Transdermal fentanyl for chronic pain in AIDS: a pilot study

Pharmacologic and Non-Pharmacologic Treatments for Chronic Pain Used by Patients with Pain, HIV, and Depression

The objective of this study was to understand pain treatment utilization, perceived efficacy, and differences in utilization by gender, clinic site, chronicity of pain, pain severity, and depression severity among people living with HIV (PLWH), chronic pain, and elevated depression symptoms. Participants included 187 PLWH at three HIV clinics in the U.S. Overall, 85% of participants reported taking a pain medication. One quarter (25%) reported non-pharmacological professional treatments for pain (e.g., massage, physical therapy), 60% reported mind-body treatments, including exercise, meditation, and yoga, and 62% reported other non-pharmacological self-administered treatments (e.g., heat/cold). Most pain treatments were considered "slightly helpful" or "moderately helpful." Non-pharmacological self-administered treatments were more commonly used among women than men and among individuals with constant vs. intermittent pain. Further research is needed to evaluate the efficacy of the preferred analgesic modalities of PLWH.

Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions

The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.

Pharmacologic and non-pharmacologic treatments for chronic pain in individuals with HIV: a systematic review

Chronic pain occurs in as many as 85% of individuals with HIV and is associated with substantial functional impairment. Little guidance is available for HIV providers seeking to address their patients' chronic pain. We conducted a systematic review to identify clinical trials and observational studies that examined the impact of pharmacologic or non-pharmacologic interventions on pain and/or functional outcomes among HIV-infected individuals with chronic pain in high-development countries. Eleven studies met inclusion criteria and were mostly low or very low quality. Seven examined pharmacologic interventions (gabapentin, pregabalin, capsaicin, analgesics including opioids) and four examined non-pharmacologic interventions (cognitive behavioral therapy, self-hypnosis, smoked cannabis). The only controlled studies with positive results were of capsaicin and cannabis, and had short-term follow-up (≤12 weeks). Among the seven studies of pharmacologic interventions, five had substantial pharmaceutical industry sponsorship. These findings highlight several important gaps in the HIV/chronic pain literature that require further research.

Pain in amaXhosa Women Living With HIV/AIDS: Translation and Validation of the Brief Pain Inventory-Xhosa

CONTEXT

Pain has been reported as the second most commonly reported symptom in people living with HIV/AIDS. In South Africa, there are more than five million people living with HIV/AIDS. Approximately, two million belong to the Xhosa cultural group. The prevalence of pain in amaXhosa living with HIV/AIDS was unknown at the commencement of the study. A culturally appropriate, valid, and reliable instrument is required to measure pain and its impact in this population.

OBJECTIVES

The objectives of this article are to document the process of translation of the Brief Pain Inventory (BPI) into the BPI-Xhosa and to present the results of the validity and reliability testing of the instrument.

METHODS

A six-stage forward-backward translation process was followed using bilingual and bicultural translators to ensure decentering of the process. The translated BPI-Xhosa, a demographic questionnaire and the European Quality of Life-5 Dimensions Xhosa version (EQ-5D-Xhosa) health-related quality of life instrument were administered to 229 amaXhosa women living with HIV/AIDS in a resource-poor urban settlement in South Africa.

RESULTS

A 74.24% (95% CI: 68.2-79.47) prevalence of pain was recorded. The BPI-Xhosa had good concurrent validity when compared with the previously validated EQ-5D-Xhosa. Factor analysis confirmed that the BPI-Xhosa had a two-factor structure (pain severity and pain interference). The instrument had good internal reliability, with Cronbach alphas of 0.77 and 0.83 for the pain severity and pain interference subscales, respectively.

CONCLUSION

The BPI-Xhosa is a valid instrument which can be used to measure pain prevalence, severity, and interference in amaXhosa women living with HIV/AIDS.

The issues around opioid prescribing in HIV-related pain

SUMMARY Opioids are very useful analgesics but reports of abuse, addiction and occasionally death have led to an increase in scrutiny, particularly for chronic opioid therapy. The development of effective antiretroviral therapy has changed the focus of treatment of people living with HIV from palliative care to the management of a chronic disease. It is appropriate, therefore, to review the issues around opioid prescribing in HIV in light of this and recent research, and to review the guidance available. This review briefly examines the epidemiology of pain in people living with HIV and then the use and issues around strong opioid prescribing in this group.

Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder

Recent data suggest that comorbid substance use disorders (SUDs) are common among chronic non-cancer pain (CNCP) patients; however, prevalence rates vary across studies and findings are limited regarding treatment options for CNCP patients with comorbid SUD. The purpose of this systematic review is to assess the prevalence, associated demographic and clinical characteristics, and treatment outcomes for CNCP patients with comorbid SUD. We conducted searches from Ovid MEDLINE, PsychINFO, and PubMED from 1950 through February 2010 and retrieved the references. Thirty-eight studies met inclusion criteria and provided data that addressed our key questions. Three to forty-eight percent of CNCP patients have a current SUD. There are no demographic or clinical factors that consistently differentiate CNCP patients with comorbid SUD from patients without SUD, though SUD patients appear to be at greater risk for aberrant medication-related behaviors. CNCP patients with SUD are more likely to be prescribed opioid medications and at higher doses than CNCP patients without a history of SUD. CNCP patients with comorbid SUD do not significantly differ in their responses to treatment compared to CNCP patients without SUD, though the quality of this evidence is low. Limited data are available to identify predictors of treatment outcome. Although clinical experience and research suggests that SUDs are common among CNCP patients, only limited data are available to guide clinicians who treat this population. Research is needed to increase understanding of the prevalence, correlates, and responses to treatment of CNCP patients with comorbid SUDs.

Transdermal fentanyl: pharmacology and toxicology

OBJECTIVE

To evaluate the underlying pharmacology, safety, and misuse/abuse of transdermal fentanyl, one of the cornerstone pharmacotherapies for patients with chronic pain.

METHODS

Literature was identified through searches of Medline (PubMed) and several textbooks in the areas of pharmacology, toxicology, and pain management. A bibliographical review of articles identified by these searches was also performed. Search terms included combinations of the following: fentanyl, transdermal, patch, pharmacology, kinetics, toxicity, and poisoning. All pertinent clinical trials, retrospective studies, and case reports relevant to fentanyl pharmacology and transdermal fentanyl administered by any route and published in English were identified. Each was reviewed for data regarding the clinical pharmacology, abuse, misuse, and safety of transdermal fentanyl. Data from these studies and information from review articles and pharmaceutical prescribing information were included in this review.

RESULTS

Fentanyl is a high-potency opioid that has many uses in the treatment of both acute and chronic pain. Intentional or unintentional misuse, as well as abuse, may lead to significant clinical consequences, including death. Both the US Food and Drug Administration (FDA) and Health Canada have warned of potential pitfalls associated with transdermal fentanyl, although these have not been completely effective in preventing life-threatening adverse events and fatalities related to its inappropriate use.

CONCLUSIONS

Clinically consequential adverse effects may occur unexpectedly with normal use of transdermal fentanyl, or if misused or abused. Misuse and therapeutic error may be largely preventable through better education at all levels for both the prescriber and patient. The prevention of intentional misuse or abuse may require regulatory intervention.

A One Year Health Economic Model Comparing Transdermal Fentanyl with Sustained-Release Morphine in the Treatment of Chronic Noncancer Pain

A Markov model was constructed to simulate the resource use and health outcomes of one year of treatment comparing the fentanyl transdermal therapeutic system (fentanyl-TTS) with oral sustained-release (SR) morphine in outpatients with noncancer pain in Denmark. Effectiveness was assessed in terms of days of good pain control and days on initial treatment. Costs included those of baseline pain management, including breakthrough pain; co-medication costs; and control of adverse events. Fentanyl-TTS was more effective than SR-morphine in achieving good pain control (99 vs. 64 days, respectively) and the incremental cost-effectiveness of fentanyl-TTS was US dollars 10.26 per extra day of good pain control. Patients treated with fentanyl-TTS remained considerably longer on initial treatment compared with those treated with SR-morphine (166 days vs. 117 days, respectively). The results of this study suggest that fentanyl-TTS is a competitive therapeutic and economic choice for the treatment of chronic noncancer pain.

The validity and utility of the BPI interference measures for evaluating the impact of osteoarthritic pain

The psychometric properties of the Brief Pain Inventory (BPI), a widely used measure of pain and its impact on functioning, were assessed using data from two clinical trials of controlled-release oxycodone in osteoarthritis (OA) patients. Specifically, the pain-related functional interference subscale and the sleep item from that subscale were examined. In Study 1 (n = 133), "night awakenings with pain" was positively correlated with the BPI interference score and sleep item and both correlated negatively with "quality of sleep." In Study 2 (n = 107), pain experienced "at night while in bed" correlated higher with sleep interference than with the BPI interference subscale. Intraclass correlations denoted adequate test-retest reliability; moderate-to-large Guyatt's statistics provided evidence of responsiveness. These analyses address a gap in the literature regarding the psychometric properties of the BPI interference measures in noncancer pain patients, confirming their reliability, validity, and responsiveness as potential endpoints in trials of pain medications involving patients with OA.

