The journal of supportive oncology
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Review
Twelve reasons for considering buprenorphine as a frontline analgesic in the management of pain.
Buprenorphine is an opioid that has a complex and unique pharmacology which provides some advantages over other potent mu agonists. We review 12 reasons for considering buprenorphine as a frontline analgesic for moderate to severe pain: (1) Buprenorphine is effective in cancer pain; (2) buprenorphine is effective in treating neuropathic pain; (3) buprenorphine treats a broader array of pain phenotypes than do certain potent mu agonists, is associated with less analgesic tolerance, and can be combined with other mu agonists; (4) buprenorphine produces less constipation than do certain other potent mu agonists, and does not adversely affect the sphincter of Oddi; (5) buprenorphine has a ceiling effect on respiratory depression but not analgesia; (6) buprenorphine causes less cognitive impairment than do certain other opioids; (7) buprenorphine is not immunosuppressive like morphine and fentanyl; (8) buprenorphine does not adversely affect the hypothalamic-pituitary-adrenal axis or cause hypogonadism; (9) buprenorphine does not significantly prolong the QTc interval, and is associated with less sudden death than is methadone; (10) buprenorphine is a safe and effective analgesic for the elderly; (11) buprenorphine is one of the safest opioids to use in patients in renal failure and those on dialysis; and (12) withdrawal symptoms are milder and drug dependence is less with buprenorphine. In light of evidence for efficacy, safety, versatility, and cost, buprenorphine should be considered as a first-line analgesic.
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Patients with advanced lung cancer experience a high symptom burden with great impact upon functional status and quality of life and poor long-term survival. Respiratory symptoms, like dyspnea, cough, and hemoptysis, are highly prevalent and cause profound distress at the time of diagnosis and as disease progresses. This review discusses common reversible causes of dyspnea and examines pharmacologic and nonpharmacologic approaches to symptom management of dyspnea, cough, and hemoptysis.
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Review
Does palliative care improve outcomes for patients with incurable illness? A review of the evidence.
Patients with incurable illness experience considerable physical and psychological distress, which negatively impacts their quality of life. Palliative care clinicians primarily seek to alleviate suffering, enhance coping with symptoms, and enable informed decision making. In this article, we review the efficacy of various palliative care interventions to improve patients' quality of life, physical and psychological symptoms, satisfaction with care, family caregiver outcomes, health-service utilization, and quality of end-of-life care. ⋯ Ten studies examined patient and/or family caregiver satisfaction with care, and seven of these reported greater satisfaction with palliative care intervention. However, data are lacking to support the benefit of palliative interventions for reducing patients' physical and psychological symptoms. We conclude the review by discussing the major obstacles and future directions in evaluating and implementing standardized palliative care interventions.
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Review Case Reports
Interventional therapies for the management of cancer pain.
Timely interventional cancer pain therapies complement conventional pain management by reducing the need for high-dose opioid therapy and its associated toxicity. All patients with upper abdominal visceral pain should be considered for celiac plexus neurolysis soon after diagnosis. ⋯ Specific interventions for vertebral metastases and other sites of metastatic bone pain, including vertebroplasty, kyphoplasty, and image-guided tumor ablation, should be understood and considered. A collaborative model of care, including pain medicine specialists with expertise in interventional therapies, should be standard in all oncologic practices in order to optimize outcomes for patients with cancer throughout the course of their treatment.
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Benign, self-limited hiccups are more of a nuisance, but persistent and intractable hiccups lasting more than 48 hours and 1 month, respectively, are a source of significant morbidity in the patient with advanced malignancy. The hiccup reflex is complex, but stimulation of vagal afferents followed by activation of efferent phrenic and intercostal nerve pathways results in contraction of the diaphragm and intercostal muscles, respectively. The etiology of hiccups in the cancer and palliative care population may include chemotherapy, electrolyte derangements, esophagitis, and neoplastic involvement of the central nervous system (CNS), thorax, and abdominal cavity. ⋯ Most patients with ongoing hiccups require pharmacotherapy, with chlorpromazine being the only US Food and Drug Administration-approved agent. However, numerous other medications have been reported to be efficacious for treating intractable hiccups. Gabapentin has recently been shown to terminate hiccups effecitvely in cancer patients and may emerge as a therapy of choice in the palliative setting due to favorable tolerability, pain-modulating effects, minimal adverse events, and lack of drug interactions.