• antispasmodics
• inflammatory bowel disease
• irritable bowel syndrome
• opioids
• pain management

• Humans
• Female
• Male
• Middle Aged
• Analgesics, Opioid/therapeutic use
• Abdominal Pain/drug therapy
• Abdominal Pain/etiology
• Inflammatory Bowel Diseases/drug therapy
• Inflammatory Bowel Diseases/complications
• Adult
• Parasympatholytics/therapeutic use
• Parasympatholytics/adverse effects
• Aged
• Adrenal Cortex Hormones/therapeutic use
• Treatment Outcome

• T32 LM012415 NLM NIH HHS
• R01 DK122364 NIDDK NIH HHS
• R01DK122364 NIDDK NIH HHS
• T32 GM118294 NIGMS NIH HHS
• T32GM118294 NIH HHS
• T32LM012415 NIH HHS

• Acute palliative care unit
• Cancer pain
• Opioids
• Palliative care

• moderate cancer pain
• morphine
• tramadol

• ErbB receptors
• Neuralgia
• cancer pain
• observational study
• palliative medicine
• panitumumab

• Cancer Pain
• ErbB Receptors/therapeutic use
• Humans
• Neoplasms/complications
• Neoplasms/drug therapy
• Neuralgia/drug therapy
• Neuralgia/etiology
• Panitumumab/therapeutic use

• Cancer pain
• EGFR-inhibitor
• Neuropathic pain
• Palliative outcomes
• Panitumumab
• Study design

While against recommendations, long-term opioid therapy (LTOT) for chronic pain is common. This study aimed to describe the prevalence of opioid prescriptions and to study the association of patient characteristics (demographics, pain characteristics, anxiety, depressive symptoms and pain coping) with future LTOT. The sample included N = 1334 chronic musculoskeletal pain patients, aged 18–65, who were assessed for Interdisciplinary Multimodal Pain Rehabilitation (IMMR) in Swedish specialist rehabilitation. Prescriptions were tracked across a two-year target period after assessment. In total, 9100 opioid prescriptions were prescribed to 55% of the sample (M_median = 6, IQR = 14). Prediction of LTOT was analyzed separately for those who did (24%) and did not (76%) receive IMMR. The odds of receiving opioids was similar for these subsamples, after controlling for differences in baseline characteristics. In both samples, there were significant associations between patient characteristics and future opioid prescriptions. Dysfunctional pain coping was a unique predictor of LTOT in those who received IMMR while pain intensity and depressive symptoms were unique predictors in those who did not receive IMMR. The results underscore that opioid treatment is common among patients in chronic pain rehabilitation and relates to pain and psychological factors. Understanding in detail why these factors relate to opioid prescription patterns is an important future study area as it is a prerequisite for better management and fundamental for preventing overuse.

• SQRP
• biopsychosocial
• chronic pain
• interdisciplinary treatment
• opioids
• rehabilitation

• Administration, Intravenous
• Analgesics, Opioid/administration & dosage
• Analgesics, Opioid/chemistry
• Analgesics, Opioid/metabolism
• Analgesics, Opioid/pharmacology
• Animals
• Biological Transport
• Blood-Brain Barrier/metabolism
• Gastrointestinal Motility/drug effects
• Male
• Mice
• Morphine Derivatives/administration & dosage
• Morphine Derivatives/chemistry
• Morphine Derivatives/metabolism
• Morphine Derivatives/pharmacology
• Nociception/drug effects
• Peptides/chemistry

• FDN-148413 CIHR
• MOP-123399 CIHR
• MOP-136871 CIHR

• Breast cancer
• chemotherapy
• drug-related problems

Background: Uncontrolled cancer pain is a significant problem in palliative medicine. Opioids are often first-line treatment that increase risks of analgesic tolerance and hyperalgesia. Topical ketamine with other adjuvant pain medications is an often-overlooked treatment, yet may be most effective in difficult-to-treat cancer pain.

Objective: We report a case series of hospice patients with uncontrolled cancer pain who were suboptimally treated with opioids and nerve blocks, whose symptoms responded to topical ketamine with other adjuvants. We review the pronociceptive properties of opioids and how topical multimodal treatment of cancer pain can be more effective than standard opioids, other topical adjuvant medications, and nerve blocks. We discuss the shortcomings of the World Health Organization (WHO) stepladder for the treatment of cancer pain and suggest an adjuvant treatment algorithm, directing physicians to appropriate adjuvant pain agents based on pain type and distinct receptor actions.

