Treating chronic pain

Quantifiable and measurable methods accurately assess pain severity and successfully guide physicians in determining which medications and modalities are appropriate and necessary for the treatment of chronic pain. A variety of pain assessment scales and the World Health Organization's three-step analgesic ladder can be the starting point for successful pain management.     

Management of pain in the cancer patient

Pain is the most common symptom experienced in patients with advanced cancer. This pain may be acute, chronic, or intermittent, and often has a definable origin, usually related to tumor recurrence and treatment. The goal of therapy is to provide patients with enough pain relief to enable them to tolerate diagnostic and therapeutic manipulations and allow them freedom of movement and choice, while limiting medication-induced adverse effects. Morphine is the medication of choice, and is available in a sustained-release oral formulation with convenient around-the-clock administration every 8 to 12 hours. Morphine can also be administered subcutaneously, intravenously, and rectally, which provides enhanced flexibility for dosing patients unable to take oral medications. The transdermal fentanyl patch may provide a convenient dosage-form alternative if oral morphine preparations are not tolerated. Some patients with advanced cancer may require other adjunctive medications such as nonsteroidal anti-inflammatory agents, tricyclic antidepressants, steroids, or benzodiazepines, as well as psychologic techniques, to assist in pain management.     

Glial fibrillar acidic protein in peripheral nerve tumors in rats

Cancer education merits a coordinated, vertical curriculum and an integrated planning strategy. It has become clear that it is as important to teach the techniques of supportive care in oncology as it is to teach the concepts of cancer biology, pathology, epidemiology, prevention, detection and aggressive treatments. Our aim is to determine whether the medical school and nursing school curricula give the students an introduction to the concepts of supportive care of the cancer patient. The spectrum of such supportive care encompasses a wide range of issues working towards a common goal of providing overall comfort with an emphasis on quality of life, and runs parallel with specific therapeutic strategies and associated problems. Do the graduate medical student and nursing student understand that cancer management is multidisciplinary and team-based? That the approach to pain management not only includes the administration of pain medications, but should also evaluate pain assessment and anesthetic, neurosurgical and behavioral approaches? That nausea and vomiting associated with chemotherapy can be ameliorated to a certain extent? That infections are common but algorithms exist for prevention and therapy? That certain metabolic complications are unique to cancer patients? That transfusions are vital procedures in patients with neoplasms undergoing aggressive treatments but are associated with certain risks and complications? That there are serious psychosocial, ethical and legal needs to be considered? To address these issues, the American Cancer Society Professors of Clinical Oncology, the American Cancer Society Professors of Oncology Nursing and the United States Cancer Center Directors were surveyed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Polyethylene wear of the Optifix cementless acetabular component after 5 years

We describe seven patients who developed symptoms including severe headache, circumoral paresthesia, and facial flushing during high-dose carmustine (BCNU) infusion as part of the preparative regimen for autologous peripheral blood stem cell (PBSC) transplantation for metastatic breast cancer. Five patients responded to pain medications, including partial and complete opiate receptor agonists. Premedication of subsequent doses of BCNU with corticosteroids, pain medications, or benzodiazepines lessened, but did not prevent the same symptoms from recurring. The incidence and mechanism of this toxicity are unknown, but this adverse syndrome should be considered when administering high-dose BCNU infusions.     

The use of complementary medications by cancer patients attending an outpatient pain and symptom clinic

Complementary medications appear to be gaining popularity among cancer patients. When we surveyed 143 advanced cancer patients attending an outpatient pain and symptom clinic at a regional cancer centre as to their use of complementary medications and nutritional supplements, we found 37% (53/143) to be making use of complementary medications. Users tended to be younger (mean age 53.3 years) and have a preference for purchase from health stores, with 61% of complementary medications being bought there. Health store staff were the primary recommenders for both men and women and especially for those over 60 years of age. Of the 197 complementary medications purchased, 78 (39.6%) were herbs, 67 (32.5%) were vitamins, 13 (6.6%) were minerals, 21 (10.7%) were other medications including shark cartilage, and 21 (10.7%) could not be identified. Both anticancer effect and the promotion of well-being were prominent among the stated reasons for using these medications.     

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.     

