Oncology Ny
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In most cancer patients who are treated with opioid analgesics for pain control, the type of opioid needs to be changed at least once because of the presence of side effects or the need to escalate analgesic doses to toxic levels. Methadone may be an excellent alternative in such patients due to its lack of known active metabolites, high lipid solubility, excellent absorption following oral and rectal delivery, and extremely low cost. ⋯ Better pharmacokinetic and clinical studies are required to establish the role of methadone in this setting. Issues to be explored include a potential role in treating patients who have poorly responsive pain syndromes, such as neuropathic pain, or who develop a rapid tolerance to other opioids; the possibility of extending dosing intervals to every 12 or 24 hours; and its possible use as a first-line opioid.
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The pharmacologic tailoring guidelines of the World Health Organization represent the accepted treatment algorithm for the management of cancer-related pain syndromes. Unfortunately, the guidelines are only effective in 70% to 90% of patients, leaving a substantial population with intractable pain. In fact, recent surveys have shown that, in the United States, only 50% of hospitalized terminally ill patients die comfortably. ⋯ If the patient is expected to survive more than 3 months, a totally implanted system is appropriate and cost-effective. Although morphine remains the gold standard for intrathecal pain therapy, other opioids such as fentanyl, hydromorphone, sufentanil, and meperidine are now being used in patients who do not tolerate morphine. Nonopioid agents for intrathecal use in patients who have pain syndromes that are poorly responsive to opioids include local anesthetics, such as bupivacaine, and clonidine.
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The economic considerations relative to neuraxial infusion can be looked at with different types of economic models, including cost-minimization, cost-effectiveness, and cost-benefit analyses. A theoretical predictive model was developed about 2 years ago using a computer spreadsheet and based on four levels of supportive data. The model shows that the breakeven point at which it becomes less expensive to administer opioids with an intrathecal/implanted pump, rather than an epidural/external pump, is between 3 and 6 months after the start of pain management. In addition, the break even point between systemic treatment and spinal delivery with an implanted system is between 1 1/2 and 2 1/2 years from start of pain treatment.
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Intraspinal drug delivery systems can be effective in controlling intractable pain. However, before these invasive pain therapies are initiated and to avoid or minimize any complications associated with their use, there must be a thorough understanding of the etiology of the pain, the underlying cancer, and antineoplastic therapy. ⋯ Based on extensive experience, the only pragmatic contraindications to neuraxial infusion device implantation are those also revelant to surgical intervention. Careful patient selection may help avoid some complications and constant vigilance may be the best defense against errors.