Epidural and intrathecal analgesia for cancer pain

Pain and Opioid Consumption After Laparoscopic Versus Open Gastrectomy for Gastric Cancer: A Secondary Analysis of a Multicenter Randomized Clinical Trial (LOGICA-Trial)

BACKGROUND

Laparoscopic gastrectomy could reduce pain and opioid consumption, compared to open gastrectomy. However, it is difficult to judge the clinical relevance of this reduction, since these outcomes are reported in few randomized trials and in limited detail.

METHODS

This secondary analysis of a multicenter randomized trial compared laparoscopic versus open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). Postoperative pain was analyzed by opioid consumption in oral morphine equivalents (OME, mg/day) at postoperative day (POD) 1-5, WHO analgesic steps, and Numeric Rating Scales (NRS, 0-10) at POD 1-10 and discharge. Regression and mixed model analyses were performed, with and without correction for epidural analgesia.

RESULTS

Between 2015 and 2018, 115 patients in the laparoscopic group and 110 in the open group underwent surgery. Some 16 patients (14%) in the laparoscopic group and 73 patients (66%) in the open group received epidural analgesia. At POD 1-3, mean opioid consumption was 131, 118, and 53 mg OME lower in the laparoscopic group, compared to the open group, respectively (all p < 0.001). After correcting for epidural analgesia, these differences remained significant at POD 1-2 (47 mg OME, p = 0.002 and 69 mg OME, p < 0.001, respectively). At discharge, 27% of patients in the laparoscopic group and 43% patients in the open group used oral opioids (p = 0.006). Mean highest daily pain scores were between 2 and 4 at all PODs, < 2 at discharge, and did not relevantly differ between treatment arms.

CONCLUSION

In this multicenter randomized trial, postoperative pain was comparable between laparoscopic and open gastrectomy. After laparoscopic gastrectomy, this was generally achieved without epidural analgesia and with fewer opioids.

TRIAL REGISTRATION

NCT02248519.

Buprenorphine versus dexamethasone as perineural adjuvants in femoral and adductor canal nerve blocks for total knee arthroplasty: a randomized, non-inferiority clinical trial

BACKGROUND

Optimal control of acute postoperative pain and prevention of chronic persistent pain in total knee arthroplasty (TKA) remain a challenge.

METHODS

A randomized, non-inferiority clinical trial (385 patients) evaluated every hour immediate postoperative pain during 24 h, using a verbal rating 11-point scale for patient self-reporting of pain (VRS11). All patients received subarachnoid anesthesia and were randomly allocated in 4 groups: single shots femoral (FNB) or adductor canal blocks (ACB), both with dexamethasone (dex) and buprenorphine (bup). Patients received intravenous analgesia (metamizole magnesium, dexketoprofen) and rescue analgesia when needed: intravenous (paracetamol and morphine) and/or regional (femoral and sciatic nerve blocks). Demographics and adverse effects were also recorded.

RESULTS

A 45.7% of patients had pain: bupACB 56.3%, bupFNB 50.0%, dexACB 40.6% and dexFNB 36.1% (p=0.022). Rescue analgesia was needed in 37.7% of patients (p=0.128). There were statistical differences in percentage of timepoints without pain (95.0±7.9%, p=0.014) and mean VRS11 (0.18±0.3, p=0.012) but no differences in distribution of intensity periods of pain. There were no significant differences in the need of rescue analgesia excepting the use of intravenous morphine (p=0.025).

CONCLUSIONS

buprenorphine is in the present trial inferior to dexamethasone by less than the established non-inferiority limit when used as perineural adjuvant in femoral nerve or adductor canal blocks in total knee arthroplasty analgesia. So, it could be considered an alternative in patients where dexamethasone is contraindicated, such as diabetics.

Initial Intrathecal Dose Titration and Predictors of Early Dose Escalation in Patients With Cancer Using a 100:1 Oral to Intrathecal Morphine Conversion Ratio

OBJECTIVE

Pain is common in patients with advanced cancer, and intrathecal drug delivery (IDD) has been successfully used for recalcitrant pain. We report on our experience using a 100:1 oral-to-intrathecal morphine conversion ratio for initial dosing and factors predictive of early dose escalation.

MATERIALS AND METHODS

Retrospective review of an intrathecal drug delivery system (IDDS) data base at the Huntsman Cancer Institute-University of Utah in cancer patients initiated on IDD with morphine or hydromorphone. Demographic characteristics, preoperative opioid use, and initial and hospital discharge IDD settings were collected.

