Managing Breakthrough Pain

Breakthrough cancer pain (BTcP) has been defined as a transitory increase in pain intensity on a baseline pain of moderate intensity in patients on regularly administered analgesic treatment. This review provides updated information about the classification, assessment, and treatment of BTcP, with special emphasis on the use of opioids. Due to its slow onset to effect, oral opioids cannot be considered an efficacious treatment of BTcP. More recently, different technologies have been developed to provide fast pain relief with potent opioid drugs, such as fentanyl, delivered by noninvasive routes. Transmucosal, buccal, sublingual, and intranasal fentanyl have been shown to provide rapid analgesia in comparison with oral morphine or placebo and are available for clinical use in most countries. All the studies performed with these delivery systems have recommended that these drugs should be administered to opioid-tolerant patients receiving doses of oral morphine equivalents of at least 60 mg. The need of titrating opioid doses for BTcP has been commonly recommended in all the controlled studies, but never has been substantiated in appropriate studies.     

Fired! Managing the process

The growth of corporate orientation for healthcare structures, with a focus on bottom-line management, has radically altered the role of nurse executives. With the organization's emphasis on performance, productivity, and results, successful nurse executives are now integrating the management of the delivery of nursing care with the management of complex corporate structures and relationships. The editor of Executive Development discusses the rapidly changing expectations and demands of the contemporary nurse executive's work.     

Managing a Chronic Pain Patient in the Perioperative Period

ABSTRACT

The chronic pain patient with and without chronic opioid medication is at risk for under- and overtreatment perioperatively. Careful planning of the perioperative period by the anesthesiologist, the pain service and the surgeon is crucial. Epidural analgesia requires reduction of preoperative opioid doses to a maximum of 50% to avoid withdrawal as well as continuous postanesthesia care unit-monitoring for the first 24 hours. Brief cognitive behavioral interventions pre- and postoperatively contribute to successful pain management. The perioperative period may be used to re-evaluate the patient's opioid requirements. A follow-up by an experienced pain management service should be available after discharge of the chronic pain patient. Individualized assessment by a pain management team is necessary for this increasing group of patients.

This report is adapted from paineurope 2013; Issue 2, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, LTD. and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication.     

We Discount the Pain of Others When Pain Has No Medical Explanation

The present studies investigated the impact of medical and psychosocial information on the observer’s estimations of pain, emotional responses, and behavioral tendencies toward another person in pain. Participants were recruited from the community (study 1: N = 39 women, 10 men; study 2: N = 41 women, 12 men) and viewed videos of 4 patients expressing pain, paired with vignettes describing absence or presence of 1) medical evidence for the pain and 2) psychosocial influences on the pain experience. A similar methodology was used for studies 1 and 2, except for the explicit manipulation of the presence/absence of psychosocial influences in study 2. For each patient video, participant estimations of each patient’s pain and their own distress, sympathy, and inclination to help were assessed. In both studies, results indicated lower ratings on all measures when medical evidence for pain was absent. Overall, no effect of psychosocial influences was found, except in study 2 where participants indicated feeling less distress when psychosocial influences were present. The findings suggest that pain is taken less seriously when there is no medical evidence for the pain. The findings are discussed in terms of potential mechanisms underlying pain estimations as well as implications for caregiving behavior.     

Managing Children's Cancer Pain in Morocco

Purpose: To identify issues in managing pain of children with cancer in the two pediatric oncology centers in Morocco.
Methods: Focus groups were conducted with pediatric oncology nurses and physicians.
Findings: Four themes were identified: (a) children's cancer pain is an overwhelming concern to the Moroccan nurses and physicians who participated in this study; (b) training and resources for children's cancer pain management are lacking in Morocco; (c) some impediments to pain relief were verbalized, such as a stoic approach to suffering and limited use of some drugs; and (d) a critical need exists for a comprehensive pain management approach for children with cancer in Morocco.
Conclusions: This study elucidated issues in managing children's cancer pain in Morocco and increased knowledge of current practice issues. A program of policy research has been initiated with the aim of establishing guidelines for practice policies for managing children's cancer pain in Morocco.     

Managing Osteoarthritis Pain in the Older Population

ABSTRACT

Challenges to pharmacological management in this patient group include treatment concordance, comorbidity, polypharmacy, and age-related physiological changes affecting pharmacokinetics. Paracetamol (acetaminophen) is generally recommended as a first-choice analgesic in osteoarthritis pain. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral formulations, and prescribing NSAIDs for older people requires careful consideration. There are some data relating to opioid use for noncancer pain in older people.     

Don't look now! Pain and attention

Attention and pain are linked inexorably. The manipulation of attention, via either distraction or focused attention, has been used as a therapeutic initiative for generations. Imaging evidence and clinical observations demonstrate that attention can be altered with associated changes at the cortical level and this may have positive or negative effects on the individual. New theories suggest that cortical remapping and visual attention may play key roles in a cortical model of pain specifically involving the motor control system. Within this system, the relationship between allocentric (external) and egocentric (internal) stimuli are managed; where conflict occurs, somaesthetic disturbances may be generated. If an individual pays too much attention to such sensory disturbances, then they may report the disturbances as abnormal symptoms, which may explain the diverse symptomatology of fibromyalgia. The use of a therapeutic optokinetic device to correct existing imbalances in the motor control system is also discussed.