scholarly journals 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

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.

Relationship between time to onset of relief and total pain relief of breakthrough pain in patients with cancer using fentanyl pectin nasal spray.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. e19544-e19544
Author(s):  
John D. Conroy ◽  
Luis M. Torres ◽  
Julia Revnic ◽  
Ravi Tayi ◽  
Michael Sidney Perelman ◽  
...  
Keyword(s):  
Pain Relief ◽  
Pain Intensity ◽  
Nasal Spray ◽  
Breakthrough Pain ◽  
Controlled Trial ◽  
Rapid Onset ◽  
Dose Titration ◽  
Total Pain ◽  
Time To Onset ◽  
The Relationship

e19544 Background: Breakthrough pain in cancer (BTPc) is typified by a rapid onset of severe pain with a limited duration. Treatment for BTPc requires rapid onset of pain relief. The main purpose of this analysis was to assess the relationship between time to onset of pain relief and overall pain relief in patients treating BTPc with fentanyl pectin nasal spray (FPNS, Lazanda, PecFent). Methods: Data were pooled from FPNS-treated episodes of 2 randomized, double-blind, crossover studies assessing efficacy of FPNS in adults who experienced BTPc despite background pain that was adequately controlled with at least 60 mg/day morphine (or equivalent). Patients initially entered a dose-titration phase to establish dose of FPNS (100 to 800 mcg) to be used during the treatment phase of each study. Pain intensity (PI) was assessed at baseline and scheduled time points on an 11-point scale (0=no pain, 10=worst possible pain). This analysis assessed the relationship of time to onset of pain relief (≥1 point reduction in PI from baseline) to total pain relief (Summed Pain Intensity Difference [SPID] at 30 and 60 min postdose [SPID30 and SPID60]) by ANOVA. Responses are also provided for the placebo-treated episodes during the placebo-controlled trial. Results: There were 831 episodes of BTPc that were treated with FPNS. Mean SPID was highest when pain relief was earliest (p<0.001). When PI difference (PID) ≥1 was attained by 5, 10, and 15 min postdose, mean (SD) SPID30 scores were 13.1 (6.7), 7.6 (4.0), and 3.5 (1.8). In the placebo-controlled trial, a similar overall response (p<0.001) was observed during the 200 placebo-treated episodes: among those attaining PID ≥1 by 5, 10, and 15 min postdose, SPID30 was 12.2 (7.0), 5.3 (3.3), and 2.5 (1.0), respectively. Similarly, significant differences were observed for SPID60 with both treatments. Conclusions: Earlier time to onset of pain intensity reduction in BTPc treatment resulted in higher SPID at 30 and 60 minutes postdose of FPNS and placebo. Results suggest that early onset of relief may be associated with a greater overall degree of relief for episodes of BTPc, which emphasizes the need for rapid-acting agents in the management of breakthrough pain.

scholarly journals Peripheral and Neuraxial Chemical Neurolysis for the Management of Intractable Lower Extremity Pain in a Patient with Terminal Cancer

2015 ◽  
Vol 18;4 (4;18) ◽  
pp. E651-E656 ◽  
Author(s):  
Mario De Pinto
Keyword(s):  
Pain Relief ◽  
Lower Extremity ◽  
Cancer Pain ◽  
Femoral Nerve ◽  
Stage Iv ◽  
Left Lower Extremity ◽  
Complete Pain Relief ◽  
Adequate Pain Relief ◽  
Patient Reported ◽  
Intractable Cancer Pain

