Journal of Pain & Palliative Care Pharmacotherapy最新文献

Cancer patients frequently experience pain and depression, yet current guidelines address these conditions separately and do not recommend a single agent for concurrent management. Ketamine and its S-enantiomer esketamine, through N-methyl-D-aspartate receptor antagonism and glutamate modulation, may offer dual benefit. This paper examined ten clinical studies published between 2018 and 2024 evaluating ketamine and esketamine for concurrent cancer-related pain and depression. Evidence was heterogeneous but promising. Two randomized controlled trials in post-surgical breast and cervical cancer patients demonstrated that intravenous (IV) esketamine and racemic ketamine improved both pain and depression, with esketamine showing greater, longer-lasting benefit. When pain was the primary outcome, results were mixed: IV esketamine provided dual benefit in one trial, whereas racemic ketamine produced variable or nonsignificant effects across IV, intranasal (IN), and oral routes. In depression-focused studies, IV and IN administration consistently improved mood, even without pain relief. Dose-response relationships were observed, with esketamine outperforming ketamine and higher IN dosing yielding stronger antidepressant effects. Adverse effects were generally mild and transient, though cardiovascular, urinary, and cognitive risks remain concerns. With rapid dual action, ketamine and esketamine may serve as valuable adjunctive therapies in palliative care. Further studies should clarify optimal dosing, route, and long-term safety.

Previous studies have shown that pharmacist involvement in inpatient palliative care programs is associated with lower daily cost expenditures and fewer patients with subsequent hospitalizations or urgent care visits. The objective of this study was to determine the impact of a new inpatient pain and palliative pharmacy service line staffed by a first year pharmacist resident. In this prospective, single center pilot study, a PGY1 pharmacy resident reviewed pain medications for hospitalized patients from February 3, 2025 through February 28, 2025, and joined with the interdisciplinary palliative care team attending daily huddle. The pharmacist resident reviewed 571 patients and made 79 interventions during the pilot duration (average 4.3 interventions per day). Most common intervention types included discontinuation of a medication, adding an adjunct medication, or dose adjustment. This study found that a dedicated pain and palliative care pharmacist resident integrated within the interdisciplinary palliative care team can make diverse interventions and recommendations to optimize pain and symptom management for hospitalized patients. Depending on the size of the medical center, the scope of such a position may need to be expanded to justify a full FTE pain and palliative pharmacist position.

This retrospective study evaluated real-world use of hospital-compounded oral ketamine in fibromyalgia patients following a course of intravenous (IV) ketamine induction. Fifty-three patients with fibromyalgia first underwent a 3-day IV ketamine infusion (1.44 mg/kg/day) in hospital and then transitioned to oral ketamine, compounded by the hospital pharmacy. Patients were categorized as complete, partial, or non-responders based on clinical outcomes after 3 months. Of the 53 patients, 41.5% were complete responders, 15% partial responders, and 43.5% non-responders. Complete responders continued oral ketamine for a mean of 15.6 months. Overall, 58.5% discontinued ketamine (23 patients within 3 months, 8 after more prolonged use), most commonly due to lack of efficacy (12 patients) or side effects (11 patients). Side effects were generally mild; significant adverse events occurred in only two patients (3.8%: one with hypertension, one with atrial fibrillation), and one patient had a isolated elevation in a liver enzyme (gamma-GT). These findings suggest sequential IV induction followed by oral ketamine maintenance can be a safe, potentially effective off-label therapy for some fibromyalgia patients refractory to standard treatments. The tolerability and sustained use observed in responders highlight the need for further prospective studies to clarify ketamine's role in chronic fibromyalgia pain management.

Kounis syndrome is an under-recognized condition characterized by the simultaneous occurrence of acute coronary syndrome and hypersensitivity reactions. While opioids are known triggers, tramadol-induced Kounis syndrome is extremely rare. A 49-year-old woman with a history of allergy to dimenhydrinate and chronic low back pain developed anaphylactic shock 4 min after receiving 50 mg of subcutaneous tramadol. She developed with dyspnea, glottic edema, muscle rigidity, chest pain, and hypotension. After stabilization with epinephrine, corticosteroids, antihistamines, fluids, and vasopressors, elevated cardiac biomarkers were detected. Electrocardiograms and echocardiography were normal. Coronary CT and invasive angiography revealed no obstructive coronary artery disease. A diagnosis of Kounis syndrome was established. This case highlights the importance of considering Kounis syndrome in patients presenting with anaphylaxis and chest pain, even in the absence of ECG changes. Early hemodynamic stabilization followed by cardiac evaluation is essential for timely diagnosis and management.

