Journal of Pain & Palliative Care Pharmacotherapy最新文献

Treatment of chronic, non-cancer pain can be challenging in the presence of long-term opioid therapy (LTOT). Buprenorphine products can provide a unique option for chronic pain treatment due to the improved safety profile with a ceiling effect on respiratory depression. Drug manufacturers provide recommendations for conversion from full mu agonist to buprenorphine which typically includes tapering to lower morphine equivalent doses (MEDD). This study will attempt to compare if there is a difference in the ability of achieving buprenorphine maintenance therapy for chronic pain based on the starting opioid MEDD. This study's primary endpoint is the difference in ability to achieve buprenorphine maintenance therapy for chronic, non-cancer pain based on baseline MEDD (i.e., ≤30 MEDD vs >30 MEDD). Secondary endpoints will describe method of conversion to buprenorphine, difference in frequency of follow up and average time to achieve maintenance doses. There was no difference in ability to achieve buprenorphine maintenance doses between either group. Approximately 40% of patients in each group achieved maintenance doses regardless of baseline MEDD. Patients on higher MEDDs had the same likelihood of achieving buprenorphine maintenance therapy for chronic pain as those were at 30 MEDD and can be considered for buprenorphine therapy without tapering first.

Buprenorphine can be an effective and safe option for patients with chronic pain. We describe a case in which a patient on long-term full opioid agonists for chronic non-cancer pain was safely transitioned from methadone to buprenorphine in the outpatient setting using a low dose buprenorphine initiation protocol. One month after the opioid rotation, the patient reported adequate analgesic effect from the buprenorphine regimen. Further studies are warranted to better guide prescribing of buprenorphine for chronic nonmalignant pain.

The purpose of this study was to better characterize morphine equivalent daily dose (MEDD) equivalencies with buccal buprenorphine, and identify real-world efficacy and safety outcomes associated with the use of buccal buprenorphine for chronic pain at a local VA Medical Center. This study was a retrospective chart review of Computerized Patient Record System (CPRS) patient records with outpatient prescriptions for buccal buprenorphine (Belbuca^®). Overall, there was a high discontinuation rate of Belbuca^®: being 60% or greater across all different patient groups. These high attrition rates may potentially be result of failure to titrate to an optimal dose of Belbuca^® needed for adequate analgesia. Those fully rotated fared marginally better than those partially rotated in that those fully rotated discontinued at a lesser rate and less quickly than those who were partially rotated. From the results of this study, a local dosing scheme for Belbuca^® based on baseline MEDD was created for facility level guidance. The exact MEDD conversion ratio, however, for individual buprenorphine products as well as MEDD contributed by these products on a patient's overall opioid related risk compared to other full agonist opioids still remains unclear and further studies are warranted.

Cancer pain (CP) is a prevalent condition with limited pharmacotherapeutic options. Cannabis-based medicinal products (CBMPs) have shown analgesic effects, but their efficacy in CP remains contentious. This study aims to evaluate the change in patient-reported outcome measures (PROMs) and adverse events (AEs) in CP patients treated with CBMPs. A case series was conducted using prospectively collected clinical data from the UK Medical Cannabis Registry. Primary outcomes were the changes in the Brief Pain Inventory (BPI), pain visual analogue scale (Pain-VAS), EQ-5D-5L, Generalized Anxiety Disorder-7 (GAD-7), Patient Global Impression of Change (PGIC) and Single-Item Sleep Quality Scale (SQS) questionnaires from baseline to 1, 3, and 6 months. AEs were recorded and graded. p < 0.050 was considered statistically significant. One hundred and sixty-eight participants were included. CBMPs were associated with improvements in all pain-specific PROMs at all follow-up periods (p < 0.050). Improvements in GAD-7, SQS, and EQ-5D-5L index scores were also observed (p < 0.050). Twenty-nine AEs (17.26%) were reported by five patients (2.98%), mostly mild-to-moderate (72.41%). Although the observational design means causality cannot be established, the findings support the development of future randomized controlled trials into CP management with CBMPs.

