A population-based study on chronic pain and the use of opioids in Portugal

Although increasing doubts exist regarding the long-term effectiveness and safety of opioids in patients with chronic pain (CP), most guidelines still recognize opioids as an option in effective management of CP. We aimed to describe the prevalence and factors associated with opioid use in subjects with CP in Portugal and to evaluate satisfaction and self-assessed treatment effectiveness. A nationwide study was conducted in a representative sample of the adult Portuguese population. The 5094 participants were selected using random digit dialing and estimates were adequately weighted for the population. The prevalence of opioid use by subjects with CP was 4.37% (95% confidence interval [CI] 3.4–5.5); and in subjects experiencing CP with and without cancer, it was 10.13% and 4.24%, respectively. Use of strong opioids was reported by only 0.17% of CP subjects. Sex, pain severity and symptoms of depression and anxiety were significantly associated with opioid use; however, in multivariate modeling, only pain-related disability remained significant. No significant differences among users and nonusers of opioids were observed regarding treatment satisfaction and self-assessed effectiveness. Although extremely high rates of use of opioids exist in a few countries, it should not be seen as a ubiquitous problem. Indeed, we showed that in Portugal, as in many other regions in the world, opioids are used much less frequently than in those few countries. Moreover, we did not find significant differences among users and nonusers of opioids regarding satisfaction and self-assessed effectiveness, eventually showing the results to be in line with reports that show doubt about opioids’ effectiveness. Further research and particular attention to and continuous monitoring of the trends of use and abuse of opioids worldwide are recommended.     

Extended‐release opioids in the management of cancer pain: A systematic review of efficacy and safety

Despite the increased availability of strong analgesics and evidence‐based recommendations for pain management, under‐treatment of cancer‐related pain is still common. Extended‐release (ER) opioids, in contrast to immediate‐release opioids, provide prolonged analgesia. In this review, we aimed to compare the efficacy and safety of ER opioid analgesics in managing moderate‐to‐severe pain in patients with cancer. We identified randomized controlled trials (RCTs) and controlled observational studies that compared ER opioids in cancer pain by searching several databases, including MEDLINE, EMBASE and the Cochrane Library. Two independent reviewers screened and evaluated retrieved records to select relevant studies. We dually assessed the risk of bias for included studies and evaluated the overall strength of evidence for six critical outcomes using Grading of Recommendations Assessment, Development and Evaluation level of evidence. A total of three double‐blind RCTs (comparative efficacy and adverse events), two non‐blinded RCTs and four observational studies (comparative adverse events) were included in this review. All randomized trials and one observational study were of high risk of bias, and three observational studies of unclear risk of bias. The level of evidence for the selected efficacy and safety outcomes was low and very low. We synthesized the findings qualitatively because of the paucity of relevant studies as well as variable study design and quality. This systematic review indicates no substantial differences in efficacy and frequent adverse events among ER opioids for cancer pain. The body of evidence, however, is limited to few comparisons and fraught with methodological shortcomings.     

Pain management autobiographies and reluctance to use opioids for cancer pain management

Although pain management education results in improved pain control for some patients, it does not work for all patients because some patients remain reluctant or unwilling to use prescribed analgesics to their optimal effect. In a randomized clinical trial that tested the effectiveness of the PRO-SELF Pain Control Program, 11 patients declined to increase their analgesic use despite moderate to severe pain. These patients were selected for a qualitative analysis of their audiotaped discussions about pain management with their intervention nurses. This analysis revealed that these patients often spontaneously provided detailed explanations about why they were reluctant or unwilling to take analgesics in general or opioids in particular. We termed these explanatory accounts pain management autobiographies because of their narrative character and multilayered, richly detailed quality. Pain management autobiographies included stories about (1) previous experience with chronic pain management, including stigmatizing interactions with clinicians and family members; (2) bad experiences with cancer pain management, including severe constipation; and 3) strongly held conventions about medication use, including the belief that all medications are "toxins" that should be avoided. The study findings suggest that a small subset of patients with cancer pain may need interventions such as individual or family counseling or alternative pain management strategies to augment education about opioids.     

Rapid onset opioids for breakthrough pain: Titrating or not titrating,this is the question!

