Opioid-induced or pain relief-reduced symptoms in advanced cancer patients (original) (raw)

Management of acute pain in patients on treatment with opioids

Pain Management, 2015

The use of opioids for both benign and cancer-related chronic pain has increased exponentially over the last few years. For this reason, increasing numbers of such patients are presenting for surgery. It is known that continuous use of opioids is associated with an increase in postoperative analgesic requirements. This is believed to be mediated by the development of tolerance and opioid-induced hyperalgesia. Patients treated with opioids have special needs in the perioperative setting and it is the anesthesiologist's responsibility to manage these needs optimally. The aim of the present paper is to briefly orient the reader in the management of postoperative pain in patients chronically treated with licit opioids.

Opioid Use in the Treatment of Pain States

Pain Control in Ambulatory Surgery Centers

Opioid medications are used ubiquitously in the treatment of moderate and severe pain. They are a safe, convenient, and reliable method used to alleviate pain related to cancer and should be considered first-line therapies. This chapter will discuss safe prescribing guidelines, practical applications of opioid medications, common medications used, strategies for the management of adverse effects, and methods of effectively achieving optimal analgesia in patients suffering from pain related to cancer. It will also offer more nuanced recommendations of treatment as they may relate to specific subpopulations of patients and specific medications used in their treatment.

Opioid complications and side effects

Pain physician, 2008

Medications which bind to opioid receptors are increasingly being prescribed for the treatment of multiple and diverse chronic painful conditions. Their use for acute pain or terminal pain is well accepted. Their role in the long-term treatment of chronic noncancer pain is, however, controversial for many reasons. One of the primary reasons is the well-known phenomenon of psychological addiction that can occur with the use of these medications. Abuse and diversion of these medications is a growing problem as the availability of these medications increases and this public health issue confounds their clinical utility. Also, the extent of their efficacy in the treatment of pain when utilized on a chronic basis has not been definitively proven. Lastly, the role of opioids in the treatment of chronic pain is also influenced by the fact that these potent analgesics are associated with a significant number of side effects and complications. It is these phenomena that are the focus of this...

Improved Opioid Analgesic Effect Following Opioid Dose Reduction

Pain Medicine, 2008

Introduction. Traditionally, opioids have been the cornerstone of therapy for patients suffering from cancer pain, regardless of the potential to develop opioid tolerance. In chronic pain patients who experience worsening pain despite increasing doses of opioids, the clinical role of opioid-induced hyperalgesia is gaining more recognition.

Oral opioid administration and hyperalgesia in patients with cancer or chronic nonmalignant pain

British Journal of Clinical Pharmacology, 2005

Previous research has reported on reduced paw withdrawal latencies to heat and mechanical stimuli after parenteral administration of opioids in animals and on increased pain sensitivity in humans subsequent to postoperative infusions of shor tacting opioids or in drug addicts. The aim of the present study was to explore the possibility that oral opioid treated patients with cancer-related or chronic nonmalignant pain differ in their pain sensitivity from patients treated with non-opioid analgesics. Methods The study population consisted of 224 patients, including 142 in the opioid-treated group and 82 in the non-opioid-treated group. Pain thresholds for punctuate measured by von Frey filaments (g), mechanical pressure measured by pressure algometer (mmHg), heat stimuli measured by quantitative sensory testing (∞ C), as well as suprathreshold tonic heat pain intensity (46.5 ∞ C for 1 min) measured by 0-10 numerical pain scale (NPS) were obtained at a nonpainful site (thenar eminence) in all patients. Results No differences between the groups were found for gender, age, duration of pain, or duration of treatment (independent variables). No significant differences between the groups were found in punctuate (difference = 17.0 g (95% CI-8.8, 42.8), P = 0. 19), pressure (2.2 mmHg (-28.7, 33.2), P = 0.89) and heat (-0.3 ∞ C (-1.5, 0.9), P = 0. 70) pain thresholds, or in suprathreshold heat pain intensity (difference between maximal pain intensities-0.4 NPS units (95% CI-1.2, 0.4), P = 0.31). Pearson correlations within the opioid-treated group failed to show significant relationships between any of the independent variables and the outcome measures. A further comparison of the outcomes between the 'weak' opioid-treated subg roup and the 'strong' opioid-treated subgroup again revealed insignificant results. Conclusions These results suggest that the administration of 'commonly used' dosages of oral opioids does not result in abnormal pain sensitivity beyond that of patients receiving non-opioid analgesia.

