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Publications American Journal of Disaster Medicine Opioid Management
Society Journal of Neurodegeneration & Regeneration Activities Directors' Quarterly for Alzheimer's & Other Dementia Patients American Journal of Recreation Therapy |
March/April 2005; pages 5-5 Newsbriefs MPA as effective as leuprolide in treating endometriosis pain. New epidural injection provides two days of postsurgical pain relief. Patient-controlled transdermal fentanyl analgesic convenient, effective after hysterectomy. Sustained-release morphine may alleviate pain in refractory patients. March/April 2005; pages 6-7
March/April 2005; pages 9-10
March/April 2005; pages 11-12
March/April 2005; pages 13-16 Abstract Introduction Opioids are often used in combination with other analgesics in multimodal approach. Pharmacotherapy in alleviating pain may require, in addition to an opioid, nonsteroidal anti-inflammatory agents. This article will help the clinician determine when to use nonsteroidal anti-inflammatory agents and which nonsteroidal anti-inflammatory agents may be better options to use in conjunction with opioid management. The cyclooxygenase 2 (COX-2) selective nonsteroidal anti-inflammatory drug (NSAID) rofecoxib (Vioxx®) was voluntarily removed from the worldwide market in September 2004. Its manufacturer (Merck) announced that the decision was based on new data from a prospective, randomized, double-blind, placebo-controlled, multicenter clinical trial called APPROVe (Adenomatous Polyp Prevention on Vioxx). The APPROVe trial revealed a twofold increase in the risk of developing cardiovascular (CV) embolic events, such as stroke and myocardial infarction, in patients receiving rofecoxib 25 mg daily for 18 months or more.1 More recently, the news of a CV signal with celecoxib (Celebrex®, Pfizer) has raised concerns that the problem of an increased CV risk may be a class effect shared by all the selective COX-2 inhibitors. In light of these apparent risks to patients, physicians and other practitioners should become familiar with the mechanisms of NSAID action, the differences among COX-2 selective NSAIDs, and alternative NSAID options.
March/April 2005; pages 17-23 Abstract This study compares two methods of detoxification available to heroin users in Western Australia: clonidine-assisted detoxification (CD) or clonidine-naloxone precipitated withdrawal under sedation (rapid opioid detoxification [ROD]). Oral naltrexone was made available to all participants following detoxification. Eighty heroin-dependent persons were randomly assigned to either ROD or CD. Most undertaking ROD commenced and completed this treatment. Less than one-third undertaking CD completed this treatment. There was no significant difference in those treated by CD or ROD in subjective assessment of degree or duration of pain, severity of withdrawal and craving, nor was there an increase in the withdrawal sequelae after treatment. Induction of oral naltrexone following ROD was greater, but oral naltrexone compliance levels and abstinence from heroin four weeks following detoxification were similar between ROD and CD groups. The level of patient satisfaction between the two treatments was also similar. The authors discuss why ROD is considered more effective than CD. Key words: rapid opioid detoxification, naloxone/naltrexone, clonidine-assisted withdrawal
March/April 2005; pages 25-30 Abstract This study aimed to investigate factors associated with analgesic use of morphine in end-of-life care. French general practitioners (GPs) and oncologists (N = 719) were asked whether they would prescribe morphine as first-line therapy to patients with terminal lung cancer suffering from dyspnea associated with cough and great anxiety. Overall, 54 percent of oncologists and 40 percent of GPs stated that they would prescribe morphine in the presented case. This prescriptive attitude correlated with physicians’ age, professional background, communication skills, and attitude toward terminally ill patients. The findings of this study indicate that improving analgesic use of opioids in end-of-life care is not only a matter of enhancing technical skills acquired through training or experience but also a matter of improving communication and empathy between physicians and patients. Key words: morphine, dyspnea, end-of-life care, lung cancer, France
