Schmerzbehandlung bei Karzinompatienten

Freedom from cancer pain is one of the four priorities of the WHO Cancer Control Programme. Every day 3.5 million people are suffering from cancer pain, and most do not receive adequate relief. A lack of training in cancer pain management at most nursing and medical schools is the principal reason for this, coupled with limited availability of oral strong opioids in many countries. Education is the key to progress in cancer pain management. Health workers must appreciate that: 1. Attention must be paid to all aspects of suffering -physical, psychological, social and spiritual. 2. In advanced cancer, most patients with pain have multiple pain. 3. Pain experienced in carcinoma is not always caused by the tumour. 4. There is more to pain management than the use of analgesics. 5. In the case of opioid-responsive pains, analgesics should be administered by mouth according to a regular time-schedule and with dose increments. 6. Adjuvant medication is generally necessary. 7. Opioid-resistant pains require other forms of treatment. 8. Pain is the physiological antagonist to the central depressant effects of opioids. 9. Opioid tolerance is not a problem in practice. 10. Psychological dependence does not occur in patients receiving opioids for pain relief. 11. Patients receiving analgesics must be carefully monitored. 12. Teamwork is necessary for good results.     

The principles of pain management in advanced cancer

Pain is the most feared symptom for patients with advanced cancer. Although effective pain relief is critical to preserving quality of life for these patients, the incidence of uncontrolled pain is high. A variety of physiological mechanisms contribute to cancer pain, and psychological, social and spiritual factors all contribute to the overall pain experience. Therefore the rationale for treatment must be appropriate. Regular assessment of both pain and treatment is indicated, as is the management of adverse reactions of treatment. In most cases, pain may be managed by conventional means (e.g. oral analgesia) but sometimes other modes of administration (e.g. transdermal/subcutaneous routes) may be more appropriate. In addition, some patients will require interventional treatment such as nerve blocks or radiotherapy, while in other patients non-drug therapies may be more appropriate. Improved assessment, education and communication can do much to alleviate pain in the patient with advanced cancer.     

Is there still a role for open cordotomy in cancer pain management?

For a small number of cancer patients, good pain control remains difficult to achieve despite adequate assessment and medical management. In nine cases, effective control of intractable pain from malignant pelvic disease was achieved by open thoracic cordotomy. The technique was well tolerated, with no major complications. Eight of the nine patients decreased their median daily oral morphine requirement from 560 mg (range 360-2600 mg) to 160 mg (range 40-1000 mg). Maximal survival time post-cordotomy was 830 days, with a median of 107 days. No patient experienced recurrent pain in the initially painful site. For patients with intractable pain associated with advanced pelvic malignancy, the use of an open cordotomy should be considered when satisfactory pain control is not achieved by medical or minimally invasive methods.     

Nouvelles techniques interventionnelles radiologiques dans le traitement des douleurs d’origine cancéreuse: infiltration, alcoolisation, vertébroplastie, cimentoplastie, radiofréquence bipolaire Algoradiologie interventionnelle de la douleur cancéreuse

Bone invasion by metastatic tumours is the most common cause of pain in cancer patients. The management of cancer pain, pain that often reveals the disease and is always present at advanced stages, is an important and difficult task. High doses of specific medications, chemotherapy and radiation therapy do not always succeed in effectively controlling pain. When these treatments do not provide adequate relief, neurolysis, infiltration, alcoholization, percutaneous vertebroplasty, cementoplasty, and radiofrequency ablation are elegant and efficient complementary alternative pain management methods. The authors helped to develop these new techniques, which rely on CT guidance, and offer their expertise in how to apply them.     

晚期肿瘤患者疼痛护理措施

目的通过对晚期肿瘤患者疼痛护理,解除或减轻患者的痛苦,以提高患者的生活质量。方法护士正确掌握三阶梯给药原则及药物不良反应与处理,对患者的疼痛进行正确评估,予以心理支持及疼痛护理。结果按三阶梯给药原则,结合有效的心理护理,50例患者疼痛有效控制率达到96%。结论护理人员通过细致入微的临床护理,给予必要的药物治疗和心理支持,减轻了晚期肿瘤患者的痛苦,改善了患者的生活质量。     

