Errors in opioid prescribing: a prospective survey in cancer pain.

Context: Cancer pain is debilitating and has multidimensional consequences. It can be treated adequately in up to 90% of patients by following pain management guidelines. Nevertheless, inadequate pain control remains a global problem.

Cancer symptom clusters: old concept but new data.

Individuals with cancer have multiple symptoms, which frequently co-occur. A nonrandom distribution of symptoms suggests a common mechanism. Symptom clusters (SCs) were considered part of various syndromes in the early years of medicine.

The cancer anorexia-cachexia syndrome: myth or reality?

Background: Controversy exists as what constitutes the cancer anorexia-cachexia syndrome (CACS), and whether it truly is a distinct clinical disorder. In this study, we aimed to: (1) assess if CACS is a distinct clinical disorder, (2) identify the symptoms characteristic of CACS, (3) evaluate CACS impact on patient outcomes (symptom burden and survival time from referral).

Methods: Consecutive patients referred to palliative medicine were assessed by 38-symptom questionnaire.

The intravenous to oral relative milligram potency ratio of morphine during chronic dosing in cancer pain.

Morphine (M) is the opioid analgesic of choice for severe cancer pain. The IV to PO M equipotent switch ratio (CR) is controversial. We designed this prospective observational cohort to confirm the efficacy and safety of M IV to PO CR of 1:3.

Validation of a simplified anorexia questionnaire.

Context: Anorexia is a common symptom in cancer and is usually assessed by multiple questions and multidimensional questionnaires. A simplified questionnaire would be less burdensome to patients and abbreviate the process.

Objectives: We compared the reliability at one point in time, sensitivity to change over time, and prognostic accuracy of a two-item questionnaire with the Functional Assessment of Anorexia and Cachexia Therapy shortened 12-question version (A/CS-12).

Opioid equianalgesic tables: are they all equally dangerous?

Pain is one of the most common symptoms in cancer patients. Opioids are widely prescribed for this and other purposes. Properly used, they are safe, but they have serious and potentially lethal side effects.

Visual analogue scales and assessment of quality of life in cancer.

Assessment of quality of life (QOL) in cancer clinical trials is important when comparing treatments, especially when prolonged survival is not expected. QOL scores may reflect physical or psychosocial functioning or distress. The choice of QOL instrument depends upon the definition, research hypothesis, cancer population, depth and sensitivity of information required, and frequency of measurement.

Strategies for pain management: cleveland clinic foundation guidelines for opioid dosing for cancer pain.

Pain remains the most common distressing symptom in advanced cancer. Opioids are the most effective drugs for pain currently available. Analgesia depends largely on appropriate administration.

The cough from hell: diazepam for intractable cough in a patient with renal cell carcinoma.

Cough is a common symptom in cancer. Its underlying cause should be managed when identified; otherwise, empiric treatment is the mainstay of symptom control. Cancer-related cough usually responds to radiation therapy, an opioid, or benzonatate, a peripheral anesthetic.

Oral nabilone capsules in the treatment of chemotherapy-induced nausea and vomiting and pain.

Background: Nabilone has been approved to treat chemotherapy-induced nausea and vomiting. Recent studies have explored cannabinoids in pain management.

Objectives: To review the evidence for the use of cannabinoids in general and nabilone in particular; i) in managing chemotherapy-induced nausea and vomiting; and ii) in treating pain.

Practical guide to opioids and their complications in managing cancer pain. What oncologists need to know.

Approximately 60% of cancer patients experience pain, and 25% to 30% have severe pain. With some cancers, opioids will be needed before chemotherapy begins and may be more frequently prescribed than chemotherapy. Given the frequency with which pain management is necessary in cancer patients, all oncologists should be familiar with opioid prescribing principles.

Cholestasis and endogenous opioids: liver disease and exogenous opioid pharmacokinetics.

A class of endogenous opioids is upregulated in liver disease particular to cholestasis, which contributes to symptoms in liver disease such as pruritus, hypotension and encephalopathy. Symptoms associated with cholestasis are reversed or at least ameliorated by mu opioid receptor antagonists. Palliation of symptoms related to cholestatic liver disease also involves bile acid binding agents.

All patient refined-diagnostic related group and case mix index in acute care palliative medicine.

