Psychosocial predictors of children's postoperative pain

The purpose of this study was to investigate the influence of psychosocial variables in the prediction of children's pain intensity following surgery. Forty-two children, ages 7 to 17 years (M = 12.26, SD = 3.06), completed an interview 1 week prior to surgery assessing anticipatory distress related to their forthcoming surgery and history of coping strategy use. Following surgery, children reported the intensity of their pain using visual analog scales. Findings demonstrated that the majority of children experienced moderate to severe postoperative pain. Hierarchical multiple regression analyses revealed that psychosocial variables added to the prediction of children's postoperative pain after controlling for the influence of surgery-related and demographic variables. These findings lend initial support for the inclusion of psychosocial assessment measures (e.g., anticipatory surgery distress) in the preoperative assessment of pediatric patients who may be at risk for excessive postsurgical pain.     

Visual function in neurofibromatosis

We performed an open-label pilot study to define analgesic efficacy, acceptability, and toxicity of transdermal fentanyl in an ambulatory population of patients with cancer pain. Our 7-day study included 35 patients, all of whom had failed a trial of an opioid analgesic conventionally used for moderate pain. Patients received either a 25 micrograms/hr or 50 micrograms/hr fentanyl transdermal patch depending on prior opioid dose. Pain was measured daily utilizing visual analogue (VAS) and categorical (CAT) scales. Hours of nighttime sleep, quality of life, toxicities, and use of rescue medication were also assessed. There was a 24%-29% reduction in mean VAS and CAT pain scores as compared with the baseline and a 25% increase in mean hours of nighttime sleep. Fifty-nine percent of those patients responding (46% of all study patients) were satisfied to very satisfied with the analgesia provided by transdermal fentanyl. Six percent of all study patients were not at all satisfied with the pain relief obtained. Toxicities were similar to those seen with other opioids. No patient developed severe sedation or respiratory depression. The 25-50 micrograms/hr patch appears to be a safe starting dosage in ambulatory patients previously receiving opioids conventionally used for moderate pain.     

ECG anomalies and axis deviations in heart transplant recipients: MRI studies]

Side effects of morphine are common when given in titrated doses to control severe pain in advanced cancer. We report a case series of acutely ill cancer patients suffering from pain, complications of advanced disease, and opioid side effects. They were treated with intravenous (i.v.) ketorolac along with i.v. morphine using repeated dosing. Excellent pain relief with improvement in the opioid bowel syndrome was achieved. We found it possible to switch from IV ketorolac to oral ketorolac along with oral morphine for long-term pain control. Ketorolac can be well tolerated in high-dose, long-term use even in this frail patient population. An algorithm is presented for the suggested use of ketorolac as a morphine sparing agent. Potential methods for studying ketorolac further in this role are discussed.     

Molecular subtyping of Treponema pallidum subspecies pallidum

PURPOSE: Psychosocial distress and patient attitude towards psychosocial support as well as the correlations with clinical and sociodemographic characteristics should be assessed. METHODS: The stress due to cancer was measured in a consecutive sample of tumor patients at the start of radiotherapy (n = 117) by use of the Hornheide Questionnaire. In addition, the interest of these patients in professional psychosocial support was assessed with the help of the Questionnaire for Psychosocial Support. RESULTS: Patients in the course of radiotherapy and patients with a poor prognosis and advanced disease were more strongly distressed. 32.7% of patients wished professional psychosocial support from the oncologist treating them, 40.6% of the patients wished support from the oncologist and additionally from a psychotherapist or social worker. Interest in professional psychosocial support correlated with the amount of distress, but not with sociodemographic variables. CONCLUSIONS: Results stress the importance of training programs for oncologists in order to improve their ability to detect psychosocial distress in cancer patients and to offer adequate emotional support to them.     

Touch relieves stress and pain

The contribution of non-biomedical factors to the experience of pain in the cancer patient has not been well established. Although intensity of pain reports cannot be fully explained by extent of identifiable nociception or neuropathy, behavioral factors have been only modest predictors of cancer pain report. Most studies that have demonstrated associations between pain and behavioral factors were conducted with highly selected groups of patients with all data collected concurrently. Thus the predictive value of the behavioral factors has been indeterminable. In this study, 358 bone marrow transplant patients (196 male, 162 female) completed pretransplant biomedical, physical functioning, psychological and social evaluations. For 25 days following transplantation, patients completed daily visual analogue scale oral pain reports and nurses recorded opioid use. At least once a week oral medicine staff completed a standardized, validated measure of observable oral mucositis as a measure of nociception. Results indicated that psychological and social variables were significant predictors of pain in this sample. Distress, particularly distress specific to the transplant, was the strongest predictor, while self-efficacy and coping style were weaker, but significantly associated with pain report for either men or women. While the psychological and social variables were significant predictors of pain, most of the variance in pain report was explained by biomedical variables rather than psychological or social variables. These results are consistent with those of previous research and indicate that biopsychosocial associations predate the onset of pain, but are at best modest predictors of cancer patients who will report greater or lesser pain. Clinical applications and limits of these data are discussed, particularly in relation to emotional distress, coping style and the differences found in predicting pain in men and women.     

