Cancer surveys
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Comparative Study Clinical Trial
The cognitive and psychomotor effects of opioid drugs in cancer pain management.
The time has come to evaluate critically our practice of cancer pain management and the assumptions on which it is based. We owe it to our patients to maximize the quality of their lives and to provide evidence for them that is based on a scientific approach rather than anecdotal experience. From the information available, opioids do have effects on cognitive and psychomotor function, and although many of these effects diminish once the patient is on a stable dose, the evidence suggests that baseline pretreatment levels are not achieved. ⋯ The management of the central adverse effects of opioids must be focused on accurate assessment and careful titration of opioids against pain. Adjuvant analgesic drugs and non-drug measures should be used whenever possible, and drugs should be chosen that will not contribute to existing difficulties. The appropriate use of psychostimulants has yet to be established as has the relative benefit of one opioid over another in cancer pain.
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In summary, our current understanding of the therapeutics of dyspnoea is inadequate and leaves plenty of room for improvement. Rationalization of the management of this symptom has the potential to improve the quality of life of countless patients with both malignant and non-malignant disease. To date, research studies addressing this issue are sparse. ⋯ The pharmacological treatment of breathlessness deserves further investigation, and clinical studies should be conducted in parallel with appropriate laboratory studies. Drug therapy is, however, but one aspect of the overall management of any symptom, and a thorough assessment of the role of non-drug interventions for dyspnoea is also essential. Well designed multicentre studies are urgently required to evaluate the symptomatic treatment of breathlessness, but such studies must be preceded by the development of valid and sensitive patient rated tools to assess this distressing and common symptom.
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Endocrine management is the best palliative management available for patients with carcinoma of the prostate. It is based on androgen withdrawal by castration or other means. Endocrine management was introduced into clinical medicine by Huggins and his associates in the early 1940s on the basis of careful clinical and experimental research establishing the biological effects of androgen withdrawal in animal systems and in humans. ⋯ Total androgen suppression seems to produce significantly better survival when compared with daily injections of LHRH alone. The use of pure anti-androgens or of 5 alpha-reductase inhibitors could potentially prevent the most significant side effect of all androgen withdrawal regimens, loss of libido and impotence. However, neither the use of pure anti-androgens as monotherapy nor the use of 5 alpha-reductase inhibitors as monotherapy has been shown to produce clinical results that are equal to castration.(ABSTRACT TRUNCATED AT 400 WORDS)
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Pain is a complex somato psychic experience that requires a multimodality approach to treatment. Pharmacologically, pain in cancer can be divided into opioid non-responsive, opioid partially responsive, opioid responsive (but do not use opioids) and opioid responsive (do use opioids). Three concepts govern the use of analgesics in opioid responsive pains: 'by the mouth', 'by the clock' and 'by the ladder'. ⋯ Useful alternative strong opioids include phenazocine, hydromorphone and buprenorphine. A number of controversial issues are discussed. These include the oral to parenteral potency ratio of morphine; the main site of metabolism of morphine; the relative merits of morphine and diamorphine; the risk of respiratory depression; the development of tolerance; and the risk of addiction.