Intensity of Withdrawal Symptoms During Opioid Taper in Patients with Chronic Pain—Individualized or Fixed Starting Dosage?

AbstractObjectiveControlled opioid withdrawal is recommended for patients with chronic noncancer pain (CNCP) with insufficient pain reduction or intolerable side effects while on opioid treatment. Few studies have investigated the management of opioid withdrawal (OW). Most common are protocols with an individualized starting dosage (ISD), calculated from the last opioid intake. After two cases of overdose, we introduced a novel withdrawal protocol using a low fixed starting dosage (FSD) for safety reasons. The present study compares the intensity of withdrawal symptoms using the Subjective Opioid Withdrawal Scale (SOWS) and incidences of serious adverse events (SAE) and dropouts in each taper schedule in 195 CNCP patients with OW in an inpatient facility.MethodsTwo protocols were compared: FSD (2014–2016): N = 68, starting dose: 90 mg morphine/d; and ISD (2010–2014): N = 127, starting dose: 70% of the patient’s daily morphine equivalent dose (MED). Outcome criteria: primary: mean daily SOWS score during the first 10 days (16 questions, daily score 0–64); secondary: change in pain intensity on a numeric rating scale (0–10), rate of dropouts and SAEs. Statistics: Student test, Mann-Whitney U test, chi-square test, analysis of variance, P < 0.05.ResultsThe mean daily SOWS score was lower in the FSD group (14.9 ± 9.4 vs 16.1 ± 10, P < 0.05) due to a lower rate of high-intensity withdrawal symptoms (12.4% vs 17.6%, P < 0.01), particularly in patients on >180 mg MED (9.7% vs 18.4%, P < 0.01). Pain intensity decreased after withdrawal, and the incidence of SAEs and dropouts was low in both groups.ConclusionsThe FSD protocol provides a lesser burden of withdrawal symptoms and equal patient safety. It can be recommended for OW in CNCP patients.

Download Full-text

Attrition of methylnaltrexone treatment-emergent adverse events in patients with chronic noncancer pain and opioid-induced constipation: a post hoc pooled analysis of two clinical trials

F1000Research ◽

10.12688/f1000research.51073.1 ◽

2021 ◽

Vol 10 ◽

pp. 891

Author(s):

Neel Mehta ◽

Neal E. Slatkin ◽

Robert J. Israel ◽

Nancy Stambler

Keyword(s):

Clinical Trials ◽

Adverse Event ◽

Adverse Events ◽

Pain Intensity ◽

Opioid Withdrawal ◽

Withdrawal Symptoms ◽

Chronic Noncancer Pain ◽

Noncancer Pain ◽

Post Hoc ◽

Gastrointestinal Adverse Events

Background: Opioids prescribed for the management of chronic noncancer pain are associated with nausea, vomiting, and constipation. Methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, has demonstrated robust efficacy and was well-tolerated in treating opioid-induced constipation without affecting central analgesia. Our objective was to assess changes in the frequency of adverse events after the first or second dose of methylnaltrexone or placebo. Methods: This post hoc analysis pooled data from two randomized, placebo-controlled clinical trials assessing methylnaltrexone for opioid-induced constipation in the outpatient setting. Patients received subcutaneous methylnaltrexone (12 mg once daily or 12 mg once every other day), oral methylnaltrexone (150, 300, or 450 mg daily), or placebo. Adverse events, opioid withdrawal symptoms, pain intensity, and rescue-free bowel movements (RFBMs) within 4 hours of the first dose (i.e., RFBM responders) were assessed. Associations between adverse event frequencies and RFBM response were also evaluated. Results: The analysis included 1263 adult patients with chronic noncancer pain. Treatment-emergent adverse event rates declined from treatment day 1 to 2 (methylnaltrexone: 16.2%–5.3%; placebo: 6.6%−5.4%). Among methylnaltrexone-treated patients, significantly greater proportions of RFBM responders versus nonresponders reported gastrointestinal adverse events on day 1. No associations between RFBM response and the frequency of adverse events were observed in the placebo group. No meaningful changes in opioid withdrawal symptoms or pain intensity were observed. Conclusions: Early-onset adverse events following methylnaltrexone treatment, particularly gastrointestinal adverse events, are at least partially due to laxation. Methylnaltrexone treatment effectively relieves opioid-induced constipation without affecting the central analgesic effects of opioids.

