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Background: Cancer pain remains a difficult problem, for which opioids are often necessary. At present it is difficult to predict the effectiveness of opioid therapy.Objectives: We aim to assess the association between patient characteristics and opioid treatment response in cancer patients, and develop a model to predict probability of response.Subjects: We used data from two previously published randomized clinical trials, in which patients with head and neck cancer were treated with fentanyl or methadone (total N=134).Measurements: Treatment success was defined as >= 50% pain reduction at one and five weeks. We analyzed patient characteristics (age, sex, depression, and anxiety), treatment characteristics (having had chemotherapy, radiotherapy, surgery, methadone, or fentanyl) and pain characteristics (neuropathic and nociceptive).Design: Based on univariable and multivariable regression analyses determinants of therapy success were assessed. Based on these analyses a prediction model was developed.Results: Our analyses show that one-week therapy success was associated with methadone (odds ratio [OR] = 5.21), duration of pain in months (OR = 1.12), neuropathic pain (OR = 3.36), and age of the patient in years (OR = 0.95). Inclusion of these four characteristics into our prediction model resulted in an area under the curve of 81.6%.Conclusions: Careful analyses of patient attributes, treatment, and pain type of patients with head and neck cancer resulted in a prediction model that allowed to predict short-term pain relief and the opioid treatment response in neuropathic and nociceptive pain owing to cancer.

Background: The opioid epidemic has spurred investigations for nonopioid options, yet limited research persists on medical marijuana's (MMJ) efficacy in managing cancer-related symptoms. Objective:...

Research shows an increased symptom burden in young adult (YA) cancer patients compared with their older adult counterpart.The purpose of this study was to identify differences in clinical characteristics and related outcomes between YA and older adult cancer patients admitted for cancer-related pain.We retrospectively identified 190 hospitalized patients in a single academic center with admissions for cancer-related pain. Patients were grouped into either "young adult" (18-39) or "older adult" (40) cohorts. We compared differences in patient characteristics and pain regimens.Median oral morphine equivalent per 24 hours was higher in the YA group (194 mg vs. 70 mg, p = 0.010). Younger patients received patient-controlled analgesia (PCA) more frequently (p = 0.023). The number of palliative care consults and adjuvants prescribed did not differ between groups (p 0.05), although YAs more frequently had an inpatient pain anesthesia consult (p = 0.047).Findings show increased opioid requirements and PCA use in YAs being treated for malignancy compared with their older adult counterpart.

Methadone has been shown to be effective for cancer pain. Most published switching methods are complete in less than three days, requiring very close supervision, usually in an inpatient setting. This need for hospitalization is a barrier to access. We present a large retrospective study of slow outpatient methadone starts and describe our starting method.Charts were reviewed of patients referred to the Pain and Symptom Management/Palliative Care clinics at the six BC Cancer Agency's regional centers that underwent initiation of methadone for analgesia over a 14-year period. Patient characteristics, method of start, and outcomes of methadone treatment were recorded.Of the 652 identified patients, we were able to determine outcomes of methadone initiation in 564 (86.5%). Among these, 422 (74.8%) were deemed successful initiations, as determined by whether or not the patient remained on methadone at follow-up with subjective improvement in pain control, on a stable dose of methadone. Of the unsuccessful trials, 97/142 were primarily due to adverse events, 16 of which were considered serious enough to require hospitalization, including two due to sudden cessation of opioid therapy leading to withdrawal. Some of the included adverse events were not necessarily causal from the initiation of methadone, for example, development of bowel obstruction or delirium. Only one death occurred from a deliberate overdose of multiple medications, including methadone.Initiation of methadone for analgesia in ambulatory cancer patients can be done safely in an outpatient setting using a start-low go-slow method, and can be expected to be helpful in ∼75% of patients. Discontinuation is more likely to be for side effects than for inadequate analgesia. Access to methadone therapy can safely be widened by slow initiation, avoiding more dangerous rapid switching protocols and reducing the need for hospitalization.

