Medicine › Anesthesiology and Pain Medicine

Pain Management and Opioid Use

Works Count: 38659

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This cluster of papers covers a wide range of topics related to pain management, with a focus on challenges in treating postoperative pain, cancer-related pain, and persistent pain in elderly patients. It also explores the genetic basis for individual variations in pain perception and the use of opioid analgesics. The papers discuss the prevalence of pain, assessment tools, and the impact of pain management on quality of life.

Keywords

Pain Management; Cancer Pain; Opioid Analgesics; Elderly Patients; Genetic Variability; Postoperative Pain; Neurolytic Block; Pain Assessment Tools; Patient-Controlled Analgesia; Quality of Life

Pain: a review of three commonly used pain rating scales

2005-06-30

Amelia Williamson , B. Hoggart

Aims and objectives. This review aims to explore the research available relating to three commonly used pain rating scales, the Visual Analogue Scale, the Verbal Rating Scale and the Numerical … Aims and objectives. This review aims to explore the research available relating to three commonly used pain rating scales, the Visual Analogue Scale, the Verbal Rating Scale and the Numerical Rating Scale. The review provides information needed to understand the main properties of the scales. Background. Data generated from pain‐rating scales can be easily misunderstood. This review can help clinicians to understand the main features of these tools and thus use them effectively. Method. A MedLine review via PubMed was carried out with no restriction of age of papers retrieved. Papers were examined for methodological soundness before being included. The search terms initially included pain rating scales, pain measurement, Visual Analogue Scale, VAS, Verbal Rating Scale, VRS, Numerical/numeric Rating Scale, NRS. The reference lists of retrieved articles were used to generate more papers and search terms. Only English Language papers were examined. Conclusions. All three pain‐rating scales are valid, reliable and appropriate for use in clinical practice, although the Visual Analogue Scale has more practical difficulties than the Verbal Rating Scale or the Numerical Rating Scale. For general purposes the Numerical Rating Scale has good sensitivity and generates data that can be statistically analysed for audit purposes. Patients who seek a sensitive pain‐rating scale would probably choose this one. For simplicity patients prefer the Verbal Rating Scale, but it lacks sensitivity and the data it produces can be misunderstood. Relevance to clinical practice. In order to use pain‐rating scales well clinicians need to appreciate the potential for error within the tools, and the potential they have to provide the required information. Interpretation of the data from a pain‐rating scale is not as straightforward as it might first appear.

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Pharmacological Management of Persistent Pain in Older Persons

2009-09-01

Drugs without a strong evidence base and outside of recommendations are too often pre- scribed for older adults. Established guidelines such as Beers criteria have identified both specific medications and … Drugs without a strong evidence base and outside of recommendations are too often pre- scribed for older adults. Established guidelines such as Beers criteria have identified both specific medications and certain drug classes as inappropriate for older adults, primarily due to adverse effects. Age-related physiological changes in distribution, metabolism, and elimination often alter the effects of pharmacotherapies in older adults. When designing a therapeutic program, all elements contributing to the pathophysiology of painful conditions should be considered, as well as the mechanisms of action of analgesic drug classes. Both appropriate and inappropriate medica- tions for older adults are detailed herein, as well as their contraindications and potential drug- drug or drug-disease interactions. The number needed to treat (NNT) can be useful in considering efficacy, while the safety of a pharmacotherapy is indicated by the calculated number needed to harm (NNH). The NNT is a measure describing the number of patients who require treatment for every 1 who reaches the therapeutic goal, and the NNH describes the number of participants who manifest side effects; these can further be segregated into numbers who withdraw from studies due to intol- erable side effects. These parameters, along with a patient's comorbidities and concomitant medica- tions, should be considered when selecting an analgesic and dose regimen. In addition, practitioners should avoid prescribing multiple-drug therapies that have overlapping pharmacodynamics or that may have an adverse pharmacokinetic interaction. Perspective: The pharmacotherapeutic armamentarium for treating pain has continued to grow. Both opioids and adjuvants are important options for treating persistent pain in older adults, a pop- ulation prone to individualistic differences requiring greater treatment tailoring and optimization. a 2011 by the American Pain Society

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Physician Attitudes and Practice in Cancer Pain Management: A Survey From the Eastern Cooperative Oncology Group

1993-07-15

Jamie H. Von Roenn

Objective: The Eastern Cooperative Oncology Group (ECOG) conducted a groupwide survey to determine the amount of knowledge about cancer pain and its treatment among physicians practicing in ECOG-affiliated institutions and … Objective: The Eastern Cooperative Oncology Group (ECOG) conducted a groupwide survey to determine the amount of knowledge about cancer pain and its treatment among physicians practicing in ECOG-affiliated institutions and to determine the methods of pain control being used by these physicians. Design: Survey. Setting: A questionnaire was sent to all ECOG physicians with patient care responsibilities (medical oncologists, hematologists, surgeons, and radiation therapists), practicing in university institutions, Community Clinical Oncology Program (CCOP) institutions, and Cooperative Group Outreach Programs (CGOP) institutions. Measurements: A physician cancer pain questionnaire developed by the Pain Research Group at the University of Wisconsin was used. The questionnaire was designed to assess physicians' estimates of the magnitude of pain as a specific problem for cancer patients, their perceptions of the adequacy of cancer pain management, and their report of how they manage pain in their own practice setting. Results: The study analyzed responses to 897 of 1800 surveys. In regard to the use of analgesics for cancer pain in the United States, 86% felt that the majority of patients with pain were undermedicated. Only 51% believed pain control in their own practice setting was good or very good; 31% would wait until the patient's prognosis was 6 months or less before they would start maximal analgesia. Adjuvants and prophylactic side-effect management should have been used more frequently in the treatment plan. Concerns about side-effect management and tolerance were reported as limiting analgesic prescribing. Poor pain assessment was rated by 76% of physicians as the single most important barrier to adequate pain management. Other barriers included patient reluctance to report pain and patient reluctance to take analgesics (both by 62%) as well as physician reluctance to prescribe opioids (61%). Conclusions: Professional education needs to focus on the proper assessment of pain, focus on the management of side effects, and focus on the use of adjuvant medications. A better understanding of the pharmacology of opioid analgesics is also needed. Physicians also need to educate patients to report pain and to effectively use the medications that are prescribed for pain management.

Palliative Care

2002-08-01

Cecilia Sepúlveda , Amanda Marlin , Tokuo Yoshida +1 more

Long-term opioid management for chronic noncancer pain

2010-01-18

Meredith Noble , Jonathan Treadwell , Stephen Tregear +5 more

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Breakthrough pain: definition, prevalence and characteristics

1990-06-01

Russell K. Portenoy , Neil A. Hagen

In the cancer population, the term breakthrough pain typically refers to a transitory flare of pain in the setting of chronic pain managed with opioid drugs. The prevalence and characteristics … In the cancer population, the term breakthrough pain typically refers to a transitory flare of pain in the setting of chronic pain managed with opioid drugs. The prevalence and characteristics of this phenomenon have not been defined, and its impact on patient care is unknown. We developed operational definitions for breakthrough pain and its major characteristics, and applied these in a prospective survey of patients with cancer pain. Data were collected during a 3 month period from consecutive patients who reported moderate pain or less for more than 12 h daily and stable opioid dosing for a minimum of 2 consecutive days. Of 63 patients surveyed, 41 (64%) reported breakthrough pain, transient flares of severe or excruciating pain. Fifty-one different pains were described (median 4 pains/day; range 1–3600). Pain characteristics were extremely varied. Twenty-two (43%) pains were paroxysmal in onset; the remainder were more gradual. The duration varied from seconds to hours (median/range: 30 min/1–240 min), and 21 (41%) were both paroxysmal and brief (lancinating pain). Fifteen (29%) of the pains were related to the fixed opioid dose, occurring solely at the end of the dosing interval. Twenty-eight (55%) of the pains were precipitated; of these, 22 were caused by an action of the patient (incident pain), and 6 were associated with a non-volitional precipitant, such as flatulence. The pathophysiology of the pain was believed to be somatic in 17 (33%), visceral in 10 (20%), neuropathic in 14 (27%), and mixed in 10 (20%). Pain was related to the tumor in 42 (82%), the effects of therapy in 7 (14%), and neither in 2 (4%). Diverse interventions were employed to manage these pains, with variable efficacy. These data clarify the spectrum of breakthrough pains and indicate their importance in cancer pain management.

Intrathecal and Epidural Administration of Opioids

1984-09-01

Lawrence J. Saldman , Michael J. Cousins , Laurence E. Mather

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Racial and Ethnic Disparities in Pain: Causes and Consequences of Unequal Care

2009-11-28

Karen O. Anderson , Carmen R. Green , Richard Payne

When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function

1995-05-01

Ronald C. Serlin , Tito R. Mendoza , Yoshio Nakamura +2 more

As a way of delineating different levels of cancer pain severity, we explored the relationship between numerical ratings of pain severity and ratings of pain's interference with such functions as … As a way of delineating different levels of cancer pain severity, we explored the relationship between numerical ratings of pain severity and ratings of pain's interference with such functions as activity, mood, and sleep. Interference measures were used as critical variable to grade pain severity. We explored the possibility that pain severity could be classified into groupings roughly comparable to mild, moderate, and severe. Our hypothesis was that mild, moderate, and severe pain would differentially impair cancer patients' function. We were able to identify boundaries among these categories of pain severity in terms of their interference with function. We also examined the extent to which cancer patients from different language and cultural groups differ in their self-reported interference as a function of pain severity level. We found optimal cutpoints that form 3 distinct levels of pain severity that can be defined on a 0-10-point numerical scale. We determined that, based on the degree of interference with cancer patients' function, ratings of 1-4 correspond to mild pain, 5-6 to moderate pain, and 7-10 to severe pain. Our analysis illustrates that the pain severity-interference relationship is non-linear. These cutpoints were the same for each of the national samples in our analysis, although there were slight differences in the specific interference items affected by pain. These cutpoints might be useful in clinical evaluation, epidemiology, and clinical trials.

Validity of the Brief Pain Inventory for Use in Documenting the Outcomes of Patients With Noncancer Pain

2004-01-01

San Keller , Carla Bann , Sheri Dodd +3 more

Objectives: The Brief Pain Inventory (BPI) is a short, self-administered questionnaire that was developed for use in cancer patients. While most empirical research with the BPI has been in pain … Objectives: The Brief Pain Inventory (BPI) is a short, self-administered questionnaire that was developed for use in cancer patients. While most empirical research with the BPI has been in pain of that etiology, the questionnaire is increasingly evident in published studies of patients with non-cancer pain. The current research addresses the need for formal evaluation of the reliability and validity of the BPI for use in non-cancer pain patients. Methods: Approximately 250 patients with arthritis or low back pain (LBP) self-administered a number of generic and condition-specific health status measures (including the BPI) in the clinic of their primary care provider at 2 time points: the initial clinic visit and the first visit following treatment. Results: The reliability of BPI data collected from non-cancer pain patients was comparable to that reported in the literature for cancer patients and sufficient for group-level analyses (coefficient alphas were greater than 0.70). The factor structure of the BPI was replicated in this sample and the relationship of the BPI to generic measures of pain was strong. The BPI exhibited similar relationships to general and condition-specific measures of health as did a generic pain scale (SF-36 Bodily Pain). Finally, the BPI discriminated among levels of condition severity and was sensitive to change in condition over time in arthritis and LBP patients. Discussion: Results support the validity of the BPI as a measure of pain in patients without cancer and, in particular, as a measure of pain for arthritis and LBP patients.

Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain

2003-09-01

Mark P. Jensen , Connie Chen , Andrew Brugger

Clinical Pharmacology of Tramadol

2004-01-01

Stefan Grond , Armin Sablotzki

A validation study of the WHO method for cancer pain relief

1987-02-15

Vittorio Ventafridda , Marcello Tamburini , Augusto Caraceni +2 more

The method for cancer pain relief proposed by the World Health Organization (WHO) consists of guidelines for a three-step treatment, from non-opioids to weak and then strong opioids, according to … The method for cancer pain relief proposed by the World Health Organization (WHO) consists of guidelines for a three-step treatment, from non-opioids to weak and then strong opioids, according to need. Adjuvant drugs can be added to each step. This report presents the 2-year experience of the WHO Collaborating Centre at the National Cancer Institute of Milan in the use of this method. This retrospective study shows that a correct use of the analgesic ladder can reduce pain to a third of its initial intensity. The use of non-opioids had an average duration of 19.2 days; in 52% of the cases treatment was discontinued due to inefficacy and in 42%, to side effects. Weak opioids were administered on an average for 28.0 days. A shift to Strong opioids was made in 92% of the cases due to inefficacy and in 8% because of side effects. Treatment with strong opioids lasted for an average of 46.6 days and can be considered the mainstay of cancer pain therapy. Performance status was not altered considerably during the study and hours of sleep were doubled. The analgesic ladder proved efficacious in 71% of the cases. Neurolytic procedures had to be used in 29%. The authors conclude that analgesics, as proposed by WHO, are the most suitable treatment arm in controlling pain in palliative treatment for advanced cancer patients. Lack of availability or underuse of opioids constitute the real obstacle to the application of this method.

