Pain is very common in advanced cancer patients, with 70% experiencing moderate to severe pain. The most common types of pain are from bone metastases and neuropathic pain. Failure to properly manage pain is due to several factors including limited resources in developing countries, legal restrictions, lack of physician education, and patients fearing addiction. Despite adequate resources, pain remains undertreated even in developed countries due to a focus on disease rather than symptom management.
Providing Hope in Terminal Cancer: When is it Appropriate and When is it Not?Teresa Muñoz Migueláñez
1. The document discusses providing hope in terminal cancer and when it is appropriate versus not. It focuses on the importance of realistic yet empathetic communication between doctors and patients about diagnosis, prognosis, and treatment options.
2. Unrealistic or false hope can be created by misinformation from external parties or an obsession with extending survival time without regard for quality of life. Hope requires a balance of realism with psychosocial and spiritual support.
3. The case study examines communicating prognosis and treatment options to a patient with advanced pancreatic cancer. It emphasizes conveying both risks and benefits of various options factually yet hopefully to help the patient make informed decisions.
The document summarizes research on cancer, stress, and personality. It finds that while stress may accelerate tumor growth in animal models, studies do not show stress causes cancer in humans. Childhood adversity is linked to increased risk behaviors but its relationship to cancer is unclear. Personality does not determine cancer risk but may impact progression. Psychotherapy improves mood in cancer patients but does not extend survival. It can reduce chemotherapy side effects through classical conditioning approaches.
The document discusses the leading causes of death worldwide due to illnesses like heart disease, malignant neoplasms, and cerebrovascular disease. It then covers various risk factors for cancer and heart disease, including smoking and diet. The rest of the document details cancer treatment methods such as staging and surgery, as well as principles of chemotherapy, radiation therapy, hormonal therapy, immunotherapy, and molecularly targeted agents. It provides examples of cancers that may be cured through chemotherapy alone or in combination with other treatments.
La campagna “The Painful truth” è nata dalla collaborazione tra organizzazioni internazionali impegnate nella lotta al dolore come Action on Pain UK, la Spanish Pain Association (EFHRE Sine Dolore) e la German Pain League (Deutsche Schmerzliga), con l’obiettivo di creare una maggiore consapevolezza sui problemi che devono affrontare coloro che soffrono di dolore cronico. In particolare, vuole evidenziare l’importanza di riconoscere e diagnosticare adeguatamente il dolore e informare i cittadini sull’assistenza fornita dal servizio sanitario e le possibilità di trattamento più innovative per curare questa malattia. Il report di questa indagine, condotta in 5 Paesi europei (Francia, Italia, Spagna, Germania e Regno Unito) su 1.010 pazienti tra i 18 e i 64 anni, non solo rivela nuovi dettagli sull’impatto del dolore cronico sulla vita del malato ma evidenzia anche i bisogni ancora insoddisfatti legati al trattamento ottimale della patologia.
Fonte: Boston Scientific
http://www.bostonscientific.com/templatedata/imports/HTML/painful-truth/dl/NM-114704-AA_INTL_Painful_Truth_Survey_Report_Final_UK.pdf
“Qualsiasi immagine/tabella/parte di testo riprodotta è riportata ad esclusivo scopo didattico/informativo gratuito. Qualora necessario, siamo disponibili al riconoscimento dei diritti di copyright agli autori, alle fonti citate e agli aventi diritto”.
1) Early studies found associations between psychosocial stress like depression and cancer diagnoses, though determining cause and effect is complex.
2) While some research links psychosocial factors like social support and fighting spirit to cancer outcomes, evidence is mixed as to whether they impact cancer incidence or progression.
3) Psychosocial stress may influence immune system activity like natural killer cells in ways that could accelerate cancer, but biological pathways are not fully understood.
Press Release to international news media outlets on findings of pain disparities between Caucasian and Non-Caucasian women with metastatic breast cancer in 19 countries.
Cancer rehabilitation addresses impairments caused by cancer and its treatment. Cancer can invade any tissue and cause impairments through pain, neural compromise, bone/joint issues, or invasion of organs. Bone metastases are common and impair mobility. Brain metastases can cause neurological deficits. Radiation therapy can cause both acute and late impairments. Physiatrists play a role in managing cancer-related fatigue, pain, and other constitutional symptoms to facilitate rehabilitation. Treatment of impairments requires a multidisciplinary approach.
This document discusses an interdisciplinary approach to increasing minority participation in cancer clinical trials based on Coale's three preconditions of fertility decline transition theory. The three preconditions are: 1) participation must enter conscious choice, 2) participation must be perceived as advantageous, and 3) effective support for participation must be available. Barriers like cancer fatalism, mistrust in the medical system, socioeconomic factors, and lack of culturally competent resources prevent the preconditions from being met for minorities. The document recommends improving cultural competency, communication, education, staff diversity, and access to address these barriers.
Providing Hope in Terminal Cancer: When is it Appropriate and When is it Not?Teresa Muñoz Migueláñez
1. The document discusses providing hope in terminal cancer and when it is appropriate versus not. It focuses on the importance of realistic yet empathetic communication between doctors and patients about diagnosis, prognosis, and treatment options.
2. Unrealistic or false hope can be created by misinformation from external parties or an obsession with extending survival time without regard for quality of life. Hope requires a balance of realism with psychosocial and spiritual support.
3. The case study examines communicating prognosis and treatment options to a patient with advanced pancreatic cancer. It emphasizes conveying both risks and benefits of various options factually yet hopefully to help the patient make informed decisions.
The document summarizes research on cancer, stress, and personality. It finds that while stress may accelerate tumor growth in animal models, studies do not show stress causes cancer in humans. Childhood adversity is linked to increased risk behaviors but its relationship to cancer is unclear. Personality does not determine cancer risk but may impact progression. Psychotherapy improves mood in cancer patients but does not extend survival. It can reduce chemotherapy side effects through classical conditioning approaches.
The document discusses the leading causes of death worldwide due to illnesses like heart disease, malignant neoplasms, and cerebrovascular disease. It then covers various risk factors for cancer and heart disease, including smoking and diet. The rest of the document details cancer treatment methods such as staging and surgery, as well as principles of chemotherapy, radiation therapy, hormonal therapy, immunotherapy, and molecularly targeted agents. It provides examples of cancers that may be cured through chemotherapy alone or in combination with other treatments.
La campagna “The Painful truth” è nata dalla collaborazione tra organizzazioni internazionali impegnate nella lotta al dolore come Action on Pain UK, la Spanish Pain Association (EFHRE Sine Dolore) e la German Pain League (Deutsche Schmerzliga), con l’obiettivo di creare una maggiore consapevolezza sui problemi che devono affrontare coloro che soffrono di dolore cronico. In particolare, vuole evidenziare l’importanza di riconoscere e diagnosticare adeguatamente il dolore e informare i cittadini sull’assistenza fornita dal servizio sanitario e le possibilità di trattamento più innovative per curare questa malattia. Il report di questa indagine, condotta in 5 Paesi europei (Francia, Italia, Spagna, Germania e Regno Unito) su 1.010 pazienti tra i 18 e i 64 anni, non solo rivela nuovi dettagli sull’impatto del dolore cronico sulla vita del malato ma evidenzia anche i bisogni ancora insoddisfatti legati al trattamento ottimale della patologia.
