Background:
Urinary retention is a poorly studied opioid-related adverse effect. There is a paucity of data regarding the treatment of such disturbance in patients with advanced cancer receiving ...opioids.
Actual case:
A young man, without comorbidities, was receiving 30 mg/day of oxycodone for abdominal pain due to pancreatic cancer, unsuccessfully. He also complained of severe urinary retention that developed after initiation of opioid therapy. Methadone therapy was effective on pain intensity, but bladder dysfunction persisted.
Possible courses of action:
Only anedoctal experience exists for opioid-induced urinary retention. The options included alpha-receptor blockers and flavoxate, which are symptomatic drugs, not addressed to the possible mechanism.
Formulation of a plan:
The use of a peripheral opioid antagonist was planned, according to the presumed mechanism of urinary retention. Thus, naldemedine 200 mcg was prescribed for relieving urinary retention.
Outcome:
The day after starting naldemedine, urinary retention completely reversed and pain was well-controlled.
Lessons:
The rational of using naldemedine was based on the component of opioid-induced urinary retention due to involvement of peripheral receptors in the bladder and sphincter.
View:
In this case report, the effect of the peripheral opioid antagonist was prompt and long-lasting. Future studies of this neglected adverse effect of opioids should be performed to confirm this observation.
Opinion statement
Opioid-induced neurotoxicity (OINT) is a neuropsychiatric syndrome observed with opioid therapy. The mechanism of OINT is thought to be multifactorial, and many risk factors may ...facilitate its development. If symptoms of OINT are seen, the prescriber should consider hydration, discontinuation of the offending opioid drug, or switching of opioid medication, or the use of some adjuvants. Multiple factors like inter- and intraindividual differences in opioid pharmacology may influence the accuracy of dose calculations for opioid switching. Experience and clinical judgment in a specialistic palliative care setting should be used and individual patient characteristics considered when applying any conversion table.
Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Although oral administration of opioids is generally ...preferable, a parenteral route may be advisable and mandatory in some clinical circumstances. Parenteral administration of opioids may accelerate the achievement of analgesia. The intravenous route fits the need of rapid achievement of analgesia in patients poorly responsive to other opioids and provides a fast analgesia in patients with breakthrough pain, that has a specific temporal pattern requiring a rapid analgesic effect. When the oral route is unavailable for the presence of nausea, vomiting, or dysphagia. the parenteral route is one of the principal options. Opioids have different pharmacokinetic and pharmacodynamic characteristics and should be chosen according to the individual needs. Thus, the knowledge and experience with these routes of administration are mandatory for anesthesiologists committed to cancer pain management.
In a recent study methadone has been reported more effective witha 3-day switch (3DS) was more effective than the stop and go strategy (SAG). Many shorcomings, however, are of concerns. The poor ...selection fo patients with low level of pain intensity, the incomprehensibile choice of of SAG or 3DS, and considerations reported in a previous controlled study with evident methodological limits, make their conclusion inaccurate. Controlled studies are fundamental in research. However, a pragmatic approach reflecting daily practice should be carefully taken into consideration. A more flexible use of SAG strategy and strict clinical observation to change doses according to the clinical response may provide the optimal treatment in patients receiving high doses of opioids.
Most patients with cancer pain can be managed with relatively simple methods using oral analgesics at relatively low doses, even for prolonged periods of time. However, in some clinical conditions ...pain may be more difficult to manage. Various factors can interfere with a desirable and favorable analgesic response. Data from several studies assessing factors of negative pain prognosis have indicated that neuropathic pain, incident pain, psychological distress, opioid addiction, and baseline pain intensity were associated with more difficult pain control. In this narrative review, the main factors that make the therapeutic response to opioids difficult are examined.
Abstract The older population continues to grow in all countries, and surgeons are encountering older patients more frequently. The management of postoperative pain in older patients can be a ...difficult task. Opioids are the mainstay of perioperative pain control. This paper assesses some pharmacokinetic age-related aspects and their relationship with the use of opioids in the perioperative period. Changes in body composition and organ function, and pharmacokinetics in older patients, as well as characteristics of opioids commonly used in the perioperative period are described. Specific problems, dose titration, and patient-controlled analgesia in the elderly are also reviewed. Opioids can be safety used in perioperative period, even in the elderly. The choice of drugs and doses can be individualized according to the surgery, opioid pharmacokinetics, comorbidities, and routes of administration.
This critical review assessed the advantages of invasive procedures that were recently included in systematic reviews, to evaluate whether the definition of refractory pain condition was correctly ...followed to select patients for invasive interventions and to analyze how data were positively interpreted. A total of 21 studies were selected for the purpose of this review. Three were randomized controlled studies, ten were prospective studies, and eight were retrospective studies. Analysis of these studies showed evident lack of proper assessment before implantation for different reasons. These included an optimistic interpretation regarding the outcomes, poor consideration of complications, and inclusion of patients with short survival. Moreover, the indication of intrathecal therapy as a condition in which a patient has failed to respond to multiple therapies provided by a pain or palliative care physician or at sufficient doses for adequate durations, as suggested by a recent research group, has been disregarded. Regretfully, this can discourage the use of intrathecal therapy in patients who are unresponsive to multiple opioid strategies subtrahend a potent means to be used in a very selective population.
The abuse of opioid drugs in the USA represents a real emergency which has led to increased pressure on the health care system. Apart from the fact that it is common observation to find casual use of ...opioids even after such procedures, an analytic review on the use of opioids for the treatment of chronic non-cancer pain has shown scientific evidence of the effectiveness of opioids in treating pain and of high variability in opioid dose requirements and side effects. ...this approach does not allow any dose titration based on patient needs and remains unclear about optimal components and their role in different surgical conditions and perioperative phases 15. A systematic review of the relative frequency and risk factors for prolonged opioid prescription following surgery and trauma among adults.
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