Download Full-text

Low Pain Intensity After Opioid Withdrawal as a First Step of a Comprehensive Pain Rehabilitation Program Predicts Long-term Nonuse of Opioids in Chronic Noncancer Pain

Clinical Journal of Pain ◽

10.1097/ajp.0b013e31827c7cf6 ◽

2013 ◽

Vol 29 (9) ◽

pp. 760-769 ◽

Cited By ~ 22

Author(s):

Elena K. Krumova ◽

Philipp Bennemann ◽

Doris Kindler ◽

Andreas Schwarzer ◽

Michael Zenz ◽

...

Keyword(s):

Pain Intensity ◽

Rehabilitation Program ◽

Opioid Withdrawal ◽

Chronic Noncancer Pain ◽

Noncancer Pain

Download Full-text

A Multivariate Analysis of Pain and Distress in Adults Undergoing BMAB

Clinical Nursing Research ◽

10.1177/1054773818807996 ◽

2018 ◽

Vol 29 (8) ◽

pp. 530-542

Author(s):

Amy E. Moore ◽

Rebecca L. Trotta ◽

Steven C. Palmer ◽

Regina S. Cunningham ◽

Rosemary C. Polomano

Keyword(s):

Pain Intensity ◽

Rating Scale ◽

Bone Marrow Aspiration ◽

Disease Status ◽

Numeric Rating Scale ◽

Linear Regression Models ◽

Opioid Use ◽

Chi Square ◽

Correlational Design ◽

First Time

Clinicians routinely perform bone marrow aspiration and biopsy (BMAB) to diagnose cancer and evaluate disease status; however, few studies address pain and distress with BMAB. A prospective descriptive–correlational design examined patients’ ( N = 152) ratings of pain intensity (numeric rating scale, 0-10) and distress (distress thermometer) at baseline and 5 min and 1 hr postprocedure. Data were analyzed using descriptive statistics, chi-square, and linear regression models. Mean postprocedure pain intensity at 5 min was moderate, 5.56 ( SD = 3.03), and opioid use was associated with decreased pain at 1 hr ( p < .001). Preprocedure administration of anxiolytics had no significant effect on distress reduction ( p = .88). Being female, first-time biopsy, and increased preprocedure pain were significant predictors of postprocedure distress ( p < .001). Treating anxiety alone may not be sufficient to lessen pain and distress. Individualized plans of care should be based on patient risk and response to procedure.

Download Full-text

Pre-Hospital Pain Management in Children with Injuries: A Retrospective Cohort Study

Journal of Clinical Medicine ◽

10.3390/jcm10143056 ◽

2021 ◽

Vol 10 (14) ◽

pp. 3056

Author(s):

Ada Holak ◽

Michał Czapla ◽

Marzena Zielińska

Keyword(s):

Pain Management ◽

Pain Intensity ◽

Pain Assessment ◽

Rating Scales ◽

Rating Scale ◽

Low Frequency ◽

Numeric Rating Scale ◽

Health Concern ◽

School Age Children ◽

Medical Teams

Background: The all-too-frequent failure to rate pain intensity, resulting in the lack of or inadequacy of pain management, has long ceased to be an exclusive problem of the young patient, becoming a major public health concern. This study aimed to evaluate the methods used for reducing post-traumatic pain in children and the frequency of use of such methods. Additionally, the methods of pain assessment and the frequency of their application in this age group were analysed. Methods: A retrospective analysis of 2452 medical records of emergency medical teams dispatched to injured children aged 0–18 years in the area around Warsaw (Poland). Results: Of all injured children, 1% (20 out of 2432) had their pain intensity rated, and the only tool used for this assessment was the numeric rating scale (NRS). Children with burns most frequently received a single analgesic drug or cooling (56.2%), whereas the least frequently used method was multimodal treatment combining pharmacotherapy and cooling (13.5%). Toddlers constituted the largest percentage of patients who were provided with cooling (12%). Immobilisation was most commonly used in adolescents (29%) and school-age children (n = 186; 24%). Conclusions: Low frequency of pain assessment emphasises the need to provide better training in the use of various pain rating scales and protocols. What is more, non-pharmacological methods (cooling and immobilisation) used for reducing pain in injured children still remain underutilized.

