WHO Pain Research Articles

Chronic Pain Management in Palliative Patients

Introduction: Chronic pain presents a public health priority, however its assessment and management remains problematic in the country posing serious obstacles in effective pain relief and improving quality of life in pain patients, in general, and in palliative patients, in particular. We aimed to study chronic pain relief quality and pain assessment and management knowledge level in primary health care institutions, being a gateway to palliative care. Methods: Cross-sectional survey was conducted in 2013-2014 on 232 randomly selected patients in palliative care clinic and 304 physicians in primary health care institutions in different regions of the country. Pain assessment tools such as Visual Analog Scale (VAS) and numeric pain rating scale along with questionnaires, composed of 20 (for patients) and 40 (for physicians) with both: open and closed questions were used. Study results were processed in SPSS software. Results: Response rates were 83% for patients and 87% for physicians. The vast majority of patients suffered of unrelieved pain at the admission to the clinic. Almost all patients (98%) were coming from primary health care institutions. Perception and expression of pain by majority of patients (85%) didn't correspond to the pain intensity, measured by the VAS and consequently, by the numerical scale (t=3.4). Pain intensity was in linear correlation with the disease stage (r=0.6). It was increasing along with the disease progression. Fifty percent of physicians in the selected primary health care facilities were unaware of WHO pain leader, 90% of them didn't use tools for evaluating of pain intensity. 89.8% prescribed opioids without a prior determination of causes and risk factors. None of the physicians knew about the role of patients in chronic pain management, resulted in the unawareness of patients toward self-management and preventive potential of chronic pain. Conclusion: 1: Majority of palliative patients are admitted to specific tertiary clinic with unrelieved pain; 2: Chronic pain assessment and management level is mainly inadequate in primary health care institutions; 3: Chronic pain education along with the enhancement of knowledge level of family physicians is of critical importance for effective pain relief.

Impact of the World Health Organization Pain Treatment Guidelines and the European Medicines Agency Safety Recommendations on Nonsteroidal Anti-Inflammatory Drug Use in Lithuania: An Observational Study

Background and objective: Irrational use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the main cause of adverse effects-associated hospitalizations among all medication groups leading to extremely increased costs for health care. Pharmacoepidemiological studies can partly reveal such issues and encourage further decisions. Therefore, the aim of our study was to evaluate the utilization of non-opioid analgesics (ATC classification N02B and M01A) in Lithuania, and to compare it with that of other Baltic and Scandinavian countries in terms of compliance to the WHO pain treatment guidelines and the EMA safety recommendations on NSAID use. Materials and methods: The dispensing data were obtained from the sales analysis software provider in the Baltic countries (SoftDent, Ltd., Kaunas, Lithuania); State Medicine Control Agencies of Lithuania, Latvia, and Estonia; Norwegian Prescription Database; Swedish Database for Medicines; and Danish Prescription Database. Data included the utilization of both prescription and over-the-counter drugs. Utilization was expressed in defined daily doses (DDD)/1000 inhabitants/day. Results: During the 11-year period, the utilization of drugs belonging to the N02B and M01A groups increased by 22.8%, from 58.37 in 2005 to 71.68 DDD/1000 inhabitants/day in 2016 in Lithuania. Contrary to the WHO guidelines on pain management, all Baltic countries were more likely to use NSAIDs than other analgesics and antipyretics: in 2015, the drugs of the M01A group were used 6.04, 5.79, and 6.11 times more than those of N02B in Lithuania, Estonia, and Latvia, respectively, whereas the Scandinavian countries preferred the N02B to the M01A group: in Denmark and Sweden, the utilization of other analgesics and antipyretics was 2.33 and 1.24, respectively, times higher than that of NSAIDs. In Norway, the use of both groups was similar. In the Scandinavian countries, paracetamol was the analgesic of first choice, whereas, in Lithuania, it took only the third place. The most popular drug in Lithuania was diclofenac, and its utilization accounted for 30.04% of all non-opioid analgesics in 2016. Although the European Medicines Agency (EMA) restricted the use of certain NSAIDs, i.e., cyclooxygenase-2 (COX-2) inhibitors, nimesulide, and diclofenac, their use consistently increased by 15.91, 2.83, and 1.41 times, respectively, showing incompliance with the international guidelines. Conclusions: Neither the EMA safety policy on NSAID use nor the WHO pain treatment guidelines had a sufficient impact on the rational use of NSAIDs in Lithuania. The use of NSAIDs restricted by the EMA (diclofenac, COX-2 inhibitors, nimesulide, and piroxicam) remains high or even increases, while the utilization of safer alternatives (paracetamol and naproxen) remains relatively low as compared with the Scandinavian countries. Incompliance with international guidelines may result in increased morbidity, mortality and higher costs for health care.

