WHO Pain Ladder Research Articles

8. Herpes zoster and post herpetic neuralgia.

Patients suffering from postherpetic neuralgia (PHN) report unilateral chronic pain in one or more dermatomes after an acute herpes zoster (HZ) infection. The incidence of acute HZ ranges between three and five patients per 1000 person-years. In one out of four patients, acute HZ-related pain will transition into PHN. PHN can be very disabling for patients and reduce quality of life. Additionally, the treatment of PHN is characterized by high failure rates. The aim of this review is to give an update on the previous practical guideline published in 2011 and revised in 2015 (published in 2019) and to provide an overview of current interventional treatment options for HZ infection and PHN. The literature on the diagnosis and treatment of HZ and PHN was systematically reviewed and summarized. The most important treatment for acute HZ-related pain is antiviral therapy within 72 h of symptom onset. Additional symptomatic treatment options are analgesic drugs according to the WHO pain ladder, tricyclic antidepressants (eg, nortriptyline), and antiepileptic drugs (eg, gabapentin). If pain is not sufficiently reduced, interventional treatment such as an epidural injection with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion (DRG) are options. Treatment for PHN is preferably transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Treatment of acute HZ-related pain especially PHN is challenging. Besides the conventional treatment for PHN, interventional management is considered a new treatment option. PRF of DRG seems to be the most promising interventional management.

Short-Term Opioid Treatment of Acute Locomotor Pain in Older Adults: Comparison of Effectiveness and Safety between Tramadol and Oxycodone: A Randomized Trial.

We conducted a head-to-head comparison of step 2 (tramadol) and step 3 (oxycodone) of the WHO pain ladder in older adults with moderate to severe acute locomotor pain. Multi-center prospective randomized study. Patients were 70 years or older, admitted to the acute geriatric ward of three hospitals, suffering from acute moderate to severe locomotor pain, and opioid-naive. Patients were randomized into two treatment groups: tramadol versus oxycodone. The Consort reporting guidelines were used. Forty-nine patients were included. Mean numeric rating scale (NRS) decreased significantly between day 0 and 2 of the inclusion in both groups. A sustained significant decrease in mean NRS was seen at day 7 in both groups. Nausea was significantly more prevalent in the tramadol group, with a trend towards a higher prevalence of delirium and falls and three serious adverse events in the same group. Opioid therapy may be considered as a short-term effective treatment for moderate to severe acute locomotor pain in older adults. Oxycodone may possibly be preferred for safety reasons. These results can have implications for geriatric practice, showing that opioids for treatment of acute moderate to severe locomotor pain in older patients are effective and safe if carefully monitored for side effects. Opioid therapy may be considered as a short-term treatment for moderate to severe acute locomotor pain in older adults, if carefully monitored for (side) effects, while oxycodone may possibly be preferred for safety reasons. These results can have implications for daily practice in geriatric, orthopedic, and orthogeriatric wards, as well as in terminal care, more precisely for the treatment of moderate to severe acute locomotor pain in older adults.

Comparison of WHO Pain Ladder Management versus Severity-based Pain Management in Patients Presented with Acute Abdominal Pain Visiting Emergency Department

Aimand Objectives: The present study was undertaken to evaluate whether patients that are administered analgesics depending on their initial pain severity are more satisfied with their treatment than those who are given analgesics in accordance with the WHO pain ladder management protocol. Materials and Methods: First consecutive 100 patients (Group I) with abdominal pain were treated with WHO pain ladder management and for the next 100 patients (Group II), the pain management was done based on their intensity of pain. All patients were assessed for relief of pain every 15 min based on visual analog scale (VAS). Results: The visual analog pain score started decreasing after the administration of analgesics in both groups. The VAS was monitored once every 15 min for 60 min and in each measurement, the score was slightly lower in Group II in comparison to Group I ( P > 0.05). At the end of 60 min, the mean score was <4 in both groups. Eighty-six percentage of the patients in Group II and 79% of the patients in Group I were satisfied with their pain relief. Although the satisfaction level of patients was higher in Group II, it was not found to be statistically significant ( P = 0.282). Conclusion: The usage of analgesics for pain management can be decided based on the severity of the pain instead of following the pain ladder management proposed by WHO. This can prevent the unnecessary usage of analgesics such as paracetamol and certain side effects due to that.

