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Treillet E, Perceau-Chambard E, Economos G, Chevalier L, Picard S, Frasca M, Pouget J, Calvel L, Tremellat-Faliere F, Majerus M, Quesnel PA, Chiquet R, Evin A, Seveque MA, Lebel A, Hardouin I, Burnod A, Renard O, Bessodes P, Giet O, Serresse L. Low-dose methadone added to another opioid for cancer pain: a multicentre prospective study. Support Care Cancer 2024; 32:716. [PMID: 39382714 PMCID: PMC11481640 DOI: 10.1007/s00520-024-08835-2] [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: 03/27/2024] [Accepted: 08/25/2024] [Indexed: 10/10/2024]
Abstract
CONTEXT The use of methadone for cancer pain management is gaining wider acceptance. However, switching to methadone treatment can still pose challenges. Consequently, there is ongoing development of its use in low doses in combination with other opioids, despite a lack of clinical evidence regarding its efficacy and safety. OBJECTIVES This study aimed to evaluate the efficacy and tolerability of low-dose methadone in combination with another opioid in patients with moderate-to-severe cancer-related pain in a clinical setting. PATIENTS AND METHODS This was a prospective, open-label study conducted in 19 pain and/or palliative care centres treating patients with cancer-related pain. Pain intensity, patients' global impression of change, and adverse effects were assessed on day 7 and day 14. The main outcome measure was the proportion of responders. RESULTS The study included 92 patients. The daily dose of methadone was 3 [3-6] mg at baseline, 9 [4-10] mg on day 7 and 10 [6-15] mg on day 14. The NRS pain ratings significantly decreased from 7 [6-8] at baseline to 5 [3-6] on visit 2 (p < .0001) and 4 [3-6] on visit 3 (p < .0001). Similarly, the VRS pain ratings decreased from 3 [3-3] at baseline to 2 [2-3] on visit 2 (p = 0.026) and 2 [1-3] (p < 0.001) on visit 3. At Visits 1 and 2, half of the patients were considered Responders. Of those responders, 73.5% were High-Responders at Visit 1 and 58.7% were High-Responders at Visit 2. No adverse events related to the risk of QT prolongation, overdose, or drug interactions were reported. CONCLUSION For patients experiencing moderate to severe cancer-related pain despite initial opioid treatment, our study found that low-dose methadone, when used in combination with another opioid, was both safe and effective. This supports the use of methadone as an adjunct to opioid-based treatment for cancer pain.
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Affiliation(s)
- Erwan Treillet
- Unité Douleur, Hôpitaux Civils de Colmar, Colmar, France.
- Unité Douleur, AP-HP, Groupe Hospitalier Universitaire APHP Nord-Université Paris Cité, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010, Paris, France.
| | | | | | - Luc Chevalier
- Département de Soins Palliatifs, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Stéphane Picard
- Unité de Soins Palliatifs, Hôpital Diaconesses-Croix Saint Simon, Paris, France
| | - Matthieu Frasca
- Département de Médecine Palliative, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Julie Pouget
- Maison de Santé Protestante de Bordeaux Bagatelle, Talence, France
| | - Laurent Calvel
- Département de Soins Palliatifs Et Soins de Support, Équipe Mobile de Soins d'accompagnement, de Soins de Support Et de Soins Palliatifs, Centre Hospitalier Universitaire de Strasbourg, Hôpital de Hautepierre, Strasbourg, France
| | | | - Maxime Majerus
- Unité de Soins Palliatifs, Centre Hospitalier de Dax, Dax, France
| | - Paul Antoine Quesnel
- Département de Soins Palliatifs, Unité de Soins Palliatifs, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Romain Chiquet
- Groupement Des Hôpitaux de L'Institut Catholique de Lille (GHICL), Lille, France
| | - Adrien Evin
- Centre Hospitalier Universitaire de Nantes, Nantes Université, Service de Soins Palliatifs Et de Support, Nantes, France
| | | | - Audrey Lebel
- AP-HP, Groupe Hospitalier Universitaire APHP Nord, Université Paris Cité, Hôpital Saint-Louis, Équipe de Soins Palliatifs, Paris, France
| | - Ines Hardouin
- Unité de Soins Palliatifs, AP-HP, Groupe Hospitalier Universitaire APHP Nord-Université Paris Cité, Hôpital Bretonneau, Paris, France
| | - Alexis Burnod
- Département de Soins de Support, PSL, Institut Curie, Paris, France
| | - Olivier Renard
- Département de Soins de Support, Centre Léon-Bérard, Lyon, France
| | | | - Olivier Giet
- Unité Douleur, Hôpitaux Civils de Colmar, Colmar, France
| | - Laure Serresse
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Service Soins Palliatifs, Accompagnement Et Soins de Support, 47-83 Bd de L'Hôpital, 75013, Paris, France.
