Pain characteristics and treatment in an outpatient cancer population

Safety and Efficacy of Surgical Implantation of Intrathecal Drug Delivery Pumps in Patients With Cancer With Refractory Pain

BACKGROUND AND OBJECTIVES

Pain management in patients with cancer is a critical issue in oncology palliative care as clinicians aim to enhance quality of life and mitigate suffering. Most patients with cancer experience cancer-related pain, and 30%-40% of patients experience intractable pain despite maximal medical therapy. Intrathecal pain pumps (ITPs) have emerged as an option for achieving pain control in patients with cancer. Owing to the potential benefits of ITPs, we sought to study the long-term outcomes of this form of pain management at a cancer center.

METHODS

We retrospectively reviewed medical records of all adult patients with cancer who underwent ITP placement at a tertiary comprehensive cancer center between 2013 and 2021. Baseline characteristics, preoperative and postoperative pain control, and postoperative complication rate data were collected.

RESULTS

A total of 193 patients were included. We found that the average Numerical Rating Scale (NRS) score decreased significantly by 4.08 points (SD = 2.13, P < .01), from an average NRS of 7.38 (SD = 1.64) to an average NRS of 3.27 (SD = 1.66). Of 185 patients with preoperative and follow-up NRS pain scores, all but 9 experienced a decrease in NRS (95.1%). The median overall survival from time of pump placement was 3.62 months (95% CI: 2.73-4.54). A total of 42 adverse events in 33 patients were reported during the study period. The 1-year cumulative incidence of any complication was 15.6% (95% CI: 10.9%-21.1%) and for severe complication was 5.7% (95% CI: 3.0%-9.7%). Eleven patients required reoperation during the study period, with a 1-year cumulative incidence of 4.2% (95% CI: 2.0%-7.7%).

CONCLUSION

Our study demonstrates that ITP implantation for the treatment of cancer-related pain is a safe and effective method of pain palliation with a low complication rate. Future prospective studies are required to determine the optimal timing of ITP implantation.

Dor no doente com câncer: características e controle

Este estudo objetivou compor o perfil da dor e do seu controle, além de verificar a influência de fatores terapêuticos na expressão do sintoma álgico em 57 doentes com doença neoplásica avançada, seqüencialmente atendidos no ambulatório de oncologia de um hospital geral. A dor foi moderada na maioria dos doentes e intensa em cerca de 1/5 dos casos, com duração média de 10 meses. Em 40,9 % das escolhas, observou-se preferência por 12 descritores do questionário de dor McGill. Descritores afetivos foram, significantemente, os mais escolhidos (p < 0,05). O alívio obtido foi insatisfatório, na maioria dos casos. O índice de controle da dor foi negativo em 49,1% dos doentes, isto é, em cerca de metade dos casos foram empregados analgésicos com potência inferior à exigida pela intensidade da dor. Não se observou correlação entre a intensidade da dor e a compatibilidade ou não dos esquemas analgésicos propostos ao padrão da OMS Constatou se que os doentes que fizeram uso dos analgésicos de modo regular, experienciaram dor de menor intensidade do que aqueles que só os utilizaram quando a dor se acentuava (p <0,05). Observou-se que a irregularidade na utilização dos fármacos associou-se a dores mais intensas.

Image-guided Cryotherapy for Musculoskeletal Tumors

BACKGROUND

This article represents a review of the use of image-guided cryotherapy in the treatment of musculoskeletal tumor lesions. Cryotherapy is able to induce a lethal effect on cancer cells through direct and indirect mechanisms. In this manuscript, we combined our experience with that of other authors who have published on this topic in order to provide indications on when to use cryotherapy in musculoskeletal oncology.

DISCUSSION

Image-Guided percutaneous cryotherapy is a therapeutic method now widely accepted in the treatment of patients with musculoskeletal tumors. It can be used both for palliative treatments of metastatic bone lesions and for the curative treatment of benign bone tumors, such as osteoid osteoma or osteoblastoma. In the treatment of bone metastases, cryotherapy plays a major role in alleviating or resolving disease-related pain, but it has also been demonstrated that it can have a role in local disease control. In recent years, the use of cryotherapy has also expanded for the treatment of both benign and malignant soft tissue tumors.

CONCLUSION

Percutaneous cryotherapy can be considered a safe and effective technique in the treatment of benign and malignant musculoskeletal tumors. Cryotherapy can be considered the first option in benign tumor lesions, such as osteoid osteoma, and a valid alternative to radiofrequency ablation. In the treatment of painful bone metastases, it must be considered secondarily to other standard treatments (radiotherapy, bisphosphonate therapy, and chemotherapy) when they are no longer effective in controlling the disease or when they cannot be repeated (for example, radiotherapy).

125I brachytherapy in the palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments

Purpose

This study sought to assess the safety and effect of ¹²⁵I seed implantation for palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments.

Materials and Methods

89 patients with painful bone metastases secondary to lung cancer were consented and enrolled in this study from June 2013 to May 2015. All patients had failed or refused conventional treatments underwent percutaneous CT-guided ¹²⁵I seed implantation. The Brief Pain Inventory (BPI) was used to measure pain intensity prior to treatment (T₀), 2, 4, 6, 8 and 12 weeks (T₂, T₄, T₆, T₈ and T₁₂) after treatment in a 24-hour period. Analgesic, quality of life (QOL) scores and complications were also recorded. Four patients were excluded as they were lost to follow-up or had incomplete data.

Results

85 patients with 126 bone metastases from lung cancer were treated. There were significantly lower scores after treatment in the visual analog scale (VAS) and analgesic. The VAS scores for worst pain was 6.3±1.8 at T₀. At T₂, T₄, T₆, T₈ and T₁₂, the score in a 24-hour period decreased to 4.9±1.2 (P<0.01), 3.7±1.3 (P<0.01), 3.4±1.2 (P<0.01), 2.6±0.9 (P<0.01), and 1.4±0.8 (P<0.01) respectively. Comparison of QOL scores showed improvements including sleep, appetite, spiritual state, and fatigue at T₂, T₄, T₆, T₈ and T₁₂ when compared to T₀. No serious complications or massive bleeding were observed.

Conclusions

¹²⁵I brachytherapy is a safe and effective method for palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments.

Concordance and discordance in patient and provider perceptions of dizziness

PURPOSE

The purpose of the present investigation was to determine whether there are significant differences in patient/healthcare provider perceptions of patient's dizziness severity, dizziness disability/handicap, anxiety, and signs of autonomic system activation.

