Intranasal dexmedetomidine: Procedural sedation in palliative care: A case report

Background: This report describes the use of intranasal dexmedetomidine to control incident pain and facilitate daily change of dressing in a patient with cutaneous breast cancer. Case presentation: A 45-year-old woman with extensive thoracic cutaneous metastatic bilateral breast cancer requiring daily 2-hour dressing changes to manage significant exudate. Pain during change of dressing was severe and unresponsive to usual analgesics. Deeper sedation was not an option as the patient was required to change position 1 hour into dressing change. Case management: Intranasal dexmedetomidine was administered 40 minutes prior to dressing change and provided effective rousable sedation and analgesia for the duration of the procedure. Case outcome: Dexmedetomidine provided rousable sedation, allowing the patient to follow commands and mobilise during the procedure. Pain was controlled. No adverse cardiovascular effects were noted with the use of intranasal dexmedetomidine. Conclusion: Intranasal dexmedetomidine is a potentially useful medication for procedural sedation in the management of complex wound dressings. It provides rousable short-term sedation, anxiolysis and analgesia. Further research into the role of intranasal dexmedetomidine to facilitate challenging dressing changes in a community setting is warranted.

Scrambler therapy for incident pain in bone metastases

Incident pain, described as pain induced by bone metastasis and produced by movement, can be devastating. The high doses of opioids needed to control such pain may sedate the patient and cause additional complications. Treatment of incident pain with pharmaceuticals has rarely been studied; only eight patients have been reported in the literature who did not receive additional opioids. We present the case of a 69 year old man with shoulder destruction due to bone metastases who was able to use his arm for normal activities without pain after three sessions of scrambler therapy, a noninvasive form of electrical neuromodulation that requires further study.

Paresthesia Predicts Increased Risk of Distal Neuropathic Pain in Older People with HIV-Associated Sensory Polyneuropathy

Objective Distal sensory polyneuropathy (DSP) is a disabling consequence of HIV, leading to poor quality of life and more frequent falls in older age. Neuropathic pain and paresthesia are prevalent symptoms, however there are currently no known curative treatments and the longitudinal course of pain in HIV-associated DSP is poorly characterized. Methods This was a prospective longitudinal study of 265 PWH enrolled in the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) study with baseline and 12-year follow-up evaluations. Since pain and paresthesia are highly correlated, statistical decomposition was used to separate the two symptoms at baseline. Multivariable logistic regression analyses of decomposed variables were used to determine the effects of neuropathy symptoms at baseline on presence and worsening of distal neuropathic pain at 12-year follow-up, adjusted for covariates. Results Mean age was 56 ± 8 years, and 21% were female at follow-up. Nearly the entire cohort (96%) was on antiretroviral therapy (ART) and 82% had suppressed (≤50 copies/mL) plasma viral loads at follow-up. Of those with pain at follow-up (n = 100), 23% had paresthesia at the initial visit. Decomposed paresthesia at baseline increased the risk of pain at follow-up (OR 1.56; 95% CI 1.18, 2.07), and decomposed pain at baseline predicted a higher frequency of pain at follow-up (OR 1.96 [1.51, 2.58]). Conclusions Paresthesias are a clinically significant predictor of incident pain at follow-up among aging PWH with DSP. Development of new therapies to encourage neuroregeneration might take advantage of this finding to choose individuals likely to benefit from treatment preventing incident pain.

Sleep disturbance as a moderator of the association between physical activity and later pain onset among American adults aged 50 and over: evidence from the Health and Retirement Study

ObjectiveTo examine whether sleep disturbance modifies the association between physical activity and incident pain.DesignProspective population-based study.SettingHealth and Retirement Study.ParticipantsAmerican adults aged ≥50 years who reported no troublesome pain in 2014 were re-assessed for pain in 2016. Of 9828 eligible baseline respondents, 8036 (82%) had complete follow-up data for adjusted analyses (weighted analysis population N=42 407 222).ExposuresPhysical activity was assessed via interview with questions about time spent in moderate and vigorous physical activity. Sleep disturbance, assessed using a modified form of the Jenkins Sleep Scale, was examined as a potential moderator.Main outcome measureTroublesome pain.ResultsIn weighted analyses, 37.9% of the 2014 baseline pain-free sample participated in moderate or vigorous physical activity once a week or less, with an overall mean Physical Activity Index Score of 9.0 (SE=0.12). 18.6% went on to report troublesome pain in 2016. Each one-point higher on the Physical Activity Index Score was associated with a reduced odds ratio (OR) of incident pain for those who endorsed sleep disturbance never/rarely (OR=0.97, 95% CI 0.94 to 0.99), but not for those who endorsed sleep disturbance sometimes (OR=0.99, 95% CI 0.97 to 1.01) or most of the time (OR=1.01, 95% CI 0.99 to 1.03). The analysis of possible interaction demonstrated that frequency of sleep disturbance moderated the physical activity and incident pain association (Wald test: p=0.02).ConclusionsThe beneficial association of physical activity on reduced likelihood of later pain was only observed in persons who endorsed low levels of sleep disturbance.

