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Mercadante S. Influence of aging on opioid dosing for perioperative pain management: a focus on pharmacokinetics. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:51. [PMID: 39085914 PMCID: PMC11292879 DOI: 10.1186/s44158-024-00182-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024]
Abstract
The older population continues to grow in all countries, and surgeons are encountering older patients more frequently. The management of postoperative pain in older patients can be a difficult task. Opioids are the mainstay of perioperative pain control. This paper assesses some pharmacokinetic age-related aspects and their relationship with the use of opioids in the perioperative period. Changes in body composition and organ function, and pharmacokinetics in older patients, as well as characteristics of opioids commonly used in the perioperative period are described. Specific problems, dose titration, and patient-controlled analgesia in the elderly are also reviewed. Opioids can be safety used in perioperative period, even in the elderly. The choice of drugs and doses can be individualized according to the surgery, opioid pharmacokinetics, comorbidities, and routes of administration.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, 90146, Italy.
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Didik S, Golosova D, Xu B, Staruschenko A. Opioids and the Kidney: A Compendium. KIDNEY360 2023; 4:1816-1823. [PMID: 37927032 PMCID: PMC10758516 DOI: 10.34067/kid.0000000000000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
Opioids are a class of medications used in pain management. Unfortunately, long-term use, overprescription, and illicit opioid use have led to one of the greatest threats to mankind: the opioid crisis. Accompanying the classical analgesic properties of opioids, opioids produce a myriad of effects including euphoria, immunosuppression, respiratory depression, and organ damage. It is essential to ascertain the physiological role of the opioid/opioid receptor axis to gain an in-depth understanding of the effects of opioid use. This knowledge will aid in the development of novel therapeutic interventions to combat the increasing mortality rate because of opioid misuse. This review describes the current knowledge of opioids, including the opioid epidemic and opioid/opioid receptor physiology. Furthermore, this review intricately relates opioid use to kidney damage, navigates kidney structure and physiology, and proposes potential ways to prevent opioid-induced kidney damage.
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Affiliation(s)
- Steven Didik
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- James A. Haley Veteran's Hospital, Tampa, Florida
| | - Daria Golosova
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Biyang Xu
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
| | - Alexander Staruschenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- James A. Haley Veteran's Hospital, Tampa, Florida
- Hypertension and Kidney Research Center, University of South Florida, Tampa, Florida
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Opioids for chronic pain management in patients with dialysis-dependent kidney failure. Nat Rev Nephrol 2022; 18:113-128. [PMID: 34621058 PMCID: PMC8792317 DOI: 10.1038/s41581-021-00484-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/30/2022]
Abstract
Chronic pain is highly prevalent among adults treated with maintenance haemodialysis (HD) and has profound negative effects. Over four decades, research has demonstrated that 50-80% of adult patients treated with HD report having pain. Half of patients with HD-dependent kidney failure (HDKF) have chronic moderate-to-severe pain, which is similar to the burden of pain in patients with cancer. However, pain management in patients with HDKF is often ineffective as most patients report that their pain is inadequately treated. Opioid analgesics are prescribed more frequently for patients receiving HD than for individuals in the general population with chronic pain, and are associated with increased morbidity, mortality and health-care resource use. Furthermore, current opioid prescribing patterns are frequently inconsistent with guideline-recommended care. Evidence for the effectiveness of opioids in pain management in general, and in patients with HDKF specifically, is lacking. Nonetheless, long-term opioid therapy has a role in the treatment of some patients when used selectively, carefully and combined with an ongoing assessment of risks and benefits. Here, we provide a comprehensive overview of the use of opioid therapy in patients with HDKF and chronic pain, including a discussion of buprenorphine, which has potential as an analgesic option for patients receiving HD owing to its unique pharmacological properties.
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Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature. Dermatol Surg 2021; 47:454-461. [PMID: 33625143 DOI: 10.1097/dss.0000000000002949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncontrolled acute postoperative pain presents a significant management challenge when opioids are used in patients with end-stage renal disease (ESRD). Currently, there is a lack of quality pharmacokinetic and pharmacodynamic data regarding opioid medication use in ESRD patients to optimize safe and effective management. OBJECTIVE To review the published literature on pharmacologic evidence for and against the use of opioid medications for acute postoperative pain following Mohs micrographic surgery in ESRD patients. METHODS A search of PubMed was conducted to identify articles on the pharmacokinetic and pharmacodynamic properties of opioid pain medications in ESRD patients through March 1, 2020. RESULTS Seventy-five articles were reviewed. Limited data exist on opioids safe for use in ESRD and are mostly confined to small case series. Studies suggest tramadol and hydromorphone could be considered when indicated. Methadone may be a safe option, but should be reserved for treatment coordinated by a trained pain subspecialist. CONCLUSION Randomized clinical trials are lacking. Studies that are available are not sufficient to perform a quantitative methodologic approach. Evidence supports the judicious use of postoperative opioid medications in ESRD patients at the lowest possible dose to achieve clinically meaningful improvement in pain and function.
