C. Stratton Hill

Teaching cancer pain management : Durability of educational effects of a role model program

Inadequate management of cancer related pain has resulted primarily from attitudinal barriers and a lack of knowledge about clinical assessment, the administration of analgesics, and therapeutic interventions.

Legislation analysis according to WHO and INCB criteria on opioid availability: a comparative study of 5 countries and the state of Texas

Opioids are not always available in many developing countries, including those in Latin America. In this study we analyzed the national laws on opioids and other controlled substances from Argentina, Colombia, Costa Rica, Peru, Mexico, and the state of Texas, according to the principles set by the World Health Organization (WHO) and the International Narcotics Control Board (INCB), as well as to the presence of over-regulations regarding their medical and scientific use. The six main principles outlined by WHO and INCB for opioid availability were analyzed by using a total of 17 criteria as shown in Table 3. The result scores ranged from 17/17 (full compliance with all criteria) to 0/17 (non-compliance). Results showed that with the exception of the state of Texas 16/17 (94%), the countries failed to adequately meet the INCB and WHO criteria: Argentina: 7/17 (41%); Colombia: 9 /17 (53%); Costa Rica: 9/17 (53%); Mexico: 4/17 (24%); and Peru: 7/17 (41%). In all 5 Latin American countries, national laws and regulations imposed limits on the number of days allowed for prescription, the potency of the dosage, and the number of doses allowed per day. In all cases, including Texas, there was confusion on the meaning and utilization of the terms physical dependence, psychological dependence, addiction, tolerance and abuse. In total, combining all cases, only 51% of the criteria were met. Additionally, all laws and regulations, especially in Argentina, include over regulations and statements that may further interfere with patient access to opioids. The prescription criteria were fully met by the state of Texas and all five countries. These results indicate that there is need to revise the existing laws and regulations in countries with opioid availability problems, and identify the potential barriers, which may be playing a significant role in the access to adequate treatment. Such review seeks to carefully consider all possible criteria, since partial resolution of legislative articles will not result in increased opioid availability.

Radiotherapy residents' knowledge of and attitudes toward management of cancer pain

PURPOSE To evaluate the fund of knowledge of and attitudes toward cancer pain management of radiotherapy residents across the nation. METHODS Radiotherapy (XRT) residents who had completed at least a year of training were surveyed by questionnaire. Residents (n = 10) from a training program who had been given instructional resources in cancer pain management skills were compared with residents from across the nation (n = 61). A validated survey used in national Cancer Pain Initiative Role Model Programs was administered by mail. The survey contained 30 questions that evaluated attitude alone (A), knowledge alone (K), and how attitude affects the application of knowledge (A/K). RESULTS The residents from the training program scored significantly higher in K (p < 0.005) and A/K (p < 0.04) than did the residents across the nation. No difference in scores evaluating A were detected (p = 0.26). Compared with the baseline knowledge of physicians in practice who had attended a workshop on cancer pain management, the national XRT residents had significantly lower scores in A (p < 0.006) and K (p < 0.001); however, no difference was found in A/K scores. After the workshop, the physicians in practice had significant gains in cancer pain management skills (p < 0.006). When the post-instruction survey was compared with the national XRT resident scores, there were marked differences in A (p < 0.00001), K (p < 0.00001) and A/K (p < 0.01). CONCLUSIONS XRT residents in the United States are empathetic, but knowledge of cancer pain management is lacking. Instruction in the principles of cancer pain management can make a profound difference in knowledge and attitude. There is a need to recognize cancer pain management as a significant aspect of radiotherapeutic practice.

The Story of the Texas Pain Society: Formation and Function of a Regional Pain Society

Abstract:  The idea of forming a Texas Pain Society came to the Founders in 1987 due to disparity and deficiencies in the practice of pain management in the United States and, in particular, the State of Texas. The Founders considered very carefully the implication of forming such a society. They diligently mapped out the mission and goals of the Texas Pain Society in those early formative years. This report is the history of Texas Pain Society as the activities unfolded from 1989 to 2011.

A method for attaining rapid and sustained pain relief and discriminating nociceptive from neuropathic pain in cancer patients

i AIM OF INVESTIQATION: To review our experience using an Intravenous rapid Injection test) In cancer patients wtth paln to determine: 1) its -uabaakfor optlmum oral doee of opiate, obviating the Incrementai dose lncreaee techntque whkh dekys optimum pain reilef, and 2) its usefulness In descrimlnatlng opiate responsive from opiate non or partlaily re+oneive pain. Recorda of 102 consecutive patients referred to the Pain Servka of the UT. M.D. AnCancer METHODS: Center evaluated by thk morphlna test were revlewed. Foilowlng a detaffed pain hktory and physkal examkatlon morphine sulfate was admlnktered either as a single dose or In seque&l doaea u&f pain wan relieved, or lt WIU evldent that pain was non or partlaliy reeponslve. Patients rated their pain Menatty prior to the lnhkl and subsequent do8w. lnltal dose determination was based on the examker’a cllnkal aeaeesreent of pein and patlent’s previous drug exposure, and ranged from 5 to 15mg. SubaequeM incrementai d&we8 were ako In this range. Response to te8t was rated as poositlve with 75% relief, partlal with Scm, and negative with leas than 50%. Patlents In the first category were Judged to have predominently nockepttve pain, the &econd mixed nocicepthrdneuropathlc pain, and the latter predomlnently neuropathk, or other opiate unreeponelve pain. The total teat dose of morphine ranged between 8 and RESULTS: 102 subjeck received 108 morphlne tests. 400mg with a medlan of 20 mg. 83 subjects were Judged posltlve responders, 13 negative, and 11 were partial responders, and one wa8 unevalwble. Of 94 poshive and partial resondem, 81 were piaced on morphine. Of these, 4S were placed on controlled releaee morphine, and 30 on Immediate relaaae morphine. An orel morphine dose wa8 calculated baaed on the Intravenous doee requlred to relieve subject’8 pain. lnltki 24 hour oral doses ranged from 60mg to 528Omg with a medlan of 270 mg. The goal of Immediate and austalned pain relief was achieved In 52,14 required elther a drug or route of admlnktratlon change, and 15 were lost to folfow-up. CONCLUSlON: We conclude the morphlne test Is a safe and valuable cllnkal tool to achieve Immediate and sustained paln control with oral opiates In cancer patients, obvlatlng the period of unneceaary paln endured with the usual method of oral dose titration. Further, we conclude thlr test k useful In determinlng varying degrees of responalveness of pain to opiates, and help8 dlscrlmlnate noclceptive from newopethk Pain.