We present the case of a 74-year-old man with Stage IV metastatic, multifocal, malignant fibrous histiocytoma (T2b, N1, M1, G4) invading the proximal area of the left lower extremity and resulting in intractable neuropathic pain along the distribution of the femoral nerve. He described the pain as being so severe to cause inability to ambulate without assistance or to sleep in a supine or prone position. After a spinal cord stimulation trial and a trial of intrathecal (IT) hydromorphone, both performed at an outside institution, had failed to achieve adequate pain relief, we decided to perform a femoral nerve chemical neurolysis with phenol under ultrasound (US) guidance. The intervention provided 6 months of almost complete pain relief. With the tumor spreading in girth distally and proximally to the scrotal and pelvic areas as well as to the lungs, and pain returning back to baseline, we proceeded with a second femoral nerve chemical neurolysis. Unfortunately we were not able to achieve adequate pain relief. Therefore we opted to proceed with a diagnostic injection of local anesthetic under fluoroscopic guidance at the left L2, L3, and L4 nerve roots level. This intervention provided 100% pain relief and was followed, a few days later, by chemical neurolysis with phenol 3%. The patient reported complete pain relief with the procedure and no sensory-motor related side effects or complications. He was able to enjoy the last 6 weeks of life with his wife and family, pain-free. With this report we add to the limited literature available regarding the management of intractable cancer pain with chemical neurolysis in and around the epidural space. Key words: Cancer, pain, chemical neurolysis, peripheral, neuraxial

Deep Friction Massage in the Management of Patellar Tendinopathy in Athletes: Short-Term Clinical Outcomes

2020 ◽  
Vol 29 (7) ◽  
pp. 860-865 ◽  
Author(s):  
Paula Chaves ◽  
Daniela Simões ◽  
Maria Paço ◽  
Sandra Silva ◽  
Francisco Pinho ◽  
...  
Keyword(s):  
Muscle Strength ◽  
Pain Intensity ◽  
Significant Interaction ◽  
Small Sample ◽  
Patellar Tendinopathy ◽  
Knee Extensors ◽  
Mean Pressure ◽  
The Mean ◽  
Time To Onset ◽  
Over Time

Context: Deep friction massage (DFM) is often used in the treatment of tendinopathies; however, the pressure applied may vary and interfere with the obtained results. Objective: To assess whether the immediate effects of DFM on pain (pain intensity and time to onset of analgesia) and muscle strength are dependent on the pressure applied during the DFM application in athletes with patellar tendinopathy. Design: Randomized, controlled, cross-over trial. Setting: University research laboratory (institutional). Participants: Ten athletes with diagnosis of unilateral patellar tendinopathy (age 27.90 [5.24] y). Interventions: All participants attended 4 sessions, 3 treatment sessions with DFM applied with different pressures (the mean pressure—previously determined for each participant—and the mean pressure ± 25%) and a control session, each of which was separated by 48 hours. Main Outcome Measures: Pain (intensity upon palpation and time to onset of analgesia), and muscle strength of knee extensors were assessed before and immediately after each session. Results: Pain intensity changed significantly over time (F1,9 = 52.364; P < .001; ) and among sessions (F3,27 = 82.588; P < .001; ), with a significant interaction for group × time (F3,27 = 19.841; P < .001; ). The knee extensors strength did not change significantly over time (F1,9 = 2.240; P = .17; ), nor a significant interaction for session × time was observed (F3,27 = 3.276; P = .07; ). Regardless of the pressure applied, the time to onset of analgesia was not significantly different (F2,18 = 1.026; P > .05; ). Conclusion: It was shown that DFM induces an immediate reduction in pain intensity upon palpation, regardless of the pressure performed. Notwithstanding, the reader should take into account the small sample size and the caution needed in the results’ interpretation.

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

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.

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

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e20621-e20621
Author(s):  
Ik-Joo Chung ◽  
Sang-Hee Cho ◽  
Jun-Eul Hwang ◽  
Jae-Sook Ahn ◽  
Won-young Choi ◽  
...  
Keyword(s):  
Adverse Effects ◽  
Pain Intensity ◽  
Breakthrough Pain ◽  
Terminal Cancer ◽  
Care Clinic ◽  
Opioid Dose ◽  
Study Results ◽  
Intravenous Morphine ◽  
The Mean ◽  
Moderate Nausea

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.