Intravenous lidocaine is an option for intractable pain caused by advancing cancer and wound care. We report a case of intractable cancer pain and wound care pain managed with concurrent use of lidocaine administered as a twice daily intravenous bolus in addition to continuous intravenous infusion.A 31-year-old male with rapidly progressing locally advanced squamous cell cancer affecting the gluteal area developed extensive painful and purulent ulcerating wounds affecting the coccyx, superior gluteal cleft, and buttocks. Laboratory tests were within normal limits, except for low albumin results. The patient's Palliative Performance Score was 60%. A trial of intravenous lidocaine 150 mg administered twice daily before dressing changes improved analgesia according to the patient's report. For additional improvement, a continuous intravenous infusion of lidocaine 1 mg/minute was initiated, in addition to the twice daily bolus infusions of lidocaine. The patient's pain score with dressing changes improved from 8-10 of 10 to 4-5 of 10 within 24 hours after initiation of the continuous intravenous lidocaine infusion. Lidocaine infusion was administered for a period of 45 days with targeted lidocaine blood levels not exceeding 5 mcg/mL. Twice daily lidocaine bolus infusions before dressing changes were administered for a total duration of 63 days. The lidocaine continuous intravenous infusion was discontinued on day 45 of therapy as a potential contributing factor to central nervous system adverse effects and in anticipation of transition to a subacute rehabilitation facility.Intravenous lidocaine added to the efficacy of standard analgesic medications and nerve block procedures in our patient. This case demonstrates increasing blood lidocaine levels with continuous intravenous infusion despite stable clinical parameters and laboratory markers of major organ function. Monitoring lidocaine levels is a prudent course of action to identify drug accumulation with administration of lidocaine by continuous intravenous infusion.

Patients with end-stage head and neck cancer suffer from many physical and psychological symptoms, however, there have been relatively few studies looking at end-of-life symptoms in the head and neck cancer population. The objective of this study was to describe the symptom patterns of patients with terminal head and neck cancer in the palliative care unit.A retrospective chart review of 94 patients with terminal head and neck cancer admitted to a palliative care unit between May 2006 and December 2008 was performed. Demographic data, performance status, primary tumor site, time from diagnosis to first hospice admission, survival time after admission, medication for pain control, and main symptoms at the time of admission were examined.The mean time from diagnosis to first hospice admission was 33.1 ± 51.6 months. The mean survival time in the hospice was 21.9 ± 18.9 days. In this study, the most common symptom experienced was weight loss, followed by pain, cough, dysphagia, feeding difficulties, and communication difficulties. A statistically significant association of communication difficulties was found with presence or absence of a tracheostomy (p 0.001). Change of morphine dosage after hospice care is related to the site location of head and neck cancer. Levels of education seem to be related to the increasing use of morphine (p = 0.025). Change of morphine dosage was statistically correlated with survival time after hospice admission (p 0.001)Numerous symptoms at the end of life highlight the complexity of head and neck cancer patients that may necessitate early hospice referral for symptom control.

Palliation of pain is universally regarded as a cardinal aspect of end-of-life care. In the early days of the palliative care and hospice movement there was concern that aggressive pain control with opioids could potentially hasten the death of the patient primarily through respiratory depression. For many ethicists and theologians who were opposed to active euthanasia, this raised the difficult question of whether it is permissible to use these potentially harmful medications. Traditional Jewish decisors also addressed this question and their writings can shed light on their attitudes toward terminal care. The purpose of this article is to analyze the view of three highly respected authorities on the use of pain medications with potentially significant side effects in terminal patients. The Jewish position demonstrates how an ancient tradition struggles to develop an ethic consistent with modern sensibilities. Religious decisors scour the ancient sources to find precedents and then apply that wisdom to contemporary questions. Jewish medical ethics by its very nature is highly pluralistic because there is no central body that determines policy and a wide spectrum of opinions are usually found. However, regarding pain treatment there appears to be a broad consensus mandating its aggressive use even at the risk of significant side effects as long as the motivation is relief of suffering.

Our aim was to evaluate the use of very-low-dose methadone with haloperidol in the acute-care setting.We reviewed the records of 735 hospitalized patients receiving a palliative care consultation between 2011 and 2014. All patients with pain on opiates were offered conversion to methadone, 2.5 mg/day to 15 mg/day, in conjunction with scheduled haloperidol. Additional doses of haloperidol or short-acting opiates were given as needed for pain. Patients receiving an opiate at a morphine-equivalent daily dose (MEDD) of ≥40 mg had pain scores assessed daily, before and after conversion. Descriptive statistics were used to summarize the results.Forty-three patients underwent conversion from another opiate (median MEDD, 78.5 mg) to methadone (median daily dose, 5 mg) and haloperidol (median daily dose, 1.5 mg). The median pain score was 5 in the week prior to conversion, 1 in week 1 after conversion (p0.001 for difference), and zero in week 2. Similar results were seen for patients with cancer and noncancer diagnoses and for those with the highest and lowest initial opiate doses.The use of very-low-dose methadone in conjunction with haloperidol in the acute-care setting resulted in improved pain control after conversion from typical opiates.

