The goals of this paper are to (1) provide a brief overview of palliative care, including its purpose and philosophy and how hospice care fits under the larger palliative care umbrella; (2) introduce pain assessment in patients with life-limiting illnesses; and (3) review pain management strategies in palliative care, with a focus on pharmacotherapy. Palliative care is a specialized field of medicine focused on providing patient- and family-centered care for those with life-limiting illnesses at any stage of their disease trajectory. When patients approach their end of life and the focus of care becomes comfort and quality of life, the decision may be made to enter hospice care. Pain management is an essential aspect of palliative and hospice care. An effective pain assessment should help elucidate the cause and type of pain, guiding selection of therapy. Options for treating pain may include nonpharmacological approaches such as physical therapy, interventions such as nerve blocks, and pharmacotherapy. Opioids are the mainstay of pain pharmacotherapy in palliative care, although, depending on patient-specific factors, nonopioids or adjuvant agents may be used instead of or in addition to opioids. Safe and effective pain medication use in serious illness requires careful consideration of which agents should be most effective and well tolerated; clinicians should also be prepared to anticipate and respond to medication adverse effects. Because of the outsized importance of safe and effective medication management to treat pain in patients with life-limiting illnesses, pharmacists are particularly well suited to intervene and help guide appropriate therapy.
Managing patients with chronic non-cancer pain (CNCP) in outpatient healthcare is challenging. Long-term opioid therapy is an option for treatment responders with guideline recommended indications. However, opioid use poses risks of severe side effects, including misuse, and therefore needs to be integrated into a high-quality healthcare process. This analysis evaluates the association between healthcare quality according to the evidence-based Chronic Care Model (CCM) in the treatment process of patients receiving long-term opioid therapy for chronic back and/or arthrosis pain, and patient-related or healthcare related variables. A cross-sectional patient survey was sent to a random sample of 3,037 individuals with long-term opioid therapy and chronic back and/or arthrosis pain insured by a large nationwide German statutory health insurance. Healthcare quality according to the CCM was assessed by the Patient Assessment of Chronic Illness Care (PACIC-5A) questionnaire. Internal reliability of the assessment instrument was determined using Cronbach's α. Descriptive analysis of the outcome scales were conducted, alongside subgroup analyses considering patient characteristics, patient's health situation, and pain treatment aspects. Testing for statistical significance was performed by Mann-Whitney U test and Kruskal-Wallis test. Effect sizes, namely Eta and Spearman's Rank correlation coefficient, were calculated. The analysis included 661 individuals. Participants were predominantly female (76%) with an average age of 69 years (SD 12.5). PACIC-5A score ratings across all (sub)scales were low, with a summary score rating of 2.4 (on a scale ranging from 1 (worst) to 5 (best)). Positive correlations with treatment quality were observed in the subgroup analysis concerning guideline-compliant pain treatment aspects such as setting therapy goals or a comprehensive treatment concept. Patient characteristics showed little to no correlations, except for a positive correlation between higher PACIC-5A rating and both lower age and higher education. Patient's health situation presented a mixed picture, with no clear correlation between pain intensity/impairment, and PACIC-5A scores. The provision of healthcare for patients with long-term opioid therapy for CNCP seems to be inadequate according to the CCM. Guideline-recommended pain treatment aspects exhibited a positive correlation with healthcare quality according to CCM. Enhancing the implementation of the CCM in the outpatient healthcare process may improve healthcare quality. German Clinical Trials Register, DRKS00024854. Registered 04/28/2021.
