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Fawoubo A, Perceau-Chambard É, Ruer M, Filbet M, Tricou C, Economos G. Methadone and neuropathic cancer pain subcomponents: a prospective cohort pilot study. BMJ Support Palliat Care 2023; 13:e273-e277. [PMID: 34620692 DOI: 10.1136/bmjspcare-2021-003220] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/30/2021] [Indexed: 11/04/2022]
Abstract
Forty per cent of cancer pain associate neuropathic and nociceptive pain simultaneously, and refractory pain affects 15% of cancer pain. Methadone is an effective opioid in treating nociceptive pain and could have an effect on neuropathic pain. Uncertainty remains on its effects on the different subcomponents of neuropathic pain. OBJECTIVES To identify which subcomponents of neuropathic cancer pain are addressed using methadone. METHODS An observational prospective cohort study of palliative care inpatients after rotation for refractory neuropathic cancer pain. Pain intensity was assessed weekly for 28 days, using a Visual Analogue Scale (VAS) and the Neuropathic Pain Symptom Inventory (NPSI). RESULTS Forty-eight patients were included and 17 completed the 28 days follow-up. VAS pain rating decreased by at least 20 mm in 47% of patients and the pain intensity was significantly lower at day 28 with 53% of patients with a VAS inferior to 4 (p<0.001). The pressure/squeezing component (NPSI score) decreased by more than 2 points in 50% of patients.A linear regression showed allodynia and pressure/squeezing were responsible for the largest part of the overall alleviation of pain (p=0.01). CONCLUSIONS Methadone could significantly improve neuropathic pain through a targeted effect of allodynia and its pressure/squeezing component.
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Affiliation(s)
- Audrey Fawoubo
- Palliative Care, Hospices Civils de Lyon, Pierre benite, France
| | | | - Murielle Ruer
- Palliative Care, Hospices Civils de Lyon, Pierre benite, France
| | - Marilene Filbet
- Palliative Care, Hospices Civils de Lyon, Pierre benite, France
| | - Colombe Tricou
- Palliative Care, Hospices Civils de Lyon, Pierre benite, France
| | - Guillaume Economos
- Palliative Care, Hospices Civils de Lyon, Pierre benite, France
- Centre d'innovation en cancérologie de lyon, Centre d'Innovation en cancérologie de Lyon (CICLY), Oullins Cedex, France, France
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Rana MH, Khan AAG, Khalid I, Ishfaq M, Javali MA, Baig FAH, Kota MZ, Khader MA, Hameed MS, Shaik S, Das G. Therapeutic Approach for Trigeminal Neuralgia: A Systematic Review. Biomedicines 2023; 11:2606. [PMID: 37892981 PMCID: PMC10604820 DOI: 10.3390/biomedicines11102606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/05/2023] [Accepted: 09/13/2023] [Indexed: 10/29/2023] Open
Abstract
This umbrella review aimed to determine the various drugs used to treat trigeminal neuralgia (TN) and to evaluate their efficacies as well as side effects by surveying previously published reviews. An online search was conducted using PubMed, CRD, EBSCO, Web of Science, Scopus, and the Cochrane Library with no limits on publication date or patients' gender, age, and ethnicity. Reviews and meta-analyses of randomized controlled trials pertaining to drug therapy for TN, and other relevant review articles added from their reference lists, were evaluated. Rapid reviews, reviews published in languages other than English, and reviews of laboratory studies, case reports, and series were excluded. A total of 588 articles were initially collected; 127 full-text articles were evaluated after removing the duplicates and screening the titles and abstracts, and 11 articles were finally included in this study. Except for carbamazepine, most of the drugs had been inadequately studied. Carbamazepine and oxcarbazepine continue to be the first choice for medication for classical TN. Lamotrigine and baclofen can be regarded as second-line drugs to treat patients not responding to first-line medication or for patients having intolerable side effects from carbamazepine. Drug combinations using carbamazepine, baclofen, gabapentin, ropivacaine, tizanidine, and pimozide can yield satisfactory results and improve the tolerance to the treatment. Intravenous lidocaine can be used to treat acute exaggerations and botulinum toxin-A can be used in refractory cases. Proparacaine, dextromethorphan, and tocainide were reported to be inappropriate for treating TN. Anticonvulsants are successful in managing trigeminal neuralgia; nevertheless, there have been few studies with high levels of proof, making it challenging to compare or even combine their results in a statistically useful way. New research on other drugs, combination therapies, and newer formulations, such as vixotrigine, is awaited. There is conclusive evidence for the efficacy of pharmacological drugs in the treatment of TN.
