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Albrecht PJ, Liu Y, Houk G, Ruggiero B, Banov D, Dockum M, Day A, Rice FL, Bassani G. Cutaneous targets for topical pain medications in patients with neuropathic pain: individual differential expression of biomarkers supports the need for personalized medicine. Pain Rep 2024; 9:e1119. [PMID: 38375092 PMCID: PMC10876238 DOI: 10.1097/pr9.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/30/2023] [Accepted: 11/07/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction Numerous potential cutaneous targets exist for treating chronic pain with topically applied active pharmaceutical ingredients. This preliminary human skin tissue investigation was undertaken to characterize several key biomarkers in keratinocytes and provide proof-of-principle data to support clinical development of topical compounded formulations for peripheral neuropathic pain syndromes, such as postherpetic neuralgia (PHN). Objectives The study intended to identify objective biomarkers in PHN skin on a patient-by-patient personalized medicine platform. The totality of biopsy biomarker data can provide a tissue basis for directing individualized compounded topical preparations to optimize treatment efficacy. Methods Referencing 5 of the most common actives used in topical pain relief formulations (ketamine, gabapentin, clonidine, baclofen, and lidocaine), and 3 well-established cutaneous mediators (ie, neuropeptides, cannabinoids, and vanilloids), comprehensive immunolabeling was used to quantify receptor biomarkers in skin biopsy samples taken from ipsilateral (pain) and contralateral (nonpain) dermatomes of patients with PHN. Results Epidermal keratinocyte labeling patterns were significantly different among the cohort for each biomarker, consistent with potential mechanisms of action among keratinocytes. Importantly, the total biomarker panel indicates that the enriched PHN cohort contains distinct subgroups. Conclusion The heterogeneity of the cohort differences may explain studies that have not shown statistical group benefit from topically administered compounded therapies. Rather, the essential need for individual tissue biomarker evaluations is evident, particularly as a means to direct a more accurately targeted topical personalized medicine approach and generate positive clinical results.
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Affiliation(s)
| | - Yi Liu
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - George Houk
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Beth Ruggiero
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Daniel Banov
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - Marilyn Dockum
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - A.J. Day
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - Frank L. Rice
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Gus Bassani
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
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Healy CR, Gethin G, Pandit A, Finn DP. Chronic wound-related pain, wound healing and the therapeutic potential of cannabinoids and endocannabinoid system modulation. Biomed Pharmacother 2023; 168:115714. [PMID: 37865988 DOI: 10.1016/j.biopha.2023.115714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
Chronic wounds represent a significant burden on the individual, and the healthcare system. Individuals with chronic wounds report pain to be the most challenging aspect of living with a chronic wound, with current therapeutic options deemed insufficient. The cutaneous endocannabinoid system is an important regulator of skin homeostasis, with evidence of system dysregulation in several cutaneous disorders. Herein, we describe the cutaneous endocannabinoid system, chronic wound-related pain, and comorbidities, and review preclinical and clinical evidence investigating endocannabinoid system modulation for wound-related pain and wound healing. Based on the current literature, there is some evidence to suggest efficacy of endocannabinoid system modulation for promotion of wound healing, attenuation of cutaneous disorder-related inflammation, and for the management of chronic wound-related pain. However, there is 1) a paucity of preclinical studies using validated models, specific for the study of chronic wound-related pain and 2) a lack of randomised control trials and strong clinical evidence relating to endocannabinoid system modulation for wound-related pain. In conclusion, while there is some limited evidence of benefit of endocannabinoid system modulation in wound healing and wound-related pain management, further research is required to better realise the potential of targeting the endocannabinoid system for these therapeutic applications.
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Affiliation(s)
- Catherine R Healy
- Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway City, Ireland; Galway Neuroscience Centre, University of Galway, Galway City, Ireland; Centre for Pain Research, University of Galway, Galway City, Ireland; CÚRAM, SFI Research Centre for Medical Devices, University of Galway, Galway City, Ireland
| | - Georgina Gethin
- CÚRAM, SFI Research Centre for Medical Devices, University of Galway, Galway City, Ireland; School of Nursing and Midwifery, University of Galway, Galway City, Ireland; Alliance for Research and Innovation in Wounds, University of Galway, Galway City, Ireland
| | - Abhay Pandit
- CÚRAM, SFI Research Centre for Medical Devices, University of Galway, Galway City, Ireland
| | - David P Finn
- Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway City, Ireland; Galway Neuroscience Centre, University of Galway, Galway City, Ireland; Centre for Pain Research, University of Galway, Galway City, Ireland; CÚRAM, SFI Research Centre for Medical Devices, University of Galway, Galway City, Ireland.