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Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases

1986-05-01

Russell K. Portenoy , Kathleen M. Foley

Thirty-eight patients maintained on opioid analgesics for non-malignant pain were retrospectively evaluated to determine the indications, course, safety and efficacy of this therapy. Oxycodone was used by 12 patients, methadone … Thirty-eight patients maintained on opioid analgesics for non-malignant pain were retrospectively evaluated to determine the indications, course, safety and efficacy of this therapy. Oxycodone was used by 12 patients, methadone by 7, and levorphanol by 5; others were treated with propoxyphene, meperidine, codeine, pentazocine, or some combination of these drugs. Nineteen patients were treated for four or more years at the time of evaluation, while 6 were maintained for more than 7 years. Two-thirds required less than 20 morphine equivalent mg/day and only 4 took more than 40 mg/day. Patients occasionally required escalation of dose and/or hospitalization for exacerbation of pain; doses usually returned to a stable baseline afterward. Twenty-four patients described partial but acceptable or fully adequate relief of pain, while 14 reported inadequate relief. No patient underwent a surgical procedure for pain management while receiving therapy. Few substantial gains in employment or social function could be attributed to the institution of opioid therapy. No toxicity was reported and management became a problem in only 2 patients, both with a history of prior drug abuse. A critical review of patient characteristics, including data from the 16 Personality Factor Questionnaire in 24 patients, the Minnesota Multiphasic Personality Inventory in 23, and detailed psychiatric evaluation in 6, failed to disclose psychological or social variables capable of explaining the success of long-term management. We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.

The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain

2003-09-01

Carmen R. Green , Karen O. Anderson , Tamara A. Baker +7 more

Pain has significant socioeconomic, health, and quality-of-life implications. Racial- and ethnic-based differences in the pain care experience have been described. Racial and ethnic minorities tend to be undertreated for pain … Pain has significant socioeconomic, health, and quality-of-life implications. Racial- and ethnic-based differences in the pain care experience have been described. Racial and ethnic minorities tend to be undertreated for pain when compared with non-Hispanic Whites.To provide health care providers, researchers, health care policy analysts, government officials, patients, and the general public with pertinent evidence regarding differences in pain perception, assessment, and treatment for racial and ethnic minorities. Evidence is provided for racial- and ethnic-based differences in pain care across different types of pain (i.e., experimental pain, acute postoperative pain, cancer pain, chronic non-malignant pain) and settings (i.e., emergency department). Pertinent literature on patient, health care provider, and health care system factors that contribute to racial and ethnic disparities in pain treatment are provided.A selective literature review was performed by experts in pain. The experts developed abstracts with relevant citations on racial and ethnic disparities within their specific areas of expertise. Scientific evidence was given precedence over anecdotal experience. The abstracts were compiled for this manuscript. The draft manuscript was made available to the experts for comment and review prior to submission for publication.Consistent with the Institute of Medicine's report on health care disparities, racial and ethnic disparities in pain perception, assessment, and treatment were found in all settings (i.e., postoperative, emergency room) and across all types of pain (i.e., acute, cancer, chronic nonmalignant, and experimental). The literature suggests that the sources of pain disparities among racial and ethnic minorities are complex, involving patient (e.g., patient/health care provider communication, attitudes), health care provider (e.g., decision making), and health care system (e.g., access to pain medication) factors. There is a need for improved training for health care providers and educational interventions for patients. A comprehensive pain research agenda is necessary to address pain disparities among racial and ethnic minorities.

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Management of Pain in Elderly Patients With Cancer

1998-06-17

Roberto Bernabei

Context.—Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor.Objective.—To evaluate the adequacy of … Context.—Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor.Objective.—To evaluate the adequacy of pain management in elderly and minority cancer patients admitted to nursing homes.Design.—Retrospective, cross-sectional study.Setting.—A total of 1492 Medicare-certified and/or Medicaid-certified nursing homes in 5 states participating in the Health Care Financing Administration's demonstration project, which evaluated the implementation of the Resident Assessment Instrument and its Minimum Data Set.Study Population.—A group of 13625 cancer patients aged 65 years and older discharged from the hospital to any of the facilities from 1992 to 1995. Data were from the multilinked Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database.Main Outcome Measures.—Prevalence and predictors of daily pain and of analgesic treatment. Pain assessment was based on patients' report and was completed by a multidisciplinary team of nursing home personnel that observed, over a 7-day period, whether each resident complained or showed evidence of pain daily.Results.—A total of 4003 patients (24%, 29%, and 38% of those aged ≥85 years, 75 to 84 years, and 65 to 74 years, respectively) reported daily pain. Age, gender, race, marital status, physical function, depression, and cognitive status were all independently associated with the presence of pain. Of patients with daily pain, 16% received a WHO level 1 drug, 32% a WHO level 2 drug, and only 26% received morphine. Patients aged 85 years and older were less likely to receive either weak opiates or morphine than those aged 65 to 74 years (13% vs 38%, respectively). More than a quarter of patients (26%) in daily pain did not receive any analgesic agent. Patients older than 85 years in daily pain were also more likely to receive no analgesia (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.13-1.73). Other independent predictors of failing to receive any analgesic agent were minority race (OR, 1.63; 95% CI, 1.18-2.26 for African Americans), low cognitive performance (OR, 1.23; 95% CI, 1.05-1.44), and the number of other medications received (OR, 0.65; 95% CI, 0.5-0.84 for 11 or more medications).Conclusions.—Daily pain is prevalent among nursing home residents with cancer and is often untreated, particularly among older and minority patients.

Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases

1983-10-01

Randall L. Daut , Charles S. Cleeland , Randall C. Flanery

This paper reports the development of a self-report instrument designed to assess pain in cancer and other diseases. It is argued that issues of reliability and validity should be considered … This paper reports the development of a self-report instrument designed to assess pain in cancer and other diseases. It is argued that issues of reliability and validity should be considered for every pain questionnaire. Most research on measures of pain examine reliability to the relative neglect of validity concerns. The Wisconsin Brief Pain Questionnaire (BPQ) is evaluated with regard to both reliability and validity. Data from patients with cancer at 4 primary sites and from patients with rheumatoid arthritis suggest that the BPQ is sufficiently reliable and valid for research purposes. Additional methodological and theoretical issues related to validity are discussed, and the need for continuing evaluation of the BPQ and other measures of clinical pain is stressed.

Defining the clinically important difference in pain outcome measures

2000-12-01

John T. Farrar , Russell K. Portenoy , Jesse A. Berlin +2 more

The purpose of this study was to determine the levels of change on standard pain scales that represent clinically important differences to patients. Data from analgesic studies are often difficult … The purpose of this study was to determine the levels of change on standard pain scales that represent clinically important differences to patients. Data from analgesic studies are often difficult to interpret because the clinical importance of the results is not obvious. Differences between groups, as summarized by a change in mean values over time, can be difficult to apply to clinical care. Baseline scores vary widely and group mean differences could reflect large changes in a few patients, small changes in many patients, or any combination of these outcomes. Determination of the proportion of patients who have a clinically important improvement in their pain would provide a more interpretable result with direct clinical implications. However, determining a clinically important outcome requires information about the degree of change over time that is clinically important. Data from the titration phase of a multiple cross-over randomized clinical trial of oral transmucosal fentanyl citrate (OTFC) for the treatment of cancer-related breakthrough pain were re-analyzed to examine the differences in pain scores between treatment episodes that did and did not yield adequate pain relief. The scales evaluated were absolute pain intensity difference (PID, 0–10 scale), percentage pain intensity difference (PID%, 0–100% scale), pain relief (PR, 0 (none), 1 (slight), 2 (moderate), 3 (lots), 4 (complete)), sum of the pain intensity difference (SPID over 60 min), percentage of maximum total pain relief (% Max TOTPAR over 60 min), and global medication performance (0 (poor), 1 (fair), 2 (good), 3 (very good), 4 (excellent)). Adequate relief was defined by the patient's decision not to use another dose of opioid medication as a rescue, in addition to the study medication, to treat each painful episode. One hundred thirty OTFC naive patients contributed data on 1268 episodes of breakthrough pain. The scales that were converted to a percentage change yielded the best accuracy in predicting adequate relief, with balanced sensitivity and specificity. The best cut-off point for both the % Max TOTPAR and the PID% was 33%. The best cut-off points for the absolute scales were absolute pain intensity difference of 2, pain relief of 2 (moderate), and SPID of 2. The global medication performance of 2 (good) had excellent values as well. This study presents data-derived cut-off points for the changes in several pain scales, each reflecting the clinically important improvement for patients treating breakthrough cancer pain episodes with OTFC. Confirmation in other patient populations and different pain syndromes will be needed. The use of consistent clinically important cut-off points as the primary outcome in future pain therapy clinical trials will enhance their validity, comparability, and clinical applicability.

Breakthrough pain: characteristics and impact in patients with cancer pain

1999-05-01

Russell K. Portenoy , David K. Payne , Paul B. Jacobsen

Few surveys have been performed to define the characteristics and impact of breakthrough pain in the cancer population. In this cross-sectional survey of inpatients with cancer, patients responded to a … Few surveys have been performed to define the characteristics and impact of breakthrough pain in the cancer population. In this cross-sectional survey of inpatients with cancer, patients responded to a structured interview (the Breakthrough Pain Questionnaire) designed to characterize breakthrough pain, and also completed measures of pain and mood (Memorial Pain Assessment Card (MPAC)), pain-related interference in function (Brief Pain Inventory (BPI)), depressed mood (Beck Depression Inventory (BDI)), and anxiety (Beck Anxiety Inventory (BAI)). Of 178 eligible patients, 164 (92.2%) met the criteria for controlled background pain. The median age was 50.6 years (range 26 to 77 years), 52% were men, and 80.6% were Caucasian. Tumor diagnoses were mixed, 75% had metastatic disease, 65% had pain caused directly by the neoplasm, and a majority had mixed nociceptive-neuropathic pain. The median Karnofsky Performance Status score was 60 (range 40 to 90). Eighty-four (51.2%) patients had experienced breakthrough pain during the previous day. The median number of episodes was six (range 1 to 60) and the median interval from onset to peak was 3 min (range 1 s to 30 min). Although almost two-thirds (61.7%) could identify precipitants (movement 20.4%; end-of-dose failure 13.2%), pain was unpredictable in a large majority (78.2%). Patients with breakthrough pain had more intense (P<0.001) and more frequent (P<0.01) background pain than patients without breakthrough pain. Breakthrough pain was also associated with greater pain-related functional impairment (difference in mean BPI, P<0.001), worse mood (mood VAS, P<0.05; BDI, P<0.001), and more anxiety (BAI, P<0.001). Multivariate analysis confirmed that breakthrough pain independently contributed to impaired functioning and psychological distress. These data confirm that cancer-related breakthrough pain is a prevalent and heterogeneous phenomenon. The presence of breakthrough pain is a marker of a generally more severe pain syndrome, and is associated with both pain-related functional impairment and psychological distress. The findings suggest the need for further studies of breakthrough pain and more effective therapeutic strategies.

Patient-related barriers to management of cancer pain

1993-03-01

Sandra E. Ward , Nancy Goldberg , Vickie Miller-McCauley +6 more

Patients' reluctance to report pain and to use analgesics are considered major barriers to pain management. To explore this problem, 270 patients with cancer completed a 27-item self-report questionnaire (BQ) … Patients' reluctance to report pain and to use analgesics are considered major barriers to pain management. To explore this problem, 270 patients with cancer completed a 27-item self-report questionnaire (BQ) that assessed the extent to which they have concerns about reporting pain and using pain medication. The 8 specific concerns included fear of addiction, beliefs that 'good' patients do not complain about pain, and concern about side effects. Patients also completed a measure of pain severity and pain interference (the BPI). The percentages of patients having concerns assessed by the BQ ranged from 37% to 85%. Those who were older, less educated, or had lower incomes were more likely to have concerns. Higher levels of concern were correlated with higher levels of pain. Based on their reports of pain medications used in the past week and on their reports of pain severity, patients were categorized as under-medicated versus adequately medicated. Those who were under-medicated reported significantly higher levels of concern. The data are discussed in terms of implications for research and practice.