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Abstract
Chronic pain and prescription opioid use are prevalent among patients with end-stage kidney disease treated with hemodialysis. Vulnerabilities to complications from opioid use are high in this patient population, as shown in many recent, well-conducted, patient-oriented studies. Such studies have highlighted the need for a balanced approach to pain management in hemodialysis patients that includes careful assessment of the risks and benefits of opioid prescriptions in this population. In this article, we review the available literature and experience regarding opioid prescriptions among hemodialysis patients, discuss clinical implications, and outline ongoing research.
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Affiliation(s)
- Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Karen S Lyons
- William F. Connell School of Nursing, Boston College, Boston, MA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Dolati S, Tarighat F, Pashazadeh F, Shahsavarinia K, Gholipouri S, Soleimanpour H. The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article. Anesth Pain Med 2020; 10:e105754. [PMID: 34150565 PMCID: PMC8207885 DOI: 10.5812/aapm.105754] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/19/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.
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Affiliation(s)
- Sanam Dolati
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faezeh Tarighat
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariba Pashazadeh
- Research Center for Evidence-Based Medicine, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kavous Shahsavarinia
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saina Gholipouri
- Department of Medical Sciences, University of Western Ontario, Ontario, Canada
| | - Hassan Soleimanpour
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran. ,
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Opioid Safety and Concomitant Benzodiazepine Use in End-Stage Renal Disease Patients. Pain Res Manag 2019; 2019:3865924. [PMID: 31772694 PMCID: PMC6854236 DOI: 10.1155/2019/3865924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/17/2019] [Indexed: 11/17/2022]
Abstract
Background Opioid use is common in end-stage renal disease (ESRD) patients. However, safety of individual opioids and concomitant benzodiazepine use has not been studied. Objective To study the epidemiology of opioid and concomitant benzodiazepine use in ESRD population. To study the clinical safety profile of individual opioids in patients on hemodialysis. Design Retrospective analysis of the U.S. Renal Data System. A comprehensive review of the current literature was performed to update currently used opioid safety classification. Participants ESRD patients ≥18 years on hemodialysis who were enrolled in Medicare A and B and Part D between 2006 and 2012, excluding those with malignancy. Main Measures Hospital admission with diagnosis of prescription opioid overdose within 30, 60, and 90 days of prescription; death due to opioid overdose. Results Annually, the percentage of patients prescribed any opioid was 52.2%. Overall trend has been increasing except for a small dip in 2011, despite which the admissions due to opioid overdose have been rising. 30% of those who got a prescription for opioids also got a benzodiazepine prescription. 56.5% of these patients received both prescriptions within a week of each other. Benzodiazepine use increased the odds of being on opioids by 3.27 (CI 3.21–3.32) and increased the odds of hospitalization by 50%. Opioids considered safe such as fentanyl and methadone were associated with 3 and 6 folds higher odds of hospitalization within 30 days of prescription. Hydrocodone had the lowest odds ratio (1.9, CI 1.8–2.0). Conclusions Concurrent benzodiazepine use is common and associated with higher risk of hospitalization due to opioid overdose. Possible opioid-associated hospital admission rate is 4-5 times bigger in ESRD population than general population. Current safety classification of opioids in these patients is misleading, and even drugs considered safe based on pharmacokinetic data are associated with moderate to very high risk of hospitalization. We propose a risk-stratified classification of opioids and suggest starting to use them in all ESRD patients.
