Use Of Adjuvant Medications Research Articles

Assessment of neuropathic pain management knowledge, attitudes, and practices among urology trainees and consultants in prostate cancer care: a survey-based study

BackgroundEffective neuropathic pain management is crucial in improving the quality of life for patients with prostate cancer. There is an abundance of research about cancer pain and guidelines that have been developed by World Health Organization including the analgesia stepladder, yet patients with cancer pain are still sub optimally analgesed. This is due to a variety of both patient and physician factors which include: lack of knowledge on the use of adjuvant medication, fear of addiction and poor characterization of the type of pain. This study intended to assess the knowledge, attitudes, and practices of urology trainees and consultants in the the context of neuropathic pain in prostatecancer care.MethodsThe study involved 91 urologists, comprising of junior registrars, medical officers and experienced specialists who are members of the South African Urological Association (SAUA). Data was collected through a 25-question web-based survey. The survey covered: demographic information, knowledge, attitudes, and practices related to cancer pain management.ResultsThe study revealed that a significant proportion of urologists assessed neuropathic pain reactively, with only 8% of respondents being familiar with screening scales. Approximately, one-third preferred referrals, and 74% expressed confidence in self-treatment. Concerns regarding opioid prescription were observed in 40.4% of respondents. Furthermore, the usage of adjuvant medications was limited, with only 35% proficiently combining analgesia and adjuvants. Notably, 65% continued to escalate analgesic monotherapy.ConclusionEffective neuropathic pain management in prostate cancer care necessitates a multidisciplinary approach, comprehensive assessment and expertise in adjuvant medication usage. The discrepancies observed among urologists are likely due to variations in experience levels. The study identifies knowledge gaps and suboptimal practices in neuropathic pain management among urologists. Addressing these issues through education, awareness, and interdisciplinary collaboration is imperative to enhance patient outcomes and improve the quality of life for individuals with prostate cancer. This study underscores the need for improved education and interdisciplinary collaboration among urologists in managing neuropathic pain among prostate cancer patients. Enhancing these aspects is essential to achieve better patient outcomes and overall quality of life.

Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal

The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown. To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool. This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks' gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024. Opioid treatment for NOWS and the ESC care approach. For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics. In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001). When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later. ClinicalTrials.gov Identifier: NCT04057820.

Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease.

Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.

How can the surgeon reduce recurrence after surgery for ileocolic Crohn's disease?

Disease recurrence after surgery for ileocolic Crohn's is common, and repeat surgery is necessary for approximately one-third of patients within ten years. This recurrence rate is influenced by many factors, some of which relate to the disease phenotype. Others may be influenced by the patient (i.e., smoking) or the gastroenterologist with careful disease monitoring and the judicious use of adjuvant medication. The surgeon may also be able to reduce recurrence in the both preoperative preparation of the patient, the timing of surgery, and the intra-operative surgical technique. Evidence of how the surgeon can influence recurrence is discussed in this manuscript, considering current definitions, pathophysiology, and risk factors for recurrence.

Six-year trends in postoperative prescribing and use of multimodal analgesics following total hip and knee arthroplasty: A single-site observational study of pain management.