Pain and palliative medicine

Severe pain is highly prevalent, with rates of 40% to 70% in patients with advanced cancer, liver disease, heart failure, human immunodeficiency virus, and renal failure. Wide variations in pain assessment and reporting methods and the measurement of multiple symptoms should be addressed in future studies. Regarding psychological approaches, determining whether hypnotherapy or other individual psychotherapeutic interventions reduce pain and/or psychological distress in a palliative care population is difficult. Interest is increasing in the concept of demoralization syndromes and the role of posttraumatic stress disorder in modulating responses to pain at the end of life. We review evidence from multiple studies that the use of rehabilitative therapy improves functional status and pain control among patients with advanced cancer, and we raise the possibility that rehabilitation therapy will be helpful in patients with other advanced diseases. We summarize ongoing clinical trials of electronic order sets, clinical care pathways, and care management pathways to improve pain management in palliative care. Wagner's Chronic Illness Model provides a way of analyzing how healthcare systems can be changed to provide adequate and continuing pain management in palliative care. Much work remains to ensure that pain is recognized, treated, and monitored effectively.     

789例癌症患者疼痛及生活质量的研究

疼痛是癌症患者尤其是中晚期患者的最常见症状之一，在以疼痛及其它症状处理为主要内容的姑息性治疗过程中，追求好的生活质量（ＱＯＬ）就成为最高准则。本文研究了癌症患者疼痛对其ＱＯＬ的影响。研究结果表明：疼痛对患者的躯体方面、精神心理方面、社会人际关系方面（依影响程度大小排列）均可产生不同程度的影响，从面全面影响患者的ＱＯＬ；其中疼痛程度及疼痛时间是影响患者ＱＯＬ的主要原因，疼前治疗情况对ＱＯＬ无显著性影     

Barriers to effective cancer pain management: a review of the literature

As many as 90% of patients with cancer-related pain can attain satisfactory relief through available pharmacological and medical means. However, as many as 45% of patients in the earlier stages of cancer and 75% of patients in the advanced stages experience at least some pain. Although published guidelines are available, the research literature suggests that health care providers continue to hold some negative misconceptions about cancer pain and its treatment. Patients also harbor similar misconceptions that contribute to ineffective management. Interventions have been discussed in the literature, and although some have proven successful, much still needs to be done to remedy this problem. This review outlines the published guidelines for cancer pain management and describes the literature related to provider and patient barriers, as well as some interventions designed to facilitate effective cancer pain management.     

Management of cancer pain. Safe, adequate analgesia to improve quality of life

Pain is one of the most common problems for cancer patients, and its management is often hindered by barriers created by patients and physicians alike. By avoiding potential barriers and understanding the principles of pain management and drug selection and titration provided here by Dr Hartmann and colleagues, physicians can safely administer adequate pain relief to their patients in need.     

Attitudes about cancer pain: A survey of Wisconsin's first-year medical students

A brief questionnaire was administered to 317 first-year students at Wisconsin's two medical schools to assess their attitudes about cancer pain prior to their entry into medical school. Although the students had a realistic perspective of the prevalence and severity of cancer pain, they displayed a number of negative attitudes that if unchanged would contribute to future inadequate pain treatment. Students (a) greatly exaggerated the incidence of psychological dependence (addiction) in patients treated with opioid analgesics, (b) inappropriately timed maximal analgesic therapy to the duration of life expectancy, (c) felt that a majority of patients with cancer currently receive adequate or excessive analgesic therapy, and (d) believed that increasing pain was invariably related to the development of drug tolerance rather than to progression of the disease. Curricular efforts need to be directed at bringing about changes in students' negative attitudes about cancer pain and its management.     

Osteoarthritis: current concepts in diagnosis and management

Most patients with osteoarthritis seek medical attention because of pain. The safest initial approach is to use a simple oral analgesic such as acetaminophen (perhaps in conjunction with topical therapy). If pain relief is inadequate, oral nonsteroidal anti-inflammatory drugs or intra-articular injections of hyaluronic acid-like products should be considered. Intra-articular corticosteroid injections may provide short-term pain relief in disease flares. Alleviation of pain does not alter the underlying disease. Attention must also be given to nonpharmacologic measures such as patient education, weight loss and exercise. Relief of pain and restoration of function can be achieved in some patients with early osteoarthritis, particularly if an integrated approach is used. Patients with advanced disease may eventually require surgery, which generally provides excellent results.     

Management of postoperative pain after T6 corpectomy: use of epidural bupivacaine and sufentanil--a case report

The objective of this case report is to discuss the successful postoperative analgesic management in a patient who had disseminated rectal cancer pain and failed to obtain pain relief despite high-dose intravenous hydromorphone. A 45-year-old male had metastatic rectal cancer involving multiple vertebrae. After a T6 corpectomy, the patient failed to obtain effective pain relief with massive doses of parenteral opioids. The epidural catheter was placed under fluoroscopy. The patient subsequently failed to obtain relief with epidural administration of bupivacaine and hydromophone. Epidural sufentanil was used to obtain adequate pain control. Postoperative epidural analgesia is a technique worthy of consideration for patients with extreme opioid dependency for corpectomy. Epidural sufentanil can successfully be administered for postoperative pain control for patients receiving a large dose of opioids for cancer pain.     

