Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study

BACKGROUND

Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown.

OBJECTIVE

This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians.

METHODS

This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer.

RESULTS

Data collection began in October 2022 and is anticipated to end by November 2024.

CONCLUSIONS

Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54953.

Dysregulation of sphingolipid metabolism in pain

Pain is a clinical condition that is currently of great concern and is often caused by tissue or nerve damage or occurs as a concomitant symptom of a variety of diseases such as cancer. Severe pain seriously affects the functional status of the body. However, existing pain management programs are not fully satisfactory. Therefore, there is a need to delve deeper into the pathological mechanisms underlying pain generation and to find new targets for drug therapy. Sphingolipids (SLs), as a major component of the bilayer structure of eukaryotic cell membranes, also have powerful signal transduction functions. Sphingolipids are abundant, and their intracellular metabolism constitutes a huge network. Sphingolipids and their various metabolites play significant roles in cell proliferation, differentiation, apoptosis, etc., and have powerful biological activities. The molecules related to sphingolipid metabolism, mainly the core molecule ceramide and the downstream metabolism molecule sphingosine-1-phosphate (S1P), are involved in the specific mechanisms of neurological disorders as well as the onset and progression of various types of pain, and are closely related to a variety of pain-related diseases. Therefore, sphingolipid metabolism can be the focus of research on pain regulation and provide new drug targets and ideas for pain.

Cingulotomy for Intractable Pain: A Systematic Review of an Underutilized Procedure

Pain management is a critical aspect of cancer treatment and palliative care, where pain can significantly impact quality of life. Chronic pain, which affects a significant number of people worldwide, remains a prevalent and challenging symptom for patients. While medications and psychosocial support systems play a role in pain management, surgical and radiological interventions, including cingulotomy, may be necessary for refractory cases. Cingulotomy, a neurosurgical procedure targeting the cingulate gyrus, aims to disrupt neural pathways associated with emotional processing and pain sensation, thereby reducing the affective component of pain. Although cingulotomy has shown promise in providing pain relief, particularly in patients refractory to traditional medical treatment, its use has declined in recent years due to advancements in non-destructive therapies and concerns about long-term efficacy and patient suitability. Modern stereotactic methods have enhanced the precision and safety of cingulotomy, reducing associated complications and mortality rates. Despite these advancements, questions remain regarding its long-term efficacy and suitability for patients with limited life expectancy, particularly those with cancer. A comprehensive systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, aimed at providing insights into the efficacy, potential benefits, and limitations of this neurosurgical procedure in managing intractable pain. An electronic search of PubMed, Embase, Scopus, and Web of Science was conducted with open database coverage dates. The review focused on outcomes such as pain intensity and quality of life. The inclusion criteria encompassed human studies of any age experiencing intractable cancer or non-cancer pain, with cingulotomy as the primary intervention. Various study designs were considered, including observational studies, clinical trials, and reviews focusing on pain and cingulotomy. Exclusion criteria included non-human studies, non-peer-reviewed articles, and studies unrelated to pain or cingulotomy. This review highlights the efficacy of stereotactic anterior cingulotomy in managing intractable pain, particularly when conventional treatments fail. Advanced MRI-guided techniques enhance precision, but challenges like cost and expertise persist. Studies included in this review showed significant pain relief with minimal adverse effects, although the optimal target remains debated. Neurocognitive risks exist, but outcomes are generally favorable. Expected adverse events include transient effects like urinary incontinence and confusion. Reoperation may be necessary for inadequate pain control, with a median pain relief duration of three months to a year. A double stereotactic cingulotomy appears to be safe and effective for refractory pain.

Cannabinoids for Cancer-related Pain Management: An Update on Therapeutic Applications and Future Perspectives

Pain is a debilitating phenomenon that dramatically impairs the quality of life of patients. Many chronic conditions, including cancer, are associated with chronic pain. Despite pharmacological efforts that have been conducted, many patients suffering from cancer pain remain without treatment. To date, opioids are considered the preferred therapeutic choice for cancer-related pain management. Unfortunately, opioid treatment causes side effects and inefficiently relieves patients from pain, therefore alternative therapies have been considered, including Cannabis Sativa and cannabinoids. Accumulating evidence has highlighted that an increasing number of patients are choosing to use cannabis and cannabinoids for the management of their soothing and non-palliative cancer pain and other cancer-related symptoms. However, their clinical application must be supported by convincing and reproducible clinical trials. In this review, we provide an update on cannabinoid use for cancer pain management. Moreover, we tried to turn a light on the potential use of cannabis as a possible therapeutic option for cancer-related pain relief.

Integrative Medicine for Cancer-Related Pain: A Narrative Review

Cancer-related pain (C-RP) is a prevalent and debilitating concern among patients with cancer, with conventional treatments limited in their ability to provide adequate relief, and by the adverse effects associated with their use. Complementary and integrative medicine (CIM) modalities have been shown to be potentially effective and safe for the treatment of pain and related symptoms, when used in conjunction with conventional medications and under medical supervision. An increasing number of oncology centers provide CIM within their conventional supportive and palliative care service, in an "Integrative Oncology" (IO) setting. A large body of clinical research, including systematic reviews and guidelines such as those published in 2022 by the Society for Integrative Oncology (SIO), in collaboration with the American Society for Clinical Oncology (ASCO), support the use of some CIM modalities for C-RP and related concerns. These include acupuncture for general and peri-operative/procedural pain, as well as aromatase inhibitor-associated arthralgia (AIA); reflexology or acupressure for pain during systemic therapy for cancer; hypnosis for procedural pain or pain due to diagnostic workup; and massage for pain experienced by patients during palliative and hospice care. Further research is needed, within both randomized control trials and pragmatic non-controlled studies which are more reflective of the real-life IO setting. This review summarizes the evidence supporting the use of CIM for C-RP; the analgesic mechanism of the modalities presented; and the challenges facing IO researchers, as well as the implementation of the 2022 SIO-ASCO guideline recommendations.

Access to psychological treatment for chronic cancer-related pain in Sweden

OBJECTIVES

Cancer-related pain (CRP) is among the most frequent collateral effects of cancer, with chronic CRP, lasting at least 3 months, affecting >40% of cancer survivors. Evidence-based treatments, including pain-focused cognitive behavioral therapy (CBT), are available, but it appears that cancer patients/survivors are often poorly informed about CRP or the potential benefits of CBT for such pain. This study examined current experience of Swedish cancer patients/survivors in relation to CRP.

METHODS

Participants (N = 276; 83% female; mean age = 55.5 years, SD = 11.9) were recruited to an online survey via cancer websites in Sweden, and they provided information about their history of chronic CRP and whether they received information about or treatment for CRP from a healthcare professional.

RESULTS

Participants had a history of breast (36%), gynecological (12%), lung (10%), colon (8%), and other forms of cancer (36%). A majority (74%) reported a history of chronic CRP and being prescribed analgesic medications (70%). Less than half (47%) received information from their healthcare provider about the risk of CRP and only 13% with chronic CRP received psychological treatment, and of these, only 33% received CBT. Among those receiving psychological treatment for chronic CRP, satisfaction rates were moderate, reported as an average of 6 on a 0-10 scale (standard deviation 2.6).