Design: This is a retrospective case series of patients who responded to topical multimodal pain treatment with implementation of findings into an addendum to the WHO stepladder.

Subjects: Subjects were from a case series of community-based hospice patients with previously uncontrolled cancer pain.

Measurement: Measurement was made by self-report of pain levels using the 10-point numeric pain rating scale.

Results: Patients' pain was controlled with topical adjuvant medications with return to previously lost function and prevention of otherwise escalating opioid dosing.

Conclusions: These patient cases reveal how ketamine-based topical treatment for cancer pain can be more effective than standard opioids, other topical adjuvant medications, and nerve blocks with no noted side effects and observed reduction in opioid consumption.

• adjuvants
• cancer
• ketamine
• pain
• topical

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on palliative care aspects in cancer pain in adults provide a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking was made available on the ISSP website and circulated by E-mail to all the ISSP and Indian Association of Palliative Care (IAPC) members. In a cancer care setting, approaches toward managing pain vary between ambulatory setting, home care setting, acute inpatient setting, and end-of-life care in hospice setting. We aim to expound the cancer pain management approaches in these settings. In an ambulatory palliative care setting, the WHO analgesic step ladder is used for cancer pain management. The patients with cancer pain require admission for acute inpatient palliative care unit for poorly controlled pain in ambulatory and home care settings, rapid opioid titration, titration of difficult drugs such as methadone, acute pain crisis, pain neuromodulation, and pain interventions. In a palliative home care setting, the cancer pain is usually assessed and managed by nurses and primary physicians with a limited input from the specialist physicians. In patients with cancer at the end of life, the pain should be assessed at least once a day. Moreover, physicians should be trained in assessing patients with pain who are unable to verbalize or have cognitive impairment.

• Acute inpatient palliative care
• Indian Association of Palliative Care
• Indian Society for Study of Pain
• ambulatory palliative care
• cancer pain management guidelines
• cancer pain special interest group
• end-of-life palliative care
• home-based palliative care
• hospice

• Critical Care/methods
• Critical Illness
• Female
• Humans
• Male
• Nerve Block/methods
• Pain/etiology
• Pain Management/methods
• Palliative Care/methods
• Pancreatic Neoplasms/complications
• Point-of-Care Systems
• Switzerland

• Adverse effect
• Effectiveness
• Low-dose morphine
• Moderate cancer pain
• Tramadol

• clinical trials
• health-related quality of life
• multiple myeloma

The vitamin C deficiency disease scurvy is characterised by musculoskeletal pain and recent epidemiological evidence has indicated an association between suboptimal vitamin C status and spinal pain. Furthermore, accumulating evidence indicates that vitamin C administration can exhibit analgesic properties in some clinical conditions. The prevalence of hypovitaminosis C and vitamin C deficiency is high in various patient groups, such as surgical/trauma, infectious diseases and cancer patients. A number of recent clinical studies have shown that vitamin C administration to patients with chronic regional pain syndrome decreases their symptoms. Acute herpetic and post-herpetic neuralgia is also diminished with high dose vitamin C administration. Furthermore, cancer-related pain is decreased with high dose vitamin C, contributing to enhanced patient quality of life. A number of mechanisms have been proposed for vitamin C’s analgesic properties. Herein we propose a novel analgesic mechanism for vitamin C; as a cofactor for the biosynthesis of amidated opioid peptides. It is well established that vitamin C participates in the amidation of peptides, through acting as a cofactor for peptidyl-glycine α-amidating monooxygenase, the only enzyme known to amidate the carboxy terminal residue of neuropeptides and peptide hormones. Support for our proposed mechanism comes from studies which show a decreased requirement for opioid analgesics in surgical and cancer patients administered high dose vitamin C. Overall, vitamin C appears to be a safe and effective adjunctive therapy for acute and chronic pain relief in specific patient groups.