Patients with advanced cancer often experience severe symptoms that significantly impact their quality of life, leading to frequent emergency department visits for pain management. These visits not only diminish patient quality of life, but also impose substantial costs on the healthcare system. While palliative care (PC) has been shown to improve quality of life in cancer patients, its impact on reducing ED utilization for pain remains unclear. This study aimed to evaluate the relationship between PC and ED utilization for pain management in advanced cancer patients within a large integrated healthcare system. We conducted a retrospective cross-sectional study involving adults aged 18 + diagnosed with stage IV cancer who died within 1 year of diagnosis, stratified by outpatient PC enrollment. Data were obtained from the Kaiser Permanente Northern California database, from January 1, 2015, to June 30, 2022. Multivariable Poisson regression models were used to analyze the prevalence of any opioid use during ED visits and cumulative ED visits with opioid use, adjusting for socio-demographics, clinical characteristics, and high-dimensional propensity scores. The study included 4739 stage IV cancer patients with a total of 12,727 ED visits during their final year of life. Of these, 2243 (47%) received PC. Patients receiving PC had a 24% to 31% lower prevalence of any opioid administration during ED visits across different models, adjusting for baseline characteristics. Additionally, PC was associated with lower cumulative number of ED visits with opioid administration (PRR 0.83, 95% CI, 0.77-0.89). Our study highlights the significant role that PC can play in reducing ED utilization for pain management needs among advanced cancer patients, improving quality of life and alleviating healthcare burdens. These findings underscore the importance of prioritizing access to PC and future research should focus on prospective studies to further explore the causal relationships and optimize PC delivery across diverse healthcare settings.
Head and neck cancers (HNC) significantly impact patients' quality of life (QOL), with oral health often being significantly compromised, especially in advanced stages. Green tea, with its known anti-inflammatory and antioxidant properties, may help to improve oral health in these patients. Therefore, this study aims to investigate the effect of green tea-based mouth rinse on oral health status, pain, and QOL of advanced HNC patients. This randomized controlled trial was conducted in the palliative care outpatient department of a tertiary hospital in New Delhi. Then, 64 patients with stage III/IV HNC receiving palliative care were randomly assigned to the experimental and control groups. In addition to usual care, the experimental group used a green tea-based mouth rinse thrice daily for 6 weeks. The study examined oral health status as the primary outcome, which was assessed at baseline and every 2 weeks up to 6 weeks using the Oral Assessment Guide (OAG) and Oral Hygiene Index-Simplified (OHI-S). The secondary outcomes pain and quality of life of the patients were assessed using the Numerical Pain Rating Scale and Oral Health Impact Profile-14 (OHIP-14), respectively. Repeated measure ANOVA revealed that experimental group had significantly improved OAG-score (F = 34.32, P = < 0.001, ŋp2 = 0.39) and OHI-S-score (F = 5.67, P = < 0.001, ŋp2 = 0.11) over time. However, any significant between-group difference is not found in terms of pain (P = 0.73) and QOL (P = 0.34). Green tea-based mouth rinse was found to be effective in improving the oral health status of advanced HNC patients. Nurses should incorporate such cost-effective options to improve the oral health of cancer patients. The trial had been registered under the Clinical Trial Registry of India on 17/05/2024. (Registration No: CTRI/2024/05/067571).
