Opioid rotation with extended-release opioids: where should we begin?

Opioid rotation is a common and necessary clinical practice in the management of chronic non-cancer pain to improve therapeutic efficacy with the lowest opioid dose. When dose escalations fail to achieve adequate analgesia or are associated with intolerable side effects, a trial of a new opioid should be considered. Much of the scientific rationale of opioid rotation is based on the wide interindividual variability in sensitivity to opioid analgesics and the novel patient response observed when introducing an opioid-tolerant patient to a new opioid. This article discusses patient indicators for opioid rotation, the conversion process between opioid medications, and additional practical considerations for increasing the effectiveness of opioid therapy during a trial of a new opioid. A Patient vignette that demonstrates a step-wise approach to opioid rotation is also presented

Burden of Illness Associated with Peripheral and Central Neuropathic Pain among Adults Seeking Treatment in the U nited S tates: A Patient‐Centered Evaluation

Objective The aim of this study was to evaluate patient‐reported burden associated with peripheral and central neuropathic pain ( NeP ) by pain severity and NeP condition. Design Six hundred twenty‐four subjects with one of six NeP conditions were recruited during routine office visits. Subjects consented to retrospective chart review and completed a one‐time questionnaire (including E uro Q ol‐5 dimensions, 12‐item S hort‐ F orm H ealth S urvey, B rief P ain I nventory‐ S hort F orm, M edical O utcomes S tudy S leep S cale, H ospital A nxiety and D epression S cale, and demographic and clinical characteristics). Pain severity scores were used to stratify subjects by mild, moderate, and severe pain. Summary statistics and frequency distributions were calculated. Differences by severity level were compared using K ruskal– W allis (continuous variables) and chi‐square or F isher's exact test (categorical variables). Effect size was computed with C ohen's d (mild vs severe). Results Subjects' mean age was 55.5. The majority (80.8%) had moderate or severe pain. Patient‐reported outcomes (health status, physical and mental health, pain interference with function, sleep, anxiety, and depression) were significantly worse among subjects with greater pain severity (all P  0.95) for all others. The observed burden was most substantial among chronic low back pain‐ NeP , although the pattern of disease burden was similar across the six NeP conditions. Conclusions Subjects across NeP conditions exhibited high pain levels, which were significantly associated with poor function, compromised health status and sleep, and increased anxiety and depression. Results indicate substantial patient burden across broad NeP , particularly among subjects with severe pain.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109996/1/pme12502.pd

Tramadol/paracetamol fixed-dose combination in the treatment of moderate to severe pain

Pain is the most common reason patients seek medical attention and pain relief has been put forward as an ethical obligation of clinicians and a fundamental human right. However, pain management is challenging because the pathophysiology of pain is complex and not completely understood. Widely used analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol (acetaminophen) have been associated with adverse events. Adverse event rates are of concern, especially in long-term treatment or at high doses. Paracetamol and NSAIDs are available by prescription, over the counter, and in combination preparations. Patients may be unaware of the risk associated with high dosages or long-term use of paracetamol and NSAIDs. Clinicians should encourage patients to disclose all medications they take in a "do ask, do tell" approach that includes patient education about the risks and benefits of common pain relievers. The ideal pain reliever would have few risks and enhanced analgesic efficacy. Fixed-dose combination analgesics with two or more agents may offer additive or synergistic benefits to treat the multiple mechanisms of pain. Therefore, pain may be effectively treated while toxicity is reduced due to lower doses. One recent fixed-dose combination analgesic product combines tramadol, a centrally acting weak opioid analgesic, with low-dose paracetamol. Evidence-based guidelines recognize the potential value of combination analgesics in specific situations. The current guideline-based paradigm for pain treatment recommends NSAIDs for ongoing use with analgesics such as opioids to manage flares. However, the treatment model should evolve how to use low-dose combination products to manage pain with occasional use of NSAIDs for flares to avoid long-term and high-dose treatment with these analgesics. A next step in pain management guidelines should be targeted therapy when possible, or low-dose combination therapy or both, to achieve maximal efficacy with minimal toxicit