Cancer surveys
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Comparative Study Clinical Trial
The cognitive and psychomotor effects of opioid drugs in cancer pain management.
The time has come to evaluate critically our practice of cancer pain management and the assumptions on which it is based. We owe it to our patients to maximize the quality of their lives and to provide evidence for them that is based on a scientific approach rather than anecdotal experience. From the information available, opioids do have effects on cognitive and psychomotor function, and although many of these effects diminish once the patient is on a stable dose, the evidence suggests that baseline pretreatment levels are not achieved. ⋯ The management of the central adverse effects of opioids must be focused on accurate assessment and careful titration of opioids against pain. Adjuvant analgesic drugs and non-drug measures should be used whenever possible, and drugs should be chosen that will not contribute to existing difficulties. The appropriate use of psychostimulants has yet to be established as has the relative benefit of one opioid over another in cancer pain.
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Important differences become evident in a comparison of cancer pain between children and adults. Management of pain in children is commonly multidisciplinary, is less dependent on invasive measures and relies more on systemic therapy. Children are not little adults: their immaturity, developing cognition and dependence all influence their experience and interpretation of pain. ⋯ We are opposed to euthanasia. Psychosocial and cultural issues all influence the family's experience of palliative care. Further research is necessary in all of these areas.(ABSTRACT TRUNCATED)
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For tolerance development studies, computer modelling and statistical tests suggested that the equation which best described the decrement of analgesic effect was best served by an exponential decay function. Further analysis of the time course data led to the tentative conclusion that all groups of animals became tolerant at the same rate, regardless of drug or dose. A literature search revealed then, as it does now, that although there are many statements regarding the rate of opioid tolerance, there has been little systematic investigation of this. ⋯ The possibility of probe administration to the same region of CNS that was rendered tolerant, as in the Y-catheter method, further enhances the focus on the pharmacodynamic mechanisms of tolerance without the ancillary and literally peripheral concerns of a dispositional nature. A posological approach to these studies cannot be overemphasized, as it is only through such time consuming and costly experiments that rigorous, quantitative data can be obtained. Such data may help to guide the hand of the physician towards rational therapeutic intervention in the treatment of patients with chronic pain and opioid tolerance.
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In summary, our current understanding of the therapeutics of dyspnoea is inadequate and leaves plenty of room for improvement. Rationalization of the management of this symptom has the potential to improve the quality of life of countless patients with both malignant and non-malignant disease. To date, research studies addressing this issue are sparse. ⋯ The pharmacological treatment of breathlessness deserves further investigation, and clinical studies should be conducted in parallel with appropriate laboratory studies. Drug therapy is, however, but one aspect of the overall management of any symptom, and a thorough assessment of the role of non-drug interventions for dyspnoea is also essential. Well designed multicentre studies are urgently required to evaluate the symptomatic treatment of breathlessness, but such studies must be preceded by the development of valid and sensitive patient rated tools to assess this distressing and common symptom.