Comparative Effect of Collaborative Care, Pain Medication, and Duloxetine in the Treatment of Major Depressive Disorder and Comorbid (Sub)Chronic Pain: Results of an Exploratory Randomized, Placebo-Controlled, Multicenter Trial (CC:PAINDIP).

Evidence exists for the efficacy of collaborative care (CC) for major depressive disorder (MDD), for the efficacy of the consequent use of pain medication against pain, and for the efficacy of duloxetine against both MDD and neuropathic pain. Their relative effectiveness in comorbid MDD and pain has never been established so far. This study explores the effectiveness of CC with pain medication and duloxetine, and CC with pain medication and placebo, compared with duloxetine alone, on depressive and pain symptoms. This study was prematurely terminated because of massive reorganizations and reimbursement changes in mental health care in the Netherlands during the study period and is therefore of exploratory nature. Three-armed, randomized, multicenter, placebo-controlled trial at three specialized mental health outpatient clinics with patients who screened positive for MDD. Interventions lasted 12 weeks. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible, where paracetamol, COX inhibitors, and pregabalin are offered as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as non-compliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089). Sixty patients completed the study. Patients in all treatment groups reported significantly less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease in depressive symptoms compared with the duloxetine alone group (b = -0.78; p = 0.01). Non-compliant patients (n = 31) did not improve over the 12-week period, in contrast to compliant patients (n = 29). Pain outcomes did not differ between the three groups. In MDD and pain, patient's compliance and placebo effects are more important in attaining effect than choice of one of the treatments. Active pain management with COX inhibitors and pregabalin as alternatives to tramadol or other opiates might provide an attractive alternative to the current WHO pain ladder as it avoids opiate prescription as much as possible. The generalizability is limited due to the small sample size. Larger studies are needed.

(248) - Profile of the pharmacological approach needed in order to achieve the best pain control in a population of advanced cancer patients

Pain is still a challenging symptom in advanced cancer patients. The World Health Organisation set up the three-step analgesic ladder in order to better clarify the optimal pharmacological approach in order to achieve a good balance between pain control and adverse related effects. The objective of this study is to analyse the changes observed in the use of the WHO analgesic ladder drugs in relation of pain intensity in a population of advanced cancer patients attended in the out-patient clinic (OPC).The study was carried out on a consecutive sample of advanced cancer patients attended at the OPC. Inclusion criteria: age >18 years, diagnosis of advanced cancer, lack of cognitive impairment (Pfeiffer test ≤ 4), pain with VAS > 3 on first evaluation and agreed to participate. Variables recorded: Categorical variables were summarized as percentages (absolute numbers). The sample was divided according to pain intensity on the first evaluation (VAS < 7 vs ≥7) and the analgesic regime used according to the WHO analgesic ladder (first/second/third step). The third step was further divided in long acting opioid (LAO), short acting opioids (SAO) and rapid onset opioids (ROO).We used the chi-squared test to compare groups. For the significative differences (P < 0,05) the McNemar test was applied. A total of 211 patients were included in the study. Mean of age 64, 0 ± 14 years. Men 87, 2%. Lung cancer 41, 2%; Upper-digestive 15, 6%. 136 patients with an initial VAS ≥ 7 (64,45%). Differences were found in the second step of the WHO on pain control (P = .045). Regarding the third step, the differences were related to the first evaluation: third step (global) P = .002, LAO (P = .028) and ROO (P = .043). Those data suggest that significative differences can be found between the use of the different analgesics the WHO ladder and pain intensity.