• Cancer quality of life
• Chronic regional pain syndrome
• Opioid requirements
• Post-herpetic neuralgia
• Vitamin C

• cancer
• daily clinical practice
• neuropathic pain
• opiate rotation
• pain
• quality of life
• review
• tapentadol

Treating cancer pain continues to possess a major challenge. Here, we report that a traditional Chinese medicine Xiao-Ai-Tong (XAT) can effectively suppress pain and adverse reactions following morphine treatment in patients with bone cancer pain. Visual Analogue Scale (VAS) and Quality of Life Questionnaire (EORTC QLQ-C30) were used for patient's self-evaluation of pain intensity and evaluating changes of adverse reactions including constipation, nausea, fatigue, and anorexia, respectively, before and after treatment prescriptions. The clinical trials showed that repetitive oral administration of XAT (200 mL, bid, for 7 consecutive days) alone greatly reduced cancer pain. Repetitive treatment with a combination of XAT and morphine (20 mg and 30 mg, resp.) produced significant synergistic analgesic effects. Meanwhile, XAT greatly reduced the adverse reactions associated with cancer and/or morphine treatment. In addition, XAT treatment significantly reduced the proinflammatory cytokines interleukin-1β and tumor necrosis factor-α and increased the endogenous anti-inflammatory cytokine interleukin-10 in blood. These findings demonstrate that XAT can effectively reduce bone cancer pain probably mediated by the cytokine mechanisms, facilitate analgesic effect of morphine, and prevent or reduce the associated adverse reactions, supporting a use of XAT, alone or with morphine, in treating bone cancer pain in clinic.

• Comprehensive Health Care/methods
• Evidence-Based Practice
• Humans
• Neoplasms/complications
• Pain/diagnosis
• Pain/etiology
• Pain/physiopathology
• Pain/psychology
• Pain Management/methods
• Pain Measurement/methods
• Quality Improvement
• Quality of Life
• Treatment Outcome

• NCI P 30 006973 PHS HHS

• cancer bone pain
• ongoing pain
• conditioned place preference
• rostral anterior cingulate cortex
• morphine
• diclofenac
• dopamine release

• Adenocarcinoma/complications
• Adenocarcinoma/pathology
• Analgesics, Opioid/therapeutic use
• Anesthetics, Local/pharmacology
• Animals
• Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
• Behavior, Animal/drug effects
• Behavior, Animal/physiology
• Bone Neoplasms/complications
• Cell Line, Tumor
• Diclofenac/therapeutic use
• Disease Models, Animal
• Female
• Gyrus Cinguli/drug effects
• Gyrus Cinguli/metabolism
• Lidocaine/therapeutic use
• Morphine/therapeutic use
• Naltrexone/administration & dosage
• Naltrexone/analogs & derivatives
• Narcotic Antagonists/administration & dosage
• Nucleus Accumbens/drug effects
• Nucleus Accumbens/metabolism
• Pain/drug therapy
• Pain/etiology
• Pain/metabolism
• Pain/physiopathology
• Rats
• Rats, Inbred F344

• T32 NS070201 NINDS NIH HHS
• P20 GM103643 NIGMS NIH HHS
• R01 NS066958 NINDS NIH HHS
• T32CA009213 NCI NIH HHS
• R01 DA034975 NIDA NIH HHS
• T32 CA009213 NCI NIH HHS

• Cancer pain
• Prevalence of pain
• Severe pain

The goal of the research was to determine the efficacy of a fixed combination of tramadol and paracetamol (acetaminophen) in the treatment of pain of patients with the advanced stage of cancer.

A prospective study was conducted at the Center for Palliative Care, University Clinical Center Tuzla, Bosnia and Herzegovina, from January 1^st to December 31^st 2013. A total of 353 patients who were treated with a fixed combination of tramadol and acetaminophen (37.5 mg and 325 mg) at the initial dosage 3x1 tablet (112.5 mg tramadol and 975 mg acetaminophen) for pain intensity 4, up to 4x2 tablets (300 mg of tramadol and 2600 mg paracetamol) for pain intensity 7 and 8. If the patient during previous day has two or more pain episodes that required a “rescue dose” of tramadol, increased was the dose of fixed combination tramadol and acetaminophen to a maximum of 8 tablets daily (300 mg of tramadol and 2600 mg paracetamol). Statistical analysis was performed by biomedical software MedCalc for Windows version 9.4.2.0. The difference was considered significant for P<0.05.

The average duration of treatment with a fixed combination tramadol and acetaminophen was 57 days (13-330 days). Already after 24 hours of treatment the average pain score was significantly lower (p<0.0001) compared to the admission day [5.00 (4:00 to 8:00) during the first days versus 2.00 (1:00 to 7:00) during the second day of treatment]. The average dose of the fixed combination tramadol and acetaminophen tablets was 4.8 ± 1.8 (180 mg of tramadol and 1560 mg paracetamol). Side effects, in the treatment of pain with a fixed combination tramadol and acetaminophen, were found in 29.18% of patients, with a predominance of nausea and vomiting.

