Personalized Pain Goal Research Articles

A Phase II Study About Efficacy and Safety of the Continuous IntraVenous Infusion of Ketamine as Adjuvant to Opioids in Terminally Ill Cancer Patients With Refractory Cancer Pain (CIVIK Trial).

Ketamine has been used to control refractory cancer pain as an adjuvant to opioids. We conducted a prospective phase II study to investigate the efficacy and safety of 5-day continuous intravenous infusion (CIVI) of Ketamine in terminally ill cancer patients with refractory cancer pain. Hospitalized terminally ill cancer patients with refractory cancer pain were enrolled. Refractory cancer pain was indicated by requirements for 4 or more rescue opioids or pain intensity using numerical rating scale > personalized pain goal (PPG) despite of intravenous morphine equivalent daily dose (IV MEDD) ≥ 120mg/day. The CIVI of ketamine was increased from .05mg/kg/hour to .5mg/kg/hour by .05 every 8 hours if pain intensity exceeded PPG or if number of rescue opioids ≥2 during prior 8 hours was required. The primary end-point was overall pain response rate, which indicates complete response (both rescue opioid ≤3/day and pain intensity ≤ PPG) plus partial response (rescue opioid ≤3/day), without unacceptable toxicities. Among 21 eligible patients enrolled between September 2019 and January 2023, 20 were analyzed. Most pain mechanisms were mixed type (n = 15, 75%), with neuropathic component (n = 17, 85%). The baseline background opioids were IV MEDD 186mg/24hour (range, 124-592), number of rescue opioids was 6 (IQR, 5-9), and median PPG was 4 (IQR, 3-4). The overall pain response rate was 50% (n = 10) including 40% (n = 8) for complete pain response and 10% (n = 2) for partial pain response. This study showed efficacy of gradually increasing CIVI of ketamine for terminally ill cancer patients with refractory cancer pain. CIVI of ketamine could be a useful tool in these patients considering the limited treatment options. (NCT03362073, Initial Release: November 15, 2017).

Psychological Barriers to the Use of Opioid Analgesics for Treating Pain in Patients With Advanced Recurrent Cancer: A Multicenter Cohort Study.

We aimed to gain insight into psychological barriers toward initiation of strong opioid analgesic use in patients with advanced recurrent cancer. This study included 46 patients who were prescribed with opioid analgesics for advanced recurrent cancer. The primary outcome was psychological barriers assessed using the Japanese version of the Barriers Questionnaire-II (JBQ-II). The secondary outcomes were psychological changes and pain relief one week after the induction of strong opioid analgesics. The mean age of participants was 63.6 years. Furthermore, 26.1% had an Eastern Cooperative Oncology Group (ECOG) performance status of ≥3. The mean JBQ-II total score was 1.97 (95% confidence interval: 1.75-2.19). At the initiation of opioid therapy, there was no difference in the total scores between the baseline and one week later. Nevertheless, there was a significant difference in the subscale "disease progression" score (mean 2.97 vs. 2.59, difference in means 0.38, standard error 0.16, p = 0.026). Personalized Pain Goal (PPG) was achieved in about half of the participants, and a trend toward a higher score in the subscale "harmful effects" (concern about adverse events) was observed in those who did not achieve PPG. This study showed that patients with advanced recurrent cancer have psychological barriers to opioid induction. The relationship between the presence of psychological barriers before and after induction of opioid analgesics and the speed of pain improvement was determined. The results may provide fundamental information for prospective intervention studies to develop individualized education programs for patients with psychological barriers to opioids.Clinical Trial Registration Number UMIN000042443.

