- Email: [email protected]
137 Topical Seminar Summary: PRACTICAL CONSIDERATIONS IN INTERVENTIONAL PAIN MANAGEMENT AT THE END OF LIFE
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European Journal of Pain 2006, Vol 10 (suppl S1)
in a clinical sample of parents of children with juvenile rheumatic diseases (N = 86; 52 mothers, 34 fathers; mean age of children 13.33 years). Results: For the experimental study using a pain induction methodology (study 1), results will be presented on bottom-up and top-down variables which may explain parent’s cognitive (judgments of their child’s pain), affective (e.g., distress) and behavioural empathic responses (e.g., desire to comfort their child) to facing their child’s pain. Concerning the questionnaire study in the clinical sample (study 2), results will be presented on bottom-up and top-down variables explaining affective empathic responses of mothers and fathers to observing their child’s pain. Conclusions: The results of these studies will be discussed in relation to existing theories and how such understanding can contribute to our understanding of the roles parents play in the treatment of acute and chronic paediatric pain. 134 EMPATHY FOR PAIN IN LABORATORY MICE J.S. Mogil ° . Dept. of Psychology, McGill University, Montreal, QC, Canada Background and Aims: Although Darwin conceived of empathy as a phylogenetically continuous ability, currently empathy is presumed by most to be specific to humans or at least higher primates. Some experiments performed almost 50 years ago purported to demonstrate empathy in animals, but these findings were controversial and never replicated. We hypothesized that if empathy does indeed exist in mice, the real-time observation of one mouse in pain might affect the responses of its conspecifics to painful stimuli. Methods: In a series of experiments, mice were tested for pain of various modalities alone, or in dyads formed between strangers or cagemates. Results: We find that pain behavior and nociceptive thresholds of test mice are affected by the pain status of the neighboring mouse. These effects are not seen in strangers, but only in cagemates (>14 days of co-housing), and do not require close genetic relationship. The findings cannot be easily explained by either stress or imitation. Conclusions: Our data are fully consistent with predictions of the perception-action model of empathy, and thus suggest that mice are capable of a simple form of empathy for pain (“emotional contagion”) in familiars. This model may hold considerable utility for the mechanistic understanding of empathy in mammals. 135 SHARING OF EMOTIONS: DIFFERENCES BETWEEN ACUTE AND CHRONIC SOCIAL ILLNESS G. Herbette ° , B. Rim´e. Psychology Department, University of Louvain, Louvain-la-Neuve, Belgium Background and Aims: Research on verbalizing emotions has mainly focused its attention on acute emotional episodes. Studies showed that people socially share their emotions to a very large extent, they believe that it is beneficial for them, and they are also eager to listen to other people’s emotional experiences. Yet, little attention has been paid to chronic situations: is verbalizing emotions associated to such situations beneficial for the sharer? Do they always arouse positive reactions in the support providers? Methods: We first conducted three field studies aimed at investigating chronic pain patients’ beliefs regarding the communication of emotions, their verbalizing behavior according to their perception of others’reactions, and consequences on their general well-being. Then, two studies using the vignette methodology addressed factors that may account for others’ reactions to chronic pain sufferers. Results: Fields studies reveal a strong belief in chronic pain patients that sharing their health-related emotions is not beneficial. They behave in accordance to such a belief, despite deleterious consequences on their well-being. Vignette studies’ results will present variables that account to a certain extent for observers’ lack of empathic reactions to chronic sufferers. Conclusions: To conclude, hypothetic strategies that could enhance others’ empathic reactions will be discussed.
