Clinical use of opioids for cancer pain

A real-world study of the quality of Outpatient Pain Management in patients with Cancer

PURPOSE

Up to 40% patients with cancer reporting pain may not receive optimal analgesia indicating inadequate treatment of pain. We examined the patterns of outpatient pain management in patients with cancer who reported pain.

METHODS

We used the National Ambulatory Medical Care Survey data for outpatient visits from 2006 to 2018 for patients with any cancer and reporting pain. The primary outcome was prescription of pain medications among these patients. We performed multinomial logistic regression to identify factors associated with analgesic prescriptions among patients with cancer who reported pain.

RESULTS

We captured an estimated total of 412 million outpatient visits of which 22 million visits dealt with patients with cancer reporting pain. An estimated total of 13.8 million (61.33%) patient visits had pain reported but were not prescribed any pain medications. 5.5 million (24.44%) patient visits had non-opioid analgesic prescription while opioid analgesics were prescribed during 3.2 million (14.22%) visits. Patients who were black, aged 45-64 years, residing in rural geographical areas, visiting medical subspecialty practices, and having cancers of the respiratory and digestive systems had higher odds of receiving opioid prescription.

CONCLUSIONS

As one of the largest pain management studies among patients with cancer in the outpatient setting, covering 412 million patient visits, our study shows that a significant proportion of patients with cancer who reported pain did not receive a prescription for analgesics suggesting a possibility of undertreatment of pain.

IMPLICATIONS FOR CANCER SURVIVORS

Undertreatment of pain continues to remain a major unmet need in patients with cancer.

Executive Dysfunction After Fourth-Ventricle Epidermoid Cyst Resection

Intracranial epidermoid cysts are rare, comprising 0.2% to 1.8% of all primary intracranial expanding lesions, of which <5% occur within the fourth ventricle. Epidermoid cysts are frequently congenital, and patients often present in the fourth decade of life. These cysts produce symptoms as a result of mass effect on surrounding structures, most commonly the cerebellum and cranial nerves. Symptoms can include hearing impairment, trigeminal neuralgia (severe facial pain), facial tics, headaches, double vision, and facial palsy. However, no research has focused on the neuropsychological effects on a patient after surgical resection of these cysts. This case report presents the cognitive profile of a woman after resection of an epidermoid cyst in the fourth ventricle. The 49-year-old patient underwent neuropsychological assessment after removal of the cyst, completing a comprehensive set of cognitive tests of estimated premorbid intelligence, attention, memory, social cognition, language, visual perception, and executive functioning. Test results indicated executive dysfunction and reduced visuospatial memory in the acute stage after surgical removal of the epidermoid cyst. These findings suggest that cognitive deficits can occur after resection of space-occupying lesions in brain regions not typically associated with cognition. To our knowledge, this is the first report of the neuropsychological consequences of surgical removal of a congenital epidermoid cyst in the fourth ventricle. An understanding of the neuropsychological sequelae of this rare cerebral cyst will allow patients, families, and health professionals to better anticipate and manage postoperative difficulties.

[Proposition and evaluation of the educational activities for effective utilization of opioids performed by pharmacists in palliative home care]

Recently, it is required that community pharmacists participate in palliative home care. In this study, we designed educational activities for palliative home care to local residents as a new approach performed by community pharmacists. In addition, we proposed this approach to community pharmacists and discussed its roles to promote palliative home care in the future. We designed and held an educational seminar on palliative home care focusing on safe use of opioids in local residents. After this seminar, we conducted a questionnaire survey of the participants. Then, we made a proposition of this new approach by presentation of a seminar to community pharmacists (members of "Heartfulcare INC"). After the proposition, a questionnaire survey of the seminar on palliative home care was performed. In total, 79 people participated in the educational seminar. Most (87.3%) participants thought that it was informative. Furthermore, about 40% of participants answered "misunderstanding of opioids" or "anxiety regarding side effects of opioids" were removed following the seminar. All participating pharmacists evaluated the seminar as useful. The educational activity in the present study seemed effective to local residents on their misunderstanding of opioids. Furthermore, this approach was appreciated as an important role of community pharmacists in the palliative home care not only by local residents but also by pharmacists themselves. Therefore it seems important to continue such activities so as to improve palliative home care in the future.

Under-treatment of cancer pain

PURPOSE OF REVIEW

Cancer pain remains inadequately treated, despite internationally accepted management guidelines and a myriad of treatment options. Risk factors for undertreatment are reviewed, along with possible explanations. Recent studies documenting the scope of the problem as well as investigating solutions are discussed with clinical-practice recommendations outlined.

RECENT FINDINGS

Women over 65 years of age representative of a cultural minority, with earlier stage disease, cared for at home, and with high-school education or less are at highest risk of having uncontrolled cancer pain. Optimal treatment is impeded by patients' maladaptive beliefs, nonadherence, underreporting or miscommunication with caregivers; from a healthcare provider perspective, it may be due to inadequate assessment, documentation, knowledge, and communication. Emerging data support the vital influence of lay caregivers on appropriate pain management. Although home-education programs may decrease pain and improve quality of life, there are also less intensive approaches deliverable by individuals to holistically address pain.

SUMMARY

Prospective study of barriers to both delivery and receipt of adequate pain management is needed, as the majority of published literature is based on survey studies. Treatment must be individualized based on clinical circumstances and patient wishes, with the goal of maximizing function and quality of life.

Cognitive effects of opioids

Although opioid analgesics are safe and effective tools for the treatment of moderate to severe pain, there remain large gaps in understanding of the effects of these drugs on the many dimensions of functioning. This article summarizes the biomedical evidence addressing cognitive effects of the opioid analgesics. Current evidence indicates that cognitive function can be influenced by use of opioid analgesics, although the effects vary between drugs, are thought to be most significant with mixed-activity drugs, codeine, propoxyphene, and meperidine, and are generally most concerning during the first few days after starting opioid therapy, before tolerance develops. Blanket policies regarding the activities of driving and working are inappropriate; this issue is best addressed on a patient-specific basis.