The use of intravenous morphine for breakthrough pain in terminal cancer patients admitted to hospice center.

e20621 Background: The adequate opioid dose to be administered for breakthrough pain(BTP) is still controversial. Dosing recommendations are based on patient’s(pts) total daily opioid dose. Intravenous morphine(IV-M) has been found to be effective and safe for the management of BTP. However, physicians are often reluctant in using large doses of IV-M because of the possible adverse events in terminal cancer pts. The aim of this study was to evaluate whether pts were treated appropriately for their BTP in hospice setting. Methods: A total of 94 consecutive terminal cancer pts who were admitted in the Hospice and Palliative Care Clinic at Jeonnam Regional Cancer Center from June 2012 to Nov 2012 were analyzed in this study. Results: In total, 1,213 BTP events treated by IV-M were recorded and the mean number of events per pts was 13.6 (95% confidence interval (CI) 10.5-15.4). The mean dose of IV-M was 13.9mg (95% CI 12.5-14.5mg, range 3-90mg) and was equivalent to 7.1% of the total daily opioid dose. For each episode, pain intensity and opioid-related symptoms were recorded at the base (T0) and within 30 minutes after (T1). Pain intensity decreased from a mean of 5.1(on a 0-10 numeric scale) at base to 1.8 at T1. A decrease in pain of more than 30%, 50% and 70% was observed in 1179 (97.2%), 958 (78.9%) and 460 (37.9%) BTP events, respectively. In 21 episodes, no changes in pain intensity were observed and a further dose of IV-M was given. Doses of more than 10mg, 30mg and 50mg of IV-M were given for 456 (37.6%), 200 (16.5%) and 104(8.6%). No differences in age, sex and pain location were found. Adverse effects were uncommon, moderate nausea/vomiting in 32 episodes, drowsiness in 15 episodes, and confusion in one episode. Conclusions: In the current study, IV-M was safe and effective for almost all episodes of BTP. This study shows that IV-M did not result in life-threatening adverse effects in terminal cancer pts, including older pts and those requiring relatively large doses.

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Breakthrough Pain in Patients with Lung Cancer. A Secondary Analysis of IOPS MS Study

Journal of Clinical Medicine ◽

10.3390/jcm9051337 ◽

2020 ◽

Vol 9 (5) ◽

pp. 1337

Author(s):

Sebastiano Mercadante ◽

Francesco Masedu ◽

Marco Valenti ◽

Federica Aielli

Keyword(s):

Lung Cancer ◽

Pain Intensity ◽

Breakthrough Pain ◽

Secondary Analysis ◽

Lung Cancers ◽

Future Studies ◽

Opioid Dose ◽

Background Pain ◽

The Mean ◽

Mean Time

Aim: To characterize breakthrough cancer pain (BTcP) in patients with lung cancer. Methods: This was a secondary analysis of multicenter study of patients with BTcP. Background pain intensity and opioid dose were recorded. The number of BTcP episodes, their intensity, predictability, onset, duration and interference with daily activities were collected. Opioids used for BTcP, the mean time to meaningful pain relief after taking medication, satisfaction and adverse effects were assessed. Results: 1087 patients with lung cancer were examined. In comparison with other tumors, patients with lung cancer showed: higher background pain intensity (p = 0.006), lower opioid doses (p = 0.005), higher intensity of BTcP (p = 0.005), movement (79.5%) and cough (8.2%), as principal triggers for predictable BTcP (p < 0.009), larger BTcP interference with daily activity (p = 0.0001), higher use of adjuvants (p = 0.0001). No relevant differences in the other parameters examined were found. Conclusion: Patients with lung cancer have their own peculiarities, including higher basal and BTcP pain intensity and the use of more adjuvant drugs for background pain. The most frequent triggers for predictable BTcP are movement and cough. Future studies should be performed to analyze the prevalence of BTcP in patients with different lung cancers as well as the optimal management strategy for background pain and BTcP.