March/April 2005; pages 31-35 Abstract Detoxification from opioids remains an important first step in the treatment of many patients with opioid dependence. Several pharmacologic regimens have been used for opioid detoxification. In the United States, the partial µ-opioid agonist, buprenorphine (BUP) is the most recently approved pharmacotherapy for opioid detoxification and replacement. The literature in recent years has described detoxification protocols using a single high dose of BUP and a three-day BUP regimen. In many settings, such as drug-free programs, a single-dose detoxification protocol would be of significant benefit. There have been no prior studies comparing one-day and three-day BUP- assisted opioid withdrawal. In this pilot study, we conducted an open-label, randomized trial of one-day vs. three-day BUP/naloxone sublingual tablet-assisted opioid withdrawal. Twenty patients from a therapeutic community treatment program were randomly assigned to receive either 32 mg sublingual BUP over one hour (one-day group), or 32 mg sublingual BUP over three days (three-day group). Nine of 10 subjects (90 percent) in each group completed seven days in the detoxification protocol. There was no statistically significant difference between the two groups in all other outcome variables, including retention in the treatment program, intensity of withdrawal signs and symptoms, amounts of adjunct medications used, and ability to produce opiate-free urine. This study further validates the feasibility of the single high dose of BUP as a rapid detoxification method. Key words: buprenorphine, detoxification, withdrawal, opioid, heroin
March/April 2005; pages 36-40 Abstract Breakthrough pain is a transitory flare of pain occurring in most cancer patients against a background of otherwise controlled persistent pain. Treatment of breakthrough pain is a challenging phenomenon. Oral transmucosal fentanyl citrate (OTFC; brand name Actiq®, Chephalon Inc., West Chester, PA), a new opioid formulation with a unique delivery system, reflects the characteristics of breakthrough pain (rapid onset of action and short duration), making it an effective treatment for cancer patients who already receive opioids and experience flares of pain. This review article aims to present the role of oral transmucosal fentanyl citrate in the management of breakthrough pain in cancer patients. In particular, it is going to discuss the synthesis, clinical pharmacology, pharmacokinetic and pharmacodynamic properties, toxicity, and clinical efficacy of this novel agent. Key words: oral transmucosal fentanyl citrate, breakthrough pain, cancer
March/April 2005; pages 41-48 Abstract The primary goal of this single-group study was to determine the safety of a standard opioid titration order sheet to manage pain in ambulatory cancer patients. Secondary goals were to examine opioid toxicity and efficacy of this pain protocol. Twenty-seven patients who required fixed-dose opioids and who had uncontrolled pain were enrolled. All patients had their initial opioid dose titrated by the study physician using the opioid titration order sheet. Data were obtained by the study nurse during a weekly telephone interview and used to determine if pain was controlled. After initial titration, a trained study nurse titrated opioid doses based upon the standing order sheet. At each contact, patients were assessed for adverse effects, pain intensity, and analgesics used. Patients who completed the four-week trial (n = 17) did not differ from patients who did not complete the trial. No adverse effects were observed in 39 opioid titrations completed by the study nurse. Opioid toxicities, worst pain, usual pain, and pain-related distress declined from baseline to week four. Patients who were adherent to their prescribed medications reported significantly lower pain intensity and distress (ps £ 0.06). The opioid titration order sheet, used by a trained nurse, is safe to use in ambulatory cancer patients who have moderate to severe pain. Common opioid toxicities were reduced. The protocol also demonstrated initial efficacy in improving worst and usual pain and pain-related distress. Further research to establish efficacy of the protocol is recommended. Key words: cancer pain, standing orders, opioid titration
