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Løhre ET, Jakobsen G, Solheim TS, Klepstad P, Thronæs M. Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective. Curr Oncol 2023; 30:10249-10259. [PMID: 38132380 PMCID: PMC10742182 DOI: 10.3390/curroncol30120746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/23/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
Cancer pain intensity (PI) fluctuates, but the relationship between pain flares and background pain with respect to pain management is not settled. We studied how flare and background PIs corresponded with treatment results for background cancer pain. Patients admitted to an acute palliative care unit with average and/or worst PI ≥ 1 on the 11-point numeric rating scale were included. Average and worst PI at admission and average PI at discharge were collected. We examined how the difference and ratio between worst and average PI and average PI at admission, were associated with average PI development during hospitalization. Positive differences between worst and average PI at admission were defined as pain flares. Ninety out of 131 patients had pain flares. The reduction in average PI for patients with flares was 0.9 and for those without, 1.9 (p = 0.02). Patients with large worst minus average PI differences reported the least improvement, as did those with large worst/average PI ratios. Patients with pain flares and average PI ≤ 4 at admission had unchanged average PI during hospitalization, while those with pain flares and average PI > 4 experienced pain reduction (2.1, p < 0.001). Large pain flares, in absolute values and compared to background PI, were associated with inferior pain relief.
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Affiliation(s)
- Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Morten Thronæs
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
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Abstract
PURPOSE OF REVIEW An overview on breakthrough cancer pain (BTCP), including inherent limitations of the terminology, assessment, clinical presentation, and treatment options. RECENT FINDINGS The estimated prevalence of BTCP is dependent on the defined cutoffs for controlled background pain and the magnitude of the pain flare. In addition, pain flares outside the definition of BTCP are prevalent. In the 11th Revision of the International Classification of Diseases, the temporal characteristics of cancer pain are described as continuous background pain and intermittent episodic pain. BTCP should be assessed by validated methods, and the patient perspective should be included. The pain may be related to neoplastic destruction of bone, viscera, or nerve tissue and is characterized by rapid onset, high intensity, and short duration. Treatment directed towards painful metastases must be considered. Due to pharmacological properties mirroring the pain characteristics, transmucosal fentanyl formulations are important for the treatment of BTCP. Oral immediate release opioids can be used for slow-onset or predictable BTCP. For more difficult pain conditions, parenteral, or even intrathecal pain medication, may be indicated. SUMMARY All clinically relevant episodic pains must be adequately treated in accordance with the patient's preferences. Transmucosal fentanyl formulations are effective for BTCP.
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Li S, Liu J, Huang J, Luo D, Wu Q, Ning B, Chen L, Liu J, Fu WB. Acupuncture for comorbid mild-moderate depression and chronic musculoskeletal pain: study protocol for a randomized controlled trial. Trials 2021; 22:315. [PMID: 33926511 PMCID: PMC8082965 DOI: 10.1186/s13063-021-05260-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Depression and chronic musculoskeletal pain (CMSP) are the leading causes of years lived with disabling diseases worldwide. Moreover, they often commonly coexist, which makes diagnosis and treatment difficult. A safe and effective treatment is urgently needed. Previous studies have shown that acupuncture is a cost-effective treatment for simple depression or CMSP. However, there is limited evidence that acupuncture is effective for depression comorbid with CMSP. Methods This is a randomized, sham acupuncture-controlled trial with three arms: real acupuncture (RA), sham acupuncture (SA), and healthy control (HC). Forty-eight depression combined CMSP participants and 12 healthy people will be recruited from GDTCM hospital and randomized 2:2:1 to the RA, SA, and HC groups. The patients will receive RA or SA intervention for 8 weeks, and HC will not receive any intervention. Upon completion of the intervention, there will be a 4-week follow-up. The primary outcome measures will be the severity of depression and pain, which will be assessed by the Hamilton Depression Rating Scale (HAMD-17) and Brief Pain Inventory (BPI), respectively. The secondary outcome measures will be cognitive function and quality of life, which will be measured by the Montreal Cognitive Assessment (MoCA), P300, and World Health Organization Quality of Life (WHOQOL-BREF). In addition, the correlation between brain-derived neurotrophic factor (BDNF) and symptoms will also be determined. Discussion The aim of this study is to evaluate the clinical efficacy and underlying mechanism of acupuncture in depression comorbid with CMSP. This study could provide evidence for a convenient and cost-effective means of future prevention and treatment of combined depression and CMSP. Trial registration Chinese Clinical Trial Registry ChiCTR1800014754. Preregistered on 2 February 2018. The study is currently recruiting.