Knowledge and perceptions in palliative care among undergraduate medical students in Puducherry, South India

BackgroundIn the NPCDCS program of Government of India, capacity building of health professionals on palliative care is a key component in rehabilitaion of cancer and other NCDs. However as palliative care teaching is still not mandatory in undergraduate medical curriculum, a medical graduate lacks knowledge and confidence in providing palliative care. Understanding the existing levelof knowledge and perceptions of students towards palliative care can facilitate planning a need-based curriculum. AimTo assess the knowledge and perceptions in palliative care among undergraduate medical students in Puducherry, South India. MethodsAfter ethical clearance, a semi structured questionnaire comprising 15 knowledge questions and seven perception statements on palliative care was administered to 265 pre-final and final year medical students. The data were analyzed using SPSS-23. ResultsCancer (88.6%), AIDS (28.6%), Spinal trauma (11.6%), XDR TB (5.6%) and Coma (4.5%) were mentioned as diseases that need palliative care. Improving quality of life (46.4%) and relief of pain (30.5%) were mentioned as the purposes of palliative care. Only 15.8% said palliative care starts from the time of diagnosis. About 54.7% students were unaware of main drugs in Step I & II in WHO Pain Ladder. Majority (90.2%) felt oral morphine relieves cancer pain and 47.5% felt it causes addiction. Nearly half of students (48.6%) felt that patients can be reassured during communication. Majority (83.4%) favored inclusion of palliative care teaching in undergraduate curriculum. ConclusionThe findings indicate the need for filling the knowledge gap by focussed training of undergraduate students in palliative care.

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

P1504: AN AUDIT OF PAIN EDUCATION IN PATIENTS WITH SICKLE CELL DISEASE

Background: Pain crises represent the primary reason for hospital care-seeking in individuals with sickle cell disease (SCD). The NICE guideline CG143 emphasises that patient should be treated as experts in the pain management of their sickle cell disease. Aims: To assess the performance of acute sickle cell pain crisis management at Cambridge University Hospital (CUH) and assess methods of secondary prevention of admission for pain crisis through patient pain education. Methods: Patient admission records during the year of 2021 were reviewed for a population of 85 SCD patients registered at Cambridge University Hospital (CUH). For these encounters, patient assessment at presentation, primary analgesia and ongoing management were audited against CG143 standards. All SCD patients registered with CUH were contacted for a telephone interview to discuss home pain management. Results: In a population of 85 patients living with SCD, there were 22 admissions in 17 patients during 2021, of which 5 patients had multiple admissions. Auditing CUH performance against the NICE CG143 guidelines, it was found that initial pain relief was provided within 30 minutes of presentation in 15 out of the 21 relevant admissions (71%). However, none of the patients had documented discussion of pain control education, any psychological support they may need nor were encouraged to use their own coping mechanisms for dealing with acute pain in their hospital notes. Following on from this, we conducted telephone interviews and received a total of 51 responses of which 13 patients were admitted to hospital with sickle cell pain in 2021. In the 46 patients who experience sickle cell pain crises, 20 had strong opiates, 27 had weak opiates, and all 46 had a supply of paracetamol/non-steroidal anti-inflammatory drugs (NSAIDs). 8/20 (40%) patients with a home supply of strong opiates were admitted to CUH with an acute sickle cell pain crisis in 2021 compared to 5/26(19.2%) in those who did not have strong opiates at home. Notably, only 6/46 patients were familiar with the World Health Organisation pain ladder. 2 of 6 patients who were aware of the WHO pain ladder had an admission to CUH in 2021, while 11 of 40 patients who were not aware had an admission to CUH in 2021. The findings are summarised in Table 1. Image:Summary/Conclusion: Our audit has demonstrated a significant gap in the management of acute sickle cell pain crises at CUH with the absence of patient pain education. This may have contributed to the number of admissions of SCD patients to CUH. The limited patient knowledge of optimal use of pain control in line with WHO pain ladder is significant, given that most episodes are managed at home. Frequent painful crises are associated with psychological issues and poor engagement in normal daily activities. Better home pain control should be a future priority for our service.