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3
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Liu Y, May BH, Hyde AJ, He Y, Guo X, Zhang AL, Lu C, Xue CC, Zhang H. Topical Traditional Chinese Medicines for Cancer Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Integr Cancer Ther 2023; 22:15347354231210870. [PMID: 37962002 PMCID: PMC10647965 DOI: 10.1177/15347354231210870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/22/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Safe and effective management of cancer-related pain is a worldwide challenge. In the search for treatment options, natural products used in Chinese herbal medicines (CHMs) have received attention in clinical studies for their effects on cancer-related pain. The objective of this systematic review is to evaluate the clinical evidence for topically applied CHMs as adjunctive treatments for cancer pain management. METHODS Nine biomedical databases and 4 clinical trial registries were searched for randomized-controlled trials (RCTs) that reported measures of pain and/or quality of life. Risk of bias was assessed using the Cochrane tool. Meta-analysis employed mean difference (MD) with 95% confidence intervals (random effects). RESULTS Twenty (20) RCTs (1636 participants) met the inclusion criteria. Meta-analyses were grouped based on the comparisons and outcome measures. For pain intensity, there was a greater reduction in the topical CHM group versus placebo (MD -0.72 [-1.04, -0.40]), no difference when compared to tramadol (MD -0.15 [-0.38, 0.08]), and a greater reduction when topical CHMs were combined with conventional analgesic medications (MD -0.67 [-0.93, -0.40]). Analgesic onset time was reduced in the CHM group compared to tramadol (MD -26.02 [-27.57, -24.47] minutes), and for CHMs combined with conventional medications (MD -19.17 [-21.83, -16.52] minutes). When CHMs were combined with analgesic medications, improvements were found for duration of analgesia (MD 1.65 [0.78, 2.51] hours), analgesic maintenance dose (MD -31.72 [-50.43, -13.01] milligrams/day), and quality of life. CONCLUSION Addition of topical CHMs to conventional analgesic medications was associated with improved outcomes for pain intensity, some other pain-related outcomes, and measures of quality of life. Limitations included methodological issues in some studies and considerable heterogeneity in some pooled results.
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Affiliation(s)
- Yihong Liu
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Brian H. May
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Anna J. Hyde
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Yihan He
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xinfeng Guo
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Anthony Lin Zhang
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Chuanjian Lu
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Charlie Changli Xue
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Haibo Zhang
- Guangdong Provincial Hospital of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
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Kopsky DJ, van Eijk RPA, Warendorf JK, Keppel Hesselink JM, Notermans NC, Vrancken AFJE. Enriched enrollment randomized double-blind placebo-controlled cross-over trial with phenytoin cream in painful chronic idiopathic axonal polyneuropathy (EPHENE): a study protocol. Trials 2022; 23:888. [PMID: 36273216 PMCID: PMC9587538 DOI: 10.1186/s13063-022-06806-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Patients with chronic idiopathic axonal polyneuropathy (CIAP) can have neuropathic pain that significantly impacts quality of life. Oral neuropathic pain medication often has insufficient pain relief and side effects. Topical phenytoin cream could circumvent these limitations. The primary objectives of this trial are to evaluate (1) efficacy in pain reduction and (2) safety of phenytoin cream in patients with painful CIAP. The main secondary objective is to explore the usefulness of a double-blind placebo-controlled response test (DOBRET) to identify responders to sustained pain relief with phenytoin cream. Methods This 6-week, enriched enrollment randomized double-blind, placebo-controlled triple cross-over trial compares phenytoin 20%, 10% and placebo cream in 48 participants with painful CIAP. Enriched enrollment is based on a positive DOBRET in 48 participants who experience within 30 minutes ≥2 points pain reduction on the 11-point numerical rating scale (NRS) in the phenytoin 10% cream applied area and ≥1 point difference in pain reduction on the NRS between phenytoin 10% and placebo cream applied area, in favour of the former. To explore whether DOBRET has predictive value for sustained pain relief, 24 DOBRET-negative participants will be included. An open-label extension phase is offered with phenytoin 20% cream for up to one year, to study long-term safety. The main inclusion criteria are a diagnosis of CIAP and symmetrical neuropathic pain with a mean weekly pain score of ≥4 and <10 on the NRS. The primary outcome is the mean difference between phenytoin 20% versus placebo cream in 7-day average pain intensity, as measured by the NRS, over week 2 in DOBRET positive participants. Key secondary outcomes include the mean difference in pain intensity between phenytoin 10% and phenytoin 20% cream, and between phenytoin 10% and placebo cream. Furthermore, differences between the 3 interventions will be evaluated on the Neuropathic Pain Symptom Inventory, EuroQol EQ5-5D-5L, and evaluation of adverse events. Discussion This study will provide evidence on the efficacy and safety of phenytoin cream in patients with painful CIAP and will give insight into the usefulness of DOBRET as a way of personalized medicine to identify responders to sustained pain relief with phenytoin cream. Trial registration ClinicalTrials.gov NCT04647877. Registered on 1 December 2020.
