Pathophysiology and treatment of opioid-related myoclonus in cancer patients.

Myoclonus occasionally occurs in the perioperative setting and in patients on chronic opioid therapy. It appears to be dose-related in a unpredictable manner. Different mechanisms have been proposed to explain the occurrence of a series of neuromuscular disturbances probably sharing final common pathways.

Dextropropoxyphene versus morphine in opioid-naive cancer patients with pain.

The role of opioids for moderate pain (so-called "weak" opioids) in the second step of the World Health Organization's analgesic ladder has been investigated in a prospective randomized study. Sixteen patients were administered dextropropoxyphene (DPP) in a dosage ranging from 120 mg to 240 mg daily (group 1), and 16 patients were administered the lowest doses (20 mg daily) of commercially available controlled-release morphine (group 2). Equianalgesic doses of oral morphine, pain relief, and symptoms during the first 10 days of therapy and during the last 4 weeks before death were assessed.

Treatment of pain in chronic bowel subobstruction with self-administration of methadone.

Chronic treatment with opioids in cancer patients with chronic intestinal obstruction is hazardous, as uncontrolled constipation may result in definitive bowel obstruction. Intermittent use of opioids adjusted for fluctuating pain levels may enable patients to take the lowest opioid doses that will have sufficient effect, with a consequently lower risk of intestinal side effects. Methadone has many pharmacokinetic characteristics that fit it for use in this clinical situation.

Opioid-sparing effect of diclofenac in cancer pain.

This study investigated the opioid-sparing effect of diclofenac using patient-controlled analgesia with oral methadone. Fifteen patients with advanced cancer participated. After achieving adequate analgesia with regular dosing of oral methadone (T1), patient-controlled analgesia with methadone was administered for 3 days (T2).

Octreotide may prevent definitive intestinal obstruction.

Partial bowel obstruction is indistinguishable from definitive obstruction at the onset of symptoms. No consensus exists regarding the treatment of potentially reversible states of bowel obstruction. On the basis of previous experience, octreotide was used in two patients with chronic intestinal obstruction, resulting in good control of intestinal symptoms and maintenance of a prolonged adequate intestinal transit, preventing the occurrence of definitive bowel obstruction.

Subcutaneous fentanyl infusion in a patient with bowel obstruction and renal failure.

Inoperable bowel obstruction in patients with renal failure is a difficult clinical situation. In the last days of life, an accumulation of morphine metabolites in patients with impaired renal function may cause opioid toxicity, including terminal agitation. The use of an alternative drug may prevent morphine metabolite accumulation in uremic patients.

The inappropriate use of the epidural route in cancer pain.

There continues to be controversy concerning the optimal use of the epidural route in cancer pain. Although spinal opioids undoubtedly give long-lasting analgesia with low doses, indiscriminate use cannot be recommended. Inappropriate indications for the epidural route are reported in three patients who required home palliative care.

Monitoring of opioid therapy in advanced cancer pain patients.

Until now, there have not been any parameters to monitor opioid therapy in cancer patients with pain. In this study, 325 consecutive advanced cancer patients were scheduled for a prospective longitudinal survey. After exclusions, 67 patients were surveyed.

Methadone in cancer pain.

Methadone is often considered as a second-choice drug alternative to morphine in cancer pain treatment. A lack of information regarding methadone's pharmacokinetic/pharmacodynamic relationships has contributed to limitation in its use in analgesic treatments. However, it has been recently re-evaluated in light of better knowledge of its pharmacological characteristics and wider experience.

Malignant bone pain: pathophysiology and treatment.

The presence of bone metastases predicts the presence of pain and is the most common cause of cancer-related pain. Although bone metastases do not involve vital organs, they may determine deleterious effects in patients with prolonged survival. Bone fractures, hypercalcaemia, neurologic deficits and reduced activity associated with bone metastases result in an overall compromise in the patient's quality of life.

The SAMOT supportive care programme in southern Italy.

Since 1988 a palliative care programme has been in development in Palermo, a large town in Southern Italy. The main objective is to provide home palliative care in conditions in which no other facility exists to meet the needs and reduce the distress of terminal cancer patients. This programme has been implemented and extended to other cities and villages in Sicily.

Patient-controlled analgesia with oral methadone in cancer pain: preliminary report.

Background: Methadone is a very useful drug in cancer pain because of its low cost, lack of active metabolites, high oral availability, and the rapid onset of its analgesic effect. It seems to be well tolerated in patients with difficult pain syndromes who are receiving high doses of opioids, and it may deter the development of tolerance, but a high individual variation in terminal elimination half-life can result in different rates and extents of drug accumulation. For this reason, oral patient-controlled analgesia with methadone was used in 24 advanced-disease patients with pain.

Ketamine in cancer pain: an update.

Ketamine has been shown to have potent analgesic properties at low dosages. Bioavailability is high when it is given parenterally, but low after oral or rectal administration. Active metabolites should account for part of the analgesic effect of ketamine during long-term oral administration.

Cancer pain knowledge in Southern Italy: data from a postgraduate refresher course.

A survey of Italian physicians was conducted to assess knowledge, attitudes, and beliefs on cancer pain. Physicians attending a refresher course on cancer pain and symptom relief were given a questionnaire composed of 28 questions before starting the lectures. The physicians represented the different centers treating cancer pain, or were going to deal with cancer pain, and were from all the provinces of Sicily, a southern region of Italy.

A circular diagram for representing symptom status in advanced cancer patients.

Symptom relief is the major goal of palliative care. Its assessment is essential and several methods have been described. To evaluate immediately the clinical situation, a circular diagram for a visual representation of the physical symptoms is proposed.

Nutrition in cancer patients.

Many factors can modify nutritional status in cancer patients, including cachexia, nausea and vomiting, decreased caloric intake or oncologic treatments capable of determining malabsorption. Cachexia is a complex disease characterized not only by a poor intake of nutrients or starvation, but also by metabolic derangement. Nausea and vomiting may limit the nutrient intake and are most often the consequences of oncologic treatments or opioid chronic therapy.

Propofol in terminal care.

In advanced cancer patients close to death, delirium, multifocal myoclonus, and restlessness may occur. Multi-organ failure and related metabolic changes are mostly responsible for these symptoms. A pharmacologic approach to manage the delirium is necessary in the majority of cases.

Long-term ketamine subcutaneous continuous infusion in neuropathic cancer pain.

Neuropathic cancer pain may be less responsive to opioids than other pain. Several studies suggest that N-methyl-D-aspartate (NMDA)-receptor antagonists could play a role in the treatment of neuropathic pain. Ketamine is an NMDA-receptor antagonist that is used as an anesthetic and has been suggested as a useful drug for neuropathic pain.

Parenteral nutrition at home in advanced cancer patients.

There is controversy regarding the utility of parenteral nutrition in advanced cancer patients. In selected populations, such as those with digestive tract cancers, death may result from the absence of oral intake and not progression of disease. In some cases, patients and relatives request that artificial nutrition begun in the hospital continue after discharge.

Suprascapular nerve block by catheter for breakthrough shoulder cancer pain.

Background And Objectives: Incidental shoulder pain due to movement renders pain control difficult because it requires high basal dosages or additional doses of opioids. Shoulder pain can be alleviated by suprascapular nerve block, and the placement of a catheter can permit the injection of local anesthesia as needed.

Methods: In a patient with lung cancer and continuous chest pain well controlled by opioids but with shoulder breakthrough pain necessitating extra doses of opioids, a suprascapular nerve block was performed via an indwelling catheter.