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Intrathecal Analgesia Via a Percutaneous Port For the Management of Movement-Evoked Breakthrough Cancer Pain of Refractory Lower Extremity Cancer Pain: A Retrospective Review and Commentary

10.21203/rs.3.rs-885466/v1 ◽

2021 ◽

Author(s):

Liang Zhou ◽

Zhenggang Guo

Keyword(s):

Lower Extremity ◽

Cancer Pain ◽

Pain Intensity ◽

Breakthrough Pain ◽

Infusion Therapy ◽

The Mean ◽

Intractable Cancer Pain ◽

Time To Onset ◽

Morphine Equivalent ◽

Intrathecal Analgesia

Abstract Background and Objectives: Intrathecal analgesia (ITA) is a trusty treatment option for refractory and intractable cancer pain. However, there is still no general consensus on the analgesic effect of movement-evoked breakthrough pain (MEBTP) in the ITA setting. This study examined the effect of patient-controlled intrathecal analgesia (PCIA) on analgesic efficacy, emphasizing movement evoked breakthrough pain (MEBTP) in patients with refractory lower extremity cancer pain. Methods: A retrospective chart review included all patients with refractory lower extremity cancer pain who received Intrathecal morphine infusion therapy via percutaneous port (IMITPP) at our hospital between January 2017 and December 2020. Data on the numerical pain rating scales (NRS) scores, opioid doses, and complications were collected from medical records prior to IMITPP and at a one-month postimplant visit.Results: A total of 16 patients were included in the study group. Mean SRPI (spontaneous resting pain intensity) decreased from 8.75 pre- IMITPP to 3.75 post- IMITPP, (P < 0.001); mean MEPI (movement-evoked breakthrough pain intensity) fell from 8.83 pre- IMITPP to 4.25 post- IMITPP (P < 0.001); mean daily morphine equivalent dosing decreased from 360 mg/d to 48mg/d (P< 0.001); mean daily morphine equivalent dosing for MEBTP decreased from 87 mg/d to 6 mg/d (P< 0.001). Both total and breakthrough dosing of conventional opioid medications significantly decreased following the initiation of ITT with PCIA. The mean perceived time to onset with conventional movement evoked breakthrough medications was 38 minutes, and the mean perceived time to onset with PCIA was 8 minutes (P < 0.001). Conclusions: IMITPP was associated with improved pain control in patients with refractory lower extremity cancer pain. Compared with conventional MEBTP medication, appropriate PCIA provided superior analgesia and a much faster onset of action.

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Outcomes of a specialized interdisciplinary approach for cancer patients with aberrant opioid-related behavior: A preliminary report.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.31_suppl.212 ◽

2017 ◽

Vol 35 (31_suppl) ◽

pp. 212-212

Author(s):

Tonya Edwards ◽

Joseph Anthony Arthur ◽

Suresh Reddy ◽

Kristy Nguyen ◽

David Hui ◽

...

Keyword(s):

Pain Intensity ◽

Cancer Patients ◽

Interdisciplinary Approach ◽

Clinical Effectiveness ◽

Median Number ◽

Control Group ◽

Team Approach ◽

Post Intervention ◽

Care Clinic ◽

Opioid Dose

212 Background: Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in cancer patients is lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention. Methods: The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015 and August 31, 2016 were reviewed. Results: At baseline, pain intensity (p=0.002) and opioid dose (p=0.001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from 3 pre-intervention to 0.4 post-intervention (p<0.0001). The median morphine equivalent daily dose decreased from 165mg/day at the first intervention visit to 112mg/day at the last follow up (p=0.018) although pain intensity did not significantly change (p= 0.984). ‘Request for opioid medication refills in the clinic earlier than the expected time’ was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p<0.0001) and higher ESAS anxiety score (p=0.005) were independent predictors of the presence of AB. Conclusions: The intervention was associated with a reduction in the frequency of AB and opioid utilization among cancer patients receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention. [Table: see text]

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A Comparative Assessment of Postoperative Analgesic Efficacy of Lornoxicam versus Tramadol after Open Reduction and Internal Fixation of Mandibular Fractures

Craniomaxillofacial Trauma & Reconstruction ◽

10.1055/s-0037-1600901 ◽

2017 ◽

Vol 10 (3) ◽

pp. 171-174 ◽

Cited By ~ 1

Author(s):

Ankesh Dilip Jain ◽

VSM Ravisankar ◽

KSN Siva Bharani ◽

KM Sudheesh ◽

Nisha Tewathia

Keyword(s):

