Managing pain in chronic kidney disease: patient participation in decision-making

AIM: This paper is a report of a study to examine how decisions about managing pain were made between patients with chronic kidney disease and nurses, what affected the decision style and the types of analgesics and adjuvant therapies given for pain relief in relation to a particular decision style. BACKGROUND: While pain often accompanies chronic kidney disease, little is known of how decisions are made about managing pain in clinical practice. Lack of patient involvement in decision-making may lead to inadequate care provision. In some care situations, nurses have been more concerned with medication side effects than giving effective pain relief. METHOD: An exploratory study was conducted, using observations and interviews with a purposive sample of 14 nurses and 53 patients in five adult renal units in Australia. The data were collected during 2004. FINDINGS: Of the 103 pain activities observed, 78 involved a passive decision style between the nurse and patient, 19 involved a collaborative decision style, and six used an active decision style. The majority of routine analgesic and adjuvant medications administered involved a passive decision style. Most importantly, 25.6% of passive style decisions observed resulted in no administration of an analgesic or adjuvant medication; however, all collaborative and active style decisions observed resulted in administration of an analgesic or adjuvant medication. CONCLUSION: Nurses need actively to encourage patient involvement in treatment decisions because this promotes effective pain control. More research is needed into how specific detailed information about pain treatments could improve patient participation in decision-making.     

Opioids Versus Physical Therapy for Management of Chronic Back Pain

Chronic low back pain (CLBP) is a common disabling disorder managed by a variety of interventions. The purpose of this article was to review the literature and critique the evidence to determine if opioid analgesics improved patient outcomes compared with physical therapy. No research was found that directly compared the efficacy of opioid analgesics with physical therapy. Although the evidence supports the use of physical therapy in chronic back pain, the study results are conflicting regarding the usefulness of opioid analgesics in CLBP management. More research involving the efficacy of opioid analgesic in treating CLBP is needed.     

Tapentadol Prolonged Release for Chronic Pain: A Review of Clinical Trials and 5 Years of Routine Clinical Practice Data

Tapentadol prolonged release (PR) for the treatment of moderate to severe chronic pain combines 2 modes of action. These are μ‐opioid receptor agonism and noradrenaline reuptake inhibition in a single molecule that allow higher analgesic potency through modulation of different pharmacological targets within the pain transmitting systems. At the same time, this can also serve as a clue for modulation of different pain‐generating mechanisms according to nociceptive, neuropathic, or mixed pain conditions. Tapentadol PR has now been on the market for 5 years, with over 4.6 million people treated worldwide. A panel of pain specialists convened in Germany to review the clinical program and to discuss the role of tapentadol PR in the management of chronic pain. The clinical study program demonstrated effective and generally well‐tolerated treatment for up to 2 years in a broad range of chronic pain conditions, including those with neuropathic pain components. This was confirmed in routine clinical practice observations. Head‐to‐head studies with World Health Organization (WHO) III opioids such as oxycodone controlled release and oxycodone/naloxone PR showed at least comparable pain relief in the treatment of moderate‐to‐severe musculoskeletal pain. Rotation from poorly tolerated WHO III opioids to tapentadol PR provided effective pain relief and better symptom control for musculoskeletal pain compared to previous medication. Functionality, health status and quality of life also improved under tapentadol PR treatment. The gastrointestinal tolerability profile was more favorable compared to other tested WHO III opioids. Tapentadol PR has a good safety profile and no evidence of acquired tolerance from the long‐term data so far collected. Overall, tapentadol PR represents an effective and generally well‐tolerated alternative to “classical” opioidergic drugs.     

