W. 7 No. 8 Ahmbei- I992
LJ?h?rs
440
@m-Year Pain Fellowship A l-year clinical practicum, initiated in 1989, is offered to Master’s prepared nurses with a minimum of 2 years experience in oncoIogy nursing. One nurse fellow can be accomodated each year. This program attempts to prepare qualified nurses to function as clinical specialists in their own institutional and community settings. The long-term goal is to have an identified nurse expert or cadre of such experts in each hospital or health-care delivery system, who can act as information resources and as educators in pain management, analgesic studies, and supportive care. The nurse fellow is given the opportunity for “hands on” experience with the pain consultation team, supportive care program, and pain research program. Funding for the first 3 years of this program (which provides the nurse with a stipend for living expenses) has come from the generous support of the Society of Memorial Sloan-Kettering Cancer Center. There is no charge to the nurse fellow. The source of future funding for this program is still under review. Our most recent nurse fellow has been funded by her parent institution, and it is hoped that at least partial funding for future nurse fellows will come from similar sources. These programs are not expensive. They are incorporated into the day-today activity of the interdisciplinary pain team and require no extra staE or space. However, a commitment is required from the institution of the participating nurse to provide both time and travel expenses. Some pharmaceuti-
her&y&amine
ViitingRelated
for Nausea and
to Cancer
Chemothemlbywith Ciqdatin To the Editor: In a previous study’ we found that diphenhydramine (DHM) is not a useful adjuvant antiemetic drug when it is added to high doses of metoclopramide (MCP).Also it does not prevent completely the extrapyramidal side effects of MCP.’ DHM,2n3 an
cal companies have been heipful in providing travel expenses to some participants and in the development of educational material. The success of these programs suggests that there are a variety of practical solutions to the need for continuing education of nurses in pain management and supportive care. Nonetheless, hospitals and nursing schools have been slow to recognize that pain assessment and management require a specific lcnowledge base and level of expertise. Unless this recognition develops, funding will not be provided for nurses to participate in such and professionals who are not programs, qualified will continue to teach in this area. Nessa Coyle, RN and Jean Adelhardt, RN Department of Neurology, Pain Service Memorial Sloan-Kettering Cancer Center New York, New York
1. Ferrell BR, McCaffery M, Rhiner W. Pain and addiction: an urgent need for change in nursing education. J Pain Symptom Manage 1992;7:117-124. 2. McCaffery M, Ferrell BR, Page EO, Lester M, Ferrell BA. Nurses’ knowledge of opioid analgesics and addiction. Cancer Nurs 1990;13:21-27. 3. Spross J, McGuire D, Schmitt R. Oncology Nursing Society position paper on cancer pain. Oncol Nurs Forum 1990;17:595-614. 4. Hamiton J, Edgar L. A survey of nurses’ knowledge of pain control. J Pain Symptom Manage 1992;7:1819. 5. Watt-Watson J. Nurses’ knowledge of pain issues: a survey. J Pain Symptom Manage 1987;2:207-211.
antihistaminic agent, was intended to potentiate the antiemetic efficacy through blocking of histamine receptors in the brainstem and to counteract any extrapyramidal reaction induced by MCP.5 In other trials,**sMCP and DHM were used in combination with dexamethasone (DXM), so we continued our study using three drugs (MCP, DXM, and DHM). A group of 47 hospitalized patients who received previous cisplatin-based chemotherapy at a dose of 100 mg/m2 of body
Vol.7 hr0. 8 Nomnber I992
L&ken
Table 1 Characteristics Number of patients Age in years Mean Range Sex Maie Female Performance 90-100 Status 80 (Karnofsky) 70 Type of cancer Lung (NSCLC) Ovaries Head and neck Several other Previous chemotherapy
Number of patients
intervals
after
47
d infnsed in 15 min. was given every 6 br, for four intramuscular doses.
54 41-69 31 16 16 21 10
111 l/z-,
29 3 5 10 47
Table 2 of Antiemetic
way of administration. These results support our previous findings. Nicolas B. Tsavaris, MD Department of Pathology/Physiology Athens University School of Medicine Athens, Greece
Trea Croups
Number
intervals after
The results are presented in Tables 2-4.
surface area in 30-min intravenous infusion, and their clinical characteristics, are presented in Table 1. They were entered in this trial, following the same methodology as in y. First they received previ and in the next cycle M, an and DXM as follows: 1. MCP was given at a dose of 2 mg/kg every 2 hr for five intravenous doses. e first
Nausea-vomiting
1’7 */2-hr
Grade
of patients
MCP + DXM
of patients MCP + DXM + DHM
P
47
47
Vomiting
with gastric content
0 1 2 3
25 10 2 0
28 14 4 1
NS NS NS NS
Vomiting
without gastric content
0 1 2 3 4
13 19 6 6 4
19 16 6 4 2
NS
No Yes
8 39
10 37
NS NS
160 O-920
145 O-1080
NS
Existence
of nausea
Duration Mean
of nausea in minutes
Range MCP, metoclopramide; DXM, dexamethasone; DHM. diphenhydmmine;
and NS, not significant.
