highly underreported. This article discusses the need to strengthen national safety database by promoting and mandating reporting of adverse events by all the stakeholders.

Blinded Patient Preference for Morphine Compared to Placebo in the Setting of Chronic Refractory Breathlessness--An Exploratory Study

CONTEXT

Patients' preference for morphine therapy has received little attention in the setting of chronic refractory breathlessness. However, this is one important factor in considering longer term therapy.

OBJECTIVES

The aim of this secondary analysis was to explore blinded patient preference of morphine compared to placebo for this indication and to define any predictors of preference.

METHODS

Data were pooled from three randomized, double-blind, crossover, placebo-controlled studies of morphine (four days each) in chronic refractory breathlessness. Blinded patient preferences were chosen at the end of each study. A multivariable regression model was used to establish patient predictors of preference.

RESULTS

Sixty-five participants provided sufficient data (60 men; median age 74 years; heart failure 55%, chronic obstructive pulmonary disease 45%; median Eastern Cooperative Oncology Group performance status 2). Forty-three percent of participants preferred morphine (32% placebo and 25% no preference). Morphine preference and younger age were strongly associated: odds ratio = 0.85, 95% confidence interval 0.78-0.93; P < 0.001). There was also an inverse association between morphine preference and sedation (odds ratio = 0.77, 95% confidence interval 0.60-0.99; P < 0.05). An inverse association was also seen between nausea and morphine preference in the univariate model only (P < 0.05). No association was seen between morphine preference and breathlessness intensity, either at baseline or change from baseline.

CONCLUSION

Participants preferred morphine over placebo for the relief of chronic refractory breathlessness. Morphine offers clinically important improvement, but net benefit can be easily outweighed by side effects, reducing net benefits. Side effects require aggressive management to allow more patients to realize benefits.

Tapentadol prolonged release for patients with multiple myeloma suffering from moderate-to-severe cancer pain due to bone disease

Context

Myeloma bone disease (MBD) is a devastating complication of multiple myeloma that leads to severe pain.

Objectives

The aim of this study was to evaluate the efficacy and tolerability of tapentadol prolonged release (PR) in the management of patients with MBD suffering from moderate-to-severe cancer pain.

Methods

A 12-week prospective study was carried out in 25 opioid-naïve MBD patients. Patients initially received twice-daily doses of tapentadol PR 50 mg. Doses were then managed to maintain adequate relief or dose-limiting toxicity. The following parameters were recorded at weekly intervals for 4 weeks, and then at weeks 8 and 12: pain, opioid-related adverse effects, use of other analgesics, DN4 (Douleur Neuropathique 4) score. Quality of life (SF-36 [36-item short-form health survey]) was measured at baseline and at final evaluation.

Results

Of 25 patients, 22 completed the study. Pain intensity significantly decreased from baseline to all the week intervals (P<0.01). Quality of life significantly improved with respect to all SF-36 subscale parameters (P<0.01), and so did both the physical and mental status (P<0.01). Tapentadol PR significantly reduced DN4 mean value (P<0.01) and the number of patients with neuropathic component (DN4 ≥4) (P<0.01). After 8 weeks of treatment, all patients were negative for the DN4 score. Tapentadol PR was well tolerated, and the use of other analgesics was reduced during the study period.

Conclusion

Tapentadol PR started in doses of 100 mg/day was effective and well tolerated in opioid-naïve MBD patients with moderate-to-severe pain. Tapentadol PR can be considered a first-choice opioid in cancer patients suffering from mixed pain with a neuropathic component.

Optimizing quality of life in multiple myeloma patients: current options, challenges and recommendations

Multiple myeloma (MM) is a plasma cell neoplasm with a chronic disease course that primarily affects elderly individuals. The introduction of novel agents such as thalidomide, lenalidomide and bortezomib has significantly improved the outcome for MM patients, including the elderly. Quality of life in MM is influenced by disease-related symptoms, treatment-related toxicity and treatment response. In addition to conventional endpoints as response, quality of life should be carefully evaluated during each therapeutic phase. Caring for older adults with MM is particularly challenging because of the heterogeneity of aging and the presence of comorbidities and frailty, with a potential risk of over- or under-treatment. Moreover, elderly patients may sometimes prioritize maintaining quality of life above prolonging survival. A careful evaluation of comorbidities and a geriatric assessment can facilitate risk-stratification of elderly patients to identify the older population fit enough to tolerate standard drug dosing, and to detect the frail patients who need age-adapted treatment.