The impact of psychosocial features of employment status on emotional distress in chronic pain and healthy comparison samples

This study examined the extent to which measures of psychosocial features of employment status predict emotional distress in chronic pain (n = 83) and healthy comparison (n = 88) samples. Participants completed measures of emotional distress, pain severity, psychosocial features of employment status, and demographic data. After controlling for length of current unemployment, number of pain sites, and level of current pain severity, psychosocial measures (structured and purposeful time use, perceived financial security, skill use, social support form formal sources) were significant predictors of emotional distress in the chronic pain sample. Similar results were obtained for the healthy comparison sample. Structured and purposeful time use emerged as the most significant individual predictor of emotional distress for both samples. Findings are discussed in terms of their potential implications for treating chronic pain patients and the need to develop multidimensional measures that assess features of employment status within chronic pain samples.     

Respiratory depression following administration of intrathecal bupivacaine to an opioid-dependent patient

OBJECTIVE: To document two cases of respiratory depression in patients receiving morphine once the stimulating effect of pain on respiration was removed by bupivacaine. CASE SUMMARIES: Case 1: A 72-year-old 84-kg white man with cancer of the bladder and bone metastases had intense back and leg pain that was treated with intrathecal morphine for 6 months at an increasing dosage up to 10 mg twice daily. The intrathecal route was avoided for 4 days because of a suspected local infection at the site of the intrathecal catheter. During this 4-day period the patient received extended-release morphine and subcutaneous morphine daily. When the intrathecal route was used again, he received an identical dose of morphine plus bupivacaine and epinephrine. Ten minutes after the injection, fatal respiratory distress occurred. Case 2: A 92-year-old white woman was admitted for revascularization of arteritis on her left leg. To treat a painful sacrum and heel bedsores, she received extended-release oral morphine for 8 days. Induction of the intrathecal anesthesia was performed with bupivacaine. After 10 minutes, the patient became subcomatose, with miosis and apnea. Intravenous naloxone restored spontaneous respiration and normal consciousness. CONCLUSIONS: Pain is a physiologic antagonist of the respiratory depressant effects of opioid analgesics. By reducing pain stimulation, bupivacaine may make patients more susceptible to opioid respiratory depression. Such situations require titration of bupivacaine and other analgesics as well as increased monitoring of the patient.     

Opioid therapy for chronic noncancer back pain. A randomized prospective study

STUDY DESIGN: A randomized, open, long-term, repeated-dose comparison of an anti-inflammatory drug and two opioid regimens in 36 patients with back pain. OBJECTIVES: To examine the long-term safety and efficacy of chronic opioid therapy in a randomized trial of patients with back pain. METHODS: All participants underwent a 4-week washout period of no opioid medication before being randomly assigned to one of three treatment regimens for 16 weeks: 1) naproxen only, 2) set-dose oxycodone, or 3) titrated-dose oxycodone and sustained-release morphine sulfate. All patients then were assigned to a titrated dose of opioids for 16 weeks and then gradually tapered off their medication for 12 weeks. Finally, all participants were monitored for a 1-month posttreatment washout period. Each patient was called once a week for a report on pain, activity, mood, medication, hours awake, and adverse effects and was monitored carefully for signs of abuse and noncompliance. RESULTS: Weekly reports during the experimental phase showed the titrated-dose group to have less pain (P < 0.001) and less emotional distress (P < 0.001) than the other two groups. Both opioid groups were significantly different from the naproxen-only group. During the titration phase, patients also reported significantly less pain and improved mood. Few differences were found in activity or hours asleep, or between average pretreatment and posttreatment phone-interview and questionnaire variables. No adverse events occurred, and only one participant showed signs of abuse behavior. CONCLUSIONS: The results suggest that opioid therapy has a positive effect on pain and mood but little effect on activity and sleep. Opioid therapy for chronic back pain was used without significant risk of abuse. However, tapered-off opioid treatment is palliative and without long-term benefit.     

A case of paraquat poisoning and subsequent fatality presenting to an emergency department

Paraquat (1,1'-dimethyl-4,4'-dipyridylium) is an herbicide associated with both accidental and intentional ingestion, leading to severe and often fatal toxicity. Prognosis is largely dependent on the amount of paraquat absorbed. Rapid identification of the symptoms of paraquat toxicity (burns or ulceration at the site of ingestion or injection, acute respiratory distress, and renal failure) can facilitate early treatment intervention to limit absorption. We report a case of a 71-year-old man with a suicidal ingestion of paraquat 2 days prior to presentation. Serum paraquat levels, time elapsed since ingestion, and clinical symptoms all indicated poor prognosis. The patient developed severe respiratory distress and progressive renal failure, and died 6 days after admission to the hospital.     