Phase II study about efficacy and safety of the continuous intravenous infusion of ketamine as adjuvant to opioids in terminally ill cancer patients with refractory cancer pain.

e24139 Background: The ketamine is used to control refractory cancer pain as adjuvant to opioids. However, usefulness of ketamine has not yet been confirmed due to lack of previous studies. Additionally, most of prior studies were studied in heterogenous patients, and continuous intravenous infusion (CIVI) method was rare. The CIVI method using gradual dose titrations of ketamine is safe. So, it is suitable to terminally ill cancer patients who have available IV access but vulnerable to AEs. This phase II single-arm study investigated efficacy and safety of CIVI of Ketamine in these population. Methods: Cancer patients with expected limited survival time within several months and refractory cancer pain were enrolled. Refractory cancer pain indicates requirements of breakthrough analgesics ≥ 4 times/day or average pain score > personalized pain goal (PPG) in spite of intravenous Morphine Equivalent Daily Dose (MEDD) > 120 mg/day. The CIVI of ketamine was increased from 0.05 mg/kg/hr to 0.5 mg/kg/hr by 0.05 mg/kg/hr every 8hr when average pain score exceeded PPG or breakthrough was needed ≥ 2 times/8hr during 5 days. The primary end-point was overall pain response rate, which indicates complete response (both breakthrough ≤ 3/day and NRS ≤ PPG) plus partial response (breakthrough ≤ 3/day), without unacceptable toxicities. A total of 26 patients are needed to verify assumption of response rate of 40% with width of 0.4 for two-sided 95% CI and assuming 5% drop-out rate. This study was prematurely terminated at enrollment of 21 patients. Results: Among 21 enrolled patients between SEP 2019 and JAN 2023, 20 were analyzed except 1 due to early transfer. Most pain mechanisms were mixed type (n = 15, 75%), while some reported nociceptive pain (n = 3, 15%) or neuropathic pain (n = 2, 10%). The baseline background opioids were MEDD 186 mg/day (range, 124-592), number of breakthrough opioids were 5 (IQR, 5-7). The median PPG were 4 (range, 3-6). After application of ketamine, overall pain response rate was 45% (n = 9), complete pain response was 35% (n = 7) and partial pain response was 10% (n = 2). The other 11 were non-responders (six failed to achieve overall pain response despite of maximal dose or completing 5 days of ketamine, five patients discontinued the treatment due to AEs). AEs included confusion (n = 9, 45%), dizziness (n = 3, 15%), and hypertension (n = 2, 10%). Communication capacities were sustained in 10 patients and decreased in other 10 patients. OS were 21 days (95% CI, 18.1-23.9). Conclusions: Our study showed efficacies and safeties of gradually increasing CIVI of ketamine for terminally ill cancer patients with refractory cancer pain. The CIVI of ketamine can be a useful tool in these patients considering limited treatment options. Further studies comparing usefulness of CIVI of ketamine and usual practice with opioids escalation are needed (NCT03362073). Clinical trial information: NCT03362073 .

Clinical characteristics of alexisomia in patients with incurable cancer.

Alexisomia is a clinical concept that describes difficulties in the awareness and expression of bodily feelings regarding physical diseases and symptoms. The study aim was to investigate whether incurable cancer patients with alexisomia had a higher incidence of latent trigger points, higher pain intensity, and higher pain-improvement goals. A multicenter cross-sectional survey was conducted among patients with incurable cancer referred to a palliative care service at two university hospitals in Japan. Alexisomia was evaluated using the Shitsu-Taikan-Sho Scale (STSS). All patients were manually examined on their upper trapezius to identify latent trigger points. Patients who experienced pain reported their pain numerical rating scale (PNRS) and personalized pain goal (PPG) scores. A total of 262 patients were selected as participants. Incurable cancer patients with alexisomia were observed in 30.2% of all participants [95% confidence interval (CI): 24.7-35.7]. The latent trigger points risk ratio in the alexisomic group versus the non-alexisomic group was 4.06 (95% CI: 2.24-7.37). Incurable cancer patients with alexisomia tended to have higher PNRS and PPG scores (P<0.001), but there was no significant difference in PPG achievement (P=0.641). In examining incurable cancer patients with alexisomia, we must recognize that their latent trigger points risk ratio and PPGs are higher (lower symptom improvement goals) than cancer patients without alexisomia, and their rate of seeking help for pain may be low.

