Search

This chapter presents a brief history of the use of methadone for analgesia and discusses the need for universal access to methadone for pain management where appropriate. The mechanisms of action, side-effects, drug interactions, and special considerations that are different to other opioids are discussed, with particular attention to QT interval prolongation and cytochrome P450 enzyme metabolism. Methods of methadone initiation and switching are described and compared. Use of non-oral routes of administration are presented for use in patients in whom the oral route is not possible.

In this chapter, the history of medical cannabis use is briefly reviewed and the endocannabinoid system is described in basic terms. The use of cannabis-based medicines is discussed from a cancer patient’s perspective. Essential information for prescribers is presented, including the rationale for choice of preparations, therapeutic uses, potential side-effects, and interactions. The primary cannabinoids are discussed, and the existence of many non-cannabinoid molecules in plant-derived cannabis products are also introduced, e.g. terpenes. A simple approach to therapy of using a low-tetra-hydro cannabinol (THC)-containing oil, administered via an oral transmucosal route, with the product derived from a legal source (in Canada, a Health Canada-approved ‘Licensed Producer’), in a ‘Start Low, Go Slow’ manner, is recommended. The chapter concludes with brief discussion of the innovative wound management potential for topical cannabinoids.

This chapter describes and discusses the World Health Organization Cancer’s pain ladder, including modifications to reflect current practice, specifically the limited role for Step 2, and the need to consider a Step 4 of interventional pain management procedures and techniques. The chapter lists the characteristics of the commonly available opioid analgesics: morphine, hydromorphone, oxycodone and fentalyl, both generally and with specific reference to circumstances in which one opioid might be preferred over another, particularly renal failure. Buprenorphine and sublingual sufentanil are included. Methadone is coverd in a separate chapter and is not discussed in detail here. Common opioids side-effects are described, along with their prevention and mitigation recommendations. Opioid initiation and switching strategies are described, and the concept of opioid equianalgesic dosing ratios is explained. Tolerance and hyperalgesia are discussed with reference to opioid switching.

Interventional radiological techniques are proving to be vital in the relief of physical suffering and improving function, both of which are also goals for modern palliative care. The need for all medical specialties to be able to deliver at least basic palliative care as a core competency is now widely recognized. A Palliative Approach to Care provided by a diverse range of health care professionals from the time of diagnosis can meet the needs of most patients and their families living with serious illnesses, allowing Specialist Palliative Care services to take care of those with the most complex needs. Palliative care primarily impacts three domains: symptom management, communication around goals of care, and collaboration between all the different people and services involved. Awareness of how interventional radiologists, anesthesiologists and specialist palliative care teams can collaborate is particularly important when carrying out procedures on people with complex needs who are suffering greatly. A common understanding of the principles of palliative care will facilitate future integration throughout the health care system so that the relief of suffering for our most vulnerable patients is promptly achieved, whatever their prognosis.

Background: Metastases to the bone are common in cancer patients, and it has been estimated that up to 50% of patients with pelvic bone metastases will not achieve adequate pain control with medications alone. This has led to a paradigm shift over recent years towards the use and development of minimally invasive image-guided treatment options for palliation of bony metastases. Despite these developments, large metastatic lesions are still often considered to be “hopeless cases” that would garner little to no benefit from image-guided intervention. This study is the first large series to describe the novel use of combination percutaneous cryoablation and cementoplasty for palliation of such large metastases to the pelvis. Objectives: We aim to evaluate the efficacy and safety of image-guided percutaneous cryoablation and cementoplasty for palliation of large pelvic bone metastases. Study Design: This retrospective analysis was approved by our institutional review board. This study was conducted from January 2013 to December 2016, where consecutive patients referred for pain management of large pelvic bone metastases underwent combination percutaneous cryoablation and cementoplasty. Setting: This study took place at a tertiary care center after patients were referred following formal review from a multidisciplinary conference, which was comprised of interventional radiologists, pain management and palliative care physicians, radiation and medical oncologists, and when available, anesthesiologists. Methods: Forty-eight patients (36 men and 12 women) with a mean cohort age of 77.5 years (range: 52 – 89 years) were referred from the multidisciplinary conference for palliation of pelvic bone metastases. The inclusion criteria included patients with metastases greater or equal to 5.0 cm and significant pain refractory to conventional pain management regimens. All of the patients were deemed not to be surgical candidates. Mean pain scores were collected at numerous time-points along with procedural technical success rates and complication rates. Results: Combination cryoablation and cementoplasty was performed on 48 consecutively referred patients with a 100% technical success rate and no immediate complications. The pain levels demonstrated a significant decrease (P < 0.001) following intervention, with mean pain scores of 7.9 (range: 5 – 10) and 1.2 (range: 0 – 7) throughout the week prior to intervention and at 24 hours postintervention, respectively. The post-intervention pain scores remained stable at 1 to 9 weeks followup (mean: 4.1 weeks). Three patents (6.3%) reported no change in pain following the intervention; however, no patients reported worsened pain. Limitations: The limitations of this study include its retrospective nature and the length of follow-up, which was often restricted given the life expectancy of our patient cohort. Conclusion: Combination cryoablation and cementoplasty is a novel and efficacious treatment option for palliation of large pelvic bone metastases. Marked improvements in pain, as well as mobility and quality of life, are often attainable. Key words: Pain, palliative care, palliation, percutaneous, cryoablation, cementoplasty, metastases, pelvis, interventional radiology, thermal ablation

