Management Of Noncancer Pain Research Articles

Perspective of Pain Clinicians in Three Global Cities on Local Barriers to Providing Care for Chronic Noncancer Pain Patients.

An increasing proportion of the global chronic pain population is managed through services delivered by specialized pain clinics in global cities. This paper describes the results of a survey of pain clinic leaders in three global cities on barriers influencing chronic noncancer pain (CNCP) management provided by those clinics. It demonstrates a pragmatic qualitative approach for characterizing how the global city location of the clinic influences those results. A cross-sectional prospective survey design was used, and data were analyzed using quantitative and qualitative content analysis. Key informants were pain clinicians (n = 4 women and 8 men) responsible for outputs of specialized pain clinics in academic hospital settings in three global cities: Toronto, Kuwait, and Karachi. Krippendorff's thematic clustering technique was used to identify the repetitive themes in the data. All but one of the key informants had their primary pain training from Europe or North America. In Kuwait and Karachi, pain specialists were anesthesiologists and provided CNCP management services independently. In Toronto, pain clinic leaders were part of some form of the multidisciplinary team. Using the results of a question that asked informants to list their top three barriers, ten themes were identified. These themes were artificially organized in three thematic domains: infrastructure, clinical services, and education. In parallel, 31 predefined barriers identified from the literature were scored. The results showed variation in perception of barriers that not only depended on the clinic location but also demonstrated shared experiences across thematic domains. This study demonstrates a simple methodology for informing global and local efforts to improve access to and implementation of CNCP services globally.

Magnesium for the Management of Chronic Noncancer Pain in Adults: Protocol for a Systematic Review.

BackgroundChronic pain is a highly prevalent and complex health problem that is associated with a severe symptom burden, as well as substantial economic and social impact. Many patients with chronic pain still suffer from unrelieved or undertreated pain due to the incomplete efficacy and dose-limiting adverse effects of current therapies. Long-term and high-dose opioid use has considerably increased in the past 20 years despite limited evidence supporting its effectiveness in several chronic pain conditions, and serious concerns have emerged regarding adverse effects and potential misuse. Until recently, the steady increase in opioid prescribing rates has been associated with rising opioid-related mortality and other serious problems, emphasizing the need for better nonopioid therapies. Emerging evidence supports the safe use of magnesium in controlling chronic pain, but its overall efficacy and safety is still unclear.ObjectiveThis paper aims to assess the efficacy and safety of magnesium compared with a placebo for the treatment of chronic noncancer pain.MethodsWe will conduct a detailed search on Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from their inception until the date the searches are run to identify relevant randomized controlled trials. The reference lists of retrieved studies as well as Web-based trial registries will also be searched. We will include randomized double-blind trials comparing magnesium (at any dose, frequency, or route of administration) with placebo using participant-reported pain assessment. Two reviewers will independently evaluate studies for eligibility, extract data, and assess trial quality and potential bias. Risk of bias will be assessed using criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes for this review will include any validated measure of pain intensity or pain relief. Dichotomous data will be used to calculate the risk ratio and number needed to treat or harm. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.ResultsThis protocol is grant-funded and has undergone a peer-review process through the Queen’s University Department of Anesthesiology and Perioperative Medicine Vandewater Endowed Studentship. This project is also supported, in part, by the Chronic Pain Network of the Canadian Institutes of Health Research Strategy for Patient-Oriented Research. The electronic database search strategies are currently being developed and modified. The entire review is expected to be completed by January 1, 2019.ConclusionsThe completion of this review is expected to identify available high-quality evidence describing the efficacy and safety of magnesium for the treatment of chronic noncancer pain.International Registered Report Identifier (IRRID)PRR1-10.2196/11654

Understanding the evidence for medical cannabis and cannabis-based medicines for the treatment of chronic non-cancer pain.

