Adult cancer pain.

Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.

Intracerebroventricular morphine for refractory cancer pain: transitioning to the home setting.

Refractory cancer pain may be effectively controlled by titrating intracerebroventricular (ICV) preservative-free opioid. In this case report, a continuous infusion of ICV morphine permitted our patient with lung cancer and painful spinal metastases to be discharged to home hospice with family. The approach exploits the high potency of morphine injected into cerebrospinal fluid (CSF). Sterile, injectable, preservative-free morphine is directly infused into CSF through a subcutaneous Ommaya reservoir placed under the scalp by a neurosurgeon, with an attached catheter passed through a burr hole in the skull with its tip in a cerebral ventricle. Although investigators have described home care of patients receiving intraspinal analgesics, no report describes the process of transitioning the patient receiving continuous ICV morphine infusion to the home setting.

Percutaneous-guided pain control: exploiting the neural basis of pain sensation.

The gastroenterologist deals frequently with painful conditions and suffering patients. Performing regular pain assessments and applying basic pain medicine principles will augment the care of patients in pain. Percutaneous-guided pain therapy techniques play a role in the multidisciplinary approach to pain medicine. Systemic opioid analgesia is the primary means of controlling cancer pain. However, 10% to 15% of cancer patients may need additional interventions to control pain. Sympathetic ganglion nerve blocks with neurolytic agents such as alcohol or phenol are reserved mostly for cancer pain. The efficacy and safety of these tools are validated by several decades of clinical application and published studies. Although the procedures are operator-dependent, in the hands of experienced clinicians, patients achieve sustained relief in the majority of cases. Although these techniques have been attempted in some benign conditions,such as chronic pancreatitis, with limited success, studies of newer imaging localization techniques such as endoscopic ultrasonography may expand future indications. Patients of the gastroenterologist who experience malignant abdominal pain may benefit from referral for percutaneous-guided pain control techniques.

The qualifications of pain physicians in Ohio.

Pain physicians in Ohio come from many medical backgrounds and use different medical boards to claim board certification in the field of pain medicine. Our goal was to explore the number, demographics, and qualifications of pain physicians in Ohio. The names of Ohio physicians designating themselves as pain physicians were collected from the State Medical Board of Ohio and the American Medical Association. The directories of the American Board of Medical Specialties (ABMS), the American Board of Pain Medicine, the American Academy of Pain Management, and the American Board of Medical Acupuncture were referenced for certification in pain medicine, pain management, or medical acupuncture. The requirements for these credentials vary widely, yet they have all been used to claim "board certification." Board certification in medicine implies recognition by an ABMS member board as having completed the required training, met the standards, and then passed an examination that validates qualifications, and knowledge in a specific medical field. In 2002, there were 335 Ohio physicians designating themselves as pain physicians. Two-hundred-eighteen (65%) had at least one pain board certification. Ninety-six (29%) of the Ohio pain physicians were certified in pain medicine by the American Board of Anesthesiology, the American Board of Physical Medicine and Rehabilitation, or the American Board of Psychiatry and Neurology, which are all member boards of the ABMS. One-hundred-seventeen (35%) of the self-declared Ohio pain physicians held no pain-related board certification. Anesthesiologists comprise the majority of all pain physicians and are the majority in all four pain boards.

Self-administration of morphine in bone marrow transplant patients reduces drug requirement.

Bone marrow transplant recipients were randomly assigned to receive morphine by either continuous infusion (32 patients) or self-administration of small boluses (patient-controlled analgesia (PCA), 26 patients) for control of chemoradiotherapy-induced oral mucositis pain. All patients received morphine for a minimum of 9 days and most required morphine for at least 14 days. Patients rated their pain and side-effect intensity daily using visual analogue scales. Patient pain ratings did not differ between the groups although PCA patients used only 53% as much morphine as the continuous infusion group. Tolerance did not develop in the PCA group; in patients receiving continuous infusion morphine dosage continued to increase throughout the study while pain scores remained constant, indicating that tolerance had developed. Nausea, alertness and respiratory rate measurements did not differ between groups. PCA appeared more effective than the hospital staff determined treatment at delivering the least amount of morphine required to produce maximal pain relief. Patients self-administering morphine did not appear to restrict morphine intake in order to minimize opioid side-effects.

Naloxone fails to reverse pain thresholds elevated by acupuncture: acupuncture analgesia reconsidered.

We were unable to demonstrate the reversal of dental acupunctural analgesia following the injection of 0.4 mg naloxone using evoked potential methodology. Since our findings differed from those of Mayer, Price and Rafii who used pain threshold methods, we attempted to replicate their study. Subjects who demonstrated acupunctural analgesia during electrical stimulation of the LI-4 point on the hands received either 1.2 mg naloxone or normal saline under double blind conditions. Pain thresholds elevated by acupuncture failed to reverse when naloxone was given. Review of experimental design issues, other related human subjects research, and animal studies on acupunctural analgesia provided little convincing evidence that endorphins play a significant role in acupunctural analgesia. Because endorphins can be released in response to a stressor, endorphin presence sometimes correlates with acupunctural treatment in animal studies and some human studies, especially those involving pain patients. The primary analgesia elicited by acupunctural stimulation seems to involve other mechanisms.

Event-related potential correlates of analgesia; comparison of fentanyl, acupuncture, and nitrous oxide.

This study was undertaken to determine whether different analgesic treatments result in a common change in the event-related potentials (ERP) elicited during painful dental stimulation. The effects of electrical acupuncture delivered at 2 Hz to LI-4, the opiate fentanyl 0.1 mg i.v., and the inhalation analgesia mixture of 33% nitrous oxide in oxygen were examined in volunteers undergoing painful tooth pulp stimulation. ERPs were recorded at vertex and subjects provided reports of pain intensity. Discriminant function analysis was used to determine which subset of the pain report and ERP variables could best discriminate baseline from treatment conditions without regard to specificity of treatment. Together with pain report, amplitude of the ERP positive deflection at 250 msec was a significant indicator of analgesia across the 3 treatments. Other changes specific to the individual treatments were also observed. Since the 250 msec amplitude measure was not redundant statistically with pain report, the ERP data provided significant new information about analgesia even though pain report was a very sensitive measure. Pain report alone could account for 48% of the variance across treatments while ERP measures alone accounted for 34%.

Evoked potential assessment of acupunctural analgesia: attempted reversal with naloxone.

The effects of electrical acupunctural stimulation (2 Hz) on pain judgments and evoked potentials are reported for two experiments using dental dolorimetry. In the first experiment subjects received acupuncture at points located in the same neurologic segment as the test tooth. In the second experiment subjects received acupuncture at points on the hands located on acupuncture meridians. In both instances acupuncture resulted in a reduction in pain intensity and smaller evoked potential amplitudes, but naloxone neither reversed the analgesia nor did it affect the evoked potentials. A pilot study was carried out to determine whether manual rather than electrical stimulation would produce an analgesia reversible by naloxone, but it failed to do so. These findings contribute to the growing evidence that acupunctural stimulation significantly reduces pain sensibility in volunteers undergoing dolorimetric testing, but they do not support the hypothesis that endorphin release is a mechanism by which acupuncture exerts analgesia.