Guidelines for acute postoperative pain management recommend administering analgesics in multimodal combination to facilitate synergistic benefit, reduce opioid requirements and decrease side-effects. However, limited observational research has examined the extent to which multimodal analgesics are prescribed and administered postoperatively following joint replacement. In this longitudinal study, we used three-point prevalence surveys to observe the 6-year trends in prescribing and use of multimodal analgesics on the orthopaedic wards of a single Australian private hospital. We collected baseline postoperative data from total hip and knee arthroplasty patients in May/June 2010 (Time 1, n=86), and follow-up data at 1year (Time 2, n=199) and 5years (Time 3, n=188). During the follow-up, data on prescribing practices were presented to anaesthetists. We found a statistically significant increase in the prescribing (p<0.001) and use (p<0.001) of multimodal analgesics over time. The use of multimodal analgesics was associated with lower rest pain (p=0.027) and clinically significant reduction in interference with activities (p<0.001) and sleep (p<0.001). However, dynamic pain was high and rescue opioids were likely under-administered at all time points. Furthermore, while patients reported high levels of side-effects, use of adjuvant medications was low. We observed significant practice change in inpatient analgesic prescribing in favour of multimodal analgesia, in keeping with contemporary recommendations. Surveys, however, appeared to identify a clinical gap in the bedside assessment and management of breakthrough pain and medication side-effects, requiring additional targeted interventions. Evaluation of 6-year trends in a large Australian metropolitan private hospital indicated substantial growth in postoperative multimodal analgesic prescribing. In the context of growing global awareness concerning multimodal analgesia, findings suggested diffusion of best-evidence prescribing into clinical practice. Findings indicated the effects of postoperative multimodal analgesia in real-world conditions outside of experimental trials. Postoperative multimodal analgesia in the clinical setting was only associated with a modest reduction in rest pain, but substantially reduced interference from pain on activities and sleep.

A retrospective chart review of outcomes resulting from a three-day tramadol taper for acute opioid withdrawal

The purpose of the study was to describe patient outcomes with a 3-day tramadol taper for acute opioid withdrawal on the detoxification unit at Summa Health System. The primary endpoint was the change in Clinical Institute Narcotic Assessment (CINA) score from the start of the taper until completion or discharge. Secondary endpoints were length of stay, use of adjuvant medications, taper completion rates, highest CINA score, adverse events, and 30-day readmission rates. A retrospective, quality improvement, cohort study was performed describing outcomes of opioid dependent patients in acute withdrawal admitted on the detoxification unit between September 2014 and September 2016 receiving the 3-day tramadol taper. All patients ≥18 years of age admitted for opioid dependence were included. Pregnant patients were excluded. Forty-five patients were included in the analysis. Patient ages ranged from 18-67 and 25 (55.6%) were male. The full taper was completed in 67.7% of admissions and 75.8% of patients were discharged by the physician. There was a statistically significant change of the pre-taper score compared to the score at completion or discharge in the per protocol group (-1.58, p = 0.010). There were no reported seizures or falls. The 3-day tramadol taper proved to be safe and effective therapy for treating acute opioid withdrawal. In the Summa Health System detoxification unit, patients treated with a 3-day tramadol taper for acute opioid withdrawal had their pre-taper CINA scores reduced by over 25% at the completion of the taper or discharge.

The Assessment and Treatment of Antipsychotic-Induced Akathisia.

Akathisia is a common and distressing neuropsychiatric syndrome associated with antipsychotic medication, characterised by subjective and objective psychomotor restlessness. The goal of this guideline is to provide clinicians with recommendations on the assessment and treatment of akathisia. We performed a systematic review of therapeutic studies assessing the treatment of antipsychotic-induced extrapyramidal symptoms. Forty studies on akathisia and 4 systematic reviews evaluating the adverse effects of antipsychotics were used in the formulation of recommendations. Studies were rated for methodological quality using the American Academy of Neurology Risk of Bias Classification system. The overall level of evidence classifications and grades of recommendation were made using the Scottish Intercollegiate Guidelines Network framework. As a good practice point, clinicians should systematically assess akathisia with a validated scale before starting antipsychotics and during antipsychotic dosage titration. For the management of akathisia, there was adequate evidence to allow recommendations regarding antipsychotic dose reduction, antipsychotic polypharmacy, switching antipsychotic medication, and the use of adjuvant medications including beta-blockers, anticholinergics, 5HT2A antagonists, benzodiazepines, and vitamin B6. The treatment of antipsychotic-induced akathisia should be personalised, with consideration of antipsychotic dose reduction, cessation of antipsychotic polypharmacy, and switching to an antipsychotic with a perceived lower liability for akathisia, before the use of adjuvant medications. The choice of adjuvant medications should favour the more established treatments, with careful consideration of contraindications and side effects. Limitations in the evidence should be acknowledged and prompt cautious prescribing, particularly with respect to the duration of use of adjuvant medications, is warranted.