An Exploratory Analysis on the Effectiveness of Four Strong Opioids in Patients with Cancer Pain

Pain Medicine, 2012

Objective. This analysis, carried out in the context of a wider observational prospective study, tried to explore whether four World Health Organization/ step-III opioids (morphine, oxycodone, fentanyl, and buprenorphine) had different effectiveness when using several different outcomes and endpoints. Design. Cross-sectional and longitudinal design. Setting. Oncologic, palliative, and pain centers in Italy. Patients. Two hundred fifty-eight cancer patients monitored over a 3-week follow-up program. Intervention. Not applicable. Outcome Measures. The analgesic efficacy was assessed using effectiveness endpoints, such as pain intensity, pain intensity difference (PID), proportion of nonresponders (NR) and full-responders (FR) subjects, percentage of switches and dose escalation. Results. Mean values of PID led to differences among opioids ranging from 10% to 30%. FR (PID Ն 30%) were more frequent in buprenorphinefentanyl-oxycodone groups than in morphine; NR (PID Յ 0%) were variable. The percentage of switches resulted three times more frequent when using morphine than buprenorphine (24.4% vs 8.6%). An increase of dose Ն5% a day was observed in 33.3% of fentanyl patients vs 15% of buprenorphine. As a whole, opioids show some different behaviors on the basis of the considered endpoints. Conclusions. The observed results, even if the small sample size and the nature itself of the study do not allow a definitive evaluation of the effectiveness of the drugs, underline a degree of variability among opioids and address toward a correct planning of a comparative randomized clinical trial that is now underway in Italy. For this reason, a confirmative effectiveness randomized controlled trial is required.

Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review

The Journal of Pain, 2003

Side effects can limit opioid dosage and reduce quality of life. The purpose of this systematic review was to assess the management of opioid side effects in the context of cancer pain management or, in the event that no evidence was available for cancer pain, for chronic noncancer pain. The side effects studied were constipation, pruritus, nausea and vomiting, myoclonus, sedation, respiratory depression, and delirium. Opioid rotation to manage side effects was also studied. For each side effect, we searched MEDLINE and the Cochrane Controlled Trials Register and identified 657 possible titles for inclusion. Of these, 67 studies met inclusion criteria for analysis. The lack of well-designed, randomized controlled trials and the heterogeneity of populations and study designs made the drawing of firm conclusions difficult and precluded performance of meta-analysis. The type, strength, and consistency of evidence for available interventions to manage opioid side effects vary from strong (eg, on the use of naloxone to reverse respiratory depression or constipation) to weak (eg, changing from the oral to epidural route of morphine administration to manage sedation). Well-designed trials in the specified populations are required to furnish clinicians with secure evidence on managing opioid side effects successfully.

Opioids in cancer-related pain: current situation and outlook

Supportive Care in Cancer, 2019

Purpose Despite progress in treatments, cancer pain remains underestimated, poorly assessed and under-treated. Prescribing strong opioids, because of their specificities, requires precision in management considering their pharmacology but also a clear understanding of recommendations. Some clinicians highlight the risk of addiction, excessive sedation and respiratory depression and their need for information. Our objective in this review is to suggest some clinical guidance for the positioning and daily use of opioids within cancer pain management. Methods Critical reflection based on literature analysis and clinical practice. Results Strong opioids may be initiated as soon as pain diagnosis is defined. Factors to consider are pain aetiology, opioid pharmacokinetics and pharmacodynamics, genetic polymorphism, physiology (age, gender, weight and pregnancy), comorbidities (especially renal, hepatic, cardiovascular diseases), chronobiology, environmental factors, medication interference and treatment adherence. Achieving the best-balanced opioid treatment for background pain is complex, mainly due to the variable benefit/risk ratio between individuals and the experience of breakthrough cancer pain. Opioid initiation alongside a dynamic reassessment of pain should be fully integrated into the patient's management to optimise analgesia. The efficacy and safety of a strong opioid treatment need to be re-evaluated and adapted to individuals constantly as it varies over time. Conclusions Cancer pain is multimorphic and permanently changing due to disease evolution, curative treatments and disruptive events (concomitant treatments, pain from associated disease, comorbidities and complications, modifications of the environment). Well-managed opioids are the cornerstone of a complex environment requiring multidisciplinary dynamic assessments integrated into the patient's care pathway.

Opioid titration in cancer pain: A critical review

European Journal of Pain, 2007

Initiation of therapy with strong opioids is a challenging phase to obtain the maximum benefit and to gain the patient's compliance. The approach could be different, depending on the clinical situation and type of opioid regimen. Substantially, the need to titrate the dose of strong opioids emerges in different conditions: (a) in opioid-naive patients who require an opioid treatment; (b) in patients no longer responsive to weaker drugs requiring strong opioids; (c) in patients already receiving strong opioids requiring higher doses because of an increase in pain intensity or a new acute pain problem; (d) in patients who are severely suffering and need an intensive as well as rapid intervention, due to previous persistent undertreatment. Whilst there is a vast literature confirming the effectiveness of most opioid drugs for the treatment of chronic pain, there is a lack of information regarding opioid titration. This review assesses the principal titration methods and outcomes regarding the different opioid drugs and their modalities of administration, in different clinical contexts.

Effectiveness of opioids in the treatment of chronic non-cancer pain

Pain physician, 2008

For thousands of years, opioids have been used to treat pain, and they continue to be one of the most commonly prescribed medications for pain. It is estimated that 90% of patients presenting to pain centers and receiving treatment in such facilities are on opioids. Opioids can be considered broad-spectrum analgesics that act at multiple points along the pain pathway. Unfortunately, opioids also have the potential for great harm, with multiple side effects and potential complications, some of which are lethal. They are also uniquely addictive, which can lead to misuse and diversion. We reviewed the relevant English literature and did thorough manual searches of the bibliographies of known primary and review articles. We utilized pain relief as the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, improvement in work status, and evidence of addiction. Short-term use and improvement was defined as less than 6 months and l...