RESULTS

A total of 275 patients were identified between June 2014 and May 2020. The median oral-to-intrathecal morphine conversion ratio for initial IDD dosing was 105.5:1 (interquartile range [IQR] 90-120, range 75-150). No serious adverse effects including respiratory depression or sedation were noted and the median length of stay was one night (IQR 1-2, range 1-22). Ninety-six percent of patients discontinued opioids immediately following IDDS implant. Initial IDD dosing was adequate in 42% of patients. Dose reduction was required in 4% prior to discharge due to nausea, patient request, weakness, pruritus, or urinary retention. Dose escalation was required in 54%, with a median dose increase of 66.7% (IQR 33-150%, range 5-1150%). Patients in the highest quartile of dose escalation, ≥70% between IDD initiation and discharge, had associations with younger age, higher preoperative opioid use, and inpatient status. No significant associations were found in patients who required dose reduction as compared to other patients.

CONCLUSIONS

An oral-to-intrathecal morphine conversion ratio of approximately 100:1 for initiation of IDD in patients with cancer pain was safe and well tolerated and may facilitate rapid elimination of systemic opioids. Dose reduction was rare, while a majority of patients required further dose escalation prior to discharge.

A randomized clinical trial comparing six techniques of postoperative analgesia for elective total hip arthroplasty under subarachnoid anesthesia with opioids

BACKGROUND

Optimal control of acute postoperative pain and prevention of chronic persistent pain in total hip arthroplasty (THA) remain a challenge. The main hypothesis was that peripheral nerve blocks improve postoperative analgesia.

METHODS

Immediate postoperative pain (24 hours) was evaluated every hour in 510 patients using a verbal rating 11-point scale for patient self-reporting of pain (VRS-11). All patients received subarachnoid anesthesia (SA) and were randomly allocated in six groups: SA with morphine 0.1 (SA0.1) or 0.2 mg (SA0.2), fascia iliaca compartment block with dexamethasone 4 mg + levobupivacaine 0.375% 20 (FICB20) or 30 mL (FICB30), lateral femoral cutaneous nerve block with levobupivacaine 0.25% 5 mL (LFCNB) and FICB20+LFCNB. Standardized analgesia included intravenous metamizole magnesium, dexketoprofen and rescue with paracetamol and morphine, and/or regional rescue (FICB, LFCNB, femoral and sciatic nerve blocks).

RESULTS

About 37.5% of patients had at least one episode of pain, 31.3% of them needed rescue analgesia while the remaining 6.2% did not request analgesia. There were no significant differences between the groups in paracetamol, morphine and rescue nerve blocks requirements. There was pain only in 5.4% of the total PACU pain records: 3.1% mild pain, 1.7% moderate pain and 0.6% severe pain.

CONCLUSIONS

combined with a multimodal analgesic approach, infra-inguinal FICB and LFCNB did not improve immediate postoperative analgesia for THA in our hospital. Other options and longer-term studies should be more extensively investigated to determine the role of peripheral blocks in postoperative pain treatment protocols.

Rectal enema of bupivacaine in cancer patients with tenesmus pain - case series

Introduction: Rectal tenesmus pain in cancer patients most frequently appears in patients with colon cancer, and as a consequence of radiotherapy of the hypogastrium region. Treatment with opioids and adjuvant analgesics is often ineffective. Patients and methods: Here, we report on two female patients diagnosed with colon and ovary cancer, respectively, who had very severe tenesmus pain (numerical rating scale 8-10) despite using high doses of opioids, including methadone with corticosteroids, anticonvulsants, antidepressants and ketamine. Results: In both patients, bupivacaine was administered via a rectal enema. In the first patient, bupivacaine was administered at a dose of 100 mg 0.1% (100 mL), and subsequently 100 mg 0.2% (50 mL), leading to effective analgesia for 8 and 12 hrs, respectively. In the second patient, 100 mg 0.1% (100 mL) was initially administered, followed by 100 mg 0.2% (50 mL), leading to effective analgesia for 12 and 17 hrs, respectively, with only dull abdominal pain reported that was relieved by 100 mg IV ketoprofen and complete disappearance of tenesmus pain. Rectal bupivacaine administration did not cause neurologic adverse effects, heart function disturbances or decreased blood pressure. A volume of 50 mL was enough to cover a painful area in the colon. Initial bupivacaine concentrations in the blood serum did not exceed 50 ng/mL and eventually dropped to 20 ng/mL and below. Conclusions: Administration of 100 mg bupivacaine as a rectal enema is safe and provides effective analgesia, and this procedure may be conducted in hospital departments and out-patient clinics. Furthermore, this procedure in the case of pain recurrence, can be repeated, and by providing effective pain relief often allows time for the patient to be transferred to a specialized pain center.

