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Mercadante S. Opioid dose titration for cancer pain. Eur J Pain 2024; 28:359-368. [PMID: 37947151 DOI: 10.1002/ejp.2194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Opioid dose titration is a fundamental process of opioid therapy in cancer pain. AIMS To assess data opioid dose titration. METHODS The principal opioid dose titration methods, outcomes, and modalities of administration regarding the different opioid preparations were examined in different clinical contexts. RESULTS Most studies suggested that opioid-naive patients should be started at doses of 15-30 mg/day of oral morphine equivalents. Opioid-tolerant patients may receive low or higher doses of oral morphine equivalents, depending on the level of opioid tolerance. Generally, dose increments of 30%-50% seem to be indicated to start dose titration. Some patients with severe excruciating cancer pain may present as an emergency requiring a rapid application of powerful analgesic strategies. The intravenous use of opioids may circumvent this problem providing a faster pain relief, due to the large availability and rapid achievement of effective plasma concentrations. DISCUSSION Opioid dose titration is a delicate passage in patients with cancer pain. This approach may be different according to different clinical conditions. Opioid dose titration requires expertise to optimize cancer pain management while minimizing the development of adverse effects. CONCLUSION While most approaches are meaningful and partially supported by existing literature, more studies are necessary to establish advantages and disadvantages in different clinical conditions. Optimization of opioid dose titration is of paramount importance. SIGNIFICANCE This review provides the most recent insights on the different modalities of opioid dose titration in cancer pain management.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
- Regional Home Care Program, SAMOT, Palermo, Italy
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Mercadante S, Cascio AL, Casuccio A. Switching to Intravenous Methadone in Advanced Cancer Patients: A Retrospective Analysis. J Pain Symptom Manage 2023; 66:287-292. [PMID: 37236430 DOI: 10.1016/j.jpainsymman.2023.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/17/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
CONTEXT Information about opioid switching to intravenous methadone is lacking. OBJECTIVES The aim of this study was to assess the outcome of opioid switching to intravenous methadone (IV-ME) in patients admitted to an acute supportive/palliative care unit (ASPCU). The secondary outcome was to assess the conversion ratio from IV-ME to oral methadone at time of hospital discharge. METHODS We retrieved from the pharmacy registry the list of patients who were prescribed IV-ME during their ASPCU admission for a period of 47 months. Poor analgesia with previous opioids and/or adverse effects were the main indications for opioid switching. IV-ME was titrated until acceptable analgesia was achieved. The effective dose was multiplied by three to establish the intravenous daily dose, given as a continuous infusion. Doses were then changed according to the clinical needs. Once the patient was stabilized, IV-ME dose was converted to oral methadone, by using an initial ratio of 1:1.2. Further dose changes were made according to clinical needs until stabilization, before patients' discharge. Information about patients' characteristics, pain scores on the Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire, previous opioids and their doses, expressed as oral morphine equivalents (OME), were recorded. The effective bolus of IV-ME, initial daily infusion rate, and oral methadone doses were assessed, and conversion ratios calculated. RESULTS Forty-one patients were taken into consideration for the study. The mean effective bolus of IV-ME titrated for achieving acceptable analgesia was 9 mg (range 5-15 mg). The mean daily continuous infusion rate of IV-ME was 27.6 mg/day (SD 21). The mean daily dose of oral methadone at time of discharge was 46.8 mg/day (SD 43). Discharge occurred within a median of seven days (range 6-9) after admission. Previous opioid (OME)/IV-ME, oral-IV-ME, and previous opioid (OME)/oral methadone were 6.25, 1.7, and 3.7, respectively. CONCLUSION IV-ME dose titration followed by intravenous infusion allowed a rapid pain control in few minutes in patients with severe pain intensity, not responsive to previous opioids. Conversion to oral route was successful and facilitated home discharge. Further studies should be performed to confirm these preliminary results.
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Affiliation(s)
- Sebastiano Mercadante
- Department of Health Promotion (S.M., A.L.C.), Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.
| | - Alessio Lo Cascio
- Department of Health Promotion (S.M., A.L.C.), Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Alessandra Casuccio
- Mean regional center for Pain relief and palliative care Unit (A.C.), La Maddalena Cancer Center, Palermo, Italy
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Odoma VA, Pitliya A, AlEdani E, Bhangu J, Javed K, Manshahia PK, Nahar S, Kanda S, Chatha U, Mohammed L. Opioid Prescription in Patients With Chronic Kidney Disease: A Systematic Review of Comparing Safety and Efficacy of Opioid Use in Chronic Kidney Disease Patients. Cureus 2023; 15:e45485. [PMID: 37727840 PMCID: PMC10506738 DOI: 10.7759/cureus.45485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/18/2023] [Indexed: 09/21/2023] Open
Abstract
Patients with diminished renal function necessitate special care. In patients with chronic kidney disease (CKD), opioid analgesics should be prescribed based on the severity of renal insufficiency; this will determine treatment options at the beginning and throughout the management of pain in CKD patients. The dosage of hydrophilic drugs and drugs with active metabolites should be adjusted according to the severity of CKD, and the process of treatment should be monitored by modifying drug dosages as necessary for background and breakthrough pain. Patients with CKD may benefit from opioid analgesics that are lipophilic, such as methadone, fentanyl, and buprenorphine, as the first line; however, fentanyl is inappropriate for patients undergoing hemodialysis. Opioid prescription in CKD patients is the subject of this systematic review, which aims to compare their safety and efficacy. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations. Using three databases (PubMed, ScienceDirect, and Google Scholar), we collected and reviewed articles, including literature reviews, randomized control trials (RCTs), and systematic reviews published between 1980 and 2022, to enable us to gather enough valuable data on this rare topic. After applying appropriate filters, a total of 109 results were obtained. They were further screened and subjected to quality assessment tools, which finally yielded 11 studies included in this systematic review. This consisted of two RCTs, two systematic reviews, and seven narrative reviews. This review focused on the safety and appropriate use of opioids in patients with CKD. The accumulation of morphine and codeine metabolites may result in neurotoxic side effects. Hydromorphone and oxycodone are considered safe to administer but require careful adjustments in dosage. Common comorbidities among patients with CKD may amplify opioid-related adverse effects.
