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Grant DR, Schoenleber SJ, McCarthy AM, Neiss GI, Yorgova PK, Rogers KJ, Gabos PG, Shah SA. Are We Prescribing Our Patients Too Much Pain Medication? Best Predictors of Narcotic Usage After Spinal Surgery for Scoliosis. J Bone Joint Surg Am 2016; 98:1555-62. [PMID: 27655983 DOI: 10.2106/jbjs.16.00101] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Physicians play a role in the current prescription drug-abuse epidemic. Surgeons often prescribe more postoperative narcotic pain medication than patients routinely need. Although narcotics are effective for severe, acute, postoperative pain, few evidence-based guidelines exist regarding the routinely required amount and duration of use post-hospital discharge. METHODS Patients in a prospective cohort undergoing posterior spinal fusion for idiopathic scoliosis were asked preoperatively to rate their pain level, the level of pain expected each week postoperatively, and their pain tolerance. Post-discharge pain scores and narcotic use were reported at weekly intervals for 4 weeks postoperatively. Demographic data, preoperative Scoliosis Research Society (SRS)-22 scores, operative details, perioperative data, and self-reported pain levels were analyzed with respect to their association with total medication use and refills received. Disposal plans were also assessed. RESULTS Seventy-two patients were enrolled, and 85% completed the surveys. The mean patient age was 14.9 years; 69% of the patients were female. The cohort was divided into 3 groups on the basis of total medication usage. The mean number of pills used in the middle (average-use) group was 49 pills. In postoperative week 4, narcotic usage was minimal (a mean of 2.9 pills by the highest-use group). Also by this time point, pain scores had, on average, returned to preoperative levels. Older age, male sex, a higher body mass index, and a higher preoperative pain score were associated with increased narcotic use. Sixty-seven percent of the patients planned to dispose of their unused medication, although only 59% of those patients planned on doing so in a manner recommended by the U.S. Food and Drug Administration. CONCLUSIONS Postoperative narcotic dosing may be improved by considering patient age, weight, sex, and preoperative pain score. The precise estimation of individual narcotic needs is complex. Patient and family education on the importance and proper method of narcotic disposal is an essential component of minimizing the availability of unused postoperative medication. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel R Grant
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia
| | - Scott J Schoenleber
- Department of Orthopaedic Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Alicia M McCarthy
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Geraldine I Neiss
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Petya K Yorgova
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Kenneth J Rogers
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Peter G Gabos
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Suken A Shah
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
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Dhingra L, Ahmed E, Shin J, Scharaga E, Magun M. Cognitive Effects and Sedation. PAIN MEDICINE 2016; 16 Suppl 1:S37-43. [PMID: 26461075 DOI: 10.1111/pme.12912] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/06/2015] [Accepted: 08/10/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Cognitive effects and sedation (CES) are prevalent in chronic nonmalignant pain populations receiving long-term opioid therapy and are among the most common reasons patients discontinue opioid use. In this narrative review, we describe the phenomenology, epidemiology, mechanisms, assessment, and management of opioid-related CES. DESIGN We reviewed the empirical and theoretical literature on CES in opioid-treated populations with chronic pain. Data on long-term opioid therapy (≥ 3 months in duration) in chronic nonmalignant pain patients were sought. RESULTS The phenomenology of CES includes: inattention, concentration difficulties, memory deficits, psychomotor dysfunction, perceptual distortions, and executive dysfunction and somnolence, sleep disorders, and lethargy. Deficits may be caused by unrelieved pain or opioid therapy alone, or from a combination of these and other factors. Mechanisms include central nervous system effects, for example, direct toxic effects on neurons resulting in decreased consciousness; direct effects on processing and reaction resulting in cognitive or psychomotor impairment, and inhibitory effects on cholinergic activity. Pharmacological management approaches may include opioid dose reduction and rotation or psychostimulant use. Nonpharmacological approaches may include cognitive-behavioral therapy, mindfulness-based stress reduction, acupuncture, exercise, and yoga. CONCLUSIONS The most prevalent CES include: memory deficits (73-81%), sleep disturbance (35-57%), and fatigue (10%). At its most severe, extreme cognitive dysfunction can result in frank delirium and decreased alertness can result in coma. Emotional distress, sleep disorders, and other comorbidities and treatments can worsen CES, particularly among the elderly. Conclusions about the neuropsychological domains affected by opioids are limited due to the heterogeneity of studies and methodological issues.
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Affiliation(s)
- Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Ebtesam Ahmed
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA.,St. John's University, College of Pharmacy and Health Sciences, Queens, New York, USA
| | - Jae Shin
- Division of Hepatology, California Pacific Medical Center, San Francisco, CA, USA
| | - Elyssa Scharaga
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Maximilian Magun
- St. John's University, College of Pharmacy and Health Sciences, Queens, New York, USA
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Jebaraj B, Khanna P, Baidya DK, Maitra S. Efficacy of epidural local anesthetic and dexamethasone in providing postoperative analgesia: A meta-analysis. Saudi J Anaesth 2016; 10:322-7. [PMID: 27375389 PMCID: PMC4916818 DOI: 10.4103/1658-354x.179096] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Dexamethasone is a potent anti-inflammatory, analgesic, and antiemetic drug. Individual randomized controlled trials found a possible benefit of epidural dexamethasone. The purpose of this meta-analysis is to estimate the benefit of epidural dexamethasone on postoperative pain and opioid consumption and to formulate a recommendation for evidence-based practice. MATERIALS AND METHODS Prospective, randomized controlled trials comparing the analgesic efficacy of epidural local anesthetic and dexamethasone combination, with local anesthetic alone for postoperative pain management after abdominal surgery, were planned to be included in this meta-analysis. PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration (CENTRAL) databases were searched for eligible controlled trials using the following search words: "Epidural", "dexamethasone", and "postoperative pain", until February 20, 2015. RESULTS Data from five randomized control trials have been included in this meta-analysis. Epidural dexamethasone significantly decreased postoperative morphine consumption (mean difference -7.89 mg; 95% confidence interval [CI]: -11.66 to -3.71) and number of patients required postoperative rescue analgesic boluses (risk ratio: 0.51; 95% CI: 0.41-0.63). CONCLUSION The present data shows that the addition of dexamethasone to local anesthetic in epidural is beneficial for postoperative pain management.
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Affiliation(s)
- B Jebaraj
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - P Khanna
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - D K Baidya
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - S Maitra
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Yu SW, Szulc AL, Walton SL, Davidovitch RI, Bosco JA, Iorio R. Liposomal Bupivacaine as an Adjunct to Postoperative Pain Control in Total Hip Arthroplasty. J Arthroplasty 2016; 31:1510-5. [PMID: 26872584 DOI: 10.1016/j.arth.2016.01.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/23/2015] [Accepted: 01/06/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although pain management affects rehabilitation, length of stay, and functional outcome, an optimized pain management protocol has yet to be standardized. Opioids are the primary agent used to control acute postoperative pain; however, they are associated with a wide range of side effects. Liposomal bupivacaine (LB), a long-acting analgesic agent administered intraoperatively, has been introduced as a new modality to control pain for up to 72 hours after operation without affecting motor function. METHODS Six hundred eighty-six primary total hip arthroplasty (THA) patients, who received the standard THA pain management protocol, were compared to a cohort of 586 primary THA patients, who were treated with an additional intraoperative injection of LB. All other pain management parameters and standard of care were identical. Statistical significance was set at P ≤ .05. RESULTS Although patient-reported pain scores were statistically similar, the LB cohort demonstrated a significant decrease in total narcotic use (P < .001), specifically up to postoperative day 2 (P = .016). Physical therapy milestones were significantly achieved to a greater degree (P < .001) in the LB cohort. Operation time and hospital cost were unaffected (P = .072 and .811, respectively); however, the LB cohort exhibited a decrease in length of stay by 0.31 days (P < .001) and improvement in discharge disposition to home (P = .017). CONCLUSION LB is a valuable adjunct to our THA pain management protocol, as we strive to achieve improved patient outcomes, reductions in length of stay, and enhanced quality of THA care.