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.

Metastases to the bone are common in cancer patients, and it has been estimated that up to 50% of patients with pelvic bone metastases will not achieve adequate pain control with medications alone. This has led to a paradigm shift over recent years towards the use and development of minimally invasive image-guided treatment options for palliation of bony metastases. Despite these developments, large metastatic lesions are still often considered to be "hopeless cases" that would garner little to no benefit from image-guided intervention. This study is the first large series to describe the novel use of combination percutaneous cryoablation and cementoplasty for palliation of such large metastases to the pelvis.We aim to evaluate the efficacy and safety of image-guided percutaneous cryoablation and cementoplasty for palliation of large pelvic bone metastases.This retrospective analysis was approved by our institutional review board. This study was conducted from January 2013 to December 2016, where consecutive patients referred for pain management of large pelvic bone metastases underwent combination percutaneous cryoablation and cementoplasty.This study took place at a tertiary care center after patients were referred following formal review from a multidisciplinary conference, which was comprised of interventional radiologists, pain management and palliative care physicians, radiation and medical oncologists, and when available, anesthesiologists.Forty-eight patients (36 men and 12 women) with a mean cohort age of 77.5 years (range: 52 - 89 years) were referred from the multidisciplinary conference for palliation of pelvic bone metastases. The inclusion criteria included patients with metastases greater or equal to 5.0 cm and significant pain refractory to conventional pain management regimens. All of the patients were deemed not to be surgical candidates. Mean pain scores were collected at numerous time-points along with procedural technical success rates and complication rates.Combination cryoablation and cementoplasty was performed on 48 consecutively referred patients with a 100% technical success rate and no immediate complications. The pain levels demonstrated a significant decrease (P0.001) following intervention, with mean pain scores of 7.9 (range: 5 - 10) and 1.2 (range: 0 - 7) throughout the week prior to intervention and at 24 hours post-intervention, respectively. The post-intervention pain scores remained stable at 1 to 9 weeks follow-up (mean: 4.1 weeks). Three patents (6.3%) reported no change in pain following the intervention; however, no patients reported worsened pain.The limitations of this study include its retrospective nature and the length of follow-up, which was often restricted given the life expectancy of our patient cohort.Combination cryoablation and cementoplasty is a novel and efficacious treatment option for palliation of large pelvic bone metastases. Marked improvements in pain, as well as mobility and quality of life, are often attainable.Pain, palliative care, palliation, percutaneous, cryoablation, cementoplasty, metastases, pelvis, interventional radiology, thermal ablation.

