Breakthrough pain: characteristics and impact in patients with cancer pain.

Few surveys have been performed to define the characteristics and impact of breakthrough pain in the cancer population. In this cross-sectional survey of inpatients with cancer, patients responded to a structured interview (the Breakthrough Pain Questionnaire) designed to characterize breakthrough pain, and also completed measures of pain and mood (Memorial Pain Assessment Card (MPAC)), pain-related interference in function (Brief Pain Inventory (BPI)), depressed mood (Beck Depression Inventory (BDI)), and anxiety (Beck Anxiety Inventory (BAI)). Of 178 eligible patients, 164 (92.2%) met the criteria for controlled background pain. The median age was 50.6 years (range 26 to 77 years), 52% were men, and 80.6% were Caucasian. Tumor diagnoses were mixed, 75% had metastatic disease, 65% had pain caused directly by the neoplasm, and a majority had mixed nociceptive-neuropathic pain. The median Karnofsky Performance Status score was 60 (range 40 to 90). Eighty-four (51.2%) patients had experienced breakthrough pain during the previous day. The median number of episodes was six (range 1 to 60) and the median interval from onset to peak was 3 min (range 1 s to 30 min). Although almost two-thirds (61.7%) could identify precipitants (movement 20.4%; end-of-dose failure 13.2%), pain was unpredictable in a large majority (78.2%). Patients with breakthrough pain had more intense (P < 0.001) and more frequent (P < 0.01) background pain than patients without breakthrough pain. Breakthrough pain was also associated with greater pain-related functional impairment (difference in mean BPI. P < 0.001), worse mood (mood VAS, P < 0.05; BDI, P < 0.001), and more anxiety (BAI, P < 0.001). Multivariate analysis confirmed that breakthrough pain independently contributed to impaired functioning and psychological distress. These data confirm that cancer-related breakthrough pain is a prevalent and heterogeneous phenomenon. The presence of breakthrough pain is a marker of a generally more severe pain syndrome, and is associated with both pain-related functional impairment and psychological distress. The findings suggest the need for further studies of breakthrough pain and more effective therapeutic strategies.     

Neurologic pain syndromes in patients with cancer

One third of cancer patients in active therapy and two thirds of patients with far-advanced disease have significant pain. A series of specific neurologic pain syndromes occur in this population and are unique to this pain population. Early diagnosis and treatment are critical to prevent irreversible neurologic damage and chronic neuropathic pain.     

Breakthrough cancer pain: prevalence and characteristics in patients in Catalonia,Spain

Breakthrough pain (BTP), a transitory exacerbation of pain superimposed on a background of persistent, usually adequately controlled pain, has been reported to occur in 50% to 75% of cancer patients. However, a 23% prevalence of BTP was recently reported in a study of Spanish patients with advanced cancers, showing probably a low detection rate of this clinical problem. The purpose of the present study was to determine the prevalence of BTP among oncology patients managed by palliative care teams in Catalonia, Spain, and to characterize the frequency, intensity, and treatment of BTP episodes. Sixty-two teams studied 397 patients on a predetermined index day. BTP was reported by 163 (41%) patients, with a total of 244 episodes (mean 1.5 episodes/patient/day). Mean (SD) intensity of BTP episodes was 7.3 (2.0), compared with 2.9 (2.7) for persistent pain (both 0-10 scales). Morphine was used to treat 52% of BTP episodes, while 25% were untreated. These findings indicate that BTP remains underrecognized and undertreated in Spain.     

Regional pain syndromes in cancer patients

Pain is one of the cardinal presenting symptoms in cancer patients and often seems to progress in the natural history of the disease. In light of the past neglect of this problem, it is becoming crucial for clinicians and researchers in the fields of oncology, pain management, and others dealing with this patient population to have a thorough understanding of the often complex pain syndromes that are relevant to managing cancer. In this article we briefly review the important topics related to cancer pain syndromes with some emphasis on those that typically generate localized pain.     