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Affiliation(s)
- Stephen W Yu
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Alessandra L Szulc
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Sharon L Walton
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Roy I Davidovitch
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
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Docimo S, Mathew A, Shope AJ, Winder JS, Haluck RS, Pauli EM. Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy. Surg Endosc 2016; 31:795-800. [PMID: 27338580 DOI: 10.1007/s00464-016-5034-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 06/11/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Per-oral endoscopic myotomy (POEM) is a less invasive therapy for achalasia with a shorter hospitalization but with similar short- and long-term outcomes as a laparoscopic Heller myotomy (LHM). Previous literature comparing POEM to LHM has focused primarily on postoperative outcome parameters such as complications, dysphagia scores and gastro-esophageal reflux severity. This study specifically compares postoperative pain following POEM to pain following LHM, the current gold-standard operation. METHODS A retrospective review of all patients undergoing POEM or LHM for achalasia was performed from 2006 to 2015. Data collection included demographics, comorbidities, length of stay (LOS) and pain scores (arrival to the recovery room, 1 h postoperative, average first 24 h and upon discharge). Statistical analysis was performed using Student's t test and Chi-square test. RESULTS Forty-four POEM patients and 122 LHM patients were identified. The average age (52.2 ± 20.75 vs 50.9 ± 17.89 years, p = 0.306) and BMI (28.1 ± 7.62 vs 27.6 ± 7.07 kg/m2, p = 0.824) did not differ between the POEM and LHM groups, respectively; however, the American Society of Anesthesiology scores were higher in the POEM patients (2.43 ± 0.62 vs 2.11 ± 0.71, p = 0.011). There were no differences in rates of smoking, diabetes, cardiac disease or pulmonary disease. The average pain scores upon arrival to the recovery room and 1 h postoperatively were lower in the POEM group (2.3 ± 3.014 vs 3.61 ± 3 0.418, p = 0.025 and 2.2 ± 2.579 vs 3.46 ± 3.063, p = 0.034, respectively). There was no difference in the average pain score over the first 24 h (2.7 ± 2.067 vs 3.29 ± 1.980, p = 0.472) or at the time of discharge (1.6 ± 2.420 vs 2.09 ± 2.157, p = 0.0657) between the POEM and LHM groups. After standardizing opioid administration against 10 mg of oral morphine, the POEM group used significantly less narcotics that the LHM group (35.8 vs 101.8 mg, p < 0.001) while hospitalized. The average LOS for the POEM group was 31.2 h and 55.79 for the LHM group (p < 0.0001). At discharge, fewer POEM patients required a prescription for a narcotic analgesic (6.81 vs 92.4 %, p < 0.0001). CONCLUSION POEM demonstrated significantly less postoperative pain upon arrival to the recovery room and 1 h postoperatively. To achieve similar pain scores during the first 24 h and at discharge, LHM patients required more narcotic analgesic administration. Despite a significantly shorter LOS, fewer POEM patients require a prescription for narcotic analgesics compared to LHM. POEM is a less painful procedure for achalasia than LHM, permitting earlier hospital discharge with little need for home narcotic use.
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Affiliation(s)
- Salvatore Docimo
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA.
| | - Abraham Mathew
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Alexander J Shope
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
| | - Joshua S Winder
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
| | - Randy S Haluck
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
| | - Eric M Pauli
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
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Dorn S, Lembo A, Cremonini F. Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach. ACTA ACUST UNITED AC 2016; 2:31-7. [PMID: 25207610 DOI: 10.1038/ajgsup.2014.7] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Opioids affect motor and sensory function throughout the gastrointestinal tract, and are frequently associated with a number of gastrointestinal symptoms including constipation, which impairs the quality of life and may limit the dose of opioid or result in discontinuation altogether. Patients with opioid-induced constipation should be assessed by careful history and physical examination, and in some cases where the diagnosis is unclear with select diagnostic tests. Few clinical studies have been conducted to assess the efficacy of various treatments. However, it is generally recommended that first-line therapy begin with opioid rotation, as well as with low-cost and low-risk approaches such as lifestyle changes, consumption of fiber-rich food, stool softeners, and laxatives.
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Affiliation(s)
- Spencer Dorn
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anthony Lembo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Argoff CE, Viscusi ER. The use of opioid analgesics for chronic pain: minimizing the risk for harm. ACTA ACUST UNITED AC 2016; 2:3-8. [PMID: 25207607 DOI: 10.1038/ajgsup.2014.3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Chronic noncancer pain is common and consequential, affecting ∼100 million people in the United States alone and costing, when direct and indirect costs are combined, in excess of $635 billion. For certain individuals, opioids may be an effective option for the management of chronic pain; however, a series of critical decisions must be made before prescribing opioids to ensure that their potential benefits and possible risks are appropriately and realistically addressed. A thorough history, physical examination, and appropriate testing, including an assessment of risk for substance abuse, misuse, or addiction, should be conducted in patients who are being considered for opioid therapy. Proactively developing a treatment plan that matches the needs and expectations of the patient, while minimizing the potential for substance abuse, is central to the success of pain management. Current standard of care suggests that for most patients, a trial of nonopioid therapies should generally be tried first. There is no single opioid of choice that universally provides the best outcomes for all patients; thus, it is critical for the health-care practitioner to become familiar with the available subclasses, formulations, and modes of administration, and base the treatment plan on clinical experience with the drug, prior patient experience, the availability of the formulation, and cost and coverage. Pain is a dynamic phenomenon in that its characteristics and response to treatment evolve over time, as does the patient's general health state. Both positive and negative changes over time may necessitate a change in medication. Opioids can be prescribed safely and effectively, and when used with appropriate attention to individual patient characteristics may have a positive impact on pain and function. When contemplating initiation of opioid analgesics, clinicians would do well to make it clear to their patient that they will be prescribed on a trial basis with a clear exit strategy for discontinuing such treatment if there is no clear benefit including lack of analgesia, insurmountable adverse effects, and/or frank misuse or abuse of the prescribed drug.
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Affiliation(s)
- Charles E Argoff
- Department of Neurology, Albany Medical College, Albany, New York, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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108
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Pharmacologic and Non-Pharmacologic Treatment of Osteoarthritis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016. [DOI: 10.1007/s40674-016-0042-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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109
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Wilder CM, Miller SC, Tiffany E, Winhusen T, Winstanley EL, Stein MD. Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain. J Addict Dis 2016; 35:42-51. [PMID: 26566771 PMCID: PMC4751580 DOI: 10.1080/10550887.2016.1107264] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Rising overdose fatalities among U.S. veterans suggest veterans taking prescription opioids may be at risk for overdose. However, it is unclear whether veterans prescribed chronic opioids are aware of this risk. The objective of this study was to identify risk factors and determine awareness of risk for opioid overdose in veterans treated with opioids for chronic pain, using veterans treated with methadone or buprenorphine for opioid use disorder as a high-risk comparator group. In the current study, 90 veterans on chronic opioid medication, for either opioid use disorder or pain management, completed a questionnaire assessing risk factors, knowledge, and self-estimate of risk for overdose. Nearly all veterans in both groups had multiple overdose risk factors, although individuals in the pain management group had on average a significantly lower total number of risk factors than did individuals in the opioid use disorder group (5.9 versus 8.5, p < .0001). On average, participants treated for pain management scored slightly but significantly lower on knowledge of opioid overdose risk factors (12.1 versus 13.5, p < .01). About 70% of participants, regardless of group, believed their overdose risk was below that of the average American adult. There was no significant relationship between self-estimate of overdose risk and either number or knowledge of opioid overdose risk factors. Our results suggest that veterans in both groups underestimated their risk for opioid overdose. Expansion of overdose education to include individuals on chronic opioids for pain management and a shift in educational approaches to overdose prevention may be indicated.
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Affiliation(s)
- Christine M. Wilder
- Department of Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229
| | - Shannon C. Miller
- Department of Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229
| | - Elizabeth Tiffany
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229
| | - Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229
| | - Erin L. Winstanley
- James L. Winkle College of Pharmacy, University of Cincinnati, PO Box 670004, Cincinnati, OH 45267-0004
| | - Michael D. Stein
- Department of Medicine, Alpert School of Medicine of Brown University, Butler Hospital, 345 Blackstone Blvd, Providence, RI 09206
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Daoudia M, Decruynaere C, Le Polain de Waroux B, Thonnard JL, Plaghki L, Forget P. Biological inflammatory markers mediate the effect of preoperative pain-related behaviours on postoperative analgesics requirements. BMC Anesthesiol 2015; 15:183. [PMID: 26674471 PMCID: PMC4681155 DOI: 10.1186/s12871-015-0167-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 12/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The predictive value of an individual's attitude towards painful situations and the status of his immune system for postoperative analgesic requirements are not well understood. These may help the clinician to anticipate individual patient's needs. METHODS Sixty patients, who underwent a laparoscopic cholecystectomy under standardised general anaesthesia, were included. The total analgesic requirements during the first 48 h were the primary endpoint (unitary dosage, UD). The individual's attitude towards imaginary painful situations was measured with the Situational Pain Scale (SPS). The emotional status was assessed by the Hospital Anxiety and Depression Scale (HADS) and the inflammatory status by the neutrophil-to-lymphocyte ratio (NLR). RESULTS Univariate analyses revealed a significant association between UD and SPS, HADS and NLR. A negative relationship between SPS and NLR (NLR = 0.820-0.180*SPS;R(2) = 0.211;P < 0.001) and a positive relationship between SPS and HADS (HADS = 14.8 + 1.63*SPS; R(2) = 0.159;P = 0.002) were observed. A multiple linear regression analysis showed that the contribution of NLR to the UD was the most effective. A mediation analysis showed a complete mediation of the effect of SPS on UD (R(2) = 0.103;P = 0.012), by the NLR (SPS on NLR: R(2) = 0.211;P = <0.001), the HADS (SPS on HADS: R(2) = 0.159;P = 0.002). The variance in UD explained by the SPS was indirect and amounts to 46% through NLR and to 34% through HADS. CONCLUSIONS In this series, preoperative pain-related attitudes (SPS) were associated with the postoperative analgesic requirements (UD) after a cholecystectomy. Eighty per cent of this effect was mediated by the HADS and the NLR.