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Affiliation(s)
- David J Kopsky
- Institute for Neuropathic Pain, Amsterdam / Soest / Bosch en Duin, The Netherlands. .,Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Ruben P A van Eijk
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Janna K Warendorf
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Nicolette C Notermans
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Albrecht PJ, Houk G, Ruggiero E, Dockum M, Czerwinski M, Betts J, Wymer JP, Argoff CE, Rice FL. Keratinocyte Biomarkers Distinguish Painful Diabetic Peripheral Neuropathy Patients and Correlate With Topical Lidocaine Responsiveness. FRONTIERS IN PAIN RESEARCH 2021; 2:790524. [PMID: 35295428 PMCID: PMC8915676 DOI: 10.3389/fpain.2021.790524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/03/2021] [Indexed: 01/11/2023] Open
Abstract
This study investigated quantifiable measures of cutaneous innervation and algesic keratinocyte biomarkers to determine correlations with clinical measures of patient pain perception, with the intent to better discriminate between diabetic patients with painful diabetic peripheral neuropathy (PDPN) compared to patients with low-pain diabetic peripheral neuropathy (lpDPN) or healthy control subjects. A secondary objective was to determine if topical treatment with a 5% lidocaine patch resulted in correlative changes among the quantifiable biomarkers and clinical measures of pain perception, indicative of potential PDPN pain relief. This open-label proof-of-principle clinical research study consisted of a pre-treatment skin biopsy, a 4-week topical 5% lidocaine patch treatment regimen for all patients and controls, and a post-treatment skin biopsy. Clinical measures of pain and functional interference were used to monitor patient symptoms and response for correlation with quantitative skin biopsy biomarkers of innervation (PGP9.5 and CGRP), and epidermal keratinocyte biomarkers (Nav1.6, Nav1.7, CGRP). Importantly, comparable significant losses of epidermal neural innervation (intraepidermal nerve fibers; IENF) and dermal innervation were observed among PDPN and lpDPN patients compared with control subjects, indicating that innervation loss alone may not be the driver of pain in diabetic neuropathy. In pre-treatment biopsies, keratinocyte Nav1.6, Nav1.7, and CGRP immunolabeling were all significantly increased among PDPN patients compared with control subjects. Importantly, no keratinocyte biomarkers were significantly increased among the lpDPN group compared with control. In post-treatment biopsies, the keratinocyte Nav1.6, Nav1.7, and CGRP immunolabeling intensities were no longer different between control, lpDPN, or PDPN cohorts, indicating that lidocaine treatment modified the PDPN-related keratinocyte increases. Analysis of the PDPN responder population demonstrated that increased pretreatment keratinocyte biomarker immunolabeling for Nav1.6, Nav1.7, and CGRP correlated with positive outcomes to topical lidocaine treatment. Epidermal keratinocytes modulate the signaling of IENF, and several analgesic and algesic signaling systems have been identified. These results further implicate epidermal signaling mechanisms as modulators of neuropathic pain conditions, highlight a novel potential mode of action for topical treatments, and demonstrate the utility of comprehensive skin biopsy evaluation to identify novel biomarkers in clinical pain studies.
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Affiliation(s)
- Phillip J. Albrecht
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
- Division of Health Sciences, University at Albany, Albany, NY, United States
- *Correspondence: Phillip J. Albrecht
| | - George Houk
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | - Elizabeth Ruggiero
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | - Marilyn Dockum
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | | | - Joseph Betts
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | - James P. Wymer
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Charles E. Argoff
- Department of Neurology, Albany Medical Center, Albany, NY, United States
| | - Frank L. Rice
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
- Division of Health Sciences, University at Albany, Albany, NY, United States
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D'Andre S, McAllister S, Nagi J, Giridhar KV, Ruiz-Macias E, Loprinzi C. Topical Cannabinoids for Treating Chemotherapy-Induced Neuropathy: A Case Series. Integr Cancer Ther 2021; 20:15347354211061739. [PMID: 34841942 PMCID: PMC8646190 DOI: 10.1177/15347354211061739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Chemotherapy-induced peripheral neuropathy is a common and often severe side effect from many chemotherapeutic agents, with limited treatment options. There is no literature on the use of topical cannabinoids for chemotherapy-induced neuropathy. CASE PRESENTATIONS The current manuscript presents a case series of patients presenting in oncology clinics at Sutter Health, CA and Mayo Clinic, Rochester, MN from April 2019 to December 2020 with chemotherapy-induced peripheral neuropathy who used topical creams containing the cannabinoids delta-nine-tetrahydrocannabinol (THC) and/or cannabidiol (CBD). CONCLUSIONS This case series suggests that topical cannabinoids may be helpful for patients with chemotherapy-induced peripheral neuropathy. This paper also discusses the potential mechanisms of action by which topical cannabinoids might alleviate established CIPN symptoms. A randomized placebo-controlled trial using a standardized product is planned to study the actual efficacy of such treatment.