March/April 2005; pages 49-53 Abstract Many studies have brought to light the facts that repeated use of drugs significantly influences one’s cognitive functions, and that cognitive problems could interfere directly with one’s capacity to participate in a rehabilitation program. In this research, we used the Global Deterioration Scale (GDS) to assess the cognitive status of 101 hospitalized patients in an opiate detoxification program. The results reveal that a majority of the tested patients present cognitive abnormalities to varying degrees of severity. Furthermore, these cognitive deficits are correlated with four Addiction Severity Index (ASI) scales (medical, alcohol use, drug use, and psychiatry, respectively). Considering the results, because cognition is a major issue in detoxification and rehabilitation programs, simple cognitive screening (as with the GDS) coupled with a particular interest in some aspects of a patient’s anamnesis could lead to better management of opiate-dependent patients. Key words: detoxification, rehabilitation, cognitive function, addiction Book review Pain Medicine and Management: Just the Facts, edited by Mark S. Wallace and Peter S. Staats. New York: McGraw-Hill, 2005; 379 pages. Gilbert J. Fanciullo, MD, MS March/April 2005; pages 54-55 Journal of Opioid Management May/June 2005, Volume 1, Number 2 Newsbriefs Dr. William Hurwitz sentenced to 25 years for prescription practices. Morphine plus gabapentin better for neuropathic pain. Opioid highlights from the 21st Annual Meeting of the American Academy of Pain Medicine. No class action for OxyContin case. May/June 2005; pages 63-64
May/June 2005; pages 67-69
May/June 2005; pages 70-72
May/June 2005; pages 73-76 Abstract Prolongation of the QT interval associated with ventricular arrhythmias has been the most common cause of the restriction or withdrawal of drugs from the market in the past 10 years. Methadone, a synthetic opioid that is increasingly used for the management of chronic pain, has recently been implicated in the development of the prolonged QT syndrome. We present a case report of a patient who developed a prolonged QT while being treated with oral methadone for a chronic pain syndrome. Of particular interest in this patient is the fluctuation of the QT interval at a stable dose of methadone, suggesting that a single normal electrocardiogram (ECG) does not guarantee that the patient is not at risk of ventricular arrhythmias. After reviewing the current literature, we suggest that there is no dose of methadone that may be considered to be completely safe. Other risk factors for prolonged QT interval such as underlying cardiac abnormalities, electrolyte disturbances, and concurrent medications should be sought, and all patients should be monitored with serial ECGs even when methadone doses remain stable. Key words: methadone, prolonged QT interval, chronic pain syndrome, electrocardiogram
May/June 2005; pages 77-82 Abstract Recent studies suggest that intraperitoneal application of local anesthetics is useful in abdominal surgery. Tramadol and clonidine have specific effects on peripheral nerves when used alone. We aimed to evaluate the effects of intraperitoneal application of bupivacaine and the combinations of bupivacaine plus tramadol and bupivacaine plus clonidine on postoperative pain in total abdominal hysterectomy. After standard anesthetic procedure during closure of the abdomen, Group 1 (n = 20) was given 20 mL bupivacaine 0.5 percent, Group 2 (n = 20) was given 20 mL bupivacaine 0.5 percent plus 100 mg tramadol, and Group 3 (n = 20) was given 20 mL bupivacaine 0.5 percent plus 1 µg per kg clonidine, all into the peritoneal cavity. Postoperative pain was evaluated with the visual analog scale (VAS) at 30 minutes, and two, four, six, 12, and 24 hours after extubation. While patients were supine and seated, mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation (SpO2) values were noted. When VAS scores were 4 to 7, 0.5 mg per kg of meperidine was given intramuscularly (IM); above 7, 1 mg per kg of meperidine was given IM; and when VAS scores were 2 to 4, 500 mg acetaminophen was given orally. For evaluating quality of analgesia, rescue analgesic dose, analgesia time, and side effects were noted. The groups were similar in respect to SpO2; however, when Group 1 was compared to Groups 2 and 3 at 30 minutes, and two, four, and six hours, MAP and HR measurements were found to be significantly higher (p < 0.05). VAS values in sitting and supine positions at 30 minutes and two hours were significantly lower in Group 2 (p < 0.05) when compared to Group 1. VAS values for Group 3 at 30 minutes, and two and four hours in the supine position, and at 30 minutes and two hours in the sitting position, were found to be significantly lower than those in Group 1 (p < 0.05). There were no significant differences between Groups 2 and 3. The mean dosage of meperidine used was 76.7 ± 10.5 mg in Group 1, 63.9 ± 8.4 mg in Group 2, and 70 ± 5.2 mg in Group 3. When Group 1 was compared to Group 2, there were significant differences found (p < 0.05). First analgesic requirement time was found to be 30 (range, 30 to 30) minutes in Group 1, 120 (range, 30 to 240) minutes in Group 2, and 110 (range, 30 to 240) minutes in Group 3. There were significant differences found when Groups 2 and 3 were compared to Group 1 (p < 0.05). We concluded that the combinations of bupivacaine plus tramadol and bupivacaine plus clonidine administered intraperitoneally in total abdominal hysterectomy operations provide more effective analgesia than bupivacaine alone during the early postoperative period. Key words: postoperative analgesia, intraperitoneal administration, bupivacaine, tramadol, clonidine
