Initial Experiences With Integration of Palliative Medicine and Specialist Pain Services in a Tertiary Cancer Care Center in India.

Pain management constitutes a pivotal aspect of palliative care. Certain instances of distressing pain are significantly relieved through interventional pain methodologies, demanding the expertise of pain specialists. Our perspective revolves around the integration of these 2 facets, envisaging a symbiotic relationship that could enhance patient outcomes. A prospective assessment was carried out within a collaborative clinic, uniting the realms of pain management and palliative medicine. Anonymized patient information was scrutinized to grasp the advantages of this amalgamation and identify strategies to address any inherent deficiencies. Furthermore, an illustrative case study was delineated, spotlighting the collaborative dynamics at a systemic level. During the period spanning from November 2020 to June 2021, a total of 43 patients received consultations at this collaborative clinic. Each patient was exposed to a comprehensive pain management regimen, with the most frequently conducted procedure being an intercostal nerve block, which was administered in 9.30% of cases. For the provision of effective pain relief within the palliative care context, the confluence of joint consultations from cancer pain specialists emerges as a requisite measure. This approach carries the promise of optimizing pain control and augmenting the quality of palliative care.

Multimodal opioid sparing onco-anesthesia: A consensus practice guideline from Society of Onco-Anesthesia and Perioperative Care (SOAPC).

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Onco-Anaesthesiology and palliative medicine: Opportunities and challenges.

Global cancer burden is on the rise and many more patients present for surgery or other oncological diagnostic or therapeutic interventions requiring anaesthesia. Oncology therapy is unique as it requires a multidisciplinary team of surgical, medical and radiation oncologists apart from palliative medicine (PM) specialists, and anaesthesiologists. Anaesthetic management can affect the outcome of oncology treatment both by ensuring early return to oncology treatment and some anaesthetic techniques being innately associated with recurrence. Hence, the time has come for a separate super-speciality of onco-anaesthesiology to cater to the complex unmet needs of cancer patients. PM is the fourth dimension of oncology care and so mandatory education and training should be included in the undergraduate curriculum.

Diclofenac versus tramadol for mucositis related pain in head and neck cancer patients undergoing concurrent chemoradiation-a phase 3 study.

BACKGROUND: Oral mucositis related pain during CTRT in head and neck cancers is a common problem. Unfortunately, in spite of it being common, there is limited evidence for selection of systemic analgesic in this situation. Hence, this study was designed to compare the analgesic effect of a non-steroidal anti-inflammatory drug (diclofenac) versus a weak opioid (tramadol). PATIENTS AND METHODS: This was an open-label, parallel design, superiority randomised controlled study. In this study, head and neck cancer patients undergoing radical or adjuvant chemoradiation, who had grade 1 or above mucositis (in accordance with Common Terminology Criteria for Adverse Events version 4.03) and had pain related to it were randomly assigned to either diclofenac or tramadol for mucositis related pain control. The primary endpoint was analgesia after the first dose. The secondary endpoints were the rate of change in analgesic within 1 week, adverse events and quality of life. RESULTS: One hundred and twenty-eight patients were randomised, 66 in diclofenac and 62 in tramadol arm. The median area under the curve for graph of pain across time after first dose of pain medication for the diclofenac arm and the tramadol arm was 348.936 units (range: 113.64-1,969.23) and 420.87 (101.97-1,465.96), respectively, (p = 0.05619). Five patients (8.1%) in the tramadol arm and 11 patients (16.7%) in the diclofenac arm required a change in analgesic within 1 week of starting the analgesic (p = 0.184). There was no statistically significant difference in any adverse events between the two arms. However, the rate of any grade of renal dysfunction was numerically higher in the diclofenac arm (10.6% versus 4.8%, p = 0.326). CONCLUSION: In this phase 3 study, evaluating diclofenac and tramadol for chemoradiation induced mucositis pain, there was no statistical difference in analgesic activity of these two drugs.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines, for the Diagnosis and Assessment of Cancer Pain.

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group (SIG) guidelines, for the diagnosis and assessment of cancer pain in adults provide a structured, step-wise approach which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs of patient population and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by E-mail to all the ISSP and Indian Association of Palliative Care (IAPC) members. We recommend that a comprehensive pain assessment of all the patients should be conducted before initiating treatment. The patients should be educated about all the available pain control interventions. For assessing cancer pain, unidimensional tools such as Numeric Rating Scale, Visual Analog Scale, and Visual Rating Scale should always be used routinely. Patients with cancer pain should routinely be screened for distress and other psychological disorders, using the Patient Health Questionnaire-9. The most reliable assessment of pain is patients' self-reporting.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Pharmacological Management of Cancer Pain (Part II).