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Affiliation(s)
- Myriam Daoudia
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Céline Decruynaere
- Haute Ecole Leonard de Vinci, Institut Parnasse-Deux Alice, Brussels, Belgium
| | - Bernard Le Polain de Waroux
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Jean-Louis Thonnard
- Institute of Neuroscience (pole COSY), Université catholique de Louvain, Brussels, Belgium
| | - Léon Plaghki
- Institute of Neuroscience (pole COSY), Université catholique de Louvain, Brussels, Belgium
| | - Patrice Forget
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
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111
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Affiliation(s)
- Eric E. Prommer
- Division of Hematology/Oncology, Veterans Integrated Palliative Care Program, Veterans Integrated Palliative Care, David Geffen School of Medicine, University of California, Los Angeles, California
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112
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Bollinger AJ, Butler PD, Nies MS, Sietsema DL, Jones CB, Endres TJ. Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures? Geriatr Orthop Surg Rehabil 2015; 6:202-8. [PMID: 26328237 PMCID: PMC4536513 DOI: 10.1177/2151458515588560] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures. METHODS A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated. RESULTS Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01). CONCLUSION The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home. LEVEL OF EVIDENCE Therapeutic level III.
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Affiliation(s)
- Alexander J. Bollinger
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Paul D. Butler
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Matthew S. Nies
- Department of Orthopaedic Surgery, University of Wisconsin, Madison, WI, USA
| | - Debra L. Sietsema
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Clifford B. Jones
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Terrence J. Endres
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
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Setnik B, Roland CL, Sommerville KW, Pixton GC, Berke R, Calkins A, Goli V. A multicenter, primary-care-based, open-label study to assess the success of converting opioid-experienced patients with chronic moderate-to-severe pain to morphine sulfate and naltrexone hydrochloride extended-release capsules using a standardized conversion guide. J Pain Res 2015; 8:347-60. [PMID: 26185466 PMCID: PMC4501243 DOI: 10.2147/jpr.s82395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To evaluate the conversion of opioid-experienced patients with chronic moderate-to-severe pain to extended-release morphine sulfate with sequestered naltrexone hydrochloride (MSN) using a standardized conversion guide. METHODS This open-label, single-arm study was conducted in 157 primary care centers in the United States. A total of 684 opioid-experienced adults with chronic moderate-to-severe pain were converted to oral administration of MSN from transdermal fentanyl and oral formulations of hydrocodone, hydromorphone, methadone, oxycodone, oxymorphone, and other morphine products using a standardized conversion guide. The primary endpoint was the percentage of patients achieving a stable MSN dose within a 6-week titration phase. Secondary endpoints included duration of time to stable dose, number of titration steps, safety and efficacy measures, and investigator assessment of conversion guide utility. RESULTS Of the 684 patients, 51.3% were converted to a stable dose of MSN (95% confidence interval: 47.5%, 55.1%). The mean (standard deviation) number of days to stable dose was 20 (8.94), and number of titration steps to stable dose was 2.4 (1.37). The majority of adverse events were mild/moderate and consistent with opioid therapy. Mean pain scores at stable dose decreased from baseline. Investigators were generally satisfied with the conversion guide and, in 94% of cases, reported they would use it again. CONCLUSION Conversion to MSN treatment using the standardized MSN conversion guide was an attainable goal in approximately half of the population of opioid-experienced patients with chronic moderate-to-severe pain. Investigators found the guide to be a useful tool to assist conversion of opioid-experienced patients to MSN.
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Affiliation(s)
| | | | | | | | - Robert Berke
- Family Health Medical Services PLLC, Mayville, Buffalo, NY, USA
- Department of Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY, USA
| | - Anne Calkins
- New York Spine & Wellness Center, Syracuse, NY, USA
| | - Veeraindar Goli
- Pfizer Inc, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
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Chronic intermittent hypoxia is independently associated with reduced postoperative opioid consumption in bariatric patients suffering from sleep-disordered breathing. PLoS One 2015; 10:e0127809. [PMID: 26010491 PMCID: PMC4444020 DOI: 10.1371/journal.pone.0127809] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/19/2015] [Indexed: 11/19/2022] Open
Abstract
Background Evidence suggests that recurrent nocturnal hypoxemia may affect pain response and/or the sensitivity to opioid analgesia. We tested the hypothesis that nocturnal hypoxemia, quantified by sleep time spent at an arterial saturation (SaO2) < 90% and minimum nocturnal SaO2 on polysomnography, are associated with decreased pain and reduced opioid consumption during the initial 72 postoperative hours in patients having laparoscopic bariatric surgery. Methods With Institutional Review Board approval, we examined the records of all patients who underwent laparoscopic bariatric surgery between 2004 and 2010 and had an available nocturnal polysomnography study. We assessed the relationships between the time-weighted average of pain score and total opioid consumption during the initial 72 postoperative hours, and: (a) the percentage of total sleep time spent at SaO2 < 90%, (b) the minimum nocturnal SaO2, and (c) the number of apnea/hypopnea episodes per hour of sleep. We used multivariable regression models to adjust for both clinical and sleep-related confounders. Results Two hundred eighteen patients were included in the analysis. Percentage of total sleep time spent at SaO2 < 90% was inversely associated with total postoperative opioid consumption; a 5-%- absolute increase in the former would relatively decrease median opioid consumption by 16% (98.75% CI: 2% to 28%, P = 0.006). However, the percentage of total sleep time spent at SaO2 < 90% was not associated with pain. The minimum nocturnal SaO2 was associated neither with total postoperative opioid consumption nor with pain. In addition, neither pain nor total opioid consumption was significantly associated with the number of apnea/hypopnea episodes per hour of sleep. Conclusions Preoperative nocturnal intermittent hypoxia may enhance sensitivity to opioids.
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Hu H, Qin B, He D, Lu Y, Zhao Z, Zhang J, Wang Y, Wang S. Regional versus General Anesthesia for Percutaneous Nephrolithotomy: A Meta-Analysis. PLoS One 2015; 10:e0126587. [PMID: 25961831 PMCID: PMC4427359 DOI: 10.1371/journal.pone.0126587] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/06/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To compare the effectiveness and safety of regional anesthesia (RA) and general anesthesia (GA) for percutaneous nephrolithotomy (PNL). PATIENTS AND METHODS PubMed, EMBASE, The Cochrane Library, and the Web of Knowledge databases were systematically searched to identify relevant studies. After literature screening and data extraction, a meta-analysis was performed using the RevMan 5.3 software. RESULTS Eight randomized controlled trials (RCTs) and six non-randomized controlled trials (nRCTs) involving 2270 patients were included. Patients receiving RA were associated with shorter operative time (-6.22 min; 95%CI, -9.70 to -2.75; p = 0.0005), lower visual analgesic score on the first and third postoperative day (WMD, -2.62; 95%CI, -3.04 to -2.19; p < 0.00001 WMD, -0.38; 95%CI, -0.58 to -0.18; p = 0.0002), less analgesic requirements (WMD, -59.40 mg; 95%CI, -78.39 to -40.40; p<0.00001), shorter hospitalization (WMD, -0.36d; 95%CI, -0.66 to -0.05; p = 0.02), less blood transfusion (RR, 0.61; 95%CI, 0.41 to 0.93; p = 0.02), fewer modified Clavion-Dindo Grade II (RR, 0.56; 95%CI, 0.37 to 0.83; p = 0.005), Grade III or above postoperative complications (RR, 0.51; 95%CI, 0.33 to 0.77; p = 0.001), and potential benefits of less fever (RR, 0.79; 95%CI, 0.61 to 1.02; p = 0.07), nausea or vomiting (RR, 0.54; 95%CI, 0.20 to 1.46; p = 0.23), whereas more intraoperative hypotension (RR, 3.13; 95%CI, 1.76 to 5.59; p = 0.0001) when compared with patients receiving GA. When nRCTs were excluded, most of the results were stable but the significant differences were no longer detectable in blood transfusion, Grade II and more severe complications. No significant difference in the total postoperative complications and stone-free rate were found. CONCLUSIONS Current evidence suggests that both RA and GA can provide safe and effective anesthesia for PNL in carefully evaluated and selected patients. Each anesthesia technique has its own advantages but some aspects still remain unclear and need to be explored in future studies.