Oncology services in the Gaza Strip have been severely disrupted by the ongoing war since 2023. Therefore, the region provides a crucial example for understanding how pain affects health-related quality of life (HRQoL), psychological distress, and spiritual well-being under extreme conditions. We conducted a cross-sectional study of 349 adult cancer patients attending the three operational outpatient cancer clinics in Gaza (July-August 2025). Data were collected using convenience sampling and employed the validated Arabic versions of the Brief Pain Inventory-Short Form (BPI-SF), the EORTC QLQ-C30, the PHQ-4, and the FACIT-Sp-12. Patients with a BPI-SF worst pain score ≥ 4 were classified as "having pain." Analgesic adequacy was assessed using the Pain Management Index (PMI). Group comparisons between patients with and without pain were performed using Mann-Whitney U and Chi-square tests, and associations were assessed using Spearman's rank correlation. Mediation analyses were conducted to test whether psychological distress mediated the relationship between pain and both spiritual well-being and global health status (QLQ-C30 GHS), using ordinary least squares regression with 2,000 bootstrap resamples, adjusting for age, sex, and income. Among participants, 53.6% reported having cancer pain. Pain undertreatment was common: 41% of all participants were inadequately managed, and only about 10% received strong opioids. Those experiencing pain had markedly poorer HRQoL, with lower scores in global health status and functional domains and worse financial difficulties (all p < 0.001), along with substantially higher symptom burdens, including fatigue, nausea, insomnia, and appetite loss. Psychological distress was greater among patients with pain (PHQ-4 median 4.0, IQR 3.0-7.0, vs. 2.5, IQR 0.0-5.0; p < 0.001), with over one-third experiencing moderate-to-severe distress compared to about one-fifth without pain (35.8% vs. 21.0%). Spiritual well-being was also worse (FACIT-Sp: 32.0 vs. 38.0, p < 0.001), with lower scores on meaning, peace, and faith. Pain intensity correlated positively with psychological distress (ρ = 0.36, p < 0.001) and negatively with spiritual well-being (ρ = -0.37, p < 0.001), while psychological distress and spiritual well-being were strongly inversely related (ρ = -0.69, p < 0.001). Mediation analyses suggested that psychological distress may partially account for the association between pain and spiritual well-being (indirect effect = - 0.51, 95% CI - 0.68 to - 0.35; 56% of the total effect), and, to a lesser extent, the association between pain and global health status (indirect effect = - 1.01, 95% CI - 1.40 to - 0.66; 26% of the total effect). Cancer patients in Gaza face significant multidimensional suffering, including undertreatment, poor HRQoL, and inadequate pain management. These findings underscore the pressing need for integrated pain, psychosocial, and palliative care services, as well as international efforts to safeguard healthcare services and ensure access to essential medicines in conflict zones.
Germany is among the countries with the highest per capita consumption of opioid analgesics, which are mostly applied for chronic non-cancer pain (CNCP). The high-quality guideline LONTS, which is not disease-specific, gives treatment recommendations for long-term opioid therapy. Our aim was to explore physicians' knowledge of and their attitude towards this guideline, as well as their perception of the guideline's impact. A cross-sectional survey was conducted in September 2021 and a reminder sent out in January 2022. A standardized questionnaire was circulated among 1,854 physicians working in outpatient healthcare. The sample consisted of a random sample of primary care physicians, orthopedists, and neurologists from the pool of an address provider (n = 1,300), as well as the members of the Professional Association of Physicians and Psychological Psychotherapists in Pain and Palliative Medicine in Germany ("Berufsverband der Ärzte und Psychologischen Psychotherapeuten in der Schmerz- und Palliativmedizin in Deutschland", BVSD) (n = 554). The questionnaire was completed by 422 physicians. The majority of physicians was older than 50 years (79%) and male (64%). One third of the participating physicians were primary care physicians (33%), 46% were anesthetists. A majority of the participants knew the LONTS guideline (83%). Their attitude towards following the LONTS guideline recommendations varied between "rare deviation in reasonable cases" (41%) and "regular deviation in reasonable cases" (52%). Though a majority of participating physicians (78%) thought that multimodal non-pharmaceutical treatment, as recommended by the LONTS guideline, is important, only 17% regarded it as being implementable. The level of knowledge and implementation of the LONTS guideline fell within the range of other guidelines. The recommendation for multimodal non-pharmaceutical treatment accompanying long-term opioid therapy was considered important but unrealistic in current healthcare practice.
