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De Rosa F, Giannatiempo B, Charlier B, Coglianese A, Mensitieri F, Gaudino G, Cozzolino A, Filippelli A, Piazza O, Dal Piaz F, Izzo V. Pharmacological Treatments and Therapeutic Drug Monitoring in Patients with Chronic Pain. Pharmaceutics 2023; 15:2088. [PMID: 37631302 PMCID: PMC10457775 DOI: 10.3390/pharmaceutics15082088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/29/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
Pain is an unpleasant sensory and emotional experience that affects every aspect of a patient's life and which may be treated through different pharmacological and non-pharmacological approaches. Analgesics are the drugs most commonly used to treat pain, and in specific situations, the use of opioids may be considered with caution. These drugs, in fact, do not always induce optimal analgesia in patients, and several problems are associated with their use. The purpose of this narrative review is to describe the pharmacological approaches currently used for the management of chronic pain. We review several aspects, from the pain-scale-based methods currently available to assess the type and intensity of pain, to the most frequently administered drugs (non-narcotic analgesics and narcotic analgesics), whose pharmacological characteristics are briefly reported. Overall, we attempt to provide an overview of different pharmacological treatments while also illustrating the relevant guidelines and indications. We then report the strategies that may be used to reduce problems related to opioid use. Specifically, we focus our attention on therapeutic drug monitoring (TDM), a tool that could help clinicians select the most suitable drug and dose to be used for each patient. The actual potential of using TDM to optimize and personalize opioid-based pain treatments is finally discussed based on recent scientific reports.
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Affiliation(s)
- Federica De Rosa
- Department of Medicine, Surgery and Dentistry, Postgraduate School of Clinical Pharmacology and Toxicology, University of Salerno, 84084 Fisciano, Italy; (F.D.R.); (B.G.); (B.C.); (A.C.); (A.F.)
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (A.C.); (O.P.)
| | - Bruno Giannatiempo
- Department of Medicine, Surgery and Dentistry, Postgraduate School of Clinical Pharmacology and Toxicology, University of Salerno, 84084 Fisciano, Italy; (F.D.R.); (B.G.); (B.C.); (A.C.); (A.F.)
| | - Bruno Charlier
- Department of Medicine, Surgery and Dentistry, Postgraduate School of Clinical Pharmacology and Toxicology, University of Salerno, 84084 Fisciano, Italy; (F.D.R.); (B.G.); (B.C.); (A.C.); (A.F.)
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (A.C.); (O.P.)
| | - Albino Coglianese
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (A.C.); (O.P.)
- Department of Medicine, Surgery and Dentistry, Postgraduate School of Clinical Pathology and Clinical Biochemistry, University of Salerno, 84084 Fisciano, Italy
| | - Francesca Mensitieri
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Fisciano, Italy; (F.M.); (G.G.)
| | - Giulia Gaudino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Fisciano, Italy; (F.M.); (G.G.)
| | - Armando Cozzolino
- Department of Medicine, Surgery and Dentistry, Postgraduate School of Clinical Pharmacology and Toxicology, University of Salerno, 84084 Fisciano, Italy; (F.D.R.); (B.G.); (B.C.); (A.C.); (A.F.)
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry, Postgraduate School of Clinical Pharmacology and Toxicology, University of Salerno, 84084 Fisciano, Italy; (F.D.R.); (B.G.); (B.C.); (A.C.); (A.F.)
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (A.C.); (O.P.)
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Fisciano, Italy; (F.M.); (G.G.)
| | - Ornella Piazza
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (A.C.); (O.P.)
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Fisciano, Italy; (F.M.); (G.G.)
| | - Fabrizio Dal Piaz
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (A.C.); (O.P.)
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Fisciano, Italy; (F.M.); (G.G.)
| | - Viviana Izzo
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (A.C.); (O.P.)
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84084 Fisciano, Italy; (F.M.); (G.G.)
