A comparison of the analgesic effects of methotrimeprazine and morphine in patients with cancer

Methotrimeprazine for the management of End-Of-Life Symptoms in Infants and Children

Objective: This retrospective chart review assessed the efficacy, dose, and safety of methotrimeprazine in palliating end-of-life symptoms in children and infants. Methods: A retrospective chart review was conducted of 18 hospitalized pediatric patients who were treated with methotrimeprazine in their last two weeks of life. Data collected included age, diagnosis, symptoms, methotrimeprazine dose, route, efficacy, and any documented adverse effects. Results: Patients’ ages ranged from 16 days to 17 years. Underlying conditions included malignancies, trauma, and various neurodegenerative and congenital diseases. All patients (n=18) were treated for symptoms of agitation, delirium, or restlessness. Most patients also experienced respiratory secretions/congestion (n=15), pain (n=13), and/ or dyspnea (n=9). Less common symptoms included nausea/emesis (n=5) and spasticity (n=1). Methotrimeprazine dosages ranged from 0.02 mg/kg/dose to 0.5 mg/kg/dose. Routes of administration included intravenous (n=13), oral/gastrostomy tube (n=6), or subcutaneous (n=4). Sedation (n=6) was the only documented adverse effect, although when agitation was present, this was potentially an intended and perceived-to-be-beneficial effect. Conclusion: Methotrimeprazine, an old drug with diverse receptor activity and multiple routes of administration, appears to be an effective tool in treating complicated end-of-life symptoms in children and infants. This study provides a foundation for analysis with prospective and comparative trials, which may further quantify its benefit.

Evidence for the use of Levomepromazine for symptom control in the palliative care setting: a systematic review

BACKGROUND

Levomepromazine is an antipsychotic drug that is used clinically for a variety of distressing symptoms in palliative and end-of-life care. We undertook a systematic review based on the question "What is the published evidence for the use of levomepromazine in palliative symptom control?".

METHODS

To determine the level of evidence for the use of levomepromazine in palliative symptom control, and to discover gaps in evidence, relevant studies were identified using a detailed, multi-step search strategy. Emerging data was then scrutinized using appropriate assessment tools, and the strength of evidence systematically graded in accordance with the Oxford Centre for Evidence-Based Medicine's 'levels of evidence' tool. The electronic databases Medline, Embase, Cochrane, PsychInfo and Ovid Nursing, together with hand-searching and cross-referencing provided the full research platform on which the review is based.

RESULTS

33 articles including 9 systematic reviews met the inclusion criteria: 15 on palliative sedation, 8 regarding nausea and three on delirium and restlessness, one on pain and six with other foci. The studies varied greatly in both design and sample size. Levels of evidence ranged from level 2b to level 5, with the majority being level 3 (non-randomized, non-consecutive or cohort studies n = 22), with the quality of reporting for the included studies being only low to medium.

CONCLUSION

Levomepromazine is widely used in palliative care as antipsychotic, anxiolytic, antiemetic and sedative drug. However, the supporting evidence is limited to open series and case reports. Thus prospective randomized trials are needed to support evidence-based guidelines.

Review article: palliative care in gynecologic oncology

Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.

Decreased Pain and Improved Quality of Life in Fibromyalgia Patients Treated with Olanzapine, an Atypical Neuroleptic

Fibromyalgia is a significant clinical problem associated with generalized pain and significant interference with daily activities. Although a variety of treatment modalities have been utilized, clinicians have struggled to find an effective means of treatment. Therefore, this study assessed the efficacy of the atypical neuroleptic olanzapine for the treatment of fibromyalgia symptoms. To examine the efficacy of olanzapine for the treatment of fibromyalgia symptoms, the charts of 51 patients treated with olanzapine were evaluated for improvements in pain and daily life functioning. At the time of initial assessment, patients had been diagnosed with a variety of medical and psychiatric disorders and a history of neuroleptic treatment. Pain was widespread and characteristic of pain associated with fibromyalgia. Pretreatment ratings on pain and the interference scales averaged 6.54-8.69 on a 0-10 scale. Post-treatment ratings on the same scales revealed significant improvement on virtually all scales. The benefits of olanzapine to improve fibromyalgia symptoms must, however, be carefully considered because there were a variety of side effects (i.e., weight gain, somnolence/sedation) that were of sufficient strength to cause a number of patients to discontinue treatment. In general, the data provide strong support that olanzapine can, in certain patients, improve symptoms associated with fibromyalgia in patients who have had limited success with other treatment modalities.