The All Patient Refined-Diagnostic Related Group (APR-DRG) is a modification of the traditional DRG that adds four classes of illness severity and four classes of mortality risk. The APR-DRG is a more accurate assessment of the complexity of care. When individuals with advanced illness are admitted to an acute inpatient palliative medicine unit, there may be a perception that they receive less intense acute care.

Acute inpatient palliative medicine in a cancer center: clinical problems and medical interventions--a prospective study.

The clinical characteristics and medical interventions of the 100 consecutive cancer admissions to the acute care inpatient palliative medicine unit at the Cleveland Clinic for 2 months are described. Median age was 62 years (range, 31 to 92 years). The male-female ratio was 1:1.

Respiratory function during parenteral opioid titration for cancer pain.

Background: Respiratory depression is the most feared opioid-related side-effect yet research on the topic is sparse. We evaluated changes in respiratory parameters during parenteral opioid titration for cancer pain to determine if opioid titration was associated with evidence of hypoventilation. The primary outcome measure was to measure changes in end-tidal CO(2) (ET-CO(2)) during opioid titration to pain control.

Deaths in an academic medical center.

The number of inpatient deaths in a calendar year in an academic medical center was reviewed from a computerized database. The total number was 1222. The median length of hospital stay for those who died was 7 days (range, 1-190); 404 (33%) were 75 years or older.

The pharmacological importance of cytochrome CYP3A4 in the palliation of symptoms: review and recommendations for avoiding adverse drug interactions.

Background: Adverse drug interactions are major causes of morbidity, hospitalizations, and mortality. The greatest risk of drug interactions occurs through in the cytochrome system. CYP3A4, the most prevalent cytochrome, accounts for 30-50% of drugs metabolized through type I enzymes.

The emerging role of cannabinoid neuromodulators in symptom management.

Introduction: The cannabinoids nabilone (Cesamet) and dronabinol (Marinol) are indicated for the management of chemotherapy-induced nausea and vomiting (CINV) in cancer patients who have failed to respond adequately to conventional antiemetic therapy.

Discussion: The endocannabinoid (CB) system interacts with numerous other systems and pharmaceutical cannabinoids target ubiquitous CB1 and CB2 receptors in the central nervous system and periphery, relieving nausea and vomiting and pain.

Summary: The benefits of this novel class of medications in cancer may extend beyond CINV, as indicated by data from preclinical studies and animal models.

Does trazodone have a role in palliating symptoms?

Introduction: Trazodone is a unique antidepressant, which blocks the postsynaptic serotonin (5-HT) receptors, 5-HT(2A) and 5-HT(2C), and weakly inhibits presynaptic 5-HT transporters.

Discussion: Trazodone is well-absorbed by the mouth and is metabolized by three cytochromes: CYP1A2, CYP2D6, and CYP3A4. Clinical benefits include reduced insomnia in those depressed and/or on antidepressants.

What is new in neuropathic pain?

Introduction: Neuropathic pain occurs in 1% of the population and is difficult to manage. Responses to single drugs are limited in benefit. Thirty percent will fail to respond altogether.

Parenteral morphine prescribing patterns among inpatients with pain from advanced cancer: a prospective survey of intravenous and subcutaneous use.

Prescribing patterns for parenteral morphine for symptom control in advanced cancer were studied in 50 consecutive hospital admissions (27 men, 23 women, median age, 62 years). Patients were interviewed daily (median time, 9 days) concerning analgesia while they were receiving parenteral morphine. Five major inpatient prescribing patterns were identified: (1) intravenous to oral, (2) intravenous to subcutaneous, (3) intravenous only, (4) subcutaneous only, and (5) mixed.

The adverse effects of morphine: a prospective survey of common symptoms during repeated dosing for chronic cancer pain.

Little information is available about the incidence, prevalence, or severity of morphine side effects during repeated individualized dosing for chronic cancer pain, although it has been widely used in this way for more than 30 years. The authors' aim was to describe the prevalence of symptoms possibly attributable to morphine side effects in a convenience sample of patients with pain due to advanced cancer. They used a prospective survey of inpatients and outpatients on regularly dosed morphine, with a questionnaire administered weekly for 4 weeks.

Management of fatigue in cancer patients.

Cancer-related fatigue (CRF) is either a symptom or a syndrome depending on criteria for diagnosis. CRF is present in 20% to 30% of long-term cancer survivors and 80% to 90% during treatment and at the end of life. Assessment requires determining the presence, severity, and interference with daily activities.