Does pain intensity predict a poor opioid response in cancer patients?

Abstract Aim The aim of this study was to test the hypothesis that initial pain intensity is not a predictive factor of poor opioid response in advanced cancer patients, as suggested by a recent work. Methods A secondary analysis of one-hundred-sixty-seven patients referred for treatment of cancer-related pain was conducted. Pain intensity at admission was recorded and patients were divided in three categories of pain intensity: mild, moderate and severe. Patients were offered a treatment with opioid dose titration, according to department policy. Data regarding opioid doses and pain intensity were collected after dose titration was completed. Four levels of opioid response were considered:…

Low doses of transdermal fentanyl in opioid-naive patients with cancer pain.

The aim of this study was to evaluate the effect and tolerability of low doses of transdermal (TD) fentanyl patches in opioid-naive patients with cancer pain.This was a nonrandomized, open-label, uncontrolled study in fifty consecutive opioid-naive patients with advanced cancer and moderate pain. TD fentanyl was initiated at a dose of 12 µg/h. Doses were then adjusted according to the clinical response. Pain intensity, opioid-related adverse effects, TD fentanyl doses, and quality of life were monitored over 4 weeks. The time to dose stabilization and indexes of dose escalation were also calculated.Thirty-one patients completed all 4 weeks of the study. Pain control was achieved within a me…

Caregiver Distress in Home Palliative Care

Aim: This study aims to determine the symptom burden of caregivers who were following their loved ones at home and factors associated with this burden. Methods: From a consecutive number of patients followed at home by a specialistic palliative care team, a sample of 46 couples of patients-caregivers was screened. Epidemiological data of both patients and caregivers were collected, also including some variables, such as the level of religiousness, education, economic conditions, and financial distress. The Edmonton Symptom Assessment System (ESAS) was measured in both patients and caregivers. Caregivers were asked to provide a comment in a semi-structured interview, about “what do you thin…

Effectiveness and tolerability of amidotrizoate for the treatment of constipation resistant to laxatives in advanced cancer patients.

Abstract Context Constipation is a common problem for advanced cancer patients, and is generally inadequately treated. Objectives The aim of this study was to prospectively evaluate the effectiveness and tolerability of amidotrizoate (AM) in patients unresponsive to current laxatives. Methods A consecutive sample of advanced cancer patients was surveyed. Inclusion criteria were no bowel movements for three days despite receiving regular doses of senna or lactulose. AM 50mL was administered orally; the dose could be repeated the day after, based on clinical judgment and/or patients' preference. Age, sex, primary tumor, previous abdominal surgery, chemotherapy and radiotherapy performed in th…

Supportive care services in hemato-oncology centers: a national survey

Background: In the field of hemato-oncology, there is paucity of data assessing models of integration between hemato-oncology and other partner specialties. The aim of this national survey was to gather information about the status of the integration of this kind of activity in hemato-oncologic units existing in Italy. Methods: A national telephone survey was conducted to gather information about the status of the integration of hemato-oncologic and supportive care/anesthesiological services. From the national registry of hemato-oncology units, 149 centers were contacted by phone and a dedicated doctor was identified to gather information about the center through a telephone interview. Resu…

Opioid Plasma Concentrations during a Switch from Transdermal Fentanyl to Methadone

Opioid switching is often used to improve the opioid response in patients with cancer experiencing poor analgesia or adverse effects. When switching between drugs with delayed effect because of pharmacokinetics or type of delivery, concerns exist about the correct timing of introducing the second drug after stopping the previous one. The aim of this study was to assess plasmatic changes of fentanyl and methadone underlying the clinical events occurring during opioid switching. Eighteen patients with cancer receiving transdermal fentanyl with uncontrolled pain and/or moderate to severe opioid adverse effects, were switched to oral methadone using an initial fixed ratio of 1:20. Fentanyl patc…

Switching from morphine to methadone to improve analgesia and tolerability in cancer patients: A prospective study

PURPOSE: To evaluate the clinical benefits of switching from morphine to oral methadone in patients who experience poor analgesia or adverse effects from morphine. PATIENTS AND METHODS: Fifty-two consecutive cancer patients receiving oral morphine but with uncontrolled pain and/or moderate to severe opioid adverse effects were switched to oral methadone administered every 8 hours using different dose ratios. Intensity of pain and adverse effects were assessed daily, and the symptom distress score (DS) was calculated before and after switching. RESULTS: Data were analyzed for 50 patients. Switching was considered effective in 80% of the patients; results were achieved in an average of 3.65 …

Incidence of chronic pain in patients with end-stage renal disease on dialysis

Effects of age and gender in patients receiving doses of opioids for breakthrough pain proportional to background opioid doses.

Aim: To identify the role of age and gender in analgesic and adverse effects after administering fentanyl products for breakthrough pain (BT), given in doses proportional to opioid doses given for background pain. Methods: Data from nine studies, in which patients with BP were given fentanyl products in doses proportional to their basal opioid regimen, were analyzed. Results: A total 462 patients presenting 1905 episodes of BP were included in this analysis. In older patients, the decrease in pain intensity was more pronounced 15 min after administration of a BP medication. No gender differences were found. No significant differences in frequency and intensity of adverse effects for age and…

Pharmacological Management of Cancer Pain in the Elderly

Existing studies indicate a high prevalence rate and poor management of cancer pain in the elderly. Pain is often considered an expected concomitant of aging, and older patients are considered more sensitive to opioids. Despite the well known pharmacokinetic changes in the elderly, the complex network of factors involved in the opioid response make the evaluation of a single element, such as age, more difficult. Notwithstanding such difficulties, appropriate analgesic treatment is able to control cancer pain in the elderly in most cases. Skills necessary to optimise pain control in older cancer patients include the ability to objectively assess functional age (not necessarily related to chr…

Emergencies in patients with advanced cancer followed at home.

Abstract CONTEXT: Patients with advanced cancer stay at home for most of their time, and acute problems may occur during home care. Caregivers may call medical services for an emergency, which can result in patients being admitted to the hospital. No data exist on emergencies in patients followed by a home care team. OBJECTIVES: The aim of this multicenter prospective study was to assess the frequency, reasons for, and subsequent course of emergency calls for patients followed at home by a palliative care team. METHODS: A consecutive sample of patients admitted to home care programs was surveyed for a period of seven months. Epidemiological data, and characteristics of emergency calls and o…

Effects of Caffeine as an Adjuvant to Morphine in Advanced Cancer Patients

Psychomotor abnormalities are one of the complications of opioid therapy in advanced cancer patients. Caffeine has potential properties to counteract the central effects of morphine. Twelve patients receiving stable doses of slow release morphine with adequate pain relief were scheduled for this double-blind placebo-controlled crossover trial. The treatment consisted of an intravenous dose of 1/6 of the daily morphine dose, using an intravenous/oral conversion ratio of 1:3. The dose calculated was administered in 5 minutes. Patients were randomly divided to received in a double-blind manner an infusion of 200 mg of caffeine or saline solution intravenously over one hour. A crossover took pl…

The course of symptom frequency and intensity in advanced cancer patients followed at home

Four hundred consecutive patients who were referred to a home palliative care program were prospectively surveyed to estimate the prevalence and severity of common symptoms according to the changes in the performance status. Patients were admitted for the presence of different symptoms and psychosocial support. Common symptoms included in a standard form were rated for severity (absent 0, mild 1, moderate 2, severe 3) for each visit. Pain intensity was rated on a numerical scale (0-10). For each level of Karnofsky performance score (K), the frequency and the worse symptom intensity were recorded until patient's death. Data from 370 patients were analyzed. Pain was effectively controlled. In…

Gastrointestinal Bleeding In Advanced Cancer Patients

Fentanyl Pectin Nasal Spray Versus Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Comparative Study

Context Fentanyl products have shown superiority over oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use an appropriate patient selection, and drugs have been compared using a different rationale. Objectives The aim of this randomized, crossover, controlled study was to compare the efficacy and safety of fentanyl pectin nasal spray (FPNS) and oral morphine (OM), given in doses proportional to opioid daily doses. Methods Cancer patients with pain receiving ≥60 mg of OM equivalents/day and presenting with ≤3 episodes of BTcP/day were included. Patients received, in a randomized, crossover manner, FPNS or OM at doses proportional to the d…

An Italian survey on the attitudes in treating breakthrough cancer pain in hospice.

As recognition and treatment of breakthrough cancer pain (BcP) depend on the education and knowledge of palliative care physicians, it is important to systematically explore the attitudes of palliative care physicians in hospices or palliative care units. The aim of this study was to assess the knowledge and attitudes of hospice physicians in Italy regarding BcP and its treatment. All hospices existing in Italy were interviewed to gather information about provision of BP medication, drugs of choice, preferred route of administration, methods to choose the dose, and choice of BcP medication based on opioid administered for background analgesia. Of 158 hospices registered, 122 centers agreed …

Management of painful bone metastases.

PURPOSE OF REVIEW: This review examines recent data on the pathophysiology and mechanisms of bone pain; it highlights the use of multiple and interdisciplinary treatments rather than sole use of traditional analgesics. RECENT FINDINGS: Bone pain has been shown to have a unique pathophysiology. Recent experimental (animal) models have revealed that, parallel to increased bone destruction, ipsilateral spinal cord segments that receive primary input from the cancerous femur exhibit several notable neurochemical changes. These mandate the use of opioid doses sufficient to inhibit the observed nociceptive behaviours; these doses are greater than those required to alleviate pain behaviours of com…

World Health Organization guidelines for cancer pain: a reappraisal

Pain is a prevalent symptom experienced by at least 30% ofpatients undergoing an oncological treatment for metastaticdisease and by more than 70% of advanced cancer patients[1]. In 1986 the World Health Organization [2] published a setof guidelines for cancer pain management based on the three-step analgesic ladder [2]. The main aim of WHO guidelienswas to legitimize the prescribing of strong opioids, arisingfrom evidence of poor management of cancer pain, due toreluctance of health care professionals, institutions, and gov-ernment to use opioids because of fears of addition, toleranceand illegal abuse.Its application is reported to achieve satisfactory pain reliefin up to 90% of patients w…

Delirium assessed by Memorial Delirium Assessment Scale in advanced cancer patients admitted to an acute palliative/supportive care unit

Background: Delirium is often unrecognized in cancer patients. The aim of this study was to investigate the prevalence of delirium assessed by the Memorial Delirium Assessment Scale (MDAS) and possible associated factors on admission to an acute palliative/supportive care unit (APSCU). The secondary outcome was to assess changes in MDAS and symptom burden at time of discharge. Methods: A consecutive sample of advanced cancer patients who were admitted to an APSCU was prospectively assessed for a period of 10 months. Patient demographics, including age, gender, primary diagnosis, Karnofsky status, stage of disease, and educational level were collected. The Edmonton Symptom Assessment Scale (…

Breakthrough pain in oncology: A longitudinal study

Abstract Context Existing studies on breakthrough pain (BP) have reported different prevalence rates because of different settings, populations, and assessment methods. These studies have used cross-sectional designs, and the relationship of BP with analgesic treatment has not been evaluated. Objectives The aim of this study was to longitudinally assess BP in cancer patients admitted to oncology units. Methods A consecutive sample of patients admitted to oncology centers was selected. At admission (T0), three months after admission (T3), and six months after admission (T6), data on background pain and BP were recorded. BP was assessed in terms of its intensity, duration, number of episodes,…

Analgesic Treatment of Bone Metastases

The presence of bone metastases predicts the presence of pain and is the most common cause of cancer-related pain. Although bone metastases do not involve vital organs, they may determine deleterious effects in patients with prolonged survival. Bone fractures, hypercalcaemia, neurologic deficits and reduced activity associated with bone metastases result in an overall compromise in the patient’s quality of life. A metastasis is a consequence of a cascade of events including a progressive growth at the primary site, vascularization phase, invasion, detachment, embolization, survival in the circulation, arrest at the site of a metastasis, extravasion, evasion of host defense and progressive g…

Pattern and characteristics of patients admitted to a hospice connected with an acute palliative care unit in a comprehensive cancer center

Purpose: Information about inpatient hospice activity is limited. No data exist about the pattern and the characteristics of advanced cancer patients admitted to a hospice connected to an acute supportive/palliative care unit (ASPCU). Methods: Data of hospice admissions were retrieved from the database where all data were prospectively collected. The Edmonton Symptom Assessment Scale (ESAS) and the use of analgesics and adjuvant were recorded at admission (T0), 1 week (T7), 2 weeks (T14), and the day before death (T-end). The use of palliative sedation and its indication, duration, and drugs end doses used were recorded. The number of hospice deaths, discharges, and hospice staying were rec…

Relationship between background cancer pain, breakthrough pain, and analgesic treatment: a preliminary study for a better interpretation of epidemiological and clinical studies

Abstract Abstract Background: The different operational definitions of breakthrough cancer pain (BTcP) has generated unclear epidemiological data. Methods: A consecutive sample of patients was categorized on the basis of their background pain intensity, background analgesic treatment, and the presence of BTcP. Results: A total of 265 patients were surveyed; 117 patients had background pain and 91 patients presented peaks of pain intensity distinguishable from background pain. Of 117 patients with background pain, 49 patients were re-assessed after optimization of background analgesia (T1) within a mean of 8.2 days. Pain intensity significantly decreased in comparison with values recorded at…

Financial distress and its impact on symptom expression in advanced cancer patients

Aim: To assess financial distress (FD) and its impact on symptom expression and other quality of life issues Patients and methods: Advanced cancer patients admitted to inpatient and outpatient clinics were selected. Standard epidemiological data including age, gender, primary cancer diagnosis, and Karnofsky level were recorded. Data regarding marital status, number of cohabitants, religious belief, educational level, and family income (< 1000, 1000–3.000, > 3000 euros), as well as extra costs not covered by health care system, were collected. Symptom burden including FD was measured by Edmonton Symptom Assessment Scale (ESAS), FACT-G (Functional Assessment of Cancer Therapy-General), …

Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction

In advanced cancer patients with inoperable bowel obstruction, the administration of antisecretive and antiemetic drugs has proved to be effective in controlling gastrointestinal symptoms caused by bowel obstruction. However, controlled studies concerning the most effective antisecretive drug are lacking. The aim of this randomized controlled study was to determine whether octreotide or hyoscine butylbromide was the more effective antisecretive drug for use in states of inoperable bowel obstruction. Eighteen patients with inoperable bowel obstruction randomly received octreotide 0.3 mg daily (n = 9) or hyoscine butylbromide (HB) 60 mg daily (n = 9) s.c. The following parameters were measure…

The use of pilocarpine in opioid-induced xerostomia

Oral dryness can be a symptom of asystemic disease, an adverse effect of anticholin-ergic, antiadrenergic or cytotoxic drug treatment, orit can be due to local radiotherapy. Opioid use isstrongly associated with xerostomia, although themechanism for this remains unclear; in one studypatients receiving morphine were four times morelikely to have a dry mouth than patients taking otherdrugs known to cause xerostomia.