The use of medical cannabis and cannabis-based medicines has received increasing interest in recent years; with a corresponding surge in the number of studies and reviews conducted in the field. Despite this growth in evidence, the findings and conclusions of these studies have been inconsistent. In this paper, we outline the current evidence for medical cannabis and cannabis-based medicines in the treatment and management of chronic non-cancer pain. We discuss limitations of the current evidence, including limitations of randomised control trials in the field, limits on generalisability of previous findings and common issues such as problems with measurements of dose and type of cannabinoids. We discuss future directions for medicinal cannabinoid research, including addressing limitations in trial design; developing frameworks to monitor for use disorder and other unintended outcomes; and considering endpoints other than 30% or 50% reductions in pain severity.

Opioid utilization patterns among patients with cancer and non-cancer pain.

Opioid pain medication continues to be an important treatment option for patients with moderate to severe cancer and non-cancer pain; however, limited evidence is available regarding differences in opioid use between these two populations. The objective of this analysis was to compare real-world opioid use patterns over time in these two populations. Retrospective analysis of administrative claims data. HealthCore Integrated Research Environment database. Adults with ≥1 opioid pharmacy claim (and a confirmed cancer diagnosis for the cancer pain cohort). Opioid doses and dose changes following the initial prescribed (index) dose were determined. In the cancer pain (n = 9,209) and non-cancer pain (n = 409,703) cohorts, median index opioid doses were 51.7 and 45.0 morphine-equivalent units (MEU), respectively, and median post-index opioid doses were 55.8 and 45.1 MEU for the cancer pain and non-cancer pain cohorts, respectively. The most common dose escalation in both groups was up to a dose doubling (cancer pain, 31.8 percent; non-cancer pain, 28.3 percent). The proportions of patients with dose increases exceeding two times the index dose were low and clinically comparable between cohorts (cancer pain, 9.9 percent; non-cancer pain, 7.4 percent). Opioid use was consistent between patients with cancer pain and non-cancer pain, including clinically comparable total daily opioid doses and consistent rates of dose escalations and chronic utilization. Opioid medications are an important element of cancer and non-cancer pain management; thus, access to appropriate therapies, use patterns, and risk assessment and management are important for both patient populations.

<p>General practitioners and management of chronic noncancer pain: a cross-sectional survey of influences on opioid deprescribing</p>

BackgroundGeneral practitioners’ (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs’ beliefs about deprescribing, including their decisions to deprescribe different types of POAs.AimTo determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing.Design and settingIn 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken.MethodsA mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone.ResultsA response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples’ long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient.ConclusionsMany GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately.

Methadone – demystifying an old pain killer

Methadone is a µ-opioid receptor agonist and NMDA recep­tor antagonist which is often indicated for the management of severe refractory cancer or non-cancer pain, as well as for opioid addiction. This two-part article provides an overview of methadone use in pain management, and its use in opioid addiction will not be covered here. Metha­done has several advantages over other opioids. These ad­van­ta­ges include extended analgesic activity, multiple routes of administration, longer bioavailability, lack of ac­tive metabolites, predominantly intestinal excretion, and its relatively low cost compared to other opioids. This makes methadone an appealing option for patients with impaired creatinine clearance and for those facing finan­cial constraints in obtaining medications. On the other hand, there are notable concerns with this medication that make its use more complex than of other opioids. Metha­done has a variable individual plasma half-life that can lead to ac­cu­mu­lation and toxicity, and extensively utilizes cyto­chrome CYP450, therefore its metabolism can be affected when used in conjunction with inducers and especially in­hi­bi­tors of this cytochrome system. Methadone has also variable and quite complicated conversion formulas when transitioning from other opioids. Additionally, there is a risk for abuse that can lead to accidental overdose or even death. Finally, metha­done can cause QT interval pro­lon­ga­tion that may result in dangerous cardiac arrhythmias such as torsades de points and ventricular tachyarrhythmia. Des­pite its mul­­ti­­ple advantages in pain control, cautionary mes­sages from the European Association for Palliative Care (EAPC) and Na­­tio­­nal Comprehensive Cancer Network (NCCN) ad­vise for use of methadone only by experienced clinicians. It is highly re­­com­­mended that patients are counseled exten­sively on me­tha­­done safety use due to its numerous risks.