Validation of the brief pain inventory for chronic nonmalignant pain

2004-03-01

Gabriel Tan , Mark P. Jensen , John I. Thornby +1 more

Short-term Quality-of-Life Outcomes Following Laparoscopic-Assisted Colectomy vs Open Colectomy for Colon Cancer<SUBTITLE>A Randomized Trial</SUBTITLE>

2002-01-16

Jane C. Weeks , Heidi Nelson , Shari Gelber +2 more

Laparoscopic-assisted colectomy (LAC) has emerged as the preferred minimally invasive surgical strategy for diseases of the colon. The safety and efficacy of LAC for colon cancer are unknown, and the … Laparoscopic-assisted colectomy (LAC) has emerged as the preferred minimally invasive surgical strategy for diseases of the colon. The safety and efficacy of LAC for colon cancer are unknown, and the nature and magnitude of any quality-of-life (QOL) benefit resulting from LAC for colon cancer is also unknown.To compare short-term QOL outcomes after LAC vs open colectomy for colon cancer.Multicenter, randomized controlled trial (Clinical Outcomes of Surgical Therapy [COST]). Between September 1994 and February 1999, 37 of 48 centers provided data for the QOL component of the trial for 449 consecutive patients with clinically resectable colon cancer.Scores on the Symptoms Distress Scale (SDS), Quality of Life Index, and a single-item global rating scale at 2 days, 2 weeks, and 2 months postoperative; duration of postoperative in-hospital analgesic use; and length of stay.Of 449 patients, 428 provided QOL data. In an intention-to-treat analysis comparing SDS pain intensity, SDS summary, QOL Index summary, and global rating scale scores at each time point, the only statistically significant difference observed between groups was the global rating scale score for 2 weeks postsurgery. The mean (median) global rating scale scores for 2 weeks postsurgery were 76.9 (80) for LAC vs 74.4 (75) for open colectomy (P =.009). While in the hospital, patients assigned to LAC required fewer days of both parenteral analgesics compared with patients assigned to open colectomy (mean [median], 3.2 [3] vs 4.0 [4] days; P<.001) and oral analgesics (mean [median], 1.9 [1] vs 2.2 [2] days; P =.03).Only minimal short-term QOL benefits were found with LAC for colon cancer compared with standard open colectomy. Until ongoing trials establish that LAC is as effective as open colectomy in preventing recurrence and death from colon cancer, this procedure should not be offered to patients with colon cancer.

International Association for the Study of Pain

2002-08-01

Harald Breivik

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Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization step III Opioids (Buprenorphine, Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone)

2008-05-23

Joseph V. Pergolizzi , Rainer H. Böger , Keith Budd +7 more

SUMMARY OF CONSENSUS: 1. The use of opioids in cancer pain: The criteria for selecting analgesics for pain treatment in the elderly include, but are not limited to, overall efficacy, … SUMMARY OF CONSENSUS: 1. The use of opioids in cancer pain: The criteria for selecting analgesics for pain treatment in the elderly include, but are not limited to, overall efficacy, overall side-effect profile, onset of action, drug interactions, abuse potential, and practical issues, such as cost and availability of the drug, as well as the severity and type of pain (nociceptive, acute/chronic, etc.). At any given time, the order of choice in the decision-making process can change. This consensus is based on evidence-based literature (extended data are not included and chronic, extended-release opioids are not covered). There are various driving factors relating to prescribing medication, including availability of the compound and cost, which may, at times, be the main driving factor. The transdermal formulation of buprenorphine is available in most European countries, particularly those with high opioid usage, with the exception of France; however, the availability of the sublingual formulation of buprenorphine in Europe is limited, as it is marketed in only a few countries, including Germany and Belgium. The opioid patch is experimental at present in U.S.A. and the sublingual formulation has dispensing restrictions, therefore, its use is limited. It is evident that the population pyramid is upturned. Globally, there is going to be an older population that needs to be cared for in the future. This older population has expectations in life, in that a retiree is no longer an individual who decreases their lifestyle activities. The "baby-boomers" in their 60s and 70s are "baby zoomers"; they want to have a functional active lifestyle. They are willing to make trade-offs regarding treatment choices and understand that they may experience pain, providing that can have increased quality of life and functionality. Therefore, comorbidities--including cancer and noncancer pain, osteoarthritis, rheumatoid arthritis, and postherpetic neuralgia--and patient functional status need to be taken carefully into account when addressing pain in the elderly. World Health Organization step III opioids are the mainstay of pain treatment for cancer patients and morphine has been the most commonly used for decades. In general, high level evidence data (Ib or IIb) exist, although many studies have included only few patients. Based on these studies, all opioids are considered effective in cancer pain management (although parts of cancer pain are not or only partially opioid sensitive), but no well-designed specific studies in the elderly cancer patient are available. Of the 2 opioids that are available in transdermal formulation--fentanyl and buprenorphine--fentanyl is the most investigated, but based on the published data both seem to be effective, with low toxicity and good tolerability profiles, especially at low doses. 2. The use of opioids in noncancer-related pain: Evidence is growing that opioids are efficacious in noncancer pain (treatment data mostly level Ib or IIb), but need individual dose titration and consideration of the respective tolerability profiles. Again no specific studies in the elderly have been performed, but it can be concluded that opioids have shown efficacy in noncancer pain, which is often due to diseases typical for an elderly population. When it is not clear which drugs and which regimes are superior in terms of maintaining analgesic efficacy, the appropriate drug should be chosen based on safety and tolerability considerations. Evidence-based medicine, which has been incorporated into best clinical practice guidelines, should serve as a foundation for the decision-making processes in patient care; however, in practice, the art of medicine is realized when we individualize care to the patient. This strikes a balance between the evidence-based medicine and anecdotal experience. Factual recommendations and expert opinion both have a value when applying guidelines in clinical practice. 3. The use of opioids in neuropathic pain: The role of opioids in neuropathic pain has been under debate in the past but is nowadays more and more accepted; however, higher opioid doses are often needed for neuropathic pain than for nociceptive pain. Most of the treatment data are level II or III, and suggest that incorporation of opioids earlier on might be beneficial. Buprenorphine shows a distinct benefit in improving neuropathic pain symptoms, which is considered a result of its specific pharmacological profile. 4. The use of opioids in elderly patients with impaired hepatic and renal function: Functional impairment of excretory organs is common in the elderly, especially with respect to renal function. For all opioids except buprenorphine, half-life of the active drug and metabolites is increased in the elderly and in patients with renal dysfunction. It is, therefore, recommended that--except for buprenorphine--doses be reduced, a longer time interval be used between doses, and creatinine clearance be monitored. Thus, buprenorphine appears to be the top-line choice for opioid treatment in the elderly. 5. Opioids and respiratory depression: Respiratory depression is a significant threat for opioid-treated patients with underlying pulmonary condition or receiving concomitant central nervous system (CNS) drugs associated with hypoventilation. Not all opioids show equal effects on respiratory depression: buprenorphine is the only opioid demonstrating a ceiling for respiratory depression when used without other CNS depressants. The different features of opioids regarding respiratory effects should be considered when treating patients at risk for respiratory problems, therefore careful dosing must be maintained. 6. Opioids and immunosuppression: Age is related to a gradual decline in the immune system: immunosenescence, which is associated with increased morbidity and mortality from infectious diseases, autoimmune diseases, and cancer, and decreased efficacy of immunotherapy, such as vaccination. The clinical relevance of the immunosuppressant effects of opioids in the elderly is not fully understood, and pain itself may also cause immunosuppression. Providing adequate analgesia can be achieved without significant adverse events, opioids with minimal immunosuppressive characteristics should be used in the elderly. The immunosuppressive effects of most opioids are poorly described and this is one of the problems in assessing true effect of the opioid spectrum, but there is some indication that higher doses of opioids correlate with increased immunosuppressant effects. Taking into consideration all the very limited available evidence from preclinical and clinical work, buprenorphine can be recommended, while morphine and fentanyl cannot. 7. Safety and tolerability profile of opioids: The adverse event profile varies greatly between opioids. As the consequences of adverse events in the elderly can be serious, agents should be used that have a good tolerability profile (especially regarding CNS and gastrointestinal effects) and that are as safe as possible in overdose especially regarding effects on respiration. Slow dose titration helps to reduce the incidence of typical initial adverse events such as nausea and vomiting. Sustained release preparations, including transdermal formulations, increase patient compliance.

Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study

1995-10-01

D. Zech , Stefan Grond , John Lynch +2 more

This paper reports on the experience gained using World Health Organization Guidelines for cancer pain relief over a 10-year period in an anaesthesiology-based pain service associated with a palliative care … This paper reports on the experience gained using World Health Organization Guidelines for cancer pain relief over a 10-year period in an anaesthesiology-based pain service associated with a palliative care programme. The course of treatment of 2118 patients was assessed prospectively over a period of 140,478 treatment days. Non-opioid analgesics (WHO step I) were used on 11%, weak opioids (WHO step II) on 31% and strong opioids (WHO step III) on 49% of treatment days. Administration was via the enteral route on 82% and parenterally on 9% of treatment days. On the remaining days, either spinally applied opioids (2%) or other treatments (6%) were utilised. Fifty-six percent of the patients were treated with morphine. Morphine dose escalation was observed in about one-half of the patients being cared for until death, whereas the other half had stable or decreasing doses over the course of treatment. Co-analgesics were administered on 37% of days, most often antidepressants (15%), anticonvulsants (13%) and corticosteroids (13%). Adjuvants to treat symptoms other than pain were prescribed on 79% of days, most commonly laxatives (42%), histamine-2-receptor antagonists (39%) and antiemetics (35%). In addition, palliative antineoplastic treatment was performed in 42%, nerve blocks in 8%, physiotherapy in 5%, psychotherapy in 3% and TENS in 3% of patients. A highly significant pain reduction was achieved within the 1st week of treatment (P < 0.001). Over the whole treatment period, good pain relief was reported in 76%, satisfactory efficacy in 12% and inadequate efficacy in 12% of patients. In the final days of life, 84% rated their pain as moderate or less, while 10% were unable to give a rating. Analgesics remained constantly effective in all 3 steps of the WHO ladder. Other clinical symptoms were likewise significantly reduced at 1 week after initial assessment, with the exception of neuropsychiatric symptoms. During the course of treatment, the latter were the major symptoms on 23% of days, followed by nausea (23%), constipation (23%) and anorexia (20%). Our results emphasise once again the marked efficacy and low rate of complications associated with oral and parenteral analgesic therapy as the mainstay of pain treatment in the palliative care of patients with advanced cancer. Wide dissemination of WHO guidelines among doctors and healthcare workers is thus necessary to effect a clear improvement in the treatment of the many patients suffering from cancer pain in the clinical and home setting.

Morphine and alternative opioids in cancer pain: the EAPC recommendations

2001-01-01

G.W. Hanks , Franco De Conno , Nathan I. Cherny +7 more

An expert working group of the European Association for Palliative Care has revised and updated its guidelines on the use of morphine in the management of cancer pain. The revised … An expert working group of the European Association for Palliative Care has revised and updated its guidelines on the use of morphine in the management of cancer pain. The revised recommendations presented here give guidance on the use of morphine and the alternative strong opioid analgesics which have been introduced in many parts of the world in recent years. Practical strategies for dealing with difficult situations are described presenting a consensus view where supporting evidence is lacking. The strength of the evidence on which each recommendation is based is indicated.

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

2012-01-31

Augusto Caraceni , G.W. Hanks , Stein Kaasa +7 more

Assessing symptom distress in cancer patients

2000-10-01

Charles S. Cleeland , Tito R. Mendoza , Xin Shelley Wang +4 more

BACKGROUND The purpose of this project was to develop the M. D. Anderson Symptom Inventory (MDASI), a brief measure of the severity and impact of cancer-related symptoms. METHODS A list … BACKGROUND The purpose of this project was to develop the M. D. Anderson Symptom Inventory (MDASI), a brief measure of the severity and impact of cancer-related symptoms. METHODS A list of symptoms was generated from symptom inventories and by panels of clinicians. Twenty-six symptoms and 6 interference items were rated by a validation sample of 527 outpatients, a sample of 30 inpatients from the blood and bone marrow transplantation service, and a cross-validation sample of 113 outpatients. Clinical judgment and statistical techniques were used to reduce the number of symptoms. Reliability, validity, and sensitivity of the MDASI were examined. RESULTS Cluster analysis, best subset analysis, and clinical judgment reduced the number of symptoms to a "core" list of 13 that accounted for 64% of the variance in symptom distress. Factor analysis demonstrated a similar pattern in both outpatient samples, and two symptom factors and the interference scale were reliable. Expected differences in symptom pattern and severity were found between patients with "good" versus "poor" performance status and between patients in active therapy and patients who were seen for follow-up. Patients rated fatigue-related symptoms as the most severe. Groups of patients classified by disease or treatment had severe symptoms that were not on the "core" list. CONCLUSIONS The core items of the MDASI accounted for the majority of symptom distress reported by cancer patients in active treatment and those who were followed after treatment. The MDASI should prove useful for symptom surveys, clinical trials, and patient monitoring, and its format should allow Internet or telephone administration. Cancer 2000;89:1634–46. © 2000 American Cancer Society.