CONCLUSIONS

Greater efforts are needed to raise awareness among cancer patients/survivors and healthcare providers about the risk of CRP and evidence-based interventions, including CBT, the first-line intervention for chronic pain. These efforts will need to be matched with increases in treatment capacity, particularly pain-focused CBT.

Spinal cord stimulation for chronic pain treatment following sacral chordoma resection: illustrative case

BACKGROUND

Cancer-related or postoperative pain can occur following sacral chordoma resection. Despite a lack of current recommendations for cancer pain treatment, spinal cord stimulation (SCS) has demonstrated effectiveness in addressing cancer-related pain.

OBSERVATIONS

A 76-year-old female with a sacral chordoma underwent anterior osteotomies and partial en bloc sacrectomy. She subsequently presented with chronic pain affecting both buttocks and posterior thighs and legs, significantly impeding her daily activities. She underwent a staged epidural SCS paddle trial and permanent system placement using intraoperative neuromonitoring. The utilization of percutaneous leads was not viable because of her history of spinal fluid leakage, multiple lumbosacral surgeries, and previous complex plastic surgery closure. The patient reported a 62.5% improvement in her lower-extremity pain per the modified Quadruple Visual Analog Scale and a 50% improvement in the modified Pain and Sleep Questionnaire 3-item index during the SCS trial. Following permanent SCS system placement and removal of her externalized lead extenders, she had an uncomplicated postoperative course and reported notable improvements in her pain symptoms.

LESSONS

This case provides a compelling illustration of the successful treatment of chronic pain using SCS following radical sacral chordoma resection. Surgeons may consider this treatment approach in patients presenting with refractory pain following spinal tumor resection.

Different Outcomes According to Needling Point Location Used in Sham Acupuncture for Cancer-Related Pain: A Systematic Review and Network Meta-Analysis

Numerous acupuncture studies have been conducted on cancer-related pain; however, its efficacy compared to sham acupuncture remains controversial. We confirmed whether the outcome of acupuncture differs according to the needling points of sham acupuncture for cancer-related pain. We searched 10 databases on 23 May 2023 to screen acupuncture trials using sham acupuncture or waiting list as controls for cancer-related pain. Sham acupuncture was classified into two types, depending on whether the needling was applied at the same locations as verum acupuncture (SATV) or not (SATS). A network meta-analysis (NMA) was performed on the basis of a frequentist approach to assess pain severity. Eight studies (n = 574 participants) were included in the review, seven of which (n = 527 participants) were included in the NMA. The pain severity was not significantly different between SATV and verum acupuncture, but verum acupuncture significantly improved pain severity compared to SATS. The risk of bias affecting the comparisons between the verum and sham acupuncture was generally low. Previous acupuncture trials for cancer-related pain showed differing outcomes of sham and verum acupuncture, depending on the needling points of sham acupuncture. The application of SATV cannot be considered a true placebo, which leads to an underestimation of the efficacy of verum acupuncture.

The role of cancer nurses in cancer-related pain management in Europe

Cancer pain is a common symptom in patients with cancer and can largely affect their quality of life. Pain management is important to minimize the impact of pain on daily activities. Cancer nurses are significantly involved in all steps of pain management and contribute to the success of therapy through their knowledge and expertise. While they generally play an important role in the screening, assessment, diagnosis, treatment and follow-up of patients and their (pain) symptoms, this varies from country to country in Europe. An important aspect is their role in educating patients and their families about what pain is, what impact it can have, how it can be treated pharmacologically or non-pharmacologically and what effects or problems can occur during treatment. While there is a great discrepancy between education and training opportunities for cancer nurses in different European countries, there is a continued need for education and training in pain management. Cancer is increasingly becoming a chronic disease, and the management of pain in cancer survivors will be crucial to maintain an adequate quality of life. With this, the crucial role of cancer nurses is becoming even more important.

A Case of Nerve Root Radiofrequency Thermocoagulation for Pain Due to Pleural Metastasis of Lung Cancer Leading to Improvement in the Patient's Quality of Life

Advances in medicine have made long-term survival of cancer patients possible. Hence, it is now necessary to consider how to approach common symptoms, such as cancer-related pain, in these patients. In this study, we describe a lung cancer patient in whom relief of intractable thoracic pain caused by pleural metastasis was achieved through thoracic radiofrequency thermocoagulation (RF), improving his quality of life (QOL). The patient was a man in his 70s with right upper lobe lung cancer, left 9th -11th rib metastasis, and left thoracic pain associated with parietal pleural metastasis. The patient experienced insomnia and weight loss due to poor appetite caused by opioid analgesics and inadequate pain control. Therefore, RF was performed as interventional treatment, resulting in a decrease in the numerical rating scale score from 10/10 to 2/10, and an improvement in QOL. In cases wherein long-term survival is expected, a long-term treatment plan for chronic cancer-related pain, which has a tendency to become persistent, becomes necessary. RF for the nerve roots might be a viable option for pain caused by pleural metastasis in cancer survivors.

Managing opioids and mitigating opioid risks in patients with cancer: An environmental scan of the attitudes, confidence, and practices of ambulatory, community and hospital pharmacists practicing in Canada

INTRODUCTION

Canada is in the midst of an overdose crisis. The use of prescription opioids in Canada has increased steadily over the past two decades, with stark increases in opioid-induced respiratory depression and related deaths. Opioids are the mainstay of treatment for cancer-related pain. Patients with cancer are not immune to the risks associated with opioid use but are underrepresented in available literature outlining risk mitigation strategies. Pharmacists are ideally placed to employ opioid risk mitigation practices to support safe and effective opioid use for patients with cancer-related pain. However, the current attitudes, confidence, and safety practices of pharmacists around how to best support these patients are not known.

METHODS

This study was a descriptive environmental scan of pharmacists who provide direct patient care in Canada. An electronic questionnaire was built using the web based Opinio software. It was distributed via email by several provincial and national pharmacy organizations and online platforms. The questionnaire consisted of Likert-scale and open-ended questions and was open to participants for a 6-week period from February 12th to March 23rd, 2020. Analysis was conducted using descriptive statistics and qualitative content analysis.

RESULTS

Eighty-one responses from pharmacists in nine provinces were included in the analysis. Respondents endorsed limited and varied practices when caring for patients receiving opioids for cancer-related pain. Further, they demonstrated wide ranging confidence and attitudes regarding opioid risk mitigation practices and beliefs. Less than 50% of pharmacists were aware of resources available for their patients with non-medical opioid use, and/or patients at high risk of opioid-induced respiratory depression. Education, resources, and communication were the most commonly reported perceived facilitators and barriers to resource use.

CONCLUSIONS

Pharmacists in Canada report employing opioid risk mitigation practices with low and varied frequency when caring for patients receiving opioids for cancer-related pain. They endorsed varied confidence and limited awareness of available provider and patient resources. These findings may help inform the development of new education models and evidence-based guidelines. New education models and evidence-based guidelines will support pharmacists in their pharmaceutical care of this vulnerable patient population, ultimately aiming to improve patient outcomes.

