A STUDY TO ASCERTAIN THE ADVERSE EFFECTS OF MORPHINE IN CANCER PATIENTS BEING TREATED FOR SEVERE PAIN

Pain is a distressing symptom of cancer that affects the quality of life of patients, families, and caregivers. Moderate to severe pain is common throughout the disease trajectory of cancer, and its prevalence increases throughout the course of illness, it has been reported in 59% of patients undergoing anticancer treatment, in 64% of those with advanced/metastatic cancer, and in 33% of those having completed curative treatment. Adequate management of cancer pain is the cornerstone of symptom management for patients with cancer. [1] WHO guidelines on cancer pain continue to provide a framework approach for pharmacologic management of cancer pain management in terms of a Pain Ladder, wherein Step 1 for mild pain is prescribed NSAIDS, Step 2 for moderate pain is prescribed NSAIDS along with synthetic opioids and adjuvants and step 3 for severe pain is prescribed strong opioids like Morphine along with NSAIDS and adjuvants. Morphine being an excellent analgesic for severe pain is nowadays standard of care for terminal cancer patients with severe pain. However, its potency is a double edged sword and can give rise to side effects as well as much feared adverse effects. This study was undertaken to assess the undesirable effects on cancer patients being treated with Morphine. AIM To find the association of morphine and its adverse effects (by 4 point verbal rating scale) in cancer patient on long term morphine therapy. MATERIAL AND METHODS It is a hospital based longitudinal observational study, conducted in palliative care center, SMS hospital, Jaipur, after obtaining due approval from ethics committee and research review board of the institution. DURATION OF STUDY: One year. TOTAL PATIENTS: 30 patients evaluated one month after initiation of opioid therapy. ELIGIBILITY CRITERIA: Inclusion criteria 1. Cancer patients visiting palliative care OPD for distressing, somatic symptom like pain requiring treatment with strong opioids (step 3 WHO ladder). 2. Patients of all ages and both sexes. 3. Patients willing to give informed consent 4. Patients who understand the four point symptom rating scale. Exclusion Criteria: 1. Patients with deranged liver and kidney functions. 2. Patient with predominantly neuropathic pain. 3. Patients with altered sensorium. 4. Patient not willing to give informed consent.

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Analysis of Severe Pain and its Treatment in a Palliative Care Unit in a Regional Cancer Centre

IRA-International Journal of Applied Sciences (ISSN 2455-4499) ◽

10.21013/jas.v7.n3.p1 ◽

2017 ◽

Vol 7 (3) ◽

pp. 103

Author(s):

Kannan P ◽

Gunaseelan K ◽

Parthasarathy V

Keyword(s):

Palliative Care ◽

Cancer Pain ◽

Pain Score ◽

Cancer Patients ◽

Severe Pain ◽

Palliative Care Unit ◽

Cancer Centre ◽

Prevalence Of Pain ◽

Regional Cancer Centre

Objective: Pain is one of the most common symptoms that troubles cancer patients and precludes satisfactory quality of life. Globally, nearly 80% of the cancer patients receive little or no pain medication and cancer pain is barely controlled. This study was done to analyse the prevalence of pain and pain treatment in patients presenting to palliative care unit in a regional cancer centre. Methods: Palliative care registry and follow-up forms of 2142 patients who got registered in our palliative care unit were analysed to obtain the demographic details, treatment characteristics and to determine the prevalence of pain, its severity, and treatment in cancer patients in our regional cancer centre. Results: Nearly 50% of the cancer population had head and neck and gastrointestinal tract malignancies and received only best supportive care. Stage IV disease was found in 40% of patients, and skeletal metastasis (52%) was most common. This study showed a 92.4% prevalence of cancer pain in our centre. About 40% of patients with pain had a pain score of 7-10 by Numerical rating scale on initial presentation to the palliative care unit. About 65% of the patients with severe pain had a response to treatment withmorphine during their first follow-up to palliative care unit after initial registration. The average overall pain score of the patients per visit decreased from around 7 to 4 at a median follow-up of ten months. Significance of results: Thus, there is a high prevalence of pain in cancer patients and patients with severe pain receive little or no opioid medication at all probably due to the lack of adequate education and training to the primary oncologists and residents regarding prescription of strong opioids. This audit may help in the modification of existing and formulation of new policies in the delivery of palliative care.