Adverse Effects ◽

Internal Fixation ◽

Pain Intensity ◽

Pain Control ◽

Open Reduction ◽

Opioid Analgesic ◽

Maxillofacial Surgery ◽

Analgesic Efficacy ◽

Mandibular Fractures ◽

Study Results

Pain after any surgical procedure is inevitable but can be controlled by administration of analgesics in most cases. Postoperative pain after surgical treatment of mandibular fractures can be treated by nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics. The purpose of this study is to critically compare the postoperative analgesic efficacy of small doses of intravenous TRAMADOL (opioid analgesic) versus LORNOXICAM (NSAID) in patients with mandibular trauma undergoing open reduction and internal fixation (ORIF) and to assess the presence of any adverse effects due to NSAID or opioid use. Forty adult ASA grade I–II patients with mandibular trauma, scheduled for ORIF under general anesthesia in the Department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere, were selected for the study. The patients were randomly assigned into a tramadol group (Group T) and a lornoxicam group (Group L) and were administered intravenous tramadol 50 mg and intravenous lornoxicam 8 mg, respectively, at specific postoperative intervals. Pain intensity was quantitatively assessed at the 2nd, 4th, 6th, 12th, and 24th postoperative hours using a visual analog scale of 10 cm. Adverse effects of the analgesics were also recorded and compared. Both the drugs resulted in a significant decrease in pain intensity from 2nd to 24th postoperative hours, but better pain control was observed in Group L at 24th postoperative hour. Only two patients experienced nausea and vomiting in Group T and one patient experienced gastric acidity in Group L. The comparative results clearly demonstrate that pain control by intravenous lornoxicam is significantly better than by intravenous tramadol at 24th postoperative hour after ORIF of mandibular trauma. Side effects produced by both the drugs were minor and had no apparent effect on the study results.

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Effect of Nebulized Morphine vs. Intravenous Morphine in Decreased Pain in Renal Colic Patient

Journal of Shahid Sadoughi University of Medical Sciences ◽

10.18502/ssu.v27i9.2309 ◽

2020 ◽

Author(s):

Mehrnaz Nikouyeh ◽

Mohammad ali Jafari nedoushan ◽

Mahmood Vakili ◽

Majid Hajimaghsoudi ◽

Mehdi Bagherabadi ◽

...

Keyword(s):

Pain Relief ◽

Pain Intensity ◽

Normal Saline ◽

Renal Colic ◽

Chi Square ◽

Mean Intensity ◽

Significant Difference ◽

Intravenous Morphine ◽

The Mean ◽

The Difference

Introduction: Renal colic refers to one or more acute and painful short-term attacks due to the movement and excretion of kidney stones. The aim of this study was to determine the effect of intravenous morphine and inhaled morphine on pain relief in renal colic patients. Methods: This clinical trial study was performed on 50 patients of Shahid Sadoghi Hospital and Shahid Rahnemoon Hospital with renal colic symptoms who were randomly divided into two groups. The first group received 5 mg intravenous morphine and 5 cc normal saline (placebo) and the second group received 10 mg inhaled morphine and 5 cc normal saline. Severity of pain was assessed at the time of emergency and onset of Visual Analog Scale and then questionnaires were completed at 10, 20 and 30 minutes intervals. The data through SPSS Inc., Chicago, IL; Version 16 and the Friedman, Mann-Whitney, and Chi-square tests were analyzed. Results: Our study showed the mean intensity of pain was 9.52±1.12 (nebulized) and 9.24±1.51 (intravenous) on admission without significant difference (p=0.46). After 10 minutes, mean pain intensity in both nebulized and intravenous groups was 7.76±1.3 and 6.68±2.03, respectively. There was a significant difference between the two groups (p=0.03). After 20 minutes, the mean pain intensity was 5.68±1.72 and 4.32±2.17, respectively, and the difference between the two groups was significant. After 30 minutes, the mean intensity of pain in two groups of nebulized and intravenous was 3.88±3.14 and 3.36±3.34, respectively. The difference between the two groups was not significant (p = 0.57).The mean pain intensity in the intravenous method was lower than the nebulized, but in the nebulized method it was showed a decreasing trend. Conclusion: Nebulized morphine relieves pain in the patients with renal colic, but pain relief is faster by intravenous morphine. Accordingly, this method is more preferred in renal colic patients.