Chronic renal failure: assessing the Fatigue Severity Scale for use among caregivers

Background. Quality of life for caregivers of end‐stage renal disease patients has not been well addressed yet the physical and psychological status of this overlooked group can be important in the recovery or adaptation of patients with chronic renal failure, not to mention the caregivers themselves. One particular feature of the overall quality of life of such caregivers is that of fatigue. Aims and objectives. The purpose of the study was to test the Fatigue Severity Scale for potential usefulness in assessing fatigue among a non‐medical population, caregivers of end‐stage renal disease patients. Methods. Subjects completed a short battery of measures at either a dialysis centre or at home. Results. The Short Form‐12 of the Short Form‐36 and the Center for Epidemiologic Studies Depression Scale accounted for 56% of the variance on the Fatigue Severity Scale. The results suggest that physical fatigue may be more prominent than mental fatigue as a feature of caregiver quality of life. Conclusions. The Fatigue Severity Scale which has been used for multiple sclerosis patients may prove to be useful as a short assessment of fatigue among the non‐medical population of end‐stage renal disease caregivers. This may result in improved interventions for the population of caregivers. Relevance to clinical practice. Physicians, nurses and allied health professionals will be called on more frequently to assess and intervene with fatigued and overburdened caregivers in addition to patients themselves. A more thorough understanding of the nature of caregiver fatigue may drive changes or innovations with caregivers who are too often overlooked in the current era of scarce resources. Accordingly results of the study suggest that the direction in intervention may focus more on rest and respite as opposed to a need for psychosocial support or counselling. While there are various modes for assessing end‐stage renal disease caregivers’ fatigue, a simple measure like the Fatigue Severity Scale is brief enough to be administered without undue demand on practitioners or caregivers.     

Short wave diathermy in the symptomatic management of chronic pelvic inflammatory disease pain: A randomized controlled trial

Background and Purpose. Chronic pelvic inflammatory disease (PID) refers to both residue of acute and sub‐acute recurrence of a previous infection or/and as a result of late detection of and intervention for upper tract pelvic infection. Owing to the chronic nature of the disease, which may require large doses of analgesics and/or antibiotics both of which may have side effects on the body, there is a need for a non‐invasive therapeutic and symptomatic chronic pain management. The main purpose of this study was to determine the efficacy of short wave diathermy (SWD) in the symptomatic management of chronic PID pain. Method. An independent group; double blind random assignment design was used in data collection. A total of 32 subjects diagnosed as chronic PID patients referred for physiotherapy were randomly assigned to three (SWD, control and analgesic) groups. The SWD group received antibiotics, placebo (sham analgesic) tablets and SWD using the crossfire technique for an average of 15 exposures lasting for 20 minutes on alternate days of the week. Other groups; Analgesic group received antibiotics, Analgesics and sham SWD; while the control group received antibiotics, sham SWD and placebo tablets. The study lasted for a period of 30 days. Result. Findings of the study revealed significant effect of SWD over analgesic and control in pain responses and resolution of inflammation at p < 0.05. Conclusion. It was concluded that SWD may be an effective and non invasive therapy in the management of chronic PID pain. Copyright © 2010 John Wiley & Sons, Ltd.     

Economic burden of chronic kidney disease

Objectives To define the cost of care and evaluate interventions associated with improving outcomes and delaying the progression of chronic kidney disease (CKD). Methods Using the PubMed database, a systematic review of the literature was conducted describing (i) the cost of care associated with treating earlier stages of CKD, and (ii) the role of early referral, erythropoiesis‐stimulating proteins and anti‐hypertensive agents in improving clinical outcomes and reducing the cost of CKD. Results The higher costs associated with treatment of the CKD population are largely due to higher rates and duration of comorbidity‐driven hospitalizations. Studies suggest that early referral to a nephrologist, use of erythropoiesis‐stimulating proteins and anti‐hypertensive agents may be associated with better outcomes and lower costs. In some instances, however, higher target haemoglobin levels could have harmful effects in CKD patients. Conclusion The substantial costs incurred during earlier stages of CKD increase markedly during the transition to renal replacement and remain elevated thereafter. An increase in awareness among health care providers may result in more timely interventions. More proactive management, in turn, can lead to improved clinical and economic outcomes through the slowing of disease progression and prevention of comorbidities.     