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Opioid titration with sustained-release oxycodone and immediate-release morphine for moderate/severe cancer pain: A pilot assessment of the CoDem protocol

Journal of Opioid Management ◽

10.5055/jom.2014.0189 ◽

2014 ◽

Vol 10 (1) ◽

pp. 29 ◽

Cited By ~ 6

Author(s):

Boaz Gedaliahu Samolsky Dekel, MD, PhD, MA ◽

Marco Tomasi, MD ◽

Alessio Vasarri, MD ◽

Alberto Gori, MD ◽

Marco Adversi, MD ◽

...

Keyword(s):

Adverse Effects ◽

Sustained Release ◽

Cancer Pain ◽

Rating Scale ◽

Pain Treatment ◽

Numerical Rating Scale ◽

Immediate Release ◽

Rescue Dose ◽

Numerical Rating ◽

Strong Opioids

Objectives: Opioid titration is the first challenging stage for rapid control of moderate/severe cancer pain. Evidence shows that sustained-release formulations may be used for opioid titration. We set a pilot assessment of the efficacy and tolerability of our in-house protocol (continuous and on demand opioids [CoDem]) of the association of sustained-release oxycodone and immediate-release morphine as rescue dose for opioid titration/rotation in opioid-naïve (NAOP, n = 13), tolerant to weak (WOP, n = 20), or strong opioids (STOP, n = 44) in-patients with moderate/severe cancer pain.Methods: Observational and retrospective analysis of cancer in-patients treated for ≥7 days with the CoDem protocol.Outcome measures: Pain intensity (patients self-reported pain with numerical rating scale [NRS] under static [NRSs] and dynamic [NRSd] conditions), amount of drug consumption, opioid adverse effects, and patient satisfaction.Efficacy endpoints: In more than 50 percent of the patients and in <72 hours, steady NRSs and NRSd score reduction of at least two points, NRSs ≤ 3 and NRSd ≤4; and mean daily morphine consumption < mean of one rescue dose and t1:t6 ratio of mean oxycodone daily dose < 1:2.Results: Endpoints were reached within 24 hours both within the sample and subgroups. Only NAOP patients reached NRSd ≤ 4 endpoint within 48 hours. Against moderate and transient adverse effects, most patients (84.4 percent) found pain treatment to be good or excellent.Conclusions: The CoDem protocol was shown to be effective and reasonably tolerated for titration for moderate/severe cancer pain relief in both opioid-naïve or opioid-tolerant cancer in-patients. This pilot assessment warrants prospective and comparative studies with larger samples for more generalized results.

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Effectiveness of rapid titration with intravenous administration of oxycodone injection in advanced cancer patients with severe pain

Japanese Journal of Clinical Oncology ◽

10.1093/jjco/hyz145 ◽

2019 ◽

Vol 49 (11) ◽

pp. 1061-1064

Author(s):

Nobuhisa Nakajima

Keyword(s):

Pain Relief ◽

Adverse Effects ◽

Cancer Patients ◽

Advanced Cancer ◽

Severe Pain ◽

Rating Scale ◽

Numeric Rating Scale ◽

Advanced Cancer Patients ◽

Morphine Group ◽

Time Required

Abstract Some cancer patients suddenly develop severe, excruciating pain that requires rapid management using opioid medication. This study aimed to evaluate the effectiveness of rapid titration using oxycodone injection. Study subjects were advanced cancer patients who experienced severe pain (numeric rating scale ≥7) and needed prompt pain relief. Primary endpoint was (i) time required for the initial sign of significant analgesia to become evident. Secondary endpoints were (ii) pain relief stabilization success rate and (iii) adverse effects. Groups treated with oxycodone (oxycodone group) and morphine (morphine group) were retrospectively compared. The oxycodone group had 33 cases and the morphine group had 32 cases: (i) 15.6 ± 4.3 min in the oxycodone group and 19.3 ± 4.7 min in the morphine group (P = 0.001); (ii) 70 and 63% within 24 hours, and 88 and 84% within 48 hours in the oxycodone group and the morphine group, respectively (P = 0.36, 0.48). Although (iii) adverse effects appeared in both groups in the form of respiratory suppression, etc., the effects were mild. Rapid titration using oxycodone injections may be considered a beneficial choice.