Intensity and treatment of symptoms in 3,030 palliative care patients: A cross-sectional survey of the EAPC Research Network

This study aimed to describe intensity and treatment of symptoms other than pain in European palliative care units. A total of 3,030 patients, including 2,064 that used an opioid, were included from 143 palliative care centers, in 21 European countries. Pain was treated with analgesics corresponding to the WHO pain ladder step I (n = 374), II (n = 497), and III (n = 1,567). Frequencies of symptoms observed as moderate or severe were for generalized weakness (50 percent), fatigue (48 percent), anxiety (28 percent), anorexia (26 percent), constipation (18 percent), focal weakness (18 percent), depression (18 percent), and dyspnoea (15 percent). When comparing WHO-groups, cancer diagnoses, metastasis sites, countries, and genders, we found that some of the symptom intensities and treatments differed significantly between subgroups. A majority of patients used drugs for symptom management. Still, more than one-third of patients assessed to have moderate or severe constipation did not receive any treatment. The corresponding numbers for depression, confusion, nausea, vomiting, or anxiety were approaching 40 percent and for poor sleep about 50 percent. Prescription practice of antiemetics, laxatives, and psychotropic drugs varied widely between countries both in terms of preparation and percent of patients receiving a specific treatment. This survey shows that clinically relevant symptoms are frequent and that one-third to half of the patients with a symptom observed as moderate or severe do not receive any treatment aimed to reduce the symptom intensity. Several symptoms and treatments differed between WHO-groups, cancer diagnoses, metastasis locations, countries, and genders. Prescription practice varied between countries both in terms of medication administered and percent of patients receiving specific treatment.

Effect of enhanced recovery after surgery on immune function in patients with acute abdomen

Objective To evaluate the effect of enhanced recovery after surgery (ERAS) on immune function and clinical signs in patients with acute abdomen. Methods From March 2016 to March 2017, patients with acute abdominal admitted in the Emergency Care Center of the First Affiliated Hospital of Zhengzhou University were collected and randomized into ERAS group and conventional peri-operative management group(CPM group). In addition to clinical signs (the time of bowel movemtn recovery, the time of first postoperative ingestion and ambulation, hospital stay, complication rates), the celluar immunity (CD4+ , CD8+ , CD4+ /CD8+ ) were determined during peri-operation period. Results A cohort of 240 patients were in ERAS group and 192 patients in CPM group. There was no significant difference in general condition between the two groups (P> 0.05). On the first day after operation, the levels of CD4+ , CD4+ /CD8+ decreased in both groups (P<0.05), but the CPM group had lower levels of CD4+ , CD4+ /CD8+ than the ERAS groups. On the 3rd and 7th days after surgery, the ERAS groups had higer levels of CD4+ , CD4+ /CD8+ than the CPM groups, (the levels of CD4+ , CD4+ /CD8+ recovery on the 3rd and 7th day after operation, and the ERAS group was significantly better than the CPM group) (P<0.05). Compared with CPM group, the recovery of bowel movement appeared earlier after operation in ERAS group with sooner resuming ingestion and ambulation after operation, shorter hospital stay, and lower WHO pain rating scale and complication rates(P<0.05). Conclusions ERAS for patients with acute abdomen can alleviate postoperative suppression of immunity, preserving immune function intact and accelerating postoperative rehabilitation. Key words: Enhanced recovery after surgery; Acute abdomen; Operation; Cellular immunity

Perioperative pain management for hip fracture patients

A hip fracture is the most common reason for admission to an orthopaedic ward, yet the management of acute pain in this group of patients is often difficult. Good multi-modal analgesia is important to reduce the incidence of delirium, which is frequently a problem. Other challenges involve age related differences in pharmacokinetics and pharmacodynamics, which can make drug selection more complicated.This article discusses delirium (its causes and how to treat it); the assessment of pain (including in the cognitively impaired); reviews the drugs commonly available to clinicians progressing through the WHO pain ladder, including opioid-sparing techniques (i.e. local anaesthetic nerve blocks). The rationale for recommending intravenous paracetamol, oral oxycodone (instead of morphine) and fascia iliaca blocks are also explored. Finally, suggested pain pathways are described.

Prescription Pattern of Analgesic Drugs for Patients Receiving Palliative Care in a Teaching Hospital in India.