The Path of Cicely Saunders: The “Peculiar Beauty” of Palliative Care

This paper is aimed at focusing on the writings and the experience of the Hospice movement Founder, Dame Cicely Saunders. The in-depth analysis carried out had the objective of verifying if “the way” of Cicely to understand, live and propose palliative care was still current and “beautiful”, so that we can nowadays refer to her fascinating “Original Palliative Care”. With “beauty” we mean, on the one hand, a way able to allow a personal path of research of the meaning of the disease and of the care, both for those who care and for those who are cared for. On the other hand, it seems to us that Cicely strongly suggests how this path can not be carried out alone, but is only possible within …

Role of Octreotide, Scopolamine Butylbromide, and Hydration in Symptom Control of Patients with Inoperable Bowel Obstruction and Nasogastric Tubes

Bowel obstruction may be an inoperable complication in patients with end-stage cancer. Scopolamine butylbromide (SB) and octreotide (OCT) have been successfully used with the aim of reducing gastrointestinal (GI) secretions to avoid placement of a nasogastric tube (NGT); however, there have been no comparative studies concerning the efficacy of these drugs. Furthermore, there is little information about the role played by parenteral hydration in symptom control of these patients. In a prospective trial that involved all 17 inoperable bowel-obstructed patients presenting to our services with a decompressive NGT, patients were randomized to OCT 0.3 mg/day or SB 60 mg/day for 3 days through a …

Symptom Expression in Patients with Advanced Cancer Admitted to an Acute Supportive/Palliative Care Unit With and Without Delirium

Abstract Aim The aim of this study was to investigate the relationship between delirium and symptom expression in patients with advanced cancer admitted to an acute supportive/palliative care unit (ASPCU). Methods A consecutive sample of patients with advanced cancer who were admitted to an ASPCU was prospectively assessed for a period of 10 months. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS (Memorial Delirium Assessment Scale) were measured at admission (T0) and after 7 days of palliative care (T7). Results Two hundred forty-six patients had complete data regarding MDAS measurements, at either T0 and T7. Of these, 75 (30.5%) and 63 patients (25.6%) had delirium at T0 and aft…

Opioid titration in cancer pain: a critical review.

Initiation of therapy with strong opioids is a challenging phase to obtain the maximum benefit and to gain the patient's compliance. The approach could be different, depending on the clinical situation and type of opioid regimen. Substantially, the need to titrate the dose of strong opioids emerges in different conditions: (a) in opioid-naive patients who require an opioid treatment; (b) in patients no longer responsive to weaker drugs requiring strong opioids; (c) in patients already receiving strong opioids requiring higher doses because of an increase in pain intensity or a new acute pain problem; (d) in patients who are severely suffering and need an intensive as well as rapid intervent…

The long and winding road of non steroidal antinflammatory drugs and paracetamol in cancer pain management: A critical review

The aim of this review was to assess the value of NSAIDs and paracetamol in patients with cancer pain to update a previous review performed ten years ago on this topic. The approach was analytic and based on clinical considerations, rather than on raw evidence, which often does not provide useful information in clinical practice. Both published reports from an extensive search of electronic data bases were collected from January 2001 to December 2011. A free-text search method was used including the following words and their combination: “Anti-inflammatory drugs OR paracetamol OR acetaminophen” AND/OR “cancer pain”. Any randomized-controlled trial was considered. Thirteen reports fulfitted …

Rapid onset opioids for breakthrough pain: Titrating or not titrating, this is the question!

Abstract Breakthrough cancer pain (BTcP) has been defined as a transitory increase in pain intensity that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. Traditional dosing recommendations for BTcP have suggested that the effective dose of oral opioids should be a percentage of a patient’s total daily opioid dose. In the last years a number of new formulations that deliver fentanyl directly through mucous membranes have been developed in an effort to provide a more rapid onset of effect (rapid onset opioids, ROOs). Recent recommendations suggest that the dose of ROOs for BTcP…

Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey

Background: The aim of this paper is to collect data on the practice of palliative care, withholding and withdrawal of life-sustaining therapies, and management of end of life (EOL) in Italian intensive care units (ICUs). Methods: Web-based survey among Italian anesthesiologists endorsed by the Italian Society of Anesthesiology Analgesia Reanimation and Intensive Care (SIAARTI). The survey consists of 27 close-ended and 2 open-ended questions. Results: Eight hundred and five persons responded to the full list of questions. The highest proportion of respondents was of 36–45 years of age (34%) and catholic (66%). Almost 70% of responders declared that palliative/supportive care are applied …

Low morphine doses in opioid-naive cancer patients with pain

Cancer pain can be managed in most patients through the use of the analgesic ladder proposed by the World Health Organization. Recent studies have proposed to skip the second "rung" of the ladder by using a so-called "strong" opioid for moderate pain. However, usual doses of strong opioids commonly prescribed for the third rung of the analgesic ladder may pose several problems in terms of tolerability in opioid-naive patients. The aim of this multicenter study was to evaluate the efficacy and tolerability of very low doses of morphine in advanced cancer patients no longer responsive to nonopioid analgesics. A sample of 110 consecutive opioid-naive patients with moderate-to-severe pain were …

Spinal neuronal correlates of tapentadol analgesia in cancer pain: A back-translational approach

Background Pain is a common and highly debilitating complication for cancer patients significantly compromising their quality of life. Cancer-induced bone pain involves a complex interplay of multiple mechanisms including both inflammatory and neuropathic processes and also some unique changes. Strong opioids are a mainstay of treatments but side effects are problematic and can compromise optimal pain control. Tapentadol is a novel dual-action drug, both stimulating inhibitory μ-opioid receptors (MOR) and mediating noradrenaline reuptake inhibition (NRI) leading to activation of the inhibitory α-2 adrenoceptor. It has been demonstrated to treat effectively both acute and chronic pain. We he…

Spinal analgesia for advanced cancer patients: An update

In the nineties, spinal analgesia has been described as an useful means to control pain in advanced cancer patients. The aim of this review was to update this information with a systematic analysis of studies performed in the last 10 years. 27 papers pertinent with the topic selected for review were collected according to selection criteria. Few studies added further information on spinal analgesia in last decade. Despite a lack of a clinical evidence, spinal analgesia with a combination of opioids, principally morphine, and local anesthetics may allow to achieve analgesia in patients who had been intensively treated unsuccessfully with different trials of opioids. Some adjuvant drugs such …

The use of opioids for breakthrough pain in acute palliative care unit by using doses proportional to opioid basal regimen.

OBJECTIVES: To determine the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP). METHODS: In 66 patients consecutive patients admitted to a pain relief and palliative care unit, the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP) were assessed. The choice of the opioid to be administered as rescue medication was based on the characteristics of patients, clinical stability, compliance, preference, and so on. For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging prob…

The lower the expectations in controlling the symptoms of advanced cancer patients, the better the clinical response.

Aim The aim of this study was to compare patients' global impression (PGI) and the achievement of personalised symptom goal response (PSGR), after a comprehensive palliative care treatment in advanced cancer patients having high (HPSG) and low symptom goals (LPSG). Patients and methods Advanced cancer patients admitted to palliative care units rated symptoms intensity by the Edmonton Symptom Assessment Score (ESAS) at admission and then after one week of comprehensive palliative care treatment. For each symptom, patients were divided into two groups, according to their patient symptom goal (PSG): ≥4 (HPSG), and 0-2 (LPSG). PGI and PSGR were evaluated after one week of palliative care. The M…

Sympathetic blocks for visceral cancer pain management: A systematic review and EAPC recommendations.

The neurolytic blocks of sympathetic pathways, including celiac plexus block (CPB) and superior hypogastric plexus block (SHPB) , have been used for years. The aim of this review was to assess the evidence to support the performance of sympathetic blocks in cancer patients with abdominal visceral pain. Only comparison studies were included. All data from the eligible trials were analyzed using the GRADE system. Twenty-seven controlled studies were considered. CPB, regardless of the technique used, improved analgesia and/or decrease opioid consumption, and decreased opioid-induced adverse effects in comparison with a conventional analgesic treatment. In one study patients treated with superi…

Equipotent doses to switch from high doses of opioids to transdermal buprenorphine.

INTRODUCTION: The aim of this study was to evaluate the equianalgesic ratio of transdermal buprenorphine (TD BUP) with oral morphine and TD fentanyl in a sample of consecutive cancer patients receiving stable doses of 120-240 mg of oral morphine or 50-100 microg of TD fentanyl, reporting adequate pain and symptom control. MATERIALS, METHODS, AND RESULTS: Patients receiving daily stable doses of opioids for more than 6 days, with no more than two doses of oral morphine (20 and 40 mg, respectively) as needed, were switched to TD BUP using a fentanyl-BUP ratio of 0.6:0.8 and an oral morphine-BUP ratio of 70:1. Opioid doses, pain and symptom intensity, global satisfaction, and number of breakth…

Palliative sedation in advanced cancer patients followed at home: A retrospective analysis

Abstract CONTEXT: Data regarding palliative sedation at home in dying patients are lacking. OBJECTIVES: To describe the frequency, indication, and modality of palliative sedation (PS) in patients followed at home. METHODS: A retrospective analysis of home care cancer patients was performed. Patients who received PS before dying were selected and information about epidemiologic characteristics, indications, duration, drugs, and outcomes was collected. RESULTS: Of 370 medical charts of patients who died at home, 49 patients received PS before dying. PS was proposed by the team, relatives, or both in 63.3%, 4.1%, and 32.6% of cases, respectively. Delirium alone or in combination with other sym…

Intravenous Use of Methadone: Efficacy and Safety

Parenteral methadone could be helpful in specific conditions, particularly in unstable conditions of when the oral route is unavailable. Intravenous methadone should be the preferred parenteral route, due to concerns about the local toxicity of subcutaneous route. This chapter assesses aspects regarding the pharmacokinetic issues, the clinical use, the problems associated with the use of intravenous methadone for chronic pain, as well as the perioperative use of intravenous methadone.

Meaningful cut-off pain intensity for breakthrough pain changes in advanced cancer patients

Abstract OBJECTIVES: To assess the level of pain intensity at which patients feel the impetus to ask for a breakthrough cancer pain (BTcP) medication, and level of pain intensity at which patients consider they have achieved acceptable pain control after receiving a BTcP medication. METHODS: A consecutive sample of patients who were receiving oral morphine equivalents equal to or more than 60 mg daily, and were prescribed rapid onset opioids for the management of episodes of BTcP, were included in the study. Focused educational activities regarding BTcP and numerical scales were established during hospital admission. At discharge patients were interviewed to find out what was the pain inten…

Conversion ratios for opioid switching in the treatment of cancer pain: a systematic review

In this paper we describe the results of a systematic search of the literature on conversion ratios during opioid switching. This is part of a project of the European Palliative Care Research Collaboration to update the European Association for Palliative Care recommendations for the use of opioid analgesics in the treatment of cancer pain. Studies were eligible for inclusion if they involved adult patients with chronic cancer pain, contained data on opioid conversion ratios, were prospective and were written in English. Thirty-one studies were identified and included. The majority of the studies had methodological flaws and were not designed to explore or demonstrate equianalgesic dose da…

The effect of age on opioid switching to methadone: a systematic review.

The aim of this review was to assess from the existing literature the effect of age on the outcome of opioid switching to methadone, and the possible influence on conversions ratios.Older patients represent a challenge for physicians, as a further factor may play a role in dosing methadone and possibly on successful switching. Although existing data are not conclusive because this aspect did not receive particular attention in most studies, at the present time age has not been found to be independently associated with the dose ratio. Further prospective studies in a large sample of patients, subgrouped for classes of age, opioid doses, and reasons to switch, should be designed to provide mo…

Breakthrough Pain in Advanced Cancer Patients Followed at Home: A Longitudinal Study

The aim of this study was to longitudinally assess breakthrough pain (BP) in advanced cancer patients who were admitted to home palliative care. One hundred and one consecutive patients who were admitted to one of the two home care programs and were representative of the cancer population followed at home in Italy were included. Patients were excluded only if at admission they were cognitively impaired or too unwell to provide reliable answers to questions regarding data collection. At admission (T(0)), and one month later (T(1)), data were recorded about the pharmacological treatment of background pain and its effectiveness; the presence of BP and its intensity, duration, and number of epi…

Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review.

The use of symptomatic agents has greatly improved the medical treatment of advanced cancer patients with inoperable bowel obstruction. A systematic review of studies of the most popular drugs used in the medical management of inoperable malignant bowel obstruction was performed to assess the effectiveness of these treatments and provide some lines of evidence. Randomized trials that involved patients with a clinical diagnosis of intestinal obstruction due to advanced cancer treated with these drugs were reviewed. Five reports fulfilled inclusion criteria. Three studies compared octreotide (OC) and hyoscine butylbromide (HB), and two studies compared corticosteroids (CSs) and placebo. Globa…

Intravenous morphine for management of cancer pain.

Summary In recent years, a growing interest in palliative care and in routes of administration other than oral have prompted more aggressive measures to improve the efficacy of analgesic interventions in patients with difficult pain conditions. This review provides an overview of the use of intravenous morphine to control pain in patients with cancer. Intravenous morphine has been increasingly used in different clinical situations—including breakthrough pain, poor pain control with escalating doses of oral opioids, retitrating patients with acute pain, treating patients with long-standing poor pain control and unpredictable needs, and optimising opioid therapy to prevent incident pain assoc…

Personalized Symptom Goals and Patient Global Impression on Clinical Changes in Advanced Cancer Patients.

Abstract Background The aim of this study was to assess the patients’ global impression (PGI) after symptom management, as well as the achievement of personalized symptom goals (PSG). The secondary outcome was to assess related factors. Subjects, Materials, and Methods Advanced cancer patients admitted to palliative care units rated symptom intensity by using the Edmonton Symptom Assessment Score (ESAS) at admission and then after 1 week. For each symptom, patient-reported PGI and PSG, as well as the rate of PSG response, were evaluated. Results Eight hundred seventy-six patients were taken into consideration for this study. A mean of 1.71–2.16 points was necessary to perceive a bit better …

Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: A prospective randomized trial

Bowel obstruction may be an inoperable complication in patients with end-stage cancer. Scopolamine butylbromide (SB) and octreotide (OCT) have been successfully used with the aim of reducing gastrointestinal (GI) secretions to avoid placement of a nasogastric tube (NGT); however, there have been no comparative studies concerning the efficacy of these drugs. Furthermore, there is little information about the role played by parenteral hydration in symptom control of these patients. In a prospective trial that involved all 17 inoperable bowel-obstructed patients presenting to our services with a decompressive NGT, patients were randomized to OCT 0.3 mg/day or SB 60 mg/day for 3 days through a …

Assessing age and gender in studies of breakthrough pain medications

AbstractObjective:The present review was performed to identify possible differences observed between adults and elderly patients and between males and females in randomized clinical trials of breakthrough pain (BTP).Methods:A systematic search of the existing literature from 1998 to September 2013 was performed. Randomized clinical trials reporting data on older patients were selected.Results:Sixteen comparative studies were selected. The age range of inclusion criteria patients was mainly between 18–80 or ≥18 years. In some cases this data was unreported. The mean age of patients was 48–64 years, but information regarding the number of elderly patients was present in three studies only. Ge…

Fentanyl Buccal Tablet vs. Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Randomized, Crossover, Comparison Study

Fentanyl products have shown superiority to oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use appropriate patient selection, and drugs have been compared by using different rationales.The aim of this randomized, crossover, controlled study was to compare efficacy and safety of fentanyl buccal tablets (FBTs) and oral morphine (OM), given in doses proportional to opioid daily doses.Cancer patients with pain receiving ≥60 mg or more of oral morphine equivalents per day and presenting with ≤3 episodes of BTcP per day were included. In a randomized, crossover manner, patients received FBT or OM at doses proportional to the daily opioid regimen…

Octreotide for malignant bowel obstruction: Twenty years after

Malignant bowel obstruction (MBO) is a challenging complication of advanced cancer. Conservative treatment of inoperable MBO in terminal cancer patients has been found to be effective in controlling the distressing symptoms caused by this complication in inoperable cancer patients. Twenty years ago, octreotide was proposed to treat symptoms related to malignant bowel obstruction. Since then several reports have confirmed the efficacy of octreotide in the management of gastrointestinal symptoms of MBO. Fifteen randomized controlled trials or observational reports with a significant number of patients treated with octreotide have been reviewed; 281 patients were surveyed. Authors reported a t…

Palliative Care in Advanced Cancer Patients: How and When? And Where?