Of the 11.9 million Americans living with cancer, 44% experience cancer-related pain. High-dose opioids remain the mainstay of treatment but often reduce quality-of-life (QoL) due to side effect burden, and 40% of patients do not achieve adequate analgesia. Intranasal ketamine offers analgesia without the dose-limiting gastrointestinal or respiratory effects of opioids. It's intranasal formulation allows easier self-administration. This case series highlights the adverse effects of self-administered intranasal ketamine. Describe the impact of self-administered intranasal racemic ketamine on adverse effects, pain intensity, and perceived QoL in patients with cancer-related pain. Three patients followed by palliative care and pain medicine services at a tertiary academic center were prescribed intranasal racemic ketamine. Pain scores, opioid consumption (oral morphine equivalents (OME), and adverse effect burden were summarized from clinical encounters. All three patients reported analgesic benefit, including reductions in OME up to 90%. Despite this, each patient developed adverse effects: fatigue, cognitive slowing, and dissociation warranting termination of therapy. Treatment duration ranged from 1 to 8 months with dosing from 50 mg TID to 100 mg QID. Intranasal ketamine may reduce opioid requirements in cancer-related pain, but adverse effects can limit tolerability. Future research should identify high-risk patients and develop risk mitigation strategies. Many people living with cancer have severe, ongoing pain. Opioid pain medicines (like morphine or oxycodone) can help, but they often cause side effects such as sleepiness and constipation, and they do not work well for everyone. Ketamine is another medicine that can ease pain. It can be taken as a nose spray (“intranasal ketamine”), which patients can use at home.We describe three adults with cancer whose doctors prescribed intranasal ketamine. All three had long-standing pain despite opioid treatment.All three patients reported less pain and needed fewer opioids after starting ketamine.Opioid dose reductions ranged from substantial to very large (for example, from 135 mg to 15 mg of morphine-equivalents per day; another patient reduced from 498 mg to 240 mg).Doses of ketamine ranged from 50 mg three times daily to 100 mg four times daily; treatment lasted 4 weeks to 8 months.All three patients developed side effects that led them to stop using ketamine.Reported issues included fatigue and slowed thinking, and “dissociation” (feeling detached or “spacey”).One patient began taking extra doses for the brief euphoric, good, feeling, raising concern for misuse/addiction and causing self-harmful behaviors.Intranasal ketamine can reduce cancer pain and opioid use, but it can also cause side effects that disrupt daily life or relationships, and it may be misused. Because many ketamine products are not FDA-approved and home use is unsupervised, careful patient selection, close monitoring, and family input are essential. More research should identify who benefits most and who is at higher risk of harm.
Cancer pain distresses pediatric patients, affects quality of life, and is a psychological burden for families. The purpose of this study was to clarify the role of pharmacists in assisting children with cancer pain and their families. Between February and May 2024, a nationwide questionnaire survey was conducted among hospital pharmacists from the Japanese Society for Pharmaceutical Palliative Care and Sciences. The survey examined pharmacist involvement with children <15 years of age with cancer pain and their families, particularly in pain assessment, explaining analgesic use, and managing psychological, social, and spiritual pain. Of 2,720 pharmacists, 219 (8.1%) responded, 57 of whom (26.0%) had pediatric palliative care experience. Most pharmacists performed pain assessments, provided analgesic explanations (86.0%), and intervened in psychological, social, and spiritual pain (54.4%). Among those who intervened, more than 90% either communicated with patients and their families or listened to their concerns. Pharmacists with ≥5 years of experience were significantly more involved in psychological, social, and spiritual pain than were those with <5 years of experience (odds ratio, 3.46; 95% confidence interval, 1.04-11.54). However, most pharmacists reported difficulties in pain assessment and providing analgesic explanations; the main reasons were "due to patient age and comprehension" (87.0%) and "reluctance to initiate opioid analgesics by patients or their families" (68.3%), respectively. Pharmacists were actively engaged in pain management for children with cancer and their families. However, most reported difficulties, particularly in pain assessment and analgesic explanations. Therefore, educational programs should be developed to facilitate effective pain management.
Over half of patients with advanced or recurrent esophageal cancer experience malnutrition, psychological distress, and cancer-related pain, which impair immune function, diminish quality of life, and attenuate responses to immunotherapy. Whether a precision palliative care (PC) model that integrates nutritional, psychological, and symptomatic support can improve survival and quality of life in these patients undergoing anti-PD-1/PD-L1 immunotherapy remains unknown. We are conducting a multicenter randomized trial to evaluate the superiority of a precision PC model compared with standard oncology care in improving patients' overall survival (OS). All patients will be randomly assigned to either the Standard Arm (standard oncology care)or the Precision Arm (standard oncology care + precision PC). Patients in the Standard Arm receive anti-PD-1/PD-L1 immunotherapy-based standard oncology care. Patients assigned to the Precision Arm receive anti-PD-1/PD-L1 immunotherapy-based standard oncologic care and precision PC, in which patients meeting any of the following criteria are stepped up to meet with the precision PC clinicians every 4 weeks: (1) malnutrition (NRS2002 ≥ 3 or meeting GLIM criteria), (2) psychological distress (GAD-7 ≥ 5 or PHQ-9 ≥ 5), or (3) moderate-to-severe symptoms (any MDASI symptom score ≥4). The primary endpoint is overall survival (OS). The secondary endpoints are quality of life and progression-free survival (PFS).Clinical trial registration: NCT06787313 (clinicaltrials.gov). Immunotherapy is the standard treatment for people with advanced esophageal cancer. But many patients also face other problems during treatment – like not getting enough nutrition, feeling very anxious or sad, or dealing with physical pain. These issues can hurt their overall health and may even make the immunotherapy work less well. We know that giving extra support early can help. But there are not enough trained experts to provide this kind of care to every patient who needs it. To solve this problem, we created a new study to test a program called “precision palliative care.” The goal is to see if this program can help patients live longer and feel better. The study will have 624 patients. There are two groups: one group will get standard cancer treatment only and the other group will get standard treatment plus the new support program. In the second group, a team of specialists – including doctors, dietitians, and psychologists – will regularly check how each patient is doing. They will look at nutrition, emotions, and symptoms like pain. If a patient is struggling in any of these areas, they will get help right away. The main goal is to find out if this personalized support helps patients live longer than those who only get standard treatment. The results will help doctors understand the best way to support people going through immunotherapy for esophageal cancer.