Naltrexone is an opioid antagonist approved by the Food and Drug Administration (FDA) for alcohol use disorder and opioid use disorder. More recently, naltrexone has been used off-label at low doses of 4.5 mg daily for chronic pain due to fibromyalgia, neuropathy, complex regional pain syndrome, and multiple sclerosis. While several studies show the promise of low-dose naltrexone in treating chronic pain, most had small sample sizes and short-term follow up, which warrants additional investigation into the effectiveness of low-dose naltrexone. This medication use evaluation aimed to evaluate the effectiveness of low-dose naltrexone for chronic pain in Veterans through retrospective chart review. The average duration of low-dose naltrexone therapy was 123 days with approximately half of Veterans still taking it at the time of chart review. The average change in pain score from initiation to most recent visit was -0.83. Low-dose naltrexone was generally well-tolerated with 32% (13 of 41) of Veterans reporting adverse effects including vivid dreams, drowsiness, dizziness, and nausea. Low-dose naltrexone resulted in a small decrease in pain, although may be considered after a patient has failed multiple lines of therapy for additional pain control after a risk versus benefits discussion.

This study compares the efficacy of hydrodilatation (HD) alone with intra-articular corticosteroid injection (ICI) in treating frozen shoulder (FS). A total of 48 patients with FS were randomly assigned to two groups: 24 patients received HD treatment, while the other 24 patients received ICI treatment. HD involved 20 mL 0.9% normal saline solution with 3 mL 2% lidocaine, and ICI included 1 mL of 40 mg/mL methylprednisolone acetate with 1 mL 2% lidocaine and 3 mL normal saline. Outcome measures included Visual Analog Scale (VAS), Shoulder Pain and Disability Index (SPADI), and passive range of motion (ROM) at baseline, two-, four-, and eight-week follow-ups. Both treatments demonstrated significant improvement in the VAS, SPADI, and passive ROM, when between-times comparison was conducted in each group at all follow-up points over the eight-week study period (p < 0.001). However, no significant differences were found in between groups comparison at study end (p > 0.05), with no significant interaction between groups and times (p > 0.05). Absolute changes from baseline to eight-week follow-up were not significantly different between HD and ICI (p > 0.05). In the short term, HD alone demonstrates strong efficacy in managing FS, matching the effectiveness of ICI.

IgE-mediated opioid hypersensitivities, or true allergies, are rare and most adverse reactions to opioids can be attributed to side effects or to pseudo-allergies. Given that immune-mediated allergies to opioids are uncommon, literature regarding cross-reactivity among opioid classes are limited. This retrospective study aimed to determine the rates of cross-reactivity and tolerance among patients with previously documented opioid allergy or adverse drug reaction (ADR) across three opioid drug classes (natural, semisynthetic, and synthetic opioids). Patients with documented allergy(s) and/or ADR(s) to opioids were assessed for outcomes of subsequent opioid exposure during any hospital admission at a Veterans Affairs hospital over a 10-year time-period. Veterans were sorted into three cohorts based on the opioid class of the previously documented allergy or ADR. Each cohort had three study arms, one for each class of subsequent opioid exposure. A total of 1507 patients were identified with previously documented allergy or ADR to at least one opioid and at least one subsequent opioid drug exposure. No cross-reactivity among any of the opioid drug classes were found resulting in 100% re-exposure tolerance rates with all study arms. These findings could increase confidence in utilizing opioids in patients with historically documented opioid allergies or ADRs.

Mirtazapine is a selective serotonergic antidepressant that functions by blocking adrenergic alpha2-autoreceptors and heteroreceptors and inhibiting 5-HT2 and 5-HT3 receptors. It is a noradrenergic drug. Mirtazapine has anxiolytic or sleep-quality-improving effects, aggravates appetite-stimulation, and has stomach emptying functions. When treating poly-symptoms such as appetite loss, anxiety, depression, nausea, and sleeplessness off-label, mirtazapine is being used more and more. A not so common side effect of mirtazapine medication is peripheral edema. The ensuing case study will demonstrate how peripheral edema is an uncommon mirtazapine adverse effect. Peripheral edema was observed in a patient with advanced oral cavity cancer three days after starting a daily dose of 15 mg of mirtazapine for polysymptomatology. The peripheral edema completely resolved after stopping mirtazapine. To the best of our knowledge, this is the first instance of a patient with advanced oral cavity cancer experiencing peripheral edema as a result of receiving mirtazapine medication. Our study will assist medical professionals in identifying the potential use of mirtazapine in situations where peripheral edema develops quickly, facilitating its quick clearance.