Efficacy and Security of Tetrodotoxin in the Treatment of Cancer-Related Pain: Systematic Review and Meta-Analysis

The pharmacological treatment of cancer-related pain is unsatisfactory. Tetrodotoxin (TTX) has shown analgesia in preclinical models and clinical trials, but its clinical efficacy and safety have not been quantified. For this reason, our aim was to perform a systematic review and meta-analysis of the clinical evidence that was available. A systematic literature search was conducted in four electronic databases (Medline, Web of Science, Scopus, and ClinicalTrials.gov) up to 1 March 2023 in order to identify published clinical studies evaluating the efficacy and security of TTX in patients with cancer-related pain, including chemotherapy-induced neuropathic pain. Five articles were selected, three of which were randomized controlled trials (RCTs). The number of responders to the primary outcome (≥30% improvement in the mean pain intensity) and those suffering adverse events in the intervention and placebo groups were used to calculate effect sizes using the log odds ratio. The meta-analysis showed that TTX significantly increased the number of responders (mean = 0.68; 95% CI: 0.19-1.16, p = 0.0065) and the number of patients suffering non-severe adverse events (mean = 1.13; 95% CI: 0.31-1.95, p = 0.0068). However, TTX did not increase the risk of suffering serious adverse events (mean = 0.75; 95% CI: -0.43-1.93, p = 0.2154). In conclusion, TTX showed robust analgesic efficacy but also increased the risk of suffering non-severe adverse events. These results should be confirmed in further clinical trials with higher numbers of patients.

A perspective on a precision approach to pain in cancer; moving beyond opioid therapy

PURPOSE

Cancer-related pain is primarily treated with opioids which while effective can add significant patient burden due to side effects, associated stigma, and timely access. The purpose of this perspective discussion is to argue for a precision approach to pain in cancer based on a biopsychosocial and spiritual model which we argue can offer a higher quality of life while limiting opioid use.

CONCLUSIONS

Pain in cancer represents a heterogenous process with multiple contributing and modulating factors. Specific characterization of pain as either nociceptive, neuropathic, nociplastic, or mixed can allow for targeted treatments. Additional assessment of biopsychosocial and spiritual issues can elucidate further points of targeted intervention which can lead to overall greater pain control.Implications for RehabilitationPrecision Pain Management in CancerPain in cancer is complex and heterogeneous with multiple contributing etiologies.A comprehensive assessment addressing the biopsychosocial and spiritual aspects of pain may lead to better control.Utilizing multiple targeted treatment strategies may help to curb opioid use.

Analgesic and potentiated photothermal therapy with ropivacaine-loaded hydrogels

Rationale: Tumor ablation can cause severe pain to patients, but there is no satisfactory means of analgesia available. In addition, recurrence of residual tumors due to incomplete ablation threatens patient safety. Photothermal therapy (PTT), a promising approach for tumor ablation, also faces the aforementioned problems. Therefore, developing novel photothermal agents that can efficiently relieve PTT-associated pain and potentiate the PTT efficacy are urgently needed. Methods: The Pluronic F127 hydrogel doped with indocyanine green (ICG) was served as photothermal agent for PTT. Mouse model that inoculation of tumor near the sciatic nerve was constructed to assess the PTT-evoked pain. Subcutaneous and sciatic nerve vicinal tumor-bearing mice were used to test the efficacy of PTT. Results: PTT-evoked pain depends on an increase in tumor temperature and is accompanied by the activation of TRPV1. A simple introduction of local anesthetic (LA) ropivacaine into ICG-loaded hydrogels relieves PTT-induced pain and exerts long-lasting analgesia compared with opioid analgesia. More interestingly, ropivacaine upregulates major histocompatibility complex class I (MHC-I) in tumor cells by impairing autophagy. Therefore, a hydrogel co-doped with ropivacaine, TLR7 agonist imiquimod and ICG was rationally designed. In the hydrogel system, imiquimod primes tumor-specific CD8⁺ T cells through promoting DCs maturation, and ropivacaine facilitates tumor cells recognition by primed CD8⁺ T cells through upregulating MHC-I. Consequently, the hydrogel maximumly increases CD8⁺ T cells infiltration into tumor and potentiates PTT efficacy. Conclusion: This study for the first time provides an LA-dopped photothermal agents for painless PTT and innovatively proposes that a LA can be used as an immunomodulator to potentiate the PTT efficacy.

Hypoxia-Inducible Factor-1: A Novel Therapeutic Target for the Management of Cancer, Drug Resistance, and Cancer-Related Pain

Hypoxia-inducible factor-1 (HIF-1) is a key transcription factor that regulates the transcription of many genes that are responsible for the adaptation and survival of tumor cells in hypoxic environments. Over the past few decades, tremendous efforts have been made to comprehensively understand the role of HIF-1 in tumor progression. Based on the pivotal roles of HIF-1 in tumor biology, many HIF-1 inhibitors interrupting expression, stabilization, DNA binding properties, or transcriptional activity have been identified as potential therapeutic agents for various cancers, yet none of these inhibitors have yet been successfully translated into clinically available cancer treatments. In this review, we briefly introduce the regulation of the HIF-1 pathway and summarize its roles in tumor cell proliferation, angiogenesis, and metastasis. In addition, we explore the implications of HIF-1 in the development of drug resistance and cancer-related pain: the most commonly encountered obstacles during conventional anticancer therapies. Finally, the current status of HIF-1 inhibitors in clinical trials and their perspectives are highlighted, along with their modes of action. This review provides new insights into novel anticancer drug development targeting HIF-1. HIF-1 inhibitors may be promising combinational therapeutic interventions to improve the efficacy of current cancer treatments and reduce drug resistance and cancer-related pain.

Exploring the Barriers to Buprenorphine Therapy for Cancer-Related Pain and Concurrent Opioid Use Disorder: A Case Report

Although buprenorphine is widely accepted as a treatment option for opioid use disorder (OUD), it is underutilized as a treatment for cancer-related pain. Owing to its decreased side effect profile, various formulations (depending on FDA indication of pain versus OUD), and ability to simultaneously address OUD and pain, buprenorphine is gaining popularity in the outpatient palliative medicine setting. Despite these compelling benefits, there are significant barriers to initiating therapy. These barriers include clinician experience, insurance authorization, pharmacy supply, and stigma. We present a complicated case to describe the practical clinical experience of an attempt at low-dose initiation of buprenorphine to treat cancer-related pain in a patient with concurrent OUD and to discuss ways to start overcoming the encountered barriers.

Is the Erector Spinae Plane Block Effective for More than Perioperative Pain? A Retrospective Analysis

Introduction: The thoracic Erector Spinae Plane Block (ESPB) is an ultrasound-guided block that has gained popularity and is widely used in acute pain setups. However, data regarding its role in chronic and cancer-related pain are anecdotal. Material and Methods: The study is a retrospective analysis of patients who underwent ESPB. The cohort was divided into subgroups based on three determinants: etiology, pain type, and chronicity. Results: One hundred and ten patients were included, and genders were affected equally. The average age was 61.2 ± 16.1 years. The whole group had a statistically significant reduction in a numerical rating scale (NRS) (7.4 ± 1.4 vs. 5.0 ± 2.6, p-value > 0.001). NRS reduction for 45 patients (41%) exceeded 50% of the pre-procedural NRS. The mean follow-up was 7.9 ± 4.6 weeks. Baseline and post-procedure NRS were comparable between all subgroups. The post-procedural NRS was significantly lower than the pre-procedural score within each group. The proportion of patients with over 50% improvement in NRS was lower for those with symptom duration above 12 months (p-value = 0.02). Conclusions: Thoracic ESPB is a simple and safe technique. The results support the possible role of ESPB for chronic as well as cancer-related pain.