Do The Second-Generation “Atypical Neuroleptics” Have Analgesic Properties? A Structured Evidence-Based Review: Table 1

STUDY DESIGN

This is a structured, evidence-based review of all available studies on the potential effectiveness of the atypical neuroleptics for the treatment of pain (analgesia). To determine what evidence, if any, exists for, or against, the effectiveness of the atypical neuroleptics for analgesia.

SUMMARY OF BACKGROUND DATA

There has been significant controversy over whether the conventional neuroleptics (non-atypicals) have analgesic properties. A recent review (Patt et al. 1994) did conclude that the evidence for effectiveness was sparse, except for methotrimeprazine. However, that review did not include a new class of neuroleptics: the atypicals such as olazapine, risperidone, quetiapine, etc.

METHODS

A computer and manual search for studies relating to the atypicals and their analgesic effectiveness produced 10 studies/reports. These were reviewed in detail, and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized by the type of study it represented according to the guidelines developed by the Agency for Health Care Policy and Research (AHCPR). The strength and consistency of the evidence represented by the 10 studies were then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results.

RESULTS OF DATA SYNTHESIS

Of the 10 studies/reports, four were characterized by AHCPR guidelines as Type II (experimental), two were Type III (quasiexperimental), two were Type IV (nonexperimental), and two were Type V (case reports). Of these studies/reports, 90% indicated that the atypicals did have an analgesic effect. The overall strength and consistency of this evidence using the AHCPR guidelines was, therefore, categorized as B (generally consistent from Type II, Type III, and Type IV studies).

CONCLUSIONS

Based on the above results, it was concluded that the reviewed data were generally consistent, suggesting that some of the atypicals may have an analgesic effect. There were, however, few double-blind, placebo-controlled studies, and many of the reports/studies had less than 50 patients. As such, this question requires further research.

Management of insomnia in patients with chronic pain conditions

The management of insomnia in patients experiencing chronic pain requires careful evaluation, good diagnostic skills, familiarity with cognitive-behavioural interventions and a sound knowledge of pharmacological treatments. Sleep disorders are characterised by a circular interrelationship with chronic pain such that pain leads to sleep disorders and sleep disorders increase the perception of pain. Sleep disorders in individuals with chronic pain remain under-reported, under-diagnosed and under-treated, which may lead--together with the individual's emotional, cognitive and behavioural maladaptive responses--to the frequent development of chronic sleep disorders. The moderately positive relationship between pain severity and sleep complaints, and the specificity of pain-related arousal and mediating variables such as depression, illustrate that insomnia in relation to chronic pain is multifaceted and poorly understood. This may explain the limited success of the available treatments. This article discusses the evaluation of patients with chronic pain and insomnia and the available pharmacological and nonpharmacological interventions to manage the sleep disorder. Non-pharmacological interventions should not be considered as single interventions, but in association with one another. Some non-pharmacological interventions especially the cognitive and behavioural approaches, can be easily implemented in general practice (e.g. stimulus control, sleep restriction, imagery training and progressive muscle relaxation). Hypnotics are routinely prescribed in the medically ill, regardless of their adverse effects; however, their long-term efficacy is not supported by robust evidence. Antidepressants provide an interesting alternative to hypnotics, since they can improve pain perception as well as sleep disorders in selected patients. Sedative antipsychotics can be considered for sleep disturbances in those patients exhibiting psychotic features, or for those with contraindications to benzodiazepines. Low doses of sedative antipsychotics may improve chronic insomnia in the elderly. However, no intervention is likely to be effective unless a good physician-patient relationship is developed.

Palliative care and the child with cancer

There is a growing awareness and a WHO directive that the palliative care paradigm should be incorporated into the care of all children with cancer, irrespective of geographic location. The barriers to pediatric palliative care identified by pediatric oncologists [3] are lack of formal courses in pediatric palliative care, a high reliance on trial-and-error learning, lack of strong role models, and lack of access to a pain and palliative care service. These barriers must be overcome.

Olanzapine for the treatment of fibromyalgia symptoms

Fibromyalgia is a chronic condition that is diagnosed primarily by the presence of generalized pain along with tenderness on palpation of certain body regions. Unfortunately, the pharmacological treatment of fibromyalgia remains problematic. Two patients are described who highlight the use of the atypical neuroleptic olanzapine for the control of symptoms related to fibromyalgia. Prior to the use of olanzapine, both patients had received a multitude of treatments, none of which greatly improved their ability to function in daily activities. With olanzapine, both patients reported a significant decrease in pain and marked improvement in daily functioning. In one case, the pain returned during a period of time when olanzapine was discontinued, an effect that was reversed when olanzapine was reintroduced. The paucity of serious side effects (i.e., extrapyramidal signs) with the atypical neuroleptic olanzapine strongly favors further exploration and use of this drug for the treatment of fibromyalgia symptoms.

