Background: Patients with cancer-related pain use opioids for nociceptive pain, while gabapentinoids are common to treat neuropathic pain. The simultaneous use of opioids with gabapentinoids has been associated with an increased risk of opioid-related death.
Objectives: Determine the frequency of combined use of gabapentinoids among patients receiving opioids for cancer-related pain. We also examined if concomitant use of opioids and gabapentinoids together was associated with increased scores of fatigue and drowsiness on the Edmonton Symptom Assessment Scale (ESAS) compared to patients on opioids.
Design: Retrospective study of patients on opioids and opioids plus gabapentinoids at their third visit to the outpatient Supportive Care Center.
Results: We found that 48% (508/1059) of patients were on opioids. Of these patients, 51% (257/508) were on opioids only, and 49% (251/508) were on opioids plus gabapentinoids. The median (interquartile range [IQR]) morphine equivalent daily dose for patients on opioids was 75 (45, 138) mg, and opioids plus gabapentinoids was 68 (38, 150) mg (p = 0.94). The median (IQR) gabapentinoid equivalent daily dose was 900 (300, 1200) mg. The median (IQR) for ESAS-fatigue in patients on opioids was 5 (3, 7), and opioids plus gabapentinoids was 5 (3, 7) (p = 0.27). The median (IQR) for ESAS-drowsiness in patients on opioids was 3 (0, 5), and opioids plus gabapentinoids was 3 (0, 6) (p = 0.11).
Conclusion: Almost 50% of advanced cancer patients receiving opioids for pain were exposed to gabapentinoids. Maximal efforts should be made to minimize potential complications from the concomitant use of opioids with gabapentinoids.
Pain is a common symptom leading to referrals to specialized home palliative care (SHPC) services and is known to affect patients’ quality of life. To date, little is known about the impact of referral source on its management. To assess changes to pain medication profile in the course of SHPC and to identify potential differences in relation to referral source. This exploratory study is a retrospective analysis of 501 electronic medical records of a SHPC team in Germany. This included the assessment of baseline pain medication profiles according to the WHO analgesic ladder and changes to analgesic treatment in the course of SHPC with respect to referral source. At the time of admission, 77.4% of patients referred by a hospital and 78.8% of patients referred by the outpatient sector received a fixed analgesic regimen. In all, 61.9% of the inpatient group versus 62.9% of the outpatient group were treated with opioids, and 79.0% received modifications to pain medication at one point in time following admission. Thereby, patients referred by the outpatient sector received significantly earlier modifications and more supplementations of pain medication. Our study suggests positive development in the prescription of opioid analgesics compared to earlier studies in Germany. On the one hand, it highlights the relevance of thorough assessment and responsive evaluation of pain in SHPC, and on the other hand it reveals possible training needs of referring physicians, particularly those working in the outpatient sector. Our results inspired further research examining more closely the links between referral source and pain management.
BACKGROUND: Pain of a moderate or severe intensity affects over half of patients with advanced cancer and remains undertreated in at least one-third of these patients.
AIM: The aim of this study was to provide a pragmatic overview of the evidence supporting the use of interventions in pain management in advanced cancer and to identify where encouraging preliminary results are demonstrated but further research is required.
DESIGN: A scoping review approach was used to examine the evidence supporting the use of guideline-recommended interventions in pain management practice.
DATA SOURCES: National or international guidelines were selected if they described pain management in adult cancer patients and were written within the last 5 years in English. The Cochrane Database of Systematic Reviews (January 2014 to January 2019) was searched for 'cancer' AND 'pain' in the title, abstract or keywords. A MEDLINE search was also made.
RESULTS: A strong opioid remains the drug of choice for treating moderate or severe pain. Bisphosphonates and radiotherapy are also effective for cancer-related bone pain. Optimal management requires a tailored approach, support for self-management and review of treatment outcomes. There is likely a role for non-pharmacological approaches. Paracetamol should not be used in patients taking a strong opioid to treat pain. Cannabis-based medicines are not recommended. Weak opioids, ketamine and lidocaine are indicated in specific situations only.