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The PROVIEW+ tool: Developing and validating a tool to predict risk of poor performance status and severe symptoms in cancer patients over time.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.12095 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 12095-12095

Author(s):

Hsien Seow ◽

Rinku Sutradhar ◽

Lisa Catherine Barbera ◽

Peter Tanuseputro ◽

Dawn Guthrie ◽

...

Keyword(s):

Decision Making ◽

Palliative Care ◽

Cancer Patients ◽

Severe Pain ◽

Performance Status ◽

Well Being ◽

Assessment System ◽

Low Performance ◽

Performance Scale ◽

Over Time

12095 Background: There are numerous predictive cancer tools that focus on survival. However, no tools predict risk of low performance status or severe symptoms, which are important for patient decision-making and early integration of palliative care. The aim of this study was to develop and validate a model for all cancer types that predicts the risk for having low performance status and severe symptoms. Methods: A retrospective, population-based, predictive study using linked administrative data from cancer patients from 2008-2015 in Ontario, Canada. Patients were randomly selected for model derivation (60%) and validation (40%). The derivation cohort was used to develop a multivariable logistic regression model to predict the risk of having the reported outcomes in the subsequent 6 months. Model performance was assessed using discrimination and calibration plots. The main outcome was low performance status using the Palliative Performance Scale. Secondary outcomes included severe pain, dyspnea, well-being, and depression using the Edmonton Symptom Assessment System. Outcomes were recalculated after each of 4 annual survivor marks. Results: We identified 255,494 cancer patients (57% female; median age of 64; common cancers were breast (24%) and lung (13%)). At diagnosis, the risk of having low performance status, severe pain, well-being, dyspnea, and depression in 6-months is 1%, 3%, 6%, 13% and 4%, respectively for the reference case (i.e. male, lung cancer, stage I, no symptoms). Generally these covariates increased the outcome risk by > 10% across all models: obstructive lung disease, dementia, diabetes; radiation treatment; hospital admission; high pain; depression; Palliative Performance Scale score of 60-10; issues with appetite; or homecare. Model discrimination was high across all models. Conclusions: The model accurately predicted changing cancer risk for low performance status and severe symptoms over time. Providing accurate predictions of future performance status and symptom severity can support decision-making and earlier initiation of palliative care, even alongside disease modifying therapies.

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Amitriptyline in Neuropathic Cancer Pain in Patients on Morphine Therapy: A Randomized Placebo-controlled, Double-blind Crossover Study

Tumori Journal ◽

10.1177/030089160208800310 ◽

2002 ◽

Vol 88 (3) ◽

pp. 239-242 ◽

Cited By ~ 69

Author(s):

Sebastiano Mercadante ◽

Edoardo Arcuri ◽

Walter Tirelli ◽

Patrizia Villari ◽

Alessandra Casuccio

Keyword(s):