Breakthrough pain in children with cancer

The aims of this prospective study were to determine the prevalence, characteristics, and impact of breakthrough pain in children with cancer. Twenty-seven pediatric inpatients with cancer (aged 7-18 years) who had severe pain requiring treatment with opioids and who received care in the Oncology Unit at the Children's Hospital at Westmead, Sydney, Australia participated in this study. The children responded to a structured interview (Breakthrough Pain Questionnaire for Children), designed to characterize breakthrough pain in children. Measures of pain, anxiety, and depressed mood were completed. Fifty-seven percent of the children experienced one or more episodes of breakthrough pain during the preceding 24 hours, each episode lasting seconds to minutes, occurring 3-4 times/d, and most commonly characterized as "sharp" and "shooting" by the children. Younger children (7-12 years) had a significantly higher risk of experiencing breakthrough pain compared to teenagers. No statistical difference could be shown between children with and without breakthrough pain in regard to anxiety and depression. The most effective treatment of an episode of breakthrough pain was a patient-controlled analgesia opioid bolus dose. Further studies of breakthrough pain in children and more effective treatment strategies in this age group are necessary.     

Clinical characteristics of patients with idiopathic pain syndromes. Depressive symptomatology and patient pain drawings

The frequency of depressive symptomatology as estimated by means of self-rating on a visual analogue scale and the pain drawings by patients were compared between healthy volunteers, patients with neurogenic pain syndromes and patients with idiopathic pain syndromes. All patients with chronic pain syndromes had significantly more depressive symptomatology than the healthy volunteers. Patients with idiopathic pain syndromes had significantly more inhibition symptoms--memory disturbances and concentration difficulties--than patients with neurogenic pain syndromes. In the pain drawings, estimated by means of the technique suggested by Margolis et al. [10], the idiopathic pain patients had significantly higher scores on both raw scores and weighted body surface scores than the patients with neurogenic pain syndromes. Thus, both self-rating of depressive symptomatology and pain drawings can be of some help in the difficult clinical delineation between patients with idiopathic and neurogenic pain syndromes, respectively, but used as single measures, both methods have low discriminative power.     

Breakthrough pain: assessment and management in cancer patients

This article provides an overview of breakthrough pain in cancer patients, what causes it, current treatment options and the impact it has on individuals. It considers the importance of accurate assessment, the use of assessment tools and the growing role of nurses in managing this challenging pain syndrome. The article aims to open the debate on the need for new choices in pain management. While many advances have been made in the treatment of pain, there is still room for improvement in both the pharmaceutical and general management of the condition. Suggestions are made as to how these may be met.     

An international survey of patients living with spasticity

Purpose: To better understand patient perspectives on the life impact of spasticity.

Methods: Global Internet survey (April 2014–May 2015) of 281 people living with spasticity.

Results: Respondents indicated that spasticity has a broad impact on their daily-life: 72% reported impact on quality of life, 44% reported loss of independence and 44% reported depression. Most respondents (64%) were cared for by family members, of whom half had stopped working or reduced their hours. Overall, 45% reported dissatisfaction with the information provided at diagnosis; main reasons were “not enough information” (67%) and “technical terminology” (36%). Respondents had high treatment expectations; 63% expected to be free of muscle spasm, 41% to take care of themselves and 36% to return to a normal routine. However, 33% of respondents had not discussed these expectations with their physician. The most common treatments were physiotherapy (75%), botulinum neurotoxin (BoNT, 73%) and oral spasmolytics (57%). Of those treated with BoNT, 47% waited?>1 year from spasticity onset to treatment.

Conclusions: This survey emphasises the broad impact of spasticity and highlights unmet needs in the patient journey. Improvements with regards to communication and the therapeutic relationship would be especially welcomed by patients, and would help manage treatment expectations.

• Implications of Rehabilitation

• Spasticity has broad impact on the lives of patients and their families that extends beyond the direct physical disability.