The Management of Persistent Pain in Older Persons

2002-06-01

Betty Ferrell , David Casarett , J. Epplin +7 more

Management of cancer pain

1999-05-01

Russell K. Portenoy , Pauline Lesage

Assessment of pain

2008-05-17

Harald Breivik , Petter C. Borchgrevink , Sara Maria Allen +5 more

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The short-form McGill pain questionnaire

1987-08-01

Ronald Melzack

A short form of the McGill Pain Questionnaire (SF-MPQ) has been developed. The main component of the SF-MPQ consists of 15 descriptors (11 sensory; 4 affective) which are rated on … A short form of the McGill Pain Questionnaire (SF-MPQ) has been developed. The main component of the SF-MPQ consists of 15 descriptors (11 sensory; 4 affective) which are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate or 3 = severe. Three pain scores are derived from the sum of the intensity rank values of the words chosen for sensory, affective and total descriptors. The SF-MPQ also includes the Present Pain Intensity (PPI) index of the standard MPQ and a visual analogue scale (VAS). The SF-MPQ scores obtained from patients in post-surgical and obstetrical wards and physiotherapy and dental departments were compared to the scores obtained with the standard MPQ. The correlations were consistently high and significant. The SF-MPQ was also shown to be sufficiently sensitive to demonstrate differences due to treatment at statistical levels comparable to those obtained with the standard form. The SF-MPQ shows promise as a useful tool in situations in which the standard MPQ takes too long to administer, yet qualitative information is desired and the PPI and VAS are inadequate.

Opioids in chronic non-cancer pain: systematic review of efficacy and safety

2004-10-21

Eija Kalso , Jayne Edwards , Andrew Moore +1 more

Opioids are used increasingly for chronic non-cancer pain. Controversy exists about their effectiveness and safety with long-term use. We analysed available randomised, placebo-controlled trials of WHO step 3 opioids for … Opioids are used increasingly for chronic non-cancer pain. Controversy exists about their effectiveness and safety with long-term use. We analysed available randomised, placebo-controlled trials of WHO step 3 opioids for efficacy and safety in chronic non-cancer pain. The Oxford Pain Relief Database (1950-1994) and Medline, EMBASE and the Cochrane Library were searched until September 2003. Inclusion criteria were randomised comparisons of WHO step 3 opioids with placebo in chronic non-cancer pain. Double-blind studies reporting on pain intensity outcomes using validated pain scales were included. Fifteen randomised placebo-controlled trials were included. Four investigations with 120 patients studied intravenous opioid testing. Eleven studies (1025 patients) compared oral opioids with placebo for four days to eight weeks. Six of the 15 included trials had an open label follow-up of 6-24 months. The mean decrease in pain intensity in most studies was at least 30% with opioids and was comparable in neuropathic and musculoskeletal pain. About 80% of patients experienced at least one adverse event, with constipation (41%), nausea (32%) and somnolence (29%) being most common. Only 44% of 388 patients on open label treatments were still on opioids after therapy for between 7 and 24 months. The short-term efficacy of opioids was good in both neuropathic and musculoskeletal pain conditions. However, only a minority of patients in these studies went on to long-term management with opioids. The small number of selected patients and the short follow-ups do not allow conclusions concerning problems such as tolerance and addiction.

Prevalence of pain in patients with cancer: a systematic review of the past 40 years

2007-03-14

M.H.J. van den Beuken-van Everdingen , J.M. de Rijke , A. G. H. Kessels +3 more

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Randomized Clinical Trial of an Implantable Drug Delivery System Compared With Comprehensive Medical Management for Refractory Cancer Pain: Impact on Pain, Drug-Related Toxicity, and Survival

2002-09-26

Thomas J. Smith , Peter S. Staats , Timothy R. Deer +7 more

Implantable intrathecal drug delivery systems (IDDSs) have been used to manage refractory cancer pain, but there are no randomized clinical trial (RCT) data comparing them with comprehensive medical management (CMM).We … Implantable intrathecal drug delivery systems (IDDSs) have been used to manage refractory cancer pain, but there are no randomized clinical trial (RCT) data comparing them with comprehensive medical management (CMM).We enrolled 202 patients on an RCT of CMM versus IDDS plus CMM. Entry criteria included unrelieved pain (visual analog scale [VAS] pain scores >/= 5 on a 0 to 10 scale). Clinical success was defined as >/= 20% reduction in VAS scores, or equal scores with >/= 20% reduction in toxicity. The main outcome measure was pain control combined with change of toxicity, as measured by the National Cancer Institute Common Toxicity Criteria, 4 weeks after randomization.Sixty of 71 IDDS patients (84.5%) achieved clinical success compared with 51 of 72 CMM patients (70.8%, P =.05). IDDS patients more often achieved >/= 20% reduction in both pain VAS and toxicity (57.7% [41 of 71] v 37.5% [27 of 72], P =.02). The mean CMM VAS score fell from 7.81 to 4.76 (39% reduction); for the IDDS group, the scores fell from 7.57 to 3.67 (52% reduction, P =.055). The mean CMM toxicity scores fell from 6.36 to 5.27 (17% reduction); for the IDDS group, the toxicity scores fell from 7.22 to 3.59 (50% reduction, P =.004). The IDDS group had significant reductions in fatigue and depressed level of consciousness (P <.05). IDDS patients had improved survival, with 53.9% alive at 6 months compared with 37.2% of the CMM group (P =.06).IDDSs improved clinical success in pain control, reduced pain, significantly relieved common drug toxicities, and improved survival in patients with refractory cancer pain.

Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain

1995-12-20

Mitchell B. Max

To develop quality improvement (QI) guidelines and programs to improve treatment outcomes for patients with acute pain and cancer pain.Twenty-four members of the American Pain Society (APS) participated in preparing … To develop quality improvement (QI) guidelines and programs to improve treatment outcomes for patients with acute pain and cancer pain.Twenty-four members of the American Pain Society (APS) participated in preparing the statement, including 15 nurses (oncology, general medical-surgical nursing, pediatrics, and QI research), seven physicians (clinical pharmacology, neurology, anesthesiology, radiation oncology, and physiatry), one psychologist, and one statistician. Participants were self-selected from the 3000 members of the APS, which supported the process and held annual open committee meetings and scientific symposia beginning in 1988.MEDLINE was searched (1980 to 1995) to identify all articles on pain assessment, treatment of acute pain or cancer pain, and QI or education related to pain.Following panel discussions, one member (M.B.M.) prepared successive drafts and circulated them to the panel and APS membership for comments. After publication of a prototype version in 1991, 14 panelists carried out formal studies of implementation of the guidelines at three medical centers. This article was prepared based on this research, a new literature review, and suggestions from 50 pain clinicians and researchers.Quality improvement programs to improve treatment of acute pain and cancer pain should include five key elements: (1) Assuring that a report of unrelieved pain raises a "red flag" that attracts clinicians' attention; (2) making information about analgesics convenient where orders are written; (3) promising patients responsive analgesic care and urging them to communicate pain; (4) implementing policies and safeguards for the use of modern analgesic technologies; and (5) coordinating and assessing implementation of these measures. Several short-term studies suggest that this QI approach may improve patient satisfaction and facilitate recognition of institutional obstacles to optimal pain treatment, but it is not a panacea for undertreated pain. By making the magnitude of the problem apparent and committing the institution to change, pain treatment QI programs can provide a foundation for a multifaceted approach that includes education of clinicians and patients, design of informational tools to minimize errors in prescribing, and improved coordination of the process of assessing and treating pain.

American Pain Society Recommendations for Improving the Quality of Acute and Cancer Pain Management

2005-07-25

Debra B. Gordon , June L. Dahl , Christine Miaskowski +7 more

The American Pain Society (APS) set out to revise and expand its 1995 Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain and to facilitate improvements in … The American Pain Society (APS) set out to revise and expand its 1995 Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain and to facilitate improvements in the quality of pain management in all care settings.Eleven multidisciplinary members of the APS with expertise in quality improvement or measurement participated in the update. Five experts from organizations that focus on health care quality reviewed the final recommendations. MEDLINE and Cumulative Index to Nursing and Allied Health Literature databases were searched (1994-2004) to identify articles on pain quality measurement and quality improvement published after the development of the 1995 guidelines. The APS task force revised and expanded recommendations on the basis of the systematic review of published studies. The more than 3000 members of the APS were invited to provide input, and the 5 experts provided additional comments. The task force synthesized reviewers' comments into the final set of recommendations.The recommendations specify that all care settings formulate structured, multilevel systems approaches (sensitive to the type of pain, population served, and setting of care) that ensure prompt recognition and treatment of pain, involvement of patients and families in the pain management plan, improved treatment patterns, regular reassessment and adjustment of the pain management plan as needed, and measurement of processes and outcomes of pain management.Efforts to improve the quality of pain management must move beyond assessment and communication of pain to implementation and evaluation of improvements in pain treatment that are timely, safe, evidence based, and multimodal.

Prevalence of undertreatment in cancer pain. A review of published literature

2008-07-17

Silvia Deandrea , Mauro Montanari , Lorenzo Moja +1 more

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Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes

2009-02-25

Harald Breivik , Nathan I. Cherny , Brent R. Collett +5 more

Pain Management: A Fundamental Human Right

2007-06-14

Frank Brennan , Daniel B. Carr , Michael J. Cousins

This article surveys worldwide medical, ethical, and legal trends and initiatives related to the concept of pain management as a human right. This concept recently gained momentum with the 2004 … This article surveys worldwide medical, ethical, and legal trends and initiatives related to the concept of pain management as a human right. This concept recently gained momentum with the 2004 European Federation of International Association for the Study of Pain (IASP) Chapters-, International Association for the Study of Pain- and World Health Organization-sponsored "Global Day Against Pain," where it was adopted as a central theme. We survey the scope of the problem of unrelieved pain in three areas, acute pain, chronic noncancer pain, and cancer pain, and outline the adverse physical and psychological effects and social and economic costs of untreated pain. Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. The biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Strategies currently applied for improvement include framing pain management as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies. The role of the World Health Organization is discussed, particularly with respect to opioid availability for pain management. We conclude that, because pain management is the subject of many initiatives within the disciplines of medicine, ethics and law, we are at an "inflection point" in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.

Pain assessment: global use of the Brief Pain Inventory.

1994-03-01

Cleeland Cs , Ryan Km

Poorly controlled cancer pain is a significant public health problem throughout the world. There are many barriers that lead to undertreatment of cancer pain. One important barrier is inadequate measurement … Poorly controlled cancer pain is a significant public health problem throughout the world. There are many barriers that lead to undertreatment of cancer pain. One important barrier is inadequate measurement and assessment of pain. To address this problem, the Pain Research Group of the WHO Collaborating Centre for Symptom Evaluation in Cancer Care has developed the Brief Pain Inventory (BPI), a pain assessment tool for use with cancer patients. The BPI measures both the intensity of pain (sensory dimension) and interference of pain in the patient's life (reactive dimension). It also queries the patient about pain relief, pain quality, and patient perception of the cause of pain. This paper describes the development of the Brief Pain Inventory and the various applications to which the BPI is suited. The BPI is a powerful tool and, having demonstrated both reliability and validity across cultures and languages, is being adopted in many countries for clinical pain assessment, epidemiological studies, and in studies of the effectiveness of pain treatment.

Pain and Its Treatment in Outpatients with Metastatic Cancer

1994-03-03

Charles S. Cleeland , René Gonin , Alan K. Hatfield +4 more

Pain is often inadequately treated in patients with cancer. A total of 1308 outpatients with metastatic cancer from 54 treatment locations affiliated with the Eastern Cooperative Oncology Group rated the … Pain is often inadequately treated in patients with cancer. A total of 1308 outpatients with metastatic cancer from 54 treatment locations affiliated with the Eastern Cooperative Oncology Group rated the severity of their pain during the preceding week, as well as the degree of pain-related functional impairment and the degree of relief provided by analgesic drugs. Their physicians attributed the pain to various factors, described its treatment, and estimated the impact of pain on the patients' ability to function. We assessed the adequacy of prescribed analgesic drugs using guidelines developed by the World Health Organization, studied the factors that influenced whether analgesia was adequate, and determined the effects of inadequate analgesia on the patients' perception of pain relief and functional status.