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Affiliation(s)
- Henglong Hu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Baolong Qin
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Deng He
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuchao Lu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhenyu Zhao
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaqiao Zhang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yufeng Wang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shaogang Wang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Toyama K, Uchida N, Ishizuka H, Sambe T, Kobayashi S. Single-dose evaluation of safety, tolerability and pharmacokinetics of newly formulated hydromorphone immediate-release and hydrophilic matrix extended-release tablets in healthy Japanese subjects without co-administration of an opioid antagonist. J Clin Pharmacol 2015; 55:975-84. [DOI: 10.1002/jcph.501] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/19/2015] [Indexed: 01/15/2023]
Affiliation(s)
- Kaoru Toyama
- Translational Medicine and Clinical Pharmacology Department; Daiichi Sankyo Co., Ltd; Shinagawa-ku Tokyo Japan
| | - Naoki Uchida
- Department of Clinical Pharmacology; Showa University, School of Medicine; Shinagawa-ku Tokyo Japan
| | - Hitoshi Ishizuka
- Translational Medicine and Clinical Pharmacology Department; Daiichi Sankyo Co., Ltd; Shinagawa-ku Tokyo Japan
| | - Takehiko Sambe
- Department of Clinical Pharmacology; Showa University, School of Medicine; Shinagawa-ku Tokyo Japan
| | - Shinichi Kobayashi
- Showa University Clinical Research Institute for Clinical Pharmacology and Therapeutics; Setagaya-ku Tokyo Japan
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Webster LR, Brewer R, Morris D, Cleveland JM, Setnik B. Opioid Titration and Conversion in Patients Receiving Morphine Sulfate and Naltrexone Hydrochloride Extended Release Capsules. Postgrad Med 2015; 123:155-64. [DOI: 10.3810/pgm.2011.09.2471] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Heim M. Noninterventional study of transdermal fentanyl (fentavera) matrix patches in chronic pain patients: analgesic and quality of life effects. PAIN RESEARCH AND TREATMENT 2015; 2015:198343. [PMID: 25861472 PMCID: PMC4377521 DOI: 10.1155/2015/198343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/25/2015] [Accepted: 03/02/2015] [Indexed: 01/14/2023]
Abstract
Fentanyl is considered to be an effective, transdermal treatment of chronic, cancer, and noncancer pain. This noninterventional, clinical practice-based study, on 426 patients attending 42 practices, assessed a proprietary, Aloe vera-containing, transdermal fentanyl matrix patch (Fentavera), for its analgesic effects, patients' quality of life (QoL) effects, tolerability, and adhesiveness. Study outcomes were mean changes from baseline of patient (11-point scales) and physician (5-point scales) ratings. After 1 and 2 months treatment, there were significant (P < 0.0001) decreases in patients' ratings of pain intensity, and impairment of walking, general activity, sleep quality, and QoL. For each parameter, the patient response rate was >30% at 2 months (response = 2-point decrease on 11-point rating scale). In a large majority of patients, the physicians rated the matrix patch as good or very good for analgesic effect, systemic and local tolerance, and adhesiveness. There were 30 adverse events in 4.2% of patients and analgesic comedications were reduced during treatment compared to before treatment. It is concluded, from this population-based data, that the proprietary, transdermal fentanyl matrix patch is effective and safe for chronic pain management in clinical practice, with significant positive analgesic and QoL effects, while being well tolerated and exhibiting good or very good adhesiveness.
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Affiliation(s)
- Manuel Heim
- Faculty of Biology, University of Freiburg, Schänzlestraße 1, 79104 Freiburg, Germany
- MSL Consulting, Lujo Brentanos Strasse 11a, 83209 Prien, Germany
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Sánchez del Águila MJ, Schenk M, Kern KU, Drost T, Steigerwald I. Practical Considerations for the Use of Tapentadol Prolonged Release for the Management of Severe Chronic Pain. Clin Ther 2015; 37:94-113. [DOI: 10.1016/j.clinthera.2014.07.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 05/28/2014] [Accepted: 07/16/2014] [Indexed: 01/11/2023]
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Webster LR, Reisfield GM, Dasgupta N. Eight principles for safer opioid prescribing and cautions with benzodiazepines. Postgrad Med 2014; 127:27-32. [PMID: 25526233 DOI: 10.1080/00325481.2015.993276] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The provision of long-term opioid analgesic therapy for chronic pain requires a careful risk/benefit analysis followed by clinical safety measures to identify and reduce misuse, abuse, and addiction and their associated morbidity and mortality. Multiple data sources show that benzodiazepines, prescribed for comorbid insomnia, anxiety, and mood disorders, heighten the risk of respiratory depression and other adverse outcomes when combined with opioid therapy. Evidence is presented for hazards associated with coadministration of opioids and benzodiazepines and the need for caution when initiating opioid therapy for chronic pain. Clinical recommendations follow, as drawn from 2 previously published literature reviews, one of which proffers 8 principles for safer opioid prescribing; the other review presents risks associated with benzodiazepines, suggests alternatives for co-prescribing benzodiazepines and opioids, and outlines recommendations regarding co-prescribing if alternative therapies are ineffective.
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121
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Assessing the response to opioids in cancer patients: a methodological proposal and the results. Support Care Cancer 2014; 23:1867-73. [PMID: 25475736 DOI: 10.1007/s00520-014-2536-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/21/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The efficacy of treatment with opioids in cancer pain is variable. To evaluate this variability, we (1) applied two parameters, changes in pain intensity (PI) and opioid daily doses (DDs), to distinguish different responses to opioids. The need to switch to another opioid was recorded. We then (2) evaluated the distribution of the responses depending on these parameters, alone and taken together, in cancer patients with pain. METHODS The cutoffs between positive and negative responses related to PI and DD were defined on the basis of the literature. For PI, responders were patients who obtained simultaneously a decrease of 30% or more and a final score ≤4 points (numerical rating scale 0 to 10). For DD changes, we applied the opioid escalation index percentage, a positive response corresponding to a dose increase ≤5%. These criteria were applied to 201 cancer patients treated with WHO step III "strong" opioids for 21 days. The results were mainly analyzed case by case. RESULTS Of the patients, 63.7% obtained a positive analgesic response and 80.1% a dose-related positive response. Combining the parameters, the response was double positive in 55.2% of cases, double negative in 11.4%, a good analgesic response with a large dose escalation in 8.5%, and no pain relief with a stable dose in 24.9%. Switches were made 21 times, 15 because of the lack of analgesia. CONCLUSIONS Different degrees of response to opioids were observed, PI and DD changes both contributing. Only over half the patients had a full positive response.
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Chambaere K, Bernheim JL, Downar J, Deliens L. Characteristics of Belgian "life-ending acts without explicit patient request": a large-scale death certificate survey revisited. CMAJ Open 2014; 2:E262-7. [PMID: 25485252 PMCID: PMC4257563 DOI: 10.9778/cmajo.20140034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND "Life-ending acts without explicit patient request," as identified in robust international studies, are central in current debates on physician-assisted dying. Despite their contentiousness, little attention has been paid to their actual characteristics and to what extent they truly represent nonvoluntary termination of life. METHODS We analyzed the 66 cases of life-ending acts without explicit patient request identified in a large-scale survey of physicians certifying a representative sample of deaths (n = 6927) in Flanders, Belgium, in 2007. The characteristics we studied included physicians' labelling of the act, treatment course and doses used, and patient involvement in the decision. RESULTS In most cases (87.9%), physicians labelled their acts in terms of symptom treatment rather than in terms of ending life. By comparing drug combinations and doses of opioids used, we found that the life-ending acts were similar to intensified pain and symptom treatment and were distinct from euthanasia. In 45 cases, there was at least 1 characteristic inconsistent with the common understanding of the practice: either patients had previously expressed a wish for ending life (16/66, 24.4%), physicians reported that the administered doses had not been higher than necessary to relieve suffering (22/66, 33.3%), or both (7/66, 10.6%). INTERPRETATION Most of the cases we studied did not fit the label of "nonvoluntary life-ending" for at least 1 of the following reasons: the drugs were administered with a focus on symptom control; a hastened death was highly unlikely; or the act was taken in accordance with the patient's previously expressed wishes. Thus, we recommend a more nuanced view of life-ending acts without explicit patient request in the debate on physician-assisted dying.