Abstracts, 5th EFIC Congress, Invited Presentations
Topical Seminar: CLINICAL CASE DISCUSSION: SHOULD PATIENTS UNDER CHRONIC PAIN THERAPY BE ALLOWED TO DRIVE THEIR CAR? 136 Topical Seminar Summary: SHOULD PATIENTS UNDER CHRONIC PAIN THERAPY BE ALLOWED TO DRIVE THEIR CAR? K.A. Lehmann ° , R. Sabatowski. Department of Anaesthesiology, Cologne University, Koeln, Germany An increasing number of patients with chronic pain are being treated with long-term opioid, antidepressant or anticonvulsant therapy. Although there is some evidence for the development of tolerance to drugrelated neurological side-effects such as sedation and drowsiness, driving ability of patients treated with opioids and other central acting compounds such as tricyclic antidepressants, neuroleptics or anticonvulsants still is under discussion. The influence of pain medications on cognitive function and psychomotor performance has been examined in different settings, starting with simple paper-and-pencil methods to more elaborated tests using on-theroad driving equipment, driving simulators and computerized laboratory evaluations. Under these conditions, studies with healthy volunteers and patients receiving single and repeated bolus doses or long-term analgesic therapy have demonstrated a range from no effect at all to significantly impaired psychomotor function and/or cognition. In order to provide reasonable recommendations to patients and authorities, pain specialists cannot just rely on data from experimental and clinical trials, but have also to consider legal and ethical aspects, which might vary quite a lot between different areas in the world. During this session, available diagnostic tools, results and interpretation from driving ability trials and their clinical relevance will be discussed with the audience. Legal aspects in the different European countries and strategies to solve the problem in daily practice is also open for debate.
Topical Seminar: PRACTICAL CONSIDERATIONS IN INTERVENTIONAL PAIN MANAGEMENT AT THE END OF LIFE 137 Topical Seminar Summary: PRACTICAL CONSIDERATIONS IN INTERVENTIONAL PAIN MANAGEMENT AT THE END OF LIFE S. Kaasa ° . Norway The primary aim of this session is to focus on clinically relevant controversies on combating pain during end of life care, mostly in cancer patients with short life expectancy. There are several challenges on all levels of treating cancer pain in this population. In order to understand how intensive diagnoses and treatment should be a prognostic evaluation is necessary to perform. Further more there is an urgent need to establish international consensus on how to assess pain and other relevant symptoms. This should be done prospectively in a clinical setting in order to make rapid changes in medications if necessary. On average 25–30% of cancer patients do not receive satisfactory pain control by following the WHO pain letter approach. There might be several reasons for this lack of optimal achievement such as lack of optimal diagnostic procedures, not optimal symptom assessment and not optimal use of opioids and other types of pain treatment. The session will cover a brief introduction on prognostication in palliative care with regard to survival and symptoms as well as how to evaluate symptoms in a clinical and a research setting. Further more invasive procedures to apply analgesics as well as new trends in opioid
Topical Seminar: MECHANISMS AND ASSESSMENT OF MUSCULOSKELETAL PAIN treatment including opioid rotation and switching the route will be covered. Finally it is a need to combine analgesia with tumor directed treatment ie chemo and radiotherapy. How this can best be done in a multidisciplinary setting will be discussed as well as indications and contraindications for modern chemotherapy, radiotherapy as well as bisphosphonates. 138 ONTOLOGICAL TREATMENT INCLUDING CHEMO- AND RADIOTHERAPY: INDICATIONS AND CONTRA INDICATIONS IN PATIENTS WITH SHORT LIFE EXPECTANCY S. Kaasa ° . Norway Abstract not available at time of printing. 139 INVASIVE PROCEDURES TO TREAT PAIN IN PATIENTS WITH SHORT LIFE EXPECTANCY – INDICATIONS AND CONTRAINDICATIONS H. Breivik ° . University of Oslo, Dept of Anaesth, Rikshospitalet, Oslo, Norway The general indications for invasive procedures to treat pain in patients with short life expectancy are overwhelming pain that is intractable by conventional analgesic and co-analgesic treatment, or when adverse effects of such treatments are severe and markedly reduce quality of life. Typical cases are patients who have incomplete pain relief while on level three of the WHO-analgesic ladder, or have severe breakthrough pain provoked by mobilisation, bowel-movement or nursing care, and in addition already has dose-related nausea, vomiting, dizziness, severely blunted emotional abilities, and opioid induced bowel dysfunction and obstinate constipation. Contraindications, or relative contraindications, to invasive procedures are clearly increased risks of bleeding into the spinal canal (for neuraxial procedures), high risks of thrombosis and occlusions of arteries to vital organs from injections of strongly inflammatory solutions used for neurolytic blockades. Type of invasive procedures: • Subarachnoid (which is superior to epidural) infusions of local anaesthetic solutions containing low concentrations of an opioid and adrenaline and/or clonidine, at an appropriate segmental level. • Peripheral neurolytic procedures using radiofrequency denervation, ethanol or phenol around a peripheral nerve, spinal nerve root or sympathetic ganlia or nerves. • Nervi splanchnici can be selectively interrupted by radiofrequency, or the coeliac plexus can be severed by injection of 50% ethanol. The latter two procedures are particularly useful for pain and nausea caused by tumours in the upper abdominal cavity. References Breivik H. Local anaesthetic blocks and epidurals. Chapter 33 in McMahon SB and Koltzenburg M (Eds): Wall and Melzack’s Textbook of Pain. Elsevier, London 2005. Breivik H. Nerve blocks – simple injections, epidurals, spinals, and more complex blocks. Cpt 8 In Simpson KH, and Budd K (Eds): Cancer Pain Management Oxford University Press, Oxford, 2000.