Substantial resources have been spent to improve pain control for dying patients, and increased opioid administration has been presumed. Oregon has been a consistent leading state in per capita use for morphine for the past 10 years, as recorded by the Automation of Reports and Consolidated Orders System (ARCOS). Health policy experts, extrapolating from World Health Organization methods, have suggested these data are indicative of the quality of end-of-life care in Oregon. To determine whether trends in opioid prescription at the state and national levels reflect increased opioid use for inpatients during the final week of life, chart reviews were conducted to record all opioid medications administered in the last week of life to 877 adult inpatients who died from natural causes between January 1, 1997 and December 31, 1999. Inpatient morphine use did not increase significantly for dying patients from 1997 to 1999. However, overall morphine use for both Oregon and the United States as measured by ARCOS data increased significantly. Comparisons revealed no significant difference between linear trends for Oregon and U.S. morphine use, but both were significantly greater than the dying inpatients. This pattern was also found for all other opioids. These findings suggest that ARCOS data do not necessarily provide information about opioid use for specific subpopulations of patients and raise questions about the meaning of observed increases in ARCOS data.

In 1996, the United Hospital Fund (UHF) awarded planning grants to 12 hospitals to analyze their needs, resources, capacities, and program development strategies. Beth Israel Medical Center in New York City was one of five programs to receive a further implementation grant from UHF in 1998 to continue their efforts.a The Department of Pain Medicine and Palliative Care (DPMPC) was established in 1997–1998 under the leadership of Russell Portenoy, M.D., a neurologist with expertise in pain management and palliative care. By drawing together the specialized care and resources involved in pain medicine, inpatient and outpatient palliative care, and hospice care, this department is the first of its kind to exist as an integrated department within a hospital system. As such, it provides one of the most comprehensive models for palliative medicine found in the United States. With its focus on multidisciplinary teamwork, symptom management, and pain control, and the integration of hospice into the practice of palliative medicine, Beth Israel Medical Center’s DPMPC brings together the benefits of expert medical practice and psychosocial care to patients and families in one comprehensive center. The DPMPC is one of three recipients of the American Hospital Association’s 2001 Circle of Life Award. In the following interview with Innovations Associate Editor Karen S. Heller, Ph.D., Dr. Portenoy speaks about the unique opportunity he has had to create an integrated department within the hospital institution. He discusses the strengths and successes of such a comprehensive and coordinated program, as well as the limitations and challenges that still lie ahead in the field of palliative care. This interview is excerpted from the thematic issue, “Institutionalizing Palliative Care,” Volume 3, Number 4, 2001 of the online journal Innovations in End-of-Life Care at .

The celiac plexus block is an approved method for the relief of upper abdominal cancer pain. Classically, fluoroscopy-guided posterior approach to the celiac plexus block has been used. Computed tomography-guided anterior approach and endoscopic ultrasound-guided approach have also been utilized. An ultrasound-guided anterior approach to celiac plexus neurolysis with median plane single-needle entry technique has been described that targets the preaortic area between the origins of celiac trunk and superior mesenteric artery. We describe our experience with and decision to use the bedside ultrasound-guided anterior approach to celiac plexus neurolysis using bilateral paramedian needle entry technique.

Among the knowledge required by healthcare professionals to manage pain is an understanding of the differences between opioid agents and formulations. As the list of new opioid formulations continues to grow, it is increasingly important that clinicians understand the basic pharmacology of these analgesics and how to calculate equianalgesic doses. Administering an equianalgesic dose increases the likelihood that the transition to another opioid or route will be tolerated without loss of pain control or excessive side effects. Although calculation of equianalgesic doses requires relatively simple mathematical skills, few clinicians are prepared to compute them. The purpose of this article is to provide a basic review of the pharmacology of opioids, explain how to calculate an equianalgesic dose, and briefly describe some of the current controversies of the relative potencies of opioids listed in equianalgesic tables.