Long-term opioid treatment and endocrine measures in patients with cancer-related pain: a systematic review

OBJECTIVES

Opioid analgesics are the main stay for cancer pain management; however, long-term opioid treatment (L-TOT) may suppress the endocrine system. This systemic review aimed at investigating effects of L-TOT on the endocrine system in patients with cancer-related pain.

METHODS

A search on MEDLINE, EMBASE and Web of Science databases was performed. Inclusion criteria were clinical studies investigating endocrine measures in adult patients with cancer-related pain in L-TOT (≥4 weeks). Outcomes and quality of evidence were assessed.

RESULTS

A total of 252 abstracts were identified; out of which 247 were excluded and five cross-sectional studies were included and analyzed. L-TOT was associated with lower serum concentration levels of total- and free testosterone in males, follicular stimulating hormone in females, and luteinizing hormone in both sexes. Moreover, higher morphine equivalent daily doses (MEDDs) were correlated with higher levels of cortisol and lower levels of LH in both sexes, and lower levels of total- and free testosterone in males. Sexual dysfunction was associated with low sex hormone levels. Level of evidence was low/very low.

CONCLUSIONS

The studies identified demonstrated that patients with cancer-related pain in L-TOT may have gonadal hypofunction causing sexual dysfunction, which may be correlated with opioid dose level. In addition, high serum concentrations of cortisol were positively correlated with high opioid dose levels. However, the evidence was weak and further research is necessary. PROSPERO, ID-number: CRD42020213059.

Parental Experiences of Adolescent Cancer-Related Pain: A Qualitative Study

Objective

Despite advancing medical treatments, pain remains a significant outcome of adolescent cancer, as both a problematic and distressing symptom. With adolescents spending substantial periods of time at home during cancer treatment, parents perceive themselves as central to the experience and management of adolescents’ pain. The present study aimed to explore parental experiences of adolescent cancer-related pain during, and recently after, completing cancer treatment.

Methods

We interviewed 21 parents of adolescents (aged 12–18 years) with cancer, recruited through a hospital in South West England. Interviews were analyzed using reflexive inductive thematic analysis.

Results

Two themes were generated. The first theme, “Parental perceptions of being at the heart of pain management,” focused on the role of parents in adolescents’ pain journeys, and the vast knowledge they gained. The second, “Adapting and readjusting expectations,” captured parents’ journeys in learning to adjust their lives according to adolescents’ pain and difficulties they faced throughout this process.

Conclusions

Findings highlighted parents’ crucial role throughout adolescents’ pain experiences; learning how to manage adolescents’ pain, and supporting them with the detrimental impact on their lives. The findings emphasize the importance of a multidisciplinary approach to supporting families to manage pain. They also indicate a need for targeted research studies investigating parental experiences of adolescent cancer-related pain. This will help professionals understand how best to support parents and adolescents throughout the cancer journey and ultimately improve the physical and psychological outcomes of young people in the longer term.

Adherence to Analgesics Among Outpatients Seriously Ill With Cancer

BACKGROUND

Adherence to prescribed analgesics for patients seriously ill with cancer pain is essential for comfort.

OBJECTIVE

The objective of this study was to determine the analgesic adherence in seriously ill patients with cancer and its association with clinical and demographic characteristics.

METHODS

This is a cross-sectional study. At home, 202 patients with cancer (mean age, 59.9 ± 14.2 years; 58% female, 48% Black, and 42% White) admitted to hospice/palliative care completed measures on a pen tablet: PAIN Report It, Symptom Distress Scale, mood state item, Pittsburgh Sleep Quality Index item, and Pain Management Index.

RESULTS

The mean current pain intensity was 4.4 ± 2.9, and the mean worst pain in the past 24 hours was 7.2 ± 2.7. More than one-half of participants were not satisfied with their pain level (54%) and reported their pain was more intense than they wanted to tolerate for 18 hours or longer in the last 24 hours (51%). Only 12% were not prescribed analgesics appropriate for the intensity of their pain. Adherence rates were variable: nonsteroidal anti-inflammatory drugs (0.63 ± 0.50), adjuvants (0.93 ± 0.50), World Health Organization step 2 opioids (0.63 ± 0.49), and step 3 opioids (0.80 ± 0.40). With setting/clinical/demographic variables in the model, dose intervals of less than 8 hours were associated with less adherence ( P < .001).

CONCLUSION

Little progress has been made toward improving analgesic adherence even in settings providing analgesics without cost. Research focused on targeting analgesic dose intervals and barriers not related to cost is needed.

IMPLICATION FOR PRACTICE

Dose intervals of 8 hours or longer were significantly associated with higher adherence rates; therefore, use of longer-acting analgesics is one strategy to improve pain control at the end of life.

Factors Associated with Cancer-Related Pain Requiring High-Dose Opioid Use in Palliative Cancer Patients

Background: There are no universal tools to predict the necessity of high-dose opioid use for cancer-related pain. Early recognition and interventions for intractable cancer pain could minimize the distress of palliative patients.

Objective: We sought to identify the clinical factors associated with high-dose opioid use in advanced cancer patients to recognize palliative patients who would develop intractable cancer pain, as early as possible.

Setting/Subjects: Among 385 in-hospital cancer patients from April 1, 2014 to July 31, 2019, who were referred to the palliative care team for cancer-related pain, clinical factors significantly correlated to high-dose opioid use were retrospectively analyzed.

Measurements: We conducted a multiple logistic regression analysis to identify variables significantly related to high-dose opioid use (>120 mg/day oral morphine equivalent dose).

Results: Independent factors of high-dose opioid use included younger age (odds ratio [OR] 0.965, 95% confidence interval [CI] 0.944–0.986, p = 0.001), respiratory cancers (OR 1.882, 95% CI 1.069–3.312, p < 0.001), and opioid switch (OR 2.869, 95% CI 1.497–5.497, p = 0.001). The percentage of correct classifications of the regression equation was 86.9%.

Conclusions: Younger age, respiratory cancers, and opioid switch were related to high-dose opioid use. Our findings may help palliative caregivers to deal with intractable cancer pain in palliative patients, and thus relieve their distress.

Preliminary effects of low-intensity focused ultrasound treatment program for cancer-related neuropathic pain

Aim: To evaluate the effectiveness of low-intensity focused ultrasound (LIFU) therapy in the management of cancer-related neuropathic pain (CNP). Methods: A retrospective review with 22 patients with CNP treated with LIFU therapy (frequency 3 Hz, 3 W/cm², pulse mode duty cycle 50%) was conducted. Results: Out of the 22 patients, 15 had CNP secondary to chemotherapy-induced peripheral neuropathy. Compared with baseline, there was a significant reduction in numeric pain rating scale (p < 0.001). Additionally, 76.5% of patients (n = 13) were considered to be responders to LIFU therapy. Conclusion: LIFU therapy may be a viable treatment modality in the management of CNP, specifically chemotherapy-induced peripheral neuropathy, with a minimal side effect profile. Larger, prospective studies with a structured protocol are necessary.