Pain assessment and registration in medical oncology clinics: operationalised through the lens of health care professionals and patients

Background: Pain is a common symptom in patients who survive cancer and in those who live with progressive advanced disease. Systematic screening and documentation of pain are necessary to improve the quality of cancer pain treatment, because a key pain-related barrier is that patients are reluctant to discuss pain, due to fear that reporting pain will distract the healthcare professional from their cancer treatment.Methods: This study adopted an explanatory sequential mixed-methods design. Data collection incorporated three strands. The first strand involved a quantitative enquiry in which medical chart reviews of patients (n=100) attending the medical oncology outpatient clinic were examined. The second qualitative strand comprised of semi-structured interviews with patients (n=10) attending that service. The third strand was qualitative and consisted of focus group discussions with healthcare professionals (n=12).Results: All 100 patients had cancer. The quantitative findings confirmed the suboptimum assessment and subsequent recording of patient’s pain, that seemed to afford a reality check for all healthcare professionals. For patients, the outcomes of the anti-cancer treatment were their priority, and pain was perceived as inevitable, being associated with a cancer diagnosis. There were multifaceted complexities voiced amongst healthcare professionals associated with balancing the benefits and harms aligned with treating cancer pain.Conclusions: Pain assessment in medical records was not systematically recorded by healthcare professionals. Patients were reluctant to self-report pain during their medical oncology outpatient review. The expectation that patients will self-report pain can be accommodated by healthcare professionals if a personalized pain goal is part of the cancer pain management plan during each clinical encounter. Healthcare professionals reported a need to take distinct responsibility for supplementing their dearth of knowledge, skills and beliefs regarding assessing and managing patients’ cancer pain. Optimal pain management stems from an interprofessional approach that was applied in this study design.

Pain assessment and registration in medical oncology clinics: operationalised through the lens of health care professionals and patients.

Background: Pain is a common symptom in patients who survive cancer and in those who live with progressive advanced disease. Systematic screening and documentation of pain are necessary to improve the quality of cancer pain treatment, because a key pain-related barrier is that patients are reluctant to discuss pain, due to fear that reporting pain will distract the healthcare professional from their cancer treatment. Methods: This study adopted an explanatory sequential mixed-methods design. Data collection incorporated three strands. The first strand involved a quantitative enquiry in which medical chart reviews of patients (n=100) attending the medical oncology outpatient clinic were examined. The second qualitative strand comprised of semi-structured interviews with patients (n=10) attending that service. The third strand was qualitative and consisted of focus group discussions with healthcare professionals (n=12). Results: All 100 patients had cancer. The quantitative findings confirmed the suboptimum assessment and subsequent recording of patient's pain, that seemed to afford a reality check for all healthcare professionals. For patients, the outcomes of the anti-cancer treatment were their priority, and pain was perceived as inevitable, being associated with a cancer diagnosis. There were multifaceted complexities voiced amongst healthcare professionals associated with balancing the benefits and harms aligned with treating cancer pain. Conclusions: Pain assessment in medical records was not systematically recorded by healthcare professionals. Patients were reluctant to self-report pain during their medical oncology outpatient review. The expectation that patients will self-report pain can be accommodated by healthcare professionals if a personalized pain goal is part of the cancer pain management plan during each clinical encounter. Healthcare professionals reported a need to take distinct responsibility for supplementing their dearth of knowledge, skills and beliefs regarding assessing and managing patients' cancer pain. Optimal pain management stems from an interprofessional approach that was applied in this study design.

Factors associated with chronic thoracic spine and low back pain in caregivers of cancer patients.