Background:Drugs used in the palliative care unit for managing symptoms are major contributors toward the expenditure occurring in palliative care. This study was conducted to understand the prescription pattern of analgesic drugs in the patients who are receiving palliative care in a teaching hospital in India by a retrospective study of case records.Methods:Case record based, retrospective, descriptive study was conducted at the Pain and Palliative Care Department of St. John's Medical College Hospital, Bengaluru. Case record files of all patients referred to Pain and Palliative Care Department for the treatment of pain in the year of 2012 were studied. Patients’ age, gender, diagnoses, numerical pain rating scale (0–10), drugs prescribed, dosage, frequency, route of administration were recorded. The difference in drug utilization between the genders was done using Chi-square test. Data were collected from 502 patients of which 280 (56%) were males and 222 (44%) were females. Twelve percent of patients had mild pain (1–3), 34% had moderate pain (4–6), and 54% had severe pain (7–10). The most commonly used analgesic drugs were opioids (47%), followed by nonsteroidal anti-inflammatory drugs (36%). The opioids used were tramadol (56%), and morphine (38%). Ninety percent of patients with numerical pain scale more than 6 received morphine. There was no difference in analgesic drug utilization with regards to gender. Prescription pattern differed depending on the severity of pain. Opioids were the most commonly used drugs for pain management.Conclusion:The study shows that prescription pattern in palliative care unit of this hospital was in accordance with WHO pain management guidelines. The study showed the current trend in prescription of analgesic drugs in the teaching hospital where the study was conducted.

F31 - External beam radiation therapy (EBRT) use and safety with radium-223 dichloride (Ra-223) in patients (pts) with castration-resistant prostate cancer (CRPC) and symptomatic bone metastases (mets) from the ALSYMPCA trial

Background: In ALSYMPCA, Ra-223, a first-in-class &agr;-emitter, improved overall survival and delayed time to first symptomatic skeletal event vs placebo (pbo). This post hoc analysis evaluated safety and efficacy of Ra-223 plus EBRT. Methods: Pts had symptomatic (recent EBRT for bone pain or any regular analgesic use) CRPC with ≥ 2 bone and no visceral mets; best standard of care; and prior docetaxel (pD) or were unfit for or declined docetaxel (no pD). Pts were stratified by pD use (yes/no), baseline total alkaline phosphatase level (tALP; < 220 U/L or ≥ 220 U/L), and current bisphosphonate (bp) use (yes/no) and randomized 2:1 to 6 Ra-223 injections (50 kBq/kg IV q 4 wk) or pbo. EBRT for bone pain was permitted within 12 weeks prior to randomization and during study. Baseline pain by prior EBRT, time to first on-study EBRT use for bone pain, and adverse events (AEs) by concomitant EBRT (cEBRT) were analyzed. Results: Pts with no prior EBRT had less pain at baseline; a WHO pain score ≤ 1 (no opioid use) was present in 46% (355/724) of pts with no prior EBRT vs 36% (53/147) of pts with prior EBRT. Ra-223 vs pbo significantly reduced EBRT use in the overall population (HR = 0.67, P = 0.001) and in pts with ≤ 20 bone mets (HR = 0.49, P < 0.001), current bp use (HR = 0.47, P = 0.004), tALP < 220 U/L (HR = 0.66, P = 0.008), and no pD (HR = 0.65, P = 0.038). At 6 months, the percentage of Ra-223 pts requiring EBRT was similar for prior and no prior EBRT subgroups (24% vs 20%), increasing at 12 months (38% vs 29%). cEBRT did not affect Ra-223 safety, and myelosuppression was low (Table). Conclusions: cEBRT did not adversely affect Ra-223 hematologic safety. Ra-223 significantly reduced risk of EBRT use. In Ra-223 pts, prior EBRT did not appear to affect later EBRT use. Clinical trial information: NCT00699751Table: F31cEBRTcEBRTNo cEBRTNo cEBRTPatients with AEs, n (%)Ra-223n = 227Pbon = 140Ra-223n = 373Pbon = 161HematologicAnemia77 (34)51 (36)110 (30)41 (26)Neutropenia14 (6)1 (1)16 (4)2 (1)Thrombocytopenia27 (12)8 (6)42 (11)9 (6)NonhematologicDiarrhea71 (31)26 (19)80 (21)19 (12)Nausea98 (43)61 (44)115 (31)43 (27)Vomiting56 (25)26 (19)55 (15)15 (9)Constipation54 (24)35 (25)54 (15)29 (18) Open table in a new tab

N07 - Adherence to WHO pain guidelines in a community hospital

N07 - Adherence to WHO pain guidelines in a community hospital

Tramadol in palliative care #290.