Breakthrough cancer pain (BTcP) has been defined as a transitory increase in pain intensity that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain.Traditional dosing recommendations for BTcP have suggested that the effective dose of oral opioids should be a percentage of a patient’s total daily opioid dose. In the last years a number of new formulations that deliver fentanyl directly through mucous membranes have been developed in an effort to provide a more rapid onset of effect (rapid onset opioids, ROOs). Recent recommendations suggest that the dose of ROOs for BTcP should be determined by individual titration. However, the need of titrating ROOs doses for BTcP may make the practical use of these drugs difficult in the daily activity, particularly at home or in outpatients. The question of how to dose ROOs for BTcP remains controversial.The aim of this review was to analyze the robustness of the statement that dose of ROOs should be titrated for BTcP, assessing controlled studies of ROOs for BTcP. From the available literature there are no consistent data to recommend dose titration of ROOs for BTcP.Randomized studies with an appropriate design comparing advantages and disadvantage of ROOs titration versus fixed doses proportional to around the clock opioid doses should provide the answer to this question.     

Assessing the impact of breakthrough cancer pain

Breakthrough pain is a transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger despite relative stable and adequately controlled background pain. Breakthrough pain is a common and distinct component of cancer pain and is typically of rapid onset, severe in intensity, and generally self-limiting with an average duration of 30-60minutes. Despite the self-limiting nature of breakthrough pain, it can place significant physical, psychological, and economic burdens on both patients and their carers. Patients with breakthrough pain are often less satisfied with their analgesic therapy, they have decreased functioning because of their pain, and may also experience social and psychosocial consequences, such as increased levels of anxiety and depression. Successful management of breakthrough pain is best achieved by a thorough assessment which includes determining the severity, pathophysiology, and aetiology of the pain and takes into account both background and breakthrough pains while considering whether the underlying disease, co-morbidities or precipitating events are amenable to interventions. The features of breakthrough pain and the challenges it presents to patients, their carers, and health professionals are illustrated with a case study.     

Cognitive impairment in cancer pain patients receiving opioids: a pilot study

This study aimed to compare cognitive function of cancer pain patients being given opioids during their cancer treatment (n = 14) with that of patients receiving treatment without opioids (n = 12). Correlations between cognitive function, pain intensity, and opioid dose were analyzed. Patients were assessed 3 times in a 1-month period, using the Trail-Making Test, Mini-Mental State Examination, Digit Span, and Brief Cognitive Screening Battery. Opioid use was not associated with clear cognitive impairment. Patients being treated without opioids did perform better in the Digit Span Test reverse-order test (P = .029) and the clock drawing test (P = .023), but the differences arose in just 1 assessment in each case. Pain intensity correlated negatively with scores in the Mini-Mental State Examination (P = .001) and some Brief Cognitive Screening Battery tests (incidental recall, immediate recall, and late recall; P 相似文献   

Opioids for cancer breakthrough pain: a pilot study reporting patient assessment of time to meaningful pain relief

Breakthrough pain is a common and distinct component of cancer pain that is usually managed with normal release opioids (also known as rescue medication) either before or soon after its onset. A prospective survey of hospice inpatients with breakthrough pain was undertaken to characterize their pain and then compare the time to onset of pain relief of their rescue medication. Patients presented with, on average, 1.7 different types of breakthrough pains (range, 1–4). The average number of breakthrough pains was four per day (range, 1–8), and the average duration of breakthrough pain was 35 minutes (range, 15–60); most occurred suddenly and unpredictably. Patients used morphine, oxycodone, hydromorphone, methadone, or oral transmucosal fentanyl citrate as rescue medication and the average time to meaningful pain relief following their administration was 31 minutes (range, 5–75). No difference was found between morphine, oxycodone, and hydromorphone. Methadone appeared to work faster than morphine (P < 0.01) but no faster than oxycodone or hydromorphone, whereas oral transmucosal fentanyl citrate worked faster than morphine, oxycodone, hydromorphone, and methadone (P < 0.001).     

Ketamine for chronic non‐cancer pain: A meta‐analysis and trial sequential analysis of randomized controlled trials

Background

Ketamine has been suggested to be efficient in relieving chronic pain. However, there is inconsistency across studies investigating the effect of ketamine for chronic pain management. We aimed to perform a meta‐analysis in order to assess the efficacy of this compound during chronic non‐cancer pain conditions.

Methods

The study consisted in a meta‐analysis of clinical trials comparing ketamine to a placebo during chronic non‐cancer pain. The primary endpoint of this study was pain relief 4 weeks after the beginning of treatment. Secondary outcomes were: pain relief 1, 2, 8 and 12 weeks after the beginning of treatment and incidence of psychedelic manifestations.

