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Vitin AA, Egan TD. Remifentanil-induced hyperalgesia: the current state of affairs. Curr Opin Anaesthesiol 2024; 37:371-378. [PMID: 38841986 DOI: 10.1097/aco.0000000000001400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Remifentanil-induced hyperalgesia (RIH) is a part of a general opioid-induced hyperalgesia (OIH) syndrome, seemingly resulting from abrupt cessation of continuous remifentanil infusion at rates equal or exceeding 0.3 mcg/kg/min. The intricate mechanisms of its development are still not completely understood. However, hyperactivation of the N -methyl d -aspartate receptor system, descending spinal facilitation and increased concentration of dynorphin (a κ-opioid ligand) are commonly proposed as possible mechanisms. Several ways of prevention and management have been suggested, such as slow withdrawal of remifentanil infusion, the addition of propofol, pretreatment with or concomitant administration of ketamine, buprenorphine, cyclooxygenase-2 inhibitors (NSAIDs), methadone, dexmedetomidine. In clinical and animal studies, these strategies exhibited varying success, and many are still being investigated.
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Affiliation(s)
| | - Talmage D Egan
- Department of Anesthesiology, Perioperative & Pain Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
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2
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Cairns J, Feng TL, Ong MC. Continuous ketamine infusion for the management of opioid-induced hyperalgesia following amputation. BMJ Case Rep 2024; 17:e255333. [PMID: 38176753 PMCID: PMC10773323 DOI: 10.1136/bcr-2023-255333] [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] [Indexed: 01/06/2024] Open
Abstract
We discuss the use of an inpatient multi-day continuous intravenous ketamine infusion for the treatment of opioid-induced hyperalgesia (OIH) and high fentanyl requirements in the case of a patient with a background of fibromyalgia/central sensitisation syndrome who underwent a complicated post-operative course following a right below-knee amputation for high-grade myxoid fibrosarcoma. The patient was successfully tapered off a total fentanyl patch dose of 162 mcg/hour every 72 hours (morphine equivalent dose of 389 mg/day) to short-acting hydromorphone 2 mg orally two times per day as needed (equivalent of 8 mg morphine sustained-release twice per day) during a 2-week admission with only mild withdrawal symptoms. We discuss the pharmacology of ketamine and its possible application in the treatment of OIH.
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Affiliation(s)
- James Cairns
- Neurology, The University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Tanya Lei Feng
- Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - May C Ong
- Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
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3
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Ruggiero E, Pambuku A, Caccese M, Lombardi G, Gallio I, Brunello A, Ceccato F, Formaglio F. Case report: The lesson from opioid withdrawal symptoms mimicking paraganglioma recurrence during opioid deprescribing in cancer pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1256809. [PMID: 37810433 PMCID: PMC10556467 DOI: 10.3389/fpain.2023.1256809] [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: 07/18/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Pain is one of the predominant and troublesome symptoms that burden cancer patients during their whole disease trajectory: adequate pain management is a fundamental component of cancer care. Opioid are the cornerstone of cancer pain relief therapy and their skillful management must be owned by physicians approaching cancer pain patients. In light of the increased survival of cancer patients due to advances in therapy, deprescription should be considered as a part of the opioid prescribing regime, from therapy initiation, dose titration, and changing or adding drugs, to switching or ceasing. In clinical practice, opioid tapering after pain remission could be challenging due to withdrawal symptoms' onset. Animal models and observations in patients with opioid addiction suggested that somatic and motivational symptoms accompanying opioid withdrawal are secondary to the activation of stress-related process (mainly cortisol and catecholamines mediated). In this narrative review, we highlight how the lack of validated guidelines and tools for cancer patients can lead to a lower diagnostic awareness of opioid-related disorders, increasing the risk of developing withdrawal symptoms. We also described an experience-based approach to opioid withdrawal, starting from a case-report of a symptomatic patient with a history of metastatic pheochromocytoma-paraganglioma.
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Affiliation(s)
- Elena Ruggiero
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Ardi Pambuku
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Mario Caccese
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Ivan Gallio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
| | - Antonella Brunello
- Department of Oncology, Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Fabio Formaglio
- Pain Therapy and Palliative Care with Hospice Unit, Veneto Institute of Oncology IOV—IRCCS, Padua, Italy
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4
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Delgado MA, Ferreira LA, Gomes BJDS, Leite IKO, Gomez MV, Castro-Junior C. Preclinical study in a postoperative pain model to investigate the action of ketamine, lidocaine, and ascorbic acid in reversing fentanyl-induced, non-glutamate-dependent hyperalgesia. Pain Rep 2023; 8:e1062. [PMID: 37731750 PMCID: PMC10508464 DOI: 10.1097/pr9.0000000000001062] [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: 07/21/2022] [Revised: 11/18/2022] [Accepted: 11/30/2022] [Indexed: 04/03/2023] Open
Abstract
Introduction Opioid-induced hyperalgesia (OIH) is a paradoxical phenomenon in which exposure to opioids can increase sensitivity to painful stimuli. Currently, several drugs have been used in an attempt to prevent OIH. We design this study to address the effect of preemptive treatment with ketamine, lidocaine, and ascorbic acid in a rat preclinical model of perioperative opioid-induced hyperalgesia. Methods To reproduce OIH in a model of postoperative pain, rats received successive doses of fentanyl subcutaneously and underwent an incision in the paw. In an attempt to prevent OIH, ketamine, lidocaine, and ascorbic acid were administered before treatment with fentanyl. The von Frey test and the hot-plate test were used to evaluate mechanical allodynia and thermal hyperalgesia, respectively, with a follow-up period from 1 hour up to 7 days after surgery. Spinal cord nerve terminals (synaptosomes) were used to assess glutamate release under our experimental conditions. Results Consecutive fentanyl injections increased the postoperative pain as indicated by increased thermal hyperalgesia and allodynia 48 hours after incision. Ketamine, lidocaine, and the combination of ketamine + lidocaine were able to prevent thermal hyperalgesia but not mechanical allodynia. Ascorbic acid did not prevent the hyperalgesia induced by fentanyl. We found no correlation between spinal glutamate release and the pharmacological treatments. Conclusion Fentanyl induced a hyperalgesic effect that last few days in a postoperative model of pain. Hyperalgesic effect was not totally inhibited by ketamine and lidocaine in rats. Increased glutamate release was not the main molecular mechanism of fentanyl-induced hyperalgesia.
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Affiliation(s)
- Marina Ayres Delgado
- Programa de pós graduação em ciências da saúde, Santa Casa de Belo Horizonte Ensino e Pesquisa, Belo Horizonte, Minas Gerais, Brazil
| | - Luana Assis Ferreira
- Programa de pós graduação em ciências da saúde, Santa Casa de Belo Horizonte Ensino e Pesquisa, Belo Horizonte, Minas Gerais, Brazil
| | - Bianka Jaciara dos Santos Gomes
- Programa de pós graduação em ciências da saúde, Santa Casa de Belo Horizonte Ensino e Pesquisa, Belo Horizonte, Minas Gerais, Brazil
| | - Isis Katarine Orlandi Leite
- Programa de pós graduação em ciências da saúde, Santa Casa de Belo Horizonte Ensino e Pesquisa, Belo Horizonte, Minas Gerais, Brazil
| | - Marcus Vinícius Gomez
- Programa de pós graduação em ciências da saúde, Santa Casa de Belo Horizonte Ensino e Pesquisa, Belo Horizonte, Minas Gerais, Brazil
| | - Célio Castro-Junior
- Programa de pós graduação em ciências da saúde, Santa Casa de Belo Horizonte Ensino e Pesquisa, Belo Horizonte, Minas Gerais, Brazil
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5
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Koponen ME, Forget P. Pharmacological Interventions for Opioid-Induced Hyperalgesia: A Scoping Review of Preclinical Trials. J Clin Med 2022; 11:jcm11237060. [PMID: 36498635 PMCID: PMC9735807 DOI: 10.3390/jcm11237060] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/18/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Opioid analgesics are the most effective pharmacological agents for moderate and severe pain. However, opioid use has several limitations such as opioid-induced hyperalgesia (OIH), which refers to the increased pain sensitivity that occurs once analgesia wears off after opioid administration. Several pharmacological interventions have been suggested for OIH, but the current literature does not provide guidelines on which interventions are the most effective and whether they differ depending on the opioid that induces hyperalgesia. This scoping review aimed to identify and describe all the preclinical trials investigating pharmacological interventions for OIH caused by remifentanil, fentanyl, or morphine as the first step towards evaluating whether the most effective OIH interventions are different for different opioids. METHODS Electronic database searches were carried out in Embase, PubMed, and Web of Science. Detailed data extraction was conducted on the eligible trials. RESULTS 72 trials were eligible for the review. Of these, 27 trials investigated remifentanil, 14 trials investigated fentanyl, and 31 trials investigated morphine. A total of 82 interventions were identified. The most studied interventions were ketamine (eight trials) and gabapentin (four trials). The majority of the interventions were studied in only one trial. The most common mechanism suggested for the interventions was inhibition of N-methyl-D-aspartate (NMDA) receptors. CONCLUSION This scoping review identified plenty of preclinical trials investigating pharmacological interventions for OIH. Using the current literature, it is not possible to directly compare the effectiveness of the interventions. Hence, to identify the most effective interventions for each opioid, the interventions must be indirectly compared in a meta-analysis.