140 NEW TRENDS IN OPIOID TREATMENTS – HOW TO APPLY THEM TO PATIENTS WITH SHORT LIFE EXPECTANCY L. Radbruch ° , F. Elsner. Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany The range of opioids available for pain management has increased in recent years. A multitude of new application forms has further extended the range therapeutical options. New trends in opioid management of malignant pain are the noninvasive parenteral application of opioids such as buprenorphine or fentanyl via the buccal, nasal or transdermal route. The significance these application routes in patients with short life expectancy will have to be discussed critically.
S39
The transdermal application for example has been advocated for patients with advanced cancer, as many of these patients suffer from nausea and vomiting and others have difficulties swallowing due to increasing cognitive impairment of physical deterioration. However, many physicians do not realize that the transdermal opioid systems have slow and sluggish pharmacokinetics, and that rapidly changing opioid requirements in many patients in the final and prefinal phase of their disease require an opioid regimen that can be adapted quickly. Transmucosal oral or nasal application of fentanyl with sticks or sprays may be more suitable for rapid adaptation, but these application forms have been used only as rescue medication for breakthrough pain and not for basal around-the-clock medication. The plasma concentration peaks after application and the short elimination half-lives might render them unsuitable for continuous medication. New developments such as the use of tailored liposomes or gas jet injection systems (needleless syringe) will lead to applications systems for noninvasive parenteral application of other opioids with different pharmacokinetics, raising hope for easy to apply, safe and effective application systems for patients with reduced physical and/or cognitive resources. For the time being many patients in the final stages of life will benefit most from subcutaneous or intravenous opioid regimens. Fast titration for pain exacerbations, fast dose adaptations with deteriorating state of health and easy around-the-clock application have been demonstrated with these application routes, using morphine or other opioids in different in- and outpatient settings. However, the development of an increasing number of application forms and routes has increased the options for systemic non-invasive opioid management, resulting in a dramatic decline of nerve blocks and spinal drug regimens in patients with restricted live expectancy.
Topical Seminar: MECHANISMS AND ASSESSMENT OF MUSCULOSKELETAL PAIN 141 Topical Seminar Summary: MECHANISMS AND ASSESSMENT OF MUSCULOSKELETAL PAIN A.K.P. Jones ° . Human Pain Research Group, Hospital, Salford, UK Musculoskeletal pain is the commonest cause of long-term disability. Most patients who present to their general practitioner with musculoskeletal pain have no obvious physical cause of their pain and probably experience pain in the absence of a nociceptive input. Patients with arthritis experience variable pain that is often poorly related to the severity of their disease. Current animal models of experimental pain can only provide partial explanations for common painful conditions such as arthritic pain and chronic widespread and regional pain syndromes. Recent advances in the measurement of physiological responses to pain in man, including functional brain imaging techniques, have provided the basis for an integrated model of human musculoskeletal pain. This workshop will provide the framework for an understanding of the fine balance between ‘bottom-up’ (nociceptive) and top-down (cortically driven-non-nociceptive) mechanisms. We will propose that it is the fine balance between the two that determines the presence or absence of musculoskeletal pain and who attends our clinics. 142 CORTICAL MECHANISMS OF MUSCULOSKELETAL PAIN PERCEPTION A.K.P. Jones ° . Human Pain Research Group, Hope Hospital, Salford, UK Pain perception can only be explained in terms of brain mechanisms as it is only the brain that can perceive pain. Peripheral and spinal processing will determine what nociceptive traffic is presented to the brain. The brain will determine what components of this traffic contribute to the conscious experience of pain.