MATERIALS AND METHODS

This was a prospective investigation of 30 patient-provider dyads drawn as a sample of convenience from an otology clinic in a large, tertiary care, medical center. Patients completed both the Dizziness Handicap Inventory (DHI) and the Vestibular Symptom Scale (VSS) prior to vestibular function testing. Providers were instructed to complete the same measures following the patient's clinic visit from what they estimated was the patient's point of view. The two measures were analyzed for concordance and discordance.

RESULTS

Patient/provider differences in DHI and VSS vertigo subscale scores were not significantly different. However, difference scores on the VSS anxiety/autonomic subscale indicated that providers significantly under-estimated patient anxiety and symptoms of autonomic system activation.

CONCLUSIONS

The results suggest that providers may be missing information pertinent to the role anxiety and autonomic system activation may play in patient visits for complaints of dizziness. We suggest that this problem can be mitigated by administrating to patients prior to their clinic visit a standardized measure that quantifies patient self-report dizziness, vertigo, anxiety and autonomic system arousal. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders that are rooted in clinically significant anxiety either related to, or unrelated to, a history of vestibular system impairment.

Cryoablation combined with zoledronic acid in comparison with cryoablation and zoledronic acid alone in the treatment of painful bone metastases

This study aimed to examine the efficacy and safety of cryoablation, combined with zoledronic acid or alone, in the treatment of bone metastatic pain. A total of 84 patients were randomly divided into three groups: group A (cryoablation plus zoledronic acid), group B (cryoablation) and group C (zoledronic acid). In group A, the overall response [OR = complete response (CR) + partial response (PR)] was 85.7% (24/28), the CR was 35.7% (10/28) and the PR was 50.0% (14/28). In group B, the OR was 50.0% (14/28), the CR was 14.3% (4/28) and the PR was 35.7% (10/28). In group C, the OR was 67.9% (19/28), the CR was 21.4% (6/28) and the PR was 46.4% (13/28). The differences in OR, CR and PR among the three groups were statistically significant (P<0.05). The mean onset time of pain relief for the cryoablation combined with zoledronic acid treatment group was 1.96±2.26 days, for cryoablation treatment alone was 1.43±1.79 days and for zoledronic acid alone was 11.67±3.14 days; there were statistically significant differences among the three groups (P<0.05). The response duration was 146.68±1.89 days in group A, 71.60±2.94 days in group B and 112.99±1.37 days in group C; the differences among the three groups were statistically significant (P<0.01). In conclusion, cryoablation combined with zoledronic acid is an effective and safe therapeutic strategy for the treatment of bone metastatic pain.

[Intractable cancer pain as a reason for referral : Analysis of pain etiology and previous drug treatment.]

Many studies have demonstrated that cancer pain can be relieved in most cases by suitable analgesic medication. Patients with a diagnosis of "intractable cancer pain", however, are referred to our pain clinic nearly every day. A retrospective study of 1140 patients was therefore performed to evaluate the pain mechanisms and whether analgesic pretreatment had been adequate. Half of the patients (53%) were suffering from pain at more than one site. The most frequent locations were the back (36% of the patients), abdomen (30%), and the thoracic (22%) region. The main pain etiologies were compression or infiltration of pain-sensitive structures by the tumor (84% of the patients), and less frequently oncological treatment (18%), debilitating disease (10%), or causes unrelated to tumor or therapy (9%). Pain could be classified with almost equal frequency as neuropathic, visceral, soft tissue-related, or bone-related. Upon admission to our pain clinic, most patients (86%) indicated pain of severe intensity. The principal causes for the inadequacy of the analgesic pretreatment were: failure to prescribe analgesics (10% of the patients), irregular intake schedule or prolonged intervals between applications (66%), underdosage of nonopioid analgesics (27%) or opioids (42%), and withholding of nonopioid analgesics (30%), strong opioids (14%), or co-analgesic drugs (17%), although their prescription was indicated. The severe pain was thus caused in many patients by simple mistakes in the prescription of analgesics. Terms like "intractable" should be used with caution when referring to cancer pain because they are often unreflected and can make patients and physicians feel helpless or insecure.

Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial

BACKGROUND

This study sought to describe the results of a single-arm multicenter clinical trial using image-guided percutaneous cryoablation for the palliation of painful metastatic tumors involving bone.

METHODS

Over a 44-month period, 61 adult patients with 1 or 2 painful bone metastases with a score of 4 or more on a scale of 0 to 10 (≥4/10) worst pain in a 24-hour period who had failed or refused conventional treatment were treated with percutaneous image-guided cryoablation. Patient pain and quality of life was measured using the Brief Pain Inventory prior to treatment, 1 and 4 days after the procedure, weekly for 4 weeks, and every 2 weeks thereafter for a total of 6 months. Patient analgesic use was also recorded at these same follow-up intervals. Complications were monitored. Analysis of the primary endpoint was undertaken via paired comparison procedures.

RESULTS

A total of 69 treated tumors ranged in size from 1 to 11 cm. Prior to cryoablation, the mean score for worst pain in a 24-hour period was 7.1/10 with a range of 4/10 to 10/10. At 1, 4, 8, and 24 weeks after treatment, the mean score for worst pain in a 24-hour period decreased to 5.1/10 (P < .0001), 4.0/10 (P < .0001), 3.6/10 (P < .0001), and 1.4/10 (P < .0001), respectively. One of 61 (2%) patients had a major complication with osteomyelitis at the site of ablation.

CONCLUSIONS

Percutaneous cryoablation is a safe, effective, and durable method for palliation of pain due to metastatic disease involving bone.

Palliation of painful metastatic disease involving bone with imaging-guided treatment: comparison of patients' immediate response to radiofrequency ablation and cryoablation

OBJECTIVE

The purpose of this article was to compare periprocedural analgesic requirements and hospital length of stay for treatment of patients with painful metastatic tumors involving bone using either percutaneous radiofrequency ablation (RFA) or cryoablation.

MATERIALS AND METHODS

A retrospective review was conducted of patients who underwent either imaging-guided cryoablation or imaging-guided RFA for painful metastatic tumors involving bone. The total analgesic usage for 24 hours after the procedure was expressed as a standard morphine-equivalent dose. Analgesic usage at admission served as a baseline for comparison. Total hospital stay was used as an additional measurement of procedure-related morbidity.