Fixed combination of tramadol and acetaminophen can be used as an effective combination in the treatment of chronic cancer pain, with frequent dose evaluation and mild side effects.

• carcinoma pain
• fixed combination tramadol and paracetamol
• side effects

• Analgesics (opioid)
• Clinical attributes
• Drug classification
• Mechanism of action
• Opioid categories
• Regulatory controls

• Analgesics, Opioid/classification
• Analgesics, Opioid/pharmacology
• Humans
• Pain/drug therapy

Patients requiring chronic opioid therapy may not respond to or tolerate the first opioid prescribed to them, necessitating rotation to another opioid. They may also require dose increases for a number of reasons, including worsening disease and increased pain. Dose escalation to restore analgesia using the primary opioid may lead to increased adverse events. In these patients, rotation to a different opioid at a lower-than-equivalent dose may be sufficient to maintain adequate tolerability and analgesia. In published trials and case series, opioid rotation is performed either using a predetermined substitute opioid with fixed conversion methods, or in a manner that appears to be no more systematic than trial and error. In clinical practice, opioid rotation must be performed with consideration of individual patient characteristics, comorbidities (eg, concurrent psychiatric, pulmonary, renal, or hepatic illness), and concurrent medications, using flexible dosing protocols that take into account incomplete opioid cross-tolerance. References cited in this review were identified via a search of PubMed covering all English language publications up to May 21, 2013 pertaining to opioid rotation, excluding narrative reviews, letters, and expert opinion. The search yielded a total of 129 articles, 92 of which were judged to provide relevant information and subsequently included in this review. Through a review of this literature and from the authors’ empiric experience, this review provides practical information on performing opioid rotation in clinical practice.

• chronic pain
• opioid analgesics
• opioid rotation

• cancer
• chemotherapy
• fatigue
• quality of life
• vitamin C

• Adverse effects
• Cancer pain
• Palliative care
• Tapentadol

• Aged
• Analgesics, Opioid/administration & dosage
• Cohort Studies
• Dose-Response Relationship, Drug
• Drug Dosage Calculations
• Drug Monitoring
• Female
• Humans
• Italy
• Karnofsky Performance Status
• Male
• Middle Aged
• Morphine/administration & dosage
• Neoplasms/complications
• Pain/diagnosis
• Pain/drug therapy
• Pain/etiology
• Pain Management
• Pain Measurement
• Phenols/administration & dosage
• Prospective Studies
• Receptors, Opioid, mu/agonists
• Tapentadol
• Treatment Outcome

Opioids continue to be first-line pharmacotherapy for patients suffering from cancer pain. Unfortunately, subtherapeutic dosage prescribing of pain medications remains common, and many cancer patients continue to suffer and experience diminished quality of life. A large variety of therapeutic options are available for cancer pain patients. Analgesic pharmacotherapy is based on the patient’s self-report of pain intensity and should be tailored to meet the requirements of each individual. Most, if not all, cancer pain patients will ultimately require modifications in their opioid pharmacotherapy. When changes in a patient’s medication regimen are needed, adequate pain control is best maintained through appropriate dosage conversion, scheduling immediate release medication for withdrawal prevention, and providing as needed dosing for breakthrough pain. Transdermal opioids are noninvasive, cause less constipation and sedation when compared to oral opioids, and may improve patient compliance. A relative potency of 100:1 is recommended when converting the patient from oral morphine to transdermal fentanyl. Based on the limited data available, there is significant interpatient variability with transdermal buprenorphine and equipotency recommendations from oral morphine of 75:1–110:1 have been suggested. Cancer patients may require larger transdermal buprenorphine doses to control their pain and may respond better to a more aggressive 75–100:1 potency ratio. This review outlines the prescribing of transdermal fentanyl and transdermal buprenorphine including how to safely and effectively convert to and use them for those with cancer pain.