Caregiving for people with cancer can cause chronic back pain (CBP) in family caregivers, but little is known about the associated caregiving-related factors. The study aim was to examine relationship between pain location and the factors related to care of cancer patients by family caregivers. A cross-sectional survey was conducted among 320 family caregivers of advanced cancer patients from 2016 to 2018 at a single-unit university hospital. CBP locations were categorized as thoracic spine and lower back, and achievement of pain improvement goals defined as pain intensity (PI) ≤ personalized pain goal (PPG). Cancer caregiving-related factors were examined using a self-report questionnaire measuring subjective psychological stresses in family caregivers: depression, anxiety, insomnia, and caregiver burden. Medical records were used to determine patients' cancer severity based on performance status and time from survey until death. Multivariate logistic regression analysis was conducted. The dependent variable was presence of thoracic spine/low back pain; the independent variables were care recipient performance status and duration from survey until death, and caregiver scores on the Hospital Anxiety and Depression ScaleDepression, Hospital Anxiety and Depression Scale-Anxiety, Pittsburgh Sleep Quality Index-J, and Zarit Caregiver Burden Interview-J. In total, 31.4% of family caregivers had chronic thoracic spine pain and 28.3% chronic lower back pain. Of these, 60.0% of those with thoracic spine pain and 46.7% of those with lower back pain achieved their pain improvement goal. Logistic regression analysis showed that depression score was associated with chronic thoracic spine pain (both PI ≤ PPGs and PI > PPGs) (P=0.001 and P=0.027) and sleep score with chronic thoracic spine pain (PI > PPGs) (P=0.018). Performance status and time from survey until death were associated with chronic lower back pain (PI > PPGs) (P=0.034 and P=0.017). Our results suggest that the factors related to caregiving in cancer patients differ according to back pain location. To reduce CBP, it is important to address subjective psychological stress and physical burden with reference to back pain location.

Alexithymia in Family Caregivers of Advanced Cancer Patients Is Associated with High Personalized Pain Goal Scores: A Pilot Study

Background: Alexithymia, or difficulty identifying and describing emotions and sensations, contributes to an increased risk of chronic pain, and low help-seeking. Objective: To investigate whether family caregivers of advanced cancer patients visiting a palliative care department had alexithymia, and whether this was related to their pain intensity, personalized pain goals, and help-seeking for chronic musculoskeletal pain. Design: A single-center cross-sectional survey. Measurements: Pain intensity was evaluated using a numerical rating scale. Pain improvement was evaluated against personal goals. Alexithymia was assessed using the Toronto Alexithymia Scale-20 (TAS-20), and anxiety and depression using the Hospital Anxiety and Depression Scale. Setting/Subjects: Of 320 family caregivers visiting the palliative care department, 152 (47.5%) had chronic musculoskeletal pain; all 152 were included in the study. Results: Alexithymia was observed in 36.2% of participants. Participants with higher scores on the TAS-20 tended to have higher pain intensity scores and personal pain goal scores. TAS-20 score had the strongest correlation with personal pain goals, with a correlation coefficient of 0.555 (p < 0.001). Conclusions: Pain intensity in family caregivers with alexithymia tended to be high. These participants set higher personal pain goals (lower goals for symptom improvement) than those without alexithymia. We found no difference in personal pain goal response between family caregivers with and without alexithymia. When we examine pain in family members with alexithymia who are caring for cancer patients, we need to recognize that they may set higher personal pain goals and seek less help.

Pharmacogenetic (PGx) guided cancer pain management in an oncology palliative medicine (PM) clinic.

117 Background: About 30% of cancer patients presenting with pain have symptomatic improvement using conventional strategies within one month. PGx may help personalize opioid selection and improve cancer pain management. Methods: This is a pragmatic pilot trial investigating the feasibility and application of PGx testing to improve pain management in adults with uncontrolled cancer pain referred to an oncology PM clinic. PM providers assessed patients using Edmonton Symptom Assessment Scale at baseline and opioid therapy was initiated or modified. A buccal swab was obtained for genotyping single nucleotide polymorphisms in: COMT, CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5, and OPRM1. The first assessment occurred within one week of baseline and a second within another week if intervention was required. PGx results were available before the first assessment and utilized, if applicable, throughout the one-month study period. Pain improvement rate (≥ 2-point reduction on a 0-10 scale) from baseline to final visit, was compared to historical control data by a one-sided exact binomial test of proportions. Results: Of 75 undergoing PGx testing, 52 were evaluable for the primary endpoint (54% female, 81% white, 17% black, median age 63, 75% stage 3 or 4 disease, median personalized pain goal 3 [0-6]). 56% had pain improvement compared to 30% in historical controls (p &lt; 0.001). At final assessment, 35% met their personalized pain goal. Of 26 (50%) requiring opioid adjustments, 18 (69%) had an actionable genotype with a 61% pain improvement rate. The two most common genes for opioid adjustment were CYP2D6 (16/18; 89%) and COMT (8/18; 44%). The most common PGx-guided modification involved switching from a CYP2D6-metabolized drug (hydrocodone, oxycodone, tramadol) to a non-CYP2D6-metabolized drug (fentanyl, hydromorphone, methadone, morphine). Conclusions: PGx implementation in an oncology PM clinic was feasible and improved pain management. Half of those requiring opioid adjustments had an actionable genotype, with the largest impact from CYP2D6 polymorphisms. Future studies should focus on preemptive PGx testing to guide initial drug selection and confirm clinical utility in a randomized trial. Clinical trial information: NCT02542397.