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique, F-75005, Paris, France.
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Mercadante S. An overview of the current drug treatment strategies for moderate to severe, chronic malignant tumor-related pain. Expert Opin Pharmacother 2024; 25:171-179. [PMID: 37016731 DOI: 10.1080/14656566.2023.2200137] [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: 03/10/2022] [Accepted: 04/04/2023] [Indexed: 04/06/2023]
Abstract
INTRODUCTION The pharmacological management of cancer pain is a complex issue that requires knowledge and experience in the use of analgesics. The aim of this expert review is to provide a panorama of the pharmacological strategies in cancer pain management. AREAS COVERED Opioid dose titration is a delicate process regarding the start of opioid treatment in different clinical conditions. How to improve the opioid response is a fundamental step, which includes different strategies when an initial treatment with opioids fails. The use of adjuvants is another relevant issue that should be considered in some specific circumstances to optimize the management of cancer pain management. Some clinical conditions, such as neuropathic pain and breakthrough pain, deserve a special attention. Relevant literature was selected to provide an overview of cancer pain management strategies. EXPERT OPINION Opioid therapy still remains the cornerstone of pharmacological management of cancer pain. Opioids should be used according to the level of tolerance, also personalizing the treatment (route, drug, and dosing). Adjuvant drugs may help in specific conditions, although their use should be balanced with the adverse effects. Breakthrough pain requires expertise in tailoring a treatment according to patient's profile and characteristics of episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center of pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
- Home palliative care program, Regional Home care program, SAMOT, Palermo, Italy
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Fürst P. The Use of Low-Dose Methadone as Add-On to Ongoing Opioid Treatment in Palliative Cancer Care-An Underrated Treatment? Life (Basel) 2022; 12:679. [PMID: 35629347 PMCID: PMC9143404 DOI: 10.3390/life12050679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this review is to summarize the current knowledge of low-dose methadone treatment in palliative cancer care. In Sweden, methadone is quite common in specialized palliative care, where almost a tenth of patients are prescribed this drug. Negative attitudes towards methadone do not seem to prevent it from being used for pain management, and by starting with low doses and then increasing slowly and gradually, methadone can apparently be introduced safely. It is still uncertain whether methadone has a better analgesic effect than other opioids. However, for pain relief in cancer patients with severe and complex cancer-related pain, NMDA receptor inhibition with methadone may, in selected cases, be an attractive alternative, especially in the form of low-dose supplements to other ongoing opioids. Due to long half-life and complex metabolism, the use of methadone requires an experienced physician and solid follow-up. Continuous administration of opioids, including low-dose methadone, has been proven effective and safe in reducing pain in dying patients without increasing the risk of confusion, regardless of age.
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Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden;
- Palliative Medicine, Stockholms Sjukhem Foundation, SE-112 19 Stockholm, Sweden
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Mercadante S, Adile C, Ferrera P, Pallotti MC, Ricci M, Bonanno G, Casuccio A. OUP accepted manuscript. Oncologist 2022; 27:323-327. [PMID: 35380722 PMCID: PMC8982366 DOI: 10.1093/oncolo/oyab081] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Aim The aim of this study was to assess the efficacy and adverse effects of methadone when used as first-line therapy in patients that are either receiving low doses of opioids or none. Methods Patients with advanced cancer were prospectively assessed. Opioid-naive patients (L-group) were started with methadone at 6 mg/day. Patients receiving weak or other opioids in doses of <60 mg/day of OME (H-group) were started with methadone at 9 mg/day. Methadone doses were changed according to the clinical needs to obtain the most favorable balance between analgesia and adverse effects. Edmonton Symptom Asssement Score (ESAS), Memorial Delirium Assessment Score (MDAS), doses of methadone, and the use of adjuvant drugs were recorded before starting the study treatment (T0), 1 week after (T7), 2 weeks after (T14), 1 month after (T30), and 2 months after (T60). Methadone escalation index percent (MEI%) and in mg (MEImg) were calculated at T30 and T60. Results Eighty-two patients were assessed. In both groups H and L, there were significant changes in pain and symptom intensity at the different times during the study. Adverse effects as causes of drop-out were minimal. Mean MEImg was 0.09 (SD 0.28) and 0.02 (SD 0.07) at T30 and T60, respectively. MEI% was 1.01 (SD 3.08) and 0.27 (SD 0.86) at T30 and T60, respectively. Conclusion Methadone used as a first-line opioid therapy provided good analgesia with limited adverse effects and a minimal opioid-induced tolerance.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief & Supportive/Palliative Care, La Maddalena Cancer center, Palermo, Italy