May/June 2005; pages 83-90 Abstract Preclinical data and limited studies in humans have suggested that morphine-6-glucuronide (M6G) has analgesic activity and morphine-3-glucuronide (M3G), contributes adversely to the therapeutic effect of morphine. This open point-prevalence study in 103 patients on oral morphine for cancer-related pain investigated the correlations between morphine doses, metabolites, and the degree of pain relief or toxicity. Morphine, M6G, and M3G were assayed by high-performance liquid chromatography on a single blood sample taken between two and four hours after dose. Pain, analgesia, and toxicity were recorded on numerical and visual analog scales. Patients received a median dose of 60 (range, 10 to 620) mg per day morphine, for a median of 4.1 weeks (range, 0.2 to 46.0 weeks). M3G:M6G ratios fell within a narrow range, with a median value of 4.39 (interquartile range, 3.78 to 6.96; range, 2.18 to 14.95). There were no significant correlations between M3G:M6G and morphine dose, or any measure of analgesia. The correlation between plasma concentration and pain score (i.e., better analgesia) was stronger for M6G (r = 0.308, p < 0.01) than morphine (r = 0.197, p = 0.05). These data suggest that M6G contributes significantly to the analgesic potency of oral morphine. No evidence was found for differences in M3G:M6G ratios contributing to analgesia or toxicity. Key words: morphine, cancer pain, glucuronides, analgesia
May/June 2005; pages 91-97 Abstract Prescription opioids are used medically to treat pain, but their diversion and abuse continues to escalate in the United States.1 Abuse of OxyContin (Purdue Pharma LP, Stamford, CT), a timed-release form of oxycodone, is a major focus of public health and law enforcement agencies.2 The rise in opioid abuse may lead to an increase in opioid dependence in pregnancy, which was a focus of this study. Our retrospective chart review examined the demographics and patterns of opioid addiction of pregnant women admitted to an inpatient psychiatric unit in an academic medical center in central Kentucky. Charts of 94 women admitted from January 2001 to May 2004 were reviewed. Information obtained included demographics and details of their opioid use, including the specific opioid(s) used, route of administration, and duration of use. Treatment information included length of hospital stay, stabilizing dose of methadone, comorbid drug use, and concomitant Axis I diagnoses. Most women were in their mid-twenties and in the second trimester of pregnancy when they sought treatment. Benzodiazepines were the most common comorbid drugs of abuse and the most frequent medical complication of their drug use was hepatitis C, newly diagnosed in 11 patients. This study demonstrates the need for further research in prescription opioid dependency in pregnancy, methadone maintenance therapy, the safety of detoxification, and neonatal outcomes. Key words: opioids, oxycodone, methadone maintenance therapy, addiction, pregnancy
May/June 2005; pages 98-108 Abstract Deficiencies in practice, knowledge, and competence among physicians are important contributing factors to the unsatisfactory level of analgesic care in hospitalized patients. By way of a comprehensive survey, we characterized these deficiencies within an internal medicine residency program as an initial step in designing remedial educational strategies. To do so, an anonymous 43-item survey was administered to residents in an internal medicine program. A total of 61 residents (69 percent) responded. The results indicated that patient-controlled analgesia (PCA), a standardized pain scale, and an opioid equivalence table were underused. Competence in opioid conversion was suboptimal, but completion of an oncology rotation and familiarity with the opioid equivalence table predicted greater competence in this area (p = 0.007 and p = 0.001, respectively). Self-perceptions of adequacy of training and pain-management competence were predictors of knowledge (p = 0.026 and p = 0.038, respectively). Attitudes regarding opioid analgesia were generally satisfactory (i.e., low “opiophobia” score), although the risk of addiction was still overestimated. The characterization of deficiencies in pain management in a residency program is an essential step in the design and implementation of educational interventions. Administration of a comprehensive survey is a simple and effective method of gathering this data and has the additional benefit of promoting awareness of pain management issues. Our experience served to establish, among other findings, the didactic value of experience on an oncology floor; this result substantiates the value of practical experience in the gaining of clinical competence in pain management. Interventions that capitalize on the findings of the survey and the interest in pain management generated by its administration are currently ongoing at our institution. Key words: education, opioid analgesia, pain management, survey