Switching from reservoir to matrix systems for the transdermal delivery of fentanyl: a prospective, multicenter pilot study in outpatients with chronic pain

Matrix systems for transdermal fentanyl will replace the reservoir systems in Europe. In an industry-independent, prospective, multicenter pilot study, 46 outpatients with chronic pain were asked to assess pain intensity, sleep interference, adverse events, and multiple secondary parameters during administration of the last reservoir and the first two matrix patches. There was no difference in pain intensity, sleep interference, and the rate of adverse events between both systems. Self assessment on a 6-step numeric rating scale (1 = very good, 6 = insufficient) comparing the two systems (reservoir vs. matrix) showed that skin compatibility (2.6 vs. 1.5), adhesive properties (3.2 vs. 1.8), wearability/comfort (2.8 vs. 1.5), and general satisfaction (2.5 vs. 1.8) improved significantly with the new matrix technology. At study endpoint, 91% of patients preferred the matrix system for future use. The new fentanyl matrix system is characterized by a high level of general satisfaction, ease of use, patient acceptance, and improved skin compatibility. Reservoir and matrix systems appear to have comparable efficacy and safety so that outpatients can be switched directly from the reservoir to the matrix system without difficulties and new dose titration.

HIV infection and shoulder pain: a challenging case

With better understanding of the pathogenesis of AIDS and the advent of anti-retroviral medications, patients with HIV are living longer and the probability that they will suffer musculoskeletal complications are increasing. There is a vast array of musculoskeletal impairments including rheumatologic, infectious, and non-infectious conditions. We report a 53-year-old man with longstanding shoulder pain, weakness, and spasticity of the upper extremity which was diagnosed as adhesive capsulitis secondary to brain abscess. Musculoskeletal problems may be complicated with neurological involvement as in our case and patients should be investigated for possible underlying life-threatening disease.

Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain

OBJECTIVES

The Brief Pain Inventory (BPI) is a short, self-administered questionnaire that was developed for use in cancer patients. While most empirical research with the BPI has been in pain of that etiology, the questionnaire is increasingly evident in published studies of patients with non-cancer pain. The current research addresses the need for formal evaluation of the reliability and validity of the BPI for use in non-cancer pain patients.

METHODS

Approximately 250 patients with arthritis or low back pain (LBP) self-administered a number of generic and condition-specific health status measures (including the BPI) in the clinic of their primary care provider at 2 time points: the initial clinic visit and the first visit following treatment.

RESULTS

The reliability of BPI data collected from non-cancer pain patients was comparable to that reported in the literature for cancer patients and sufficient for group-level analyses (coefficient alphas were greater than 0.70). The factor structure of the BPI was replicated in this sample and the relationship of the BPI to generic measures of pain was strong. The BPI exhibited similar relationships to general and condition-specific measures of health as did a generic pain scale (SF-36 Bodily Pain). Finally, the BPI discriminated among levels of condition severity and was sensitive to change in condition over time in arthritis and LBP patients.

DISCUSSION

Results support the validity of the BPI as a measure of pain in patients without cancer and, in particular, as a measure of pain for arthritis and LBP patients.

Costs of opioid therapy for chronic nonmalignant pain in Germany: an economic model comparing transdermal fentanyl (Durogesic) with controlled-release morphine

The fentanyl transdermal therapeutic system (fentanyl-TTS;Durogesic) has a distinct route of administration and safety profile compared with other opioids used in the treatment of moderate to severe pain.These aspects are likely to have an impact on patient acceptance and functioning as well as efficacy. We compared the cost-utility of fentanyl-TTS and controlled-release morphine (cr-morphine) in the treatment of moderate to severe nonmalignant pain in outpatients in Germany. A 1-year, three-phased decisionanalytic model was constructed, incorporating estimates of a variety of aspects of pain control.Use of fentanyl-TTS was predicted to incur higher costs than cr-morphine over 1 year of treatment (DM 6950 vs.DM 6186, respectively) but was associated with a higher number of quality-adjusted life days (234 vs. 216, respectively), thus achieving an incremental cost-utility ratio of DM 15,960 per quality-adjusted life-year gained.The results of the decision-analytic model support the use of fentanyl-TTS as a favorable cost-effective option for the treatment of moderate to severe nonmalignant pain.