Quality Of Life ◽

Neuropathic Pain ◽

Adverse Effects ◽

Cancer Pain ◽

Pain Intensity ◽

Cancer Patients ◽

Double Blind ◽

Blind Crossover Study ◽

Double Blind Crossover Study

Aims and Background Amitriptyline is the most common analgesic adjuvant used in cancer patients with neuropathic pain, even though no specific studies have demonstrated a benefit. A randomized placebo-controlled, double-blind crossover study was designed to evidence the effects of amitriptyline in patients with neuropathic cancer pain. Methods Sixteen advanced cancer patients with neuropathic pain on systemic morphine therapy, no longer receiving oncologic treatment, presenting moderate pain (about 4 or more, but less than 7, on a numerical scale of 0-10) in the last week, and given a stable morphine dose in the last 2 days were admitted to the study. During the first week of study, patients were administered 25 mg of amitriptyline or equivalent drops of placebo at night for 3 days and 50 mg for the following 4 days. Doses for patients aged more than 65 years were 15 mg (first 3 days) and 30 mg (3 days after). After a week, a crossover took place for the second week, with the other treatment at an inverse sequence. Opioid consumption, pain intensity, symptoms and adverse effects, mood, sleep, patient's preference, quality of life before starting the study, the first week after and the second week after were recorded. Results No significant benefits in analgesia were found in the global pain intensity of the previous week of treatment, the least pain intensity or the pain evaluated just after a week of treatment, at the moment of the visit, when amitriptyline was compared with placebo. A significant difference was evidenced for the worst pain (P < 0.035). No differences in opioid doses during the period of study were found. Drowsiness, confusion and dry mouth were significantly more intense with amitriptyline than with placebo (P < 0.036, 0.003, and 0.034, respectively). There were no substantial differences between the two treatments in Spitzer's quality of life score and for each item. No differences in patients' preference for the two treatment periods were found. The analgesic effects of amitriptyline were slight and associated with adverse effects. Conclusions In light of the results obtained in the study, the extensive use of the drug for cancer pain should be questioned.

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Tailoring of neurosurgical ablative procedures in the management of refractory cancer pain

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101566 ◽

2020 ◽

Vol 45 (9) ◽

pp. 696-701

Author(s):

Uri Hochberg ◽

Asaf Berger ◽

Miri Atias ◽

Rotem Tellem ◽

Ido Strauss

Keyword(s):

Pain Relief ◽

Cancer Pain ◽

Rating Scale ◽

Numerical Rating Scale ◽

Treatment Plan ◽

Metastatic Cancer ◽

Spinothalamic Tract ◽

Pain Syndromes ◽

Intractable Cancer Pain ◽

Ablative Procedures

IntroductionNeurosurgical ablative procedures can offer immediate and effective pain relief for patients suffering from refractory cancer pain. However, choosing the appropriate procedure for each patient may not be straightforward and warrants an interdisciplinary approach. The purpose of the current study was to evaluate the outcome of patients with cancer who were carefully selected for neurosurgical intervention by a dedicated interdisciplinary team composed of a palliative physician and nurse practitioner, a pain specialist and a neurosurgeon.MethodsA retrospective review was carried out on all patients who underwent neurosurgical ablative procedures in our institute between March 2015 and September 2019. All patients had advanced metastatic cancer with unfavorable prognosis and suffered from intractable oncological pain. Each treatment plan was devised to address the patients’ specific pain syndromes.ResultsA total of 204 patients were examined by our service during the study period. Sixty-four patients with localized pain and nineteen patients with diffuse pain syndromes were selected for neurosurgical interventions, either targeted disconnection of the spinothalamic tract or stereotactic cingulotomy. Substantial pain relief was reported by both groups immediately (cordotomy: Numerical Rating Scale (NRS) 9 ≥1, p=0.001, cingulotomy: NRS 9 ≥2, p=0.001) and maintained along the next 3-month follow-up visits.ConclusionsAn interdisciplinary collaboration designated to provide neurosurgical ablative procedures among carefully selected patients could culminate in substantial relief of intractable cancer pain.Trial registration numberIR0354-17.

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Comorbidity and survival in cancer patients receiving palliative care

Journal of Clinical Oncology ◽

10.1200/jco.2007.25.18_suppl.9066 ◽

2007 ◽

Vol 25 (18_suppl) ◽

pp. 9066-9066

Author(s):

V. T. Chang ◽

N. Sambamoorthi ◽

B. Zhou ◽

H. Yan ◽

M. L. Gonzalez ◽

...

