Journal of pain and symptom management
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The treatment of severe pain requires the use of potent opioid analgesic medications. Many patients with opioid sensitive pain are being undermedicated. This results in increased morbidity and needless suffering. ⋯ Dependence and tolerance are virtually inevitable outcomes of long-term opioid use, but they are neither sufficient to cause addiction nor the equivalent of it. Indeed, the evidence shows that only a tiny fraction of patients treated with opioids become addicted. There is little risk of addiction for those patients receiving properly administered opioids for pain.
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This review draws on data obtained in the cancer pain, nonmalignant pain, and addict populations to examine critically the major issues raised by the use of chronic opioid therapy in nonmalignant pain. The available evidence suggests that there is probably a selected subpopulation of patients with chronic nonmalignant pain who may obtain sustained partial analgesia without the development of toxicity or the psychologic and behavioral characteristics of addiction. Future discussions of this approach must adequately define the terminology of addiction and strive to distinguish medical considerations from the societal and regulatory influences that may affect prescribing behavior. Those who treat patients with chronic pain must actively participate in these discussions lest decisions with enormous impact on patient care be made solely by those whose primary responsibility is the elimination of substance abuse.
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J Pain Symptom Manage · Feb 1990
Relationship among cultural, educational, and regulatory agency influences on optimum cancer pain treatment.
Evidence is presented that supports the allegation that cancer pain is inadequately treated. This is true despite the existence of more knowledge about the anatomy, physiology, pharmacology, and pathology of pain; more professional organizations dedicated to expanding and disseminating information about pain; and the reputation of physicians as persons of compassion. Not all cancer patients with pain, however, fail to get adequate treatment. ⋯ The reasons these patients have a problem with treatment are, in descending order of influence on physicians' prescribing practices: (a) cultural and societal barriers to the appropriate and adequate use of opioids, (b) real and perceived pressures from government regulatory agencies, and (c) knowledge deficits among health care providers because of newer knowledge gained from pharmacologic studies of cancer pain patients. Factors in each category are discussed. Correction of the problem will require fundamental changes in cultural attitudes, which will distinguish legitimate uses of opioids from drug abuse.
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J Pain Symptom Manage · Feb 1990
Comparative StudyPalliative care in a cancer center: results in 1984 versus 1987.
We reviewed the charts of 48 consecutive patients treated by our Palliative Care Team (PCT) during 1984 and compared these results with 50 consecutive patients treated during 1987. The composition of the PCT did not change between 1984 and 1987. The median equivalent daily dose of parenteral morphine (MEDD) before referral, after initial treatment by the PCT, and at the maximum prescribed by the PCT were 43 mg, 48 mg, and 96 mg in 1984, respectively, versus 60 mg (p less than 0.03), 60 mg (p less than 0.03), and 120 mg (p less than 0.12) in 1987, respectively. ⋯ Poor pain control after the initial treatment was observed in 42% of patients in 1984 versus 26% in 1987 (p less than 0.01). Our results suggest that patients are being treated more aggressively by their physicians before referral to the PCT in 1987, that our PCT is using more aggressive initial treatment than in 1984, and that, notwithstanding these changes, there is still a significant proportion of patients in whom pain cannot be controlled before death. These results suggest that more research is necessary to better define intractable pain syndromes and develop adequate treatments for them.
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J Pain Symptom Manage · Feb 1990
Comparative StudySubarachnoid and epidural calcitonin in patients with pain due to metastatic cancer.
Nine patients with metastatic cancer who had pain refractory to traditional treatments received a subarachnoid injection of salmon calcitonin. Eight of the nine patients reported pain relief after subarachnoid injection varying from 1 hr to 5 days. Four of the responding patients subsequently received an epidural injection of salmon calcitonin, and two of these patients reported pain relief. Although many patients experienced pain relief, nausea and vomiting appeared to be a significant side effect, occurring in seven out of nine patients.