Preface: policy issues related to clinical practice guidelines

A simple and effective daily pain management method for patients receiving radiation therapy for painful bone metastases

PURPOSE

The incidence of painful bone metastases increases with longer survival times. Although external beam radiation therapy (EBRT) is an effective palliative treatment, it often requires several days from the start of treatment to produce a measurable reduction in pain scores and a qualitative amelioration of patient pain levels. Meanwhile, the use of analgesics remains the best approach early on in the treatment course. We investigated the role of radiation therapists as key personnel for collecting daily pain scores to supplement assessments by physician and oncology nursing staff and manage pain more effectively during radiation treatment.

METHODS AND MATERIALS

Daily pain scores were obtained by the radiation therapists for 89 patients undertaking a total of 124 courses of EBRT for bone metastases and compared with pretreatment pain scores. The majority of patients (71%) were treated to 30 Gy (range, 20-37.5) in 10 fractions (range, 8-15 fractions).

RESULTS

One hundred nineteen treatment courses (96%) were completed. Pain scores declined rapidly to 37.5%, 50%, and 75% of the pretreatment levels by Days 2, 4, and 10, respectively. Pain was improved in 91% of patients with only 4% of worse pain at the end of treatment. Improved pain scores were maintained in 83% of patients at 1-month follow-up, but in 35% of them, the pain was worse than at the end of treatment.

CONCLUSIONS

Collection of daily pain scores by radiation therapists was associated with an effective reduction in pain scores early on during EBRT of painful osseous metastases.

Assessment and management of acute pain in adult medical inpatients: a systematic review

OBJECTIVE

To review the literature addressing effective care for acute pain in inpatients on medical wards.

METHODS

We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions.

RESULTS

We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion.

CONCLUSIONS

Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.

Evaluation of a Cancer Pain Education Module

PURPOSE/OBJECTIVES

To assess whether a case-based cancer pain education module would lead to acquisition and retention of knowledge and attitudes at the graduate nursing student level.

DESIGN

Quasi-experimental pretest, post-test, and follow-up.

SETTING

Three nursing schools in the New England area.

SAMPLE

92 graduate nursing students.

METHODS

An oncology nurse specialist delivered seven two- to four-hour seminars integrated in existing pharmacology, primary care, or adult health courses. Participants' cancer pain knowledge was assessed at four time points with a paper-and-pencil test: before the seminar, immediately after, and approximately 6 and 24 months after the seminar.

MAIN RESEARCH VARIABLE

Cancer pain knowledge.

FINDINGS

The intervention was effective in improving students' knowledge of cancer pain management and assessment (p = 0.0001), and the effect was retained at 6 and 24 months (p = 0.0001 and p = 0.0024, respectively).

CONCLUSIONS

Policymakers, clinicians, and professional organizations have recommended providing cancer pain education during professional training to overcome the continuing problem of the undertreatment of cancer pain. The education module used was effective in changing students' knowledge of cancer pain management, and the results suggest that this knowledge is lasting.

IMPLICATIONS FOR NURSING

Early cancer pain education for nurses may play an important role in improving pain control for patients with cancer. Although this study did not evaluate the application of cancer pain knowledge to clinical practice, the results support the notion that advanced practice nurses can improve their cancer pain management knowledge and attitudes while in training. One implication is that this shift in attitudes and knowledge will translate to effective management of pain in varied healthcare settings.

Schmerzerfassung bei invasiven diagnostischen Prozeduren

BACKGROUND AND OBJECTIVE

Pain measurement during diagnostic procedures is an accepted prerequisite for appropriate therapy. In this study, the agreement between rankings of pain intensity on a numerical and a verbal rating scale was analyzed.

METHODS

Patients attending a haematological outpatient clinic who underwent bone marrow puncture were requested to assess pain intensity perceived during the procedure on a elen-point numerical and a six-point verbal rating scale.

RESULTS

Analysis of patients' pain ratings in 263 bone marrow punctures showed a very good correlation between numerical and verbal rating scale (Spearman correlation coefficient 0,86). By means of a transfer instruction categories of the verbal rating scale were assigned to figures of the numerical rating scale (0 - no pain, 1 or 2 - mild p., 3, 4 or 5 moderate p., 6 or 7 severe p., 8, 9 or 10 - very severe and worst possible pain). The resulting transfer table showed a good agreement with a weighted kappa of 0.72 (95% confidence interval: 0.66-0.79).

CONCLUSION

Both scales can be employed efficiently for pain assessment during diagnostic procedures. Verbal categories can be assigned to numerical values and vice versa numerical values to verbal categories. However, in view of the inter-individual variations it appears appropriate to re-assure pain perception with each patient in order to avoid over- or undertreatment.

