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Brauneis S, Araimo F, Rossi M, Russo D, Mammucari M, Maggiori E, di Marzo R, Vellucci R, Gori F, Bifarini B, Chiné E, Carpenedo R, Paolucci T, Giorgio C, Ritarossi R, Calò A, Luongo L, Natoli S. The role of mesotherapy in the management of spinal pain. A randomized controlled study. Clin Ter 2023; 174:336-342. [PMID: 37378503 DOI: 10.7417/ct.2023.2447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Background Mesotherapy is a technique through which active ingredients are administered into the thickness of the skin in order to increase the local analgesic effect. Methods 141 patients with spinal pain not responding to systemic therapy with NSAIDs were randomized to receive one or more intra-cutaneous drugs on a weekly basis. Results All patients achieved a pain reduction of at least 50% compared to baseline, and all tolerated the therapy without having to resort to systemic drug dose increases. Conclusions The data from our study show that the active ingredients infiltrated into the skin induce a mesodermal modulation between the infiltrated liquid and the cutaneous nervous and cellular structures from which the typical drug-saving effect of mesotherapy arises. Although further studies are needed to establish how to integrate mesotherapy in various clinical settings, it appears to be a useful technique available to the practicing physician. This research is also useful in guiding future clinical research.
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Affiliation(s)
- S Brauneis
- Department of Anesthesiology, Critical Care and Pain Medicine, La Sapienza University of Rome, Rome, Italy
| | - F Araimo
- Department of Anesthesiology, Critical Care and Pain Medicine, La Sapienza University of Rome, Rome, Italy
| | - M Rossi
- Section Of Anesthesia in Specialty Surgeries, Department of Emergency and Internal Medicine, Policlinico Universitario Agostino Gemelli, Sacro Cuore Catholic University, Rome, Italy
| | - D Russo
- San Marco Hospice and Palliative Care, Latina, Italy
| | | | | | - R di Marzo
- San Marco Hospice and Palliative Care, Latina, Italy
| | - R Vellucci
- alliative Care and Pain Therapy Unit - Anesthesiology and Resuscitation Department of Careggi University Hospital, Florence, Italy
| | - F Gori
- Section of Anesthesia, Intensive Care, and Pain Medicine, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - B Bifarini
- Section of Anesthesia, Intensive Care, and Pain Medicine, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - E Chiné
- Unit of Pain Therapy, Policlinic of Tor Vergata, Rome, Italy
| | - R Carpenedo
- Unit of Pain Therapy, Policlinic of Tor Vergata, Rome, Italy
| | - T Paolucci
- Department of Medical and Oral Sciences and Biotechnologies (DiSmob), Physical medicine and Rehabilitation unit, G. D'Annunzio University of Chieti-Pescara, Italy
| | - C Giorgio
- Rehabilitation Unit, F. Pirinei Hospital, Altamura, BA, Italy
| | - R Ritarossi
- Department of Anesthesiology, Critical Care and Pain Medicine, La Sapienza University of Rome, Rome, Italy
| | - A Calò
- Department of Anesthesiology, Critical Care and Pain Medicine, La Sapienza University of Rome, Rome, Italy
| | - L Luongo
- Department of experimental medicine, division of pharmacology, universita della Campania "L. Vanvitelli" Naples, Italy
| | - S Natoli
- Dept. of Clinical Science and Translational Medicine. University of Rome Tor Vergata, Italy
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Vellucci R, Fornasari D. Appropriate use of tapentadol: focus on the optimal tapering strategy. Curr Med Res Opin 2023; 39:123-129. [PMID: 36427080 DOI: 10.1080/03007995.2022.2148459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Due to its opioid and non-opioid mechanism of action, tapentadol is considered an atypical opioid with improved gastrointestinal tolerability versus traditional opioids. As for all opioid analgesics it is important to understand how to discontinue a treatment when it is not needed anymore. The aim of this article was to provide an overview of opioid therapy in non-cancer pain, with a specific focus on tapering of tapentadol in patients with chronic non-cancer pain, and suggestions on how to achieve tapering. METHODS Studies for this narrative review were identified via PubMed using a structured search strategy, focusing on management of chronic non-cancer pain with opioids, and the efficacy, tolerability, and pharmacology of tapentadol prolonged release. Publications were limited to English-language articles published within the last ∼10 years. RESULTS The review discusses the use and discontinuation of opioids in general, as well clinical data on discontinuation of tapentadol specifically. We provide a flow chart, which can be used by clinicians in the context of their own clinical experience to appropriately taper tapentadol in patients with chronic non-cancer pain. The flow chart can be easily tailored to individual patient characteristics, duration of tapentadol treatment, response to progressive dosage reduction, and likelihood of withdrawal symptom occurrence. CONCLUSIONS While tapentadol is associated with a low frequency of opioid withdrawal symptoms after abrupt discontinuation, use of a tapering strategy is prudent. Tapering strategies developed for opioids in general can potentially be safely individualized in tapentadol-treated patients, although research on tapering strategies for tapentadol is required.
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Affiliation(s)
- Renato Vellucci
- University of Florence, Pain and Palliative Care Clinic, University Hospital of Careggi, Florence, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
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Bifarini B, Gori F, Russo D, Mammucari M, Maggiori E, Di Marzo R, Migliore A, Massafra U, Ronconi G, Ferrara PE, Paolucci T, Vellucci R, Mediati D, Violo B, Natoli S, Brauneis S. Intradermal therapy (mesotherapy): the lower the better. Clin Ter 2022; 173:79-83. [PMID: 35147651 DOI: 10.7417/ct.2022.2396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Intradermal therapy (mesotherapy) is a technique used to inject drugs into the surface layer of the skin. The intradermal micro deposit allows to modulate the kinetics of drugs, slowing down its absorption and prolonging the local mechanism of action. This technique is applied in the treatment of some forms of localized pain when a systemic drug-saving effect is useful, when it is necessary to synergize with other pharmacological or non-pharmacological thera-pies, when other therapies have failed or cannot be used. AIM The purpose of our study was to evaluate the effect of a mixture with respect to its lower concentration. We also wanted to evaluate the number of sessions needed to reach the therapeutic goal (50% reduction in pain from baseline) in patients with acute or chronic neck pain. METHOD We analyzed retrospectively data from 62 patients with cervicobrachial pain treated with intradermal drugs. Group A received a mixture of drugs; group B received half the dose of drugs. RESULTS Patients who received a lower concentration of drugs achieved similar results to those who received a higher dose. The therapeutic goal was achieved on average with 3.5 + 1.7 sessions on a weekly basis (min 1; max 9). Subjects in group A required 4+1.7 treatments (min 1; max 9), while subjects in group B required 3+1.5 treatments (min 1; max 7). CONCLUSIONS Our study confirms that even a lower dose of drugs can induce a clinically useful result. This study confirms that the useful effect of mesotherapy is only partly due to the pharmacological action. Further randomized prospective studies are needed to standardize the technique in the various pain syndromes, but it is recommended to follow the guidelines of the Italian Society of Mesotherapy to ensure patients receive appropriate treatment.
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Affiliation(s)
- B Bifarini
- Section of Anesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - F Gori
- Section of Anesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - D Russo
- "San Marco" Hospice and Palliative Care, Latina, Italy
| | | | | | - R Di Marzo
- Member of the Italian So-ciety of Mesotherapy, Rome, Italy
| | - A Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - U Massafra
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - G Ronconi
- University Policlinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - P E Ferrara
- University Policlinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - T Paolucci
- Unit of Physical Medicine and Rehabilitation, G. D'Annunzio University of Chieti-Pescara, Department of Oral Medical Science and Biotechnology (DSMOB), Italy
| | - R Vellucci
- Anesthesiology department, University hospital Careggi, Florence, Italy
| | - D Mediati
- Anesthesiology department, University hospital Careggi, Florence, Italy
| | - B Violo
- Pain Therapy Unit, S. Spirito Nuovo Regina Margherita Hospital, Rome, Italy
| | - S Natoli
- Department of Clinical Science and Translational Medicine, Tor Vergata University, Rome, Italy
| | - S Brauneis
- Pain Center "Enzo Borzomati", University Hospital of Rome "Policlinico Umberto I", Rome, Italy
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Cascella M, Marinangeli F, Vittori A, Scala C, Piccinini M, Braga A, Miceli L, Vellucci R. Open Issues and Practical Suggestions for Telemedicine in Chronic Pain. Int J Environ Res Public Health 2021; 18:ijerph182312416. [PMID: 34886140 PMCID: PMC8656645 DOI: 10.3390/ijerph182312416] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/20/2021] [Accepted: 11/24/2021] [Indexed: 11/20/2022]
Abstract
Telemedicine represents a major opportunity to facilitate continued assistance for patients with chronic pain and improve their access to care. Preliminary data show that an improvement can be expected of the monitoring, treatment adherence, assessment of treatment effect including the emotional distress associated with pain. Moreover, this approach seems to be convenient and cost-effective, and particularly suitable for personalized treatment. Nevertheless, several open issues must be highlighted such as identification of assessment tools, implementation of monitoring instruments, and ability to evaluate personal needs and expectations. Open questions exist, such as how to evaluate the need for medical intervention and interventional procedures, and how to define when a clinical examination is required for certain conditions. In this context, it is necessary to establish dynamic protocols that provide the right balance between face-to-face visits and telemedicine. Useful tips are provided to start an efficient experience. More data are needed to develop precise operating procedures. In the meantime, the first experiences from such settings can pave the way to initiate effective care pathways in chronic pain.