Survey of pain specialists regarding conversion of high-dose intravenous to neuraxial opioids

The conversion of high-dose intravenous (IV) opioids to an equianalgesic epidural (EP) or intrathecal (IT) dose is a common clinical dilemma for which there is little evidence to guide practice. Expert opinion varies, though a 100 IV:10:EP:1 IT conversion ratio is commonly cited in the literature, especially for morphine. In this study, the authors surveyed 724 pain specialists to elucidate the ratios that respondents apply to convert high-dose IV morphine, hydromorphone, and fentanyl to both EP and IT routes. Eighty-three respondents completed the survey. Conversion ratios were calculated and entered into graphical scatter plots. The data suggest that there is wide variation in how pain specialists convert high-dose IV opioids to EP and IT routes. The 100 IV:10 EP:1 IT ratio was the most common answer of survey respondent, especially for morphine, though also for hydromorphone and fentanyl. Furthermore, more respondents applied a more aggressive conversion strategy for hydromorphone and fentanyl, likely reflecting less spinal selectivity of those opioids compared with morphine. The authors conclude that there is little consensus on this issue and suggest that in the absence of better data, a conservative approach to opioid conversion between IV and neuraxial routes is warranted.

Morphine and clonidine combination therapy improves therapeutic window in mice: synergy in antinociceptive but not in sedative or cardiovascular effects

Opioids are used to manage all types of pain including acute, cancer, chronic neuropathic and inflammatory pain. Unfortunately, opioid-related adverse effects such as respiratory depression, tolerance, physical dependence and addiction have led to an underutilization of these compounds for adequate pain relief. One strategy to improve the therapeutic utility of opioids is to co-administer them with other analgesic agents such as agonists acting at α₂-adrenergic receptors (α₂ARs). Analgesics acting at α₂ARs and opioid receptors (ORs) frequently synergize when co-administered in vivo. Multimodal analgesic techniques offer advantages over single drug treatments as synergistic combination therapies produce analgesia at lower doses, thus reducing undesired side effects. This inference presumes, however, that the synergistic interaction is limited to the analgesic effects. In order to test this hypothesis, we examined the effects of α₂AR/OR combination therapy in acute antinociception and in the often-undesired side effects of sedation and cardiovascular depression in awake unrestrained mice. Morphine, clonidine or their combination was administered by spinal or systemic injection in awake mice. Antinociception was determined using the warm water tail flick assay (52.5°C). Sedation/motor impairment was evaluated using the accelerating rotarod assay and cardiovascular function was monitored by pulse oximetry. Data were converted to percent maximum possible effect and isobolographic analysis was performed to determine if an interaction was subadditive, additive or synergistic. Synergistic interactions between morphine and clonidine were observed in the antinociceptive but not in the sedative/motor or cardiovascular effects. As a result, the therapeutic window was improved ∼200-fold and antinociception was achieved at non-sedating doses with little to no cardiovascular depression. In addition, combination therapy resulted in greater maximum analgesic efficacy over either drug alone. These data support the utility of combination adrenergic/opioid therapy in pain management for antinociceptive efficacy with reduced side-effect liability.

Bupivacaine administered intrathecally versus rectally in the management of intractable rectal cancer pain in palliative care

Background

Unacceptable adverse effects, contraindications to and/or ineffectiveness of World Health Organization step III “pain ladder” drugs causes needless suffering among a population of cancer patients. Successful management of severe cancer pain may require invasive treatment. However, a patient’s refusal of an invasive procedure necessitates that clinicians consider alternative options.

Objective

Intrathecal bupivacaine delivery as a viable treatment of intractable pain is well documented. There are no data on rectal bupivacaine use in cancer patients or in the treatment of cancer tenesmoid pain. This study aims to demonstrate that bupivacaine administered rectally could be a step in between the current treatment options for intractable cancer pain (conventional/conservative analgesia or invasive procedures), and to evaluate the effect of the mode of administration (intrathecal versus rectal) on the bupivacaine plasma concentration.