Potentiation of opioid analgesia by psychostimulant drugs: a review

Recent research has investigated drug combinations that enhance the analgesic effectiveness of their component substances. Many studies have examined the combination of opioids and psychostimulant drugs, such as amphetamine and methylphenidate. Despite the positive results reported in the literature, this combination is rarely used in clinical practice. The purpose of this paper is to review the literature on the opioid-amphetamine combination. Experiments with animal and human subjects provide convincing evidence that d-amphetamine or methylphenidate potentiate the analgesic effects of morphine. Psychostimulant drugs have been shown in animal studies to possess intrinsic analgesic properties and to have the ability to enhance the analgesic properties of opioids when both types of drugs are given in combination. Studies with human subjects have confirmed the enhancement of opioid analgesia by amphetamines and, in addition, have demonstrated that psychostimulant drugs produce a decrease in somnolence and an increase in general cognitive abilities. The greater cognitive alertness, moreover, allows the use of larger opioid doses, which can produce a substantial increase in analgesia. These results indicate another possible method to enhance the quality of life in patients with difficult pain problems. Although the enhanced cognitive effects are well established, the effects on pain need further study to determine the mechanisms of action and the drug combinations and administration patterns that would maximize their effects.

Psychotropic adjuvant analgesics for pain in cancer and AIDS

The 'WHO Analgesic Ladder' is a well validated approach for the selection of appropriate analgesic therapy for cancer pain as well as pain in AIDS. The mainstay of analgesic intervention for cancer and AIDS pain of moderate to severe intensity continues to be the appropriate use of opioid analgesics. There is, however, a growing appreciation for the role of adjuvant analgesics, such as antidepressants and other psychotropic medications, at each step of the WHO Analgesic Ladder, particularly in the treatment of neuropathic pain. Knowledge of the indications and usefulness of psychotropic analgesic drugs in cancer and AIDS pain populations will be most important to clinicians practicing in psycho-oncology/AIDS settings, particularly since these drugs are useful not only in the treatment of psychiatric complications of cancer and AIDS, but also as adjuvant analgesic agents in the management of pain. This paper reviews the literature on the use of antidepressants, psychostimulants, neuroleptics, anticonvulsants and other psychotropic analgesics in the management of cancer and AIDS pain. Mechanisms of analgesia, drug selection, and recommendations for clinical usage are discussed. The appropriate and timely use of psychotropic adjuvant analgesic drugs represents an opportunity for active psychiatric contribution to the multidisciplinary management of cancer and AIDS pain.

Adjuvant analgesic agents

Adjuvant analgesics are usually considered when the patient with cancer pain fails to attain a satisfactory balance between analgesia and side effects during opioid therapy, or experiences a comorbid symptom or disorder that may be amenable to one of the adjuvant drugs. When pain is the primary indication, the use of adjuvant analgesics is one strategy that must be evaluated in comparison with other potentially analgesic approaches. The potential costs, inconvenience, and risks associated with polypharmacy must be balanced by demonstrable benefits. To offer the most informed recommendation, the clinician must have a strong working knowledge of the many drugs currently used as adjuvant analgesics and a detailed assessment of the patient and pain syndrome.

Identifying patients at risk for, and treatment of major psychiatric complications of cancer

A critically important aspect of supportive care in cancer is the prompt recognition and effective treatment of psychiatric complications. Psychiatric disorders such as depression, anxiety and delirium occur in a significant percentage of cancer patients, particularly as disease advances and as cancer treatments become more aggressive. This paper reviews factors that can be utilized to identify patients who are at increased risk for developing psychiatric complications, such as those with advanced disease, certain cancer treatments, uncontrolled physical symptoms, functional limitations, lack of social support, and past history of psychiatric disorder. Methods of diagnostic assessment and strategies for managing depression, anxiety, delirium and suicidal ideation are also reviewed.

The neuroleptics as adjuvant analgesics

The role of neuroleptic drugs as adjuvant analgesics has been a subject of longstanding controversy. Despite frequent claims of efficacy, evidence from controlled trials supports neither claims of intrinsic analgesic properties nor the routine use of the neuroleptics as a means to reliably induce clinically useful analgesia. Methotrimeprazine is unique in that there is evidence for reliable dose-related analgesia that is comparable to opioid-mediated analgesia, although routine use is not recommended. Despite probable interaction with opioid receptors, there is insufficient evidence to support a role for the butyrophenone category of neuroleptics as adjuvant analgesics. Limited trials of the neuroleptics may be considered for pain that has been unresponsive to more conventional pharmacologic approaches, especially when associated with headache, nerve injury, or psychological distress. The neuroleptics have an important role in the symptomatic management of agitation, delirium, and nausea, particularly in patients with cancer.