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Affiliation(s)
- Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori—IRCCS—Fondazione Pascale, 80131 Napoli, Italy;
| | - Franco Marinangeli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO, Ospedale Pediatrico Bambino Gesù IRCCS, 00165 Rome, Italy
- Correspondence: or ; Tel.: +39-06-68592397
| | - Cristina Scala
- UOC Anesthesia, Intensive Care and Pain Therapy, Senigallia Hospital, 60123 Ancona, Italy;
| | - Massimo Piccinini
- Anesthesia, Critical Care, Palliative Medicine and Pain Therapy Service, L’Aquila ASL1 Abruzzo, 67100 L’Aquila, Italy;
| | | | - Luca Miceli
- Department of Clinical and Experimental Pain Medicine, IRCCS CRO of Aviano, 33081 Aviano, Italy;
| | - Renato Vellucci
- Pain and Palliative Care Clinic, University Hospital of Careggi, 50121 Florence, Italy;
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Mammucari M, Paolucci T, Russo D, Maggiori E, Di Marzo R, Migliore A, Massafra U, Ronconi G, Ferrara PE, Gori F, Bifarini B, Brauneis S, Vellucci R, Mediati RD, Violo B, Natoli S, Pediliggieri C, Di Campli C, Collina MC. A Call to Action by the Italian Mesotherapy Society on Scientific Research. Drug Des Devel Ther 2021; 15:3041-3047. [PMID: 34285471 PMCID: PMC8285234 DOI: 10.2147/dddt.s321215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023] Open
Abstract
Mesotherapy (local intradermal therapy, LIT) is a technique used to slowly spread drugs in tissues underlying the site of injection to prolong the pharmacological effect with respect to intramuscular injection. Recommendations for proper medical use of this technique have been made for pain medicine and rehabilitation, chronic venous disease, sport medicine, musculoskeletal disorders, several dermatological conditions, skin ageing, and immune-prophylaxis. Although mesotherapy is considered a valid technique, unresolved questions remain, which should be answered to standardize methodology and dosing regimen as well as to define the right indications in clinical practice. New randomized controlled trials are needed to test single products (dose, frequency of administration, efficacy and safety). Even infiltration of substances for dermo-cosmetic purposes must be guided by safety and efficacy tests before being proposed by mesotherapy. In this article, we put forth a preclinical and clinical research plan and a health technology assessment as a call to action by doctors, researchers and scientific societies to aid national health authorities in considering mesotherapy for prevention, treatment and rehabilitation paths.
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Affiliation(s)
| | - Teresa Paolucci
- Unit of Physical Medicine and Rehabilitation, G. D’ Annunzio University of Chieti-Pescara, Department of Oral Medical Science and Biotechnology (DSMOB), Chieti, Italy
| | | | | | | | - Alberto Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Umberto Massafra
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Gianpaolo Ronconi
- Physical Medicine and Rehabilitation Unit, IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Paola Emilia Ferrara
- Physical Medicine and Rehabilitation Unit, IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Fabio Gori
- Section of Anaesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - Barbara Bifarini
- Section of Anaesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - Stefano Brauneis
- Pain Centre “Enzo BorzomatI”, University Hospital of Rome “Policlinico Umberto I”, Rome, Italy
| | - Renato Vellucci
- Anaesthesiology Department, University Hospital Careggi, Florence, Italy
| | | | - Bartolomeo Violo
- Pain Therapy Unit, S. Spirito Nuovo Regina Margherita Hospital, Rome, Italy
| | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, Tor Vergata University, Rome, Italy
| | - Carmen Pediliggieri
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
| | - Cristiana Di Campli
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
| | - Maria Chiara Collina
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
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Mammucari M, Russo D, Maggiori E, Paolucci T, Di Marzo R, Brauneis S, Bifarini B, Ronconi G, Ferrara PE, Gori F, Mediati RD, Vellucci R, Migliore A, Natoli S. Evidence based recommendations on mesotherapy: an update from the Italian society of Mesotherapy. Clin Ter 2021; 171:e37-e45. [PMID: 33346324 DOI: 10.7417/ct.2021.2278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Mesotherapy, also known as local intradermal therapy, widely used all over the world, is a technique used to inject substances into the surface layer of the skin. There are no international guidelines for the correct use of this technique and in many countries, it is still applied empirically without valid patient consent. The Italian society of mesotherapy has planned a study to assess the rationale and clinical applications based on current evidence. METHODS An independent steering committee, based on the available scientific literature, has formulated a series of clinical questions. 21 experts responded by writing an evidence-based document. From this document 30 statements were obtained which were presented to 114 experts using the Delphi method. RESULTS 28 statements reached a broad agreement on definition, technique, pharmacological rationale, indications and some crucial ethical aspect. CONCLUSIONS Although further studies are needed to establish the clinical role of this technique in each field of application, our statements recommend the correct application according to the needs of the individual patient in full respect of ethics.
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Affiliation(s)
| | - D Russo
- San Marco Hospice and Palliative Care, Latina
| | | | - T Paolucci
- University G. D'Annunzio Chieti, Department of Medical and Oral Sciences and Biotechnologies, Chieti-Pescara
| | - R Di Marzo
- Member of the Italian Society of Mesotherapy, Rome
| | - S Brauneis
- Pain Center "Enzo Borzomati", University Hospital of Rome "Policlinico Umberto I", Rome
| | - B Bifarini
- Section of Anesthesia, Intensive Care, and Pain Medicine, Azienda Ospedaliera-Universitaria Santa Maria Della Misericordia, Perugia
| | - G Ronconi
- University Policlinic Foundation A. Gemelli IRCCS, Rome
| | - P E Ferrara
- University Policlinic Foundation A. Gemelli IRCCS, Rome
| | - F Gori
- Section of Anesthesia, Intensive Care, and Pain Medicine, Azienda Ospedaliera-Universitaria Santa Maria Della Misericordia, Perugia
| | - R D Mediati
- Department of Anesthesia of Careggi University Hospital, Florence
| | - R Vellucci
- Department of Anesthesia of Careggi University Hospital, Florence
| | - A Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome
| | - S Natoli
- Dept of Clinical Science and Translational Medicine, University of Rome Tor Vergata AND Unit of Pain Therapy, Polyclinic of Tor Vergata - Rome, Italy
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Vellucci R, De Rosa G, Piraccini E. Pain reduction induced by tapentadol in patients with musculoskeletal chronic pain fosters better sleep quality. Drugs Context 2021; 10:dic-2020-12-9. [PMID: 33953781 PMCID: PMC8060026 DOI: 10.7573/dic.2020-12-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background Poor sleep may predict the increase and intensification of pain over time with increased insomnia symptoms being both a predictor and an indicator of worse pain outcomes and physical functioning status over time. However, the impact of different analgesic therapies on quality of life, functional recovery and sleep has been poorly assessed to date, whereas these evaluations may greatly help clinicians in the selection of treatment when dealing with patients with chronic pain (CP). Methods To explore whether tapentadol-induced pain relief may drive improved sleep quality, we carried out a pooled analysis of real-world data collected from 487 patients with CP (mean age, 68.3 years; 57.7% women) suffering from a wide range of chronic musculoskeletal pain conditions and treated with tapentadol. Results Following tapentadol treatment, patients experienced an 80% reduction in the frequency of very disturbed sleep as well as a 50% reduction in the predominant sleep complaint reported by patients with CP - that is, nocturnal awakenings. A significantly greater proportion of patients reported good/restful sleep at the end of the study period compared to baseline (72.4% versus 25.3%; p<0.01). This benefit was observed regardless of the clinical setting, treatment duration, posology or patient age and was associated with a higher proportion of patients reporting an improved global health status and good tolerability. Conclusion The reduction in pain intensity provided by tapentadol fosters sleep quality and favours a better quality of life. Therefore, our findings provide the rationale for addressing sleep quality as a relevant outcome, complementary to pain relief in CP management.