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Affiliation(s)
- Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Jan L Bernheim
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - James Downar
- Department of Medicine, University Health Network, Toronto, Ont. ; University of Toronto, Toronto, Ont
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium ; Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium
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Rakel BA, Zimmerman BM, Geasland K, Embree J, Clark CR, Noiseux NO, Callaghan JJ, Herr K, Walsh D, Sluka KA. Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial. Pain 2014; 155:2599-2611. [PMID: 25270585 DOI: 10.1016/j.pain.2014.09.025] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 09/11/2014] [Accepted: 09/22/2014] [Indexed: 11/18/2022]
Abstract
This study evaluated the efficacy of transcutaneous electrical nerve stimulation (TENS) in reducing pain and hyperalgesia and increasing function after total knee arthroplasty (TKA). We hypothesized that participants using TENS during rehabilitation exercises would report significantly lower pain during range-of-motion (ROM) activity and fast walking but not at rest, would have less hyperalgesia, and would have better function than participants receiving placebo-TENS or standard care. We also hypothesized that change in ROM pain would differ based on psychological characteristics (trait anxiety, pain catastrophizing, and depression) and treatment group. This prospective, randomized study used intent-to-treat analyses in 317 participants after primary, unilateral TKA. Assessors, blinded to treatment allocation, measured pain, function (ROM and gait speed), and hyperalgesia (quantitative sensory tests) postoperatively and 6 weeks after surgery. Analgesic intake, anxiety, depression, and pain catastrophizing were also assessed. TENS participants used it 1 to 2 times per day at 42 mA (on average) and had less pain postoperatively during active knee extension (P=.019) and fast walking (P=.006) than standard care participants. TENS and placebo-TENS were not significantly different. TENS participants who scored low on anxiety and pain catastrophizing had a greater reduction in ROM pain at 6 weeks than those who scored high on these factors (P=.002 and P=.03). Both TENS and placebo-TENS participants had less postoperative mechanical hyperalgesia (P=.03-.01) than standard care participants. Supplementing pharmacologic analgesia with TENS during rehabilitation exercises reduces movement pain postoperatively, but a placebo influence exists and the effect is gone by 6 weeks. Patients with low anxiety and pain catastrophizing may benefit most from TENS.
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Affiliation(s)
- Barbara A Rakel
- The University of Iowa College of Nursing, Iowa City, IA, USA Department of Biostatistics, The University of Iowa College of Public Health, Iowa City, IA, USA Department of Orthopedics and Rehabilitation, The University of Iowa College of Medicine, Iowa City, IA, USA School of Health Sciences, University of Ulster, Northern Ireland, UK Department of Physical Therapy and Rehabilitation Science, The University of Iowa College of Medicine, Iowa City, IA, USA
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MacKintosh D, Brady A, Carr S. Dangerous rotations – Switching from high-dose oxycodone to morphine. PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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125
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Skaer TL. Dosing considerations with transdermal formulations of fentanyl and buprenorphine for the treatment of cancer pain. J Pain Res 2014; 7:495-503. [PMID: 25170278 PMCID: PMC4145844 DOI: 10.2147/jpr.s36446] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Opioids continue to be first-line pharmacotherapy for patients suffering from cancer pain. Unfortunately, subtherapeutic dosage prescribing of pain medications remains common, and many cancer patients continue to suffer and experience diminished quality of life. A large variety of therapeutic options are available for cancer pain patients. Analgesic pharmacotherapy is based on the patient’s self-report of pain intensity and should be tailored to meet the requirements of each individual. Most, if not all, cancer pain patients will ultimately require modifications in their opioid pharmacotherapy. When changes in a patient’s medication regimen are needed, adequate pain control is best maintained through appropriate dosage conversion, scheduling immediate release medication for withdrawal prevention, and providing as needed dosing for breakthrough pain. Transdermal opioids are noninvasive, cause less constipation and sedation when compared to oral opioids, and may improve patient compliance. A relative potency of 100:1 is recommended when converting the patient from oral morphine to transdermal fentanyl. Based on the limited data available, there is significant interpatient variability with transdermal buprenorphine and equipotency recommendations from oral morphine of 75:1–110:1 have been suggested. Cancer patients may require larger transdermal buprenorphine doses to control their pain and may respond better to a more aggressive 75–100:1 potency ratio. This review outlines the prescribing of transdermal fentanyl and transdermal buprenorphine including how to safely and effectively convert to and use them for those with cancer pain.
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Affiliation(s)
- Tracy L Skaer
- College of Pharmacy, Washington State University, Spokane, WA, USA
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Kestenbaum MG, Vilches AO, Messersmith S, Connor SR, Fine PG, Murphy B, Davis M, Muir JC. Alternative routes to oral opioid administration in palliative care: a review and clinical summary. PAIN MEDICINE 2014; 15:1129-53. [PMID: 24995406 DOI: 10.1111/pme.12464] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.
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Reddy A, Yennurajalingam S, de la Cruz M, Palla SL, Wang X, Kwon JH, Frisbee-Hume S, Bruera E. Factors associated with survival after opioid rotation in cancer patients presenting to an outpatient supportive care center. J Pain Symptom Manage 2014; 48:92-8. [PMID: 24210704 DOI: 10.1016/j.jpainsymman.2013.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 08/06/2013] [Accepted: 08/13/2013] [Indexed: 11/20/2022]
Abstract
CONTEXT Data on cancer outpatients undergoing opioid rotation (OR) are limited. Understanding the characteristics of patients who do not follow up after OR could facilitate optimization of OR. OBJECTIVES To compare the characteristics and overall survival of patients with and without follow-up after OR. METHODS In this preliminary ad hoc analysis, we reviewed consecutive patients who presented to our supportive care center in 2008 for OR. Data about demographics, scores on the Edmonton Symptom Assessment System and Memorial Delirium Assessment Scale (MDAS), opioid use, and indications for OR were collected. Univariate logistic regression models were used to determine the factors associated with follow-up. Kaplan-Meier curves were used to evaluate survival. RESULTS Of the 190 patients who underwent OR, 120 (63%) had a follow-up visit. Follow-up visits occurred more frequently in patients with localized disease (89%; 24/27; P = 0.0023), history of substance abuse (100%; 12/12; P = 0.0085), performance status ≤ 2 (66%; 97/146; P = 0.0002), no delirium (67%; 118/177; P = 0.002), and uncontrolled pain as reason for OR (66%; 97/146; P = 0.036). Patients who underwent OR for opioid-induced neurotoxicity (44%; 15/34; P = 0.01) and had higher MDAS scores (P = 0.0009) were less likely to follow up. Both follow-up after OR (P < 0.001) and successful OR (P = 0.012) were associated with longer overall survival, with a difference in median survival of 4.3 and 3 months, respectively. CONCLUSION Our preliminary study suggests that patients with advanced cancer, poorer performance status, opioid-induced neurotoxicity, and higher MDAS scores are less likely to follow up after OR and may have shorter overall survival and, therefore, require closer follow-up. Patients with unsuccessful OR also may have a shorter overall survival. Further studies are warranted.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Sriram Yennurajalingam
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Maxine de la Cruz
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Shana L Palla
- Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Xuan Wang
- Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Jung Hye Kwon
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Internal Medicine, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Susan Frisbee-Hume
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Abstract
The management of pain is an essential aspect of comprehensive cancer care. Positive outcomes can be achieved in most patients with widely available therapies. There is a broad consensus that opioid-based pharmacotherapy is the first-line strategy for the treatment of moderate or severe chronic pain in populations with active disease, and treatment guidelines have been developed from the known pharmacology of these drugs, extant data, and extensive clinical experience. This article describes the major opioid analgesics available for the treatment of cancer-related pain and reviews the key elements for safe and effective prescribing, including selection of the best drug and route, approaches to titration and long-term administration of baseline and supplemental doses, rotation from one drug to another in poorly responsive patients, and management of opioid risks.
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Affiliation(s)
| | - Ebtesam Ahmed
- All authors: Beth Israel Medical Center, New York, NY
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Persaud N. Questionable content of an industry-supported medical school lecture series: a case study. JOURNAL OF MEDICAL ETHICS 2014; 40:414-8. [PMID: 23760579 PMCID: PMC4033027 DOI: 10.1136/medethics-2013-101343] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 04/12/2013] [Accepted: 05/21/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Medical schools are grappling with how best to manage industry involvement in medical education. OBJECTIVE To describe a case study of industry-supported undergraduate medical education related to opioid analgesics. METHOD Institutional case study. RESULTS As part of their regular curriculum, Canadian medical students attended pain pharmacotherapy lectures that contained questionable content about the use of opioids for pain management. The lectures were supported by pharmaceutical companies that market opioid analgesics in Canada and the guest lecturer was a member of speakers bureaus of the same companies. These conflicts of interests were not fully disclosed. A reference book that reinforced some of the information in the lectures and that was paid for by a sponsoring company was made available to students. This is the first report of an association between industry sponsorship and the dissemination of potentially dangerous information to medical students. CONCLUSIONS This case demonstrates the need for better strategies for preventing, identifying and dealing with problematic interactions between the pharmaceutical industry and undergraduate medical education. These might include the avoidance of unnecessary conflicts of interest, more disclosure of conflicts, an open process for dealing with recognised problems and internationally harmonised conflict of interest policies.