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Cai J, He L, Wang H, Rong X, Chen M, Shen Q, Li X, Li M, Peng Y. Genetic liability for prescription opioid use and risk of cardiovascular diseases: a multivariable Mendelian randomization study. Addiction 2022; 117:1382-1391. [PMID: 34859517 DOI: 10.1111/add.15767] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 11/08/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Observational studies have yielded conflicting results on the association of prescription opioid use (POU) with the risk of cardiovascular diseases (CVD). Residual confounding and potential reverse causality are inevitable in such conventional observational studies. This study used Mendelian randomization (MR) design to estimate the causal effect of POU on the risk of CVD, including coronary heart disease (CHD), myocardial infarction (MI) and ischemic stroke (IS), as well as their common risk factors. DESIGN We estimated the causal effect of genetic liability for POU on CVD in a two-sample MR framework. Complementary sensitivity analyses were conducted to test the robustness of our results. SETTING Genome-wide association studies (GWAS) that were based on predominantly European ancestry. PARTICIPANTS The sample sizes of the GWAS used in this study ranged from 69 033 to 757 601 participants. MEASUREMENTS Genetic variants predictive of the POU and their corresponding summary-level information in the outcomes were retrieved and extracted from the respective GWAS. FINDINGS Using univariable MR, we found evidence for a causal effect of genetic liability for POU on an increased risk of CHD [odds ratio (OR) = 1.09; 95% confidence interval (CI) = 1.02-1.16; P = 0.008] and MI (OR = 1.13; 95% CI = 1.04-1.22; P = 0.002). In multivariable MR, the association remained after accounting for comorbid pain conditions, but was attenuated with adjustment for potential mediators, including body mass index (BMI), waist circumference (WC) and type 2 diabetes (T2D). CONCLUSION Mendelian randomization estimates provide robust evidence for the causal effects of genetic liability for prescription opioid use on an increased risk of coronary heart disease and myocardial infarction, which might be mediated by obesity-related traits.
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Affiliation(s)
- Jiahao Cai
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lei He
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hongxuan Wang
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoming Rong
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Chen
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingyu Shen
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiangpen Li
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mei Li
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Peng
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Zeeshan S, Naveed M, Khan A, Atiq A, Arif M, Ahmed MN, Kim YS, Khan S. N-Pyrazoloyl and N-thiopheneacetyl hydrazone of isatin exhibited potent anti-inflammatory and anti-nociceptive properties through suppression of NF-κB, MAPK and oxidative stress signaling in animal models of inflammation. Inflamm Res 2019; 68:613-632. [PMID: 31079165 DOI: 10.1007/s00011-019-01245-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/27/2019] [Accepted: 05/02/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Hydrazide derivatives constitute an important class of compounds for new drug development as they are reported to possess good anti-inflammatory and analgesic activity. The present study was aimed to investigate the role of newly synthesized hydrazide derivatives N-pyrazoloyl hydrazone of isatin (PHI) and N-thiopheneacetyl hydrazone of isatin (THI) in acute and chronic inflammatory pain models induced by carrageenan and complete Freud's adjuvant (CFA). MATERIALS PHI and THI (0.1, 1 and 10 mg/kg) pretreatments were provided intraperitoneally to male BALB/c mice prior to inflammatory inducers. Behavioral responses to inflammation and pain were evaluated by assessment of paw edema, mechanical allodynia, mechanical and thermal hyperalgesia. Cytokines production and NF-κB levels were evaluated by ELISA. Western blot analysis was performed for the detection of IκBα, p38, JNK and ERK. Hematoxylin and eosin (H&E) staining and radiographic analysis were performed to evaluate the effect of PHI and THI treatment on bone and soft tissues. Oxidative stress was determined by reduced glutathione, glutathione-S-transferase and catalase assays. Evans blue dye was used to monitor vascular protein leakage. RESULT PHI and THI dose dependently (0.1, 1 and 10 mg/kg) reduced inflammation and pain in mice, however, the dose of 10 mg/kg exhibited significant activity. The anti-inflammatory and analgesic effects were attributed to suppression of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6) production levels. PHI and THI significantly blocked CFA-induced activation of NF-κB and MAPK signaling pathways. Oxidative stress and plasma nitrite levels were reduced remarkably. The PHI and THI (10 mg/kg) treatment did not exhibit any apparent toxicity on the liver, kidney, muscles strength, and motor co-ordination in mice. CONCLUSION Both PHI and THI possess significant anti-inflammatory and analgesic activity via inhibition of inflammatory mediators.
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Affiliation(s)
- Sara Zeeshan
- Department of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, Pakistan
| | - Muhammad Naveed
- Department of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, Pakistan
| | - Adnan Khan
- Department of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, Pakistan
| | - Ayesha Atiq
- Department of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, Pakistan
| | - Maryam Arif
- Department of Chemistry, University of Azad Jammu and Kashmir, Muzaffarabad, Pakistan
| | - Muhammad Naeem Ahmed
- Department of Chemistry, University of Azad Jammu and Kashmir, Muzaffarabad, Pakistan
| | - Yeong Shik Kim
- College of Pharmacy, Seoul National University, Seoul, 151-742, South Korea
| | - Salman Khan
- Department of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, Pakistan. .,College of Pharmacy, Seoul National University, Seoul, 151-742, South Korea.