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Affiliation(s)
- Renato Vellucci
- University of Florence, Pain and Palliative Care Clinic, University Hospital of Careggi, Florence, Italy
| | | | - Emanuele Piraccini
- Anesthesia, Intensive Care Nord and Pain Management Unit, Bellaria Hospital, Bologna, Italy
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Varrassi G, Coluzzi F, Guardamagna VA, Puntillo F, Sotgiu G, Vellucci R. Personalizing Cancer Pain Therapy: Insights from the Rational Use of Analgesics (RUA) Group. Pain Ther 2021; 10:605-617. [PMID: 33730338 PMCID: PMC8119556 DOI: 10.1007/s40122-021-00248-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/15/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction A previous Delphi survey from the Rational Use of Analgesics (RUA) project involving Italian palliative care specialists revealed some discrepancies between current guidelines and clinical practice with a lack of consensus on items regarding the use of strong opioids in treating cancer pain. Those results represented the basis for a new Delphi study addressing a better approach to pain treatment in patients with cancer. Methods The study consisted of a two-round multidisciplinary Delphi study. Specialists rated their agreement with a set of 17 statements using a 5-point Likert scale (0 = totally disagree and 4 = totally agree). Consensus on a statement was achieved if the median consensus score (MCS) (expressed as value at which at least 50% of participants agreed) was at least 4 and the interquartile range (IQR) was 3–4. Results This survey included input from 186 palliative care specialists representing all Italian territory. Consensus was reached on seven statements. More than 70% of participants agreed with the use of low dose of strong opioids in moderate pain treatment and valued transdermal route as an effective option when the oral route is not available. There was strong consensus on the importance of knowing opioid pharmacokinetics for therapy personalization and on identifying immediate-release opioids as key for tailoring therapy to patients’ needs. Limited agreement was reached on items regarding breakthrough pain and the management of opioid-induced bowel dysfunction. Conclusion These findings may assist clinicians in applying clinical evidence to routine care settings and call for a reappraisal of current pain treatment recommendations with the final aim of optimizing the clinical use of strong opioids in patients with cancer. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-021-00248-x.
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Affiliation(s)
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Anesthesiology, Intensive Care, and Pain Medicine Unit, Sant'Andrea University Hospital, Rome, Italy
| | | | - Filomena Puntillo
- Department of Interdisciplinary Medicine (DIM), University of Bari; Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, 70124, Bari, Italy.
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Renato Vellucci
- University of Florence, Pain and Palliative Care Clinic, Careggi Hospital, 50139, Florence, Italy
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De Santis S, Simone MD, Mercadante S, Mediati RD, Vellucci R, Marchetti P, Tonini G, Cuomo A, Caraceni A, Natoli S, Armento G, Blasi L, Mammucari M. Oxycodone/Acetaminophen: The Tailoring Combination Treatment for Specific Clinical Profile of Opioid Well-Responsive Cancer Pain. Cancer Manag Res 2021; 13:1747-1756. [PMID: 33642876 PMCID: PMC7903954 DOI: 10.2147/cmar.s290551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/31/2021] [Indexed: 11/23/2022] Open
Abstract
Background International guidelines recommend moderate-to-severe cancer pain to be treated with strong opioids. However, pain management remains an unsolved matter, at least in the demanding oncology and palliative care setting. Although cancer pain consists of multiple components, which interact in complex ways where combination therapy can better intercept multiple pain characteristics, few studies have used a non-opioid/opioid association to exploit possible synergistic actions. Even the efforts of a recent approach emphasizing appropriate pain assessment and accurate classification to obtain personalized pain management have not produced a satisfactory analgesic strategy. Objective This analysis was intended to evaluate the effectiveness of the immediate release fixed combination of oxycodone/acetaminophen (OxyIR/Par) for the treatment of moderate-to-severe intensity background pain used alone or in combination with other strong opioids in cancer patients with breakthrough cancer pain (BTcP). This is a secondary analysis of a wider observational, prospective, multicenter study [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] performed on 179 patients treated with opioids for cancer pain who received the fixed combination of oxycodone/acetaminophen (OxyIR/Par) for the treatment of background pain (BGP). Results Cancer patients with breakthrough cancer pain and controlled BGP (Background Pain) were classified according to the presence of analgesic therapy with tablets of fixed combination OxyIR/Par alone (group A, n=120) or tablets of fixed combination OxyIR/Par combined with other strong opioids (group B, n=59). Clinical features of group A were different to group B: higher mean Karnofsky Performance Status Index 70.3% (95% CI=67.2–73.5; median=70, CI=60–80) vs 58.3 (95% CI=53.4–63.2; median=50, CI=45–70) (P<0.001), and mainly group A patients were treated in an ambulatory setting (55.0% group A vs 33.9% group B) (p<0.001). Both groups had managed BGP with similar mean dosages (group A: 12.0, CI=10.5–13.4; group B: 13.1, CI=11.0–15.1) and frequencies of OxyIR/Par alone for group A and in association to other opioids for group B, but Breakthrough cancer Pain (BTcP) exhibited different characteristics in the two groups, showing a lower mean intensity numerical rating scale (NRS) of 7.5 (95% CI=7.2–7.7; median=7, CI=7–8 group A) vs 7.9 (95% CI=7.6, 8.2; median= 8, CI=7–9 group B) (P=0.04) and a higher percentage of patients had a faster onset, defined as the maximum intensity reached in less than 10 minutes, 81.7% (N=98) in group A vs 59.3% (n=35) in group B (P=0.002). Conclusion This is the first analysis about the efficacy of an immediate-release fixed combination of OxyIR/Par in the real world for moderate-to-severe background cancer pain and breakthrough cancer pain. The oral fixed combination OxyIR/Par provided an adequate level of analgesia for moderate–severe background cancer pain, in a different cohort of cancer patients with different performance status, both in ambulatory and palliative settings. The low dosage of fixed combination OxyIR/Par was effective alone or in association with other opioids.
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Affiliation(s)
- Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | - Sebastiano Mercadante
- Anesthesia and Intensive Care & Pain Relief and Supportive Care, La Maddalena, Palermo, Italy
| | | | - Renato Vellucci
- Palliative Care and Pain Therapy Unit, Careggi Hospital, Florence, Italy
| | - Paolo Marchetti
- Molecular and Clinical Medicine Medical Oncology, La Sapienza University of Rome, Rome, Italy
| | - Giuseppe Tonini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Arturo Cuomo
- Anesthesiology, Resuscitation, and Pain Therapy Department, National Cancer Institute, IRCCS Foundation, Naples, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, National Cancer Institute, IRCCS Foundation, Milan, Italy
| | - Silvia Natoli
- Department of Clinical Science and Translational Medicine - University of Rome Tor Vergata and Department of Emergency, Admission and Critical Area - Policlinic of Tor Vergata, Rome, Italy
| | - Grazia Armento
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
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Pantano F, Manca P, Armento G, Zeppola T, Onorato A, Iuliani M, Simonetti S, Vincenzi B, Santini D, Mercadante S, Marchetti P, Cuomo A, Caraceni A, Mediati RD, Vellucci R, Mammucari M, Natoli S, Lazzari M, Dauri M, Adile C, Airoldi M, Azzarello G, Blasi L, Chiurazzi B, Degiovanni D, Fusco F, Guardamagna V, Liguori S, Palermo L, Mameli S, Masedu F, Mazzei T, Melotti RM, Menardo V, Miotti D, Moroso S, Pascoletti G, De Santis S, Orsetti R, Papa A, Ricci S, Scelzi E, Sofia M, Aielli F, Valle A, Tonini G. Breakthrough Cancer Pain Clinical Features and Differential Opioids Response: A Machine Learning Approach in Patients With Cancer From the IOPS-MS Study. JCO Precis Oncol 2020; 4:2000158. [PMID: 33283139 PMCID: PMC7713587 DOI: 10.1200/po.20.00158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A large proportion of patients with cancer suffer from breakthrough cancer pain (BTcP). Several unmet clinical needs concerning BTcP treatment, such as optimal opioid dosages, are being investigated. In this analysis the hypothesis, we explore with an unsupervised learning algorithm whether distinct subtypes of BTcP exist and whether they can provide new insights into clinical practice. METHODS Partitioning around a k-medoids algorithm on a large data set of patients with BTcP, previously collected by the Italian Oncologic Pain Survey group, was used to identify possible subgroups of BTcP. Resulting clusters were analyzed in terms of BTcP therapy satisfaction, clinical features, and use of basal pain and rapid-onset opioids. Opioid dosages were converted to a unique scale and the BTcP opioids-to-basal pain opioids ratio was calculated for each patient. We used polynomial logistic regression to catch nonlinear relationships between therapy satisfaction and opioid use. RESULTS Our algorithm identified 12 distinct BTcP clusters. Optimal BTcP opioids-to-basal pain opioids ratios differed across the clusters, ranging from 15% to 50%. The majority of clusters were linked to a peculiar association of certain drugs with therapy satisfaction or dissatisfaction. A free online tool was created for new patients’ cluster computation to validate these clusters in future studies and provide handy indications for personalized BTcP therapy. CONCLUSION This work proposes a classification for BTcP and identifies subgroups of patients with unique efficacy of different pain medications. This work supports the theory that the optimal dose of BTcP opioids depends on the dose of basal opioids and identifies novel values that are possibly useful for future trials. These results will allow us to target BTcP therapy on the basis of patient characteristics and to define a precision medicine strategy also for supportive care.