A Naturalistic Evaluation of Change in Antidepressant Prescription in Patients With Affective and Anxiety Disorders in a Tertiary Care Hospital of India

Although many studies have evaluated prescription patterns, there is lack of information on the choice of antidepressants among patients who do not respond antidepressants. Similarly, information on switching strategies is also limited. This naturalistic study aimed to evaluate the switching strategies and preferred antidepressants by the psychiatrists among patients who do not respond to or who are not able to tolerate an antidepressant. A cross-sectional observational study design was followed. Patients diagnosed with affective and anxiety disorders, who were recommended a change in antidepressant, were recruited. Details of antidepressant before switching, antidepressants considered at the time of switching, coprescription advised at the time of switching, reasons considered for switching, and strategy advised at the time of switching were noted down. A total of 102 patients were recruited. The most common change strategy was selective serotonin reuptake inhibitor (SSRI) to a serotonin norepinephrine reuptake inhibitor (SNRI) (N = 42; 41.17%), and this was followed by SSRI to SSRI (N = 18; 17.64%) and SNRI to SSRI (N = 10; 9.8%). In majority of the patients (N = 79; 77.45%) cross-taper of older antidepressant with gradual increase in dose of newer antidepressants was followed. About 44.1% of the patients were on adjuvant medications at the time of considering change in antidepressants, and 37.25% of the patients were additionally started on some adjuvant medications during the change of antidepressants. The present study suggests that the most common strategy followed during change of antidepressant is from SSRI to SNRI and this is followed by SSRI to SSRI and SNRI to SSRI. Cross-taper switching strategy along with the use of adjuvant medications like benzodiazepines during the process of switching is most commonly followed.

Adjuvant analgesics in spinal surgery.

Peri- and postoperative pain control can present a challenge to any doctor, particularly in the setting of spinal surgery. The use of adjuvant pain agents and multimodal analgesia is changing the face of modern anaesthesia and offering clinicians more avenues to control perioperative pain. This article discusses the use of adjuvant medications and some of the evidence surrounding their use in spinal surgery.

Assessing Prescribing Trends of Adjuvant Medication Therapy in Outpatients With a Diagnosis of Noncancer Chronic Pain.

Chronic pain affects over 100 million adults in the United States, yet continues to be difficult to treat. Concerns continue to mount over the use of opioids to treat noncancer chronic pain (NCCP). Guidelines support the use of adjuvant medications as one of the preferred options for treating chronic pain over opioids. To examine reported usage of adjuvants in the treatment of chronic pain via the National Ambulatory Medical Care Survey (NAMCS). A retrospective, cross-sectional study evaluating reported usage of adjuvant pain medications for the treatment of NCCP was conducted using NAMCS data from 2000 to 2007. Weighted samples were analyzed with regard to several patient variables. Logistic regression models provided 95% confidence intervals and an adjusted odds ratio to determine statistically significant differences in reported usage for the evaluated patient variables. In total, 244,797,406 weighted visits were included for analysis. The analysis showed an almost 2-fold increase in adjuvant use during the study period. Statistically significant differences were identified for several factors evaluated. Younger age, female sex, care from a nonprimary care physician, comorbidities with pain, and >5 current medications were associated with higher rates adjuvant therapy use. Overall adjuvant usage dramatically increased during the study period. Analysis of data demonstrated adjuvant use in chronic pain varied based patient-specific characteristics. These results may allow clinicians, policy makers, and medical educators to identify potential gaps in adjuvant use in certain populations and target areas for clinical, populations-based, and educational improvements in managing NCCP.