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The use of anticoagulants in terminal cancer patients admitted in hospice center.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.e21503 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. e21503-e21503 ◽

Cited By ~ 1

Author(s):

Hyun Jeong Shim ◽

Ka-rham Kim ◽

Jun Eul Hwang ◽

Woo Kyun Bae ◽

Sang-Hee Cho ◽

...

Keyword(s):

Cancer Patients ◽

Hospice Care ◽

Clinical Signs ◽

Study Patient ◽

Cancer Center ◽

Terminal Cancer ◽

Care Clinic ◽

Terminal Cancer Patients ◽

The Mean ◽

The Impact

e21503 Background: Venous thromboembolism (VTE) is common in patients with cancer and the risk increases with advanced disease. However, no management guidelines exist specific to terminal cancer patients in hospice. We conducted a retrospective analysis to determine the patterns of anticoagulant use in hospice setting. Methods: We identified patients who were prescribed anticoagulants in the Hospice and Palliative Care Clinic at Jeonnam Regional Cancer Center from August 2008 to September 2016 in this study. Patient characteristics included age, gender, cancer diagnosis, length of hospice stay, type and duration of anticoagulation. Results: Of 1,494 consecutive patients who received hospice care in our center, 57 (3.8%) were prescribed ≥ 1 anticoagulants. Types of anticoagulants prescribed were; LMWH only (n = 44, 77.2%), warfarin only (n = 7, 12.3%), rivaroxaban (n = 2, 3.5%) and both LMWH and warfarin (n = 4, 7%). Indications for anticoagulation were DVT (n = 17, 29.8%), PTE (11 = 19.3%), clinical suspicion of DVT with leg swelling (n = 23, 40.4%) and atrial fibrillation (n = 6, 10.5%), respectively. The mean age was 65 years (range 28-84) and 37 (52.6%) were male. The mean age was 63.5 years in LMWH treated patients and 67 years in warfarin treated patients (p < 0.95). The median duration of hospice stay and anticoagulation use were 18.5 days and 11.2 days. The reasons for discontinuation of anticoagulants were bleeding (n = 8, 14%), no palliative benefit (n = 10, 17.5%) and clinical signs of impending death (n = 39, 68.4%). Conclusions: In this retrospective study, anticoagulants were used in highly selected patients. In the absence of specific evidence, decisions are difficult for clinicians to initiate and stop anticoagulation treatment in hospice patients with terminal cancer. Further research is needed to determine the impact of anticoagulation on outcomes, especially cost, quality of life and complications for cancer patients in hospice.

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Establishing the safety and efficacy of an opioid titration protocol

Journal of Opioid Management ◽

10.5055/jom.2005.0011 ◽

2005 ◽

Vol 1 (1) ◽

pp. 41

Author(s):

Nancy Wells, DNSc, RN ◽

Barbara Murphy, MD ◽

Stacey Douglas, MSN, RN ◽

Nancy Yelton, MSN, RN

Keyword(s):

Adverse Effects ◽

Pain Intensity ◽

Cancer Patients ◽

Fixed Dose ◽

Opioid Dose ◽

Study Nurse ◽

Standing Order ◽

Lower Pain ◽

Titration Protocol ◽

Study Physician

The primary goal of this single-group study was to determine the safety of a standard opioid titration order sheet to manage pain in ambulatory cancer patients. Secondary goals were to examine opioid toxicity and efficacy of this pain protocol.Twenty-seven patients who required fixed-dose opioids and who had uncontrolled pain were enrolled. All patients had their initial opioid dose titrated by the study physician using the opioid titration order sheet. Data were obtained by the study nurse during a weekly telephone interview and used to determine if pain was controlled. After initial titration, a trained study nurse titrated opioid doses based upon the standing order sheet. At each contact, patients were assessed for adverse effects, pain intensity, and analgesics used.Patients who completed the four-week trial (n = 17) did not differ from patients who did not complete the trial. No adverse effects were observed in 39 opioid titrations com-pleted by the study nurse. Opioid toxicities, worst pain, usual pain, and pain-related distress declined from baseline to week four. Patients who were adherent to their prescribed medications reported significantly lower pain intensity and distress (ps < 0.06).The opioid titration order sheet, used by a trained nurse, is safe to use in ambulatory cancer patients who have moderate to severe pain. Common opioid toxicities were reduced. The protocol also demonstrated initial efficacy in improving worst and usual pain and pain-related distress. Further research to establish efficacy of theprotocol is recommended.