Nonsteroidal Anti-Inflammatory Drugs, Alone or Combined With Opioids, for Cancer Pain

Purpose

To assess the safety and efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), alone or combined with opioids, for the treatment of cancer pain.

Patients and Methods

Forty-two trials involving 3,084 patients met inclusion criteria: eight compared NSAID with placebo; 13 compared one NSAID with another; 23 compared NSAID with opioid, NSAID or opioid versus NSAID plus opioid combinations, or NSAID plus opioid combinations versus NSAID plus opioid combinations; and nine studies assessed the effect of increasing NSAID dose.

Results

Sixteen studies lasted 1 week or longer and 11 evaluated a single dose. Seven of eight trials demonstrated superior efficacy of single doses of NSAID compared with placebo. Only four of 13 studies reported increased efficacy of one NSAID compared with another; four other studies found that one NSAID had fewer side effects than one or more others. Thirteen of 14 studies found no difference, or minimal clinical difference, when comparing an NSAID plus opioid combination versus either drug alone. Comparisons between various NSAID plus opioid combinations were inconclusive. Four studies demonstrated increased efficacy with increased NSAID dose, without dose-dependent increases in side effects.

Conclusion

Heterogeneity of study methods and outcomes precluded meta-analyses. Short duration of studies undermines generalization of findings on efficacy and safety. On the basis of limited data, NSAIDs appear to be more effective than placebo for cancer pain; clear evidence to support superior safety or efficacy of one NSAID compared with another is lacking; and trials of combinations of an NSAID with an opioid have disclosed either no significant difference, or at most a slight but statistically significant advantage, compared with either single entity.

Cancer Pain Education for Medical Students: The Development of a Short Course on CD-ROM: Table 1

OBJECTIVE

The purpose of this study was to assess the educational value and acceptability of a short CD-ROM course on cancer pain management given to third-year medical students at the University of Kentucky.

METHODS

Thirty-six medical students were given a short-course CD-ROM on cancer pain assessment and management. The Cancer Pain CD-ROM included textual instruction as well as video clips and a 15-item interactive self-assessment examination on cancer pain management. Students were asked to evaluate the computerized course with an 18-item survey using a Likert scale (1 = strongly disagree; 5 = strongly agree).

RESULTS

Twenty-seven medical students completed the course, however, only 11 returned evaluations. In general, the medical students appreciated the CD-ROM material, with the exception of the video clips. Students agreed most strongly (mean +/- standard deviation [SD]) that the educational material on the CD-ROM was presented clearly (3.9 +/- 1.1), the CD-ROM format was easy to use (4.0 +/- 0.8), the CD-ROM course improved knowledge of opioid use for cancer pain (4.0 +/- 0.7), and the course improved understanding of opioid-related side effects (4.0 +/- 0.7). The self-assessment examination on cancer pain was rated easy to use and felt to be helpful (4.0 +/- 0.9) for students to identify cancer pain knowledge deficits. The authors estimate that 150 man-hours were needed to complete production of the CD-ROM without any specialized training in computer skills.

CONCLUSIONS

A short-course computer format program was developed by the authors to teach the basics of cancer pain management to medical students. A minority of students evaluated the program and agreed the material was clearly presented, improved knowledge of opioid analgesia, and was easy to use.

The Development of a Technique for Radiofrequency Lesioning of Splanchnic Nerves

This article describes the development of a technique for radiofrequency lesioning of the splanchnic nerves. It features point neurolysis and improvement in safety from previously described techniques with the use of a curved, blunt needle. After extensive anatomic studies, the site of entry has been identified 4 cm lateral to the spinous process at the costovertebral angle of either the T11 or T12 vertebral body, and the placement of the needle tip at the junction of posterior two thirds to the anterior one third of the vertebral body. The use of a sharp, straight needle has been discouraged to prevent pneumothorax, and bowel, kidney, or nerve root injury. The radiofrequency lesion permits a point neurolysis, thus decreasing the rate of complications. Our experience of 22 patients treated with this technique has been complication-free, and the outcome was effective for all 10 patients with cancer. In the nonmalignancy group, some patients needed a second neurolysis (radiofrequency) procedure 4 months apart. There were also no secondary complications in these patients. We expect multicenter data accumulation in the coming years, which will determine the true efficacy of the radiofrequency of splanchnic nerves.