Narcotic-only Epidural Infusion for Posterior Spinal Fusion Patients: A Single-Center, Retrospective Review.

Adequate and safe postoperative analgesia for patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) remains challenging and controversial. A past adverse event in this patient population triggered a change of our institution's practice from epidurals containing bupivacaine and has resulted in use of epidurals containing solely narcotic (hydromorphone) for postoperative analgesia. This retrospective review looks at our experiences with hydromorphone patient-controlled epidural analgesia for postoperative analgesia in this patient population. Electronic medical records of all children with a diagnosis of idiopathic scoliosis who underwent PSF surgery at our institution during the period of January 2011 to October 2011 were reviewed from the time they entered the PACU through the first 72 hours following PACU discharge. Specifically, the charts were reviewed for pain scores, sedation scores, narcotic use, use of adjuvant medications, antiemetics, antipruritics, hours to first ambulation, hours to first oral intake, respiratory rate, SpO2 values, need for any respiratory interventions, length of stay, and any adverse events. Fifty-six patients were enrolled. Three patients had their epidurals removed within the first 24 hours (5.4% failure rate). Highest mean pain scores ranged from 5.6±2.3 to 5.8±2.2 with median pain scores ranging from 4 to 6. There were no respiratory or neurological adverse events. Ambulation occurred on either postoperative day 1 or 2. The incidence of vomiting in this study was 34% in the first 24 hours post-PACU discharge and during this period, 61% of patients received ondansetron, for either nausea or pruritus. The mean length of stay for our patients was 3.95 days, with a median of 4 days. This retrospective review suggests that hydromorphone epidurals used for pain control in postoperative PSF patients are a reasonable alternative to IV-PCA, in terms of analgesia, side-effect profile, and length of stay. Level III-retrospective study.

Pediatric Oncology: Managing Pain at the End of Life.

Pain is a common and highly distressing symptom in pediatric patients with advanced malignancies. Prompt recognition, assessment, and treatment of pain are necessary, especially at the end of life. Opioid medications remain the mainstay of treatment of malignant pain in children at the end of life and the amount of opioids required for adequate pain control in patients is highly variable. Nonpharmacological approaches including behavioral and physical approaches in addition to non-opioid pain medications should be used when possible to augment pain control. Identification and treatment of any underlying pathology is important and use of adjuvant medications based on pathophysiology and source of pain should be considered. In cases where adequate pain control is not achieved through these multiple modalities, an interdisciplinary approach including potential interventional techniques and alternative treatments is required. This multimodal approach to pain management is best provided by interdisciplinary teams, as these teams can best address the complex causes of pain and associated distress that occurs in patients and within families.

Preventing Opioid Misuse and Potential Abuse: The Nurse's Role in Patient Education

Nurses play a vital role in providing patient education for proper use of opioids. This descriptive study was designed to explore nurses' knowledge of opioids. Nurses in two large urban East Coast medical centers in the United States were invited to participate in the study, and 133 nurses completed the survey in its entirety. Registered nurses' knowledge of and attitudes about opioid use were assessed using a 48-item web-based questionnaire sent via e-mail. Frequencies were computed for all items on the questionnaire. Chi-squared testing was used to analyze data for all questions that fewer than 50% of participants answered correctly. The results of this study revealed a pain management knowledge gap among nurses caring for patients who are receiving opioid analgesics. This gap includes patient assessment; pharmacologic management; use of adjuvant medications; risks of addiction; risks of respiratory depression; and disposal and storage of opioid analgesics. Only 25% of the nurses answered 50% of the survey questions correctly. Demographic variables such as experience working as a nurse and length of time as a nurse did not influence how nurses performed on the questionnaire, nor did educational level. However, nurses who received education on opioids as a separate class of medication answered a higher percentage of questions correctly than those who did not receive education on opioids. The results of this study reveal a knowledge gap and nurses' lack of sufficient information about opioids that may affect their ability to provide effective medication instructions to their patients.

Use of non-opioid analgesics as adjuvants to opioid analgesia for cancer pain management in an inpatient palliative unit: does this improve pain control and reduce opioid requirements?

Cancer pain is complex, and despite the introduction of the WHO cancer pain ladder, few studies have looked at the prevalence of adjuvant medication use in an inpatient palliative medicine unit. In this study, we evaluate the use of adjuvant pain medications in patients admitted to an inpatient palliative care unit and whether their use affects pain scores or opiate dosing. In this retrospective observational study, patients admitted to the inpatient palliative care unit over a 3-month period with a diagnosis of cancer on opioid therapy were selected. Data pertaining to demographics, diagnosis, oral morphine dose equivalent of the opioid at the time of discharge, adjuvant analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and pain scores as reported by nurses and physicians were collected. Seventy-seven patients were eligible over a 3-month period, out of which 65 (84 %) were taking an adjuvant medication. The most commonly prescribed adjuvant was gabapentin (70 %). Fifty-seven percent were taking more than one adjuvant. There were more women in the group receiving adjuvants (57 vs. 17%, p = 0.010). Those without adjuvants compared with those on adjuvants did not have worse pain scores on discharge as reported by physicians (0.8 ± 0.8 vs. 1.0 ± 0.7, p = 0.58) or nurses (2.0 ± 2.7 vs. 2.1 ± 2.6, p = 0.86). There was no difference in morphine equivalent doses of the opioid in both groups (median (min, max); 112 (58, 504) vs. 200 (30, 5,040)) at the time of discharge; 75-80 % of patients had improvement in pain scores as measured by a two-point reduction in numerical rating scale (NRS). This study shows that adjuvant medications are commonly used for treating pain in patients with cancer. More than half of study population were on two adjuvants or an adjuvant plus NSAID along with an opioid. We did not demonstrate any benefit in terms of improved pain scores or opioid doses with adjuvants, but this could reflect confounding variables and physician choice. Larger prospective studies are needed to define the opioid-sparing effects of adjuvants. Adjuvant agents are used in over 80 % of those treated for cancer pain.

Report of an HIV clinic-based pain management program and utilization of health status and health service by HIV patients

Current reports on human immunodeficiency virus (HIV) pain are limited to epidemiological data on neuropathic pain in HIV and most studies were conducted before the availability of highly active antiretroviral therapy. Complex pain was reported to be highly prevalent and associated with advanced disease. The authors conducted a retrospective review of the medical records of 81 patients from the Center for Positive Living (CPL) at Montefiore Medical Center who were newly referred to a pain management program in 2006 to identify the potential benefits of integrating a pain management team into the care of persons living with HIV and etiologies of pain. A standardized chart abstraction tool was used to capture clinical data. Data related to health service utilization and viral outcomes were obtained from the clinical information systems. The most common pain diagnoses were multiple syndromes, degenerative disc disease or spinal stenosis, and neuropathy. There was a decrease in emergency room utilization in the 12 months following an initial pain management appointment (p < 0.0001) and an increase in use of primary care (p = 0.0017). The use of adjuvant medications increased after intake into the pain clinic (p < 0.0001). Having an opioid dose in excess of 200 mg/d oral morphine equivalents and maintenance of each palliative care and infectious disease clinic appointment were inversely associated with viral loads in excess of 75 copies: odds ratio (OR) = 0.21 (95% confidence interval/CI], 0.11-0.44), OR = 0.77 (95% CI, 0.68-0.86), and 0.94 (95% CI, 0.93-0.99), respectively. The decrease in emergency room visits and increase in use of adjuvant analgesics and compliance with primary care and nonmedication approaches for the management of pain in the 12 months subsequent to initial palliative/pain clinic appointments highlight potential improved quality of care associated with the integration of a pain management team into the primary care of persons living with HIV disease.