Population Pharmacokinetics of Oxycodone and Metabolites in Patients with Cancer-Related Pain

Simple Summary

Patients with moderate to severe cancer-related pain are frequently treated with oxycodone, a strong-acting opioid. However, treatment with oxycodone does not always lead to sufficient analgesic action. In order to determine which factors affect treatment outcomes, we performed an observational study and developed a population pharmacokinetic model. The model described oxycodone, nor-oxycodone and nor-oxymorphone pharmacokinetics. The association between oxycodone or oxycodone metabolites’ exposure with pain scores and adverse events was not significant. The combined oxycodone, nor-oxycodone and nor-oxymorphone model is a good starting point for further unravelling the factors that affect the pharmacokinetic/pharmacodynamic relation of oxycodone and its metabolites.

Abstract

Oxycodone is frequently used for treating cancer-related pain, while not much is known about the factors that influence treatment outcomes in these patients. We aim to unravel these factors by developing a population-pharmacokinetic model to assess the pharmacokinetics of oxycodone and its metabolites in cancer patients, and to associate this with pain scores, and adverse events. Hospitalized patients with cancer-related pain, who were treated with oral oxycodone, could participate. Pharmacokinetic samples and patient-reported pain scores and occurrence and severity of nine adverse events were taken every 12 h. In 28 patients, 302 pharmacokinetic samples were collected. A one-compartment model for oxycodone and each metabolite best described oxycodone, nor-oxycodone, and nor-oxymorphone pharmacokinetics. Furthermore, oxycodone exposure was not associated with average and maximal pain scores, and oxycodone, nor-oxycodone, and nor-oxymorphone exposure were not associated with adverse events (all p > 0.05). This is the first model to describe the pharmacokinetics of oxycodone including the metabolites nor-oxycodone and nor-oxymorphone in hospitalized patients with cancer pain. Additional research, including more patients and a more timely collection of pharmacodynamic data, is needed to further elucidate oxycodone (metabolite) pharmacokinetic/pharmacodynamic relationships. This model is an important starting point for further studies to optimize oxycodone dosing regiments in patients with cancer-related pain.

Genetic implications in quality palliative care and preventing opioid crisis in cancer-related pain management

The prevalence of cancer-related pain is 64% among patients with metastatic, advanced, or terminal cancer, 59% among patients undergoing anticancer treatment, and 33% among patients who completed curative treatment. According to the World Health Organization cancer pain relief guidelines, opioid analgesics are the mainstay analgesic therapy in addition to conventional first-step analgesics, such as non-steroidal anti-inflammatory drugs and acetaminophen. The indications for strong opioids have recently been expanded to include mild-to-moderate pain in addition to moderate-to-severe pain. The U.S. Centers for Disease Control and Prevention guidelines emphasize that realistic expectations should be weighed against potential serious harm from opioids, rather than relying on the unrealized long-term benefits of these drugs. Therefore, treatment strategies for both cancer-related chronic or acute pain have been unfortunately deviated from opioid analgesics. The barriers hindering adequate cancer-related pain management with opioid analgesics are related to the inadequate knowledge of opioid analgesics (e.g., effective dose, adverse effects, and likelihood of addiction or tolerance). To achieve adequate opioid availability, these barriers should be overcome in a clinically suitable manner. Genetic assessments could play an important role in overcoming challenges in opioid management. To balance the improvement in opioid availability and the prevention of opioid misuse and addiction, the following two considerations concerning opioids and genetic polymorphisms warrant attention: (A) pain severity, opioid sensitivity, and opioid tolerance; and (B) vulnerability to opioid dependence and addiction.

Palliative Spine Surgery in a Patient with Advanced Cancer: A Case Report and Decision-Making Guide

The spine is a frequent site of cancer metastasis leading to intractable pain, functional impairment, and poor quality of life. When analgesic regimens and nonpharmacological interventions fail, spine surgery may be indicated. For patients with advanced disease, the decision to operate can become a dilemma. A patient with colon cancer metastatic to his spine, who had undergone multiple procedures for back pain, was admitted to a palliative care unit, where pain persisted despite high-dose opioids and adjuvant analgesics. Owing to progressive disease, he was told of a prognosis of six months by his oncologist. He eventually underwent percutaneous pedicle screw fixation. Shortly after surgery, he settled on a regimen merely equivalent to 45 mg of morphine per day. The article explores the role of palliative spine surgery in managing intractable cancer-related back pain. The authors offer a guide when considering surgical procedures for patients with limited prognosis.

Top Ten Tips Palliative Care Clinicians Should Know About Interventional Pain and Procedures

Pain is a common symptom for patients with advanced illness. Palliative care (PC) clinicians are experts in pharmacologic and nonpharmacologic treatment of pain and other symptoms for these patients. True multimodal pain control should include consideration of interventional procedures and pumps to improve difficult-to-manage pain. This article, written by clinicians with expertise in interventional pain and PC, outlines and explains many of the adjunctive and interventional therapies that can be considered for patients with pain in the setting of serious illness. Only by understanding and considering all available options can we ensure that our patients are receiving optimal care.

Association of Opioid Use in the Week Before Death Among Patients With Advanced Lung Cancer Having Sepsis

Opioid use can induce immunosuppression; however, it is unclear whether opioid use increases infections in patients with advanced cancers. This study assessed the association between opioid use in the week before death and mortality among patients with advanced lung cancer having sepsis. Data on opioid usage in the week before death, general information, and clinical information of the patients were collected retrospectively. The primary outcome was the association between opioid use in the week before death and mortality after sepsis. The study included 980 patients who died of advanced lung cancer between January 2003 and June 2017 (sepsis related: 413, unrelated to sepsis: 567). The average morphine equivalent daily dose in the final week was higher in the sepsis group (313.5 ± 510.5 mg) than in the nonsepsis group (125.2 ± 246.9 mg, P < .001). A significant association was found between the average morphine equivalent daily dose in the final week and mortality due to sepsis (odds ratio: 1.02, 95% confidence interval: 1.01-1.02, P < .001). This was especially evident when the dose was increased by 10 mg in the final week. Furthermore, older age, male sex, and a lower body mass index were associated with an increased risk of mortality after developing sepsis. Opioid use in the week before death may be associated with mortality for patients with advanced lung cancer having sepsis.

Opioid Misuse Risk: Implementing Screening Protocols in an Ambulatory Oncology Clinic

With morbidity and mortality related to opioid use continuing to increase, clinicians need to better understand the risk for opioid misuse in patient populations. Screening for opioid misuse risk has not been routinely adopted as a standard practice in clinical settings. A pilot study was performed to determine the feasibility of screening for future opioid misuse risk using the Opioid Risk Tool (ORT) in an ambulatory oncology clinic. Twelve patients in this sample scored in the moderate- to high-risk range for aberrant behavior, and 8 patients reported a personal history of substance abuse, indicating a need for opioid misuse risk screening in populations of patients with cancer. Because it is easy and quick to use, the ORT may be a feasible tool to incorporate into standard practice.