NS NS NS NS
Ipot.7 No. 8 November 1992
Letters
442
Table 3 Side Effects
of Treatment Groups of patients MCP + DXM
MCP + DXM + DHM
47
47
0
38
31
NS
: 3
36 0
58 3
:: NS
Appetite
0 1 2 3
17 9 12 9
18 6 13 10
NS NS NS NS
Activity
0
1 2
22 17 8
27 12 8
NS
0 1 2 3
34 4 8 1
35 2 6 4
NS NS NS NS
Side effects grade Number of patients Sedative effects
Diarrhea
MCP, metoclopramide; DXM, dexamethasone: DHM, diphenhydmine;
P
and NS, not significant.
Table 4 Side Effects Groups of patients MCP + DXM
Number of patients Chills Diaphoresis Headache Dizziness Hypotension (>30 mm Hg) Extrapyramidal manifestation Mouth dryness MCP, metocloptamide;
DXM. dexamethasone;
MCP+DXM+ DHM
48 2 16
47 5 15 10 1 0 3 13
: 2 6 10 DHM, diphenhydmnine;
1. Tsavaxis N, Zamanis N, Zinelis A, et al. Diphenhydramine for nausea and vomiting related to cancer chemotherapy. J Pain Symptom Manage 1991;6:461474. 2. Andrews PLR, Rapoport WC, Sanger GJ. Neuro pharmacology of emesis induced by anti-cancer therapy. Trends Phannacol Sci 1988;9:334. 3. Rris MG, Gralla RJ, Tyson LB, et al. Improved
P
NS NS NS NS NS NS NS
and NS, not significant.
control of cisplatin induced emesis with high-dose metoclopramide and with combinations of metoclopramide, dexamethaxone and diphenhydramine. Cancer 1985;55:527. 4. Peroutka SJ, Snyder SH. Antiemetics: neurotransmitter receptor binding predicts therapeutic actions. Lancet 1982;1:658. 5. Rris MC, Tyson LB, G&la RJ, Allen JC, Reilly LR. Extrapyramidal reactions with high dose metoclopramide. N Engl J Med 1983;309:433.
LJ?h?rs
440
@m-Year Pain Fellowship A l-year clinical practicum, initiated in 1989, is offered to Master’s prepared nurses with a minimum of 2 years experience in oncoIogy nursing. One nurse fellow can be accomodated each year. This program attempts to prepare qualified nurses to function as clinical specialists in their own institutional and community settings. The long-term goal is to have an identified nurse expert or cadre of such experts in each hospital or health-care delivery system, who can act as information resources and as educators in pain management, analgesic studies, and supportive care. The nurse fellow is given the opportunity for “hands on” experience with the pain consultation team, supportive care program, and pain research program. Funding for the first 3 years of this program (which provides the nurse with a stipend for living expenses) has come from the generous support of the Society of Memorial Sloan-Kettering Cancer Center. There is no charge to the nurse fellow. The source of future funding for this program is still under review. Our most recent nurse fellow has been funded by her parent institution, and it is hoped that at least partial funding for future nurse fellows will come from similar sources. These programs are not expensive. They are incorporated into the day-today activity of the interdisciplinary pain team and require no extra staE or space. However, a commitment is required from the institution of the participating nurse to provide both time and travel expenses. Some pharmaceuti-
her&y&amine
ViitingRelated
for Nausea and
to Cancer
Chemothemlbywith Ciqdatin To the Editor: In a previous study’ we found that diphenhydramine (DHM) is not a useful adjuvant antiemetic drug when it is added to high doses of metoclopramide (MCP).Also it does not prevent completely the extrapyramidal side effects of MCP.’ DHM,2n3 an
cal companies have been heipful in providing travel expenses to some participants and in the development of educational material. The success of these programs suggests that there are a variety of practical solutions to the need for continuing education of nurses in pain management and supportive care. Nonetheless, hospitals and nursing schools have been slow to recognize that pain assessment and management require a specific lcnowledge base and level of expertise. Unless this recognition develops, funding will not be provided for nurses to participate in such and professionals who are not programs, qualified will continue to teach in this area. Nessa Coyle, RN and Jean Adelhardt, RN Department of Neurology, Pain Service Memorial Sloan-Kettering Cancer Center New York, New York
1. Ferrell BR, McCaffery M, Rhiner W. Pain and addiction: an urgent need for change in nursing education. J Pain Symptom Manage 1992;7:117-124. 2. McCaffery M, Ferrell BR, Page EO, Lester M, Ferrell BA. Nurses’ knowledge of opioid analgesics and addiction. Cancer Nurs 1990;13:21-27. 3. Spross J, McGuire D, Schmitt R. Oncology Nursing Society position paper on cancer pain. Oncol Nurs Forum 1990;17:595-614. 4. Hamiton J, Edgar L. A survey of nurses’ knowledge of pain control. J Pain Symptom Manage 1992;7:1819. 5. Watt-Watson J. Nurses’ knowledge of pain issues: a survey. J Pain Symptom Manage 1987;2:207-211.