Eduardo Bruera et al. [1] recently published an exhaustive paper in which they underscore the importance of the integration between oncology and palliative care, suggesting how and when to provide palliative care in advanced cancer patients. We agree that this integrative model allows prompt evaluation and treatment of symptoms, a reduction in costs resulting from inappropriate hospitalization, and better survival outcomes. In their conclusion, Bruera et al. [1] affirm that the two most important resources for palliative care delivery are outpatient palliative care centers and inpatient palliative care units. Although we are on the same wavelength as Bruera et al. [1], we would like to poin…

685 EFFICACY OF INTRANASAL FENTANYL SPRAY (INFS) VERSUS ORAL TRANSMUCOSAL FENTANYL CITRATE (OTFC) FOR BREAKTHROUGH CANCER PAIN: OPEN‐LABEL CROSSOVER TRIAL

Breakthrough pain: On the road again

Pharmacotherapy for Breakthrough Cancer Pain

Breakthrough pain (BTP) is a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. The principal pharmacological treatment of BTP is represented by the administration of opioids as needed. Oral opioids have traditionally been the only available drugs for BTP. However, the onset and duration of action of oral opioids such as morphine or oxycodone may not be suitable for treating many episodes of BTP that are of short onset and duration. Transmucosal administration of lipophilic substances has gained a growing popularity in recent years due to the …

Opioid metabolism and clinical aspects.

Opioids are are commonly used for the management of acute and chronic pain. Opioids have different physicochemical and pharmacokinetic characteristics, which explain the profound changes in the clinical effect in several clinical conditions. Pharmacokinetics influences the opioid response affecting bioavailability, production of metabolites with residual clinical activity, and elimination. Generality of opioid metabolism and clinical implications for specific opioids in different clinical conditions were reviewed to bridge the gap between pharmacokinetics and clinical response. The knowledge of opioid metabolism is essential, particularly for older and complicated patients who receive multi…

Aberrant opioid use behaviour in advanced cancer.

ObjectivesTo evaluate the presence of aberrant behaviour in a consecutive sample of patients with advanced cancer treated with opioids in a country like Italy, with its peculiar attitudes towards the use opioids. The second objective was to detect the real misuse of opioids in clinical practice.MethodsProspective observational study in two palliative care units in Italy in a period of 6 months. At admission the Edmonton Symptom Assessment Scale, the Memorial Delirium Assessment Scale, Brief Pain Inventory (BPI) and the Hospital Anxiety Depression Scale were measured. For detecting the risk of aberrant opioid use, the Screener and Opioid Assessment for Patients With Pain (SOAAP), the Opioid …

Clinical and financial analysis of an acute palliative care unit in an oncological department

The aim of this article is to describe the clinical activity and medical intervention of an acute model of palliative care unit (APC), as well as the reimbursement procedures and economic viability. A sample of 504 patients admitted at an APC in 1 year was surveyed. Indications for admission, pain and symptom intensity, analgesic treatments, procedures, instrumental examinations and modalities of discharge were recorded. For each patient, tariff for reimbursement was calculated according to the existent disease related grouping (DRG) system. The mean age was 62 years, and 246 patients were males. The mean hospital stay was 5.4 days. Pain control was the most frequent indication for admissi…

Characteristics and care pathways of advanced cancer patients in a palliative-supportive care unit and an oncological ward.

Abstract BACKGROUND: A supportive palliative care unit (SPCU) may have a positive impact on patients' care. The aim of this study was to compare the pattern of patients admitted to a specialized SPCU and to a traditional oncologic ward (OW) in a consecutive sample of advanced cancer patients. METHODS: Data on patients demographics, reasons for and kind of admission, care-giver, anticancer treatments, being on/off treatment or uncertain, origin setting, who proposed hospital admission, the use of opioids, and hospitalization were gathered. The same parameters were recorded at discharge. A follow-up was performed by phone 1 month after discharge. RESULTS: Two-hundred patients were surveyed. A…

Home Palliative Care: The Challenge in Palermo

Patients' Acceptability of Different Fentanyl Products for Breakthrough Cancer Pain

OTFC (6) 1.7 (0.5) 1.5 (0.5) 2.0 (0.6) 1.5 (0.8) 1.5 (0.5) 33.1 (43.5) FBT (19) 2.0 (0.6) 2.0 (0.7) 1.8 (0.7) 1.8 (0.8) 1.9 (0.7) 15.9 (7.3) SLF (37) 2.1 (0.5) 2.2 (0.4) 1.8 (0.4) 2.0 (0.6) 2.1 (0.5) 16.7 (12.5) INFS (7) 2.1 (0.4) 2.1 (0.4) 2.0 (0.6) 2.0 (0.8) 2.0 (0.8) 15.7 (13.7) PFEN (11) 2.4 (0.5) 2.2 (0.4) 1.8 (0.4) 1.9 (0.7) 2.1 (0.5) 15.0 (13.7) P 0.120 0.043* 0.870 0.595 0.178 0.015x *,x Oral transmucosal fentanyl was significantly considered to be more problematic.

Patients' and relatives' perceptions about intravenous and subcutaneous hydration.

Hydration during palliative care is a controversial topic. Most of the arguments are based on anedoctal reports that have not been substantiated with scientific data. Given that the choice is problematic from a clinical perspective, preferences of patients and family should dictate whether intravenous fluids are administered. The aim of this study was to evaluate patient and family perceptions about hydration and two modes of providing hydration. Fifty-four consecutive patients admitted to an acute pain relief and palliative care unit who required hydration completed a questionnaire regarding their perceptions on hydration and modes of hydration. Similarly, the principal family carer was ch…

The role of tapentadol as a strong opioid in cancer pain management: a systematic and critical review

The aim of this review was to assess the role of tapentadol given at medium-high doses in opioid-tolerant patients for cancer pain management in place of step-3 analgesics.A systematic literature search was performed out of which six studies and one secondary analysis provided data regarding tapentadol used as a step-3 analgesic for this review. Tapentadol, when used at ≥60 mg of oral morphine equivalents in opioid-tolerant patients with cancer pain, or passing from step-2 doses to ≥60 mg of oral morphine equivalents, was well tolerated and effective and could be considered as a flexible drug to be used for the management of moderate-to-severe cancer pain. The limited occurrence of gastroin…

Cancer pain undertreatment and prognostic factors

Tapentadol at medium to high doses in patients previously receiving strong opioids for the management of cancer pain.

Abstract Abstract Objective: The aim of this study was to assess the efficacy and tolerability of tapentadol (TP) for a period of 4 weeks in patients who were already treated by opioids. Methods: A convenience sample of 30 patients was selected for a prospective observational cohort study. Cancer patients who were receiving at least 60 mg of oral morphine equivalents were selected. Patients discontinued their previous opioid analgesics before starting TP, in doses calculated according the previous opioid consumption (1:3.3 ratio with oral morphine equivalents). The subsequent doses were changed according to the patients' needs for a period of 4 weeks. Oral morphine was offered as a breakthr…

The use of fentanyl buccal tablets for breakthrough pain by using doses proportional to opioid basal regimen in a home care setting.

Abstract The dose of rapid onset opioids to be given for breakthrough cancer pain (BTcP) is controversial. Dose proportional to the basal opioid regimen seem to be safe and effective in hospital units. However, data in other less protected settings, like home care, are lacking. The aim of this open-label study was to assess the efficacy and safety in a group of patients with BTcP followed at home, after giving a dose of fentanyl buccal tablets (FBT) proportional to the opioid basal regimen, skipping the steps for dose titration. Consecutive patients admitted to a home care program presenting BTcP episodes and receiving stable doses of opioids for background pain were selected. Data from fou…

Effect of aging on pain relief in the older cancer patients: pharmacokinetic and pharmacodynamic aspects.

The prevalence of cancer rises with advancing age. A large number of cancer patients are aged over 65 years, and it is expected that even more patients will develop cancer as a consequence of the g...

Problematic discharge from hospital for patients prescribed opioids for cancer pain.

Analgesic effects of nonsteroidal anti-inflammatory drugs in cancer pain due to somatic or visceral mechanisms.

The role of nonsteroidal anti-inflammatory drugs (NSAIDs) is well established in the treatment of cancer pain. This class of drugs is considered particularly effective in pain due to somatic mechanisms, although proof of this observation is lacking. To ascertain whether NSAIDs are more effective in specific nociceptive forms of cancer pain, they were administered alone or added to opioids in 32 patients with a sole pain mechanism, somatic pain due to bone metastases (17 patients) or visceral pain (15 patients), respectively. Pain intensity, mean doses of opioids used, and symptoms were recorded after starting NSAID. A significant reduction in pain intensity was found at 3, 7, and 14 days. N…

Breakthrough Cancer Pain: Ten Commandments

The term "breakthrough cancer pain" (BTcP) was introduced about 25 years ago. Peaks of pain intensity reported in patients with cancer had been invariably examined in the past years, providing relevant information for a better knowledge of this phenomenon and its treatment. The aim of this critical review was to provide the golden rules, namely, the 10 commandments, for a correct diagnostic pathway of BTcP and a consequent personalized pharmacological treatment. These are as follows: 1) assessment of background analgesia, 2) drugs used for background analgesia, 3) BTcP is a frequent phenomenon, 4) characteristics of BTcP, 5) diagnosis of BTcP, 6) continuous assessment, 7) tailored pharmacol…

Outcome of opioid switching 4 weeks after discharge from a palliative care unit.

Despite the favorable effects reported with opioid switching performed in a specialized unit in the short term, data on long-term basis are poor, particularly after discharging patients home or in other settings.The aim of this prospective study was to evaluate the long-term outcome of patients who were switched in an acute palliative care unit at a high volume of opioid switching. A consecutive sample of patients who underwent opioid substitution during admission in an acute palliative care unit were assessed for a period of 1 year. Patients were followed-up for 4 weeks after being discharged. Patients were contacted by phone or visited at the outpatient clinic 4 weeks after discharge. Epi…

The use of low doses of a sublingual fentanyl formulation for breakthrough pain in patients receiving low doses of opioids

Objective: The aim of this study was to prospectively assess the efficacy and safety of low doses of sublingual fentanyl (SLF) for the treatment of breakthrough pain (BTP) in cancer patients in patients who were receiving low opioid doses for background analgesia. Methods: A sample of cancer patients presenting BTP episodes and receiving stable low doses of opioids for background pain (less than 60 mg of oral morphine equivalents) was selected to assess the efficacy and safety of low doses of SLF (67 μg). For each patient, data from four consecutive episodes were collected. For each episode, changes in pain intensity and adverse effects when pain got severe (T0), and 5, 10, and 15 min a…

Nurse-based monitoring and management of breakthrough pain in an acute pain relief and palliative care unit

To assess the nurses' performance in assessing, treating, and documenting breakthrough pain (BTP) in a palliative care unit where traditionally there is continuous training.The study was performed in an acute palliative care unit. Once a week, a research nurse examined the documentation regarding all the episodes of BTP registered in a specific pain chart, designed by the institutional nurse board, as part of the routine nurse activity.The charts of 50 consecutive eligible patients (32 M/18 F), were analysed. The mean number of episodes/patient was 3.3 (SD 1.61; range 1-7). 166 episodes occurred. The main BTP pain intensity was 7.06 (SD 0.82). In 7 episodes, pain intensity was not evaluated…

Hyperalgesia and opioid switching

Opioids, intended to abolish pain, can unexpectedly produce hyperalgesia, particularly during rapid opioid escalation. Opioid switching could be a therapeutic option in a condition of opioid-induced tolerance or hyperalgesia, but conversion ratios between opioids are difficult to apply in this context and require strict surveillance and expertise. This situation is challenging, because the rapid escalation of opioid doses, possibly due to the development of opioid-induced tolerance, can cause hyperalgesia. To avoid this adverse effect, clinicians need to refine their assessment of pain treatment and consider opioid switching. The authors present a case report in which switching from fentan…

Naloxone in Treating Central Adverse Effects During Opioid Titration for Cancer Pain

Celiac plexus block for pancreatic cancer pain: Factors influencing pain, symptoms and quality of life

Neurolytic celiac plexus block (NCPB) is claimed to be an effective method of pain control for pancreatic cancer pain. However, the factors that may influence long-term analgesia, adverse effects, and quality of life after performing NCPB have never been determined. In a prospective multicenter study, 22 patients who underwent NCPB were followed until death. Numerous parameters other than pain and symptom intensity were evaluated, including age, gender, initial site of cancer, sites of pain, possible peritoneal involvement, technique, and oncologic interventions. Indices were calculated to determine the opioid consumption ratio (EAS) and the trend of opioid escalation (OEI). NCPB was effect…

Opioid escalation in patients with cancer pain: the effect of age.

Elderly people are commonly considered more susceptible to opioid effects. However, no data regarding the need for opioid escalation in patients already receiving opioids for the management of chronic pain are available. The purpose of this study was to evaluate the differences between younger and older patients during the crucial phase of opioid titration. One hundred consecutive patients with cancer pain requiring further opioid dose refinement were recruited for this cohort study. Pain intensity, dose of opioids, number of opioids used (need to switch), routes of administration used, and opioid-related symptoms were measured from admission until dose stabilization. Opioid escalation inde…

Unexpected death on an acute palliative care unit

Although most deaths in patients with advanced cancer are expected, no data are available on unexpected death (UD). This event can be really stressful for physicians who are unable to anticipate, prevent, or discuss UD, and for relatives who are not ready for such an acute emotional burden, despite previous good communication about the short-term prognosis. There is the need for more information, particularly in the setting of an acute palliative care unit where most patients are discharged to follow different therapeutic pathways, including continuing oncologic treatment, home care, or hospice.1,2 The aim of this prospective study was to assess the characteristics of patients who died unex…

Pain intensity as prognostic factor in cancer pain management

Aim The aim of this study was to prospectively assess the prognostic value of initial pain intensity and its duration in advanced cancer patients. Methods A prospective study was conducted in a sample of patients with cancer requiring pain control. Patients underwent standard analgesic strategies used in our palliative care units. Pain intensity was measured at admission (T0) and after successful dose titration or opioid/route switching within a week (Ts). Patients were also asked about their pain intensity reported 15 days before admission (T-15). Doses of opioids and duration of opioid use were recorded. Patients were also assessed for the presence of incident pain, neuropathic pain, alco…

Pattern of symptoms and symptomatic treatment in adults and the aged population: a retrospective analysis of advanced cancer patients followed at home.