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Affiliation(s)
- Sheng Li
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jing Liu
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jianpeng Huang
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ding Luo
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Qian Wu
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Baile Ning
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ling Chen
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jianhua Liu
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China.
| | - Wen-Bin Fu
- Department of Acupuncture and Moxibustion, the 2nd clinical hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China.
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Episodic Cancer Pain: Patient Reporting, Prevalence, and Clinicodemographic Associations at Initial Cancer Pain Clinic Assessment. Pain Res Manag 2020; 2020:6190862. [PMID: 32566062 PMCID: PMC7261329 DOI: 10.1155/2020/6190862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/02/2020] [Indexed: 01/11/2023]
Abstract
Background Better understanding of the episodic cancer pain (CP) spectrum, including pains that occur in addition to its conventionally defined breakthrough CP (BTcP) and incident CP (IcP) components, may inform CP assessment and management. This study aimed to determine the prevalence of episodic patient-reported CP and the prevalence and associations of study-defined BTcP (S-BTcP) and IcP (S-IcP) in patients with CP. Methods In a cross-sectional study at their first CP clinic attendance, participants with CP had the following assessments: Brief Pain Inventory (BPI); Pain Management Index (PMI), with PMI-negative status indicating undertreatment; standardized neuropathic pain component (NPC) status; S-BTcP (no trigger identified) and S-IcP (trigger identified) status, based on a preceding 7-day history of transitory pain flares distinct from background pain, and BPI-Worst or BPI-Now pain intensity ≥ 4. Clinicodemographic variables' association with S-BTcP and S-IcP was examined in logistic regression analyses. Results Of 371 participants, 308 (83%) had episodic CP by history alone; 140 (37.7%) and 181 (48.8%) had S-BTcP and S-IcP, respectively. Multivariable analyses demonstrated significant (p < 0.05) associations (odds ratios: 95% CIs) for 6 variables with S-BTcP: head and neck pain location (2.53; 1.20–5.37), NPC (2.39; 1.34–4.26), BPI average pain (1.64; 1.36–1.99), abdominal pain (0.324; 0.120–0.873), S-IcP (0.207; 0.116–0.369), and PMI-negative status (0.443; 0.213–0.918). Similar independent associations (p < 0.05) occurred for S-IcP with NPC, BPI average pain, and PMI-negative status, in addition to radiotherapy, S-BTcP, soft tissue pain, and sleep interference. Conclusions Episodic or transient patient-reported CP flares often do not meet the more conventional criteria that define BTcP and IcP, the principal episodic CP types. Both BTcP and IcP occur frequently and both are associated with a NPC, higher pain intensity, and less opioid underuse in the management of CP. Further studies are warranted to both better understand the complex presentations of episodic CP and inform its classification.