- Corresponding author: Sebastiano Mercadante, MD, Main Regional Center for Pain Relief & Supportive/Palliative Care, La Maddalena Cancer center, La Maddalena, Via San Lorenzo 312, 90146 Palermo, Italy. , 03sebellemail.com
| | - Claudio Adile
- Main Regional Center for Pain Relief & Supportive/Palliative Care, La Maddalena Cancer center, Palermo, Italy
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief & Supportive/Palliative Care, La Maddalena Cancer center, Palermo, Italy
| | - Maria Caterina Pallotti
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Marianna Ricci
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy
| | - Giuseppe Bonanno
- Main Regional Center for Pain Relief & Supportive/Palliative Care, La Maddalena Cancer center, Palermo, Italy
| | - Alessandra Casuccio
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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Duarte FCN, Ferraro LHDC, Ferreira A, Sakata RK. A Randomized Controlled Trial Evaluating the Analgesic Effect of the Combination of Methadone With Morphine for Cancer Related Pain. Clin J Pain 2021; 37:664-668. [PMID: 34265791 DOI: 10.1097/ajp.0000000000000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/19/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT AND OBJECTIVES Although opioids play an indispensable role in the management of cancer-related pain, inadequate pain relief still occurs. The primary objective of this study was to evaluate whether the combination of a low dose of methadone with morphine promotes a reduction in opioid consumption; the secondary objectives were if the association promotes lower pain intensity, and adverse effects (AEs). MATERIALS AND METHODS A sample if 41 patients with cancer-related pain in palliative setting were included. Patients were starting the third step of the analgesic ladder, and 1 group (n=21) achieve methadone (2.5 mg/12 h) in combination with morphine/methadone, and another group (n=20) received morphine alone. Both groups could use morphine (5 mg) as needed to maintain pain intensity <4, and adjuvant in stable dose. The following outcomes were evaluated: total morphine dose, pain intensity, and AEs. RESULTS There was no difference in the number of adjuvants, and the dose of morphine used. Pain intensity was significantly lower in the morphine/methadone group after 2 weeks, with no statistically significant difference at other timepoints. There was no difference between groups in the AEs. CONCLUSION Low dose of methadone in combination with morphine provided faster pain control as compared with morphine alone, and although this study was not powered to show differences in AEs, we did not notice a difference.
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Fürst P, Lundström S, Klepstad P, Strang P. Continuous subcutaneous infusion for pain control in dying patients: experiences from a tertiary palliative care center. BMC Palliat Care 2020; 19:172. [PMID: 33172459 PMCID: PMC7657347 DOI: 10.1186/s12904-020-00681-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous subcutaneous infusion (CSCI) via ambulatory infusion pump (AIP) is a valuable method of pain control in palliative care. When using CSCI, low-dose methadone as add-on to other opioids might be an option in complex pain situations. This study aimed to investigate the effects, and adverse effects, of CSCI for pain control in dying patients, with particular interest in methadone use. METHODS This was an observational cohort study. Imminently dying patients with pain, admitted to specialized palliative inpatient wards and introduced on CSCI, were monitored daily by staff for symptoms (Integrated Palliative Care Outcome Scale - IPOS), sedation (Richmond Agitation and Sedation Scale - RASS), performance status (Eastern Cooperative Oncology Group - ECOG) and delirium (Confusion Assessment Method - CAM). RESULTS Ninety-three patients with a median survival of 4 days were included. Of the 47 patients who survived ≥3 days, the proportion of patients with severe/overwhelming pain decreased from 45 to 19% (p < 0.001) after starting CSCI, with only a moderate increase in morphine equivalent daily dose of opioids (MEDD). Alertness was marginally decreased (1 point on the 10-point RASS scale, p = 0.001), whereas performance status and prevalence of delirium, regardless of age, remained unchanged. Both patients with methadone as add-on (MET, n = 13) and patients with only other opioids (NMET, n = 34), improved in pain control (p < 0.05 and 0.001, respectively), despite that MET patients had higher pain scores at baseline (p < 0.05) and were on a higher MEDD (240 mg vs.133 mg). No serious adverse effects demanding treatment stop were reported. CONCLUSIONS CSCI via AIP is an effective way to reduce pain in dying patients without increased adverse effects. Add-on methadone may be beneficial in patients with severe complex pain.
