Journal of Pain & Palliative Care Pharmacotherapy最新文献

Palliative care is essential for life-threatening illnesses. However, Nepal still faces significant challenges in accessing primary palliative care services, including required medications, particularly in rural areas. This commentary highlights the need for policies and guidelines to ensure equitable access to palliative care with medicines. While limited studies in Nepal confirmed the demand, challenges persist in rural areas with deficient access to quality healthcare. This article discusses the existing efforts and noteworthy initiatives implemented by healthcare institutions. However, these efforts are currently limited in scale. We recommend including essential palliative care medicines in government healthcare policies, establishing training programs for healthcare professionals, and developing comprehensive policies with detailed field research work to meet the growing demand. Addressing these issues will significantly improve the quality of life for palliative care patients in Nepal.

The Commercially Insured health Plan Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (CIP-RIOSORD) is an evidence-based tool to determine serious opioid-induced respiratory depression (OIRD) or overdose risk. The CIP-RIOSORD total score determines a risk class and estimates the probability for an OIRD event within the next 6 months. We performed a single-center, retrospective analysis to determine CIP-RIOSORD baseline scores and the most common predictive factors in patients with cancer. Patients (n = 160) were split into new consultations (n = 83, Group 1) versus the first documented follow-up consultation (n = 77, Group 2). Most patients were Caucasian women with metastatic gastrointestinal cancer. CIP-RIOSORD scores for Group 1 patients were 14.8 ± 15.2 (mean ± SD, risk class 4). Group 2 patients had higher CIP-RIOSORD scores (16.6 ± 14.9, risk class 4). For Group 1, the most common CIP-RIOSORD predictive factors were use of a long-acting opioid formulation (n = 24, 29%) and daily oral morphine equivalent (OME) ≥100 (n = 20, 24%); for Group 2, predictive factors were use of an antidepressant (n = 34, 44%) and a long-acting opioid formulation (n = 27, 35%). Based on the CIP-RIOSORD, there is a 15% probability of experiencing a serious OIRD event or overdose within the next 6 months.

Cancer-related pain (CrP) is a significant public health problem, and opioids are the mainstay of CrP treatment. Considering the persistent problem of inadequate treatment of cancer pain in Turkey, the study was conducted to determine the prevalence of reluctance to prescribe opioids among physicians in oncology departments. The descriptive cross-sectional study included oncology residents and residents without oncology specialization in oncology departments. One thousand physicians were invited by e-mail to the Google Forms survey platform. Two hundred and seventy-eight physicians completed the survey and were included, of which 50% (n: 139) were female. More than half (n: 166; 59.7%) of them were oncology subspecialists. The prevalence of reluctance to prescribe opioids was calculated to be 38.1% (n: 106). A significant positive association was found between the factor associated with reluctance to prescribe opioids and fear of opioid use disorder (β = 0.964; 95% CI = 0.362-1.566; p = .002). Reluctance to prescribe opioids was inversely related to the oncology subspecialty (β = -0.878; 95% CI = -1.54 to -0.213; p = 0.010) and education about CrP and opioid management (β = -1.707; 95% CI = -2.404 to -1.009; p = 0.01). Reluctance to prescribe opioids appears to be associated with a lack of knowledge and fear of opioid use disorder.

While morphine is the recommended first-line treatment for pain management in patients with acute coronary syndrome, recent studies have raised concerns about its association with adverse outcomes. Morphine has been found to cause delayed antiplatelet effects, decreased ticagrelor absorption, increased platelet reactivity, and compromised efficacy of dual antiplatelet therapy (DAPT). Alternative analgesics, such as lidocaine, fentanyl, and acetaminophen, have begun to emerge as viable alternatives, each with unique mechanisms and potential benefits. Lidocaine is demonstrated to have superior effects in reducing microvascular obstruction and fewer adverse events compared to fentanyl, despite being less effective in pain reduction. Fentanyl, which shows rapid onset and powerful analgesic properties, may interfere with ticagrelor absorption, potentially affecting platelet inhibition. Acetaminophen, a centrally acting analgesic, emerges as a safer alternative with comparable pain relief efficacy and minimal side effects. The results of multiple clinical trials emphasize the significance of customizing pain management approaches to match individual patient profiles and achieving the optimal balance between pain relief and potential adverse outcomes.

Subcutaneous patient-controlled analgesia (SCPCA) in home-based palliative care is a potentially valuable option for providing effective pain relief to some patients, particularly when conventional analgesic approaches prove ineffective or are refused. Our case report illustrates the use of SPCA for the management of breakthrough pain in a patient receiving palliative care at home with no improvement after multiple previous treatments. SCPCA was found to be safe and successful. Future research is essential to explore its precise role, appropriate indications, prescription guidelines, and safety considerations across various palliative care contexts.