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Affiliation(s)
- Muhammad Haseeb Rana
- Department of Prosthodontics, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia;
| | - Abdul Ahad Ghaffar Khan
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (A.A.G.K.); (I.K.); (M.I.); (F.A.H.B.); (M.Z.K.)
| | - Imran Khalid
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (A.A.G.K.); (I.K.); (M.I.); (F.A.H.B.); (M.Z.K.)
| | - Muhammad Ishfaq
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (A.A.G.K.); (I.K.); (M.I.); (F.A.H.B.); (M.Z.K.)
| | - Mukhatar Ahmed Javali
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (M.A.J.); (M.A.K.)
| | - Fawaz Abdul Hamid Baig
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (A.A.G.K.); (I.K.); (M.I.); (F.A.H.B.); (M.Z.K.)
| | - Mohammad Zahir Kota
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (A.A.G.K.); (I.K.); (M.I.); (F.A.H.B.); (M.Z.K.)
| | - Mohasin Abdul Khader
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (M.A.J.); (M.A.K.)
| | - Mohammad Shahul Hameed
- Department of Diagnostic Sciences and Oral Biology, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia;
| | - Sharaz Shaik
- Department of Prosthetic Dentistry, Lenora Institute of Dental Sciences, Rajahmundry 533101, India;
| | - Gotam Das
- Department of Prosthodontics, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia;
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Gajda JM, Asiedu M, Morrison G, Dunning JA, Ghoreishi-Haack N, Barth AL. NYX-2925, A NOVEL, NON-OPIOID, SMALL-MOLECULE MODULATOR OF THE N-METHYL-d-ASPARTATE RECEPTOR (NMDAR), DEMONSTRATES POTENTIAL TO TREAT CHRONIC, SUPRASPINAL CENTRALIZED PAIN CONDITIONS. MEDICINE IN DRUG DISCOVERY 2021. [DOI: 10.1016/j.medidd.2020.100067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abstract
Methadone is increasingly being used for its analgesic properties. Despite the increasing popularity, many healthcare providers are not familiar with methadone's complex pharmacology and best practices surrounding its use. The purpose of this narrative review article is to discuss the pharmacology of methadone, the evidence surrounding methadone's use in acute pain management and both chronic cancer and non-cancer pain settings, as well as highlight pertinent safety, monitoring, and opioid rotation considerations. Methadone has a unique mechanism of action when compared with all other opioids and for this reason methadone has come to hold a niche role in the management of opioid-induced hyperalgesia and central sensitization. Understanding of the mechanisms of variability in methadone disposition and drug interactions has evolved over the years, with the latest evidence revealing that CYP 2B6 is the major determinant of methadone elimination and plays a key role in methadone-related drug interactions. From an acute pain perspective, most studies evaluating the use of intraoperative intravenous methadone have reported lower pain scores and post-operative opioid requirements. Oral methadone is predominantly used as a second-line opioid treatment for select chronic pain conditions. As a result, several oral morphine to oral methadone conversion ratios have been proposed, as have methods in which to rotate to methadone. From an efficacy standpoint, limited literature exists regarding the effectiveness of methadone in the chronic pain setting with most of the available efficacy data pertaining to methadone's use in the treatment of cancer pain. Many of the prospective studies that exist feature low participant numbers. Few clinical trials investigating the role of methadone as an analgesic treatment are currently underway. The complicated pharmacokinetic properties of methadone and risks of harm associated with this drug highlight how critically important it is that healthcare providers understand these features before prescribing/dispensing methadone. Particular caution is required when converting patients from other opioids to methadone and for this reason only experienced healthcare providers should undertake such a task. Further randomized trials with larger sample sizes are needed to better define the effective and safe use of methadone for pain management.
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Affiliation(s)
- Denise Kreutzwiser
- Pain Management Program, St. Joseph's Hospital, St. Joseph's Health Care London, London, ON, Canada.