Context Data regarding symptom burden and symptomatic drugs in palliative population in different classes of age are lacking. Objective The aim of this retrospective study was to assess the symptom burden, and the profile of symptomatic drugs in the last four weeks of life in adults and older cancer patients followed at home. Methods Charts of 412 patients were retrospectively analyzed by using a backward analysis. Patients were divided into three groups: adults (<65 years, A), old (65-74 years, O1), very old (75-84 years, O2), and the oldest (≥85 years, O3). Results At -4W Karnofsky status was significantly lower for older people (p = 0.03). No significant effect of age on the vector of sy…

The Role of Religiosity in Symptom Expression of Advanced Cancer Patients

Aim: The aim of this study was to assess the religious pattern and its impact on symptom expression in patients with advanced cancer. Methods: A consecutive sample of advanced cancer patients screened at admission to palliative care. Standard epidemiological data were recorded. Patients were asked about their religious beliefs, the degree of social relationship to existing religions, the role of religion in their life, and the frequency of their prayer. The Edmonton Symptom Assessment Scale (ESAS) and Hospital Anxiety Depression scale (HADS) were assessed. Results: Two-hundred-eighty-three patients were screened. Age and gender were found to be independently correlated with religious belief…

The use of ketamine in a palliative-supportive care unit: a retrospective analysis.

Background: To assess the response to ketamine in patients with difficult pain syndromes. Methods: The charts of patients with uncontrolled pain despite opioid dose escalation of at least two opioids or a combination of them, selected for a burst of ketamine and midazolam were reviewed. One hundred mg/day of ketamine and midazolam 15 mg/day by a continuous intravenous infusion for about 48 hours was offered to patients. Results: Forty-four patients received a burst of ketamine. Ten patients did not achieve any improvement. Pain intensity decreased from a mean of 7.8 (SD, 1.6) to 2.8 (SD, 1.3) (P<0.0005). The outcome was considered optimal, good, and mild in 24, 9, and 1 patients, respective…

Treatment strategies for cancer patients with breakthrough pain.

Breakthrough pain (BTP) is a transitory flare of pain superimposed on an otherwise stable pain pattern in patients treated with opioids. It is normally severe in intensity, has a rapid onset, has a variable duration (on average 30 min) and is considered a negative prognostic factor. OBJECTIVE: To verify the data in the literature about therapy strategies for BTP in cancer patients. METHODS: To find clinical trials investigating drug therapy for BTP. CONCLUSION: The treatment of BTP in cancer patients receiving opioids is principally based on the use of opioids, preferentially with a short onset. Fentanyl delivered by recently developed systems seems to be the best option to cover the tempor…

686 EASE OF USE AND PREFERENCE FOR INTRANASAL FENTANYL SPRAY (INFS) VERSUS ORAL TRANSMUCOSAL FENTANYL CITRATE (OTFC) FOR BREAKTHROUGH CANCER PAIN

Attitudes Among Patients With Advanced Cancer Toward Euthanasia and Living Wills

Euthanasia has been invariably discussed throughout Europe. In some countries, euthanasia has been legalized under specific conditions that must be fulfilled. These include a properly reported request to be considered carefully, unbearable suffering, no other reasonable alternatives, and a consultation with an independent physician. A living will, also called an advance directive, is a written document that allows a patient to give explicit instructions about medical treatments to be administered when the patient is terminally ill and unable to communicate. In Italy, euthanasia remains illegal, and living wills are not used. These issues have been the subject of constant debate.2 Such discu…

Opioid switching in patients with advanced cancer followed at home. A retrospective analysis.

Abstract CONTEXT: Opioid switching has been found to improve opioid responsiveness in different conditions. However, data on opioid switching performed at home are almost nonexistent, despite the fact that most patients are followed at home. OBJECTIVES: The aim of this retrospective survey was to determine frequency, indications, usefulness, and safety of opioid switching when treating advanced cancer-related pain in patients followed at home. METHODS: A retrospective review of data from patients with advanced cancer followed at home by three home care teams for a period of two years was performed. Patients who had their opioids switched were selected. Reasons for switching opioid doses and…

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

Abstract Context Home care programs in Italy. Objectives The aim of this study was to assess a protocol for palliative sedation (PS) performed at home. Methods A total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam. Results A total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P = 0.012). The principal reasons to start PS were agitated delirium (n = 20) and dyspnea (n = 4).…

Recent progress in the pharmacotherapy of cancer pain.

Cancer pain can be relatively well managed with primary therapies, according to the WHO ladder. However, different conditions may limit the response to the analgesic drug used, which are mainly oploids. Specifically, adverse effects may prevail against the analgesic activity in the clinical setting. New pharmacological strategies may enable a more satisfactory response to be obtained, in terms of balance between analgesia and adverse effects. The change of route of administration or the use of alternative opioids is a first-line option. The use of adjuvant drugs may also improve analgesia with different mechanisms. Recent studies have demonstrated the value of these alternative approaches. …

Controlled sedation for refractory symptoms in dying patients.

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and s…

Tapentadol in cancer pain management: a prospective open-label study.

OBJECTIVES: The aim of this prospective, open-label study was to evaluate the efficacy and tolerability of tapentadol (TP) in the management of cancer pain. METHODS: A 4 weeks' prospective study was carried out in 50 opioid-naive cancer patients with moderate-severe pain. Each patient initially received twice-daily doses of slow-release TP 50 mg. Doses were then managed to maintain adequate relief or dose-limiting toxicity, on the basis of the clinical response. The following parameters were recorded at weekly intervals for 4 weeks: pain and opioid-related adverse effects, quality of life measured with the Spitzer score, TP escalation index percent (TPEI%) and TP escalation index in mg (TPE…

High flow nasal therapy in perioperative medicine: from operating room to general ward

Abstract Background High flow nasal therapy (HFNT) is a technique in which humidified and heated gas is delivered to the airways through the nose via small nasal prongs at flows that are higher than the rates generally applied during conventional oxygen therapy. The delivered high flow rates combine mixtures of air and oxygen and enable different inspired oxygen fractions ranging from 0.21 to 1. HFNT is increasingly used in critically ill adult patients, especially hypoxemic patients in different clinical settings. Main body Noninvasive ventilation delivers positive pressure (end-expiratory and inspiratory pressures or continuous positive airway pressure) via different external interfaces. …

Barriers and Adherence to Pain Management in Advanced Cancer Patients

Aim To assess patients' barriers to pain management and analgesic medication adherence in patients with advanced cancer. Methods This was a prospective cross-sectional study in patients with advanced cancer receiving chronic opioid therapy. Age, gender, cancer diagnosis, Karnofsky level, and educational status were recorded. The Brief Pain Inventory (BPI), Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Barriers Questionnaire II (BQ-II), Medication Adherence Rating Scale (MARS), and Hospital Anxiety and Depression Scale (HADS) were the measurement instruments used. Results One-hundred-thirteen patients were analyzed. The mean age was 68 (±13) years, and …

Symptom hyper-expression in advanced cancer patients with anxiety and depression admitted to an acute supportive/palliative care unit

Purpose: The aim of this study was to compare symptom expression in advanced cancer patients with depression and anxiety and in patients with no such symptoms. Methods: Secondary analysis of a previous study assessing the role of an acute palliative supportive care unit (APSCU) in a comprehensive cancer center. Patients completed the Edmonton Symptom Assessment System (ESAS) at admission (T0) and 7 days after or at discharge (T7). Results: Three hundred-fourteen consecutive cancer patients admitted to the APSCU were surveyed. Eighty-six and 66 patients improved their level of depression and anxiety, respectively (passing from ≥ 4 to 0–3, from T0 to T7), after that palliative care interventi…

Optimization of opioid therapy for preventing incident pain associated with bone metastases

Breakthrough pain is a transitory flare of Pain superimposed on an otherwise stable pain pattern in patients treated with opioids. One form of breakthrough pain is incident pain, which is due to movement and is commonly associated with bone metastases. The development of this pain is rapid and no medication, administered "as needed," has such a rapid onset that it parallels this temporal Pattern of Pain. This study used a construct based on the prevention of this event, and implemented a new experimental paradigm. Specifically, the study determined whether increasing the opioid doses above those sufficient to control pain at rest would. reduce the occurrence of these pains. Twenty-five cons…

Amitriptyline in neuropathic cancer pain in patients on morphine therapy: A randomized placebo-controlled, double-blind crossover study

Aims and Background Amitriptyline is the most common analgesic adjuvant used in cancer patients with neuropathic pain, even though no specific studies have demonstrated a benefit. A randomized placebo-controlled, double-blind crossover study was designed to evidence the effects of amitriptyline in patients with neuropathic cancer pain. Methods Sixteen advanced cancer patients with neuropathic pain on systemic morphine therapy, no longer receiving oncologic treatment, presenting moderate pain (about 4 or more, but less than 7, on a numerical scale of 0-10) in the last week, and given a stable morphine dose in the last 2 days were admitted to the study. During the first week of study, patient…

The evidence of neuraxial administration of analgesics for cancer-related pain: a systematic review

Background The present systematic review analysed the existing evidence of analgesic efficacy and side effects of opioids without and with adjuvant analgesics delivered by neuraxial route (epidural and subarachnoid) in adult patients with cancer. Methods Search strategy was elaborated with words related to cancer, pain, neuraxial route, analgesic and side effects. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. Studies were analysed according to methods, results, quality of evidence, and strength of recommendation. Results The number of abstracts retrieved was 2147, and 84 articles were selected for full reading. The final selection comprised nin…

Frequency, indications, outcomes, and predictive factors of opioid switching in an acute palliative care unit.

The aim of this study was to prospectively evaluate the frequency, indications, outcomes, and predictive factors associated with opioid switching, using a protocol that had been clinically applied and viewed as effective for many years. A prospective study was carried out on a cohort of consecutive cancer patients who were receiving opioids but had an unacceptable balance between analgesia and adverse effects, despite symptomatic treatment of side effects. The initial conversion ratio between opioids and routes was as follows (mg/day): oral morphine 100=intravenous morphine 33=transdermal fentanyl 1=intravenous fentanyl 1=oral methadone 20=intravenous methadone 16=oral oxycodone 70=transder…

Combined oral prolonged-release oxycodone and naloxone in chronic pain management

Introduction: The use of opioids is associated with unwanted adverse effects, particularly opioid-induced constipation (OIC). The adverse effects of opioids on gastrointestinal function are mediated by the interaction with opioid receptors in the gastrointestinal tract. The most common drugs used for relieving OIC are laxatives, which do not address the opioid receptor-mediated bowel dysfunction and do not provide sufficient relief. Areas covered: This paper discusses the role of a combination of prolongedrelease formulation of oxycodone (OX) and naloxone (N) in the prevention and management of OIC, reporting efficacy and safety outcome of controlled studies. In a therapeutic area of great …

Frequency and Indications of Parenteral Nutrition in an Acute Palliative Care Unit

The aim of this study was to estimate the use of parenteral nutrition (PN) in advanced cancer patients enrolled in an acute pain relief and palliative care unit of a comprehensive cancer center and the appropriateness of the criteria to select patients for PN. Fourteen out of 750 patients (1.8%) admitted to an acute palliative care unit were administered PN. Patients were referred from various settings. The mean age was 58 yr (range 37-79), and 9 were males. The mean hospital stay was 7.7 days (range 3-14), and the mean Karnofsky level was 35 (range 10-50). The principal indication was bowel obstruction. Ten patients (71%) were already receiving PN before admission, and 2 of them discontinu…

Association between alcoholism and symptom expression, patient symptom goals, and clinical response in advanced cancer patients

Aim: The aim of this study was to determine the influence of alcoholism on symptom expression, personalized symptom goal (PSG) and patient goal response (PGR), and patient global impression (PGI) in advanced cancer patients. Methods: This was a secondary analysis of an international multicenter study. Advanced cancer patients who had a history of alcohol dependence positive, according to CAGE (cut down, annoy, guilt, eye-opener), were selected. Thirty patients (3.45%) were CAGE-positive. This sample was matched with 30 patients with similar characteristics who were CAGE-negative. Patients rated symptom intensity by using the Edmonton Symptom Assessment Score (ESAS) at admission (T0) and the…

Pain Mechanisms Involved and Outcome in Advanced Cancer Patients with Possible Indications for Celiac Plexus Block and Superior Hypogastric Plexus Block

Aims and Background There is controversy about the role of neurolytic sympathetic blocks in advanced cancer, when pain syndromes may assume other characteristics, with a possible involvement of structures other than visceral. The aim of the present study was to assess the pain characteristics and the analgesic response of a consecutive sample of home care patients with pancreatic and pelvic pain, which would have possible indications for a celiac plexus block and a superior hypogastric block, respectively. Methods From January 1999 to December 1999, 400 consecutive advanced cancer patients were surveyed for a prospective longitudinal survey. We considered only patients who had pancreatic ca…

Low doses of transdermal buprenorphine in opioid-naive patients with cancer pain: A 4-week, nonrandomized, open-label, uncontrolled observational study

OBJECTIVE: The aim of this study was to evaluate the effect and tolerability of low doses of transdermal (TD) buprenorphine patches in opioid-naive patients with cancer pain. METHODS: This was a nonrandomized, open-label, uncontrolled study in consecutive opioid-naive patients with advanced cancer and moderate pain. TD buprenorphine was initiated at a dose of 17.5 microg/h (0.4 mg/d), with patch changes every 3 days. Doses were then adjusted according to the clinical response. Pain intensity, opioid-related adverse effects, TD buprenorphine doses, and quality of life were monitored over 4 weeks. The time to dose stabilization and indexes of dose escalation were also calculated. RESULTS: Thi…

Fentanyl buccal tablets for breakthrough pain in highly tolerant cancer patients: preliminary data on the proportionality between breakthrough pain dose and background dose.

Abstract Context Cancer patients receiving high doses of opioids as background medication are challenging, and it would be useful clinically to know whether a rapid-onset opioid (ROO) for breakthrough cancer pain (BTcP) may be started at a dose proportional to the background opioid dose. Objectives The aim of this study was to assess the efficacy and safety of the fentanyl buccal tablet (FBT) in doses proportional to the opioid dose administered for background analgesia in a sample of patients with BTcP who were receiving high doses of opioids. Methods Twelve patients who were receiving opioids for background analgesia at doses equivalent to more than 500 mg of oral morphine and had adequat…

Methadone versus morphine for postoperative pain in patients undergoing surgery for gynecological cancer: A randomized controlled clinical trial.

Abstract Study objective The aim of this study was to compare methadone and morphine for the management of postoperative. Design Open, controlled study. Setting Postoperative recovering area, ward. Patients Sixty-four patients, ASA I-III, undergoing gynecological surgery for cancer. Interventions Morphine or methadone 0.15 mg/kg given preoperatively. After operation an intravenous morphine or intravenous methadone infusion at doses of 12 mg/day was started. Measurements Pain intensity and opioid consumption. Main results Methadone infusion provided a better analgesia in comparison with morphine infusion on the second day. Opioid consumption was significantly lower in the methadone group. No…

Symptom burden in mesothelioma patients admitted to home palliative care

Context: Mesothelioma is a very aggressive cancer that is brought on by asbestos exposure. Because there is a long latency period between exposure to asbestos and symptoms of disease, most patients with mesothelioma present with advanced disease and survive an average of 8–12 months. Thus, best supportive care should be considered critical to optimally manage these patients. Aim: The aim of this study was to examine the epidemiological characteristics and symptom burden of mesothelioma patients when admitted to home palliative care. Methods: The charts of a consecutive sample of patients admitted to the home palliative care program with a diagnosis of mesothelioma in an endemic industrial…

Palliative ventilatory support: same knowledge, different goal.