Tramadol has an important position as a Step II agent on the WHO pain ladder, where it is effective for a variety of syndromes in patients with mild to moderate pain intensity. Its recommended dosing adjustments, potential ceiling effect, cost, pertinent drug interactions, and risk for significant adverse drug reactions may limit its chronic use in patients with significant pain.

Analgesic treatment of cancer pain

Cancer pain can be nociceptive, neuropathic or mixed. It is linked to the tumour, to the metastases and to the treatments for the disease and is managed by multimodal analgesia corresponding to the pain relief drugs of the WHO's pain ladder, antidepressants, antiepileptic drugs and local anaesthetics.

External beam radiation therapy (EBRT) use and safety with radium-223 dichloride (Ra-223) in patients (pts) with castration-resistant prostate cancer (CRPC) and symptomatic bone metastases (mets) from the ALSYMPCA trial.

182 Background: In ALSYMPCA, Ra-223, a first-in-class α-emitter, improved overall survival and delayed time to first symptomatic skeletal event vs placebo (pbo). This post hoc analysis evaluated safety and efficacy of Ra-223 plus EBRT. Methods: Pts had symptomatic (recent EBRT for bone pain or any regular analgesic use) CRPC with ≥ 2 bone and no visceral mets; best standard of care; and prior docetaxel (pD) or were unfit for or declined docetaxel (no pD). Pts were stratified by pD use (yes/no), baseline total alkaline phosphatase level (tALP; &lt; 220 U/L or ≥ 220 U/L), and current bisphosphonate (bp) use (yes/no) and randomized 2:1 to 6 Ra-223 injections (50 kBq/kg IV q 4 wk) or pbo. EBRT for bone pain was permitted within 12 weeks prior to randomization and during study. Baseline pain by prior EBRT, time to first on-study EBRT use for bone pain, and adverse events (AEs) by concomitant EBRT (cEBRT) were analyzed. Results: Pts with no prior EBRT had less pain at baseline; a WHO pain score ≤ 1 (no opioid use) was present in 46% (355/724) of pts with no prior EBRT vs 36% (53/147) of pts with prior EBRT. Ra-223 vs pbo significantly reduced EBRT use in the overall population (HR = 0.67, P = 0.001) and in pts with ≤ 20 bone mets (HR = 0.49, P &lt; 0.001), current bp use (HR = 0.47, P = 0.004), tALP &lt; 220 U/L (HR = 0.66, P = 0.008), and no pD (HR = 0.65, P = 0.038). At 6 months, the percentage of Ra-223 pts requiring EBRT was similar for prior and no prior EBRT subgroups (24% vs 20%), increasing at 12 months (38% vs 29%). cEBRT did not affect Ra-223 safety, and myelosuppression was low (Table). Conclusions: cEBRT did not adversely affect Ra-223 hematologic safety. Ra-223 significantly reduced risk of EBRT use. In Ra-223 pts, prior EBRT did not appear to affect later EBRT use. Clinical trial information: NCT00699751. [Table: see text]

Evaluation of WHO guided pain management protocol in cases of cancer cervix

Introduction and Aims: Pain is a common debilitating symptom of cancer cervix. It occurs in 25-50% patients with newly diagnosed malignancies and in more than 75% of those with advanced disease. Yet, it is one of the most unattended problem. Henceforth, this study was planned to assess pain and to evaluate the response to pain management according to WHO step ladder protocol in cases of cancer cervix. Materials and Methods: This was a prospective cohort study that included patients of cancer cervix with pain. Patients of cancer cervix with severe systemic debilitating illness and those who had undergone major surgery in past 2 weeks were excluded from the study. The severity of pain was assessed by using visual analogue scale. Pain was managed according to WHO step ladder protocol for pain. Result: Total 61.5% patients of cancer cervix presented with pain. Success rate of WHO pain management protocol was 95.3%. Conclusion: Pain management was done effectively using WHO guided step ladder pain management protocol in 95.3% of cases. Oral Morphine is an effective drug for pain management. It is easily titratable and has a favorable benefit to risk ratio.

