Bridging the Gap Among Clinical Practice Guidelines for Pain Management in Cancer and Sickle Cell Disease.

Opioids are a critical component of pain relief strategies for the management of patients with cancer and sickle cell disease. The escalation of opioid addiction and overdose in the United States has led to increased scrutiny of opioid prescribing practices. Multiple reports have revealed that regulatory and coverage policies, intended to curb inappropriate opioid use, have created significant barriers for many patients. The Centers for Disease Control and Prevention, National Comprehensive Cancer Network, and American Society of Clinical Oncology each publish clinical practice guidelines for the management of chronic pain. A recent JAMA Oncology article highlighted perceived variability in recommendations among these guidelines. In response, leadership from guideline organizations, government representatives, and authors of the original article met to discuss challenges and solutions. The meeting featured remarks by the Commissioner of Food and Drugs, presentations on each clinical practice guideline, an overview of the pain management needs of patients with sickle cell disease, an overview of perceived differences among guidelines, and a discussion of differences and commonalities among the guidelines. The meeting revealed that although each guideline varies in the intended patient population, target audience, and methodology, there is no disagreement among recommendations when applied to the appropriate patient and clinical situation. It was determined that clarification and education are needed regarding the intent, patient population, and scope of each clinical practice guideline, rather than harmonization of guideline recommendations. Clinical practice guidelines can serve as a resource for policymakers and payers to inform policy and coverage determinations.

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology.

In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.

NCCN Frameworks for Resource Stratification of NCCN Guidelines: Adult Cancer Pain and Palliative Care.

The NCCN Framework aims to provide adapted guidelines for low- and middle-resource countries to improve the experience of patients with cancer. In particular, the NCCN Frameworks for Adult Cancer Pain and Palliative Care and were designed to help expand access to pain management and palliative care for patients in low-resource countries. The NCCN Framework is one of several tools that can improve cancer care in the developing world. The NCCN Harmonized Guidelines for Sub-Saharan Africa, a collaborative effort between NCCN, American Cancer Society, Clinton Health Access Initiative, and African Cancer Coalition, was developed to harmonize NCCN recommendations with local guidelines across Africa and to make best use of available services and resources.

The management of pain in patients with cancer.

More than 30% of patients with cancer report chronic pain, which is an indication of both the frequency of cancer-related pain and the failure to optimally manage it. Although access to opioid analgesics has greatly improved over the past 25 years, much remains to be done for patients experiencing severe pain. Opioids are far from ideal analgesics, noted Dr. Robert A. Swarm at the recent NCCN 18th Annual Conference. Universal screening for cancer pain is part of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain. This is not a one-time effort but should be part of management throughout the cancer care continuum.

Adult cancer pain.

Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.

Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency: a prospective, randomized, clinical trial.

BACKGROUND: Severe preamputation pain is associated with phantom limb pain (PLP) development in limb amputees. We investigated whether optimized perioperative analgesia reduces PLP at 6-month follow-up. METHODS: A total of 65 patients underwent lower-limb amputation and were assigned to five analgesic regimens: (1) Epi/Epi/Epi patients received perioperative epidural analgesia and epidural anesthesia; (2) PCA/Epi/Epi patients received preoperative intravenous patient-controlled analgesia (PCA), postoperative epidural analgesia, and epidural anesthesia; (3) PCA/Epi/PCA patients received perioperative intravenous PCA and epidural anesthesia; (4) PCA/GA/PCA patients received perioperative intravenous PCA and general anesthesia (GA); (5) controls received conventional analgesia and GA. Epidural analgesia or intravenous PCA started 48 h preoperatively and continued 48 h postoperatively. The results of the visual analog scale and the McGill Pain Questionnaire were recorded perioperatively and at 1 and 6 months. RESULTS: At 6 months, median (minimum-maximum) PLP and P values (intervention groups vs. control group) for the visual analog scale were as follows: 0 (0-20) for Epi/Epi/Epi (P = 0.001), 0 (0-42) for PCA/Epi/Epi (P = 0.014), 20 (0-40) for PCA/Epi/PCA (P = 0.532), 0 (0-30) for PCA/GA/PCA (P = 0.008), and 20 (0-58) for controls. The values for the McGill Pain Questionnaire were as follows: 0 (0-7) for Epi/Epi/Epi (P < 0.001), 0 (0-9) for PCA/Epi/Epi (P = 0.003), 6 (0-11) for PCA/Epi/PCA (P = 0.208), 0 (0-9) for PCA/GA/PCA (P = 0.003), and 7 (0-15) for controls. At 6 months, PLP was present in 1 of 13 Epi/Epi/Epi, 4 of 13 PCA/Epi/Epi, and 3 of 13 PCA/GA/PCA patients versus 9 of 12 control patients (P = 0.001, P = 0.027, and P = 0.009, respectively). Residual limb pain at 6 months was insignificant. CONCLUSIONS: Optimized epidural analgesia or intravenous PCA, starting 48 h preoperatively and continuing for 48 h postoperatively, decreases PLP at 6 months.