CONCLUSION: Interventions commonly recommended by guidelines are not always supported by a robust evidence base. Research is required to evaluate the efficacy of non-steroidal anti-inflammatory drugs, anti-convulsants, anti-depressants, corticosteroids, some invasive anaesthetic techniques, complementary therapies and transcutaneous electrical nerve stimulation.
But de l'étude : évaluer l'efficacité analgésique de l'injection de morphiniques par une chambre à cathéter implantable intrathécal pour les douleurs cancéreuses réfractaires.
Type d'étude : étude prospective expérimentale, mono centrique.
Matériel et méthode : nous avons inclus tous les patients de plus de 18 ans vus en consultation douleur, de mars 2015 à juin 2018 qui présentaient une douleur chronique d'origine cancéreuse. Ceux qui présentaient une contre-indication à la technique ou une injection-test non efficace non pas été inclus. Mise en place du cathéter intrathécal lombaire et administration de la morphine dont la posologie est fonction du résultat obtenu lors de l'injection-test. Les critères de jugements principaux sont : l'évaluation de l'intensité de la douleur par l'échelle visuelle analogique, et la qualité de vie des malades. L'analyse statistique a utilisé le logiciel Statistical Package for the Social Sciences.
Résultats : 61 patients étaient inclus dans l'étude, mais seulement 24 patients ont bénéficié d'un site implantable intrathécal. L'âge moyen à l'instauration de l'analgésie était de 55,45 ans plus ou moins 7,12 années. Le délai entre le diagnostic et l'implantation était de 3,61 ans en moyenne. La localisation du cancer primitif est essentiellement génito-urinaire et digestif, et la localisation des douleurs est essentiellement pelvi-péritonéale. On note que la douleur a chuté de 54,58 %, avec une nette amélioration de la qualité de vie. Un cas de fuite du liquide céphalorachidien, une infection locale au point de ponction, et un cas d'infection de la loge, qui ont répondu au traitement.
Conclusion : au terme de cette analyse, il fau bien reconnaître que l'analgésie intrathécale procure une analgésie de très bonne qualité, mais il existe une proportion non négligeable de complications, pour cela elle n'est proposée qu'aux patients qu'en dernier recours.
Despite its complex pharmacology and its associated stigma from opioid addiction treatment, methadone remains a viable analgesic option for seriously ill adults and children. Oral methadone is the preferred route of administration and typically can be accomplished via methadone tablets, soluble tablets, or oral solutions of various concentrations. Still, select patients may be unable to tolerate oral methadone. This Fast Fact reviews nonoral formulations of methadone. See Fast Facts #75, 86, and 171 for additional methadone prescribing information.
Objective: Polypharmacy (PP) is a burden in elderly patients with cancer pain; however, risk factors for PP remain unclear. The purpose of this study was to investigate the risk factors for PP in this patient population.
Methods:We retrospectively reviewed the medical charts of patients aged = 65 years with cancer pain who were treated at Osaka University Hospital between February 2014 and June 2016 according to the World Health Organization 3-step ladder for cancer pain relief. We defined PP as =5 medications and conducted exploratory research to examine the association between PP and patient characteristics. Performance status (PS) was estimated according to the Eastern Cooperative Oncology Group system and is categorized as good PS (0-1) and poor PS (2-4).
Results: We reviewed 206 patients (122 men and 84 women) with a median age of 71 years (range, 65-89 years) and found that 174 patients (84.5%) had PP. In multivariate logistic analysis, PP was significantly associated with an increased number of comorbidities (odds ratio [OR]: 4.93, 95% confidence interval [CI], 2.57-11.42, P < .001), poor PS (OR: 4.50, 95% CI, 1.06-31.68, P = .039), and administration of an anticancer or molecular targeted drug (OR: 2.78, 95% CI, 1.13-7.16, P = .025).
Conclusions: An increased number of comorbidities, poor PS, and administration of an anticancer or molecular targeted drug were considered risk factors for PP in elderly patients with cancer pain. Sharing these risk factors with medical staff will help reduce the occurrence of problems associated with PP.