Herpes zoster-prevention, diagnosis, and treatment

Herpes zoster (HZ) is acommon skin disease resulting from aregionally limited reactivation of alatent infection with the varicella zoster virus (VZV). Despite its usually self-limiting course, HZ is associated with aconsiderable individual and public health burden of disease, particularly due to its high rate of postherpetic neuralgia (PHN). To improve knowledge of the current recommendations for the prevention, diagnosis and treatment. Narrative review and summary of current guideline recommendations. In Germany, the recombinant VZV subunit zoster vaccine is recommended for all adults of 60+ years and for immunocompromised persons of 50+ years. The diagnosis of HZ is clinical; in case of uncertainty, laboratory investigations can help confirm the diagnosis. For patients with HZ ophthalmicus, HZ oticus or neurological complications, an interdisciplinary approach is advantageous. Antiviral treatment should be started as early as possible; various factors, including the duration and location of the disease, the patient's age and signs of acomplicated course, serve to determine the indication to initiate an antiviral medication. The choice of the appropriate treatment depends, among other factors, on the intravenous availability, comorbidities and intake preferences. Early and sufficient analgesic treatment according to the WHO pain ladder and, if required, with anticonvulsant adjuvants is necessary to treat acute pain and to reduce the risk for PHN. Implementation of the current recommendations for the prevention, diagnosis and treatment of HZ and PHN is important to reduce the high burden of disease and improve quality of life of the patients.

Pain, Weight Loss, and Quality of Life in a Supportive Care Trial for Patients With Advanced Head and Neck Cancer

Symptom management is critical during radiation therapy (RT) for head and neck cancer (HNC). Worse pain during RT has been associated with worse treatment tolerance, weight loss, and worse quality of life (QoL). This study further explored the relationship between pain control, weight loss, and QoL in a prospective cohort of patients receiving RT for HNC.This study was a secondary analysis of a clinical trial of microsphere oxycodone (NCT03317730) during RT for locally advanced HNC. Participants had RT dose > 50 Gy, ECOG 0-2, and no known history of substance abuse. Analgesia was prescribed in accordance with the WHO Pain Ladder, but the extended-release opioid option was limited to microsphere oxycodone. QoL was assessed with the Brief Pain Inventory and EORTC HN-35 forms at baseline and 1- and 3-months post-RT. Correlations were assessed using Pearson's r and differences in means were determined with the independent samples T-test. Analysis was performed using IBM SPSS software.Responses were available from participants at 1 month post-RT (n = 23) and at 3 months post-RT (n = 21). At baseline, BMI positively correlated with pain control. In addition, at baseline, worst pain correlated with amount of pain interfering with enjoying life as well as with the ability to eat solid foods (Table). Change in worst 24-hour pain from enrollment to 1- and 3-months post-RT was significantly associated with change in ability to enjoy life due to pain. At 3-months post-RT, change in worst pain negatively correlated with overall ability to enjoy life and ability to eat solid food. Change in BMI correlated with change in relief with pain medication at 1-month and 3-months post-RT. No significant difference in pain relief was noted when considering men vs women (2.06 vs 0.33, P = 0.3).This study supports the hypothesis that response to pain medication is associated with change in weight during and shortly after completion of RT. Pain levels were significantly correlated with QoL, particularly the ability to enjoy life and eat food at both 1- and 3-months post-RT. Ongoing research is needed to better elucidate the relation between pain control and patient outcomes, and to develop new interventions to promote QoL among patients with HNC.

528 EVALUATING THE PRESCRIPTION OF OPIATES IN PATIENTS WITH NECK OF FEMUR FRACTURES IN OUT OF HOSPITAL AND EMERGENCY CARE SETTING