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Cao FL, Xu M, Wang Y, Gong KR, Zhang JT. Tanshinone IIA attenuates neuropathic pain via inhibiting glial activation and immune response. Pharmacol Biochem Behav 2015; 128:1-7. [DOI: 10.1016/j.pbb.2014.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/26/2014] [Accepted: 11/01/2014] [Indexed: 01/05/2023]
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Chung C, Carteret AF, McKelvy AD, Ringkamp M, Yang F, Hartke TV, Dong X, Raja SN, Guan Y. Analgesic properties of loperamide differ following systemic and local administration to rats after spinal nerve injury. Eur J Pain 2012; 16:1021-32. [PMID: 22508374 DOI: 10.1002/j.1532-2149.2012.00148.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND The analgesic properties and mechanisms of loperamide hydrochloride, a peripherally acting opioid receptor agonist, in neuropathic pain warrant further investigation. METHODS We examined the effects of systemic or local administration of loperamide on heat and mechanical hyperalgesia in rats after an L5 spinal nerve ligation (SNL). RESULTS (1) Systemic loperamide (0.3-10 mg/kg, subcutaneous in the back) dose dependently reversed heat hyperalgesia in SNL rats, but did not produce thermal analgesia. Systemic loperamide (3 mg/kg) did not induce thermal antinociception in naïve rats; (2) systemic loperamide-induced anti-heat hyperalgesia was blocked by pretreatment with intraperitoneal naloxone methiodide (5 mg/kg), but not by intraperitoneal naltrindole (5 mg/kg) or intrathecal naltrexone (20 μg/10 μL); (3) local administration of loperamide (150 μg), but not vehicle, into plantar or dorsal hind paw tissue induced thermal analgesia in SNL rats and thermal antinociception in naïve rats; (4) the analgesic effect of intraplantar loperamide (150 μg/15 μL) in SNL rats at 45 min, but not 10 min, post-injection was blocked by pretreatment with an intraplantar injection of naltrexone (75 μg/10 μL); (5) systemic (3.0 mg/kg) and local (150 μg) loperamide reduced the exaggerated duration of hind paw elevation to noxious pinprick stimuli in SNL rats. Intraplantar injection of loperamide also decreased the frequency of pinprick-evoked response in naïve rats. CONCLUSIONS These findings suggest that both systemic and local administration of loperamide induce an opioid receptor-dependent inhibition of heat and mechanical hyperalgesia in nerve-injured rats, but that local paw administration of loperamide also induces thermal and mechanical antinociception.
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Affiliation(s)
- C Chung
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, USA
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Varrassi G, Angeletti C, Guetti C, Marinangeli F, Paladini A. Systemic opioid and chronic pain. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eujps.2009.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Carman WJ, Su S, Cook SF, Wurzelmann JI, McAfee A. Coronary heart disease outcomes among chronic opioid and cyclooxygenase-2 users compared with a general population cohort. Pharmacoepidemiol Drug Saf 2011; 20:754-62. [PMID: 21567652 DOI: 10.1002/pds.2131] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 01/20/2011] [Accepted: 01/25/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND We estimated the incidence of myocardial infarction (MI) and coronary revascularization (CR) among users of chronic opioid therapy (COT) and compared risks across categories of morphine-equivalent doses of COT and comparator cohorts. METHODS We conducted a retrospective claims-based study using de-identified data from a commercially insured population. A cohort of 148,657 adult users of COT, a matched cohort of the general population, and three cohorts of users of chronic cyclooxygenase-2 (COX-2) inhibitor therapy totaling 122,810 were identified. Incidence rates and incidence rate ratios (IRRs) of MI and MI/CR were estimated. RESULTS Adjusted IRRs for MI ranged from 1.21 (95% confidence interval [95%CI], 1.02-1.45) among those receiving low COT doses to 1.89 (95%CI, 1.54-2.33) among those receiving high doses compared with those receiving very low doses, averaging <15 mg/day. Similar patterns were shown for MI/CR. IRRs standardized to the age-sex distribution of the general cohort and adjusted for coronary heart disease risk factors showed 2.7 times the rate of MI and 2.4 times the rate of MI/CR in the COT cohort compared with the general population. Using the same analysis, COX-2 users had 1.7-1.9 times the rate of MI and MI/CR compared with the general cohort. CONCLUSIONS Chronic analgesic use with either COT or COX-2 was associated with an increased risk of cardiovascular outcomes. These findings suggest either a selection of high-risk patients to chronic analgesic treatment, coupled with unmeasured or residual confounding, or a potential cardiovascular effect of these medications. Further research is warranted to evaluate causes for this association.