Personalized Pain Goals and Responses in Advanced Cancer Patients.

To assess the personalized pain intensity goal (PPIG), the achievement of a personalized pain goal response (PPGR), and patients' global impression (PGI) in advanced cancer patients after a comprehensive pain and symptom management. Prospective, longitudinal. Acute pain relief and palliative/supportive care. 689 advanced cancer patients. Measurement of Edmonton Symptom Assessment Score (ESAS) and personalized pain intensity goal (PPIG) at admission (T0). After a week (T7) personalized pain goal response (PPGR) and patients' global impression (PGI) were evaluated. The mean PPIG was 1.33 (SD 1.59). A mean decrease in pain intensity of - 2.09 was required on PPIG to perceive a minimal clinically important difference (MCID). A better improvement corresponded to a mean change of - 3.41 points, while a much better improvement corresponded to a mean of - 4.59 points. Patients perceived a MCID (little worse) with a mean increase in pain intensity of 0.25, and a worse with a mean increase of 2.33 points. Higher pain intensity at T0 and lower pain intensity at T7 were independently related to PGI. 207 (30.0%) patients achieved PPGR. PPGR was associated with higher PPIG at T0 and T7, and inversely associated to pain intensity at T0 and T7, and Karnofsky level. Patients with high pain intensity at T0 achieved a favorable PGI, even when PPIG was not achieved by PPGR. PPIG, PPGR and PGI seem to be relevant for evaluating the effects of a comprehensive management of pain, assisting decision-making process according to patients' expectations. Some factors may be implicated in determining the individual target and the clinical response.

Achieving pain control with patient-reported personalized pain goals among patients with cancer in the inpatient setting.

e18534Background: Cancer pain is highly prevalent in patients with cancer. Personalized pain goal (PPG) is a patient-reported outcome of a pain management goal that allows the patient to achieve co...

Personalized Pain Goal as an Outcome Measure in Routine Cancer Pain Assessment

BackgroundThere is currently no universally accepted outcome measure in cancer pain management. The personalized pain goal (PPG) has been shown to be a relevant outcome measure. We examined its use in routine outpatient practice and compared it with the clinically important difference (CID, ≥2 points or 30%), a pain outcome measure frequently used in several clinical studies. MeasuresInitial and follow-up clinical information of outpatients with advanced cancer pain were retrospectively reviewed. PPG response was defined as pain ≤ PPG and CID response as ≥30% or ≥2-point decrease in pain intensity at follow-up. OutcomesPPG was successfully completed in 375 of 387 eligible patients (97%) with cancer pain. The median baseline PPG was three for all patients and remained unchanged at follow-up. One hundred thirty-two of 375 (35%) had a PPG response and 243 of 375 (65%) were non-responders. The odds ratio for PPG non-response was 1.01 for each milligram increase in morphine equivalent daily dose (P = 0.001), 1.46 for each point increase in the number of adjuvant analgesics (P = 0.006), 2.63 for severe pain (P = 0.002), and 2.55 for moderate depression (P = 0.006). Using PPG response as the gold standard for pain relief, the overall sensitivity and specificity of CID response were 83% and 77%, respectively. ConclusionPPG was successfully completed in the vast majority of patients, suggesting its feasibility as a pain outcome measure in routine clinical practice. Higher baseline pain intensity, depression, opioid dose, and number of adjuvant analgesics were independent predictors of poor pain relief. Further research is needed to further evaluate its clinical importance in cancer pain management.