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Davison SN. Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure. Clin J Am Soc Nephrol 2019; 14:917-931. [PMID: 30833302 PMCID: PMC6556722 DOI: 10.2215/cjn.05180418] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pain is common and poorly managed in patients with advanced CKD, likely due to both under and over prescription of appropriate analgesics. Poorly managed pain contributes to patients' poor quality of life and excessive health care use. There is tremendous variability within and between countries in prescribing patterns of analgesics, suggesting that factors other than patient characteristics account for these differences. This article discusses the pharmacologic management of acute and chronic pain in patients with advanced CKD, and the role analgesics, including opioids, play in the overall approach to pain management.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Reis A, Luecke C, Davis TK, Kakajiwala A. Pain Management in Pediatric Chronic Kidney Disease. J Pediatr Pharmacol Ther 2018; 23:192-202. [PMID: 29970975 PMCID: PMC6027978 DOI: 10.5863/1551-6776-23.3.192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 11/11/2022]
Abstract
Pain is a common problem in children with chronic kidney disease (CKD); however, limited data exist regarding its management. Although most pain is managed pharmacologically, in some instances non-pharmacologic management can aid in safely ameliorating discomfort. Because of the accumulation of toxic metabolites, many common pain medications have adverse effects on kidney function or altered pharmacokinetics in the setting of CKD. Decreased clearance impacts safe dosing of analgesics. The pain management of patients on renal replacement therapy requires an understanding of drug clearance due to the different modalities of dialysis. This educational review highlights pain medications that are safe, albeit often with adjusted dosing, as well as drugs best avoided in the management of pediatric kidney disease. Acetaminophen should be used as a first-line therapy for pain management in children with CKD. Opioids may be added to control moderate to severe pain. Although data are currently lacking, buprenorphine holds promise as a potentially useful drug for the treatment of pain in pediatric patients with CKD. The addition of adjuvant pain medications and non-pharmacologic therapies maybe also be helpful. Despite these options, pain often remains difficult to treat in children with CKD.
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Simon L. A laplace transform-based technique for solving multiscale and multidomain problems: Application to a countercurrent hemodialyzer model. Comput Biol Med 2017; 87:230-235. [DOI: 10.1016/j.compbiomed.2017.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
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Nagar VR, Birthi P, Salles S, Sloan PA. Opioid Use in Chronic Pain Patients with Chronic Kidney Disease: A Systematic Review. PAIN MEDICINE 2017; 18:1416-1449. [DOI: 10.1093/pm/pnw238] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Brooks MR, Golianu B. Perioperative management in children with chronic pain. Paediatr Anaesth 2016; 26:794-806. [PMID: 27370517 DOI: 10.1111/pan.12948] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 12/28/2022]
Abstract
Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.
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Affiliation(s)
- Meredith R Brooks
- Department of Anesthesiology, Cook Children's Hospital, Fort Worth, TX, USA
| | - Brenda Golianu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Linares OA, Schiesser WE, Fudin J, Pham TC, Bettinger JJ, Mathew RO, Daly AL. In silico ordinary differential equation/partial differential equation hemodialysis model estimates methadone removal during dialysis. J Pain Res 2015; 8:417-29. [PMID: 26229501 PMCID: PMC4516209 DOI: 10.2147/jpr.s84615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background There is a need to have a model to study methadone’s losses during hemodialysis to provide informed methadone dose recommendations for the practitioner. Aim To build a one-dimensional (1-D), hollow-fiber geometry, ordinary differential equation (ODE) and partial differential equation (PDE) countercurrent hemodialyzer model (ODE/PDE model). Methodology We conducted a cross-sectional study in silico that evaluated eleven hemodialysis patients. Patients received a ceiling dose of methadone hydrochloride 30 mg/day. Outcome measures included: the total amount of methadone removed during dialysis; methadone’s overall intradialytic mass transfer rate coefficient, km; and, methadone’s removal rate, jME. Each metric was measured at dialysate flow rates of 250 mL/min and 800 mL/min. Results The ODE/PDE model revealed a significant increase in the change of methadone’s mass transfer with increased dialysate flow rate, %Δkm=18.56, P=0.02, N=11. The total amount of methadone mass transferred across the dialyzer membrane with high dialysate flow rate significantly increased (0.042±0.016 versus 0.052±0.019 mg/kg, P=0.02, N=11). This was accompanied by a small significant increase in methadone’s mass transfer rate (0.113±0.002 versus 0.014±0.002 mg/kg/h, P=0.02, N=11). The ODE/PDE model accurately predicted methadone’s removal during dialysis. The absolute value of the prediction errors for methadone’s extraction and throughput were less than 2%. Conclusion ODE/PDE modeling of methadone’s hemodialysis is a new approach to study methadone’s removal, in particular, and opioid removal, in general, in patients with end-stage renal disease on hemodialysis. ODE/PDE modeling accurately quantified the fundamental phenomena of methadone’s mass transfer during hemodialysis. This methodology may lead to development of optimally designed intradialytic opioid treatment protocols, and allow dynamic monitoring of outflow plasma opioid concentrations for model predictive control during dialysis in humans.