Opioid prescribing at the end of life varies widely across clinical contexts, yet real-world evidence from Asian advanced cancer populations remains limited. This study characterized end-of-life opioid prescribing patterns and examined differences according to palliative care consultation status. We conducted a retrospective cohort study using tertiary hospital clinical records linked to Korean National Health Insurance claims data. Patients with advanced cancer who received a palliative care consultation were matched 1:1 with those without consultation using propensity scores. Opioid prescribing during the last 30 days of life was evaluated, including time-specific patterns across three intervals (30-15, 14-8, and 7-0 days before death) and opioid strength (strong vs. weak). Among 18,048 eligible patients, 3,742 were matched in each group. Opioid prescriptions were more common among patients who received palliative care, with the largest differences observed 30-15 days before death and narrowing toward the final week. Strong opioid use remained consistently higher in the palliative care group across all intervals, whereas weak opioid use showed minimal variation. Differences were most pronounced in older adults and in stomach, colorectal, and pancreatobiliary cancers. Patients who received a palliative care consultation showed different patterns of end-of-life opioid prescribing, especially for strong opioids. Understanding such variation may support ongoing efforts to improve symptom management near the end of life.
Resistant cancer pain (RCP) remains a challenge in oncology, affecting patients whose pain persists despite guideline-based treatment. While advancements in pharmacological and interventional strategies have improved cancer pain management, barriers such as opioid access restrictions, provider knowledge gaps, and underutilization of specialized pain interventions contribute to inadequate relief. Understanding the epidemiology, classification, and risk factors for RCP is essential for improving treatment. This review examines the prevalence, pathophysiology, and burden of RCP, highlighting its impact on quality of life and healthcare systems. Pain severity is commonly assessed using numerical rating scales, but comprehensive frameworks like the Edmonton Classification System for Cancer Pain (ECS-CP) provide better insight into complex pain syndromes. Breakthrough pain, neuropathic pain, and cancer-induced bone pain are frequently linked to treatment resistance. While opioids remain central to pharmacological management, many patients require multimodal approaches, including adjuvant analgesics, interventional procedures, and radiation therapy. Neurosurgical options such as cordotomy, intrathecal drug delivery, and myelotomy offer pain relief in select cases but are underutilized due to limited awareness and training. RCP remains a major unmet medical need, affecting many cancer patients despite advances in pain management. Effective treatment requires a multimodal, individualized approach integrating pharmacological, interventional, and neurosurgical strategies. While neurosurgical interventions provide substantial relief in selected patients, their use is often limited by referral delays and lack of provider awareness. Overcoming systemic barriers, refining pain classification, and expanding access to specialized pain management are essential to improving RCP care.