Intravenous lidocaine infusion has been clearly demonstrated as effective for pain in randomized controlled trials, but the belief that cardiac monitoring is required for safe administration is a barrier to access in the palliative care setting. There are also multiple infusion protocols reported in the literature. We have been administering lidocaine infusions for severe cancer pain at the BC Cancer Agency (BCCA) since 2003, without electrocardiographic (ECG) monitoring. Our simple protocol is for 5 mg/kg to be infused over 1 hour, with the option for subsequent doses to be increased if necessary, up to a maximum of 10 mg/kg. Our aim with this study is to share 11 years of our experience with this protocol.This is a retrospective case series. Records of patients who received at least one lidocaine infusion for pain between 2003 and 2013 at the BCCA were reviewed. The primary end points were the documentation of clinical benefit and adverse effects.A total of 122 lidocaine infusions were administered in 51 individual patients. Twenty-five (49%) had a major response, 12 (23.5%) had a minor response, and 14 (27.5%) were considered nonresponders. Twenty-two (43.1%) patients were noted to have some adverse effect during at least one of the infusions, but only 1 (1.9%) patient had the infusion permanently discontinued. The most common side effects were drowsiness (30.7%), perioral numbness (13.4%), nausea (5.7%), and minor fluctuations of blood pressure (3.8%).This case series demonstrates that our protocol of infusional lidocaine can be beneficial to patients with cancer with severe opioid-refractory pain, and can safely be administered with close observation and vital sign monitoring, without ECG monitoring. Lidocaine infusion is a useful option to consider when other pain treatments have not been successful. Although only approximately half of patients will respond well, there is little harm to be expected from a trial of lidocaine infusion and responders can be repeatedly treated. This treatment could be delivered in palliative care units, hospices, or even patients' homes, providing suitable nursing supervision can be provided.

There is increasing support for the use of cannabis in terminal illness. Sixty-eight patients from a palliative population were surveyed for their attitudes and beliefs about the use of cannabis in terminal illness. Symptomatic patients with advanced illness were surveyed for attitudes, beliefs and symptom severity. Participants showed concern about cannabis' possible side effects and social consequences, with some significant differences between ethnic groups. Comfort with the use of cannabis for symptoms was reported by 80.9% and willingness to participate in a research study using cannabis was reported by 73.5%. Many felt cannabis was safer than morphine for pain management. Patients preferred an oral route of administration and had concerns about smoking cannabis. Despite significant concerns about using cannabis, most palliative patients were still willing to try it for symptom relief. This may have implications if cannabis access regulations are relaxed, in that access will come before clin...

Background: This case report describes a patient who developed severe bradycardia due to transdermal fentanyl. There have been no prior case reports of this occurring in palliative care, but the frequency of association of fentanyl with bradycardia in the anesthesia setting suggests it may be more common than realized. Palliative care settings often have a policy of not routinely checking vital signs, and symptoms of bradycardia could be misinterpreted as the dying process. Case presentation: A patient with recurrent ovarian cancer was admitted with nausea and abdominal pain due to bowel obstruction and fever from a urinary tract infection. A switch from injectable hydromorphone to transdermal fentanyl resulted in symptomatic severe bradycardia within 36 h, without any other signs of opioid toxicity and with good analgesic effect. Case management: The fentanyl patch was removed. Atropine was not required. Case outcome: The patient made an uneventful recovery. Transdermal buprenorphine was subsequently used satisfactorily for long-term background pain control, with additional hydromorphone when needed. Conclusions: The delayed absorption of fentanyl via the transdermal route makes early identification of fentanyl-induced bradycardia key to prompt reversal. Patients with resting or relative bradycardia may be at higher than average risk.

This chapter examines case studies to display the necessary skills, attitudes, and knowledge required to assess and manage genitourinary symptoms. It takes as its starting point several questions such as: How to further assess Mrs M. C., a sixty-three-year-old woman who has been diagnosed two years previously with carcinoma of the cervix after reporting heavy vaginal bleeding? What problems might Mrs M.C. develop as her cancer progresses, and how should they be dealt with? How to approach the management of ureteric obstruction? What are the four types of urinary incontinence, and how do they relate to the anatomy and physiology of urinary function?

There are relatively well-defined and preferred therapies for neuropathic pain including newer generation anticonvulsants (such as gabapentin), TCAs, and opioids in select patients. In patients with ongoing pain despite treatment with these agents, or who are intolerant to them, venlafaxine or duloxetine may be helpful. There are no comparative studies between nontricyclics for neuropathic pain, thus an agent should be selected based on its side effect profile, cost, and familiarity with use.