RESULTS

Fifty-eight patients underwent either cryoablation (n = 36) or RFA (n = 22) for painful metastatic tumors involving bone. Twenty-two primary tumors were treated. The most common treatment site was the pelvis (n = 31). There was no significant difference between the two groups with regard to tumor histologic type (p = 0.52) and location (p = 0.72). The median tumor diameter was 4.4 cm for the cryoablation group and 5.0 cm for the RFA group (p = 0.63). Pretreatment pain scores, measured on a scale of 0 to 10, were not significantly different between the two groups: 6.5 for cryoablation and 6.0 for RFA (p = 0.78). Analgesic use in the 24 hours immediately after the procedure decreased significantly by 24 morphine-equivalent doses after cryoablation, whereas it increased by a median of 22 morphine-equivalent doses after RFA (p = 0.03). Total hospital length of stay for patients undergoing cryoablation was a median of 2.5 days less than that for patients receiving RFA (p = 0.003).

CONCLUSION

The use of cryoablation compared with RFA is associated with a greater reduction in analgesic dose and shorter hospital stays after the procedure in the perioperative time frame.

Association of IL-6, Hypothalamus-Pituitary-Adrenal Axis Function, and Depression in Patients With Cancer

Background: Evidence suggests that cytokines (IL-6) and alteration of the hypothalamic—pituitary—adrenal (HPA) axis play a crucial role in the etiology of depression. Patients with cancer show elevated prevalence rates for depression. The objective of this cross-sectional study was to investigate the associations between these abnormalities and depression. Methods: Plasma concentrations of IL-6 and cortisol were measured in cancer patients with (N = 31) and without depression (N = 83). The relative diurnal variation of cortisol (cortisol VAR), expressed in percentage, was calculated. Results: There was a significant difference in median plasma concentration of IL-6 between the patients with depression and those without (18.7 vs 2.7 pg/mL; P < .001). Relative cortisol VAR was decreased in depressed patients as compared with patients without depression (11.72% vs 60.6%, P = .037). A positive correlation between the depressive symptoms and IL-6 concentration was found ( r = 0.469, P < .001). Negative correlations were found between cortisol VAR versus depressive symptoms and cortisol VAR versus IL-6 ( r = -0.6, P < .001 and r = -0.52, P < .001, respectively). IL-6 (odds ratio [OR] = 1.1; 95% confidence interval [CI] = 1.0-1.2; P = .006) and cortisol VAR (OR = 1.3; 95%CI = 1.0-1.4; P = .02) are independently associated with depression. Conclusions: Depression in cancer is associated with increased plasma IL-6 concentrations and dysfunction of the HPA axis.

Core aspects of satisfaction with pain management: cancer patients' perspectives

CONTEXT

The coexistence of high levels of satisfaction and high levels of pain has been perplexing.

OBJECTIVES

The aims of this study were to 1) describe patient expectations related to the experience of cancer-related pain, 2) explore the cognitive processes and meaning that underlie patient judgments about satisfaction and dissatisfaction with pain management, and 3) explore the discrepancies between ratings of high satisfaction with pain management with high pain intensity.

METHODS

The sample included 33 patients: 18 with advanced cancer and 15 experiencing pain after a surgery for a cancer diagnosis. All patients had experienced "worst pain" of at least moderate intensity and were interviewed using standard pain measures from the American Pain Society Patient Outcome Questionnaire and open-ended questions about the underlying meaning of their answers. We systematically analyzed the transcribed qualitative data using NVivo software.

RESULTS

Fifty-five percent of patients were females and were aged 25-78 years. Most (75%) were satisfied or very satisfied with their overall pain management. Key findings indicate that for some, the worst pain rating was often brief, even momentary. Most patients expected pain relief. Four key themes were important to the quality of pain management: being treated right, having a safety net, being in a partnership with their health care team, and having pain treatment that was efficacious. Key aspects of the patient-provider relationship that mattered were how the nurses and doctors behaved toward them and how quickly they responded to reports of pain. For some, an important factor was whether they had control of the amount of pain they experienced.

CONCLUSION

The findings inform measurement of patient satisfaction with the quality of pain management.

Classification of pain in cancer patients--a systematic literature review

One of the aims of the European Palliative Care Research Collaborative (EPCRC) is to achieve consensus on a classification system for cancer pain. We performed a systematic literature review to identify existing classification systems and domains/items used to classify cancer patients with pain. In a systematic search in the databases Medline and Embase, covering 1986-2006, 692 hits were obtained. 92 papers were evaluated to address pain classification. Six standardised classification systems were identified; three of them systematically developed and partially validated. Both pain characteristics and patient characteristics relevant for cancer pain classification were included in the classification systems. All but one of the standardised systems aim at predicting treatment response or adequacy of treatment. Several domains and items used to describe cancer pain but not formally described as part of a classification system were also identified and systematized. The existing approaches to pain classification in cancer patients are different, mostly not thoroughly validated, and none is widely applied. An internationally accepted classification system for cancer pain could improve research and cancer pain management. This systematic review suggests a need for developing an international consensus on how to classify pain in cancer patients.

Biomarkers of depression in cancer patients

BACKGROUND

Inflammation and perturbation of the hypothalamic-pituitary-adrenal (HPA) axis function appears to play a putative role in the etiology of depression. Patients with metastatic cancer demonstrate elevated prevalence rates for depression. The objective of the current study was to illustrate the efficacy of interleukin-6 (IL-6) and HPA axis function as adjuncts to support the diagnosis of depression in cancer patients.

METHODS

Plasma concentrations of IL-6 and cortisol were measured in 114 cancer patients with and without depression. The relative diurnal variation of cortisol (cortisol VAR), expressed as a percentage, was calculated. Receiver operating characteristics analysis was performed.

RESULTS

Depression was associated with increased plasma concentrations of IL-6 (18.7 pg/mL vs. 2.7 pg/mL; P < .001) and higher cortisol concentrations at 8 AM and 8 PM. The relative cortisol VAR (11.7% vs. 60.6%, respectively; P < .001) was found to be decreased in cancer patients with depression, indicating a disturbed circadian function of the HPA axis. As a biomarker of depression, IL-6 yielded at a cutoff value of 10.6 pg/mL, a sensitivity of 79%, and a specificity of 87% (area under the curve [AUC] = 0.86; 95% confidence interval [95% CI], 0.78-0.94), whereas cortisol VAR demonstrated a sensitivity of 81% and a specificity of 88% (AUC = 0.85; 95% CI, 0.74-0.97) at a cutoff value of 33.5%.

