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Li Q, Long YL, He YW, Long H, Xiao ZP, Li YL, Yang WZ, Jiang LP, Gao W, Zou C. Intrathecal morphine delivery at prepontine cistern to control refractory cancer-related pain: a case report of extensive metastatic and refractory cancer pain. BMC Anesthesiol 2024; 24:77. [PMID: 38408913 PMCID: PMC10895834 DOI: 10.1186/s12871-024-02426-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Extensive metastatic and refractory cancer pain is common, and exhibits a dissatisfactory response to the conventional intrathecal infusion of opioid analgesics. CASE PRESENTATION The present study reports a case of an extensive metastatic esophageal cancer patient with severe intractable pain, who underwent translumbar subarachnoid puncture with intrathecal catheterization to the prepontine cistern. After continuous infusion of low-dose morphine, the pain was well-controlled with a decrease in the numeric rating scale (NRS) of pain score from 9 to 0, and the few adverse reactions to the treatment disappeared at a low dose of morphine. CONCLUSIONS The patient achieved a good quality of life during the one-month follow-up period.
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Affiliation(s)
- Qing Li
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Yan-Ling Long
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Yun-Wu He
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Hui Long
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Zhen-Ping Xiao
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Yong-Lin Li
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Wu-Zhou Yang
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Li-Ping Jiang
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Wei Gao
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China
| | - Cong Zou
- Department of Pain and Rehabilitation, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, China.
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Zeng X, Zhu J, Li J, Chen C, Sang L, Liu M, Song L, Liu H. Patient Controlled Subcutaneous Analgesia of Hydromorphone Versus Morphine to Treat Moderate and Severe Cancer Pain: A Randomized Double-Blind Controlled Trial. J Pain Symptom Manage 2024; 67:50-58. [PMID: 37742793 DOI: 10.1016/j.jpainsymman.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/17/2023] [Accepted: 09/13/2023] [Indexed: 09/26/2023]
Abstract
CONTEXT Hydromorphone and morphine are the common drugs used for the treatment of moderate to severe cancer pain. Patient controlled subcutaneous analgesia (PCSA) is an effective technique to manage cancer pain. However, few studies have been conducted to show the efficacy and safety of PCSA of hydromorphone for the relief of cancer pain. OBJECTIVES To explore the short-term efficacy and safety of PCSA elicited by hydromorphone for moderate to severe cancer pain. METHODS This was a single-center, randomized, active-controlled, double-blind trial (from April 2019 to August 2021). Sixty patients with moderate to severe cancer pain were randomized (1:1) to hydromorphone or morphine groups according to drug delivery by PCSA. The primary outcome was the pain intensity measured by a numerical rating scale (NRS) at 72 hours. Secondary outcomes included pain intensity measured by NRS at baseline, 15 minutes, 30 minutes, two hours, eight hours, 24 hours and 48 hours. The daily occurrence of breakthrough pain (BTP), impact of pain on quality of life measured by the brief pain inventory (BPI), the daily additional consumption of opioids and the incidence of adverse events were also recorded. Adverse events included nausea, vomiting, dizziness, constipation and respiratory depression. RESULTS A total of 57 patients (28 patients in the hydromorphone group and 29 patients in the morphine group) in the West China Hospital of Sichuan University were investigated. The mean (standard deviation [SD]) NRS in the two groups at baseline was 7.8 (1.7) in the hydromorphone group and 7.6 (1.7) in the morphine group, and at 72 hours were 3.4 (1.8) and 3.2 (1.5), respectively. The postoperative NRS in both groups was decreased significantly compared to baseline. The mean (SD) NRS at 30 minutes in the hydromorphone group was significantly lower than in the morphine group (3.9 [2.6] vs. 5.3 [2.1], P = 0.035). The daily occurrence of BTP in both groups at 48 hours and 72 hours decreased significantly compared to the corresponding baseline (P < 0.05), and there was no significant difference between the two groups. The total scores and sub-item scores of BPI at 24 hours and 72 hours after PCSA in both groups decreased significantly from baseline. A comparison of daily additional consumption of opioids between the two groups revealed no statistically significant difference. There were no significant differences in the incidences of nausea, vomiting, dizziness or constipation between the two groups (P > 0.05). CONCLUSION This study found that the PCSA of both hydromorphone and morphine could effectively and safely relieve short-term moderate to severe cancer pain. Of note, the PCSA of hydromorphone took effect more quickly than that of morphine.