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Affiliation(s)
- Per Fürst
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden. .,Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden.
| | - Staffan Lundström
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden.,Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,European Palliative Research Centre, Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anesthesiology and Intensive Care medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Peter Strang
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden.,Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Fürst P, Lundström S, Strang P. Methadone in Swedish specialized palliative care-Is it the magic bullet in complex cancer-related pain? PLoS One 2020; 15:e0230845. [PMID: 32275723 PMCID: PMC7147740 DOI: 10.1371/journal.pone.0230845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
CONTEXT Despite being associated with dependence and social stigma, methadone is a potential end-of-life option in complex cancer pain. OBJECTIVES To explore attitudes and opinions about methadone and its potential role and current use in complex end-of-life pain. METHODS Semi-structured interviews (n = 30) with physicians in specialized palliative care, transcribed and analyzed with conventional qualitative content analysis. RESULTS According to the physicians, patients and relatives expressed unexpectedly few negative attitudes, not affecting methadone's use as an analgesic. Complex pain in bone-metastatic cancer of the prostate, breast and kidney, as well as pancreatic cancer and sarcomas were recurrent suggestions of appropriate indications. Most of the informants stated that they applied a mechanism-based treatment and mainly prescribed low-dose methadone as an add-on to an existing opioid therapy to benefit from methadone´s proposed NMDA-receptor inhibiting properties, e.g. in cases with reduced opioid sensitivity. Despite its complex pharmacokinetics with a long half-life, most informants expressed defined strategies to avoid side-effects such as respiratory depression, especially when initiating treatment in the home-care setting. While many palliative care physicians expressed an overly enthusiastic attitude, others stressed the risks of overconfidence, low precision in use, and overlooked treatment options. Besides the obvious physical pain-relieving effects, they stated that effective pain relief could result in a reduced workload and emotional empowerment, both for physicians and staff. CONCLUSION Methadone, especially in the form of low-dose add-on to other opioids is widely advocated in Swedish specialized palliative care as a practical and safe method with rapid onset in complex pain situations at the end of life.
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Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
- * E-mail:
| | - Staffan Lundström
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Peter Strang
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Corli O, Porcu L, Santucci C, Bosetti C. The Complex Balance between Analgesic Efficacy, Change of Dose and Safety Profile Over Time, in Cancer Patients Treated with Opioids: Providing the Clinicians with an Evaluation Tool. J Clin Med 2020; 9:jcm9020502. [PMID: 32059572 PMCID: PMC7073698 DOI: 10.3390/jcm9020502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/21/2020] [Accepted: 02/10/2020] [Indexed: 01/29/2023] Open
Abstract
Background: Scanty data exist on the integration between the analgesic effect of opioids, dose changes, and adverse events in cancer patients. Methods: To provide further information on this issue, we analysed data on 498 advanced-stage cancer patients treated with strong opioids. At baseline and three visits (at days 7, 14, and 21), pain intensity, oral morphine-equivalent daily dose, and the prevalence of major adverse events were measured. The proportion of responders (pain intensity decrease ≥30% from baseline) and non-responders, as well as of patients with low or high dose escalation, was calculated. Results: Pain intensity strongly decreased from baseline (pain intensity difference −4.0 at day 7 and −4.2 at day 21) in responders, while it was quite stable in non-responders (pain intensity difference −0.8 at day 7 and −0.9 at day 21). In low dose escalation patients (82.4% at final visit), daily dose changed from 52.3 to 65.3 mg; in high dose escalation patients (17.6%), it varied from 94.1 to 146.7 mg. Among responders, high dose escalation patients experienced significantly more frequent adverse events compared to low or high dose escalation patients, while no differences were observed in non-responders. Conclusions: The response to opioids results from the combination of three clinical aspects, which are strongly interrelated. These results provide some thoughts to help clinical evaluations and therapeutic decisions regarding opioid use.
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Affiliation(s)
- Oscar Corli
- Department of Oncology, Laboratory of Methodology for Clinical Research, Unit of Pain and Palliative Care Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
- Correspondence: ; Tel.: +39-0239014-654
| | - Luca Porcu
- Department of Oncology, Laboratory of Methodology for Clinical Research, Unit of Methodological Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy;
| | - Claudia Santucci
- Department of Oncology, Laboratory of Methodology for Clinical Research, Unit of Cancer Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (C.S.); (C.B.)
| | - Cristina Bosetti
- Department of Oncology, Laboratory of Methodology for Clinical Research, Unit of Cancer Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (C.S.); (C.B.)