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Affiliation(s)
- Victor A Odoma
- Cardiology/Oncology, Indiana University Health, Bloomington, USA
| | - Aakanksha Pitliya
- Internal Medicine, Sri Aurobindo Institute of Medical Science, Indore, IND
| | - Esraa AlEdani
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Japneet Bhangu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Khalid Javed
- Anesthesiology, Internal Medicine, St. George's University School of Medicine, Chicago, USA
| | - Prabhleen Kaur Manshahia
- Medicine, All India Institute of Medical Sciences, Rishikesh, IND
- Internal Medicine, JC Medical Institute, Orlando, USA
| | - Shamsun Nahar
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Srishti Kanda
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Uzair Chatha
- Medicine, Lahore Medical and Dental College, Lahore, PAK
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Kumar V, Sirohiya P, Garg R, Gupta N, Bharti SJ, Velpandian T, Mishra S, Bhatnagar S. Comparison of two techniques (intermittent intravenous bolus morphine vs. morphine infusion) for analgesic titration in patients who had advanced cancer with severe pain: a prospective randomised study. BMJ Support Palliat Care 2023; 13:338-344. [PMID: 32895226 DOI: 10.1136/bmjspcare-2020-002397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/16/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the analgesic efficacy of two techniques of morphine titration (intermittent intravenous bolus vs infusion) by calculating rescue dosage in a day at 1 week after analgesic titration. METHODS One hundred and forty cancer patients were randomised into two groups. In group 1, intravenous morphine 1.5 mg bolus given every 10 min until Numerical Rating Scale (NRS) pain score <4 is achieved. Total intravenous dose converted to oral dose (1:1) and administered every 4 hours. In group 2, intravenous bolus morphine 0.05 mg/kg body weight administered followed by 0.025 mg/kg/hour intravenous infusion. The NRS pain score was recorded every 10 min but infusion rate was titrated every 30 min if required. The infusion rate of morphine was doubled if the pain score was unchanged and increased to 50% when NRS was between 4 and baseline. If NRS<4, then infusion at same rate was continued. Once the NRS<4 for two consecutive hours, total intravenous dose for 24 hours was calculated and converted to oral morphine in a ratio of 1:3 and divided into six doses given over 24 hours. For rescue (pain score ≥4) analgesia, one-sixth of the total daily oral dose was prescribed. The primary outcome of this study was to note the number of rescue doses of oral morphine in a day at 1 week. RESULTS The rescue dosage in a day at 1-week post discharge from the palliative care unit was significantly higher in group 1 as compared with group 2. CONCLUSION Intravenous infusion morphine may be a better analgesic titration technique for analgesia in patients with advanced cancer. TRIAL REGISTRATION NUMBER CTRI/2018/04/013369.
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Affiliation(s)
- Vinod Kumar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Sirohiya
- Anaesthesia, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sachidanand Jee Bharti
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Thirumurthy Velpandian
- Department of Ocular Pharmacology, Dr Rajendra Prasad Centre for Opthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
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Mercadante S. The Use of Parenteral Opioids in Cancer Pain Management. Cancers (Basel) 2023; 15:3778. [PMID: 37568594 PMCID: PMC10417386 DOI: 10.3390/cancers15153778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Although oral administration of opioids is generally preferable, a parenteral route may be advisable and mandatory in some clinical circumstances. Parenteral administration of opioids may accelerate the achievement of analgesia. The intravenous route fits the need of rapid achievement of analgesia in patients poorly responsive to other opioids and provides a fast analgesia in patients with breakthrough pain, that has a specific temporal pattern requiring a rapid analgesic effect. When the oral route is unavailable for the presence of nausea, vomiting, or dysphagia. the parenteral route is one of the principal options. Opioids have different pharmacokinetic and pharmacodynamic characteristics and should be chosen according to the individual needs. Thus, the knowledge and experience with these routes of administration are mandatory for anesthesiologists committed to cancer pain management.
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Mercadante S, Adile C, Ferrera P, Cascio AL, Casuccio A. Rapid Titration With Intravenous Oxycodone for Severe Cancer Pain and Oral Conversion Ratio. J Pain Symptom Manage 2022; 64:532-536. [PMID: 36115502 DOI: 10.1016/j.jpainsymman.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT to assess a dose titration with intravenous oxycodone to achieve rapid pain relief of cancer pain of severe intensity. The second objective was to provide a conversion ratio with the oral route. METHODS Cancer patients admitted for severe pain were prospectively assessed. At admission (T0) previous opioid doses were recorded. Edmonton symptom assessment scale (ESAS) was collected from T0 until the conclusion of the observation. Intravenous boluses of oxycodone were given until the initial signs of significant analgesia were detected. The effective dose was multiplied for six and given as intravenous continuous infusion. When the patient was considered stabilized the intravenous daily dose was converted to oral oxycodone using an initial ratio of 1:2. Subsequently, doses of oral oxycodone were changed according to the clinical situation. RESULTS Twenty-nine patients were examined. A mean effective bolus dose of oxycodone was 9.5 mg (SD 8.0) allowed to achieve a meaningful pain relief in a mean of 10.4 minutes (SD 3.3). The mean initial and the final infusion doses were 51.0 mg/day (standard deviation 40.9) and 69.7 mg/day ( standard deviation76.6), respectively. A significant change in pain intensity was observed at the different time intervals (P<0.0005). Conversion to oral route occurred after a mean of 2.7 days (standard deviation1.2) of intravenous oxycodone. The final mean conversion ratio was 1:2,12 ( standard deviation0.36). CONCLUSION Rapid intravenous oxycodone dose titration resulted in rapid pain relief. The intravenous-oral conversion ratio of 1:2 is reliable. Further studies are necessary to confirm this preliminary observation.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center for pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Main regional center for pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
| | - Patrizia Ferrera
- Main regional center for pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
| | - Alessio Lo Cascio
- Main regional center for pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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Abstract
Management of cancer pain is challenging. Despite the poor evidence, opioid therapy still remains the cornerstone for the management of cancer-related pain. Opioids should be given according to the clinical presentation in the different stages of disease. There is no drug of choice, as most opioids are effective. Thus, the choice should be based on the individual characteristics of patients. Optimization of opioid therapy may allow individual treatment according to the patient's characteristics and pain syndromes, providing timely alternatives in the different stages of disease. While most patients respond to an appropriate treatment associated with a comprehensive assessment and symptom control, a high level of experience and knowledge is necessary in determining conditions to maximize the analgesic response, eventually adding adjuvants in some specific circumstances. Alternative opioids may improve the balance between analgesia and adverse effects in the presence of a poor response to the first opioid in a large number of patients. Finally, a selected population can benefit from some interventional procedures.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
- Regional Home Care Program, SAMOT, Palermo, Italy.
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Abstract
Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.
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Affiliation(s)
- Farrah N Daly
- EvenBeam Neuropalliative Care, Leesburg, VA, United States.
| | - Usha Ramanathan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Lin R, Lin S, Feng S, Wu Q, Fu J, Wang F, Li H, Li X, Zhang G, Yao Y, Xin M, Lai T, Lv X, Chen Y, Yang S, Lin Y, Hong L, Cai Z, Wang J, Lin G, Lin S, Zhao S, Zhu J, Huang C. Comparing Patient-Controlled Analgesia Versus Non-PCA Hydromorphone Titration for Severe Cancer Pain: A Randomized Phase III Trial. J Natl Compr Canc Netw 2021; 19:1148-1155. [PMID: 34343968 DOI: 10.6004/jnccn.2020.7699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/09/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Opioid titration is necessary to achieve rapid, safe pain relief. Medication can be administered via patient-controlled analgesia (PCA) or by a healthcare provider (non-PCA). We evaluated the efficacy of intravenous PCA versus non-PCA hydromorphone titration for severe cancer pain (≥7 at rest on the 11-point numeric rating scale [NRS]). PATIENTS AND METHODS Patients with severe cancer pain were randomized 1:1 to PCA or non-PCA titration, stratified by opioid-tolerant or opioid-naïve status. The PCA pump was set to no continuous dose, with a hydromorphone bolus dose 10% to 20% of the total previous 24-hour equianalgesic (for opioid-tolerant patients) or 0.5 mg (for opioid-naïve patients). For the non-PCA group, the initial hydromorphone bolus dose was identical to that in the PCA group, with the subsequent dose increased by 50% to 100% (for NRS unchanged or increased) or repeated at the current dose (for NRS 4-6). Hydromorphone delivery was initiated every 15 minutes (for NRS ≥4) or as needed (for NRS ≤3). The primary endpoint was time to successful titration (TST; time from first hydromorphone dose to first occurrence of NRS ≤3 in 2 consecutive 15-minute intervals). RESULTS Among 214 patients (PCA, n=106; non-PCA, n=108), median TSTs (95% CI) were 0.50 hours (0.25-0.50) and 0.79 hours (0.50-1.42) for the PCA and non-PCA groups, respectively (hazard ratio [HR], 1.64; 95% CI, 1.23-2.17; P=.001). TSTs in opioid-tolerant patients were 0.50 hours (0.25-0.75) and 1.00 hours (0.50-2.00) for the PCA and non-PCA groups, respectively (HR, 1.92; 95% CI, 1.32-2.78; P=.003); in opioid-naive patients, TST was not significantly different for the PCA versus non-PCA groups (HR, 1.35; 95% CI, 0.88-2.04; P=.162). Pain score (median NRS; interquartile range) over 24 hours was significantly lower in the PCA group (2.80; 2.15-3.22) than in the non-PCA group (3.00; 2.47-3.53; P=.020). PCA administration produces significantly higher patient satisfaction with pain control than non-PCA administration (P<.001). CONCLUSIONS Intravenous hydromorphone titration for severe cancer pain was achieved more effectively with PCA than with non-PCA administration.
