Pain Relief and Palliative Care Unit

La Maddalena, Italy

Pain Relief and Palliative Care Unit

La Maddalena, Italy
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Mercadante S.,Pain Relief and Palliative Care Unit | Ferrera P.,Pain Relief and Palliative Care Unit | Adile C.,Pain Relief and Palliative Care Unit | Casuccio A.,University of Palermo
Journal of Pain and Symptom Management | Year: 2011

Context: Cancer patients receiving high doses of opioids as background medication are challenging, and it would be useful clinically to know whether a rapid-onset opioid (ROO) for breakthrough cancer pain (BTcP) may be started at a dose proportional to the background opioid dose. Objectives: The aim of this study was to assess the efficacy and safety of the fentanyl buccal tablet (FBT) in doses proportional to the opioid dose administered for background analgesia in a sample of patients with BTcP who were receiving high doses of opioids. Methods: Twelve patients who were receiving opioids for background analgesia at doses equivalent to more than 500 mg of oral morphine and had adequately controlled pain were prospectively recruited. BTcP was treated with proportional doses of FBT: patients receiving 600 mg of oral morphine equivalents were administered 1000 μg of FBT, patients receiving 900 mg of oral morphine equivalents were administered 1500 μg of FBT, and so on. For each episode of BTcP, trained nurses collected pain intensity (on a 0-10 numerical rating scale) and emerging problems when called for increases in pain considered to be severe in intensity by patients (T0) and 15 minutes after FBT administration (T15). Results: Patients were receiving mean doses of oral morphine equivalents of 1340 mg (±585; range 720-2400). Seventy-nine events were treated with FBT (6.6 ± 4.9 for each patient). The median pain intensity of BTcP events was 8 (range 7-10), and the mean dose of FBT administered was 2233 μg (±975; range 1200-4000). In most events, a decrease in pain intensity >33% and >50% was observed (n = 14 and n = 48, respectively) 15 minutes after the administration of FBT. Data on 11 episodes were missed. Only six events were unsuccessfully treated. In all the patients, the level of adverse effects after FBT administration was mild and indistinguishable from that associated with the background opioid analgesia. Conclusion: FBT in doses proportional to the high doses of opioids used for background analgesia was efficacious and well tolerated when administered for BTcP. Controlled studies with a specific design and a large number of patients should confirm such preliminary results. © 2011 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.


Mercadante S.,Pain Relief and Palliative Care Unit | Prestia G.,Pain Relief and Palliative Care Unit | Adile C.,Pain Relief and Palliative Care Unit | Casuccio A.,University of Palermo
Journal of Pain | Year: 2014

The aim of this randomized, crossover, comparison study was to assess the analgesic and adverse effects of 2 nasal preparations, intranasal fentanyl (INFS) and fentanyl pectin nasal spray (FPNS), for breakthrough pain, given in doses proportional to opioid basal regimen. Each patient randomly received INFS or FPNS in doses proportional to opioid dosages used for background analgesia for 2 pairs of episodes. For each episode of breakthrough pain, pain intensity and adverse effects intensity were recorded just before starting the INFS or FPNS (T0) and 5 minutes (T5), 10 minutes (T10), and 20 minutes (T20) after the administration of the nasal drugs. Sixty-nine patients were studied. The mean age was 63.4 years, and 37 patients were males. For the present analysis, 188 episodes were considered. A statistical decrease in pain intensity was observed with both nasal drugs after 5, 10, and 20 minutes. A decrease in pain intensity of >33% was observed in 16, 102, and 159 treated episodes at T5, T10, and T20, respectively. Adverse effects were of mild nature in most cases or were preexistent because of basal opioid therapy. No differences were found in summed pain intensity difference 20 minutes after dosing. Most of patients did not find substantial preferences. INFS and FPNS were effective and well-tolerated treatments for breakthrough pain management. Both delivery systems, in doses proportional to the basal opioid regimen, provided significant analgesia within 10 minutes, without producing relevant adverse effects. Perspective This article showed that INFS and FPNS in doses proportional to basal opioid regimen are equally safe and effective for the management of breakthrough pain in cancer patients. These data provide new insights on the use of nasal preparations of fentanyl. © 2014 by the American Pain Society. Published by Elsevier Inc. All rights reserved.