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group (SIG) guidelines on pharmacological management of cancer pain in adults provide a structured, stepwise approach, which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire, based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend that analgesics for cancer pain management should follow the World Health Organization 3-step analgesic ladder appropriate for the severity of pain. The use of paracetamol and nonsteroidal anti-inflammatory drugs alone or in combination with opioids for mild-to-moderate pain should be used. For mild-to-moderate pain, weak opioids such as tramadol, tapentadol, and codeine can be given in combination with nonopioid analgesics. We recommend morphine as the opioid of the first choice for moderate-to-severe cancer pain. Sustained-release formulations can be started 12 hourly, once the effective 24 h dose with immediate-release morphine is established. Opioid switch or rotation should be considered if there is inadequate analgesia or intolerable side effects. For opioid-induced respiratory depression, µ receptor antagonists (e.g. naloxone) must be used promptly. Antidepressants and/or anticonvulsants should be used to treat neuropathic cancer pain, and the dose should be titrated according to the clinical response and side effects. External beam radiotherapy should be offered to all patients with painful metastatic bone pain. There is evidence on use of ketamine in cancer neuropathic pain, but with no beneficial effect, thus, it is not recommended.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Complementary Therapies for Cancer Pain.

The Indian Society for Study of Pain (ISSP), cancer pain Special Interest Group (SIG) guidelines on complementary therapies for cancer pain in adults provides a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub drafts addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend that psychological interventions, including psychoeducation, are useful and should be considered in patients with cancer pain and psychological distress. Furthermore, physical and complementary treatment can be used as an adjunctive therapy for patients with cancer pain.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Pharmacological Management of Cancer Pain (Part III).

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group, guidelines on pharmacological management of cancer pain in adults provide a structured, step-wise approach which will help to improve the management of cancer pain and to provide patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by E-mail to all the ISSP and Indian Association of Palliative Care members. Antidepressants and/or anticonvulsants should be used to treat neuropathic cancer pain and the dose should be titrated according to the clinical response and side effects. External beam radiotherapy should be offered to all patients with painful metastatic bone pain. There is evidence on the use of ketamine in cancer neuropathic pain, but with no beneficial effect, thus it is not recommended.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Palliative Care Aspects in Cancer Pain Management.

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on palliative care aspects in cancer pain in adults provide a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking was made available on the ISSP website and circulated by E-mail to all the ISSP and Indian Association of Palliative Care (IAPC) members. In a cancer care setting, approaches toward managing pain vary between ambulatory setting, home care setting, acute inpatient setting, and end-of-life care in hospice setting. We aim to expound the cancer pain management approaches in these settings. In an ambulatory palliative care setting, the WHO analgesic step ladder is used for cancer pain management. The patients with cancer pain require admission for acute inpatient palliative care unit for poorly controlled pain in ambulatory and home care settings, rapid opioid titration, titration of difficult drugs such as methadone, acute pain crisis, pain neuromodulation, and pain interventions. In a palliative home care setting, the cancer pain is usually assessed and managed by nurses and primary physicians with a limited input from the specialist physicians. In patients with cancer at the end of life, the pain should be assessed at least once a day. Moreover, physicians should be trained in assessing patients with pain who are unable to verbalize or have cognitive impairment.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Pharmacological Management of Cancer Pain (Part I).

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on pharmacological management of cancer pain in adults provides a structured, step-wise approach which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub drafts addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website, and circulated by E-mail to all the ISSP and Indian Association of Palliative Care (IAPC) members. We recommend that analgesics for cancer pain management should follow the World Health Organization three-step analgesic ladder appropriate for the severity of pain. The use of paracetamol and nonsteroidal anti-inflammatory drugs alone or in combination with opioids for mild-to-moderate pain should be used. For mild-to-moderate pain, weak opioids such as tramadol, tapentadol, and codeine can be given in combination with nonopioid analgesics. We recommend morphine as the opioid of first choice for moderate-to-severe cancer pain.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Interventional Management for Cancer Pain.

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on interventional management for cancer pain in adults provide a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend using interventional management when conventional therapy fails to offer adequate benefits or causes undesirable side effects. Vertebroplasty should be offered to patients with uncontrolled bone pain when expertise is available.

A Randomized Placebo-Controlled Trial Evaluating the Analgesic Effect of Salmon Calcitonin in Refractory Bone Metastasis Pain.

Injection calcitonin is a natural hormone inhibiting osteoclastic bone resorption have been used as an analgesic to control bone metastasis pain or pain due to osteoporosis or fracture. This randomized double blind placebo controlled trial was undertaken to determine the role of injection Salmon Calcitonin therapy to control refractory pain caused due to bone metastasis arising from cancer breast, lung, prostate or kidney. All patients had received palliative radiotherapy and were suffering unsatisfactory pain relief on NSAIDs and tab morphine. Fourteen days inj. calcitonin or placebo injections were administered in 23 patients initially as high dose induction dose (800 IU per day SC) followed 200 IU subcutaneous (SC) once a day. Patients were assessed for pain intensity and quality of life on EORTC QLQ-30 questionnaire 6 hourly for 2 days and on 7th and 30th day. Any incidence of hypercalcemia, bone fracture, nerve root and bone marrow compression were also noted. This study found a significant reduction in pain after SC calcitonin injection therapy at 14 and 30 days' assessment. No patients in the study group required rescue analgesia after 18 hrs. There was a statistically significant difference in rescue analgesics required between the groups during two days hospitalization. Global health as well as physical and social wellbeing was better at 30 and 90 days in the study group as compared to control group, however it could not reach a statistical significance which may be attributed to the small sample size of the study.