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Affiliation(s)
- Xianzheng Zeng
- Department of Pain Management (X.Z, J.L., Li.S., H.L.), West China Hospital, Sichuan University, Chengdu, China
| | - Jiang Zhu
- Department of Thoracic Oncology (J.Z.), West China Hospital, Sichuan University, Chengdu, China; Department of Medical Oncology (J.Z.), Shangjin Nanfu Hospital, Chengdu, China
| | - Jun Li
- Department of Pain Management (X.Z, J.L., Li.S., H.L.), West China Hospital, Sichuan University, Chengdu, China
| | - Chan Chen
- Department of Anesthesiology (C.C, Ling.S., M.L.), West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine (C.C), National-Local Joint Engineering Research Centre of Translational Medicine of nesthesiology (C.C), West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Sang
- Department of Anesthesiology (C.C, Ling.S., M.L.), West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Maotong Liu
- Department of Anesthesiology (C.C, Ling.S., M.L.), West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Song
- Department of Pain Management (X.Z, J.L., Li.S., H.L.), West China Hospital, Sichuan University, Chengdu, China.
| | - Hui Liu
- Department of Pain Management (X.Z, J.L., Li.S., H.L.), West China Hospital, Sichuan University, Chengdu, China
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Dupoiron D, Bienfait F, Carvajal G, Seegers V, Douillard T, Jubier-Hamon S, Delorme T, Julienne A, Pluchon YM, Ribault N, Nader E, Lebrec N. Intrathecal cervical analgesia for cancer pain: a 12-year follow-up study in a comprehensive cancer center. Reg Anesth Pain Med 2023:rapm-2023-104961. [PMID: 37973378 DOI: 10.1136/rapm-2023-104961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Intrathecal analgesia plays a key role for patients suffering refractory cancer pain. Nevertheless, intrathecal drug delivery systems (IDDS), requiring a cervical catheter tip implantation, have been poorly described in medical literature. AIMS A monocentric retrospective follow-up study was designed to evaluate results of cervical IDDS for cancer pain. PATIENTS AND METHODS From January 2010 to December 2022, all intrathecal-treated patients were prescribed a combined intrathecal analgesics regimen through a catheter placed in the cervical vertebral canal. Post-implant assessment of pain was determined using a numeric rating scale (NRS). Patients were followed via day-hospital visits and telephone calls at least monthly. Pain scores were compared using the Wilcoxon's signed rank test. RESULTS Ninety-eight patients were included in this study; all received intrathecal treatments. Implanted patients suffered from severe pain (mean presurgical maximum numerical rating score 8.02±0.24 despite a mean 562.56±127.72 mg of oral morphine equivalent daily dose). Mean survival time after intrathecal treatment start was 208.48±67 days. Intrathecal drug delivery systems provided pain relief compared with initial pain score with a significant statistical difference after 1 week, 1 month, 2 and 3 months (p<0.01). A 50% reduction in initial pain level was achieved in 93% of cases during the first week of intrathecal implant. CONCLUSIONS Results suggest that long-term intrathecal treatment using a multidrug regimen for cancer-related pain through cervical intrathecal catheters was suitable and safe in our study population. We demonstrated a clinically and statistically significant pain reduction in patients using mainly a percutaneous lumbar approach.