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Fürst P, Lundström S, Klepstad P, Strang P. The Use of Low-Dose Methadone as Add-On to Regular Opioid Therapy in Cancer-Related Pain at End of Life: A National Swedish Survey in Specialized Palliative Care. J Palliat Med 2020; 23:226-232. [DOI: 10.1089/jpm.2019.0253] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Staffan Lundström
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- European Palliative Research Centre, Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anesthesiology and Intensive Care medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Peter Strang
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Abstract
Methadone has been an unique, versatile, cost effective, synthetic opioid utilized in nociceptive as well as neuropathic pain. Pain and palliative care physicians started accepting methadone in treatment of complex pain associated with advanced cancer and neuropathic pain syndromes in which conventional opioids were no longer effective. The challenge is in accepting methadone as a main stream first line opioid, from being considered as a second line replacement/substitution drug all these years. Methadone has a significant role as opioid rotation in refractory cancer pain, especially when started early leading to successful conversion. Advantages of methadone in paediatric patients with advanced cancer were its safety and efficacy as a first-choice opioid, availability as a liquid formulation and its infrequent dose requirements. Methadone is neither recommended nor justified to be used as an anti-cancer drug and its role as an anti-cancer agent is a misconception. Many guidelines were proposed after 2008 to address methadone safety. Most of them emphasized on prevention of cardiac arrhythmia and association of methadone with QTc prolongation rather than address the real issue. Methadone has been established to be safe when used in opioid naïve patients with careful titration instituted in an ambulatory setting and has equal success in opioid rotation in outpatient setup. Methadone prescription should be carried out by experienced pain and palliative care providers with careful dose titration and clinical monitoring.
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Affiliation(s)
- S Ramkiran
- Department of Anaesthesiology, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Vishakapatnam, Andhra Pradesh, India
| | - Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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McPherson ML, Walker KA, Davis MP, Bruera E, Reddy A, Paice J, Malotte K, Lockman DK, Wellman C, Salpeter S, Bemben NM, Ray JB, Lapointe BJ, Chou R. Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper. J Pain Symptom Manage 2019; 57:635-645.e4. [PMID: 30578934 DOI: 10.1016/j.jpainsymman.2018.12.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/28/2018] [Accepted: 12/01/2018] [Indexed: 01/11/2023]
Abstract
Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.
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Affiliation(s)
| | - Kathryn A Walker
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA; MedStar Health, Baltimore, Maryland, USA
| | | | - Eduardo Bruera
- Palliative, Rehabilitation & Integrative Medicine Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; F. T. McGraw Chair in the Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Judith Paice
- Division of Hematology-Oncology, Northwestern University, Chicago, Illinois, USA; Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kasey Malotte
- Advanced Practice Pharmacist Supportive Care Medicine Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dawn Kashelle Lockman
- Hospice & Palliative Care, University of Iowa College of Pharmacy, Iowa City, Iowa, USA; Internal Medicine-Palliative Care Program, Iowa City, Iowa, USA
| | | | - Shelley Salpeter
- Stanford University School of Medicine, Stanford, California, USA; Mission Hospice and Home Care, San Mateo, California, USA
| | | | - James B Ray
- University of Iowa College of Pharmacy, Iowa City, Iowa, USA; Supportive and Palliative Care Consult Service, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Bernard J Lapointe
- Eric M. Flanders Chair in Palliative Medicine, McGill University, Montreal, Canada; Chief Supportive and Palliative Care Division, Jewish General Hospital, Montreal, Canada
| | - Roger Chou
- Division of General Internal Medicine and Geriatrics, OHSU, USA
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McPherson ML, Costantino RC, McPherson AL. Methadone: Maximizing Safety and Efficacy for Pain Control in Patients with Cancer. Hematol Oncol Clin North Am 2018; 32:405-415. [PMID: 29729777 DOI: 10.1016/j.hoc.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Methadone is a valuable opioid in the management of patients who have cancer with pain. Methadone is a mu-, kappa-, and delta-opioid agonist, and an N-methyl-D-aspartate receptor antagonist. These mechanisms of action make methadone an attractive option for complex pain syndromes. It is critically important that providers consider a patient's risk status before beginning methadone. Careful consideration must be given to dosing methadone in both opioid-naïve and opioid-tolerant patients, with vigilant monitoring for therapeutic effectiveness and potential toxicity until the patient achieves steady state.
