Journal of Pain & Palliative Care Pharmacotherapy最新文献

Serotonin toxicity (ST) is a preventable, life-threatening condition caused by serotonergic agents. It typically arises from combined drug use that affects serotonin's release and metabolism. While often presenting with mild symptoms that may be overlooked or misdiagnosed, severe toxicity is associated with significant mortality. The older population is particularly at risk due to altered drug pharmacokinetics, a tendency for multiple drug use, and symptom overlap with common neurodegenerative conditions. The case study discusses an older patient with prolonged ST developed with the use of several serotonergic drugs for postherpetic neuralgia. It emphasizes the challenges of polypharmacy in older patients, offering insights into the serotoninergic potential of multiple medicines commonly used in older adults, the pathophysiology, proper diagnosis and differential diagnoses, and management strategies of ST. Accurate diagnosis requires heightened vigilance from healthcare professionals regarding potential drug interactions and familiarity with the specific clinical criteria. Regular revision and adjustment of medications in older patients and preference for the non-pharmacological treatment of chronic pain are essential for preventing ST. This case report is a convenient way for many healthcare professionals to update their knowledge about ST, its diagnosis and management.

Naldemedine is a peripheral acting µ-opioid receptor antagonist approved by the Food and Drug Administration to treat opioid-induced constipation. Concerns about side effects like opioid withdrawal prevent its widespread use, especially for cancer patients. We performed this systematic review and meta-analysis to evaluate existing safety data of naldemedine treating opioid-induced constipation following the PRISMA guidelines. We searched PubMed and the Cochrane Library on April 16th 2024 to identify studies evaluating naldemedine treatment among patients with opioid-induced constipation. Our analysis found no differences between groups comparing naldemedine therapy with placebo-control for treatment-emergent adverse events (OR = 1.06; 95%-CI: 0.91-1.24), serious adverse events (OR = 1.02; 95%-CI: 0.76-1.38). We found no increased risk for opioid withdrawal, while an increased risk for gastrointestinal disorders (OR = 2.08; 95%-CI: 1.72-2.51), particularly higher incidences of diarrhea (OR = 2.44; 95%-CI: 1.81-3.29) and abdominal pain (OR = 3.31; 95%-CI: 2.16-5.06) were found. In the cancer subgroup, treatment-emergent and serious adverse events were more frequent. However, no increased risk for opioid withdrawal was observed. This analysis confirms naldemedine's overall safety in treating opioid-induced constipation, with manageable gastrointestinal side effects. However, the higher adverse events in cancer patients require further investigation to ensure safe use in this population.

Intravenous (IV) magnesium sulfate, a versatile electrolyte, plays a pivotal role across various medical domains. From cardiac care to obstetrics, gastrointestinal to pulmonary therapies, the impact is far-reaching among acute care services. Notably, in the postoperative phase of care, it shares intriguing similarities with ketamine as an NMDA receptor antagonist. This case series describes the difficulties experienced with postoperative analgesia in three patient cases with complex comorbidities and discusses the beneficial impact observed when magnesium was administered concomitantly with ketamine. Further research is necessary to outline the specific role, ideal population, and recommended bolus and infusion rate for optimal analgesic efficacy.

Deafferentation is an umbrella term that includes several clinical conditions. The exact mechanism is not yet known, and the different clinical conditions do not necessarily share common pathophysiology. It includes both non-painful and painful conditions, including cancer pain conditions. Clinical presentation can be immediate or delayed, sometimes years after the causative lesion. Patients experience neuropathic pain symptoms in an area of abnormal or absent sensation. Laboratory tests show denervation and loss of function. Pain management strategies can be directed toward alleviating symptoms rather than eradication. The site of origin of the pain can help decide the treatment modalities to be tried. Gabapentinoids, antidepressants, and sodium channel blockers can be used. This type of pain is typically opioid-nonresponsive, but some patients may benefit. Neuronal destructive procedures are indicated for brachial plexus avulsion injuries. Spinal cord stimulation, dorsal root entry zone rhizotomy, deep brain thalamic stimulation, and motor cortex stimulation have been suggested for the management of the complex clinical conditions under the umbrella of deafferentation.

End stage renal disease (ESRD) is known to be associated with pain, malaise and decreased quality of life. Pain management in the setting of dialysis is particularly challenging from a pharmacologic standpoint given altered pharmacokinetics of pain medications. Buprenorphine, a partial mu opioid receptor agonist, demonstrates superior safety profile compared to full mu opioid receptor agonists. In this case report, we demonstrated buprenorphine buccal film (Belbuca) as a safe and effective opioid treatment option for pain palliation in a dialysis dependent patient. Future studies may be warranted with larger sample size and longer follow up period to study the effect of buprenorphine in the setting of hemodialysis and non-dialysis dependent ESRD population.

This study explores the under-researched domain of patient-controlled analgesia (PCA) for cancer pain management in adult outpatients, focusing on the transition from patient-controlled analgesia pumps (PCA pump) to oral medications. While existing literature primarily addresses the use of PCA in inpatient settings, this descriptive study investigates the initiation of outpatient PCA in palliative care patients. The retrospective chart review includes data from all admissions between July 1, 2014, and December 31, 2020. Among the 49 identified patients, 41 were admitted for cancer-related pain, with an indication for PCA such as insufficient pain relief, highly fluctuating pain, or inadequate response to other routes. Of these patients, 13 were successfully transitioned from outpatient PCA to oral opioids. The study underscores the effective use of PCA as a transitional tool following a pain crisis that necessitates inpatient admission. Future research avenues could explore healthcare utilization, length of stay, and required outpatient resources, such as home visits or telehealth, for optimal PCA use in outpatient settings.

Chemotherapy-Induced Peripheral Neuropathy (CIPN) refers to damage of peripheral nerve fibers due to the use of neurotoxic chemotherapy to treat various cancers. It occurs in more than 30% of patients and only duloxetine has currently been identified to show limited efficacy in symptomatic treatment of CIPN. Opioids have traditionally been used to treat cancer pain, and there is evidence for their use in treatment of peripheral neuropathic pain from other causes. With a similar mechanism of action to duloxetine, methadone has rationale for treating neuropathic pain. This study is a retrospective chart review to evaluate the outcomes of using methadone for CIPN pain. Out of 31 patients, 65% felt that methadone was an effective treatment, 19% felt that it was ineffective, and 16% felt that it was partially or temporarily effective. These results suggest that analgesic response to methadone varies between patients, but that it has a potential role in painful CIPN. Its advantages for long-term use include low cost and lack of metabolites. Potential risks include a long half-life, drug interactions, and potential for QT prolongation at high doses. Prospective studies should be conducted to evaluate the role of methadone in CIPN pain management more comprehensively.

The presence of comorbidities and complex drug regimens makes palliative care patients more susceptible to opioid medication errors. Most of the studies conducted so far have mainly focused on patients admitted to hospitals or hospice facilities. During this study, we examined the frequency of medication errors with opioids and the causes and consequences for patients, followed by home palliative care teams. Errors occurred in 39% of patients (n = 378) and 27% of all prescribed opioids (n = 708). Of the 148 (39%) patients with error/s in the opioid/s prescribed, in 55% the patient and/or the caregiver were involved in the error; in 26% the health care providers were involved. An association was found between the presence of error in the prescribed opioid and the level of patient education, p = .038, and with the number of days of follow-up, p < .001. Considering their formulation, the prescribed opioids were associated with medication error, type of error, and cause of the error. The study demonstrated an association between the route of administration and error p < .004, and type of error p < .001.