Safety of multiple-dose intravenous acetaminophen in adult inpatients.
Pain Med. 2010 Dec;11(12):1841-8
Authors: Candiotti KA, Bergese SD, Viscusi ER, Singla SK, Royal MA, Singla NK
Intravenous (IV) acetaminophen provi…

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Prescription and administration of opioids to hospital in-patients, and barriers to effective use.

Pain Med. 2010 Jan;11(1):58-66

Authors: Murnion BP, Gnjidic D, Hilmer SN

OBJECTIVE: This study aimed to describe prescribing and administration of opioids in a tertiary referral teaching hospital. Secondary aims were assessment of staff knowledge of opioid pharmacology and available preparations, and of perceived barriers limiting opioid use. DESIGN: A cross-sectional survey of in-patients requiring opioid analgesia was performed. An anonymous semi-structured questionnaire was administered to medical and nursing staff. SETTING: Australian tertiary referral teaching hospital. PATIENTS: All patients prescribed opioids on study wards over 3 months (N = 190). RESULTS: Oxycodone was the most frequently prescribed opioid (51.4%). The majority (64.7%) of participants had incomplete pain relief, which was significantly associated with having opioid related side effects. There was no association between pain relief and prescribed daily dose or received daily dose of opioids. Limited understanding of opioid preparations, tolerance, and dependence was demonstrated by staff. The most common perceived barriers to opioid use included difficulties in identifying the right dose, staff time required to prescribe and monitor, and large numbers of preparations. While prescription of inadequate doses was perceived as a barrier, this study identified that submaximal doses were administered. An opioid educational session improved knowledge of opioid formulations. CONCLUSION: The majority of participants had incomplete pain relief and the maximum prescribed doses of opioids were not administered. Reported barriers included staff knowledge of opioid dose titration and opioid preparations, and time constraints. Identified barriers included poor knowledge of opioid preparations.

PMID: 19930113 [PubMed - indexed for MEDLINE]

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Assessment and management of acute pain in adult medical inpatients: a systematic review.

Pain Med. 2009 Oct;10(7):1183-99

Authors: Helfand M, Freeman M

OBJECTIVE: To review the literature addressing effective care for acute pain in inpatients on medical wards. METHODS: We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions. RESULTS: We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion. CONCLUSIONS: Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.

PMID: 19818030 [PubMed - indexed for MEDLINE]

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Efficacy and safety of mu-opioid antagonists in the treatment of opioid-induced bowel dysfunction: systematic review and meta-analysis of randomized controlled trials.

Pain Med. 2008 Sep;9(6):634-59

Authors: McNicol E, Boyce DB, Schumann R, Carr D

CONTEXT: Opioid-induced bowel dysfunction (OBD) is characterized by constipation, incomplete evacuation, bloating, and increased gastric reflux. OBD occurs both acutely and chronically, in multiple disease states, resulting in increased morbidity and reduced quality of life. OBJECTIVE: To compare the efficacy and safety of traditional and peripherally active opioid antagonists vs conventional interventions for OBD. DESIGN: We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE. Additional reports were identified from the reference lists of retrieved articles. STUDY SELECTION: Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD. DATA EXTRACTION: Data were extracted by two independent investigators and included demographic variables, diagnoses, interventions, efficacy, and adverse events. RESULTS OF DATA SYNTHESIS: Twenty-two articles met inclusion criteria and provided data on 2,352 opioid antagonist-treated patients. The opioid antagonist investigated was alvimopan (eight studies), methylnaltrexone (six), naloxone (seven), and nalbuphine (one). Meta-analysis demonstrated that methylnaltrexone and alvimopan are efficacious in reversing opioid-induced increased gastrointestinal transit time and constipation, and that alvimopan is safe and efficacious in treating postoperative ileus. The incidence of adverse events with opioid antagonists was similar to placebo and generally reported as mild-to-moderate. CONCLUSIONS: Insufficient evidence exists for the safety or efficacy of naloxone or nalbuphine in the treatment of OBD. Long-term efficacy and safety of any of the opioid antagonists is unknown, as is the incidence or nature of rare adverse events. Alvimopan and methylnaltrexone both show promise in treating OBD, but further data will be required to fully assess their place in therapy.

PMID: 18828197 [PubMed - indexed for MEDLINE]

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Titration with oxymorphone extended release to achieve effective long-term pain relief and improve tolerability in opioid-naive patients with moderate to severe pain.