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Affiliation(s)
- Mary Lynn McPherson
- Advanced Post-Graduate Education in Palliative Care, Online Master of Science and Graduate Certificates in Palliative Care, University of Maryland School of Pharmacy, 20 North Pine Street, S405, Baltimore, MD 21201, USA.
| | - Ryan C Costantino
- Pain Management/Palliative Care, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD 21201, USA
| | - Alexandra L McPherson
- Pain Management/Palliative Care, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD 21201, USA
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Improved Pain Control in Terminally Ill Cancer Patients by Introducing Low-Dose Oral Methadone in Addition to Ongoing Opioid Treatment. J Palliat Med 2018; 21:177-181. [DOI: 10.1089/jpm.2017.0157] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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14
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Sunilkumar MM, Lockman K. Practical Pharmacology of Methadone: A Long-acting Opioid. Indian J Palliat Care 2018; 24:S10-S14. [PMID: 29497249 PMCID: PMC5806300 DOI: 10.4103/ijpc.ijpc_180_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Methadone is a naturally long-acting analgesic with unique pharmacodynamic and pharmacokinetic properties compared to other opioids, available now in India, to treat severe pain. It has the potential to dramatically relieve suffering among patients with serious illness who are living with persistent physical pain. However, clinicians must appreciate its unique pharmacologic properties and its use in clinical practice safely and effectively. The available formulation in India is a racemic mixture of the S- and R-enantiomers, and as such, it will have a propensity for drug-drug and drug-genetic interactions that can increase the risk of Torsades de Point and respiratory depression. Appropriate patient selection, careful dosing and thorough monitoring of methadone will mitigate these risks.
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Affiliation(s)
- M M Sunilkumar
- Department of Pain and Palliative Medicine, Trivandrum Institute of Palliative Sciences, WHO Collaborating Centre for Training and Policy on Access to Pain Relief, Thiruvananthapuram, Kerala, India
| | - Kashelle Lockman
- Department of Pharmacy Practice and Science, University of Iowa, College of Pharmacy, Iowa City, IA 52242, USA
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15
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Vu Bach T, Pan J, Kirstein A, Grief CJ, Grossman D. Use of Methadone as an Adjuvant Medication to Low-Dose Opioids for Neuropathic Pain in the Frail Elderly: A Case Series. J Palliat Med 2016; 19:1351-1355. [PMID: 27726521 DOI: 10.1089/jpm.2016.0246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Palliative care clinicians are increasingly involved in the care of elderly patients suffering from chronic malignant and nonmalignant illnesses, of which neuropathic pain is a prevalent problem. As a person becomes more frail, pain medications such as opioid analgesics and adjuvant pain medications can result in unwanted effects such as sedation, confusion, and increased risk of falls. Treating pain in patients with advanced dementia or neurodegenerative diseases that can affect swallowing is particularly challenging because most adjuvant pain medications used to ameliorate neuropathic pain must be taken orally. Furthermore, dosing of neuropathic medications is limited by renal function, which is often impaired in the elderly due to both normal aging and renal disease. Methadone is an opioid analgesic that is effective in the treatment of neuropathic pain, is excreted by the bowels, is highly lipophilic, and can be administered through the oral, buccal, or sublingual routes. We present three cases highlighting the use of low-dose adjuvant methadone to manage complex neuropathic pain in the frail elderly.