May/June 2005; pages 111-111
May/June 2005; pages 112-112 Journal of Opioid Management July/August 2005, Volume 1, Number 3 Newsbriefs OxyContin patent deemed invalid in federal court. Generic OxyContin to be distributed by Miami-based company. Phase III study of Remoxy for osteoarthritis. Opiate cocktail may reduce morphine tolerance. July/August 2005; pages 120-121
July/August 2005; pages 123-124
July/August 2005; pages 125-130
July/August 2005; pages 131-138 Abstract Tramadol (Ultram, Ortho-McNeil Pharmaceutical, Inc., Raritan, NJ) is considered a Step 2 analgesic under the World Health Organization’s guidelines for the treatment of patients with cancer pain. It is a centrally acting analgesic that has affinity for opioid receptors and influences the action of norepinephrine and serotonin at the synapse. This dual mechanism of analgesia makes it unique among Step 2 agents. It is metabolized by CYP2D6, which increases the potential for drug interactions. Unlike other opioids, it does not cause respiratory depression. Tramadol has been studied in cancer pain and neuropathic pain. It compares well with low-dose morphine as an analgesic. The purpose of this review is to critically examine the pharmacodynamics, pharmacology, drug interactions, and adverse effects of the drug, and, based on the data presented, discuss the drug’s role in cancer care. Key words: tramadol, cancer pain, neuropathic pain, analgesia, pharmacology
July/August 2005; pages 139-145
July/August 2005; pages 147-151 Abstract Approximately 7 million people in the United States are in jail, in prison, or on probation or parole, many as a result of drug-related offenses. Individuals who use opiates account for a significant minority of this population. Methadone maintenance treatment (MMT) of opiate addiction is highly effective in reducing drug use, drug-related criminal activity, and risk of human immunodeficiency virus transmission. Recently released inmates are at particularly high risk for overdose and disease transmission. Project MOD (Managing Opioid Dependency) provides services to eliminate logistical and financial barriers to MMT entry immediately on release from incarceration. Such programs provide a promising opportunity to facilitate reentry into the community, combat disease transmission, and reduce recidivism. Key words: methadone maintenance treatment, opiate addiction, incarceration, rehabilitation
July/August 2005; pages 153-161 Abstract Opioids are responsible for 25 percent of constipation in terminally ill patients. Patients in pain require prophylaxis to prevent opioid bowel syndrome (OBS). Laxatives are the treatment of choice, but are marginally effective. The development of quaternary opioid receptor antagonists is a step toward target-specific therapy for opioid-induced bowel dysfunction. This review will discuss the pathophysiology and management of OBS. Key words: opioid bowel syndrome, pathophysiology, prophylaxis, bowel dysfunction
July/August 2005; pages 162-167 Abstract Simultaneous use of opioids with a different pharmacological profile during anesthesia may lead to unexpected prolongation of effects. In addition, long-term use of transdermal buprenorphine may result in a reduced sensitivity to opioid anesthesia. In a prospective study, possible overlap of opioid effects and vigilance was determined in a group of patients (n = 22) using a buprenorphine patch for at least two months for treatment of chronic pain, and undergoing fentanyl-based fast-track enflurane anesthesia for open-heart surgery. The patients using buprenorphine were compared with a control group (n = 21) undergoing similar open-heart procedures with no opioid other than fentanyl on board. Aside from time to extubation, total dose of fentanyl, postoperative blood gases, and vigilance assessment score were used to determine possible overlap of opioid effects and/or development of opioid tolerance in the buprenorphine group compared to the control group. Both groups had similar operation and anesthesia times and comparable doses of fentanyl (0.69 mg ± 0.23 vs. 0.67 mg ± 0.16 SD). There was no significant difference in postoperative arterial blood gases (PaO2 136 ± 48 torr vs. 128 ± 35 torr SD; PCO2 43.3 ± 3.3 torr vs. 41.9 ± 1.2 torr SD), time until extubation (27 ± 22 min vs. 33 ± 24 min), and postanesthetic vigilance and recovery score (6.8 ± 1.0 vs. 7.5 ± 0.8, arbitrary units) between the two groups. Because of adaptive mechanisms and the development of tolerance in patients using buprenorphine, respiratory depression or sedation does not project into the postoperative period. The significant (p < 0.05) lower incidence of nausea and emesis in patients with transdermal buprenorphine owes to the development of tolerance to these opioid-related side effects. Key words: transdermal buprenorphine, fentanyl, opioid anesthesia, prolongation, potentiation, side effects, open-heart surgery
July/August 2005; pages 168-168 Abstract Novel Aspects of Pain Management: Opioids and Beyond. Edited by Jana Sawynok and Alan Cowan. Published by Wiley-Liss Inc., New York, 1999; 373 pp. Journal of Opioid Management September/October 2005, Volume 1, Number 4
Abstract Labopharm and Purdue partner on once-daily tramadol. New study results for extended-release oxymorphone. Online pharmacy owner indicted. The brain and placebo effect. High risk in ultra-rapid detoxification. Methylnaltrexone and opioid-induced constipation.
September/October 2005; pages 185-192
September/October 2005; pages 193-194
September/October 2005; pages 195-200 Abstract Opioid contracts are widely used to manage opioid prescribing in the treatment of pain conditions, but they are not well studied. A notable gap in our knowledge of opioid contracts involves the factors that determine their use. As an initial inquiry, this study evaluated the responses of a Web-based survey of trainees and faculty in an academic medical training context to determine correlates of opioid contract use. All paid faculty, third- and fourth-year medical students, and residents in The University of Oklahoma College of Medicine were invited via email to participate in a Web-based survey of their attitudes and prescribing practices related to controlled prescription drugs. Respondents composing a subgroup of those who replied to the survey were identified by their prescription of opioids and by their designation that pain was the most likely diagnosis for which they would prescribe a controlled drug. Chi-square analysis was used to determine any correlation between contract use and respondents’ demographic variables and categorical survey responses. Analysis of variance was used to determine any correlation between contract use and survey responses that involved continuous variables. Our results showed that opioid contract use was significantly associated with resident status, primary care specialty, participant estimation of alcohol and illicit drug abuse by patients, and the participant’s assessment of the risks in general of prescribing controlled drugs. A majority of contract users reported that the use of this tool increased their sense of mastery and comfort with prescribing controlled drugs. The factors associated with opioid contract use found in this study suggest there are significant prescriber-specific determinants of the use of the tool, including training level, medical specialty, and risk appraisals. Opioid contracts’ effects on mastery and comfort of the physician with prescribing opioids suggest that they may play an important role in facilitating appropriate pain management with opioids. Further study is needed to elucidate environmental and patient-specific factors that may influence opioid contract use. Key words: opioids, contract use, prescription, academic medicine
September/October 2005; pages 201-203 Abstract Randomized controlled trials of prescription heroin have shown success in reducing drug-related harm among chronic opiate injection drug users (IDUs) in several European nations. We sought to explore willingness to participate in a heroin trial among a well-characterized North American cohort of IDUs, and therefore performed analyses of factors associated with willingness to participate in a prescription heroin trial among IDUs enrolled in the Vancouver Injecting Drug Users Study (VIDUS). Of 410 current heroin injectors followed between May and November 2002, injecting heroin frequently (more than once daily) [odds ratio (OR) 1.33; 95 percent confidence interval (CI) 1.06 to 1.69] and being enrolled in methadone maintenance therapy (MMT; OR 1.33, 95 percent CI 1.06 to 1.69) were associated with willingness to participate in a trial. In subanalyses, statistical associations