Buprenorphine is a mixed agonist-antagonist, safer for long-term use compared to full agonist opioids. There is no literature to describe utilization of flexible buprenorphine dosing regimens in the chronic pain population. This was a retrospective single center, observational study. Inclusion criteria were age 18 and older, diagnosis of chronic pain, and prescribed buprenorphine. Patients with a diagnosis of opioid use disorder (OUD) were excluded. Buprenorphine regimens analyzed included: scheduled buprenorphine, scheduled plus as needed (PRN) buprenorphine, PRN buprenorphine alone, and scheduled buprenorphine plus PRN full µ-opioid agonist. The primary outcome was the percent of patients on each buprenorphine regimen. The secondary outcome was duration of buprenorphine therapy. Overall, 691 patients were reviewed, with 401 meeting inclusion criteria. Scheduled buprenorphine was prescribed to 340 patients (84.4%), while 37 patients (9.2%) were prescribed scheduled plus PRN buprenorphine. Patients exposed to flexible dosing remained on treatment longer than those on scheduled buprenorphine alone (HR 3.50, CI 2.07-5.92, NNT 9.0). Flexible buprenorphine dosing was utilized for chronic pain. Patients on scheduled plus PRN buprenorphine were on treatment longer than those on scheduled buprenorphine alone. Scheduled plus PRN buprenorphine can be considered for patients with chronic pain.

Cancer pain is one of the most frequent and distressing symptoms experienced by patients and remains commonly undertreated. Understanding healthcare provider-related barriers is essential to improving pain management practices. A cross-sectional survey was conducted among healthcare providers in Hospital Umum Sarawak using the Knowledge and Attitudes Survey Regarding Pain (KASRP) questionnaire to assess knowledge and attitudes toward pain management. A total of 136 healthcare providers participated, with an overall mean KASRP score of 60.26%. Doctors achieved the highest mean score (67.69%), followed by pharmacists (62.56%) and nurses (47.69%), with statistically significant interprofessional differences. As a minimum score of 80% is considered adequate, the findings indicate substantial gaps in knowledge and attitude across all groups. Variability in pain management education within professional curricula may explain these differences. Although education and training programs were associated with improved knowledge, their effectiveness varied, highlighting the need for regular, high-quality, and targeted training. Adequate knowledge alone does not ensure high-quality pain management, as inadequate pain assessment remains a persistent barrier. Regular audits, continuous education, and tailored training initiatives are crucial to overcome healthcare provider-related barriers and enhance the quality of cancer pain management.

This single-center, retrospective chart review aims to estimate the incidence of opioid-induced hypogonadism (OIH) among chronic pain patients treated with long-term opioid therapy and determine whether the incidence differs between patients receiving buprenorphine versus those receiving full-agonist opioid agents. The primary endpoint was a composite of plasma testosterone less than 300 ng/dL, initiation of medications for testosterone replacement therapy or erectile dysfunction (ED), or a new diagnosis of ED or hypogonadism. Adult male Veterans were included if they received at least 90 d' supply of an opioid during the study period with a preceding 90-d opioid-free interval. Forty-five patients were included in the buprenorphine group and 55 in the full-agonist opioid group. There was no significant difference between groups in baseline characteristics. Fewer patients in the buprenorphine group met the primary composite endpoint as compared to the full-agonist opioid group (13.3% vs. 29.1%, p = 0.058), and patients in the buprenorphine group had fewer diagnoses of ED or hypogonadism post-treatment initiation (0% vs. 12.7%, p = 0.013). These findings support the use of buprenorphine as a treatment option when endocrine-related side effects are a concern.

Lower back pain (LBP) poses a significant health challenge globally, particularly within the Indian community. This review article synthesizes current knowledge on the epidemiology, risk factors, and culturally tailored interventions for LBP in India. Drawing from an extensive literature review and analysis of 20 surveys, we elucidate the complex interplay between lifestyle choices, occupational factors, and poor posture as primary contributors to chronic LBP. Importantly, our findings reveal a notable disparity in LBP prevalence, with rural women experiencing a disproportionately high burden attributed to stress and the demanding nature of household chores. Addressing this issue necessitates the development of interventions sensitive to cultural nuances and socioeconomic contexts. Collaborative efforts involving healthcare professionals, policymakers, and community stakeholders are paramount to implementing effective strategies for LBP management and prevention. By empowering individuals, particularly vulnerable populations like rural women, with the necessary tools and resources, we can strive toward alleviating the burden of chronic LBP within the Indian community. This manuscript contributes to the body of knowledge by offering insights into the unique challenges and opportunities for addressing LBP in India, ultimately aiming to enhance the overall quality of life and well-being of all members of society.