Transcutaneous electrical nerve stimulation for advanced cancer pain inpatients in specialist palliative care—a blinded, randomized, sham-controlled pilot cross-over trial

Purpose Transcutaneous electrical nerve stimulation (TENS) is a treatment option for cancer pain, but the evidence is inconclusive. We aimed to evaluate the efficacy and safety of TENS. Methods A blinded, randomized, sham-controlled pilot cross-over trial (NCT02655289) was conducted on an inpatient specialist palliative care ward. We included adult inpatients with cancer pain ≥ 3 on an 11-point numerical rating scale (NRS). Intensity-modulated high TENS (IMT) was compared with placebo TENS (PBT). Patients used both modes according to their preferred application scheme during 24 h with a 24-h washout phase. The primary outcome was change in average pain intensity on the NRS during the preceding 24 h. Responders were patients with at least a “slight improvement.” Results Of 632 patients screened, 25 were randomized (sequence IMT-PBT = 13 and PBT-IMT = 12). Finally, 11 patients in IMT-PBT and 9 in PBT-IMT completed the study (N = 20). The primary outcome did not differ between groups (IMT minus PBT: − 0.2, 95% confidence interval − 0.9 to 0.6). However, responder rates were higher in IMT (17/20 [85%] vs. 10/20 [50%], p = 0.0428). Two patients experienced an uncomfortable feeling caused by the current, one after IMT and one after PBT. Seven patients (35%) desired a TENS prescription. Women and patients with incident pain were most likely to benefit from TENS. Conclusion TENS was safe, but IMT was unlikely to offer more analgesic effects than PBT. Even though many patients desired a TENS prescription, 50% still reported at least “slight pain relief” from PBT. Differences for gender and incident pain aspects demand future trials.

General principles of management

Breakthrough pain is not a single entity, but a spectrum of very different entities. In most cases, the underlying cause of the pain is a direct effect of the cancer. There is emerging evidence to suggest certain oncological treatments may be effective in managing certain types of breakthrough pain. Optimal treatment of breakthrough pain depends on a variety of pain-related factors. Optimal treatment of breakthrough pain depends on a variety of patient-related factors. Avoidance or treatment of precipitating factors should be considered in patients with incident-type breakthrough pain. Movement-related/incident pain, secondary to metastatic bone disease, is a common phenomenon. Modification of the background analgesic regimen has been shown to be a useful approach in managing breakthrough pain. Multimodal approaches are often required. The cornerstone of the management of breakthrough pain episodes is the use of so-called rescue medication. The management of end-of-dose failure involves modification of the background analgesic regimen. The use of rescue medication depends on the type of breakthrough pain and acceptance depends on factors such as the route of administration of medication.

Non-opioid analgesics

Breakthrough pain is a heterogeneous condition. Non-opioid analgesics are a diverse group of drugs. Non-opioid analgesics may have a role in the management of breakthrough pain. Data on the use of most non-opioid analgesics is limited. Paracetamol and non-steroidal anti-inflammatory drugs are generally used as around-the-clock medication, although they may also be used as rescue medication. Systematic reviews of oral NSAIDs have confirmed benefits in cancer pain. Midazolam has been used in the treatment of refractory incident pain secondary to bone metastases and there is the potential for its use in the management of breakthrough pain secondary to muscle spasm. Ketamine is employed in anaesthetic doses in the management of procedural pain and in the management of predominantly non-malignant breakthrough pain. There is conflicting evidence for the use of nitrous oxide in the management of breakthrough pain.

The Patient with Difficult Cancer Pain

Most patients with cancer pain can be managed with relatively simple methods using oral analgesics at relatively low doses, even for prolonged periods of time. However, in some clinical conditions pain may be more difficult to manage. Various factors can interfere with a desirable and favorable analgesic response. Data from several studies assessing factors of negative pain prognosis have indicated that neuropathic pain, incident pain, psychological distress, opioid addiction, and baseline pain intensity were associated with more difficult pain control. In this narrative review, the main factors that make the therapeutic response to opioids difficult are examined.