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Affiliation(s)
- Denis Dupoiron
- Anesthesiology and Pain Department, Institut de Cancérologie de l'Ouest, Angers, France
| | - Florent Bienfait
- Anesthesiology and Pain Department, Institut de Cancérologie de l'Ouest, Angers, France
| | - Gabriel Carvajal
- Palliative Care, Costa Rica University, San Jose, San José, Costa Rica
| | - Valerie Seegers
- Epidemiology and Statistics Department, Institut de Cancerologie de l'Ouest Site Paul Papin, Angers, France
| | - Thomas Douillard
- Anesthesiology and Pain Department, Institut de Cancérologie de l'Ouest, Angers, France
| | - Sabrina Jubier-Hamon
- Anesthesiology and Pain Department, Institut de Cancérologie de l'Ouest, Angers, France
| | - Thierry Delorme
- Anesthesiology and Pain Department, Institut de Cancérologie de l'Ouest, Angers, France
| | - Arthur Julienne
- Anesthesiology and Pain Department, Institut de Cancérologie de l'Ouest, Angers, France
| | - Yves Marie Pluchon
- Pain Department, Centre Hospitalier Departmental La Roche-sur-Yon, La Roche-sur-Yon, Pays de la Loire, France
| | - Nicolas Ribault
- Neurosurgery Department, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | - Edmond Nader
- Neurosurgery Department, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | - Nathalie Lebrec
- Anesthesiology and Pain Department, Institut de Cancérologie de l'Ouest, Angers, France
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Mercadante S. Refractory Cancer Pain and Intrathecal Therapy: Critical Review of a Systematic Review. Pain Ther 2023; 12:645-654. [PMID: 37055698 PMCID: PMC10199986 DOI: 10.1007/s40122-023-00507-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/23/2023] [Indexed: 04/15/2023] Open
Abstract
This critical review assessed the advantages of invasive procedures that were recently included in systematic reviews, to evaluate whether the definition of refractory pain condition was correctly followed to select patients for invasive interventions and to analyze how data were positively interpreted. A total of 21 studies were selected for the purpose of this review. Three were randomized controlled studies, ten were prospective studies, and eight were retrospective studies. Analysis of these studies showed evident lack of proper assessment before implantation for different reasons. These included an optimistic interpretation regarding the outcomes, poor consideration of complications, and inclusion of patients with short survival. Moreover, the indication of intrathecal therapy as a condition in which a patient has failed to respond to multiple therapies provided by a pain or palliative care physician or at sufficient doses for adequate durations, as suggested by a recent research group, has been disregarded. Regretfully, this can discourage the use of intrathecal therapy in patients who are unresponsive to multiple opioid strategies subtrahend a potent means to be used in a very selective population.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90100, Palermo, Italy.
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Liang B, Li C, Zhou Z, Xie Y. Antitumor Effects of Hydromorphone on Human Gastric Cancer Cells in vitro. Drug Des Devel Ther 2023; 17:1037-1045. [PMID: 37057060 PMCID: PMC10086391 DOI: 10.2147/dddt.s398464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/22/2023] [Indexed: 04/09/2023] Open
Abstract
Introduction Experimental data indicate that morphine and fentanyl may have antitumor effects in gastric cancer cells (GC). Hydromorphone, as an analgesic, is used against refractory cancer pain in recent years. However, the data on hydromorphone influencing the biological characteristics of human gastric cancer cells are lacking. The aim of this study was to investigate how hydromorphone affected the growth of human gastric cancer in vitro. Material and Methods Human GC cell lines (HGC-27, MGC-803, AGS and SGC-7901) and human gastric epithelial cells GSE-1 were exposed to various concentrations of hydromorphone (0-800μM). The cell viability, invasion and migration abilities were measured using cell counting kit-8, Transwell and wound healing assays. Apoptosis and cell cycle were evaluated by flow cytometry. Results Hydromorphone was toxic in GSE-1 cells at the concentration 800μM. It showed enhanced antitumor effects at a longer incubation time and higher concentrations in HGC-27, MGC-803, AGS and SGC-7901 cells. Hydromorphone inhibited the progression of MGC- 803 cells by cell cycle arrest and apoptosis induction. Conclusion Hydromorphone suppresses the proliferation of human GC cells in a dose- and time-dependent manner. That may provide a theoretical basis for the clinical application of hydromorphone in the safe and effective treatment of GC.