Patient and provider characteristics associated with communication about opioids: An observational study

ObjectiveOur objective is to examine the relationship of patient and provider characteristics and communication with chronic non-cancer pain and opioid management in primary care. MethodWe conducted an observational study using audio-recorded primary care appointments (up to 3/patient) and self-reported assessments of primary care providers (PCPs) and patients. We coded visit transcripts for 1) opioid and pain management talk and 2) mental health and opioid safety talk. ResultsEight PCPs and 30 patients had complete data for 78 clinic visits. PCPs and patients engaged in more opioid and pain management talk when patients reported greater pain catastrophizing and PCPs reported higher psychosocial orientation. PCPs and patients engaged in talk about mental health and opioid safety when patients reported greater anxiety, higher working alliance with their PCP, and when PCPs reported higher burnout. PCPs’ negative attitudes about opioids were associated with fewer discussions about mental health and opioid safety. ConclusionsOur results should facilitate design of interventions that improve communication and, ultimately, pain outcomes for patients. Practice ImplicationsClinicians can use our results to increase patient engagement in discussions about opioid use and pain management or mental health and safety discussions.

Patients’ and clinicians’ perspectives of co-use of cannabis and opioids for chronic non-cancer pain management in primary care

BackgroundThe prevalence of opioid-associated morbidity and mortality underscores the need for research on non-opioid treatments for chronic non-cancer pain (CNCP). Pain is the most common medical condition for which patients request medical cannabis. Limited research indicates that patients are interested in cannabis as a potential addition to or replacement for opioid medication. This analysis reports on CNCP patient and clinician perceptions about the co-use of cannabis and opioids for CNCP management. MethodsWe interviewed 23 clinicians and 46 CNCP patients, using semi-structured interview guides, from six safety-net clinics across the San Francisco Bay Area, and 5 key stakeholders involved in CNCP management. We used a modified grounded theory approach to code and analyze transcripts. ResultsCNCP patients described potential benefits of co-use of cannabis and opioids for pain management and concerns about dosing and addictive potential. Patients reported seeking cannabis when unable to obtain prescription opioids. Clinicians stated that their patients reported cannabis being helpful in managing pain symptoms. Clinicians expressed concerns about the potential exacerbation of mental health issues resulting from cannabis use. ConclusionClinicians are hampered by a lack of clinically relevant information about cannabis use, efficacy and side-effects. Currently no guidelines exist for clinicians to address opioid and cannabis co-use, or to discuss the risk and benefits of cannabis for CNCP management, including side effects. Cannabis and opioid co-use was commonly reported by patients in our sample, yet rarely addressed during clinical CNCP care. Further research is needed on the risks and benefits of cannabis and opioid co-use.

Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review

BackgroundEvidence from diverse areas of medicine (e.g., cardiovascular disease, diabetes) indicates that healthcare providers (HCPs) often do not adhere to clinical practice guidelines (CPGs) despite a clear indication to implement recommendations—a phenomenon commonly termed clinical inertia. There are a variety of reasons for clinical inertia, but HCP-related factors (e.g., knowledge, motivation, agreement with guidelines) are the most salient and amenable to intervention aimed to improve adherence. CPGs have been developed to support the safe and effective prescription of opioid medication for the management of chronic non-cancer pain. The extent of physician uptake and adherence to such guidelines is not yet well understood. The purpose of this review is to synthesize the published evidence about knowledge, attitudes, beliefs, and practices that HCPs hold regarding the prescription of opioids for chronic non-cancer pain.MethodsAn experienced information specialist will perform searches of CINAHL, Embase, MEDLINE, and PsycINFO bibliographic databases. The Cochrane library, PROSPERO, and the Joanna Briggs Institute will be searched for systematic reviews. Searches will be performed from inception to the present. Quantitative and qualitative study designs that report on HCP knowledge, attitudes, beliefs, or practices in North America will be eligible for inclusion. Studies reporting on interventions to improve HCP adherence to opioid prescribing CPGs will also be eligible for inclusion. Two trained graduate-level research assistants will independently screen articles for inclusion, perform data extraction, and perform risk of bias and quality assessment using recommended tools. Confidence in qualitative evidence will be evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews (GRADE-CERQual) approach. Confidence in quantitative evidence will be assessed using the GRADE approach.DiscussionThe ultimate goal of this work is to support interventions aiming to optimize opioid prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a HCP’s ability to select the most appropriate treatment for an individual patient.Systematic review registrationPROSPERO CRD42018091640.