Breast cancer and benign breast disease patients evaluated in relation to oxidative stress

The 'WHO Analgesic Ladder' is a well validated approach for the selection of appropriate analgesic therapy for cancer pain as well as pain in AIDS. The mainstay of analgesic intervention for cancer and AIDS pain of moderate to severe intensity continues to be the appropriate use of opioid analgesics. There is, however, a growing appreciation for the role of adjuvant analgesics, such as antidepressants and other psychotropic medications, at each step of the WHO Analgesic Ladder, particularly in the treatment of neuropathic pain. Knowledge of the indications and usefulness of psychotropic analgesic drugs in cancer and AIDS pain populations will be most important to clinicians practicing in psycho-oncology/AIDS settings, particularly since these drugs are useful not only in the treatment of psychiatric complications of cancer and AIDS, but also as adjuvant analgesic agents in the management of pain. This paper reviews the literature on the use of antidepressants, psychostimulants, neuroleptics, anticonvulsants and other psychotropic analgesics in the management of cancer and AIDS pain. Mechanisms of analgesia, drug selection, and recommendations for clinical usage are discussed. The appropriate and timely use of psychotropic adjuvant analgesic drugs represents an opportunity for active psychiatric contribution to the multidisciplinary management of cancer and AIDS pain.     

Treatment of cancer-related pain: when orally administered medications fail

OBJECTIVE: To summarize the available pain-relieving interventions other than oral medications for cancer-related pain. DESIGN: The pertinent literature is reviewed, and the various options for treating pain in patients with cancer are discussed. MATERIAL AND METHODS: The appropriate situations for use of parenteral administration of opioids, spinal analgesia, neural blockade, and neurosurgical treatment are outlined, and the potential problems and complications associated with these techniques are described. RESULTS: The basic approach to the management of pain in patients with cancer is to begin treatment with less potent analgesic agents early and to progress toward use of more potent pharmaceutical agents, adjuvant drugs, and invasive procedures as needed for alleviation of pain. With parenteral administration of opioids, the dosage can be adjusted rapidly, and therapy can be continued even though a patient may have gastrointestinal dysfunction. A portable ambulatory infusion pump can be used in selected patients. The major advantage of spinal opioid analgesia is the intense analgesia provided with minimal side effects. The potential complications and the availability of treatment alternatives have limited the use of neurolytic blocks, which usually provide only temporary relief of pain. In carefully selected patients with pancreatic or other upper gastrointestinal neoplasms, however, neurolytic celiac plexus and splanchnic nerve blocks are effective. Patients who fail to respond to conservative interventions may be candidates for neurosurgical procedures, such as spinal cord, cortical, or brain-stem stimulation or neuroablative operations (most commonly, cordotomy). CONCLUSION: Cancer-related pain continues to be a major problem, and clinicians should be aware of the availability of effective treatment strategies and techniques. When orally administered medications fail to control pain or cause excessive side effects, patients should be referred to an appropriate specialist or medical center for consideration of other pain-relieving techniques.     

Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology

CONTEXT: Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor. OBJECTIVE: To evaluate the adequacy of pain management in elderly and minority cancer patients admitted to nursing homes. DESIGN: Retrospective, cross-sectional study. SETTING: A total of 1492 Medicare-certified and/or Medicaid-certified nursing homes in 5 states participating in the Health Care Financing Administration's demonstration project, which evaluated the implementation of the Resident Assessment Instrument and its Minimum Data Set. STUDY POPULATION: A group of 13 625 cancer patients aged 65 years and older discharged from the hospital to any of the facilities from 1992 to 1995. Data were from the multilinked Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database. MAIN OUTCOME MEASURES: Prevalence and predictors of daily pain and of analgesic treatment. Pain assessment was based on patients' report and was completed by a multidisciplinary team of nursing home personnel that observed, over a 7-day period, whether each resident complained or showed evidence of pain daily. RESULTS: A total of 4003 patients (24%, 29%, and 38% of those aged > or =85 years, 75 to 84 years, and 65 to 74 years, respectively) reported daily pain. Age, gender, race, marital status, physical function, depression, and cognitive status were all independently associated with the presence of pain. Of patients with daily pain, 16% received a WHO level 1 drug, 32% a WHO level 2 drug, and only 26% received morphine. Patients aged 85 years and older were less likely to receive morphine or other strong opiates [corrected] than those aged 65 to 74 years (13% vs 38%, respectively). More than a quarter of patients (26%) in daily pain did not receive any analgesic agent. Patients older than 85 years in daily pain were also more likely to receive no analgesia (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.13-1.73). Other independent predictors of failing to receive any analgesic agent were minority race (OR, 1.63; 95% CI, 1.18-2.26 for African Americans), low cognitive performance (OR, 1.23; 95% CI, 1.05-1.44), and the number of other medications received (OR, 0.65; 95% CI, 0.5-0.84 for 11 or more medications). CONCLUSIONS: Daily pain is prevalent among nursing home residents with cancer and is often untreated, particularly among older and minority patients.     

Participatory action-research for health

Patients' reluctance to report pain and to use analgesics are considered major barriers to pain management. To explore this problem, 270 patients with cancer completed a 27-item self-report questionnaire (BQ) that assessed the extent to which they have concerns about reporting pain and using pain medication. The 8 specific concerns included fear of addiction, beliefs that 'good' patients do not complain about pain, and concern about side effects. Patients also completed a measure of pain severity and pain interference (the BPI). The percentages of patients having concerns assessed by the BQ ranged from 37% to 85%. Those who were older, less educated, or had lower incomes were more likely to have concerns. Higher levels of concern were correlated with higher levels of pain. Based on their reports of pain medications used in the past week and on their reports of pain severity, patients were categorized as under-medicated versus adequately medicated. Those who were under-medicated reported significantly higher levels of concern. The data are discussed in terms of implications for research and practice.     

Ultrathin endoscopy in the assessment and treatment of upper and lower gastrointestinal tract strictures

BACKGROUND AND OBJECTIVES: Superior hypogastric plexus block has been used to treat cancer pain of the pelvis. METHODS: A patient with severe chronic nonmalignant penile pain after transurethral resection of the prostate underwent a single superior hypogastric plexus block with local anesthetic and steroid. The patient was also started on medications that treat neuropathic pain a few hours after the procedure was finished. RESULTS: The superior hypogastric plexus block resulted in complete pain relief immediately after the procedure. The pain relief continued at 1, 2, 4, and 8 months follow up. CONCLUSIONS: In this case of severe penile pain the superior hypogastric plexus block was useful diagnostically and therapeutically.     

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.     

Breakthrough pain in cancer patients: characteristics, prevalence, and treatment

"Breakthrough pain" is a common clinical term that has not been conclusively defined or described. Breakthrough pain is a transitory flare of pain experienced when baseline pain has been reduced to a mild or moderate level. Breakthrough pain may be characterized by its relationship to a fixed around-the-clock (ATC) opioid dose, rapid onset and short duration, precipitating events, predictability, pathophysiology (with nociceptive pain being most easily controlled), and etiology. The only prospective study of breakthrough pain conducted to date found a 63% prevalence of breakthrough pain in cancer patients referred to a pain service. Although prevalence figures from other studies vary widely, partly due to the populations chosen, all of the studies verify that breakthrough pain is a serious problem in cancer patients. In fact, several studies have listed incident pain, a subset of breakthrough pain, as a predictor of poor response to analgesic therapy. Breakthrough pain is currently managed with oral or parenteral breakthrough pain medications given in addition to the ATC analgesic regimen. The ATC dosage may also be increased until limited by side effects. Newer agents with a more rapid onset of analgesia and shorter duration of effect may help in the management of breakthrough pain.     

Cancer and chronic pain

BACKGROUND: The effective management of cancer pain is one of the greatest challenges for GPs. OBJECTIVE: Pain management can be best achieved with a knowledge of the fundamentals of cancer pain and its assessment. A systematic and holistic approach to its treatment needs to be individualised for each patient, taking into account the relevant physical, psychological and spiritual factors. DISCUSSION: GPs are part of a team including oncologists, palliative care specialists, nursing services, paramedical staff, counsellors and clergy and so should know about and make use of the ever-improving support services which are available to ensure that insoluble pain problems are a rare occurrence.     

