Dexmedetomidine as an Adjuvant to Analgesic Strategy During Vaso‐Occlusive Episodes in Adolescents with Sickle‐Cell Disease

Patients with sickle‐cell disease (SCD) can experience recurrent vaso‐occlusive episodes (VOEs), which are associated with severe pain. While opioids are the mainstay of analgesic therapy, in some patients with SCD, increasing opioid use is associated with continued and increasing pain. Dexmedetomidine, an α₂‐adrenoreceptor agonist with sedative and analgesic properties, has been increasingly used in the perioperative and intensive care settings and has been shown to reduce opioid requirement and to facilitate opioid weaning. Therefore, there might be a role for dexmedetomidine in pain management during VOEs in patients with SCD. Here, we present the hospital course of 3 patients who during the course of VOEs had severe pain unresponsive to opioids and ketamine and were treated with dexmedetomidine. Dexmedetomidine infusions that lasted for 3 to 6 days were associated with marked reduction in daily oral morphine‐equivalent intake and decreases in pain scores (numeric rating scale). There were no hemodynamic changes that required treatment with vasoactive or anticholinergic agents. These preliminary findings of possible beneficial effects of dexmedetomidine in decreasing opioid requirements support the hypothesis that dexmedetomidine may have a role as a possible analgesic adjuvant to mitigate VOE‐associated pain in patients with SCD.     

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.PerspectiveSafe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.     

Alcohol and smoking behavior in chronic pain patients: The role of opioids

The primary aim of this epidemiological study was to investigate associations between chronic non-cancer pain with or without opioid treatment and the alcohol and smoking behavior. The secondary aims were to investigate self-reported quality of life, sleeping problems, oral health and the use of different health care providers.The Danish health survey of 2005 was based on a region-stratified random sample of 10.916 individuals. Data were collected via personal interviews and self-administrated questionnaires. Respondents suffering from chronic pain were identified through the question ‘Do you have chronic/long-lasting pain lasting 6 months or more?’ The question concerning alcohol intake assessed the frequency of alcohol intake and binge drinking. Smoking behavior assessed the daily number of cigarettes. Individuals reporting chronic pain were stratified into two groups (opioid users and non-opioid users).In all, 7275 individuals completed a personal interview and 5552 individuals completed and returned the self-administrated questionnaire. Responders with a self-reported earlier or present cancer diagnosis were excluded from the study. Hence, the final study population consisted of 5292 individuals.We found, that individuals suffering from chronic pain were less likely to drink alcohol. In opioid users alcohol consumption was further reduced. Cigarette smoking was significantly increased in individuals suffering from chronic pain and in opioid users smoking was further increased. Poor oral health, quality of life and sleep were markedly associated with chronic pain and opioid use. The use of opioids was associated with significantly more contacts to healthcare care providers.     

Australian management strategies for oral opioid use in non-malignant pain

Chronic non-cancer pain is a complex biopsychosocial phenomenon; as such it is unlikely that any one treatment modality will achieve relief. There is increasing availability of oral opioid preparations and an associated increased level of prescribing; consequently in 1997 the Australian Pain Society drew up some management strategies for their use. This paper reviews the principles of those strategies, stressing that oral opioids should not be used in isolation nor used to treat 'distress' often associated with chronic pain. The place of a trial of opioid and informed consent are discussed.     

The use of fentanyl buccal tablets for breakthrough pain by using doses proportional to opioid basal regimen in a home care setting

The dose of rapid onset opioids to be given for breakthrough cancer pain (BTcP) is controversial. Dose proportional to the basal opioid regimen seem to be safe and effective in hospital units. However, data in other less protected settings, like home care, are lacking. The aim of this open-label study was to assess the efficacy and safety in a group of patients with BTcP followed at home, after giving a dose of fentanyl buccal tablets (FBT) proportional to the opioid basal regimen, skipping the steps for dose titration. Consecutive patients admitted to a home care program presenting BTcP episodes and receiving stable doses of opioids for background pain were selected. Data from four consecutive episodes of BTcP were collected. For each episode, patients were instructed to routinely collect changes in pain intensity and severe adverse effects when pain got severe (T0) and to reassess the same items 15 min after FBT, given as a rescue medication in doses proportional to the daily opioid doses used for background pain (T15). One hundred twenty episodes of BTcP were recorded in 30 patients. One hundred eight episodes were defined as successfully treated, while 12 episodes required a further administration of opioids. Pain intensity significantly decreased at T15 (p?<?0.001). In 95.5 and 90.8 % of episodes treated, there was a reduction in pain intensity of more than 33 and 50 %, respectively. No relevant adverse effects were recorded, even in older patients. This study suggests that FBT given in doses proportional to the basal opioid regimen for the management of BTcP is very effective and safe in clinical practice in the home care setting.     