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Affiliation(s)
- Francesco Pantano
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Paolo Manca
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy.,IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Grazia Armento
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Tea Zeppola
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Angelo Onorato
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Michele Iuliani
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sonia Simonetti
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Bruno Vincenzi
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Daniele Santini
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena, Palermo, Italy
| | - Paolo Marchetti
- Molecular and Clinical Medicine Medical Oncology, La Sapienza University of Rome, Rome, Italy
| | - Arturo Cuomo
- Anesthesiology, Resuscitation, and Pain Therapy Department, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy, and Rehabilitation, National Cancer Institute, IRCCS Foundation, Milan, Italy
| | | | - Renato Vellucci
- Palliative Care and Pain Therapy Unit, Careggi Hospital, Florence, Italy
| | | | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marzia Lazzari
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Claudio Adile
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena, Palermo, Italy
| | - Mario Airoldi
- Second Medical Oncology Division, Città della Salute e della Scienza Hospital of Turin, Turin, Italy
| | - Giuseppe Azzarello
- Medical Specialties Department, Oncology and Oncologic Hematology, ASL 13 Mirano, Venice, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | | | | | - Flavio Fusco
- Palliative Care Unit, Department of Primary and Community Care, ASL 3 Genovese, Genoa, Italy
| | - Vittorio Guardamagna
- Palliative Care and Pain Therapy Unit, European Oncology Institute IRCCS, Milan, Italy
| | - Simeone Liguori
- Palliative Care and Pain Therapy Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Loredana Palermo
- Medical Oncology Unit, National Cancer Research Center "Giovanni Paolo II", Bari, Italy
| | - Sergio Mameli
- Pain Therapy Unit, "A. Businco" Hospital, ASL 8, Cagliari, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Teresita Mazzei
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
| | | | - Danilo Miotti
- Pain Therapy ICS Maugeri, IRCCS Foundation, Pavia, Italy
| | - Stefano Moroso
- Medical Oncology, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Gaetano Pascoletti
- Medical Oncology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Remo Orsetti
- Pain Medicine Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Alfonso Papa
- Pain Relief, A.O. Dei Colli, Monaldi Hospital, Naples, Italy
| | - Sergio Ricci
- Division of Medical Oncology, Department of Oncology, S. Chiara University Hospital, Pisa, Italy
| | - Elvira Scelzi
- Medical Oncology, Castelfranco Veneto Hospital, Treviso, Italy
| | - Michele Sofia
- Department of Palliative Care, Hospice and Pain Therapy Unit, "G. Salvini" Hospital, Milan, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Giuseppe Tonini
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
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11
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Vellucci R, Terenzi R, Kanis JA, Kress HG, Mediati RD, Reginster JY, Rizzoli R, Brandi ML. Understanding osteoporotic pain and its pharmacological treatment: supplementary presentation. Osteoporos Int 2018; 29:2153-2154. [PMID: 29992509 DOI: 10.1007/s00198-018-4536-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 04/16/2018] [Indexed: 11/24/2022]
Abstract
Osteoporosis, a disorder that affects millions of people worldwide, is characterized by decreased bone mass and microstructural alterations giving rise to an increased risk of fractures. Osteoporotic fractures can cause acute and chronic nociceptive and neuropathic pain that mainly affects elderly patients with multiple comorbidities and commonly on different drug regimens. Central sensitization seems to play a pivotal role in developing and maintaining chronicity of post-fracture pain in osteoporosis. Antiosteoporosis drugs are able to partially control pain, but additional analgesics are always necessary for pain due to bone fractures. Nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors reduce acute pain but with a poor effect on the chronic neuropathic component of pain and with relevant side effects. Opioid drugs can control the whole spectrum of acute and chronic bone pain, but they differ with respect to their efficacy on neuropathic components, their tolerability and safety. Chronic pain after osteoporotic fractures requires a multifaceted approach, which includes a large spectrum of drugs (antiosteoporosis treatment, acetaminophen, NSAIDs, selective COX-2 inhibitors, weak and strong opioids) and non-pharmacological treatment. Based on a better understanding of the pathogenesis of osteoporotic and post-fracture pain, a guided stepwise approach to post-fracture osteoporotic pain will also better meet the needs of these patients.
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Affiliation(s)
- R Vellucci
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R Terenzi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - J A Kanis
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - H G Kress
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R D Mediati
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - J-Y Reginster
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R Rizzoli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - M L Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy.
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12
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Vellucci R, Terenzi R, Kanis JA, Kress HG, Mediati RD, Reginster JY, Rizzoli R, Brandi ML. Understanding osteoporotic pain and its pharmacological treatment. Osteoporos Int 2018; 29:1477-1491. [PMID: 29619540 DOI: 10.1007/s00198-018-4476-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/06/2018] [Indexed: 01/09/2023]
Abstract
Osteoporosis, a disorder that affects millions of people worldwide, is characterized by decreased bone mass and microstructural alterations giving rise to an increased risk of fractures. Osteoporotic fractures can cause acute and chronic pain that mainly affects elderly patients with multiple comorbidities and commonly on different drug regimens. The aim of this paper is to summarize the pathogenesis and systemic treatment of osteoporotic pain. This narrative review summarizes the main pathogenetic aspects of osteoporotic pain and the cornerstones of its treatment. Osteoporotic fractures induce both acute and chronic nociceptive and neuropathic pain. Central sensitization seems to play a pivotal role in developing and maintaining chronicity of post-fracture pain in osteoporosis. Antiosteoporosis drugs are able to partially control pain, but additional analgesics are always necessary for pain due to bone fractures. Nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors reduce acute pain but with a poor effect on the chronic neuropathic component of pain and with relevant side effects. Opioid drugs can control the whole spectrum of acute and chronic bone pain, but they differ with respect to their efficacy on neuropathic components, their tolerability and safety. Chronic pain after osteoporotic fractures requires a multifaceted approach, which includes a large spectrum of drugs (antiosteoporosis treatment, acetaminophen, NSAIDs, selective COX-2 inhibitors, weak and strong opioids) and non-pharmacological treatment. Based on a better understanding of the pathogenesis of osteoporotic and post-fracture pain, a guided stepwise approach to post-fracture osteoporotic pain will also better meet the needs of these patients.
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Affiliation(s)
- R Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy
| | - R Terenzi
- Department of Surgery and Translational Medicine, University of Florence, AOU Careggi Largo Brambilla n.3, 50134, Florence, Italy
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | - H G Kress
- Department of Special Anaesthesia and Pain Medicine, Medical University/AKH of Vienna, Vienna, Austria
| | - R D Mediati
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy
| | | | - R Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, 1211, Geneva 14, Switzerland
| | - M L Brandi
- Department of Surgery and Translational Medicine, University of Florence, AOU Careggi Largo Brambilla n.3, 50134, Florence, Italy.
