Implementing measurement-based care in the analgesic management of cancer pain patients receiving intrathecal drug infusion

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The objective of this study is to assess the effectiveness of measurement-based care (MBC) in the analgesic management of cancer pain patients receiving intrathecal drug infusion. Methods Patients experiencing moderate-to-severe cancer pain and receiving intravenous patient-controlled analgesia (IV-PCA) and then intrathecal morphine patient-controlled analgesia (IT-PCA) were included. Following the MBC strategy, a comprehensive pain assessment is conducted before the treatment using the Visual Analog Scale (VAS) and the brief pain inventory. Subsequently, pain intensity, side effects and quality of life were evaluated at the initiation of intravenous PCA, after intravenous PCA, following intrathecal PCA, and at 1, 3, and 6 months during the follow-up period. Results Fifteen patients with a VAS score ≥ 7 were enrolled. A total of 60% (9/15) had chest and back pain, and more than 40% (6/15) showed obvious persistent pain, 26.7% (4/15) accompanied by paroxysmal exacerbation. The mean VAS score before PCA with morphine (8.28 ± 0.76) was decreased by 44.28% to 3.85 ± 0.7 after IV-PCA. Following morphine infusion with IT-PCA, the VAS score further decreased to 2.14 ± 0.9, resulting in a pain reduction of 76.4%. Throughout the follow-up, pain relief was sustained and the patient's quality of life was improved. Conclusion The findings of this study indicated that implementing of intrathecal morphine control analgesic technology based on MBC strategy can lead to effective individualized analgesic treatment, reduce side effects and improve quality of life for cancer pain patients. Biological sciences/Cancer Health sciences/Health care Health sciences/Medical research Health sciences/Oncology measurement-based strategy cancer pain intrathecal opioids analgesics Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Cancer pain is one of the most common and distressing syndromes in clinic, significantly affecting daily activities and quality of life of patients. 1 More than half of cancer patients experience pain, and those in the metastatic or terminal stages face a higher incidence, with 38.0% reporting moderate to severe pain. 2 Despite adhering to the guidance of the WHO's "Three-step Analgesia" program and its principles, 15% of cancer patients still experience refractory cancer pain. In the advanced stage of the disease, conventional analgesic treatment has poor efficacy, and the adverse reactions can’t be tolerated. 3 Cancer pain management is making significant strides not only in analgesic technology but also in innovative management concepts. Thus, it is an urgent to find a comprehensive pain management strategy pattern to achieve more effective pain control. 4,5 Interventional pain procedures can provide appropriate analgesia where opioids are ineffective or give undesirable side effects. Intrathecal analgesia is a pain treatment in which analgesics, such as morphine, are injected directly into the spinal cord and brain through a soft catheter, blocking the transmission of pain signals to the brain. As the dose of pain-causing drugs is greatly reduced, the opioid-related adverse reactions are also significantly reduced. At present, it has been widely popularized and recognized all over the world. Intrathecal administration of opioids may be necessary in cancer patients with intractable pain, 6,7,8,9 Intrathecal patient-controlled analgesia (PCA) with morphine has been used effectively to treat intractable cancer pain. The advantages of intrathecal drug delivery include rapid drug delivery at a constant rate and a dose as low as 1/300 of the oral dose theoretically. 10 Therefore, intrathecal delivery of opioids can relieve cancer pain and reduce their toxic effects. The best goal of pain management is to reduce pain to an acceptable level of quality of life. One of the challenges is how to apply cancer pain management strategies appropriately. 11 In the clinical management of cancer pain, issues that hinder adequate pain relief include a lack of consensus on the choice of cancer pain treatment strategies and a lack of comprehensive and timely pain assessment to the extent that analgesic drugs are inadequate. 9 Therefore, it is important to develop a therapeutic strategy for the treatment of cancer pain. In the management of cancer pain, not only the analgesic technology has made great strides forward, but also the management concept should be innovated. Evidence suggests that measurement-based care (MBC) to identify the extent of these problems and inform treatment decisions can improve usual care for these conditions. 12 MBC strategy involves determinations of symptoms and side effects, evaluation of disease severity, compliance, and tolerance, and the appropriate medication dose and treatment protocol based on this information. 13 By monitoring the patient’s condition, clinicians can promptly adjust the treatment protocol for maximum benefit. 14 MBC has been successfully used for the treatment of many diseases such as hypertension, diabetes, and depression. 15 Recently, MBC was adopted to improve clinical outcomes and prognosis of patients with chronic pain. 16,17 However, the use of MBC in analgesic and management of cancer pain has yet to be explored. This study investigated the efficacy and safety of IT-PCA with morphine for the treatment of cancer pain, and reported how implementation of MBC was approached into clinical practice of intractable cancer pain care. METHODS Patients The study was approved by the Medical Ethics Committee and included patients from two pain treatment centers who had given informed consent. This study included 15 patients with moderate-to-severe cancer pain, who received intrathecal morphine pump management. Each patient was hospitalized for comprehensive evaluation in order to assess the pain relief achieved and to determine whether there might be drug-related side effects. The severity of pain was evaluated using the self-reported visual analogue scale (VAS) and brief pain inventory (BPI). The pain VAS score of all patients before admission was greater than or equal to 7 points. The average duration of pain was greater than or equal to 6 months, and the expected survival time was greater than 3 months. The extent of pain relief was evaluated as (A-B)/A × l00%, where A represents the VAS score before pain treatment, and B denotes the VAS score after pain treatment. Relief of pain was rated based on the percentage of pain reduction as follows: <24%, no relief; 25%-49%, mild relief; 50%-74%, moderate relief; 75%-99%, substantial relief; and 100%, complete relief. The clinical goal of pain management was 30–50% pain reduction, with ≥30% pain reduction considered clinically meaningful improvement in pain. 18 Intravenous PCA with morphine Before IT-PCA, intravenous PCA (IV-PCA) with morphine was administered to patients to evaluate the individual’s response to morphine, which is based on NCCN guidelines recommending rapid titration with intravenous morphine. Based on each patient’s response to IV-PCA with morphine, the minimum effective dose for each patient was selected and used for 3 consecutive days. The efficacy of morphine treatment was subsequently evaluated. For patients with no history of opioid use, oral administration of rapid-release morphine (10mg) was given, and pain assessment was performed 60 min after the treatment. For patients with tolerance to opioid therapy, the total dosage of oral morphine within 24-h was calculated. The commonly used opioid conversion relationship is that oral morphine dose of 20mg is equivalent to oral oxycodone of 10 mg; transdermal fentanyl of 4.2mg/72-hours is equivalent to oral morphine of 60mg/day. One-tenth of the 24-hour