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Affiliation(s)
- Beiwei Liang
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Chunlai Li
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Zhan Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery After Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China
- Correspondence: Yubo Xie, Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China, Email
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Van Zundert J, Rauck R. Intrathecal drug delivery in the management of chronic pain. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Yiping S, Jiayi S, Guang H, Yun J, Bingjie M, Xuehua H, Zhiyuan Y, Pingchuan M, Ke M. The efficacy and safety of epidural morphine/hydromorphone in the treatment of intractable postherpetic neuralgia: A single-center, double-blinded, randomized controlled, prospective, and non-inferiority study. Front Pharmacol 2022; 13:1051357. [PMID: 36561344 PMCID: PMC9763618 DOI: 10.3389/fphar.2022.1051357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Objective: Postherpetic neuralgia (PHN) is a clinical puzzle, especially in patients who still suffered from moderate and severe pain after standard treatment. This single-center, double-blinded, randomized controlled, prospective, and non-inferiority study observed the safety and effectiveness of the epidural application of morphine or hydromorphone, trying to provide an alternative method for those patients with refractory PHN. Methods: Eighty PHN patients with a visual analogue scale (VAS) still greater than 50 mm after routine management were randomly divided into two groups according to 1:1, respectively. One group received epidural morphine (EMO group), and the other group received epidural hydromorphone (EHM group). VAS, the number of breakthrough pain, quality of life (QOL), and anxiety/depression assessment (GAD-7 and PHQ-9 scores) were also observed before treatment, at 1, 3, 7, 14, 21, 28, 60, and 90 days after treatment, as well as side effects. Opioid withdrawal symptoms (OWSs) were also measured from 3 to 28 days after treatment. Results: The EHM group was non-inferior to the EMO group in terms of the VAS decrease relative to baseline (VDRB) after 1-week treatment. The VAS of the two groups on all days after treatment was significantly lower than the corresponding baseline findings (p < 0.05). The breakthrough pain (BTP) decreased significantly after treatment and lasted until 14 days after treatment (p < 0.05). There was no significant difference in BTP between the two groups at each time point (p > 0.05). In terms of the QOL, GAD-7, and PHQ-9 outcomes, those were significantly improved after treatment (p < 0.05), and there was no difference between the two groups (p > 0.05). No significant AE difference across the two groups was observed in this study. Few reports of OWS were found in this trial, and there were no significant differences between the two groups (p > 0.05). Conclusion: EHM was non-inferior to EMO in terms of the VDRB after 1-week treatment. For patients with VAS still greater than 50 mm after standard treatment, short-term application of EMO or EHM can ameliorate intractable pain, improve the quality of life, and have no obvious side effects. Short-term epidural opioid application will not lead to the appearance of OWS.