CONCLUSIONS

Depression is associated with increased plasma IL-6 concentrations in patients with cancer. These patients demonstrate a dysfunction of the HPA-axis, characterized by a decreased diurnal variation of cortisol. The high sensitivity and specificity of these parameters biomarkers of depression make IL-6 and cortisol VAR helpful tools in the diagnosis of depression in patients with cancer.

Symptom management needs of oncology outpatients

QUESTION

What were the needs of outpatients for symptom management?

METHOD

A multidisciplinary team assembled to determine the need for a symptom management clinic. Two surveys were developed for potential users: one for the outpatients and the other for the attending oncologists.

INTERVENTION

During a 3-week period, outpatients were approached after registering for the oncology clinic and while waiting for their appointment. Ninety-five percent of the outpatients approached completed the survey.

FINDINGS

A total of 112 surveys revealed that outpatients would attend a symptom management clinic for relief of pain (50%), fatigue (40%), nausea/vomiting (30%), and/or sleeping difficulty (30%). A total of 16 surveys completed by oncologists revealed that outpatients could use more assistance with pain (81%), diet (75%), depression (69%), and/or fatigue (56%). Outpatients felt they would benefit from meeting with a nurse (35%), social worker (21%), dietician (18%), and/or pharmacist (18%). While oncologists thought that the following would complement care: dietician (69%), psychologist (69%), nurse (56%), and/or social worker (56%). Fifty-one percent of the outpatients indicated that they would attend a symptom management clinic and all but one oncologist would refer to this clinic.

DISCUSSION

While there exists some disconnect between perceived need for symptom management between outpatient and oncologist, it is evident that pain is the symptom of primary concern. An interdisciplinary team of oncologist, nurse, social worker, dietician, pharmacist, and psychologist could collaboratively address the presenting symptoms. Users, both outpatients and oncologists perceive benefit from a collaborative and interdisciplinary symptom management clinic.

Preserving a sense of wonder: the integration of an ego-supportive psychodynamic approach to supervision in an AIDS psychiatry fellowship

The challenges of working with medically and mentally ill persons with a paucity of resources, inadequate networks of social support, and multiple stresses and losses maybe daunting to even the most seasoned of caregivers. A psychiatric trainee may be overwhelmed by the despair, sorrow, and desperation en-countered in the day-to-day care of the complex severely ill patient with lethalmedical and lethal psychiatric diagnoses. Individuals who are infected with HIV and hepatitis C, who are polysubstance users, and who are benzodiazepine dependent present with inordinate demands for prescribed substances to use or to sell in the street. The trainee needs to become comfortable with both limit-setting and harm reduction in order to keep the patient engaged in both lifesaving medical and psychiatric care. Nurturing and supportive supervision enables the trainee to integrate skills and work toward an understanding of countertransferences. An ego-supportive psychodynamic approach to supervision in an AIDS psychiatry fellowship facilitates conflict resolution and improves the care of patients with complex and severe medical illness.

Epidemiology of cancer pain and factors influencing poor pain control

Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct pains. The most common type of pain is related to bone metastases. Neuropathic pain occurs in one-third of patients, alone, or as a mix of nociceptive and neuropathic pain. The failure to manage pain properly is due to several factors. In developing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barriers. In developed countries, failure to manage pain properly is usually related to a "disease" rather than a "symptom" model of care, which minimizes symptom management. Other factors include lack of physician education and failure to follow existing guidelines. Patients fear addiction, drug tolerance, and side effects. Despite adequate resources, pain is still undertreated.

Spouses' and physicians' perceptions of pain severity in older women with osteoarthritis: dyadic agreement and patients' well-being

This study examined agreement between patients and two role partners (spouses and physicians) on patients' pain severity and the relationships between dyadic agreement and patients' well-being. We hypothesized that compared to disagreement between patients and role partners, dyadic agreement would be related to better psychological well-being (more disease-specific self-efficacy and positive affect, and less depression). Participants were 114 older women with osteoarthritis, their caregiving husbands, and their rheumatologists. Among patient-spouse dyads, agreement was associated with better well-being, especially when compared to spouses' underestimation of patients' pain. Contrary to predictions, patient-physician agreement was not related to better patient well-being. Agreement between patients and physicians was associated with less (rather than more) self-efficacy and positive affect when compared to physicians' underestimation of patients' pain.

Cancer pain and depression: management of the dual-diagnosed patient

Depressive disorders and pain syndromes are very common in the experience of cancer patients and may be experienced simultaneously. There is an intuitive association between cancer pain and cancer depression, both of which are multidimensional entities. Research has suggested, but not conclusively proven a cause-effect relationship. Suicidal ideation is a common concern in cancer patients with severe depression or pain. Antidepressant therapy is a mainstay of management of depression. That some antidepressants have use in the management of cancer pain may influence choice of drug selection in depressed patients. Antidepressant side effects and the patient's drug history are relevant variables. Because antidepressants that are effective as coanalgesics may not be tolerated at doses effective for depression, the clinician must be familiar with newer classes of antidepressants and psychostimulants. Combination drug therapy may be required. Psychotherapy also is common to the treatment of cancer pain and depression. With or without the intervention of pain and mental health specialists, ongoing supportive therapy from the primary clinician is essential.

Multicenter study of pain and its management in patients with advanced cancer in Korea

The aim of this study was to evaluate the prevalence, severity, and management of pain in Korean patients with advanced cancer, and to identify the predictors of inadequate management of cancer pain in Korea. From 8 university hospitals, 655 patients with advanced cancer were surveyed. Information concerning analgesics prescribed was acquired from the medical records by the investigator. Physicians, nurses and caregivers were asked to estimate patients' pain. The Korean Brief Pain Inventory and the Barrier Questionnaire were completed by the patients. The Pain Management Index was estimated. Among all patients, 70.8% (464 of 655) reported pain. Among those who had pain, 63.6% (295 of 464) reported pain rated 5 or higher on a 0-10 scale. Thirty-nine percent of the patients had not received any analgesics and 53.2% were not receiving optimal pain management. Although there was a correlation between patients' pain ratings and those of doctors, nurses, and caregivers, there was no significant correlation between patients' ratings and health care providers' ratings at pain levels above moderate intensity. Cancer pain was more poorly managed in advanced cancer than terminal cancer patients (OR:3.20, 95%C.I, 1.83-5.60), in patients with better performance(OR:3.17, 95%C.I, 1.64-6.11), and in those patients whose pain was underestimated by the doctor (OR:2.58, 95%C.I. 1.42-4.69). Despite the high prevalence and severity of pain in cancer patients, the assessment and management of cancer pain were found to be inadequate in Korea.