Fonte: Boston Scientific
http://www.bostonscientific.com/templatedata/imports/HTML/painful-truth/dl/NM-114704-AA_INTL_Painful_Truth_Survey_Report_Final_UK.pdf
“Qualsiasi immagine/tabella/parte di testo riprodotta è riportata ad esclusivo scopo didattico/informativo gratuito. Qualora necessario, siamo disponibili al riconoscimento dei diritti di copyright agli autori, alle fonti citate e agli aventi diritto”.
1) Early studies found associations between psychosocial stress like depression and cancer diagnoses, though determining cause and effect is complex.
2) While some research links psychosocial factors like social support and fighting spirit to cancer outcomes, evidence is mixed as to whether they impact cancer incidence or progression.
3) Psychosocial stress may influence immune system activity like natural killer cells in ways that could accelerate cancer, but biological pathways are not fully understood.
Press Release to international news media outlets on findings of pain disparities between Caucasian and Non-Caucasian women with metastatic breast cancer in 19 countries.
Cancer rehabilitation addresses impairments caused by cancer and its treatment. Cancer can invade any tissue and cause impairments through pain, neural compromise, bone/joint issues, or invasion of organs. Bone metastases are common and impair mobility. Brain metastases can cause neurological deficits. Radiation therapy can cause both acute and late impairments. Physiatrists play a role in managing cancer-related fatigue, pain, and other constitutional symptoms to facilitate rehabilitation. Treatment of impairments requires a multidisciplinary approach.
This document discusses an interdisciplinary approach to increasing minority participation in cancer clinical trials based on Coale's three preconditions of fertility decline transition theory. The three preconditions are: 1) participation must enter conscious choice, 2) participation must be perceived as advantageous, and 3) effective support for participation must be available. Barriers like cancer fatalism, mistrust in the medical system, socioeconomic factors, and lack of culturally competent resources prevent the preconditions from being met for minorities. The document recommends improving cultural competency, communication, education, staff diversity, and access to address these barriers.
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Reporting heterogeneity, nonresponse bias, and mortality selection do not appear to meaningfully impact estimates of social disparities in pain.
Sociodemographic disparities in chronic pain...Paul Coelho, MD
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Measurement biases like reporting heterogeneity and mortality selection may impact estimates of social disparities in pain.
Physician-assisted suicide is a controversial issue that is only legal in five U.S. states. It allows terminally ill patients with less than six months to live to request lethal medication from their doctor to end their own lives. While some see it as giving patients control at the end of life, others argue it could encourage suicide or that terminally ill patients are not in a mental state to make such a decision. There are also concerns about how to protect vulnerable patients from being coerced into suicide. The document discusses the various perspectives on this complex issue and argues rules need to be put in place to allow physician-assisted suicide as an option while also protecting doctors' and patients' rights.
This document provides an updated clinical practice guideline from the American Society of Clinical Oncology and the American Society of Hematology on the use of erythropoiesis-stimulating agents (ESAs) in adult patients with cancer. The guideline committee reviewed new data published between 2007 and 2010. For patients with chemotherapy-induced anemia and a hemoglobin level under 10g/dL, the committee recommends discussing the potential harms and benefits of ESAs or red blood cell transfusions with patients. The risks and benefits of each option should contribute to shared decisions. The committee cautions against ESA use in other circumstances and provides other recommendations, such as administering ESAs at the lowest effective dose.
This document summarizes a roundtable discussion on immuno-oncology (I-O) involving leading oncologists, patient groups, and public health experts. The participants discussed the transformative potential of I-O but also the challenges it poses, including identifying which patients will benefit, managing patient expectations, and ensuring accessible support systems for long-term treatment. They debated models for delivering I-O locally while maintaining specialist oversight and how industry could help support new delivery solutions and pathways.
The document discusses pain and addiction as co-morbid disease states. It provides epidemiological data on the prescription drug abuse epidemic, including increased rates of opioid abuse and overdose deaths. It also examines the role of physicians in fueling non-medical prescription drug use through improper prescribing practices or a lack of training in identifying addiction.
This study surveyed 304 adults in an urban community to assess perceptions and barriers to adult immunization. The key findings were:
1) Over 50% of participants received an immunization in the last year, but only 40% always get recommended immunizations.
2) Physician recommendation was the top factor influencing immunization decisions.
3) Many participants were unaware immunizations could benefit those with health conditions like asthma, diabetes, or smokers.
4) Cost and concerns about side effects were also barriers to immunization.
A review of sexual dysfunction in psoriasis with a focus on genital involvement. Genital psoriasis: Prevalence, Impact , Treatment
Increased recognition?
19. chinese medicine for side effects from chemotherapy for colorectal cancer...Dr. Wilfred Lin (Ph.D.)
Chinese herbal medicine and other traditional Chinese medicine therapies may help reduce side effects from chemotherapy for colorectal cancer. Chemotherapy can deplete healthy qi while treating cancer, worsening side effects, but Chinese medicine aims to nourish qi. Current research shows Chinese medicine may induce cancer cell apoptosis, prevent metastasis, directly relieve symptoms, boost immunity, and increase appetite and recovery. However, more rigorous clinical trials are still needed to fully understand how these treatments work and ensure their safety when combined with chemotherapy.
Dr. Nisrin Anfinan discusses challenges related to cervical cancer in Saudi Arabia. The incidence of cervical cancer in Saudi Arabia is very low at 1.9 cases per 100,000 women, accounting for only 2.6% of cancers in women. However, challenges exist in understanding the prevalence of HPV infections and abnormal pap smears in the population. Implementing an effective screening program will also be difficult without understanding sexual practices and managing sexually transmitted infections. Determining the most appropriate screening method and triaging patients will also be challenges.
Higher prescribed opioid doses are associated with elevated suicide risk among veterans with chronic pain. The study analyzed medical records of over 123,000 veterans with chronic pain receiving opioids from 2004 to 2005. It found that compared to those receiving less than 20 mg/day of opioids, the hazard ratio for suicide was 1.48 for 20 to less than 50 mg/day, 1.69 for 50 to less than 100 mg/day, and 2.15 for 100 mg/day or more, after controlling for other factors. Similarly, rates of suicide by intentional overdose increased from 8.2 per 100,000 person-years at less than 20 mg/day to 27.8 per 100,000 person-years at 100 mg
1) The study examined the association between spousal or significant other solicitous responses and opioid dose in 466 patients with chronic pain. 2) It found that higher scores on a scale measuring solicitous responses, such as asking about pain symptoms, were associated with higher daily morphine equivalent doses. 3) This association remained even after adjusting for other factors like age, sex, depression and pain severity. The findings suggest solicitous responses may influence opioid dose among chronic pain patients.