Postoperative Pain Management in Spanish Hospitals: A Cohort Study Using the PAIN-OUT Registry

Pain after surgery remains a problem worldwide, although there are no published data on postoperative outcomes in Spain. We evaluated 2,922 patients on the first day after surgery in 13 tertiary care Spanish hospitals, using the PAIN-OUT questionnaire. The aims were to: assess postoperative outcomes and anesthetic/analgesic management in Orthopedics (ORT) and General Surgery (GEN) patients; explore the influence of the analgesic therapy on outcomes and opioid requirements; evaluate and compare outcomes and analgesic management according to surgical procedure. Mean worst pain and percentage of patients in severe pain were 5.6 (on a numeric rating scale of 0–10) and 39.4%, respectively, slightly lower than those reported in Western countries (range, 5.0–8.4 and 33–55%). Patients’ pain assessment (83.1%) and information were high (63.3%), but participation in decision-making (4.8) was lower than in the United States (7.0) and Europe (Germany, France, Norway, and Denmark; mean, 5.9). Patients after orthopedic surgery had the worst outcomes. General anesthesia was more frequent in GEN patients, whereas regional (central and peripheral) was more frequent in ORT surgery patients. Mean opioid consumption (20.2 mg per patient per 24 hours, oral morphine equivalents), was lower than reported and decreased >50% after regional analgesia. Intravenous morphine patient-controlled analgesia was seldom used (6.2%). Acute opioid treatments were associated with worsened outcomes whereas multimodal analgesia (mainly antipyretic analgesics–nonsteroidal anti-inflammatory drugs–opioids) were associated with improved results. Epidurals in abdominal surgery (16.7%) were also associated with better outcomes. Presurgical chronic pain (>7) and/or chronic opioid consumption, were associated with worsened pain outcomes; the latter with a 50% increase in postoperative opioid requirements. Tibia/fibula and foot surgeries (ORT), and gastric, small intestine, and anterior abdominal wall procedures (GEN) were the most painful. Rigorous control of chronic pain before surgery, and combining opioids with adjuvants and other analgesics perioperatively, might improve postoperative outcomes.

Subcutaneous Target Stimulation (STS) in Chronic Noncancer Pain: A Nationwide Retrospective Study

Stimulation of primary afferent neurons offers a new approach for the control of localized chronic pain. We describe the results with a new neurostimulation technique, subcutaneous target stimulation (STS), for the treatment of chronic focal noncancer pain. STS applies permanent electrical stimulation directly at the painful area via a percutaneous‐placed subcutaneous lead. We reported the clinical outcomes of 111 patients with focal chronic, noncancer pain treated with STS in this first nationwide, multicenter retrospective analysis. The indications for STS were low back pain (n = 29) and failed back surgery syndrome (back pain with leg pain) (n = 37), cervical neck pain (n = 15), and postherpetic neuralgia (n = 12). Pain intensity was measured on a numerical rating scale (NRS) before and after implantation. Data on analgesic medication, stimulation systems, position, and type of leads and complications were obtained from the patients' records. After implantation, the mean pain intensity improved by more than 50% (mean NRS reduction from 8.2 to 4.0) in the entire patient group (P = 0.0009). This was accompanied by a sustained reduction in demand for analgesics. In all the patients, the STS leads were positioned directly at the site of maximum pain. Lead dislocation occurred in 14 patients (13%), infections in 7 (6%), and in 6 cases (5%), lead fractures were observed. The retrospective data analysis revealed that STS effectively provided pain relief in patients suffering from refractory focal chronic noncancer pain and that STS is an alternative treatment option. Prospective controlled studies are required to confirm these retrospective findings. This article presents a new minimally invasive technique for therapy‐resistant focal pain.     