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Currow DC, Clark K, Louw S, Fazekas B, Greene A, Sanderson CR. A randomized, double‐blind, crossover, dose ranging study to determine the optimal dose of oral opioid to treat breakthrough pain for patients with advanced cancer already established on regular opioids. Eur J Pain 2020; 24:983-991. [DOI: 10.1002/ejp.1548] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/22/2020] [Accepted: 02/12/2020] [Indexed: 11/06/2022]
Affiliation(s)
- David C. Currow
- IMPACCT Faculty of Health University of Technology Sydney Ultimo NSW Australia
- Australian National Cancer Symptom Trials Group University of Technology Sydney Ultimo NSW Australia
| | - Katherine Clark
- University of Sydney Northern Clinical School Royal North Shore Hospital St Leonard's NSW Australia
| | - Sandra Louw
- McCloud Consulting Group Belrose NSW Australia
| | - Belinda Fazekas
- IMPACCT Faculty of Health University of Technology Sydney Ultimo NSW Australia
- Southern Adelaide Palliative Services Daw Park SA Australia
| | - Aine Greene
- Southern Adelaide Palliative Services Daw Park SA Australia
| | - Christine R. Sanderson
- IMPACCT Faculty of Health University of Technology Sydney Ultimo NSW Australia
- Calvary Health Care Kogarah Kogarah NSW Australia
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Løhre ET, Thronæs M, Brunelli C, Kaasa S, Klepstad P. An in-hospital clinical care pathway with integrated decision support for cancer pain management reduced pain intensity and needs for hospital stay. Support Care Cancer 2019; 28:671-682. [PMID: 31123870 DOI: 10.1007/s00520-019-04836-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/23/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE A clinical care pathway for pain management in a palliative care unit was studied with outcomes related to patients, physicians, and health care service. Mandatory use of patient-reported outcome measures (PROMs) and physician-directed decision support (DS) were integrated parts of the pathway. METHODS Adult cancer patients with pain intensity (PI) ≥ 5 (NRS 0-10) at admission were eligible. The patients reported average and worst PI at admission, day four, and discharge. The physicians completed the DS at admission and day four. The DS presented potential needs for treatment changes based on pain severity and pathophysiology. The physicians reported treatment changes due to input from the DS system. The two primary outcomes were average and worst PI changes from admission to discharge. Hospital length of stay (LOS) was registered. RESULTS Of 52 included patients, 41 were discharged alive. For those, the mean average PI at admission and at discharge was 5.8 and 2.4, respectively, a reduction of 3.4 points (CI 95% 2.7-4.1). The corresponding worst pain intensities were 7.9 and 3.8, a reduction of 4.1 points (CI 95% 3.4-4.8). The physicians completed DS forms for all patients. Fifty-five percent (CI 95% 41-69) of the patients had pain intervention changes based on the DS. A significant reduction in LOS (4.4 days, CI 95% 0.5-8.3) was observed during the study period. CONCLUSIONS The interventions were implemented according to the intentions and PI was reduced as hypothesized. For evaluation of generalizability, the interventions should be studied in other settings and with a controlled design.
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Affiliation(s)
- Erik Torbjørn Løhre
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology , N-7491, Trondheim, Norway. .,Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Morten Thronæs
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology , N-7491, Trondheim, Norway.,Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,European Palliative Care Research Centre (PRC), Department of Oncology and Institute of Clinical Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Stein Kaasa
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology , N-7491, Trondheim, Norway.,European Palliative Care Research Centre (PRC), Department of Oncology and Institute of Clinical Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Abstract
OBJECTIVES To describe assessment and interdisciplinary management of pain in the cancer survivor over the continuum of cancer care. DATA SOURCES Review of the literature and treatment standards. CONCLUSION Pain remains a primary concern throughout the cancer trajectory across all age groups and diagnoses, emphasizing the need to integrate pain assessment and management across the continuum of cancer survivorship and across care settings. Types of pain, pain patterns, assessment of cancer pain in cancer survivors, current strategies and challenges for management, and effective communication and documentation of the process are described. Communication between and among health care clinicians in a way that effectively articulates the individual patient experience, including documentation in the electronic medical record, requires consistent workflows and terminology. The opioid crisis increases the urgency in effective strategies for interdisciplinary pain assessment and management. IMPLICATIONS FOR NURSING PRACTICE Oncology clinicians must be able to adequately assess pain, track pain over time, understand and implement a cadre of strategies to manage pain, and effectively pursue any suspicious pain patterns that may indicate recurrence or progression of cancer or other underlying etiologies. The oncology nurse is at the core of patient-clinician communication, critical to effectively describing pain as experienced by the individual patient and continues to play a key role in maintaining consistency of message that is necessary to manage pain over the continuum of cancer survivorship.
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Affiliation(s)
- Sandra Kurtin
- Director Advanced practice and Clinical Integration, The University of Arizona Cancer Center, The University of Arizona, Tucson, AZ.
| | - Abby Fuoto
- Head and Neck and Supportive Care, The University of Arizona Cancer Center, Tucson, AZ
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