Morphine versus methadone in the pain treatment of advanced-cancer patients followed up at home

PURPOSE: The aim of this study was to evaluate the analgesic and adverse effects and the doses of methadone in comparison to morphine. PATIENTS AND METHODS: A prospective randomized study was performed in a sample of 40 patients with advanced cancer who required strong opioids for their pain management. Patients were treated with sustained-release morphine or methadone in doses titrated against the effect administered two or three times daily according to clinical need. Opioid doses, adjuvant medications, symptoms associated with opioid therapy, pain intensity, and pain mechanisms were recorded. The opioid escalation indices in percentage (OEI%) and milligrams (OEImg) were calculated. The effective analgesic score (EAS) that monitors the analgesic consumption-pain ratio was also calculated at fixed weekly intervals. RESULTS: differences in pain intensity were found. Patients treated with methadone reported values of OEI significantly less than those observed in patients treated with morphine. Seven patients in the methadone group maintained the same initial dosage until death, whereas only one patient in the morphine group did not require opioid dose escalation. A more stable analgesia in time in patients treated with methadone was shown by the low number of gaps in EASs reported. Symptom frequencies and intensities were similar in the two groups. CONCLUSION: Methadone is a drug of indisputable value in the treatment of cancer pain, and an unbalanced focus on the risks of inappropriate use rather than the benefits should not compromise the use of a relevant alternative to morphine in the management of cancer pain.     

A prospective analysis of acceptance of pain and values-based action in patients with chronic pain.

Objective: Acceptance of pain and values-based action appear important in the emotional, physical, and social functioning of individuals with chronic pain. The purpose of the current study was to prospectively investigate these combined processes. Method: 115 patients attending an assessment and treatment course for chronic pain in the U.K. completed a standard set of measures on two occasions separated by an average of 18.5 weeks. Results: Correlation analyses showed that acceptance of pain and values-based action measured at Time 1 were significantly correlated with pain, pain-related distress, pain-related anxiety and avoidance, depression, depression-related interference with functioning, and physical and psychosocial disability measured at Time 2. Multiple regression analyses, in which pain and relevant patient background variables were controlled, showed that the combined acceptance and values measures accounted for between 6.5% and 27.0% of variance in six key measures of patient functioning later in time. Conclusion: These results support the importance of acceptance and values-related processes in relation to chronic pain. These results also encourage continued applications of a functional contextual model of psychopathology, the model underlying Acceptance and Commitment Therapy and related approaches such as Contextual Cognitive-Behavioral Therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Knowledge and attitudes of health-care providers toward cancer pain management: a comparison of physicians, nurses, and pharmacists in the state of New Hampshire

The knowledge and attitudes toward cancer pain management of physicians, nurses, and pharmacists in the state of New Hampshire were examined through the use of a statewide survey. Many of the providers who completed the survey, and thus indicated that they treated patients with cancer pain on a regular basis, were not pain or oncology specialists. Most of these providers were quite well informed about the fundamentals of cancer pain management. Approximately 90% of providers in all three groups were not concerned about addiction among cancer patients. Yet, there was a small percentage of providers who responded in less than optimal ways to items dealing with opioid pharmacology, pain assessment, and the importance of pain relief. Comparison of responses among provider groups indicated that nurses were the most knowledgeable and pharmacists the least knowledgeable about pain assessment. Physicians were the most knowledgeable regarding opioid pharmacology but seemed the least committed to providing optimal pain relief. Further analysis identified a small group of physicians that included a disproportionately high percentage of family practitioners and surgeons who consistently responded in less than optimal ways to items dealing with the importance of pain relief. The results of this study indicate a continuing need for broad-based educational programs in cancer pain management and for new initiatives focused on practitioners who see relatively few cancer patients and may have difficulty accessing traditional educational programs.     

Psychosocial impact of illness intrusiveness moderated by self-concept and age in end-stage renal disease.

This study assesses whether a person's self-concept as a "chronic kidney patient" differentially moderates the psychosocial impact of illness intrusiveness—illness-induced lifestyle disruptions—across the life span. Renal transplant (n?=?52) and maintenance dialysis patients (n?=?49) completed the Illness Intrusiveness Ratings Scale, a semantic-differential self-concept measure, and structured interviews measuring psychosocial well-being and emotional distress. Across ages, distress rose with increasing illness intrusiveness when self-concept was similar, but not dissimilar, to the chronic kidney patient stereotype. The relation between illness intrusiveness and psychosocial well-being differed significantly between younger and older respondents depending on whether they construed themselves as similar versus dissimilar to the chronic kidney patient. Although self-definition moderates the psychosocial impact of chronic disease, this varies across the life span and across affect states. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chemical interventions for pain.