Mineral metabolism disturbances in patients with chronic kidney disease

BACKGROUND: Kidney disease, especially chronic kidney disease (CKD), is a worldwide public health problem with serious adverse health consequences for affected individuals. Secondary hyperparathyroidism, a disorder characterized by elevated serum parathyroid hormone levels, and alteration of calcium and phosphorus homeostasis are common metabolic complications of CKD that may impact cardiovascular health. MATERIALS AND METHODS: Here, we systematically review published reports from recent observational studies and clinical trials that examine markers of altered mineral metabolism and clinical outcomes in patients with CKD. RESULTS: Mineral metabolism disturbances begin early during the course of chronic kidney disease, and are associated with cardiovascular disease and mortality in observational studies. Vascular calcification is one plausible mechanism connecting renal-related mineral metabolism with cardiovascular risk. Individual therapies to correct mineral metabolism disturbances have been associated with clinical benefit in some observational studies; clinical trials directed at more comprehensive control of this problem are warranted. CONCLUSIONS: There exists a potential to improve outcomes for patients with CKD through increased awareness of the Bone Metabolism and Disease guidelines set forth by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative. Future studies may include more aggressive therapy with a combination of agents that address vitamin D deficiency, parathyroid hormone and phosphorus excess, as well as novel agents that modulate circulating promoters and inhibitors of calcification.     

慢性肾脏病患者疾病感知与疼痛感知的关系研究

目的探讨慢性肾脏病患者疼痛感知与疾病感知的相关性,并分析影响因素,为制订相关干预措施提供参考。方法采用一般资料调查表、简明疾病感知问卷、简明疼痛问卷——长版对259例慢性肾脏病患者进行问卷调查。结果 259例未透析慢性肾脏病患者疾病感知总分为(43.07±9.46)分、疼痛强度得分5.00分,疼痛影响各条目得分为2.00～3.00分。疾病感知总分与疼痛影响总分呈显著正相关(r=0.282,P<0.01)。多元线性回归分析结果显示,疾病感知的影响因素为性别、个人月收入、慢性肾脏病分期以及疼痛影响与他人关系(P<0.01或P<0.05)。结论女性、个人收入越低、肾脏病分期越晚、疼痛影响患者与个人关系越严重的未透析患者,其疾病感知可能越负面,临床专业人员可采取相应干预措施,治疗或缓解患者的疼痛症状,改变疾病感知水平,以期提高患者的身心健康。     

Opioids: How to Improve Compliance and Adherence

Abstract: Chronic pain has been recognized as a major worldwide health care problem. Today, medical experts and health agencies agree that chronic pain should be treated with the same priority as the disease that caused it, and patients should receive adequate pain relief. To achieve good analgesia, patient adherence to a prescribed pain treatment is of high importance. Patients with chronic pain often do not use their medication as prescribed, but change the frequency of intake. This can result in poor treatment outcomes and may necessitate additional emergency treatment, which increases the overall costs. Factors that influence adherence include knowledge of the disease, realistic treatment expectations, perceived benefit from treatment, side effects, depression, dosing frequency, and attitudes of relatives/significant others toward opioids. Addressing all these factors should ensure a good treatment outcome. Good adherence to pain therapy is associated with improved efficacy in pain relief and quality of life. Opioids have become an integral part of the treatment of moderate to severe chronic noncancer pain. They may cause unpleasant side effects such as nausea, vomiting, and constipation. Patients should be informed adequately about side effects, which should be treated pro‐actively to foster adherence to treatment. Signs of tolerance, hyperalgesia, and drug abuse should be monitored as these may occur in some patients. An individualized treatment algorithm with a clear treatment goal and regular treatment reassessment is key for successful treatment. Long‐acting opioids offer sustained pain relief over 24 hours with manageable side effects—they simplify treatment thereby supporting treatment adherence.     