An open posterior component separation (PCS) is a commonly utilized surgical approach for repair of complex abdominal wall defects and hernias. Although this approach may improve surgical outcomes, significant postoperative pain can be expected given the required laparotomy and extensive abdominal wall manipulation. Both systemic opioids and thoracic epidural analgesia (TEA) are viable postoperative analgesic options, and both are commonly utilized. Although the benefits of TEA have been investigated following a variety of surgeries, there is a paucity of literature related to its efficacy for this particular surgery. The aim of this study was to evaluate the benefits of TEA following open PCS under the hypothesis that the incorporation of TEA into the postoperative analgesic regimen would hasten bowel recovery. Patients who previously underwent an open PCS were identified through an electronic medical record query. A retrospective chart review was then performed, and patients who had TEA, either alone or combined with systemic opioids, were compared with patients who had only systemic opioids. The primary end point was a comparison of the postoperative day (POD) on which a full diet was started. Secondarily, time to liquid diet, postsurgical length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and the rates of several postoperative adverse events were compared. A post hoc analysis was also performed, using the same end points, to compare the subgroup of TEA patients who avoided systemic opioids with all patients who received systemic opioids, whether alone or combined with TEA. One hundred and one patients were ultimately included for analysis. Time to full diet was not significantly different between patients who had TEA, either with or without systemic opioids, and those who received only systemic opioids (TEA 2.6 ± 1.7 vs. systemic opioids 3.1 ± 2.1 [mean POD ± SD], P = .21). Additionally, no statistically significant differences were found for any secondary outcome. In the post hoc analysis, the subgroup of TEA patients who avoided systemic opioids had a significantly faster time to bowel recovery when compared with all patients who received systemic opioids (2.2 ± 1.0 vs. 3.2 ± 2.2, P = .0033). This subgroup also had a significantly shorter time to liquid diet and a decreased postoperative LOS. In conclusion, for patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not by itself hasten the return of bowel function. However, when TEA was utilized and systemic opioids were avoided, bowel recovery occurred significantly sooner and resulted in a shortened hospital LOS.
Aim: The aim of this study was to evaluate the therapeutic efficacy and safety profile of orally administered low-dose ketamine for procedural pain management in pediatric cancer patients undergoing lumbar puncture (LP) in a resource-limited hospital setting.
Methods: Patients between 4 and 15 years of age, with leukemia, undergoing LP were asked to participate. The study was designed as a two-armed blinded placebo-controlled trial where 0.8 mg/kg (bodyweight) of ketamine mixed in juice was given 30 minutes before the procedure to Group K (ketamine) compared with placebo, only juice, to Group P (placebo). In addition, topical analgesia (EMLA®) was given according to established standard of care. Patients and caregivers assessed the pain using the Wong–Baker Faces Pain Rating Scale.
Results: A total number of 52 patients, equally distributed between Group K and Group P, were included in the study. The placebo-controlled group had significantly higher self-reported pain score than the group receiving ketamine (p = 0.046), as well as in caregiver-assessed pain (p = 0.033). Only three incidents of mild adverse effects were reported.
Conclusion: Low-dose oral ketamine can be safely administered for procedural analgesia in pediatric cancer patients undergoing LP in a resource-limited hospital setting and have significant pain-reducing effect compared with placebo.
INTRODUCTION : L'HAD est l'un des acteurs principaux dans le champ de la prise en charge de patients en fin de vie. Avec plus du quart de son activité consacré aux soins palliatifs, l'HAD est une ressource potentielle pour le domicile, pour les établissements médico-sociaux et sociaux dans le cadre d'un accompagnement de personnes en fin de vie.
MÉTHODES : une étude descriptive rétrospective monocentrique a été effectuée, les dossiers de 130 patients décédés en HAD sur l'année 2016, déclarés en soins palliatifs, ont été analysé.
RÉSULTATS : de la totalité des patients décédés en HAD en 2016,96,3% ont été déclarés en soins palliatifs. La moyenne d'âge est de 78,9 ans, les patients pris en charge pour une pathologie cancéreuse sont plus jeunes avec une moyenne d'âge à 75 ans et les patients décédés dans un contexte de polypathologie sont plus âgé, la moyenne d'âge étant de 89 ans. 23% des séjours sont des séjours très courts.