Presented at American Association for Cancer Research (AACR) at New Orleans 2016 annual conference. Fight Colorectal Cancer and Cancer Research Institute joint effort.
Presented by
Al B. Benson III, MD FACP FASCO
Professor of Medicine
Associate Director for Cooperative Groups Robert H. Lurie Comprehensive Cancer Center of Northwestern University
This study analyzed national ED visit data to identify predictors of ambulance use for transport to the ED for patients over age 45 with chest pain. The study found that private insurance, Hispanic ethnicity, and treatment at a non-metropolitan hospital were associated with decreased odds of ambulance use, while public insurance, lack of insurance, and higher triage acuity were associated with increased ambulance use. Race was not associated with differences in ambulance arrival. Efforts to increase ambulance transport for these high-risk patients may include expanding insurance coverage and improving rural EMS systems, as well as targeted patient education.
1) Palliative care aims to improve quality of life for patients facing life-threatening illness through pain and symptom relief.
2) A WHO demonstration project in Jordan helped establish palliative care policies, increase opioid availability, and provide education to healthcare workers.
3) The Jordan Palliative Care Society was formed to help implement palliative care across the country through additional training, ensuring drug access, and creating a palliative care network.
Near the end of life, providing aggressive chemotherapy can compromise quality of life goals of palliative care. While patients and families may want to continue "fighting cancer", doctors must consider perspectives of patients, families, and palliative care. Guidelines recommend against chemotherapy for patients expected to die within 6 months without clear evidence of benefit, to avoid unnecessary suffering at the end of life. Effective communication and palliative care consultation can help align treatment with patient priorities and values as death approaches.
This study analyzed over 300,000 fractures in 18 bones to identify risk factors for fracture nonunion using a large US health claims database. The overall nonunion rate was 4.9%. Certain fractures like scaphoid, tibia/fibula and femur fractures had nonunion rates over 10%. Multiple risk factors were associated with increased odds of nonunion on multivariate analysis, including open fractures, multiple concurrent fractures, prescription NSAID and opioid use, anticoagulant use, and osteoarthritis with rheumatoid arthritis - all increasing the risk of nonunion by over 50%. The probability of nonunion can be estimated based on patient characteristics and fracture severity available at initial presentation.
This document discusses cancer and disasters. It notes that cancer patients are vulnerable during disasters as infrastructure damage can disrupt treatment and medical records. Access to oncologists, medications, treatment continuity and transportation are challenges. Social isolation is a risk, and chronic illnesses may be exacerbated by disaster conditions like lack of resources. The document provides recommendations for cancer patients during disasters such as keeping medication logs, drinking fluids, and educating on their disease and resources. It also recommends outreach programs and incorporating local chronic needs into disaster planning and response.
Final Project - Projet Technique et Scientifique.
A brief introduction to cancer; some major guidelines that may help fighting back cancer and an international questionnaire to assess general perception of oncologic diseases.
Sorbonne Université - 5th Year - 1st Semester - Master Biologie Intégrative et Physiologie.
This document discusses overlapping chronic pain conditions (COPCs), where many common pain conditions frequently co-occur. It notes the high degree of overlap is often not accounted for in clinical trials. The failure to consider the heterogeneous and overlapping nature of chronic pain may result in treatments with only small effects. It presents the concept of COPCs and reviews their epidemiology, finding significant overlap between conditions like headaches, neck pain, and jaw pain in the general US population based on a national health survey. It concludes more research is needed that considers the overlapping nature of chronic pain conditions.
This document discusses overlapping chronic pain conditions (COPCs), where many common pain conditions frequently co-occur and overlap. It notes that COPCs are more prevalent in women than men. The failure to account for the heterogeneous and overlapping nature of most chronic pain conditions may result in small treatment effects when administered to general chronic pain populations. It recommends advancing the understanding of COPCs by considering their overlapping nature in clinical trials and pain condition classifications.
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Reporting heterogeneity, nonresponse bias, and mortality selection do not appear to meaningfully impact estimates of social disparities in pain.
Sociodemographic disparities in chronic pain...Paul Coelho, MD
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Measurement biases like reporting heterogeneity and mortality selection may impact estimates of social disparities in pain.
Physician-assisted suicide is a controversial issue that is only legal in five U.S. states. It allows terminally ill patients with less than six months to live to request lethal medication from their doctor to end their own lives. While some see it as giving patients control at the end of life, others argue it could encourage suicide or that terminally ill patients are not in a mental state to make such a decision. There are also concerns about how to protect vulnerable patients from being coerced into suicide. The document discusses the various perspectives on this complex issue and argues rules need to be put in place to allow physician-assisted suicide as an option while also protecting doctors' and patients' rights.
This document provides an updated clinical practice guideline from the American Society of Clinical Oncology and the American Society of Hematology on the use of erythropoiesis-stimulating agents (ESAs) in adult patients with cancer. The guideline committee reviewed new data published between 2007 and 2010. For patients with chemotherapy-induced anemia and a hemoglobin level under 10g/dL, the committee recommends discussing the potential harms and benefits of ESAs or red blood cell transfusions with patients. The risks and benefits of each option should contribute to shared decisions. The committee cautions against ESA use in other circumstances and provides other recommendations, such as administering ESAs at the lowest effective dose.
This document summarizes a roundtable discussion on immuno-oncology (I-O) involving leading oncologists, patient groups, and public health experts. The participants discussed the transformative potential of I-O but also the challenges it poses, including identifying which patients will benefit, managing patient expectations, and ensuring accessible support systems for long-term treatment. They debated models for delivering I-O locally while maintaining specialist oversight and how industry could help support new delivery solutions and pathways.
The document discusses pain and addiction as co-morbid disease states. It provides epidemiological data on the prescription drug abuse epidemic, including increased rates of opioid abuse and overdose deaths. It also examines the role of physicians in fueling non-medical prescription drug use through improper prescribing practices or a lack of training in identifying addiction.
This study surveyed 304 adults in an urban community to assess perceptions and barriers to adult immunization. The key findings were:
1) Over 50% of participants received an immunization in the last year, but only 40% always get recommended immunizations.
2) Physician recommendation was the top factor influencing immunization decisions.
3) Many participants were unaware immunizations could benefit those with health conditions like asthma, diabetes, or smokers.
4) Cost and concerns about side effects were also barriers to immunization.
A review of sexual dysfunction in psoriasis with a focus on genital involvement. Genital psoriasis: Prevalence, Impact , Treatment
Increased recognition?
19. chinese medicine for side effects from chemotherapy for colorectal cancer...Dr. Wilfred Lin (Ph.D.)
Chinese herbal medicine and other traditional Chinese medicine therapies may help reduce side effects from chemotherapy for colorectal cancer. Chemotherapy can deplete healthy qi while treating cancer, worsening side effects, but Chinese medicine aims to nourish qi. Current research shows Chinese medicine may induce cancer cell apoptosis, prevent metastasis, directly relieve symptoms, boost immunity, and increase appetite and recovery. However, more rigorous clinical trials are still needed to fully understand how these treatments work and ensure their safety when combined with chemotherapy.