[Systematic review and Meta-analysis of efficacy and safety of Huachansu in treating cancer-related pain]

To evaluate the effectiveness and safety of Huachansu in the treatment of cancer-related pain,four Chinese databases( CNKI,VIP,Wan Fang,Sino Med) and three English databases( Cochrane Library,Medline,PubMed) were systematically and comprehensively retrieved since the establishment of each database to October 2018. Randomized controlled trials( RCTs) for the treatment of cancer-related pain with Huachansu were screened out according to pre-established inclusion criteria and exclusion criteria. Rev Man5. 3 software was used for Meta-analysis. A total of 241 articles were retrieved,and finally 10 studies were included. The total sample size was 1 293,including 648 in the experimental group and 645 in the control group. The overall quality of the included studies was generally low. The results of Meta-analysis showed that Huachansu combined with Western medicine acesodynes was superior to the single use of Western medicine acesodynes in the treatment of short-term pain relief,improvement of quality of life and reduction of constipation,nausea and vomiting,dizziness,drowsiness,anorexia and other adverse reactions. And it also has the advantage of a shorter onset time and longer duration time of analgesia,but cannot reduce the incidence of dysuria. Based on the findings,Huachansu had a certain effect in the treatment of cancer-related pain,and a significant positive effect on the improvement of quality of life and the reduction of adverse reactions. No serious adverse reactions occurred. However,due to the small number of studies included,the low quality of the included studies,published biases and other restrictions,the evidence in this study has a low quality,and the conclusion shall be adopted with caution. The effectiveness and safety of Huachansu in the treatment of cancer-related pain remained to be further confirmed in the future with a well-designed,rigorous,and standardized report,with a large sample size,multiple centers,and sufficient follow-up time for randomized controlled trials.

Something Must Be Wrong with the Implementation of Cancer-pain Treatment Guidelines. A Lesson from Referrals to a Pain Clinic

OBJECTIVE

The World Health Organization's (WHO) guidelines for cancer pain management were intentionally made simple in order to be widely implemented by all physicians treating cancer patients. Referrals to pain specialists are advised if pain does not improve within a short time. The present study examined whether or not a reasonable use of the WHO guideline was made by non-pain specialists prior to referral of patients with cancer-related pain to a pain clinic.

METHODS

Cancer patients referred to a pain specialist completed several questionnaires including demographics, medical history, and cancer-related pain; the short-form McGill Pain Questionnaire (SF-MPQ); and the Short Form Health Survey SF-12. Data from referral letters and medical records were obtained. Treatments recommended by pain specialists were recorded and categorized as "unjustified" if they were within the WHO ladder framework, or "justified" if they included additional treatments.

RESULTS

Seventy-three patients (44 women, 29 men) aged 55 years (range, 25-85) participated in the study. Their pain lasted for a mean of 6 (1-192) months. Mean pain intensity scores on a 0-10 numerical rating scale were 7 (2-10) at rest and 8 (3-10) upon movement. Most patients complied with their referring physician's recommendations and consumed opioids. Adverse events were frequent. No significant correlation was found between the WHO analgesic medication step used and mean pain levels reported. There were 63 patient referrals (85%) categorized as "unjustified," whereas only 11 patients (15%) required "justified" interventions.

CONCLUSIONS

These findings imply that analgesic treatment within the WHO framework was not reasonably utilized by non-pain specialists before referring patients to pain clinics.

Referral Pattern to a Tertiary Care Cancer Pain Clinic in India

The study aimed to identify patterns of patient referral from oncology services, including pain severity, prior analgesics, impact of patient's literacy on referral, and adequacy of pain relief offered by the pain clinic. A retrospective analysis of pain clinic data from August 2014 to February 2015 at the Tata Memorial Hospital was carried out, wherein adult cancer patients referred for the first time to the pain clinic were included. Two thousand patients were included: 38.1% of the referred were at pretreatment stage, 28.8% advanced. Most referrals were from head and neck (27.3%), gastrointestinal (26.2%), and thoracic (18.3%) disease management groups (DMGs); The earliest referrals were from gastrointestinal and thoracic DMGs; 75%-80% had advanced disease. There were few referrals from hemato-oncology and medical oncology. Among the patients, 88% had moderate to severe pain, a third were on analgesics, and less than a fifth were on opioids. Pain scores were lower in the literate group, and this group were referred significantly earlier than the illiterate. Literacy could therefore hold the key to better awareness and compliance with pain management. Our findings demonstrate that pain as yet does not receive a much needed priority even at a tertiary care cancer centre.

Efficacy and safety of sustained-release oxycodone compared with immediate-release morphine for pain titration in cancer patients: A multicenter, open-label, randomized controlled trial (SOCIAL)

BACKGROUND

The study aims to investigate the effect and safety of sustained-release oxycodone hydrochloride as background dose on pain titration in patients with moderate-to-severe cancer pain.

MATERIAL AND METHODS

Adult patients scheduled with a regular strong opioid for cancer-related pain were recruited and randomly assigned to sustained-release oxycodone group (tablets, 12 hourly) and immediate-release morphine group (5 mg initially, hourly). All patients were hourly reassessed for efficacy and dose titration.

RESULTS

The primary end point was the number of titration cycles required to achieve adequate pain relief (numerical rating scale, NRS ≤ 3). Secondary end points included the proportion of patients achieving adequate pain relief during each cycle, potential predictive factors for titration performance, and side effects. Ninety (94.7%) patients in oxycodone group and 78 (86.7%) patients in morphine group achieved adequate pain control during 1 to 4 cycles of titration. Patients in oxycodone group reached adequate pain control within the first 2 cycles of titration, which was significantly shorter than morphine group wherein the number of titration cycles ranged from 1 to 4 (P = .034). Oxycodone prescription significantly increased the response rate of patients to morphine titration during the first cycle of titration (P = .010). The initial NRS score and oxycodone administration were significantly associated with titration performance. The mild or moderate adverse effects were similar in 2 groups, while severe adverse effects were only identified in morphine group (P = .001).

CONCLUSION

Use of background sustained-release oxycodone is more efficient and better tolerated on dose titration than immediate-release morphine.

Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects

Interventional techniques to manage cancer-related pain may be efficient treatment modalities in patients unresponsive or unable to tolerate systemic opioids. However, indication and selection of the right technique demand knowledge, which is still incipient among clinicians. The present article summarizes the current evidence regarding the five most essential groups of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. Furthermore, indication, mechanism, drug agents, contraindications, and complications of the main techniques of each group are discussed.

Fulranumab as Adjunctive Therapy for Cancer-Related Pain: A Phase 2, Randomized, Double-Blind, Placebo-Controlled, Multicenter Study

This randomized, double-blind (DB), placebo-controlled, phase 2 study assessed the efficacy and safety of fulranumab as a pain therapy adjunctive to opioids in terminally ill cancer patients. Ninety-eight patients were randomized (2:1) to receive one subcutaneous injection of fulranumab (9 mg) or placebo in the 4-week DB phase. Seventy-one (72%) patients entered the 48-week open-label extension phase and were administered 9 mg of fulranumab every 4 weeks. The study failed to demonstrated efficacy at the end of the DB phase (primary endpoint, mean [SD] change in average cancer-related pain intensity was -.8 (1.26) for fulranumab and -.7 (1.56) for placebo; P = .592). However, potential benefit is suggested based on secondary endpoints (30% responder rate [P = .020], Brief Pain Inventory-Short Form [BPI-SF] pain intensity subscale [P = .003], and pain interference subscale [P = .006]). The most commonly reported treatment-emergent adverse events were (fulranumab vs placebo): asthenia (16% vs 10%), decreased appetite (12% vs 6%), fatigue (10% vs 0%), and malignant neoplasm progression (10% vs 0%). Although no differences were seen between fulranumab and placebo groups on the primary endpoint, improvements in BPI-SF pain subscale scores and responder rates support further research of anti-nerve growth factor therapy in cancer-related pain. PERSPECTIVE: Efficacy and safety of fulranumab as adjunctive pain therapy in terminally ill cancer patients were assessed. Results suggest that anti-NGF agents may prove to be novel additions in helping to optimize pain relief in cancer patients who fail to respond adequately to opioids and other common co-analgesics.

