Ongoing controversies in the pharmacological management of cancer pain.

Pain management remains a problem in advanced cancer. Despite the ready availability of effective analgesia and good evidence to support the prescription of medications, concerns continue over the safety of this practice. The aim of the present paper was to review often-raised questions when considering the use of opioids, especially in cancer pain, to ascertain the levels of evidence that already exist to support opioid-prescribing practice and to identify areas where further research is needed.

Asking questions can help: development and preliminary evaluation of a question prompt list for palliative care patients.

Question prompt lists (QPLs) have been shown to be an inexpensive and effective communication tool for patients in oncology consultations. We aimed to develop and pilot a QPL for palliative care (PC) patients. In order to identify suitable questions for inclusion in the QPL, we conducted focus groups and individual interviews with 19 patients, 24 carers and 22 PC health professionals. A further 21 health professionals reviewed the draft document. The draft QPL was piloted in 23 patients. In total, 112 questions were identified and grouped into eight categories. All participants felt that the QPL, in booklet form, could be a useful tool. Out of 23 patients in the pilot study, 22 agreed that the QPL was helpful, contained useful questions, was easy to understand and would be useful in the future. State anxiety (STAI) decreased after receiving the booklet and seeing the doctor in 16 out of 19 patients (overall anxiety decreased by a median of 8, IQR 1-13). Participants in the pilot study endorsed the inclusion of end-of-life issues in the QPL, despite some reservations expressed about this by health professionals in the individual interviews. We have identified a specific QPL that might facilitate useful dialogue between PC patients and their doctor. The QPL has strong support from patients, their carers and relevant health professionals.

Independent prospective validation of the PaP score in terminally ill patients referred to a hospital-based palliative medicine consultation service.

The aim of this prospective study was to validate the Palliative Prognostic (PaP) Score in a population of hospitalized patients in Australia in order to determine its applicability in a different setting to that in which it was originally developed. Individual PaP scores were calculated for 100 terminally-ill patients consecutively referred to a palliative medicine consultation service based in a university teaching hospital. The PaP score was able to subdivide this heterogeneous patient population into three groups, the differences being highly statistically significant. Median survivals for the three groups were, respectively, 60 days (95% confidence interval 41-89 days), 34 days (25-40), and 8 days (2-11). The percentage survival at 30 days for the three groups was 66%, 54%, and 5% respectively. These data suggest that the PaP scoring system is a reasonably robust method for prognostication in advanced cancer that appears to be independent of the setting. The short survival of the third group in this study, which is consistent with the presence of a subset of gravely ill patients within the hospital setting who are referred to specialist palliative care services very late in the course of their illness, raises important issues for the care and treatment of these individuals.

Can we do better in end-of-life care? The mixed management model and palliative care.

The increasing duration of life from disease diagnosis to death in cancer and chronic non-malignant illnesses argues for a revised approach to end-of-life care that incorporates the principles of palliative care from an earlier stage (ie, a stage at which curative and/or life-prolonging treatments are still being provided). The provision of active treatment and comfort measures/death preparation in parallel has been called the "mixed management model" of end-of life care.

Pain in patients with HIV infection: issues for the new millennium.

Pain is a common problem in people infected with the human immunodeficiency virus (HIV), particularly when they develop the acquired immune deficiency syndrome (AIDS). Until recently AIDS was a progressive fatal illness with a short prognosis, so the assessment and treatment of AIDS-related pain was logically based on the approach taken for the management of cancer pain. The cancer pain paradigm may no longer be appropriate for pain in patients with HIV infection, however, because the natural history of HIV disease has been transformed into a chronic illness by highly active anti-retroviral therapy (HAART), available since the late 1990s. In resource-poor countries of the Asia Pacific region where access to HAART is limited, the cancer pain paradigm may still be relevant. In this paper, the clinical characteristics of pain in HIV disease are described, along with current approaches to assessment and treatment. These are compared and contrasted with the characteristics, assessment and treatment of cancer pain. Data are presented which emphasize these similarities and differences, and highlight the need for a multidisciplinary, comprehensive approach to managing pain in HIV disease, now a chronic illness. There is a great need for more research on HIV-related pain in the HAART era.