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Affiliation(s)
- Mia Elena Koponen
- Neuroscience with Psychology, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Correspondence:
| | - Patrice Forget
- Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Department of Anaesthesia, National Health Service (NHS) Grampian, Aberdeen AB25 2ZN, UK
- Pain and Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, 1000 Brussels, Belgium
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6
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Kim EJ, Hwang EJ, Yoo YM, Kim KH. Prevention, diagnosis, and treatment of opioid use disorder under the supervision of opioid stewardship programs: it's time to act now. Korean J Pain 2022; 35:361-382. [PMID: 36175336 PMCID: PMC9530691 DOI: 10.3344/kjp.2022.35.4.361] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
The third opium war may have already started, not only due to illicit opioid trafficking from the Golden Crescent and Golden Triangle on the international front but also through indiscriminate opioid prescription and opioid diversion at home. Opioid use disorder (OUD), among unintentional injuries, has become one of the top 4 causes of death in the United States (U.S.). An OUD is defined as a problematic pattern of opioid use resulting in clinically significant impairment or distress, consisting of 2 or more of 11 problems within 1 year, as described by the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Observation of aberrant behaviors of OUD is also helpful for overworked clinicians. For the prevention of OUD, the Opioid Risk Tool and the Current Opioid Misuse Measure are appropriate screening tests before and during opioid administration, respectively. Treatment of OUD consists of 3 opioid-based U.S. Food and Drug Administration-approved medications, including methadone, buprenorphine, and naltrexone, and non-opioid-based symptomatic medications for reducing opioid withdrawal syndromes, such as α2 agonists, β-blockers, antidiarrheals, antiemetics, non-steroidal anti-inflammatory drugs, and benzodiazepines. There are at least 6 recommendable guidelines and essential terms related to OUD. Opioid stewardship programs are now critical to promoting appropriate use of opioid medications, improving patient outcomes, and reducing misuse of opioids, influenced by the successful implementation of antimicrobial stewardship programs. Despite the lack of previous motivation, now is the critical time for trying to reduce the risk of OUD.
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Affiliation(s)
- Eun-Ji Kim
- Department of Pharmacy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Eun-Jung Hwang
- Department of Pharmacy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yeong-Min Yoo
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Kyung-Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
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7
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Ellerbroek H, van den Heuvel SAS, Dahan A, Timmerman H, Kramers C, Schellekens AFA. Buprenorphine/naloxone versus methadone opioid rotation in patients with prescription opioid use disorder and chronic pain: study protocol for a randomized controlled trial. Addict Sci Clin Pract 2022; 17:47. [PMID: 36057608 PMCID: PMC9441071 DOI: 10.1186/s13722-022-00326-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background Opioids are effective in pain-management, but long-term opioid users can develop prescription opioid use disorder (OUD). One treatment strategy in patients with OUD is rotating from a short-acting opioid to a long-acting opioid (buprenorphine/naloxone (BuNa) or methadone). Both BuNa and methadone have been shown to be effective strategies in patients with OUD reducing opioid misuse, however data on head-to-head comparison in patients with chronic non-malignant pain and prescription OUD are limited. Methods This two-armed open-label, randomized controlled trial aims to compare effectiveness between BuNa and methadone in patients with chronic non-malignant with prescription OUD (n = 100). Participants receive inpatient rotation to either BuNa or methadone with a flexible dosing regimen. The primary outcome is opioid misuse 2 months after rotation. Secondary outcomes include treatment compliance, side effects, analgesia, opioid craving, quality of life, mood symptoms, cognitive and physical functioning over 2- and 6 months follow-up. Linear mixed model analysis will be used to evaluate change in outcome parameters over time between the treatment arms. Discussion This is one of the first studies comparing buprenorphine/naloxone and methadone for treating prescription OUD in a broad patient group with chronic non-malignant pain. Results may guide future treatment for patients with chronic pain and prescription OUD. Trial registrationhttps://www.trialregister.nl/, NL9781
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Affiliation(s)
- Hannah Ellerbroek
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Sandra A S van den Heuvel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Timmerman
- Department of Anesthesiology, Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Pharmacology-Toxicology and Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Center for Medical Neuroscience, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands.,Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
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8
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Wang A, Shulman M, Choo T, Pavlicova M, Langleben DD, Nunes EV, Rotrosen J. Baseline- and treatment-associated pain in the X:BOT comparative effectiveness study of extended-release naltrexone versus buprenorphine-naloxone for OUD. Addict Biol 2022; 27:e13112. [PMID: 34877769 DOI: 10.1111/adb.13112] [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: 04/16/2021] [Revised: 10/06/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022]
Abstract
Chronic pain is highly prevalent among patients with opioid use disorder (OUD). However, little is known about how pharmacological treatments for OUD, for example, extended-release naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX), affect pain. To begin addressing this question, we performed a secondary analysis of pain data on a large prospective 24-week, open-label, randomized-controlled comparative effectiveness trial of XR-NTX versus BUP-NX (X:BOT trial). Participants' pain status was measured by the EuroQol (EQ-5D). Based on their responses to the pain question at baseline, participants were dichotomized into "Pain" versus "No Pain" categories. Participant's pain status was evaluated every 4 weeks. A mixed effects longitudinal logistic regression model was fitted to examine the differential effect of XR-NTX versus BUP-NX on pain, modelling pain at all available follow-up assessments, adjusted for age, sex, and baseline pain. A total of 474 individuals who were successfully inducted onto their assigned medications were included in this analysis. Among participants endorsing pain at baseline, substantial reductions in pain were observed over the course of the study in both treatment groups. Howecver reduction in pain was slightly greater in the group treated with XR-NTX than the one treated with BUP-NX (OR = 1.60 [95% CI: 1.07-2.40], P = 0.023). Future research using instruments and design specifically focused on pain could extend the present observations and evaluate their clinical significance.
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Affiliation(s)
- An‐Li Wang
- Addiction Institute of Mount Sinai, Department of Psychiatry Icahn School of Medicine at Mount Sinai New York New York USA
| | - Matisyahu Shulman
- Department of Psychiatry Columbia University Irving Medical Center and New York State Psychiatric Institute New York New York USA
| | - Tse‐Hwei Choo
- Department of Psychiatry Columbia University Irving Medical Center and New York State Psychiatric Institute New York New York USA
| | - Martina Pavlicova
- Department of Biostatistics Columbia University Mailman School of Public Health New York New York USA
| | - Daniel D. Langleben
- Department of Psychiatry University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Edward V. Nunes
- Department of Psychiatry Columbia University Irving Medical Center and New York State Psychiatric Institute New York New York USA
| | - John Rotrosen
- Department of Psychiatry NYU Grossman School of Medicine New York New York USA
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9
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Fujii T, Nishiwaki K. Ketamine reduces the dose of remifentanil required during prolonged head and neck surgery: a propensity-matched analysis. NAGOYA JOURNAL OF MEDICAL SCIENCE 2022; 84:1-6. [PMID: 35392017 PMCID: PMC8971040 DOI: 10.18999/nagjms.84.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/11/2021] [Indexed: 11/29/2022]
Abstract
High-dose opioids induce hyperalgesia and tolerance, which negatively affects postoperative recovery. Prolonged surgery inevitably requires higher opioid doses. Ketamine reduces perioperative opioid consumption and prevents opioid-induced tolerance. However, its effects in cases of prolonged surgery remain unknown. This study aimed to evaluate the dose of intraoperative remifentanil, an ultrashort-acting µ-opioid agonist, administered after an intravenous ketamine bolus during prolonged head and neck surgery. This single-center, retrospective, observational study included 251 patients who underwent head and neck surgery (operation time ≥8 h) between January 2015 and December 2019. The participants were stratified into two groups: those who received an intravenous bolus of ketamine and those who did not (ketamine group and non-ketamine group, respectively). Propensity score-matching was used to match patients in a 1:1 ratio between the two groups, based on their covariates. The difference in intraoperative remifentanil dose administered between the two groups was assessed. After 1:1 propensity score-matching, 89 matched patients were selected from each group. The mean ± standard deviation dose of remifentanil administered was significantly lower in the ketamine group than in the non-ketamine group before (0.15±0.05 vs 0.17±0.05 µg/kg/min; P=0.01) and after matching (0.15±0.06 vs 0.17±0.05 µg/kg/min; P=0.03). In conclusion, intravenous ketamine administration may reduce the intraoperative dose of remifentanil required during prolonged head and neck surgery. However, further studies are required to evaluate the effect of this finding on enhanced recovery after surgery.