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Affiliation(s)
- Stacy D'Andre
- Sutter Institute for Medical Research, Sacramento, CA, USA
| | - Sean McAllister
- Sutter California Pacific Medical Research Institute, San Francisco, CA, USA
| | - Jasdeepa Nagi
- Sutter Institute for Medical Research, Sacramento, CA, USA
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Fulas OA, Laferrière A, Ware DMA, Shir Y, Coderre TJ. The effect of a topical combination of clonidine and pentoxifylline on post-traumatic neuropathic pain patients: study protocol for a randomized, double-blind placebo-controlled trial. Trials 2021; 22:149. [PMID: 33596969 PMCID: PMC7890866 DOI: 10.1186/s13063-021-05088-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 02/01/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND First-line pharmacotherapy for neuropathic pain entails the use of systemic antidepressants and anticonvulsants. These drugs are not optimally effective and poorly tolerated, especially for older patients with comorbid conditions. Given the high number of such patients, there is a need for a greater repertoire of safer and more effective analgesics. Clonidine and pentoxifylline are vasodilator agents that work synergistically to enhance tissue perfusion and oxygenation. The topical administration of these drugs, individually and in combination, has shown anti-nociceptive properties in rodent models of neuropathic pain. A topically-administered combination of clonidine and pentoxifylline also effectively reduced the intensity of both spontaneous and evoked pain in healthy volunteers with experimentally-induced neuropathic pain. The next step in advancing this formulation to clinical use is the undertaking of a phase II clinical study to assess its efficacy and safety in neuropathic pain patients. METHODS/DESIGN This is a study protocol for a randomized, double-blind, placebo-controlled, phase II clinical trial with a cross-over design. It is a single-centered, 5-week study that will enroll a total of 32 patients with post-traumatic peripheral neuropathic pain. Patients will be treated topically with either a combination of clonidine and pentoxifylline or placebo for a period of 2 weeks each, in randomly assigned order across patients, with an intervening washout period of 1 week. The primary outcome measures of the study are the intensity of spontaneous pain recorded daily in a pain diary with a visual analog scale, and the degree of mechanical allodynia evoked by a brush stimulus. The secondary outcome measures of the study include scores of pain relief and change in the area of punctate hyperalgesia. This trial has been prospectively registered with ClinicalTrials.gov on November 1, 2017. ClinicalTrials.gov Identifier: NCT03342950 . DISCUSSION The analgesic use of topical treatment with clonidine and pentoxifylline in combination has not been investigated in post-traumatic neuropathic pain. This study could generate the first evidence for the efficacy and safety of the formulation in alleviating pain in patients with neuropathic pain. Furthermore, this trial will provide objective grounds for the investigation of other agents that enhance tissue oxygenation in the topical treatment of peripheral neuropathic pain. TRIAL REGISTRATION This trial has been registered with ClinicalTrials.gov owned by NIH's US National Library of Medicine. ClinicalTrials.gov NCT03342950 . Registered on November 1, 2017 (trial was prospectively registered). PROTOCOL VERSION AND IDENTIFIERS This is protocol version 5, dated June 2018. McGill University Health Center (MUHC) Reaseach Ethics Board (REB) identification number: TTNP 2018-3906.
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Affiliation(s)
- Oli Abate Fulas
- Department of Anesthesia, McGill University, 3655 Promenade Sir William Osler, Montreal, QC, H3G 1Y6, Canada
| | - André Laferrière
- Department of Anesthesia, McGill University, 3655 Promenade Sir William Osler, Montreal, QC, H3G 1Y6, Canada
| | - D Mark A Ware
- Alan Edwards Pain Management Unit, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Yoram Shir
- Alan Edwards Pain Management Unit, McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Terence J Coderre
- Department of Anesthesia, McGill University, 3655 Promenade Sir William Osler, Montreal, QC, H3G 1Y6, Canada.