The Use of Personalized Pain Goal in Routine Pain Assessment Among Outpatients with Advanced Cancer (S759)

The Use of Personalized Pain Goal in Routine Pain Assessment Among Outpatients with Advanced Cancer (S759)

Comparison of Indicators for Achievement of Pain Control With a Personalized Pain Goal in a Comprehensive Cancer Center

ContextThe achievement of a personalized pain goal (PPG) is advocated as an individualized pain relief indicator. ObjectivesPain relief indicators, including PPG, pain intensity (PI), and interference with daily activities (interference), were compared herein. MethodsThis was a single-center cross-sectional study. Adult patients with cancer on opioid medications who visited the outpatient clinic at the National Cancer Center Hospital East between March and September 2015 were consecutively enrolled. Patients conducted a self-report questionnaire, including reports of average PI, interference, PPG, and the need for further analgesic treatment. We compared the proportion of patients achieving PPG (PI ≤ PPG) and other pain relief indicators including PI ≤3 or interference ≤3 and the percentage of patients who did not need further analgesic treatment among those who fulfilled each pain relief indicator. ResultsA total of 347 patients (median age 64; 38% females) were analyzed. Median (interquartile range [IQR]) of PPG, PI, and interference was 2 (IQR 1–3), 2 (IQR 1–4), and 2 (IQR 0–5), respectively. The proportion of patients achieving PPG was 45.3% and significantly lower than those with PI ≤3 (69.0%; P < 0.001) and interference ≤3 (70.2%; P < 0.001). Eighty percent of patients achieving PPG did not need further analgesic treatment, whereas 70.8% of patients with PI ≤3 (P < 0.001) and 73.3% with interference ≤3 did need further analgesic treatment (P < 0.001). ConclusionThe achievement of PPG was a stricter pain relief indicator than PI and interference and may reflect a real need for pain control.

What is stable pain control? A prospective longitudinal study to assess the clinical value of a personalized pain goal

Background: A universal consensus regarding standardized pain outcomes does not exist. The personalized pain goal has been suggested as a clinically relevant outcome measure. Aim: To assess the feasibility of obtaining a personalized pain goal and to compare a clinically based personalized pain goal definition versus a research-based study definition for stable pain. Design: Prospective longitudinal descriptive study. Measures: The attending physician completed routine assessments, including a personalized pain goal and the Edmonton Classification System for Cancer Pain, and followed patients daily until stable pain control, death, or discharge. Stable pain for cognitively intact patients was defined as pain intensity less than or equal to desired pain intensity goal (personalized pain goal definition) or pain intensity ⩽3 (Edmonton Classification System for Cancer Pain study definition) for three consecutive days with <3 breakthroughs per day. Setting/participants: A total of 300 consecutive advanced cancer patients were recruited from two acute care hospitals and a tertiary palliative care unit. Results: In all, 231/300 patients (77%) had a pain syndrome; 169/231 (73%) provided a personalized pain goal, with 113/169 (67%) reporting a personalized pain goal ⩽3 (median = 3, range = 0–10). Using the personalized pain goal definition as the gold standard, sensitivity and specificity of the Edmonton Classification System for Cancer Pain definition were 71.3% and 98.5%, respectively. For mild (0–3), moderate (4–6), and severe (7–10) pain, the highest sensitivity was for moderate pain (90.5%), with high specificity across all three categories (95%–100%). Conclusion: The personalized pain goal is a feasible outcome measure for cognitively intact patients. The Edmonton Classification System for Cancer Pain definition closely resembles patient-reported personalized pain goals for stable pain and would be appropriate for research purposes. For clinical pain management, it would be important to include the personalized pain goal as standard practice.

Assessing the prognostic features of a pain classification system in advanced cancer patients.