Keyword(s):

Palliative Care ◽

Cancer Patients ◽

Advanced Cancer ◽

Rating Scale ◽

Cox Regression ◽

Early Stage ◽

Karnofsky Performance Status ◽

Performance Status ◽

Survival Analyses ◽

Comorbidity Index

9066 Background: Comorbidity has received increasing attention in the assessment of patients with early stage cancer, or at diagnosis. We studied whether three indices of comorbidity, the Charlson Comorbidity Index (CMI), the Cumulative Illness Rating Scale (CIRS), and the Kaplan Feinstein Index (KFI) add prognostic information for cancer patients receiving palliative care. Methods: In an IRB approved protocol, 103 patients with advanced cancer were seen at the time they were starting palliative care. They had a Karnofsky Performance Status (KPS) determination, and were followed longitudinally. Comorbidity scores were coded from the medical record. At this time, all patients had died and survival analyses were performed. Results: The median age was 69 years (range 41–87), median Karnofsky Performance Status (KPS) was 70% (range 20–90); primary sites were lung 41 pts (40%), prostate 23pts (22%), colorectal 10 pts (10%), other cancers 29 pts (28%). Median survival was 111 days (range 4–1,145 days). Median CMI was 10 (range 4–14), CIRS15 4 (2–5), CIRS16 9 (4–12), CIRS17 2.3 (1.5–3.33), CIRS18 1 (0–3), KFI 2 (0–3). In univariate survival analyses, when bisected by median values, the KPS, age, CMI, and subscales of the CIRS (CIRS 16, CIRS 17, CIRS18) were significantly related to survival, but not the KFI. In multivariate Cox regression analyses that included KPS (p<0.0001) and age (p<0.003) and a comorbidity index, the CMI (p<0.0001), and certain subscales of the CIRS were independently predictive of survival, specifically the CIRS 15 (p<0.0001), CIRS16 (p<0.0001), CIRS 17 (p<0.0001), and CIRS18 (p<0.0001). The primary site was not an independent survival predictor. Conclusion: In patients with advanced cancer receiving palliative care, measures of comorbidity may contribute to refining estimates of prognosis and ultimately to health care resource utilization. The optimal comorbidity measure remains to be determined. These results will be confirmed in larger populations. Supported in part by the Soros Open Society Institute Project Death in America and VA HSRD IIR 02–103 No significant financial relationships to disclose.

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High-flow oxygen (HFO) and bilevel positive airway pressure (BiPAP) for refractory dyspnea in patients with advanced cancer: A randomized controlled trial.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.9611 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 9611-9611

Author(s):

David Hui ◽

Margarita Morgado ◽

Gary B. Chisholm ◽

Laura Withers ◽

Quan Nguyen ◽

...

Keyword(s):

Adverse Effects ◽

Cancer Patients ◽

Advanced Cancer ◽

Rating Scale ◽

Rank Test ◽

Randomized Controlled ◽

Bilevel Positive Airway Pressure ◽

High Flow Oxygen ◽

Before And After ◽

Physiologic Parameters

9611 Background: Dyspnea is one of the most common and distressing symptoms in cancer patients. Few treatments are evidence based because research in this area is difficult. The role of HFO and BiPAP in the palliation of severe refractory dyspnea has not been well characterized.We examined the changes in dyspnea, physiologic parameters and adverse effects in patients receiving HFO and BiPAP. Methods: In this phase II “pick the winner” randomized trial, we assigned hospitalized advanced cancer patients with refractory dyspnea to either HFO or BiPAP for 2 hours. We assessed dyspnea with the numeric rating scale (NRS) and modified Borg scale (MBS) before and after intervention. We also documented the vital signs, transcutaneous carbon dioxide and adverse effects. We used the sign rank test to compare before and after each intervention, and the Wilcoxon rank sum test to compare between arms with intention-to-treat analysis. Results: Thirty patients were enrolled (1:1 ratio) and 23 (77%) completed the assigned intervention. The median baseline dyspnea NRS was 7/10 (Q1-Q3 5-8), despite being on supplemental oxygen and opioids. Both HFO and BiPAP were associated with significant improvement in dyspnea after 2 h, with no differences detected between arms (Table). We observed prolonged dyspnea relief in 6 patients 1 h after completion of the study intervention. HFO improved oxygen saturation. No adverse effects were observed. Conclusions: HFO and BiPAP alleviated dyspnea, improved physiologic parameters and were safe. Our results justify larger randomized controlled trials to confirm these findings. Clinical trial information: NCT01518140. [Table: see text]