Effectiveness of opioid rotation in the control of cancer pain: The ROTODOL Study

2014 ◽  
Vol 10 (6) ◽  
pp. 395 ◽  
Author(s):  
Jesús González-Barboteo, MD ◽  
Xavier Gómez-Batiste Alentorn, MD, PhD ◽  
Felipe A. Calvo Manuel, MD, PhD ◽  
Vicente Alberola Candel, MD ◽  
M. Amalia Palacios Eito, MD ◽  
...  
Keyword(s):  
Cancer Pain ◽  
Pain Intensity ◽  
Rating Scale ◽  
Breakthrough Pain ◽  
Numerical Rating Scale ◽  
Gastrointestinal Symptoms ◽  
Tertiary Hospital ◽  
Opioid Rotation ◽  
Average Pain ◽  
Control Pain

Objective: To assess the effectiveness of opioid rotation (OR) to manage cancer pain. To describe the adverse events (AEs) associated with OR. Setting: Thirty-nine tertiary hospital services.Patients: Sixty-seven oncological patients with cancer-related pain treated at outpatient clinics.Intervention: Prospective multicenter study. Pain intensity was scored using a Numerical Rating Scale (NRS) of 0-10. Average pain (AP) intensity in the last 24 hours, breakthrough pain (BTP), and the number of episodes of BTP on the days before and 1 week after OR were assessed. The pre-OR and post-OR opioid were recorded. The presence and intensity of any AEs occurring after OR were also recorded.Results: In the 67 patients evaluated, 75 ORs were recorded. In all cases, the main reason for OR was poor pain control. Pain intensity decreased by ≥2 points after OR in 75.4 percent and 57.8 percent of cases for AP and BTP, respectively. If the initial NRS score was ≥4, a decrease below <4 accounted for 50.9 percent and 32.3 percent of cases for AP and BTP, respectively. The number of episodes of BTP also decreased significantly (p < 0.001). A total of 107 AEs were reported, most of which were mild in intensity, with gastrointestinal symptoms predominating.Conclusions: Opioid rotation appears to be both safe and effective in the management of basal and breakthrough cancer pain.

scholarly journals The effect of breakthrough pain on heart and lung function during the cancer pain treatment in palliative care

2011 ◽  
Vol 1 (2) ◽  
pp. 103-109
Author(s):  
Samir Husić ◽  
Dženita Ljuca ◽  
Senad Izić ◽  
Hasan Karahasan
Keyword(s):  
Blood Pressure ◽  
Palliative Care ◽  
Lung Function ◽  
Cancer Pain ◽  
Respiratory Function ◽  
Pain Treatment ◽  
Breakthrough Pain ◽  
Systolic Pressure ◽  
Oral Morphine ◽  
The Mean

Introduction: The aim of the research was to determine the effect of breakthrough pain (BTP) on heart and lung function in patients whose cancer pain had been treated with strong opiates.Methods: A prospective study was conducted on 80 patients who were treated in recumbent patients’ hospice of Palliative Care Centre (hospice) University Clinical Centre Tuzla. The effect of pain breakthrough onheart function was monitored by blood pressure and pulse measuring outside. The effect on respiratory function was monitored by measuring the respiration number with SpO2 and pCO2 and pO2 capillary blood valuesoutside, during and after relieving pain breakthrough.Results: Mean value for Karnofsky score for patients upon admission was 47.13 ± 11.05 and on discharge 51.25 ± 11.73. The total number of pain breakthroughs for patients within the 10 days of the treatment was1396. During the pain breakthrough the mean of systolic pressure was 133.1 mmHg and it was statistically significantly higher than the mean of systolic pressure measured after BTP relief with oral morphine. Themean of diastolic pressure measured outside of pain breakthrough was 75.9 mmHg and after the BTP relief it was 72.9 mmHg. The mean pulse outside of pain breakthrough was 92.7 heartbeats per minute and afterthe BTP relief 8 9.1 heartbeats per minute.Conclusion: Pain breakthrough leads to pulse acceleration, increased systolic and diastolic blood pressure and it also affects respiratory function by accelerating the respiration

scholarly journals Ziconotide Adverse Events in Patients with Cancer Pain: A Multicenter Observational Study of a Slow Titration, Multidrug Protocol

2012 ◽  
Vol 5;15 (5;9) ◽  
pp. 395-403
Author(s):  
Denis Dupoiron
Keyword(s):  
Adverse Events ◽  
Cancer Pain ◽  
Initial Dosage ◽  
Oral Morphine ◽  
Intrathecal Therapy ◽  
High Dose ◽  
Serious Adverse Events ◽  
Patients With Cancer ◽  
Intractable Cancer Pain ◽  
Intrathecal Analgesia