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Affiliation(s)
- Tasuku Fujii
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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10
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Hino C, Ran-Castillo D, Akhtari M, Cao H, Silvestre J. Role of Ketamine and Opioid Rotation in the Management of Opioid Induced Hyperalgesia in a Patient With Acute Promyelocytic Leukemia. J Oncol Pharm Pract 2022:10781552221074285. [DOI: 10.1177/10781552221074285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Opioid analgesics are commonly used to manage moderate to severe cancer related pain. However long-term use of opioids has been known to lead to several unintended side effects, including opioid induced hyperalgesia (OIH) which is defined as the paradoxical increase in pain sensitization to pain stimulus following opioid exposure. Currently there are limited reports on the association between patients with cancer and OIH, and this phenomenon is rarely described in patients with leukemia or lymphoma. Here we report a patient with acute promyelocytic leukemia who developed opioid induced hyperalgesia following rapid escalation of opioids. Case report A 36-year-old female being treated for acute promyelocytic leukemia presented with rapidly worsening acute on chronic hip pain requiring increasing opioid requriements. Given the rapid escalation of opioid dose with minimal response and physical exam findings consistent with allodynia/hyperalgesia a diagnosis of opioid induced hyperalgesia was made. Management and outcome Following recognition of opioid induced hyperalgesia, the patient was managed with opioid rotation and ketamine, which resulted in prompt alleviation of pain. Discussion Opioid induced hyperalgesia is likely an underrecognized phenomenon in patients with cancer-related pain. A high index of clinical suspicion are necessary for diagnosis and proper management of this disease entity.
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Affiliation(s)
- Christopher Hino
- Department of Internal Medicine, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Dan Ran-Castillo
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Mojtaba Akhtari
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Huynh Cao
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Julio Silvestre
- Department of Palliative care, Loma Linda University, Loma Linda, California, USA
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11
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Effects of opioid rotation to buprenorphine/naloxone on pain, pain thresholds, pain tolerance, and quality of life in patients with chronic pain and opioid use disorder. Pain 2021; 163:955-963. [PMID: 34433769 DOI: 10.1097/j.pain.0000000000002462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Long-term opioid use in patients with chronic noncancer pain (CNCP) can lead to opioid use disorder (OUD) and has been associated with hyperalgesia and reduced quality of life (QoL). Studies suggest antihyperalgesic properties of buprenorphine, and buprenorphine or naloxone (BuNa) has shown beneficial effects on QoL in patients with OUD without CNCP. This study investigated the added value of BuNa in patients with CNCP with OUD on self-reported pain, pain thresholds, pain tolerance, and QoL. In the current study, 43 outpatients with CNCP and OUD were included for inpatient conversion from full μ-receptor agonist opioids to BuNa. Self-reported pain, pain thresholds, pain tolerance, and QoL were determined at baseline and after 2 months of follow-up, using, respectively, a Visual Analogue Scale (VAS-pain and VAS-QoL), quantitative sensory testing, and EuroQol-5 dimensions. In total, 37 participants completed the protocol, and their data were analyzed. The mean VAS-pain score decreased from 51.3 to 37.2 (27.5%, F = 3.3; P = 0.044), whereas the pressure pain threshold and electric pain threshold or tolerance increased after substitution (F = 7.8; P = 0.005 and F = 44.5; P < 0.001, respectively), as well as QoL (EuroQol-5 dimensions questionnaire: F = 10.4; P = 0.003 and VAS-QoL: F = 4.4; P = 0.043). We found that conversion of full μ-receptor agonists to BuNa, in patients with CNCP with OUD, was accompanied with lower self-reported pain, higher pain thresholds, higher pain tolerance, and improved QoL. Despite several study limitations, these data suggest that BuNa might be of value in patients with CNCP with OUD. Future studies should investigate long-term effects of BuNa in randomized trials.
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12
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Beneficial Effects of Opioid Rotation to Buprenorphine/Naloxone on Opioid Misuse, Craving, Mental Health, and Pain Control in Chronic Non-Cancer Pain Patients with Opioid Use Disorder. J Clin Med 2021; 10:jcm10163727. [PMID: 34442024 PMCID: PMC8396821 DOI: 10.3390/jcm10163727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic non-cancer pain (CNCP) often use opioids for long periods of time. This may lead to opioid use disorder (OUD) and psychiatric symptoms: mainly depression and anxiety. The current study investigated the effect of buprenorphine/naloxone (BuNa) rotation on opioid misuse, craving, psychiatric symptoms and pain in patients with CNCP and OUD. Forty-three participants with CNCP and OUD were converted from a full mu-receptor agonist opioid (mean morphine equivalent dose: 328.3 mg) to BuNa, in an inpatient setting. Opioid misuse, craving, co-occurring psychiatric symptoms, and pain perception were determined at baseline and after a two-month follow-up, using the following self-report questionnaires: Current Opioid Misuse Measurement (COMM), Visual Analog Scale (VAS-craving and VAS-pain) and Depression, Anxiety and Stress Scale (DASS), respectively. VAS-craving and VAS-pain were also determined immediately after conversion. A total of 37 participants completed the protocol. The mean COMM decreased from 17.1 to 6.7 (F = 36.5; p < 0.000), the mean VAS-craving decreased from 39.3 to 5.3 (−86.6%; F = 26.5, p < 0.000), the mean DASS decreased from 12.1 to 6.6 (F = 56.3, p < 0.000), and the mean VAS-pain decreased from 51.3 to 37.2 (−27.4%, F = 3.3; p = 0.043). Rotation to BuNa in patients with CNCP and OUD was accompanied by reductions in (i) opioid misuse, (ii) opioid craving, (iii) the severity of co-occurring psychiatric symptoms, and (iv) self-reported pain. BuNa as opioid agonist treatment may therefore be a beneficial strategy in CNCP patients with OUD. The limited sample size and the observational nature of this study underline the need for the replication of the current findings in large-scale, controlled studies.
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Hanna V, Senderovich H. Methadone in Pain Management: A Systematic Review. THE JOURNAL OF PAIN 2021; 22:233-245. [DOI: 10.1016/j.jpain.2020.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/27/2020] [Accepted: 04/26/2020] [Indexed: 01/05/2023]
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Prakash S, Gupta AK, Meena JP, Seth R. A review of the clinical applications of ketamine in pediatric oncology. Pediatr Blood Cancer 2021; 68:e28785. [PMID: 33128439 DOI: 10.1002/pbc.28785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022]
Abstract
Ketamine is a dissociative anesthetic agent with excellent analgesic properties and a favorable safety profile. The feasibility and efficacy of various routes of administration have been established, including intravenous (IV), intramuscular (IM), oral, intranasal, rectal, and transdermal routes. The advent of newer anesthetic agents has led to a decline in the use of ketamine as an anesthetic, but its utility in short-term sedation and analgesia has expanded. Its value for chronic pain management in children with cancer is being increasingly recognized but requires more evidence. The use of topical ketamine is largely in investigational stages. Medical use of ketamine is, to a great extent, free from significant long-term neurological side effects. The objective of this review is to provide a brief account of the pharmacology of ketamine and primarily focus on the clinical applications of ketamine in pediatric oncology.
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Affiliation(s)
- Satya Prakash
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rachna Seth
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Bertin C, Delage N, Rolland B, Pennel L, Fatseas M, Trouvin AP, Delorme J, Chenaf C, Authier N. Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management. Neurosci Biobehav Rev 2020; 121:160-174. [PMID: 33358994 DOI: 10.1016/j.neubiorev.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/21/2022]
Abstract
Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.