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Affiliation(s)
- Sun Yiping
- Department of Clinical Research, Xinhua Hospital, Medical School, Shanghai Jiaotong University, Shanghai, China
| | - Shen Jiayi
- Department of Clinical Research, Xinhua Hospital, Medical School, Shanghai Jiaotong University, Shanghai, China
| | - Hei Guang
- Department of Algology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ji Yun
- Department of Algology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, Shanghai, China
| | - Ma Bingjie
- Department of Algology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, Shanghai, China
| | - Huang Xuehua
- Department of Algology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, Shanghai, China
| | - Yu Zhiyuan
- Department of Algology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, Shanghai, China
| | - Ma Pingchuan
- High School of Jiguang, Hongkou District, Shanghai, China
| | - Ma Ke
- Department of Algology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, Shanghai, China,*Correspondence: Ma Ke,
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Ding L, Chen D, Chen Y, Wei X, Zhang Y, Liu F, Li Q. Intrathecal hydromorphone for analgesia after partial hepatectomy: a randomized controlled trial. Reg Anesth Pain Med 2022; 47:rapm-2021-103452. [PMID: 35977778 DOI: 10.1136/rapm-2021-103452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 08/06/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION There is substantial interest in adding intrathecal opioids, such as hydromorphone to the multimodal pain management strategies. We conducted a randomized controlled trial to examine whether adding intrathecal hydromorphone to a multimodal strategy could safely improve analgesic efficacy for patients undergoing partial hepatectomy. METHODS A total of 126 adult patients undergoing partial hepatectomy under general anesthesia were randomly assigned to receive intrathecal hydromorphone (100 μg) or no block. The primary outcome was the incidence of moderate to severe pain during movement at 24 hours after surgery. Secondary outcomes included the incidence of moderate to severe pain during rest or movement at different times within 72 hours, pain scores during rest or movement within 72 hours after surgery, analgesic use, adverse events, and indicators of postoperative recovery. RESULTS Among the 124 patients analyzed, the intrathecal hydromorphone group showed a lower incidence of moderate to severe pain during movement at 24 hours after surgery (29.0% vs 50%; RR 0.58, 95% CI 0.37 to 0.92) than the control group. However, the absolute difference in pain scores on a numerical rating scale was less than 1 between the two groups at 24 hours after surgery. Mild pruritus within the first 24 hours after surgery was more frequent in the intrathecal hydromorphone group (19.4% vs 4.8%; p=0.01). DISCUSSION Intrathecal hydromorphone 100 μg reduced the incidence of moderate to severe pain and pain scores during movement within 24 hours after partial hepatectomy. However, the difference in pain scores may not be clinically significant, and intrathecal hydromorphone 100 μg did not significantly improve other analgesic or functional outcomes. Further investigation is needed to optimize the intrathecal hydromorphone dose. TRIAL REGISTRATION NUMBER ChiCTR2000030652.
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Affiliation(s)
- Lin Ding
- Department of Anesthesiology, West China Hospital of Medicine, Chengdu, Sichuan, China
| | - Dongxu Chen
- Department of Anesthesiology, West China Hospital of Medicine, Chengdu, Sichuan, China
| | - Yu Chen
- Department of Anesthesiology, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Xiongli Wei
- Department of Anesthesiology, Liuzhou Worker's Hospital, Liuzhou, Guangxi, China
| | - Yabing Zhang
- Department of Anesthesiology, West China Hospital of Medicine, Chengdu, Sichuan, China
| | - Fei Liu
- Department of Anesthesiology, West China Hospital of Medicine, Chengdu, Sichuan, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital of Medicine, Chengdu, Sichuan, China
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Ma C, Zhao D, Hu X, Li C, Zhang J, Zhang Y, Yuan L. Perioperative Effects of Hydromorphone in Gynecological Laparoscopic Surgery under General Anesthesia. INT J PHARMACOL 2022. [DOI: 10.3923/ijp.2022.534.542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Analgesic Effect of Ropivacaine Combined with Hydromorphone following Surgery for Mixed Hemorrhoids: A Pilot Study. Pain Res Manag 2022; 2022:2033580. [PMID: 35154550 PMCID: PMC8837450 DOI: 10.1155/2022/2033580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/17/2022] [Indexed: 11/17/2022]
Abstract
Background Postoperative pain is a major adverse effect of surgery for mixed hemorrhoids. We evaluated whether spinal anesthesia with ropivacaine and hydromorphone provided safe and effective analgesia after surgery for mixed hemorrhoids. Methods This single-center, double-blind pilot study included patients with mixed hemorrhoids who underwent a procedure for prolapse and hemorrhoids (PPH) and external hemorrhoidectomy under spinal anesthesia at Zhejiang Hospital, China (October 2020 to December 2020). Patients were randomized to a hydromorphone group (spinal anesthesia with 0.5% ropivacaine and 75 μg hydromorphone) or morphine group (spinal anesthesia with 0.5% ropivacaine and 150 μg morphine). Pain scores (numerical rating scale), incidences of vomiting and itching, and length of hospital stay (LoS) were recorded at 6, 12, 18, and 24 hours after surgery. Results The analysis included 40 patients in each group. Median (interquartile range) pain score in the hydromorphone group was higher than that in the morphine group at 12 hours (1 (0–2] vs. 0 (0–2), p=0.044) but not significantly different between groups at 6 hours (0 (0–1) vs. 0 (0-0) p=0.228), 18 hours (2 (2–3) vs. 2 (1–3) p=0.060) or 24 hours (2 (2–3) vs. 2 (1–3) p=0.081). The hydromorphone group had a lower incidence of pruritus than the morphine group (47.5% vs. 67.5%, p=0.018). There were no significant differences between groups in vomiting incidence or LoS. Conclusion In patients with mixed hemorrhoids, spinal anesthesia with ropivacaine/hydromorphone has a comparable analgesic effect and a lower incidence of pruritus during the first 24 hours after surgery than spinal anesthesia with ropivacaine/morphine.