A Multi-Center Analysis Evaluating Factors Associated with Spinal Cord Stimulation Outcome in Chronic Pain Patients

In addition to its conventional use as a treatment for refractory neuropathic extremity pain, spinal cord stimulation (SCS) has recently emerged as a possible treatment for visceral and arthritic pain. But concurrent with the expansion of possible conditions amenable to SCS, other studies have questioned the long-term efficacy of SCS for traditional indications. These disparate findings argue strongly for the refinement of selection criteria. The purpose of this study is to identify correlates of outcome for SCS. Data were retrospectively collected on 244 patients who underwent a SCS trial at two academic medical centers. Success was predefined as ≥50% pain relief sustained for ≥6 months. Variables analyzed for their association with outcome included demographics, location of pain, diagnosis, presence of coexisting diseases, pain descriptors, opioid and adjuvant medication use, duration and pain relief during trial, and complications. The presence of allodynia and/or hyperalgesia correlated with both a positive SCS trial (P = 0.01) and long-term implantation outcome (P = 0.05). History of substance abuse was associated with a negative permanent SCS outcome (P = 0.05) but bore no relationship to trial results. The variable most strongly associated with an SCS outcome was experiencing <50% pain relief during the trial, which strongly presaged a negative result (P < 0.001). Although weak associations with outcome were noted for several clinical variables, none was strongly associated with trial and permanent implantation results. The strongest predictor of a negative SCS outcome was obtaining <50% pain relief during the trial period.

Problem Drinking and Low-Dose Naltrexone-Assisted Opioid Detoxification

The influence of alcohol use on opioid dependence is a major problem that warrants a search for more effective treatment strategies. The addition of very-low-dose naltrexone (VLNTX) to methadone taper was recently associated with reduced withdrawal intensity during detoxification. In a secondary analysis of these data, we sought to determine whether problem drinking affects detoxification outcomes and whether symptoms are influenced by VLNTX use. Opioid-dependent patients (N = 174) received naltrexone (0.125 or 0.250 mg/day) or placebo in a double-blind, randomized design during methadone-based, 6-day inpatient detoxification. Alcohol consumption was assessed at admission using the Addiction Severity Index and selfreport. Outcome measures were opioid withdrawal intensity, craving, and retention in treatment. Problem drinking-opioid dependent patients (n = 79) showed episodic heavy alcohol use and reported increased subjective opioid withdrawal intensity (p = .001), craving (p = .001), and significantly lower rate of retention in treatment (p = .02). Individuals with problem drinking and opioid dependence who were treated with VLNTX (n = 55) showed reduced withdrawal (p = .05) and a lower rate of treatment discontinuation (p = .03), resuming alcohol intake in smaller numbers the day following discharge (p = .03). Treatment effects were more pronounced on anxiety, perspiration, shakiness, nausea, stomach cramps, and craving. There were no group differences in use of adjuvant medications and no treatment-related adverse events. Heavy drinking is associated with worse opioid detoxification outcomes. The addition of VLNTX is safe and is associated with reduced withdrawal symptoms and better completion rate in these patients. Further studies should explore the use of VLNTX in detoxification and long-term treatment of combined alcohol-opioid dependence and alcohol dependence alone.