Actualización del tratamiento analgésico

The diagnosis of pain requires the use of a pathophysiological classification system with therapeutic implications. We differentiate 4 fundamental pathophysiological types of pain: somatic, visceral, neuropathic and psychogenic. The treatment of chronic pain requires an overall approach, which we can initially divide into drug and nondrug treatment. However, a multimodal therapy that allows for the simultaneous use of various therapeutic modalities provides more effective analgesia and reduces the potential adverse effects by enabling finer dosage adjustments and administration frequency of the drug treatment. The therapeutic decision-making process starts with appropriate use of the WHO's pain ladder. Treatment for any chronic pain should be based on the use of orally administered medication, whenever possible.

Complex regional pain syndrome (CRPS)

SummaryIntroduction: Complex regional pain syndrome (CRPS) is a relatively rare disorder, but one that is extremely serious for the affected patient. It usually occurs in the area distal to a primary limb injury. The clinical symptoms and the pain are out of all proportion to the inciting event and in approximately 10 % of CRPS patients, there is no triggering event at all. CRPS leads to long-term disability and high treatment and follow-up costs In about half of those affected.Clinical symptoms: Two forms exist. In CRPS type 1, no nerve lesions are present, whereas in CRPS type 2, injury has occurred to a nerve or the main branch of a nerve. However, in terms of their clinical course, there is no difference between the two forms. Approximately 90 % of all cases involve CRPS type 1, formerly known as “Sudeck’s atrophy”. The cardinal symptom is pain. In addition, trophic disturbances, such as swelling, local skin discolouration or asymmetric skin temperatures, can also occur. Impaired mobility and function of the affected limb also occur frequently and are very difficult to treat.Diagnosis: Initially, it can be difficult to distinguish between CRPS and a normal post-traumatic course. Subsequently, the severe symptoms are out of all proportion to the inciting event. The diagnosis of CRPS is based mainly on the clinical symptoms. The Budapest criteria help to confirm the diagnosis.Therapy: Early and interdisciplinary rehabilitation is of crucial importance in CRPS treatment. Occupational therapy and physiotherapy are supplemented by good analgesic management and psychological support, if required. Analgesia should be based on the WHO pain ladder. Methadone is of proven efficacy in cases of severe hyperalgesia and gabapentin or pregabalin are used to treat refractory pain. Bisphosphonates have shown a good analgesic effect, particularly in patients with confirmed bone lesions. Chronic oedema and inflammation may require short-term steroid administration. A further clinical goal is the avoidance of sequelae, such as osteoporosis. Patients with suspected CRPS should be referred to a multidisciplinary treatment team, preferably one with considerable experience in treating this clinical presentation. One physician should coordinate the patient’s treatment. The earlier the treatment is started, the better the prognosis.

Wound pain

SummaryIn acute and chronic wounds, pain represents a common and central medical problem. Wound pain can be caused by multiple factors, such as macro- or microvascular as well as inflammatory processes.The basic concept of pain management is based on the WHO pain ladder. Often this concept of pain therapy remains insufficient. Apart from the conventionally used anal-getics, there are not yet established guidelines for the use of alternative substances.Ultimately the adequate wound pain therapy must be adjusted to each patient and his comorbidities.

Pain control in the continuity of care

As cancer is earlier diagnosed and its treatments improve, palliative care is increasingly playinga vital role in the oncology population. The concept and the timing of application of palliativecare have evolved in the last decades. The WHO pain ladder and the greater understanding ofappropriate multimodal pain control treatments have dramatically improved the managementof cancer pain. Integration of palliative care, which appears crucial for a proper management ofpatients, can be defined as the provision of palliative care both during curative cancer treatmentand after curative treatment has ceased. Clinical assistance should be delivered by specialisedphysicians in different fields, psychologists and nurses, and should include all aspects of advancedcancercare, from diagnosis to the treatment of symptoms. A further aspect of integration ofpalliative care concerns the role of the continuity of care in acute or emergency contexts bothfor out- and inpatients. Further improvements in the management of cancer pain are needed.First, the WHO ladder should be modified with further steps, like those of interventional paincontrol procedures and techniques, with the aim of being effective also for the small proportion ofnonresponsive patients. Second, more research is needed to find out which interventions aimingto improve continuity of care of cancer patients are beneficial to improve patient, providerand process of care outcomes and to identify which outcomes are the most sensitive to change.Of crucial importance would be the development of a standardised instrument to measure thecontinuity of care in cancer patients.This article is a brief overview on the management of cancer pain, from the pharmacologicaltreatments reported by WHO ladder, to the need for integration and continuity of care.