Origine : BDSP. Notice produite par BIUSANTE pC8AR0xp. Diffusion soumise à autorisation
Introduction: Les douleurs réfractaires aux traitements sont un problème en soins palliatifs. Dans ces situations il est possible de réaliser une sédation avec du midazolam. Nous proposons le cas d’une patiente qui a bénéficié d’une sédation-analgésie à la kétamine face à une douleur réfractaire aux traitements usuels.
Présentation du cas: Patiente de 60 ans, poids estimé à 60kg, suivie pour un lymphome B diffus à grandes cellules. La prise en charge est devenue palliative devant l’apparition d’une atteinte méningée avec tétraplégie et d’une altération profonde de son état général. Devant des douleurs réfractaires aux traitements et en accord avec la patiente et sa famille une sédation a été décidée. Une sédation-analgésie de confort a été démarrée avec de la kétamine, une dose de fond de départ à 100mg par jour a été majorée progressivement jusqu'à 150mg en 10jours. Cette sédation-analgésie à la kétamine a permis des moments de réveil plus serein à la patiente lui laissant la possibilité d’échanger avec sa famille à un moment crucial de sa vie.
Discussion: On constate que la sédation-analgésie à la kétamine n’a pas entraîné d’effet indésirable majeur ou inconfortable pour la patiente. Elle a permis de dépasser une situation inextricable en offrant du temps à la patiente et sa famille ce qu’une sédation au midazolam seul n’aurait pas pu faire.
Conclusion: La réalisation d’une sédation-analgésie par kétamine pour la prise en charge de douleurs réfractaires en soins palliatifs semble être une possibilité thérapeutique intéressante à utiliser avant de s’orienter vers une sédation profonde au midazolam seul. Toutefois cette pratique se doit d’être étudiée de façon plus précise par des études cliniques rigoureuses.
Aim: To describe (i) the timing of initiation of advance care planning (ACP) after nursing home admission; (ii) the association of dementia and physical health with ACP initiation; and (iii) if and how analgesic use and use of lipid modifying agents is related to ACP, in a cohort of newly admitted residents.
Methods: A prospective, observational cohort study of nursing home residents was carried out. Data were collected 3 months, 15 months (year 1) and 27 months (year 2) after admission, using a structured questionnaire and validated measuring tools.
Results: ACP was never initiated during the 2-year stay for 38% of the residents, for 22% ACP was initiated at admission, for 21% during year 1 and for 19% during year 2 (n = 323). ACP initiation was strongly associated with dementia, but not with physical health. Residents without dementia were more likely to have ACP initiation at admission or not at all, whereas ACP initiation was postponed for residents with dementia. Between admission and year 2, analgesic use increased (from 34% to 42%), and the use of lipid-modifying agents decreased (from 28% to 21%). Analgesic use increased more in residents with ACP initiation during year 1 and year 2. The use of lipid-modifying agents was not associated with ACP.
Conclusions: The timing of ACP initiation differed significantly for residents with and without dementia, which highlights the importance of an early onset of ACP before residents lose their decision-making capacity. ACP conversations might create opportunities to discuss adequate pain and other symptom treatment, and deprescribing at the end of life.