Pain Med. 2008 Oct;9(7):777-85

Authors: Rauck R, Ma T, Kerwin R, Ahdieh H

OBJECTIVE: Assess the effectiveness and tolerability of a program of gradual dose titration with oxymorphone extended release (ER) for treatment of moderate to severe chronic pain in opioid-naive patients. DESIGN: Open-label, nonrandomized 6-month study with a titration/stabilization period of <or=1 month followed by a 5-month maintenance period. SETTING: Multidisciplinary pain centers in the United States. PATIENTS: Adult opioid-naive patients with moderate to severe chronic pain. INTERVENTIONS: Patients were gradually titrated from a 5-mg dose of oxymorphone ER (taken every 12 hours) to a stabilized dose that provided effective pain relief and was well tolerated. OUTCOME MEASURES: Brief Pain Inventory Short Form questions 5 and 9, patient and physician global assessments of pain relief, adverse events (AEs), and discontinuations. RESULTS: The majority (94/126; 75%) of patients were stabilized on a dose of oxymorphone ER that provided effective pain relief with tolerable AEs. Most (81/94; 86%) required <24 days to reach a stable dose. Sixteen percent of patients in the titration period and 17% of patients in the maintenance period discontinued because of AEs possibly or probably related to oxymorphone ER. Patients completing the entire 5-month maintenance period experienced effective pain relief with significant (>50%) reductions of pain interference with quality-of-life measures. There was minimal dose escalation over the 5 months and low use of rescue medication. CONCLUSIONS: Oxymorphone ER provided effective pain relief from moderate to severe chronic pain in opioid-naive patients. Gradual titration was well tolerated, with a low rate of discontinuations caused by AEs.

PMID: 18950436 [PubMed - indexed for MEDLINE]

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Combination therapy with flupirtine and opioid: open-label case series in the treatment of neuropathic pain associated with cancer.

Pain Med. 2008 Oct;9(7):939-49

Authors: Goodchild CS, Nelson J, Cooke I, Ashby M, Jackson K

OBJECTIVES: This study is a case series that was designed to provide data on the efficacy and the incidence and duration of adverse effects of flupirtine in the treatment of cancer-related neuropathic pain. DESIGN: This was an 8-day, open-label study of palliative care patients with neuropathic pain despite maximal opioid treatment. They received an initial dose of flupirtine 100 mg orally four times daily (QID) that could be titrated. Efficacy measures included: a neuropathic pain discriminant score; scales measuring average pain and quality of life activities; and a score of percentage pain relief. RESULTS: Ten patients were recruited. Only one patient was withdrawn because of side effects. Several pain measurements were used. All patients were able to participate in these measurements apart from two who did not understand the concept of percentage pain relief. There were significant reductions of average pain (P < 0.01) and neuropathic pain discriminant scores (P < 0.01), as well as an increase in percentage pain relief (P < 0.01). There was no statistically significant change in overall opioid use but 8/10 patients had some reduction in opioid use and three of those required substantially reduced doses of opioid when flupirtine was added to their treatment regime. Eight patients elected to continue to take flupirtine after the trial, two taking 200 mg QID and the others 100 mg QID. Of these eight, six said that flupirtine was of considerable help and two said it helped a little. All of these continued to take flupirtine with very good pain control until death, one of which was 18 months after the trial course. CONCLUSIONS: These results in humans follow animal studies that suggest a role for flupirtine in the treatment of neuropathic pain. This short duration open-label study in 10 subjects suggests that flupirtine may be useful in the treatment of neuropathic pain when used in combination with opioids.

PMID: 18950447 [PubMed - indexed for MEDLINE]

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A systematic review of opioid conversion ratios used with methadone for the treatment of pain.

Pain Med. 2008 Jul-Aug;9(5):595-612

Authors: Weschules DJ, Bain KT

OBJECTIVE: Review and analyze the evidence base comprising methadone conversion methods and associated dosing ratios for the treatment of pain. DESIGN: Systematic review. METHODS: Clinical trials and retrospective analyses, case series, and case reports of human subjects published in the English language between January 1966 and June 2006 were included; review articles and reports with incomplete opioid data were excluded. Scatterplots displayed the relationship between previous morphine dose and final methadone dose and dose ratio. Correlation analyses were conducted using Pearson’s and Spearman’s correlation coefficient with a one-tailed test of significance. RESULTS: Twenty-two clinical studies and 19 case reports or series were reviewed (N = 730 patients). Methadone rotations were most common in cancer patients (N = 625, 88.9%) and those prescribed morphine (N = 259 patients, 41.7% of rotations where prerotation opioid was identified [N = 621]) or hydromorphone (N = 234 patients, 37.7% of rotations). In clinical studies, the most common reason for switching to methadone was a combination of inadequate analgesia and adverse effects (N = 254, 38.6%). Despite various approaches, 46-89% of rotations were successful. Overall, there was a relatively strong, positive correlation between the previous morphine dose and the final methadone dose and dose ratio, but ratios varied widely. CONCLUSIONS: There was no evidence to support the superiority of one method of rotation to methadone over another. Patients may be successfully rotated to methadone despite discrepancies between rotation ratios initially used and those associated with stabilization. Further research is needed to identify patient-level factors that may explain the wide variance in successful methadone rotations.

PMID: 18565004 [PubMed - indexed for MEDLINE]

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