Evaluating the impact of pain management (PM) education on physician practice patterns--a continuing medical education (CME) outcomes study.

California Assembly Bill AB487 mandates that all practicing physicians are required to obtain 12 h of Continuing Medical Education in Pain Management and End of Life Care before the year 2006 in order to renew their state license to practice medicine. In order to determine the effectiveness of this bill in influencing the practice of medicine, we conducted the first of five planned annual Pain Management seminars and utilized physician questionnaires to determine possible practice changes as a result of this seminar. Eighty-one physicians representing 17 multiple specialties of medicine enrolled in this seminar. The topics included: management of malignant and non-malignant pain, pharmacology and management of side effects of opiate and non-opiate analgesics, and adjunctive therapies including depression management and spirituality issues. Physicians were asked to respond to an immediate post-seminar questionnaire and were subsequently queried 4 months following the conference. Fifty-one out of 81 physician registrants responded to an immediate post-attendance questionnaire, and 31 responded to the 4-month follow-up questionnaire. Responses included: [Please see text]. This audience represents the most motivated group of practitioners electing to receive Pain Management Education long before the mandated deadline. Sixty-seven percent expressed an interest in changing their practice following this intensive educational experience. Ninety percent responding to the follow-up evaluation indicated that their practices had changed, suggesting that this seminar series is effective in altering physician practice patterns (supported by Cancer Center Support Grant CA 33572 and Sarnat Foundation).

Donepezil in the treatment of opioid-induced sedation: report of six cases.

Donepezil, an oral acetylcholinesterase inhibitor approved for the treatment of Alzheimer's disease, was given to 6 cancer pain patients having sedation related to the analgesic use of opioids. Each patient was taking more than 200 mg of oral morphine equivalents per day, and several were receiving complex analgesic regimens consisting of multiple adjuvant medications. Sedation improved at least moderately in 5 of the patients and mildly in 1 after they began taking donepezil. Patients reported a decrease in episodes of spontaneous sleeping during the day, fewer myoclonic twitches, improved daily function and greater social interaction. Several also reported improved sleep at night. Analgesia was not compromised by the use of donepezil, and in some cases it appeared improved. Donepezil may be a valuable alternative to psychostimulants in the treatment of opioid-induced sedation. A prospective controlled trial comparing the treatment effects of psychostimulants and donepezil on patients having opioid-induced sedation is underway.

Managing breakthrough cancer pain: a new approach.

Every day, nurses in all clinical settings work closely with patients who are experiencing various types and intensities of pain. Advances in pain management have given present patients and their families a variety of options that allow them a renewed dimension to the quality of their lives; an ability to live more productively and face the end of life in comfort. Because all nurses must keep up to date on basic principles of assessment, pain management, and current pharmacologic and nonpharmacologic approaches to pain, AJN and Home Healthcare Nurse are proud to provide our readers with important information about pain management and a new medication recently approved by the FDA: oral transmucosal fentanyl citrate (Actiq). You can apply the information in this supplement in your daily practice as you assess your patients' level of pain, plan and evaluate interventions, and collaborate with members of the interdisciplinary team. Your goal--to help patients determine the appropriate treatments and dosages for their own unique pain needs--is supported throughout the following pages. We would like to thank the Anesta Corp. and Abbott Laboratories, Hospital Products Division, for making this supplement possible through an educational grant. We know that not only our colleagues but our patients and their families will greatly benefit from the information presented.

Oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough pain in cancer patients: a controlled dose titration study.