Prediction of Individual Analgesic Response to Intravenous Lidocaine in Painful Diabetic Peripheral Neuropathy: A Randomized, Placebo-controlled, Crossover Trial.

OBJECTIVES: Intravenous lidocaine can alleviate painful diabetic peripheral neuropathy (DPN) in some patients. Whether quantitative sensory testing (QST) can identify treatment responders has not been prospectively tested. MATERIALS AND METHODS: This was a prospective, randomized, double-blind, crossover, placebo-controlled trial comparing intravenous lidocaine to normal saline (placebo) for painful DPN. Thirty-four participants with painful DPN were enrolled and administered intravenous lidocaine (5 mg/kg ideal body weight) or placebo as a 40-minute infusion, after a battery of QST parameters were tested on the dorsal foot, with a 3-week washout period between infusions. RESULTS: Thirty-one participants completed both study sessions and were included in the final analysis. Lidocaine resulted in a 51% pain reduction 60 to 120 minutes after infusion initiation, as assessed on a 0 to 10 numerical rating scale, while placebo resulted in a 33.5% pain reduction (difference=17.6%, 95% confidence interval [CI], 1.9%-33.3%, P=0.03). Neither mechanical pain threshold, heat pain threshold, or any of the other measured QST parameters predicted the response to treatment. Lidocaine administration reduced mean Neuropathic Pain Symptom Inventory paresthesia/dysesthesia scores when compared with placebo by 1.29 points (95% CI, -2.03 to -0.55, P=0.001), and paroxysmal pain scores by 0.84 points (95% CI, -1.62 to -0.56, P=0.04), without significant changes in burning, pressing or evoked pain subscores. DISCUSSION: While some participants reported therapeutic benefit from lidocaine administration, QST measures alone were not predictive of response to treatment. Further studies, powered to test more complex phenotypic interactions, are required to identify reliable predictors of response to pharmacotherapy in patients with DPN.

Bridging the Gap Among Clinical Practice Guidelines for Pain Management in Cancer and Sickle Cell Disease.

Opioids are a critical component of pain relief strategies for the management of patients with cancer and sickle cell disease. The escalation of opioid addiction and overdose in the United States has led to increased scrutiny of opioid prescribing practices. Multiple reports have revealed that regulatory and coverage policies, intended to curb inappropriate opioid use, have created significant barriers for many patients. The Centers for Disease Control and Prevention, National Comprehensive Cancer Network, and ASCO each publish clinical practice guidelines for the management of chronic pain. A recent JAMA Oncology article highlighted perceived variability in recommendations among these guidelines. In response, leadership from guideline organizations, government representatives, and authors of the original article met to discuss challenges and solutions. The meeting featured remarks by the Commissioner of Food and Drugs, presentations on each clinical practice guideline, an overview of the pain management needs of patients with sickle cell disease, an overview of perceived differences among guidelines, and a discussion of differences and commonalities among the guidelines. The meeting revealed that although each guideline varies in the intended patient population, target audience, and methodology, there is no disagreement among recommendations when applied to the appropriate patient and clinical situation. It was determined that clarification and education are needed regarding the intent, patient population, and scope of each clinical practice guideline, rather than harmonization of guideline recommendations. Clinical practice guidelines can serve as a resource for policymakers and payers to inform policy and coverage determinations.

Epidurals in Pancreatic Resection Outcomes (E-PRO) study: protocol for a randomised controlled trial.

