Management of pain in leukemic children using the WHO analgesic ladder.

Objective. To ascertain the effectiveness of WHO analgesic ladder in pain management in children with leukemia. Methods. Children with leukemia who were referred to a pain and palliative care clinic attached to the Department of Pediatrics of a medical teaching hospital during a period of 6 months, were included in the study. Results. Thirty nine (39) children, who constituted 64% of children on treatment for leukemia, required referral to pain and palliative care services during the study period. Of these 92% had Acute Lymphocytic Leukemia (ALL) and 8% had Acute Non Lymphocytic Leukemia (ANLL). 95% of children had nociceptive pain and 5% had neuropathic pain. Step – 1 analgesia was effective in 12 (31%) children and 21 (54%) could be managed with Step – 2 analgesia. Step – 3 analgesia was required in only 6 (15%) children. Step 3 analgesia was required in children with neuropathic pain and bone pain. Conclusions. WHO analgesic ladder is effective in managing pain in children with leukemia. Majority of cases of cancer pain in children could be managed by the treating physician using non-opioids, weak opioids and adjuvants as per the WHO guidelines. Children with bone pain and neuropathic pain may require referral to specialist services and use of strong opioids like morphine. The study emphasizes the need for establishing specialist pain management services in all centres where children with cancer are treated.

Medicina paliativa: una respuesta para el paciente con cáncer avanzado / Palliative medicine: an answer for patients with advanced stage cancer

El cáncer avanzado representa un desafío para los equipos de salud, considerando que epidemiológicamente el problema del cáncer muestra un crecimineto sostenido en el mundo. Esto crea una necesidad creciente de manejo de los problemas biofísicos y psicosociales asociados, bajo una forma integral e interdisciplinaria característica de la Medicina Paliativa. El control del dolor es el primer objetivo de este cuidado. Las recomendaciones de la OMS desde hace 20 años promueve el uso de una terapia en escalera de 3 peldaños combinando AINEs, opioides débiles o potentes y coadyuvantes. El uso de los opioides siempre ha estado obstaculizado por confusiones entre los conceptos de tolerancia, dependencia y adicción. Otros métodos intervencionales han aportado algunas alternativas para el control del dolor de los pacientes. Además del dolor los pacientes con cáncer avanzado experimentan muchos otros síntomas que requieren el enfoque integral de la Medicina Paliativa para intentar mejorar la calidad de vida. Actualmente existe suficiente evidencia científica y experiencia clínica para validar la Medicina paliativa en los programas de Cáncer de distintos países del mundo.

Advanced stage cancer represents a challenge for medical teams if we consider that from an epidemiologic perspective, the number of cancer patients has been increasing steadily all over the world. This lead to a greater need to manage the associated biophysical and psychosocial issues using the integral and multidisciplinary approach of Palliative Medicine. Pain control is the primary objective in the field of care. The HWO has been promoting for the last 20 yearsthe use of a three step therapy using a combination of AINEs, weak or strong opiates and soothing agents. The use of opiates has always encountered difficulties because the meaning of words such as tolerance, dependency and adiction has always been confused. Other intervention methods have provided some alternatives to pain control. In addition to pain cancer patients at an advanced stage have many other symptoms that require the integral approach of Palliative Medicine to improve the quality of their lives. There is at present enough scientific evidence and clinical experience to validate Palliative Medicine in Cancer programs in many countries of the world.

Botulinum toxin type A in refractory chronic migraine: an open-label trial

Botulinum toxin type A (BT-A) has been described as an important strategy to various types of pain such as cervical dystonia, myofascial pain syndrome and headache. Although BT-A efficacy has not been proven in tension type headache, its use in migraine continues controversial. In this open trial, we evaluated the efficacy of BT-A in refractory migraine. BT-A was injected in patients diagnosed with migraine who had previously used three classes of prophylactic drugs by at least one year with no response. The most important improvement was observed within 30 days, but pain intensity and frequency of headache had been decreased until the end of three months of follow up. Side effects of BT-A were mild and self limited. We conclude that BT-A seems to be a safe and effective treatment to refractory migraine patients.