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Affiliation(s)
- Tammy Vu Bach
- 1 Baycrest Health Sciences , Toronto, Ontario, Canada .,2 Division of Palliative Care, Department of Family and Community Medicine, University of Toronto , Toronto, Ontario, Canada
| | - Jonathan Pan
- 3 Leslie Dan Faculty of Pharmacy, University of Toronto , Toronto, Ontario, Canada
| | - Anne Kirstein
- 1 Baycrest Health Sciences , Toronto, Ontario, Canada .,3 Leslie Dan Faculty of Pharmacy, University of Toronto , Toronto, Ontario, Canada
| | - Cindy Joanne Grief
- 1 Baycrest Health Sciences , Toronto, Ontario, Canada .,4 Division of Geriatric Psychiatry, Department of Psychiatry, University of Toronto , Toronto, Ontario, Canada
| | - Daphna Grossman
- 2 Division of Palliative Care, Department of Family and Community Medicine, University of Toronto , Toronto, Ontario, Canada .,5 Freeman Centre for the Advancement of Palliative Care, North York General Hospital , Toronto, Ontario, Canada
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16
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Sugiyama Y, Sakamoto N, Ohsawa M, Onizuka M, Ishida K, Murata Y, Iio A, Sugano K, Maeno K, Takeyama H, Akechi T, Kimura K. A Retrospective Study on the Effectiveness of Switching to Oral Methadone for Relieving Severe Cancer-Related Neuropathic Pain and Limiting Adjuvant Analgesic Use in Japan. J Palliat Med 2016; 19:1051-1059. [DOI: 10.1089/jpm.2015.0303] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yosuke Sugiyama
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Pharmacy, Nagoya City University Hospital, Nagoya, Japan
| | - Nobuhiro Sakamoto
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Masahiro Ohsawa
- Department of Neuropharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Mami Onizuka
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Kyoko Ishida
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yuki Murata
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Ayaka Iio
- Department of Neuropharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan,
| | - Ken Maeno
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Hiromitsu Takeyama
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Tatsuo Akechi
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Kazunori Kimura
- Department of Pharmacy, Nagoya City University Hospital, Nagoya, Japan
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17
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Courtemanche F, Dao D, Gagné F, Tremblay L, Néron A. Methadone as a Coanalgesic for Palliative Care Cancer Patients. J Palliat Med 2016; 19:972-8. [PMID: 27399839 DOI: 10.1089/jpm.2015.0525] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Methadone offers many advantages for treating cancer pain. However, its pharmacokinetic profile makes its use as a full-dose opioid challenging. OBJECTIVES To evaluate the efficacy and safety of low-dose methadone as an adjunct to opioids in the treatment of cancer pain in palliative care patients. DESIGN A cohort was followed retrospectively for up to 60 days after the initiation of methadone as a coanalgesic. SETTING/SUBJECTS Patients were eligible if they were prescribed methadone as a coanalgesic for cancer pain management and followed by the palliative care team. MEASUREMENTS The primary efficacy end point was reduction of pain intensity (11-point numerical rating scale). Variables associated with pain intensity reduction were explored using logistic regressions. Adverse events were collected throughout the follow-up. RESULTS Seventy-two of the 146 subjects (49%) qualified as significant responders (≥30% reduction in pain intensity). Median time to significant response was seven days, and pain intensity on the day of methadone initiation predicted the response to treatment. The most frequently reported adverse events were drowsiness, confusion, constipation, and nausea. As expected in a palliative care population, there was a substantial amount of missing data. CONCLUSIONS A significant reduction in pain can be seen rapidly after the addition of methadone as a coanalgesic, particularly among patients with high pain intensity. More studies are needed to corroborate the efficacy of methadone as an adjunct to opioids.
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Affiliation(s)
- Fanny Courtemanche
- 1 Faculté de Pharmacie Pavillon Jean-Coutu, Université de Montréal , Montréal, Canada .,2 Centre Hospitalier de l'Université de Montréal (CHUM) , Montréal, Canada
| | - Denis Dao
- 1 Faculté de Pharmacie Pavillon Jean-Coutu, Université de Montréal , Montréal, Canada .,2 Centre Hospitalier de l'Université de Montréal (CHUM) , Montréal, Canada
| | - Félixe Gagné
- 1 Faculté de Pharmacie Pavillon Jean-Coutu, Université de Montréal , Montréal, Canada .,2 Centre Hospitalier de l'Université de Montréal (CHUM) , Montréal, Canada
| | - Lydjie Tremblay
- 1 Faculté de Pharmacie Pavillon Jean-Coutu, Université de Montréal , Montréal, Canada .,2 Centre Hospitalier de l'Université de Montréal (CHUM) , Montréal, Canada
| | - Andrée Néron
- 1 Faculté de Pharmacie Pavillon Jean-Coutu, Université de Montréal , Montréal, Canada .,2 Centre Hospitalier de l'Université de Montréal (CHUM) , Montréal, Canada
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Abstract
This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Lundeberg S. Pain in children--are we accomplishing the optimal pain treatment? Paediatr Anaesth 2015; 25:83-92. [PMID: 25279762 DOI: 10.1111/pan.12539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2014] [Indexed: 12/01/2022]
Abstract
Morphine, paracetamol and local anesthetics have for a long time been the foremost used analgesics in the pediatric patient by tradition but not always enough effective and associated with side effects. The purpose with this article is to propose alternative approaches in pain management, not always supported up by substantial scientific work but from a combination of science and clinical experience in the field. The scientific literature has been reviewed in parts regarding different aspects of pain assessment and analgesics used for treatment of diverse pain conditions with focus on procedural and acute pain. Clinical experience has been added to form the suggested improvements in accomplishing an improved pain management in pediatric patients. The aim with pain management in children should be a tailored analgesic medication with an individual acceptable pain level and optimal degree of mobilization with as little side effects as possible. Simple techniques of pain control are as effective as and complex techniques in pediatrics but the technique used is not of the highest importance in achieving a good pain management. Increased interest and improved education of the doctors prescribing analgesics is important in accomplishing a better pain management. The optimal treatment with analgesics is depending on the analysis of pain origin and analgesics used should be adjusted thereafter. A multimodal treatment regime is advocated for optimal analgesic effect.