Efficacy and safety of once-daily,extended-release hydrocodone in individuals previously receiving hydrocodone/acetaminophen combination therapy for chronic pain

Background: Hydrocodone/acetaminophen combination analgesics are frequently prescribed for chronic pain management; however, acetaminophen presents potential hepatotoxicity to patients and thus dose limitations. These opioid medications are also widely abused. Once-daily, single-entity hydrocodone (Hysingla? ER tablets [HYD]) is a novel formulation with abuse-deterrent properties for the management of chronic pain and represents a suitable option for those patients receiving analgesics containing the same opioid analgesic, hydrocodone. This post-hoc analysis evaluated the efficacy and safety of HYD in patients whose primary pre-study analgesic was hydrocodone/acetaminophen analgesics (23–31% of the study populations). Methods: Data were analyzed from two Phase III trials, a 12-week randomized, placebo-controlled trial (RCT) and an open-label, 52-week trial. In both trials, a dose-titration period with HYD was followed by respective periods of fixed-dose double-blind (randomized controlled trial [RCT]) or open-label, flexible-dose maintenance treatment. Pain intensity was assessed using a numerical rating scale (0–10, 0 = no pain). For the RCT, primary and sensitivity analyses of pain scores used different approaches to handle missing data. Safety data for both studies were summarized. Results: In the RCT, the mean baseline pain score was 7.3. Pain relief was greater with HYD than placebo during double-blind treatment. In the open-label, flexible-dose trial, the majority of patients were maintained on their titrated dose. Mean baseline pain score was 6.3, about 57% of patients completed the 1-year maintenance period, and mean pain scores were between 3.6 and 4.1 during the maintenance period. Use of supplemental pain medication decreased or was maintained during the maintenance treatment with HYD. Adverse events in both trials were typical of those associated with opioid analgesics. Conclusion: In patients whose primary pretrial analgesic was hydrocodone/acetaminophen combination tablets, single-entity HYD was effective in reducing pain intensity and in maintaining analgesia over time without need for continued dose increase. HYD’s safety and tolerability profiles were similar to other opioid analgesics.     

Current Considerations for the Treatment of Severe Chronic Pain: The Potential for Tapentadol

Abstract Studies suggest that around 20% of adults in Europe experience chronic pain, which not only has a considerable impact on their quality of life but also imposes a substantial economic burden on society. More than one‐third of these people feel that their pain is inadequately managed. A range of analgesic drugs is currently available, but recent guidelines recommend that NSAIDs and COX‐2 inhibitors should be prescribed cautiously. Although the short‐term efficacy of opioids is good, adverse events are common and doses are frequently limited by tolerability problems. There is a perceived need for improved pharmacological treatment options. Currently, many treatment decisions are based solely on pain intensity. However, chronic pain is multifactorial and this apaproach ignores the fact that different causative mechanisms may be involved. The presence of more than one causative mechanism means that chronic pain can seldom be controlled by a single agent. Therefore, combining drugs with different analgesic actions increases the probability of interrupting the pain signal, but is often associated with an increased risk of drug/drug interactions, low compliance and increased side effects. Tapentadol combines μ‐opioid receptor agonism and noradrenaline reuptake inhibition in a single molecule, with both mechanisms contributing to its analgesic effects. Preclinical testing has shown that μ‐opioid agonism is primarily responsible for analgesia in acute pain, whereas noradrenaline reuptake inhibition is more important in chronic pain. In clinical trials in patients with chronic pain, the efficacy of tapentadol was similar to that of oxycodone, but it produced significantly fewer gastrointestinal side‐effects and treatment discontinuations. Pain relief remained stable throughout a 1‐year safety study. Thus, tapentadol could possibly overcome some of the limitations of currently available analgesics for the treatment of chronic pain.     