• Patients with spasticity need to be well informed about their condition and treatments available and should be given the opportunity to discuss their expectations.

• Physicians need to be aware of the patient’s individual needs and expectations in order to better help them achieve their therapeutic goals.

     

Pain in patients with cancer: Profile of patients and common pain syndromes

Although most pain in patients with cancer is associated with disease or treatment and is usually interpreted by the patient and family as such, this is not always the case. Pain unrelated to cancer or cancer therapy accounted for approximately 3% of inpatients' complaints of pain in this population.The clinical assessment of pain in the patient with cancer is an integral part of medical and nursing assessments. Pain may be the presenting complaint leading to a diagnosis of the primary tumor. It may be the first and only sign of recurrence, or it may be unrelated to the cancer. Additionally, it may represent the major complaint of the dying patient or it may occur transiently as a side effect of therapy. In all instances, the complaint must be respected and carefully evaluated in order to provide effective management.     

Breakthrough pain: definition, prevalence and characteristics.

In the cancer population, the term breakthrough pain typically refers to a transitory flare of pain in the setting of chronic pain managed with opioid drugs. The prevalence and characteristics of this phenomenon have not been defined, and its impact on patient care is unknown. We developed operational definitions for breakthrough pain and its major characteristics, and applied these in a prospective survey of patients with cancer pain. Data were collected during a 3 month period from consecutive patients who reported moderate pain or less for more than 12 h daily and stable opioid dosing for a minimum of 2 consecutive days. Of 63 patients surveyed, 41 (64%) reported breakthrough pain, transient flares of severe or excruciating pain. Fifty-one different pains were described (median 4 pains/day; range 1-3600). Pain characteristics were extremely varied. Twenty-two (43%) pains were paroxysmal in onset; the remainder were more gradual. The duration varied from seconds to hours (median/range: 30 min/1-240 min), and 21 (41%) were both paroxysmal and brief (lancinating pain). Fifteen (29%) of the pains were related to the fixed opioid dose, occurring solely at the end of the dosing interval. Twenty-eight (55%) of the pains were precipitated; of these, 22 were caused by an action of the patient (incident pain), and 6 were associated with a non-volitional precipitant, such as flatulence. The pathophysiology of the pain was believed to be somatic in 17 (33%), visceral in 10 (20%), neuropathic in 14 (27%), and mixed in 10 (20%). Pain was related to the tumor in 42 (82%), the effects of therapy in 7 (14%), and neither in 2 (4%). Diverse interventions were employed to manage these pains, with variable efficacy. These data clarify the spectrum of breakthrough pains and indicate their importance in cancer pain management.     

Breakthrough pain: a qualitative study involving patients with advanced cancer

Context  

Breakthrough cancer pain is associated with a high burden of physical, psychological and social problems in quantitative studies. Individual experiences of living with breakthrough pain have not been studied.     

A long-term survey of morphine in cancer pain patients.

We surveyed 550 cancer patients who experienced pain and were treated with morphine for a total of 22,525 treatment days. Sufficient pain relief was achieved during more than 80% of this time using an average oral morphine dose of 82.4 mg--significantly lower than other studies. The use of this low dose, which was possible due to the concomitant administration of nonopioids and specific coanalgesics in most patients, resulted in a low incidence of side effects. Constipation and nausea/vomiting were the most common of these side effects. Physical dependence posed no practical problem in discontinuation of morphine treatment. Long-term opioid intake and development of tolerance did not appear to be linked; an increase in morphine dosage was most often explained by progression of the terminal disease. Addiction was a negligible problem, with only one observed case.     

Update in cancer pain syndromes

Cancer pain assessment and management are integral to palliative medicine. This paper reviews recent publications in the period 1999-2004 in the broad categories of epidemiology, pain assessment, nonpharmacologic approaches to cancer pain (radiation therapy, anesthetic blocks, palliative surgery and chemotherapy, complementary and alternative medicine), and in nociceptive pain, neuropathic pain, visceral pain, and bone pain.     