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Affiliation(s)
- Stefan Lundeberg
- Pediatric Pain Treatment Service, Department of Pediatric Anesthesia, Operating Services and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Intitutet, Stockholm, Sweden
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Reddy A, Yennurajalingam S, Bruera E. Dual opioid therapy using methadone as a coanalgesic. Expert Opin Drug Saf 2014; 14:181-2. [DOI: 10.1517/14740338.2015.979389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Poulain P, Michenot N, Delorme T, Filbet M, Hubault P, Jovenin N, Rostaing S, Colin E, Chvetsoff G, Ammar D, Delorme C, Diquet B, Krakowski I, Magnet M, Minello C, Morere JF, Serrie A. Mise au point sur l’utilisation pratique de la méthadone dans le cadre des douleurs en oncologie. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.douler.2014.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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22
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Management of Fungating Tumors and Pressure Ulcers in a Patient With Stage IV Cutaneous Malignant Melanoma. J Hosp Palliat Nurs 2014. [DOI: 10.1097/njh.0000000000000059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Lee SK, Dawson J, Lee JA, Osman G, Levitin MO, Guzel RM, Djamgoz MB. Management of cancer pain: 1. Wider implications of orthodox analgesics. Int J Gen Med 2014; 7:49-58. [PMID: 24470767 PMCID: PMC3891517 DOI: 10.2147/ijgm.s42187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In this review, the first of two parts, we first provide an overview of the orthodox analgesics used commonly against cancer pain. Then, we examine in more detail the emerging evidence for the potential impact of analgesic use on cancer risk and disease progression. Increasing findings suggest that long-term use of nonsteroidal anti-inflammatory drugs, particularly aspirin, may reduce cancer occurrence. However, acetaminophen may raise the risk of some hematological malignancies. Drugs acting upon receptors of gamma-aminobutyric acid (GABA) and GABA “mimetics” (eg, gabapentin) appear generally safe for cancer patients, but there is some evidence of potential carcinogenicity. Some barbiturates appear to slightly raise cancer risks and can affect cancer cell behavior in vitro. For cannabis, studies suggest an increased risk of squamous cell carcinoma of the tongue, larynx, and possibly lung. Morphine may stimulate human microvascular endothelial cell proliferation and angiogenesis; it is not clear whether this might cause harm or produce benefit. The opioid, fentanyl, may promote growth in some tumor cell lines. Opium itself is an emerging risk factor for gastric adenocarcinoma and possibly cancers of the esophagus, bladder, larynx, and lung. It is concluded that analgesics currently prescribed for cancer pain can significantly affect the cancer process itself. More futuristically, several ion channels are being targeted with novel analgesics, but many of these are also involved in primary and/or secondary tumorigenesis. Further studies are needed to elucidate possible cellular and molecular effects of orthodox analgesics and their possible long-term impact, both positive and negative, and thus enable the best possible clinical gain for cancer patients.
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Affiliation(s)
| | - Jill Dawson
- Healthcare Communications Consultancy, Danville, CA, USA
| | - Jack A Lee
- College of Arts and Sciences, Vanderbilt University, Nashville, TN, USA
| | - Gizem Osman
- Department of Chemical Engineering, Loughborough University, Loughborough, UK
| | - Maria O Levitin
- Division of Cell and Molecular Biology, Neuroscience Solutions to Cancer Research Group, South Kensington Campus, Imperial College London, London, UK
| | - Refika Mine Guzel
- Division of Cell and Molecular Biology, Neuroscience Solutions to Cancer Research Group, South Kensington Campus, Imperial College London, London, UK
| | - Mustafa Ba Djamgoz
- Division of Cell and Molecular Biology, Neuroscience Solutions to Cancer Research Group, South Kensington Campus, Imperial College London, London, UK ; Cyprus International University, Biotechnology Research Centre, Haspolat, North Cyprus, Mersin, Turkey
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