Palliative care as a clinical field emerged in the 1990s, aiming at improving end-of-life (EOL) experience for seriously ill patients (1). It changed the way to approach families saying them that their loved ones were approaching the end limiting life support while maintain comfort (2). It is now also evident that palliative care has not only to be seen as the job of consultants or by specialists in this field but also an approach to care at the “primary” level by intensivist, intensive care unit (ICU) nurses, and other clinicians (2).

Factors involved in gastrointestinal bleeding in advanced cancer patients followed at home

Abstract There is a lack of information on the frequency of symptomatic gastrointestinal bleeding in patients with advanced cancer. This group of patients presents several risk factors for developing gastrointestinal bleeding. The aim of this multicenter longitudinal survey was to assess the frequency of gastrointestinal bleeding and possible factors implicated in advanced cancer patients followed at home. A consecutive sample of 439 patients who referred to home palliative care program entered the study. Age, gender, primary cancer and known metastases, possible associated pathologies, history of peptic disease, use of previous or actual nonsteroidal anti-inflammatory drugs (NSAIDs) and st…

Morphine versus methadone in the pain treatment of advanced-cancer patients followed up at home

PURPOSE The aim of this study was to evaluate the analgesic and adverse effects and the doses of methadone in comparison to morphine. PATIENTS AND METHODS A prospective randomized study was performed in a sample of 40 patients with advanced cancer who required strong opioids for their pain management. Patients were treated with sustained-release morphine or methadone in doses titrated against the effect administered two or three times daily according to clinical need. Opioid doses, adjuvant medications, symptoms associated with opioid therapy, pain intensity, and pain mechanisms were recorded. The opioid escalation indices in percentage (OEI%) and milligrams (OEImg) were calculated. The eff…

Analgesic Effect of Intravenous Ketamine in Cancer Patients on Morphine Therapy

Pain not responsive to morphine is often problematic. Animal and clinical studies have suggested that N-methyl-D-aspartate (NMDA) antagonists, such as ketamine, may be effective in improving opioid analgesia in difficult pain syndromes, such as neuropathic pain. A slow bolus of subhypnotic doses of ketamine (0.25 mg/kg or 0.50 mg/kg) was given to 10 cancer patients whose pain was unrelieved by morphine in a randomized, double-blind, crossover, double-dose study. Pain intensity on a 0 to 10 numerical scale; nausea and vomiting, drowsiness, confusion, and dry mouth, using a scale from 0 to 3 (not at all, slight, a lot, awful); Mini-Mental State Examination (MMSE) (0-30); and arterial pressure…

Morphine versus oxycodone in pancreatic cancer pain: a randomized controlled study.

Objective: According to experimental findings, oxycodone (OX) could have some advantages over morphine (MO) in clinical models of visceral pain. It was hypothesized that OX could have some advantages over MO in terms of efficacy and dose escalation in pancreatic cancer pain. Methods: Sixty patients with pancreatic cancer with a pain intensity rating of 4/10 who required opioids were included in the study. Patients were randomized to receive 30mg/d of sustained release oral MO or sustained release oral OX (20mg/d). Opioid doses were increased according to the clinical needs. Daily doses of opioids, pain and symptom intensity were recorded at admission (T0) and at weekly intervals for the sub…

Rapid Titration With Intravenous Oxycodone for Severe Cancer Pain and Oral Conversion Ratio.

to assess a dose titration with intravenous oxycodone to achieve rapid pain relief of cancer pain of severe intensity. The second objective was to provide a conversion ratio with the oral route.Cancer patients admitted for severe pain were prospectively assessed. At admission (T0) previous opioid doses were recorded. Edmonton symptom assessment scale (ESAS) was collected from T0 until the conclusion of the observation. Intravenous boluses of oxycodone were given until the initial signs of significant analgesia were detected. The effective dose was multiplied for six and given as intravenous continuous infusion. When the patient was considered stabilized the intravenous daily dose was conver…

Cancer pain management in an oncological ward in a comprehensive cancer center with an established palliative care unit

Abstract BACKGROUND: This survey was performed to draw information on pain prevalence, intensity, and management from a sample of patients who were admitted to an oncologic center where a palliative care unit (PCU) has been established for 13 years. METHODS: Cross-sectional survey in an oncological department performed 1 day per month for six consecutive months. RESULTS: Of the 385 patients, 69.1, 19.2, 8.6, and 3.1 % had no pain, mild, moderate, and severe pain, respectively. Inpatients and patients with a low Karnofsky score showed higher levels of pain intensity (p < 0.0005). One hundred twenty-eight patients with pain or receiving analgesics were analyzed for pain management index (PMI)…

Hyperalgesia: An Emerging Iatrogenic Syndrome

Clinical reports suggest that opioids, intended to abolish pain, can unexpectedly produce hyperalgesia. This paradoxical effect may be mechanistically related to tolerance induced by increasing doses of opioids. Two case reports illustrate a syndrome characterized by increasing pain pursued by escalating opioid doses, which results in a worsening of the clinical picture. Several experimental data may help explain the course of this challenging clinical condition. In escalating opioid doses rapidly, a risk of opioid-induced hyperalgesia should be recognized, as higher doses of opioids may stimulate rather than inhibit the central nervous system by different mechanisms. Alternative procedures…

Interventional Pain Procedures: A Narrative Review Focusing on Safety and Complications. Part 1 Injections for Spinal Pain

In recent years, there has been a considerable increase in the number of image-guided interventional procedures performed for the management of acute and chronic pain. Concomitantly, there has also been an increase in the complication rate related to these procedures. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopic- or ultrasound-guided) interventional procedures. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and…

Minimally invasive procedures for the management of vertebral bone pain due to cancer: The EAPC recommendations.

Image-guided percutaneous ablation methods have proved effective for treatment of benign bone tumors and for palliation of metastases involving the bone. However, the role of these techniques is controversial and has to be better defined in the setting of palliative care.A systematic review of the existing data regarding minimally invasive techniques for the pain management of vertebral bone metastases was performed by experts of the European Palliative Care Research Network.Only five papers were taken into consideration after performing rigorous screening according to inclusion and exclusion criteria (low number of patients, retrospective series, proceedings).According to the present data …

Maddalena Opioid Switching Score in patients with cancer pain

Evaluation of opioid switching (OS) for cancer pain has not been properly assessed. The aim of this study was to assess an integrated score (Maddalena Opioid Switching Score) as a simple and repeatable tool to evaluate the outcomes of OS, facilitating the interpretation and comparison of studies, and information exchange among researchers. The integrated score took into account pain intensity, intensity of opioid-related symptoms, and cognitive function by using an author's formula. Physical and psychological symptoms were evaluated by the Edmonton Symptom Assessment Scale and Patient Global Impression (PGI) by the minimal clinically important difference. One hundred six patients were analy…

The use of corticosteroids in home palliative care

Evidence for the effectiveness of corticosteroids in palliative care is anecdotal, and more information is required. From January to December 1999 a total of 376 consecutive patients admitted to a home palliative care program were longitudinally surveyed. Patients who started a corticosteroid treatment after admission on the basis of common indications prescribed by their home care physicians were selected. Fifty patients were enrolled in the study. Dexametha-sone, in doses ranging from 4 to 16 mg, was the drug of choice. Corticosteroids were found to be effective in anorexia, weakness, headache, and nausea and vomiting. The reduction of symptom intensity was achieved in less than 3 days on…

A Randomized-Controlled Study of Intrathecal Versus Epidural Thoracic Analgesia in Patients Undergoing Abdominal Cancer Surgery

Background. We sought to determine the effectiveness of continuous intrathecal thoracic analgesia (ITA) in comparison with continuous epidural thoracic analgesia (ETA) for the management of postoperative pain after abdominal cancer surgery in a randomised controlled study. Materials and methods. Catheters were inserted at T8-10 level for both techniques. Sixty patients were randomized to receive ITA providing levobupivacaine 0.25%, at 0.5-0-7 ml/h, associated with a single bolus of morphine 0.15 mg, or ETA with levobupivacaine 0.25% 4-6 ml/h and a single bolus of epidural morphine 2-3 mg. Data were collected before discharging from recovery room to the surgical ward, 1, 2, 3, 8, 12, 24 h, a…

Application of palliative ventilation: potential and clinical evidence in palliative care.

Dosing fentanyl buccal tablet for breakthrough cancer pain: dose titration versus proportional doses.

Abstract OBJECTIVES: The aim of this study was to compare the efficacy and safety of doses of fentanyl buccal tablet (FBT) proportional to doses of opioids used for background analgesia versus dose titration starting with the minimal dose for the management of breakthrough cancer pain (BTcP). METHODS: A total of 82 cancer patients with BTcP who were receiving strong opioids in doses of at least 60 mg of oral morphine equivalents and having acceptable background analgesia, were selected for a multicenter unblinded study. Forty-one patients were randomized to receive FBT in doses proportional to the daily opioid doses for four consecutive episodes of BTcP (group P). Forty-one patients underwe…

Why are our patients still suffering pain?

Legal barriers, restricted resources, lack of physician training, and physician and patient worries about potential opioid addiction can be barriers to effective and rational pain management in patients with cancer pain. Sebastiano Mercadante discusses these issues, as well as suggesting interventions for improving care.

Opioid Poorly-Responsive Cancer Pain. Part 2

Basic research in experimental pain models may illuminate the phenomenon of cancer pain that is poorly responsive to opioid drugs. Research findings can be valuable in formulating new strategies in clinical practice. This review evaluated experimental observations in terms of the events that occur in cancer patients receiving opioid therapy for pain.

Prevalence of opioid-related dysuria in patients with advanced cancer having pain.

The aim of this study was to assess the prevalence of opioid-induced dysuria in patients with advanced cancer having pain and to evaluate the possible factors associated. A consecutive sample of cancer patients admitted to an acute pain relief and palliative care unit during 8 months was surveyed. Most patients (147, 86.5%) were receiving opioids at admission. The mean age was 65.1 (SD 12.2) and 106 patients were males. Twenty-five patients presented with dysuria at admission (of which 22 were taking opioids, 14.9%). Eleven patients were inserted a bladder catheter at admission for urine monitoring and 18 patients had urinary incontinence. During admission, 31 patients presented dysuria (19…

Sleep Disturbances in Patients with Advanced Cancer in Different Palliative Care Settings.

Abstract Context Information regarding sleep disturbances in the population with advanced cancer is meager. Objectives To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care settings. Methods This was an observational study performed in different settings of palliative care. A consecutive sample of patients with advanced cancer was prospectively assessed for a period of six months. Epidemiological and clinical data, treatments received in the last month, Karnofsky status, Edmonton Symptom Assessment System scores, and concomitant medical treatment were recorded.…

High-dose furosemide and small-volume hypertonic saline solution infusion for the treatment of leg edema in advanced cancer patients.

Peripheral edema is a common feature in populations with advanced cancer, although it is seldom recognized. Diuretics are commonly employed and may show some benefit, but there are insufficient clinical trial data to draw useful conclusions about their clinical use. The aim of this prospective study was to evaluate the efficacy and tolerability of high-dose furosemide and small-volume hypertonic saline solution infusion in reducing leg edema in patients with advanced cancer treated unsuccessfully with diuretics. A prospective study was performed in a consecutive sample of 24 patients admitted to a pain relief and palliative care unit over a period of 18 months. To be eligible to enter the t…

Changes of QTc interval after opioid switching to oral methadone.

Abstract A consecutive sample of patients who were switched from strong opioids to methadone in a period of 1 year was surveyed. QTc was assessed before switching (T0) and after achieving adequate analgesia and an acceptable level of adverse effects (Ts). Twenty-eight of 33 patients were switched to methadone successfully. The mean initial methadone doses at T0 were 67.1 mg/day (SD ±80.2, range 12-390). The mean QTc interval at T0 was 400 ms (SD ±30, range 330-450). The mean QTc interval at Ts (median 5 days) was 430 ms (SD ±26, range 390-500). The difference (7.7 %) was significant (p < 0.0005). Only two patients had a QTc of 500 ms. No serious arrhythmia was observed. At the linear regres…

Sustained-release oral morphine versus transdermal fentanyl and oral methadone in cancer pain management.

The aim of this study was to compare the analgesic and adverse effects, doses, as well as cost of opioid drugs, supportive drug therapy and other analgesic drugs in patients treated with oral sustained-release morphine, transdermal fentanyl, and oral methadone.One hundred and eight cancer patients, no longer responsive to opioids for moderate pain, were selected to randomly receive initial daily doses of 60 mg of oral sustained-release morphine, 15 mg of oral methadone, or 0.6 mg (25 microg/h) of transdermal fentanyl. Oral morphine was used as breakthrough pain medication during opioid titration. Opioid doses, pain intensity, adverse effects, symptomatic drugs, were recorded at week interva…

Topical amitriptyline and ketamine for the treatment of neuropathic pain.

A neuropathy is a disturbance of function or pathological change in nerves. In some cases, peripheral neuropathic pain may occur due to a lesion or disease of the peripheral somatosensory nervous system. Efficacy of different agents for peripheral neuropathic pain conditions is less than optimal. The administration of topical analgesics might be an option, due to the potential of reduced adverse effects and increased patient compliance. There is major interest in compounding topical analgesics for peripheral neuropathic pain, but several challenges remain for this approach. Topical analgesics have the potential to be a valuable additional approach for the management of peripheral neuropathi…

Withdrawal Acute Psychosis After Corticosteroid Discontinuation

The effects of alcoholism and smoking on advanced cancer patients admitted to an acute supportive/palliative care unit

Aim: The aim of this prospective study was to determine the characteristics and symptom burden of advanced cancer patients with alcoholism problems and smoking, who were referred to an acute palliative/supportive care unit (ASPCU) of a comprehensive cancer center. Methods: Patients’ characteristics, indications for admission, kind of admission, awareness of prognosis, and anticancer treatments were recorded. The Edmonton Symptom Assessment Scale (ESAS) was used to assess physical and psychological symptoms, and the CAGE questionnaire for the diagnosis of alcoholism. Patients were also divided in three groups: persistent smokers (PS), former smokers (FS), and non-smokers (NS). The Memorial…

Factors Influencing Clinical and Setting Pathways after Discharge from an Acute Palliative/Supportive Care Unit

Aim The aim of this study was to assess the factors which influence the care pathway after discharge from an acute palliative supportive care unit (APSCU). Methods Patients' demographics, indications for admission, kind of admission, the presence of a caregiver, awareness of prognosis, data on anticancer treatments in the last 30 days, ongoing treatment (on/off or uncertain), the previous care setting, analgesic consumption, and duration of admission were recorded. The Edmonton Symptom Assessment Scale (ESAS) at admission and at time of discharge (or the day before death), CAGE (cut down, annoy, guilt, eye-opener), and the Memorial Delirium Assessment Scale (MDAS), were used. At time of dis…

Refractory Death Rattle: Deep Aspiration Facilitates the Effects of Antisecretory Agents

Anticholinergic drugs, including atropine, hyoscine butylbromide, and scopolamine, have been shown to be equally effective in the treatment of death rattle. However, anticholinergic drugs may only be effective in reducing the production of further secretions, rather than eliminating the existing ones. A case is described in which a preventive procedure was undertaken to carefully eliminate secretions before starting anticholinergic drugs. Airway aspiration under light anesthesia removed secretions before starting anticholinergic drugs. Low doses of propofol were given intravenously to make a laryngoscopy feasible, allowing the complete aspiration of large amounts of tracheal secretions. No …

Safety and effectiveness of intravenous morphine for episodic breakthrough pain in patients receiving transdermal buprenorphine.

