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Although the vast majority of patients with cancer pain receive effective analgesia from standard therapy, a few patients, particularly those with neuropathic pain, continue to experience severe pain despite large doses of systemic or intraspinal opioids. Animal studies suggest intraspinal alpha 2-adrenergic agonists may be effective in such cases. Eighty-five patients with severe cancer pain despite large doses of opioids or with therapy-limiting side effects from opioids were randomized to receive, in a double-blind manner, 30 micrograms/h epidural clonidine or placebo for 14 days, together with rescue epidural morphine. Pain was assessed by visual analog score (VAS), McGill Pain Questionnaire, and daily epidural morphine use. Success was defined as a decrease in either morphine use of VAS pain, with the alternative variable either decreasing or remaining constant. Blood pressure, heart rate, and degree of nausea and sedation were monitored. Successful analgesia was more common with epidural clonidine (45%) than with placebo (21%). This was particularly prominent in those with neuropathic pain (56% vs. 5%). Pain scores were lower at the end of the treatment period in patients with neuropathic pain treated with clonidine rather than placebo, whereas morphine use was unaffected. Clonidine, but not placebo, decreased blood pressure and heart rate. Hypotension was considered a serious complication in 2 patients receiving clonidine and in 1 patient receiving placebo. This study confirms the findings from previous animal studies which showed the effective, potent analgesic properties of intraspinal alpha 2-adrenergic agonists and suggests that epidural clonidine may provide effective relief for intractable cancer pain, particular of the neuropathic type.
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PMID:Epidural clonidine analgesia for intractable cancer pain. The Epidural Clonidine Study Group. 747 82

In this study we compared 293 patients with cancer pain undergoing treatment in the years 1987 until 1993. 165 patients (55.7%) suffering from cancer localized at the organs of gastrointestinal tract. Comparing the therapeutic results of WHO pattern with patients after implantation of port systems with epidural or intrathecal catheters and portable external morphine pumps we found at port-patients a significant lower number of side effects like nausea, vomiting, obstipation and weariness. Furthermore we noted at port-patients lower values of pain score (VAS). We think the high incidence of uncomfortable side effects of drugs at patients with gastrointestinal cancer may be caused by the type of special illness. Therefore we discuss the possibility of an earlier use of the method of port implantation at special indications.
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PMID:[Pain therapy of tumor patients with special reference to tumors of the gastrointestinal tract. WHO staged schedule versus para-spinal analgesia techniques]. 752 43

In this retrospective study, we reviewed the patterns of use of the Edmonton Injector (EI) in 100 consecutive cancer patients. Seventy-eight patients used the EI for an average of 23 +/- 27 days. The main reasons for starting the EI were nausea (37 patients) and severe pain (31 patients). The median opioid dose equivalent to parenteral morphine (MEDD) was 264 +/- 443 mg/day. The mean duration of the subcutaneous injection site was 6.5 +/- 9.2 days. The most frequent reasons for change were accidental needle pulling (59%) and erythema (12%). Only two patients developed local infection (1% of 196 sites). The average cost of treatment was $1.65 Canadian per patient per day. No mechanical problems or refusals to start or continue treatment were detected. We conclude that the EI is a safe and simple device that allows for cost-effective parenteral administration of opioids for cancer pain.
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PMID:Use of the Edmonton Injector for parenteral opioid management of cancer pain: a study of 100 consecutive patients. 752 82

Pain treatment for 17 pediatric cancer patients in our institution was evaluated and disirable cancer pain management for children was discussed. Most of the patients (aged 1-17 years) suffering severe pain for about one month were in the advanced stage of the malignant diseases (e.g. leukemia). The pain etiology was mostly tumor-associated while therapy-related pain accounted for 23.5%. These pains were treated with NSAIDs or pentazocine before the consultation with inadequate relief. Oral morphine sulfate or continuous intravenous morphine chloride was administered to 16 patients with successful pain relief and side effects such as nausea (52.9%) and drowsiness (41.2%). It took 5.5 days on average until adequate pain control methods were determined. It is known that most NSAIDs frequently used for pediatric pain possibly cause adverse effects such as platelet dysfunction or mucous membrane injury with a suppository, which could lead to a fatal disorder in clinically ill pediatric cancer patients. Moreover sufficient doses for the pain relief are not necessarily given to the pediatric patients because of a limit to the dosage of NSAIDs. The period of pediatric cancer pain in which the patient require a methodical treatment and receive benefit from pain relief is relatively short in the advanced stage, not to mention the early stage in which chemotherapy is efficacious against cancer disease itself. Therefore, to obtain effective pain control within a short time, the authors propose the pain management for advanced pediatric cancer patients by the two-step analgesic ladder prescribing weak or strong opioid analgesics first, adapted from the three-step ladder of the WHO Cancer Pain Relief, 1986.
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PMID:[Pain management in advanced pediatric cancer patients--a proposal of the two-step analgesic ladder]. 754 19