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Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

2016-05-01

M.H.J. van den Beuken-van Everdingen , Laura Hochstenbach , Elbert A.J. Joosten +2 more

Opioid Therapy for Chronic Pain

2003-11-12

Jane C. Ballantyne , Jianren Mao

A difficult decision for physicians who treat patients with chronic pain not associated with terminal disease is whether and how to prescribe opioid therapy, which can relieve pain and improve … A difficult decision for physicians who treat patients with chronic pain not associated with terminal disease is whether and how to prescribe opioid therapy, which can relieve pain and improve mood and level of functioning in many such patients. This review considers current guidelines for opioid therapy in patients with chronic pain unrelated to malignant conditions and outlines caveats, areas of uncertainty, and management strategies.

Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines

2018-04-20

Marie Fallon , Raffaele Giusti , Federica Aielli +4 more

Pain is common in cancer patients, particularly in the advanced stage of disease when the prevalence is estimated to be more than 70% [1.Portenoy R.K. Treatment of cancer pain.Lancet. 2011; … Pain is common in cancer patients, particularly in the advanced stage of disease when the prevalence is estimated to be more than 70% [1.Portenoy R.K. Treatment of cancer pain.Lancet. 2011; 377: 2236-2247Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar], contributing to poor physical and emotional well-being. The most comprehensive systematic review indicates pain prevalence ranging from 33% in patients after curative treatment, to 59% in patients on anticancer treatment and to 64% in patients with metastatic, advanced or terminal disease [2.van den Beuken-van Everdingen M.H. de Rijke J.M. Kessels A.G. et al.Prevalence of pain in patients with cancer: a systematic review of the past 40 years.Ann Oncol. 2007; 18: 1437-1449Abstract Full Text Full Text PDF PubMed Scopus (1160) Google Scholar]. Pain has a high prevalence earlier in disease in specific cancer types such as pancreatic (44%) and head and neck cancer (40%) [3.Burton A.W. Fanciullo G.J. Beasley R.D. et al.Chronic pain in cancer survivor: a new frontier.Pain Med. 2007; 8: 189-198Crossref PubMed Scopus (159) Google Scholar]. Increased survival with either life-prolonging treatment or curative treatment results in increased numbers of patients experiencing persistent pain due to treatment or disease, or a combination of both [4.Glare P.A. Pamela S. Davies P.S. et al.Pain in cancer survivors.J Clin Oncol. 2014; 32: 1739-1747Crossref PubMed Scopus (149) Google Scholar]. Approximately 5%–10% of cancer survivors have chronic severe pain that interferes significantly with functioning [5.Brown M.D.R. Juan D. Ramirez J.D. Paul Farquhar-Smith P. Pain in cancer survivors.Br J Pain. 2014; 8: 139-153Crossref PubMed Scopus (49) Google Scholar]. Despite guidelines and the availability of opioids (the mainstay of moderate to severe cancer pain management), undertreatment is common. European studies [6.Breivik H. Cherny N. Collett F. et al.Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes.Ann Oncol. 2009; 20: 1420-1433Abstract Full Text Full Text PDF PubMed Scopus (511) Google Scholar] confirmed these data from the United States, showing that different types of pain or pain syndromes were present in all stages of cancer (Table 1) and were not adequately treated in a significant percentage of patients, ranging from 56% to 82.3%.Table 1Non-tumour-related causes of pain in cancer patientsAcute procedural painIatrogenic pain causesComorbidity-related painPain in cancer survivorsAdjuvant setting–Diagnostic intervention–Lumbar puncture ± headache–Transthoracic needle biopsy–Endoscopy ± visceral dilatation–Bone marrow aspiration/biopsy–Blood sampling–Central line position–Arterial line injections–Medication of skin ulcers–Myelography and lumbar puncture–Thoracentesis–Surgery–Chemotherapy–Hormonal therapy–Targeted therapy–Osteonecrosis of the jaw–RT–Steroids (pain due to skin lesions, peripheral neuropathy, mucositis, aseptic femoral head necrosis, infections)–Cardiovascular–Pulmonary–Diabetic neuropathy–Vasomotor headache–Fibromyalgia–May be worsened by anticancer treatments and/or cancer-related pain–Postherpetic neuralgia–Acute thrombosis pain–Follow-up procedures–Persisting postsurgical pain–Persisting anticancer drug-related pain–Persisting RT-related pain–Postherpetic neuralgiaNeo-adjuvant setting– As adjuvant setting plus diagnostic and prognostic tissue biopsy– As adjuvant setting without surgery-related pain– As adjuvant setting– As adjuvant settingLocally advanced setting– As adjuvant setting plus pleurodesis, tumour embolisation, suprapubic catheterisation and nephrostomy insertion– As adjuvant setting plus cryosurgery, thermal ablation, TACE, spinal/epidural injection and opioid hyperalgesia– As adjuvant setting– As adjuvant settingMetastatic setting– As locally advanced setting plus liver, lung or soft tissue diagnostic biopsies, wound care and movement procedural pain– As neo-adjuvant setting– As adjuvant setting– As adjuvant setting plus synergistic pain effects between iatrogenic and disease-related causes in long-term cancer survivorsRT, radiotherapy; TACE, transarterial chemoembolisation. Open table in a new tab RT, radiotherapy; TACE, transarterial chemoembolisation. According to a systematic review published in 2014 [7.Greco M.T. Roberto A. Corli O. et al.Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer.J Clin Oncol. 2014; 32: 4149-4154Crossref PubMed Scopus (234) Google Scholar] using the Pain Management Index (PMI) [8.Cleeland C.S. Gonin R. Hatfield A.K. et al.Pain and its treatment in outpatients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1666) Google Scholar], approximately one-third of patients do not receive appropriate analgesia proportional to their pain intensity (PI). High prevalence has also been documented in haematology patients at diagnosis, during therapy and in the last month of life [9.Bandieri E. Sichetti D. Luppi M. et al.Is pain in patients with haematological malignancies under-recognised? The results from Italian ECAD-O survey.Leuk Res. 2010; 34: e334-e335Crossref PubMed Scopus (0) Google Scholar]. These data reinforce the recommendation that patients with advanced or metastatic cancer require management within an integrated system for palliative care [7.Greco M.T. Roberto A. Corli O. et al.Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer.J Clin Oncol. 2014; 32: 4149-4154Crossref PubMed Scopus (234) Google Scholar]. Cancer-related pain may be presented as a major issue of healthcare systems worldwide: ∼14.1 million new cancer cases and 8.2 million deaths occurred worldwide in 2012, based on GLOBOCAN estimates [10.Torre L.A. Bray F. Siegel R.L. et al.Global cancer statistics, 2012.CA Cancer J Clin. 2015; 65: 87-108Crossref PubMed Scopus (20769) Google Scholar] and incidence will be > 15 million in 2020, based on projections [11.Frankish H. 15 million new cancer cases per year by 2020, says WHO.Lancet. 2003; 361: 1278.Abstract Full Text Full Text PDF PubMed Google Scholar]. Initial and ongoing assessment of pain should be an integral part of cancer care and indicates when additional comprehensive assessment is needed (Table 2). The regular self-reporting of PI with the help of validated assessment tools is the first step towards effective and individualised treatment. The most frequently used standardised scales [12.Caraceni A. Cherny N. Fainsinger R. et al.Pain measurement tools and methods in clinical research in palliative care: recommendations of an expert working group of the European Association of Palliative Care.J Pain Symptom Manage. 2002; 23: 239-255Abstract Full Text Full Text PDF PubMed Scopus (331) Google Scholar] are reported in Figure 1 and are the visual analogue scale (VAS), the verbal rating scale (VRS) and the numerical rating scale (NRS).Table 2Guidelines for the adequate assessment of the patient with pain at any stage of the disease1. Assess and re-assess the pain Causes, onset, type, site, absence/presence of radiating pain, duration, intensity, relief and temporal patterns of the pain, number of BTcPs, pain syndrome, inferred pathophysiology, pain at rest and/or moving Presence of trigger factors and signs and symptoms associated with the pain Presence of relieving factors Use of analgesics and their efficacy and tolerability Description of the pain quality:–Aching, throbbing, pressure: often associated with somatic pain in skin, muscle and bone–Aching, cramping, gnawing, sharp: often associated with visceral pain in organs or viscera–Shooting, sharp, stabbing, tingling, ringing: often associated with NP caused by nerve damage2. Assess and re-assess the patient Clinical situation by means of a complete/specific physical examination and the specific radiological and/or biochemical investigations Interference of pain with the patient's daily activities, work, social life, sleep patterns, appetite, sexual functioning, mood, well-being and coping Impact of the pain, the disease and the therapy on the physical, psychological and social conditions Presence of a caregiver, psychological status, degree of awareness of the disease, anxiety and depression and suicidal ideation, his/her social environment, QoL, spiritual concerns/needs, problems in communication, personality disorders Presence and intensity of signs, physical and/or emotional symptoms associated with cancer pain syndromes Presence of comorbidities (i.e. diabetic, renal and/or hepatic failure, etc.) Functional status Presence of opiophobia or misconception related to pain treatment Alcohol and/or substance abuse3. Assess and re-assess your ability to inform and to communicate with the patient and the family Spend time with the patient and the family to understand their needsBTcP, breakthrough cancer pain; NP, neuropathic pain; QoL, quality of life. Open table in a new tab BTcP, breakthrough cancer pain; NP, neuropathic pain; QoL, quality of life. Assessment of the pain descriptors improves the choice of therapy. Pain can be:(i)Nociceptive: caused by ongoing tissue damage, either somatic (such as bone pain) or visceral (such as gut or hepatic pain); or(ii)Neuropathic: caused by damage or dysfunction in the nervous system, such as in brachial plexopathy or in spinal cord compression by tumour [13.Sun V. Borneman T. Piper B. et al.Barriers to pain assessment and management in cancer survivorship.J Cancer Surviv. 2008; 2: 65-71Crossref PubMed Scopus (48) Google Scholar]. Most patients with advanced cancer have at least two types of cancer-related pain, resulting from a variety of pathophysiology [14.Portenoy R.K. Koh M. Cancer pain syndromes.in: Bruera E. Portenoy R.K. Cancer Pain. Assessment and Management. 4. Cambridge University Press, Cambridge2010: 53-88Google Scholar]. Initial assessment of cancer-related pain for all patients should include:(i)Ask a key screening question, which is not paraphrased and is used consistently. That question should be: 'What has been your worst pain in the last 24 hours on a scale of 0–10?', where 0 is no pain and 10 is the worst imaginable [15.Fallon M. Walker J. Colvin L. et al.Pain management in cancer center inpatients: a cluster randomized trial to evaluate a systematic integrated approach-the Edinburgh pain assessment and management tool.J Clin Oncol. 2018; 36: 1284-1290Crossref PubMed Google Scholar].(ii)Monitor if the pain is < 3.(iii)Move to a more detailed assessment if the worst pain is ≥ 3 or if the patient is distressed by pain (as per Table 2). This should also include average pain and pain 'right now'.(iv)Administer appropriate analgesic and reassess both pain and analgesic side effects.(v)Review analgesic regimen if side effects to prescribed analgesics are present and/or pain persists. Recommendation:•The intensity of pain and the treatment outcomes should be assessed regularly and consistently using the VAS or NRS using the question: 'What has been your worst pain in the last 24 hours?' [V, D]. In elderly patients, limited communicative skills and/or cognitive impairment make self-reporting of pain more difficult, although there is no evidence of clinical reduction in pain-related suffering. When cognitive deficits are severe, observation of pain-related behaviours and discomfort (e.g. facial expression, body movements, verbalisation or vocalisations, changes in interpersonal interactions, changes in routine activity) is an alternative strategy for assessing the presence of pain (but not its intensity) [16.van Herk R. van Dijk M. Baar F.P.M. et al.Observational scales for pain assessment in older adults with cognitive impairments or communication difficulties.Nurs Res. 2007; 56: 34-43Crossref PubMed Scopus (67) Google Scholar]. Observational scales are available [16.van Herk R. van Dijk M. Baar F.P.M. et al.Observational scales for pain assessment in older adults with cognitive impairments or communication difficulties.Nurs Res. 2007; 56: 34-43Crossref PubMed Scopus (67) Google Scholar]; however, none is validated in different languages. Sensitivity to a light touch can signal neuropathic pain (NP). A detailed appraisal of the literature pertaining to pain assessment in patients with cognitive impairment is outside the scope of this guideline but, given the global challenge and projected increase in dementia, this will become increasingly important [17.Lichtner V. Dowding D. Esterhuizen P. et al.Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools.BMC Geriatr. 2014; 14: 138.Crossref PubMed Google Scholar]. Assessment and management of pain in children are not considered in this manuscript, but guidelines have been developed by the World Health Organization (WHO) [18.World Health Organization. WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses, 2012. www.who.int/medicines/areas/quality_safety/guide_perspainchild/en/ (11 April 2018, date last accessed).Google Scholar]. Recommendation:•Observation of pain-related behaviours and discomfort is indicated in patients with cognitive impairment to assess the presence of pain [V, C]. Psychosocial distress is strongly associated with cancer pain and should be assessed [19.Syrjala K.L. Jensen M.P. Mendoza M.E. et al.Psychological and behavioural approaches to cancer pain management.J Clin Oncol. 2014; 32: 1703-1711Crossref PubMed Scopus (0) Google Scholar]. Psychological distress may amplify pain and similarly, inadequately controlled pain may cause psychological distress [20.Tracey I. Neuroimaging mechanisms in pain: from discovery to translation.Pain. 2017; 158: S115-S122Crossref PubMed Google Scholar]. Recommendation:•The assessment of all components of suffering, such as psychosocial distress, should be considered and evaluated [II, B]. Patients must be informed about possible onset of pain at any stage of the disease, both during/after diagnostic interventions and as a consequence of cancer and/or anticancer treatments. Patients should be empowered and encouraged to communicate with the physician and/or the nurse about their suffering, the efficacy of therapy and side effects. Patient education should include information on the appropriate use of opioids; this should be set in context with other analgesic and non-pharmacological approaches [21.Reid C.M. Gooberman-Hill R. Hanks G.W. Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer.Ann Oncol. 2008; 19: 44-48Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar]. Patient involvement in pain management improves both communication and pain relief through enhancing both patient understanding and physician assessment and prescribing [22.Bennett M.I. Bagnall A.M. José Closs S. How effective are patient-based educational interventions in the management of cancer pain? Systematic review and meta-analysis.Pain. 2009; 143: 192-199Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 23.Sheinfeld Gorin S. Krebs P. Badr H. et al.Meta-analysis of psychosocial interventions to reduce pain in patients with cancer.J Clin Oncol. 2012; 30: 539-547Crossref PubMed Scopus (154) Google Scholar]. It is important to prescribe a therapy that can be managed simply by patients and families themselves. The oral route, if well tolerated, should be considered as the preferred route of administration [24.World Health Organization Cancer Pain Relief.2. World Health Organization, Geneva1996Google Scholar, 25.Hanks G.W. De Conno F. Ripamonti C. et al.Morphine in cancer pain: modes of administration.BMJ. 1996; 312: 823-826Crossref PubMed Google Scholar]. Breakthrough cancer pain (BTcP), defined as 'a transitory flare of pain that occurs on a background of relatively well-controlled baseline pain', requires careful assessment and appropriate management. Typical BTcP episodes are of moderate to severe intensity, rapid in onset (minutes) and of relatively short duration (median 30 minutes) [26.Portenoy R.K. Hagen N.A. Breakthrough pain: definition, prevalence, and characteristics.Pain. 1990; 41: 273-281Abstract Full Text PDF PubMed Scopus (778) Google Scholar]. Recommendations:•Patients should be informed about pain and pain management and should be encouraged to take an active role in their pain management [II, B].•The onset of pain should be prevented by means of around-the-clock (ATC) administration, taking into account the half-life, bioavailability and duration of action of different drugs [II, B].•Analgesics for chronic pain should be prescribed on a regular basis and not on an 'as required' schedule [V, D].•The oral route of administration of analgesic drugs should be advocated as the first choice [IV, C]. The type and dose of analgesic drugs are influenced by the PI and must be promptly adjusted to reach a balance between optimal pain relief and minimum side effects. Rescue doses [as-needed (prn) doses] should be prescribed proactively for the relief of BTcP pain and to overcome end-of-dose failure. Rescue medication used for end-of-dose failure should help with calculating the daily titration of regular doses. The oral route is preferred except when oral intake is not possible because of severe vomiting, bowel obstruction, severe dysphagia or severe confusion, and in the case of poor pain control which requires rapid dose escalation and/or in the presence of oral opioid-related adverse effects. The WHO proposes a strategy (currently under review) for cancer pain treatment based on a sequential three-step analgesic ladder, from non-opioids to weak opioids to strong opioids, according to PI [24.World Health Organization Cancer Pain Relief.2. World Health Organization, Geneva1996Google Scholar]. The WHO ladder recommends non-opioid analgesics as possible options at all steps; however, this is of greater relevance for the first two steps of the WHO ladder. In practical terms, this means paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) (step 1). Opioid analgesics are the mainstay of analgesic therapy and are classified according to ability to control pain from mild to moderate (step 2) to moderate to severe intensity (step 3) [24.World Health Organization Cancer Pain Relief.2. World Health Organization, Geneva1996Google Scholar, 25.Hanks G.W. De Conno F. Ripamonti C. et al.Morphine in cancer pain: modes of administration.BMJ. 1996; 312: 823-826Crossref PubMed Google Scholar, 26.Portenoy R.K. Hagen N.A. Breakthrough pain: definition, prevalence, and characteristics.Pain. 1990; 41: 273-281Abstract Full Text PDF PubMed Scopus (778) Google Scholar]. However, some authors have suggested eliminating the second step of the analgesic ladder, with weak opioids being replaced with low doses of oral morphine [27.Bandieri E. Romero M. Ripamonti C. et al.Randomized trial of low-dose morphine versus weak opioids in moderate cancer pain.J Clin Oncol. 2016; 34: 436-442Crossref PubMed Scopus (69) Google Scholar, 28.Fallon M. Do We Need Step 2 of the WHO Pain Ladder—An EAPC Research Network Study. EAPC Abstract Book. EAPC, Madrid2017Google Scholar]. Analgesic drugs are only one part of cancer pain management, and an integrated approach to cancer pain management should be adopted; this should incorporate:(i)primary antitumour treatments;(ii)interventional analgesic therapy and(iii)a variety of non-invasive techniques such as psychological and rehabilitative interventions [29.Paice J.A. Ferrell B. The management of cancer pain.CA Cancer J Clin. 2011; 61: 157-182Crossref PubMed Scopus (150) Google Scholar]. Paracetamol and NSAIDs are universally accepted as part of the treatment of cancer pain at any stage of the WHO analgesic ladder. Several relevant systematic reviews are available regarding the efficacy of paracetamol and NSAIDs for cancer pain management, either when used alone or in combination with opioids. Paracetamol is the mainstay of the first two steps of the WHO analgesic ladder in many countries. However, a Cochrane systematic review highlights the lack of knowledge about the effectiveness of paracetamol for cancer pain [30.Wiffen P.J. Derry S. Moore R.A. et al.Oral paracetamol (acetaminophen) for cancer pain.Cochrane Database Syst Rev. 2017; 7: CD012637PubMed Google Scholar]. In 2017, Cochrane identified 11 studies of oral NSAIDs in adults with cancer pain [31.Derry S. Wiffen P.J. Moore R. et al.Oral nonsteroidal anti-inflammatory drugs (NSAIDs) for cancer pain in adults.Cochrane Database Syst Rev. 2017; 12: CD012638Google Scholar]. These included 949 participants; however, no studies examined the effects of NSAIDs together with an opioid (such as morphine), although this is how they are often used. All studies were compromised by small numbers. With any NSAID, moderate or severe cancer pain was reduced to no worse than mild pain in 26%–51% of patients, after 1 or 2 weeks in 4 of the 11 studies. Based on this 2017 Cochrane review, there is no conclusive evidence to support or refute the use of NSAIDs alone or in combination with opioids for the treatment of mild cancer pain. (There is limited evidence that some people with moderate or severe cancer pain can obtain substantial levels of benefit within 1 or 2 weeks.) It is important to monitor and reassess the long-term use of NSAIDs or cyclo-oxygenase-2 (COX-2) selective inhibitors [32.British National Formulary. BNF 75 March–September 2018, 75th edition. London: British Medical Association and Royal Pharmaceutical Society of Great Britain 2018.Google Scholar] because of their significant toxicity (e.g. gastrointestinal bleeding, platelet dysfunction and renal failure). COX-2 selective inhibitors may increase the risk of thrombotic cardiovascular adverse reactions [33.European Medicines Agency. Public statement: European Medicines Agency Announces Regulatory Action on COX-2 Inhibitors (EMEA/62838/2005). www.ema.europa.eu/docs/en_GB/document_library/Public_statement/2009/11/WC500014818.pdf (11 April 2018, date last accessed).Google Scholar] and do not reduce the risk of renal failure. Dipyrone is another non-opioid analgesia that a recent systematic review concluded could be used for the treatment of cancer pain, alone or in combination with opioids [34.Gaertner J. Stamer U.M. Remi C. et al.Metamizole/dipyrone for the relief of cancer pain: a systematic review and evidence-based recommendations for clinical practice.Palliat Med. 2017; 31: 26-34Crossref PubMed Scopus (22) Google Scholar]. Recommendations:•Analgesic treatment should start with drugs indicated by the WHO analgesic ladder appropriate for the severity of pain [II, B].•There is no significant evidence to support or refute the use of paracetamol alone or in combination with opioids for mild to moderate pain [I, C].•There is no significant evidence to support or refute the use of NSAIDs alone or in combination with opioids for mild to moderate pain [I, C]. There are few options to treat mild to moderate cancer pain before moving to strong opioids such as morphine. Tramadol, dihydrocodeine and codeine are the widely available options. There is widespread use of tramadol in palliative care, even though the data on its use are limited and adverse effects can be severe [27.Bandieri E. Romero M. Ripamonti C. et al.Randomized trial of low-dose morphine versus weak opioids in moderate cancer pain.J Clin Oncol. 2016; 34: 436-442Crossref PubMed Scopus (69) Google Scholar, 35.Wiffen P.J. Derry S. Moore R.A. Tramadol with or without paracetamol (acetaminophen) for cancer pain.Cochrane Database Syst Rev. 2017; 5: CD012508.PubMed Google Scholar, 36.World Health Organization. WHO Model List of Essential Medicines: 20th WHO Essential Medicines List (EML), March 2017. www.who.int/medicines/publications/essentialmedicines/en/ (11 April 2018, date last accessed).Google Scholar]. Tramadol has a potential role on step 2 of the analgesic ladder, particularly if other step 2 drugs are not tolerated, but adequate studies comparing tramadol with other step 2 drugs (e.g. codeine or dihydrocodeine) are missing. Tramadol can have significant side effects, such as dizziness, nausea, vomiting and constipation [37.Rodriguez R.F. Bravo L.E. Castro F. et al.Incidence of weak opioids adverse events in the management of cancer pain: a double-blind comparative trial.J Palliat Med. 2007; 10: 56-60Crossref PubMed Scopus (36) Google Scholar]. Tramadol affects serotonin metabolism or availability, potentially leading to serotonin toxicity, particularly in the elderly, and can lower seizure thresholds. Tramadol has a much-reduced analgesic effect in cytochrome P450 2D6 (CYP2D6) poor metabolisers. Dihydrocodeine is also a substrate for CYP2D6; its partial metabolism is limited in poor metabolisers and is blocked by CYP2D6 inhibitors. However, there is no evidence that such inhibition reduces its analgesic effect. Codeine has no or little analgesic effect until metabolised to morphine, mainly via CYP2D6. In poor metabolisers, it is therefore essentially ineffective, while in ultrarapid metabolisers, it is potentially toxic. The second step of the WHO ladder has several controversial aspects. The first criticism concerns the absence of a definitive proof of efficacy of weak opioids. A meta-analysis of data from randomised controlled trials (RCTs) showed no significant difference between the effectiveness of non-opioid analgesics alone and non-opioids in combination with weak opioids [38.Eisenberg E. Berkey C. Carr D.B. et al.Efficacy and safety of nonsteroidal antiinflammatory drugs for cancer pain: a meta-analysis.J Clin Oncol. 1994; 12: 2756-2765Crossref PubMed Google Scholar]. The available studies do not demonstrate a clear difference in the effectiveness of the drugs between the first and the second step [39.Management of cancer pain evidence report technology assessment: number 35–management of cancer pain summary.J Pain Palliat Care Pharmacother. 2002; 16: 91-102Google Scholar]. A 2014 Cochrane review of weak opioids in cancer pain including 15 studies with 721 participants, although providing newer data, was not able to help formulate recommendations [40.Straube C. Derry S. Jackson K.C. et al.Codeine, alone and with paracetamol (acetaminophen), for cancer pain.Cochrane Database Syst Rev. 2014; 9: CD006601Google Scholar]. The available evidence indicates that codeine is more effective against cancer pain in adults than placebo, but with increased risk of nausea, vomiting and constipation [41.Larkin P.J. Cherny N.I. La Carpia D. et al.Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines.Annal Oncol. 2018; 29: iv94-iv108Google Scholar]. Work is evolving in the exploration of the place of step 2 in the WHO three-step ladder. Historical work with uncontrolled studies showed that the effectiveness of the second step of the WHO ladder has a time limit of 30–40 days for most patients and that the shift to the third step is mainly due to insufficient analgesia, and 'ceiling effect' with weak opioids, rather than to adverse effects [42.Ventafridda V. Tamburini M. Caraceni A. et al.A validation study of the WHO method for cancer pain relief.Cancer. 1987; 59: 850-856Crossref PubMed Scopus (584) Google Scholar]. Given the lack of data on effectiveness of tramadol, dihydrocodeine and codeine on cancer pain, many authors have proposed the abolition of the second step of the WHO analgesic ladder, in favour of the early use of morphine at low doses, which is not in the current WHO guideline. The evidence base is evolving, with one study in favour of a low-dose morphine approach already reported and results from another RCT expected shortly [27.Bandieri E. Romero M. Ripamonti C. et al.Randomized trial of low-dose morphine versus weak opioids in moderate cancer pain.J Clin Oncol. 2016; 34: 436-442Crossref PubMed Scopus (69) Google Scholar, 28.Fallon M. Do We Need Step 2 of the WHO Pain Ladder—An EAPC Research Network Study. EAPC Abstract Book. EAPC, Madrid2017Google Scholar]. Recommendations:•For mild to moderate pain, weak opioids such as tramadol, dihydrocodeine and codeine can be given in combination with non-opioid analgesics [III, C].•As an alternative to weak opioids, low doses of strong opioids could be an option, although this recommendation is not currently part of WHO guidance [II, C].•There is no evidence of increase in adverse effects from the use of low-dose strong opioids instead of the standard step 2 approach with weak opioids [II, C]. Strong opioids are the mainstay of analgesic therapy in treating moderate to severe cancer-related pain. Although a variety of strong opioids exist and there is no superiority of one over another, morphine is the most widely available and prescribed. In spite of the global agreement that access to opioids is essential, both access to and use of opioids remains poor in many countries. Various factors contribute to poor access and use, which is still problematic in Eastern and South Eastern Europe [43.Manjiani D. Paul D.B. Kunnumpurath S. et al.Availability and utilization of opioids for pain management: global issues.Ochsner J. 2014; 14: 208-215PubMed Google Scholar, 44.Duthey B. Scholten W. Adequacy of opioid analgesic consumption at country, global, and regional levels in 2010, its relationship with development level, and changes compared with 2006.J Pain Symptom Manage. 2014; 47: 283-297Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 45.Berterame S. Erthal J. Thomas J. et al.Use of and barriers to access to opioid anal