The Zero Acceptance of Pain (ZAP) Quality Improvement Project: evaluation of pain severity, pain interference, global quality of life, and pain-related costs

The Zero Acceptance of Pain (ZAP) Quality Improvement Project was a multi-site effort to improve the lives of outpatients with cancer pain by enhancing the clinical practice of pain assessment and management. Independent samples of patients completed self-report measures of severity of pain, pain interference, global quality of life, pain treatment satisfaction, general medical treatment satisfaction, pain attitudes, and pain-related medical costs before and after the implementation of ZAP. Results suggested that ZAP decreased the severity of recent pain, decreased interference of pain on daily functioning, and improved satisfaction with pain treatment and attitudes about addiction to opioid medication. Direct medical costs consisting of pain-related hospitalizations, emergency department visits, and physician office visits were greatly reduced. In summary, the findings of this study support the idea that clinic-based efforts to improve the practice of pain management are effective in improving the lives of cancer patients who are experiencing pain.

Painful metastases involving bone: feasibility of percutaneous CT- and US-guided radio-frequency ablation

PURPOSE

To determine the safety and efficacy of radio-frequency (RF) ablation for pain reduction, quality of life improvement, and analgesics use reduction in patients with skeletal metastases.

MATERIALS AND METHODS

Over 10 months, 12 adult patients with a single painful osteolytic metastasis in whom radiation therapy or chemotherapy had failed and who reported severe pain (pain score > or = 4 [scale of 0-10]) over a 24-hour period were treated with percutaneous imaging-guided RF ablation with a multi-tined electrode while under general anesthesia. Patient pain was measured with a Brief Pain Inventory 1 day after the procedure, every week for 1 month, and thereafter every other week (total follow-up, 6 months). Patient analgesics use was also recorded at these follow-up intervals. Follow-up contrast material-enhanced computed tomography was performed 1 week after the procedure. Complications were monitored. Analysis of the primary end point was undertaken with paired comparison procedures.

RESULTS

Lesion size was 1-11 cm. Before RF ablation, mean worst pain score in a 24-hour period in 12 patients was 8.0 (range, 6-10). At 4 weeks after treatment, mean worst pain decreased to 3.1 (P =.001). Mean pain before treatment was 6.5 and decreased to 1.8 (P <.001) 4 weeks after treatment. Mean pain interference in general activity decreased from 6.6 to 2.7 (P =.002) 4 weeks after treatment. Eight of 10 patients using analgesics reported reduced use at some time after RF ablation. No serious complications were observed.

CONCLUSION

RF ablation of painful osteolytic metastases is safe, and the relief of pain is substantial.

Clients' perceptions of the benefits of reflexology on their quality of life

Awareness has increased among health-care professionals, patients and the general public of the importance of an holistic approach to cancer care. Psychosocial interventions, including complementary therapies, may help to improve the quality of life (QoL) of people with cancer by helping to reduce the distress associated with the diagnosis and treatment of cancer and by facilitating improved psychological adjustment to the experience of cancer. The following article presents anecdotal findings at ARC Cancer Support Centre Dublin, Ireland, of clients' perceptions of the benefits of reflexology interventions on their QoL. Reflexology interventions were perceived to impact positively upon clients' levels of impairment and functional status, including physical and psychological function, with implications for general health perceptions. The paper discusses how these findings might form the basis of further, more rigourous evaluation of the benefits of reflexology for people with cancer at ARC Cancer Support Centre.

Prevalence and management of cancer pain in South Africa

Inadequate relief from cancer pain is an international health problem. The aim of this study was to document the prevalence and patterns of cancer pain management in the Republic of South Africa. The first phase of this study consisted of screening 263 patients to document the prevalence of cancer pain in varying settings. A total of 94 patients were experiencing cancer-related pain; this comprised 35.7% of the sample. Inpatients had a higher prevalence than outpatients, which is likely due to the fact that these patients are more acutely ill. Blacks (56.1%) had a higher prevalence of pain than whites (29.4%, P<0.005); this difference was most pronounced in the outpatient setting. Phase 2 consisted of asking 426 patients with cancer pain from different settings to complete a questionnaire that included the brief pain inventory and was designed to learn about their pain and how it was managed. Nearly one-third of the entire sample experienced 'worst pain' of severe intensity. There was little difference between the public and private cancer care centers. The lowest percentage of patients with severe 'worst pain' was in the hospice setting, but even in this group about one-fourth of the patients had peak pain that was severe. Of non-whites combined, 81% experienced 'worst pain' of moderate to severe intensity as compared to 65% of whites (P<0.001). Only 21% of patients reported that they had achieved 100% pain relief. Patients experienced interference in general activity, mood, walking, working, relations with others, sleeping, and enjoyment of life related to their pain. 30.5% of the entire sample had a negative score on the pain management index, a comparison of the most potent analgesic used by a patient relative to their worst pain. Of this group, 58.1% were experiencing severe 'worst pain'. Unrelieved cancer pain is a significant problem. Government and non-government leaders, educators, and practitioners must collaborate to address the barriers to effective pain management and to implement improvements in education, health policy, and health care delivery.

Assessment of depression among cancer patients: the role of pain, cancer type and treatment

One hundred consecutive cancer patients were assessed using two structured methods for assessing major depressive disorder-Structured Clinical Interview for DSM III-R (SCID) and Endicott criteria-and using a depression rating scale-Hamilton Depression Rating Scale (HAMD). Forty-nine percent of patients were depressed using SCID (DSM III-R criteria), whereas 29% of patients were depressed using Endicott criteria. Twenty-eight percent of patients were depressed using both criteria. Age and sex did not have any influence on the assessment of major depression. Both the structured interview and the rating scale were able to identify suicide ideation. Depressed patients were not shown to have more lifetime depression than non-depressed patients using both structured methods. Patients who were depressed using both assessments of depression had more metastasis and pain than non-depressed patients.

