Mark J. Stillman

Implementing Guidelines for Cancer Pain Management: Results of a Randomized Controlled Clinical Trial

PURPOSE Pain and symptom management is an integral part of the clinical practice of oncology. A number of guidelines have been developed to assist the clinician in optimizing comfort care. We implemented clinical guidelines for cancer pain management in the community setting and evaluated whether these guidelines improved care. PATIENTS AND METHODS Eighty-one cancer patients, aged 37 to 76 years, were enrolled onto a prospective, longitudinal, randomized controlled study from the outpatient clinic settings of 26 western Washington-area medical oncologists. A multilevel treatment algorithm based on the Agency for Health Care Policy and Research Guidelines for Cancer Pain Management was compared with standard-practice (control) pain and symptom management therapies used by community oncologists. The primary outcome of interest was pain (Brief Pain Inventory); secondary outcomes of interest were all other symptoms (Memorial Symptom Assessment Scale) and quality of life (Functional Assessment of Cancer Therapy Scale). RESULTS Patients randomized to the pain algorithm group achieved a statistically significant reduction in usual pain intensity, measured as slope scores, when compared with standard community practice (P < .02). Concurrent chemotherapy and patient adherence to treatment were significant mediators of worst pain. There were no significant differences in other symptoms or quality of life between the two treatment groups. CONCLUSION This guideline implementation study supports the use of algorithmic decision making in the management of cancer pain. These findings suggest that comprehensive pain assessment and evidence-based analgesic decision-making processes do enhance usual pain outcomes.

Patient training in cancer pain management using integrated print and video materials: A multisite randomized controlled trial☆

&NA; Standard guidelines for cancer pain treatment routinely recommend training patients to reduce barriers to pain relief, use medications appropriately, and communicate their pain‐related needs. Methods are needed to reduce professional time required while achieving sustained intervention effectiveness. In a multisite, randomized controlled trial, this study tested a pain training method versus a nutrition control. At six oncology clinics, physicians (N = 22) and nurses (N = 23) enrolled patients (N = 93) who were over 18 years of age, with cancer diagnoses, pain, and a life expectancy of at least 6 months. Pain training and control interventions were matched for materials and method. Patients watched a video followed by about 20 min of manual‐standardized training with an oncology nurse focused on reviewing the printed material and adapted to individual concerns of patients. A follow‐up phone call after 72 h addressed individualized treatment content and pain communication. Assessments at baseline, one, three, and 6 months included barriers, the Brief Pain Inventory, opioid use, and physician and nurse ratings of their patients’ pain. Trained versus control patients reported reduced barriers to pain relief (P < .001), lower usual pain (P = .03), and greater opioid use (P < .001). No pain training patients reported severe pain (>6 on a 0–10 scale) at 1‐month outcomes (P = .03). Physician and nurse ratings were closer to patients’ ratings of pain for trained versus nutrition groups (P = .04 and <.001, respectively). Training efficacy was not modified by patient characteristics. Using video and print materials, with brief individualized training, effectively improved pain management over time for cancer patients of varying diagnostic and demographic groups.

Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: a case series.

▪ Abstract:  Persistent occipital neuralgia can produce severe headaches that are difficult to control by conservative or surgical approaches. We retrospectively describe a series of six patients with severe occipital neuralgia who received conservative and interventional therapies, including oral antidepressants, membrane stabilizers, opioids, and traditional occipital nerve blocks without significant relief. This group then underwent occipital nerve blocks using the botulinum toxin type A (BoNT‐A) BOTOX® Type A (Allergan, Inc., Irvine, CA, U.S.A.) 50 U for each block (100 U if bilateral). Significant decreases in pain Visual Analog Scale (VAS) scores and improvement in Pain Disability Index (PDI) were observed at four weeks follow‐up in five out of six patients following BoNT‐A occipital nerve block. The mean VAS score changed from 8 ± 1.8 (median score of 8.5) to 2 ± 2.7 (median score of 1), while PDI improved from 51.5 ± 17.6 (median 56) to 19.5 ± 21 (median 17.5) and the duration of the pain relief increased to an average of 16.3 ± 3.2 weeks (median 16) from an average of 1.9 ± 0.5 weeks (median 2) compared to diagnostic 0.5% bupivacaine block. Following block resolution, the average pain scores and PDI returned to similar levels as before BoNT‐A block. In conclusion, BoNT‐A occipital nerve blocks provided a much longer duration of analgesia than diagnostic local anesthetics. The functional capacity improvement measured by PDI was profound enough in the majority of the patients to allow patients to resume their regular daily activities for a period of time. ▪