with willingness to participate in a trial among current MMT users were frequent injection of heroin (OR 2.12, CI 1.16 to 3.88) and speedballs (OR 2.57, CI 1.02 to 6.48), frequent crack cocaine use (OR 1.84, CI 1.11 to 3.06), lending of syringes (OR 3.22, CI 1.08 to 9.65), and requiring help to inject (OR 1.83, CI 1.01 to 3.33). Among IDUs, willingness to enroll in a heroin prescription program was associated with high-intensity heroin injection and high-risk behaviors and was particularly prevalent among individuals who have been unable to significantly reduce their injection drug use on MMT alone. These findings indicate that a clinical trial of prescribed heroin should be able to enroll an appropriate sample of drug users and properly assess the treatment potential of prescribed opiate pharmacotherapy. Key words: prescription heroin, methadone maintenance therapy, injection drug use, treatment
September/October 2005; pages 204-210 Abstract Radiotherapy (R/T) is frequently used for palliative treatment of painful bone metastases; however, complete alleviation of pain is not always achieved. This study was designed to evaluate pain management outcomes and quality of life (QoL) measures in cancer patients with metastatic bone pain receiving a combination of R/T and either transdermal therapeutic fentanyl (TTS-F) patches or codeine/paracetamol. A total of 460 palliative care patients with bone metastases who received R/T were enrolled in this prospective, open-label study. The patients were randomized to initially receive a total dose of 120 mg codeine/paracetamol per day or TTS-F patches releasing 25 µg fentanyl per hour. Pain measures were assessed on the basis of selected questions from the Greek-Brief Pain Inventory. Overall treatment satisfaction (scale, 1 to 4), QoL, and European Collaborative Oncology Group status were also recorded. Among the 460 patients, 422 were eligible for evaluation. Pain measures in the TTS-F group demonstrated statistically significant improvements during the study that were superior to those in the codeine/paracetamol group (p < 0.05). Likewise, there was a significantly greater increase (p < 0.05) in the mean satisfaction score for patients in TTS-F group at every visit between baseline and month two. The vast majority (95.8 percent) of patients in the codeine/paracetamol group increased their medication dosage until the end of the study, whereas in the TTS-F group the respective percentage was only 6.1. Both treatments were generally well tolerated, with constipation as the most common side effect followed by sleep disturbances and nausea. The overall frequencies of side effects were higher in the codeine/paracetamol group. The results therefore indicate that TTS-F offers more effective pain relief than codeine/paracetamol, in combination with R/T, in patients with metastatic bone pain, obtaining complete treatment satisfaction matched by improvements in their QoL. Key words: bone metastases, pain, radiotherapy, fentanyl, codeine/paracetamol, palliation
September/October 2005; pages 211-217
September/October 2005; pages 219-220
September/October 2005; pages 221-222
September/October 2005; pages 223-224 Journal of Opioid Management November/December 2005, Volume 1, Number 5
Abstract European authorities recommend approval for IONSYS; Opioid use and NSAIDs in migraines; Phase II trial for abuse-resistant extended-release opioid; m-opioid therapy and chronic arthritis pain; Reduced opioid availability in minority areas
November/December 2005; pages 237-239
November/December 2005; pages 240-243
November/December 2005; pages 244-248
November/December 2005; pages 249-256 Abstract Naltrexone’s current use has been limited by compliance. Subcutaneous implants would seem to offer a solution to this problem and improve long-term outcomes. The aim of the present study was to compare groups of patients who had received oral naltrexone or a naltrexone implant after detoxification and to follow their progress. Forty-one patients received an implant, and 42 patients received oral naltrexone. They were surveyed at one, three, six, and 12 months after detoxification. Their designated support person was also contacted to confirm the self-reports of the participants. Patients were compared on gender, age, and length of time since detoxification. Implant patients showed much higher abstinence rates, while those in both groups who were abstinent showed greater compliance to naltrexone (time spent in treatment) and attended more counseling sessions. Although the participants were not randomly allocated to each treatment condition, the preliminary evidence indicates that implants can improve compliance rates and outcomes. Key words: naltrexone, implant, social support, compliance, opiate addiction
