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…

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…

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…

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 (…

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…

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 …

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…

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 …

Pegylated Liposomal Doxorubicin with Vinorelbine in Metastatic Breast Carcinoma

A multicenter phase I-II trial was carried out with the aim of identifying the dose-limiting toxicity and the maximum tolerated dose of vinorelbine (VNR) in combination with pegylated liposomal doxorubicin at a dose of 20 mg/m<sup>2</sup> every 15 days in patients with metastatic breast carcinoma. In the phase I part of the trial, VNR was given at a dose of 20 mg/m<sup>2</sup> every 15 days to a group of 3 patients. In absence of unacceptable toxicity, VNR was escalated to 25, 30, and 35 mg/m<sup>2</sup> for subsequent groups of 3 patients, until the dose-limiting toxicity was reached. No case of palmar-plantar erythrodysesthesia was recorded in these pat…

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…

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…

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…

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

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…

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…

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…

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…

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…

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…

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…

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…

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…

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…

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…

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…

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…

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…

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

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…

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 < .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…

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 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…

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…

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…

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 …

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…

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 <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…

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 …

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…

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.

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…

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…

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…

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…