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Affiliation(s)
- Rongbo Lin
- 1Department of Gastrointestinal Medical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou.,2Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou
| | - Sunzhi Lin
- 3Department of Pain Medicine, Mindong Hospital, Ningde
| | - Shuitu Feng
- 4Department of Medical Oncology, Xiamen Haicang Hospital, Xiamen
| | - Qingyi Wu
- 5Department of Medical Oncology, Guangqian Hospital, Quanzhou
| | - Jianqian Fu
- 6Department of Medical Oncology, Xiamen Fifth Hospital, Xiamen
| | - Fang Wang
- 7Department of Medical Oncology, Longyan Hospital of Traditional Chinese Medicine, Longyan
| | - Hui Li
- 1Department of Gastrointestinal Medical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou
| | - Xiaofeng Li
- 8Department of Medical Oncology, Quanzhou First Hospital, Quanzhou
| | | | - Yongzhi Yao
- 10Department of Oncology, Putian People Hospital, Putian
| | - Min Xin
- 11Department of Medical Oncology, Fujian Armed Police Corps Hospital, Fuzhou
| | - Tianyang Lai
- 12Department of Medical Oncology, Longyan Boai Hospital, Longyan
| | - Xia Lv
- 13Department of Medical Oncology, Xiamen Humanity Hospital and Fujian Medical University Xiamen Humanity Hospital, Xiamen
| | - Yigui Chen
- 1Department of Gastrointestinal Medical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou
| | - Shangwang Yang
- 14Department of Medical Oncology, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou
| | - Yubiao Lin
- 4Department of Medical Oncology, Xiamen Haicang Hospital, Xiamen
| | - Lixia Hong
- 15Department of Gastroenterology, Hanjiang Hospital, Putian
| | - Zhenyu Cai
- 16Department of Pain Medicine, The First Affiliated Hospital of Xiamen University, Xiamen
| | - Jianfeng Wang
- 1Department of Gastrointestinal Medical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou
| | - Gen Lin
- 17Department of Thoracic Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou; and
| | - Shaowei Lin
- 18School of Public Health, Fujian Medical University, Fuzhou, China
| | - Shen Zhao
- 1Department of Gastrointestinal Medical Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou.,2Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou
| | - Jinfeng Zhu
- 8Department of Medical Oncology, Quanzhou First Hospital, Quanzhou
| | - Cheng Huang
- 13Department of Medical Oncology, Xiamen Humanity Hospital and Fujian Medical University Xiamen Humanity Hospital, Xiamen.,17Department of Thoracic Oncology, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou; and
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Dyal BW, Powell-Roach KL, Robison J, Campbell B, Yoon SL, Wilkie DJ. Sublingual Versus Swallowed Morphine: A Comparison. Cancer Nurs 2021; 44:E13-E22. [PMID: 31895174 DOI: 10.1097/ncc.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal route for immediate-release morphine administration is controversial. The known physical characteristics of morphine that allow absorption are counter to the unproven belief that sublingual morphine is absorbed more quickly. OBJECTIVE The aim of this study was to compare swallowed and sublingual morphine for effects on plasma morphine concentrations (PMCs), pain relief, and taste. METHODS Ten participants with cancer (mean age, 50 ± 12 years) received a 10-mg morphine tablet in a randomized crossover design with repeated premeasure and postmeasure for 60 minutes. Measures included PMC and visual analog scale (100 mm) scores for pain relief and taste. RESULTS Interindividual variability in maximum PMC was 25-fold (2.2-55 ng/mL). At 60 minutes, sublingual and swallowed routes were not significantly different for mean area under the curve for PMC (swallowed, 329 ± 314 ng/mL; sublingual, 314 ± 299 ng/mL) or for mean pain relief scores (swallowed, 81 ± 32; sublingual, 78 ± 31). Taste scores at 5 (P < .05), 10 (P < .04), 15 (P < .02), and 20 (P < .04) minutes after swallowed doses were significantly less unpleasant than after sublingual doses. CONCLUSION In this crossover design, between-group PMCs were similar for sublingual and swallowed morphine and resulted in a similar level of pain relief. Given the 25-fold across-participant differences in PMC after the same dose, additional research is warranted to identify the sources of this tremendous variability in PMC. IMPLICATIONS FOR PRACTICE Because of unpleasant taste, which could influence adherence and subsequent analgesia, clinicians should encourage patients to swallow their morphine doses and restrict use of sublingual morphine to individuals who are unable to swallow.
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Affiliation(s)
- Brenda W Dyal
- Author Affiliations: Department of Biobehavioral Nursing Science, College of Nursing (Drs Dyal, Powell-Roach, Yoon, and Wilkie), and Department of Community Dentistry and Behavioral Science, College of Dentistry (Dr Powell-Roach), University of Florida, Gainesville; Center for Palliative Care Research & Education (Drs Dyal, Powell-Roach, Yoon, and Wilkie), Gainesville, Florida; Multicare Deaconess Cancer and Blood Specialty Center (Dr Robison); and School of Nursing and Human Physiology, Gonzaga University (Dr Robison), Spokane, Washington; and University of Wisconsin Carbone Cancer Center (Ms Campbell), Madison
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Dolati S, Tarighat F, Pashazadeh F, Shahsavarinia K, Gholipouri S, Soleimanpour H. The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article. Anesth Pain Med 2020; 10:e105754. [PMID: 34150565 PMCID: PMC8207885 DOI: 10.5812/aapm.105754] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/19/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.
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Affiliation(s)
- Sanam Dolati
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faezeh Tarighat
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariba Pashazadeh
- Research Center for Evidence-Based Medicine, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kavous Shahsavarinia
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saina Gholipouri
- Department of Medical Sciences, University of Western Ontario, Ontario, Canada
| | - Hassan Soleimanpour
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran. ,
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Thota RS, Ramanjulu R, Ahmed A, Jain P, Salins N, Bhatnagar S, Chatterjee A, Bhattacharya D. Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Pharmacological Management of Cancer Pain (Part II). Indian J Palliat Care 2020; 26:180-190. [PMID: 32874031 PMCID: PMC7444569 DOI: 10.4103/0973-1075.285693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group (SIG) guidelines on pharmacological management of cancer pain in adults provide a structured, stepwise approach, which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire, based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend that analgesics for cancer pain management should follow the World Health Organization 3-step analgesic ladder appropriate for the severity of pain. The use of paracetamol and nonsteroidal anti-inflammatory drugs alone or in combination with opioids for mild-to-moderate pain should be used. For mild-to-moderate pain, weak opioids such as tramadol, tapentadol, and codeine can be given in combination with nonopioid analgesics. We recommend morphine as the opioid of the first choice for moderate-to-severe cancer pain. Sustained-release formulations can be started 12 hourly, once the effective 24 h dose with immediate-release morphine is established. Opioid switch or rotation should be considered if there is inadequate analgesia or intolerable side effects. For opioid-induced respiratory depression, μ receptor antagonists (e.g. naloxone) must be used promptly. Antidepressants and/or anticonvulsants should be used to treat neuropathic cancer pain, and the dose should be titrated according to the clinical response and side effects. External beam radiotherapy should be offered to all patients with painful metastatic bone pain. There is evidence on use of ketamine in cancer neuropathic pain, but with no beneficial effect, thus, it is not recommended.
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Affiliation(s)
- Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Raghavendra Ramanjulu
- Department of Pain and Palliative Care, Cytecare Hospital, Bengaluru, Karnataka, India
| | - Arif Ahmed
- Department of Anaesthesia, Critical Care and Pain Management, CK Birla Hospital for Women, Gurugram, Haryana, India
| | - Parmanand Jain
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Chatterjee
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dipasri Bhattacharya
- Department of Anaesthesiology, Critical Care and Pain, R. G. Kar Medical College, Kolkata, West Bengal, India
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Nakajima N. Effectiveness of rapid titration with intravenous administration of oxycodone injection in advanced cancer patients with severe pain. Jpn J Clin Oncol 2019; 49:1061-1064. [PMID: 31612910 DOI: 10.1093/jjco/hyz145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 09/02/2019] [Indexed: 11/14/2022] Open
Abstract
Some cancer patients suddenly develop severe, excruciating pain that requires rapid management using opioid medication. This study aimed to evaluate the effectiveness of rapid titration using oxycodone injection. Study subjects were advanced cancer patients who experienced severe pain (numeric rating scale ≥7) and needed prompt pain relief. Primary endpoint was (i) time required for the initial sign of significant analgesia to become evident. Secondary endpoints were (ii) pain relief stabilization success rate and (iii) adverse effects. Groups treated with oxycodone (oxycodone group) and morphine (morphine group) were retrospectively compared. The oxycodone group had 33 cases and the morphine group had 32 cases: (i) 15.6 ± 4.3 min in the oxycodone group and 19.3 ± 4.7 min in the morphine group (P = 0.001); (ii) 70 and 63% within 24 hours, and 88 and 84% within 48 hours in the oxycodone group and the morphine group, respectively (P = 0.36, 0.48). Although (iii) adverse effects appeared in both groups in the form of respiratory suppression, etc., the effects were mild. Rapid titration using oxycodone injections may be considered a beneficial choice.
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Affiliation(s)
- Nobuhisa Nakajima
- Division of Community-based Medicine and Primary Care, University of the Ryukyus Hospital, Japan
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Yan XB. Breakthrough Cancer Pain. FROM CONVENTIONAL TO INNOVATIVE APPROACHES FOR PAIN TREATMENT 2019. [DOI: 10.5772/intechopen.84581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Mercadente S. Small repeated boluses are unreliable to provide rapid analgesia with intravenous morphine titration and mislead conversion ratio to oral morphine. Ann Oncol 2018; 29:2147-2148. [DOI: 10.1093/annonc/mdy327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, Ripamonti CI. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv166-iv191. [PMID: 30052758 DOI: 10.1093/annonc/mdy152] [Citation(s) in RCA: 416] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Fallon
- Edinburgh Cancer Research Centre, IGMM, University of Edinburgh, Edinburgh, UK
| | - R Giusti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome
| | - F Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, Hertfordshire, UK
| | - R Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - M Sharma
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - C I Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Fallon M, Ripamonti CI. Reply to the letter to the editor 'Small repeated boluses are unreliable to provide rapid analgesia with intravenous morphine titration and mislead conversion ratio to oral morphine' by Mercadante S. Ann Oncol 2018; 29:2148-2149. [PMID: 30412220 DOI: 10.1093/annonc/mdy328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Fallon
- Edinburgh Cancer Research Centre, IGMM, University of Edinburg, Edinburgh, UK
| | - C I Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy.
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Kannampallil TG, McNutt R, Falck S, Galanter WL, Patterson D, Darabi H, Sharabiani A, Schiff G, Odwazny R, Vaida AJ, Wilkie DJ, Lambert BL. Learning optimal opioid prescribing and monitoring: a simulation study of medical residents. JAMIA Open 2018; 1:246-254. [PMID: 31984336 PMCID: PMC6951957 DOI: 10.1093/jamiaopen/ooy026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/21/2018] [Accepted: 06/05/2018] [Indexed: 12/23/2022] Open
Abstract
Objective Hospitalized patients often receive opioids. There is a lack of consensus regarding evidence-based guidelines or training programs for effective management of pain in the hospital. We investigated the viability of using an Internet-based opioid dosing simulator to teach residents appropriate use of opioids to treat and manage acute pain. Materials and methods We used a prospective, longitudinal design to evaluate the effects of simulator training. In face-to-face didactic sessions, we taught 120 (108 internal medicine and 12 family medicine) residents principles of pain management and how to use the simulator. Each trainee completed 10 training and, subsequently, 5 testing trials on the simulator. For each trial, we collected medications, doses, routes and times of administration, pain scores, and a summary score. We used mixed-effects regression models to assess the impact of simulation training on simulation performance scores, variability in pain score trajectories, appropriate use of short- and long-acting opioids, and use of naloxone. Results Trainees completed 1582 simulation trials (M = 13.2, SD = 6.8), with sustained improvements in their simulated pain management practices. Over time, trainees improved their overall simulated pain management scores (b = 0.05, P < .01), generated lower pain score trajectories with less variability (b = −0.02, P < .01), switched more rapidly from short-acting to long-acting agents (b = −0.50, P < .01), and used naloxone less often (b = −0.10, P < .01). Discussion and conclusions Trainees translated their understanding of didactically presented principles of pain management to their performance on simulated patient cases. Simulation-based training presents an opportunity for improving opioid-based inpatient acute pain management.
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Affiliation(s)
- Thomas G Kannampallil
- Department of Family Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Robert McNutt
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Suzanne Falck
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - William L Galanter
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA.,Departments of Pharmacy Practice and Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Dave Patterson
- Discerning Systems Inc., Burnaby, British Columbia, Canada
| | - Houshang Darabi
- Department of Mechanical & Industrial Engineering, College of Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ashkan Sharabiani
- Department of Mechanical & Industrial Engineering, College of Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gordon Schiff
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Allen J Vaida
- Institute for Safe Medication Practices, Horsham, Pennsylvania, USA
| | - Diana J Wilkie
- Center for Palliative Care Research and Education, College of Nursing, University of Florida, Gainesville, Florida
| | - Bruce L Lambert
- Center for Communication and Health, Department of Communication Studies, Northwestern University, Chicago, Illinois, USA
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Treat chronic pain with appropriate non-oral formulations of opioids in patients who have difficulty swallowing. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0456-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Patients with chronic pain often develop dysphagia during the course of an advanced disease such as cancer. Opioids are the cornerstone of the management of cancer pain and are commonly administered orally. However, the oral route does not suit patients with dysphagia, who require alternative methods to administer analgesic drugs. Opioids given by parenteral or transdermal routes provide adequate pain control, being at least as efficacious as the oral route, but knowledge and experience in conversion ratios are mandatory when using these routes of administration. For breakthrough pain, transmucosal fentanyl preparations should be the preferred option and these can be given as needed due to the route of absorption. In addition, a new class of opioid formulations has been developed for use in dysphagic patients that are administered via nasogastric or enteral tubes while maintaining their sustained-release properties.
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Affiliation(s)
- Sebastiano Mercadante
- Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
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Nagar VR, Birthi P, Salles S, Sloan PA. Opioid Use in Chronic Pain Patients with Chronic Kidney Disease: A Systematic Review. PAIN MEDICINE 2017; 18:1416-1449. [DOI: 10.1093/pm/pnw238] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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22
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Mercadante S. Parenteral routes for opioid administration in cancer pain management. Eur J Intern Med 2016; 34:e39-e40. [PMID: 27449119 DOI: 10.1016/j.ejim.2016.06.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 06/22/2016] [Accepted: 06/27/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
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Abstract
Opioid dosing strategies for acute pain differ from strategies for chronic pain management. The basic principles of effective, safe dosing are rapid titration to the onset of analgesia followed by maintenance infusions based upon the titrated dose. This article presents guidelines and case histories for safe and effective dosing.
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Affiliation(s)
- Mellar P Davis
- Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Parodi G. Editor's Choice-Chest pain relief in patients with acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:277-81. [PMID: 25904757 DOI: 10.1177/2048872615584078] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/03/2015] [Indexed: 11/16/2022]
Abstract
Chest pain is the prevalent symptom at presentation in patients with acute myocardial infarction (AMI). Despite the complete absence of rigorous studies designed to assess the impact of morphine administration in patients with AMI, clinical practice guidelines strongly recommend morphine for analgesia. However, when using morphine to relieve chest pain in AMI patients, physicians must be aware that hypotension, respiratory depression, vomiting, and delayed onset of action of antiplatelet agents are potential unwanted side effects of the drug. The purpose of this report is to review morphine's clinical and side effects and to propose strategies able to reduce chest pain in AMI patients.
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Affiliation(s)
- Guido Parodi
- The Cardiovascular and Thoracic Department, Careggi Hospital, Florence, Italy The Post-graduate School in Cardiology, University of Florence, Italy
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Abstract
There are many ways to add to children's quality of life within the hospital environment. Inpatient settings offer both opportunities and challenges with respect to providing care to children with life-threatening illnesses. The barriers to pediatric palliative care (PPC) on hospital wards, as with those in other settings, frequently stem from misconceptions. However, some barriers are intensified by characteristics of acute inpatient centers. Yet some characteristics of the inpatient setting, including the availability of human resources and unique interventions, offer creative ways to ease distress and improve quality of life for children and their families.
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Affiliation(s)
- Adam Rapoport
- Paediatric Advanced Care Team (PACT), The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Kevin Weingarten
- Paediatric Advanced Care Team (PACT), The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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Abstract
Despite published guidelines and educational programs on the assessment and treatment of cancer-related pain, in any stage of oncological disease, unrelieved pain continues to be a substantial worldwide public health concern either in patients with solid and haematological malignancies. The proper and regular self-reporting assessment of pain is the first step for an effective and individualized treatment. Opioids are the mainstay of analgesic therapy and can be associated with non-opioids drugs such as paracetamol or non-steroidal anti-inflammatory drugs and to adjuvant drugs (for neuropathic pain and symptom control). The role and the utility of weak opioids (i.e. codeine, dihydrocodeine, tramadol) are a controversy point. Morphine has been placed by World Health Organization on its Essential Drug List. In the comparative study with other strong opioids (hydromorphone, oxycodone), there is no evidence to show superiority or inferiority with morphine as the first choice opioid. Oral methadone is a useful and safe alternative to morphine. Methadone presents the potential to control pain difficult to manage with other opioids. although the oral route of opioid administration is considered the one of choice, intravenous, subcutaneous, rectal, transdermal, sublingual, intranasal, and spinal routes must be used in particular situation. Transdermal opioids such as fentanyl and buprenorphine are best reserved for patients whose opioid requirements are stable. Switching from one opioid to another can improve analgesia and tolerability.
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Affiliation(s)
- C I Ripamonti
- Supportive Care in Cancer Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Milano, Italy.
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Lvovschi V, Arhan A, Juillien G, Montout V, Bendahou M, Goulet H, Saïdi K, Riou B. Morphine consumption is not modified in patients with severe pain and classified by the DN4 score as neuropathic. Am J Emerg Med 2012; 30:1877-83. [DOI: 10.1016/j.ajem.2012.03.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 03/30/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022] Open
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Neumeyer JL, Zhang B, Zhang T, Sromek AW, Knapp BI, Cohen DJ, Bidlack JM. Synthesis, binding affinity, and functional in vitro activity of 3-benzylaminomorphinan and 3-benzylaminomorphine ligands at opioid receptors. J Med Chem 2012; 55:3878-90. [PMID: 22439881 PMCID: PMC3375359 DOI: 10.1021/jm3001086] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A series of 3-benzylamino-3-desoxymorphinan (I) and 3-benzylamino-3-desoxymorphine (II) derivatives were synthesized and evaluated for their binding affinities, and functional activity data are presented at MOR, KOR, and DOR. Some of these ligands were found to have high binding affinity at MOR and KOR and displayed increased selectivity at MOR over KOR and DOR compared to butorphan or cyclorphan. The most selective compound, 3-(3'-hydroxybenzyl)amino-17-methylmorphinan (4g) (24-fold MOR to KOR and 1700-fold MOR to DOR) also showed high binding affinity (0.42 nM to MOR) and was a full agonist in the [(35)S]GTPγS binding assay. 2-(3'-Hydroxybenzyl)amino-17-cyclopropylmethylmorphinan (17) was found to be a KOR-selective ligand (150-fold over MOR and >10000-fold over the DORs). Most 3-benzylaminomorphinan derivatives were partial agonists at MOR and full agonists at KOR in the [(35)S]GTPγS binding assay.
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Affiliation(s)
- John L Neumeyer
- Alcohol and Drug Abuse Research Center, McLean Hospital, Harvard Medical School, 115 Mill Street, Belmont, Massachusetts 02478-9106, USA.
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Sédation et analgésie en structure d’urgence. Quelles sédation et analgésie chez le patient en ventilation spontanée en structure d’urgence ? ACTA ACUST UNITED AC 2012; 31:295-312. [DOI: 10.1016/j.annfar.2012.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, Dale O, De Conno F, Fallon M, Hanna M, Haugen DF, Juhl G, King S, Klepstad P, Laugsand EA, Maltoni M, Mercadante S, Nabal M, Pigni A, Radbruch L, Reid C, Sjogren P, Stone PC, Tassinari D, Zeppetella G. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 2012; 13:e58-68. [PMID: 22300860 DOI: 10.1016/s1470-2045(12)70040-2] [Citation(s) in RCA: 772] [Impact Index Per Article: 64.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Here we provide the updated version of the guidelines of the European Association for Palliative Care (EAPC) on the use of opioids for the treatment of cancer pain. The update was undertaken by the European Palliative Care Research Collaborative. Previous EAPC guidelines were reviewed and compared with other currently available guidelines, and consensus recommendations were created by formal international expert panel. The content of the guidelines was defined according to several topics, each of which was assigned to collaborators who developed systematic literature reviews with a common methodology. The recommendations were developed by a writing committee that combined the evidence derived from the systematic reviews with the panellists' evaluations in a co-authored process, and were endorsed by the EAPC Board of Directors. The guidelines are presented as a list of 16 evidence-based recommendations developed according to the Grading of Recommendations Assessment, Development and Evaluation system.
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Affiliation(s)
- Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Klepstad P, Kaasa S, Borchgrevink PC. Starting step III opioids for moderate to severe pain in cancer patients: dose titration: a systematic review. Palliat Med 2011; 25:424-30. [PMID: 21708850 DOI: 10.1177/0269216310386280] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The European Association for Palliative Care recommendation for starting morphine for cancer pain is dose titration with immediate release (IR) oral morphine given every 4 h with additionally doses for breakthrough pain. As part of a EU 6th framework programme to revise the guidelines we review the evidence regarding starting treatment and dose titration of opioids in adult patients with moderate to severe cancer pain. Relevant papers were identified though a systematic search in Medline for papers published until the end of 2009. We identified 15 relevant papers. Thirteen papers were descriptive papers reporting the results from starting treatment with oral morphine (six studies), starting treatment with intravenous morphine (two studies) and starting treatment with transdermal fentanyl (four studies). All treatment strategies resulted in acceptable pain control and were well tolerated. Two randomized controlled trials were identified. One study compared starting opioid treatment with intravenous morphine versus IR oral morphine and one study compared IR oral morphine versus sustained release oral morphine.
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Affiliation(s)
- Pål Klepstad
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
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Abstract
Patients and families struggling with cancer fear pain more than any other physical symptom. There are also significant barriers to optimal pain management in the emergency setting, including lack of knowledge, inexperienced clinicians, myths about addiction, and fears of complications after discharge. In this article, we review the assessment and management options for cancer-related pain based on the World Health Organization (WHO) 3-step approach.
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Affiliation(s)
- Paul L Desandre
- Department of Emergency Medicine, Beth Israel Medical Center, First Avenue, 16th Street, New York, NY 10003, USA
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Lasheen W, Walsh D, Mahmoud F, Sarhill N, Rivera N, Davis M, Lagman R, Legrand S. The intravenous to oral relative milligram potency ratio of morphine during chronic dosing in cancer pain. Palliat Med 2010; 24:9-16. [PMID: 19910396 DOI: 10.1177/0269216309346595] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Morphine (M) is the opioid analgesic of choice for severe cancer pain. The IV to PO M equipotent switch ratio (CR) is controversial. We designed this prospective observational cohort to confirm the efficacy and safety of M IV to PO CR of 1:3. Consecutive cancer patients admitted to an inpatient palliative medicine unit were screened for inclusion. Pain was managed by palliative medicine specialists. They were blinded to the patient data collected, and the calculated CR. The switch was considered successful if the following criteria were met: (1) Pain adequately controlled: pain rated as none or mild (2) Number of RD less than 4 (for non incident pain) per 24 hours (3) No limiting side effects. We used Day 3 ATC M dose for CR calculations. The major outcome measures were the IV : PO CR ratio, morphine doses (mg/day), pain severity, number of PRN doses, and day 1 and day 3side effects. Descriptive statistics were used to report mean, median, standard deviation and range of different variables. Two hundred and fifty six consecutive admissions were screened, and 106 were eligible for the study. Sixty two underwent a successful M route switch and were included in this analysis. A ratio of 1:3 was safely implemented over a wide M dose range. About 80% were successfully switched with a calculated CR of 1:3. 20% required an oral M dose adjustment after route switch either to better pain control or reduce side effects with a resultant higher (e.g. 1:4) or lower (e.g. 1:2) calculated potency ratios respectively. A potency ratio of 1:3 was safe as evaluated by common M side-effects, the dose also easy to calculate. The 1: 3 M IV to PO relative milligram potency ratio appears correct and practical for most patients over a wide M dose range.
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Affiliation(s)
- Wael Lasheen
- The Harry R Horvitz Center for Palliative Medicine, Cleveland, OH 44195, USA
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Niscola P, Sorrentino F, Scaramucci L, de Fabritiis P, Cianciulli P. Pain syndromes in sickle cell disease: an update. PAIN MEDICINE 2009; 10:470-80. [PMID: 19416438 DOI: 10.1111/j.1526-4637.2009.00601.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pain has a critical role in the management of sickle cell disease (SCD). Patients may suffer from several pain syndromes, which may be or not may be associated with other clinical complications, such as anemia, organ failures, and infections. DESIGN Data for review were identified by using PubMed to search MEDLINE, limiting the search to abstract/articles in English, Italian, French, and Dutch. The key words pain, sickle cell disease, anemia, hemoglobin, hemoglobinopathy, analgesics, opioids, morphine, acetaminophen, paracetamol, nonsteroidal anti-inflammatory drugs, hematology, and quality of life were variously combined in the title, abstract, and key word search list. The abstract database of most hematological congresses and the bibliographies of most relevant articles were also considered. RESULTS There are two major types of SCD pain: acute and chronic. Sometimes, mixed and neuropathic pain can be also observed. Acute pain is mostly related to vaso-occlusion. Chronic pain may be due to some SCD complications, such as leg ulcers and avascular necrosis. CONCLUSIONS Pain management in the SCD setting needs multidisciplinary approaches, given the several syndromes and the pathogenic mechanisms that are likely involved. Pain management is not standardized and often difficult, so that many patients with SCD are still poorly treated. Further efforts to develop care plans and treatment protocols as well as management guidelines are required.
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Abstract
Patients and families struggling with cancer fear pain more than any other physical symptom. There are also significant barriers to optimal pain management in the emergency setting, including lack of knowledge, inexperienced clinicians, myths about addiction, and fears of complications after discharge. In this article, we review the assessment and management options for cancer-related pain based on the World Health Organization (WHO) 3-step approach.
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Affiliation(s)
- Paul L Desandre
- Department of Emergency Medicine, Beth Israel Medical Center, First Avenue, 16th Street, New York, NY 10003, USA
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Computer-based simulation as a teaching tool for residents treating patients with cancer-related pain crises. Qual Manag Health Care 2008; 17:192-9. [PMID: 18641500 DOI: 10.1097/01.qmh.0000326722.70708.0d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
CONTEXT Residents often fail to escalate narcotics to ensure pain relief in patients with cancer because of fear of overdose. A computer simulation of patients in pain may provide a way to improve management without fear of harm. We developed a pain care simulation to train residents. STUDY DESIGN/MEASURES: Thirty-one residents trained on 2 to 3 consecutive simulated patients. Simulated cases were assigned variable tolerances to narcotics and starting pain scores. The goals of training were as follows: (1) rapid induction of pain relief, (2) measurement of pain response at appropriate times, and (3) early institution and escalation in care long-acting pain medication to ensure stable pain control for 48 hours. Seven reviewers judged graphical summaries of care and assessed if pain improved, worsened, or stayed the same. RESULTS Thirty-one residents participated: 25 completed 3 simulations; 6 completed only 2. Sixty-eight percent improved from case 1 to 2; 90% improved by 3. The average pain score declined from 2.5 in case 1 to 1.9 in case 3 (P = .04). Rescue medication use declined from 37% for the first case to 23% by the third (P = .18). Reviewers' intraclass correlation for improved pain care was 0.821 (95% CI, 0.721-0.895). CONCLUSIONS Residents improved using a pain treatment simulator. A graphical representation of pain scores more than 48 hours of care that provides a useful way to assess pain control. Lessons learned may translate into improved patient care.
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Lvovschi V, Aubrun F, Bonnet P, Bouchara A, Bendahou M, Humbert B, Hausfater P, Riou B. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med 2008; 26:676-82. [PMID: 18606320 DOI: 10.1016/j.ajem.2007.10.025] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 10/12/2007] [Accepted: 10/12/2007] [Indexed: 12/22/2022] Open
Affiliation(s)
- Virginie Lvovschi
- Department of Emergency Medicine and Surgery, Centre hospitalo-universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6, 75013 Paris, France
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Harting B, Abrams R, Hasler S, Odwazny R, McNutt R. Effects of Training on a Simulator of Pain Care on the Quality of Pain Care for Patients With Cancer-Related Pain. Qual Manag Health Care 2008; 17:200-3. [PMID: 18641501 DOI: 10.1097/01.qmh.0000326723.70708.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mercadante S, Intravaia G, Villari P, Ferrera P, Riina S, Mangione S. Intravenous morphine for breakthrough (episodic-) pain in an acute palliative care unit: a confirmatory study. J Pain Symptom Manage 2008; 35:307-13. [PMID: 18178368 DOI: 10.1016/j.jpainsymman.2007.04.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 04/11/2007] [Accepted: 04/12/2007] [Indexed: 10/22/2022]
Abstract
The aim of this prospective cohort study was to confirm the safety of intravenous morphine (IV-M) used in doses proportional to the basal opioid regimen for the management of breakthrough pain and to record the nurse compliance on regularly recording data regarding breakthrough pain treated by IV-M. Over a one-year period, 99 patients received IV-M for breakthrough pain during 116 admissions. The IV-M dose was 1/5 of the oral daily dose, converted using an equianalgesic ratio of 1/3 (IV/oral). For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to reassess the patient 15minutes after IV-M injection (T15). Nurses were unaware of the aim of the study and just followed department policy. In total, 945 breakthrough events treated by IV-M were recorded and the mean number of events per patient per admission was eight (95% confidence interval (CI) 6.9-9.5). The mean dose of IV-M was 12mg (95% CI 9-14mg). In the 469 events (49.6%) with a complete assessment, a decrease in pain of more than 33% and 50% was observed in 287 (61.2%) and 115 (24.5%) breakthrough events, respectively. The mean pain intensity decreased from 7.2 (T0) to 2.7 (T15). In eight episodes, no changes in pain intensity were observed and a further dose of IV-M was given. The remaining patients did not require further interventions. No clinical events requiring medical intervention were recorded. In this confirmatory study, IV-M was administered for the management of breakthrough pain in doses proportional to the basal opioid regimen to all patients, including older patients and those requiring relatively large doses. This did not result in life-threatening adverse effects in a large number of patients and was effective in most cases. The role of nurses is of paramount importance in monitoring and collecting data and gathering information for audit purposes on the unit.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, University of Palermo, Palermo, Italy.
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Binhas M, Krakowski I, Marty J. Douleurs cancéreuses par excès de nociception chez l'adulte: mise au point sur les recommandations concernant les traitements antalgiques médicamenteux. ACTA ACUST UNITED AC 2007; 26:502-15. [DOI: 10.1016/j.annfar.2007.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 03/07/2007] [Indexed: 12/11/2022]
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Recommandations pour l’indication et l’utilisation de la PCA à l’hôpital et à domicile pour l’administration de morphine chez le patient atteint de cancer et douloureux, en soins palliatifs – mars 2006. MÉDECINE PALLIATIVE : SOINS DE SUPPORT - ACCOMPAGNEMENT - ÉTHIQUE 2007. [DOI: 10.1016/s1636-6522(07)89737-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mercadante S. Opioid titration in cancer pain: a critical review. Eur J Pain 2007; 11:823-30. [PMID: 17331764 DOI: 10.1016/j.ejpain.2007.01.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2006] [Revised: 12/22/2006] [Accepted: 01/15/2007] [Indexed: 11/19/2022]
Abstract
Initiation of therapy with strong opioids is a challenging phase to obtain the maximum benefit and to gain the patient's compliance. The approach could be different, depending on the clinical situation and type of opioid regimen. Substantially, the need to titrate the dose of strong opioids emerges in different conditions: (a) in opioid-naive patients who require an opioid treatment; (b) in patients no longer responsive to weaker drugs requiring strong opioids; (c) in patients already receiving strong opioids requiring higher doses because of an increase in pain intensity or a new acute pain problem; (d) in patients who are severely suffering and need an intensive as well as rapid intervention, due to previous persistent undertreatment. Whilst there is a vast literature confirming the effectiveness of most opioid drugs for the treatment of chronic pain, there is a lack of information regarding opioid titration. This review assesses the principal titration methods and outcomes regarding the different opioid drugs and their modalities of administration, in different clinical contexts.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
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44
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Mercadante S. Scoring the effect of radiotherapy for painful bone metastases. Support Care Cancer 2006; 14:967-9. [PMID: 16572316 DOI: 10.1007/s00520-006-0036-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Accepted: 02/02/2006] [Indexed: 10/24/2022]
Abstract
RATIONALE The evaluation of the analgesic effects of radiotherapy in painful bone metastases is a matter of controversies due to a lack of appropriate tools to define the outcome. An integration of competences in monitoring the pain response and modifying the opioid treatment according to changes of the clinical condition is mandatory. PROPOSED METHOD A meaningful score, used in previous works to monitor the global response to an analgesic intervention in advanced cancer patients, is proposed. A case report, in which opioids are first titrated and then tapered, is described as an example of application of this method.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia & Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Via San Lorenzo, Palermo, Italy.
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Niscola P, Scaramucci L, Romani C, Giovannini M, Maurillo L, del Poeta G, Cartoni C, Arcuri E, Amadori S, De Fabritiis P. Opioids in pain management of blood-related malignancies. Ann Hematol 2006; 85:489-501. [PMID: 16572325 DOI: 10.1007/s00277-005-0062-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2005] [Accepted: 12/01/2005] [Indexed: 10/24/2022]
Abstract
Opioids are basic analgesics used in the treatment of moderate to severe pain in patients affected by blood-related malignancies. They should be sequentially administered according to the World Health Organisation scale for cancer pain. Initial treatment and titration with opioids should be based on immediate-release preparations, to be administered at appropriate intervals in order to relieve pain and to satisfy the individual opioid requirement. Once a relatively good pain control has been achieved, a slow release formulation at equivalent doses can be given. Most patients can be adequately managed using oral formulation opioids. However, a small group, such as those presenting severe mucositis or requiring a rapid pain relief, should be managed by intravenous continuous infusion and/or by a patient-controlled analgesia system; while for patients in the community, there are distinct advantages to using the subcutaneous route. Other available routes of administration for opioids, can be used in selected circumstances, including rectal, transdermal, epidural, intrathecal and intramuscular. The invasive neuraxial route has a very limited role in patients with haematological malignancies, given the high risk of infection and bleeding. Through a close observation and a careful management, opioid-related side effects can be effectively prevented and treated. This article reviews the principles of opioid therapy and how opioids can be adapted for patients with pain due to haematological malignancies.
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Affiliation(s)
- Pasquale Niscola
- Hematology Division, Sant'Eugenio Hospital, Tor Vergata University, Via dell'Umanesimo 10, 00144, Rome, Italy.
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Elsner F, Radbruch L, Loick G, Gaertner J, Sabatowski R. Intravenous versus Subcutaneous Morphine Titration in Patients with Persisting Exacerbation of Cancer Pain. J Palliat Med 2005; 8:743-50. [PMID: 16128648 DOI: 10.1089/jpm.2005.8.743] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with cancer pain with initially adequate analgesia under oral sustained-release opioid medication may suffer from persisting pain exacerbations. Sometimes even fast help is needed and then optimally performed by intravenous application (IVA) of immediate-release (IR) opioids. This IVA, however, may only be performed by physicians in Germany. OBJECTIVE We wanted to find out if subcutaneous application of IR-opioids might be an adequate alternative to IVA in persisting pain exacerbations of patients with cancer pain because this could be performed by the nursing staff in Germany as well. DESIGN An open randomized controlled trial was used to compare intravenous versus subcutaneous morphine titration in persisting pain exacerbations in patients with cancer pain. SETTING/SUBJECTS Thirty-nine patients with cancer (21 intravenously, 18 subcutaneously) of the pain management department of the university hospital of Cologne, Germany were included into the study. MEASUREMENTS Calculated from preexisting analgesic medication boli of morphine were given every 5 minutes (intravenously) or 30 minutes (subcutaneously) up to adequate analgesia or intolerable side effects. Pain intensity, nausea, sedation, and some vital parameters were documented before the start, after each application and at the end of titration. RESULTS Thirty-five patients were pretreated with oral opioids, 4 patients with nonopioid analgesics. Six patients stopped titration because of intolerable side effects (sedation, vomiting). Thirty patients (77%) reported at least sufficient pain reduction, 3 patients were free of pain (intravenously). Mean pain intensity decreased on a visual analogue scale (VAS, 0-100) from 83 to 32 (intravenously) and from 68 to 42 (subcutaneously). Morphine doses ranged from 4 mg to 32 mg (intravenously; mean, 18.5 +/- 9.2 mg) and from 10 mg to 200 mg (subcutaneously mean, 57.9 +/- 59.6 mg). Mean time up to adequate analgesia was 53 (intravenously) 77 min (subcutaneously), respectively. There was no change in vital parameters but an increase of sedation in both groups. The adaptation of the continuous analgesic medication resulted in a stable and lasting pain relief after 4 days in both groups. CONCLUSIONS Intravenous and subcutaneous-morphine titration are adequate to antagonize persisting pain exacerbations in cancer pain patients quickly and to adapt the continuous opioid analgesic medication.
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Affiliation(s)
- F Elsner
- Department of Palliative Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany.
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Mercadante S, Villari P, Ferrera P, Casuccio A. Optimization of opioid therapy for preventing incident pain associated with bone metastases. J Pain Symptom Manage 2004; 28:505-10. [PMID: 15504626 DOI: 10.1016/j.jpainsymman.2004.02.024] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2004] [Indexed: 11/29/2022]
Abstract
Breakthrough pain is a transitory flare of pain superimposed on an otherwise stable pain pattern in patients treated with opioids. One form of breakthrough pain is incident pain, which is due to movement and is commonly associated with bone metastases. The development of this pain is rapid and no medication, administered "as needed," has such a rapid onset that it parallels this temporal pattern of pain. This study used a construct based on the prevention of this event, and implemented a new experimental paradigm. Specifically, the study determined whether increasing the opioid doses above those sufficient to control pain at rest would reduce the occurrence of these pains. Twenty-five consecutive patients with movement-related episodic pain associated with bone metastases, and no evident fractures, were selected for the study. They received a rapid intravenous titration of the opioid dose to obtain pain relief at rest. Then, opioid doses were increased to challenge the therapeutic window. The dose ceiling was determined by the development of limiting adverse effects, rather than optimal pain control at rest. Opioid dose increases were then stopped, or doses were even reduced, according to patients' satisfaction or development of adverse effects with moderate-severe intensity. Basal pain intensity and pain induced by movement were measured using a numerical scale from 0-10. Opioid-related symptoms were assessed using a scale from 0 to 3 (absent, slight, moderate, severe), and global daily doses of oral morphine and other symptomatic drugs were also recorded at daily intervals, and at time of discharge, when the best balance was presumed to be reached. Basal pain control was achieved after rapid intravenous titration. The day after, pain induced by movement significantly improved using mean doses of oral morphine equivalents of 102 mg. In the following days, the subsequent increase in opioid doses prescribed despite optimal basal pain control allowed an acceptable level of incident pain intensity until patients' discharge. A minority of patients developed adverse effects with an intensity of 2-3 on the scale, requiring symptomatic treatment or decreases in opioid doses. Data from this study suggest that the intensity of incident pain may be reduced by increasing the opioid dose above that effective for controlling pain at rest. This approach is based on experimental bone models showing a hypersensitivity to some innocuous stimuli, such as movement, requiring pre-emptive higher doses of basal opioid medication to reduce the increased pain input.
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Aubrun F, Valade N, Riou B. La titration intraveineuse de morphine. ACTA ACUST UNITED AC 2004; 23:973-85. [PMID: 15501627 DOI: 10.1016/j.annfar.2004.08.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2003] [Accepted: 08/06/2004] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe principles of intravenous (i.v.) morphine titration. To analyse current knowledge based on the experimental and clinical studies. To describe clinical implications in the operating room, postanaesthesia care unit (PACU), prehospital care, emergency and intensive care units (ICU), and cancerology. To provide recommendations for clinical practice. DATA SOURCES Search in the Medline database without limitation, using the following keywords: morphine titration. STUDY SELECTION All types of articles were selected including prospective randomised (or not randomised) studies in adults and children, practice guidelines, reviews, editorials and case reports. DATA SYNTHESIS Intravenous (i.v.) morphine titration is a pharmacological method which involves morphine boluses administration until pain relief, allowing a limitation in morphine side effects which are mainly dose dependent. I.v. morphine titration is widely used in prehospital care, emergency unit, PACU, ICU, and cancerology, in young and elderly patients. In the PACU, when the VAS (visual analogue scale) increases to more than 30 mm, i.v. morphine titration every five minutes with an unlimited number of 2 or 3 mg boluses provides an efficient analgesic regimen in adults. Titration is performed until pain relief (VAS < or =30), sedation that is the most frequent side effect during i.v. morphine titration (Ramsay score >1), severe side effects (like respiratory depression). CONCLUSION Because of important pharmacological variability in morphine need, iv morphine titration is a simple method which allows a rapid and efficient pain relief notably in the postoperative care.
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Affiliation(s)
- F Aubrun
- Département d'anesthésie-réanimation chirurgicale, groupe hospitalier Pitié-Salpétrière, assistance publique-hôpitaux de Paris, université Pierre-et-Marie-Curie, 47-83, boulevard de l'Hôpital, 75651 Paris 13, France.
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Mercadante S, Villari P, Ferrera P, Arcuri E. Prolonged uncontrolled pain, psychological distress, and opioid escalation. J Pain Symptom Manage 2004; 28:1-3. [PMID: 15223077 DOI: 10.1016/j.jpainsymman.2004.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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50
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Davis MP, Weissman DE, Arnold RM. Opioid Dose Titration for Severe Cancer Pain: A Systematic Evidence-Based Review. J Palliat Med 2004; 7:462-8. [PMID: 15265356 DOI: 10.1089/1096621041349581] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Dosing strategies to achieve rapid analgesia in patients with severe or crescendo cancer pain are important. A systematic review of research trials for treatment of severe or crescendo cancer pain was conducted; nine studies were identified. Eight trials were prospective; two were randomized between different dosing strategies. Dosing frequency predicted onset to analgesia regardless of baseline opioid dose. None of the trials were associated with evidence of respiratory depression. The studies all suffered significant methodological problems limiting broad conclusions. Until better data exist, opioid dose titration for severe/crescendo pain will be guided by expert opinion and experience.
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Affiliation(s)
- Mellar P Davis
- The Harry R. Horvitz Center for Palliative Medicine, Cleveland, Ohio, USA.
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