Education for patients with chronic kidney disease in Taiwan: a prospective repeated measures study

Aim. To investigate the physical, knowledge and quality of life outcomes of an educational intervention for patients with early stage chronic kidney disease. Background. A comprehensive predialysis education care team can be effective in slowing the progression of chronic kidney disease. Design. A single group repeated measures design was used to evaluate the effects of the intervention. Methods. Participants were recruited through health department community health screen data banks. A predialysis, team‐delivered educational intervention covering renal function health care, dietary management of renal function and the effects of Chinese herb medication on renal function was designed and implemented. Data were collected at baseline, six and 12 months. Study outcomes included physical indicators, knowledge (renal function protection, use of Chinese herbs and renal function and diet) and quality of life. Data were analysed using repeated measure anova to test for change over time in outcome variables. Results. Sixty‐six persons participated in this study. The predialysis educational intervention showed significant differences at the three time points in overall knowledge scores, waist–hip ratio, body mass index and global health status. Knowledge measures increased at month 6 and decreased at month 12. The primary indicator of renal function, glomerular filtration rate, remained stable throughout the 12 months of follow‐up, despite the relatively older mean age of study participants. Conclusion. A predialysis education care team can provide effective disease‐specific knowledge and may help retard deterioration of renal function in persons with early‐stage chronic kidney disease. The intervention dose may need to be repeated every six months to maintain knowledge effects. Relevance to clinical practice. A predialysis educational program with disease‐specific knowledge and information is feasible and may provide positive outcomes for patients. Topics on the uses of Chinese herbs should be included for people who are likely to use alternative therapies.     

Intranasal Ketorolac as Part of a Multimodal Approach to Postoperative Pain

Despite recent advances in the knowledge of pain mechanisms and pain management, postoperative pain continues to be a problem. Inadequately managed postsurgical pain has both clinical and economic consequences such as longer recovery times, delayed ambulation, higher incidence of complications, increased length of hospital stay, and potential to develop into chronic pain. Generally, opioids are the mainstay option for pain management in patients with moderate‐to‐severe postsurgical pain; however, opioids have significant side effects and have abuse potential. To improve patient and economic outcomes after surgery, postoperative pain guidelines have suggested incorporating a multi‐modal/multi‐mechanistic approach to pain treatment. A multi‐modal approach is the simultaneous use of a combination of two or more (usually opioid and non‐opioid) analgesics that provide two different mechanisms of actions. Utilizing a multi‐modal approach may result in a greater reduction in pain vs. single therapies in addition to minimizing opioid use, thus reducing opioid related side effects. However, not all approaches may be effective for all types of patients and not all analgesics may be a viable option for outpatient settings, ambulatory surgery, or the fast‐track surgical procedures. In this report, we present a review of the literature with a focus on intranasal ketorolac in order to provide a timely update regarding past, present, and future multi‐modal treatment options for postoperative pain.     

Are psychedelics the answer to chronic pain: A review of current literature

Aims

We aim to provide an evidence-based overview of the use of psychedelics in chronic pain, specifically LSD and psilocybin.

Content

Chronic pain is a common and complex problem, with an unknown etiology. Psychedelics like lysergic acid diethylamide (LSD) and psilocybin, may play a role in the management of chronic pain. Through activation of the serotonin-2A (5-HT2A) receptor, several neurophysiological responses result in the disruption of functional connections in brain regions associated with chronic pain. Healthy reconnections can be made through neuroplastic effects, resulting in sustained pain relief. However, this process is not fully understood, and evidence of efficacy is limited and of low quality. In cancer and palliative related pain, the analgesic potential of psychedelics was established decades ago, and the current literature shows promising results on efficacy and safety in patients with cancer-related psychological distress. In other areas, patients suffering from severe headache disorders like migraine and cluster headache who have self-medicated with psychedelics report both acute and prophylactic efficacy of LSD and psilocybin. Randomized control trials are now being conducted to study the effects in cluster headache Furthermore, psychedelics have a generally favorable safety profile especially when compared to other analgesics like opioids. In addition, psychedelics do not have the addictive potential of opioids.

Implications

Given the current epidemic use of opioids, and that patients are in desperate need of an alternative treatment, it is important that further research is conducted on the efficacy of psychedelics in chronic pain conditions.     

