Cancer pain management: basic information for the young pain physicians

Multidisciplinary Firms and the Treatment of Chronic Pain: A Case Study of Low Back Pain

Sixteen million people suffer with chronic low back pain and related healthcare expenditures can be as high as $USD 635 billion. Current pain treatments help a significant number of acute pain patients, allowing them to obtain various treatments and then “exit the market for pain services” quickly. However, chronic patients remain in pain and need multiple, varying treatments over time. Often, a single pain provider does not oversee their care. Here, we analyze the current pain market and suggest ways to establish a new treatment paradigm. We posit that more cost effective treatment and better pain relief can be achieved with multi-disciplinary care with a provider team overseeing care.

Low-dose ketamine adjuvant treatment for refractory pain in children, adolescents and young adults with cancer: a pilot study

OBJECTIVES

Ketamine, an N-methyl-D-aspartate receptor antagonist, is effective at relieving adult cancer pain, although there have been very few reports to date regarding its use in children and in adolescents and young adults (AYA). This study assessed the efficacy, safety and opioid-sparing effects of low doses of ketamine added to opioid analgesics to alleviate persistent cancer pain.

METHODS

This prospective, multicentre, observational trial collected data regarding demographics, pain characteristics, pain score assessment within the first 48 hours of ketamine administration, tolerance and satisfaction from 38 patients aged 2-24 years prescribed with ketamine as an adjuvant antalgic for refractory cancer pain in 10 French paediatric oncology centres.

RESULTS

The mean visual analogue scale pain score decreased from 6.7 to 4.3 out of 10 (n=39, p<0.001) from day 1 to day 3 and by at least 2 points in 56% of the patients (n=22) 48 hours after initiation of ketamine. Nine patients experienced poor tolerance (≥2 side effects), all with infusion rates lower than 0.05 mg/kg/hour. None had limiting toxicities. An opioid-sparing effect was highlighted in four patients. Fifty-four per cent of the prescribers and 47% of the patients found the addition of ketamine 'very helpful'.

CONCLUSIONS

Low doses of ketamine as an adjuvant to opioids significantly reduced the intensity of pain in half of the study population. A tendency towards better pain control is shown, although a lack of statistical power somewhat limits our conclusions, especially in children. Nevertheless, ketamine may be a useful option for improving the treatment of refractory pain in children and AYA with cancer.

Predictors and Prevalence of Pain and Its Management in Four Regional Cancer Hospitals in India

PURPOSE

More than 1 million new occurrences of cancer are diagnosed in India annually. Among patients with cancer, pain is a common and persistent symptom of the disease and its treatment. However, few studies to date have evaluated the prevalence of pain and the adequacy of pain management in Indian hospitals. This cross-sectional study aimed to assess the prevalence and sociodemographic patterns of cancer pain and pain management among a sample of inpatients and newly registered outpatients at four large regional cancer centers in India.

METHODS

A sample of 1,600 patients with cancer who were current inpatients or newly registered outpatients were recruited and administered a questionnaire that was based on the Brief Pain Inventory. The survey tool included questions on demographics, medical history, and extent of clinical pain experienced. In addition, a pain management index score was created to link the severity of cancer pain with medication prescribed to treat it.

RESULTS

A total of 88% of patients reported pain in the past 7 days, and approximately 60% reported that their worst pain was severe. Several demographic and medical characteristics of the study population predicted severe pain, including the following: lower educational level, outpatient status, and debt incurred as a result of illness. A total of 67% of patients were inadequately treated with analgesics. Inadequate pain management was associated with both treatment hospital and patient type, and patients who reported debt as a result of their illness were more likely to have inadequate pain management.

CONCLUSION

A majority of Indian patients with cancer experience significant pain and receive inadequate pain management. Improvement of pain management for Indian patients with cancer is needed urgently.

Difficult conversations: from diagnosis to death

BACKGROUND

Communication is the cornerstone of good multidisciplinary medical care, and the impact of conversations about diagnosis, treatment, and prognosis is indisputable. Healthcare providers must be able to have difficult conversations that accurately describe diagnostic procedures, treatment goals, and the benefits and/or risks involved.

METHODS

This paper reviews the literature about the importance of communication in delivering bad news, the status of communication training, communication strategies, and psychosocial interventions.

RESULTS

Although many published guidelines address difficult communication, communication training is lacking. Consequently, many clinicians may have difficulties with, or in the worst-case scenario, avoid delivering bad news and discussing end-of-life treatment. Clinicians also struggle with how to have the last conversation with a patient and how to support patient autonomy when they disagree with a patient's choices.

CONCLUSION

There is a clinical imperative to educate physicians and other healthcare workers on how to effectively deliver information about a patient's health status, diagnostic avenues to be explored, and decisions to be made at critical health junctions. Knowing how to implement the most rudimentary techniques of motivational interviewing, solution-focused brief therapy, and cognitive behavioral therapy can help physicians facilitate conversations of the most difficult type to generate positive change in patients and families and to help them make decisions that minimize end-of-life distress.

An Exploratory Analysis of Levels of Evidence for Articles Published in Indian Journal of Palliative Care in the years 2010-2011

CONTEXT

Indian Journal of Palliative Care (IJPC) provides a comprehensive multidisciplinary evidence base for an evidence-informed clinical decision making.

AIMS

To analyze the levels of evidence of articles published in IJPC in the years 2010-2011.

SETTINGS AND DESIGN

Systematic review of palliative care journals.

MATERIALS AND METHODS

Systematic review of articles was done and was scored according to Center for Evidence-Based Medicine levels of evidence into any of the five grades. The articles were categorized based upon article type, number of authors, study approach, age focus, population focus, disease focus, goals of care, domains of care, models of care, and year of publication.

STATISTICAL ANALYSIS USED

All descriptive analysis was done using frequencies and percentiles, and association between all categorical variables was done using Chi-square test at 95% confidence interval (CI) using Statistical Package for Social Sciences (SPSS) version 16 for Windows (SPSS Inc, Chicago, IL).

RESULTS

There was a greater prevalence of low level evidence (level 4: n = 46, 51%; level 5: n = 35, 39%) among the 90 selected articles, and article type (original articles with higher level of evidence, P = 0.000), article approach (analytical studies with higher level of evidence, P = 0.000), domains of palliative care (practice-related studies with higher level of evidence, P = 0.000) and models of care (biological or psychosocial model with higher level of evidence, P = 0.044) had a significant association with the grade of levels of evidence. Association with other factors was not statistically significant (P < 0.05).

CONCLUSIONS

The levels of research evidence for palliative care provided by articles published in IJPC were predominantly level 4 and level 5, and there is scope for more high quality evidence to inform palliative care decisions in the developing countries.

The Fifth Vital Sign

Adolescent oncology patients with chronic pain require holistic management using interdisciplinary care, multimodal therapies, and family-centered treatment. Adolescents are at a crucial stage of development and require unique assessment that incorporates seeking their input, valuing their opinion, and establishing a developmentally appropriate treatment plan to give them a sense of control. This article discusses the essential elements of assessment that pediatric nurse practitioners should use when evaluating chronic pain in this unique patient population. A comprehensive assessment should determine the biological, psychosocial, and developmental functioning of the patient through objective and subjective measurements. The purpose of this literature review is to outline the mainstays of evaluating pain in a vulnerable population. Ascertaining the barriers that lead to underreporting and undertreating this symptom may lead to more effective management. This article assembles concepts established in research conducted on adolescents with nonmalignant chronic pain and studies on pain in the general pediatric oncology population to assist in evaluating adolescent oncology patients with chronic pain.