Background: Ziconotide is a new analgesic agent administered intrathecally. It is challenging to use and can induce several and sometimes serious adverse events. A low initial dosage followed by slow titration may reduce serious adverse events. Objective: To determine whether a low starting dosage of ziconotide, followed by slow titration, decreases the incidence of major adverse events associated with ziconotide when used for intractable cancer pain. Study Design: Observational cohort study. Setting: Three French cancer centers. Methods: Patients with incurable cancer causing chronic pain rated above 6/10 on a numerical scale while receiving high-dose opioid therapy (more than 200 mg/d of oral morphine equivalent) and/or exhibiting severe opioid-related adverse events received intrathecal infusions of ziconotide combined with morphine, ropivacaine, and clonidine. Results: Seventy-seven patients were included. Adverse events were recorded in 57% of them; moderate adverse events occurred in 51%. Adverse events required treatment discontinuation in 7 (9%) including 5 (6%) for whom a causal role for ziconotide was highly likely; among them 4 (5%) were serious. All patients experienced a significant and lasting decrease in pain intensity (by 48%) in response to intrathecal analgesic therapy that included ziconotide. Limitations: Limitations include the nonrandomized, observational nature of the study. Determining the relative contributions of each drug to adverse events was difficult, and some of the adverse events manifested as clinical symptoms of a subjective nature. Conclusions: The rates of minor and moderate adverse events were consistent with previous reports. However, the rate of serious adverse events was substantially lower. Our study confirms the efficacy of intrathecal analgesia with ziconotide for relieving refractory cancer pain. These results indicate that multimodal intrathecal analgesia in patients with cancer pain should include ziconotide from the outset in order to provide time for subsequent slow titration. Key words: Ziconotide, adverse events, intrathecal therapy, cancer pain, morphine, ropivacaine, clonidine.

scholarly journals Analgesic Prescription Patterns and Pain Outcomes in Southeast Asia: Findings From the Analgesic Treatment of Cancer Pain in Southeast Asia Study

2018 ◽  
pp. 1-10 ◽  
Author(s):  
Dang Huy Quoc Thinh ◽  
Wimonrat Sriraj ◽  
Marzida Mansor ◽  
Kian Hian Tan ◽  
Cosphiadi Irawan ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Pain Management ◽  
Southeast Asia ◽  
Cancer Pain ◽  
Sleep Disturbance ◽  
Pain Intensity ◽  
The Past ◽  
Patient Reported ◽  
The Mean

Purpose To identify patterns of analgesic prescription and to explore patient-reported pain intensity, sleep disturbance, and quality of life among cancer patients with pain in Southeast Asia (SEA). Methods This cross-sectional observational study included 465 adult outpatients prescribed analgesics for cancer pain for 1 month or longer at 22 sites in Indonesia, Malaysia, Philippines, Singapore, Thailand, and Vietnam. Data on analgesic prescription and cancer characteristics were extracted from medical records. Pain intensity, sleep disturbance, and quality of life measures were recorded via questionnaires. Results Most patients (84.4%) had stage III or IV cancer. A total of 419 patients (90.7%) were prescribed opioids; of these, 42.2% received only weak opioids, whereas 57.8% received at least one strong opioid. The mean worst pain intensity during the past 24 hours was 4.76 (standard deviation [SD], 2.47) on a scale of 0 (no pain) to 10 (worst possible pain); the mean current pain intensity was 4.10 (SD, 2.61). More than half of patients (54.8%) reported sleep disturbance caused by pain in the past 7 days. The majority of patients reported problems with pain/discomfort (82.3%), usual activities (65.8%), mobility (58.2%), and anxiety/depression (56.3%). The median daily dose prescribed in oral morphine equivalents was 30 mg for both morphine and tramadol. Conclusion Despite unrelieved pain, sleep disturbance, and issues with quality of life, a notable proportion of patients were prescribed only weak opioids, and opioid doses prescribed were generally low. Efforts focused on encouragement of prescriptions with analgesic strength and/or doses proportional to the pain management needs of patients are vital to improve the status of cancer pain management in the region.

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