antihistaminic agent, was intended to potentiate the antiemetic efficacy through blocking of histamine receptors in the brainstem and to counteract any extrapyramidal reaction induced by MCP.5 In other trials,**sMCP and DHM were used in combination with dexamethasone (DXM), so we continued our study using three drugs (MCP, DXM, and DHM). A group of 47 hospitalized patients who received previous cisplatin-based chemotherapy at a dose of 100 mg/m2 of body
Vol.7 hr0. 8 Nomnber I992
L&ken
Table 1 Characteristics Number of patients Age in years Mean Range Sex Maie Female Performance 90-100 Status 80 (Karnofsky) 70 Type of cancer Lung (NSCLC) Ovaries Head and neck Several other Previous chemotherapy
Number of patients
intervals
after
47
d infnsed in 15 min. was given every 6 br, for four intramuscular doses.
54 41-69 31 16 16 21 10
111 l/z-,
29 3 5 10 47
Table 2 of Antiemetic
way of administration. These results support our previous findings. Nicolas B. Tsavaris, MD Department of Pathology/Physiology Athens University School of Medicine Athens, Greece
Trea Croups
Number
intervals after
The results are presented in Tables 2-4.
surface area in 30-min intravenous infusion, and their clinical characteristics, are presented in Table 1. They were entered in this trial, following the same methodology as in y. First they received previ and in the next cycle M, an and DXM as follows: 1. MCP was given at a dose of 2 mg/kg every 2 hr for five intravenous doses. e first
Nausea-vomiting
1’7 */2-hr
Grade
of patients
MCP + DXM
of patients MCP + DXM + DHM
P
47
47
Vomiting
with gastric content
0 1 2 3
25 10 2 0
28 14 4 1
NS NS NS NS
Vomiting
without gastric content
0 1 2 3 4
13 19 6 6 4
19 16 6 4 2
NS
No Yes
8 39
10 37
NS NS
160 O-920
145 O-1080
NS
Existence
of nausea
Duration Mean
of nausea in minutes
Range MCP, metoclopramide; DXM, dexamethasone; DHM. diphenhydmmine;
and NS, not significant.
NS NS NS NS
Ipot.7 No. 8 November 1992
Letters
442
Table 3 Side Effects
of Treatment Groups of patients MCP + DXM
MCP + DXM + DHM
47
47
0
38
31
NS
: 3
36 0
58 3
:: NS
Appetite
0 1 2 3
17 9 12 9
18 6 13 10
NS NS NS NS
Activity
0
1 2
22 17 8
27 12 8
NS
0 1 2 3
34 4 8 1
35 2 6 4
NS NS NS NS
Side effects grade Number of patients Sedative effects
Diarrhea
MCP, metoclopramide; DXM, dexamethasone: DHM, diphenhydmine;
P
and NS, not significant.
Table 4 Side Effects Groups of patients MCP + DXM
Number of patients Chills Diaphoresis Headache Dizziness Hypotension (>30 mm Hg) Extrapyramidal manifestation Mouth dryness MCP, metocloptamide;
DXM. dexamethasone;
MCP+DXM+ DHM
48 2 16
47 5 15 10 1 0 3 13
: 2 6 10 DHM, diphenhydmnine;
1. Tsavaxis N, Zamanis N, Zinelis A, et al. Diphenhydramine for nausea and vomiting related to cancer chemotherapy. J Pain Symptom Manage 1991;6:461474. 2. Andrews PLR, Rapoport WC, Sanger GJ. Neuro pharmacology of emesis induced by anti-cancer therapy. Trends Phannacol Sci 1988;9:334. 3. Rris MG, Gralla RJ, Tyson LB, et al. Improved
P
NS NS NS NS NS NS NS
and NS, not significant.
control of cisplatin induced emesis with high-dose metoclopramide and with combinations of metoclopramide, dexamethaxone and diphenhydramine. Cancer 1985;55:527. 4. Peroutka SJ, Snyder SH. Antiemetics: neurotransmitter receptor binding predicts therapeutic actions. Lancet 1982;1:658. 5. Rris MC, Tyson LB, G&la RJ, Allen JC, Reilly LR. Extrapyramidal reactions with high dose metoclopramide. N Engl J Med 1983;309:433.