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Choi E, Nahm FS, Han WK, Lee PB, Jo J. Topical agents: a thoughtful choice for multimodal analgesia. Korean J Anesthesiol 2020; 73:384-393. [PMID: 32752601 PMCID: PMC7533183 DOI: 10.4097/kja.20357] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 12/11/2022] Open
Abstract
For over a thousand years, various substances have been applied to the skin to treat pain. Some of these substances have active ingredients that we still use today. However, some have been discontinued due to their harmful effect, while others have been long forgotten. Recent concerns regarding the cardiovascular and renal risk from nonsteroidal anti-inflammatory drugs, and issues with opioids, have resulted in increasing demand and attention to non-systemic topical alternatives. There is increasing evidence of the efficacy and safety of topical agents in pain control. Topical analgesics are great alternatives for pain management and are an essential part of multimodal analgesia. This review aims to describe essential aspects of topical drugs that physicians should consider in their practice as part of multimodal analgesia. This review describes the mechanism of popular topical analgesics and also introduces the most recently released and experimental topical medications.
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Affiliation(s)
- Eunjoo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Anesthesiology and Pain Medicine Seoul National University College of Medicine, Seoul, Korea
| | - Woong Ki Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Pyung-Bok Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Anesthesiology and Pain Medicine Seoul National University College of Medicine, Seoul, Korea
| | - Jihun Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Gudin JA, Dietze DT, Hurwitz PL. Improvement of Pain and Function After Use of a Topical Pain Relieving Patch: Results of the RELIEF Study. J Pain Res 2020; 13:1557-1568. [PMID: 32617016 PMCID: PMC7326193 DOI: 10.2147/jpr.s258883] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/19/2020] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Pain is the most common reason for patients to consult primary care providers. Identification of effective treatments with minimal adverse events is critical to safer opioid-sparing and multi-modal approaches to pain treatment. Topical analgesic patches target medication to peripheral sites of pain while potentially avoiding adverse effects associated with systemic medications. Opioids, prescription nonsteroidal anti-inflammatory drugs, and over-the-counter oral medications are associated with systemic toxicities, increasing morbidity and mortality. This study evaluated a topical analgesic pain-relieving patch in reducing pain severity and improving function in patients with mild to moderate arthritic, neurological, or musculoskeletal pain. PATIENTS AND METHODS This Institutional Review Board-approved study evaluated the effectiveness of a topical pain-relieving patch in reducing Brief Pain Inventory (BPI) scores in patients. The treatment group (TG) (n=152) received patches for 14 days. A control group (CG) (n=47) did not receive the patch. After day 14, 34 CG patients crossed over to treatment (CROSSG) with the patch. Surveys were administered to patients at baseline and 14 days to assess changes in pain severity and interference. Changes in oral pain medication use, side effects, and satisfaction use were also assessed. RESULTS Paired data were collected in the CG, TG and CROSSG. At day 14, TG pain severity score and pain interference score decreased (49% and 58.1%, respectively). Pain severity and interference scores decreased less in the CG (12.3% and 14.8%, respectively). In the study, 60.5% of the TG were using concomitant oral pain medications "a lot less", and 90.8% were very/extremely satisfied with the patch. CROSSG patients showed similar reductions in pain severity and interference scores after patch treatment. No side effects of treatment were reported. CONCLUSION Results indicate that this topical analgesic pain-relieving patch can reduce BPI pain severity and interference scores in adult patients with mild to moderate arthritic, neurological, and musculoskeletal pain and should be considered as a treatment option.
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Affiliation(s)
- Jeffrey A Gudin
- Englewood Hospital Medical Center, Englewood, NJ; Rutgers New Jersey Medical School, Department of Anesthesiology, Newark, NJ, USA
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10
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Gudin J, Mavroudi S, Korfiati A, Theofilatos K, Dietze D, Hurwitz P. Reducing Opioid Prescriptions by Identifying Responders on Topical Analgesic Treatment Using an Individualized Medicine and Predictive Analytics Approach. J Pain Res 2020; 13:1255-1266. [PMID: 32547186 PMCID: PMC7266406 DOI: 10.2147/jpr.s246503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose Chronic pain is a life changing condition, and non-opioid treatments have been lately introduced to overcome the addictive nature of opioid therapies and their side effects. In the present study, we explore the potential of machine learning methods to discriminate chronic pain patients into ones who will benefit from such a treatment and ones who will not, aiming to personalize their treatment. Patients and Methods In the current study, data from the OPERA study were used, with 631 chronic pain patients answering the Brief Pain Inventory (BPI) validated questionnaire along with supplemental questions before and after a follow-up period. A novel machine learning approach combining multi-objective optimization and support vector regression was used to build prediction models which can predict, using responses in the baseline, the four different outcomes of the study: total drugs change, total interference change, total severity change, and total complaints change. Data were split to training (504 patients) and testing (127 patients) sets and all results are measured on the independent test set. Results The machine learning models extracted in the present study significantly overcame other state of the art machine learning methods which were deployed for comparative purposes. The experimental results indicated that the machine learning models can predict the outcomes of this study with considerably high accuracy (AUC 73.8–87.2%) and this allowed their incorporation in a decision support system for the selection of the treatment of chronic pain patients. Conclusion Results of this study revealed the potential of machine learning for an individualized medicine application for chronic pain therapies. Topical analgesics treatment were proven to be, in general, beneficial but carefully selecting with the suggested individualized medicine decision support system was able to decrease by approximately 10% the patients which would have been subscribed with topical analgesics without having benefits from it.
