British journal of pain
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British journal of pain · Nov 2014
Pain services and palliative medicine - an integrated approach to pain management in the cancer patient.
The vast majority of cancer patients will experience pain during the course of their illness. Thankfully, in most instances, the consistent application of analgesic guidelines, tailored to the unique needs of each individual patient, will deliver a satisfactory outcome. These guidelines recommend the skilled use of analgesic medications, often in conjunction with a range of adjuvant therapies as may be required. ⋯ Even in circumstances in which palliative medicine and pain services co-exist in the same region, there may be poor integration between the two services. Each specialty area holds a unique set of skills and competencies, yet there is considerable overlap. Patient care and outcomes will be enhanced by establishing more formal relationships between these two specialty areas.
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Cancer and its treatment exert a heavy psychological and physical toll. Of the myriad symptoms which result, pain is common, encountered in between 30% and 60% of cancer survivors. Pain in cancer survivors is a major and growing problem, impeding the recovery and rehabilitation of patients who have beaten cancer and negatively impacting on cancer patients' quality of life, work prospects and mental health. ⋯ Pain can arise both due to the underlying disease and the various treatments the patient has been subjected to. Chemotherapy causes painful chemotherapy-induced peripheral neuropathy (CIPN), radiotherapy can produce late effect radiation toxicity and surgery may lead to the development of persistent post-surgical pain syndromes. This review explores a selection of the common causes of persistent pain in cancer survivors, detailing our current understanding of the pathophysiology and outlining both the clinical manifestations of individual pain states and the treatment options available.
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Mechanisms of inflammatory and neuropathic pains have been elucidated and translated to patient care by the use of animal models of these pain states. Cancer pain has lagged behind since early animal models of cancer-induced bone pain were based on the systemic injection of carcinoma cells. This precluded systematic investigation of specific neuronal and pharmacological alterations that occur in cancer-induced bone pain. ⋯ Changes in certain neurotransmitters implicated in brain modulation of spinal function are also altered with implications for the affective components of cancer pain. Treatments are described in terms of mechanistic insights and in the case of opioids, which modulate pain transmission at spinal and supraspinal sites, their use can be compromised by opioid-induced hyperalgesia. We discuss evidence for how this comes about and how it may be treated.