HIV/AIDS-related Pain as a Chronic Pain Condition: Implications of a Biopsychosocial Model for Comprehensive Assessment and Effective Management

This paper reviews the current literature focusing on pain in HIV/AIDS, including prevalence, pathophysiology, substance abuse, treatment issues, and psychosocial contributions. In light of the high prevalence of pain among individuals with HIV/AIDS, attention is paid to the negative psychosocial impacts of pain in this population and to psychosocial barriers to optimal HIV/AIDS-related pain treatment. The paper conceptualizes HIV/AIDS pain as chronic pain. Subsequently, a biopsychosocial model of chronic pain assessment and treatment is applied. A multidimensional framework is presented for appropriate assessment and treatment of HIV/AIDS patients with pain, and specific recommendations and guidelines are offered for assessment and multimodal treatment of HIV/AIDS-related pain informed by the model.

"We don't carry that"--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

BACKGROUND

We have observed that many black and Hispanic patients receiving palliative care at a major urban teaching hospital are unable to obtain prescribed opioids from their neighborhood pharmacies. In this study, we investigated the availability of commonly prescribed opioids in New York City pharmacies.

METHODS

We surveyed a randomly selected sample of 30 percent of New York City pharmacies to obtain information about their stock of opioids. For each pharmacy, U.S. Census estimates for 1997 were used to determine the racial and ethnic composition of the neighborhood (defined as the area within a 0.4-km [0.25-mile] radius of the pharmacy) and the proportion of residents who were more than 65 years old. Data on robberies, burglaries, and arrests involving illicit drugs in 1997 were obtained for the precinct in which each pharmacy was located. We used a generalized linear model to examine the relation between the racial or ethnic composition of neighborhoods and the opioid supplies of pharmacies, while controlling for the proportion of elderly persons at the census-block level and for crime rates at the precinct level.

RESULTS

Pharmacists representing 347 of 431 eligible pharmacies (81 percent) responded to the survey. A total of 176 pharmacies (51 percent) did not have sufficient supplies of opioids to treat patients with severe pain. Only 25 percent of pharmacies in predominantly nonwhite neighborhoods (those in which less than 40 percent of residents were white) had opioid supplies that were sufficient to treat patients in severe pain, as compared with 72 percent of pharmacies in predominantly white neighborhoods (those in which at least 80 percent of residents were white) (P<0.001).

CONCLUSIONS

Pharmacies in predominantly nonwhite neighborhoods of New York City do not stock sufficient medications to treat patients with severe pain adequately.

A survey of pain services for pediatric oncology patients: their composition and function

The purpose of this survey was to examine the composition and function of pain services/teams at facilities that provide pain management services to pediatric oncology patients across the United States. A questionnaire was mailed to facilities identified by the 1994 Pain Facilities Directory as providing pain services to cancer patients. Thirty-five facilities that identified oncology patients as one of the primary pediatric populations treated at their institution were the focus of this study. Eight facilities that managed bone marrow aspirations and/or lumbar punctures for pediatric oncology patients also participated in a telephone interview regarding analgesia/sedation practices for procedure-related pain. Provision of direct patient care was a primary function of the pain services surveyed, although delivery of services varied across settings. Postoperative and chronic pain were the most frequent reasons for referral. Only 17% and 3% of facilities had established written standard guidelines for pharmacological and nonpharmacological approaches to pain management, respectively. Most facilities reported using a local anesthetic and conscious sedation to manage bone marrow aspiration and lumbar punctures. Implications from these findings and recommendations for provision of pediatric pain services are discussed.

Presenting symptoms in patients referred to a multidisciplinary clinic for bone metastases

Symptom control is the goal of palliative irradiation. Approximately 1 month is required before symptomatic relief is accomplished with radiotherapy. However, many patients with cancer-related pain do not receive adequate analgesics, and opioids are often not prescribed until patients fail to respond to palliative irradiation. The presenting symptoms of 108 patients who were referred to a multidisciplinary clinic for bone metastases were evaluated with the Wisconsin Brief Pain Inventory (BPI). This validated instrument evaluates the severity of pain using a 0-10 scale; 10 represents the worst pain imaginable. The population comprised 65 men (60%) and 43 women whose ages ranged from 33 years to 81 years; median age was 55 years, and 69% of patients were less than 65 years of age. Despite the presence of metastatic disease, 21% of patients were working full-time outside the home, and 6% were employed part-time outside the home; 13% were homemakers. Only 17 patients (16%) were unemployed. The time since diagnosis ranged from 2 weeks to 23 years; the median time since diagnosis was 22 months, and 30% of patients had been diagnosed with the past 6 months. Pain was a presenting symptom in 74% (N = 80) of patients at diagnosis. At its worst, the pain was rated as severe (levels 7-10) by 78% and intolerable (level 10) in 22% of the patients in the 24 hr prior to the clinic appointment. On average, the pain was rated moderate to severe (levels 4-10) in 79% and severe in 23% of patients. Only 45% of patients experienced good relief from the prescribed analgesics, and 23% of patients indicated that the prescribed analgesics were ineffective. This survey demonstrates that bone metastases incur significant pain that is often undertreated with analgesics before antineoplastic therapy is administered.