Patient Reported Outcomes in Women With IBS Using Opioids for Chronic Non-Cancer Pain: ACG/Radhika Srinivasan Gender-Based Research Award: Presidential Poster Award

Introduction: Opioids can reduce gut motility, causing a number of adverse GI effects including vomiting, nausea, and constipation. These side effects are further exacerbated in individuals with functional bowel disorders such as IBS. Consequently, opioids are not recommended to treat pain in IBS. Yet, opioids continue to be prescribed at alarming rates particularly for chronic noncancer pain, and there is limited research on the extent to which an IBS diagnosis would discourage a clinician from prescribing narcotics to a patient. We sought to better understand opioid use and health outcomes in women with chronic noncancer pain and comorbid IBS. Methods: Cross-sectional data on comorbidities, current medication use, and patient-reported outcomes relating to physical health, mental health, and pain interference was collected as part of a larger study assessing patient preferences for chronic noncancer pain management. We conducted a subgroup analysis on respondents who selected IBS as a comorbidity (N = 209), restricting the sample to females (N = 194) due to insufficient male response (N = 15). Linear regressions were used to examine differences in PROMIS t-scores for mental health, physical health, and pain interference among opioid users and non-users, after adjusting for age and ethnicity. Results: 42.8% of female respondents with chronic pain and comorbid IBS reported currently using opioids compared to 36.3% of women without IBS (p = 0.107). Respondents had mean t-scores of 38, 32, and 64 for mental health, physical health, and pain interference, respectively. Adjusting for age and ethnicity, women using opioids reported lower PROMIS mental health scores (B = -4.37; p = 0.018) and physical health scores (B = -3.15; p < 0.001) than those not using opioids. Pain interference did not differ between women using opioids and those not using opioids, independent of age and ethnicity (p = 0.652).Conclusion: Opioid use in women with chronic pain and comorbid IBS was associated with reduced mental and physical health. Pain interference was higher than the general population for women with comorbid IBS, with no improvement in pain interference observed as a result of opioid use. Despite this, women with IBS using opioids to treat a primary pain condition reported similar rates of opioid use as respondents without IBS, indicating that an IBS diagnosis may not discourage opioid prescribing. Further research should investigate the risks and benefits of opioid use in women with chronic pain and IBS.460_A Figure 1. Mean mental health t-score as measured by PROMIS Global Health for women with comorbid IBS currently using opioids and those not using opioids.460_B Figure 2. Mean physical health t-score as measured by PROMIS Global Health for women with comorbid IBS currently using opioids and those not using opioids.460_C Figure 3. Mean pain interference t-score as measured by PROMIS Pain Interference for women with comorbid IBS currently using opioids and those not using opioids.

Integrating Patient-Controlled Analgesia Using Implanted Intrathecal Pumps for Postoperative Pain Management: A Case Report.

Intrathecal patient-controlled analgesia (IT-PCA) through implanted intrathecal infusion pumps has been increasingly utilized for severe cancer and chronic noncancer pain management. However, its application for acute postoperative pain management has not been reported to date. We present a case of a patient with an implanted intrathecal pump for chronic nonmalignant back pain who underwent an extensive spinal fusion surgery. The IT-PCA functionality of her intrathecal pump was successfully integrated into her postoperative multimodal pain regimen. Hence, IT-PCA can be safely incorporated into acute postoperative pain management with vigilant monitoring and close multidisciplinary collaboration.