Results

Six studies were included in this meta‐analysis. Overall, 99 patients received ketamine and 96 received placebo. Ketamine did not decrease pain intensity at 4 weeks (MD (on a 0 to 10 scale) = ?1.12 [?2.33, 0.09], GRADE evidence: very low). However, analysing studies with no high‐risk bias found ketamine to decrease pain intensity at 4 weeks and increased the level of GRADE evidence to moderate. Trial sequential analysis confirmed the overall result and revealed the lack of power of this meta‐analysis. Ketamine also decreased pain intensity at all other evaluated points in time. Ketamine increased the incidence of psychedelic manifestations in comparison to placebo.

Conclusion

Results of this meta‐analysis found moderate evidence suggesting the efficacy of ketamine during chronic pain. Further studies are warranted to conclude about the effect of ketamine during chronic pain conditions and to determine optimal administration regimes of this agent during this condition.

Significance

Ketamine has been found interesting for managing chronic pain. We performed a meta‐analysis aiming to confirm those results. Ketamine was found efficient in alleviating pain up to 12 weeks after the beginning of treatment. However, overall evidence favouring the use of this compound was very low.

     

The "pain pen" for breakthrough cancer pain: a promising treatment

Breakthrough pain has been recognized as a challenging pain phenomenon in cancer. Oral transmucosal fentanyl citrate (OTFC) recently has been recommended as treatment, but OTFC is not widely available. Therefore, alternatives are needed. In two separate pilot studies, 58 patients were instructed to self-administer subcutaneous (SC) rescue opioids (hydromorphone (n=43), morphine (n=11), or sufentanil (n=4), using a standard injection-pen for breakthrough pain. Patients were asked to rate the overall efficacy of SC rescue opioids on a 3-point scale (not noticeable, moderate, or good). The efficacy was rated as good in 49 patients (84%, 95% CI: 73-91%), moderate in 8 patients (14%), and not noticeable in 1 patient (2%). The median dose per injection was equianalgesic to 25 mg of SC morphine (range: 4-150 mg). Twenty-nine patients (50%) were treated until death (n=26) or were on ongoing treatment (n=3). Patients were treated for a median of 6 weeks (1 day-41 months).     

Multi‐centre European study of breakthrough cancer pain: Pain characteristics and patient perceptions of current and potential management strategies

This study involved 320 cancer patients from four Northern European countries. Patients with breakthrough pain were questioned about the characteristics of their pain, the current management of their pain, and the acceptability/utility of alternative routes of administration. The median number of episodes was 3/day. Forty‐four percent patients reported incident‐type pain, 39% spontaneous‐type pain, and 17% a combination of these pains. The median duration was 60 min, and the median time to peak intensity was 15 min. Three percent patients reported “mild” pain, 37% “moderate” pain, and 60% “severe” pain. Ninety percent patients stated that the pain interfered with their daily activities. All patients were using opioids as rescue medication (mainly oral morphine/oxycodone), whilst 28% patients were using non‐opioids, and 50% patients were using non‐pharmacological interventions. Only 55% patients took rescue medication every time they experienced breakthrough pain. Sixty‐five percent patients would definitely consider using an oral transmucosal product; patients from Denmark were less likely to answer positively, and a positive response was associated with previous use of the route for breakthrough pain. Seventy‐three percent patients reported regular oral problems. Forty‐two percent patients would definitely consider using an intranasal product, with 26% patients stating they would definitely not use such a preparation; patients from Denmark and Sweden were less likely to answer positively, and a positive response was associated with male gender, and previous use of the route. Forty‐four percent patients reported regular nasal problems. Sixty percent patients would definitely consider using a subcutaneous product, and 44% patients would definitely consider using an intrapulmonary product.     

Factors influencing sexual risk behaviors among adolescents: A community‐based participatory study

Pregnancy rates and unprotected sex among Thai adolescents continue to increase. The aim of this community‐based participatory study was to identify gender differences in sexual behaviors and sexual risk factors, and to examine factors associated with sexual risk behaviors among 397 adolescents in northern Thailand. Twenty two community researchers facilitated the data collection by using smart phones or tablet computers on a privacy basis. Ordinal and logistic regressions identified predictors influencing pre‐coital behaviors and sexual behaviors. The results showed that males were more likely than females to engage in pre‐coital and sexual behaviors. Significant predictors of higher pre‐coital behaviors were age, sexual refusal self‐efficacy, having boyfriends/girlfriends, authoritarian parenting style, parental approval of sex, and perceived peer norms. Pre‐coital behaviors were positively correlated with sexual behaviors, and significant predictors of sexual behaviors were age, parent–adolescent communication, parental monitoring, perceived peer norms, and type of school. To better address the sexual risk behaviors of adolescents, we need to include key stakeholders to develop multi‐modal culturally‐ and gender‐specific sexual‐prevention programs to account for information delivery, acceptability, and dealing with peer pressure.