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Update in pain and supportive care research

Issue: September 10, 2011

ByBiren Saraiya, MD

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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.

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.