European Journal of Pain 2006, Vol 10 (suppl S1)
in a clinical sample of parents of children with juvenile rheumatic diseases (N = 86; 52 mothers, 34 fathers; mean age of children 13.33 years). Results: For the experimental study using a pain induction methodology (study 1), results will be presented on bottom-up and top-down variables which may explain parent’s cognitive (judgments of their child’s pain), affective (e.g., distress) and behavioural empathic responses (e.g., desire to comfort their child) to facing their child’s pain. Concerning the questionnaire study in the clinical sample (study 2), results will be presented on bottom-up and top-down variables explaining affective empathic responses of mothers and fathers to observing their child’s pain. Conclusions: The results of these studies will be discussed in relation to existing theories and how such understanding can contribute to our understanding of the roles parents play in the treatment of acute and chronic paediatric pain. 134 EMPATHY FOR PAIN IN LABORATORY MICE J.S. Mogil ° . Dept. of Psychology, McGill University, Montreal, QC, Canada Background and Aims: Although Darwin conceived of empathy as a phylogenetically continuous ability, currently empathy is presumed by most to be specific to humans or at least higher primates. Some experiments performed almost 50 years ago purported to demonstrate empathy in animals, but these findings were controversial and never replicated. We hypothesized that if empathy does indeed exist in mice, the real-time observation of one mouse in pain might affect the responses of its conspecifics to painful stimuli. Methods: In a series of experiments, mice were tested for pain of various modalities alone, or in dyads formed between strangers or cagemates. Results: We find that pain behavior and nociceptive thresholds of test mice are affected by the pain status of the neighboring mouse. These effects are not seen in strangers, but only in cagemates (>14 days of co-housing), and do not require close genetic relationship. The findings cannot be easily explained by either stress or imitation. Conclusions: Our data are fully consistent with predictions of the perception-action model of empathy, and thus suggest that mice are capable of a simple form of empathy for pain (“emotional contagion”) in familiars. This model may hold considerable utility for the mechanistic understanding of empathy in mammals. 135 SHARING OF EMOTIONS: DIFFERENCES BETWEEN ACUTE AND CHRONIC SOCIAL ILLNESS G. Herbette ° , B. Rim´e. Psychology Department, University of Louvain, Louvain-la-Neuve, Belgium Background and Aims: Research on verbalizing emotions has mainly focused its attention on acute emotional episodes. Studies showed that people socially share their emotions to a very large extent, they believe that it is beneficial for them, and they are also eager to listen to other people’s emotional experiences. Yet, little attention has been paid to chronic situations: is verbalizing emotions associated to such situations beneficial for the sharer? Do they always arouse positive reactions in the support providers? Methods: We first conducted three field studies aimed at investigating chronic pain patients’ beliefs regarding the communication of emotions, their verbalizing behavior according to their perception of others’reactions, and consequences on their general well-being. Then, two studies using the vignette methodology addressed factors that may account for others’ reactions to chronic pain sufferers. Results: Fields studies reveal a strong belief in chronic pain patients that sharing their health-related emotions is not beneficial. They behave in accordance to such a belief, despite deleterious consequences on their well-being. Vignette studies’ results will present variables that account to a certain extent for observers’ lack of empathic reactions to chronic sufferers. Conclusions: To conclude, hypothetic strategies that could enhance others’ empathic reactions will be discussed.
