Chronic and Refractory Pain: A Systematic Review of Pharmacologic Management in Oncology

Using a multimodal approach to manage difficult visceral cancer pain: A case study

Difficult visceral cancer pain is defined as pain that does not improve with conventional non-pharmacological and pharmacological strategies, including opioids and adjuvants, and occurs in up to 15% of patients with cancer. In oncological practice, we must be prepared to establish strategies for dealing with such complex cases. Different analgesic strategies have been described in the literature, including managing refractory pain through palliative sedation; however, this might become a dilemma from a clinical and bioethical point of view in end-of-life situations. We present the case of a young male patient with moderately differentiated intestinal-type adenocarcinoma of the left colon, with intra-abdominal sepsis, and for whom despite the multimodal treatment for difficult visceral cancer pain, the pain was refractory leading to palliative sedation. Difficult visceral cancer pain is a pathology that affects the quality of life of patients and is a challenge for pain specialists, for both pharmacological and non-pharmacological management.

Non-pharmacological integrative therapies for chronic cancer pain

Objective

Chronic pain is one of the most detrimental symptoms exhibited by cancer patients, being an indication for opioid therapy in up to half of the patients’ receiving chemotherapy and in 90% of advanced cases. Various successful non-pharmacological integrative therapy options have been explored and implemented to improve the quality of life in these patients. This review aims to highlight the mechanisms implicated; assessment tools used for cancer pain and summarize current evidence on non-pharmacological approaches in the treatment of chronic cancer pain.

Data sources

A review of the literature was conducted using a combination of MeSH keywords including “Chronic cancer pain,” “Assessment,” “Non-pharmacological management,” and “Integrative therapy.”

Data summary

Data on the approach and assessment of chronic cancer pain as well as non-pharmacological integrative options have been displayed with the help of figures and tables. Of note, non-pharmacological integrative management was divided into three subcategories; physical therapy (involving exercise, acupuncture, massage, and transcutaneous electric nerve stimulation), psychosocial therapy (e.g. mindful practices, supportive therapy), and herbal supplementation.

Conclusions

The use of non-pharmacological integrative therapy in the management of chronic cancer pain has been grossly underestimated and must be considered before or as an adjuvant of other treatment regimens to ensure appropriate care.

Relationship between prescribed opioids, pain management satisfaction, and pain intensity in oncology outpatients

BACKGROUND

Pain is the most severe and commonest symptom for patients with cancer. Patients' pain management satisfaction is an essential indicator of quality care and further affects their willingness to seek care.

PURPOSE

This study aimed to examine the correlations between patients' prescribed opioids, pain management satisfaction, and pain intensity.

METHODS

This study adopted a cross-sectional correlation design, recruited a total of 123 patients with cancer pain through convenience sampling, and used two research scales, namely the Chinese version of the Pain Treatment Satisfaction Scale and the Brief Pain Inventory-Short Form.

RESULTS

The findings indicated that the correlations of prescribed opioid dosage with pain management satisfaction (r =  - .10, p > .05) and pain intensity (worst pain, least pain, average pain, and pain right now; r =  - .05 to .01, p > .05) were nonsignificant. The correlations of pain management satisfaction with pain intensity (r = .24 to .32, p < .01), pain interference (r = .32, p < .01), and pain relief (r =  - .25, p < .01) were all significant, but that with the worst pain (r = .06, p > .05) was nonsignificant.

CONCLUSIONS

Medical professionals providing cancer pain management should focus on medicines strategies and individuals' pain relief requirements. In particular, patients with the worst pain require extra investigations into their needs, and their satisfaction with their level of pain should be further evaluated.

[Radiosurgical hypophysectomy in cancer pain treatment. Literature review and clinical case]

Cancer pain is one of the main problem in modern medicine. According European Society for Medical Oncology data, cancer pain prevalence is 64% among patient with terminal stage of disease and in 46% standard pain therapy was ineffective. Radiosurgical hypophysectomy is one of the important and perspective method in cancer pain treatment. This method could be offered patient with chronic disease. According literature review, endocrinology complications were very rare and occurred 10 months after therapy. Value of analgesic effect was 70-90%. In some trials, procedure was effective not only nociceptive, but also in neuropathic pain. More trials require for determination of indications and mechanism of action. The case of successful relief of resistant pain in patient with pancreatic cancer by means of radiosurgical hypophysectomy is described.

Neuroinflammation, Pain and Depression: An Overview of the Main Findings

Chronic pain is a serious public health problem with a strong affective-motivational component that makes it difficult to treat. Most patients with chronic pain suffer from severe depression; hence, both conditions coexist and exacerbate one another. Brain inflammatory mediators are critical for maintaining depression-pain syndrome and could be substrates for it. The goal of our paper was to review clinical and preclinical findings to identify the neuroinflammatory profile associated with the cooccurrence of pain and depression. In addition, we aimed to explore the regulatory effect of neuronal reorganization on the inflammatory response in pain and depression. We conducted a quantitative review supplemented by manual screening. Our results revealed inflammatory signatures in different preclinical models and clinical articles regarding depression-pain syndrome. We also identified that improvements in depressive symptoms and amelioration of pain can be modulated through direct targeting of inflammatory mediators, such as cytokines and molecular inhibitors of the inflammatory cascade. Additionally, therapeutic targets that improve and regulate the synaptic environment and its neurotransmitters may act as anti-inflammatory compounds, reducing local damage-associated molecular patterns and inhibiting the activation of immune and glial cells. Taken together, our data will help to better elucidate the neuroinflammatory profile in pain and depression and may help to identify pharmacological targets for effective management of depression-pain syndrome.

Cancer Pain Management Considerations in Older Adults

OBJECTIVE

To address the pharmacokinetics and pharmacodynamics of aging and its impact on the complexities of pain management in older adults with cancer. To describe assessment and nursing strategies for individualized care and side effect management DATA SOURCES: Peer-reviewed articles.

CONCLUSION

Cancer pain is a complex problem in older adults because of the variations in aging and alterations in pharmacokinetics and pharmacodynamics. Pain management must be based on thorough assessment, incorporating the unique factors of each patient. Ongoing follow-up is critical to ensure adequate pain control with optimization of functional status.

IMPLICATIONS FOR NURSING PRACTICE

Awareness of physiological changes of aging is important in caring for older adults. Oncology nurses can play a key role in the assessment of older adults with cancer and education of patients and caregivers regarding pain medications, side-effects, and oral adherence.

Pain Management in the Cancer Survivor

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.

Assessment and Management of Cancer Pain in Older Adults: Strategies for Success

Pain is a significant problem in older adults with cancer as older adults often receive suboptimal pain management. While overmedication can lead to adverse effects, under management of pain can lead to physiological and psychological problems such as functional decline and depression. This manuscript will discuss the assessment and management of pain in older adults, in consideration of the pharmacodynamic changes related to aging and other individual considerations. Current evidence from filtered and unfiltered sources, PubMed, current guidelines. Unrelieved pain can have a detrimental impact on older adults. A team approach is essential to assess patients at each encounter, consider the social environment in which the patient resides, and employ pharmacologic and nonpharmacologic strategies that are evidence-based and are tailored to the specific cancer pain syndrome.