Mechanisms of cancer-induced bone pain.

Cancer-induced bone pain (CIBP) is common and challenging to treat. Common therapies, such as opioids, radiotherapy and bisphosphonates, are often only partially effective. CIBP is a different entity to inflammatory or neuropathic pain and needs to be considered as such. This overview examines the mechanisms of CIBP; the imbalance of bone turnover, peripheral and central nervous involvement and key neurochemical mediators. The current understanding of the underlying pathophysiology of CIBP is discussed.

Benchmarking opioids in the last 24 hours of life.

BACKGROUND/AIMS: Opioid dosages are titrated against symptoms with large variations between patients. For self-assessment of prescribing, and for clinical governance, it is important to know the normal prescribing patterns across New Zealand (NZ). The aims of this study were to document opioids and dosages given to patients in the last 24 h of life to identify normal practice and allow prescribers to reflect on their own practice. METHODS: A cross-sectional benchmarking design with retrospective chart review was carried out among 14 NZ hospices. Data (n = 352) on opioid dosages were analysed for inter-hospice variability (ANOVA). Parenteral morphine equivalent daily dose was used to analyse the dosage of different opioids. RESULTS: Overall, 95% of dying patients received an opioid. Of these 71% received morphine, 17% fentanyl, 10% methadone 9.5% oxycodone. The dosages delivered are conservative compared with international data, with a geometric mean of 47.8 mg. There was no significant difference in mean dosages of opioids prescribed between hospice teams. There was, however, a significant difference between the dosage of opioid for those on the Liverpool Care Pathway for the Care of the Dying and those who were not (63.1-44.4 mg), and between those with malignant and non-malignant disease (53.8-26.0 mg). Opioid footprints show different hospices have different patterns of opioid use. CONCLUSION: The parameters of what normal opioid prescribing is in the last days of life in NZ can be described from these data. There is value in repeating this exercise both for clinical governance and for professional reflection and self-assessment.