Mercadante S.,Pain Relief and Palliative Care Unit | Vitrano V.,Pain Relief and Palliative Care Unit
Minerva Anestesiologica | Year: 2010

The aim of this study was to review the Italian literature regarding attitudes toward palliative care in cancer patients, as well as cultural, educational and organizational problems in Italy with respect to palliative care services. The Italian literature published in the last ten years on PUBMED was reviewed. Clinical trials were excluded from this analysis, as their focus was beyond the scope of this study. Non-cancer studies were also excluded. Thirty-nine papers were retrieved. Several weaknesses were recognized in the studies, including a lack of knowledge and negative attitudes regarding cancer pain management and the use of alternative treatments. Communication with patients and family was also inadequate. In general, poor organization of palliative care services was also shown. An appropriate place to die was often not guaranteed and was dependent on the availability of local resources. However, the most striking finding was that there were geographical differences in the distribution of palliative care resources. The development of a range of palliative care programs integrating primary territorial care and specialized palliative services may constitute the ideal synthesis to respond to patients' needs.


Mercadante S.,Pain Relief and Palliative Care Unit | Mercadante S.,University of Palermo
Current Medical Research and Opinion | Year: 2011

Pain is still one of the most prevalent and distressing symptom in patients with chronic pain. Opioids are the most potent existing analgesics available in clinical practice. However, they are not always effective, particularly in the non-cancer population. Alternately adverse effects may limit their analgesic activity. Several different drug-development strategies have attempted to reduce side effects by exploiting anatomic barriers to drug distribution and to provide different analgesic mechanisms, as in the case of the oxycodonenaloxone combination or tapentadol. New delivery systems have been developed for a more effective management of breakthrough pain. Pharmacogenetics could play a critical role in personalizing pain management in the future. © 2011 Informa UK Ltd.


Mercadante S.,Pain Relief and Palliative Care Unit | Vitrano V.,Pain Relief and Palliative Care Unit
Lung Cancer | Year: 2010

This review analyses the characteristics of the principal pain syndromes associated with lung cancer, their physiopathology and causes, and provides updated information on available treatments. Pain associated with lung cancer is characterized by multiple expressions, due to either the progression of disease and/or induced by oncological treatment. The analgesic treatment is principally based on the use of opioids. Other than the oral route, which is the preferred one, alternative modalities to administer opioids may be helpful in different clinical circumstances. According to the opioid response, other routes and other opioids, may improve the balance between analgesia and adverse effects providing the best individual response to a specific opioid drug. More complex strategies, such as interventional procedures, are seldom necessary and require an appropriate selection of patients. © 2009.


Mercadante S.,Pain Relief and Palliative Care Unit | Vitrano V.,Pain Relief and Palliative Care Unit | Catania V.,Pain Relief and Palliative Care Unit
Supportive Care in Cancer | Year: 2010

Introduction Sexuality is an important aspect of life involving physical, psychological, interpersonal, and behavioral aspects. The aim of this review was to examine the literature regarding sexuality in advanced cancer patients, after taking into consideration the principal changes produced by the disease and its treatment. Methods This review considered references through a search of PubMed by use of the search terms "advanced cancer," "palliative care," in combination with "sexuality" and/or "intimacy." Results Surgery, chemotherapy, hormonal therapy, radiotherapy, and drugs commonly given for the symptomatic treatment have relevant consequences on sexuality, also in the advanced stage of disease. Sexual dysfunction is a multifaceted issue and different causes may concomitantly have a role, including the psychological and clinical status. The existing clinical studies have shown important cultural barriers on sexuality. Sexuality is not considered a medical concern compared with the priority of treating cancer or symptoms. Although this issue is very private, unaddressed sexuality changes can be among the most negative influences on the social well being of a cancer patient. It is increasingly acknowledged that issues surrounding sexuality are an important factor in quality of life for patients with cancer and that sexuality is a legitimate area of concern in oncology and palliative care. Few studies have assessed sexuality in the advanced stage of disease. Nevertheless, advanced cancer patients are willing to talk about their sex lives and the impact of the disease on their sexual function. Conclusions To provide this component of care, professionals need to have good communication skills, an open and non-judgmental approach, and knowledge of the potential ramifications of disease and treatment of sexuality problems. © 2010 Springer-Verlag.