Prescribing Trends of Palliative Care Team's Use of Dexamethasone for Cancer-Related Pain

Opioids are first-line therapy for cancer-related pain. In addition, corticosteroids are commonly utilized as adjuvant analgesics for pain and other symptoms in the oncology setting with limited supporting data. A retrospective analysis was conducted evaluating adult hospitalized patients receiving opioids who received once-daily dexamethasone on the recommendation of a specialty palliative care team during their hospitalization from January 1, 2015, to January 1, 2016. Primary end point was to describe prescribing patterns of dexamethasone in this patient population and secondarily examining any effect on oral morphine equivalent daily dose (MEDD), numeric pain score (NPS), and unwanted effects at 24 and 48 hours after the first dose of dexamethasone. Fifty-nine patients received an average dose of 13 mg (SD = 10) of dexamethasone for cancer-related pain, primarily acute pain (n = 36, 61%). Many died before hospital discharge or soon thereafter (n = 28, 47.5%). Although not statistically significant, our study shows a decrease of 23% and 19% in MEDD and NPS, respectively, without change in WBC after dexamethasone. A specialty palliative care team most often used once-daily dexamethasone for cancer-related pain in patients near the end of life. There were trends toward lower MEDD and NPS, but more robust studies are needed for validation.

An mHealth Pain Coping Skills Training Intervention for Hematopoietic Stem Cell Transplantation Patients: Development and Pilot Randomized Controlled Trial

BACKGROUND

Pain is a challenge for patients following hematopoietic stem cell transplantation (HCT).

OBJECTIVE

This study aimed to develop and test the feasibility, acceptability, and initial efficacy of a Web-based mobile pain coping skills training (mPCST) protocol designed to address the needs of HCT patients.

METHODS

Participants had undergone HCT and reported pain following transplant (N=68). To guide intervention development, qualitative data were collected from focus group participants (n=25) and participants who completed user testing (n=7). After their input was integrated into the mPCST intervention, a pilot randomized controlled trial (RCT, n=36) was conducted to examine the feasibility, acceptability, and initial efficacy of the intervention. Measures of acceptability, pain severity, pain disability, pain self-efficacy, fatigue, and physical disability (self-report and 2-min walk test [2MWT]) were collected.

RESULTS

Participants in the focus groups and user testing provided qualitative data that were used to iteratively refine the mPCST protocol. Focus group qualitative data included participants' experiences with pain following transplant, perspectives on ways to cope with pain, and suggestions for pain management for other HCT patients. User testing participants provided feedback on the HCT protocol and information on the use of videoconferencing. The final version of the mPCST intervention was designed to bridge the intensive outpatient (1 in-person session) and home settings (5 videoconferencing sessions). A key component of the intervention was a website that provided personalized messages based on daily assessments of pain and activity. The website also provided intervention materials (ie, electronic handouts, short videos, and audio files). The intervention content included pain coping advice from other transplant patients and instructions on how to apply pain coping skills while engaging in meaningful and leisure activities. In the RCT phase of this research, HCT patients (n=36) were randomized to receive the mPCST intervention or to proceed with the treatment as usual. Results revealed that the mPCST participants completed an average of 5 out of 6 sessions. The participants reported that the intervention was highly acceptable (mean 3/4), and they found the sessions to be helpful (mean 8/10) and easy to understand (mean 7/7). The mPCST participants demonstrated significant improvements in pre- to post-treatment pain, self-efficacy (P=.03, d=0.61), and on the 2MWT (P=.03, d=0.66), whereas the patients in the treatment-as-usual group did not report any such improvements. Significant changes in pain disability and fatigue were found in both groups (multiple P<.02); the magnitudes of the effect sizes were larger for the mPCST group than for the control group (pain disability: d=0.79 vs 0.69; fatigue: d=0.94 vs 0.81). There were no significant changes in pain severity in either group.

CONCLUSIONS

Using focus groups and user testing, we developed an mPCST protocol that was feasible, acceptable, and beneficial for HCT patients with pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01984671; https://clinicaltrials.gov/ct2/show/NCT01984671 (Archived by WebCite at http://www.webcitation.org/6xbpx3clZ).

A Chinese medicine warm compress (Wen Jing Zhi Tong Fang), combined with WHO 3-step analgesic ladder treatment for cancer pain relief: A comparative randomized trial

INTRODUCTION

This study aimed to assess the effectiveness of Chinese medicine warm compress (CMWC) on back meridians in relieving cancer pain, reducing adjuvant analgesic doses and adverse reactions, and improving the quality of life (QOL).

METHODS

A total of 62 patients (age range 39-82 years) diagnosed with a malignant tumor and suffering from cancer-related pain were randomly divided into a treatment group (group A) and a control group (group B) (n = 31 for each). The patients in both groups were administered appropriate drugs for 2 cycles of 7-day treatments according to the World Health Organization (WHO) 3-step ladder for cancer pain relief in adults. In addition, a CMWC was given to patients in group A. Pain relief was assessed using the visual analogue scale (VAS) at various time points before and after interventions in each group. Alteration of analgesic doses, adverse reactions, performance status (PS), and QOL were evaluated and any differences between groups A and B evaluated.

RESULTS

VAS scores at various time points after treatment were significantly decreased compared with the baseline level in group A. Overall response rate was significantly improved in group A compared with group B (70.97% vs 29.03%, P < .001). Significant differences in clinical pain relief efficacy in various locations were found in group A after treatment vs before treatment (P < .05). Adjuvant analgesic doses were significantly changed in the control group compared to the treatment group after 1 cycle of 7-day treatment (22.58% vs 12.90%, P = .023). QOL were improved more in group A than in group B (3.00 ± 4.23 vs -2.06 ± 2.38, P < .001). Significantly reduced adverse reactions were observed after treatment of group A compared with group B in terms of the overall incidence (3.23% vs 80.65%, P < .05) or incidence of constipation (3.23% vs 77.42%, P < .05).

CONCLUSIONS

The application of CMWC on back meridians combined with WHO 3-step analgesic ladder treatment was effective in relieving cancer-related pain with reduced doses, less adverse reactions, and improved QOL.