Chronic pain in children continues to pose significant challenges. The pharmacological approach most often revolves around trials and errors, expert opinions, and extrapolation of adult study findings. Ketamine is one of the agents used for chronic pain, especially with a neuropathic component. This article aims to provide an overview of its properties and highlight the current evidence for its use in malignant and nonmalignant chronic pain management. A search on the use of ketamine for chronic pain in children up to 18 years of age covering the period from January 1, 2000, to December 14, 2022, was performed through PubMed, Cochrane Library, EBSCO, EBM Review, Wiley, BMJ, Web of Science, Google Scholar, and the Saudi Digital Library. 218 articles were found and 42 underwent full review. Currently, the evidence about ketamine efficacity and safety for chronic pain management is at best of moderate to low quality. The heterogeinity of ketamine infusion protocols and frequent concomitant use of other analgesics make it difficult to draw robust conclusions. The long-term effect of prolonged usage also remains a concern. Nevertheless, with careful monitoring, the drug may be a reasonable choice for malignant and nonmalignant pain management in selected cases, especially for refractory pain not responding to conventional approaches.

Opioids refer to chemicals that agonize opioid receptors in the body resulting in analgesia and sometimes, euphoria. Opiates include morphine and codeine; semi-synthetic opioids include heroin, hydrocodone, oxycodone, and buprenorphine; and fully synthetic opioids include tramadol, fentanyl and methadone. In 2021, an estimated 5.6 million individuals met criteria for opioid use disorder. This article provides an overview of the pharmacology of heroin and non-prescription fentanyl (NPF) and its synthetic analogues, and summarizes the literature related to the management of opioid use disorder, overdose, and withdrawal. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population.

The objective of this quality improvement (QI) project was to assess the impact of an evidence based clinical pharmacist practitioner (CPP) model applied to perioperative pain management by integrating a CPP into the perioperative orthopedic surgery clinical pathway. Secondary objective was to assess the effect of CPP pain management service on surgical team satisfaction. This QI project expanded CPP pain management services for patients who were scheduled for an orthopedic surgery. Surgical provider satisfaction of CPP pain management services was assessed through a provider survey. Pain management recommendations by the Pain CPP were implemented 61% (n = 23/38) of the time by the orthopedic surgeon. The impact of the Pain CPP on perioperative pain management was demonstrated by improvement in the Clinically Aligned Pain Assessment Tool, which was similar in patients where CPP recommendations were accepted compared to surgeon only recommended regimens (p = 0.048). Five orthopedic surgical providers responded to our satisfaction survey, 80% (n = 4/5) strongly agree that a pain management CPP should become a permanent member of the care team. Through an evidence-based CPP model we observed a reduction in quantity of opioid prescribed and morphine equivalent daily dose utilized in patients who underwent an orthopedic surgery.

Naltrexone is a mu-opioid receptor antagonist increasingly used as an analgesic for chronic pain at low doses. This retrospective, observational cohort study was conducted at an academic medical center to evaluate low-dose naltrexone (LDN) efficacy and describe its use in routine clinical practice. Adults receiving LDN, doses <10 mg for ≥1 month, seen at an outpatient pain clinic from January 1, 2014 to April 1, 2022 were included. The primary outcome was change in the Pain, Enjoyment of Life, and General Activity (PEG) score after LDN. Thirty-one patients were included. Median age was 50 years and 71% were female. Median duration of pain at baseline was 5 years. Mean PEG scores were 7.27 ± 1.39 and 6.62 ± 2.04 at baseline and follow-up, respectively. Mean difference was 0.66 (95% CI [0.10-1.21], p = 0.022). Eighty-seven percent (27) of patients discontinued LDN, 52% (16) for lack of benefit, 23% (7) for loss of benefit, 10% (3) for side effects, and 3% (1) for other reasons. Seven (23%) reported side effects. LDN was associated with a statistically significant reduction in PEG in adult chronic pain patients, however the clinical significance is unclear as over 75% of patients discontinued LDN due to lack of benefit.

A retrospective, cohort, single center, chart review was conducted to compare rates of opioid-associated serious adverse events (SAEs) in a patient cohort 6 months before and 6 months after data-based opioid risk review. The primary objective was the composite reduction in opioid-related SAEs including suicide-related events and opioid overdoses. The impact of the reviews was assessed via multivariate logistic regression and a McNemar's test to analyze difference in rates of opioid-associated SAEs. This study demonstrates that data-based opioid risk review can reduce opioid-related SAEs, opioid overdoses, and suicide-related events in the 6 months post-review. The primary outcome was not statistically significant with a p-value of 0.080. In the population that underwent opioid tapers, the hazard ratios (HR) for suicide-related events and opioid-related SAEs were 6.64 (1.09-40.53, p = 0.05) and 10.43 (0.48-226.80, p = 0.02) respectively when compared to non-tapered patients. The HR for suicide-related events and opioid-related SAEs when opioid therapy was discontinued were 9.95 (2.16-45.94, p = 0.009) and 15.64 (1.09-225.19, p = 0.001) respectively when compared to continuation of opioids. This study showed that data-based opioid risk review may reduce incidence of opioid-related SAEs in patients with chronic pain. Additionally, opioid tapers and discontinuations are significant risk factors for suicide-related events and opioid-related SAEs.