Endoscopic transnasal neurolytic sphenopalatine ganglion block for head and neck cancer pain.

Nasal endoscopy is a valuable adjunct to the localization of the sphenopalatine ganglion. Twenty-two patients with advanced malignancies of the head and neck region whose pain was not adequately controlled with conventional medications, including oral morphine, were given nasal endoscopically guided neurolytic sphenopalatine ganglion block with six per cent phenol after a prognostic block with local anaesthetic solution. Seventeen patients had good immediate relief. One had partial relief and four had inadequate relief. On follow-up for one month, the patients had significantly lower pain intensity and the pain was more manageable with oral medication. The vicious cycle of pain was broken. This block is relatively safe and can be usefully performed as an out-patient procedure.

Feasibility of quantitative pain assessment in outpatient oncology practice.

PURPOSE: Although physicians view failure to assess pain systematically as the most important barrier to outpatient cancer pain management, little is known about pain assessment in this setting. We sought to determine whether pain is routinely assessed and whether routine quantitative pain assessment is feasible in a busy outpatient oncology practice. PATIENTS AND METHODS: We conducted a pre- and postintervention chart review of 520 randomly selected medical and radiation oncology patient visits at a community hospital-based private outpatient practice. The intervention consisted of training health assistants (HAs) to measure and document patient pain scores by using a visual analog scale. The main outcome measures included HA documentation of patient pain scores, quantitative and qualitative mention of pain in the physician note, and analgesic treatment before and after the intervention. RESULTS: After the intervention, HA documentation of pain scores increased from 1% to 75.6% (P < .0001). Physician documentation increased from 0% to 4.8% for quantitative documentation (P < .01), and from 60.0% to 68.3% for qualitative documentation (not significant). Of all the patients, 23.1% reported significant pain. Subgroups with greater pain included patients actively receiving radiation treatments and patients with lung cancer. Of patients with significant pain, 28.2% had no mention of pain in the physician note and 47.9% had no documented analgesic treatment. CONCLUSION: Quantitative pain assessment was virtually absent before our intervention but easily implemented and sustained in a busy outpatient oncology practice. Pain score collection identified a high prevalence of pain, patient subgroups at risk for pain, and a significant proportion of patients with pain that was neither evaluated nor treated by their oncologists.

Cancer pain management in developing countries: a mosaic of complex issues resulting in inadequate analgesia.

Cancer pain is often undertreated even in developed countries with abundant resources and easy access to oral, parenteral, and transdermal opioids. The problems in developing nations are more complex, and as a result, these medications are not available to the vast majority of patients in Latin and South America, Eastern Europe, Asia, and Africa. Some of the reasons for this are reviewed, with India cited as a case example. In spite of serious efforts by the World Health Organization and other bodies to make oral opioids available and to educate government officials and physicians, little progress has been made in relieving pain in cancer patients in the developing world. Novel approaches that address fundamental concerns regarding opioid availability in these countries are desperately needed. One such approach, which is currently under development, is presented in this manuscript. This has the potential to make opioids available to patients in rural areas, improve compliance in the poorly educated patient, reduce the number of follow-up visits necessary for medication refills, and reduce the risk that opioids will be diverted to illicit channels. The potential for relieving cancer pain and the magnitude of this problem worldwide make it imperative that innovative approaches be tailored to the complex social issues and limited resources common to developing nations.