• analgesic pharmacotherapy
• breakthrough pain
• equipotency ratio
• immediate release medication
• opioid withdrawal
• opioids
• pain treatment modification

• Adult
• Aged
• Analgesics/therapeutic use
• Breakthrough Pain/drug therapy
• Breakthrough Pain/etiology
• Cross-Sectional Studies
• Female
• Humans
• Karnofsky Performance Status
• Male
• Middle Aged
• Neoplasms/complications
• Neoplasms/drug therapy
• Pain/drug therapy
• Pain/etiology
• Pain Management/methods
• Pain Measurement
• Palliative Care/methods
• Prevalence
• Young Adult

• 5-Fluorouracil
• Apoptosis
• Bax
• Bcl-2
• Morphine
• Tumor

• Acute Pain/drug therapy
• Acute Pain/etiology
• Adult
• Aged
• Analgesics, Opioid/administration & dosage
• Breakthrough Pain/drug therapy
• Breakthrough Pain/etiology
• Continuity of Patient Care
• Drug Prescriptions
• Female
• Humans
• Male
• Morphine/administration & dosage
• Neoplasms/complications
• Pain Measurement/drug effects
• Palliative Care/methods
• Patient Discharge

Mechanism-based classification (MBC) was established with current evidence and physical therapy (PT) management methods for both cancer and for noncancer pain.

This study aims to describe the efficacy of MBC-based PT in persons with primary complaints of cancer pain.

A prospective case series of patients who attended the physiotherapy department of a multispecialty university-affiliated teaching hospital.

A total of 24 adults (18 female, 6 male) aged 47.5 ± 10.6 years, with primary diagnosis of heterogeneous group of cancer, chief complaints of chronic disabling pain were included in the study on their consent for participation The patients were evaluated and classified on the basis of five predominant mechanisms for pain. Physical therapy interventions were recommended based on mechanisms identified and home program was prescribed with a patient log to ensure compliance. Treatments were given in five consecutive weekly sessions for five weeks each of 30 min duration.

Pre–post comparisons for pain severity (PS) and pain interference (PI) subscales of Brief pain inventory-Cancer pain (BPI-CP) and, European organization for research and treatment in cancer-quality of life questionnaire (EORTC-QLQ-C30) were done using Wilcoxon signed-rank test at 95% confidence interval using SPSS for Windows version 16.0 (SPSS Inc, Chicago, IL).

There were statistically significant (P < 0.05) reduction in pain severity, pain interference and total BPI-CP scores, and the EORTC-QLQ-C30.

MBC-PT was effective for improving BPI-CP and EORTC-QLQ-C30 scores in people with cancer pain.

• Cancer pain
• Pain mechanisms
• Palliative care
• Physical therapy

• Analgesics, Opioid/administration & dosage
• Analgesics, Opioid/therapeutic use
• Delayed-Action Preparations/therapeutic use
• Humans
• Morphine/administration & dosage
• Morphine/therapeutic use
• Narcotics/administration & dosage
• Narcotics/therapeutic use
• Neoplasms
• Pain/drug therapy
• Palliative Care
• Phenols/administration & dosage
• Phenols/therapeutic use
• Prospective Studies
• Receptors, Opioid, mu/agonists
• Tapentadol

Outcomes in hepatic resectional surgery (HRS) have improved as a result of advances in the understanding of hepatic anatomy, improved surgical techniques, and enhanced peri-operative management. Patients are generally cared for in specialist higher-level ward settings with multidisciplinary input during the initial post-operative period, however, greater acceptance and understanding of HRS has meant that care is transferred, usually after 24-48 h, to a standard ward environment. Surgical trainees will be presented with such patients either electively as part of a hepatobiliary firm or whilst covering the service on-call, and it is therefore important to acknowledge the key points in managing HRS patients. Understanding the applied anatomy of the liver is the key to determining the extent of resection to be undertaken. Increasingly, enhanced patient pathways exist in the post-operative setting requiring focus on the delivery of high quality analgesia, careful fluid balance, nutrition and thromboprophlaxis. Complications can occur including liver, renal and respiratory failure, hemorrhage, and sepsis, all of which require prompt recognition and management. We provide an overview of the relevant terminology applied to hepatic surgery, an approach to the post-operative management, and an aid to developing an awareness of complications so as to facilitate better confidence in this complex subgroup of general surgical patients.

• Hepatic surgery
• Terminology postoperative management
• Complications
• Training

• Aged
• Analgesics/therapeutic use
• Female
• Humans
• Male
• Middle Aged
• Neoplasms/complications
• Pain/drug therapy
• Pain/etiology
• Pain Measurement
• Phenols/therapeutic use
• Prospective Studies
• Tapentadol

• Clinical trial
• analgesic
• cancer pain
• efficacy
• long-term
• open-label
• safety
• tetrodotoxin