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Abstract
Neuraxial drug administration, i.e., the injection of drugs into the epidural or intrathecal space to produce anesthesia or analgesia, is a technique developed more than 120 years ago. Today, it still is widely used in daily practice in anesthesiology and in acute and chronic pain therapy. A multitude of different drugs have been introduced for neuraxial injection, only a part of which have obtained official approval for that indication. A broad understanding of the pharmacology of those agents is essential to the clinician to utilize them in a safe and efficient manner. In the present narrative review, we summarize current knowledge on neuraxial anatomy relevant to clinical practice, including pediatric anatomy. Then, we delineate the general pharmacology of neuraxial drug administration, with particular attention to specific aspects of epidural and intrathecal pharmacokinetics and pharmacodynamics. Furthermore, we describe the most common clinical indications for neuraxial drug administration, including the perioperative setting, obstetrics, and chronic pain. Then, we discuss possible neurotoxic effects of neuraxial drugs, and moreover, we detail the specific properties of the most commonly used neuraxial drugs that are relevant to clinicians who employ epidural or intrathecal drug administration, in order to ensure adequate treatment and patient safety in these techniques. Finally, we give a brief overview on new developments in neuraxial drug therapy.
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Abstract
BACKGROUND This is an update of the original Cochrane Review first published in Issue 10, 2016. For people with advanced cancer, the prevalence of pain can be as high as 90%. Cancer pain is a distressing symptom that tends to worsen as the disease progresses. Evidence suggests that opioid pharmacotherapy is the most effective of these therapies. Hydromorphone appears to be an alternative opioid analgesic which may help relieve these symptoms. OBJECTIVES To determine the analgesic efficacy of hydromorphone in relieving cancer pain, as well as the incidence and severity of any adverse events. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and clinical trials registers in November 2020. We applied no language, document type or publication status limitations to the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared hydromorphone with placebo, an alternative opioid or another active control, for cancer pain in adults and children. Primary outcomes were participant-reported pain intensity and pain relief; secondary outcomes were specific adverse events, serious adverse events, quality of life, leaving the study early and death. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We calculated risk ratio (RR) and 95% confidence intervals (CI) for binary outcomes on an intention-to-treat (ITT) basis. We estimated mean difference (MD) between groups and 95% CI for continuous data. We used a random-effects model and assessed risk of bias for all included studies. We assessed the evidence using GRADE and created three summary of findings tables. MAIN RESULTS With four new identified studies, the review includes a total of eight studies (1283 participants, with data for 1181 participants available for analysis), which compared hydromorphone with oxycodone (four studies), morphine (three studies) or fentanyl (one study). All studies included adults with cancer pain, mean age ranged around 53 to 59 years and the proportion of men ranged from 42% to 67.4%. We judged all the studies at high risk of bias overall because they had at least one domain with high risk of bias. We found no studies including children. We did not complete a meta-analysis for the primary outcome of pain intensity due to skewed data and different