全人／整体护理对晚期癌症患者生活质量的影响

目的探讨全人／整体护理对晚期癌症患者生活质量的影响。方法将2007年11月-2008年7月60例确诊为晚期癌症的患者随机分为试验组和对照组,均规范接受阿片类药物镇痛和针对其他痛苦症状的药物控制治疗。在此基础上,试验组再增加躯体照护、心理疏导、灵性关怀等全人／整体护理,并就两组在疼痛缓解、活动能力和生活质量改善等方面的效果进行比较。结果观察期内,试验组在疼痛缓解、活动能力及生活质量改善方面明显优于对照组,两组比较差异均有统计学意义（P〈0．05）。结论在药物治疗基础上,运用全人／整体护理能够明显提高晚期癌症患者及其家属的生活质量。     

Developing a pain management program through continuous improvement strategies

Pain affects more than one third of cancer patients in the early stages of their disease, dramatically rising above 70% in the advanced stages. Numerous studies have been conducted in the pursuit of cancer pain relief, yet the prevalence of pain persists. This article focuses on a pain management program, developed by a performance improvement team, which addressed the inadequacies of current pain management. Performance improvement activities are described through the process of assessment, planning, implementation, and evaluation of the pain management program. This pain management program is uniquely derived from a unit core value that all staff is responsible and accountable for pain management.     

The development of use of oral morphine within the last 10 years in Japan

Japan's national cancer relief programme was initiated with a field-test of the WHO guidelines for cancer pain management in 1982. It revealed in an excellent result that 87% of 156 cancer patients could be completely relieved of their persistent pain, but this result were ignored by most Japanese health professionals, because of their lack of interest in cancer pain relief. The WHO guidelines were published in 1986 and made quite an impact on those health professionals in Japan. In 1987, a special research team appointed by the Ministry of Health and Welfare of Japan (MOHW) initiated discussion on the philosophy of palliative care in Japan. According to the recommendations made by this research team, the MOHW established a new policy on palliative care, edited manuals on palliative care for terminally ill cancer patients which included guidelines on cancer pain management, and revised narcotics control measures by 1992 in order to much improve the accessibility of opioid analgesics to cancer patients who need them for effective pain relief. The annual consumption of morphine for medical purposes was only 65 kg in 1986 in Japan, but it rose to 973 kg in 1999. Currently, morphine is mostly given by mouth and two-thirds of morphine preparations consumed are MS Contin Tablets. However, the current morphine consumption per capita in Japan is still less than one-sixth of the consumption in the United States.In order to achieve further improvement, educational effort should be much emphasized. In the 1990s, approximately 70% of medical and nursing schools in Japan have initiated their educational curriculum for cancer pain relief and palliative care. There have been government-sponsored, medical, nursing and pharmaceutical societies-sponsored seminar courses on appropriate morphine use in cancer pain management, palliative care and opioid availability, all of which have increasingly strengthened postgraduate education.     

晚期肺癌病人癌性疼痛管理障碍现状及其影响因素分析

目的:探讨晚期肺癌病人癌性疼痛(CP)管理障碍现状及其影响因素。方法:回顾性分析2019年1月—2021年7月就诊于医院的98例晚期肺癌病人临床资料,分析晚期肺癌病人CP管理障碍现状及其影响因素。结果:晚期肺癌病人癌性疼痛控制障碍问卷(BQ)评分为(3.22±0.25)分;单因素分析显示：家庭人均月收入、文化程度、医疗付费方式、接受过疼痛管理相关培训、疾病不确定感高、慢性疼痛自我效能、应对方式与晚期肺癌病人CP管理障碍有关(P<0.05);多因素分析显示：家庭人均月收入<4 000元、文化程度低、自费付费方式、未接受过疼痛管理相关培训、疾病不确定感高、慢性疼痛自我效能低、消极应对方式是影响晚期肺癌病人CP管理障碍的高危因素(P<0.05)。结论:晚期肺癌病人CP管理障碍处于较高水平,其与家庭人均月收入、文化程度、医疗付费方式、接受过疼痛管理相关培训、疾病不确定感、慢性疼痛自我效能、应对方式有关。     

A Quebec survey of issues in cancer pain management.