China has the highest global burden of new cancer diagnoses and cancer-related mortality, with approximately 60%-85% of patients with advanced malignancies experiencing moderate-to-severe pain. Although the WHO's analgesic ladder is widely implemented, approximately 20% of cancer-related pain remains refractory. This persistent pain is often further complicated by opioid-induced side effects and the risk of opioid use disorders. Methadone, a potent opioid with distinct pharmacokinetic and pharmacodynamic properties, has shown potential in managing refractory cancer pain; however, there is a lack of standardised and evidence-based protocols for methadone conversion, particularly in patients requiring high-dose opioids. This multicentre, open-label randomised controlled trial will enrol 164 Chinese patients with cancer and oral morphine equivalent daily dose requirements of ≥300 mg. Participants will be randomised to receive either the 3 day switch (3DS) strategy or the National Comprehensive Cancer Network (NCCN)-recommended methadone conversion method. The primary endpoints include time to stable analgesia, methadone conversion efficiency and overall pain relief rate. Secondary endpoints will evaluate pain intensity, frequency of breakthrough pain, corrected QT interval changes, incidence of adverse events and health-related quality of life. This trial is designed to generate high-quality clinical evidence to inform methadone conversion strategies for patients with refractory cancer pain who are dependent on high-dose opioids. By addressing existing gaps in clinical practice and pharmacoeconomic decision-making, the study aims to support the development of standardised methadone protocols. This study was approved by the Medical Ethics Committee of Zhejiang Cancer Hospital (approval number: IRB-2024-314(IIT)) on 3 April 2024 and registered with the Chinese Clinical Trial Registry (ChiCTR2400085332) on 5 June 2024. The outcomes will be disseminated through national and international presentations and peer-reviewed publications. ChiCTR2400085332.
Human immunodeficiency virus (HIV) was historically considered a terminal illness. However, medical advancements, including antiretroviral therapy (ART), have extended the lifespan of people with HIV (PWH), emphasizing the importance of maximizing quality of life (QoL) in this aging population. These populations face unique health challenges due to various structural and environmental barriers, and comorbidities. This review aims to consolidate recent data on pain management and other palliative needs in older people with HIV (OPWH). Recent research developments focus on providing relief by incorporation of geriatric and palliative care (PC) principles, use of long-acting injectable-antiretroviral therapies (LAI-ARTs), cannabinoids, exercise and self-management interventions, and tailored cognitive-behavioral therapy (CBT) for older people with HIV (OPWH; ≥50 years). The potential of these novel interventions can fulfil the needs of this underserved demographic suffering from a niche subset of physical and psychosocial issues. Yet, there remains variability in access to these services, with disparities often linked to healthcare infrastructure and socioeconomic factors. Interventions for an aging population of PWH should take a person-centered approach, balancing different priorities and exploring multiple avenues for symptom relief.
Managing osteoarthritis aims to relieve pain, improve joint function and quality of life. Current guidelines recommend combining non-drug and pharmacological approaches. A non-medication solution integrating an endorphin-stimulating millimeter wave device, mobile application, and coaching program was evaluated. This combined approach is evaluated in a real-world evidence study over three months in patients with osteoarthritis-related pain. The primary endpoint was patient-perceived change at three months using the Patient Global Impression of Change (PGIC). Secondary outcomes, assessed at baseline and three months, included pain intensity (mean and maximum), frequency of pain crises, quality of life, sleep, mental health, and medication use. Among 156 participants completing follow-up, 80.1% reported improvement (PGIC > 4). Quality of life improved by 29.8%, while sleep and mental health improved by 13.1% and 13.5%, respectively. Mean and maximum pain intensity decreased by 33.9% and 33.1%. Pain crises became less frequent, and patients reported reduced medication use. These results align with recent randomized controlled trial findings, supporting millimeter wave neuromodulation as an innovative, non-drug strategy targeting both nociceptive and nociplastic pain mechanisms to improve quality of life in osteoarthritis patients. Osteoarthritis causes joint pain and limits daily activities. Its treatment focuses on reducing pain, improving movement, and enhancing quality of life. Current recommendations suggest combining lifestyle changes with medication. This study evaluated a millimeter wave device that stimulates natural endorphins, a mobile app, and a coaching program, used for three months by people with osteoarthritis pain. After three months, 80% of participants reported feeling better. Pain levels decreased by about one-third, and quality of life improved by nearly 30%. Sleep, mood, and daily comfort also improved, and many participants reported using less medication. These findings suggest that millimeter wave therapy is a promising, non-drug approach that may help people with osteoarthritis manage pain and improve their well-being.