oral morphine dose was intravenously administered via a PCA pump as the starting dose (Shanghai Grase by Medical Instrument, Shanghai, China). Intrathecal PCA with morphine Each patient underwent minimally invasive implantation of a semi-implantable intrathecal drug infusion system during the same hospitalization. The procedure was performed under local anesthesia. Spinal puncture was performed at an interspace between L2 and L4 in 14 patients, and at the level of T7/8 interspace in 1 patient (with intraspinal hepatocellular carcinoma metastasis). Once the intrathecal space was verified by free flow of the cerebrospinal fluid, an intrathecal infusion catheter (Omnitest Medical, Germany) was placed and a subcutaneous pocket for the injection port was created at the right costal arch. The catheter was subcutaneously tunneled toward the pocket and connected to the injection port. After the wound was closed, a PCA device was connected to the subcutaneous injection port via a non-coring needle. Measurement based care strategy Medical staff use the pain assessment scale for quantitative and qualitative assessment to determine the degree and nature of pain, the duration of pain and the impact of pain on patients' lives. Timely adjustment of PCA dosage and combined drug use in accordance with the dynamic monitoring and reevaluation process to complete rapid titration. The long-term effect assessment is to assess the effectiveness of pain management and whether there is a need to adjust treatment. The initial dose of intrathecal morphine titration is determined by the successful dose of intravenous morphine titration. The intravenous morphine dose given to opioid-tolerant patients after admission is based on 10% of their total oral morphine dose in the previous 24 hours. PCA pump 15-minute morphine dose and background infusion rate were determined based on pain assessment. A single PCA supplemental dose was 10% of the background infusion dose and required pain and adverse reactions to be assessed every 15 minutes. The morphine dose was then adjusted according to the assessment results until the VAS score was below 4. If the VAS score did not change or increase, the morphine dose increased by 50–100%. If the VAS score was reduced to 4–6, the morphine dose was increased by 50%. If the VAS score fell to 1–3, the dose was maintained for the next 60 minutes. Daily morphine consumption was titrated according to whether the patient experienced wakefulness during sleep and whether there was an outbreak of painful episodes. Intrathecal morphine titration with PCA was achieved within 24-hours, and then the 24h total morphine dose was calculated after IT-PCA with morphine 1, 2, 3, 7 days (at discharge), and 1, 3, 6 months (After discharge, the patient was followed up by telephone during home treatment) Pain assessment The Single-dimensional VAS scale, multi-dimensional Brief Pain Inventory (BPI) and LANSS scale were selected as pain assessment tools. When the VAS scale was used to evaluate pain, 1–3 were classified as mild pain. 4–6 for moderate pain; 7 to 10 is severe pain. The BPI scale is a pain assessment tool that has been recorded before and after pain management, and self-evaluated according to 7 criteria including daily life, emotion, walking ability, daily work, and relationships with other people, sleep, and life interest. Each item was scored 0–10 with 0 representing the best and 10 the worst. The Leeds Neurological Signs and Symptoms Assessment (LANSS) scale was used before treatment because the LANSS scale is a commonly used, reliable, and effective tool for screening for neuropathic pain. Individualized treatment The mechanism of cancer pain in each patient was fully evaluated. In addition to intrathecal opioid analgesics, adjuvant analgesics such as non-steroidal anti-inflammatory drugs, antidepressants or anticonvulsants were also used [19]. Morphine doses were recorded every 24 hours before pain treatment, during IV-PCA and IT-PCA, and at 1 and 3 months after pain treatment. Follow-up was completed for 3 to 6 months. Opioid-related adverse reactions such as constipation, dysuria, nausea, vomiting, and drowsiness were recorded. Statistical analysis Analyses were performed using SPSS 13.0. Continuous variables are presented as mean ± standard deviation, and categorical data are presented as numbers and percentages. Repeated measurement analysis of variance was used to compare data at different time points, and then post-hoc least significant difference tests. P < 0.05 was considered statistically significant. RESULTS Patient characteristics During the time period in question, fifteen patients were given a trial of IT analgesia using the above-described procedure. All the patients’ age was 62.6 ± 8.8 years (range, 45–75 years), All patients with cancer pain were confirmed by pathology with the characteristics of these patients listed in Table 1 . Among the patients, there were 6 cases of lung cancer, 3 cases of pancreatic cancer, 2 cases of liver cancer, 1 case of pelvic soft tissue sarcoma, 1 case of cardiac adenocarcinoma, 1 case of ascending colon cancer, 1 case of breast cancer, and 5 cases complicated with bone metastasis. A total of 9 patients (60%) had chest and back pain, and more than 40% showed obvious persistent pain, 26.7% accompanied by paroxysmal exacerbation. After discharge, these patients continued to receive medical management and actively completed follow-up. During that time, 11 cases completed 3-month follow-up. Among then, 7 cases completed 6-month follow-up. In these patients in hospital, VAS score averaged 7.07 ± 1.10 prior to admission, Median pain duration was 6 months (range 1–48 months). Two patients had LANSS scores greater than 12, indicating that neuropathic pain is the primary mechanism of cancer pain. The median LANSS score was 8 (range 1–24). Two patients had LANSS scores greater than 12, indicating that neuropathic pain is the primary mechanism of cancer pain. All patients underwent rapid intravenous PCA drip 1 to 3 days after admission, and the drug dose was titrated to the lowest effective dose according to tolerance, while preoperative preparation was made. For each patient, the consumption and dosage of morphine increased for 24 hours before the start and after the completion of intravenous titration (Table 2 ), with a maximum increase of 500%, indicating inadequate analgesia before admission. Table 1. Patient characteristics a Variable Patients Subjects, n 15 Age, y 62.6 ± 8.8 Gender (female) 9 (60.0%) Primary tumor Hepatic carcinoma 2 (13.3%) Lung cancer 6 (40.0%) Pancreatic cancer 3 (20.0%) Colon cancer 1 (6.7%) Breast cancer 1 (6.7%) Pelvic soft tissue sarcoma 1 (6.7%) Cardiac adenocarcinoma 1 (6.7%) Pain location Chest and back 9 (60%) Lower back 2 (13.3%) Abdomen 2 (13.3%) Limbs 2 (13.3%) Admission pain Persistent pain 6 (40.0%) Persistent involved like pain, paroxysmal increase 4 (26.7%) Rheumatic pain 1 (6.7%) Numbness 1 (6.7%) Stabbing pain\Cutting pain 1 (6.7%) Swelling pain 2 (13.3) Duration (months) b 6 (1-48) VAS 7.07 ± 1.10 LANSS pain rating b 8 (2-24) a Reported as n (%), unless indicated otherwise; b median (range) Table 2 Morphine daily dosage at baseline (oral) and after IV-PCA a Patients Baseline, mg Post-IV-PCA, mg Change (%) b 1 120 66 65 2 - 80 200 3 0 20 0 4 160 80 50 5 30 62 520 6 60 52 160 7 640 310 46 8 200 160 80 9 140 160 128.67 10 240 120 50 11 60 90 350 12 540 300 66.67 13 60 90 200 14 50 32 92 15 250 80 4 a Reported as mg/d, unless shown otherwise; b reported as percent of baseline. Pain assessment Compared with the VAS score at the beginning of IV-PCA with morphine, the maximum, minimum, and average VAS scores were significantly lower after IV-PCA with morphine, after IT-PCA with morphine, at discharge, and at one-month follow-up ( P < 0.05, Fig. 1A). After intravenous PCA with morphine, the mean VAS