Oral transmucosal fentanyl citrate (OTFC) is a novel opioid formulation in which the potent synthetic mu-agonist fentanyl is embedded in a sweetened matrix that is dissolved in the mouth. It is undergoing investigation as a treatment for cancer-related breakthrough pain, a prevalent phenomenon defined as a transitory flare of moderate to severe pain that interrupts otherwise controlled persistent pain. There have been no controlled trials of other treatments for this condition. To evaluate the safety and efficacy of ascending doses of OTFC, a novel controlled dose titration methodology was developed that applied blinding and randomization procedures to the evaluation of recurrent pains in the home environment. The study was a multicenter, randomized, double-blind dose titration study in ambulatory cancer patients. The sample comprised adult patients receiving a scheduled oral opioid regimen equivalent to 60-1000 mg oral morphine per day, who were experiencing at least one episode per day of breakthrough pain and had achieved at least partial relief of this pain by use of an oral opioid rescue dose. After collection of 2 days of baseline data concerning the efficacy of the usual rescue drug, patients were randomly treated with either 200 or 400 microg OTFC unit doses in double-blind fashion. Up to two breakthrough pains each day could be treated with up to four OTFC unit doses per pain. OTFC in unit doses containing 200, 400, 600, 800, 1200 or 1600 microg of fentanyl citrate were available for the study. The unit dose was titrated upward in steps until the patient had 2 consecutive days on which breakthrough pain could be treated with the single unit dose, titration was ineffective at a 1600 microg unit dose, or 20 days elapsed. To maintain the double-blind, orders to titrate up were ignored one-third of the time according to a pre-defined randomization schedule accessible only to an unblinded study pharmacist. Main outcome measures included, numeric or categorical measures of pain intensity, pain relief, and global assessment of drug performance. Dose response relationships were found suggesting that the methodology was sensitive to opioid effects. Seventy-four percent of patients were successfully titrated. There was no relationship between the total daily dose of the fixed schedule opioid regimen and the dose of OTFC required to manage the breakthrough pain. Although the study was not designed to provide a definitive comparison between OTFC and the usual rescue drug, exploratory analyses found that OTFC provided significantly greater analgesic effect at 15, 30 and 60 min, and a more rapid onset of effect, than the usual rescue drug. Adverse effects of the OTFC were typically opioid-related, specifically somnolence, nausea and dizziness. Very few adverse events were severe or serious. This study demonstrated the feasibility of controlled trial methodology in studies of breakthrough pain. OTFC appears to be a safe and effective therapy for breakthrough pain, and dose titration can usually identify a unit dose capable of providing adequate analgesia. If the lack of a relationship between the effective OTFC dose and fixed schedule opioid regimen is confirmed, dose titration may be needed in the clinical use of this formulation. Further investigation of OTFC as a specific treatment for breakthrough pain is warranted.

Survey of the provision of supportive care services at National Cancer Institute-designated cancer centers.

PURPOSE: The purpose of this survey was to determine the scope of supportive care services (SCS) designed to promote quality of life during cancer therapies at National Cancer Institute (NCI)-designated cancer centers. METHODS: A survey was mailed to the medical directors and nursing directors of 52 NCI-designated comprehensive (n = 26), clinical (n = 11), and planning cancer centers (n = 15) in the United States. Only one survey was completed from each institution. Survey questions identified services provided such as pain management, terminal care, psychosocial programs, and spiritual care. RESULTS: Thirty-nine questionnaires were received for a total response rate of 75%. Of the respondents, 45% were comprehensive cancer centers, 24% clinical cancer centers, and 29% planning centers. One center did not identify their NCI designation. Sixty-one percent of the centers reported research programs in supportive care. Outside funding was reported in 51% of the respondents, with 39% having American Cancer Society (ACS) or National Institutes of Health (NIH) funding and 28% having private industry funding. Overall SCS self-ratings improved from a 21% rating of excellent to very good 5 years ago to the current 54% rating. CONCLUSION: Survey results provide data on SCS across a representative sample of NCI cancer centers and can be used to develop standards for future cancer control programs.

The experience of pediatric cancer pain, Part I: Impact of pain on the family.

This two-part article reports on the results of qualitative data derived from the study on the impact of pediatric cancer pain on the family. Part I of this two-part article explores the family caregivers' description of a child with cancer, the helplessness experienced in the management of the child's pain, and the impact of pain on the entire family. Study findings support existing literature identifying inadequate assessment and management of pediatric cancer pain. Parents identified the benefits of pain management teams for the child and for themselves. Family caregivers also identified the stresses associated with managing pain at home. Part II will describe the role of the parents in managing their child's pain. This study provided valuable information that can enable health care professionals with an opportunity to intervene not only with the child but also with the family.

The experience of pediatric cancer pain, Part II: Management of pain.

This paper reports on the results of qualitative data derived from a study on the impact of pediatric cancer pain on the family. Part I of this two-part article reported on the family caregivers' description of a child with cancer, the helplessness experienced in the management of the child's pain, and the impact of pain on the entire family. This article will describe the role of the parents in managing their child's pain, including use of pharmacological and nondrug interventions, family caregivers' perspectives on what physicians and nurses could do to improve the care of patients in pain, and family caregivers' advice to other families when placed in a similar situation of trying to manage pediatric pain. Five major themes were identified related to the role of family caregivers in managing the child's pain. Parents also identified six major ways in which physicians and nurses could help to improve care related to pain management. Although some parents were unable to identify information that may be useful for other parents in similar situations, nine major themes were identified. Study data demonstrates the experience of family caregivers in caring for a child with cancer pain and provides health care professionals with information that can promote effective pain relief for the pediatric cancer patient with pain as well as address issues affecting the family.

The family experience of cancer pain management in children.