Physicians' knowledge and attitudes toward the use of analgesics for cancer pain management: a survey of two medical centers in Taiwan

The purposes of this study were to examine the attitudes of physicians regarding the optimal use of analgesics for cancer pain management (CPM), to evaluate their knowledge and attitudes toward opioid prescribing, and to comprehend their perceptions of the barriers to optimal CPM. A survey was conducted on 356 physicians with cancer patient care responsibilities practicing in two medical centers in Taiwan. A total of 204 (57%) physicians responded, including internists (28%), surgeons (27%), oncologists (11%), anesthesiologists (10%), and other specialties (24%). The majority of physicians displayed significantly inadequate knowledge and negative attitudes toward the optimal use of analgesics and opioid prescribing. Multivariate analyses showed that the following six categories of physicians would be inclined to have inadequate knowledge of opioid prescribing: 1) those with perception of good medical school training in CPM, 2) those with perception of poor residency or fellowship training in CPM, 3) those with a medical specialty in surgery, medicine, or oncology (vs. anesthesiology), 4) those with limited clinical experience in cancer patient care (number of patients less than 30), 5) those with a limited aim of pain relief, and 6) those with an underestimation of analgesic effect. Additionally, physicians with inadequate knowledge of opioid prescribing and with hesitation to intervene earlier with maximal dose of analgesia would be inclined to have reluctant attitudes toward opioid prescribing. The most important barriers to optimal CPM identified by physicians themselves were physician-related problems, such as inadequate guidance from a pain specialist, inadequate knowledge of CPM, and inadequate pain assessment. The results of this study suggest that active analgesic education programs are urgently needed in Taiwan.

Improving communication with cancer patients

If doctors and nurses involved in cancer care are to help patients and their families achieve an optimal level of quality of life and psychological adjustment they must be able to carry out key communication tasks successfully. Yet, objective scrutiny of their consultations confirms that deficiencies in their ability to conduct these tasks remain. The reasons for this are discussed before important innovations in training and their impact are described.

Assessing the reliability of patient, nurse, and family caregiver symptom ratings in hospitalized advanced cancer patients

PURPOSE

The purpose of this study was to examine the reliability of symptom assessments in advanced cancer patients under various conditions, including multiple raters (patients, nurses, and family caregivers), occasions, and symptoms.

PATIENTS AND METHODS

The study sample consisted of 32 advanced cancer patients admitted to a tertiary palliative care unit. Symptom assessments were completed for each patient on two separate occasions, approximately 24 hours apart. On each occasion, the patient, the primary care nurse, and a primary family caregiver independently completed an assessment using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale for assessing symptoms in palliative patients. The reliability of the assessments (r) was examined using generalizability theory.

RESULTS

Three important findings emerged from this analysis. First, the analysis of individual symptom ratings provided a more meaningful representation of the symptom experience than total symptom distress ratings. Secondly, patients, nurses, and caregivers varied in their ratings across different patients, as well as in their ratings of shortness of breath, which may have been a result of individual rater variability. Finally, reliability estimates (r), based on a single rater and one occasion, were less than.70 for all symptoms, except appetite. These estimates improved substantially (r >/=.70) for all symptoms except anxiety and shortness of breath, using three raters on a single occasion or two raters across two occasions.

CONCLUSION

The findings from this study reinforce the need for the development of an integrated symptom assessment approach that combines patient and proxy assessments. Further research is needed to explore individual differences among raters.

Improving communication with cancer patients

If doctors and nurses involved in cancer care are to help patients and their families achieve an optimal level of quality of life and psychological adjustment they must be able to carry out key communication tasks successfully. Yet, objective scrutiny of their consultations confirms that deficiencies in their ability to conduct these tasks remain. The reasons for this are discussed before important innovations in training and their impact are described.

A comparison of patient and proxy symptom assessments in advanced cancer patients

The purpose of this study was to compare patient and proxy (physician and nurse) assessments of symptoms in advanced cancer patients. The sample consisted of 49 patients with advanced cancer admitted to an acute palliative care unit. Three independent assessments were completed for each patient on two occasions within 11 days of admission. On each occasion, symptoms were rated independently by the patient and two proxies (treating physician and nurse), using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale (VAS) for assessing pain, activity, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath. Symptom ratings were compared using a repeated-measures ANOVA procedure and correlations. Average physician ratings were generally lower than average patient ratings for both occasions. Average nurse ratings agreed more closely with patient ratings, with a trend towards lower ratings on occasion 1 and higher ratings on occasion 2. There was a significant rater (person rating the effects) effect (P < 0.01) for three of the nine symptoms: physicians rated drowsiness, shortness of breath and pain significantly lower than patients. For drowsiness and shortness of breath, these differences were clinically relevant, representing a difference of more than 12 mm on a 100-mm VAS. The accuracy of assessments amongst those rating the symptoms did not improve over time. Proxy assessments of symptom intensity, particularly by physicians, were significantly lower than patient assessments for three of the nine symptoms. Further research regarding the reliability of patient and proxy assessments is needed to assess and manage symptoms in advanced cancer effectively.

Presenting symptoms in patients referred to a multidisciplinary clinic for bone metastases

Symptom control is the goal of palliative irradiation. Approximately 1 month is required before symptomatic relief is accomplished with radiotherapy. However, many patients with cancer-related pain do not receive adequate analgesics, and opioids are often not prescribed until patients fail to respond to palliative irradiation. The presenting symptoms of 108 patients who were referred to a multidisciplinary clinic for bone metastases were evaluated with the Wisconsin Brief Pain Inventory (BPI). This validated instrument evaluates the severity of pain using a 0-10 scale; 10 represents the worst pain imaginable. The population comprised 65 men (60%) and 43 women whose ages ranged from 33 years to 81 years; median age was 55 years, and 69% of patients were less than 65 years of age. Despite the presence of metastatic disease, 21% of patients were working full-time outside the home, and 6% were employed part-time outside the home; 13% were homemakers. Only 17 patients (16%) were unemployed. The time since diagnosis ranged from 2 weeks to 23 years; the median time since diagnosis was 22 months, and 30% of patients had been diagnosed with the past 6 months. Pain was a presenting symptom in 74% (N = 80) of patients at diagnosis. At its worst, the pain was rated as severe (levels 7-10) by 78% and intolerable (level 10) in 22% of the patients in the 24 hr prior to the clinic appointment. On average, the pain was rated moderate to severe (levels 4-10) in 79% and severe in 23% of patients. Only 45% of patients experienced good relief from the prescribed analgesics, and 23% of patients indicated that the prescribed analgesics were ineffective. This survey demonstrates that bone metastases incur significant pain that is often undertreated with analgesics before antineoplastic therapy is administered.