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Affiliation(s)
- Oscar A Linares
- Translational Genomic Medicine Lab, Plymouth Pharmacokinetic Modeling Study Group, Plymouth, MI, USA
| | - William E Schiesser
- Department of Chemical and Biomolecular Engineering, Lehigh University, Bethlehem, PA, USA
| | - Jeffrey Fudin
- University of Connecticut School of Pharmacy, Storrs, CT, USA ; Western New England College of Pharmacy, Springfield, MA, USA ; Albany College of Pharmacy and Health Sciences, Albany, NY, USA ; Stratton VA Medical Center, Albany, NY, USA
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Boyle SM, Jacobs B, Sayani FA, Hoffman B. Management of the Dialysis Patient with Sickle Cell Disease. Semin Dial 2015; 29:62-70. [PMID: 26174870 DOI: 10.1111/sdi.12403] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While patients with sickle cell disease currently constitute a very small minority of the US dialysis population (0.1%), there is anticipated growth of this group as the life expectancy of those with sickle cell disease (SCD) increases. SCD patients suffer a high burden of morbidity, which is enhanced by the presence of end-stage renal disease (ESRD). In this review, we discuss the pathophysiology of SCD and the basic tenets of its management with focus on the dialysis patient with SCD. Anemia in dialysis patients with SCD is a unique challenge. The hemoglobin target in SCD dialysis patients with ESRD should not exceed 10 g/dl. SCD patients, and particularly those on dialysis, are likely to be poorly responsive to erythropoietin-stimulating agent (ESA) therapy and might be at increased risk for vaso-occlusive crisis (VOC) with ESA. Iron chelation and hydroyxurea therapy require special considerations and modifications in dialysis patients with SCD. There are theoretical advantages to both hemodialysis (HD) and peritoneal dialysis (PD) in SCD patients. With HD, there is a secure vascular access available for both standard and exchange blood transfusion in patients who need them. With PD, the absence of an acute rise in hematocrit with ultrafiltration (UF) might offer lower risk of VOC. During VOC, reduction in UF goals should be considered but administration of intravenous fluids should be reserved only for clear cases of volume depletion. Finally, renal transplantation appears to confer a survival advantage to dialysis in SCD patients and should be pursued when possible.
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Affiliation(s)
- Suzanne M Boyle
- Division Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Benjamin Jacobs
- Hematology and Oncology Division, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Farzana A Sayani
- Hematology and Oncology Division, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brenda Hoffman
- Renal, Hypertension and Electrolyte Division, Penn Presbyterian Medical Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Koncicki HM, Brennan F, Vinen K, Davison SN. An Approach to Pain Management in End Stage Renal Disease: Considerations for General Management and Intradialytic Symptoms. Semin Dial 2015; 28:384-91. [PMID: 25864854 DOI: 10.1111/sdi.12372] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The prevalence and severity of symptoms in patients with advanced chronic kidney disease is higher than those of the general population and comparable to those with other chronic and serious medical conditions. Despite the prevalence and severity in this population, symptoms continue to be under-recognized and inadequately managed. The recognition of specific intradialytic pain syndromes such as pain related to arteriovenous access, headaches, muscle cramps or generalized pain by providers may aid in improving patient compliance and quality of life. The approach to pain management in end stage renal disease patients follows that of the general population with specific considerations regarding clearance and potential side effects guiding selection of agents. Overall, evidence is limited regarding the pharmacology of many medications in this population.
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Affiliation(s)
- Holly M Koncicki
- Division of Kidney Diseases & Hypertension, Department of Internal Medicine, Hofstra North Shore-LIJ School of Medicine, Great Neck, New York
| | - Frank Brennan
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Katie Vinen
- Department of Renal Medicine, Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sara N Davison
- Division of Nephrology & Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Abstract
INTRODUCTION Cancer pain is one of the most important symptoms of malignant disease, which has a major impact on the quality of life of cancer patients. Therefore, it needs to be treated appropriately after a careful assessment of the types and causes of pain. AREAS COVERED The mainstay of cancer pain management is systemic pharmacotherapy. This is, in principle, still based on the WHO guidelines initially published in 1986. Although these have been validated, they are not evidence-based. The principles are a stepladder approach using non-opioids, weak and then strong opioids. In addition, adjuvants can be added at any step to address specific situations such as bone or neuropathic pain. Patients, even if they are on long-acting opioids, need to be provided with immediate-release opioids for breakthrough pain. In case of inefficacy or severe adverse effects of one opioid, rotation to another opioid is recommended. EXPERT OPINION There is a major need for more and better randomized controlled trials in the setting of cancer pain as the lack of evidence is hampering the improvement of current treatment guidelines.
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Affiliation(s)
- Stephan A Schug
- Professor, Chair of Anaesthesiology, The University of Western Australia, School of Medicine and Pharmacology, Pharmacology, Pharmacy and Anaesthesiology Unit , Perth , Australia
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