The July issue of Palliative Medicine
features22 systemic reviews of topics relating to opioid treatment in cancer
pain. This was done as part of updating the European Association for Palliative
Care guidelines. As the editorial by Drs. Kassa and Haugen suggests, even with
the advances in pain research in recent years, there is still a great need for
systematic research in pain.
Here are some of the findings that confirm the current
guidelines:
- Morphine is an effective opioid, yet there are no adequate
comparisons among morphine, oxycodone and hydromorphone to suggest whether one
is superior to another.
- Transdermal opioids have been studied as first-line therapy for
moderate to severe pain, yet the power of the studies and benefit is lacking
compared with oral morphine. There is a suggestion of lower gastrointestinal
adverse effects (nausea, vomiting and constipation) with transdermal
opioids.
- Research in opioid switching strategies to improve pain control or
reduce adverse effects is lacking randomized trials, but these strategies may
help some patients.
- The conversion ratio from opioid to oral methadone for pain relief
remains controversial. A range of 5:1 to 10:1 is advised. Checking an
electrocardiogram before starting methadone for long-term pain relief is
advised.
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Biren Saraiya
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The July issue of the Journal of Palliative
Medicine highlighted a single-institution study of a subcutaneous
implantable pleural port for managing recurrent malignant pleural effusion in
168 patients. Researchers from Institut Curie in Paris reported that more than
97% of patients reported complete or partial relief of symptoms from dyspnea.
Spontaneous pleurodesis was reported in nearly 37% of patients. Six
complications, including three infections and three mechanical complications,
were noted.
This work builds on a previous report from the
University of California, Davis, in 2009 published in the same journal. In that
report, researchers reviewed their experience with subcutaneous pleural and
peritoneal ports. Retrospective chart reviews and patient-clinician interviews
for quality of life, convenience and comfort with the port were reported.
Thirty patients receiving home nursing care or hospice had ports implanted.
Both patients and clinicians reported an improved high degree of convenience,
improved symptoms and comfort with aspiration. One of the 30 ports had to be
removed due to symptoms.
Thus, subcutaneous implantable pleural ports may provide
an additional mechanism to help patients with malignant pleural effusion
besides the existing mechanism such as repeat thoracentesis, pleurodesis
through chest tube or with video-assisted thoracic surgery (VATS) or PleurX
catheter implantation.
For more information:
- Kaasa S. Palliat Med. 2011; 25:392-393.
- Kriegel I. J Palliat Med. 2011;14:829-834.
- Monsky WL. J Palliat Med. 2009;12:811-817.