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Affiliation(s)
- Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France; Fondation Institut Analgesia, Faculté de Médecine, F-63001, Clermont-Ferrand, France.
| | - Noémie Delage
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), CH Le Vinatier, Université de Lyon, UCBL1, INSERM U1028, CNRS UMR 5292, Bron, France
| | - Lucie Pennel
- Service Universitaire de Pharmaco-Addictologie - CSAPA, CHU Grenoble Alpes, UFR de médecine, Université Grenoble-Alpes, 38043 Grenoble, France
| | - Mélina Fatseas
- University of Bordeaux, 33076 Bordeaux Cedex, France; CNRS-UMR 5287- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA), Bordeaux, France; CHU de Bordeaux, France
| | - Anne-Priscille Trouvin
- Centre d'Evaluation et Traitement de la Douleur, Université Paris Descartes, Hôpital Cochin, Paris, France; U987, INSERM, Boulogne Billancourt, France
| | - Jessica Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Chouki Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Nicolas Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France; Fondation Institut Analgesia, Faculté de Médecine, F-63001, Clermont-Ferrand, France
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Rieb LM, DeBeck K, Hayashi K, Wood E, Nosova E, Milloy MJ. Withdrawal-associated injury site pain prevalence and correlates among opioid-using people who inject drugs in Vancouver, Canada. Drug Alcohol Depend 2020; 216:108242. [PMID: 32861135 PMCID: PMC7850369 DOI: 10.1016/j.drugalcdep.2020.108242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pain can return temporarily to old injury sites during opioid withdrawal. The prevalence and impact of opioid withdrawal-associated injury site pain (WISP) in various groups is unknown. METHODS Using data from observational cohorts, we estimated the prevalence and correlates of WISP among opioid-using people who inject drugs (PWID). Between June and December 2015, data on WISP and opioid use behaviours were elicited from participants in three ongoing prospective cohort studies in Vancouver, Canada, who were aged 18 years and older and who self-reported at least daily injection of heroin or non-medical presciption opioids. RESULTS Among 631 individuals, 276 (43.7 %) had a healed injury (usually pain-free), among whom 112 (40.6 %) experienced WISP, representing 17.7 % of opioid-using PWID interviewed. In a multivariable logistic regression model, WISP was positively associated with having a high school diploma or above (Adjusted Odds Ratio [AOR] = 2.23, 95 % Confidence Interval [CI]: 1.31-3.84), any heroin use in the last six months (AOR = 2.00, 95 % CI: 1.14-3.57), feeling daily pain that required medication (AOR = 2.06, CI: 1.18-3.63), and negatively associated with older age at first drug use (AOR = 0.96, 95 % CI: 0.93-0.99). Among 112 individuals with WISP, 79 (70.5 %) said that having this pain affected their opioid use behaviour, of whom 57 (72.2 %) used more opioids, 19 (24.1 %) avoided opioid withdrawal, while 3 (3.8 %) no longer used opioids to avoid WISP. CONCLUSIONS WISP is prevalent among PWID with a previous injury, and may alter opioid use patterns. Improved care strategies for WISP are warrented.
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Affiliation(s)
- Launette Marie Rieb
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, British Columbia, Canada
| | - Kora DeBeck
- School of Public Policy, Simon Fraser University, 515 West Hastings Street, Office 3269, Vancouver, British Columbia, Canada,British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, British Columbia, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, British Columbia, Canada,Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, Burnaby, British Columbia, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, British Columbia, Canada,Department of Medicine, University of British Columbia, 2775 Laurel Street, 10thFloor, Vancouver, British Columbia, Canada
| | - Ekaterina Nosova
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, British Columbia, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, 10thFloor, Vancouver, British Columbia, Canada.
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Opioid Induced Hyperalgesia, a Research Phenomenon or a Clinical Reality? Results of a Canadian Survey. J Pers Med 2020; 10:jpm10020027. [PMID: 32326188 PMCID: PMC7354508 DOI: 10.3390/jpm10020027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/14/2020] [Accepted: 04/16/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Very little is known regarding the prevalence of opioid induced hyperalgesia (OIH) in day to day medical practice. The aim of this study was to evaluate the physician's perception of the prevalence of OIH within their practice, and to assess the level of physician's knowledge with respect to the identification and treatment of this problem. METHODS An electronic questionnaire was distributed to physicians who work in anesthesiology, chronic pain, and/or palliative care in Canada. RESULTS Of the 462 responses received, most were from male (69%) anesthesiologists (89.6%), in the age range of 36 to 64 years old (79.8%). In this study, the suspected prevalence of OIH using the average number of patients treated per year with opioids was 0.002% per patient per physician practice year for acute pain, and 0.01% per patient per physician practice year for chronic pain. Most physicians (70.2%) did not use clinical tests to help make a diagnosis of OIH. The treatment modalities most frequently used were the addition of an NMDA antagonist, combined with lowering the opioid doses and using opioid rotation. CONCLUSIONS The perceived prevalence of OIH in clinical practice is a relatively rare phenomenon. Furthermore, more than half of physicians did not use a clinical test to confirm the diagnosis of OIH. The two main treatment modalities used were NMDA antagonists and opioid rotation. The criteria for the diagnosis of OIH still need to be accurately defined.
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Khare R, Yasir M, Singh P, Shrivastava R. Diagnostic aids for early detection of oral squamous cell carcinoma: concepts and emerging techniques. MINERVA BIOTECNOL 2020. [DOI: 10.23736/s1120-4826.19.02586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Jabbour H, Jabbour K, Abi Lutfallah A, Abou Zeid H, Nasser-Ayoub E, Abou Haidar M, Naccache N. Magnesium and Ketamine Reduce Early Morphine Consumption After Open Bariatric Surgery: a Prospective Randomized Double-Blind Study. Obes Surg 2019; 30:1452-1458. [DOI: 10.1007/s11695-019-04317-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
After intensive care unit (ICU) treatment, the recollection of experienced pain is one of the most burdensome aftermaths. In addition, pain has several negative physiological consequences. The majority of patients report moderate to severe pain while being treated on an ICU, often caused by diagnostic or therapeutic procedures. Pain and its functional consequences during ICU treatment should therefore be systematically recorded and treated. Due to their high analgesic potency, pharmacological pain therapy focuses on opioids; however, gastrointestinal motility disturbance and development of tolerance are disadvantages. When applying non-opioids, such as non-steroidal anti-inflammatory drugs (NSAID) and paracetamol, attention should be paid to their possible organ toxicity. Ketamine and α2-antagonists can complement the analgesic concept. Analogous to its perioperative administration, intravenous lidocaine in intensive care seems acceptable because of a favorable impact on opioid requirements and gastrointestinal motility. When using regional anesthesia the positive therapeutic effect and the possible complications need to be carefully weighed. Non-pharmaceutical procedures, especially transcutaneous electrical nerve stimulation (TENS), have proven successful in postoperative pain management. Even if only limited data from intensive care are available, a therapeutic attempt seems justifiable because of the low risk of complications.
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Affiliation(s)
- Katharina Rose
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
| | - Winfried Meißner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland.
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Perioperative use of opioids: Current controversies and concerns. Best Pract Res Clin Anaesthesiol 2019; 33:341-351. [DOI: 10.1016/j.bpa.2019.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
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Abstract
Supplemental Digital Content is Available in the Text. This descriptive case series among adults documents that pain can return temporarily at healed, previously pain-free injury sites during acute opioid withdrawal. Withdrawal pain can be a barrier to opioid cessation. Yet, little is known about old injury site pain in this context. We conducted an exploratory mixed-methods descriptive case series using a web-based survey and in-person interviews with adults recruited from pain and addiction treatment and research settings. We included individuals who self-reported a past significant injury that was healed and pain-free before the initiation of opioids, which then became temporarily painful upon opioid cessation—a phenomenon we have named withdrawal-associated injury site pain (WISP). Screening identified WISP in 47 people, of whom 34 (72%) completed the descriptive survey, including 21 who completed qualitative interviews. Recalled pain severity scores for WISP were typically high (median: 8/10; interquartile range [IQR]: 2), emotionally and physically aversive, and took approximately 2 weeks to resolve (median: 14; IQR: 24 days). Withdrawal-associated injury site pain intensity was typically slightly less than participants' original injury pain (median: 10/10; IQR: 3), and more painful than other generalized withdrawal symptoms which also lasted approximately 2 weeks (median: 13; IQR: 25 days). Fifteen surveyed participants (44%) reported returning to opioid use because of WISP in the past. Participants developed theories about the etiology of WISP, including that the pain is the brain's way of communicating a desire for opioids. This research represents the first known documentation that previously healed, and pain-free injury sites can temporarily become painful again during opioid withdrawal, an experience which may be a barrier to opioid cessation, and a contributor to opioid reinitiation.