Clinical and Preclinical Rationale for CGRP‐Receptor Antagonists in the Treatment of Migraine

Calcitonin gene‐related peptide (CGRP) is linked to migraine and other primary headache disorders. It is found in every location described in migraine genesis and processing, including meninges, trigeminal ganglion, trigeminocervical complex, brainstem nuclei, and cortex. It is released in animal models following stimulation of the CNS similar to that seen in migraine, and triptans inhibit this release. Injection of CGRP into migraineurs results in delayed headache similar to migraine. Elevation of CGRP occurs during migraine, resolving following migraine‐specific treatment. Finally, and most importantly, CGRP receptor antagonists terminate migraine with efficacy similar to triptans. Both intravenous olcegepant (BIBN 4096 BS) and oral telcagepant (MK‐0974) have been effective, safe, and well tolerated in phase I and II studies. Telcagepant is currently in phase III trials, and preliminary results are favorable.

Treatment of primary headache disorders with intravenous valproate: initial outpatient experience.

Objective.—To evaluate the effectiveness of intravenous valproate in managing moderate to severe headaches.

Testosterone replacement therapy for treatment refractory cluster headache.

Objectives.—To describe the clinical characteristics and laboratory findings of cluster headache patients whose headaches responded to testosterone replacement therapy.

Differences in Physician Access Patterns to Hospice Care

Few issues in health care have recently generated as much discussion as the two seemingly unrelated topics of out-of-hospital health care financing and compassionate care of patients at the end of life. These two topics meet where health care costs cross paths with the economic viability of hospice and palliative medicine. In this study, we evaluated 101 admissions to a large Medicare-certified hospice in the last quarter of 1995 to assess factors associated with timing of referral to hospice. Mean length of stay in hospice was 55 days; median was 23 days. The majority of patients had cancer diagnoses (74%). Contrary to our hypothesis, there was no statistically significant difference in mean patient lengths of stay between oncologist-referred and nononcologist-referred patients. However, when we compared patient lengths of stay lasting less than--versus longer than--30 days, more patients referred by nononcologists were in hospice longer than 30 days (chi 2 = 3.92, P < 0.05). With further evaluation, this difference was attributable to longer stays by patients covered by the Medicine hospice benefit, by those with noncancer diagnoses, and by those who were older. More of these patients were referred by nononcologists. The difference in referral patterns between oncologists and nononcologists disappeared when only cancer patients were considered. Consistent with initial hypotheses, caregivers of patients with shorter lengths of stay were significantly less satisfied with hospice care (t = -4.06, P < 0.001). These results suggest that health care benefits and other patient-specific issues influence timing of hospice referral rather than simply preferences by types of physicians. The impact on Medicare expenditures and hospice viability is discussed.

A Practice Guide for Continuous Opioid Therapy for Refractory Daily Headache: Patient Selection, Physician Requirements, and Treatment Monitoring

(Headache 2010;50:1175‐1193)

Traditional and Evidence‐Based Acupuncture in Headache Management: Theory, Mechanism, and Practice

Acupuncture, traditional Chinese needle therapy, has become widely used for the relief of headache. The history of the practice of acupuncture in the United States and the theoretical framework for acupuncture in Chinese medicine are reviewed. The basic scientific background and clinical application of acupuncture in the headache management are discussed.

Do psychiatric comorbidities influence headache treatment outcomes? Results of a naturalistic longitudinal treatment study

ABSTRACT This study examined if the presence of one or more psychiatric disorders influences headache treatment outcomes in patients in headache specialty treatment centers. Using a naturalistic, longitudinal design, 223 patients receiving preventive therapy for headache disorders completed 30‐day daily diaries that assessed headache days/month and severity at acute therapy baseline and 6‐month evaluation and also provided data on headache disability and quality of life at acute therapy baseline, preventive therapy initiation, preventive therapy adjustment, and 6‐month evaluation visits. Psychiatric diagnoses were determined using the Primary Care Evaluation for Mental Disorders (PRIME MDs). Of the 223 patients, 34% (n = 76) had no psychiatric disorder, 21% (n = 46) were diagnosed with Depression‐Only; 13% (n = 29) were diagnosed with Anxiety‐Only; and 32% (n = 72) were diagnosed with Depression‐and‐Anxiety. Prior to initiating new preventive therapy, patients with one or more psychiatric disorders reported more frequent and disabling headaches and poorer life quality compared to patients with no psychiatric disorders. Rates of improvement in headache days/month, disability, and quality of life were significant and comparable across the four groups. Contrary to clinical wisdom, patients with psychiatric disorders respond very favorably to contemporary headache treatments administered in headache specialty treatment centers.