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Level of Stress and Adapting approaches among Caretakers of Cancer Patients receiving Palliative Care

International Journal of Research in Pharmaceutical Sciences ◽

10.26452/ijrps.v10i4.1619 ◽

2019 ◽

Vol 10 (4) ◽

pp. 3182-3185

Author(s):

Jagadeeswari J ◽

Prathap Mohan M

Keyword(s):

Palliative Care ◽

Cancer Patients ◽

Rating Scale ◽

Sampling Technique ◽

Structured Interview ◽

Hindu Religion ◽

Multistage Sampling ◽

And Training ◽

Day By Day ◽

Moderate Stress

Cancer influences the patients as well as his/her whole house. Managing Cancer patients is a regular task of handling them. In the expansion of making stress to the clients, it puts monetary, individual, stress and social disturbance to the relatives. The study focuses on evaluating the level of stress and Adapting approaches among Caretakers of Cancer Patients receiving Palliative Care. A descriptive study was conducted among caretakers of cancer patients receiving palliative care, Data were assembled using self-administered stress rating scale, COPE inventory, and structured interview schedule. Multistage sampling technique was adopted. The sample size was 60. The outcomes demonstrated that 72% of the members were females, and 28% of them were placed with the age bunch of 51 and 60 years. 52% of them belong to the Hindu religion, and 41% were jobless. 63% of the patients were reliant on relatives for all tasks of day by day living. Evaluation of stress uncovered that 85% of the members had moderate stress, and 15% had severe stress. Members received both negative and positive adapting. There was a huge negative connection (r = 0.80, P = 0.01) among stress and adapting. Palliative care is stressful, testing and can affect the parental figure's physical, enthusiastic, mental, and social prosperity. Comprehension lived encounters of caretakers of cancer patients receiving palliative care is significant for the health personnel's to improve the help, direction, and training given to the caretakers of cancer patients receiving palliative care.

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Different semantic and affective meaning of the words associated to physical and social pain in cancer patients on early palliative/supportive care and in healthy, pain-free individuals

PLoS ONE ◽

10.1371/journal.pone.0248755 ◽

2021 ◽

Vol 16 (3) ◽

pp. e0248755

Author(s):

Eleonora Borelli ◽

Sarah Bigi ◽

Leonardo Potenza ◽

Fabrizio Artioli ◽

Sonia Eliardo ◽

...

Keyword(s):

Supportive Care ◽

Cancer Pain ◽

Cancer Patients ◽

Metastatic Cancer ◽

Survey Study ◽

Emotional Impact ◽

Physical Pain ◽

Social Pain ◽

Cross Sectional Survey ◽

Pain Experience

Early palliative/supportive care (ePSC) is a medical intervention focused on patient’s needs, that integrates standard oncological treatment, shortly after a diagnosis of advanced/metastatic cancer. ePSC improves the appropriate management of cancer pain. Understanding the semantic and emotional impact of the words used by patients to describe their pain may further improve its assessment in the ePSC setting. Psycholinguistics assumes that the semantic and affective properties of words affect the ease by which they are processed and comprehended. Therefore, in this cross-sectional survey study we collected normative data about the semantic and affective properties of words associated to physical and social pain, in order to investigate how patients with cancer pain on ePSC process them compared to healthy, pain-free individuals. One hundred ninety patients and 124 matched controls rated the Familiarity, Valence, Arousal, Pain-relatedness, Intensity, and Unpleasantness of 94 words expressing physical and social pain. Descriptive and inferential statistics were performed on ratings in order to unveil patients’ semantic and affective representation of pain and compare it with those from controls. Possible effects of variables associated to the illness experience were also tested. Both groups perceived the words conveying social pain as more negative and pain-related than those expressing physical pain, confirming previous evidence of social pain described as worse than physical pain. Patients rated pain words as less negative, less pain-related, and conveying a lower intense and unpleasant pain than controls, suggesting either an adaptation to the pain experience or the role played by ePSC in improving patients’ ability to cope with it. This exploratory study suggests that a chronic pain experience as the one experienced by cancer patients on ePSC affects the semantic and affective representation of pain words.

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