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13
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Morlion BJ, Mueller-Lissner SA, Vellucci R, Leppert W, Coffin BC, Dickerson SL, O'Brien T. Oral Prolonged-Release Oxycodone/Naloxone for Managing Pain and Opioid-Induced Constipation: A Review of the Evidence. Pain Pract 2017; 18:647-665. [DOI: 10.1111/papr.12646] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 09/14/2017] [Accepted: 09/21/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Bart J. Morlion
- Leuven Centre for Algology and Pain Management; Anaesthesiology and Algology; Department of Cardiovascular Sciences; University Hospitals Leuven; University of Leuven; Leuven Belgium
| | | | - Renato Vellucci
- Palliative Care and Pain Therapy Unit; University Hospital; Careggi Florence Italy
| | - Wojciech Leppert
- Department of Palliative Medicine; Poznan University of Medical Sciences; Poznan Poland
- Department of Quality of Life Research; Medical University of Gdansk; Gdansk Poland
| | - Benoît C. Coffin
- Department of Gastroenterology; Louis Mourier Hospital; Assistance Publique - Hôpitaux de Paris; Colombes France
- University Denis Diderot-Paris VII; Paris France
| | - Sara L. Dickerson
- Mundipharma International Ltd; Cambridge Science Park; Cambridge U.K
| | - Tony O'Brien
- Marymount University Hospital and Hospice; Cork Ireland
- Cork University Hospital and College of Medicine and Health; University College Cork; Cork Ireland
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14
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Vellucci R, Mediati RD, Gasperoni S, Mammucari M, Marinangeli F, Romualdi P. Assessment and treatment of breakthrough cancer pain: from theory to clinical practice. J Pain Res 2017; 10:2147-2155. [PMID: 29066928 PMCID: PMC5604430 DOI: 10.2147/jpr.s135807] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Breakthrough cancer pain (BTcP) is a common condition in oncological patients. However, its management is still suboptimal. Improved knowledge of BTcP and its management in clinical practice may have immediate importance for all physicians involved in the supportive care of cancer patients. This review critically discusses the most important concepts for the correct diagnosis of BTcP and presents some intriguing cases of the management of this condition in clinical practice. Overall, the most appropriate therapeutic choice appears to be a rapid-onset opioid (ROO), and in particular, the nasal route of administration is the quickest and most convenient mode of administration for the management of BTcP, especially when the patient needs rapid resolution of pain. To this end, intranasal fentanyl spray may have a particular relevance in clinical practice. Future research should focus on accepted definitions of BTcP to investigate the optimal management of this highly heterogeneous pain condition. Therapeutic decision-making of patients, clinicians, and payers will likely be driven from results of well-designed clinical trials of ROOs.
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Affiliation(s)
- Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence
| | | | - Silvia Gasperoni
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence
| | | | - Franco Marinangeli
- Department of Life, Health and Environmental Sciences, University of L'Aquila, l'Aquila
| | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
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15
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Vellucci R, Fanelli G, Pannuti R, Peruselli C, Adamo S, Alongi G, Amato F, Consoletti L, Lamarca L, Liguori S, Lo Presti C, Maione A, Mameli S, Marinangeli F, Marulli S, Minotti V, Miotti D, Montanari L, Moruzzi G, Palermo S, Parolini M, Poli P, Tirelli W, Valle A, Romualdi P. What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion. Drugs 2016; 76:315-30. [PMID: 26755179 PMCID: PMC4757619 DOI: 10.1007/s40265-015-0519-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Clinical management of breakthrough cancer
pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five ‘things to do’ and five ‘things not to do’ in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.
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Affiliation(s)
| | - R Vellucci
- SOD Cure Palliative e Terapia del Dolore, Ospedale Universitario Careggi, Florence, Italy.
| | - G Fanelli
- SC Anestesia, Rianimazione e Terapia Antalgica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - R Pannuti
- Fondazione ANT Italia Onlus, Andria, Italy
| | - C Peruselli
- SC Cure Palliative, Ospedale di Biella, Ponderano, BI, Italy
| | - S Adamo
- UO Terapia del Dolore, ARNAS Civico di Palermo, Palermo, Italy
| | - G Alongi
- Hospice e Cure Palliative, ASP 1di Agrigento, Agrigento, Italy
| | - F Amato
- UOC Terapia del Dolore e Cure Palliative, Azienda ospedaliera di Cosenza, Cosenza, Italy.,Past President Feder Dolore-SICD, Cosenza, Italy
| | - L Consoletti
- Struttura di Medicina del Dolore, Ospedale Universitario "Ospedali Riuniti", Foggia, Italy
| | - L Lamarca
- UOS Cure Palliative e Terapia Antalgica, Azienda ULSS N. 10 "Veneto Orientale", San Donà di Piave, VE, Italy
| | - S Liguori
- USC Cure Palliative Terapia del Dolore, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - C Lo Presti
- UOD Terapia del Dolore e Cure Palliative, ACO San Filippo Neri, ASLRME, Rome, Italy
| | - A Maione
- Terapia antalgica e Cure Palliative, Presidio Ospedaliero "S. Maria della Pietà", Nola, NA, Italy
| | - S Mameli
- SC Terapia del Dolore, Presidio Ospedaliero "A. Businco", Cagliari, Italy
| | - F Marinangeli
- Scuola di Specializzazione di Anestesia, Rianimazione e Terapia Intensiva, Università dell'Aquila, L'Aquila, Italy
| | - S Marulli
- OC Anestesia, Rianimazione e Terapia Iperbarica, UOS-I Gruppo Operatorio, Ospedale "Vito Fazzi", Lecce, Italy
| | - V Minotti
- SC Oncologia Medica, Azienda Ospedaliera "S.M. della Misericordia", Perugia, Italy
| | - D Miotti
- UO Cure Palliative e Terapia del Dolore, Fondazione Salvatore Maugeri-IRCCS, Pavia, Italy
| | - L Montanari
- UO Semplice Cure Palliative, Ravenna, Italy.,Dipartimento Onco-ematologico, AUSL della Romagna c/o Presidio Ospedaliero Umberto I, Lugo di Ravenna, Italy
| | - G Moruzzi
- UOS Hospice, Azienda Sanitaria Provinciale di Siracusa, Siracuse, Italy
| | - S Palermo
- UOC Terapia Antalgica, IRCCS San Martino-IST, Genoa, Italy
| | - M Parolini
- UOC Anestesia e Rianimazione B, Azienda Universitaria integrata di Verona, Verona, Italy
| | - P Poli
- UO Terapia del Dolore, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - W Tirelli
- Centro di Terapia del Dolore, Hospice "Fondazione Roma Sanità", Rome, Italy.,Centro di Rianimazione e Terapia del Dolore e Cure Palliative, Istituto Nazionale Tumori "Regina Elena", Rome, Italy
| | - A Valle
- Fondazione FARO, Turin, Italy
| | - P Romualdi
- Dipartimento di Farmacia e Biotecnologie, Alma mater studiorum, Università di Bologna, Bologna, Italy
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16
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Abstract
Bone loss is asymptomatic and will progress without pain and other symptoms until the occurrence of a fracture. The occurrence of a breaking bone induce acute pain determined and supported by a mechanical, inflammatory and neuropathic component. Very often the acute component evolves in a chronic musculoskeletal component. Overall objectives of the analgesic therapy can be summarized in pain relief, improving sleep, improve mobility, reduce anxiety, emotional component and depression. Osteoporosis is predominantly a condition of the elderly, more likely to have coexisting cardiovascular disease and age-related decline in renal function, receiving treatment for one or more comorbid conditions, taking multiple medications. Analgesic treatment with NSAIDs has negative effects on skeletal health and healing of the injured skeleton and increase risk of adverse events especially in older patients. Despite all opioids therapy represents a mainstay in the treatment of patients with moderate to severe pain, it can induce an endocrinopathy, which may affect bone metabolism. The negative effects of opioids on hormonal axis are not the same for all molecule and the choice of drug can be crucial in the treatment of patients with chronic pain.