Tramadol is a centrally acting analgesic which possesses opioid agonist properties and activates monoaminergic spinal inhibition of pain. It may be administered orally, rectally, intravenously or intramuscularly. In patients with moderate to severe postoperative pain, intravenous or intramuscular tramadol has generally proved to be of equivalent potency to pethidine (meperidine) and one-fifth as potent as nalbuphine. Intravenous tramadol 50 to 150mg was equivalent in analgesic efficacy to morphine 5 to 15mg in patients with moderate pain following surgery; however, when administered epidurally tramadol was one-thirtieth as potent as morphine. Tramadol has demonstrated efficacy in a few studies in the short term treatment of chronic pain of various origins. Orally administered tramadol was found to be an effective analgesic in step 2 of the World Health Organization's guidelines for the treatment of patients with cancer pain. Tramadol is well tolerated in short term use with dizziness, nausea, sedation, dry mouth and sweating being the principal adverse effects. Respiratory depression has been observed in only a few patients after tramadol infusion anaesthesia. When used for pain relief during childbirth, intravenously administered tramadol did not cause respiratory depression in neonates. The tolerance and dependence potential of tramadol during treatment for up to 6 months appears to be low, although the possibility of dependence with long term use cannot be entirely excluded. Thus, evidence to date of the analgesic effectiveness of tramadol combined with a low respiratory depressant effect and low dependence potential in short term use, suggests that the drug may become a useful alternative to the opioid analgesics currently available for the treatment of patients with moderately severe acute or chronic pain.
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PMID:Tramadol. A preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. 769 19

Intraspinal delivery of opioids is a proven method of pain management therapy for severe cancer pain. Effective analgesia can be achieved with spinal opioid infusions while minimizing central side effects such as sedation, nausea, and severe constipation. Indications for intraspinal opioids include unmanageable side effects with increasing doses of oral or parenteral opioids or little or no pain relief with increasing dosages of strong opioids. The purpose of this case study is to illustrate the multidisciplinary approach required and multiple analgesics needed to effectively assess and manage a challenging pain management situation. This patient required the administration of intraspinal morphine, intravenous hydromorphone, and intravenous midazolam in order to effectively manage his pain. The use of spinal analgesia and multiple analgesics offers challenges to oncology and hospice nurses but is an effective modality for otherwise intractable cancer pain.
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PMID:High-tech pain management utilizing multiple analgesics--a case study. 769 2

More than 60% of cancer patients suffers from unbearable pain, especially towards their terminal stages. Anaesthesiologists are involved in cancer pain management because of their expertise in analgesic pharmacology and neurolytic procedures. This manuscript reported on the experience of treating cancer pain in Chinese patient in Hong Kong with reference to current literature in other parts of the world. One hundred and sixty two Chinese patients were referred from other specialists to the Department of Anaesthesiology, Queen Mary Hospital for further management because of their cancer pain control were considered difficult. Upon referral, the mean visual analogue scale of pain (VAS) was 5.8 +/- 2.7. The pain caused insomnia (66.7%) and appetite loss (45%) as well. By far most (80%) patients' pain were successively controlled with oral systemic analgesics. These were prescribed in form of a combination of NSAID (72.2%), potent opioids (76.5%) and co-analgesics (21.6%). In our series, the mean oral morphine (MS Continus) requirements was 96.0 +/- 68.3 mg on discharge. Frequent nausea and constipation persisted in 16.0% and 8.0% respectively despite active treatment with anti-emetics and laxatives. Twenty eight neurolytic blocks was performed in 22 (13.6%) patients. Good pain relief was achieved in 78.6%. Overall speaking most patients (90.7%) were able to achieve adequate analgesia before death.
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PMID:Cancer pain management: a recent experience by anaesthesiologists in a teaching hospital in Hong Kong. 792 65