Mercadante S.,Pain Relief and Palliative Care Unit | Craig D.,H. Lee Moffitt Cancer Center and Research Institute | Giarratano A.,University of Palermo
Drugs | Year: 2012

Prescriptions for opioid analgesics to manage moderate-to-severe chronic non-cancer pain have increased markedly over the last decade. An unintentional consequence of greater prescription opioid utilization has been the parallel increase in misuse, abuse and overdose, which are serious risks associated with all opioid analgesics. In response to disturbing rises in prescription opioid abuse, the US Food and Drug Administration (FDA) has proposed the implementation of aggressive Risk Evaluation and Mitigation Strategies (REMS). While REMS could dramatically change the development, release, marketing and prescription of extended-release opioids, questions remain on how these programmes may influence prescribing practices, patient safety and ultimately patient access to these agents. The extent of the availability and misuse of prescription opioids in Europe is difficult to assess from the data currently available, due in large part to the considerable differences in prescribing patterns and regulations between countries. Balancing the availability of prescription opioids for those patients who have pain, while discouraging illicit use, is a complex challenge and requires effective efforts on many levels, particularly in Europe where policies are quite different between countries.


Gardner-Nix J.,University of Toronto | Mercadante S.,Pain Relief and Palliative Care Unit
Pain Practice | Year: 2010

The vast majority of cancer patients experience pain, and treatment with opioids offers the most effective option for pain management. Long-lasting opioid formulations are usually used as cancer pain management strategies. This review surveys the available literature on the only available once-daily sustained-release formulation of hydromorphone, and its use in cancer pain management. Sustainedrelease (SR) formulations have a more consistent opioid plasma concentration, thereby minimizing the peaks and troughs associated with immediate-release opioid formulations. OROS® hydromorphone (Jurnista™, Janssen Pharmaceuticals, NV, Beerse, Belgium) releases hydromorphone over a 24-hour dosing period. Studies comparing its efficacy with other opioids such as morphine and oxycodone found comparable results overall. Recent trials have provided evidence of decreased rescue medication use for breakthrough pain, a good safety profile, and quality of life benefits. It appears to be an efficacious and well-tolerated treatment. The pharmacokinetics of OROS® hydromorphone are linear and doseproportional, and only minimally affected by the presence or absence of food. In addition, the SR properties of OROS® hydromorphone are maintained in the presence of alcohol, with no dose dumping of hydromorphone. This formulation shows promise as an addition to cancer pain management strategies, although further randomized, double-blind trials are needed to confirm this. © 2009 World Institute of Pain.


Mercadante S.,Pain Relief and Palliative Care Unit | Mercadante S.,University of Palermo | Ferrera P.,Pain Relief and Palliative Care Unit | Adile C.,Pain Relief and Palliative Care Unit
Supportive Care in Cancer | Year: 2011

Several studies have shown that an oxycodone/naloxone combination (ratio 2:1) provides analgesia and less constipation in non-cancer patients receiving relatively low doses of this formulation. A case report of a cancer patient who was receiving increasing doses of oxycodone with an unexpected declining analgesia is presented. The substitution with the same doses (240 mg/day) of regular controlled-release oxycodone was effective in regaining adequate analgesia. © 2011 Springer-Verlag.


Mercadante S.,Pain Relief and Palliative Care Unit | Giarratano A.,Pain Relief and Palliative Care Unit
Current Medical Research and Opinion | Year: 2014

Objective: The present review was performed to identify possible differences observed between adults and elderly patients and between males and females in randomized clinical trials of breakthrough pain (BTP). Methods: A systematic search of the existing literature from 1998 to September 2013 was performed. Randomized clinical trials reporting data on older patients were selected. Results: Sixteen comparative studies were selected. The age range of inclusion criteria patients was mainly between 18-80 or ≥18 years. In some cases this data was unreported. The mean age of patients was 48-64 years, but information regarding the number of elderly patients was present in three studies only. Gender distribution was more or less 50%:50%. No subgroup analysis of efficacy or adverse effects of BTP medications for age and gender was reported. Conclusion: There is a need for more information regarding the use of opioids for BTP according to age and gender. © 2014 All rights reserved.

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