Chronic pain management and the development of opioid use disorder

Chronic pain is a common condition that impacts quality of life and often precipitates the need for medical attention. Despite evidence that long-term opioid use provides limited relief, prescription opioid therapy remains a cornerstone in the medical management of chronic non-cancer pain. Presently, 13% of Canadians are prescribed opioids for pain management, and physicians play a crucial role in preventing the development of opioid use disorders. However, Canadian physicians lack knowledge of and comfort with evidence-based principles of opioid stewardship. In this article, we aim to highlight ongoing Canadian efforts to address physician discomfort and improve clinical practice. We focus on 2017 Canadian guidelines that provide clinicians with evidence-based recommendations for opioid use in chronic non-cancer pain management. In addition, we call attention to provincial efforts to implement physician accountability measures. In reviewing the existing literature, we uncovered inadequacies in pain management curricula within the Canadian undergraduate and continuing medical education (CME) systems. We consulted the educational practices of the European Pain Federation and the Centers for Disease Control and Prevention to make recommendations for improvement to current Canadian pain curricula. Based on our findings, we recommend that (1) Canadian medical institutions expand upon current core pain curricula, (2) pain management education be made compulsory, (3) academic detailing be emphasized as a means of CME, and (4) multidisciplinary non-medical management of chronic pain be featured more extensively.

Updates on chronic non-cancer pain management in face of the opioid crisis

Chronic pain not associated with malignancy is experienced by a significant proportion of the Canadian population. As the quality of life and physical functioning are markedly impaired in patients with chronic non-cancer pain, clinicians have commonly turned to opioid therapy for pain management. Since the 1990s, the steady increase in dispensing of prescription opioids has paralleled trends in opioid-related hospitalizations, overdoses, and fatalities. In fact, over-prescription and longterm opioid therapy are among the many root causes fueling Canada’s rise in opioid addiction and opioid-related deaths. Physicians and medical regulators have responded to this public health crisis by developing the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. The new evidence-based guideline aims to encourage safe prescribing practices, reduce and eliminate the use of opioid analgesics and promote non-opioid pharmacotherapy. While clear clinical guidelines will optimize physician prescribing patterns, it is imperative to recognize the need for non-pharmacological modalities for pain management, treatment, and care to holistically address the complex roots of opioid abuse.

Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines.

Pain is common among hospitalized patients. Inpatient prescribing of opioids is not without risk. Acute pain management guidelines could inform safe prescribing of opioids in the hospital and limit associated unintended consequences. To evaluate the quality and content of existing guidelines for acute, noncancer pain management. The National Guideline Clearinghouse, MEDLINE via PubMed, websites of relevant specialty societies and other organizations, and selected international search engines. Guidelines published between January 2010 and August 2017 addressing acute, noncancer pain management among adults were considered. Guidelines that focused on chronic pain, specific diseases, and the nonhospital setting were excluded. Quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Four guidelines met the selection criteria. Most recommendations were based on expert consensus. The guidelines recommended restricting opioids to severe pain or pain that has not responded to nonopioid therapy, using the lowest effective dose of short-acting opioids for the shortest duration possible, and co-prescribing opioids with nonopioid analgesics. The guidelines generally recommended checking the prescription drug monitoring program when prescribing opioids, developing goals for patient recovery, and educating patients regarding the risks and side effects of opioid therapy. Additional recommendations included using an opioid dose conversion guide, avoidance of co-administration of parenteral and oral opioids, and using caution when co-prescribing opioids with other central nervous system depressants. Guidelines, based largely on expert opinion, recommend judicious prescribing of opioids for severe, acute pain. Future work should assess the implications of these recommendations on hospital-based pain management.

A Pharmacological Rationale to Reduce the Incidence of Opioid Induced Tolerance and Hyperalgesia: A Review.