Dr. Nisrin Anfinan discusses challenges related to cervical cancer in Saudi Arabia. The incidence of cervical cancer in Saudi Arabia is very low at 1.9 cases per 100,000 women, accounting for only 2.6% of cancers in women. However, challenges exist in understanding the prevalence of HPV infections and abnormal pap smears in the population. Implementing an effective screening program will also be difficult without understanding sexual practices and managing sexually transmitted infections. Determining the most appropriate screening method and triaging patients will also be challenges.
Higher prescribed opioid doses are associated with elevated suicide risk among veterans with chronic pain. The study analyzed medical records of over 123,000 veterans with chronic pain receiving opioids from 2004 to 2005. It found that compared to those receiving less than 20 mg/day of opioids, the hazard ratio for suicide was 1.48 for 20 to less than 50 mg/day, 1.69 for 50 to less than 100 mg/day, and 2.15 for 100 mg/day or more, after controlling for other factors. Similarly, rates of suicide by intentional overdose increased from 8.2 per 100,000 person-years at less than 20 mg/day to 27.8 per 100,000 person-years at 100 mg
1) The study examined the association between spousal or significant other solicitous responses and opioid dose in 466 patients with chronic pain. 2) It found that higher scores on a scale measuring solicitous responses, such as asking about pain symptoms, were associated with higher daily morphine equivalent doses. 3) This association remained even after adjusting for other factors like age, sex, depression and pain severity. The findings suggest solicitous responses may influence opioid dose among chronic pain patients.
Presented at American Association for Cancer Research (AACR) at New Orleans 2016 annual conference. Fight Colorectal Cancer and Cancer Research Institute joint effort.
Presented by
Al B. Benson III, MD FACP FASCO
Professor of Medicine
Associate Director for Cooperative Groups Robert H. Lurie Comprehensive Cancer Center of Northwestern University
This study analyzed national ED visit data to identify predictors of ambulance use for transport to the ED for patients over age 45 with chest pain. The study found that private insurance, Hispanic ethnicity, and treatment at a non-metropolitan hospital were associated with decreased odds of ambulance use, while public insurance, lack of insurance, and higher triage acuity were associated with increased ambulance use. Race was not associated with differences in ambulance arrival. Efforts to increase ambulance transport for these high-risk patients may include expanding insurance coverage and improving rural EMS systems, as well as targeted patient education.
1) Palliative care aims to improve quality of life for patients facing life-threatening illness through pain and symptom relief.
2) A WHO demonstration project in Jordan helped establish palliative care policies, increase opioid availability, and provide education to healthcare workers.
3) The Jordan Palliative Care Society was formed to help implement palliative care across the country through additional training, ensuring drug access, and creating a palliative care network.
Near the end of life, providing aggressive chemotherapy can compromise quality of life goals of palliative care. While patients and families may want to continue "fighting cancer", doctors must consider perspectives of patients, families, and palliative care. Guidelines recommend against chemotherapy for patients expected to die within 6 months without clear evidence of benefit, to avoid unnecessary suffering at the end of life. Effective communication and palliative care consultation can help align treatment with patient priorities and values as death approaches.
This study analyzed over 300,000 fractures in 18 bones to identify risk factors for fracture nonunion using a large US health claims database. The overall nonunion rate was 4.9%. Certain fractures like scaphoid, tibia/fibula and femur fractures had nonunion rates over 10%. Multiple risk factors were associated with increased odds of nonunion on multivariate analysis, including open fractures, multiple concurrent fractures, prescription NSAID and opioid use, anticoagulant use, and osteoarthritis with rheumatoid arthritis - all increasing the risk of nonunion by over 50%. The probability of nonunion can be estimated based on patient characteristics and fracture severity available at initial presentation.
This document discusses cancer and disasters. It notes that cancer patients are vulnerable during disasters as infrastructure damage can disrupt treatment and medical records. Access to oncologists, medications, treatment continuity and transportation are challenges. Social isolation is a risk, and chronic illnesses may be exacerbated by disaster conditions like lack of resources. The document provides recommendations for cancer patients during disasters such as keeping medication logs, drinking fluids, and educating on their disease and resources. It also recommends outreach programs and incorporating local chronic needs into disaster planning and response.
Final Project - Projet Technique et Scientifique.
A brief introduction to cancer; some major guidelines that may help fighting back cancer and an international questionnaire to assess general perception of oncologic diseases.
Sorbonne Université - 5th Year - 1st Semester - Master Biologie Intégrative et Physiologie.
This document discusses overlapping chronic pain conditions (COPCs), where many common pain conditions frequently co-occur. It notes the high degree of overlap is often not accounted for in clinical trials. The failure to consider the heterogeneous and overlapping nature of chronic pain may result in treatments with only small effects. It presents the concept of COPCs and reviews their epidemiology, finding significant overlap between conditions like headaches, neck pain, and jaw pain in the general US population based on a national health survey. It concludes more research is needed that considers the overlapping nature of chronic pain conditions.
This document discusses overlapping chronic pain conditions (COPCs), where many common pain conditions frequently co-occur and overlap. It notes that COPCs are more prevalent in women than men. The failure to account for the heterogeneous and overlapping nature of most chronic pain conditions may result in small treatment effects when administered to general chronic pain populations. It recommends advancing the understanding of COPCs by considering their overlapping nature in clinical trials and pain condition classifications.
Palliative care aims to relieve suffering and improve quality of life for patients with chronic or terminal illnesses. It provides comprehensive pain and symptom management as well as psychological, emotional, and spiritual support for both patients and their families. Cancer pain is a major problem, with up to 80% of cancer patients experiencing moderate to severe pain at some point. Cancer pain can be somatic, visceral, neuropathic, or breakthrough in nature. A thorough assessment of pain is important for effective management.
This study investigated the relationship between pain catastrophizing and outcomes in 253 chronic pain patients prescribed opioids in primary care settings. Patients completed measures of pain catastrophizing, intensity, disability, side effects, and opioid misuse at baseline and 6-month follow up. The results showed that patients with high catastrophizing reported greater pain, disability, negative affect, side effects, and opioid misuse compared to low catastrophizing patients, both at baseline and over 6 months. Higher catastrophizing was associated with worse pain outcomes and increased risk of opioid misuse among chronic pain patients prescribed opioids in primary care.
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
Intensity of chronic pain — the wrong metric Paul Coelho, MD
The document discusses how pain intensity is an imperfect metric for evaluating chronic pain treatment outcomes. While pain intensity was widely used as the goal of acute and end-of-life pain treatment, it fails as a measure for chronic pain, which has different causes and meanings. For chronic pain patients, factors like suffering, distress, disability, and quality of life may be better indicators of treatment success than pain intensity alone. The document advocates for moving beyond a focus solely on pain intensity and adopting multimodal treatments and a biopsychosocial approach that considers the complex nature of chronic pain.
This document provides guidelines for the management of cancer pain. It discusses that pain is a common symptom in cancer patients, with a prevalence of over 50% depending on cancer stage. While pain is undertreated in many cancer patients, comprehensive assessment and appropriate treatment including opioids can effectively manage cancer pain. The guidelines cover principles of cancer pain management, diagnosis and assessment of pain, classification of cancer pain, and tools for assessing pain intensity and quality.
iCAAD London 2019 - Mel Pohl - CHRONIC PAIN AND ADDICTION: HOW WE MISSED THE...iCAADEvents
The document discusses chronic pain and addiction. It notes that while all pain is real, emotions drive the experience of chronic pain. Opioids are often ineffective in treating chronic pain and can actually make pain worse. The goals of pain management should be to maintain or improve function rather than just reducing pain. Non-medication treatments like exercise, massage, and mindfulness can be effective alternatives or supplements to medication for chronic pain.
1. Cancer pain affects a large percentage of cancer patients, with moderate to severe pain reported in over 33% of cases. Proper pain management is important to relieve unnecessary suffering and reduce further weakening of patients.
2. Cancer pain can be nociceptive (from tissue damage) or neuropathic (from nerve damage) in nature, with bone pain being very common. Treatment involves modifying the pathological process, elevating pain thresholds, interrupting pain pathways, and lifestyle modifications.
3. Effective cancer pain management requires a rational approach using the WHO guidelines, with an emphasis on relieving pain at all stages of disease through various pharmacological and non-pharmacological means.
This document discusses the management of cancer pain. It begins with an overview and discusses the magnitude of cancer pain, noting that 30-50% of cancer patients experience moderate to severe pain. It then covers types and etiology of cancer pain, clinical evaluation, and the management approach using a multidisciplinary team. Key aspects of management include the WHO analgesic ladder using non-opioid and opioid medications. Barriers to effective pain management and strategies to address cancer pain such as modifying the pain source or altering central perception are also summarized.
Diagnosis and Management of Chronic pain associated with depression.pptxssuser40df77
Chronic pain and depression are often comorbid conditions that can mutually exacerbate one another through shared neural pathways and neuroplasticity changes in the brain. Approximately half of patients with depression report chronic pain, while 30-60% of individuals with chronic pain meet criteria for depression. Regions implicated in both chronic pain processing and mood regulation include the insular cortex, prefrontal cortex, anterior cingulate, thalamus, hippocampus and amygdala. Greater functional connectivity between the nucleus accumbens and prefrontal cortex in patients with sub-acute back pain has been found to predict transition to chronic pain. Effective treatment of depression may help alleviate chronic pain.
This document discusses the basic principles of palliative care, including definitions, goals, ethical issues and barriers. It provides statistics on palliative care needs in Palestine, including causes of death, cancer rates and lack of services. Recommendations are made to establish national palliative care policies and programs, train healthcare workers, ensure availability of pain medications, and incorporate palliative care into existing healthcare systems to improve end of life care.
This document summarizes challenges facing oncology nurses in managing pain for cancer patients in the Palestinian Authority. It finds that 73% of cancer patients have moderate to severe pain. Major challenges include complicated rules limiting opioid prescription; nurses' lack of training in pain management; and patients' and families' beliefs that pain is normal and opioids are addictive. Future recommendations include establishing palliative care policies, educating healthcare workers, and providing psychosocial support for patients and families.
The association between a history of lifetime traumatic events and pain sever...Paul Coelho, MD
This study examined the associations between a history of lifetime abuse and affective distress, fibromyalgia symptoms, pain severity, interference, and physical functioning in 3,081 chronic pain patients. The study found that those with a history of abuse had greater depression, anxiety, worse physical functioning, greater pain severity, worse pain interference, higher catastrophizing, and higher scores on the 2011 Fibromyalgia Survey criteria. Mediation models showed that fibromyalgia survey scores and affective distress independently mediated the relationship between abuse history and pain severity and physical functioning. The findings support a biopsychosocial model where affective distress and fibromyalgia symptoms interact to play roles in how abuse relates to increased pain morbidity.
The document describes a case study of a 58-year-old man referred to physical therapy for low back pain. During the initial evaluation, the physical therapist discovered an abdominal aortic aneurysm (AAA) as the likely cause of the patient's symptoms through abdominal palpation. Computed tomography imaging confirmed a 5.5 cm AAA. The purpose of the case study was to demonstrate the clinical reasoning that led to the identification of an AAA despite the patient's reported mechanical low back pain, and to describe an evidence-based approach for evaluating patients with possible AAAs.
Meta-Analysis of population studies on the prevalence of chronic pain in UK –...Pubrica
Chronic pain, which includes illnesses like low back pain and osteoarthritis, was recently highlighted as one of the most common causes of disability worldwide by the Global Burden of disease studies in a meta-analysis study.
Reference : https://bit.ly/3Ki4o96
Our services : https://pubrica.com/services/research-services/meta-analysis/
Why Pubrica:
When you order our services, We promise you the following – Plagiarism free | always on Time | 24*7 customer support | Written to international Standard | Unlimited Revisions support | Medical writing Expert | Publication Support | Biostatistical experts | High-quality Subject Matter Experts.
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Chronic pelvic pain is a complex condition with no single cause. It often involves both physical and psychological factors. The document discusses the evaluation and treatment of chronic pelvic pain. It describes how understanding of the condition has evolved over time to recognize that visible pathology often does not fully explain a patient's pain. A multidisciplinary approach is needed that considers potential contributors beyond just organic findings, such as muscle tension, trauma history, and central sensitization. A thorough history and physical exam aim to identify all potential pain generators that can be addressed through treatment.
This document discusses pain assessment and management after cesarean section. It provides information on common pain scales like numeric, visual analogue, and Wong-Baker FACES scales. It summarizes a study that assessed pain quality using the Pain Quality Assessment Scale in 153 post-cesarean women. Scores showed unpleasant sensation was most common, followed by intensity and tenderness. While pain interfered more with physical health, most women reported feeling healthy overall. Adherence to medication was moderate. The study concluded that age, education, and occupation impacted pain levels with primiparous women experiencing slightly more severe pain.
Meta-Analysis of population studies on the prevalence of chronic pain in UK –...Pubrica
Chronic pain, which includes illnesses like low back pain and osteoarthritis, was recently highlighted as one of the most common causes of disability worldwide by the Global Burden of disease studies in a meta-analysis study.
Reference : https://bit.ly/3Ki4o96
Our services : https://pubrica.com/services/research-services/meta-analysis/
Why Pubrica:
When you order our services, We promise you the following – Plagiarism free | always on Time | 24*7 customer support | Written to international Standard | Unlimited Revisions support | Medical writing Expert | Publication Support | Biostatistical experts | High-quality Subject Matter Experts.
Contact us:
Web: https://pubrica.com/
Blog: https://pubrica.com/academy/
Email: sales@pubrica.com
WhatsApp : +91 9884350006
United Kingdom: +44-1618186353
Medical Management of Chronic Pelvic Pain: The Evidence.Alex Swanton
Chronic pelvic pain (CPP) is a significant problem for both general practitioners in the primary care setting and gynaecologists alike. The incidence of CPP has often been overlooked due, partially, to an inappropriate referral pattern, but also due to the inherent difficulty in correctly diagnosing the condition.
Similar to Am j hosp palliat care 2004-davis-137-42 (20)
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...rightmanforbloodline
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TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
1. Abstract
Pain is one of the most commonly
experienced and feared symptoms of
advanced cancer. Most cancer patients
experience pain, usually of moderate to
severe intensity, and most also have a
number of distinct pains. The most com-
mon type of pain is related to bone
metastases. Neuropathic pain occurs in
one-third of patients, alone, or as a mix
of nociceptive and neuropathic pain.
The failure to manage pain proper-
ly is due to several factors. In develop-
ing countries, it is likely to be related
to geography and limited resources.
Legal restrictions also present barri-
ers. In developed countries, failure to
manage pain properly is usually relat-
ed to a “disease” rather than a “symp-
tom” model of care, which minimizes
symptom management. Other factors
include lack of physician education and
failure to follow existing guidelines.
Patients fear addiction, drug tolerance,
and side effects. Despite adequate re-
sources, pain is still undertreated.
Key words: pain, opioids, pallia-
tive care, epidemiology, cancer
Introduction
Pain is an unpleasant sensory or
emotional experience associated with
actual or potential tissue damage or an
experience described in terms of such
damage.1
Even though pain is associat-
ed with tissue destruction, pain intensi-
ty is not proportional to the type or
extent of tissue damage. Pain is modu-
lated at various sites within the nervous
system, including the dorsal horn, peri-
aqueductal gray, brain stem, medial
thalamus, and anterior cingulate
cortex.2
Pain is also influenced by past
experience, mood, and cognitive func-
tion. Therefore, pain perception is best
described as a biopsychosocial experi-
ence.3
Pain can be subdivided into: 1)
somatic pain, 2) neuropathic pain, and
3) visceral pain.4,5
The prevalence of
pain in cancer is governed by the type
of cancer, stage, location of metasta-
sis, and comorbidity.6
Incident pain,
tenesmus, colic, and neuropathic pain
are difficult to manage. Personal fac-
tors associated with uncontrolled pain
are delirium, depression, anxiety, and
substance abuse.6
Psychological fac-
tors that modulate pain experience are
rarely initiators of pain in a cancer
patient. Depression is associated with
advanced disease and uncontrolled
pain.7
Since advanced cancer patients
experience a high prevalence and
severity of nonpain symptoms, pain
management must be combined with
systematic symptom control embed-
ded in the framework of palliative
care.8
137American Journal of Hospice & Palliative Medicine
Volume 21, Number 2, March/April 2004
Epidemiologyofcancerpainandfactors
influencing poor pain control
Mellar P. Davis, MP, MD, FCCP
Declan Walsh, MSc, FACP, FRCP (Edin)
MellarP.Davis,MP,MD,FCCP,DirectorofResearch,
The Harry R. Horvitz Center for Palliative Medicine,
ClevelandClinicFoundation,Cleveland,Ohio.
Declan Walsh, MSc, FACP, FRCP (Edin),
Medical Director, Director, The Harry R. Horvitz
Center for Palliative Medicine, Cleveland Clinic
Foundation, Cleveland, Ohio.
Palliative oncology update
at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
2. Epidemiology
Cancer causes 20 percent of all
deaths each year in the US, with
approximately one million new cases
per year. Of these patients, 500,000 or
more die as a result of their cancer.
Seventy percent of patients with
advanced cancer experience moderate
to severe pain. Many of these patients
have chronic pain as a result of past
treatment for their underlying disease.9
The incidence of cancer worldwide is
six to seven million patients per year,
with half or more occurring in develop-
ing countries.9,10
Every year, approx-
imately 4½ million patients die from
cancer, and 3½ million suffer from can-
cer pain daily. Only a fraction of those
will receive adequate pain treatment.10
Cancer incidence increases with
age. By the year 2015, the population
in developing countries will increase
by 60 percent, but the number of peo-
ple over 65 will more than double.
Therefore, despite a stable cancer
incidence, the absolute number of
cancer patients will also double. The
westernization of many developing
countries, particularly with regard to
tobacco consumption, will further
increase the incidence of cancer.11
Only 3 percent of the gross national
product of the average developing coun-
try is spent on healthcare.12
Global
resources for cancer control are finan-
cially limited. Therapies for advanced
cancer are expensive, technologically
involved, limited in benefit, and usually
beyond the means of developing
countries. Palliative medicine, though
often relegated to secondary impor-
tance in healthcare expenditures, is
much more important and affordable
in most countries.12
Pain characteristics
in advanced cancer
Patients with advanced cancer have
an increased frequency and intensity of
pain compared with early-stage cancer
patients. During treatment for their
cancer, 35 to 56 percent will have pain,
with 20 to 34 percent experiencing
severe pain. Pain type by percentage
includes: 1) somatic nociceptive pain
(50 percent); 2) neuropathic pain (33
percent); and 3) visceral nociceptive
pain (20 percent), with a median num-
ber of three types of pain per patient.
Six to 17 percent of patients with
nonmetastatic cancer have pain directly
attributable to cancer compared to 35 to
56 percent of those with metastatic dis-
ease. Pain is found in 76 percent of hos-
pice patients,13
and 84 percent require
opioids on the last day of life.14
Twenty
to 34 percent of patients have severe
pain, which directly influences their
quality of life and daily function (i.e.,
pain interference). Early-stage lung
cancer, breast cancer, cervical cancer,
and ovarian cancer rarely produce pain.
Prostate cancer and colon cancer pro-
duce pain even in the early stages by
obstruction of the urinary tract or fecal
stream, respectively.15,16
Solid tumors
produce more pain than leukemias and
lymphomas. Induction therapies for
acute leukemia are associated with pain
in 40 to 50 percent of patients on days
16 through 20 due to mucositis from
chemotherapy17
and neutropenia.
Grond et al.18
investigated cancer
pain etiologies and used a verbal catego-
ry rating scale to separate pain into cate-
gories: 1) pain related to cancer metas-
tases; 2) pain related to cancer treatment;
3) pain associated with complications
from cancer or its treatment (debility,
herpes zoster, etc.); and 4) pain unrelated
to cancer, treatment, or complications.
Pain was found most frequently in pa-
tients with advanced head and neck can-
cers, gastrointestinal malignancies, and
genitourinary tumors. Seventy-seven
percent of patients with pain had a verbal
rating of severe pain. Somatic nocicep-
tive pain was most frequently found
with breast cancer, genitourinary
tumors, bone primaries, and lym-
phoreticular malignancies. In compar-
ison, head and neck cancers produced a
mix of nociceptive and neuropathic pain.
Not surprisingly, gastrointestinal cancers
were associated with visceral nocicep-
tive pain. Nearly 40 percent of patients
had two pain syndromes, and 30 percent
had three or more separate pain syn-
dromes. Eighty percent of patients had
more than one anatomical site of pain.
The distribution of pain was nociceptive
in 50 percent of patients, usually due to
bone metastases. Twenty-five to 33 per-
cent of patients had neuropathic pain,
and a smaller subset had visceral pain.
Ten to 20 percent of patients had pain
caused by therapy rather than the under-
lying malignancies. Fewer than 10 per-
cent of patients had pain unrelated to
their cancer.
A survey by Twycross19
found one-
third of patients with bone pain, one-
third with neuropathic pain, and one-
third with pain caused by soft tissue
infiltration. One-third of patients also
had visceral pain, and 11 percent had
muscle spasms. In a second study by
Twycross,20
the median number of dis-
tinct pains was approximately three, and
40 percent of patients had more than four
separate pains. After four weeks of pal-
liative treatment, 78 percent of patients
still had more than one type of pain,
although the median number decreased
to 1.5. By numerical scale, there was a
graded influence of pain severity with
pain interference. When the pain in-
tensity rating exceeded 4 out of a possi-
ble score of 10, daily activities were
impaired. When pain intensity ex-
ceeded 6, significant interference with
enjoyment of life occurred.20
Pain in palliative outpatients.
Painwaspresentin61percentofpatients
attending a palliative day care clinic.21
The number of nonpain symptoms expe-
rienced in addition to pain range from
two to 11. Metastatic disease correlat-
ed with the number of symptoms and
the severity of pain. Associated non-
pain symptoms included nausea, dysp-
nea, insomnia, xerostoma, constipation,
irritability, sadness or depression, and
dizziness. One-quarter of patients had
138 American Journal of Hospice & Palliative Medicine
Volume 21, Number 2, March/April 2004
at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
3. severe to very severe pain as observed in
a number of studies.12,22-26
Pain in pediatric patients. Child-
ren can complete a modified Memorial
Symptom Assessment Scale (MSAS)
adapted for children. As rated by the
MSAS, pain occurred in more than 35
percent and was associated with a high
degree of distress.27
Half of pediatric
patients admitted to an inpatient unit had
pain, and one-quarter of outpatients
experienced pain.28
Treatment-related
pain is more common than cancer-
related pain in adults. Pain related to
procedures (bone marrow, spinal taps)
and pain associated with surgery or
chemotherapy were the predominant
factors influencing pain prevalence.
Tumors cause pain in one-third of inpa-
tients and 20 percent of outpatients.
Tumor-related pain was mainly caused
by bony invasion, which is similar to the
findings for adults. Physicians tended to
underevaluate and underestimate pain
severity in children, as reflected in the
patient self-assessment visual analog
scales or face scales.
Breakthrough pain
Breakthrough pain (a transitory flare
of an underlying chronic pain) occurs in
most patients, and its incidence corre-
lates with pain severity.29,30
Break-
through pain has been described as inci-
dent pain (pain related to movement),
nonincident breakthrough pain, or end-
of-dose failure pain. Incident pain relat-
ed to bone metastases is the most com-
mon cause of breakthrough pain.
Sudden paroxysmal pain is a type of
neuropathic pain, usually caused by
compression or infiltration of peripheral
nerves or spinal nerve roots. Episodic
cramping abdominal pain is associated
with obstruction of a hollow viscus.
About 50 to 90 percent of patients
with chronic pain have breakthrough
pain. The severity of breakthrough pain
may be independent of the chronic
underlying pain, particularly incident
pain, and frequently requires dosing
independent of the around-the-clock
analgesic dose for chronic pain.
Breakthrough pain requires indepen-
dent assessment. The underlying can-
cer causes 76 percent of breakthrough
pain, while 20 percent is related to
treatment. The median pain duration
is approximately 30 minutes. Most
breakthrough pain is similar in charac-
ter to the chronic underlying pain.
Precipitating factors are found in 50
percent of the pain. Approximately
one-third of breakthrough pain is
somatic, 27 percent is neuropathic,
and 20 percent is a mixture of neuro-
pathic and nociceptive pain.29-32
Epidemiology of failed
pain management
Despite available universal guide-
lines, most studies demonstrate a fail-
ure to relieve pain in 38 to 74 percent
of cancer patients.12,33,34
Palliative
units that adopt the WHO stepladder
analgesic guidelines successfully
manage pain in 90 percent of
patients.35-37
The failed quality of care
in advanced cancer pain management
is usually described in terms of one or
two elements, though most failures
are the result of multiple factors. The
following are process barriers to pain
management:
• structural model of “disease”;
• failure to assess pain;
• lack of knowledge of opioid
pharmacology, conversion, equi-
analgesia, and rotation;
• failure to use adjuvants;
• failure to treat side effects;
• fear of opioid side effects, anal-
gesic tolerance, and addiction;
• lack of priority given to symp-
tom management;
• analgesia based on prognosis
rather than severity of pain;
• failure to document drug, dose,
timing, breakthrough pain, and
laxatives; and
• failure to follow up.
As described by deWit and col-
leagues,38
a Donabedian structure,
process, and outcome model for health-
care delivery can be used to evaluate the
shortcomings with pain therapy.39
The
Donabedian structure includes morphine
availability both nationally and interna-
tionally, arrangements for procurement
ofmorphine,proceduralmanuals,guide-
lines, assessment tools, patient educa-
tion, and educational materials for
healthcare providers. The Donadebian
process describes the practice of
guidelines within the patient-physician
relationship. The process includes actual
pain treatment practice with assessment
tools, dose adjustments, opioid switch,
the addition of adjuvants, continuity of
care, the use of patient education tools,
provisions to improve patient knowl-
edgeabouttreatments,andtheconsistent
practice of established guidelines. The
Donabedian outcomes are assessment of
response, quality of life, and patient sat-
isfaction with treatment. The failure of
pain management in developing coun-
tries occurs mainly within the structural
component of the Donabedian model. In
developed countries, failure most fre-
quently occurs within process of care.
International treaties began in 1912
with the Opium Convention, which was
created to minimize opioid abuse and
prevent the illegal trade of opioids.
These treaties required governments to
ensure the availability of opioids for
medicinal purposes. The International
Opium Conventions of 1925 set up a
permanent Central Opium Board that
monitored production and consumption
of opioids internationally. Until then,
most opioid abuse resulted from diver-
sion of legitimate sources.
139American Journal of Hospice & Palliative Medicine
Volume 21, Number 2, March/April 2004
at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
4. The Single Narcotic Convention in
1961 established an International Nar-
cotic Central Board, which monitored
importsandexportsofopium.Incooper-
ation with national governments, the
board monitored opioid traffic to detect
diversion. This board was also estab-
lished to prevent a shortage of opioids
for legitimate purposes. In the United
States, the Drug Enforcement Agency
(DEA) was established to register
importers, manufacturers, and practi-
tioners who handled opioids. The focus
of these international treaties has been to
prevent abuse, but they have failed to
promote the legitimate use of opioids.