Abstracts, 5th EFIC Congress, Invited Presentations
Topical Seminar: CLINICAL CASE DISCUSSION: SHOULD PATIENTS UNDER CHRONIC PAIN THERAPY BE ALLOWED TO DRIVE THEIR CAR? 136 Topical Seminar Summary: SHOULD PATIENTS UNDER CHRONIC PAIN THERAPY BE ALLOWED TO DRIVE THEIR CAR? K.A. Lehmann ° , R. Sabatowski. Department of Anaesthesiology, Cologne University, Koeln, Germany An increasing number of patients with chronic pain are being treated with long-term opioid, antidepressant or anticonvulsant therapy. Although there is some evidence for the development of tolerance to drugrelated neurological side-effects such as sedation and drowsiness, driving ability of patients treated with opioids and other central acting compounds such as tricyclic antidepressants, neuroleptics or anticonvulsants still is under discussion. The influence of pain medications on cognitive function and psychomotor performance has been examined in different settings, starting with simple paper-and-pencil methods to more elaborated tests using on-theroad driving equipment, driving simulators and computerized laboratory evaluations. Under these conditions, studies with healthy volunteers and patients receiving single and repeated bolus doses or long-term analgesic therapy have demonstrated a range from no effect at all to significantly impaired psychomotor function and/or cognition. In order to provide reasonable recommendations to patients and authorities, pain specialists cannot just rely on data from experimental and clinical trials, but have also to consider legal and ethical aspects, which might vary quite a lot between different areas in the world. During this session, available diagnostic tools, results and interpretation from driving ability trials and their clinical relevance will be discussed with the audience. Legal aspects in the different European countries and strategies to solve the problem in daily practice is also open for debate.
Topical Seminar: PRACTICAL CONSIDERATIONS IN INTERVENTIONAL PAIN MANAGEMENT AT THE END OF LIFE 137 Topical Seminar Summary: PRACTICAL CONSIDERATIONS IN INTERVENTIONAL PAIN MANAGEMENT AT THE END OF LIFE S. Kaasa ° . Norway The primary aim of this session is to focus on clinically relevant controversies on combating pain during end of life care, mostly in cancer patients with short life expectancy. There are several challenges on all levels of treating cancer pain in this population. In order to understand how intensive diagnoses and treatment should be a prognostic evaluation is necessary to perform. Further more there is an urgent need to establish international consensus on how to assess pain and other relevant symptoms. This should be done prospectively in a clinical setting in order to make rapid changes in medications if necessary. On average 25–30% of cancer patients do not receive satisfactory pain control by following the WHO pain letter approach. There might be several reasons for this lack of optimal achievement such as lack of optimal diagnostic procedures, not optimal symptom assessment and not optimal use of opioids and other types of pain treatment. The session will cover a brief introduction on prognostication in palliative care with regard to survival and symptoms as well as how to evaluate symptoms in a clinical and a research setting. Further more invasive procedures to apply analgesics as well as new trends in opioid
Topical Seminar: MECHANISMS AND ASSESSMENT OF MUSCULOSKELETAL PAIN treatment including opioid rotation and switching the route will be covered. Finally it is a need to combine analgesia with tumor directed treatment ie chemo and radiotherapy. How this can best be done in a multidisciplinary setting will be discussed as well as indications and contraindications for modern chemotherapy, radiotherapy as well as bisphosphonates. 138 ONTOLOGICAL TREATMENT INCLUDING CHEMO- AND RADIOTHERAPY: INDICATIONS AND CONTRA INDICATIONS IN PATIENTS WITH SHORT LIFE EXPECTANCY S. Kaasa ° . Norway Abstract not available at time of printing. 139 INVASIVE PROCEDURES TO TREAT PAIN IN PATIENTS WITH SHORT LIFE EXPECTANCY – INDICATIONS AND CONTRAINDICATIONS H. Breivik ° . University of Oslo, Dept of Anaesth, Rikshospitalet, Oslo, Norway The general indications for invasive procedures to treat pain in patients with short life expectancy are overwhelming pain that is intractable by conventional analgesic and co-analgesic treatment, or when adverse effects of such treatments are severe and markedly reduce quality of life. Typical cases are patients who have incomplete pain relief while on level three of the WHO-analgesic ladder, or have severe breakthrough pain provoked by mobilisation, bowel-movement or nursing care, and in addition already has dose-related nausea, vomiting, dizziness, severely blunted emotional abilities, and opioid induced bowel dysfunction and obstinate constipation. Contraindications, or relative contraindications, to invasive procedures are clearly increased risks of bleeding into the spinal canal (for neuraxial procedures), high risks of thrombosis and occlusions of arteries to vital organs from injections of strongly inflammatory solutions used for neurolytic blockades. Type of invasive procedures: • Subarachnoid (which is superior to epidural) infusions of local anaesthetic solutions containing low concentrations of an opioid and adrenaline and/or clonidine, at an appropriate segmental level. • Peripheral neurolytic procedures using radiofrequency denervation, ethanol or phenol around a peripheral nerve, spinal nerve root or sympathetic ganlia or nerves. • Nervi splanchnici can be selectively interrupted by radiofrequency, or the coeliac plexus can be severed by injection of 50% ethanol. The latter two procedures are particularly useful for pain and nausea caused by tumours in the upper abdominal cavity. References Breivik H. Local anaesthetic blocks and epidurals. Chapter 33 in McMahon SB and Koltzenburg M (Eds): Wall and Melzack’s Textbook of Pain. Elsevier, London 2005. Breivik H. Nerve blocks – simple injections, epidurals, spinals, and more complex blocks. Cpt 8 In Simpson KH, and Budd K (Eds): Cancer Pain Management Oxford University Press, Oxford, 2000.