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CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

2016-03-17

Deborah Dowell , Tamara M. Haegerich , Roger Chou

cognitive impairment, and those with cancer and at the end of life, can be at risk for inadequate pain treatment (4).Patients can experience persistent pain that is not well controlled.There … cognitive impairment, and those with cancer and at the end of life, can be at risk for inadequate pain treatment (4).Patients can experience persistent pain that is not well controlled.There are clinical, psychological, and social consequences associated with chronic pain including limitations in complex activities, lost work productivity, reduced quality of life, and stigma, emphasizing the importance of appropriate and compassionate patient care (4).Patients should receive appropriate pain treatment based on a careful consideration of the benefits and risks of treatment options.Chronic pain has been variably defined but is defined within this guideline as pain that typically lasts >3 months or past the time of normal tissue healing (5).Chronic pain can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or an unknown cause (4).Estimates of the prevalence of chronic pain vary, but it is clear that the number of persons experiencing chronic pain in the United States is substantial.The 1999-2002 National Health and Nutrition Examination Survey estimated that 14.6% of adults have current widespread or localized pain lasting at least 3 months (6).Based on a survey conducted during 2001-2003 (7), the overall prevalence of common, predominantly musculoskeletal pain conditions (e.g., arthritis, rheumatism, chronic back or neck problems, and frequent severe headaches) was estimated at 43% among adults in the

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Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy.

1979-06-01

H. Merskey

Rethinking nociplastic pain: implications for the Philippines and beyond

2025-06-25

Jose Eric M Lacsa | The Korean journal of pain

Editorial: Pain in the older adult patient

2025-06-24

Luca Tagliafico , Rose Penfold , Sofía Duque +1 more | Frontiers in Medicine

Optimization of Post-operative Pain Following Orthognathic Surgery with Personalized Opioid Prescription and Tapering Protocols

2025-06-24

Amr Alsabbagh , Jay Doucet | International Journal of Oral and Maxillofacial Surgery

Opioid Use and Neurodegenerative Disorders

2025-06-20

Abhishek Ghosh , Ankita Chattopadhyay , Shinjini Choudhury | CRC Press eBooks

Letter to the editor: a commentary on “Acute pain service for postoperative pain in adults a network meta-analysis”

2025-06-20

Hong Deng , Sha Xie , Xianfu Cai +2 more | International Journal of Surgery

First reports of illegal fentanyl sales in Peru: the beginning of a crisis?

2025-06-20

Aldo Álvarez-Risco , Shyla Del-Aguila-Arcentales , Neal M. Davies +2 more | Frontiers in Psychiatry

Cervical Subarachnoid Neurolytic Block

2025-06-20

Steven D. Waldman | Elsevier eBooks

Celiac Plexus Block: Two-Needle Transcrural Technique

2025-06-20

Steven D. Waldman | Elsevier eBooks

Lumbar Subarachnoid Neurolytic Block

2025-06-20

Steven D. Waldman | Elsevier eBooks

Trialing Strategies Prior to Intrathecal Drug Delivery in Cancer-Related Pain: A Narrative Review

2025-06-19

Elizabeth le Roux , Alan D. Kaye , Sudeep R. Shah +2 more | Current Pain and Headache Reports

Triple-target radiosurgery for intractable cancer pain of mixed origin: Two-centre experience in Central America

2025-06-18

Paola Del Cid , Luciana Carla Martins de Aquino , Alejandra Moreira +6 more | British Journal of Pain

Cancer pain is one of the most severe components of the symptom burden among cancer patients, especially those with advanced or metastatic disease. Palliative interventions are necessary to alleviate cancer … Cancer pain is one of the most severe components of the symptom burden among cancer patients, especially those with advanced or metastatic disease. Palliative interventions are necessary to alleviate cancer pain and reduce opioid-related side effects, thereby minimizing patient suffering. Radiosurgery has been effectively used to target the medial thalamus and the hypophysis for the treatment of chronic pain syndromes. These two areas are critical for pain modulation and control, and their precise targeting with radiosurgery and its non-invasive nature can provide relief for patients suffering from cancer-related intractable pain. Our previous work with single target irradiation of the hypophysis revealed promising pain relief in terminal cancer patients, albeit more suited for hormone-mediated tumours or bone-derived pain rather than complex mixed pain syndromes. Given that, we previously introduced the concept of triple-target irradiation (hypophysis + both thalami) in a small report of terminally ill cancer patients. Here, we report a larger case series of terminally ill patients (n = 8) with complex cancer pain treated with a triple-target approach, with radiation doses generally considered low or non-ablative (90 Gy), in contrast to the usual single-target, ablative approach comprising higher doses. We noted a substantial decrease in VAS scores and the medications needed to manage pain across all patients, experiencing minimal to no side effects. Our findings indicate that a minimally invasive triple-target method, utilising low radiation doses, effectively alleviates pain, lowers medication dependency, and enhances the quality of life with few side effects. Furthermore, additional research is essential to optimise pain relief and ensure long-term effectiveness.

Rol de las nuevas tecnologías basadas en inteligencia artificial en el manejo del dolor del paciente oncológico. Una revisión de alcance

2025-06-18

Santiago Patricio Ruiz Pérez , Jefferson Andrés Guerrero Andrade , Katherine Johana Puruncajas Pila | Ciencia Latina Revista Científica Multidisciplinar

La medicina junto a la inteligencia artificial avanza en el diagnóstico y tratamiento de las enfermedades oncológicas, sin embargo, no está claro cómo influye en la terapia del dolor. El … La medicina junto a la inteligencia artificial avanza en el diagnóstico y tratamiento de las enfermedades oncológicas, sin embargo, no está claro cómo influye en la terapia del dolor. El propósito de este documento fue mapear la evidencia bibliográfica disponible sobre el rol de las nuevas tecnologías basadas en inteligencia artificial en el manejo del dolor en pacientes oncológicos. Se llevó a cabo una revisión de alcance de las bases de datos PubMed, Scopus, Springer Link y Science direct aplicando la metodología PRISMA -ScR. Para la valoración del nivel y calidad de evidencia se aplicó el modelo de la Práctica Basada en Evidencia de Johns Hopkins. Mediante la cadena de búsqueda se extrajo 401 artículos, solo 12 cumplieron los criterios de elegibilidad. Cinco fueron considerados de nivel III y siete de buena calidad. Se reconocieron varias utilidades de la inteligencia artificial especialmente para clasificar el dolor, monitorización remota, telesalud, toma de decisiones en tratamientos individualizados, control de otros síntomas postratamiento, educación, y apoyo psicosocial. Las herramientas con inteligencia artificial son aceptadas por los usuarios finales en particular aquellas que mejoran la autogestión del tratamiento. No hay suficiente evidencia que permita profundizar el tema, la escasez de ensayos controlados dificulta la interpretación de la utilidad de las nuevas tecnologías en este contexto.

Pharmacologie des opioïdes

2025-06-18

D. Lassagne , Dominique Fletcher , V. Martinez | EMC-Anesthésie réanimation/Encyclopédie médico-chirurgicale. Anesthésie, réanimation

Virtual reality for pain relief in gynaecological care

2025-06-17

Josep Estadella | Facts Views and Vision in ObGyn

The Missing Link: Integrating Interventional Pain Management in the Era of Multimodal Oncology

2025-06-17

Alberto Corriero , Mariateresa Giglio , Rossana Soloperto +7 more | Pain and Therapy

Effect of educational interventions in pain intensity and related outcomes in adults with oncological pain: a systematic review and meta-analysis

2025-06-17

Lourdes Carrillo Bermúdez , L Palacios , Ilem D. Rosero +2 more | BMJ Supportive & Palliative Care

Background Pain is the second most prevalent symptom in patients with cancer after fatigue and is highly debilitating. There is an increasing emphasis on the prescription of non-pharmacological interventions, among … Background Pain is the second most prevalent symptom in patients with cancer after fatigue and is highly debilitating. There is an increasing emphasis on the prescription of non-pharmacological interventions, among which pain education is a prominent option. This study aimed to determine the effects of educational interventions on pain intensity and related outcomes in patients with oncological pain. Methods A systematic review was conducted following Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with registration in PROSPERO CRD42022343205 from searches in the main databases such as PubMed, Science Direct, Taylor and Francis, Cochrane (CENTRAL) and Scopus without language restriction, including randomised clinical trials and observational studies using the following keywords: “Pain Education” AND “Cancer”. The PEDro (Physiotherapy Evidence Database scale) scale and MINORS (methodological index for non-randomised studies) criteria were used to analyse the risk of bias. Results 35 articles involving the use of educational interventions for patients with cancer pain were analysed in this study. Most protocols involved sessions implementing audiovisual aids, which the patient could easily access. The protocols showed significant results in terms of improvement in pain intensity, stress, quality of life and catastrophising in the intervened groups. Due to the heterogeneity of the interventions in the quantitative analysis, it was only possible to include six articles, which yielded significant results in improving pain (−0.65 (−1.18 to −0.12)). Conclusions It is concluded that educational interventions can be effective in the treatment of cancer pain and should be considered as a complement to palliative care treatment. PROSPERO registration number CRD42022343205.

Coccygectomy for chronic coccydynia in a 70-year-old patient: a case report illustrating the paramedian approach in coccygectomy

2025-06-17

Jun-Yong Cha , Seong Choi , Jae Hyeon Lim +2 more | Journal of Korean Society of Geriatric Neurosurgery

Proceso de atención de enfermería a paciente con dolor agudo, un estudio de caso

2025-06-16

Ángel Humberto Villanueva , Paola Andrea Arias Murcia , Valentina Gutiérrez Hernández +1 more | Salud Uninorte

El dolor es una experiencia sensorial y emocional desagradable que puede surgir como resultado de daño tisular real o potencial, sin embargo, se hace énfasis en que es una experiencia … El dolor es una experiencia sensorial y emocional desagradable que puede surgir como resultado de daño tisular real o potencial, sin embargo, se hace énfasis en que es una experiencia individual y subjetiva; la presencia de dolor se puede relacionar con modificaciones fisiopatológicas en diferentes órganos y sistemas; su tratamiento requiere de la intervención de un equipo multidisciplinario. El objetivo de este estudio fue describir una situación clínica de enfermería. Se trata de un paciente masculino de 27 años, quien presenta dolor agudo de intensidad severa, hospitalizado por politraumatismo por accidente de tránsito y postquirúrgico de estabilización de fracturas. Se elaboró un plan de cuidado de enfermería siguiendo las taxonomías NANDA-I, NOC y NIC, aplicando la teoría de los síntomas desagradables de Elizabeth Lenz. Las intervenciones fueron farmacológicas y no farmacológicas, con enfoques multidisciplinarios para promover la recuperación del estado de bienestar. En la fase de evaluación se logró determinar cambios en los indicadores que reflejan la efectividad de las actividades, demostrando la utilidad de la teoría aplicada y la importancia del rol de la enfermera en el acto del cuidado y recuperación de la salud.

