Evidence-based guidelines on the use of opioids in chronic non-cancer pain--a consensus statement by the Pain Association of Singapore Task Force

<p><b>INTRODUCTION</b>While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed.</p><p><b>MATERIALS AND METHODS</b>A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions.</p><p><b>RESULTS</b>Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour.</p><p><b>CONCLUSION</b>Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as secondor third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required.</p>

Interventional management of chronic pain

Chronic non-cancer pain is a common clinical condition affecting a significant part of the population. This article aims to review the interventional options for non-cancer pain. Multiple searches using Medline were carried out and additional searches were made using reference lists of published papers and book chapters. The article discussed procedures ranging from selective nerve root or zygapophyseal (facet) joint block with local anaesthetics to irreversible neurodestruction with radiofrequency energy or neurolytic agents and neuromodulation with spinal cord stimulation. Other techniques include intraspinal delivery of analgesics. There is evidence that these interventional procedures are valuable both diagnostically and therapeutically.

Intrathecal analgesia in patients with cancer pain--an audit in a tertiary institution

<p><b>INTRODUCTION</b>Cancer pain is one of the most frequently encountered pain syndromes. With the application of the World Health Organization analgesic ladder, adequate analgesia is achieved in 75% to 90% of patients. The remaining patients suffer from intractable pain requiring intrathecal analgesia. The aim of this study was to retrospectively analyse the pain intensity before and after intrathecal analgesia and review the complications associated with the implantation and the care of the intrathecal device.</p><p><b>MATERIALS AND METHODS</b>We reviewed medical records of all cancer patients whose pain were managed by intrathecal catheter implants in our centre from February 2005 to August 2008. The pain intensity, medication and complications related to intrathecal catheter insertion or drug delivery were reviewed at the time before starting the intrathecal analgesia (T0) and time of discharge from the hospital/time prior to death during their stay in the hospital (Tdsc).</p><p><b>RESULTS</b>Twenty-nine patients were included. Out of these 29 patients, 86.2% had metastatic cancer. The most common indication was poor pain control. Pain intensity was reduced significantly at the time of discharge from hospital (P < 0.001). The number of patients with side effects from opioids decreased after intrathecal treatment. We found 4 patients with short-term catheter complications e.g. kinked or displaced catheter and catheter-related infection.</p><p><b>CONCLUSION</b>Intractable cancer pain could be managed effectively by intrathecal analgesia with a significant decrease in pain intensity and reduced opioid-related side effects. The side effects due to intrathecal opioids and complications from intrathecal catheter were minimal.</p>

The role of interventional therapies in cancer pain management

Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.