The illicit diversion from legitimate
sources of opium has become rare as a
result of these treaties.40,41
The unintended victim of the war
against illicit drug use is the cancer
patient. Increased regulation leads
directly to underprescribing and reduced
per capita consumption of morphine
nationally and internationally, but does
not alter illicit drug use. The increase in
regulations suggests to the public that
opioids are dangerous substances to be
avoided, and it implies that addiction to
opioids is common. The definitions of
addiction at the federal level are not per-
fect, but it is clear that cancer patients do
not fit the definition. However, at the
state level, the definition of addiction by
the state medical boards frequently fails
to separate psychological dependence
(addiction) from analgesic tolerance and
physical dependence.42
Morphine ad-
dictionissometimesdefinedas“habitual
use,” even though the pain management
guidelines encourage most patients with
chronic cancer pain to use morphine
habitually.42
In addition to the confus-
ing and misleading definitions of addic-
tion, another factor affecting opioid use
is the failure of most state medical
boards to promote the appropriate use
of opioids. Unlike federal authorities,
state law does not necessarily assure
opioid availability, and it can limit the
amounts prescribed. Some states require
prescriptions in triplicate, which can
reduce appropriate morphine use by
50 percent.41-46
Problems of pain management
in developing countries
India uses the same amount of mor-
phine as Denmark, even though
Denmark has 900 million fewer peo-
ple. India is a poor country and spends
six percent of its gross national prod-
uct on healthcare. Antibiotic acquisi-
tion and vaccines are given high prior-
ity, while pain management and
palliative medicine are of secondary
importance.47
Geographically, 75 per-
cent of India’s population is rural and
most pain centers are located in urban
areas. Patients are required to travel fre-
quently to urban pain centers to renew
their pain medications. Since there are
24 different languages spoken in India
and one-third of the males and two-
thirds of the females are illiterate, prop-
er pain assessment and pain diaries are
difficult to complete.47
Latin American countries face a
number of different problems. In
Argentina, the education of physicians
in the field of opioid pharmacology is
below par and often sporadic.48
Commercial opioids are expensive
and acquisition strains the limited
budget of the average citizen. There is
no overarching policy concerning pal-
liative care, nor are there adequate
insurance provisions for palliative
medicine and long-term domiciliary
care. In Columbia, the national supply
of opioids is inadequate and the anti-
quated law fails to recognize the benefits
of opioids in cancer pain management.49
In addition, the duration of opioid pre-
scriptions is limited. The war on drugs
has significantly hampered opioid avail-
ability. The average parenteral dose of
morphine in South American coun-
tries is approximately 9 mg/d com-
pared with 44 mg/d in the US.48-50
Opioid phobia is common in China,
particularly in areas affected by the
heroin traffic ranging from Laos to
Vietnam and into southern China.
Morphine is believed to be more
addicting than pethidine (meperidine).
Methadone is used only for addiction
therapy. Other barriers to appropriate
opioid use include inadequate assess-
ment, excessive regulations, inade-
quate physician knowledge of pain
assessment, and limited access to
potent opioids.51
Problems of pain management
in developed countries
Israel, where opioids are readily
available, also faces problems with pain
management.52
Healthcare workers have
inadequate knowledge of opioids and a
reluctance to prescribe morphine due to
the fear of addiction. Ninety percent of
physicians inadequately assess pain, and
training in pain management is also
inadequate.52
Most physicians are not
able to convert doses between various
opioids, nor can they calculate the
conversion of oral to parenteral equiv-
alents. Twenty percent of nurses are
reluctant to adequately medicate
patients.52
Patients under-report pain
and are reluctant to take pain medica-
tions out of fear of tolerance and
addiction.
In Canada, 67 percent of physicians
felt their education in pain manage-
ment was fair to poor.53,54
Fifty per-
cent of physicians do not use WHO
step three opioids as initial therapy for
severe cancer pain; and inadequately
titrate opioids. Assessment of patients
is also inadequate. Some patients are
reluctanttoreportpainortotakeopioids.
In Germany, even when an appro-
priate opioid is prescribed, 20 percent
of pharmacists counsel patients
against taking them, and one-third of
general community physicians dis-
continue the medication once the
patient returns to their care, because of
their own prejudice—not because the
therapy was ineffective.55
In the United States, opioids are read-
ily available and pain management
140 American Journal of Hospice & Palliative Medicine
Volume 21, Number 2, March/April 2004
at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
5. guidelines are well established. How-
ever, among oncologists of the Eastern
Cooperative Oncology Group, manage-
ment of cancer pain was felt to be less
than optimal in 80 percent of patients.56
Poor pain assessment occurs in 75 per-
cent of patients. Sixty-five percent of
physicians express concerns about side
effects, and most admit to being poorly
trained in pain management. Thirty per-
cent of physicians prescribe opioids
based on prognosis rather than pain
severity.56
Fewer than half of patients
within the hospital have recorded pain
assessments.57
Some professionals be-
lieve there is a ceiling to step three opi-
oids. There is underuse of adjuvant
coanalgesics and a general ignorance
of equianalgesic dosing.
Nearly 40 percent of nurses are
reluctant to give an adequate dose of
pain medications. Characteristically,
physicians undertreat by dose and nurses
undertreat by extending intervals be-
tween doses. Only 42 to 51 percent of
patients within a cancer center receive
adequate analgesics. Thirty percent of
those patients experiencing pain are not
treated. Almost two-thirds of patients are
reluctant to take pain medications out of
fear of tolerance, addiction, or side
effects. Curiously, there is poor correla-
tion between physician knowledge of
opioid pharmacology and a physician’s
prescribinghabits.Acultureofpoorpain
management tends to be self-propagat-
ing, and accountability for poorly con-
trolled pain was rarely reinforced until
recently.Apatientislesslikelytoreceive
adequate analgesia if elderly, female, a
member of a minority group, or within a
lower socioeconomic group.58,59
Summary
Pain is one of the most commonly
experienced and feared symptoms of
advanced cancer. Most cancer patients
experience pain, usually of moderate to
severe intensity, and most also have a
number of distinct types of pain.
Thefailuretomanagepainproperlyis
due to several factors. In developing
countries, it is likely to be related to
geography and limited resources. Legal
restrictions also present barriers. In
developed countries, it is usually related
to a “disease” rather than a “symptom”
model of care, which minimizes symp-
tom management. Other factors include
lackofphysicianeducationandfailureto
follow existing guidelines.59,60
Patients
fear addiction, drug tolerance, and side
effects.
Despite adequate resources, pain is
still undertreated. The WHO recog-
nizes the importance of pain manage-
ment as part of routine cancer care.
The establishment of effective pain
management requires comprehensive
assessment, competency with anal-
gesics, and communication with patients
and families.61
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