Pain management in palliative care. Reviewing the issues.

BACKGROUND: Cancer pain remains significantly undertreated despite being one of the most prevalent and feared symptoms associated with cancer. Approximately 90% of patients can have their cancer pain controlled through relatively simple measures. OBJECTIVE: The aim of this review is to facilitate the current optimal approach to the assessment and management of cancer pain within the context of the multidimensional nature of the pain experience. DISCUSSION: Each component of the pain experience is addressed using a four point approach to pain and involves pharmacological and nonpharmacological measures. The general practitioner's role is pivotal in optimal cancer pain management. This is the first of two articles by Kiran Virik and Paul Clare on pain management in palliative care. The second, outlining treatment options, will appear in the December issue of Australian Family Physician.

Subcutaneous emphysema in advanced cancer.

Spontaneous subcutaneous emphysema is a rare and usually benign entity that may occasionally be symptomatic. We report a case of a patient with advanced cancer who developed extensive but asymptomatic subcutaneous emphysema shortly before death. Perforation of the lower gastrointestinal tract, perhaps as a result of straining due to severe unrelieved constipation or due to fistula formation, is suspected to have been the mechanism. The causes, treatment, and implications for management of this condition are discussed.

Pain management in palliative care. Morphine and the 'new' opioids in 2000.

BACKGROUND: Although morphine is the mainstay of pharmacological therapy in cancer pain, it remains feared and suboptimally used. Different formulations and the advent of 'new' opioids facilitate the attainment of pain control. OBJECTIVE: To clarify the current role of various opioids including morphine in the management of cancer pain. To provide a practical framework to guide 'best practice' opioid use in a general practice setting. DISCUSSION: The optimal application of opioids is governed by their clinical pharmacology and hindered by unfounded fears and misunderstanding. Different formulations within different types of opioids augment a favourable balance in the pain relief versus adverse effects equation and used within a four point approach, should serve to deliver optimal pain control.

Use of a metallic stent for relief of symptoms caused by superior vena caval obstruction in a patient with advanced cancer: a case report.

This report describes the insertion of a metallic stent in the superior vena cava to relieve the symptoms of malignant superior vena caval obstruction in a 75-year-old woman with far-advanced lung cancer in whom other methods of symptom control had been ineffective. Her symptoms were quickly relieved by insertion of the stent. She died 1 month following the procedure, without recurrence of the symptoms. The technical aspects of the procedure and the issues affecting the clinical decision-making process in this case are discussed.

Problems with opiates in cancer pain: parenteral opioids.

Morphine is the preferred drug for the management of moderate-severe chronic cancer pain. The best route of administration is by mouth, because it is simple, safe, convenient, inexpensive and effective. Non-oral modes of administration should be only considered if (a) the oral route becomes unavailable or (b) there is documentation of failure of maximal doses of oral morphine and coanalgesic drugs. Recent developments have made new routes of morphine administration fashionable--in the absence of supportive pharmacokinetic or pharmacodynamic data--even when departure from established practice is not justified. It is important for clinicians to be familiar with the practicalities and problems that limit the utility of the non-oral routes, and the state of current understanding of these options will be reviewed.

A prospective, within-patient, crossover study of continuous intravenous and subcutaneous morphine for chronic cancer pain.