comparators investigated across the studies (oxycodone, morphine and fentanyl). Comparison 1: hydromorphone compared with placebo We identified no studies comparing hydromorphone with placebo. Comparison 2: hydromorphone compared with oxycodone Participant-reported pain intensity We found no clear evidence of a difference in pain intensity (measured using a visual analogue scale (VAS)) in people treated with hydromorphone compared with those treated with oxycodone, but the evidence is very uncertain (3 RCTs, 381 participants, very low-certainty evidence). Participant-reported pain relief We found no studies reporting participant-reported pain relief. Specific adverse events We found no clear evidence of a difference in nausea (RR 1.13 95% CI 0.74 to 1.73; 3 RCTs, 622 participants), vomiting (RR 1.18, 95% CI 0.72 to 1.94; 3 RCTs, 622 participants), dizziness (RR 0.91, 95% CI 0.58 to 1.44; 2 RCTs, 441 participants) and constipation (RR 0.92, 95% CI 0.72 to 1.19; 622 participants) (all very low-certainty evidence) in people treated with hydromorphone compared with those treated with oxycodone, but the evidence is very uncertain. Quality of life We found no studies reporting quality of life. Comparison 3: hydromorphone compared with morphine Participant-reported pain intensity We found no clear evidence of a difference in pain intensity (measured using the Brief Pain Inventory (BPI) or VAS)) in people treated with hydromorphone compared with those treated with morphine, but the evidence is very uncertain (2 RCTs, 433 participants; very low-certainty evidence). Participant-reported pain relief We found no clear evidence of a difference in the number of clinically improved participants, defined by 50% or greater pain relief rate, in the hydromorphone group compared with the morphine group, but the evidence is very uncertain (RR 0.99, 95% CI 0.84 to 1.18; 1 RCT, 233 participants; very low-certainty evidence). Specific adverse events At 24 days of treatment, morphine may reduce constipation compared with hydromorphone, but the evidence is very uncertain (RR 1.56, 95% CI 1.12 to 2.17; 1 RCT, 200 participants; very low-certainty evidence). We found no clear evidence of a difference in nausea (RR 0.94, 95% CI 0.66 to 1.30; 1 RCT, 200 participants), vomiting (RR 0.87, 95% CI 0.58 to 1.31; 1 RCT, 200 participants) and dizziness (RR 1.15, 95% CI 0.71 to 1.88; 1 RCT, 200 participants) (all very low-certainty evidence) in people treated with hydromorphone compared with those treated with morphine, but the evidence is very uncertain. Quality of life We found no studies reporting quality of life. Comparison 4: hydromorphone compared with fentanyl Participant-reported pain intensity We found no clear evidence of a difference in pain intensity (measured by numerical rating scale (NRS)) at 60 minutes in people treated with hydromorphone compared with those treated with fentanyl, but the evidence is very uncertain (1 RCT, 82 participants; very low-certainty evidence). Participant-reported pain relief We found no studies reporting participant-reported pain relief. Specific adverse events We found no studies reporting specific adverse events. Quality of life We found no studies reporting quality of life. AUTHORS' CONCLUSIONS The evidence of the benefits and harms of hydromorphone compared with other analgesics is very uncertain. The studies reported some adverse events, such as nausea, vomiting, dizziness and constipation, but generally there was no clear evidence of a difference between hydromorphone and morphine, oxycodone or fentanyl for this outcome. There is insufficient evidence to support or refute the use of hydromorphone for cancer pain in comparison with other analgesics on the reported outcomes. Further research with larger sample sizes and more comprehensive outcome data collection is required.