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Affiliation(s)
- Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy
| | - Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anesthesiology, Intensive care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, "Polo Pontino", "Sapienza" University of Rome, Latina, Italy
| | - Ludovica Celidonio
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anesthesiology, Intensive care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, "Polo Pontino", "Sapienza" University of Rome, Latina, Italy
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17
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Abstract
Bone pain in elderly people dramatically affects their quality of life, with osteoporosis being the leading cause of skeletal related events. Peripheral and central mechanisms are involved in the pathogenesis of the nervous system sensitization. Osteoporosis in the elderly has been associated with increased density of bone sensory nerve fibers and their pathological modifications, together with an over-expression of nociceptors sensitized by the lowering pH due to the osteoclastic activity. The activation of N-methyl-D-aspartate (NMDA) receptors and the microglia, as a response to a range of pathological conditions, represent the leading cause of central sensitization. Unfortunately, osteoporosis is named the "silent thief" because it manifests with painful manifestation only when a fracture occurs. In the management of patients suffering from bone pain, both the nociceptive and the neuropathic component of chronic pain should be considered in the selection of the analgesic treatment.
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Affiliation(s)
- Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesiology, Intensive care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, "Polo Pontino", "Sapienza" University of Rome, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesiology, Intensive care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, "Polo Pontino", "Sapienza" University of Rome, Italy
| | - Ludovica Celidonio
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesiology, Intensive care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, "Polo Pontino", "Sapienza" University of Rome, Italy
| | - Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy
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18
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Ceniti S, Amato F, Mameli S, Pisanu G, Vellucci R, Palmieri V, Consoletti L, Magaldi D, Notaro P, Conforti S. High dosages of the fixed combination OXYCODONE/NALOXONE in cancer pain: mid-term efficacy and tolerability. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw344.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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Vellucci R, Fanelli G, Cortesi PA, Pannuti R, Peruselli C, Romualdi P. Reply-Letter to the Editor: What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion. Drugs 2016; 76:1063-5. [PMID: 27324270 PMCID: PMC4920836 DOI: 10.1007/s40265-016-0594-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
| | - R Vellucci
- SOD Cure Palliative e Terapia del Dolore, Ospedale Universitario Careggi, Florence, Italy.
| | - G Fanelli
- SC Anestesia, Rianimazione e Terapia Antalgica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - P A Cortesi
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - R Pannuti
- Fondazione ANT Italia Onlus, Andria, Italy
| | - C Peruselli
- SC Cure Palliative, Ospedale di Biella, Ponderano, BI, Italy
| | - P Romualdi
- Dipartimento di Farmacia e Biotecnologie, Alma mater studiorum, Università di Bologna, Bologna, Italy
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20
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Leonardi C, Vellucci R, Mammucari M, Fanelli G. Opioid risk addiction in the management of chronic pain in primary care: the addition risk questionnaire. Eur Rev Med Pharmacol Sci 2015; 19:4898-4905. [PMID: 26744882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Chronic pain is one of the most common complaints for people seeking medical care, with a series of potential detrimental effects on the individual and his social texture. Despite the heavy impact of chronic pain on patients' quality of life, epidemiological data suggest that chronic pain is often untreated or undertreated. An accurate diagnostic flow and appropriate treatment should be considered as key factors for optimal management of patients with chronic pain. Opioids are recommended for treatment of chronic cancer pain (CCP) and chronic non-cancer pain (CNCP) in guidelines and can safely and effectively relieve pain in a number of patients with chronic pain. Conversely, fears of addiction and adverse events could result in ineffective pain management. Recent epidemiological and clinical data demonstrate that only low percentages of patients treated with opioids for chronic pain have a risk to develop addiction, with a prevalence rate similar to that observed in the general population. METHODS Despite the iatrogenic risk can be considered as low, validated tools for the early identification of patients at higher risk of addiction can help health professionals in the overall management of chronic pain. CONCLUSIONS Due to the increasing relevance of primary care physicians in chronic pain management, we propose a 28-item questionnaire to validate specifically conceived for GPs' and aimed at the preliminary evaluation of the risk of addiction in patients with chronic pain.
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Affiliation(s)
- C Leonardi
- Drug Addiction Department, ASL RMC, Rome, Italy.
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Mediati RD, Vellucci R, Dodaro L. Pathogenesis and clinical aspects of pain in patients with osteoporosis. Clin Cases Miner Bone Metab 2014; 11:169-172. [PMID: 25568647 PMCID: PMC4269137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Bone pain is one of the most frequent kinds of chronic pain, mainly in elderly patients. It causes a significant worsening of functional capacity and deterioration in the quality of life in people affected. Mechanisms of pain in osteoporosis are poorly known and often extrapolated by other pathologies or other experimental model. One of principal causes would be a "hyper-remodeling" of bone, that involves osteoclasts activity and pathological modifications of bone innervation. Several studies show that osteoclasts play a significant role in bone pain etiology. Pain in osteoporosis is mainly nociceptive, if it become persistent a sensitization of peripheral and central nervous system can occur, so underlining the transition to a chronic pain syndrome. Central sensitization mechanisms are complex and involve several neuromediators and receptors (Substance P, NMDA, etc.). Most common manifestations of osteoporosis are vertebral compression fractures that cause persistent pain, though to differentiate from pain originating in structures as joint or muscle. First manifestation can be an acute pain due to pathological fracture, those of hip often causes disability. Pain in osteoporosis is an important clinical challenge. Often its complications and consequences on patient quality of life are underestimated with not negligible social implications. A balanced and early multimodal pain therapy including opioids as necessary, even in cases of acute pain, improve the functional capacity of patients and helps to prevent neurological alterations that seems to contribute in significant way in causing irreversible pain chronic syndromes.
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Affiliation(s)
- Rocco Domenico Mediati
- Address for correspondence: Rocco Domenico Mediati, MD, Palliative Care and Pain Therapy Unit, Oncologic Department, “AOU Careggi”, Florence, Italy, Phone: +39 055 7947734, E-mail:
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Vellucci R, Mediati RD, Ballerini G. Use of opioids for treatment of osteoporotic pain. Clin Cases Miner Bone Metab 2014; 11:173-6. [PMID: 25568648 PMCID: PMC4269138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The prevalence of osteoporosis increases markedly with age: currently it is estimated that over 200 million people suffer from osteoporosis worldwide. One of the most feared and more frequent complications of osteoporosis is pain, which affects 85% of patients. Commonly in the treatment of chronic pain the therapeutic strategy is based on a three-ladder approach, involving opioids for moderate and severe pain. As proposed by the World Health Organization (WHO), according to the intensity of chronic pain, analgesic treatment can be established. Despite the debate and updates to the analgesic ladder for pain published in 1986 by the WHO, the benefits resulting from its worldwide use are uncontested. In case the pain was not responsive to drugs of pain ladder, is necessary to resort to specialized practices (e.g. subarachnoid infusion of drugs). The oral route for administering analgesics should be preferred, provided that the patients are able to use it. About 50% of all opioid users experience at least one side effect, and more than 20% discontinued treatment due to a serious adverse event. Despite published guidelines and WHO's pain ladder for the management of chronic pain, the treatment of this condition remains suboptimal. Given the physiopsychopathology and complexity of the problems of chronic osteoporotic pain, a multimodal and multidisciplinary approach is still considered the best way to diagnose and treat this disease.
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Affiliation(s)
- Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital Careggi, Florence, Italy
| | | | - Giovanna Ballerini
- Palliative Care and Pain Therapy Unit, University Hospital Careggi, Florence, Italy
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Müller-Schwefe GHH, Wimmer AM, Dejonckheere J, Eggers A, Vellucci R. Patients' and physicians' perspectives on opioid therapy for chronic cancer and musculoskeletal pain in Germany, Italy, and Turkey: PAin RESearch (PARES) survey. Curr Med Res Opin 2014; 30:339-47. [PMID: 24224687 DOI: 10.1185/03007995.2013.861349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Under-treatment or lack of appropriate treatment for chronic pain remains an ongoing major healthcare problem. Opioids are being increasingly recognized as an effective option for chronic pain management. The objective of this survey was to understand the perspective of patients treated with opioids on quality of treatment, preferences, and possibilities to improve treatment and communication between patients and physicians. RESEARCH DESIGN A large-scale PAin RESearch (PARES) survey of 2860 patients (Germany, Italy, and Turkey) with chronic cancer or musculoskeletal pain prescribed opioid therapy was conducted to assess various factors such as ease of use and compliance, sleep, quality-of-life, and polymedication. A physician component was also included. Relationships between variables and differences between groups were tested using Spearman and Wilcoxon signed-rank tests, respectively. RESULTS Of the patients surveyed, 61% received strong opioids (WHO III) and 39% weak opioids (WHO II). Nearly 65% of the patients were currently on a twice daily or more dosing schedule; however, 61.5% of the patients responded that they considered once-daily dosing to be the most convenient schedule. Patients' responses indicated that different dosing schedules significantly influenced the occurrence of end-of-dose pain, feeling limited by the remaining level of pain, problems in falling asleep, and episodes of waking up at night or early in the morning. Physicians' responses showed that they were not surprised by 68.5% of patient responses; they also felt the need to change some aspect of pain treatment for a third of the patients, the commonest being pain medication (52.4%). CONCLUSIONS The results of the survey suggest that patients prefer a convenient dosing scheme, which may have a positive impact on compliance. Physicians may have to communicate more closely with patients about their needs.
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Labianca R, Sarzi-Puttini P, Zuccaro SM, Cherubino P, Vellucci R, Fornasari D. Adverse effects associated with non-opioid and opioid treatment in patients with chronic pain. Clin Drug Investig 2013; 32 Suppl 1:53-63. [PMID: 23389876 DOI: 10.2165/11630080-000000000-00000] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic pain is a debilitating condition that is associated with many common diseases; this places a major burden on the healthcare system. There are currently numerous analgesic agents available for the treatment of chronic pain. In general, the oral non-opioid analgesic, paracetamol, is recommended for the initial treatment of mild to moderate pain. Therapeutic doses of paracetamol do not appear to result in hepatotoxicity, although overdose may lead to acute liver failure. Current data suggest that paracetamol has acceptable gastrointestinal tolerability. Another class of non-opioid analgesic with confirmed efficacy for the treatment of chronic mild to moderate pain are non-steroidal anti-inflammatory drugs (NSAIDs), although this efficacy is offset by the potential of adverse gastrointestinal events. In particular, non-selective NSAIDs, also known as cyclooxygenase (COX) inhibitors, carry an increased risk of serious upper gastrointestinal complications, including ulcers, perforation and bleeding. The introduction of COX-2 inhibitors provided a NSAID-based option with improved gastrointestinal safety, but increased risk of cardiovascular effects. Opioids are powerful analgesic agents used to treat moderate to severe chronic pain. However, treatment with opioids is associated with a number of common adverse effects, including constipation, nausea or vomiting, pruritus, somnolence or cognitive impairment, dry mouth, tolerance or dependence and urinary retention. Although there are multiple strategies in place to manage adverse events that arise from both non-opioid and opioid analgesic therapy, a better understanding of the mechanisms involved in the development of specific drug-related adverse effects is required along with proper prescribing practices and adequate physician/patient education. Balanced against the adverse effects of pain management medications, there is a need to be mindful of the widespread, often serious, adverse consequences of poorly managed pain itself.
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Abstract
Chronic pain is a widespread public health issue that has many effects on physical, emotional and cognitive functions. An estimated 10-55% of all adults are thought to have chronic pain. Chronic pain is a multifactorial condition, caused by the complex interplay of nociceptive, neuropathic or mixed pathogenic mechanisms. Chronic pain is associated with specific and non-specific medical conditions such as cancer, HIV/AIDS, rheumatoid arthritis, fibromyalgia, osteoarthritis, low back pain or spinal stenosis and is broadly categorized as cancer pain and non-cancer pain. Evaluation of chronic pain requires a clear understanding of the nature of the pain and its underlying pathophysiology. Adequate assessment of pain, using validated tools, is an essential prerequisite of successful pain management. Unidimensional scales are useful for the measurement of pain intensity, while multidimensional scales measure both pain intensity and the extent to which pain interferes with life activity and emotional functioning. Patients should be reassessed and followed up in order to monitor progress and measure improvements in pain.
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Affiliation(s)
- Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy.
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Abstract
Despite the availability of effective pain treatments, there are numerous barriers to effective management resulting in a large proportion of patients not achieving optimal pain control. Chronic pain is inadequately treated because of a combination of cultural, societal, educational, political and religious constraints. The consequences of inadequately treated pain are physiological and psychological effects on the patient, as well as socioeconomic implications. Unreasonable failure to treat pain is viewed as unethical and an infringement of basic human rights. The numerous barriers to the clinical management of pain vary depending on whether they are viewed from the standpoint of the patient, the physician, or the institution. Identification and acknowledgement of the barriers involved are the first steps to overcoming them. Successful initiatives to overcome patient, physician and institutional barriers need to be multifaceted in their approach. Multidisciplinary initiatives to improve pain management include dissemination of community-based information, education and awareness programmes to attempt to change attitudes towards pain treatment. A better awareness and insight into the problems caused by unrelieved pain and greater knowledge about the efficacy and tolerability of available pain management options should enable physicians to seek out and adhere to treatment guidelines, and participate in interventional and educational programmes designed to improve pain management, and for institutions to implement the initiatives required. Although much work is underway to identify and resolve the issues in pain management, many patients still receive inadequate treatment. Continued effort is required to overcome the known barriers to effective pain management.
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Gatti A, Mediati RD, Reale C, Cuomo A, Vellucci R, Russo G, Costantini A, Canneti A, Luzi M, Mammucari M, Sabato AF. Breakthrough pain in patients referred to pain clinics: the Italian pain network retrospective study. Adv Ther 2012; 29:464-72. [PMID: 22622488 DOI: 10.1007/s12325-012-0022-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Despite breakthrough pain (BTP) being one of the most severe forms of pain, there are no definitive data on its prevalence. METHODS The authors performed a retrospective survey of the prevalence of BTP in consecutive patients in four Italian pain clinics, subsequent to application of an Italian law mandating detailed clinical records on pain characteristics, treatment, and results. Mean pain intensity was assessed with a numerical rating scale from 0 to 10. RESULTS The authors analyzed records of 1,401 patients (58% women, 33.1% patients with cancer). Transient episodes of severe pain or BTP were referred by 790 patients (56.4%), including 58.2% of the men (342 of 588) and 55.1% of the women (448 of 813). Among the 464 patients with cancer, 70.3% reported daily exacerbation of pain. The mean BTP intensity was 8.31 ± 1.58 and 31.1% of patients reported experiencing three episodes per day. CONCLUSION Despite some limitations of the study, the authors show that transient episodes of severe pain or BTP are significantly present both in cancer and other diseases, and that many patients are not yet receiving appropriate opioid therapy. The authors need validated tools at international level for the diagnosis and treatment of BTP in patients with cancer and for transitory and patients with severe non-cancer pain. A survey at national level is needed to estimate the prevalence of BTP in different settings, to plan specific medical education.
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Sarzi-Puttini P, Vellucci R, Zuccaro SM, Cherubino P, Labianca R, Fornasari D. The Appropriate Treatment of Chronic Pain. Clin Drug Investig 2012; 32 Suppl 1:21-33. [DOI: 10.2165/11630050-000000000-00000] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Gatti A, Reale C, Luzi M, Canneti A, Mediati RD, Vellucci R, Mammucari M, Sabato AF. Effects of opioid rotation in chronic pain patients: ORTIBARN study. Clin Drug Investig 2010; 30 Suppl 2:39-47. [PMID: 20670048 DOI: 10.2165/1158413-s0-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Opioid rotation is currently the subject of considerable debate for two reasons: firstly as a strategy for pain treatment, and secondly because of the difficulty in determining equianalgesic doses. Switching from one slow-release (SR) opioid analgesic to another raises a number of critical issues, and there are no widespread studies that support a standard protocol. Initiation of opioid therapy must consider gradual dose titration of the drug until the minimum effective and maximum tolerated dosage for each patient is found. OBJECTIVE This study aimed to evaluate the effects of SR opioid rotation after a stabilization period with normal-release (NR) morphine ('start therapy') in patients with cancer or non-cancer pain not controlled with their current SR opioid. METHODS This is a multicentre, open-label, prospective study. A total of 326 consecutive patients were enrolled who were affected by chronic cancer or non-cancer pain that was not controlled by an SR opioid administered as either monotherapy or in combination with other analgesic drugs. Following start therapy with oral NR morphine at a dosage of 5 mg or 10 mg every 4 hours, rotation to an SR opioid of a different type from that previously administered was carried out. RESULTS After about 3 days of start therapy with NR morphine, rotation to an SR opioid allowed a significant decrease of both baseline pain and daily episodes of breakthrough pain. No significant difference was detected between dosages and type of opioid administered, both prior to and after the start therapy period with NR morphine. CONCLUSIONS Rotation to another opioid preceded by a brief period of opioid receptor resetting by start therapy with NR morphine allows a good level of pain control and avoids rotation to inappropriate opioid dosages or combinations analgesics.
