Opioid Crises—the Perspective From a Developing Country

Comprehensive Targeted Treatment for Neuropathic and Nociceptive Pain in Palliative Care Patients

BACKGROUND

Pain is a common symptom in patients with advanced, metastatic, or terminal cancer. Neuropathic pain and psycho-emotional suffering are factors that increase the difficulty of pain management. Pain control in patients with cancer remains a challenge for medical professionals.

STUDY QUESTION

What is the evolution of neuropathic/mixed pain compared with nociceptive pain under standardized treatment in patients with cancer?

STUDY DESIGN

A prospective, longitudinal, open-label, nonrandomized study was conducted on patients with cancer pain.

MEASURES AND OUTCOMES

Pain type was assessed at admission using the modified Brief Pain Inventory, and pain intensity was assessed daily using the Numerical Rating Scale for 14 days and on days 21 and 28. Screening of depression was performed on days 1, 7, 14, 21, and 28 using the Hamilton Depression Rating Scale. Patients with pain and depression received analgesics with antidepressants, while patients without depression received analgesics or analgesics with an anticonvulsant depending on the pain subtype.

RESULTS

Of 72 patients, 23 had nociceptive pain and 49 had neuropathic/mixed pain. At admission, pain intensity was higher for patients with neuropathic/mixed pain compared with nociceptive pain (mean values: 7.06 vs. 5.82) with statistical significance (P = 0.001) and remained as such at the end of this study (mean values: 3.77 vs. 2.73). A decrease in the mean pain intensity was observed in all types of pain, but without statistical significance regardless of pain type and treatment protocol used (P = 0.77). If depression was present, antidepressants combined with analgesics decreased pain and depression scores significantly (P = 0.001).

CONCLUSIONS

Patients with neuropathic/mixed pain have higher levels of pain and lower response to treatment. Identifying psycho-emotional suffering can improve pain control by intervening in the physical and psycho-emotional components of pain.

Pharmacological Management of Heroin Withdrawal Syndrome: A Century of Expert Opinions in Cecil Textbook of Medicine

BACKGROUND

Opioid use disorder continues to have a significant impact on public health morbidity and mortality throughout the United States and elsewhere. Managing opioid withdrawal is a critical treatment goal in individuals entering treatment with an active opioid use.

STUDY QUESTION

What are the milestones of the changes in the expert approach to the pharmacological management of heroin withdrawal syndrome in the past century?

STUDY DESIGN

To determine the changes in the expert approach to the management of heroin withdrawal syndrome, as presented in a widely used textbook in the United States.

DATA SOURCES

The chapters on opioid dependence in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020.

RESULTS

Opioid replacement taper with morphine (1927-1947), codeine (1931-1943), and methadone (1951-present) administered more than 3-10 days has remained the main intervention. The anticholinergic drugs, scopolamine and atropine, were recommended from 1927 to 1943, but their use has never been backed by scientific evidence. Newer approaches relied on clonidine, an alpha-2 receptor agonist used since 1982, and buprenorphine, an opioid agonist/antagonist endorsed for the treatment of heroin withdrawal in 2000. The most recent additions place withdrawal management in the context of treatment of opioid use disorder as a chronic illness that is best managed using medications for opioid use disorder.

CONCLUSIONS

The pharmacological management of heroin withdrawal syndrome in the past century has progressed from the introduction of methadone to the utilization of clonidine and buprenorphine. More recent advances in treating opioid use disorder have changed the goals of opioid withdrawal management to achievement of abstinence from all opioids to facilitation of long-term treatment with medications for opioid use disorder.

Common Pathways for Pain and Depression-Implications for Practice

BACKGROUND

Pain and depression have a high impact on caring for the people who need palliative care, but both of these are neglected compared with the approach for other symptoms encountered by these patients.

AREAS OF UNCERTAINTY

There are few studies in humans that support the existence of common neural circuits between depression and pain that also explore the use of drugs with effects in both conditions. More knowledge is needed about the relationship of these clinical entities that will lead to the optimization of the treatment and improvement of quality of life.

DATA SOURCES

We conducted a search in PubMed to identify relevant articles and reviews that have been published in the last 5 years, concerning the topic of common pathways between depression and pain (2014-April 2019).

THERAPEUTIC ADVANCES

The connections between the 2 clinical entities start at the level of the cortical regions. The hippocampus is the main site of neural changes, modification of the immune system, neuromodulators, neurotransmitters, and signaling pathways implicated in both conditions. Increased levels of peripheral proinflammatory cytokines and neuroinflammatory changes are related to the physiopathology of these entities. Inflammation links depression and pain by altering neural circuits and changes in their common cortical regions. Antidepressants are used to treat depression and chronic, pain but more experimental studies are needed to determine which antidepressant drugs are the most effective in treating the 2 entities.

CONCLUSIONS

Pharmacological and nonpharmacological interventions targeting cortical changes in pain and depression are promising, but more clinical studies are needed to validate their usefulness.