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Balch RJ, Trescot A. Extended-release morphine sulfate in treatment of severe acute and chronic pain. J Pain Res 2010; 3:191-200. [PMID: 21197323 PMCID: PMC3004644 DOI: 10.2147/jpr.s6529] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Indexed: 11/26/2022] Open
Abstract
Morphine is the archetypal opioid analgesic. Because it is a short-acting opioid, its use has been limited to the management of acute pain. The development of extended-release formulations have resulted in the increased utilization of morphine in chronic pain conditions. This review documents the history of morphine use in pain treatment, and describes the metabolism, pharmacodynamics, formulations, and efficacy of the currently available extended-release morphine medications.
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Affiliation(s)
- Robert J Balch
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA USA
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Fichna J, Gach K, Perlikowska R, Cravezic A, Bonnet JJ, do-Rego JC, Janecka A, Storr MA. Novel endomorphin analogues with antagonist activity at the mu-opioid receptor in the gastrointestinal tract. ACTA ACUST UNITED AC 2010; 162:109-14. [PMID: 20083143 DOI: 10.1016/j.regpep.2010.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/04/2010] [Accepted: 01/05/2010] [Indexed: 12/19/2022]
Abstract
Opioid bowel dysfunction (OBD) summarizes common adverse side effects of opiate-based management of pain. A promising therapeutic approach to prevent OBD and other opioid-related disorders of the gastrointestinal (GI) tract is the co-administration of opiates with peripherally-restricted mu-opioid receptor (MOR)-selective antagonists. The aim of this study was to investigate the selectivity and efficacy of three novel peptide antagonists: antanal-1, antanal-2, and antanal-2A at MOR in the GI tract in vitro and in vivo. The effects of the antanals on GI motility were studied in vitro, using isolated preparations of mouse ileum and colon and in vivo, by measuring colonic propulsion in mice. Additionally, in vitro stability against enzymatic degradation and blood-brain barrier (BBB) permeability using the hot plate test in mice were examined. The antanals significantly reduced the inhibitory effect of the MOR agonists endomorphin-2, morphine, and loperamide on mouse ileum and colon contractions in vitro and blocked morphine-induced decrease of colonic bead expulsion in vivo. The hot plate test in mice showed that the antagonist activity of all antanals was restricted to the periphery. Antanal-1, antanal-2, and antanal-2A are promising MOR antagonists with limited BBB permeability, which may be developed into future therapeutics of opioid-related GI dysfunction.
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Affiliation(s)
- Jakub Fichna
- Division of Gastroenterology, Department of Medicine, University of Calgary, Canada
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Choo CY, Ong CYY, Chan SY. Oxycodone – An Audit of its Prescription in a Local Hospital. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n11p947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Aim: This study aims to evaluate the prescription patterns and side effects of oxycodone in a local hospital setting.
Materials and Methods: This is a retrospective analysis of all patients who were prescribed oxycodone for acute or chronic pain from June to November 2007. Patients’ names were obtained from the hospital pharmacy and data were collected with a set of question- naire after review of their casenotes. Prescription was compared with other recommended opioid prescription guidelines. Side effects to oxycodone use were documented.
Results: One hundred and thirty patients were prescribed oxycodone for the 6-month study period. Prescription by the orthopaedic surgeons was the highest, followed by the pain service. Most patients had a clear indication for use of oxycodone and appropriate dosing regimes. However, two thirds of the patients prescribed oxycodone were not reviewed with regard to their analgesia within 24 hours and one third did not have titration of the drug to their pain symptoms. Majority of the patients had outpatient follow-up within 4 weeks of discharge. Common side effects included nausea, vomiting and constipation.
Conclusion: This is the first local audit that profiles oxyco- done prescription patterns and its side effects. Prescription of oxycodone was appropriate for the majority of the study population. Patient assessment upon initiation of oxycodone therapy and titration of the drug to patients’ pain symptoms was suboptimal. Oxycodone was well toler- ated by the study population with minimal side effects. Further quality measures and ongoing education of clinicians will ensure future patients obtain safe and effective analgesia.
Key words: Opioid prescription, Pain
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