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Continuous Intravenous Morphine Infusions for Terminal Pain Control: A Retrospective Review

Drug Intelligence & Clinical Pharmacy ◽

10.1177/106002808602001211 ◽

1986 ◽

Vol 20 (12) ◽

pp. 968-972 ◽

Cited By ~ 10

Author(s):

Glenda J. Stuart ◽

E. Bruce Davey ◽

Susan E. Wight

Keyword(s):

Adverse Effects ◽

Retrospective Review ◽

Medical Records ◽

Pain Control ◽

Terminal Cancer ◽

Dosage Calculation ◽

Intravenous Morphine ◽

Control Terminal ◽

Effective Use ◽

Infusion Duration

The continuous intravenous infusion of morphine may control terminal cancer pain unrelieved by conventional narcotic therapy. A retrospective review was conducted of the medical records of 79 terminal cancer patients who received a total of 84 intravenous morphine infusions. Data were recorded on morphine dosage, pain control, adverse effects, duration of infusion, and concomitant medication requirements. Infusion duration varied from less than 24 hours to 162 days (median: 7 days). Morphine dosage ranged from 0.5 to 300 mg/h. All patients experienced an improvement in baseline pain control; however, 54 percent required additional medication to enhance analgesia. Serious adverse effects, including marked sedation, hallucinations, diaphoresis, and respiratory depression, were recorded in 14 patients. These effects may be a reason for reducing the dose. Guidelines for the use of continuous intravenous morphine infusions are presented. Accurate pain assessment, morphine dosage calculation, and monitoring of adverse effects are essential to insure the safe and effective use of these infusions.

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Elimination of three doses of gentamicin over three consecutive days using a polyacrylonitrile-derived filter: An in vitro assessment

The International Journal of Artificial Organs ◽

10.1177/03913988211032236 ◽

2021 ◽

pp. 039139882110322

Author(s):

Frédéric J Baud ◽

Vanessa Seif ◽

Pascal Houzé ◽

Jean-Herlé Raphalen ◽

Benoît Pilmis ◽

...

Keyword(s):

Life Span ◽

Bolus Dose ◽

Central Compartment ◽

Daily Session ◽

Progressive Decrease ◽

Time Dependency ◽

Study Results ◽

In Vitro Assessment ◽

The Mean

Introduction: Adsorption of gentamicin in a polyacrylonitrile filter was previously evidenced in a session lasting 6 h using the NeckEpur model. We extended the study over three consecutive days to mimic the 72-h life span of a filter. Methods: Prismaflex® monitor and ST150® filter were used in the continuous diafiltration (CDF) mode at a 2.5 L/h flowrate. The daily session started with a 6-h session of CDF. Thereafter, the 5-L central compartment was changed using a bag free of gentamicin to assess gentamicin release over the following 18 h. Experiments were repeated on Day 2 and stopped at the end of the 6-h session of CDF on Day 3. The experiment was performed in duplicate. Results: At a 2.5 L/h diafiltration flowrate, the mean daily clearances of gentamicin were 5.5, 4.0, and 3.3 L/h, respectively. The mean diafiltration and adsorption ratios in the daily elimination of gentamicin were 32/68%, 58/42%, and 88/12%, respectively. During days 1 and 2, the mean amount of gentamicin released from the ST150® filter were 14 and 34 mg, respectively. Conclusion: The pharmacokinetics of gentamicin over 3 days is strongly altered by adsorption in the same filter with a progressive decrease of elimination by adsorption, suggesting saturation of the filter. One limitation of our study results from the mode of administration using a bolus dose instead of an infusion over 30 min. Adsorption adds a clearance to those of diafiltration. The time-dependency of gentamicin clearance precludes using a constant dosage regimen over the filter’s life span.

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