Cases

We present two Caucasian, elderly inpatients admitted to hospice due to intractable rectal/tenesmoid pain. The first case is a female with vulvar cancer, and malignant infiltration of the rectum/vagina. Bupivacaine was used intrathecally (0.25–0.5%, 1–2 mL every 6 hours). The second case is a female with ovarian cancer and malignant rectal infiltration. Bupivacaine was adminstered rectally (0.05–0.1%, 100 mL every 4.5–11 hours).

Methods

Total bupivacaine plasma concentrations were determined using the high-performance liquid chromatography-ultraviolet method.

Results

Effective pain control was achieved with intrathecal bupivacaine (0.077–0.154 mg·kg⁻¹) and bupivacaine in enema (1.820 mg·kg⁻¹). Intrathecal bupivacaine (0.5%, 2 mL) caused a drop in blood pressure; other side effects were absent in both cases. Total plasma bupivacaine concentrations following intrathecal and rectal bupivacaine application did not exceed 317.2 ng·mL⁻¹ and 235.7 ng·mL⁻¹, respectively. Bupivacaine elimination was slower after rectal than after intrathecal administration (t_½= 5.50 versus 2.02 hours, respectively).

Limitations

This study reports two cases only, and there could be inter-patient variation.

Conclusion

Bupivacaine in boluses administered intrathecally (0.25%, 2 mL) provided effective, safe analgesia in advanced cancer patients. Bupivacaine enema (100 mg·100 mL⁻¹) was shown to be a valuable option for control of end-of-life tenesmoid cancer pain.

Interventional procedures for cancer pain management

OBJECTIVE

To describe types of interventional medical procedures its rationale use and benefits for a population with cancer assisted at a private hospital in São Paulo.

METHODS

Quantitative and descriptive cross-sectional study using data from patients submitted to interventional procedures between 2007 and 2008. We used descriptive and inferential statistics (frequency, mean, and t-test) to analyze data.

RESULTS

A total of 137 patients were submitted to interventional procedures for pain and, out of this total, 14 mentioned cancer-related pain. The mean pain intensity was 7.1 before the procedure and 1.3 after it. Reduction in pain intensity was statistically significant in this population (t=9.09; p=0.001). In almost 70% of patients (n=10) a reduction of 50% of the consumption of opioid a month after the procedure was realized.

CONCLUSION

These results are in accordance with the literature and support the efficacy of interventional procedures for several types of cancer pain.

Relative contributions of peripheral versus supraspinal or spinal opioid receptors to the antinociception of systemic opioids

The contribution of supraspinal, spinal or peripheral mu-opioid receptors (MORs) to the overall antinociception of systemic centrally penetrating versus peripherally restricted opioids has not been thoroughly investigated. Therefore, we examined paw pressure thresholds in Wistar rats with complete Freund's adjuvant hindpaw inflammation following different doses of intraplantar (i.pl.) as well as intravenous (i.v.) fentanyl (6.25-50 μg/kg), morphine (1-7.5 mg/kg) or loperamide (1-7.5 mg/kg). Antagonism of the i.v. mu-opioid agonists by intracerebroventricular (i.c.v.), intrathecal (i.t.) or i.pl. naloxone-methiodide (NLXM) revealed the relative contributions of supraspinal, spinal and peripheral MOR to the overall antinociceptive effects. In parallel, the MOR density at these three levels of pain transmission was assessed by radioligand binding. Antinociceptive effects of i.v. fentanyl and morphine, but not of the peripherally restricted loperamide were two- to threefold greater and longer lasting compared with their i.pl. administration. I.c.v. but not i.pl. NLXM significantly antagonized fentanyl's and morphine's antinociception by 70-80%, whereas i.t. NLXM reduced it by 20-30%. In contrast, antinociception of i.v. loperamide was abolished by i.pl. but not by i.c.v. or i.t. NLXM. In parallel, a respective 32- and sixfold higher MOR density in supraspinal and spinal versus peripheral sensory neurons was detected. In conclusion, in comparison with supraspinal and spinal opioid receptors, peripheral opioid receptors do not significantly contribute to the antinociception of systemic fentanyl and morphine during inflammatory pain. Antinociception of their i.v. administration was superior over both i.v and i.pl. loperamide, acting exclusively via peripheral MOR. These findings may guide the future development of novel peripherally restricted opioids.

Movement-evoked breakthrough cancer pain despite intrathecal analgesia: a prospective series

BACKGROUND

Intrathecal analgesia (ITA) is a valuable treatment option for intractable cancer-related pain. However, the issue of movement-evoked breakthrough pain (BTP) has not been specifically investigated in the ITA setting. The aim of the study was to evaluate the effect of ITA on spontaneous resting pain intensity (SRPI), doses of non-ITA opioids, and specifically on movement-evoked pain intensity (MEPI).