Levomepromazine receptor binding profile in human brain--implications for treatment-resistant schizophrenia

The receptor binding profile of levomepromazine (LMP) in human brain was compared with that of clozapine (CLOZ) and chlorpromazine (CPZ). LMP showed significantly greater binding affinity for both alpha-1 and serotonin-2 binding sites than either CLOZ or CPZ, and significantly greater binding to alpha-2 sites than CPZ. A potent pharmacological effect at these receptor sites may explain the beneficial effect of LMP on psychotic symptoms and akathisia in treatment-resistant schizophrenia recently described in 2 open studies. LMP requires further appraisal as a potentially useful neuroleptic in the management of treatment-resistant schizophrenia.

Methotrimeprazine versus meperidine and dimenhydrinate in the treatment of severe migraine: a randomized, controlled trial

STUDY OBJECTIVE

To compare the effectiveness of IM administration of methotrimeprazine, a non-narcotic, nonaddicting phenothiazine derivative, with that of a combination of meperidine and dimenhydrinate in the treatment of severe migraine.

DESIGN

Double-blind, randomized, controlled trial.

SETTING

University hospital emergency department.

PARTICIPANTS

Consecutive adult patients with migraine who met eligibility criteria.

INTERVENTIONS

Random allocation to receive IM injections of either 37.5 mg methotrimeprazine (Levoprome, Nozinan) or 75 mg meperidine (Demerol) combined with 50 mg dimenhydrinate (Dramamine, Gravol).

MEASUREMENTS AND MAIN RESULTS

The 37 patients in each group who completed the study were similar in all demographic and clinical characteristics. There were no statistical differences in pain intensity one hour after treatment, change in pain intensity, or pain relief as measured on a visual-analog scale; need for additional analgesia; persistence of nausea or vomiting; adverse effects; or follow-up status, except for prolonged drowsiness, in the group receiving methotrimeprazine.

CONCLUSION

Methotrimeprazine is comparable to meperidine with dimenhydrinate for treating severe migraine and may be considered an effective, nonaddicting, IM alternative to narcotics for the management of this problem.

Subcutaneous infusions for control of cancer symptoms

Continuous subcutaneous infusions offer a safe, simple, effective alternative to intravenous or intramuscular injections when oral medications cannot be used. They are extremely useful for cancer patients suffering from pain, vomiting, seizures, and other symptoms. Hydromorphone or morphine may be combined with metoclopramide, methotrimeprazine, or haloperidol (in D5W only), in the same pump to control both pain and nausea. Seizures can be controlled by subcutaneous infusion of phenobarbital or midazolam. If proper doses are prescribed and skin irritation is watched for, they can be used safely in the patient's home.

Psychiatric management of cancer pain

Appropriate management of cancer pain is essential and requires a multidisciplinary approach that includes a major role for a psychologist and/or psychiatrist. An increased incidence of psychiatric disturbance, in particular, anxiety and depression, is found in patients with pain. Psychiatric symptoms in patients with cancer pain must be initially viewed as a consequence of uncontrolled pain. Personality factors may be quite distorted by the presence of pain, and its relief often results in the disappearance of a perceived psychiatric disorder. Reassessment after pain control is imperative. Optimal treatment of cancer pain includes pharmacologic, psychologic, behavioral, anesthetic, stimulatory, and rehabilitative approaches, often in combination. Cognitive and behavioral interventions, such as relaxation, imagery, hypnosis, distraction, and biofeedback, are effective as part of a comprehensive multimodal approach and must never be used as a substitute for appropriate analgesic management of cancer pain. Psychotropic drugs, particularly the tricyclic antidepressants, are useful as adjuvant analgesic agents in the pharmacologic management of cancer pain.

Muscarinic cholinergic and histamine H1 receptor binding of phenothiazine drug metabolites

In vitro binding affinities of chlorpromazine, fluphenazine, levomepromazine, perphenazine and some of their metabolites for dopamine D2 receptors, alpha 1- and alpha 2 adrenoceptors in rat brain were previously reported from our laboratories. The present study reports the in vitro binding affinities of the same compounds for muscarinic cholinergic receptors and for histamine H1 receptors in rat brain, using 3H-quinuclidinyl benzilate and 3H-mepyramine as radioligands. Chlorpromazine, levomepromazine, and their metabolites had 5-30 times higher binding affinities for muscarinic cholinergic receptors than fluphenazine, perphenazine and their metabolites. Levomepromazine was the most potent and fluphenazine the least potent of the four drugs in histamine H1 receptor binding. 7-Hydroxy levomepromazine, 3-hydroxy levomepromazine and 7-hydroxy fluphenazine had only 10% of the potency of the parent drug in histamine H1 receptor binding, while the 7-hydroxy-metabolites of chlorpromazine and perphenazine had about 75% of the potency of the parent drug in this binding system. Their histamine H1 receptor binding affinities indicate that metabolites may contribute to the sedative effects of chlorpromazine and levomepromazine.

Pain relief by antidepressants: possible modes of action

There is evidence that both tricyclic antidepressants and monoamine oxidase inhibitors can relieve chronic pain. There are a number of possible mechanisms for this phenomenon, recent studies suggest that this may be due to an analgesic rather than antidepressant effect.

The treatment of cancer pain

Pain is one of the most feared consequences of cancer. Control of pain from cancer should be possible with the approaches discussed above. Changing attitudes toward the effective use of narcotic analgesics, the development of novel routes and methods of administration, and a clinical approach based on scientific principles and humane care offer the promise of improved management of pain in patients with cancer.

Combination analgesics

Six rationales for using combination analgesics are identified, but most combinations are formulated with two rationales in mind: enhancement of analgesia and reduction of adverse effects by combining two analgesics with different mechanisms of action. Acetaminophen and aspirin are the mainstays of oral analgesic combinations. There is substantial evidence that combining an optimal dose of acetaminophen or aspirin with an oral opioid such as codeine, hydrocodone, or oxycodone produces an additive analgesic effect greater than that obtained by doubling the dose of either constituent administered alone. There is also some evidence that the adverse effects produced by such combinations are less than would be produced by an equi-analgesic dose of a single constituent. The physician need not be confined to existing fixed-ratio combinations; he or she may extemporize to the patient's advantage by co-administering acetaminophen, aspirin, or other nonsteroidal anti-inflammatory drugs with available oral opioids and, in select situations, co-administering oral or injectable analgesics with psychoactive drugs.

Avoiding psychic adverse effects during induction of neurolept anaesthesia with levomepromazine. A double-blind study of levomepromazine and droperidol

Levomepromazine 0.1 mg/kg or droperidol 0.15 mg/kg for induction of neurolept anaesthesia were compared in a double-blind prospective study of 60 patients undergoing upper abdominal surgery. On the morning after surgery, eight of 30 patients (26.7%) who received droperidol remembered having had unpleasant anxiety, or nightmarish or panicky experiences during induction of anaesthesia, whereas only one of 30 patients (3.3%) receiving levomepromazine experienced such unpleasant adverse effects (P less than 0.01). During anaesthesia, the patients induced with levomepromazine needed somewhat less fentanyl, had somewhat less pain intensity, during the first 3 h after surgery, and they required the first postoperative dose of morphine 1.5 h later than the patients receiving droperidol (P less than 0.02). There was no difference in the number of patients receiving naloxone at the end of anaesthesia in the two groups. However, 21 of 30 patients (70%) in the levomepromazine group and only seven of 30 patients (23.3%) in the droperidol group were given physostigmine for arousal at the end of anaesthesia (P less than 0.01). There was no difference between the two groups in the occurrence of postoperative nausea, restlessness, hallucinations, or sedation in the recovery ward. This study shows that levomepromazine is superior to droperidol for induction of neurolept anaesthesia because it gives less psychic adverse effects, more analgesia, and a deeper sedation, which is easily reversed with physostigmine at the end of anaesthesia.

The visual analog scale in multiple-dose evaluations of analgesics

A double-blind, randomized trial was carried out in patients suffering from pain after removal of an impacted lower wisdom tooth. The analgesic effects of a codeine preparation (Staralgin), a dextropropoxyphene preparation (Doleron novum), and paracetamol were compared in a multiple-dose study of 94 patients. The assessments of pain were made hourly on a visual analog scale, and the evaluation was carried out according to a method which takes into account both duration of effect and number of tablets taken. The most pronounced pain reduction and the highest proportion of pain-free patients were reached with the dextropropoxyphene preparation. The reported side effects were few and equally distributed among the treatment groups. The method of evaluation is discussed, and it was noted that the pain score at tablet intake might be of significant importance in comparison of analgesics.