Abstract Introduction Opiate based analgesia forms a key component of Hip Fracture management. If prescribed inappropriately, opiate based analgesia can lead to respiratory depression, nephrotoxicity, and delayed recovery. The aim of this project was to evaluate opiate prescription in NOF patients in both out of hospital (OOH) and Emergency Department (ED). Methods 100 consecutive patients were identified from National Hip Fracture Database between January and August 2019. Medical records were reviewed in both care settings, reviewing dose of morphine in comparison to body weight and renal function. Outcomes measured include constipation, acute kidney injury, respiratory compromise, and mortality. Statistical tests (t-test and chi square) were used to discern significance. Following the first cycle of results, results were disseminated to paramedics and at local governance meetings. Teaching was undertaken to increase awareness of harms associated with inappropriate opiate prescribing. A second cycle evaluated 30 consecutive NOFs from July 2020. Results In our study population, 74% were female and the average age was 84. The range of morphine doses given OOH ranged from 2-40 mg, in comparison to 2.5-20 mg in ED. 18% of patient suffered from Respiratory depression with 48 hours of their admission with a further 7% suffering from an acute kidney injury. After intervention, OOH morphine doses ranged between 5-10 mg, a reduction of 75% on maximum dose, with increased use of adjuvants as guided by the WHO pain ladder. No adverse outcomes were noted within 48 hours of admission. Conclusion Patient safety should be high on the agenda whilst caring for frail patients with Hip Fractures and opiate prescription is one of the most critical in the patient’s journey. Reducing harm by prescribing the optimal opiates helps to reduce mortality, morbidity, improve rehabilitation and patient flow within the NHS pathways. A guideline has been published to aid opiate prescription in elderly patients.

Multicenter evaluation of therapeutic strategies of inpatients with osteoporotic vertebral fractures in Germany.

The aim of this study was to assess therapeutic strategies of inpatients with osteoporotic thoracolumbar fractures (OTF) in Germany. Prospective multi-center study including 16 German-speaking trauma centers over a period of 7months. All inpatients with OTF were included. Radiological and clinical data on admission and treatment modalities were assessed. Seven hundred and seven (99.3%) out of 712 included patients (73.3% female) could be evaluated. Mean age was 75years (30-103). 51.3% could not remember any traumatic incident. Fracture distribution was from T2 to L5 with L1 (19%) most commonly affected. According to the Magerl classification type A1 (52.1%) and A3 (42.7%) were most common. B and C type injuries (2.6%) and neurological deficits (3.1%) were rare. Previous progression of vertebral deformation was evident in 34.4% of patients and related to t score below -3 (Odds ratio 1.9661). Patients presented with anticoagulation medication (15.4%), dementia (13%), and ASA score > 3 (12.4%) frequently. 82.3% of patients complained of pain > 4 on VAS, 37% could not be mobilized despite pain medication according to grade II WHO pain ladder. 81.6% received operative treatment. Kyphoplasty (63.8%) and hybrid stabilization including kyphoplasty with (14.4%) or without screw augmentation (7.6%) were the techniques most frequently used. Invasiveness of treatment increased with degree of instability. OTF are mostly type A compression fractures. Patients suffer from severe pain and immobilization frequently. Progression of deformity is correlated to t score below - 3. Treatment of inpatients is mainly surgical, with kyphoplasty followed by hybrid stabilization as commonly used techniques.

Pain management in patients undergoing radiation therapy for head and neck cancer- a descriptive study.

Patients with head and neck cancer (HNC) experience serious pain related to tumour, surgery, chemotherapy, and radiotherapy treatment (RT). Oral mucositis, a painful complication of RT, may require opioid analgesics to control pain.This longitudinal study, during RT but also four weeks post-RT, examines the relationships between oral mucositis, pain, and opioid doses in in HNC patients. The aim was to evaluate the clinical effectiveness of an opioid treatment strategy. Sixty-three patients with HNC undergoing radiotherapy answered self-reported questionnaires on pain intensity on a 0-10 numerical rating scale (NRS) three times a week. Oral mucositis signs were evaluated using the WHO mucositis index score, ranging from 0 (normal) to 4 (severe), and pharmacological treatment with opioids was registered prospectively once a week. All data were related to given radiation dose, and all outcome measures at each time point therefore relate to the same radiation dose (i.e.,not to when the patient was included in the study). Opioids were used by 78% of the patients. Most of the patients experienced only mild pain (NRS 0-4), although the majority developed mucositis grade 2-4 according to WHO mucositis index. Function-related pain intensity and opioid doses were highest during the sixth week of RT, with 3.67 (0-9) in NRS and 84 (0-430)mg oral morphine equivalents per day (median, range). At that same time point, significant positive correlations were found between the grade of mucositis and pain intensities. Patients with mucositis grade 2-4 were investigated further; in this subgroup, we found that opioid doses did not differ between patients with mild pain and patients with moderate to severe pain. Our multivariate data analysis defined a cluster of patients characterized by the presence of mucositis, cancer site in pharynx, concomitant chemotherapy, and the absence of surgery. In HNC patients who were followed closely by pain care personnel during and after RT, pain was often satisfactorily alleviated with a structured use of opioids, including stepwise increases of fentanyl patches and oral morphine as needed. However, some patients with oral mucositis grade 2-4 experienced severe pain. Strong opioids, i.e. the third step of the WHO pain ladder, remain the mainstay of analgesic therapy in treating moderate to severe cancer-related pain, including patients with HNC. This real-life study indicates that RT-related pain is not a fatality. A proactive stance, monitoring these patients closely and regularly, is probably crucial in order to achieve good treatment results. Further studies are needed to develop better pain treatment strategies for those patients who develop severe oral mucositis-related pain despite intensive opioid treatment.