Prescription Pattern of Drugs Used for Neuropathic Pain and Adherence to NeuPSIG Guidelines in Cancer.

OBJECTIVE: The objective of the present research was to evaluate the prescription pattern of the drugs used in the pharmacological treatment of cancer-related neuropathic pain (CRNP) and to assess the adherence of the physicians to the Neuropathic Pain Special Interest Group (NeuPSIG) Guidelines. MATERIALS AND METHODS: This was a cross-sectional, observational study where patients who presented to the pain and palliative care outpatient clinic of the tertiary care hospital with CRNP were prospectively recruited. Participants were screened for neuropathic pain using DN4 questionnaire. Demographic details, diagnosis, medication details, and adherence to NeuPSIG guidelines were assessed using a validated questionnaire. RESULTS: Of 300 patients screened, 64% were male and 36% were female, with a mean age of 48.26 ± 13.05 years. The predominant symptoms found were pin-and-needle sensation (99%) followed by tingling sensation (98.66%). The most common diagnosis was head-and-neck cancers (37.3%) followed by bone cancers (17.3%) and lung cancers (15.3%). Among the first-line drugs recommended in NeuPSIG for CRNP, pregabalin (78.7%) was the most common drug prescribed followed by amitriptyline (67%). The most common co-prescribed drugs were acid suppressants drugs (50.7%). Tapentadol, which is not part of the NeuPSIG guidelines, was prescribed on 51 occasions for neuropathic pain. Underdosing was observed in 272 prescriptions. Only 12 prescriptions completely adhered, while 275 had partial, and 13 prescriptions had poor adherence to NeuPSIG guidelines. CONCLUSION: The most commonly used drugs in the treatment of CRNP were pregabalin and amitriptyline. Most physician partially or did not adhere to the NeuPSIG guideline in the management of CRNP.

The Prevalence of Chronic Pain among Adults in India.

BACKGROUND: The prevalence of chronic pain (CP) is well described in Europe, America, and Australia. However, little knowledge is available of the prevalence of CP within Asia or Southeast Asia. Given the cultural and genetic variation in pain causation, manifestation, and reporting, the findings of previous western studies cannot be extrapolated to Asian countries. A prevalence study was needed to be carried out to quantify the magnitude and impact of CP in the adult population in India. METHODS: Two sets of questionnaires were designed. The first, a screening questionnaire was used telephonically to identify the prevalence of CP, and should there be CP; the second, a detailed questionnaire was administered, to characterize the features and impact of pain. The interviews were carried out face-to-face. RESULTS: A total of 4326 Indian patients were screened, and 836 completed a detailed pain questionnaire during 2006. The prevalence of CP was found to be 19.3% (n = 836). There was a higher prevalence in females (25.2%). Pain prevalence increased steeply beyond the age of 65 years old. There was a significant impact of CP on work and daily function. CONCLUSION: This Indian adults' population survey about CP found a higher prevalence of CP as compared to other Asian pain prevalence studies; however, the impact of pain was just as significant. In a rapidly aging population, CP is emerging as a significant healthcare problem which may likely to exert an increasing toll on the existing social infrastructure within the next two decades.

Acute pain services in India: A glimpse of the current scenario.

BACKGROUND AND AIMS: Acute postoperative pain is still a neglected and unresolved issue in day to day practice. Acute pain services were conceived three decades ago to form a dedicated team to monitor pain assessment and treatment as per laid down pain protocols and guidelines. The concept of acute pain service (APS) is slowly evolving in India. MATERIAL AND METHODS: This nationwide questionnaire survey was conducted to identify the status of postoperative pain, the prevalent treatment practices, and the prevalence of acute pain services in India. An electronic communication was sent to 4000 Indian Society of Anesthesiologists life members. RESULTS: We received only 146 responses mainly from faculties/consultants from few corporate hospitals or medical colleges. About 68 APSs were functioning, however, 20 APS do not have any training programs and 34 have no written protocols. Anesthesiologists were involved in postoperative pain management only when epidural analgesia was employed. CONCLUSION: This survey found that majority of anesthesiologists agree to establish an APS, however administrative issues seem to be a major barrier.

Audit of complications in post-operative epidural analgesia and adherence to acute pain service protocols at an Indian cancer center.

An audit of epidural anesthesia in an Indian teaching hospital is described. The authors reviewed Acute Pain Service (APS) documentation of epidural anesthesia and outcomes form the procedure over a 6-month period. Variances from established protocols were noted and reasons for these variances are discussed.