The use of rotation to fentanyl in cancer-related pain

Pain is commonly diagnosed with respect to cancer and heart diseases, being a major symptom in most neoplastic diseases. Uncontrolled pain leads to a decrease in the quality of life and an increase in the morbidity of the patient. Opioids represent the best analgetic supportive therapy and are frequently used in patients suffering from cancer and experiencing a high level of pain. Opioid treatment starts with a gradual titration of the dose until the minimum effective dose and the maximum tolerated dose are determined. Opioid rotation refers to the switch from one opioid to another in order to get a better response to analgetic therapy and reduce side effects. Fentanyl therapy is recommended to be continued during chemotherapy, radiotherapy, or in the case of surgical intervention. Rotation to fentanyl patches is an efficient and elegant solution for cancer patients, with reduced side effects. Opioid rotation, especially to fentanyl, was shown to increase the quality of life in patients with malignant disease. Finally, rotation to fentanyl is also advantageous from an economic point of view.

Morphine or oxycodone for cancer-related pain? A randomized, open-label, controlled trial

CONTEXT

There is wide interindividual variation in response to morphine for cancer-related pain; 30% of patients do not have a good therapeutic outcome. Alternative opioids such as oxycodone are increasingly being used, and opioid switching has become common clinical practice.

OBJECTIVES

To compare clinical response to oral morphine vs. oral oxycodone when used as first-line or second-line (after switching) treatment in patients with cancer-related pain.

METHODS

In this prospective, open-label, randomized, controlled trial (ISRCTN65155201) with a selected crossover phase, patients with cancer-related pain were randomized to receive either oral morphine or oxycodone as first-line treatment. Dose was individually titrated until the patient reported adequate pain control. Patients who did not respond to the first-line opioid (either because of inadequate analgesia or unacceptable adverse effects) were switched to the alternative opioid.

RESULTS

Two hundred patients were recruited. On intention-to-treat analysis (n = 198, morphine 98, oxycodone 100), there was no significant difference between the numbers of patients responding to morphine (61/98 = 62%) or oxycodone (67/100 = 67%) when used as a first-line opioid. Similarly, there was no significant difference in subsequent response when patients were switched to either morphine (8/12 = 67%) or oxycodone (11/21 = 52%). Per-protocol analysis demonstrated a 95% response rate when both opioids were available. There was no difference in adverse reaction scores between morphine and oxycodone either in first-line responders or nonresponders.

CONCLUSION

In this population, there was no difference between analgesic response or adverse reactions to oral morphine and oxycodone when used as a first- or second-line opioid. These data provide evidence to support opioid switching to improve outcomes.

A randomised, double-blind, placebo-controlled study to assess the safety and efficacy of methoxyflurane for procedural pain of a bone marrow biopsy

CONTEXT

Pain during bone marrow biopsy (BMB) under local anaesthesia (LA) is reported in 70% of patients, of whom 35% rate the pain as severe. Pain is experienced during both the biopsy and the marrow aspiration. Many medical centres use conscious sedation involving benzodiazepines and/or opioids administered orally or intravenously for BMB analgesia. Methoxyflurane (MEOF) is self-administered by a handheld device (the Penthrox inhaler), which is licensed in Australia for the relief of pain associated with short surgical procedures.

OBJECTIVES

To evaluate the efficacy and safety of MEOF analgesia in patients with cancer undergoing BMB.

METHODS

Patients received LA plus either MEOF or placebo. The primary endpoint was worst pain intensity measured with the Numerical Rating Scale. Anxiety was assessed with the State Trait Anxiety Inventory (STAI-Y-1). Patients, operators and the research nurse rated global medication performance using a 5-point Likert scale.

RESULTS

Forty-nine of the 50 patients randomised to MEOF and 48 of the 50 patients randomised to placebo effectively received the allocated intervention. Mean±SD worst pain overall was 4.90±2.07 in MEOF group and 6.0±2.24 in placebo group (p=0.011). Worst pain during the aspiration was 3.3±2.0 in MEOF group and 5.0±2.4 in placebo group (p<0.001). 49% of patients treated with MEOF rated the medication as very good or excellent compared with 16.5% of the patients treated with placebo (p=0.005). 20.4% of patients treated with MEOF had an adverse event (AE) compared with 4.2% in the placebo arm (p=0.028). All AEs were grade 1.

CONCLUSIONS

MEOF was safe and performed better than placebo for analgesia in BMB procedures.

Predictors of cancer-related pain improvement over time

OBJECTIVE

To determine the predictors of pain improvement among patients being treated for cancer-related pain over 12 months.

METHODS

A secondary analysis of the telephone care Indiana Cancer Pain and Depression trial was performed. Patients (n = 274) were interviewed at baseline and after 1, 3, 6, and 12 months. Pain improvement outcomes included both a continuous measure (Brief Pain Inventory score) and a categorical measure (pain improved versus pain not improved). Predictor variables included change in depression, age, sex, race, marital status, socioeconomic disadvantage, medical comorbidity, type of cancer, and phase of cancer. Multivariable repeated measures were conducted, adjusting for intervention group assignment, baseline pain severity, and time in months since baseline assessment.

RESULTS

Factors significantly predicting both continuous and categorical pain improvement included participating in the intervention group (β = -0.92, p < .001, odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.65-3.89), greater improvement in depression (β = -0.31, p = .003, OR = 1.84, 95% CI = 1.35-2.51), higher socioeconomic status (Socioeconomic Disadvantage index; β = 0.25, p = .034; OR = 0.73, 95% CI = 0.56-0.94), and fewer comorbid conditions (β = 0.20, p = .002; OR = 0.84, 95% CI = 0.73-0.96). Patients with more severe pain at baseline or with recurrent or progressive cancer were less likely to experience continuous or categorical pain improvement, respectively.

CONCLUSIONS

Effective management of depression and comorbid conditions along with improvement of social services could be critical components of a comprehensive pain management. Patients with more severe pain or with recurrent or progressive cancers may require closer monitoring and adequate treatment of pain. Trial Registration clinicaltrials.gov Identifier: NCT00313573.

Cancer-related pain and disability: a longitudinal study

CONTEXT

Although the cross-sectional association between cancer-related pain and disability is well established, their longitudinal relationship has been less studied.

OBJECTIVES

Data from the Indiana Cancer Pain and Depression (INCPAD) trial were analyzed to determine whether baseline cancer-related pain and changes in pain over time predict disability over 12 months.

METHODS

A total of 274 cancer survivors with cancer-related pain were accrued in the INCPAD trial. Data were collected at baseline, one, three, six, and 12 months by interviewers blinded to treatment arm. Disability outcomes included a continuous measure (Sheehan Disability Scale [SDS] score) and a categorical measure (≥14 days in the past four weeks with a ≥50% reduction in usual activities). Predictor variables, operationalized by the Brief Pain Inventory, included baseline pain severity and changes in pain severity scores between each time point. Multivariable analyses were conducted adjusting for treatment group, baseline disability, and selected covariates including depression.

RESULTS

Baseline pain severity did not predict disability outcomes at 12 months. However, improvement in pain severity predicted less disability over 12 months both in terms of SDS scores (b=-0.17, t=-5.33, P<0.001) and ≥14 disability days in the past month (odds ratio=0.85; 95% confidence interval, 0.79-0.93; P<0.001).

CONCLUSION

Disability over 12 months in patients with cancer-related pain is predicted by changes in pain severity over time. Results suggest that effective pain management may reduce subsequent disability among cancer survivors.