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Affiliation(s)
- Yan Li
- Department for Anesthesiology and Pain Management, The People's Hospital of Jizhou District, Tianjin, Tianjin, China
| | - Jun Ma
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guijun Lu
- Pain Medicine Department, Beijing Tsinghua Changgung Hospital, Bejing, China
| | - Zhi Dou
- Pain Medicine Department, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Jun Xia
- Systematic Review Solutions Ltd, The Ingenuity Centre, The University of Nottingham, Nottingham, UK
| | - Sai Zhao
- Systematic Review Solutions Ltd, The Ingenuity Centre, The University of Nottingham, Nottingham, UK
| | - Sitong Dong
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Liqiang Yang
- Pain Medicine Department, Xuanwu Hospital, Capital Medical University, Beijing, China
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Magee DJ, Schutzer-Weissmann J, Pereira EAC, Brown MRD. Neuromodulation techniques for cancer pain management. Curr Opin Support Palliat Care 2021; 15:77-83. [PMID: 33843762 DOI: 10.1097/spc.0000000000000549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Advanced pain management techniques may be indicated in 5-15% of cancer patients. Despite this, a recent review identified that, over the course of 1 year in England, only 458 patients received a procedure intended to provide analgesia and only 30 patients had intrathecal drug delivery (ITDD) devices implanted. This article describes the emerging evidence for ITDD in cancer pain and provides a narrative review of other neuromodulatory techniques (including spinal cord stimulation, peripheral nerve stimulation and acupuncture), approaches that might be employed to address this area of significant unmet clinical need. RECENT FINDINGS Numerous studies have been published within the last year reporting positive outcomes associated with ITDD in cancer pain management. Neuromodulation represents an important strategy in the management of persistent pain. Whilst the nonmalignant pain evidence-base is rapidly growing, it remains sparse for cancer pain management. The growing cohort of cancer survivors may significantly benefit from neuromodulatory techniques. SUMMARY ITDD and other neuromodulatory techniques for cancer pain management appear underutilised in the UK and offer the prospect of better treatment for cancer patients with refractory pain or intolerable side-effects from systemic analgesics.
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Affiliation(s)
- David J Magee
- Signalling and Cancer Metabolism Team, Division of Cancer Biology, The Institute of Cancer Research
- Pain Medicine Department, The Royal Marsden Hospital
| | | | - Erlick A C Pereira
- Neurosciences Research Centre, Molecular and Clinical Sciences Institute, St George's, University of London
- Department of Neurosurgery, St George's University Hospital
| | - Matthew R D Brown
- Pain Medicine Department, The Royal Marsden Hospital
- Targeted Approaches to Cancer Pain Group, The Institute of Cancer Research, London, UK
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14
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Intrathecal patient-controlled analgesia has nothing to do with breakthrough cancer pain. Pain 2021; 162:1586. [PMID: 33857033 DOI: 10.1097/j.pain.0000000000002232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Chalil A, Staudt MD, Harland TA, Leimer EM, Bhullar R, Argoff CE. A safety review of approved intrathecal analgesics for chronic pain management. Expert Opin Drug Saf 2021; 20:439-451. [PMID: 33583318 DOI: 10.1080/14740338.2021.1889513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Intrathecal (IT) drug therapy is an effective treatment option for patients with chronic pain of malignant or nonmalignant origin, with an established safety profile and fewer adverse effects compared to oral or parenteral pain medications. Morphine (a μ-opioid receptor agonist) and ziconotide (a non-opioid calcium channel antagonist) are the only IT agents approved by the U.S. Food and Drug Administration for the treatment of chronic pain. Although both are considered first-line IT therapies, each drug has unique properties and considerations.Areas Covered: This review will evaluate the pivotal trials that established the use of morphine and ziconotide as first-line IT therapy for patients with chronic pain, as well as safety and efficacy data generated from various retrospective and prospective studies.Expert Opinion: Morphine and ziconotide are effective IT therapies for patients with chronic malignant or nonmalignant pain that is refractory to other interventions. IT ziconotide is recommended as a first-line therapy due to its efficacy and avoidance of many adverse effects commonly associated with opioids. The use of IT morphine is also considered first-line; however, the risks of respiratory depression, withdrawal with drug discontinuation or pump malfunction, and the development of tolerance require careful patient selection and management.
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Affiliation(s)
- Alan Chalil
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael D Staudt
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA.,Michigan Head and Spine Institute, Southfield, Michigan, USA
| | - Tessa A Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Elizabeth M Leimer
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Ravneet Bhullar
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
| | - Charles E Argoff
- Department of Neurology, Albany Medical College, Albany, New York
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