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Affiliation(s)
| | - Seferina Mavroudi
- Department of Nursing, School of Health Rehabilitation Sciences, University of Patras, Pátrai, Greece.,InSyBio Ltd, Winchester, UK
| | | | | | - Derek Dietze
- Metrics for Learning LLC, Queen Creek, Arizona, USA
| | - Peter Hurwitz
- Clarity Science LLC, Narragansett, Rhode Island, USA
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11
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Kopsky DJ, Vrancken AFJE, Keppel Hesselink JM, van Eijk RPA, Notermans NC. Usefulness of a Double-Blind Placebo-Controlled Response Test to Demonstrate Rapid Onset Analgesia with Phenytoin 10% Cream in Polyneuropathy. J Pain Res 2020; 13:877-882. [PMID: 32431536 PMCID: PMC7200258 DOI: 10.2147/jpr.s243434] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/17/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose Topical analgesics are an upcoming treatment option for neuropathic pain. In this observational study, we performed a double-blind placebo-controlled response test (DOBRET) in patients with polyneuropathy to determine the personalized analgesic effect of phenytoin 10% cream. Patients and Methods In a double-blind fashion, 12 consecutive adult patients with symmetrical painful polyneuropathy and equal pain intensity of ≥4 on the 11-point numerical rating scale (NRS) applied phenytoin10% cream on one painful area and a placebo cream on the corresponding contralateral area. We defined responders as patients who experienced a pain reduction ≥2 NRS points from baseline and ≥1 NRS point difference in pain reduction in favour of phenytoin 10% cream compared with placebo cream within 30 minutes after application. We also evaluated the percentage of pain reduction and frequency of 30% and 50% pain relief from baseline. Results Six patients (50%) were responders. Compared with placebo cream, pain reduction was higher in phenytoin 10% cream-applied areas with mean difference in pain reduction of 1.3 (95% CI: 1.1 to 1.8; p<0.001) on the NRS and mean percentage difference in pain reduction of 22% (95% CI: 13% to 32%; p =0.03). All responders had at least 30% pain reduction, and 4 out of 6 had at least 50% pain reduction in the phenytoin 10% cream applied area. All non-responders had less than 30% pain reduction. No side effects were reported. Conclusion A DOBRET is easy to perform, quickly identifies an analgesic effect in responders and could be a useful tool to personalize neuropathic pain treatment with topical formulations.
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Affiliation(s)
- David J Kopsky
- Institute for Neuropathic Pain, Amsterdam, the Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Ruben P A van Eijk
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nicolette C Notermans
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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12
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McPherson T, Fontane P, Bilger R. Patient Experiences with Compounded Topical Pain Creams. J Pain Palliat Care Pharmacother 2020; 34:82-89. [DOI: 10.1080/15360288.2020.1733168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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Rudge JE, Raithatha M. Critical illness and multi-organ failure following topical application of skin-lightening preparation. Anaesth Rep 2019; 7:47-49. [PMID: 32051947 DOI: 10.1002/anr3.12014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 11/12/2022] Open
Abstract
Topical application of skin-lightening cream is increasingly undertaken in many non-Caucasian populations for cultural and social reasons. It is a rare cause of poisoning that has potential to lead to significant harm due to skin damage and systemic absorption of cream following application over prolonged periods of time. This case report describes for the development of multi-organ failure in an adult due to salicylate toxicity after whole-body application of a skin-lightening cream for 24 h. It highlights the need for vigilance and awareness of the toxic potential of topical salicylates.