Introducing ENIGMA-Chronic Pain: An Offshoot of the ENIGMA Consortium

2025-06-16

| Topics in Pain Management

Impactos Toxicológicos do Uso Crônico de Opioides em Pacientes Cirúrgicos

2025-06-14

Natanael Miranda Vieira , Washington Lucas Alves Da Costa , Camila Loren Costa Lima +3 more | Revista Intertox de Toxicologia Risco Ambiental e Sociedade

O uso crônico de opioides no contexto perioperatório representa um desafio crescente para a prática clínica, devido à associação com complicações como tolerância, hiperalgesia induzida por opioides, dependência e depressão … O uso crônico de opioides no contexto perioperatório representa um desafio crescente para a prática clínica, devido à associação com complicações como tolerância, hiperalgesia induzida por opioides, dependência e depressão respiratória, que comprometem a segurança do paciente e os desfechos cirúrgicos. A presente revisão analisa as repercussões toxicológicas do uso prolongado de opioides em pacientes submetidos a procedimentos cirúrgicos, abordando os mecanismos fisiopatológicos subjacentes, as principais manifestações clínicas e os impactos no manejo perioperatório. Dados epidemiológicos recentes evidenciam o aumento expressivo do consumo de opioides, especialmente sintéticos, tanto em âmbito global quanto nacional, refletindo-se em maiores taxas de internações e custos hospitalares. A análise da literatura destaca que o uso crônico de opioides está relacionado ao aumento do risco de complicações pós-operatórias, maior tempo de internação, necessidade de doses elevadas para analgesia e dificuldades no controle da dor, além de elevar a incidência de eventos adversos como depressão respiratória e atelectasia. Estratégias multimodais de manejo, avaliação pré-operatória criteriosa e monitoramento intensivo são essenciais para mitigar riscos e otimizar a recuperação desses pacientes. O estudo reforça a necessidade de políticas públicas e diretrizes clínicas baseadas em evidências para enfrentar esse cenário, promovendo segurança e melhores resultados cirúrgicos.

Historical perspectives and emerging trends in fentanyl use: Part 2 – overdose and misuse

2025-06-13

Stanila Stoeva , Maya Radeva–Ilieva , Nadezhda Karkkeselyan +6 more | Pharmacia

The misuse of fentanyl and its analogs has significantly worsened the opioid crisis, leading to a sharp increase in overdose fatalities. Fentanyl overdose primarily causes severe respiratory depression, which can … The misuse of fentanyl and its analogs has significantly worsened the opioid crisis, leading to a sharp increase in overdose fatalities. Fentanyl overdose primarily causes severe respiratory depression, which can result in hypoxia, cardiac arrest, and death, often exacerbated by co-intoxication. Additionally, the opioid in question can induce chest wall rigidity, further complicating treatment procedures. Despite international control efforts, the drug’s high potency and low cost have fueled its widespread trafficking, including in counterfeit pills. While naloxone is the primary antidote, its effectiveness is limited, highlighting the need for stronger, long-acting treatments. Factors such as polypharmacy, prescription misuse, and environmental exposure – as well as the potential for fentanyl’s use as a chemical weapon – pose significant public safety risks. In conclusion, addressing the current wave of the opioid crisis requires a comprehensive approach, integrating treatment solutions, prevention, and harm reduction strategies.

Historical perspectives and emerging trends in fentanyl use: Part 1 – Pharmacological profile

2025-06-13

Stanila Stoeva , Maya Radeva–Ilieva , Nadezhda Karkkeselyan +6 more | Pharmacia

Fentanyl, a potent synthetic opioid, is widely used for severe pain management and anesthesia but poses significant risks due to its extreme potency and addictive potential. It acts primarily on … Fentanyl, a potent synthetic opioid, is widely used for severe pain management and anesthesia but poses significant risks due to its extreme potency and addictive potential. It acts primarily on μ-opioid receptors, with additional effects on κ- and δ-receptors, producing analgesia and adverse effects, such as respiratory depression, mediated via G-protein and β-arrestin signaling pathways. Fentanyl’s pharmacokinetics include rapid onset and a short duration, with extensive liver metabolism via CYP3A4 enzymes. Its high lipophilicity allows it to cross the blood-brain barrier quickly, contributing to its rapid central nervous system effects and associated risk of respiratory depression. Despite its therapeutic value, fentanyl’s potential to induce tolerance and dependence, coupled with escalating illicit use, underscores the need for enhanced prevention strategies, improved overdose management, and stricter regulatory measures to balance therapeutic utility with abuse prevention.

Subcutaneous versus intravenous route switch from oral to parenteral morphine in patients with cancer: randomised controlled trial

2025-06-12

Eva Gravdahl , Siri Steine , Jūratė Šaltytė Benth +2 more | BMJ Supportive & Palliative Care

Background Subcutaneous (SC) administration is the preferred parenteral opioid route in palliative care, while intravenous infusion may allow faster titration. Comparative evidence remains limited. This study assessed whether intravenous or … Background Subcutaneous (SC) administration is the preferred parenteral opioid route in palliative care, while intravenous infusion may allow faster titration. Comparative evidence remains limited. This study assessed whether intravenous or SC morphine, administered by continuous infusion with bolus doses, offered advantages in (1) time to stable infusion rate and (2) time to pain relief following a bolus dose. Methods In this double-blind, double-dummy randomised controlled trial, 60 hospitalised palliative care patients with cancer requiring opioid rotation to parenteral morphine were randomised to continuous SC or intravenous infusion with bolus doses over 48 hours. Results Mean time to final infusion rate was 20.4 hours (95% CI: 15.2 to 25.6) for SC and 16.3 hours (95% CI: 10.5 to 22.2) for intravenous (mean difference: 4.1 hours, 95% CI: –3.6 to 11.7; p=0.293). Median time to effect from bolus doses was 20 min (Q1, Q3: 15, 23) for SC and 15 min (10, 20) for intravenous (HR=1.08, 95% CI: 0.61 to 1.88; p=0.795), indicating no significant difference. NRS scores decreased from 3.9 to 2.1 (SC) and 3.3 to 2.3 (intravenous). Infusion rates increased from 2.4 to 3.3 mg/hour, bolus doses from 4.6 to 6.6 mg. Of 604 boluses, the proportion of effective doses was similar between groups. One intravenous patient developed catheter-related thrombosis and infection post-intervention. Conclusion No statistically significant or clinically meaningful differences in effectiveness or safety were observed between SC and intravenous morphine administration. Both routes allowed similar titration patterns, supporting the use of either route in palliative care without compromising analgesic efficacy or safety.

Holistic and Culturally Sensitive Pain Management in Jordanian Intensive Care Settings

2025-06-10

Abdul‐Monim Batiha | Nursing in Critical Care

Pain management in intensive care units (ICUs) remains a significant challenge, with conventional pharmacological treatments often leading to adverse effects and dependency. Non-pharmacological interventions, such as recitation of religious or … Pain management in intensive care units (ICUs) remains a significant challenge, with conventional pharmacological treatments often leading to adverse effects and dependency. Non-pharmacological interventions, such as recitation of religious or spiritual texts, guided imagery and aromatherapy, have shown promise in reducing pain and improving emotional well-being, particularly in culturally and religiously homogeneous settings like Jordan. However, there is limited research on the combined use of these therapies in ICU settings. This study evaluated the effectiveness of Qur'an recitation, guided imagery and aromatherapy as integrative nursing interventions for pain management in Jordanian ICU patients, focusing on their impact on physical pain, emotional well- being and spiritual well-being and the challenges of implementation in high-stress environments. The study used a mixed-methods, quasi-experimental pretest-post-test control group design. The study had 120 ICU patients, 60 in the intervention group and 60 in the control group. The intervention group got Qur'an recitation, guided imagery and aromatherapy for 48 h, while the control group was given normal pharmaceutical pain care. Pain levels were measured using the Numerical Rating Scale (NRS) at baseline, 24 h and 48 h post-intervention. Semi-structured interviews with patients and nurses revealed the experiences and obstacles of adopting these treatments. The intervention group observed a significant reduction in pain, with mean NRS scores decreasing from 7.8 at baseline to 3.1 at 48 h post-intervention (F(2, 118) = 156.42, p < 0.001, partial η2 = 0.73). Qualitative findings revealed enhanced emotional and spiritual comfort, improved patient-nurse communication and cultural and religious appropriateness of the therapies. Nurses reported logistical challenges but acknowledged the overall positive impact on patient well-being. This study demonstrates that integrative nursing interventions, including Qur'an recitation, guided imagery and aromatherapy, significantly reduce pain and improve emotional and spiritual well-being in ICU patients. These findings support the incorporation of culturally sensitive, non-pharmacological therapies into ICU care protocols, particularly in settings where cultural and religious practices are deeply embedded. The study highlights the importance of integrating culturally and spiritually relevant therapies into ICU care to enhance patient comfort and satisfaction. Nurse training programmes should be developed to facilitate the effective delivery of these interventions, and policymakers should prioritize guidelines for integrative pain management in critical care settings.

Corrigendum to: The implementation of a pain navigator program in the department of Veterans Affairs’ (VA) health care systems: a cluster randomized pragmatic clinical trial

2025-06-06

| Pain Medicine

Factors associated with cancer-related pain among Utah cancer survivors

2025-06-05

Rachel Codden , Blessing Ofori-Atta , Marjorie E. Carter +4 more | Journal of Cancer Survivorship

Beneficios de la prehabilitación en pacientes con cáncer colorrectal: estudio de casos y controles anidado

2025-06-04

E J Frutos-Reoyo , P. Luque-Linero , Laura López-Maté +3 more | Rehabilitación

AN EVALUATION OF PATIENT-CONTROLLED ANALGESIA. EFFECTIVENESS, SAFETY, AND PATIENT SATISFACTION IN POSTOPERATIVE PAIN MANAGEMENT

2025-06-01

M Gonzalez , Ruth Isabel Solís Arias , Evelyn Paola Del Valle Merchan +2 more | Revista sanitaria de investigación.

Managing acute coccydynia in the ED: A case report of a successful blind sacrococcygeal nerve block

2025-06-01

Aakash A. Setty , Stevin M. Bienfait , Jessica Oswald | JEM Reports

The Future of Pain Management

2025-06-01

Pravarakhya Puppalla , Tara M. Pattilachan , Rodrigo Salmeron de Toledo Aguiar +2 more | Neurologic Clinics

Patient Perceptions on Opioid Therapy for Acute Pain Management in the Emergency Department and Post-Surgical Settings: A Qualitative Study

2025-06-01

Evan Lucey , Erica Dean , Brittany Chapman +4 more | Journal of Pain Research

Opioids are highly effective in treating acute pain but have various detrimental, non-therapeutic effects that may lead to the development of opioid use disorder (OUD) in certain individuals. This creates … Opioids are highly effective in treating acute pain but have various detrimental, non-therapeutic effects that may lead to the development of opioid use disorder (OUD) in certain individuals. This creates a complex landscape of opioid prescribing and use. The present manuscript uses a qualitative research lens to understand the patient experience during opioid therapy for acute pain, including perceptions, behaviors, and factors that drive both during the third wave of the opioid epidemic. Patients receiving opioids for acute pain were recruited from the emergency department and general surgery clinic as part of a larger study to perform continuous physiologic monitoring during opioid use. Semi-structured interviews were conducted within 10 days of hospital discharge. Interviews were recorded, transcribed verbatim and subject to applied thematic analysis by two independent coders. Of the 60 subjects that completed the parent study, 44 completed the semi-structured interviews (mean age 47 years, 50% female). Three main themes emerged from the interviews: the direct effects of opioid analgesia, internal factors and external factors that influenced therapy. Symptoms of opioid tolerance, withdrawal and dependence were described in a subset of participants, even with a relatively short duration of therapy. Participants expressed a desire for more education around opioid therapy, and more engagement with their plan of care. Opioid therapy, even in short courses for acute pain, can be a complicated experience for patients to navigate. Prescribers should consider how patients' unique experiences and perspectives shape their responses when providing counseling to patients and monitoring of response to opioid therapy.

Breakthrough Pain: More to Learn

2025-06-01

Rachel Mack , Mellar P. Davis | Journal of Pain and Symptom Management