Pharmacologic pain. Management for cancer patients at home

Pain management is one of the most important responsibilities of the home care nurse serving cancer patients. Patients and caregivers often fear uncontrolled pain, and need frequent reassurance that effective pain control can be achieved. This article discusses the etiology and types of cancer pain, pain assessment, pharmacologic pain management interventions, and evaluation of pain management for home care patients.     

Development of a pediatric burn pain and anxiety management program

To facilitate effective management of pain and anxiety, and to permit more objective assessment of changes in this management, a pain and anxiety guideline was developed and has been followed uniformly for 3 years. The guideline describes four patient care categories: (1) ventilated acute, (2) nonventilated acute, (3) chronic acute, and (4) reconstructive. A small and consistent formulary was emphasized. A specific guideline for background, procedural, and transition pain and anxiety management was developed for each patient care category. All pain and anxiety medications given to all acutely burned children admitted to the Institute for 12 consecutive months were recorded, and daily pain and anxiety discomfort scores were noted using a 5-level action-based bedside scoring system. Doses of individual pain and anxiety medications were calculated as mg per kg per patient-day in each category, and all doses were found to be within guideline specifications. The efficacy of the guideline was judged by four discomfort scores: (1) background pain, (2) procedural pain, (3) background anxiety, and (4) procedural anxiety, and were adequate in all patient categories. There were no complications related to overmedication experienced during the interval. Our objective was to develop a guideline for pain and anxiety management that: (1) was safe and effective over a broad range of ages and injury acuities seen in the unit, (2) was explicit in its recommendations, (3) had a limited formulary to optimize staff familiarity with agents used, and (4) took advantage of the presence of a bedside nurse to continuously evaluate efficacy and intervene when needed through dose-ranging. Although many drugs are appropriate, our choices were based on institutional familiarity and simplicity. This process of developing a clear and consistent guideline can be duplicated in any unit.     

Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants

Posttraumatic headache can be a very difficult syndrome to manage, especially if chronic. As with most other types of headache, medications are the primary treatment modality, although there is very limited evidence-based data to support any given approach. A number of physical interventions also are available to be used in conjunction with medication, particularly for headaches with a musculoskeletal component. This article will review the general principles of pharmacological treatment for headache and the physical approach to treatment of headaches and head and facial pain. The major categories of medications commonly used for treatment of many varieties of headache will be discussed. In addition, the problems encountered in diagnosing and treating chronic daily headache and analgesic rebound headache are addressed. The approach to treatment of such syndromes as myofascial pain, cervico-zygapophyseal joint pain, neuritic pain, and craniocervical somatic pain are outlined.     

Small intestine pathogens in AIDS: conventional and opportunistic

Cancer presents itself in numerous ways, adding to the complexity of any pain syndrome with which it is associated. Neuropathic pain, unlike many other pain syndromes, is difficult to treat even in the absence of cancer. The combination results in a heterogeneous group of patients with a complex set of symptoms. This makes the assessment of pain, classification of syndromes, and clinical study a challenge. If the disease is nonprogressive, general principles of care are essentially the same as in those without cancer. In patients with progressive disease and more refractory painful conditions, spinal anesthetic and neurosurgical therapies must often be considered. Under such circumstances, caregivers are forced to carefully balance uncertain benefits and risks, often without the luxury of time. More careful observation and controlled trials in these patients help facilitate this challenging process.     

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)     

The short tandem repeat loci hTPO, THO1 and FGA

PURPOSE: The purpose of this study was to describe perceptions of quality of life (QOL) of Hispanic patients with cancer pain. DESCRIPTION OF STUDY: This qualitative pilot study is guided by the conceptual framework of pain and QOL. From interviews with 17 Hispanic patients with cancer pain, data on perceptions of QOL were analyzed and are reported here. RESULTS: The study demonstrated the influence of culture on perceptions of QOL and the impact of pain on QOL. Several themes were identified for each domain of QOL, including physical, psychological, social, and spiritual well-being. The role of the family and faith in God were important components of QOL for all patients. CLINICAL IMPLICATIONS: It is important for clinicians to devote greater attention to cultural assessment and to include cultural beliefs in cancer care to improve QOL for Hispanic patients. The role of the family and religious beliefs should be included in the planning and evaluation of each patient's care.