A changing landscape of opioid prescribing in emergency medicine

Emergency Medicine providers are grappling with the dual challenges of adequately treating pain while avoiding the risks associated with opioid pain relievers. The aggressive treatment of pain with opioids for the last three decades has resulted in an epidemic of opioid use disorder and opioid related mortality. This editorial discusses the findings in a study of emergency department (ED) opioid prescribing by Yang et al. and explores the changing landscape of opioid prescribing in emergency medicine. We specifically discuss risks associated with opioid prescribing, strategies to reduce risks while improving pain management, the role of advanced practice providers in ED opioid prescribing, and the importance of further education on opioid sparing pain management strategies.     

Opioid-induced or pain relief-reduced symptoms in advanced cancer patients?

BACKGROUND: While opioids in increasing doses may produce adverse effects, the same adverse effects may be associated with poor pain control. Moreover, in the clinical setting symptomatic treatment and illness may balance the outcome of opioid titration. Some adverse effects may tend to disappear continuing the treatment in a long-term period. AIMS: The aim of this study was to monitor the effects of a rapid opioid titration combined with symptomatic treatment in patients with poor relief and to monitor these changes in the following period of 20 days. METHODS: A consecutive sample of 35 patients admitted to an acute Pain Relief and Palliative Care Unit were titrated with opioids, according to a department policy, allowing administration of parenteral opioids to assist opioid titration with oral or transdermal opioids. RESULTS: Thirty-three patients were followed up for the period of the study. Pain was adequately controlled and doses were opioid doses were stable after a mean of 40 h. Opioid escalation index (OEI) was extremely high initially, and then progressively declined at the following study intervals. Weakness and nausea and vomiting did not change, as well as confusion and appetite. Drowsiness, constipation and dry mouth significantly increased and then did not change, although a significant decrease in drowsiness was subsequently observed. Well-being improved some weeks after opioid stabilization. In multivariate analysis, drowsiness and dry mouth were correlated to opioid doses. CONCLUSION: The effects reported were often due to multiple causes. A rapid decrease in pain intensity induced by rapid opioid titration does not produce changes in weakness, nausea and vomiting, appetite. While constipation appears the most relevant problem, resistant to common symptomatic treatment, drowsiness initially produced by acute opioid dose increase and the achievement of pain relief, tends to spontaneously decrease, probably as the result of late tolerance. Improved well-being may be the late positive effect of pain relief, also influenced by the setting of home care.     

The use of long-acting opioids in chronic pain management

The consensus statement from the American Pain Society and American Academy of Pain Medicine states that the undertreatment of pain is unjustified [6]. It has been suggested that opioid therapy can be used effectively to treat noncancer pain in a subset of patients [26], and this is becoming more acceptable [3]. Providing sustained analgesia is an important aspect of therapy, and medications should be administered on an around-the-clock basis, because regular administration of doses maintains a constant level of drug in the body and helps prevent recurrence of pain. Ideal treatment for persistent pain is a long-acting opioid administered around the clock to prevent baseline pain, with the use of short-acting opioids as supplemental agents for breakthrough pain. Controlled-release formulations can lessen the inconvenience associated with around-the-clock administration of short-acting opioids. Sustained analgesia also can be achieved with transdermal fentanyl, which combines a strong opioid with a 72-hour release profile and the benefits of a parenteral route, avoiding first-pass metabolism. Controlled-release formulations of morphine and oxycodone are available in the United States, and hydromorphone preparations are being reviewed for approval. Clinical experience with these formulations and transdermal fentanyl indicates that these agents are equally effective in controlling pain. Studies have demonstrated improved quality of life with the transdermal route and with controlled-release morphine and oxycodone. Because of patch reapplication every 72 hours, the transdermal route also enhances compliance. Use of an opioid without the need for oral or intravenous administration and the opportunity to improve compliance are among the advantages of the transdermal route in clinical practice. The nurse has an important role in the management of patients receiving long-acting opioids for chronic noncancer pain, Facilitation of the conversion from short-acting to long-acting opioids may be the initial step. Individualization of therapy to determine which route and product best suits the patient's needs and lifestyle can be accomplished through a comprehensive nursing assessment. Titration of dose along with institution of a short-acting opioid for break-through pain may require frequent interventions that a nurse familiar with the patient can provide. Prevention and management of opioid-related adverse events are essential for effective opioid therapy. Providing patient and family education regarding administration, monitoring, and management of opioid therapy is an important nursing role. Lastly, documentation of pain level, functional status, and opioid-related adverse events is required for each contact with the patient, to make this information available to all who assist in the management of the patient's pain. Chronic noncancer pain is an experience that affects all aspects of a patient's life. Effective pain management with long-acting opioids may help the patient to focus on the positive aspects of life, decreasing the focus on pain.     