Download Full-text

Painful diabetic polyneuropathy and quality of life in Danish type 2 diabetic patients

Scandinavian Journal of Pain ◽

10.1016/j.sjpain.2017.04.026 ◽

2017 ◽

Vol 16 (1) ◽

pp. 173-173 ◽

Cited By ~ 4

Author(s):

Sandra Sif Gylfadottir ◽

Diana Hedevang Christensen ◽

Sia Kromann Nicolaisen ◽

Reimar Wernich Thomsen ◽

Jens Steen Nielsen ◽

...

Keyword(s):

Quality Of Life ◽

Pain Intensity ◽

Rating Scale ◽

Diabetic Polyneuropathy ◽

Numeric Rating Scale ◽

Diabetic Patients ◽

Type 2 Diabetic Patients ◽

Type 2 Diabetic

Abstract Background and aims Painful polyneuropathy (PPN) is a disabling complication of diabetes. This study aims to determine its prevalence and relationship with Quality of Life (QoL) in a nationwide prospective cohort of incident recently diagnosed Danish type 2 diabetic patients. Methods We sent a detailed questionnaire on neuropathy, pain and QoL to 6726 patients prospectively enrolled from general practitioners and hospital specialist outpatient clinics into the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) cohort. Patients who reported pain in both feet and a score ≥3 on the Douleur Neuropathique (DN4) questionnaire were considered to have possible PPN. QoL and pain intensity were measured on a numeric rating scale (NRS, 0–10). The Michigan Neuropathy Screening Instrument (MNSI) was used to assess neuropathy. Results A total of 5371 (79.8%) returned a complete questionnaire. 848 (15.8%) recently diagnosed type 2 diabetic patients reported pain in both feet. Of the 619 patients with pain who completed the DN4 questionnaire, 404 (65.2%) had a DN4 score ≥ 3, corresponding to a prevalence in the total population of possible PPN of 10.3%. Mean pain intensity was 5.2 (SD 2.2) and 89% had a MNSI score ≥ 3. Patients with possible PPN had a substantially lower QoL score than those without PPN (median QoL score 6 versus 8 (p < 0.001)), also when correcting for MNSI score. Conclusions Ten percent of newly diagnosed type 2 diabetic patients in Denmark had possible PPN. Patients with PPN had lower QoL than patients without PPN.

Download Full-text

Multimodal Analgesia in Perioperative Settings: Improvement Perspectives / Multimodāla Analgēzija Perioperatīvajā Periodā: Uzlabošanas Iespējas

Proceedings of the Latvian Academy of Sciences Section B Natural Exact and Applied Sciences ◽

10.2478/prolas-2014-0027 ◽

2014 ◽

Vol 68 (5-6) ◽

pp. 222-227

Author(s):

Iveta Golubovska ◽

Aleksejs Miščuks ◽

Ēriks Rudzītis

Keyword(s):