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Affiliation(s)
- Antonio Gatti
- Emergency Care, Critical Care Medicine, Pain Medicine and Anaesthesiology Department at Tor Vergata Polyclinic, University of Rome-Tor Vergata, Rome, Italy.
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Aloisi AM, Aurilio C, Bachiocco V, Biasi G, Fiorenzani P, Pace MC, Paci V, Pari G, Passavanti G, Ravaioli L, Sindaco G, Vellucci R, Ceccarelli I. Endocrine consequences of opioid therapy. Psychoneuroendocrinology 2009; 34 Suppl 1:S162-8. [PMID: 19540049 DOI: 10.1016/j.psyneuen.2009.05.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 05/17/2009] [Accepted: 05/19/2009] [Indexed: 02/03/2023]
Abstract
Gonadal hormones are known to be affected by morphine and other opioids. In this paper, we summarize data collected in recent years which clearly indicate that the opioid-induced effects on steroid hormones depend on the opioid used and in some cases on the sex of the subject. Indeed morphine is able to reduce hormones like testosterone and cortisol in both male and female subjects in just a few hours, probably acting directly on peripheral glands. These depressant effects of morphine on hormones are also present in the treatment of surgical pain and are quickly reversible once opioid administration is suspended. Similar actions were also found to occur in experimental animals and in vitro in glial cells, further confirming the morphine-induced reduction of testosterone cell content. Testosterone and its metabolites are well known substances involved in the development and maintenance of the brain and all body structures. Thus when treating pain with opioids, their effects on hypothalamo-pituitary-gonadal and hypothalamo-pituitary-adrenal-related hormones must be considered and, where possible, hormone replacement therapy should be started.
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Affiliation(s)
- Anna Maria Aloisi
- University of Siena, Department of Physiology, Neuroscience and Applied Physiology Section, via Aldo Moro 2, 53100 Siena, Italy.
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Vellucci R, Toppi L, Capuano LG, Picozzi P, Bove A, Pasciuto A, Lucci S, Corbellini L. [An assessment of neuronal regeneration in neural anastomoses by synthetic guide and biological systems and insulin administration: an experimental study in the rat]. G Chir 1999; 20:316-24. [PMID: 10390930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
The synthetic and biological nerve guide regeneration gives interesting perspective of use in making artificial conduits for peripheral nerve reconstruction. In sixty Wistar rats, under general anesthesia and with microsurgical technique, the ischiatic nerve was isolated. On the right side a segment of the nerve was removed in order to create a 10 mm gap. The defect then repaired using the conduit. Control were performed at 20, 90, 180 days and consisted in histological microscopy and electromyography investigation. The regeneration of the nerve fibers in the lumen of the conduit was not significantly different on the contralateral nerve limb.
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Affiliation(s)
- R Vellucci
- Istituto di III Clinica Chirurgica, Università degli Studi La Sapienza, Roma
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Capuano LG, Vellucci R, Toppi L, Caramanico G, Pasciuto A, D'Andrea V, De Antoni E, Corbellini L. [Heterotopic heart transplantation in the rat: a preliminary study]. Ann Ital Chir 1998; 69:351-6. [PMID: 9835108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The aims of this study are to settle and verify how trustful is the heterotopic transplantation of the heart in an experimental model utilizing the original technique of Abbott modified by Ono and Lindsey distinguishing from it for the administration of the anaesthesia and the preservation of the organ. In this type of operation is necessary to realize only two micro-surgical vascular anastomosis that represent the basis of any other micro-surgical operation of organ's transplantation in the rat. There have been used 30 rats of the Wistar stock of male sex and weighing about 200-300 grs. both as donor and as receiving. The anaesthesia consisted in the administration of methoxyflourane by inhalation during the operation. The heart is kept in a container with Stanford solution on ice. The 77% of the cases (23 on 30) have been successful, even considering the ischaemic damage that has been evaluated examining the cardiac beat and the color of the organ. The study of Ono and Lindsey gave as result the success of the operation on 91% of cases (147 on 161 operated), compared to the result obtained by us, on a smaller number of cases (77% of success on 30 operated rats) permits to consider this experimental model to be utilizable even for further more complex studies.
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Affiliation(s)
- L G Capuano
- Istituto di III Clinica Chirurgica, Università degli Studi di Roma La Sapienza
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Vellucci R, Toppi L, Orsi E, Capuano LG, Pasciuto A, Ortensi A, Ascenzi P, Lippolis G, Berni A, Corbellini L. [Cervical neurinomas. (Considerations in five cases operated in Day-Surgery)]. Ann Ital Chir 1997; 68:801-6. [PMID: 9646541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We report the experiment of five cases of neurinoma observed in the division of Day Surgery of the Third Surgery Clinic, operating in the Hematology Institute of University of Studies "La Sapienza" in Rome. The problems of the diagnosis of this neoplasia has been faced, though it is commonly unknown or confused with other cervical especially lymphonodules tumefactions, from which it is almost impossible to distinguish before the operation. In the period of six years on 775 cases of cervical neoformations have been operated only 5 patients bearers of neuromi; two originated from vago cervicale (right and left), one from simpatico cervicale on the left, another from the left spinal accessory and the last from the secondary medial trunk of the left brachial plexus. All the patients have been operated in Day-Surgery anaesthesia, locoregional and with calming of spontaneous breath. One case, that originated from the secondary medial trunk of the left brachial plexus, has been operated with microsurgical technique. On all the cases has been done a subcapsular exeresis to preserve nervous continuity. No post operating complications have been recorded; all the patients discharged in the evening. The diagnosis about the nature is left to the final histological test on the operating piece. The surgical removal remains even today the elective treatment able to exclude probable relapses and potential malignant transformation of these tumours.
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Affiliation(s)
- R Vellucci
- Istituto di Clinica Chirurgica III, Università degli Studi di Roma, La Sapienza
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Orsi E, Vellucci R, Toppi L, Di Matteo FM. [Surgery in hemopathies: experience in ambulatory care and day surgery]. G Chir 1997; 18:685-7. [PMID: 9479987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The one day surgery experience of our team developed in many years of a Special Surgical Service in Haematologic Diseases (within the III Surgical Department directed by Prof. G. Di Matteo of the University of Rome "La Sapienza") is herein reported. From 1989 to December 1995, 2,126 haematologic patients (1127 M, 999 F) were operated in day-surgery regimen. Five-hundred-fifty-six patients were over 65 years old. In most cases surgery was required for diagnostic purposes to ascertain the type, the stadiation or re-stadiation of the haematologic disease. Five-hundred-eighty-three operations were carried on the axillary region, 825 on the cervical region, 202 on the supraclavicular region and 163 on the groin region. In 729 patients a diagnosis of non-Hodgkin lymphoma was obtained, while 308 patients resulted affected by Hodgkin lymphoma. In 124 patients metastases from solid tumors (pulmonary, mammary, thyroidal adenocarcinoma, etc.) were found at histologic examination of the specimen. Furthermore, other types of pathologies such as lateral neck cysts, salivary gland adenomas, schwannomas, groin and crural hernias were identified. Outpatient surgery and one day surgery represent a valid procedure for the early diagnosis of haemotologic diseases also taking into account the low cost and the minimal invasiveness.
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Affiliation(s)
- E Orsi
- Istituto di III Clinica Chirurgica Generale e Terapia Chirurgica, Università degli Studi La Sapienza, Roma
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Lucci S, Mascagni D, Raschellà GF, Monti M, Danese M, Rivolta R, Vellucci R, Peparini N, Di Matteo FM, Coccia D. [Colorectal cancer in the young adult: comments on a sample of 33 patients operated on with the goal to cure]. G Chir 1994; 15:231-9. [PMID: 7946981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A retrospective study of the overall cases operated for colorectal cancer is reported. Subgroups of patients comparable for staging and grading, over 45 years of age and younger than 45 years, radically operated from January 1984 to June 1989, were analyzed in order to evaluate survival and prognosis in younger subjects. A favourable trend in relation to three-year prognosis was registered in younger patients (73% vs. 65%).
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Affiliation(s)
- S Lucci
- Istituto di III Clinica Chirurgica, Università degli Studi La Sapienza, Roma
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