Supplemental dosing of an opioid is the main treatment suggested to manage breakthrough pain in cancer patients. The intravenous route has been proven to be safe and effective, providing rapid analgesia in patients receiving oral morphine. Transdermal buprenorphine (TTS-BUP) is increasingly used in cancer pain management, but this drug has been labeled as a difficult drug to use in combination with other opioids. The aim of this open-label study was to verify the safety and effectiveness of intravenous morphine (IV-MO) for the treatment of episodic pain in cancer patients receiving TTS-BUP. A consecutive sample of 29 cancer patients, who were treated with TTS-BUP, reported an acceptable bas…

Intranasal fentanyl versus fentanyl pectin nasal spray for the management of breakthrough cancer pain in doses proportional to basal opioid regimen.

Abstract The aim of this randomized, crossover, comparison study was to assess the analgesic and adverse effects of 2 nasal preparations, intranasal fentanyl (INFS) and fentanyl pectin nasal spray (FPNS), for breakthrough pain, given in doses proportional to opioid basal regimen. Each patient randomly received INFS or FPNS in doses proportional to opioid dosages used for background analgesia for 2 pairs of episodes. For each episode of breakthrough pain, pain intensity and adverse effects intensity were recorded just before starting the INFS or FPNS (T0) and 5 minutes (T5), 10 minutes (T10), and 20 minutes (T20) after the administration of the nasal drugs. Sixty-nine patients were studied. …

US Food and Drug Administration's Risk Evaluation and Mitigation Strategy for Extended-Release and Long-Acting Opioids Pros and Cons, and a European Perspective

Prescriptions for opioid analgesics to manage moderate-to-severe chronic non-cancer pain have increased markedly over the last decade. An unintentional consequence of greater prescription opioid utilization has been the parallel increase in misuse, abuse and overdose, which are serious risks associated with all opioid analgesics. In response to disturbing rises in prescription opioid abuse, the US Food and Drug Administration (FDA) has proposed the implementation of aggressive Risk Evaluation and Mitigation Strategies (REMS). While REMS could dramatically change the development, release, marketing and prescription of extended-release opioids, questions remain on how these programmes may inf…

Personalized Pain Goals and Responses in Advanced Cancer Patients

Abstract Objective To assess the personalized pain intensity goal (PPIG), the achievement of a personalized pain goal response (PPGR), and patients' global impression (PGI) in advanced cancer patients after a comprehensive pain and symptom management. Design Prospective, longitudinal Setting Acute pain relief and palliative/supportive care. Subjects 689 advanced cancer patients. Methods Measurement of Edmonton Symptom Assessment Score (ESAS) and personalized pain intensity goal (PPIG) at admission (T0). After a week (T7) personalized pain goal response (PPGR) and patients' global impression (PGI) were evaluated. Results The mean PPIG was 1.33 (SD 1.59). A mean decrease in pain intensity of …

Opioid-induced or pain relief-reduced symptoms in advanced cancer patients?

Abstract Background While opioids in increasing doses may produce adverse effects, the same adverse effects may be associated with poor pain control. Moreover, in the clinical setting symptomatic treatment and illness may balance the outcome of opioid titration. Some adverse effects may tend to disappear continuing the treatment in a long-term period. Aims The aim of this study was to monitor the effects of a rapid opioid titration combined with symptomatic treatment in patients with poor relief and to monitor these changes in the following period of 20 days. Methods A consecutive sample of 35 patients admitted to an acute Pain Relief and Palliative Care Unit were titrated with opioids, acc…

Effects of caffeine as an adjuvant to morphine in advanced cancer Patients: A randomized, double-blind, placebo-controlled, crossover study

Psychomotor abnormalities are one of the complications of opioid therapy in advanced cancer patients. Caffeine has potential properties to counteract the central effects of morphine. Twelve patients receiving stable doses of slow release morphine with adequate pain relief were scheduled for this double-blind placebo-controlled crossover trial. The treatment consisted of an intravenous dose of 1/6 of the daily morphine dose, using an intravenous/oral conversion ratio of 1:3. The dose calculated was administered in 5 minutes. Patients were randomly divided to received in a double-blind manner an infusion of 200 mg of caffeine or saline solution intravenously over one hour. A crossover took pl…

Breakthrough Pain (BTP) in Opioid-Tolerant Cancer Patients: A Pan-European Open-Label Multicentre Study with Fentanyl Buccal Tablet (FBT)

ABSTRACT BTP, a transitory exacerbation of pain that occurs on a background of otherwise controlled persistent pain, is a common problem in cancer patients. FBT is indicated for the treatment of BTP in adults with cancer already receiving maintenance opioid therapy for chronic cancer pain and should be titrated to an effective dose that provides adequate analgesia and minimises undesirable events. In this study, patients entered a screening period and were randomized during an open-label titration period to a starting FBT dose of 100 µg (group A) or 200 µg (group B) to identify the FBT effective dose and then treated in an open-label period (for 8 BTP episodes). Patients' inclusion followed…

Rapid titration with intravenous morphine for severe cancer pain and immediate oral conversion

BACKGROUND Cancer pain emergencies presenting with severe excruciating pain require a rapid application of powerful analgesic strategies. The aim of the current study was to evaluate a method of rapid titration with intravenous morphine to achieve relief of cancer pain of severe intensity. METHODS Forty-nine consecutive patients admitted to a Pain Relief and Palliative Care Unit for severe and prolonged pain were enrolled in the study. Pain was evaluated on a numeric scale of 0–10 (0 indicated no pain and 10 indicated excruciating pain). After the initial assessment (T0), an intravenous line was inserted and boluses of morphine (2 mg every 2 minutes) were given until the initial signs of si…

Opioid plasma concentration during switching from morphine to methadone: Preliminary data

Opioid switching is often used to improve the opioid response in cancer patients experiencing poor analgesia or adverse effects. However, no data are available on plasmatic changes of opioids and their metabolites during these phases, and whether there exists a relationship with the clinical events. In a prospective study of 10 consecutive cancer patients on oral morphine but with uncontrolled pain (greater >4 on a numerical scale of 0 to 10) and/or moderate to severe opioid adverse effects (on a level of 2 and 3 of a verbal scale) and not responsive to adjuvant medications, switching to oral methadone was performed using a fixed ratio of 5:1, leaving extra-doses of 1/5 of the daily dose of…

Video-thoracoscopic surgical pleurodesis in the management of malignant pleural effusion: the importance of an early intervention.

Thoracentesis plays an important role in cancer patients with symptomatic effusions, although its effect is short-lived and symptoms recur in almost all patients. Early video-thoracoscopic surgical pleurodesis may provide added benefit to a group of patients with advanced cancer presenting with symptomatic malignant pleural effusion. Seventy-six patients with advanced cancer and pleural effusion due to pulmonary-pleural metastases were recruited. In 51 cases (67.1%), at least one thoracentesis was performed before admission for surgery. Preoperative staging consisted of chest radiograph, CT scan, and blood gas analysis. The mean Karnofsky performance status was about 50. Pleurodesis with ta…

Clinical Problems with Transdermal Fentanyl Titration from 25 to 50 μg/hr

The impact of home palliative care on symptoms in advanced cancer patients

Physical symptoms, which are highly prevalent in patients with cancer, have a major impact on many aspects of quality of life, and the best possible quality of life is the principal aim of palliative care. Few studies have reported the impact of home care on pain and symptoms among cancer patients living at home. The aim of this study was to evaluate the impact of home palliative care given by an experienced team on symptoms in advanced cancer patients. A consecutive series of 373 patients who were referred to a home palliative care program in the period 1993-1995 were prospectively evaluated. Patients were enrolled for the presence of different symptoms (pain, nausea and vomiting, dry mout…

Treating breakthrough pain in oncology

Breakthrough cancer pain (BTcP) is an episode of severe intensity in patients receiving an adequate treatment with opioids able to provide at least mild analgesia. BTcP is a heterogeneous condition as episodes vary between individuals. The aim of this article is to review the pharmacologic options for the management of BTcP. Areas covered: Recent reviews revealed that transmucosal preparations of fentanyl provided superior and more rapid pain relief as compared to placebo and oral morphine within the first 30 min after dosing. Few comparison studies among fentanyl products have been performed. Although dose titration has been recommended for years, a meaningful dosing, according to the leve…

Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC

Here we provide the updated version of the guidelines of the European Association for Palliative Care (EAPC) on the use of opioids for the treatment of cancer pain. The update was undertaken by the European Palliative Care Research Collaborative. Previous EAPC guidelines were reviewed and compared with other currently available guidelines, and consensus recommendations were created by formal international expert panel. The content of the guidelines was defined according to several topics, each of which was assigned to collaborators who developed systematic literature reviews with a common methodology. The recommendations were developed by a writing committee that combined the evidence deriv…

Pattern and characteristics of advanced cancer patients admitted to hospices in Italy

Abstract The aim of this multicenter study was to assess the pattern and the characteristics of advanced cancer patients admitted to hospices. A consecutive sample of patients admitted in a period of 6 months was taken into consideration. Two hundred thirty-six patients admitted to hospices were consecutively assessed. Ninety-six percent of patients were admitted in acute hospital in the previous 3 months, with a mean time spent in hospital of 34.5 days, and 47 % of patients had received chemotherapy the month before hospice admission. Thirty-four percent of patients for whom data were available had significant persistent pain, and 44 % of them presented episodes of breakthrough pain. Sixty…

The frequency of alcoholism in patients with advanced cancer admitted to an acute palliative care unit and a home care program

Abstract Context Cancer patients with a history of alcoholism may be problematic. The frequency of alcoholism among patients with advanced cancer has never been reported in Italy or other European countries. Objectives The aim of this prospective study was to determine the frequency of alcoholism, assessed with a simple and validated instrument, among patients with advanced cancer who were referred to two different palliative care settings: an acute inpatient palliative care unit (PCU) of a comprehensive cancer center in a metropolitan area and a home care program (HCP) in a territorial district, localized in the mountains of Italy. Methods A consecutive sample of patients admitted to an in…

Personalized goal for insomnia and clinical response in advanced cancer patients.

Aim: The aim of this study was to assess the Personalized Insomnia Intensity Goal (PIIG), the achievement of Personalized Goal Response (PGR), and Patient Global Impression (PGI) after a comprehensive symptom management. Patients and methods: Advanced cancer patients admitted to palliative care units rated pain and symptoms intensity and their PIIG by using the Edmonton Symptom Assessment Score (ESAS) (T0). In patients with significant levels of insomnia, the achievement of target expected (PIIG) was measured (patient goal response, PIGR), as well the patient global impression (PGI), by the minimal clinically important difference (MCID), after a comprehensive symptom management (T7). Result…

Oral trasmucosal fentanyl citrate for breakthrough pain treatment in cancer patients.

Breakthrough cancer pain has been defined as a transitory increase in pain intensity that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. The availability of supplemental doses of oral opioids, in addition to the continuous analgesic medication, is the main treatment suggested to manage pain flares.Oral transmucosal fentanyl citrate (OTFC) is the first product of a new generation of delivery systems, named rapid-onset opioids (ROOs), characterized by rapidity of effect and the short duration of analgesia. Controlled studies and long-term experience have shown that OTFC is an e…

A randomised controlled study on the use of anti-inflammatory drugs in patients with cancer pain on morphine therapy

The role of non-steroidal anti-inflammatory drugs (NSAIDs) in cancer pain has been well established in the treatment of mild pain and in association with opioids in the treatment of moderate to severe pain. The aim of this study was to verify the effects of NSAIDs on morphine escalation in advanced cancer patients with pain followed-up at home and to assess the pharmacoeconomic implications. A prospective randomised controlled study was carried out in 156 consecutive advanced cancer patients with pain followed-up at home in the period December 1999–December 2000. In this group of patients, 47 were selected with pain progression after 1 week of opioid stabilisation. Patients were randomly as…

Sleep disorders in advanced cancer patients: prevalence and factors associated.

Sleep disorders have been invariably reported in cancer population. However, the prevalence of this problem in advanced cancer patients has never been assessed. The aim of this study was to evaluate the frequency of sleep disturbances in terms of quantity and quality, and possible associated factors.A consecutive sample of patients admitted to a pain relief and palliative care unit were surveyed. Patients with severe cognitive problems or who were too ill were excluded. Epidemiological and clinical data, including the performance status, habits, relevant symptoms, and drug use were recorded. Patients were asked to answer a small questionnaire regarding their sleep, and duration and characte…

Neuropathic pain in cancer: systematic review, performance of screening tools and analysis of symptom profiles.

Background The objectives of this study were to evaluate the methodological quality of rigorous neuropathic pain assessment tools in applicable clinical studies, and determine the performance of screening tools for identifying neuropathic pain in patients with cancer. Methods Systematic literature search identified studies reporting use of Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Douleur Neuropathique en 4 (DN4) or painDETECT (PDQ) in cancer patients with a clinical diagnosis of neuropathic or not neuropathic pain. Individual patient data were requested to examine descriptor item profiles. Results Six studies recruited a total of 2301 cancer patients of which 1564 (68%) r…

The use of high doses of oxycodone in an acute palliative care unit.

A retrospective study of patients who were prescribed controlled-release oxycodone (CRO) in a period of 3 years (2006-2008) was performed. A total of 212 patients were prescribed at discharge CRO for background analgesia; 129, 43, and 40 patients were prescribed doses of oxycodone of less than 120 mg/day (group L), 120 to 240 mg/day (group M), and more than 240 mg/day (group L), respectively. No differences in gender, primary diagnosis, and pain mechanisms were found, but doses were significantly lower in older patients (P &lt; .0005). At discharge, adverse effects were mild and only a minority of patients were switched to other opioids. This study demonstrated that CRO administered in lar…

Switching from Transdermal Drugs: An Observational "N of 1" Study of Fentanyl and Buprenorphine

The aim of this study was to confirm that the concomitant presence of transdermal fentanyl (TTS FE) and buprenorphine (TTS BU) may be feasible without important consequences, using doses presumed to be equianalgesic. A prospective "N of 1" study was carried out in a sample of volunteers with cancer pain receiving stable doses of TTS FE or TTS BU, with adequate pain and symptom control. In the study design, each patient provided data before and after a switch from one opioid to the other and then back to the previous one. Sixteen patients receiving daily stable doses of 0.6 or 1.2 mg of TTS FE were switched to TTS BU using an FE-BU ratio of 0.6-0.8. After three days, the TTS BU patch was rem…

Intravenous morphine for breakthrough (episodic-) pain in an acute palliative care unit: a confirmatory study.