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Delafontaine A, Presedo A, Mohamed D, Lopes D, Wood C, Alberti C. Equimolar mixture of nitroux oxyde and oxygen during post-operative physiotherapy in patients with cerebral palsy: A randomized, double-blind, placebo-controlled study. Eur J Pain 2017; 21:1657-1667. [PMID: 28726270 DOI: 10.1002/ejp.1071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND The administration of an equimolar mixture of nitrous oxide and oxygen (N2O) is recommended during painful procedures. However, the evaluation of its use during physiotherapy after surgery has not been reported, although pain may hamper physiotherapy efficiency. This study investigated whether the use of N2O improves the efficacy of post-operative physiotherapy after multilevel surgery in patients with cerebral palsy. METHOD It was a randomized 1:1, double-blind, placebo-controlled study. All patients had post-operative physiotherapy starting the day after surgery. Patients received either N2O or placebo gas during the rehabilitation sessions. All patients had post-operative pain management protocol, including pain medication as needed for acute pain. The primary objective was to reach angles of knee flexion of 110° combined with hip extension of 10°, with the patient lying prone, within six or less physiotherapy sessions. Secondary evaluation criteria were the number of sessions required to reach the targeted angles, the session-related pain intensity and the analgesics consumption for managing post-operative pain. RESULTS Sixty-four patients were enrolled. Targeted angles were achieved more often in the N2O group (23 of 32, 72%, vs. Placebo: 13/ of 32, 41%; p = 0.01). CONCLUSION The administration of N2O during post-operative physiotherapy can help to achieve more quickly an improved range of motion, and, although not significant in our study, to alleviate the need for pain medication. Further studies evaluating the administration of N2O in various settings are warranted. SIGNIFICANCE During this randomized placebo-controlled double-blind study, children receiving nitrous oxide and oxygen (N2O) achieved more often the targeted range of motion during physiotherapy sessions after multilevel surgery. Compared to placebo, nitrous oxide and oxygen (N2O) enabled a better management of acute pain related to physiotherapy procedures.
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Affiliation(s)
- A Delafontaine
- AP-HP, Hôpital Robert Debré, Service de Chirurgie Orthopédique, Paris, France
| | - A Presedo
- AP-HP, Hôpital Robert Debré, Service de Chirurgie Orthopédique, Paris, France
| | - D Mohamed
- AP-HP, Hôpital Robert-Debré, URC- UEC, Paris, France
| | - D Lopes
- AP-HP, Hôpital Robert Debré, Service de Chirurgie Orthopédique, Paris, France
| | - C Wood
- Centre de la Douleur Chronique, CHU Dupuytren, Limoges, France
| | - C Alberti
- AP-HP, Hôpital Robert-Debré, URC- UEC, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, UMR-S1123, ECEVE, Paris, France.,INSERM, U1123 and CIC-1426, ECEVE, Paris, France
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Guastella A, Latchman J, Tofthagen CS. Opioid-Induced Hyperalgesia: Clinical Implications for Advanced Practice Nurses in Oncology. Clin J Oncol Nurs 2017; 21:294-296. [PMID: 28524890 DOI: 10.1188/17.cjon.294-296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Opioid-induced hyperalgesia (OIH) is a key factor in the clinical management of patients experiencing pain. However, limited knowledge exists regarding the specific mechanisms involved in OIH and its treatment. A thorough assessment is usually required, and clinical diagnosis is mainly determined by exclusion in medical practice. Patients who are taking opioids should receive ongoing, comprehensive assessment by a clinician. Early identification of OIH will lead to improved patient outcomes.
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Michelet D, Hilly J, Skhiri A, Abdat R, Diallo T, Brasher C, Dahmani S. Opioid-Sparing Effect of Ketamine in Children: A Meta-Analysis and Trial Sequential Analysis of Published Studies. Paediatr Drugs 2016; 18:421-433. [PMID: 27688125 DOI: 10.1007/s40272-016-0196-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Reducing postoperative opioid consumption is a priority given its impact upon recovery, and the efficacy of ketamine as an opioid-sparing agent in children is debated. The goal of this study was to update a previous meta-analysis on the postoperative opioid-sparing effect of ketamine, adding trial sequential analysis (TSA) and four new studies. MATERIALS AND METHODS A comprehensive literature search was conducted to identify clinical trials that examined ketamine as a perioperative opioid-sparing agent in children and infants. Outcomes measured were postoperative opioid consumption to 48 h (primary outcome: postoperative opioid consumption to 24 h), postoperative pain intensity, postoperative nausea and vomiting and psychotomimetic symptoms. The data were combined to calculate the pooled mean difference, odds ratios or standard mean differences. In addition to this classical meta-analysis approach, a TSA was performed. RESULTS Eleven articles were identified, with four added to seven from the previous meta-analysis. Ketamine did not exhibit a global postoperative opioid-sparing effect to 48 postoperative hours, nor did it decrease postoperative pain intensity. This result was confirmed using TSA, which found a lack of power to draw any conclusion regarding the primary outcome of this meta-analysis (postoperative opioid consumption to 24 h). Ketamine did not increase the prevalence of either postoperative nausea and vomiting or psychotomimetic complications. CONCLUSIONS This meta-analysis did not find a postoperative opioid-sparing effect of ketamine. According to the TSA, this negative result might involve a lack of power of this meta-analysis. Further studies are needed in order to assess the postoperative opioid-sparing effects of ketamine in children.
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Affiliation(s)
- Daphnée Michelet
- Department of Anesthesia and Intensive Care, Robert Debre University Hospital, Paris, France.,Paris Diderot University, Paris, France
| | - Julie Hilly
- Department of Anesthesia and Intensive Care, Robert Debre University Hospital, Paris, France.,Paris Diderot University, Paris, France
| | - Alia Skhiri
- Department of Anesthesia and Intensive Care, Robert Debre University Hospital, Paris, France.,Paris Diderot University, Paris, France
| | - Rachida Abdat
- Department of Anesthesia and Intensive Care, Robert Debre University Hospital, Paris, France.,Paris Diderot University, Paris, France
| | - Thierno Diallo
- Department of Anesthesia and Intensive Care, Robert Debre University Hospital, Paris, France.,Paris Diderot University, Paris, France
| | - Christopher Brasher
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Australia
| | - Souhayl Dahmani
- Department of Anesthesia and Intensive Care, Robert Debre University Hospital, Paris, France. .,Paris Diderot University, Paris, France. .,DHU PROTECT, INSERM U1141, Robert Debre University Hospital, Paris, France. .,Department of Anesthesiology, Intensive Care and Pain Management, Robert Debre Hospital, 48 Bd Sérurier, 75019, Paris, France.
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Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med 2016; 35:337-341. [PMID: 27802876 DOI: 10.1016/j.ajem.2016.10.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022] Open
Abstract
The United States is currently experiencing a public health crisis of opioid addiction, which has its genesis in an industry marketing effort that successfully encouraged clinicians to prescribe opioids liberally, and asserted the safety of prescribing opioids for chronic non-cancer pain, despite a preponderance of evidence demonstrating the risks of dependence and misuse. The resulting rise in opioid use has pushed drug overdose deaths in front of motor vehicle collisions to become the leading cause of accidental death in the country. Emergency providers frequently treat patients for complications of opioid abuse, and also manage patients with acute and chronic pain, for which opioids are routinely prescribed. Emergency providers are therefore well positioned to both prevent new cases of opioid misuse and initiate appropriate treatment of existing opioid addicts. In opioid-naive patients, this is accomplished by a careful consideration of the likelihood of benefit and harm of an opioid prescription for acute pain. If opioids are prescribed, the chance of harm is reduced by matching the number of pills prescribed to the expected duration of pain and selecting an opioid preparation with low abuse liability. Patients who present to acute care with exacerbations of chronic pain or painful conditions associated with opioid misuse are best managed by treating symptoms with opioid alternatives and encouraging treatment for opioid addiction.
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Affiliation(s)
- Reuben J Strayer
- 79-01 Broadway, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst, NY 11373, United States.
| | - Sergey M Motov
- 4802 Tenth Ave, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, United States
| | - Lewis S Nelson
- 185 South Orange Avenue, Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
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Abstract
Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.