The Edmonton Classification System for Cancer Pain (ECS-CP) has been shown to predict pain management complexity based on five features: pain mechanism, incident pain, psychological distress, addictive behavior, and cognitive function. The main objective of our study was to explore the association between ECS-CP features and pain treatment outcomes among outpatients managed by a palliative care specialist-led interdisciplinary team. Initial and follow-up clinical information of 386 eligible supportive care outpatients were retrospectively reviewed and analyzed. Between the initial consultation and the first follow-up visit, the median ESAS pain intensity improved from 6 to 4.5 (p<0.0001) and the median total symptom distress score (0-100) improved from 38 to 31 (p<0.0001). At baseline, patients with neuropathic pain (p<0.001) and those with at least one ECS-CP feature (p=0.006) used a higher number of adjuvant medications. At follow-up, patients with neuropathic pain were less likely to achieve their personalized pain goal (PPG) (29 vs 72%, p=0.015). No statistically significant association was found between increasing sum of ECS-CP features and any of the pain treatment outcomes at follow-up. Neuropathy was found to be a poor prognostic feature in advanced cancer pain management. Increasing sum of ECS-CP features was not predictive of pain management complexity at the follow-up visit when pain was managed by a palliative medicine specialist. Further research is needed to further explore these observations.

Establishment of Personalized Pain Goals in Oncology Patients to Improve Care and Decrease Costs.

Cancer-related pain is common, negatively affects quality of life and survival, and often requires treatment with opioid analgesics. Patient-reported data that describe the incidence and severity of pain, medication use, and patient satisfaction with care are lacking. We analyzed 18 months of outpatient oncology clinic encounters from the electronic medical record to obtain data on pain levels and opioid and nonopioid treatments. In June 2014, we instituted a pain intervention by creating a pain management information handout for patients, educating clinicians on opioid cost-effectiveness, and implementing a nursing protocol to document personalized pain goals (PPGs). Moderate to severe pain was reported in nearly 15% of patient encounters. We observed an increase in the percentage of encounters with a documented PPG of 16% to 71% ( P < .001). On average, PPG was achieved in 84% of patients. Rates of high-cost long-acting opioid prescriptions (oxycodone controlled release and fentanyl patches), as a total of all long-acting opioids, declined from 45% preintervention to 33% postintervention ( P = .005). Our intervention improved rates of PPG documentation and decreased the number of prescriptions for high-cost long-acting opioids. Oncology clinics can implement simple quality improvement methods, such as asking patients about their PPG and educating clinicians about opioid costs, to improve outcomes and lower treatment costs.

Evaluating the prognostic effect of a pain classification system in patients with advanced cancer.

95 Background: The Edmonton Classification System for Cancer Pain (ECS-CP) has been shown to predict pain management complexity based on five features: pain mechanism, incident pain, psychological distress, addictive behavior, and cognitive function. The main objective of our study was to explore the association between increasing sum of negative ECS-CP features and achievement of good pain control at first follow up visit at an outpatient palliative care clinic. Methods: Initial and follow up clinical information of 409 eligible supportive care outpatients such as patient demographics, ECS–CP assessment, morphine equivalent daily dose (MEDD), opioid rotation, Edmonton Symptom Assessment Score (ESAS), and personalized pain goal (PPG) were retrospectively reviewed and analyzed. Results: Between the initial consultation and the first follow up visit, the median MEDD requirement increased from 30mg/day to 45mg/day (p &lt; 0.0001) and median pain intensity improved from 6 to 4 (p &lt; 0.0001). Increasing sum of negative ECS–CP features was associated with higher MEDD at consultation, with an increase from 30mg/day with no negative features to 40mg/day with ≥2 negative features (p = 0.046). There was no significant association between increasing sum of negative ECS-CP features and achievement of pain control at follow up visit (0.991, 95% CI: 0.747 – 1.304, p = 0.948). Conclusions: Increasing sum of negative ECS-CP features was associated with higher MEDD at referral but was not predictive of pain control at the follow up visit when pain was managed by a palliative medicine specialist. Further research is needed to further explore these observations.

Pain in patients with cancer.