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Affiliation(s)
- J E Rudge
- Department of Anaesthetics Sandwell and West Birmingham Hospitals NHS Trust Birmingham UK
| | - M Raithatha
- Department of Anaesthetics Sandwell and West Birmingham Hospitals NHS Trust Birmingham UK
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14
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Improved Morphine-Loaded Hydrogels for Wound-Related Pain Relief. Pharmaceutics 2019; 11:pharmaceutics11020076. [PMID: 30759886 PMCID: PMC6409998 DOI: 10.3390/pharmaceutics11020076] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/06/2019] [Accepted: 02/10/2019] [Indexed: 12/29/2022] Open
Abstract
The use of morphine applied topically to painful wounds has potential advantages, such as dose reduction, fewer side effects and compound formulations, have been proposed for this purpose. Given the potential high impact of drug product quality on a patient’s health, the aim of the present study was to develop two stable sterile hydrogels containing morphine hydrochloride, intended for topical application on painful wounds. Two carboxymethylcellulose sodium-based hydrogels were prepared containing 0.125% w/w (F1-MH semi-solid formulation) and 1.0% w/w (F2-MH fluid formulation) morphine hydrochloride (MH), respectively. Studies included a risk assessment approach for definition of the quality target product profile (QTPP) and assessment of critical quality attributes (CQA) of the hydrogels to support product quality and safety. Safe, odourless, yellowish, translucent and homogeneous gels were obtained, with suitable microbiological and pharmaceutical characteristics. The active substance concentration was adapted according to the characteristics of the dose-metering device. Release profiles were investigated using Franz diffusion cells, and characterised by different kinetic models. Increasing gel viscosity prolonged drug release, with rates of 17.9 ± 2.2 μg·cm−2·h−1 (F1-MH) and 258.0 ± 30.4 μg·cm−2·h−1 (F2-MH), allowing for the reduction of the number of applications and improving patient compliance. The gels proved to be stable for up to 60 days at room temperature. The semi-solid and fluid MH-containing hydrogel formulations are safe, stable and suitable for use in hospital settings, which is rather important for wound-related pain management in cancer palliative care or burn patients.
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15
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16
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Rawlinson S, McLister A, Kanyong P, Davis J. Rapid determination of salicylic acid at screen printed electrodes. Microchem J 2018. [DOI: 10.1016/j.microc.2017.09.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Gudin JA, Brennan MJ, Harris ED, Hurwitz PL, Dietze DT, Strader JD. Reduction of opioid use and improvement in chronic pain in opioid-experienced patients after topical analgesic treatment: an exploratory analysis. Postgrad Med 2017; 130:42-51. [DOI: 10.1080/00325481.2018.1414551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | | | | | | | - James D Strader
- Safe Harbor Compliance and Clinical Services, LLC, Austin, TX, USA
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18
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Knezevic NN, Tverdohleb T, Nikibin F, Knezevic I, Candido KD. Management of chronic neuropathic pain with single and compounded topical analgesics. Pain Manag 2017; 7:537-558. [PMID: 29125423 DOI: 10.2217/pmt-2017-0020] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The goal of our review was to emphasize important aspects that physicians should take into consideration when prescribing topical analgesics as part of chronic neuropathic pain treatment. We discuss the dermatopharmacokinetics and microstructural components of the skin, differences between topical and transdermal drug delivery, and topical medication effects on peripheral neuropathy and central sensitization. Even though the US FDA approved topical analgesics are 8%-capsaicin and 5%-lidocaine patches for treating postherpetic neuralgia, there are many other studies conducted on the efficacy of topical ketamine cream, clonidine gel, topical gabapentin, topical baclofen and topical phenytoin for peripheral neuropathic pain, either alone or in combination with other formulations. Furthermore, we discuss new compounded topical analgesics that are becoming more popular and that are showing promising results in the management of chronic peripheral neuropathies. However, more studies are needed for elucidation of the role of topical analgesics and their effects, especially when combined with other treatments.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA.,Department of Surgery, University of Illinois, Chicago, IL 60612, USA
| | - Tatiana Tverdohleb
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA
| | - Farid Nikibin
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA
| | - Ivana Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA.,Department of Surgery, University of Illinois, Chicago, IL 60612, USA
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19
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Gudin JA, Brennan MJ, Harris ED, Hurwitz PL, Dietze DT, Strader JD. Changes in pain and concurrent pain medication use following compounded topical analgesic treatment for chronic pain: 3- and 6-month follow-up results from the prospective, observational Optimizing Patient Experience and Response to Topical Analgesics study. J Pain Res 2017; 10:2341-2354. [PMID: 29042810 PMCID: PMC5634368 DOI: 10.2147/jpr.s143513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Opioids and other controlled substances prescribed for chronic pain are associated with abuse, addiction, and death, prompting national initiatives to identify safe and effective pain management strategies including topical analgesics. Methods This prospective, observational study evaluated changes from baseline in overall mean severity and interference scores on the Brief Pain Inventory scale and the use of concurrent pain medications at 3- and 6-month follow-up assessments in chronic pain patients treated with topical analgesics. Changes in pain severity and interference and medication usage were compared between treated patients and unmatched and matched controls. Results The unmatched intervention group (unmatched-IG) included 631 patients who completed baseline and 3-month follow-up surveys (3-month unmatched-IG) and 158 who completed baseline and 6-month follow-up assessments (6-month unmatched-IG). Baseline and 3-month follow-up data were provided by 76 unmatched controls and 76 matched controls (3-month unmatched-CG and matched-CG), and 51 unmatched and 36 matched patients completed baseline and 6-month follow-up surveys (6-month unmatched-CG and matched-CG). Baseline demographic characteristics and mean pain severity and interference scores were similar between groups. There were statistically significant decreases from baseline in mean pain severity and interference scores within the 3- and 6-month unmatched-IG (all P<0.001). Significantly greater decreases in the mean change from baseline in pain severity and interference scores were evident for the 3- and 6-month unmatched-IG versus unmatched-CG (all P<0.001), with similar results when the 3- and 6-month matched-IG and matched-CG were compared. A higher percentage of the 3- and 6-month unmatched-IG and matched-IG de-escalated use of concurrent pain medications (all P<0.001), while significantly higher percentages of the unmatched-CG and matched-CG escalated medication use. Side effects were reported by <1% of the unmatched-IG. Conclusion Topical analgesics appear to be effective and safe for the treatment of chronic pain, with randomized controlled trials needed to confirm these findings.