Toxina botulínica tipo A (TB-A) tem sido descrita como importante estratégia para diversos tipos de dor como cefaléia e dores relacionadas a distonia cervical ou síndrome miofascial. Embora a eficácia da TB-A não tenha sido demonstrada na cefaléia do tipo tensional, seu uso na enxaqueca continua controverso. Nesse estudo avaliamos a eficácia da TB-A na enxaqueca refratária. TB-A foi injetada em pacientes com enxaqueca que fizeram tratamento prévio com no mínimo três classes de medicamentos profiláticos, sem resultados satisfatórios. A melhora mais significativa dos pacientes foi observada após 30 dias de aplicação de TB-A, enquanto intensidade da dor e freqüência de cefaléia continuaram reduzidas até o final de três meses de seguimento. Os efeitos colaterais observados após a aplicação de TB-A foram moderados e auto-limitados. Os nossos dados mostram que TB-A parece ser um tratamento seguro e eficaz para pacientes com enxaqueca refratária.

Midazolam for the treatment of phantom limb pain exacerbation: preliminary reports.

Phantom pain is one of the most difficult intractable pains to manage. The pain may result from the imbalance of self-sustaining neural activity that exceeds the inhibitory control. The management of acute severe exacerbation of phantom pain is extremely difficult. Midazolam acts by potentiation of gamma aminobutyric acid (GABA) and enhance the inhibitory action of glycine receptor at spinal neurons. We describe two preliminary reports of complete pain relief of severe phantom pain exacerbation by intravenous midazolam 3-5 mg.

The management of neuropathic pain in cancer: clinical guidelines for the use of adjuvant analgesics.

Neuropathic pain is seen in a third of cancer patients and is not always responsive to traditional analgesics. We describe practical guidelines for the use antidepressants and anticonvulsants as adjuvant analgesics in such situations. Newer adjuvant analgesics, interventional procedures and options for the management of pain emergencies, are also briefly outlined.

Pain relief in chronic pancreatitis with epidural buprenorphine injection.

BACKGROUND: The management of intractable pain in chronic pancreatitis is difficult. A novel method for its relief is described. METHODS: Twelve patients were given a mixture of buprenorphine (0.3 mg) and blood (10-15 mL) into the epidural space. RESULTS: All patients had pain relief lasting up to six months. CONCLUSION: Epidural buprenorphine injection is a simple, safe and effective method for pain relief in chronic pancreatitis.

Management of cancer-related pain with transdermal fentanyl.

This study demonstrates that TTS-fentanyl can provide sufficient pain relief in cancer patients equivalent to that achieved with morphine with additional benefits of convenience and reduced side effects.

La morfina peridural como analgesia complementaria en el dolor por mieloma multiple / Peridural morphine complementary analgesia in multiple myeloma pain

Se expone el resultado del empleo de la morfina peridural continua como analgesia complementaria en 5 pacientes portadores de mieloma multiple con dolor cronico, durante el tratamiento de las radiaciones ionizantes. Se analizan las caracteristicas del dolor, las localizaciones mas frecuentes en la casuistica y las ventajas de este metodo morfinico. Se concluye que el metodo es util y eficaz, cuando se utilizan dosis minimas de morfina con disminucion de la polifarmacia inicial al tratamiento

Sistemas implantáveis de infusäo de drogas em doentes com dor oncológica de difícil controle / The implant of pump system for narcotic infusion for the treatment of cancer pain

Muitos doentes com afecçöes de origem oncológica näo podem ser medicados oralmente por näo tolerarem a medicaçäo, ou por déficit no processo de absorçäo. Muitos outroa, apresentam dor rebelde aos analgésicos administrados sistematicamente. Os autores descrevem a experiência adquirida com 60 implantes de bombas e 10 implantes subcutâneos de câmara destinados à infusäo de medicaçäo narcótica, no compartimento epidural, subaracnóideo e/ou intraventricular, para o tratamento da dor de origem oncológica. Concluem que o procedimento de implante de câmara ou de bomba de infusäo é simples, seguro e eficaz

Comparison of morphine slow release tablet (MST) and morphine sulphate solution (MSS) in the treatment of cancer pain.

A cross-over, single blind trial of MST and MSS in relieving pain of advanced cancer patients is described. Forty-nine cases completed the study. Both MST and MSS gave equally excellent pain relief in the patients as judged by the pain score of VAS and pain rating scale by a nurse, and the duration of sleep. The daily effective dose was 55.5 +/- 19.7 mg for MST and 61.0 +/- 11.0 mg of MSS.