Non-opioid analgesics are widely used for pain relief in palliative medicine. However, there is a lack of evidence-based recommendations addressing the efficacy, tolerability, and safety of non-opioids in this field. A comprehensive systematic review and meta-analysis on current evidence can provide a basis for sound recommendations in clinical practice. A database search for controlled trials on the use of non-opioids in adult palliative patients was performed in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, and EMBASE from inception to 18 February 2018. Endpoints were pain intensity, opioid-sparing effects, safety, and quality of life. Studies with similar patients, interventions, and outcomes were included in the meta-analyses. Our systematic search was able to only identify studies dealing with cancer pain. Of 5991 retrieved studies, 43 could be included (n = 2925 patients). There was no convincing evidence for satisfactory pain relief by acetaminophen alone or in combination with strong opioids. We found substantial evidence of moderate quality for a satisfactory pain relief in cancer by non-steroidal anti-inflammatory drugs (NSAIDs), flupirtine, and dipyrone compared with placebo or other analgesics. There was no evidence for a superiority of one specific non-opioid. There was moderate quality of evidence for a similar pain reduction by NSAIDs in the usual dosage range compared with up to 15 mg of morphine or opioids of equianalgesic potency. The combination of NSAID and step III opioids showed a beneficial effect, without a decreased tolerability. There is scarce evidence concerning the combination of NSAIDs with weak opioids. There are no randomized-controlled studies on the use of non-opioids in a wide range of end-stage diseases except for cancer. Non-steroidal anti-inflammatory drugs, flupirtine, and dipyrone can be recommended for the treatment of cancer pain either alone or in combination with strong opioids. The use of acetaminophen in the palliative setting cannot be recommended. Studies are not available for long-term use. There is a lack of evidence regarding pain treatment by non-opioids in specific cancer entities.
BACKGROUND: Performance status, a predictor of cancer survival, and ability to maintain independent living deteriorate in advanced disease. Understanding predictors of performance status trajectory could help identify those at risk of functional deterioration, target support for independent living and reduce service costs. The relationship between symptoms, analgesics and performance status is poorly delineated.
AIM: The aim of this study is to determine whether demographics, analgesics, disease characteristics, quality-of-life domains and C-reactive protein predict the trajectory of Karnofsky Performance Status (KPS) in patients with advanced cancer.
DESIGN: The study design is the secondary data analysis of the international prospective, longitudinal European Palliative Care Cancer Symptom study (ClinicalTrials.gov: NCT01362816). A multivariable regression model was built for KPS area under the curve per day (AUC).
SETTING AND PARTICIPANTS: This included adults with advanced, incurable cancer receiving palliative care, without severe cognitive impairment and who were not imminently dying (n = 1739).
RESULTS: The mean daily KPS AUC (n = 1052) was 41.1 (standard deviation = 14.1). Opioids (p < 0.001), co-analgesics (p = 0.023), poorer physical functioning (p < 0.001) and appetite loss (p = 0.009) at baseline were explanatory factors for lower KPS AUC. A subgroup analysis of participants with C-reactive protein data (n = 240) showed that only C-reactive protein (p = 0.040) and physical function (p < 0.001) were associated with lower KPS AUC.
CONCLUSION: This study is novel in determining explanatory factors for subsequent functional trajectories in an international dataset and identifying systemic inflammation as a candidate therapeutic target to improve functional performance. The effect of interventions targeting physical function, appetite and inflammation, such as those used for cachexia management, on maintaining functional status in patients with advanced cancer needs to be investigated.
L'analgésie morphinique par voie médullaire est une technique récemment découverte qui a connu rapidement un grand développement et qui actuellement entre dans la phase où l'on redéfinit les justes indications. Parmi celles-ci l'analgésie des cancéreux algiques parvenus au stade terminal de leur maladie est à retenir. La découverte de récepteurs morphiniques au niveau de la moelle a conduit à injecter un morphinique à proximité de ces centres, c'esta-à-dire dans l'espace souas arachnoïdien, chez l'animal tout d'abord puis chez l'homme. L'injection dans l'espace péridural a été ensuite essayée avec succès. C'est essentiellement de cette technique qu'il s'agit ici, qui peut désormais être utilisée, sous certaines conditions, de façon simple en dehors du milieu hospitalier autorisant ainsi le retour à domicile.
Subcutaneous administration of medications is a well-recognised route for delivering prescribed therapies, in particular analgesia for patients requiring palliative care. Technological advancements in infusion devices and dressings can result in well-tolerated and effective methods for continuous infusions for this group of individuals. This article discusses how technological developments are resulting in subcutaneous access devices that are easy to insert and can meet the needs of a growing patient population, as well as complying with the latest guidelines on sharps safety. Combining these with staff education could result in improved patient care.
Objective: To compare the efficacy and side effects of patient-controlled intravenous analgesia (PCIA) with hydromorphone, sufentanil, and oxycodone on the management of advanced cancer patients with pain.