The aim of this qualitative study was to characterize opioid stigma in cancer remission using the Opioid Stigma Framework as a grounding theoretical framework. We conducted in-depth qualitative interviews with cancer survivors in remission who are currently or were previously prescribed opioids for moderate-to-severe pain related to their cancer diagnosis (n=17) and clinicians who routinely treat chronic cancer-related pain (n=20). Interviews occurred at a single institution from 05/2021-12/2021. The primary focus of this analysis was to describe perceived stigma from a patient perspective, as relayed by either survivors or treating clinicians. Survivors and clinicians perceived externalized stigma in a variety of healthcare settings, sometimes influenced by survivors' sociodemographic characteristics (e.g., race). Survivors and clinicians also reported stigmatizing behaviors from a variety of personal relationships, including family and community members, which then impacted decisions around prescription opioid use. Finally, survivors and clinicians described a pervasive sense of internalized stigma related to prescription opioid use in survivorship, including shame, embarrassment, and fear of addiction. Survivors and clinicians also reflected on known disparities in pain management, which in turn may have influenced experiences with opioid stigma. This research extends the Opioid Stigma Framework's concepts - previously described in patients with active cancer - to opioid stigma in cancer survivors. Given the frequency of opioid prescribing across the cancer continuum, it is crucial to develop targeted and tailored interventions to de-stigmatize clinical care and improve safe, effective chronic cancer pain management. PERSPECTIVE: Cancer survivors endorsed experiences with opioid stigma, including stigmatizing experiences with healthcare systems and personal relationships alongside negative internalized attitudes. Since opioid prescribing is common across the cancer continuum and into survivorship, it is necessary to develop tailored interventions to provide safe, effective, and de-stigmatized care to patients.
Low back pain (LBP) is a global health problem that contributes to disability, psychological distress, and reduced quality of life in older adults. Current treatment guidelines for LBP support the use of conservative therapies such as physical therapy alongside medication management. However, interventional pain management strategies for LBP such as lumbar epidural steroid injection (LESI) are rarely mentioned. We conducted this systematic review to characterize and evaluate the use and effectiveness of LESI amongst older adults with LBP. We conducted a systematic English-language literature search of Ovid MEDLINE, Ovid EMBASE, and Cochrane Library. We used an iterative approach to identify both keywords and controlled vocabulary related to treatment outcomes of epidural interventions for LBP among older adults. The results were reviewed by three members of the team. Our search of 3 databases produced a total of 2657 studies and 12 met final inclusion criteria. In all studies, the use of LESI was associated with improvement in pain and/or quality of life. As compared to medication management, LESI was associated with statistically significant improvements in pain and functional status. The addition of physical therapy was not superior to LESI alone. This systematic review is the first that focuses on the effectiveness of LESI in managing LBP in older adults. This review suggests that LESI may reduce pain and improve functional status in older adults, particularly as compared to medication management. The study was prospectively registered on Prospero (ID # 422087). Not Applicable.
The Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire measures constipation-specific quality of life; however, how small changes in the PAC-QOL scales are clinically meaningful for the prevention of opioid-induced constipation (OIC) is unknown. This study aimed to determine the minimal important change (MIC) of the PAC-QOL scales for the prevention of OIC in patients initiating opioids for cancer pain. MICs were calculated using data from a multicenter, randomized controlled trial of naldemedine for OIC prevention. MICs for the PAC-QOL overall scale and satisfaction subscale scores were calculated using an anchor-based method with two anchors, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (QLQ-C15-PAL) constipation scale and the Bowel Function Index (BFI), as well as a distribution-based method. A total of 77 patients were analyzed. The optimal cut-points for the MICs in the overall scale and satisfaction subscale based on two anchors were 0.14 and 0.20 for the QLQ-C15-PAL and 0.41 and 1.80 for the BFI, respectively. A 0.5 standard deviation and 1 standard error of measurement for the PAC-QOL were 0.26 and 0.22 for the overall scale and 0.46 and 0.53 for the satisfaction subscale, respectively. The MIC values for the PAC-QOL scales for OIC prevention ranged from 0.14 to 0.41 for the overall scale and from 0.20 to 1.80 for the satisfaction subscale. These findings enable the assessment of the preventive effect of interventions for OIC in patients initiating opioids for cancer pain.