Pain is an important concern in patients with cancer who are receiving active treatment and in long-term cancer survivors. It is one of the most feared aspects of cancer, and it can have a major adverse impact on quality of life. It has long been recognized that untreated or undertreated pain is common in patients with cancer, with little evidence of recent improvement. 1,2 Given the many advances in knowledge regarding cancer pain and its management over the past decade, this Special Series issue was assembled to provide readers with an update on the current understanding of the biology of cancer pain, the biology and mechanisms of action of the opioids used to treat cancer pain, challenges in the management of cancer pain, and evidence-based multidisciplinary approaches to management of cancer pain. We hope that the articles in this Special Series issue will enhance clinician understanding of cancer pain and its treatment and provide practical approaches to managing pain in patients with cancer. Hui and Bruera 3 outline “A Personalized Approach to Assessing and Managing Pain in Patients With Cancer.” They provide a practical yet evidence-based approach to personalized pain assessment and management in the clinic. They also discuss a paradigm shift in pain management, outlining a multistep approach that includes systematic screening, comprehensive pain assessment, characterization of pain, identification of personal modulators of pain expression, documentation of personalized pain goals, and implementation of a multidisciplinary treatment plan with subsequent customized longitudinal monitoring. Their article summarizes an expert clinician’s approach to pain management and provides practical tables and figures that will be helpful to the clinician who manages cancer pain. Falk and Dickenson 4 discuss the biology of pain in patients with cancer, with a special focus on bone pain, in their article entitled “Pain and Nociception: Mechanisms of Cancer-Induced Bone Pain.” The authors review mechanisms of cancer pain, stating that it is a “complex pain state involving components of both inflammatory and neuropathic pain, but also displaying elements that appear to be unique to cancer pain.” They discuss cancer pain as unpredictable, with highly variable intensity, which makes it difficult to manage. They also review mechanisms of acute pain, neuropathic pain, inflammatory pain, and complex cancer pain, providing informative figures that will help clinicians understand the biology of pain and may help guide the selection of management approaches. Gavril Pasternak 5 reviews “Opiate Pharmacology and Relief of Pain,” a complex area that is presented in a clear fashion. Pasternak states that opioids “selectively impact the hurt of nociceptive stimuli”; they act through activation of a pain modulating system consisting of endogenous opioid peptides and their receptors. He discusses three classes of opioid/receptors—mu, delta, and kappa—and suggests that individual responses to specific opioids may reflect differences in the biology of these receptors. Pasternak discusses important issues such as opioid cross tolerance, benefits, and risks of opioid rotation and the growing understanding of mu receptor subtypes, introducing the

Achievement of personalized pain goal in cancer patients referred to a supportive care clinic at a comprehensive cancer center.

Cancer pain initiatives recommend using the personalized pain goal to tailor pain management. This study was conducted to examine the feasibility and stability of personalized pain goal, and how it compares to the clinical pain response criteria. Records of 465 consecutive cancer patients seen in consultation at the Supportive Care Clinic were reviewed. Pain relief was assessed as clinical response (≥30% or ≥2 point pain reduction) and personalized pain goal response (pain ≤ personalized pain goal). One hundred fifty-two (34%), 95 (21%), and 163 (37%) patients presented with mild (1-4), moderate (5-6), and severe (7-10) pain, respectively. Median age (59 years), males (52%), and advanced cancer status (84%) did not differ by pain category. Median personalized pain goal at initial clinic consult was 3 (interquartile range, 2-3), was similar across pain groups, and remained unchanged (P = .57) at follow-up (median, 14 days). Clinical response was higher among patients with severe pain (60%) as compared with moderate (40%) and mild pain (33%, P < .001). Personalized pain goal response was higher among patients with mild pain (63%) as compared with moderate (44%) and severe pain (27%, P < .001). By using personalized pain goal response as the gold standard for pain relief, the sensitivity of clinical response was highest (98%) among patients with severe pain, but it had low specificity (54%). In patients with mild pain, clinical response was most specific for pain relief (98%), but had low sensitivity (52%). Personalized pain goal is a simple patient-reported outcome for pain goals. The majority of patients were capable of stating their desired level for pain relief. The median personalized pain goal was 3, and it was highly stable at follow-up assessment.