This study describes the family perspective of cancer pain management in pediatric patients. Family caregiver knowledge and attitudes regarding pain, caregiver burden associated with pain, and caregiver moods were identified. This study was conducted in a children's hospital (n = 31) and a community hospice (n = 8) with family caregivers of pediatric cancer patients as the participants. Pain intensity was rated by children and family caregivers using pain assessment scales applicable to children with cancer. Differences in pain ratings were reported. The Family Pain Questionnaire was used to identify parents' knowledge and attitudes about pain and its management. Areas for family teaching were identified with the questionnaire. Understanding the pain experience from the perspective of family caregivers and their role in pain management can assist healthcare providers in relieving pain in children with cancer.

Development and implementation of a pain education program.

Pain is a significant problem for cancer patients and is of particular concern for the elderly. This article reports on the development and implementation of a pain management educational intervention for elderly cancer patients and their family caregivers. This patient education program was developed within a research study funded by the American Cancer Society. Subjects were stratified as either elderly (60-75 years) or oldest (greater than 75 years) and then were randomly assigned to an experimental group that received the three-part, structured pain education program or a control group that received usual care. Control group subjects were offered the intervention at the conclusion of data collection. The outcomes of the pain education were measured at two times after the intervention. Study variables included patient outcomes such as pain intensity, pain knowledge and attitudes, medication compliance, and quality of life as well as family caregiver outcomes. This pain education program was developed, implemented, and evaluated in 40 patients and family caregivers in the first year of a 2-year project. In this article, the investigators present the development and structure of the three-part education program, general principles of patient education regarding pain, methods of evaluating pain education, and initial results of the pain education. Pain education includes basic principles of pain relief, pharmacologic interventions, and nondrug interventions for relief of pain. This program has demonstrated that both cancer patients and their family caregivers benefit from a structured education program for relief of cancer pain.

A structured nondrug intervention program for cancer pain.

The management of cancer pain has been a primary focus in the authors' program of oncology nursing research. A study currently in progress entitled, "Assessment and Management of Pain for Elderly Cancer Patients at Home," applies knowledge of the authors' earlier work in an educational nursing intervention for patients with cancer and their family care-givers in the home. The program consists of three parts: (1) an overview of pain, (2) pharmacologic management of pain, and (3) nondrug interventions for pain. The nondrug component of this program is particularly unique in providing structured implementation of nonpharmacologic techniques, which are often neglected in pain management. Five categories of nondrug intervention are used including heat, cold, massage/vibration, distraction, and relaxation. The purpose of this article is to report on the development and initial results of the nondrug portion of a pain education program.

Health quality of life and colorectal cancer.

BACKGROUND: Quality of life associated with cancer and radiation treatment includes the dimensions of psychologic and physical well-being, nutrition concerns/side effects, and radiation treatment-related anxiety/adjustment. An understanding of the impact of colorectal cancer and radiation treatment on these aspects of health quality of life can be reached by comparing this diagnostic group to others undergoing similar treatment. METHODS: Thirty-six patients with colorectal cancers, 41 with uterocervical cancers, 43 with genitourinary tumors, 13 with leukemia or bone metastasis, and 129 with head and neck cancers undergoing radiation therapy provided complete health quality of life index (QLI-RT) data during weeks 1 and 3 of treatment and at the first follow-up visit after treatment completion. The QLI-RT was found to be reliable and valid. RESULTS: Those with colorectal cancer had similar QLI-RT summary scores as the other groups at the beginning of treatment and during the follow-up period. QLI-RT scores tended to range from 62 to 84 for the summary score and individual-item scores; this was a narrow span considering the QLI-RT uses a 0-100-mm linear analog-response scale. The exceptions were strength, which elicited scores in the 46-68 range and a couple of responses to worrying about radiation therapy. The largest change in QLI-RT score in relation to the treatment trajectory was 11 mm. CONCLUSIONS: These findings tend to support the notion that patients with cancer try to maintain health quality of life at an acceptable level despite the occurrence of stressful negative events. Future research should explore the stable versus dynamic attributes of health quality of life to learn more about the factors that contribute to the adaptive process that maintains such quality of life at an acceptable level.

The meaning of quality of life for bone marrow transplant survivors. Part 2. Improving quality of life for bone marrow transplant survivors.

Surviving bone marrow transplant (BMT) represents a major victory against malignant disease but also creates challenges of survivorship for patients and the professionals who care for them. Part 2 of this report presents the findings of a qualitative study (N = 119) related to improving quality of life (QOL) for BMT survivors. Results are shared based on BMT survivors' perceptions of (a) what makes QOL better, (b) what makes QOL worse, and (c) what doctors or nurses could do to enhance QOL. The findings of the study have been useful in constructing a quantitative instrument to measure QOL in BMT and in understanding the conceptual basis of QOL for the BMT population. Nursing interventions can improve the QOL for the BMT patient across all phases of the transplant process and long-term issues related to survival.