INTRODUCTION: Epidural analgesia provides an important synergistic method of pain control. In addition to reducing perioperative opioid consumption, the deliverance of analgesia into the epidural space, effectively creating a sympathetic blockade, has a multitude of additional potential benefits, from decreasing the incidence of postoperative delirium to reducing the development of persistent postsurgical pain (PPSP). Prior studies have also identified a correlation between the use of epidural analgesia and improved oncological outcomes and survival. The aim of this study is to evaluate the effect of epidural analgesia in pancreatic operations on immediate postoperative outcomes, the development of PPSP and oncological outcomes in a prospective, single-blind, randomised controlled trial. METHODS: The Epidurals in Pancreatic Resection Outcomes (E-PRO) study is a prospective, single-centre, randomised controlled trial. 150 patients undergoing either pancreaticoduodenectomy or distal pancreatectomy will be randomised to receive an epidural bupivacaine infusion following anaesthetic induction followed by continued epidural bupivacaine infusion postoperatively in addition to the institutional standardised pain regimen of hydromorphone patient-controlled analgesia (PCA), acetaminophen and ketorolac (intervention group) or no epidural infusion and only the standardised postoperative pain regimen (control group). The primary outcome was the postoperative opioid consumption, measured in morphine or morphine-equivalents. Secondary outcomes include patient-reported postoperative pain numerical rating scores, trend and relative ratios of serum inflammatory markers (interleukin (IL)-1ß, IL-6, tumour necrosis factor-α, IL-10), occurrence of postoperative delirium, development of PPSP as determined by quantitative sensory testing, and disease-free and overall survival. ETHICS AND DISSEMINATION: The E-PRO trial has been approved by the institutional review board. Recruitment began in May 2016 and will continue until the end of May 2018. Dissemination plans include presentations at scientific conferences and scientific publications. TRIAL REGISTRATION NUMBER: NCT02681796.

Vertebral augmentation for compression fractures caused by malignant disease.

Vertebral compression fractures are common in malignant disease and frequently cause severe back pain. However, management of that pain with conventional medical, radiotherapy, or surgical modalities is often inadequate. Vertebral augmentation techniques, such as vertebroplasty and kyphoplasty, are minimally invasive techniques in which methylmethacrylate bone cement is percutaneously injected into compressed vertebral bodies. Vertebral augmentation often improves mechanical stability of compressed vertebrae, provides pain relief, and may prevent progression of vertebral collapse. Kyphoplasty may provide increased chance for vertebral body height restoration, but the clinical importance of slight change in vertebral body height is unclear. Vertebral augmentation can be used in conjunction with other treatment modalities, and associated pain relief may improve patient tolerance of needed antitumor therapies, such as radiation therapy. Vertebral augmentation is generally very well tolerated, and complications associated with bone cement extravasation beyond the vertebral body have rarely been reported. Because it often provides good to excellent relief of otherwise intractable pain and is generally well tolerated, vertebral augmentation is becoming a first-line agent for management of painful vertebral compression fractures, especially in the setting of malignant disease.

Interventional therapies for cancer pain management: important adjuvants to systemic analgesics.

Optimized use of systemic analgesics fails to adequately control pain in some patients with cancer. Commonly used analgesics, including opioids, nonopioids (acetaminophen and non-steroidal anti-inflammatory drugs), and adjuvant analgesics (anticonvulsants and antidepressants), have limited analgesic efficacy, and their use is often associated with adverse effects. Without adequate pain control, patients with cancer not only experience the anguish of poorly controlled pain but also have greatly diminished quality of life and may even have reduced life expectancy. Interventional pain therapies are a diverse set of procedural techniques for controlling pain that may be useful when systemic analgesics fail to provide adequate control of cancer pain or when the adverse effects of systemic analgesics cannot be managed reasonably. Commonly used interventional therapies for cancer pain include neurolytic neural blockade, spinal administration of analgesics, and vertebroplasty. Compared with systemic analgesics, which generally have broad indications for control of pain, individual interventional therapies generally have specific, narrow indications. When appropriately selected and implemented, interventional pain therapies are important components of broad, multimodal cancer pain management that significantly increases the proportion of patients able to experience adequate pain control.