We report the results of a cancer pain survey mailed to Quebec hematologist-oncologists and palliative care physicians in 1999. The survey was designed to sample views on the current status of pain management and on obstacles to the provision of adequate pain relief for patients. The survey, formulated by an ethics network centered at the Clinical Research Institute of Montreal, was distributed to all members of the Association of Hematologist-Oncologists of Quebec and to all physician members of the Quebec Palliative Care Association. Responses were obtained from 138 Palliative Care Association members (response rate 61%) and 76 hematologist-oncologists (response rate 45%). Major obstacles reported included inadequate assessment of both contributory psychosocial issues and severity of pain, patient reluctance to take opioids, and inadequate access to non-drug techniques for pain relief. Access to opioids was not regarded as a problem. Both groups felt generally competent in their ability to manage various aspects of cancer pain therapy. They gave little credit to their formal medical school or residency training. Fifty-six percent of the palliative care group and 57% of the hemato-oncologists rated their medical school experience as only "poor" or "fair" on a 4-point scale. Residency ratings were modestly better. We conclude that medical faculties should assign a high priority to teaching health professionals patient assessment techniques. Simple symptom assessment scales should be routinely used in oncology/palliative care practice. Medical school training in pain management is not highly regarded and should be enhanced. We also note that, based on response to the scenario of a patient presenting with severe pain, many physicians, while feeling competent in the use of opioids, may be overly conservative in their initial use.     

The use of music therapy to address the suffering in advanced cancer pain

Pain associated with advanced cancer is multifaceted and complex, and is influenced by physiological, psychological, social, and spiritual phenomena. Suffering may be identified in patients when pain is associated with impending loss, increased dependency, and an altered understanding of one's existential purpose. Comprehensive pain management aims to address problematic symptoms in order to improve comfort, peace of mind, and quality of life. Music therapy is a treatment modality of great diversity that can offer a range of benefits to patients with advanced cancer pain and symptoms of suffering. Music therapists perform comprehensive assessments that include reviews of social, cultural, and medical history; current medical status; and the ways in which emotions are affecting the pain. A variety of music therapy techniques may be used, including vocal techniques, listening, and instrumental techniques. These techniques provide opportunities for exploration of the feelings and issues compounding the pain experience. Case examples are presented to demonstrate the "lifting", "transporting", and "bringing of peace" qualities of music that offer patients moments of release, reflection, and renewal.     

Physician attitudes and beliefs about use of morphine for cancer pain

The recent literature asserts that mistaken physician beliefs and attitudes are critical barriers to adequate cancer pain relief. To determine the prevalence of 12 proposed myths or misconceptions about morphine use in cancer pain management (CPM), we surveyed all physicians engaged in direct patient care in Duluth, Minnesota (N = 243). A 62% response was obtained. Many physicians misunderstood concepts of morphine tolerance, both to analgesia (51%) and to side effects (39%). Many were unaware of the use of adjuvant analgesics (29%), efficacy of oral morphine (27%), and nonexistent risk of addiction in CPM (20%). Analysis of result by physician age and specialy groups confirmed significant levels of misunderstanding in all subsets. Strategies to change physician attitudes and beliefs regarding morphine in CPM should focus on tolerance concepts, dosing schemes, safety, efficacy, lack of addictive risk, use of drug combinations, and the fact that cancer pain can be relieved.     

A review of oral transmucosal fentanyl citrate: potent, rapid and noninvasive opioid analgesia

The physiochemical characteristics of the potent synthetic opioid agonist fentanyl make it ideal for noninvasive transmucosal delivery. Studies of oral transmucosal fentanyl citrate (OTFC), a candied matrix formulation administered orally as a palatable lozenge on a stick, have investigated and determined this analgesic's pharmacokinetics and pharmacodynamics in a number of clinical settings, including premedication before surgery, acute analgesia for painful medical procedures, and, most recently, for the control of breakthrough cancer pain. The onset to meaningful pain relief in patients with acute pain from surgery or breakthrough pain from cancer is between 5 and 10 minutes after initiating OTFC use, equivalent to intravenous morphine. Analgesic dose equivalency studies suggest that OTFC is, on average, about 10 times more potent than morphine, although, in randomized, controlled, and blinded studies, many patients who were using relatively high doses of opioid anlagesics on an around the- clock schedule for control of cancer pain reported that even a low dose of OTFC (i.e., 200 microg) provided adequate relief from breakthrough pain. Side effects from OTFC are similar in character and frequency to other opioids, including sedation, nausea, and pruritus. These effects appear to wane rapidly with repeated use of this medication. To date there have been no reported serious adverse events in any of the population groups studied or treated with OTFC.