Discusses properties and pharmacological effects of medications for pain, including peripherally acting analgesics, centrally acting narcotics, and adjuvant analgesics including antidepressants. The role of the endogenous opioid system in pain and depression is discussed. Clinical management issues in both inpatient and outpatient settings are explored, with emphasis on the need to address the psychosocial context in which medications are prescribed. (52 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Lumbar strengthening in chronic low back pain patients. Physiologic and psychological benefits

The effects of exercise for isolated lumbar extensor muscles were examined in 54 chronic low-back pain patients. Subjects were randomly assigned to a 10-week exercise program (N = 31) or a wait-list control group (N = 23). Results indicated a significant increase in isometric lumbar extension strength for the treatment group and a significant reduction in reported pain compared with the control group (P 0.05). Treated subjects reported less physical and psychosocial dysfunction whereas the control group increased in pain, and physical and psychosocial dysfunction. There were no concomitant changes in reported daily activity levels. These results show that lumbar extension exercise is beneficial for strengthening the lumbar extensors and results in decreased pain and improved perceptions of physical and psychosocial functioning in chronic back pain patients. However, these improvements were not related to changes in activities or psychological distress.     

Mediators of a brief hypnosis intervention to control side effects in breast surgery patients: Response expectancies and emotional distress.

Objective: The present study was designed to test the hypotheses that response expectancies and emotional distress mediate the effects of an empirically validated presurgical hypnosis intervention on postsurgical side effects (i.e., pain, nausea, and fatigue). Method: Women (n = 200) undergoing breast-conserving surgery (mean age = 48.50 years; 63% White, 15% Hispanic, 13% African American, and 9% other) were randomized to a hypnosis or to an attention control group. Prior to surgery, patients completed assessments of hypothesized mediators (response expectancies and emotional distress), and following surgery, patients completed assessments of outcome variables (pain, nausea, and fatigue). Results: Structural equation modeling revealed the following: (a) Hypnotic effects on postsurgical pain were partially mediated by pain expectancy (p p = .12); (b) hypnotic effects on postsurgical nausea were partially mediated by presurgical distress (p = .02) but not by nausea expectancy (p = .10); and (c) hypnotic effects on postsurgical fatigue were partially mediated by both fatigue expectancy (p = .0001) and presurgical distress (p = .02). Conclusions: The results demonstrate the mediational roles of response expectancies and emotional distress in clinical benefits associated with a hypnotic intervention for breast cancer surgical patients. More broadly, the results improve understanding of the underlying mechanisms responsible for hypnotic phenomena and suggest that future hypnotic interventions target patient expectancies and distress to improve postsurgical recovery. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prospective evaluation of pain in exocrine pancreatic cancer

BACKGROUND: Although pain is the most feared part of the terminal life of many patients with cancer, the intensity and the quality of the pain is all too often only scantly described. METHOD: The quality and quantity of pain were prospectively registered by five variables, including a visual analogue scale (VAS), in 46 consecutive patients with exocrine pancreatic cancer. RESULTS: Twenty-seven percent of the patients were completely pain free and 24 (53%) patients reported little or no pain at the time of diagnosis. Only 5 (11%) patients had severe pain. Patients with tumors in the head of the pancreas had less pain than patients with cancer in the body or tail of the pancreas, which could not be explained by stage or size of the tumor. With time there were less and less patients with little or no pain (VAS 0-2), but after 8 and 10 weeks about one third of the patients were still without any pain (VAS < or = 0). With time there was also a tendency to treat patients more frequently with morphine in spite of a low pain score. Preoperative pain simply measured with VAS is an addition to prognostic information. CONCLUSION: Pain in pancreatic cancer is not as common as usually stated at the time of diagnosis, but is related to the site of the tumor. Eventually more patients are treated with opioid drugs. Evaluation of the pain pattern is an addition to prognostic information.     

A short (3-day) course of azithromycin tablets versus a 10-day course of amoxycillin-clavulanic acid (co-amoxiclav) in the treatment of adults with lower respiratory tract infections and effects on long-term outcome

The majority of patients with cancer experience significant pain during their illness. Most cancer pain can be readily managed with oral analgesic therapy. However, cancer pain is often under-treated because of poor communication between physicians and patients and inadequate training of physicians in pain management. A systematic pain-oriented history, pain intensity assessment physical exam, and diagnostic evaluation are needed to delineate the cause of pain. A therapeutic plan can then be tailored to the patient's needs, preferences, and severity of pain. This paper reviews the evaluation and treatment of cancer pain, with guidelines for initiating and monitoring non-opioid and opioid analgesic therapy.