The dose, efficacy, and side effects of continuous intravenous infusion (CIVI) of morphine were compared with continuous subcutaneous infusion (CSCI) of morphine in patients with chronic cancer pain. Eligible patients were referred to the Palliative Care Program and were receiving a stable dose of CIVI of morphine. The design was a within-patient, one-way crossover; in which each patient provided data before and after a switch from CIVI to CSCI of morphine. "Rescue" doses were 50% of the hourly dose given every 2 hours as needed. Morphine was infused intravenously (i.v.) and subcutaneously (s.c.) via a McGaw/AccuPro Volumetric Infusion Pump. After baseline data, including side effects and pain assessment, were obtained, patients were evaluated twice daily for toxicity and analgesic efficacy. Those who had a stable CIVI dose for 48 consecutive hr were crossed over to the CSCI at the same dose as the intravenous (i.v.) phase. A stable dose was defined as no dose change, four or less rescue doses in the previous 24 hr, and a pain rating of none or mild. CIVI was considered equal to CSCI if these criteria were maintained for 96 consecutive hr. Fifty-seven patients were entered, and 40 were evaluable (15 women and 25 men). The median age was 67 (range 30-83 years). All 40 participants, after maintaining a stable dose throughout the i.v. phase, crossed to the s.c. phase and remained on s.c. for at least 48 hr. Thirty-two patients maintained a stable dose throughout the i.v. and s.c. phases. The mean stable i.v. dose (day 2) was 5.05 mg/hr, and the mean stable s.c. dose (day 4) was 5.7 mg/hr (P = 0.01). The mean number of rescue doses on day 2 was 0.83 per 24 hr versus 0.80 per 24 hours on day 4 (P = 0.6). The mean categorical pain score on day 2 was 0.83, and on day 4, 0.85 (P = 0.7). The mean visual analogue scale (VAS) on day 2 was 22.9 mm versus 17.6 mm on day 4 (P = 0.1). The mean incidence of side effects on day 2 was 1.7, and on day 4, 2.0 (P = 0.2). No patient was withdrawn or had a dose reduction due to unacceptable toxicity. There were two reports of local toxicity (mild erythema) at the SC needle insertion point, which required a site change. All of our 40 patients had adequate pain control with CIVI and CSCI morphine. Of the eight participants who were not maintained on the same i.v. and s.c. dose, all had adequate pain control and a similar side-effect profile on a higher s.c. morphine dose. These data suggest that the i.v. and s.c. routes are equianalgesic for most patients when administered as a continuous infusion. Pain control and side-effect profiles are quite similar and acceptable. s.c. morphine is an excellent alternative to i.v. morphine in both inpatients and outpatients requiring parenteral morphine for pain.

Contribution of a liaison clinical pharmacist to an inpatient palliative care unit.

The impact on patient care of interventions made by a liaison clinical pharmacist visiting a busy inpatient palliative care unit were evaluated using a validated six-point scoring system. Interventions made in 13% of patients could improve patient care, save money or both, but rarely involved the drugs that are commonly used for symptom control in patients with terminal cancer. Advice to rationalize inappropriate drug regimens (53%) was the commonest intervention, followed by warnings about drug interactions (24%) and advice about therapeutic drug monitoring (8%). The interventions were evaluated by the pharmacist, a palliative medicine registrar and two independent doctors, confirming that the pharmacist was valid and accurate in assessing her own work. Although more than 60% of interventions could significantly improve patient care, compliance by medical and nursing staff with advice was only 55%, reflecting possible tensions between palliative and general hospital medicine. This survey emphasizes the role of liaison clinical pharmacists in palliative care, the need for much more critical appraisal of prescribing practices and the utility of ranking pharmacist interventions as a quality assurance and educational tool. In particular, providing palliative care for patients with advanced acquired immunodeficiency syndrome (AIDS) is enhanced when a pharmacist with a specialist knowledge of AIDS therapeutics is available.

Managing HIV. Part 5: Treating secondary outcomes. 5.19 HIV and palliative care.

The goals of palliative care are the relief of pain and suffering in advanced disease and the support of the patient's carers. In HIV medicine, good palliative care often includes active treatment, and the palliative care team may work in support of the primary care doctor.