In a prospective study, the prevalence of 15 physical symptoms and symptom groups was evaluated in 1635 cancer patients referred to a pain clinic. In addition to pain, patients suffered an average of 3.3 symptoms: insomnia (59%), anorexia (48%), constipation (33%), sweating (28%), nausea (27%), dyspnea (24%), dysphagia (20%), neuropsychiatric symptoms (20%), vomiting (20%), urinary symptoms (14%), dyspepsia (11%), paresis (10%), diarrhea (6%), pruritus (6%), and dermatological symptoms (3%). While symptom prevalence was influenced by tumor site, pain intensity, and opioid treatment, only a minor relationship was seen between symptoms and gender, age, or tumor stage. The data emphasize that it is not sufficient to simply address pain during the treatment of patients with cancer pain; a more global approach to symptom management is necessary.
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PMID:Prevalence and pattern of symptoms in patients with cancer pain: a prospective evaluation of 1635 cancer patients referred to a pain clinic. 796 90

A questionnaire study was performed in order to clarify knowledge and practice of cancer pain treatment in Norway: a 10% random sample of Norwegian physicians received a questionnaire. Of 800 correctly addressed questionnaires, 549 were returned and 306 were analyzed after exclusion of those doctors who never treated cancer patients. Their knowledge of the principles and methods of cancer pain treatment were evaluated with 8 multiple-choice and 13 open questions. Their ability to apply their knowledge in practice was evaluated by analyzing their suggested treatment of 3 illustrative case histories. The results show that only 25% of Norwegian physicians treating cancer patients appear to have knowledge of the principles of the World Health Organization analgesic ladder strategy. However, the majority (86%) of the physicians were prepared to prescribe strong opioid analgesics, but in the illustrative cases where strong opioids were appropriate, 44% prescribed too small doses and often preferred neuroleptic drugs instead of increasing the analgesic to a sufficiently large dose. Patients needing step two on the analgesic ladder, in Norway often (49%) are treated with a standard combination of paracetamol and codeine. However, when a strong opioid is required, 50% of Norwegian physicians forget to continue the paracetamol or NSAID component. Two hundred seventy-four (97%) of the physicians said they experienced problems when treating cancer pain, ranging from inefficient pain relief (52%) to side effects of opioid analgesics (32%), most often sedation, in combination with nausea and constipation. Only 13% of the physicians had a correct understanding of opioid drug dependence. As many as 72% of Norwegian physicians thought their education in cancer pain treatment was insufficient.
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PMID:Treatment of cancer pain in Norway. A questionnaire study. 806 87

A new assessment of quality of life (QOL) was made for cancer patients. The QOL assessment consists of 12 items: pain; nausea; constipation; general fatigue; sleep; eating; activity; a daily life pattern; conversation; treatment acceptability; satisfaction at the present status and family exhaustion. Ranges of scores are one (best) to five (worst). For visual expression of QOL, the author made an original method called "QOL diagram", drawn with a circle which has 12 diverging lines marked five points indicating the score for each item. QOL changes after cancer pain control with either oral or intravenous morphine were examined in 22 adult cancer patients by the QOL assessment. Laxatives and anti-nausea drugs were mostly prescribed at the same time in order to avoid side effects of morphine. QOL was evaluated and recorded by the author through an individual interview with each patient. It was observed that the psychological factors were improved along with pain relief. Although items such as general fatigue, nausea, constipation, sleep and eating did not change considerably at first, they improved well with time in the oral morphine group. On the other hand, there was no marked time-dependent change in the intravenous morphine group. Items such as activity, a daily life pattern and conversation were rather negative than positive. These items seem to be more important to improve QOL of the cancer patients, in particular, whose general status is relatively good. In conclusion, the QOL diagram helped us to follow subtle changes of status and needs of cancer patients. And it enables us to easily assess risks and benefits of the treatment plans including palliative care and home supportive programs. It is designed for both patients and medical staffs to use easily and repeatedly. However, the further evaluation and refinement will be needed to verify validity and reliability of the QOL diagram before a routine clinical application.
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PMID:[A new assessment of quality of life (QOL) for cancer patients]. 815 53


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