The aim of this prospective cohort study was to confirm the safety of intravenous morphine (IV-M) used in doses proportional to the basal opioid regimen for the management of breakthrough pain and to record the nurse compliance on regularly recording data regarding breakthrough pain treated by IV-M. Over a one-year period, 99 patients received IV-M for breakthrough pain during 116 admissions. The IV-M dose was 1/5 of the oral daily dose, converted using an equianalgesic ratio of 1/3 (IV/oral). For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to reassess the patient 15minutes after IV-M injection (…

The low opioid consumption in Italy depends on late palliative care

The effects of low doses of pregabalin on morphine analgesia in advanced cancer patients

Abstract OBJECTIVES: The aim of this study was to evaluate the opioid response in patients receiving morphine and pregabalin, independently from the presumed pain mechanisms, in comparison with patients receiving morphine treatment only. METHODS: A multicenter prospective randomized controlled study was carried out in a sample of 70 advanced cancer patients with pain requiring strong opioids. Thirty-five patients (group MO) were randomized to receive sustained-release morphine using initial doses of 60 mg/day. Thirty-five patients (group MO-PR) were randomized to start the same morphine doses and pregabalin in increasing doses, starting with 25 mg/day up to 150 mg/day in one week. The follo…

The prevalence and characteristics of breakthrough cancer pain in patients receiving low doses of opioids for background pain

Simple Summary The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. This prospective study showed that in this population, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes. Abstract The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background p…

Opioid use and effectiveness of its prescription at discharge in an acute pain relief and palliative care unit

The aim of this study was to present how opioids are used in an acute pain relief and palliative care unit (APRPCU), where many patients with difficult pain conditions are admitted from GPs, home palliative care programs, oncology departments, other hospitals or emergency units, and other regional places. From a consecutive sample of cancer patients admitted to an APRPCU for a period of 6 months, patients who had been administered opioids were included in this survey. Basic information was collected as well as opioid therapy prescribed at admission and, subsequently, during admission and at time of discharge. Patients were discharged once stabilization of pain and symptoms were obtained and…

Personalized Goal for Dyspnea and Clinical Response in Advanced Cancer Patients

Abstract Background The clinical response after comprehensive symptom management is difficult to determine in terms of a clinically important difference. Moreover, therapies should try to reach the threshold perceived by the individual patient for the determination of a favorable response to a treatment. Measures The Edmonton Symptom Assessment Score (ESAS) was measured at admission (T0), and seven days after starting palliative care (T7). Patient Global Impression and Goal Response after one week of palliative care and its relation with the Personalized Dyspnea Goal were measured at T7. Intervention Patients admitted to palliative care units underwent a comprehensive symptom assessment by …

Rapid Switching Between Transdermal Fentanyl and Methadone in Cancer Patients

Purpose The aim of this study was to examine the clinical effects of switching from transdermal (TTS) fentanyl to methadone, or vice versa, in patients with a poor response to the previous opioid. Patients and Methods A prospective study was carried out on 31 patients who switched from TTS fentanyl to oral methadone, or vice versa, because of poor opioid response. A fixed conversion ratio of fentanyl to methadone of 1:20 was started and assisted by rescue doses of opioids, and then doses were changed according to clinical response. Pain and symptom intensity, expressed as distress score, were recorded before switching doses of the two opioids and after subsequent doses. The number of change…

The use of rapid onset opioids for breakthrough cancer pain: the challenge of its dosing.

Breakthrough cancer pain (BTcP) has been defined as a transitory increase in pain intensity on a baseline pain of moderate intensity in patients on analgesic treatment regularly administered. This review provides updated information about the use of opioids for the treatment of BTcP, with special emphasis on the use of new rapid onset opioids (ROOs). Due to its slow onset to effect oral opioids cannot be considered an efficacious treatment for BTcP. Parenteral opioids may provide rapid onset of analgesia, but not always available particularly at home. Different technologies have been developed to provide fast pain relief with potent opioid drugs such fentanyl, delivered by non-invasive rout…

Noninvasive Ventilation for the Treatment of Dyspnea as a Bridge from Intensive to End-of-Life Care

57 TREATMENT OF BTP IN CANCER PATIENTS — A SYSTEMATIC UPDATE ON RELEVANT TREATMENT STRATEGIES

Switching from oxycodone to methadone in advanced cancer patients

The aim of this study was to prospectively evaluate the outcomes and the conversion ratio of switching from oxycodone to methadone in advanced cancer patients admitted to an acute palliative care unit.A prospective study was carried out on a cohort of consecutive sample of patients receiving oxycodone, who were switched for different reasons mainly because of an inconvenient balance between analgesia and adverse effects. An initial conversion ratio between oxycodone and methadone was 3.3:1. Intensity of pain and symptoms associated with opioid therapy were recorded, and a distress score (DS) was also calculated as a sum of symptom intensity. A successful switching was considered when the in…

Oxycodone extended release capsules for the treatment of chronic pain

As a consequence of greater prescription opioid utilization, there has been the parallel increase in misuse, abuse, and overdose, which are serious risks. Associated new formulations may be safer. Areas covered: The introduction of abuse-deterrent opioid formulations and continuous programs to improve opioid prescribing practices may limit the opioid abuse and its consequences. Oxycodone extended release capsules are an extended-release (ER), microsphere-in-capsule abuse-deterrent-formulation designed to retain its extended-release properties following tampering or misuse (e.g., chewing, crushing). Studies have reported that this preparation is efficacious in patients with low back pain, le…

Investigation of an opioid response categorization in advanced cancer patients

The aim of this study was to investigate a possible distinction in three categories of opioid response and to identify possible factors associated with a poor response. A prospective survey was carried out in 105 consecutive patients requiring morphine for at least 4 weeks before death. Mean pain intensity, opioid doses and symptom intensity at weekly intervals, pain syndromes, and the presence of psychological distress were assessed. Opioid escalation index (OEI%) was calculated from the parameters recorded. Three categories were considered, including (1) patients with slow increments of opioid dose and a mean analgesic 10-cm visual analogue scale (VAS) less than 4 (responders), (2) patien…

Pattern of drug use by advanced cancer patients followed at home

The aim of this study was to document the drugs most commonly prescribed to control symptoms in advanced cancer patients being followed at home. We analyzed data for 128 patients admitted to a home palliative care program from January 1993 to January 1995. All patients were followed at home until death by a team consisting of doctors and nurses, and were given two or three medical examinations a week. The most frequently prescribed drugs were analgesics and drugs commonly used to prevent NSAID-induced gastric toxicity. Slow-release morphine was the analgesic used most often. Most patients received more than four drugs. Younger people received morphine more often than did older patients. Co…

Effects of red blood cell transfusion on anemia-related symptoms in patients with cancer.

The aim of this study was to assess the effects of red blood cell transfusion, and the subsequent increase in hemoglobin values, on anemia-related symptoms in a cohort of patients with cancer with different survival times. A red blood cell transfusion was recommended to a consecutive sample of patients with hemoglobin levels of 8 +/- 0.5 g/dL. The number of units to be ordered was decided according the hemoglobin values with a mean target of increasing the hemoglobin values by approximately 2 g/dL. Hemoglobin values, anemia-related signs and symptoms, including well-being, fatigue, and dyspnea, were recorded at admission (T0), 1 day after the last transfusion (T1), and 15 days afterward (T2…

Characteristics of advanced cancer patients who were readmitted to an acute palliative/supportive care unit

Objectives: The aim of this study was to assess the characteristics of patients readmitted to an acute supportive/palliative care unit (ASPCU), the reasons for readmission, and the outcome after receiving specialistic assessment and treatment. Methods: A consecutive sample of patients was assessed for a period of 10 months. Epidemiological characteristics, including age, gender, Karnofsky level, diagnosis, caregivers, education, disease awareness, kind of admission, and anticancer treatment in the previous 30 days, were recorded, as well as hospital stay, death, and discharge at home. The principal reasons for admission were recorded. Symptom intensity and opioid doses, expressed as oral …

Octreotide prevents the pathological alterations of bowel obstruction in cancer patients

Opioid switching from and to tapentadol extended release in cancer patients: conversion ratio with other opioids

Objectives: The aim of this exploratory study was to assess the conversion ratios between tapentadol and other opioids in patients requiring an opioid switching. Methods: A prospective study was carried out in a convenience sample of consecutive patients admitted to an acute palliative care unit and a home care unit for a period of 1 year. Patients who were switched from/to tapentadol were selected. The initial ratio between tapentadol and other opioids, expressed as oral morphine equivalents was 1:3.3. The subsequent doses were flexible and were changed to fit the patients’ needs. Pain intensity and distress score were recorded until opioid doses were stable. In all, 37 patients were exami…

Long-term efficacy and tolerability of intranasal fentanyl in the treatment of breakthrough cancer pain

Purpose: The aim of the present study was to assess the long-term tolerability and efficacy of intranasal fentanyl (INFS) in opioid-tolerant patients with breakthrough cancer pain (BTP).Patients and methods: A 6 months, observational, prospective, cohort study design was employed to follow advanced cancer patients with BTP receiving INFS under routine clinical practice. Eligible adult cancer patients suffering from BTP had been prescribed INFS at effective doses. Data were collected at T0 and at month intervals for six months. The principal outcomes were the evaluation of possible serious adverse effects with prolonged use of INFS, the efficacy of BTP treatment with INFS, the quality of sle…

A Prospective Randomized Study of Corticosteroids as Adjuvant Drugs to Opioids in Advanced Cancer Patients

This randomized controlled study evaluated the role of corticosteroids as adjuvants to opioid therapy in 76 advanced cancer patients with pain who requiring strong opioids. Patients were divided in 2 groups. Group O received conventional opioid treatment. Group OS received dexamethasone (8 mg orally) along with conventional treatment. Pain and symptom intensity, sense of well-being, and opioid escalation index and distress score were recorded at weekly intervals until death. No differences in pain intensity, opioid consumption, and opioid escalation index were found in 66 patients who survived 33 to 37 days. Corticosteroids did not provide significant additional analgesia to opioids, but p…

Tools for identifying cancer pain of predominantly neuropathic origin and opioid responsiveness in cancer patients.

Neuropathic pain (NP) is a difficult issue, particularly in cancer which is a dynamic condition where multiple pain etiologies are concomitantly present. Cancer pain is often labeled as mixed mechanism pain and is not easily classified as exclusively nociceptive or NP. The aim of this study was to explore the value of evaluation tools such as Neuropathic Pain Questionnaire (NPQ), complete and short form (NPQ-SF), Leeds Assessment of Neuropathic Signs and Symptoms (LANSS) and Neuropathic Pain Symptom Inventory (NPSI). The secondary outcome was to evaluate the response to opioid titration, according to the hierarchical classification of definite, possible and unlikely NP. A consecutive sample…

The use of sublingual fentanyl for breakthrough pain by using doses proportional to opioid basal regimen.

Abstract OBJECTIVE: The aim of this study was to prospectively assess the efficacy and safety of sublingual fentanyl (SLF) in doses proportional to opioid doses used for background analgesia for the treatment of BTP of cancer patients. METHODS: A sample of patients admitted to an acute palliative care unit, presenting breakthrough pain (BTP) episodes and receiving stable doses of opioids for background pain was selected to assess the efficacy and safety of SLF used in doses proportional to the basal opioid regimen used for the management of BTP. For each patient, data from four consecutive episodes were collected. For each episode, nurses collected changes in pain intensity and adverse effe…

Methadone as First-line Opioid for the Management of Cancer Pain

Abstract Aim The aim of this study was to assess the efficacy and adverse effects of methadone when used as first-line therapy in patients that are either receiving low doses of opioids or none. Methods Patients with advanced cancer were prospectively assessed. Opioid-naive patients (L-group) were started with methadone at 6 mg/day. Patients receiving weak or other opioids in doses of &amp;lt;60 mg/day of OME (H-group) were started with methadone at 9 mg/day. Methadone doses were changed according to the clinical needs to obtain the most favorable balance between analgesia and adverse effects. Edmonton Symptom Asssement Score (ESAS), Memorial Delirium Assessment Score (MDAS), doses of metha…

Methadone response in advanced cancer patients with pain followed at home

Concerns about the safety of therapy with methadone, which may arise because of its pharmacokinetic characteristics and inappropriate dosing, may deter clinicians from using this drug, especially in elderly patients. Experience is accumulating that the drug may be used safely and successfully if low doses are given initially and care is taken in the titration of the dose against the pain. A prospective study was carried out in a consecutive sample of 45 advanced cancer patients followed at home, who had never received other strong opioids for their pain. Patients were treated with an oral liquid preparation of methadone, which was administered 2-3 times daily, according to need. Doses were …

Palliative sedation in patients with advanced cancer followed at home: A systematic review

Abstract Context Patients with advanced cancer who are near the end of life may experience intolerable suffering refractory to targeted palliative therapies. Palliative sedation (PS) is considered to be an effective treatment modality for these refractory symptoms when aggressive efforts fail to provide relief. Objectives The aim of this study was to systematically review articles regarding PS performed at home in patients with intractable symptoms. Methods Literature databases searched included MedLine, PubMed, and EMBASE. The text words and MeSH/EMTREE terms "home care" and "sedation" were used for electronic database searches. Results Six articles met the inclusion criteria for research …

Breakthrough pain in cancer patients

The aim of this article was to examine the definition, the characteristics, and the management of breakthrough cancer pain (BTP) in cancer patients by a critical review of recent literature.BTP should be more correctly defined as an episode of severe intensity in patients receiving an adequate treatment with opioids able to provide at least mild analgesia. BTP is a heterogeneous condition as episodes vary between individuals. BTP can be classified into two big distinct pictures: spontaneous-type and incident-type pain. The principal pharmacological treatment of BTP is represented by the administration of opioids as needed. Recent reviews revealed that transmucosal preparation of fentanyl pr…

Episodic Breathlessness with and without Background Dyspnea in Advanced Cancer Patients Admitted to an Acute Supportive Care Unit

Aim: To characterize episodic breathlessness (EB) in patients with advanced cancer, and to determine factors influencing its clinical appearance. Methods: A consecutive sample of advanced cancer patients admitted to an acute palliative care unit was surveyed. Continuous dyspnea and EB were measured by a numerical scale. The use of drugs used for continuous dyspnea and EB was recorded. Patients were asked about the characteristics of EB (frequency, intensity, duration and triggers). The Multidimensional dyspnea profile (MDP), the Brief dyspnea inventory (BDI), the Athens sleep scale (AIS) and the Hospital Anxiety and Depression Scale (HADS) were also administered. Results: From 439 advanced …

Prognostic factors of survival in patients with advanced cancer admitted to home care

Abstract CONTEXT: Data regarding prognostication of life expectancy in patients with advanced cancer are of paramount importance to patients, families, and clinicians. However, data regarding patients followed at home are lacking. OBJECTIVES: The aim of this study was to evaluate the correlation between various factors recorded at the beginning of home care assistance and survival. METHODS: A sample of consecutive patients admitted to two home care programs was surveyed. A preliminary consensus was achieved as to the possible variables easy to be recorded at home. These included age at the time of home care admission, gender, residence, marital status, primary cancer diagnosis, Karnofsky Pe…

Classification of neuropathic pain in cancer patients: A Delphi expert survey report and EAPC/IASP proposal of an algorithm for diagnostic criteria

Neuropathic pain (NP) in cancer patients lacks standards for diagnosis. This study is aimed at reaching consensus on the application of the International Association for the Study of Pain (IASP) special interest group for neuropathic pain (NeuPSIG) criteria to the diagnosis of NP in cancer patients and on the relevance of patient-reported outcome (PRO) descriptors for the screening of NP in this population. An international group of 42 experts was invited to participate in a consensus process through a modified 2-round Internet-based Delphi survey. Relevant topics investigated were: peculiarities of NP in patients with cancer, IASP NeuPSIG diagnostic criteria adaptation and assessment, and …

Analgesic effect of intravenous ketamine in cancer patients on morphine therapy: A randomized, controlled, double-blind, crossover, double-dose study

Pain not responsive to morphine is often problematic. Animal and clinical studies have suggested that N-methyl-d-aspartate (NMDA) antagonists, such as ketamine, may be effective in improving opioid analgesia in difficult pain syndromes, such as neuropathic pain. A slow bolus of subhypnotic doses of ketamine (0.25 mg/kg or 0.50 mg/kg) was given to 10 cancer patients whose pain was unrelieved by morphine in a randomized, double-blind, crossover, double-dose study. Pain intensity on a 0 to 10 numerical scale; nausea and vomiting, drowsiness, confusion, and dry mouth, using a scale from 0 to 3 (not at all, slight, a lot, awful); Mini-Mental State Examination (MMSE) (0- 30); and arterial pressur…

The use of complementary alternative medicines in advanced cancer patients followed at home

Objectives: To assess the use of complementary alternative medicines (CAM) in advanced cancer patients followed at home. Methods: A consecutive sample of advanced cancer patients admitted to a home palliative care program was invited to participate in the study in a period of two months. Demographic characteristics, religious belief, education level, diagnosis, and socio-economic condition were recorded. Patients were asked about the use of CAM, considered to be a health-related treatment practiced outside the established health services. Information about CAM indications and those who prescribed or suggested CAM were also collected. Results: Two hundred and eighty-three advanced cancer pat…

New drugs for pain management in advanced cancer patients.

