End of dose failure pain is breakthrough pain that develops because the dosing of the around-the-clock analgesic medication is scheduled too far apart in time. Pain emerges prior to the time that the next scheduled dose of analgesic medication is due. Although this may be difficult to predict for any given patient at the onset of therapy, patterns of pain can be detected. It is important to monitor pain symptoms in relation to the dosing schedule. Once a pattern of pain is detected, pain can be prevented by using sustained-release agents and changing dosing intervals as needed.
Incident pain is defined as pain directly related to an event or an activity performed by the patient. Examples of situations in which incident pain is initiated include: turning in bed, bearing weight, defecating, swallowing, ambulating, bathing, changing clothes, wound dressing changes and disimpaction. Often, incident pain is well defined and very predictable, so that physicians can treat the pain proactively by pre-medicating the patient just prior to the event.
Spontaneous breakthrough pain is an unpredictable and sporadic pain without clear relationships to particular events or procedures. This type of pain is difficult to treat because of its unpredictable nature and its fleeting character. In some cases, adjunctive analgesics effectively provide relief. According to a review of opioids for breakthrough pain by Smith, greater than 50% of breakthrough pain is spontaneous.
Could cannabinoid therapy modulate the production of excessive saliva in ALS patients?
Patients suffering from ALS have difficulty controlling and swallowing their saliva, often resulting in distress and inconvenience to patients. In a survey by Amtmann and colleagues, patients suffering from sialorrhea reported that cannabis was effective at reducing symptoms of drooling, although doses cannot be reliably extrapolated from a survey study of this kind. Cannabis is a potent anti-salivatory compound as its use is often correlated with the adverse effect of dry mouth in numerous clinical trials.
What does it mean to establish medical necessity in a patient who is being considered for opioid therapy?
It is essential to establish medical necessity prior to initiation of opioid therapy. In other words, the patient must have an appropriate diagnosis AND he/she must have failed other non-opioid based treatments, including adjuvant medications, physical therapy, behavioral therapy, and interventional therapy.
How can the effectiveness of opioid therapy be assessed?
There are several tools that can assist a clinician in evaluating the effectiveness of opioid therapy. The most obvious is pain relief or pain reduction, typically utilizing a numeric rating scale. It is also important to evaluate the patient’s functional activity. This can be done by asking questions about the patient’s activity level to determine if there has been any improvement. These activities may range from being able to conduct activities of daily living to returning to full-time employment. More formal functional assessments can be done, which includes questionnaires such as the Oswestry Disability Index and the Neck Disability Index.
Opioid-induced hyperalgesia is sensitization to nociceptive pain occurring after prolonged exposure to opioids. In this condition, a patient receiving opioid analgesics may paradoxically report increased sensitivity to certain nociceptive stimuli after starting treatment with opioids.
Pseudoaddiction refers to a state where inadequate analgesia results in drug-seeking behaviors that mimic addictive behaviors. These behaviors improve when pain is better controlled. Initially, it may be difficult to differentiate between pseudoaddiction and true addiction in clinical practice given that in both patient populations, the drug seeking behaviors stop, at least transiently, when the opioid dose is increased. However, patients with pseudoaddiction continue to show appropriate behaviors over extended periods when adequate analgesia is reached.
Koyyalagunta et al. reviewed randomized trials that had examined the efficacy of opioids for cancer pain. The authors of that review concluded that there is evidence which supports fentanyl as an analgesic for patients with cancer pain. Fentanyl was found to improve pain scores and quality of life while also resulting in less constipation compared to morphine.