The meaning of quality of life for bone marrow transplant survivors. Part 1. The impact of bone marrow transplant on quality of life.

Quality of life (QOL) is an important concept in cancer nursing and has particular significance for bone marrow transplant (BMT). BMT survivors are faced with the demands of acute transplant symptoms as well as chronic illness demands posttransplant. The purpose of this study was to explore the concept of QOL for BMT survivors and to gain understanding of nursing interventions that may improve QOL in this population. The conceptual framework for this study was derived from the model of QOL developed by Ferrell, Grant, and Padilla (1989) that depicts the QOL domains of physical well-being, psychological well-being, social concerns, and spiritual well-being. This qualitative study consisted of a one-time interview of 119 BMT survivors using six open-ended questions. The items were based on previous research of the authors and content validity was established by a panel of BMT experts. Content analysis was performed on verbatim written responses to six questions regarding BMT and QOL. Part one of this two-part report provides analysis based on the questions regarding the meaning of QOL to BMT survivors and the impact of BMT on QOL.

Home care: maintaining quality of life for patient and family.

Cancer affects the family as well as the patient. The home is a primary site of care, which often must be intensive and complex. Attention to home care of the cancer patient is therefore a major concern in maintaining quality of life for both patient and family. The authors explore the major burdens of home care that affect both patient and family and describe four specific interventions that the health care team can initiate to optimize quality of life in these difficult situations.

Pain and addiction: an urgent need for change in nursing education.

Lack of education of health care professionals, including nurses, is frequently cited as a major reason for undertreatment of patients with pain. A reason for undertreatment of pain with opioid analgesics is the irrational fear of creating opioid addiction. To characterize the information nurses receive in their basic education that could contribute to misinformation about this issue, the authors reviewed 14 nursing textbooks, published since 1985, including 8 pharmacology texts and 6 medical surgical texts. An analysis of content revealed that only one textbook correctly stated the definition of opioid addiction and its likelihood following use of opioid analgesics for pain control. Almost all of the texts used confusing terminology, and some erroneously promoted the fear of addiction when opioids are used for pain relief. A simple solution to this problem is to encourage nursing educators to use the American Pain Society publication "Guidelines for Analgesic Use" until textbooks have the opportunity to incorporate correct information.

Pain as a metaphor for illness. Part I: Impact of cancer pain on family caregivers.

While previous research has focused on patients' or professional caregivers' perspective of pain, this study describes cancer pain from the family caregivers' perspective. Chronic pain, which is associated with malignant disease, produces an intense burden on the patient as well as on the entire family. This qualitative study included 85 family caregivers of patients with cancer pain. Data were collected using an interview guide, and verbatim responses were analyzed for themes. The results identified four themes surrounding family descriptions of pain (anatomic descriptions, hidden pain, family fear and suffering, and overwhelming/unendurable pain) and three themes surrounding family experience of pain (helplessness, coping by denying feelings, and a wish for death). This study documents the important role that family members play in cancer treatment. If the number of patients receiving care in the home from family members continues to grow, this role will become even more important. Part I of this two-part paper focuses on the impact that cancer pain has on family caregivers and concludes that pain does have a tremendous impact on the family because it is perceived as a metaphor of progressive illness and death.

Pain as a metaphor for illness. Part II: Family caregivers' management of pain.

Changes in the healthcare system have made the patient's home the primary site of cancer care. Family members, already burdened with the psychological impact of having a loved one with cancer, take on caregiving roles to meet the multiple and complex needs of the patient. Part I of this two-part article focused on family caregivers' descriptions of the patients' pain and the impact of this pain on caregivers. A model of the Caregiver Experience of Pain is provided along with implications for future inquiry and clinical practice. Themes identified in caregiver roles in medication administration included deciding what to give, deciding when to give, night duty, reminding/encouraging, keeping records, fear of addiction, and doing everything. Caregiver roles in nondrug interventions included positioning/mobility, massage, use of ointments/lotions, cold, heat, being there through touch, avoiding touch, and talk and other distractions. Caregiver perceptions of what doctors or nurses could do better included themes of being there, explain, be honest/listen, addiction concern, and giving medication. Caregiver questions included areas of future, understanding why, death, concern about medications, and fear about what to do at home. The study results offer important suggestions for oncology nurses in supporting family caregivers in the management of the patient in pain.