Variation in Pain Medication Use in End-of-Life Care

Pain is a common and distressing symptom at the end of life that medications can help relieve. We sought to explore variation in approaches to pharmaceutical management of pain among hospice-eligible patients and to determine if variation was explained by patient or site of care characteristics. Variation in medication use may suggest areas for best practices or quality improvement in medication use in end-of-life care. We conducted a secondary analysis of randomized trial data, examining use of five medication classes: opiates, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant pain medications (tricyclics and antiseizure), stimulants, and antianxiety medications in 16 study sites nationwide. Descriptive statistics were generated for patient-level data and by site. Unadjusted and adjusted odds ratios were calculated to compare patient and location of care characteristics with each medication class use by site. We found variation in medication use was not predicted by most patient characteristics or location of care (home versus facility). Use of all types of pain medications decreased with age (odds ratio [OR] 0.75 [0.63-0.90]). Medication use varied between sites: a range of 14%-83% of patients were on different types of opiates, 0%-40% on NSAIDS, 20%-69% on benzodiazepines, 0%-25% on adjuvant medications, and 0%-23% were on acetaminophen at any time during the data collection period. Pain and adjuvant medication use differs widely by site of care. Further research is needed to determine the extent to which provider and patient choice contribute to prescribing variation, and to explore associations between patient symptoms, medication variation, and patient care quality.

Frequency, Indications, Outcomes, and Predictive Factors of Opioid Switching in an Acute Palliative Care Unit

The aim of this study was to prospectively evaluate the frequency, indications, outcomes, and predictive factors associated with opioid switching, using a protocol that had been clinically applied and viewed as effective for many years. A prospective study was carried out on a cohort of consecutive cancer patients who were receiving opioids but had an unacceptable balance between analgesia and adverse effects, despite symptomatic treatment of side effects. The initial conversion ratio between opioids and routes was as follows (mg/day): oral morphine 100 = intravenous morphine 33 = transdermal fentanyl 1 = intravenous fentanyl 1 = oral methadone 20 = intravenous methadone 16 = oral oxycodone 70 = transdermal buprenorphine 1.3. The switch was assisted by opioids used as needed, and doses were changed after the initial conversion according to clinical response in an acute care setting. Intensity of pain and symptoms associated with opioid therapy were recorded. A distress score (DS) was calculated as a sum of symptom intensity. A switch was considered successful when the intensity of pain and/or DS, or the principal symptom necessitating the switch, decreased to at least 33% of the value recorded before switching. One hundred eighteen patients underwent opioid substitutions. The indications for opioid switching were uncontrolled pain and adverse effects (50.8%), adverse effects (28.8%), uncontrolled pain (15.2%), and convenience (4.2%). Overall, 103 substitutions were successful. Ninety-six substitutions were successful after the first switching, and a further substitution was successful in seven patients who did not respond to the first switch. The mean time to achieve dose stabilization after switching was 3.2 days. The presence of both poor pain control and adverse effects was related to unsuccessful switching ( P < 0.004). No relationship was identified between unsuccessful switching and the opioid dose, opioid sequence, pain mechanism, or use of adjuvant medications. Opioid switching was an effective method to improve the balance between analgesia and adverse effects in more than 80% of cancer patients with a poor response to an opioid. The presence of both poor pain relief and adverse effects is a negative factor for switching prognosis, whereas renal failure is not.

CLINICAL STUDY: Very low dose naltrexone addition in opioid detoxification: a randomized, controlled trial

Although current treatments for opioid detoxification are not always effective, medical detoxification remains a required step before long-term interventions. The use of opioid antagonist medications to improve detoxification has produced inconsistent results. Very low dose naltrexone (VLNTX) was recently found to reduce opioid tolerance and dependence in animal and clinical studies. We decided to evaluate safety and efficacy of VLNTX adjunct to methadone in reducing withdrawal during detoxification. In a multi-center, double-blind, randomized study at community treatment programs, where most detoxifications are performed, 174 opioid-dependent subjects received NTX 0.125 mg, 0.250 mg or placebo daily for 6 days, together with methadone in tapering doses. VLNTX-treated individuals reported attenuated withdrawal symptoms [F = 7.24 (2,170); P = 0.001] and reduced craving [F = 3.73 (2,107); P = 0.03]. Treatment effects were more pronounced at discharge and were not accompanied by a significantly higher retention rate. There were no group differences in use of adjuvant medications and no treatment-related adverse events. Further studies should explore the use of VLNTX, combined with full and partial opioid agonist medications, in detoxification and long-term treatment of opioid dependence.