Complexity of pain management among patients with nociceptive or neuropathic neck, back, or osteoarthritis diagnoses.

Approaches to pain management are diverse, requiring prescribers to evaluate an array of clinical issues and potential solutions. In addition to the difficult task of selecting a treatment option, pain treatment may be further complicated by multiple prescribers, multiple medications, and multiple mechanisms of pain origination. To describe patient demographics (e.g., age, gender); comorbidities; office visits (e.g., physician, chiropractor, physical therapy, psychiatry, allergist); number of different prescribers overall prescription use; pain medications as classified by the World Health Organization's (WHO) pain ladder; adjuvant medications; nonpharmacologic procedures; and potential drug interactions in a broad sample of patients with nociceptive or neuropathic neck or back diagnoses, or osteoarthritis diagnoses, in a commercial population. This claims-data analysis used a cross-sectional cohort comparison with a fixed 2-year observation period from September 1, 2006, to August 31, 2008, for patients in the PharMetrics national managed care database. The assigned cohorts were neuropathic-related neck/back diagnoses (NEURO); neuropathic and nociceptive neck/back diagnoses (NEURO/NOCI); nociceptive neck/back diagnoses without a neuropathic-related diagnosis (NOCI); and only osteoarthritis (OA) diagnoses. All analyses were conducted by cohort. The analysis included the following patient-descriptive variables: patient demographics, comorbidities, office visits, most frequent medical providers and number of different prescribers, all medications, pain medications as classified by the WHO pain ladder, adjuvant medications, adjuvant procedures and potential drug interactions. The goal for selecting these variables was to describe a range of data that might provide insight into the complexity of pain management decisions faced by clinicians. The study included 85,014 patients, classified as NEURO (n = 2,375), NEURO/NOCI (n = 37,019), NOCI (n = 39,496), and OA (n = 6,124). The most frequently occurring comorbidities (observed in > 40% of patients) included cardiovascular and neuropathic pain conditions. Considering all types of medication claims observed among all cohorts, the overall mean prescription claim count for the 2-year observation period was 57.9 claims (standard deviation 56.2). Weak opioids (WHO pain relief ladder rung 2) accounted for the majority of pain medication claims across all cohorts. Across cohorts, 25.7% of patients had 10 or more days of overlapping drug availability (for inducers or inhibitors of the cytochrome P450 system concomitantly), a measure of potential for drug interactions. Choosing the appropriate pain treatment involves assessing currently used medications for existing illnesses and deciding on the appropriate types of pain medications. However, potentially serious drug-drug interactions are a consequence of multiple drug use, and such a potential requires thoughtful consideration by those involved in patient care.

Quality of life and symptoms in patients with malignant diseases admitted to a comprehensive cancer centre

Quality of life and symptomatology in patients with malignancies admitted to comprehensive cancer centres are rarely investigated. Thus, this study aimed to investigate symptomatology and health-related quality of life of inpatients with cancer. A prospective, cross-sectional study was carried out on two occasions 5 weeks apart in haematology and oncology departments at a comprehensive cancer centre. Assessment included demographic data, WHO performance status (PS), EORTC QLQ-C30 and pain scales of brief pain inventory. Comparisons were analysed using Wilcoxon two-sample test, rank tests and Fisher's exact test. One hundred twenty-four patients were analysed, mean age=59 years (SD=13.7), 42% admitted to haematological department; lung cancer was the most frequent diagnosis (15%). Low health-related quality of life and severe symptom burden, especially fatigue and appetite loss, were observed among the inpatients. In addition, role and social functions appeared to be more impaired in haematology patients than in those admitted to oncology (P=0.0372 and 0.0167, respectively). On the other hand, pain and constipation were more severely affected in oncology patients (P=0.0194 and 0.0064, respectively). Patients in the wards of haematology and oncology had pronounced symptomatology and low quality of life. A more systematic focus on the amelioration of problems with functioning and symptoms among inpatients with malignant diseases is warranted.