Several studies have suggested that naldemedine may reduce opioid-induced constipation (OIC) as well as opioid-induced nausea and vomiting (OINV). This study aimed to investigate prophylactic effects of naldemedine on OINV in patients initiating regular, oral, strong opioids for cancer pain. In this preplanned secondary analysis of a multicenter, double-blind, randomized, placebo-controlled trial investigating the preventive effects of naldemedine on OIC, eligible patients were randomized in a 1:1 ratio to receive either naldemedine 0.2 mg or placebo once daily for 14 days. The primary endpoint was the complete response (CR) rate, defined as the proportion of patients with no vomiting episodes and no use of rescue antiemetics within the first three days of opioid initiation. The secondary endpoint was the nausea and vomiting score of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL). Of the 103 patients, 48 and 47 patients in each group started protocol treatment, respectively. The CR rate was significantly higher in the naldemedine group than in the placebo group (81.3% vs 38.3%, P < .001). Nausea and vomiting scores on the QLQ-C15-PAL at weeks 1 and 2 were significantly better in the naldemedine group (means 7.1 and 6.4) versus placebo (means 44.6 and 35.3; both P < .001). Within the total effect of naldemedine on the QLQ-C15-PAL nausea and vomiting scores at week 2, the proportion mediated through OIC reduction was 21.9%. Naldemedine may have intrinsic antiemetic potency to prevent both OIC and OINV. https://jrct.niph.go.jp/ (Japan Registry of Clinical Trials) Identifier: jRCTs031200397.
Cancer pain is often undertreated, with patients frequently referred late to specialist services. This study aimed to develop expert-led recommendations to address unmet needs in the management of persistent severe cancer pain in Europe. An online questionnaire on cancer pain management was used to identify controversies in the clinical practice of European oncologists. A series of recommendations to address these controversies was then proposed and validated, using a Delphi-like methodology, by a joint expert panel of pain specialists and oncologists. Consensus was reached on 13 recommendations. Key agreements focused on the following: (i) collaboration: establishing cancer pain committees (87% agreement) and shared protocols (100%), (i) education: implementing telematic consultations (100%) and training sessions for oncologists (100%) and (iii) referral: establishing clear referral criteria (100%) for patients with poor quality of life (QoL) (100%) or persistent pain, regardless of aetiology (87-100%), to ensure timely access to specialist care. Effective cancer pain management necessitates enhanced collaboration between specialties, targeted education for oncologists, and locally co-created protocols with clear referral criteria. These measures are essential to ensure that patients are referred to pain specialists in a timely and appropriate manner, which is crucial for improving their QoL.
Home-based palliative care (HBPC) improves quality of life by addressing distressing physical, psychosocial, and spiritual symptoms. However, symptom and medication burdens remain prevalent challenges. This study sought to characterize symptom prevalence and severity, the associated medication burden, and determine opportunities for deprescribing in the setting of HBPC. Patients referred to a home-based palliative care practice over a two-year period were included; 109 patients met inclusion criteria. Mean age was 78 years (± 11.8), and average Charlson Comorbidity Index (CCI) was 6.4 (± 2.7). The mean Palliative Performance Scale (PPS) score was 53.1, indicating moderate functional impairment. Patients reported a mean of 4.1 symptoms, with pain, depression, and lack of appetite being most common. Mean total number of medications was 11.1 (SD = 5.4), with 24% taking 15 or more medications. Average medication complexity score was 31.3 (± 16.9). Sub-optimally managed symptoms were identified in several domains, especially depression, pain, tiredness, and anxiety. Adverse Drug Reactions (ADRs) were documented in 49.5% of patient records. Opportunities for deprescribing were identified in 38.5%. Patients receiving HBPC experience significant symptom and medication burden. Optimization of symptom management and medication regimens, including targeted deprescribing, may reduce medication burden and improve outcomes.