140 NEW TRENDS IN OPIOID TREATMENTS – HOW TO APPLY THEM TO PATIENTS WITH SHORT LIFE EXPECTANCY L. Radbruch ° , F. Elsner. Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany The range of opioids available for pain management has increased in recent years. A multitude of new application forms has further extended the range therapeutical options. New trends in opioid management of malignant pain are the noninvasive parenteral application of opioids such as buprenorphine or fentanyl via the buccal, nasal or transdermal route. The significance these application routes in patients with short life expectancy will have to be discussed critically.
S39
The transdermal application for example has been advocated for patients with advanced cancer, as many of these patients suffer from nausea and vomiting and others have difficulties swallowing due to increasing cognitive impairment of physical deterioration. However, many physicians do not realize that the transdermal opioid systems have slow and sluggish pharmacokinetics, and that rapidly changing opioid requirements in many patients in the final and prefinal phase of their disease require an opioid regimen that can be adapted quickly. Transmucosal oral or nasal application of fentanyl with sticks or sprays may be more suitable for rapid adaptation, but these application forms have been used only as rescue medication for breakthrough pain and not for basal around-the-clock medication. The plasma concentration peaks after application and the short elimination half-lives might render them unsuitable for continuous medication. New developments such as the use of tailored liposomes or gas jet injection systems (needleless syringe) will lead to applications systems for noninvasive parenteral application of other opioids with different pharmacokinetics, raising hope for easy to apply, safe and effective application systems for patients with reduced physical and/or cognitive resources. For the time being many patients in the final stages of life will benefit most from subcutaneous or intravenous opioid regimens. Fast titration for pain exacerbations, fast dose adaptations with deteriorating state of health and easy around-the-clock application have been demonstrated with these application routes, using morphine or other opioids in different in- and outpatient settings. However, the development of an increasing number of application forms and routes has increased the options for systemic non-invasive opioid management, resulting in a dramatic decline of nerve blocks and spinal drug regimens in patients with restricted live expectancy.
Topical Seminar: MECHANISMS AND ASSESSMENT OF MUSCULOSKELETAL PAIN 141 Topical Seminar Summary: MECHANISMS AND ASSESSMENT OF MUSCULOSKELETAL PAIN A.K.P. Jones ° . Human Pain Research Group, Hospital, Salford, UK Musculoskeletal pain is the commonest cause of long-term disability. Most patients who present to their general practitioner with musculoskeletal pain have no obvious physical cause of their pain and probably experience pain in the absence of a nociceptive input. Patients with arthritis experience variable pain that is often poorly related to the severity of their disease. Current animal models of experimental pain can only provide partial explanations for common painful conditions such as arthritic pain and chronic widespread and regional pain syndromes. Recent advances in the measurement of physiological responses to pain in man, including functional brain imaging techniques, have provided the basis for an integrated model of human musculoskeletal pain. This workshop will provide the framework for an understanding of the fine balance between ‘bottom-up’ (nociceptive) and top-down (cortically driven-non-nociceptive) mechanisms. We will propose that it is the fine balance between the two that determines the presence or absence of musculoskeletal pain and who attends our clinics. 142 CORTICAL MECHANISMS OF MUSCULOSKELETAL PAIN PERCEPTION A.K.P. Jones ° . Human Pain Research Group, Hope Hospital, Salford, UK Pain perception can only be explained in terms of brain mechanisms as it is only the brain that can perceive pain. Peripheral and spinal processing will determine what nociceptive traffic is presented to the brain. The brain will determine what components of this traffic contribute to the conscious experience of pain.