score (3.85 ± 0.7) was 46.5% that of the baseline (before PCA morphine treatment; 8.28 ± 0.76), indicating that all patients experiencing rapid titration of intravenous morphine can achieve good pain relief. The VAS score was further decreased to 2.14 ± 0.9 after IT-PCA with morphine with a 76.4% pain reduction (Fig. 1B). The maximum, minimum, and average VAS scores were significantly lower after IT-PCA using morphine than after IV-PCA with morphine ( P 0.05, Fig. 1). Quality of life Compared to IV-PCA with morphine, intravenous and IT-PCA with morphine significantly improved the anxiety symptoms such as irritability, insomnia, and emotional despair. The brief pain inventory scores evaluating daily life, emotion, sleep, and interest in life were significantly lower after intravenous and IT-PCA with morphine than before the treatment ( P < 0.01, Fig. 2), suggesting that the patients’ quality of life was improved with pain relief. There was no significant difference in the scores evaluating walking ability, daily work, and relationships with other people at the different timepoints ( P > 0.05, Fig. 2). One patient with paraplegia due to intraspinal tumor metastasis, and one patient with 20% muscle strength due to brain and spinal tumor metastasis, lost the ability to perform activities of daily living. Follow-up pain assessment All patients achieved satisfactory analgesic effects after IT-PCA with morphine. The reduction in pain was sustained during the follow-up period. The VAS scores remained at 1–3 after intravenous and IT-PCA with morphine, and at the follow-ups at 7 days, 1 month, and 3 months, and were all significantly lower than at the beginning of treatment ( P < 0.01, Fig. 3). There were no significant differences in the VAS scores after intravenous and IT-PCA, as well as during the follow-up period of 7 days, 1 month, and 3 months. Morphine dosage A total of 14 patients with cancer pain received daily doses of 32-310mg/d after intravenous morphine titration before intrathecal infusion system insertion. Intrathecal infusion of 1 mg morphine is equivalent to epidural administration of 10mg and intravenous administration of 100mg. Therefore, the intravenous morphine dose can be converted into intrathecal administration dose. An Initial IT-PCA dose was determined as 1% of the 24-hour IV-PCA morphine dose. Thus, a background IT-PCA dose of 0.5-3 mg/d was used. The bolus dose of PCA parameters were set equal to background dose, and the l lockout time was 30min ~ 1h. Titration is usually considered satisfactory when the patient's pain relief is greater than 50% and there are no adverse reactions that are difficult to tolerate. Pain was dynamically assessed until 7 days before discharge and side effects were observed. The results showed that the effective and safe titration dose was maintained. The mean daily dose of morphine at 3-month follow-up was 1-5.5 mg/d. The exception was one patient (patient 7) who received 640 mg of morphine orally and 310 mg of morphine 24 hours after IV-PCA. Due to the patient's LANSS score more than 12 to indicate the presence of neuropathic pain mechanisms. She received oral pregabalin (75 mg twice daily) [20] and amitriptyline hydrochloride [21] (12.5 mg before bed). Intrathecal morphine doses were administered between 48 and 64 mg/d to enhance analgesia (Fig. 4). Oral pregabalin (75 mg twice daily) and amitriptyline hydrochloride (12.5 mg single oral, scheduled to be administered before sleep) were used in combination. Intrathecal morphine doses were administered between 48 and 64 mg/d to enhance analgesia (Fig. 4). Adverse reactions Throughout the study period, one of the patients had difficulty in defecation and dry stool, which was relieved after we gave the symptomatic treatment of compound polyethylene glycol warm water. 22 One patient developed nonspecific weakness on the third day after surgery, and no postoperative complications such as nausea, vomiting, or respiratory depression were found in all patients. Although the intrathecal morphine dose was slightly increased, there was still no infection, equipment-related or catheter-related complications. DISCUSSION Cancer pain management is a key part of cancer treatment. Accurate and adequate evaluation of cancer pain and pain management strategies are necessary to improve the level of cancer pain management. 23,24,25,26 In this study, we evaluated the efficacy and safety of IT-PCA versus morphine for moderate-to-severe cancer pain based on the MBC strategy. The results showed that intrathecal morphine analgesia using MBC strategy can relieve cancer pain satisfactorily, with minor side effects, and improve the quality of life of patients. Our study suggests that MBC-based intrathecal morphine may be a valuable therapeutic strategy for intractable cancer pain. Measurement-based care (MBC) is a systematic, continuous assessment aimed at monitoring treatment progress and informing clinical decision-making. 27 The MBC strategy encourages clinicians to actively evaluate pain, monitor pain development, and thus improve the quality of pain management. 16 At critical time points in the study, patients were evaluated for VAS scores during admission, intravenous and intrathecal drip schedule, follow-up time, systemic opioid dose (basal dose and additional dose during pain outbreak), intrathecal morphine dose (basal dose and bolus dose during pain outbreak), and complications were recorded. The selection of scale is particularly important for guiding the adjustment of treatment plan. The LANSS scale was selected to evaluate the nature of pain and the BPI scale was applied to comprehensively evaluate the assessment of quality of life. Intrathecal administration of opioids was found necessary to control the Intractable pain of cancer patients. 7,8,9 Opioids generate an analgesic effect by binding to opioid receptors in the dorsal horn of the spinal cord and subsequently blocking pain transmission. 28,29 The intrathecal drug delivery system has been used for the treatment of cancer pain with several advantages, such as a low intrathecal infection rate. 30 In this study, we used IT-PCA with morphine to treat the cancer pain of late-stage patients with short expected survival time. Intrathecal administration of opioids in smaller doses resulted in enhanced therapy and reduced side effects, compared with systemic administration. The largest increase was 520% of the oral dose, indicating that the number of analgesics during treatment of patients outside the hospital was not sufficient. One patient (patient 7) who had a LANSS score > 12 was administered a large dose of intravenous morphine (310 mg/d). Neuropathic pain may have contributed to the need of a larger dose of opioids for this patient. 31 No patient experienced serious postoperative complications such as nausea, vomiting, or respiratory depression. Only one patient had mild constipation, which was relieved by conservative treatment. To control pain effectively with minimal side effects, in this study the minimum effective morphine dose for each patient was used. The initial intrathecal morphine dose was determined as 1% of the 24-hour IV-PCA morphine dose, as previously described. 32,33 Fourteen of the 15 patients received 24-hour IV-PCA morphine doses ranging from 80 to 120 mg/d. Therefore, the initial IT-PCA dose of 0.5-1 mg/d was used in these patients. At the 1- and 3-month follow-ups, the morphine dose was adjusted to as low as 1-5.5mg/d, and the patients demonstrated an improved quality of life. However, the intrathecal morphine dose was as high as 48 to 64 mg/d in one patient (Patient 7) who had a LANSS score > 12. In this case neuropathic pain may have led to a greater consumption of opioid. 31 Therefore, our findings suggest that intrathecal morphine may be feasible for the treatment of moderate-to-severe pain in cancer patients. Reassessment time is very important for effectively evaluating the treatment response when applying MBC. Intrathecal administration of opioids produces analgesia in 15 to 45 minutes, and lasts for 30 hours. Therefore, in the present study, pain was evaluated every 15 min during IT-PCA with morphine. The morphine dose was then adjusted, based on the evaluation, until the VAS score was < 4. The patient’s quality of life was evaluated by a brief pain inventory, a pain evaluation system that has been used for cancer pain. 34 We found that pain severity was significantly lower after intrathecal administration of morphine compared with the baseline or after IV-PCA with morphine, and was accompanied by significantly improved quality of life. Pain relief was shown to be maintained at the 1, 3, 6-month follow-ups, accompanied by a good quality of life. Our findings suggest that the MBC strategy can be used for the management of opioid use and pain in cancer patients. Nevertheless, the sample size in this observational study was limited. Large prospective cohort trials will be designed to confirm our findings in future studies focused on cancer pain management. Based on the MBC strategy, we can quantitatively evaluate the scale and dynamically reflect the changes of pain, which is helpful to improve the treatment outcome. Our clinical practice has been shown to contribute to the optimal management of intrathecal analgesia. With the development of palliative care practice, using MBC strategy, good analgesic therapy can improve coping ability and improve quality of life in patients with advanced malignancies. CONCLUSION The findings of this study indicate that implementing of intrathecal morphine control analgesic technology based on MBC strategy can lead to effective individualized analgesic treatment, reduce side effects and improve quality of life for cancer pain patients. MBC strategies may play an integral role in assessing and managing cancer pain. It is important to help nurses realize how their pain management interventions can improve mobility and function in cancer patients. Abbreviations measurement-based care MBC intravenous patient-controlled analgesia IV-PCA intrathecal morphine patient-controlled analgesia IT-PCA Visual Analog Scale VAS brief pain inventory BPI The Leeds Neurological Signs and Symptoms Assessment LANSS Declarations Author Contributions 1.Mingling Yi: Conceptualization, Methodology, Writing - Original Draft. Designed the study framework, developed the research methodology, and led the drafting of the manuscript. 2. Panchuan Huang: Data Collection, Formal Analysis. Collected and verified the experimental data, and performed statistical analysis using R to interpret results. 3. Fangli Cao: Investigation, Resources. Conducted fieldwork/in-lab experiments, and secured necessary resources equipment for the study. 4. Wuchao Wang: Validation, Visualization. Validated the accuracy of data analysis results and designed figures/tables statistical charts for the manuscript. 6. Xiaoqiu Yang: Project Administration, Funding Acquisition. Managed the overall project timeline and logistics, and led efforts to acquire funding support for the study. Funding No funding was received to support this study. Corresponding author Correspondence to Xiaoqiu Yang and Wuchao Wang. Ethics declarations Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Ethics Committee of Chairman of the Ethics Committee of Army Medica, Center of PLA in April 2025 (reference number: 2025(149)). And the informed consent was waived by the Ethics Committee. Consent to participate Not applicable. Competing interests The authors declare no competing interests. Data availability statements The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. References Freddie Bray, Jacques Ferlay, Isabelle Soerjomataram, Rebecca L Siegel, Lindsey A Torre, Ahmedin Jemal. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018, 68(6):394-424. doi: 10.3322/caac.21492. van den Beuken-van Everdingen M.H., Hochstenbach L.M., Joosten E.A., Tjan-Heijnen V.C., Janssen D.J. Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J. Pain Symptom. 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infusion","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCancer pain is one of the most common and distressing syndromes in clinic, significantly affecting daily activities and quality of life of patients.\u003csup\u003e1\u003c/sup\u003e More than half of cancer patients experience pain, and those in the metastatic or terminal stages face a higher incidence, with 38.0% reporting moderate to severe pain.\u003csup\u003e2\u003c/sup\u003e Despite adhering to the guidance of the WHO's \"Three-step Analgesia\" program and its principles, 15% of cancer patients still experience refractory cancer pain. In the advanced stage of the disease, conventional analgesic treatment has poor efficacy, and the adverse reactions can\u0026rsquo;t be tolerated.\u003csup\u003e3\u003c/sup\u003e Cancer pain management is making significant strides not only in analgesic technology but also in innovative management concepts. Thus, it is an urgent to find a comprehensive pain management strategy pattern to achieve more effective pain control.\u003csup\u003e4,5\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eInterventional pain procedures can provide appropriate analgesia where opioids are ineffective or give undesirable side effects. Intrathecal analgesia is a pain treatment in which analgesics, such as morphine, are injected directly into the spinal cord and brain through a soft catheter, blocking the transmission of pain signals to the brain. As the dose of pain-causing drugs is greatly reduced, the opioid-related adverse reactions are also significantly reduced. At present, it has been widely popularized and recognized all over the world. Intrathecal administration of opioids may be necessary in cancer patients with intractable pain,\u003csup\u003e6,7,8,9\u003c/sup\u003e Intrathecal patient-controlled analgesia (PCA) with morphine has been used effectively to treat intractable cancer pain. The advantages of intrathecal drug delivery include rapid drug delivery at a constant rate and a dose as low as 1/300 of the oral dose theoretically.\u003csup\u003e10\u003c/sup\u003e Therefore, intrathecal delivery of opioids can relieve cancer pain and reduce their toxic effects.\u003c/p\u003e \u003cp\u003eThe best goal of pain management is to reduce pain to an acceptable level of quality of life. One of the challenges is how to apply cancer pain management strategies appropriately.\u003csup\u003e11\u003c/sup\u003e In the clinical management of cancer pain, issues that hinder adequate pain relief include a lack of consensus on the choice of cancer pain treatment strategies and a lack of comprehensive and timely pain assessment to the extent that analgesic drugs are inadequate.\u003csup\u003e9\u003c/sup\u003e Therefore, it is important to develop a therapeutic strategy for the treatment of cancer pain. In the management of cancer pain, not only the analgesic technology has made great strides forward, but also the management concept should be innovated. Evidence suggests that measurement-based care (MBC) to identify the extent of these problems and inform treatment decisions can improve usual care for these conditions.\u003csup\u003e12\u003c/sup\u003e MBC strategy involves determinations of symptoms and side effects, evaluation of disease severity, compliance, and tolerance, and the appropriate medication dose and treatment protocol based on this information.\u003csup\u003e13\u003c/sup\u003e By monitoring the patient\u0026rsquo;s condition, clinicians can promptly adjust the treatment protocol for maximum benefit.\u003csup\u003e14\u003c/sup\u003e MBC has been successfully used for the treatment of many diseases such as hypertension, diabetes, and depression.\u003csup\u003e15\u003c/sup\u003e Recently, MBC was adopted to improve clinical outcomes and prognosis of patients with chronic pain.\u003csup\u003e16,17\u003c/sup\u003e However, the use of MBC in analgesic and management of cancer pain has yet to be explored.\u003c/p\u003e \u003cp\u003e This study investigated the efficacy and safety of IT-PCA with morphine for the treatment of cancer pain, and reported how implementation of MBC was approached into clinical practice of intractable cancer pain care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThe study was approved by the Medical Ethics Committee and included patients from two pain treatment centers who had given informed consent. This study included 15 patients with moderate-to-severe cancer pain, who received intrathecal morphine pump management. Each patient was hospitalized for comprehensive evaluation in order to assess the pain relief achieved and to determine whether there might be drug-related side effects. The severity of pain was evaluated using the self-reported visual analogue scale (VAS) and brief pain inventory (BPI). The pain VAS score of all patients before admission was greater than or equal to 7 points. The average duration of pain was greater than or equal to 6 months, and the expected survival time was greater than 3 months.\u003c/p\u003e \u003cp\u003eThe extent of pain relief was evaluated as (A-B)/A \u0026times; l00%, where A represents the VAS score before pain treatment, and B denotes the VAS score after pain treatment. Relief of pain was rated based on the percentage of pain reduction as follows: \u0026lt;24%, no relief; 25%-49%, mild relief; 50%-74%, moderate relief; 75%-99%, substantial relief; and 100%, complete relief. The clinical goal of pain management was 30\u0026ndash;50% pain reduction, with \u0026ge;30% pain reduction considered clinically meaningful improvement in pain.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIntravenous PCA with morphine\u003c/h3\u003e\n\u003cp\u003e Before IT-PCA, intravenous PCA (IV-PCA) with morphine was administered to patients to evaluate the individual\u0026rsquo;s response to morphine, which is based on NCCN guidelines recommending rapid titration with intravenous morphine. Based on each patient\u0026rsquo;s response to IV-PCA with morphine, the minimum effective dose for each patient was selected and used for 3 consecutive days. The efficacy of morphine treatment was subsequently evaluated. For patients with no history of opioid use, oral administration of rapid-release morphine (10mg) was given, and pain assessment was performed 60 min after the treatment. For patients with tolerance to opioid therapy, the total dosage of oral morphine within 24-h was calculated. The commonly used opioid conversion relationship is that oral morphine dose of 20mg is equivalent to oral oxycodone of 10 mg; transdermal fentanyl of 4.2mg/72-hours is equivalent to oral morphine of 60mg/day. One-tenth of the 24-hour oral morphine dose was intravenously administered via a PCA pump as the starting dose (Shanghai Grase by Medical Instrument, Shanghai, China).\u003c/p\u003e\n\u003ch3\u003eIntrathecal PCA with morphine\u003c/h3\u003e\n\u003cp\u003eEach patient underwent minimally invasive implantation of a semi-implantable intrathecal drug infusion system during the same hospitalization. The procedure was performed under local anesthesia. Spinal puncture was performed at an interspace between L2 and L4 in 14 patients, and at the level of T7/8 interspace in 1 patient (with intraspinal hepatocellular carcinoma metastasis). Once the intrathecal space was verified by free flow of the cerebrospinal fluid, an intrathecal infusion catheter (Omnitest Medical, Germany) was placed and a subcutaneous pocket for the injection port was created at the right costal arch. The catheter was subcutaneously tunneled toward the pocket and connected to the injection port. After the wound was closed, a PCA device was connected to the subcutaneous injection port via a non-coring needle.\u003c/p\u003e\n\u003ch3\u003eMeasurement based care strategy\u003c/h3\u003e\n\u003cp\u003eMedical staff use the pain assessment scale for quantitative and qualitative assessment to determine the degree and nature of pain, the duration of pain and the impact of pain on patients' lives. Timely adjustment of PCA dosage and combined drug use in accordance with the dynamic monitoring and reevaluation process to complete rapid titration. The long-term effect assessment is to assess the effectiveness of pain management and whether there is a need to adjust treatment.\u003c/p\u003e \u003cp\u003eThe initial dose of intrathecal morphine titration is determined by the successful dose of intravenous morphine titration. The intravenous morphine dose given to opioid-tolerant patients after admission is based on 10% of their total oral morphine dose in the previous 24 hours. PCA pump 15-minute morphine dose and background infusion rate were determined based on pain assessment. A single PCA supplemental dose was 10% of the background infusion dose and required pain and adverse reactions to be assessed every 15 minutes. The morphine dose was then adjusted according to the assessment results until the VAS score was below 4. If the VAS score did not change or increase, the morphine dose increased by 50\u0026ndash;100%. If the VAS score was reduced to 4\u0026ndash;6, the morphine dose was increased by 50%. If the VAS score fell to 1\u0026ndash;3, the dose was maintained for the next 60 minutes.\u003c/p\u003e \u003cp\u003eDaily morphine consumption was titrated according to whether the patient experienced wakefulness during sleep and whether there was an outbreak of painful episodes. Intrathecal morphine titration with PCA was achieved within 24-hours, and then the 24h total morphine dose was calculated after IT-PCA with morphine 1, 2, 3, 7 days (at discharge), and 1, 3, 6 months (After discharge, the patient was followed up by telephone during home treatment)\u003c/p\u003e\n\u003ch3\u003ePain assessment\u003c/h3\u003e\n\u003cp\u003eThe Single-dimensional VAS scale, multi-dimensional Brief Pain Inventory (BPI) and LANSS scale were selected as pain assessment tools. When the VAS scale was used to evaluate pain, 1\u0026ndash;3 were classified as mild pain. 4\u0026ndash;6 for moderate pain; 7 to 10 is severe pain. The BPI scale is a pain assessment tool that has been recorded before and after pain management, and self-evaluated according to 7 criteria including daily life, emotion, walking ability, daily work, and relationships with other people, sleep, and life interest. Each item was scored 0\u0026ndash;10 with 0 representing the best and 10 the worst. The Leeds Neurological Signs and Symptoms Assessment (LANSS) scale was used before treatment because the LANSS scale is a commonly used, reliable, and effective tool for screening for neuropathic pain.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIndividualized treatment\u003c/h2\u003e \u003cp\u003eThe mechanism of cancer pain in each patient was fully evaluated. In addition to intrathecal opioid analgesics, adjuvant analgesics such as non-steroidal anti-inflammatory drugs, antidepressants or anticonvulsants were also used [19]. Morphine doses were recorded every 24 hours before pain treatment, during IV-PCA and IT-PCA, and at 1 and 3 months after pain treatment. Follow-up was completed for 3 to 6 months. Opioid-related adverse reactions such as constipation, dysuria, nausea, vomiting, and drowsiness were recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses were performed using SPSS 13.0. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical data are presented as numbers and percentages. Repeated measurement analysis of variance was used to compare data at different time points, and then post-hoc least significant difference tests. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eDuring the time period in question, fifteen patients were given a trial of IT analgesia using the above-described procedure. All the patients\u0026rsquo; age was 62.6 \u0026plusmn; 8.8 years (range, 45\u0026ndash;75 years), All patients with cancer pain were confirmed by pathology with the characteristics of these patients listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Among the patients, there were 6 cases of lung cancer, 3 cases of pancreatic cancer, 2 cases of liver cancer, 1 case of pelvic soft tissue sarcoma, 1 case of cardiac adenocarcinoma, 1 case of ascending colon cancer, 1 case of breast cancer, and 5 cases complicated with bone metastasis.\u003c/p\u003e \u003cp\u003eA total of 9 patients (60%) had chest and back pain, and more than 40% showed obvious persistent pain, 26.7% accompanied by paroxysmal exacerbation. After discharge, these patients continued to receive medical management and actively completed follow-up. During that time, 11 cases completed 3-month follow-up. Among then, 7 cases completed 6-month follow-up. In these patients in hospital, VAS score averaged 7.07 \u0026plusmn; 1.10 prior to admission, Median pain duration was 6 months (range 1\u0026ndash;48 months). Two patients had LANSS scores greater than 12, indicating that neuropathic pain is the primary mechanism of cancer pain. The median LANSS score was 8 (range 1\u0026ndash;24). Two patients had LANSS scores greater than 12, indicating that neuropathic pain is the primary mechanism of cancer pain.\u003c/p\u003e \u003cp\u003eAll patients underwent rapid intravenous PCA drip 1 to 3 days after admission, and the drug dose was titrated to the lowest effective dose according to tolerance, while preoperative preparation was made. For each patient, the consumption and dosage of morphine increased for 24 hours before the start and after the completion of intravenous titration (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with a maximum increase of 500%, indicating inadequate analgesia before admission.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Patient characteristics \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eSubjects, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eAge, y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e62.6 \u0026plusmn; 8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eGender (female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e9 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003ePrimary tumor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eHepatic carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eLung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e6 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003ePancreatic cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e3 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eColon cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eBreast cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003ePelvic soft tissue sarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eCardiac adenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003ePain location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eChest and back\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e9 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eLower back\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eAbdomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eLimbs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eAdmission pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003ePersistent pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e6 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003ePersistent involved like pain, paroxysmal increase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e4 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eRheumatic pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eNumbness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eStabbing pain\\Cutting pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eSwelling pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eDuration (months) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e6 (1-48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e7.07 \u0026plusmn; 1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 336px;\"\u003e\n \u003cp\u003eLANSS pain rating \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e8 (2-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Reported as n (%), unless indicated otherwise; \u003csup\u003eb\u003c/sup\u003e median (range)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMorphine daily dosage at baseline (oral) and after IV-PCA \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline, mg\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-IV-PCA, mg\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange (%) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e520\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e640\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e128.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e350\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Reported as mg/d, unless shown otherwise; \u003csup\u003eb\u003c/sup\u003e reported as percent of baseline.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePain assessment\u003c/h2\u003e \u003cp\u003eCompared with the VAS score at the beginning of IV-PCA with morphine, the maximum, minimum, and average VAS scores were significantly lower after IV-PCA with morphine, after IT-PCA with morphine, at discharge, and at one-month follow-up (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Fig.\u0026nbsp;1A). After intravenous PCA with morphine, the mean VAS score (3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7) was 46.5% that of the baseline (before PCA morphine treatment; 8.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76), indicating that all patients experiencing rapid titration of intravenous morphine can achieve good pain relief. The VAS score was further decreased to 2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 after IT-PCA with morphine with a 76.4% pain reduction (Fig.\u0026nbsp;1B). The maximum, minimum, and average VAS scores were significantly lower after IT-PCA using morphine than after IV-PCA with morphine (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Fig.\u0026nbsp;1). There was no significant difference in the maximum, minimum and average VAS scores after IT-PCA with morphine, at discharge, and at one-month follow-up (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life\u003c/h2\u003e \u003cp\u003eCompared to IV-PCA with morphine, intravenous and IT-PCA with morphine significantly improved the anxiety symptoms such as irritability, insomnia, and emotional despair. The brief pain inventory scores evaluating daily life, emotion, sleep, and interest in life were significantly lower after intravenous and IT-PCA with morphine than before the treatment (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, Fig.\u0026nbsp;2), suggesting that the patients\u0026rsquo; quality of life was improved with pain relief. There was no significant difference in the scores evaluating walking ability, daily work, and relationships with other people at the different timepoints (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Fig.\u0026nbsp;2). One patient with paraplegia due to intraspinal tumor metastasis, and one patient with 20% muscle strength due to brain and spinal tumor metastasis, lost the ability to perform activities of daily living.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up pain assessment\u003c/h2\u003e \u003cp\u003eAll patients achieved satisfactory analgesic effects after IT-PCA with morphine. The reduction in pain was sustained during the follow-up period. The VAS scores remained at 1\u0026ndash;3 after intravenous and IT-PCA with morphine, and at the follow-ups at 7 days, 1 month, and 3 months, and were all significantly lower than at the beginning of treatment (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, Fig.\u0026nbsp;3). There were no significant differences in the VAS scores after intravenous and IT-PCA, as well as during the follow-up period of 7 days, 1 month, and 3 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMorphine dosage\u003c/h2\u003e \u003cp\u003eA total of 14 patients with cancer pain received daily doses of 32-310mg/d after intravenous morphine titration before intrathecal infusion system insertion. Intrathecal infusion of 1 mg morphine is equivalent to epidural administration of 10mg and intravenous administration of 100mg. Therefore, the intravenous morphine dose can be converted into intrathecal administration dose. An Initial IT-PCA dose was determined as 1% of the 24-hour IV-PCA morphine dose. Thus, a background IT-PCA dose of 0.5-3 mg/d was used. The bolus dose of PCA parameters were set equal to background dose, and the l lockout time was 30min\u0026thinsp;~\u0026thinsp;1h. Titration is usually considered satisfactory when the patient's pain relief is greater than 50% and there are no adverse reactions that are difficult to tolerate. Pain was dynamically assessed until 7 days before discharge and side effects were observed. The results showed that the effective and safe titration dose was maintained.\u003c/p\u003e \u003cp\u003eThe mean daily dose of morphine at 3-month follow-up was 1-5.5 mg/d. The exception was one patient (patient 7) who received 640 mg of morphine orally and 310 mg of morphine 24 hours after IV-PCA. Due to the patient's LANSS score more than 12 to indicate the presence of neuropathic pain mechanisms. She received oral pregabalin (75 mg twice daily) [20] and amitriptyline hydrochloride [21] (12.5 mg before bed). Intrathecal morphine doses were administered between 48 and 64 mg/d to enhance analgesia (Fig.\u0026nbsp;4). Oral pregabalin (75 mg twice daily) and amitriptyline hydrochloride (12.5 mg single oral, scheduled to be administered before sleep) were used in combination. Intrathecal morphine doses were administered between 48 and 64 mg/d to enhance analgesia (Fig.\u0026nbsp;4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eAdverse reactions\u003c/h2\u003e \u003cp\u003eThroughout the study period, one of the patients had difficulty in defecation and dry stool, which was relieved after we gave the symptomatic treatment of compound polyethylene glycol warm water.\u003csup\u003e22\u003c/sup\u003e One patient developed nonspecific weakness on the third day after surgery, and no postoperative complications such as nausea, vomiting, or respiratory depression were found in all patients. Although the intrathecal morphine dose was slightly increased, there was still no infection, equipment-related or catheter-related complications.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCancer pain management is a key part of cancer treatment. Accurate and adequate evaluation of cancer pain and pain management strategies are necessary to improve the level of cancer pain management.\u003csup\u003e23,24,25,26\u003c/sup\u003e In this study, we evaluated the efficacy and safety of IT-PCA versus morphine for moderate-to-severe cancer pain based on the MBC strategy. The results showed that intrathecal morphine analgesia using MBC strategy can relieve cancer pain satisfactorily, with minor side effects, and improve the quality of life of patients. Our study suggests that MBC-based intrathecal morphine may be a valuable therapeutic strategy for intractable cancer pain.\u003c/p\u003e \u003cp\u003eMeasurement-based care (MBC) is a systematic, continuous assessment aimed at monitoring treatment progress and informing clinical decision-making.\u003csup\u003e27\u003c/sup\u003e The MBC strategy encourages clinicians to actively evaluate pain, monitor pain development, and thus improve the quality of pain management.\u003csup\u003e16\u003c/sup\u003e At critical time points in the study, patients were evaluated for VAS scores during admission, intravenous and intrathecal drip schedule, follow-up time, systemic opioid dose (basal dose and additional dose during pain outbreak), intrathecal morphine dose (basal dose and bolus dose during pain outbreak), and complications were recorded. The selection of scale is particularly important for guiding the adjustment of treatment plan. The LANSS scale was selected to evaluate the nature of pain and the BPI scale was applied to comprehensively evaluate the assessment of quality of life.\u003c/p\u003e \u003cp\u003eIntrathecal administration of opioids was found necessary to control the Intractable pain of cancer patients.\u003csup\u003e7,8,9\u003c/sup\u003e Opioids generate an analgesic effect by binding to opioid receptors in the dorsal horn of the spinal cord and subsequently blocking pain transmission.\u003csup\u003e28,29\u003c/sup\u003e The intrathecal drug delivery system has been used for the treatment of cancer pain with several advantages, such as a low intrathecal infection rate.\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, we used IT-PCA with morphine to treat the cancer pain of late-stage patients with short expected survival time. Intrathecal administration of opioids in smaller doses resulted in enhanced therapy and reduced side effects, compared with systemic administration. The largest increase was 520% of the oral dose, indicating that the number of analgesics during treatment of patients outside the hospital was not sufficient. One patient (patient 7) who had a LANSS score\u0026thinsp;\u0026gt;\u0026thinsp;12 was administered a large dose of intravenous morphine (310 mg/d). Neuropathic pain may have contributed to the need of a larger dose of opioids for this patient.\u003csup\u003e31\u003c/sup\u003e No patient experienced serious postoperative complications such as nausea, vomiting, or respiratory depression. Only one patient had mild constipation, which was relieved by conservative treatment.\u003c/p\u003e \u003cp\u003eTo control pain effectively with minimal side effects, in this study the minimum effective morphine dose for each patient was used. The initial intrathecal morphine dose was determined as 1% of the 24-hour IV-PCA morphine dose, as previously described.\u003csup\u003e32,33\u003c/sup\u003e Fourteen of the 15 patients received 24-hour IV-PCA morphine doses ranging from 80 to 120 mg/d. Therefore, the initial IT-PCA dose of 0.5-1 mg/d was used in these patients. At the 1- and 3-month follow-ups, the morphine dose was adjusted to as low as 1-5.5mg/d, and the patients demonstrated an improved quality of life. However, the intrathecal morphine dose was as high as 48 to 64 mg/d in one patient (Patient 7) who had a LANSS score\u0026thinsp;\u0026gt;\u0026thinsp;12. In this case neuropathic pain may have led to a greater consumption of opioid.\u003csup\u003e31\u003c/sup\u003e Therefore, our findings suggest that intrathecal morphine may be feasible for the treatment of moderate-to-severe pain in cancer patients.\u003c/p\u003e \u003cp\u003eReassessment time is very important for effectively evaluating the treatment response when applying MBC. Intrathecal administration of opioids produces analgesia in 15 to 45 minutes, and lasts for 30 hours. Therefore, in the present study, pain was evaluated every 15 min during IT-PCA with morphine. The morphine dose was then adjusted, based on the evaluation, until the VAS score was \u0026lt;\u0026thinsp;4. The patient\u0026rsquo;s quality of life was evaluated by a brief pain inventory, a pain evaluation system that has been used for cancer pain.\u003csup\u003e34\u003c/sup\u003e We found that pain severity was significantly lower after intrathecal administration of morphine compared with the baseline or after IV-PCA with morphine, and was accompanied by significantly improved quality of life. Pain relief was shown to be maintained at the 1, 3, 6-month follow-ups, accompanied by a good quality of life. Our findings suggest that the MBC strategy can be used for the management of opioid use and pain in cancer patients. Nevertheless, the sample size in this observational study was limited. Large prospective cohort trials will be designed to confirm our findings in future studies focused on cancer pain management.\u003c/p\u003e \u003cp\u003eBased on the MBC strategy, we can quantitatively evaluate the scale and dynamically reflect the changes of pain, which is helpful to improve the treatment outcome. Our clinical practice has been shown to contribute to the optimal management of intrathecal analgesia. With the development of palliative care practice, using MBC strategy, good analgesic therapy can improve coping ability and improve quality of life in patients with advanced malignancies.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe findings of this study indicate that implementing of intrathecal morphine control analgesic technology based on MBC strategy can lead to effective individualized analgesic treatment, reduce side effects and improve quality of life for cancer pain patients. MBC strategies may play an integral role in assessing and managing cancer pain. It is important to help nurses realize how their pain management interventions can improve mobility and function in cancer patients.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e\u0026nbsp;measurement-based care MBC\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eintravenous patient-controlled analgesia IV-PCA\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eintrathecal morphine patient-controlled analgesia IT-PCA\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVisual Analog Scale VAS\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ebrief pain inventory BPI\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Leeds Neurological Signs and Symptoms Assessment LANSS\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.Mingling Yi: Conceptualization, Methodology, Writing - Original Draft. Designed the study framework, developed the research methodology, and led the drafting of the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Panchuan Huang: Data Collection, Formal Analysis. Collected and verified the experimental data, and performed statistical analysis using R to interpret results. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. Fangli Cao: Investigation, Resources. Conducted fieldwork/in-lab experiments, and secured necessary resources equipment for the study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4. Wuchao Wang: Validation, Visualization. Validated the accuracy of data analysis results and designed figures/tables statistical charts for the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6. Xiaoqiu Yang: Project Administration, Funding Acquisition. Managed the overall project timeline and logistics, and led efforts to acquire funding support for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received to support this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to\u0026nbsp;Xiaoqiu Yang and\u0026nbsp;\u0026nbsp;Wuchao Wang.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Ethics Committee of Chairman of the Ethics Committee of Army Medica, Center of PLA in April 2025 (reference number: 2025(149)). \u003cstrong\u003eAnd the informed consent was waived by the Ethics Committee.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFreddie Bray, Jacques Ferlay, Isabelle Soerjomataram, Rebecca L Siegel, Lindsey A Torre, Ahmedin Jemal. 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J Pain. 2014; 15(1):59-67. doi: 10.1016/j.jpain.2013.09.011.\u003cbr\u003e \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"measurement-based strategy, cancer pain, intrathecal, opioids, analgesics","lastPublishedDoi":"10.21203/rs.3.rs-8397515/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8397515/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eEffective analgesic management can enhance the quality of life for patients experiencing cancer pain. The objective of this study is to assess the effectiveness of measurement-based care (MBC) in the analgesic management of cancer pain patients receiving intrathecal drug infusion.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients experiencing moderate-to-severe cancer pain and receiving intravenous patient-controlled analgesia (IV-PCA) and then intrathecal morphine patient-controlled analgesia (IT-PCA) were included. Following the MBC strategy, a comprehensive pain assessment is conducted before the treatment using the Visual Analog Scale (VAS) and the brief pain inventory. Subsequently, pain intensity, side effects and quality of life were evaluated at the initiation of intravenous PCA, after intravenous PCA, following intrathecal PCA, and at 1, 3, and 6 months during the follow-up period.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFifteen patients with a VAS score \u0026ge; 7 were enrolled. A total of 60% (9/15) had chest and back pain, and more than 40% (6/15) showed obvious persistent pain, 26.7% (4/15) accompanied by paroxysmal exacerbation. The mean VAS score before PCA with morphine (8.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76) was decreased by 44.28% to 3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 after IV-PCA. Following morphine infusion with IT-PCA, the VAS score further decreased to 2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9, resulting in a pain reduction of 76.4%. Throughout the follow-up, pain relief was sustained and the patient's quality of life was improved.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings of this study indicated that implementing of intrathecal morphine control analgesic technology based on MBC strategy can lead to effective individualized analgesic treatment, reduce side effects and improve quality of life for cancer pain patients.\u003c/p\u003e","manuscriptTitle":"Implementing measurement-based care in the analgesic management of cancer pain patients receiving intrathecal drug infusion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 06:21:35","doi":"10.21203/rs.3.rs-8397515/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-23T05:47:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-31T04:04:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T20:26:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-17T22:01:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307128465941752471254163782248594204468","date":"2026-01-09T16:14:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120652686143473713441690226319022652888","date":"2026-01-09T01:44:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20788036864448266460831547462608127457","date":"2026-01-07T19:34:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T16:09:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-07T16:08:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-01T10:48:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-31T01:25:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-12-31T01:18:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d70a7190-7002-4298-9c77-18876122f41e","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":60786623,"name":"Biological sciences/Cancer"},{"id":60786624,"name":"Health sciences/Health care"},{"id":60786625,"name":"Health sciences/Medical research"},{"id":60786626,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2026-04-23T05:24:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 06:21:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8397515","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8397515","identity":"rs-8397515","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}