Pain Management ◽

Lower Extremity ◽

Pain Intensity ◽

Severe Pain ◽

Rating Scale ◽

Multimodal Analgesia ◽

Numeric Rating Scale ◽

Plexus Brachialis ◽

Single Shot ◽

Maximum Pain

Abstract The aim of this study was to evaluate the intensity of pain in orthopaedic hospital patients and to identify unsatisfactory pain management and possibilities for improvements in the future. Data collection included Numeric Rating Scale (NRS) scores, which characterised the intensity of pain. Maximum pain on the day of surgery, mean pain on the day of surgery (D0), and mean pain on first (D1) and second (D2) postoperative days were documented. The pain of an intensity from 0 to 3 was defined as mild pain, 4 to 6 as moderate pain, and 6 to 10 as severe pain. Maximum severe pain intensity on the day of surgery was experienced by 20.5% of patients, moderate by 45.8%, and mild by 33.6%. The reported mean pain intensity according to type of surgery was as follows: hip replacement- 2.79 ± 1.6 (D0), 2.09 ± 1.4 (D1), and 1.35 ± 1.2 (D2); knee replacement - 3.39 ± 1.7 (D0), 2.98 ± (D1), 1.82 ± 1.36, and (D2); upper extremity surgery - 3.59 ± 1.9 (D0), 3.4 ± 1.7 (D1), and 2.1 ± 1.5 (D2); lower extremity surgery - 4.1 ± 2.1 (D0), 3.49 ± 1.42 (D1), and 2.58 ± 1.4 (D2); spine surgery - 3.31 ± 1.58 (D0), 2.88 ± 1.96 (D1), and 1.83 ± 1.74 (D2). Patients in the lower extremity group experienced unacceptable mean pain. The maximum pain intensity on day of surgery was experienced by patients after single-shot plexus brachialis block anaesthesia (5.24 ± 2.4). Well-designed multimodal analgesia with special attention to single shot techniques may improve pain management and functional outcomes after orthopaedic surgery.

Download Full-text

Electroanalgesia during a carboxytherapy procedure for cellulite: a study protocol for a randomized controlled trial

Pain Management ◽

10.2217/pmt-2020-0003 ◽

2020 ◽

Vol 10 (5) ◽

pp. 283-290

Author(s):

Adria Yared Sadala ◽

Érika Patrícia Rampazo da Silva ◽

Richard Eloin Liebano

Keyword(s):

Pain Intensity ◽

Study Protocol ◽

Rating Scale ◽

Controlled Trial ◽

Numeric Rating Scale ◽

Secondary Outcome ◽

Electrical Currents ◽

Electrical Nerve Stimulation ◽

Interferential Current ◽

Clinical Trials Registry

The aim of the present study is to describe a study protocol to compare different types of analgesic electrical currents on pain intensity and sensory comfort during the application of carboxytherapy for the treatment of cellulite. Seventy five women with the presence of moderate and/or severe gluteal cellulite will be randomly allocated into three groups: carboxytherapy plus transcutaneous electrical nerve stimulation, carboxytherapy plus interferential current or carboxytherapy plus Aussie current. Pain intensity, which is the primary outcome, will be measured by a numeric rating scale (0–10). The secondary outcome is sensory comfort, which will be measured using the visual analogue scale (0–10). Trial registration: Brazilian Clinical Trials Registry: ReBEC (RBR-6z82zb) www.ensaiosclinicos.gov.br/rg/RBR-6z82zb/

Download Full-text

P030: Acute pain resolution after an emergency department visit: a 14-day trajectory analysis

CJEM ◽

10.1017/cem.2019.221 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S73-S74

Author(s):

R. Daoust ◽

J. Paquet ◽

A. Cournoyer ◽

E. Piette ◽

J. Morris ◽

...

Keyword(s):

Pain Intensity ◽

Acute Pain ◽

Linear Models ◽

Rating Scale ◽

Numeric Rating Scale ◽

The Other ◽

Future Research ◽

Intensity Level ◽

Opioid Prescription ◽

Mild Pain

Introduction: The objective of the study was to evaluate the acute pain intensity evolution in ED discharged patients using Group-based trajectory modeling (GBTM). This method identified patient groups with similar profiles of change over time without assuming the existence of a particular pattern or number of groups. Methods: This was a prospective cohort study of ED patients aged ≥18 years with an acute pain condition (≤ 2 weeks) and discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level (0-10 numeric rating scale) and pain medication use. Results: Among the 372 included patients, six distinct post-ED pain intensity trajectories were identified: two started with severe levels of pain, one remained with severe pain intensity (12.6% of the sample) and the other ended with moderate pain intensity level (26.3%). Two other trajectories had severe initial pain, one decreased to mild pain (21.7%) and the other to no-pain (13.8%). Another trajectory had moderate initial pain which decreased to a mild level (15.9%) and the last one started with mild pain intensity and had no pain at the end of the 14-day (9.7%). The pain trajectory patterns were significantly associated with age, type of painful conditions, pain intensity at ED discharge, and with opioid consumption. Conclusion: Acute pain resolution following an ED visit seems to progress through six different trajectory patterns that are more informative than simple linear models and could be useful to adapt acute pain management in future research.

Download Full-text