November/December 2005; pages 257-266 Abstract The increasingly common practice of long-term opioid therapy for chronic noncancer pain must be guided by ongoing assessment of four types of outcomes: pain relief, function, side effects, and drug-related behaviors. Our objective was to gather initial pilot data on the clinical application of a specialized chart note, the Pain Assessment and Documentation Tool (PADT), which was developed and tested with 27 physicians. This pilot test provided the means to collect cross-sectional outcome data on a large sample of opioid-treated chronic pain patients. Each of the physician volunteers (located in a variety of settings across the United States) completed the PADT for a convenience sample of personally treated chronic pain patients who had received at least three months of opioid therapy. Completion of the PADT required a clinical interview, review of the medical chart, and direct clinical observation. Data from the PADTs were collated and analyzed. The results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all four relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality was generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common but viewed as an indicator of a problem (i.e., addiction or diversion) in only approximately 10 percent of cases. Using the PADT, physician ratings can be developed in four domains. In this sample, outcomes suggested that opioid therapy provided meaningful analgesia. Key words: opioids, noncancer pain, assessment, documentation, outcomes
November/December 2005; pages 267-272 Abstract The present study was performed to establish whether analgesic consumption in the first four postoperative hours is a suitable basis for selecting the demand dose and predicting the likely analgesic requirement over the next 20 hours with single-use patient-controlled analgesia (PCA) pumps, and to establish whether this method provides effective pain control. Forty-two patients who had undergone a laparotic gynecological procedure (hysterectomy) were given an electronic PCA pump (Abbott Lifecare, Abbott Laboratories, Abbott Park, IL) for four hours (phase I) with a demand dose of 1 mg piritramide and a lockout period of five minutes for dose titration. Piritramide’s potency is comparable with that of morphine. The patients then received single-use PCA pumps (Baxter Infusor/Watch, Baxter, Deerfield, IL) for the next 20 hours (phase II) with a demand dose of 0.75 mg in Group A and 1.5 mg in Group B, depending on whether more or less than 10 mg pritramide had been consumed in phase I. A specially designed electronic recorder was used to measure the exact amount consumed and number of demands. Patients experiencing pain were free to receive additional piritramide at any time as rescue medication; however, these patients were withdrawn from the study. Ninety percent of the patients in group A said they were satisfied with or undecided as to the level of analgesia. The corresponding figure in group B was 95 percent. Piritramide consumption was significantly higher in group B than in group A. There were no significant differences between the groups regarding demographic data or duration of surgery, nor did either of these two parameters affect postoperative piritramide consumption. Significant alleviation of pain and improvement in visual analog scale scores from phase I [group A, 4.7 (range, 2.0 to 6.8); group B, 4.6 (range, 3.0 to 8.3)] to phase II [group A, 3.1 (range, 0.4 to 5.2); group B, 3.2 (range, 0.4 to 6.0)] was achieved in both groups. A significant difference in analgesic consumption up to 18 hours postoperatively was seen after dose titration. In the first four hours, the rate of successful demands was significantly higher in group A (80.9 percent) than in group B (40.9 percent). The number of successful demands was comparable in the two groups during phase II (A, 98.8 percent; B, 94.5 percent). In summary, total opioid consumption during the first four hours after operation showed two groups of patients with significantly different needs for piritramide (< 10 mg per 4 hours or > 10 mg per 4 hours). Two different dose regimes were applied using a high and a low bolus size in the following 20 hours. We concluded that effective pain control without respiratory depression was achieved with single-use PCA pumps. Opioid consumption varied significantly, whereas pain levels did not. Key words: postoperative analgesia, patient-controlled analgesia, single-use, demand-dose, acute analgesia
November/December 2005; pages 273-279 |
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