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Perioperative management of a morbidly obese pregnant patient undergoing cesarean section under general anesthesia - case report. Braz J Anesthesiol 2016; 66:418-22. [PMID: 27343794 DOI: 10.1016/j.bjane.2014.05.011] [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: 01/05/2014] [Accepted: 05/06/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The increased prevalence of obesity in the general population extends to women of reproductive age. The aim of this study is to report the perioperative management of a morbidly obese pregnant woman, body mass index >50kg/m(2), who underwent cesarean section under general anesthesia. CASE REPORT Pregnant woman in labor, 35 years of age, body mass index 59.8kg/m(2). Cesarean section was indicated due to the presumed fetal macrosomia. The patient refused spinal anesthesia. She was placed in the ramp position with cushions from back to head to facilitate tracheal intubation. Another cushion was placed on top of the right gluteus to create an angle of approximately 15° to the operating table. Immediately before induction of anesthesia, asepsis was carried out and sterile surgical fields were placed. Anesthesia was induced in rapid sequence, with Sellick maneuver and administration of remifentanil, propofol, and succinilcolina. Intubation was performed using a gum elastic bougie, and anesthesia was maintained with sevoflurane and remifentanil. The interval between skin incision and fetal extraction was 21min, with the use of a Simpson's forceps scoop to assist in the extraction. The patient gave birth to a newborn weighing 4850g, with Apgar scores of 2 in the 1st minute (received positive pressure ventilation by mask for about 2min) and 8 in the 5th minute. The patient was extubated uneventfully. Multimodal analgesia and prophylaxis of nausea and vomiting was performed. Mother and newborn were discharged on the 4th postoperative day.
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Roeckel LA, Le Coz GM, Gavériaux-Ruff C, Simonin F. Opioid-induced hyperalgesia: Cellular and molecular mechanisms. Neuroscience 2016; 338:160-182. [PMID: 27346146 DOI: 10.1016/j.neuroscience.2016.06.029] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/10/2016] [Accepted: 06/16/2016] [Indexed: 12/18/2022]
Abstract
Opioids produce strong analgesia but their use is limited by a paradoxical hypersensitivity named opioid-induced hyperalgesia (OIH) that may be associated to analgesic tolerance. In the last decades, a significant number of preclinical studies have investigated the factors that modulate OIH development as well as the cellular and molecular mechanisms underlying OIH. Several factors have been shown to influence OIH including the genetic background and sex differences of experimental animals as well as the opioid regimen. Mu opioid receptor (MOR) variants and interactions of MOR with different proteins were shown important. Furthermore, at the cellular level, both neurons and glia play a major role in OIH development. Several neuronal processes contribute to OIH, like activation of neuroexcitatory mechanisms, long-term potentiation (LTP) and descending pain facilitation. Increased nociception is also mediated by neuroinflammation induced by the activation of microglia and astrocytes. Neurons and glial cells exert synergistic effects, which contribute to OIH. The molecular actors identified include the Toll-like receptor 4 and the anti-opioid systems as well as some other excitatory molecules, receptors, channels, chemokines, pro-inflammatory cytokines or lipids. This review summarizes the intracellular and intercellular pathways involved in OIH and highlights some mechanisms that may be challenged to limit OIH in the future.
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Affiliation(s)
- Laurie-Anne Roeckel
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France; Université de Strasbourg, Illkirch, France; Centre National de la Recherche Scientifique, UMR7104, Illkirch, France; Institut National de la Santé et de la Recherche Médicale, U964, Illkirch, France
| | - Glenn-Marie Le Coz
- Biotechnologie et Signalisation Cellulaire, UMR 7242 CNRS, Université de Strasbourg, Illkirch, France
| | - Claire Gavériaux-Ruff
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France; Université de Strasbourg, Illkirch, France; Centre National de la Recherche Scientifique, UMR7104, Illkirch, France; Institut National de la Santé et de la Recherche Médicale, U964, Illkirch, France; Ecole Supérieure de Biotechnologie de Strasbourg, Université de Strasbourg, France
| | - Frédéric Simonin
- Biotechnologie et Signalisation Cellulaire, UMR 7242 CNRS, Université de Strasbourg, Illkirch, France.
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Yi P, Pryzbylkowski P. Opioid Induced Hyperalgesia. PAIN MEDICINE 2015; 16 Suppl 1:S32-6. [DOI: 10.1111/pme.12914] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 08/13/2015] [Indexed: 11/28/2022]
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Arout CA, Edens E, Petrakis IL, Sofuoglu M. Targeting Opioid-Induced Hyperalgesia in Clinical Treatment: Neurobiological Considerations. CNS Drugs 2015; 29:465-86. [PMID: 26142224 DOI: 10.1007/s40263-015-0255-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Opioid analgesics have become a cornerstone in the treatment of moderate to severe pain, resulting in a steady rise of opioid prescriptions. Subsequently, there has been a striking increase in the number of opioid-dependent individuals, opioid-related overdoses, and fatalities. Clinical use of opioids is further complicated by an increasingly deleterious profile of side effects beyond addiction, including tolerance and opioid-induced hyperalgesia (OIH), where OIH is defined as an increased sensitivity to already painful stimuli. This paradoxical state of increased nociception results from acute and long-term exposure to opioids, and appears to develop in a substantial subset of patients using opioids. Recently, there has been considerable interest in developing an efficacious treatment regimen for acute and chronic pain. However, there are currently no well-established treatments for OIH. Several substrates have emerged as potential modulators of OIH, including the N-methyl-D-aspartate and γ-aminobutyric acid receptors, and most notably, the innate neuroimmune system. This review summarizes the neurobiology of OIH in the context of clinical treatment; specifically, we review evidence for several pathways that show promise for the treatment of pain going forward, as prospective adjuvants to opioid analgesics. Overall, we suggest that this paradoxical state be considered an additional target of clinical treatment for chronic pain.
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Affiliation(s)
- Caroline A Arout
- Department of Psychiatry, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA,
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33
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Webb CAJ, Mariano ER. Best multimodal analgesic protocol for total knee arthroplasty. Pain Manag 2015; 5:185-96. [DOI: 10.2217/pmt.15.8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Benevides ML, Brandão VCM, Lovera JIA. [Perioperative management of a morbidly obese pregnant patient undergoing cesarean section under general anesthesia - case report]. Rev Bras Anestesiol 2015; 66:418-22. [PMID: 25748118 DOI: 10.1016/j.bjan.2014.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 05/06/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The increased prevalence of obesity in the general population extends to women of reproductive age. The aim of this study is to report the perioperative management of a morbidly obese pregnant woman, body mass index > 50 kg/m(2), who underwent cesarean section under general anesthesia. CASE REPORT Pregnant woman in labor, 35 years of age, body mass index 59.8 kg/m(2). Caesarean section was indicated due to the presumed fetal macrosomia. The patient refused spinal anesthesia. She was placed in the ramp position with cushions from back to head to facilitate tracheal intubation. Another cushion was placed on top of the right gluteus to create an angle of approximately 15° to the operating table. Immediately before induction of anesthesia, asepsis was carried out and sterile surgical fields were placed. Anesthesia was induced in rapid sequence, with Sellick maneuver and administration of remifentanil, propofol, and succinilcolina. Intubation was performed using a gum elastic bougie, and anesthesia was maintained with sevoflurane and remifentanil. The interval between skin incision and fetal extraction was 21 minutes, with the use of a Simpson's forceps scoop to assist in the extraction. The patient gave birth to a newborn weighing 4850 g, with Apgar scores of 2 in the 1(st) minute (received positive pressure ventilation by mask for about 2 minutes) and 8 in the 5(th) minute. The patient was extubated uneventfully. Multimodal analgesia and prophylaxis of nausea and vomiting was performed. Mother and newborn were discharged on the 4(th) postoperative day.
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Affiliation(s)
- Márcio Luiz Benevides
- Departamento de Anestesiologia, Hospital Universitário Júlio Muller, Universidade Federal de Mato Grosso (UFMT), Cuiabá, MT, Brasil; Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia (CET/SBA), Cuiabá, MT, Brasil.
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Review of the Performance of Quantitative Sensory Testing Methods to Detect Hyperalgesia in Chronic Pain Patients on Long-term Opioids. Anesthesiology 2015; 122:677-85. [DOI: 10.1097/aln.0000000000000530] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Background:
Opioid-induced hyperalgesia is a clinical syndrome whereby patients on long-term opioids become more sensitive to pain while taking opioids. Opioid-induced hyperalgesia is characterized by increased pain intensity over time, spreading of pain to other locations, and increased pain sensation to external stimuli. To characterize opioid-induced hyperalgesia, laboratory methods to measure hyperalgesia have been developed. To determine the performance of these methods, the authors conducted a systematic review of clinical studies that incorporate measures of hyperalgesia in chronic pain patients on long-term opioids.