Methods: Patients allocated to receive PCIA between January 2015 and December 2016 were chosen for this study. After reviewing medical records, we verified if hydromorphone, sufentanil, or oxycodone for PCIA could equally provide effective pain relief. A numeric rating scale (NRS) of cancer pain was applied before PCIA, at 4 hours after PCIA, and at the discontinuation of PCIA. Secondary, the incidence of clinical side effects attributed to PCIA was observed.
Results: A total of 85 medical records were reviewed. PCIA with hydromorphone (n=30), sufentanil (n=34), and oxycodone (n=21) was used for cancer pain management. PCIA successfully improved pain control in 97.6% of the patients. The most common side effects were constipation (11.8%), nausea (8.2%), and sedation (5.9%). Drug addiction, delirium, or respiratory depression associated with PCIA was not reported in this case series study. No significant intergroup difference was observed in NRS at any of the abovementioned time points. There was no significant difference of analgesic effect among the hydromorphone, sufentanil, or oxycodone.
Conclusion: PCIA provided timely, safe, and satisfactory analgesia for advanced cancer patients with pain and may be useful for titration of opioids, management of severe breakthrough pain, and conversion to oral analgesia. There was no significant difference of analgesic effect and side effect among the hydromorphone, sufentanil, and oxycodone.
Breakthrough pain is an extremely painful symptom that impairs quality of life in cancer patients. It negatively impacts their emotional wellbeing, physical function, and mental health. The aim of this study is to use a qualitative methodology to examine the perception of cancer patients with breakthrough pain in the Northwest of China. A semi-structured, face-to-face interview was conducted with nine cancer patients who experienced breakthrough pain; and a qualitative content analysis was performed. Five themes were generated: (1) sufferings from breakthrough cancer pain, (2) hopelessness and helplessness, (3) perception of breakthrough cancer pain and analgesia, (4) strong as a Chinese, and (5) support needed from health care system. Although certain traditional cultural worldviews increase patients' acceptance of pain, healthcare providers need proper treatment guidelines to improve the quality of cancer patient care in Northwest China. We recommend that healthcare workers and hospital managers place cancer pain management in higher priority. Relevant pain management education programs should be provided to both healthcare providers and patients to improve their knowledge in these area. Healthcare professionals need to establish a mutual communication channel between patients and healthcare workers to meet patients' needs during breakthrough pain episodes in order to improve pain management. Nevertheless, the government and the healthcare system need to recognize the importance and urgency of palliative care services.
Oral cancers are one of the most common cancers in India. These patients have pain during the course of the disease. Various drugs including opioid and nonsteroidal anti-inflammatory drug have been used to manage pain. However, these are associated with side effects such as constipation and vomiting. An early interventional block may decrease the requirement for analgesics and improve the overall quality of life. We describe a case of oral carcinoma successfully managed with ultrasound-guided pterygopalatine block.
Introduction: Les travaux consacrés à l’évaluation et à la prise en charge de la douleur au cours du VIH sont inexistants au Bénin. Les objectifs de notre travail étaient d’évaluer les connaissances du personnel en charge des personnes vivant avec le VIH (PVVIH) sur la douleur et de déterminer les freins liés à l’analgésie.
Matériels et méthodes: Il s’agit d’une étude descriptive conduite en mars 2017 auprès du personnel des services de médecine interne et du centre de traitement ambulatoire (CTA) des PVVIH.
Résultats: Au total, 22 personnels de santé ont été enquêtés dont 15 médecins, 4 infirmiers et 3 étudiants en thèse de doctorat de médecine. Dans la pratique, ils n’évaluaient pas systématiquement la douleur chez tous les patients (36,4 %). Si évaluation, l’EN, l’EVA et l’EVS étaient les principales échelles utilisées. L’utilisation d’analgésie était freinée par l’accessibilité difficile de la morphine (59,1 %).
Conclusion: La douleur chez le PVVIH est sous-estimée et sa prise en charge reste à améliorer. Il est nécessaire de recycler le personnel de santé sur l’évaluation de la douleur et la prescription correcte d’antalgique.