A clinical evaluation of transdermal therapeutic system fentanyl for the treatment of cancer pain

Fentanyl has been incorporated into a transdermal therapeutic system (TTS) containing a rate-limiting membrane that provides constant release of the opioid. TTS fentanyl provides continuous opioid delivery for up to 72 hr without the need for special equipment. After Institutional Review Board approval, 53 patients with cancer pain requiring 45 mg or more of oral morphine daily were admitted into an open-label, prospective, multicenter evaluation of TTS fentanyl for the relief of pain. After a 1-week stabilization on oral morphine, patients were transferred from morphine to an appropriate dose of TTS-fentanyl (25, 50, 75, or 100 micrograms/hr) administered as a transdermal patch every 3 days. TTS fentanyl was titrated to pain relief, and patients were followed up for as long as 3 months. Pain relief and the side effects of the medications were assessed daily. Twenty-six men and 27 women with a mean (+/- SD) age of 61 (+/- 12) years entered the study; 23 patients completed the full 84-day study. The mean duration of TTS fentanyl use was 58 +/- 32 days. The mean (+/- SEM) daily morphine dose during the last 2 days of stabilization was 189 (+/- 20) mg, and the mean initial fentanyl patch dose was 58 (+/- 6) micrograms/hr. The mean daily morphine dose taken "as needed" for breakthrough pain at study completion was 35 mg. The mean final fentanyl dosage at study completion was 169 (+/- 29) micrograms/hr. Pain relief was rated as good or excellent by 82% of patients during the treatment period. When asked to compare pain relief during the first month of TTS-fentanyl use to that provided by their last analgesic before study entry, 63% preferred TTS fentanyl. Side effects considered related to the fentanyl patch were nausea (13%), vomiting (8%), skin rash (8%), and drowsiness (4%). Thirty percent of patients reported adverse experiences related to the fentanyl patch, and 17% had to be discontinued from the study. We conclude that TTS fentanyl administered every 3 days for the treatment of cancer pain is effective, safe, and well tolerated by most patients.

Medical student knowledge of morphine for the management of cancer pain

Inadequate training of physicians contributes to the undertreatment of cancer pain. To address these concerns, the University of Kentucky has introduced a 4-week course for final-year medical students that teaches the principles of clinical pharmacology and pain management. The purposes of this study are to assess the knowledge deficits of final-year medical students about the use of morphine for cancer pain and to assess the efficacy of a short course on cancer pain management. Eighty-six final-year medical students completed a 22-item questionnaire assessing their knowledge and attitudes toward the use of morphine for cancer pain. Students indicated their agreement with each statement on a four-point scale (one, strongly disagree; four, strongly agree). All students then completed a compulsory short course on pain management. The course content included a 1-hr lecture on chronic nonmalignant pain, a 1-hr lecture on acute pain management, and a 1-hr lecture on cancer pain management. In addition, students completed small-group, problem-based learning modules on several aspects of pain management. After the course, all students completed the same 22-item survey. The alpha reliability score of the pretest instrument was 0.55, and the posttest reliability was 0.86. Upon course completion, students agreed most strongly (mean +/- SEM) that morphine should be given on a regular schedule for cancer pain (3.41 +/- 0.08), that cancer pain management frequently requires co-analgesics (3.36 +/- 0.06), and that patients with good pain relief function better than those with continuing pain (3.39 +/- 0.08). A comparison of pretest and posttest means on specific items suggested that the greatest amount of learning took place in the following content areas: morphine is a good oral analgesic; increases in cancer pain should be treated by increasing the morphine dose; respiratory depression is not a concern for cancer pain patients; and morphine can be used over a wide range of doses. The regular use of morphine was recognized as the treatment drug of choice for cancer pain. The students showed improved knowledge scores on ten of the 22 items on the posttest survey. A significant increase in learning occurred on six knowledge and attitude items. On only one item (nausea as a side effect of morphine) did the knowledge scores decrease on the posttest. A significant minority (40%) of senior medical students had deficits in knowledge about the use of morphine for cancer pain. The risk of addiction, respiratory depression, and tolerance were misunderstood by a significant minority (25%) of students.