Methods:
PubMed and Cochrane databases were searched (terms: opioid induced hyperalgesia, study or trial, and long-term or chronic). Studies published in English were selected if they were conducted in chronic pain patients on long-term opioids and incorporated measures of hyperalgesia; acute/single-dose studies and/or conducted in healthy volunteers were excluded.
Results:
Fourteen articles made the final selection (11 were selected from the search and 3 others were found from additional sources); there was one randomized controlled trial, one prospective controlled study, three prospective uncontrolled studies, and nine cross-sectional observation studies. Hyperalgesia measurement paradigms used included cold pain, heat pain, pressure pain, electrical pain, ischemic pain, and injection pain. Although none of the stimuli were capable of detecting patients’ hyperalgesia, heat pain sensitivity showed some promising results.
Conclusions:
None of the measures reviewed herein met the criteria of a definitive standard for the measurement of hyperalgesia. Additional studies that use improved study design should be conducted.
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Gupta M, Gupta P. Is mechanism and symptom-based analgesia an answer to opioid-induced hyperalgesia? Indian J Palliat Care 2015; 21:82-4. [PMID: 25709193 PMCID: PMC4332136 DOI: 10.4103/0973-1075.150196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
“Cancer Pain” and “Pain in cancer patient” are not synonymous. Opioid-induced Hyperalgesia (OIH) is a paradoxical state of nociceptive sensitization caused by exposure to opioids. Neuropathic pain is only partially responsive to opioids; injudicious increase in dose of opioids in neuropathic pain may not only result in inadequate pain relief but also OIH. Majority of literature on OIH is in non-cancer pain with systemic use of opioids. We describe the development and successful treatment of OIH in a 55-year-old male patient with Small cell Carcinoma Lung. Opioid tapering, rotation, systemic desensitization helps in combatting OIH. The use of anti-neuropathic adjuvant analgesics helps not only in preventing and treating OIH but also in understanding putative mechanisms underlying neuropathic pain and OIH.
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Affiliation(s)
- Mayank Gupta
- Department of Medical Intensive Care Unit and Pain, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Priyanka Gupta
- Employee's State Insurance Hospital, Okhla, Delhi, India
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Rowan MP, Szteyn K, Doyle AP, Gomez R, Henry MA, Jeske NA. β-arrestin-2-biased agonism of delta opioid receptors sensitizes transient receptor potential vanilloid type 1 (TRPV1) in primary sensory neurons. Mol Pain 2014; 10:50. [PMID: 25085415 PMCID: PMC4131480 DOI: 10.1186/1744-8069-10-50] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/21/2014] [Indexed: 02/06/2023] Open
Abstract
Despite advances in understanding the signaling mechanisms involved in the development and maintenance of chronic pain, the pharmacologic treatment of chronic pain has seen little advancement. Agonists at the mu opioid receptor (MOPr) continue to be vital in the treatment of many forms of chronic pain, but side-effects limit their clinical utility and range from relatively mild, such as constipation, to major, such as addiction and dependence. Additionally, chronic activation of MOPr results in pain hypersensitivity known as opioid-induced hyperalgesia (OIH), and we have shown recently that recruitment of β-arrestin2 to MOPr, away from transient potential vanilloid eceptor type 1 (TRPV1) in primary sensory neurons contributes to this phenomenon. The delta opioid receptor (DOPr) has become a promising target for the treatment of chronic pain, but little is known about the effects of chronic activation of DOPr on nociceptor sensitivity and OIH. Here we report that chronic activation of DOPr by the DOPr-selective agonist, SNC80, results in the sensitization of TRPV1 and behavioral signs of OIH via β-arrestin2 recruitment to DOPr and away from TRPV1. Conversely, chronic treatment with ARM390, a DOPr-selective agonist that does not recruit β-arrestin2, neither sensitized TRPV1 nor produced OIH. Interestingly, the effect of SNC80 to sensitize TRPV1 is species-dependent, as rats developed OIH but mice did not. Taken together, the reported data identify a novel side-effect of chronic administration of β-arrestin2-biased DOPr agonists and highlight the importance of potential species-specific effects of DOPr agonists.
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Affiliation(s)
| | | | | | | | | | - Nathaniel A Jeske
- Departments of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at San Antonio, MC 7908, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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Stoetzer C, Kistner K, Stüber T, Wirths M, Schulze V, Doll T, Foadi N, Wegner F, Ahrens J, Leffler A. Methadone is a local anaesthetic-like inhibitor of neuronal Na+ channels and blocks excitability of mouse peripheral nerves. Br J Anaesth 2014; 114:110-20. [PMID: 25012584 DOI: 10.1093/bja/aeu206] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Opioids enhance and prolong analgesia when applied as adjuvants to local anaesthetics (LAs). A possible molecular mechanism for this property is a direct inhibition of voltage-gated Na(+) channels which was reported for some opioids. Methadone is an effective adjuvant to LA and was recently reported to inhibit cardiac Na(+) channels. Here, we explore and compare LA properties of methadone and bupivacaine on neuronal Na(+) channels, excitability of peripheral nerves, and cell viability. METHODS Effects of methadone were explored on compound action potentials (CAP) of isolated mouse saphenous nerves. Patch clamp recordings were performed on Na(+) channels in ND7/23 cells, the α-subunits Nav1.2, Nav1.3, Nav1.7, and Nav1.8, and the hyperpolarization-activated cyclic nucleotide-gated channel 2 (HCN2). Cytotoxicity was determined using flow cytometry. RESULTS Methadone (IC50 86-119 µM) is a state-dependent and unselective blocker on Nav1.2, Nav1.3, Nav1.7, and Nav1.8 with a potency comparable with that of bupivacaine (IC50 177 µM). Both bupivacaine and methadone also inhibit C- and A-fibre CAPs in saphenous nerves in a concentration-dependent manner. Tonic block of Nav1.7 revealed a discrete stereo-selectivity with a higher potency for levomethadone than for dextromethadone. Methadone is also a weak blocker of HCN2 channels. Both methadone and bupivacaine induce a pronounced cytotoxicity at concentrations required for LA effects. CONCLUSIONS Methadone induces typical LA effects by inhibiting Na(+) channels with a potency similar to that of bupivacaine. This hitherto unknown property of methadone might contribute to its high efficacy when applied as an adjuvant to LA.
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Affiliation(s)
- C Stoetzer
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - K Kistner
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - T Stüber
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - M Wirths
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - V Schulze
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - T Doll
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - N Foadi
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - F Wegner
- Department of Neurology, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - J Ahrens
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - A Leffler
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
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Kaneria A. Opioid-induced hyperalgesia: when pain killers make pain worse. BMJ Case Rep 2014; 2014:bcr-2014-204551. [PMID: 24899014 DOI: 10.1136/bcr-2014-204551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 44-year-old woman had a temporal glioma and was admitted to the hospice with pain that was not controlled despite escalating opioids. Her pain levels rose after every dose increase resulting now in continuous pain, making her very low in mood. Her short-term memory had also declined in a stepwise fashion with each increase in opioids. Additionally, her poor health had had a detrimental effect on family life. Physical examination was difficult due to allodynia but no major abnormality was found. The team suspected opioid-induced hyperalgesia and decided to cut the patient's opioids by one-third initially. This immediately improved the overall pain. The opioids continued to be decreased incrementally every 1-2 days until the pain had disappeared completely. She was stabilised on a dose almost one-seventh of her original regime. Mood and memory also improved as opioids decreased and she was discharged home after 8 days.