[Cultural concepts and the pain experience]

The aim of this investigation was to examine the influence of cultural factors in the pain intensity. Patients presenting advanced cancer and pain, under treatment in an outpatients oncologic unit were evaluated. Pain and cultural factors were evaluated through interviews based on the use of instruments adapted to portuguese language: Patient Pain Questionnaire. Pain lasted 10 months as an average. It was moderate in the majority of patients and severe in 1/5 of them. Cultural misconceptions about the impossibility of cancer pain control and the idea that doctors prescribe excessive amount of analgesics, were correlated with, higher intensities of pain (p < 0.05).

The prevalence and severity of cancer pain: a study of newly-diagnosed cancer patients in Taiwan

Cancer pain is a relatively neglected public health issue in Taiwan. To characterize the nature of this problem, interviews were conducted on newly diagnosed cancer patients admitted to the Tri-Service General Hospital during a period of 18 months. Data were collected on the prevalence and severity of cancer pain, its treatment, and impact on patients in the week before the interview. Correlates of prevalence and severity of cancer pain were also examined. The final analysis included 296 patients who had no history of recent surgery. Most of the patients (69%) were interviewed within 14 days of their definitive diagnosis of cancer. Thirty-eight percent (N = 113) of the patients had cancer-related pain. Of these 113 patients, 65% had "significant worst pain" (worst pain level at or above five on a ten-point scale) and 31% had "significant average pain" (average pain level at or above five most of the time); 69% received no pain medication at all or inadequate medication (not "by the ladder"), and 23% had pain medication that was not administered at a fixed interval (not "by the clock"). Multivariate analyses showed that cancer pain was more prevalent in non-Mainlanders, those with a lower level of insurance, those with a history of excellent pain tolerance, those with poor Eastern Cooperative Oncology Group (ECOG) performance status, and those with distant metastases. Patients who were at greater risk of "significant worst pain" were those with regional or distant metastases, those in whom an inadequate analgesic medication had been prescribed (not "by the ladder"), and those who had received an appropriate analgesic medication but no fixed schedule dosing ("by the ladder" but not "by the clock"). Patients who were at greater risk of "significant average pain" were those not undergoing any resection of the tumor lesion and those who received an appropriate drug but no fixed schedule dosing ("by the ladder" but not "by the clock").

Patients and family members: the role of knowledge and attitudes in cancer pain

Cancer pain theoretically comprises sensory, affective, and cognitive dimensions, implying that patients and family members perceive and report cancer pain based on these factors. The study reported here investigated the relationship between specific knowledge and attitudes (cognitive factors), and patients' and family members' reports of pain due to cancer. The relationship between cognitive factors and reports of cancer pain was investigated in interviews with 122 patients and their family members. Pain was measured using the Brief Pain Inventory; knowledge and attitudes were measured using a form previously developed by the authors. Patients' and family members' reports of patient pain and performance status were highly correlated, although family members consistently reported more pain and disability. Using regression analysis, cognitive factors were strongly related to family reports of patients' pain (R2 = 0.27), but contributed little to explaining pain reported by patients themselves (R2 = 0.06). Improved understanding of patients' pain assessments depends on further investigation of other cognitive factors and of sensory and affective factors. Family members' assessments of pain are significantly related to appropriate knowledge and attitudes.

Physician knowledge and attitudes about cancer pain management: a survey from the Minnesota cancer pain project

The purposes of the study were to determine the knowledge and attitudes about cancer pain management (CPM) among practicing physicians in six Minnesota communities and to determine the physician-related barriers to optimal CPM. Eligible community physicians were surveyed by telephone. The study analyzed responses of 145 physicians (response rate, 87%). The majority of the physicians were primary care specialists (73%). Significant knowledge deficits were identified in nine of 14 CPM principles, but inappropriate attitudes were found in only two of nine CPM concepts. Medical specialty had the strongest influence on knowledge and attitudes, with primary care physicians having significantly better outcomes than surgeons or medical subspecialists. Effective education strategies must address knowledge deficits, attitudes, and motivations of the relevant peer group influencing physicians, as well as those of individual physicians. The Minnesota Cancer Pain Project is testing strategies to enhance CPM by physicians and improve patient outcomes.

Pain Control Research in the Terminally ILL

The realities of clinical practice as well as the intricacies of basic science must be taken into account by future research into pain control for the terminally ill. Attention is also needed to the integration of various approaches to pain control in order to develop the best possible treatment plan for each individual. An encouraging development in this regard is the rapid growth of interdisciplinary pain clinics and hospice programs. A review of the research literature also suggests that the politics of pain control is another topic requiring closer attention. As a recent National Institutes of Health conference has found, pain control is often inadequate across all settings: acute pain, chronic non-malignant pain, and pediatric pain. It is necessary not only to make further strides in pain control per se, but also to identify those factors that facilitate or hinder the dissemination and implementation of improved techniques. The two main goals in care of the terminally ill are to optimize the quality of their remaining life and to alleviate the distress of their survivors. Pain control research has contributed significantly to meeting those goals, but continued progress is needed in both basic studies and the expanded application of new techniques.

Pain and depression in patients with cancer

BACKGROUND

Although the existence of a relationship between depression and pain in patients with cancer has been known for many years, the influence of one upon the other is still poorly understood. It has been thought that depressed individuals complain of pain more because of their psychiatric illness. Evidence from two studies indicate that pain may induce clinical depression.

METHODS

In the first study, the authors examined both current and lifetime psychiatric diagnoses among patients with cancer who had high and low pain symptoms to examine the strength of the relationship between depression and cancer pain. The sample consisted of 72 women and 24 men, with 39 women and 9 men in the high pain group, and 33 women and 15 men in the low pain group. In the second study, 35 patients with metastatic carcinoma of the breast were examined for pain intensity and frequency and mood disturbance.

RESULTS

The prevalence of depressive disorders of all types was found to be significantly higher in the high pain than in the low pain group across measures, 33 versus 13% (chi-square [degrees of freedom = 1] = 5.90, P < 0.05). Furthermore, there was a significantly higher history of major depression in the low pain group than in the high pain group (chi-square [degrees of freedom = 1] = 3.86, P < 0.05). Also, in comparison with patients in the low pain group, patients in the high pain group were significantly more anxious and emotionally distressed. In the second study, pain intensity correlated significantly with fatigue, vigor, and total mood disturbance, and pain frequency correlated significantly with fatigue, vigor, and depression.

CONCLUSIONS

This study confirms the high concomitant occurrence of pain and psychiatric morbidity and suggests that pain may play a causal role in producing depression.

Pain and its treatment in outpatients with metastatic cancer

BACKGROUND AND METHODS

Pain is often inadequately treated in patients with cancer. A total of 1308 outpatients with metastatic cancer from 54 treatment locations affiliated with the Eastern Cooperative Oncology Group rated the severity of their pain during the preceding week, as well as the degree of pain-related functional impairment and the degree of relief provided by analgesic drugs. Their physicians attributed the pain to various factors, described its treatment, and estimated the impact of pain on the patients' ability to function. We assessed the adequacy of prescribed analgesic drugs using guidelines developed by the World Health Organization, studied the factors that influenced whether analgesia was adequate, and determined the effects of inadequate analgesia on the patients' perception of pain relief and functional status.

RESULTS

Sixty-seven percent of the patients (871 of 1308) reported that they had had pain or had taken analgesic drugs daily during the week preceding the study, and 36 percent (475 of 1308) had pain severe enough to impair their ability to function. Forty-two percent of those with pain (250 of the 597 patients for whom we had complete information) were not given adequate analgesic therapy. Patients seen at centers that treated predominantly minorities were three times more likely than those treated elsewhere to have inadequate pain management. A discrepancy between patient and physician in judging the severity of the patient's pain was predictive of inadequate pain management (odds ratio, 2.3). Other factors that predicted inadequate pain management included pain that physicians did not attribute to cancer (odds ratio, 1.9), better performance status (odds ratio, 1.8), age of 70 years or older (odds ratio, 2.4), and female sex (odds ratio, 1.5). Patients with less adequate analgesia reported less pain relief and greater pain-related impairment of function.

CONCLUSIONS

Despite published guidelines for pain management, many patients with cancer have considerable pain and receive inadequate analgesia.

Psychosocial aspects of cancer pain

Pain, and especially cancer pain, is not a pure nociceptive, physical experience, but involves different dimensions of man, such as personality, affect, cognition, behavior and social relations. Cancer pain is best conceptualized as the convergence of multiple activated systems with feedback mechanisms to a complex, multidimensional model. The psychosocial aspects of this multidimensional model will be analyzed with special emphasis on results from recent research. Although most research has been conducted on the role of affect and cognition in cancer pain, data on other factors such as personality, behavior or social aspects exist and will be presented. In the second part of this paper the implications of these results for therapeutic strategies in clinical work will be discussed. Although a considerable body of knowledge exists to support the hypothesis of a multidimensional model of cancer pain, where psychosocial variables play an important role, only a few studies address the issue of to what degree different factors exercise their influence. This may be different from patient to patient and may change over the course of the disease. Whatever importance these single variables in the multidimensional model of cancer pain may have, the patient is best treated when none of these aspects is neglected in the assessment and all are taken care of in the treatment. A multidisciplinary team, with a psychiatrist as one of the team members, is often best prepared to fulfill this task.

Pain in ambulatory patients with lung or colon cancer. Prevalence, characteristics, and effect

BACKGROUND

Few studies have evaluated the epidemiology and effect of pain in ambulatory patients with cancer who are undergoing active therapy. This information is needed to develop strategies for supportive care in this population.

METHODS

The prevalence and characteristics of pain were determined in a prospective survey of ambulatory patients with lung or colon cancer. To reduce bias and acquire comprehensive information, the methodology used face-to-face interviews by trained quality assurance analysts, a multifaceted assessment instrument, and multivariate statistical analysis.

RESULTS

In a telephone interview, "persistent or frequent" pain during the previous 2 weeks was reported by 57 of 145 (39.3%) patients with lung cancer and 52 of 181 (28.7%) patients with colon cancer; 91 of these patients (47 lung and 44 colon) were interviewed in detail. All patients had excellent performance status, and with the exception of pain location, there were no significant differences between the two tumor types. One-third of the patients had more than one discrete pain. Median pain duration was 4 weeks (range, less than 1 week-468 weeks), and average pain intensity was moderate. Approximately 90% of patients experienced pain more than 25% of the time. Pain interfered moderately or more with general activity and work in approximately half of the patients; more than half reported moderate or greater pain interference in sleep, mood, and enjoyment of life. Multiple regression analysis revealed that the daily frequency of pain, the intensity of the worst pain, the score on a mood scale, and the frequency of the worst pain accounted for 58.7% of the variance in average pain intensity. Likewise, 52.1% of the variance in a derived measure of pain interference in function was explained by the mood score, frequency of the worst pain, number of pains, and pain intensity.

CONCLUSIONS

These data indicate that pain is prevalent among well-functioning ambulatory patients and substantially compromises function in approximately half of the patients who experience it. Pain is a complex symptom; aspects other than intensity, such as frequency, strongly influence its effect.

The cancer patient with pain: psychiatric complications and their management

The most common psychiatric complications in the cancer population are depression, anxiety, and delirium. All are more likely to occur in the cancer patient who has pain. This review outlines the normal responses to cancer and the psychiatric disorders frequently encountered in clinical practice. The influence of pain on the incidence and presentation of these disorders is described. Multimodal treatment, which includes pharmacologic, psychotherapeutic, and behavioral interventions, is outlined.

Misperceptions and inadequate pain management in cancer patients

This article examines misperceptions and barriers to adequate pain relief in cancer patients. Healthcare professionals have gaps in their knowledge of opioid drugs as well as misconceptions concerning tolerance, physical dependence, and addiction that often lead to the underprescribing of these agents. The pervasiveness of the "say no to drugs" message in our society and the fear of addiction on the part of patients and their families creates yet another barrier to the legitimate use of opioids to treat cancer pain. Legal and regulatory documents filled with arbitrary and ill-defined labels meant to promote the legitimate use of these drugs and curtail their misuse may instead intimidate healthcare professionals and negatively influence prescribing habits. Increased educational efforts for pharmacists and other healthcare professionals as well as the development of clinical role models and state cancer pain initiatives are cited as means to break down these barriers in order to achieve adequate pain relief for all cancer patients.