Regional cancer pain syndromes

Cancer pain often presents in a body region. This review summarizes articles from 1999-2004 relevant to cancer pain syndromes in the head and neck, chest, back, abdomen, pelvis, and limbs. Although the evidence is limited, progress is being made in further development of the evidence base to support and guide current practice.     

A survey of mouth pain and dryness in patients with advanced cancer

 An 11-item face-to-face survey was conducted in 99 consecutive patients with advanced cancer to determine the prevalence, intensity, reporting and treatment, presumed cause(s), and importance of mouth pain and dryness. Sixteen of the 99 patients (16%) reported experiencing mouth pain at a mean intensity corresponding to 5.5±SD 2.21 on a 0 (no pain) to 10 (worst possible pain) numerical scale, and 88 (88%) patients reported dry mouth at a mean intensity corresponding to 6.2±SD 2.21. Nine (56%) of the 16 patients with mouth pain and 39 (44%) of the 88 patients with mouth dryness reported these symptoms to their attending physician(s). Sixty-nine percent (27/39) of patients who reported having a dry mouth were advised by their physician(s) to pursue one or more treatments. The most common treatments recommended (and frequencies) were drinking water/taking sips of fluid (13), gargling with bicarbonate mouthwash (4), using an artificial saliva spray (4), and using an oral fungal suspension for thrush (4). The most common findings on oral examination included: possible thrush (53 patients), upper and lower dentures (33 patients), and multiple dental restorations (23 patients). The causes most frequently assumed to be responsible were ill-fitting dentures for mouth pain, and medications and possible oral fungal infections for mouth dryness. The mean values given for the importance of the symptoms of mouth pain and dryness relative to other symptoms or problems experienced by the patients were 4.4±SD 1.84 and 3.6±SD 1.67, respectively, on a Likert scale ranging from 1 (not important) to 7 (great importance). Mouth dryness was more frequently reported than mouth pain. The mean rating for the intensity of mouth pain was higher than that for mouth dryness, although both were of moderate importance to patients relative to other symptoms or problems experienced at the time. Patients tended to underreport mouth pain and dryness, and physicians tended to address such complaints inadequately. Published online: 3 August 2000     

Chronic pain syndromes in cancer survivors

Advances in medical knowledge and treatment have resulted in improved five-year survival rates for some forms of cancer. However, pain syndromes resulting from chemotherapy, radiotherapy, surgery or interventional procedures continue to have a significant effect on cancer survivors' quality of life. Nurses are uniquely placed to assess pain in cancer survivors and ensure pain management strategies are initiated. This article focuses on chronic pain syndromes that can occur following cancer treatment, examining the effect of pain on patients' quality of life.     

Electromyographic observations in patients with foot pain syndromes

Abductor hallucis muscle EMGs were performed in control subjects and in patients with chronic foot pain (9 affected by the disease of the metatarsophalangeal joint of the big toe, 6 affected by chronic foot strain) to investigate pathophysiological mechanisms of muscle pain syndromes. Unlike control subjects, patients showed an abnormal involuntary activity when standing. All patients presented a decrease of abnormal EMG activity when postural changes were induced either by variations in body weight distribution on the feet, or by changes of position in the weight-bearing foot achieved by arch supports or by boards of variable thickness applied under the forefeet or the heels. Anaesthesia of the metatarsophalangeal joint of the hallux (injection into the joint cavity of 2-3 ml 0.50% bupivacaine) reduced the abnormal EMG activity only in patients with hallux valgus, whereas it did not affect muscular activity in the other patients. Present results support the idea of the role of abnormal muscular activity in causing and maintaining chronic pain and suggest that alterations of postural mechanisms and of afferent input, in particular that arising from joint receptors, are involved in the genesis of this abnormal muscular activity.