Chronic pain is an important health and social problem. Misuse and abuse of opioids in chronic non-cancer pain management seem to be a huge problem, in some countries. This could probably affect the normal use of such analgesics in patients in need of them. Basic and clinical researches should find the solution to mitigate the potential damage. Dysregulation of mast cell and microglia activation plays an important role in the pathogenesis and management of chronic pain. Persistent mast cell activation sensitizes nociceptors and initiates central nervous system inflammatory processes, involving microglial cell activation and sensitization of spinal somatosensory neurons. Exposure of mast cells and microglia to opioids is well known to provoke activation of these non-neuronal immune cell populations, thereby contributing to an exacerbation of pro-inflammatory and pro-nociceptive processes and promoting, over the long-term, opioid-induced hyperalgesia and tolerance. This review is intended to provide the reader with an overview of the role for these non-neuronal cells in opioid-induced chronic pain and tolerance as a consequence of prolonged exposure to these drugs. In addition, we will examine a potential strategy with the aim to modulate opioid-induced over-activation of glia and mast cells, based on endogenous defense mechanisms and fatty acid amide signaling molecules.

Intrathecal drug delivery for management of cancer and noncancer pain

Intrathecal drug delivery (ITDD) has been an option for the management of persistent pain since the 1980s. The discovery of opioid receptors in the central nervous system was the impetus for early attempts to deliver opioids intraspinally. Approximately, 10-20 percent patients with cancer pain get inadequate analgesia from conventional medical management; this group particularly may benefit from ITDD. However, there is also some evidence for the use of ITDD in those with noncancer pain. This review presents options for ITDD, available drugs, evidence for efficacy, principles of patient selection, and problems with the intrathecal route.

Do pain specialists meet the needs of the referring physician? A survey of primary care providers

To study the factors that influence the use of opioids in the management of chronic noncancer pain (CNCP) by primary care providers (PCPs) for patients returning from a pain specialist. A survey of PCPs. Two physician groups in the Minneapolis-St. Paul metropolitan area. Two seventy-six PCPs surveyed and 80 surveys returned. Participants rated the importance of specific concerns regarding the role of pain specialists and the use of opioids in the management of CNCP. Past experience with pain specialists, comfort using opioids, and opinions regarding a trilateral opioid agreement were also examined. The top concerns for PCPs were as follows: the use of opioids in patients with chemical dependency or psychological issues, the escalation of opioid dosing, and the use of opioids in pain states without objective findings. They also ranked highly the importance of coordinating the return of patients from a pain specialist with explicit opioid instructions and the availability of consultation by phone or a timely follow-up visit. PCPs were supportive of the concept of a trilateral opioid agreement. PCPs have significant concerns regarding the prescribing of opioids in CNCP. They desire closer collaboration with pain specialists, including more explicit plans of care when patients are transferred back to them. The trilateral agreement may provide one framework for better collaboration.

Oxymorphone and oxymorphone extended release: A pharmacotherapeutic review

The treatment of chronic pain remains an enormous challenge in the United States. Opioid analgesics are an important component of pharmacotherapy for chronic pain and have proven efficacy in the management of cancer and noncancer chronic pain. The newest addition to oral opioid pharmacotherapy is oral oxymorphone, a semisynthetic opioid agonist that is now available in oral immediate-release (IR) and extended-release (ER) formulations. This review discusses the pharmacology, pharmacokinetics, pharmacodynamics, pharmacotherapeutics, and clinical use of oral oxymorphone IR and ER formulations for the management of moderate to severe pain for different types of patients in a variety of settings. Two published studies evaluated the efficacy and safety of oxymorphone IR in patients with moderate to severe postoperative pain and demonstrated that it provides rapid and effective analgesia and is generally well tolerated. Six published randomized controlled trials and three published open-label studies evaluated the efficacy and safety of oxymorphone ER for chronic cancer or noncancer pain. These trials found analgesic efficacy and tolerability comparable to that provided by morphine controlled release (CR) or oxycodone CR; treatment effects with oxymorphone ER were durable for treatment periods of 12 weeks at the same dose or up to 1 year with little dose escalation. Titrated doses of oxymorphone ER were effective and generally well tolerated in both opioid-experienced and opioid-naïve patients. Aspects of oxymorphone metabolism and limited protein binding may simplify treatment in certain populations.

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease