Integration of Specialized Pain Control Services in Palliative Care: A Nationwide Web-based Survey

Integrating an Interventional Pain Management Curriculum in Hospice and Palliative Medicine Fellowship Training: A Feasibility Study

BackgroundPain is a common symptom for patients with cancer. Hospice and Palliative Medicine (HPM) physicians are expected to be experts in both pharmacologic and non-pharmacologic treatment of pain for this patient population. Insufficient knowledge of non-pharmacologic, interventional approaches to pain management is a barrier to providing optimal care. This study assesses the feasibility and effectiveness of an interventional pain management curriculum on HPM fellow knowledge at a single institution.ObjectivesThe primary objective was to implement an interventional pain management curriculum for HPM fellows' and secondly to measure its effects on their knowledge and confidence in interventional pain management approaches.MethodsWe executed an interventional pain management curriculum for HPM fellows. The curriculum consisted of 6 fifty-minute virtual lectures. Anonymous pre- and post-curriculum surveys were used to assess curricular impact.ResultsPost-course surveys showed a significant increase in HPM fellows' knowledge and confidence in interventional pain management techniques.ConclusionsAn interventional pain management curriculum for HPM fellows is a feasible and promising intervention to significantly impact fellows' knowledge and confidence in non-pharmacologic treatment of cancer pain.

Availability of, Barriers to Performing, and Educational Practices of Interventional Procedures for Refractory Pain in Cancer Patients: A Nationwide Survey of Designated Cancer Hospitals in Japan

Background

Because of the limitations of pharmacological therapy, nonpharmacological therapies including intervention procedures are also important for quality of cancer pain management.

Objective

To clarify the availability of, number performed, barriers to performing, and educational practices of four interventional procedures (celiac plexus neurolysis/splanchnic nerve neurolysis, phenol saddle block, epidural analgesia, and intrathecal analgesia) in designated cancer hospitals.

Design

Cross-sectional survey.

Setting

Designated cancer hospitals certified by the Japanese Government.

Methods

We administered self-administered questionnaires to collect general information about the facility and interventional procedures for refractory cancer pain between January and April 2021.

Results

Questionnaires were sent to 402 facilities, and we received 199 valid responses (49.5%). Regarding availability, 36.7%-59.8% of the designated cancer hospitals reported that each procedure was available. Regarding the frequency of these procedures performed in the past 3 years, medians ranged from 1 to 4 times for each procedure. Among designated cancer hospitals, 44.7-65.8% reported the presence of barriers. Barriers such as "no/few physicians technically able to perform the procedure," "inability to follow-up after the procedure is implemented," and "the facilities to which patients may be referred after implementation are limited" were particularly pronounced. Training and treatment practice were provided by 30.7-55.8% of designated cancer hospitals for the procedures. Moreover, 12.6%-15.6% of designated cancer hospitals educated physicians and nurses responsible for cancer care in the region about pain treatment for the procedures.

Conclusions

Our findings suggest that designated cancer hospitals need to improve the availability, training, and education of interventional procedures.

Initial Experiences With Integration of Palliative Medicine and Specialist Pain Services in a Tertiary Cancer Care Center in India

Pain management constitutes a pivotal aspect of palliative care. Certain instances of distressing pain are significantly relieved through interventional pain methodologies, demanding the expertise of pain specialists. Our perspective revolves around the integration of these 2 facets, envisaging a symbiotic relationship that could enhance patient outcomes. A prospective assessment was carried out within a collaborative clinic, uniting the realms of pain management and palliative medicine. Anonymized patient information was scrutinized to grasp the advantages of this amalgamation and identify strategies to address any inherent deficiencies. Furthermore, an illustrative case study was delineated, spotlighting the collaborative dynamics at a systemic level. During the period spanning from November 2020 to June 2021, a total of 43 patients received consultations at this collaborative clinic. Each patient was exposed to a comprehensive pain management regimen, with the most frequently conducted procedure being an intercostal nerve block, which was administered in 9.30% of cases. For the provision of effective pain relief within the palliative care context, the confluence of joint consultations from cancer pain specialists emerges as a requisite measure. This approach carries the promise of optimizing pain control and augmenting the quality of palliative care.

Availability of and factors related to interventional procedures for refractory pain in patients with cancer: a nationwide survey

Background

Cancer pain may be refractory to standard pharmacological treatment. Interventional procedures are important for quality of analgesia. The aim of the present study was to clarify the availability of four interventional procedures (celiac plexus neurolysis/splanchnic nerve neurolysis, phenol saddle block, epidural analgesia, and intrathecal analgesia), the number of procedures performed by specialists, and their associated factors. In addition, we aimed to establish how familiar home hospice physicians and oncologists are with the different interventional procedures available to manage cancer pain.

Methods

A cross-sectional survey using a self-administered questionnaire was conducted. Subjects were certified pain specialists, interventional radiologists, home hospice physicians, and clinical oncologists.

Results

The numbers of valid responses/mails were 545/1,112 for pain specialists, 554/1,087 for interventional radiology specialists, 144/308 for home hospice physicians, and 412/800 for oncologists. Among pain specialists, depending on intervention, 40.9-75.2% indicated that they perform each procedure by themselves, and 47.5-79.8% had not performed any of the procedures in the past 3 years. Pain specialists had performed the four procedures 4,591 times in the past 3 years. Among interventional radiology specialists, 18.1% indicated that they conduct celiac plexus neurolysis/splanchnic nerve neurolysis by themselves. Interventional radiology specialists had performed celiac plexus neurolysis/splanchnic nerve neurolysis 202 times in the past 3 years. Multivariate analysis revealed that the number of patients seen for cancer pain and the perceived difficulty in gaining experience correlated with the implementation of procedures among pain specialists. Among home hospice physicians and oncologists, depending on intervention, 3.5-27.1% responded that they were unfamiliar with each procedure.

Conclusions

Although pain specialists responded that the implementation of each intervention was possible, the actual number of the interventions used was limited. As interventional procedures are well known, it is important to take measures to ensure that pain specialists and interventional radiology physicians are sufficiently utilized to manage refractory cancer pain.

Integrated approach to pain management for a patient with multiple bone metastases of uterine cervical cancer

Background

Pain management for multiple bone metastases is complex and often requires multidisciplinary treatment. We herein describe patient-centered multidisciplinary pain management for metastatic cancer.

Case presentation: A 61-year-old woman with multiple bone metastases of uterine cervical cancer developed intractable low back pain. After external beam radiotherapy failed, we performed lumbar spinal intralesional curettage, pedicle screw fixation, and nerve decompression. However, the neuralgia persisted. We then percutaneously injected epirubicin into the intervertebral foramina under computed tomography guidance for L5 dorsal root ganglion destruction. Osteoplasty was performed under C-arm X-ray guidance; however, the sacrum was mistaken for the ilium, and treatment was ineffective. We administered zoledronic acid and strontium-89. The last resort was outpatient implantation of an epidural bupivacaine-morphine infusion system. A visual analog scale (VAS) was used for pain evaluation. Lumbar spinal intralesional curettage and fixation, epirubicin-induced ganglion destruction, and administration of zoledronic acid and strontium-89 decreased her VAS pain score from 7–8 to 3–4. Radiotherapy and nerve decompression and release were ineffective, as was osteoplasty because of the location error. The epidural infusion system decreased the VAS score from 7–8 to 2–3 and was highly efficient.

Conclusions

Multidisciplinary integrated treatment for metastatic cancer can be effective.