METHODS

We prospectively studied 28 consecutive patients who graded SRPI and MEPI on a 0-10 numerical rating scale (NRS) at the time of ITA procedure, after 1 week, and after 1 month. Mild pain was defined as NRS ≤ 3 and severe pain as NRS ≥ 7. Concomitant doses of opioids were registered.

RESULTS

After 1 week, no patient had severe SRPI compared with 31% before ITA, and the proportion of patients with mild SRPI had increased from 27% to 76%. Meanwhile, the median daily dose of non-ITA opioids decreased from 575 to 120 mg of oral morphine equivalents. The effect on SRPI and on doses of non-ITA opioids remained essentially unchanged during the study month, but the proportion of patients having severe MEPI did not change significantly: 44% still had severe MEPI after 1 week and 40% after 1 month.

CONCLUSION

Movement-evoked BTP was a major clinical problem throughout the study month despite otherwise successful ITA. Improving the quality of life of patients with intractable cancer-related pain should include developing strategies to better deal with movement-evoked BTP.

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.

Challenges associated with spinal opioid therapy for pain in patients with advanced cancer: a report of three cases

Intraspinal opioid therapy has been increasingly used for the management of cancer pain refractory to traditional treatment. However, this approach may present challenges in patients with advanced cancer. Three cases are presented that highlight the challenges associated with using neuraxial analgesia to manage cancer pain that was felt to be "refractory" to conventional treatment. Before an invasive procedure, such as placement of a permanent intrathecal opioid delivery system, a rigorous assessment and treatment of total pain (physical, psychological, spiritual, social, and practical) by an interdisciplinary team would be prudent.

The Role of Interventional Therapies in Cancer Pain Management

Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed. Key words: Intractable pain, Intrathecal analgesia, Neurolysis

Intrathecal analgesia for refractory cancer pain

The use of intrathecal analgesics is an important treatment consideration for many patients with chronic cancer pain. This review describes the various opioid and nonopioid analgesics that have been used in this setting, including morphine, hydromorphone, fentanyl, meperidine, methadone, sufentanil, local anesthetics, clonidine, ketamine, baclofen, midazolam, betamethasone, and octreotide. We discuss available evidence for their analgesic and adverse effects.

Neuraxial pain relief for intractable cancer pain

Most patients with cancer pain achieve good analgesia using traditional analgesics and adjuvant medications; however, an important minority of patients (2% to 5%) suffers from severe and refractory cancer pain. For these individuals, spinal analgesics (intrathecal or epidural) provide significant hope for pain relief over months or years of treatment to help improve quality of life. Spinal analgesics have been suggested as the fourth step in the World Health Organization guidelines in the management of cancer pain, and thus the pain physician should be familiar with principles of use. Most patients achieve pain relief using spinal analgesics, with a minimum of complications that are easily managed at home. A variety of opioids, local anesthetics, clonidine, ketamine, and other analgesics are available for the spinal route of administration and should be titrated to clinical effect or intolerable side effect. This article discusses the appropriate selection of patients for spinal analgesics, reviews current recommended infusion systems and current spinal analgesics, discusses possible complications, and includes practical suggestions for patient management.

Rational Use of Sublingual Opioids in Palliative Medicine

The sublingual administration of opioid analgesics has been a mainstay in the pain management of homebound dying hospice patients who are no longer able to swallow. It is also a potentially useful route of administration in other situations in which the oral route is not available and other routes are impractical or inappropriate. Potential advantages of the sublingual route include rapid analgesic onset and avoidance of hepatic first-pass metabolism. Pharmacokinetic and pharmacodynamic studies have yielded widely disparate data on sublingual morphine. Other opioids have been less studied. Available data suggests limited sublingual availability of hydrophilic opioids (e.g., morphine, oxycodone, and hydromorphone) and superior absorption of the lipophilic opioids (e.g., methadone and the fentanils). Buprenorphine, a potent, lipophilic, partial mu-opioid receptor agonist, appears promising but awaits further study.

Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia

A 51-year-old patient scheduled for surgery under general anaesthesia was accidentally given remifentanil 150 microg and propofol 1% 10 ml through an intracerebroventricular totally implantable access port placed in the right infraclavicular region, which was mistakenly thought to be an intravenous line. Severe pain in the head and neck caused the mistake to be discovered rapidly, and 20 ml of a mixture of cerebrospinal fluid and the anaesthetic drugs were aspirated from the implantable access port. The patient suffered no apparent adverse neurological sequelae.

Update in Cancer Pain Syndromes

Cancer pain assessment and management are integral to palliative medicine. This paper reviews recent publications in the period 1999-2004 in the broad categories of epidemiology, pain assessment, nonpharmacologic approaches to cancer pain (radiation therapy, anesthetic blocks, palliative surgery and chemotherapy, complementary and alternative medicine), and in nociceptive pain, neuropathic pain, visceral pain, and bone pain.

Methadone for treatment of cancer pain

Methadone is a unique mu opioid agonist, which also has delta receptor affinity and properties of N-methyl-D-aspartate receptor antagonism and monoamine reuptake inhibition. It is mainly used in the setting of uncontrolled pain or dose-limiting toxicity. Caution is advised when switching to methadone, especially from high doses of previous opioid, due to its variable conversion ratio and the potential for delayed toxicity due to its long half-life. Increasing evidence of risk also exists for a prolonged QT interval and torsades de pointes with very large doses of methadone. Methadone is likely safer when used at lower doses as a first-line opioid, but its potential as such has not received enough formal evaluation. Randomized controlled trials are needed to assess the effectiveness and safety of methadone compared with other opioids and to further evaluate its role in the treatment of neuropathic pain.

Understanding pain, part 2: pain management

This article is the second in a two-part series which explores pain and its management from a physiological perspective. Nurses play an important role in assessing and managing pain. Effective pain management by nurses requires them to have an understanding of the biological basis of the pain interventions which may be used to control pain. This article emphasizes the importance of pain assessment as a precursor for effective pain management and explores the biological basis of pain interventions which contribute to pain control. The role of non-pharmacological approaches in alleviating pain and their actions which contribute to pain relief are explored. The three main types of pharmaceutical agents used, non-opioids, opioids and adjuvant drugs, are introduced and their mechanisms of actions discussed.

Intrathecal ziconotide for refractory pain

For cancer and AIDS patients, 10-30% of pain is refractory to strong opioids, requiring intraspinal administration for pain management. Ziconotide is a selective N-type calcium channel blocker, which inhibits neurotransmitter release, and following intrathecal administration will affect primary nociceptive afferents. In 108 patients with previously unmanaged refractory pain despite the use of systemic or intrathecal opioids, in the initial titration phase, the mean Visual Analogue Scale of Pain Intensity scores improved more in the ziconotide group (53%) than the placebo group (18%). Serious adverse effects were more common in the ziconotide group (31%) than placebo group (10%) in the initial titration phase. In the 48 patients receiving ziconotide, who proceeded to the maintenance phase, the benefit of ziconotide was continued. Until a new approach with a better effectiveness/adverse effects profile than ziconotide for refractory pain emerges, further optimisation of ziconotide for use in the treatment of refractory pain should be undertaken.

Pain and Terminal Delirium Research in the Elderly

This article highlights new developments in assessment and management of pain and delirium.

Epidural and intrathecal analgesia is effective in treating refractory cancer pain

The use of neuraxial (intrathecal and epidural) analgesia has been suggested in treatment guidelines put forth for the treatment of refractory cancer pain. We review the literature and present our algorithm for using neuraxial analgesia. We also present our outcomes using this algorithm over a 28-month period. We used neuraxial analgesia in 87 of 4,107 patients, approximately 2% of those seen for pain consultation. Evaluation of those patients at an 8-week follow-up revealed improved pain control. After institution of neuraxial analgesia, there was a significant reduction in the proportion of patients with severe pain (defined as a "pain worst" score in the severe range of 7-10), from 86% to 17%, noted to be highly statistically significant. At follow-up, numerical pain scores decreased significantly from 7.9 +/- 1.6 to 4.1 +/- 2.3. No difference was noted between the intrathecal and epidural groups. Oral opioid intake after instituting neuraxial analgesia revealed a significant decrease from 588 mg/day oral morphine equivalents to 294 mg/day. At follow-up, self-reported drowsiness and mental clouding (0-10) also significantly decreased from 6.2 +/- 3.0 and 5.4 +/- 3.4 to 3.2 +/- 3.0 and 3.1 +/- 3.0, respectively. This retrospective review shows promising efficacy of neuraxial analgesia in the context of failing medical management.