Advanced cancer patients represent a frail population, often requiring aggressive pain management, particularly in the late stage of disease, when untreated pain is one the most important causes of suffering. Areas covered: In the last decade, a series of new analgesics have been introduced in the market to offer additional options amongst existent drugs. The characteristics of these drugs, their efficacy and tolerability are examined on the basis of existent studies. Expert opinion: Although new analgesic preparations have been developed in recent years, no specific drug has provided a better analgesic performance in comparison with others. Some technologies have been developed to increase…

The use of opioids in the last week of life in an acute palliative care unit.

The aim of this survey was to assess the opioid use in the last week of life of cancer patients admitted at an acute palliative care unit. From a consecutive sample of patients surveyed for a period of one year, patients who died in the unit were selected. Type of opioid, route of administration, and doses were recorded one week before death (or at admission time if the interval admission-death was less than one week) (-7), and on the day of death (Tend). Seventy-seven patients died in the unit in the period taken into consideration (12.4%). Oral morphine equivalents were 170 mg/day and 262 mg/day at -7 and Tend, respectively. Patients were receiving transdermal drugs or intravenous morphi…

Cancer: New Needs, New Models. Is It Time for a Community Oncologist? Another Brick in the Wall

Simple Summary Community care activity in the oncology field does not exist. This unmet need contrasts with the increasing number of patients with a previous diagnosis of cancer. Abstract Over the last few decades, thanks to early detection, effective drugs, and personalized treatments, the natural history of cancer has radically changed. Thanks to these advances, we have observed how survival of cancer patients has increased, becoming an ever more important goal in cancer care. Effective clinical governance of survivorship care is essential to ensure a successful transition between active and post-treatment life, identifying optimization of healthcare outcomes and quality of life for patie…

Opioid Responsiveness-Primary Diagnosis Relationship in Advanced Cancer Patients Followed At Home

The aim of this study was to evaluate the influence of the primary cancer on pain characteristics and opioid response, in terms of analgesia and adverse effects, in advanced cancer patients followed at home. A prospective study was carried out in a sample of 434 consecutive advanced cancer patients who required opioids during the last four weeks of life. One hundred eighty-one patients received opioids for longer than the four weeks and were considered for this analysis. Demographic data, primary diagnosis, and pain mechanisms were recorded, and mean opioid doses, pain intensity, and symptoms were assessed at weekly intervals during the last four weeks of life. In the group of 181 patients,…

Aggressive Pharmacological Treatment for Reversing Malignant Bowel Obstruction

Early and intensive pharmacological treatment not only may reduce gastrointestinal symptoms but also reverse malignant bowel obstruction. Fifteen consecutive advanced cancer patients with inoperable bowel obstruction received a combination of drugs including metoclopramide, octreotide, dexamethasone and an initial bolus of amidotrizoato. Recovery of intestinal transit was reported within 1-5 days in fourteen patients, who continued this treatment without presenting symptoms of bowel obstruction until death. This case series establishes that the combination of propulsive and antisecretive agents can act synergistically to allow a fast recovery of bowel transit without inducing unpleasant col…

Transmucosal fentanyl vs intravenous morphine in doses proportional to basal opioid regimen for episodic-breakthrough pain

The use of supplemental doses of opioids is commonly suggested to manage breakthrough pain. A comparative study of intravenous morphine (IV-MO) and oral transmucosal fentanyl citrate (OTFC) given in doses proportional to the basal opioid regimen was performed in 25 cancer patients receiving stable opioid doses. For each episode, when it occurred and 15 and 30 min after the treatment, pain intensity and opioid-related symptoms were recorded. Fifty-three couples of breakthrough events, each treated with IV-MO and OTFC, were recorded. In episodes treated with IV-MO, pain intensity decreased from a mean of 6.9 to 3.3 and to 1.7 at T1 and T2, respectively. In episodes treated with OTFC, pain int…

Local anesthetic switching for intrathecal tachyphylaxis in cancer patients with pain.

IMPLICATIONS Switching from bupivacaine to lidocaine may improve intrathecal morphine analgesia in advanced cancer patients, possibly because of different spinal mechanisms limiting the hyperalgesic processes.

Rapid switching from morphine to methadone in cancer patients with poor response to morphine

PURPOSE: The aim of this study was to evidence the clinical effects of an abrupt substitution of morphine with methadone using a fixed ratio of 1:5 in patients for whom limiting adverse effects occurred before adequate analgesia was achieved with oral morphine. PATIENTS AND METHODS: A cross-sectional prospective study was carried out on 24 consecutive patients who were switched from oral morphine to oral methadone because they experienced substantial adverse effects that limited further increase in morphine dose. A fixed conversion morphine-to-methadone ratio of 5:1 was chosen. Subsequently, doses were changed according to clinical need, with frequent visits or phone contacts. Pain and sym…

Palliative care in intensive care units: Why, where, what, who, when, how

Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering when “curative” therapies are futile. In the Intensive Care Unit (ICU), critically ill patients receive life-sustaining therapies with the goal of restoring or maintaining organ function. Palliative Care in the ICU is a widely discussed topic and it is increasingly applied in clinics. It encompasses symptoms control and end-of-life management, communication with relatives and setting goals of care ensuring dignity in death and decision-making power. However, effective application of Palliative Care in ICU presupposes specific knowledge and training which ane…

The anesthesiologist and end-of-life care

Purpose of review Anesthesiologists may face problematic situations when patients are close to death, in which clinical problems, decision-making processes, and ethical issues are often interconnected and dependent on each of them. The aim of this review is to assess the recent literature regarding the anesthesiological role for advanced cancer patients. Recent findings Palliative sedation in the dying patients, end-of-life problems in the ICU, and pain control in advanced cancer patients have been the subject of recent research. All these issues have shown that anesthesiologist would be expert in the field of pain and symptom control at the end of life. End-of-life care problems are common…

Addition of a second opioid may improve opioid response in cancer pain: preliminary data

Recent experimental data suggest a possible use of an opioid combination to improve analgesia. In cancer patients, a rapid opioid escalation due to either worsening of the pain condition or the development of tolerance is a critical phase, as this condition is associated with a negative prognosis. The aim of this study was to assess the effects of adding a second opioid at low doses in patients with a poor analgesic benefit after dose escalation. Fourteen patients receiving strong opioids who had increased their dosage more than 100% in the last week unsuccessfully were randomly chosen to add a second opioid to the first using an initial equivalent dosage of 20% of the previous therapy. The…

Safety and effectiveness of intravenous morphine for episodic (breakthrough) pain using a fixed ratio with the oral daily morphine dose

Breakthrough pain is normally severe in intensity and has a rapid onset. The availability of supplemental doses of opioids (rescue medication) in addition to the continuous analgesic medication is the main treatment suggested to manage these pain flares. The intravenous (i.v.) route may provide analgesia fast enough, but has never been assessed in clinical studies. The aim of this open-label study was to verify the safety and effectiveness of an i.v. dose equal to one-fifth the calculated equianalgesic total daily dose in advanced cancer patients with episodic pain. A consecutive sample of 48 cancer patients treated with oral morphine, who reported an acceptable basal analgesia and reported…

Ineffectiveness of dextromethorphan in cancer pain

Experimental studies have indicated that N-methyl-D-aspartate (NMDA) receptor antagonists may be effective analgesics in a wide variety of chronic pain states. The mechanism is presumed to be related to decreased firing of dorsal horn neurons after constant repeated C-fiber stimulation. Dextromethorphan (DM), a potent NMDA antagonist with a good safety profile, may be a promising agent for the treatment of persistent pain. An open-label randomized trial was designed to examine the effects of combining DM with NSAIDs, dextropropoxyphene, or morphine in cancer patients with pain. Patients who required a change in the step of the World Health Organization's (WHO) analgesic ladder because of a …

Alternative treatments of breakthrough pain in patients receiving spinal analgesics for cancer pain.

Patients who experience a poor response to different systemic opioid trials (oral and intravenous) are candidates for spinal treatment. Breakthrough pain occurring in this group of patients is challenging for physicians. This phenomenon has never been described in this context and the treatment is quite difficult, as patients already demonstrated a poor response to systemic opioids. We report a preliminary experience of alternative methods, including the intrathecal injection of local anesthetic boluses as needed, or alternatively, the use of sublingual ketamine. Twelve consecutive patients with advanced cancer and pain were selected for intrathecal treatment after receiving different trial…

Pharmacological management of cancer pain in children

The aim of this review was to assess cancer pain management in children on the basis of research published in the last ten years. Nine were papers providing clinical data, with a minimum of ten patients. No controlled studies were found. Regardless of general principles and existing recommendations, clinical data should confirm the applicability of this concept. The trials published in the last years did not provide further information to improve cancer pain management in children, because of the experience and the low number of drugs used, reflecting only meaningful opinions of experts in the field. The amount and the quality of data still remain poor, as only 737 subjects (about 80 patien…

Orphan symptoms in advanced cancer patients followed at home

Abstract Orphan symptoms are rarely assessed, particularly at home. The aim of this multicenter prospective study was to assess the prevalence of these symptoms and eventual factors possibly associated in advanced cancer patients at admission of a home care program. A prospective study was performed at three home care programs in Italy. Patients' data were collected, including age, sex, diagnosis, and Karnofsky status. Possible contributing factors were analyzed; preexisting neurological diseases, cerebral metastases, hyperthermia, diabetes, a state of dehydration clinically evident and/or oliguria, possible biochemical parameters when available, data regarding recent chemotherapy, opioids …

The palliative-supportive care unit in a comprehensive cancer center as crossroad for patients' oncological pathway

Aim The aim of this study was to assess how an admission to an acute palliative-supportive care unit (APSCU), may influence the therapeutic trajectory of advanced cancer patients. Methods A consecutive sample of advanced cancer patients admitted to APCU was assessed. The following parameters were collected: patients demographics, including age, gender, primary diagnosis, marital status, and educational level, performance status and reasons for and kind of admission, data about care-givers, recent anticancer treatments, being on/off treatment or uncertain, the previous care setting, who proposed the admission to APSCU. Physical and psychological symptoms were evaluated at admission and at ti…

Breakthrough pain in patients with abdominal cancer pain.

Abstract OBJECTIVE: Characterization of breakthrough cancer pain (BTcP) in patients with abdominal cancer is lacking. The aim of this study was to assess the characteristics of BTcP in patients with abdominal cancer pain. PATIENTS AND METHODS: In an observational cohort study, from a consecutive sample of patients admitted to a pain relief and supportive care unit for a period of 13 months, patients with abdominal disease due to cancer, including primary cancer or metastases, were assessed for the presence of chronic abdominal pain; its mechanism, intensity of background pain, and pain flares, which were distinguishable from the baseline pain, were recorded. Patients presenting with pain fl…

Opioid Poorly-Responsive Cancer Pain. Part 1

Pain that is poorly responsive to opioid analgesics is challenging for physicians who deal with cancer patients. Numerous factors may influence analgesic response during the course of the illness. These include changing nociception associated with disease progression, the appearance of intractable side effects, the development of tolerance, the presence of neuropathic pain, the temporal pattern, the effects produced by the production of opioid metabolites, and many others. These factors influence the delicate balance between pain relief and opioid toxicity that must be achieved in cancer patients with pain.

Epidemiology and Characteristics of Episodic Breathlessness in Advanced Cancer Patients. An Observational Study

Abstract Context Episodic breathlessness is a relevant aspect in patients with advanced cancer. Objectives The aim of this study was to assess the different aspects of this clinical phenomenon. Methods A consecutive sample of patients with advanced cancer admitted to different settings for a period of six months was surveyed. The presence of background breathlessness and episodic breathlessness, their intensity (numerical scale 0–10), and drugs used for treatment were collected. Factors inducing episodic breathlessness and its influence on daily activities were investigated. Results Of 921 patients, 29.3% ( n  = 269) had breathlessness and 134 patients (49.8%) were receiving drugs for backg…

Characteristics of patients with an unplanned admission to an acute palliative care unit

The aim of this cohort study is to compare the symptom burden of patients who have an unplanned admission to an acute palliative care unit (APCU) with patients who have a regular planned admission. A consecutive sample of advanced cancer patients who were admitted to an APCU was prospectively assessed. The reasons and the kind of admission were recorded (unplanned, UP, or planned, P). Anticancer treatments, whether patients were on/off treatment or uncertain, previous care setting, and who referred the patient to the unit were also recorded. The Edmonton Symptom Assessment Scale (ESAS) was used at admission and at time of discharge, as well as the Memorial Delirium Assessment Scale. Analges…

Opioid poorly-responsive cancer pain. Part 3. Clinical strategies to improve opioid responsiveness.

Some pain syndromes may be difficult to treat due to a poor response to opioids. This situation demands a range of alternative measures, including the use of adjuvant drugs with independent effects, such as antidepressants, sodium channel-blocking agents, steroids and anti-inflammatory drugs (NSAIDs); drugs that reduce opioid side effects; and drugs that enhance analgesia produced by opioids, such as N-methyl-D-aspartate (NMDA) antagonists, calcium channel antagonists, and clonidine. Other approaches, including opioid trials, neural blockade when necessary, and psychological interventions, also may be useful.

Analgesics for breakthrough pain

Factors influencing the opioid response in advanced cancer patients with pain followed at home: The effects of age and gender

The aim of this study was to evaluate the influence of age and gender on pain characteristics and opioid response in advanced cancer patients followed at home. A perspective study was carried out in a sample of 181 consecutive advanced cancer patients who required opioids in the last 4 weeks before death. Pain intensity and symptoms associated with opioid therapy at weekly intervals for 4 weeks were recorded, as were the previous oncological treatments. Opioid doses increased over time, but remained stable in the last 2 weeks of life, while pain intensity decreased over time despite unchanged use of NSAIDs. A considerable increase in symptom intensity was observed in the last weeks of life,…

Additional file 1: of Palliative care in intensive care units: why, where, what, who, when, how

Critical care physician’s most frequent questions about palliative care in ICU. The figure depicts critical care physician’s doubts facing a clinical picture of a patient where the curative plan seems no longer effective. The questions describe most frequent open question about palliative care in ICU. (TIFF 4303 kb)