Opioid formulations: tailoring to the needs in chronic pain

Opioids are one of the standard therapies used in the management of chronic pain. They were first widely adopted for the treatment of chronic pain associated with cancer and are now considered important in the alleviation of non-cancer and neuropathic pain. Around-the-clock (ATC) medication has been found to be an effective approach in treating chronic pain. Guidelines issued by the American Pain Society (1999) note that in most cases the preferred route of administering opioids is oral, because of convenience, flexibility, and relative steadiness of the opioid concentrations in the blood. The advantages of ATC therapy and oral medication are some of the reasons for the development of controlled-release, oral formulations of opioids (e.g. morphine, oxycodone, hydromorphone, and hydrocodone). The reduced dosing frequency makes the oral medication more convenient for patients, making it easier for them to comply with the dosing regimen. ATC therapeutic coverage and the possible increased compliance afforded by controlled-release formulations can make opioids even more effective in managing chronic pain.     

The pharmacological basis of contemporary pain management

Pain management has become an increasingly well researched area in medicine over recent years, and there have been advances in a number of areas. While opioids remain an integral part of pain-management strategies, there is now an emphasis on the use of adjuvant drugs, such as paracetamol and anti-inflammatory agents, which through physiological or pharmacological synergism, both enhance pain control and reduce opioid use. The management of neuropathic pain continues to be a challenge. Anti-epileptics and antidepressants, together with clonidine and ketamine, provide the foundations for treatment. Another area of interest has been the widespread use of patient-controlled analgesia and the administration of some drugs, especially opioids, by means other than traditional oral and parenteral routes. The number of new drugs that have reached the stage of clinical trials has been small, yet they offer exciting possibilities. The epibatidine analogue ABT-594 and zinconitide both offer novel approaches to the management of neuropathic pain states, while selective cyclo-oxygenase-2 inhibitors and nitroaspirins may see advances in the management of nociceptive pain states.     

Pain Management Practice and Guidelines in Jordanian Pediatric Intensive Care Units

Limited knowledge exists of current pain management practices and supporting guidelines in Jordanian pediatric intensive care units. To determine the current pain management practices and the availability and content of practice guidelines in Jordanian pediatric intensive care units, we conducted a cross-sectional and multisite survey of four pediatric intensive care units in Jordan. A questionnaire was developed and orally administered over the phone or in person to head nurses or their nominees to capture pain management practices and the existence and content of guidelines. All units had written pain management guidelines that included pain assessment, documentation, and management. All four units used one or more pain assessment tools. In three units, pain management was considered multidisciplinary and routinely discussed on unit rounds. In two units, continuous infusion of intravenous opioids was used as well as sedatives and neuromuscular blockers for most ventilated patients. In the two other units, continuous intravenous infusion of opioids was not used and only sedatives were administered for patients on mechanical ventilation. In two units, there were no specific guidelines on the use of nonopioid analgesics, patient-controlled anesthesia, or the management of postoperative pain. No unit used an opioid or sedative withdrawal assessment tool or had pain management guidelines on the use of topical anesthetic agents or sucrose. Pain management practices and guidelines varied across the four units, suggesting that there is an opportunity for improvement in pain management in pediatric intensive care units in Jordan.     

Rediscovery of Methadone to Improve Outcomes in Pain Management

Clinically, methadone is most known for its use in the treatment of opioid maintenance therapy. However, methadone's pharmacological profile makes it an excellent analgesic that can enhance acute and chronic pain management. It is a potent μ-receptor agonist with a longer elimination half-life than most clinically used opioids. In addition, methadone inhibits serotonin and norepinephrine uptake, and it is an N-methyl-D-aspartate antagonist. These distinct analgesic pathways mediate hyperalgesic, allodynic, and neuropathic pain. Its unique analgesic properties provide several essential benefits in perioperative use, neuropathic pain, cancer, and noncancer pain. Despite these proven clinical utilities, methadone has not been used widely to treat acute and chronic pain in opioid naïve patients. This article describes the unique pharmacology of methadone and provides emerging evidence to support its application in acute and chronic pain management. Pain management options and guidelines for surgical patients on methadone are discussed as well.