| | - Qutaiba A Tawfic
- Department of Anesthesia and Perioperative Medicine, Western University, London Health Sciences Centre, and St. Joseph's Health Care London, London, ON, Canada
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Fürst P, Lundström S, Strang P. Methadone in Swedish specialized palliative care-Is it the magic bullet in complex cancer-related pain? PLoS One 2020; 15:e0230845. [PMID: 32275723 PMCID: PMC7147740 DOI: 10.1371/journal.pone.0230845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
CONTEXT Despite being associated with dependence and social stigma, methadone is a potential end-of-life option in complex cancer pain. OBJECTIVES To explore attitudes and opinions about methadone and its potential role and current use in complex end-of-life pain. METHODS Semi-structured interviews (n = 30) with physicians in specialized palliative care, transcribed and analyzed with conventional qualitative content analysis. RESULTS According to the physicians, patients and relatives expressed unexpectedly few negative attitudes, not affecting methadone's use as an analgesic. Complex pain in bone-metastatic cancer of the prostate, breast and kidney, as well as pancreatic cancer and sarcomas were recurrent suggestions of appropriate indications. Most of the informants stated that they applied a mechanism-based treatment and mainly prescribed low-dose methadone as an add-on to an existing opioid therapy to benefit from methadone´s proposed NMDA-receptor inhibiting properties, e.g. in cases with reduced opioid sensitivity. Despite its complex pharmacokinetics with a long half-life, most informants expressed defined strategies to avoid side-effects such as respiratory depression, especially when initiating treatment in the home-care setting. While many palliative care physicians expressed an overly enthusiastic attitude, others stressed the risks of overconfidence, low precision in use, and overlooked treatment options. Besides the obvious physical pain-relieving effects, they stated that effective pain relief could result in a reduced workload and emotional empowerment, both for physicians and staff. CONCLUSION Methadone, especially in the form of low-dose add-on to other opioids is widely advocated in Swedish specialized palliative care as a practical and safe method with rapid onset in complex pain situations at the end of life.
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Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
- * E-mail:
| | - Staffan Lundström
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Peter Strang
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Balhara YPS, Singh S, Kalra S. Pragmatic Opioid Use in Painful Diabetic Neuropathy. EUROPEAN ENDOCRINOLOGY 2020; 16:21-24. [PMID: 32595765 DOI: 10.17925/ee.2020.16.1.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022]
Abstract
The management of painful diabetic neuropathy poses a tough clinical challenge. Although opioid analgesics are considered as second- or third-line agents in the management of moderate-to-severe neuropathic pain, prescription of opioids for this indication is higher than expected. This narrative review is a recommendation on how to ensure pragmatic use of opioids for those with painful diabetic neuropathy while avoiding complications such as opioid overdose, opioid diversion and the development of opioid-use disorder. Risk mitigation strategies at the level of the clinician include periodic assessment and documentation of clinical details, treatment history and psychosocial status. Using a multimodal approach to pain management, medication counselling, adherence monitoring programmes, evidence-based opioid dosing strategies and empowering patients to make treatment decisions are effective strategies in reducing risk associated with prolonged opioid use. At the organisational and policy level, using prescription drug monitoring programmes, carrying out periodic opioid utilisation reviews and providing training to patients and physicians on safe opioid use are useful, implementable strategies.
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Affiliation(s)
- Yatan Pal Singh Balhara
- Department of Psychiatry, National Drug Dependence Treatment Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Shalini Singh
- Institute of Liver and Biliary Sciences (ILBS), New Delhi, India
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Lynch M, Moulin D, Perez J. Methadone vs. morphine SR for treatment of neuropathic pain: A randomized controlled trial and the challenges in recruitment. Can J Pain 2019; 3:180-189. [PMID: 35005408 PMCID: PMC8730636 DOI: 10.1080/24740527.2019.1660575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: Accumulating evidence has identified a number of advantages for methadone over other opioids for the treatment of chronic pain including: agonist action at both μ and δ opioid receptors, N-methyl-d-aspartate (NMDA) antagonist activity and the ability to inhibit the reuptake of monoamines. It was hypothesized that with these three mechanisms of action methadone might be a good option for the treatment of neuropathic pain. Methods: This was a double-blind randomized controlled trial comparing methadone to controlled-release morphine. The primary objective was to determine whether methadone is clinically inferior versus noninferior to morphine as an analgesic. Results: We attempted recruitment at three academic pain centers over a 3-year period. In the end only 14 participants were able to be recruited; 5 withdrew and only 9 completed the trial. This study was underpowered. All participants showed a mean reduction in pain intensity according to the Numeric Rating Scale for Pain Intensity (morphine 5.86 to 4.38, methadone 6.11 to 4.5) and reported pain relief compared to pretreatment, but the sample size was too small for statistical analysis. Discussion: Reasons for challenges in recruitment included tight inclusion and exclusion criteria and high participant burden. In addition, there was significant heterogeneity of patients between the three sites, leading to differences in reasons for exclusion. This included seemingly disparate reasons at the different sites, including few participants who were methadone naïve vs. avoidance or fear of opioids. In the end, we were unable to answer the question of the study.
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Affiliation(s)
- Mary Lynch
- Anesthesia, Pain Management and Perioperative Medicine, Psychiatry and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dwight Moulin
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada.,Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
| | - Jordy Perez
- Department of Anesthesia, Alan Edwards Pain Management Unit, McGill University Health Centre (MUHC), Montreal, Quebec, Canada
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