Assessment of Patient's Satisfaction and Associated Factors regarding Postoperative Pain Management at the University of Gondar Compressive Specialized Hospital, Northwest Ethiopia.

Objective We aimed to assess the level of patient's satisfaction and associated factors regarding postoperative pain management. Methods An institution-based cross-sectional study was conducted from April to May 2018 at the University of Gondar, and comprehensive specialized hospital data were collected through semistructured questionnaire and chart review. Level of satisfaction was measured using five-point Likert scale. Statistical analysis was done using SPSS software version 23. Both bivariable and multivariable logistic regression analyses were done. Variables of P value ≤0.2 in the bivariable analysis were a candidate for multivariable logistic regression. A P value ≤0.05 was considered as significantly associated with patient's level of satisfaction at 95% CI. Results A total of 418 patients were included in this study with a response rate of 98.58%. The overall proportion of patients who were satisfied with pain management services was 72.2% (95% CI: 67.7–76.6). ASA1 (AOR = 3.55: 95% CI = 1.20–10.55) and ASA2 patients (AOR = 3.72: 95% CI = 1.04–13.28), absence of postoperative pain (AOR = 1.86: 95% CI = 1.02–3.39), peripheral nerve block done (AOR = 9.14: 95% CI = 3.93 20.86), received analgesic before request (AOR = 6.90: 95% CI = 3.72–12.83), and received systemic analgesics (AOR = 6.10: 95% CI = 1.17–33.91) were significantly associated with the level of satisfaction. Conclusion The level of patient satisfaction with postoperative pain management was considerably low. Hence, it is vital to implement time-interval pain assessment method during the first 24 hours of postoperative period and treat accordingly based on the WHO pain ladder. Moreover, we suggested that all patients who underwent major surgery should receive peripheral nerve block as part of multimodal analgesia to decrease the incidence and severity of post op pain.

Lipid microsphere bound oxycodone for pain management in patients receiving radiotherapy for head and neck cancer

Wax microsphere bound oxycodone was developed as an abuse-deterrent opioid and maintains a similar pharmacokinetic profile whether administered with or without an intact capsule. We hypothesized that microsphere oxycodone could be utilized for extended release analgesia in patients undergoing radiation (RT) for head-and-neck cancer (HNC) and would not need to be discontinued due to dysphagia or gastrostomy tube dependence. We performed a prospective trial that enrolled participants > 18years with histologically confirmed HNC who were scheduled to receive RT. Analgesia was prescribed in accordance with the WHO pain ladder. Microsphere oxycodone was initiated when total daily opioid dose exceeded 30mg of morphine sulfate equivalent and was titrated weekly during RT. Pain level and effect on quality of life were assessed using the Brief Pain Inventory. The primary feasibility endpoint was frequency of microsphere oxycodone discontinuation within 3months of RT for reasons other than pain resolution. Twenty-six eligible patients were enrolled. Microsphere oxycodone was initiated in 16 (61.5%) patients. Six (23.1%) patients utilized a gastrostomy tube to administer microsphere oxycodone during all or part of RT. Microsphere oxycodone was discontinued in 1 (7.6%) patient due to perceived inefficacy. No patients were discontinued due to toxicity or difficulty with administration. Ratings for average pain was 3.1 (± 3.4) at enrollment, 4.0 (± 2.4) at week 6 of RT, and 1.8 (± 2.2) at 3-month follow-up. These results support the feasibility and safety of microsphere oxycodone for extended release analgesia among patients with HNC undergoing RT.