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Affiliation(s)
- Jeffrey A Gudin
- Pain Medicine and Palliative Care, Englewood Hospital and Medical Center, Englewood, NJ
| | | | | | | | | | - James D Strader
- Safe Harbor Compliance and Clinical Services, LLC, Austin, TX, USA
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20
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Salicylate Poisoning Potential of Topical Pain Relief Agents: From Age Old Remedies to Engineered Smart Patches. MEDICINES 2017; 4:medicines4030048. [PMID: 28930263 PMCID: PMC5622383 DOI: 10.3390/medicines4030048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 01/04/2023]
Abstract
The pain relief capabilities of methyl salicylate are well established and a multitude of over-the-counter products populate pharmacy shelves. Over-application of the topical preparation containing the drug, or its accidental ingestion, invariably result in salicylate poisoning and in severe cases can be fatal. The drug has been a regular feature of the US National Poison Database Survey over the past decade and continues to pose a risk to children and adults alike. The aim of the review has been to cast a spotlight on the drug and assess why its use remains problematic, how technology could offer more efficacious delivery regimes, and minimise the possibility of accidental or intentional misuse.
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21
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Glinn MA, Lickteig AJ, Weber L, Recer S, Salske M, Harvey A, Rappold B, Stensland J, Bell P. Urinary Concentrations of Topically Administered Pain Medications. J Anal Toxicol 2017; 41:127-133. [PMID: 28376226 DOI: 10.1093/jat/bkw110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/21/2016] [Indexed: 11/12/2022] Open
Abstract
A common treatment for chronic pain is prescription of analgesics, but their long-term use entails risk of morbidity, addiction and misuse. One way to reduce the risk of abuse is prescribing of analgesics in a topical form. Physicians are urged to perform urine drug testing to ensure that patients are compliant with their medication regimens. However, there is little data on the efficiency of transdermal delivery for many analgesic drugs, and no data on expected urine drug levels. This study includes data from over 29,000 specimens tested for gabapentin, ketamine, cyclobenzaprine or amitriptyline used orally or topically. Gabapentin and amitriptyline concentrations were more likely to be below the limits of detection (25-40 ng/mL) in the urine of patients using them topically as compared with patients using them orally. Levels in gabapentin-positive topical specimens were much lower than in gabapentin-positive oral specimens (261 ng/mL vs >10,000 ng/mL). In contrast, ketamine and cyclobenzaprine were more readily detectable in the urine of topical users. Ketamine topical specimens were positive 12% more often than oral specimens, and mean topical specimen levels were 68-100% those of oral specimens. Cyclobenzaprine specimens were equally likely to be positive whether the dose was oral or topical, although mean levels after topical dosing were approximately 13-21% those after oral dosing. These findings are consistent with the reported percutaneous absorption efficiencies of gabapentin and ketamine, and are likely to be related to the absorption efficiencies of cyclobenzaprine and amitriptyline.
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Affiliation(s)
- Michele A Glinn
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Andrew J Lickteig
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Luke Weber
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Sherri Recer
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Matthew Salske
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Audrey Harvey
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Brian Rappold
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Julie Stensland
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
| | - Patrick Bell
- Essential Testing LLC, 1616 Eastport Plaza Dr, Collinsville, IL 62234, USA
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22
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Worley SL. New Directions in the Treatment of Chronic Pain: National Pain Strategy Will Guide Prevention, Management, and Research. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2016; 41:107-114. [PMID: 26909001 PMCID: PMC4745638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
More than four years after the release of a landmark report by the Institute of Medicine focused attention on pain in America, there are encouraging signs that the nation may be poised to undergo the "cultural transformation" advocated by the report.
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