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JABBOUR HJ, NACCACHE NM, JAWISH RJ, ABOU ZEID HA, JABBOUR KB, RABBAA-KHABBAZ LG, GHANEM IB, YAZBECK PH. Ketamine and magnesium association reduces morphine consumption after scoliosis surgery: prospective randomised double-blind study. Acta Anaesthesiol Scand 2014; 58:572-9. [PMID: 24635528 DOI: 10.1111/aas.12304] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Scoliosis repair is a major orthopaedic surgery associated with severe post-operative pain. Ketamine and magnesium have an established efficacy as morphine-sparing agents. Our purpose was to evaluate the morphine-sparing effect of both magnesium and ketamine given simultaneously compared with ketamine alone during scoliosis surgery. METHODS Fifty patients scheduled for posterior instrumentation were randomised in a prospective double-blind study. The Gr (K + Mg) received, after induction, an intravenous (IV) bolus of ketamine 0.2 mg/kg and magnesium 50 mg/kg, followed by continuous infusion of ketamine (0.15 mg/kg/h) and magnesium (8 mg/kg/h) until extubation. The Gr (K) received the same dose of ketamine associated with bolus and continuous infusion of normal saline. All patients received multimodal analgesia associated with IV morphine administered via patient-controlled analgesia pump. Morphine consumption, visual analogue scale (VAS) pain scores and occurrence of side effects were followed until 48 h post-operatively. Sleep quality and patient satisfaction were also followed. P < 0.05 was considered statistically significant. RESULTS The average cumulative morphine consumption was significantly lower in the Gr (K + Mg) compared with the Gr (K) at post-operative hours 4, 8, 12, 18, 30, 36 and 48. The relative difference in the post-operative morphine consumption was 29.5%: Gr (K + Mg) 51.53 mg vs. Gr (K) 73.16 mg. VAS scores were not statistically different between the two groups. However, qualities of sleep and satisfaction scores on the first night were significantly better in the Gr (K + Mg) (P = 0.027 and P = 0.016, respectively). CONCLUSION Ketamine and magnesium association reduces the post-operative morphine consumption after scoliosis surgery. It seems to provide a better sleep quality and improves patient satisfaction.
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Affiliation(s)
- H. J. JABBOUR
- Departments of Anesthesia and Critical Care; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
| | - N. M. NACCACHE
- Departments of Anesthesia and Critical Care; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
| | - R. J. JAWISH
- Departments of Anesthesia and Critical Care; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
| | - H. A. ABOU ZEID
- Departments of Anesthesia and Critical Care; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
| | - K. B. JABBOUR
- Departments of Anesthesia and Critical Care; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
| | - L. G. RABBAA-KHABBAZ
- Department of Pharmacy; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
| | - I. B. GHANEM
- Department of Orthopedic Surgery; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
| | - P. H. YAZBECK
- Departments of Anesthesia and Critical Care; Hôtel Dieu de France; Université Saint Joseph; Beirut Lebanon
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Rowan MP, Bierbower SM, Eskander MA, Szteyn K, Por ED, Gomez R, Veldhuis N, Bunnett NW, Jeske NA. Activation of mu opioid receptors sensitizes transient receptor potential vanilloid type 1 (TRPV1) via β-arrestin-2-mediated cross-talk. PLoS One 2014; 9:e93688. [PMID: 24695785 PMCID: PMC3973553 DOI: 10.1371/journal.pone.0093688] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 03/07/2014] [Indexed: 11/18/2022] Open
Abstract
The transient receptor potential family V1 channel (TRPV1) is activated by multiple stimuli, including capsaicin, acid, endovanilloids, and heat (>42C). Post-translational modifications to TRPV1 result in dynamic changes to the sensitivity of receptor activation. We have previously demonstrated that β-arrestin2 actively participates in a scaffolding mechanism to inhibit TRPV1 phosphorylation, thereby reducing TRPV1 sensitivity. In this study, we evaluated the effect of β-arrestin2 sequestration by G-protein coupled receptors (GPCRs) on thermal and chemical activation of TRPV1. Here we report that activation of mu opioid receptor by either morphine or DAMGO results in β-arrestin2 recruitment to mu opioid receptor in sensory neurons, while activation by herkinorin does not. Furthermore, treatment of sensory neurons with morphine or DAMGO stimulates β-arrestin2 dissociation from TRPV1 and increased sensitivity of the receptor. Conversely, herkinorin treatment has no effect on TRPV1 sensitivity. Additional behavioral studies indicate that GPCR-driven β-arrestin2 sequestration plays an important peripheral role in the development of thermal sensitivity. Taken together, the reported data identify a novel cross-talk mechanism between GPCRs and TRPV1 that may contribute to multiple clinical conditions.
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Affiliation(s)
- Matthew P. Rowan
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Sonya M. Bierbower
- Department of Physiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Michael A. Eskander
- Department of Pharmacology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Kalina Szteyn
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Elaine D. Por
- Department of Pharmacology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Ruben Gomez
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Nicholas Veldhuis
- Departments of Pharmacology and Medicine, Monash Institute of Pharmacological Sciences, Parkville, Victoria, Australia
| | - Nigel W. Bunnett
- Departments of Pharmacology and Medicine, Monash Institute of Pharmacological Sciences, Parkville, Victoria, Australia
| | - Nathaniel A. Jeske
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
- Department of Pharmacology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
- Department of Physiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
- * E-mail:
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Opioid analgesics and narcotic antagonists. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/b978-0-444-62635-6.00008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
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[Dependency syndrome and hyperalgesia due to an opioid therapy for curative treatable pain. Case report of an apparent palliative patient]. Schmerz 2013; 27:506-12. [PMID: 24005817 DOI: 10.1007/s00482-013-1353-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Opioids are an essential part of cancer pain management but particularly in this patient group physicians could misinterpret opioid-induced potentially life-threatening side effects within the central nervous system (CNS) or hyperalgesia as a consequence of tumor progression. In this case increasing the opioid dose or switching to rapidly acting opioids may trigger a vicious circle. We describe a case report of a male patient who was treated with high doses of transdermal and endonasal fentanyl 2 years after pancreatomy due to cancer. The patient was referred to the palliative care unit presenting with delirious behavior and 30-40 severe abdominal pain attacks/day. After withdrawal of the opioid medication all CNS symptoms disappeared. Further diagnostics revealed multiple incisional hernia as the reason of the pain syndrome. The patient recovered after herniotomy and has now been pain free without any pain medication for more than 16 months. This case report underlines again the necessity of pain diagnostics also in assumed palliative patients with the risks of high dose opioid treatment.
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Varney SM, Bebarta VS. Opioid-induced hyperalgesia—worsening pain in opioid-dependent patients. Am J Emerg Med 2013; 31:458.e5-6. [DOI: 10.1016/j.ajem.2012.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 07/29/2012] [Indexed: 10/27/2022] Open
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Johnson JL, Hutchinson MR, Williams DB, Rolan P. Medication-overuse headache and opioid-induced hyperalgesia: A review of mechanisms, a neuroimmune hypothesis and a novel approach to treatment. Cephalalgia 2012; 33:52-64. [PMID: 23144180 DOI: 10.1177/0333102412467512] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction Patients with chronic headache who consume large amounts of analgesics are often encountered in clinical practice. Excessive intake of analgesics is now considered to be a cause, rather than simply a consequence, of frequent headaches, and as such the diagnosis “medication-overuse headache” (MOH) has been formulated. Despite the prevalence and clinical impact of MOH, the pathophysiology behind this disorder remains unclear and specific mechanism-based treatment options are lacking. Discussion Although most acute headache treatments have been alleged to cause MOH, here we conclude from the literature that opioids are a particularly problematic drug class consistently associated with worsening headache. MOH may not be a single entity, as each class of drug implicated may cause MOH via a different mechanism. Recent evidence indicates that chronic opioid administration may exacerbate pain in the long term by activating toll-like receptor-4 on glial cells, resulting in a pro-inflammatory state that manifests clinically as increased pain. Thus, from the available evidence it seems opioid-overuse headache is a phenomenon similar to opioid-induced hyperalgesia, which derives from a cumulative interaction between central sensitisation, due to repeated activation of nociceptive pathways by recurrent headaches, and pain facilitation due to glial activation. Conclusion Treatment strategies directed at inhibiting glial activation may be of benefit alongside medication withdrawal in the management of MOH.
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Affiliation(s)
| | | | - Desmond B Williams
- School of Pharmacy and Medical Sciences, University of South Australia, Australia
| | - Paul Rolan
- Discipline of Pharmacology, University of Adelaide, Australia
- Pain and Anaesthesia Research Clinic, Royal Adelaide Hospital, Australia
- Pain Management Unit, Royal Adelaide Hospital, Australia
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Muñoz-Ramón JM, Galván Guijo B. [Acute tolerance and opioid-induced hyperalgesia in a multi-operated patient]. Med Intensiva 2012; 37:366-7. [PMID: 23131575 DOI: 10.1016/j.medin.2012.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 09/06/2012] [Indexed: 11/25/2022]
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Pasero C, McCaffery M. Opioid-Induced Hyperalgesia. J Perianesth Nurs 2012; 27:46-50. [DOI: 10.1016/j.jopan.2011.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 11/01/2011] [Indexed: 11/29/2022]
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Lamacraft G. The link between acute postoperative pain and chronic pain syndromes. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2012. [DOI: 10.1080/22201173.2012.10872823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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