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Affiliation(s)
- Navindra Persaud
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
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130
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Mobbs RJ, Li J, Sivabalan P, Raley D, Rao PJ. Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article. J Neurosurg Spine 2014; 21:179-86. [PMID: 24878273 DOI: 10.3171/2014.4.spine13420] [Citation(s) in RCA: 167] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECT The development of minimally invasive surgical techniques is driven by the quest for better patient outcomes. There is some evidence for the use of minimally invasive surgery for degenerative lumbar spine stenosis (LSS), but there are currently no studies comparing outcomes with matched controls. The object of this study was to compare outcomes following minimally invasive unilateral laminectomy for bilateral decompression (ULBD) to a standard "open" laminectomy for LSS. METHODS The authors conducted a prospective, 1:1 randomized trial comparing ULBD to open laminectomy for degenerative LSS. The study enrolled 79 patients between 2007 and 2009, and adequate data for analysis were available in 54 patients (27 in each arm of the study). Patient demographic characteristics and clinical characteristics were recorded and clinical outcomes were obtained using pre- and postoperative Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores for leg pain, patient satisfaction index scores, and postoperative 12-Item Short Form Health Survey (SF-12) scores. RESULTS Significant improvements were observed in ODI and VAS scores for both open and ULBD interventions (p < 0.001 for both groups using either score). In addition, the ULBD-treated patients had a significantly better mean improvement in the VAS scores (p = 0.013) but not the ODI scores (p = 0.055) compared with patients in the open-surgery group. ULBD-treated patients had a significantly shorter length of postoperative hospital stay (55.1 vs. 100.8 hours, p = 0.0041) and time to mobilization (15.6 vs. 33.3 hours, p < 0.001) and were more likely to not use opioids for postoperative pain (51.9% vs. 15.4%, p = 0.046). CONCLUSIONS Based on short-term follow-up, microscopic ULBD is as effective as open decompression in improving function (ODI score), with the additional benefits of a significantly greater decrease in pain (VAS score), postoperative recovery time, time to mobilization, and opioid use.
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131
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Syrmis W, Good P, Wootton J, Spurling G. Opioid conversion ratios used in palliative care: is there an Australian consensus? Intern Med J 2014; 44:483-9. [DOI: 10.1111/imj.12401] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 02/21/2014] [Indexed: 12/31/2022]
Affiliation(s)
- W. Syrmis
- St Vincent's Private Hospital Brisbane; University of Queensland; Brisbane Queensland Australia
| | - P. Good
- St Vincent's Private Hospital Brisbane, Mater Health Services; University of Queensland; Brisbane Queensland Australia
- Mater Research Institute; University of Queensland; Brisbane Queensland Australia
| | - J. Wootton
- St Vincent's Private Hospital Brisbane; University of Queensland; Brisbane Queensland Australia
| | - G. Spurling
- Discipline for General Practice, School of Medicine; University of Queensland; Brisbane Queensland Australia
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132
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Deng D, Wu X, Fu L, Zhao Y, Zhang G, Liang C, Xie C, Zhou Y. The role of analgesic adjustment strategies in achieving analgesic efficacy in opioid-tolerant hospice patients in China. Am J Hosp Palliat Care 2014; 31:315-21. [PMID: 23838450 DOI: 10.1177/1049909113494745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Diverse strategies of analgesic adjustment are often, respectively, used to sustain analgesic efficiency for opioid-tolerant patients with different refractory factors of pain. In order to select effective analgesic adjustment strategy for hospice patient without knowing explicit causes of diminishing analgesic efficiency, a retrospective data of 743 patients among 3760 hospice patients were analyzed. The efficacy and adverse effects were not significantly different among analgesic adjustment strategies at each adjustment. Opioid duration was not associated with clinical characteristics. For opioid-tolerant hospice patients, the analgesic adjustment strategy can be selected for individual patient. After repeated analgesic adjustments, opioid tapering may also occur.
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Affiliation(s)
- Di Deng
- 1Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
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133
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Passik SD, Kirsh KL, Webster L. Pseudoaddiction revisited: a commentary on clinical and historical considerations. Pain Manag 2014; 1:239-48. [PMID: 24646390 DOI: 10.2217/pmt.11.12] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The term 'pseudoaddiction' has been in the pain management lexicon for two decades. Over this time, pain management has changed significantly - in no small part as a result of a landmark publication by Weissman and Haddox in 1989. The original paper, which describes the experience of a single case study in which a young inpatient with cancer became sullen and difficult when left in uncontrolled pain, is reviewed. It is time for a critical re-examination of the concept, its use and its influence on the pain literature, and finally, how it should be applied today. A commentary is offered along with a brief literature review to determine the presence of pseudoaddiction in published literature. Arriving in the literature at a time when the application of opioid therapy to non-malignant pain was being seriously considered, based on principles borrowed from the cancer pain experience, its impact on the way in which patients' behaviors on opioids are to be interpreted has been profound. The fact that problematic drug-related behavior can be driven by uncontrolled pain and extinguished with adequate pain control became a fundamental rule of opioid therapy. This led to practices such as escalating doses in the face of noncompliance and has been extended to include behaviors unintended by the original authors (e.g., excusing the use of marijuana for pain or symptom control while on opioids for non-malignant pain).
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Affiliation(s)
- Steven D Passik
- Pain Treatment Center of the Bluegrass, 2416 Regency Road, Lexington, KY 40503, USA
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134
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Gregory TB. Hydromorphone: evolving to meet the challenges of today's health care environment. Clin Ther 2013; 35:2007-27. [PMID: 24290733 DOI: 10.1016/j.clinthera.2013.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/06/2013] [Accepted: 09/21/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hydromorphone, a potent analogue of morphine, has long had an important role in pain management and is included in several international guidelines for managing pain. Advances in hydromorphone formulations and the ways in which hydromorphone is being used clinically today warrant a review of the drug's pharmacotherapeutic utility. OBJECTIVE The history and recent advances in hydromorphone pharmacotherapy are reviewed. Areas covered include the pharmacologic and metabolic profile of hydromorphone, the role of hydromorphone in pain management, formulations and routes of administration, and issues related to relative opioid potencies, equianalgesic ratios, and opioid rotation. Because hydromorphone, like all opioids, carries a risk of misuse, abuse, and illicit diversion, the related issues of tamper-resistant formulations and "dose-dumping" of extended-release formulations are discussed. CONCLUSIONS Due to the epidemic of prescription opioid overdoses associated with prescription opioid abuse in the United States, development of tamper-resistant opioid formulations that avoid dose-dumping issues has become a significant goal of pharmaceutical manufacturers. The current formulation of hydromorphone extended-release potentially provides the benefits of long-acting hydromorphone (ie, continuous pain control, increased quality of life, freedom to perform daily activities) to appropriate patients, while reducing the risks of abuse and without compromising safety.
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Affiliation(s)
- Thomas B Gregory
- Department of Pharmacy, Truman Medical Centers-Hospital Hill, Kansas City, Missouri.
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135
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Faure D, Giniès P, Eiden C, Portet L, Peyrière H. Opioïdes forts dans le traitement des douleurs chroniques non cancéreuses : analyse rétrospective de patients pris en charge pour un sevrage. Therapie 2013; 68:385-92. [DOI: 10.2515/therapie/2013066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/05/2013] [Indexed: 11/20/2022]
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Viswanathan A, Bruera E. Cordotomy for treatment of cancer-related pain: patient selection and intervention timing. Neurosurg Focus 2013; 35:E6. [DOI: 10.3171/2013.6.focus13237] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Many neurosurgical interventions for the management of cancer-related pain have been tried, but their role in today's advanced supportive and palliative care is not well described. The authors discuss the current knowledge gaps that prevent successful integration of neurosurgical interventions and patients with cancer-related pain.
Two patients underwent percutaneous CT-guided cordotomy for refractory cancer-related pain: one patient had melanoma and the other had ovarian carcinoma. Both patients seemed to have unilateral, somatic, nociceptive cancer-related pain.
Cordotomy was effective for only 1 patient.
Percutaneous CT-guided cordotomy is a low-risk intervention that can benefit carefully selected patients with cancer-related pain. There is a clear need for prospective controlled studies to evaluate the effectiveness of cordotomy for patients receiving optimal medical treatment. A multidisciplinary study design could help to identify factors correlated with a positive outcome.
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Affiliation(s)
| | - Eduardo Bruera
- 2Palliative Care & Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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137
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Drewes AM, Jensen RD, Nielsen LM, Droney J, Christrup LL, Arendt-Nielsen L, Riley J, Dahan A. Differences between opioids: pharmacological, experimental, clinical and economical perspectives. Br J Clin Pharmacol 2013; 75:60-78. [PMID: 22554450 DOI: 10.1111/j.1365-2125.2012.04317.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Clinical studies comparing the response and side effects of various opioids have not been able to show robust differences between drugs. Hence, recommendations of the regulatory authorities have been driven by costs with a general tendency in many countries to restrict physician's use of opioids to morphine. Although this approach is recognized as cost-effective in most cases there is solid evidence that, on an individual patient basis, opioids are not all equal. Therefore it is important to have an armamentarium of strong analgesics in clinical practice to ensure a personalized approach in patients who do not respond to standard treatment. In this review we highlight differences between opioids in human studies from a pharmacological, experimental, clinical and health economics point of view. We provide evidence that individuals respond differently to opioids, and that general differences between classes of opioids exist. We recommend that this recognition is used to individualize treatment in difficult cases allowing physicians to have a wide range of treatment options. In the end this will reduce pain and side effects, leading to improved quality of life for the patient and reduce the exploding pain related costs.
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Affiliation(s)
- Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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138
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Brennan MJ. Update on prescription extended-release opioids and appropriate patient selection. J Multidiscip Healthc 2013; 6:265-80. [PMID: 23900563 PMCID: PMC3726523 DOI: 10.2147/jmdh.s38562] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Chronic pain is largely underdiagnosed, often undertreated, and expected to increase as the American population ages. Many patients with chronic pain require long-term treatment with analgesic medications, and pain management may involve use of prescription opioids for patients whose pain is inadequately controlled through other therapies. Yet because of the potential for abuse and addiction, many clinicians hesitate to treat their patients with pain with potentially beneficial agents. Finding the right opioid for the right patient is the first - often complicated - step. Ensuring that patients continue to properly use the medication while achieving therapeutic analgesic effects is the long-term goal. Combined with careful patient selection and ongoing monitoring, new formulations using extended-release technologies incorporating tamper-resistant features may help combat the growing risk of abuse or misuse, which will hopefully reduce individual suffering and the societal burden of chronic pain. The objective of this manuscript is to provide an update on extended-release opioids and to provide clinicians with a greater understanding of which patients might benefit from these new opioid formulations and how to integrate the recommended monitoring for abuse potential into clinical practice.
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139
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Webster LR. Eight principles for safer opioid prescribing. PAIN MEDICINE 2013; 14:959-61. [PMID: 23841682 DOI: 10.1111/pme.12194] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Lynn R Webster
- American Academy of Pain Medicine; CRI Lifetree, Salt Lake City, Utah, USA
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140
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Abstract
BACKGROUND Many medical professionals use smartphone applications (apps) on a daily basis to support clinical decision making. Opioid switching (conversion of one opioid to another at equianalgesic dose) is common in clinical practice and often challenging for doctors. Apps providing an opioid conversion tool can therefore be a useful resource. Despite rapid growth in the use of medical apps, the lack of robust regulation and peer review to ensure the accuracy and reliability of app content is currently an area of concern. METHOD We searched major online app stores for apps providing an opioid dose conversion tool. We assessed output variability between apps in the dose calculation of seven opioid switches, as well as assessing the level of professional medical involvement in the authorship, creation and design of the apps. RESULTS Of 23 different apps identified, more than half (n = 12; 52 %) had no stated medical professional involvement and only 11 (48 %) apps provided direct references to primary sources for their opioid conversion ratios. Conversion of 1 mg of oral morphine to oral codeine demonstrated the largest conversion output range (median 6.67 mg, range 3.333-12 mg). Conversion of 1 mg of oral morphine to methadone ranged from 0.05-0.67 mg, with only 44 % of methadone-converting apps (n = 4) commenting that the conversion ratio changes with magnitude of methadone dose. Overall, 35 % of apps (n = 8) did not warn the user about the standard practice of dose reduction when opioid switching. There was a statistically significant difference in the mean conversion output for hydromorphone (oral) between apps with and without medical professional involvement (0.2256 vs 0.2536; p = 0.0377). CONCLUSIONS There are significant concerns with regard to the reliability of information provided by apps offering opioid dose conversion, with lack of information regarding evidence-based content and peer review in many cases. It is crucial that better regulation of medical apps is instigated in order to ensure that patient safety is maintained.
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141
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Saokaew S, Oderda GM. Quality assessment of the methods used in published opioid conversion reviews. J Pain Palliat Care Pharmacother 2013; 26:341-7. [PMID: 23216173 DOI: 10.3109/15360288.2012.734904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The study objective was to assess methodological quality of opioid conversion systematic reviews. The electronic databases PubMed, EMBASE, and Scopus were used to identify the systematic reviews from the earliest available date until April 2012. Studies were not restricted based on type of opioid, country, or languages. Methodological quality was evaluated using the "Assessment of Multiple Systematic Reviews (AMSTAR)." A total of 2772 articles were found from which five met inclusions criteria. No review mentioned about the duplicate study selection and data extraction. Two reviews included a list of studies that were excluded studies. One study did not provided information on the characteristics of primary studies that were included. Of the three reviews that evaluated the quality of primary studies, two used the quality of included studies in formulating conclusions. Only two reviews provided information about conflicts of interest. Of the five included systematic reviews, three reached a moderate score; two had poor quality. Specific recommendations to improve methodological quality would include performing the data selection and extraction in duplicate, listing or showing the flowchart of studies that were included and excluded along with the reasons, including the main studies data illustrating tables, and including an assessment of the quality of the primary included studies.
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Affiliation(s)
- Surasak Saokaew
- Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
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142
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Hale ME, Nalamachu SR, Khan A, Kutch M. Effectiveness and gastrointestinal tolerability during conversion and titration with once-daily OROS® hydromorphone extended release in opioid-tolerant patients with chronic low back pain. J Pain Res 2013; 6:319-29. [PMID: 23658495 PMCID: PMC3645948 DOI: 10.2147/jpr.s39980] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose To describe the efficacy and safety of hydromorphone extended-release tablets (OROS hydromorphone ER) during dose conversion and titration. Patients and methods A total of 459 opioid-tolerant adults with chronic moderate to severe low back pain participated in an open-label, 2- to 4-week conversion/titration phase of a double-blind, placebo-controlled, randomized withdrawal trial, conducted at 70 centers in the United States. Patients were converted to once-daily OROS hydromorphone ER at 75% of the equianalgesic dose of their prior total daily opioid dose (5:1 conversion ratio), and titrated as frequently as every 3 days to a maximum dose of 64 mg/day. The primary outcome measure was change in pain intensity numeric rating scale; additional assessments included the Patient Global Assessment and the Roland–Morris Disability Questionnaire scores. Safety assessments were performed at each visit and consisted of recording and monitoring all adverse events (AEs) and serious AEs. Results Mean (standard deviation) final daily dose of OROS hydromorphone ER was 37.5 (17.8) mg. Mean (standard error of the mean [SEM]) numeric rating scale scores decreased from 6.6 (0.1) at screening to 4.3 (0.1) at the final titration visit (mean [SEM] change, −2.3 [0.1], representing a 34.8% reduction). Mean (SEM) change in Patient Global Assessment was −0.6 (0.1), and mean change (SEM) in the Roland–Morris Disability Questionnaire was −2.8 (0.3). Patients achieving a stable dose showed greater improvement than patients who discontinued during titration for each of these measures (P < 0.001). Almost 80% of patients achieving a stable dose (213/268) had a ≥30% reduction in pain. Commonly reported AEs were constipation (15.4%), nausea (11.9%), somnolence (8.7%), headache (7.8%), and vomiting (6.5%); 13.0% discontinued from the study due to AEs. Conclusion The majority of opioid-tolerant patients with chronic low back pain were successfully converted to effective doses of OROS hydromorphone ER within 2 to 4 weeks.
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143
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Nicholson B. Primary care considerations of the pharmacokinetics and clinical use of extended-release opioids in treating patients with chronic noncancer pain. Postgrad Med 2013; 125:115-27. [PMID: 23391677 DOI: 10.3810/pgm.2013.01.2627] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Extended-release (ER) opioid analgesics are associated with prolonged analgesia and greater stability in pain relief compared with immediate-release formulations. Due to the pharmacokinetic (PK) characteristics of ER opioids and additional clinical advantages, the use of ER opioids for patients with moderate-to-severe chronic noncancer pain has increased. Primary care physicians are the major prescribers of opioids and require an in-depth understanding of the risks and benefits of opioid treatment in pain management. With appropriate knowledge of PK profiles and clinical outcomes of commonly prescribed ER opioids, primary care physicians can safely and effectively manage this patient population. In addition, the development of ER opioids with abuse-deterrent features marks an important milestone in potentially reducing abuse and may be factored into the clinical decision-making process. This article provides a comprehensive review of the PK and clinical effects of ER opioids and discusses novel ER opioid formulations that may limit abuse potential.
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Affiliation(s)
- Bruce Nicholson
- Division of Pain Medicine, Lehigh Valley Health Network, Allentown, PA 18103, USA.
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144
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Bradley AM, Valgus JM, Bernard S. Converting to transdermal fentanyl: avoidance of underdosing. J Palliat Med 2013; 16:409-11. [PMID: 23477303 DOI: 10.1089/jpm.2012.0424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Converting between the various opioid agents continues to be challenge for many practitioners. Specifically, variable recommendations for converting to the transdermal fentanyl patch may lead to confusion among clinicians and errors in dosing. OBJECTIVE Our aim was to describe the inconsistencies among available opioid conversions with regard to transdermal fentanyl and to provide recommendations for safe and effective utilization of this product in patients with chronic pain. RESULTS Available reports support the use of the morphine intravenous to oral ratio of 1:3 during the conversion to transdermal fentanyl product. CONCLUSIONS Underdosing is an often overlooked complication of switching to transdermal fentanyl. Current recommendations for converting to transdermal fentanyl do not reflect contemporary clinical practice and should be reevaluated.
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Affiliation(s)
- Amber M Bradley
- University of Georgia College of Pharmacy, Augusta, GA 30912, USA.
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145
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Saunders DL, Messina J, Darwish M, Xie F, Leary KJ, Cantilena LR. Assessment of the Relative Potency of Fentanyl Buccal Tablet to Intravenous Morphine in Healthy Volunteers Using a Thermally Induced Hyperalgesia Pain Model. J Clin Pharmacol 2013; 52:870-9. [DOI: 10.1177/0091270011407496] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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146
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Ziemann-Gimmel P, Hensel P, Koppman J, Marema R. Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2013; 9:975-80. [PMID: 23499469 DOI: 10.1016/j.soard.2013.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/31/2013] [Accepted: 02/04/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND After bariatric surgery, patients are at risk for narcotic-related side effects. Multimodal pain management strategies should be used when possible to reduce the consumption of narcotic medication. The purpose of this study was to investigate whether multimodal analgesia reduces narcotic consumption and may have an influence on opioid-related side effects in patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). METHODS In this retrospective data analysis, we examined the data of a total of 181 consecutive patients undergoing LRYGB. In January 2011, i.v. acetaminophen became clinically available. Hydromorphone patient controlled analgesia (PCA) was replaced by i.v. acetaminophen and i.v. ketorolac (TNT-Tylenol and Toradol). The first 89 patients received postoperative hydromorphone PCA (PCA group). The next 92 patients received i.v. acetaminophen and i.v. ketorolac every 6 hours for the first 24 hours (TNT group). In the TNT group, 8 patients were excluded in the analysis. RESULTS There were no differences in clinical characteristics between the groups except for smoking history. Patients treated with PCA required 4.2 mg hydromorphone in the postoperative period. Patients in the TNT group required 1.1 mg hydromorphone. This was a statistically significant reduction of opioids by 73.8%. After discharge from postanesthesia care unit, 34.8% of patients required antiemetic rescue medication (AERM) compared with 20.2% in the TNT group (P<.001). The relative risk (AERM/no AERM) in the postoperative period after postanesthesia care unit discharge is 1.75 (95% CI, 1.05-2.92). CONCLUSION This study suggests that a multimodal analgesic regimen (TNT) can reduce postoperative narcotic consumption, which may lead to a reduction in the number of patients requiring AERM.
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Affiliation(s)
- Patrick Ziemann-Gimmel
- Coastal Anesthesiology Consultants, US Bariatrics, Flagler Hospital, St. Augustine, Florida.
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147
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Mercadante S, Valle A, Porzio G, Fusco F, Aielli F, Adile C, Casuccio A. Opioid switching in patients with advanced cancer followed at home. A retrospective analysis. J Pain Symptom Manage 2013; 45:298-304. [PMID: 23102561 DOI: 10.1016/j.jpainsymman.2012.02.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 02/17/2012] [Accepted: 02/20/2012] [Indexed: 10/27/2022]
Abstract
CONTEXT Opioid switching has been found to improve opioid responsiveness in different conditions. However, data on opioid switching performed at home are almost nonexistent, despite the fact that most patients are followed at home. OBJECTIVES The aim of this retrospective survey was to determine frequency, indications, usefulness, and safety of opioid switching when treating advanced cancer-related pain in patients followed at home. METHODS A retrospective review of data from patients with advanced cancer followed at home by three home care teams for a period of two years was performed. Patients who had their opioids switched were selected. Reasons for switching opioid doses and routes of administration and outcomes were collected. RESULTS Two hundred one (17%) of 1141 patients receiving "strong" opioids were switched. The mean Karnofsky Performance Status score was 35.6, and the median survival was 30 days. The most frequent reason to switch was for convenience, and the most frequent switch was to parenteral morphine. In most patients, a better analgesic response was observed. Patients who were switched to parenteral morphine had a shorter survival in comparison with other opioid sequences (P<0.0005). After switching, opioid doses were increased by 23% and 41%, after a week and at time of death, respectively. CONCLUSION Opioid switching was useful for most patients in the home environment, at least in less complex circumstances, when done by experienced home care teams. Prospective studies are needed to provide information about the decision to admit to hospital for this purpose and the predictive factors that may relatively contraindicate transportation to a facility in severely ill patients.
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148
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Elsamra SE, Leone AR, Lasser MS, Thavaseelan S, Golijanin D, Haleblian GE, Pareek G. Hand-Assisted Laparoscopic Versus Robot-Assisted Laparoscopic Partial Nephrectomy: Comparison of Short-Term Outcomes and Cost. J Endourol 2013; 27:182-8. [DOI: 10.1089/end.2012.0210] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Sammy E. Elsamra
- Division of Urology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew R. Leone
- Division of Urology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael S. Lasser
- Division of Urology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Simone Thavaseelan
- Division of Urology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dragan Golijanin
- Division of Urology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - George E. Haleblian
- Division of Urology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Gyan Pareek
- Division of Urology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Kim GW, Kang SA, Cha YD, Lee DI, Song JH. Two cases of opioid rotation applied to patients with chronic pain. Korean J Anesthesiol 2013; 65:S141-2. [PMID: 24478850 PMCID: PMC3903838 DOI: 10.4097/kjae.2013.65.6s.s141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Gun Woo Kim
- Department of Anesthesiology and Pain Medicine, Inha University, Inha University Hospital, Incheon, Korea
| | - Sung An Kang
- Department of Anesthesiology and Pain Medicine, Inha University, Inha University Hospital, Incheon, Korea
| | - Young Deog Cha
- Department of Anesthesiology and Pain Medicine, Inha University, Inha University Hospital, Incheon, Korea
| | - Doo Ik Lee
- Department of Anesthesiology and Pain Medicine, Inha University, Inha University Hospital, Incheon, Korea
| | - Jang Ho Song
- Department of Anesthesiology and Pain Medicine, Inha University, Inha University Hospital, Incheon, Korea
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Reddy A, Yennurajalingam S, Pulivarthi K, Palla SL, Wang X, Kwon JH, Frisbee-Hume S, Bruera E. Frequency, outcome, and predictors of success within 6 weeks of an opioid rotation among outpatients with cancer receiving strong opioids. Oncologist 2012; 18:212-20. [PMID: 23238913 DOI: 10.1634/theoncologist.2012-0269] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Opioid rotation is used to treat uncontrolled pain and/or opioid-related adverse effects. Our aim was to determine the frequency, indications, outcomes, and predictors of successful opioid rotation in outpatients with cancer. METHODS Medical records of consecutive outpatients with cancer who received strong opioids and returned for follow-up visit within ≤6 weeks to our supportive care center from January to December 2008 were reviewed. Data on patient characteristics, symptoms, opioid use, indications for opioid rotation, outcomes, and morphine equivalent daily dose were collected. Successful opioid rotation was defined as a two-point or 30% reduction in the symptom score or the resolution of opioid-induced neurotoxicity and continuation of the new opioid at follow-up. RESULTS Opioid rotation was performed in 120 of 385 patients (31%). The median patient age was 55 years. There were 6/120 patients with missing data. Of the 114 evaluable patients, 68 (60%) were men, 81 (71%) were white, 27 (24%) had gastrointestinal cancer, and 90 (80%) had advanced-stage disease. The median Eastern Cooperative Oncology Group score was 1 (interquartile range: 1-2) and the median time between opioid rotation and follow-up was 14 days (interquartile range: 7-21 days). The most common indications for opioid rotation were uncontrolled pain (95/114; 83%) and opioid-induced neurotoxicity (13/114; 12%). A total of 35 patients (31%) had partial opioid rotation. The median improvements in pain and symptom distress score were -2 (interquartile range: -4 to 0; p < .001) and -5 (interquartile range: -14 to 7; p = .004), respectively. The morphine equivalent daily dose did not change significantly after opioid rotation (p = .156). A total of 65% of patients (74/114) had successful opioid rotation. There were no clinically significant independent predictors for successful opioid rotation. CONCLUSION Opioid rotation was conducted in 31% of outpatients with cancer, with a 65% success rate. The most frequent reason for opioid rotation was uncontrolled pain. There were no independent predictors for successful opioid rotation.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX 77030, USA
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