Intrathecal Drug Administration in Chronic Pain Syndromes

Chronic pain may recur after initial response to strong opioids in both patients with cancer and patients without cancer or therapy may be complicated by intolerable side effects. When minimally invasive interventional pain management techniques also fail to provide satisfactory pain relief, continuous intrathecal analgesic administration may be considered. Only 3 products have been officially approved for long‐term intrathecal administration: morphine, baclofen, and ziconotide. The efficacy of intrathecal ziconotide for the management of patients with severe chronic refractory noncancer pain was illustrated in 3 placebo‐controlled trials. A randomized study showed this treatment option to be effective over a short follow‐up period for patients with pain due to cancer or AIDS. The efficacy of intrathecal opioid administration for the management of chronic noncancer pain is mainly derived from prospective and retrospective noncontrolled trials. The effect of intrathecal morphine administration in patients with pain due to cancer was compared with oral or transdermal treatment in a randomized controlled trial, which found better pain control and fewer side effects with intrathecal opioids. Other evidence is derived from cohort studies. Side effects of chronic intrathecal therapy may either be technical (catheter or pump malfunction) or biological (infection). The most troublesome complication is, however, the possibility of granuloma formation at the catheter tip that may induce neurological damage. Given limited studies, the evidence for intrathecal drug administration in patients suffering from cancer‐related pain is more compelling than that of chronic noncancer pain.     

Oral Prolonged‐Release Oxycodone/Naloxone for Managing Pain and Opioid‐Induced Constipation: A Review of the Evidence

Background

Opioids provide effective relief from moderate‐to‐severe pain and should be prescribed as part of a multifaceted approach to pain management when other treatments have failed. Fixed‐dose oxycodone/naloxone prolonged‐release tablets (OXN PR) were designed to address the opioid class effect of opioid‐induced constipation (OIC) by combining the analgesic efficacy of oxycodone with the opioid receptor antagonist, naloxone, which has negligible systemic availability when administered orally. This formulation has abuse‐deterrent properties, since systemic exposure to naloxone by parenteral administration would antagonize the euphoric effects of oxycodone.

Methods

A literature search was conducted to assess the evidence base for OXN PR to treat moderate‐to‐severe pain and its impact on bowel function, based on published clinical trials and observational studies.

Results

Extensive data demonstrate that OXN PR provides effective analgesia and clinically relevant improvements in bowel function in patients with OIC and moderate‐to‐severe cancer‐related pain and noncancer pain types such as low back pain, neuropathic pain, and musculoskeletal pain. OXN PR has also been found to improve bowel function in patients with OIC refractory to multiple types of laxatives, and improve Parkinson's disease–related pain. No unanticipated safety concerns have been reported in elderly patients.

Conclusions

Evidence from clinical trials and observational studies confirms that for selected patients OXN PR significantly improves moderate‐to‐severe chronic pain and provides relief from OIC. Treatment should be tailored to individual patients to establish the lowest effective dose. An absence of analgesic ceiling effect was seen across the clinically relevant dose range investigated (≤ 160/80 mg/day).     

Chronic pain syndromes in the emergency department: identifying guidelines for management

Objectives: To explore current literature on chronic pain syndromes and develop ED recommendations for the management and minimalization of chronic non‐cancer pain. Methods: A focused literature review. Results: Chronic pain is a common presentation to the ED but is poorly understood and managed. Research into the psychophysiology of chronic pain shows that there are definite changes in the receptive and processing pathways in patients suffering chronic pain syndromes. Evidence shows the effectiveness of early recognition with multimodal treatment, however high level evidence is lacking. All experts recommend balanced drug therapy, cognitive and behavioural interventions. Certain interventions are appropriate to the ED setting. Conclusions: Emergency Medicine lacks a cohesive, informed strategy for management of chronic pain. The proposed guidelines represent the first step toward establishing consistency in the management of patients with chronic pain syndromes. Further work needs to be undertaken at a national level in developing evidence based guidelines.