309P - Evaluation of a pharmacist-led opioid de-escalation (PLODE) program after chemoradiotherapy completion in head and neck cancer patients

BackgroundIt is important to consider that prolonged opioid use or opioid overuse for a patient who completed radiation therapy (RT) can have harmful effects. In 2018, pharmacists working with oncologists at outpatient clinics conducted an opioid de-escalation program for HNC patients who completed radiation therapy (RT) at the National Cancer Center Hospital East (NCCHE). The aim of this retrospective study was to evaluate the feasibility of a pharmacist-led opioid de-escalation (PLODE) program for HNC patients by comparing the outcomes of patients who participated in the PLODE program and those who did not. MethodsThis time-series analysis compared the outcomes of patients who participated in the PLODE program after CRT completion between June 2018 and February 2019 and those of patients who completed CRT between June 2017 and March 2018 and did not participate in the program. The PLODE program consisted of (1) number of opioid rescues, (2) patient’s complaints and (3) purpose of opioid use to patients based on the WHO Pain Ladder. ResultsSixty-one patients completed CRT between June 2018 and February 2019. Of these 61 patients, 16 (26%) used opioids at the time of CRT completion and participated in the PLODE program. Ninety-three patients completed CRT between June 2017 and March 2018, and 32 patients (34%) used opioids at the time of CRT completion; these patients were evaluated as the control group. Patients who participated in the PLODE program discontinued opioids statistically earlier than those in the control group (median time to opioid discontinuation 11 days vs 24.5 days, HR 0.31, 95% CI 0.16-0.60, p < 0.001). Between the two groups, there were no differences in time to opioid use, maximum opioid dosing, incidence of grade 3 oral mucositis or time to oral mucositis occurrence. No patients in the PLODE group restarted opioid use after opioid discontinuation or escalated opioid dosing due to the worsening of pain. ConclusionsThe study showed the feasibility of a PLODE program for HNC patients who completed CRT. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

General, regional and combination anesthesia in knee arthroplasty: A multicenter cohort-study of 15326 cases analyzing patient satisfaction and perioperative pain management

Aims and Objectives: In recent years, a steadily increasing number of total knee arthroplasty implants have been reported. After having ameliorated operation techniques and material, pain management and anesthetic methods have come into focus. Various anesthesia procedures for the surgical procedure itself as well as pain management programs have been developed. One of the main goals is to reduce postoperative pain and enable better and faster mobilization in the postoperative period. The present study aims to compare the use of general and regional anesthesia and their combination in terms of perioperative pain management and patient satisfaction. Materials and Methods: In the present cohort study, 15.326 patients were examined in 46 orthopedic departments after knee replacement surgery from 2009-2015. The parameters were analyzed on the first postoperative day as part of the project “QUIPS - Quality Improvement in Postoperative Pain Management”, an initiative to compare the outcome parameters in participating hospitals. Primary outcome values were pain levels (activity, minimum and maximum pain, and pain management satisfaction) on a NRS scale. Pain medication necessity was analyzed using the WHO pain ladder classification. Parameters were compared between the types of anesthesia used: general, regional and combination anesthesia. Results: Pain scores and pain management satisfaction were significantly better in the groups of either spinal or peripheral anesthesia combined with general anesthesia (p0.001, respectively). Patients who received the combination of general and spinal anesthesia were associated with the lowest need for opioids (p0.001). Conclusion: The use of a combined general and spinal anesthesia as well as using a combination of general and peripheral anesthesia in knee arthroplasty was associated with a highly significant advantage to other anesthetic techniques regarding perioperative pain management in daily clinical practice, but maybe below clinical relevance. Furthermore they were associated with positive tendency considering side effects and subjective well-being parameters.

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.

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.

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.

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.