High opioid dosage rapid detoxification of cancer patient in palliative care with the Raffaeli model
Keywords:opioid, detoxification, cancer pain, tolerance, hyperalgesia, retrospective study
Background: Chronic opioid administration can induce adverse drug-dependent events and tolerance and/or hyperalgesia development. Opioid rotation is the treatment option in this case; however, it can expose patients to long periods of ineffectiveness and/or development of withdrawal syndrome, overdose, or adverse events. To overcome this issue, a method of rapid detoxification from opioids has been developed.
Aims: To assess feasibility and efficacy of our opioid detoxification protocol in patients affected from chronic cancer pain.
Settings/Patients: We studied 15 patients, with chronic cancer pain, who were afferent to Hospice of Rimini, Italy, were in therapy with high doses of opioid and needed opioid rotation or a therapeutic variation because of opioid toxicity, inefficacy, tolerance, or hyperalgesia. Each patient received a fixed dose of endovenous morphine and clonidine plus oral ketoprofen or ibuprofen, and oral lorazepam, if required, for at least 3 days, suspending the previous opioid therapy. We monitored withdrawal symptoms, pain intensity, type, and intensity of adverse events.
Results: Withdrawal symptoms were experienced by four (26.6 percent) patients. The average Numerical Rating Scale for pain decreased significantly (p < 0.05) from 8.3 ± 1.57 to 3.6 ± 1.4 at the end of the detoxification and to 2.4 ± 1 at the end of the rotation or therapeutic adjustment. Average duration of the detoxification was 6.86 ± 6.4 days (range 3-22).
Conclusions: The results suggested that the detoxification protocol may be effective in preventing withdrawal signs in patients needing a therapeutic change because of opioid-induced tolerance, hyperalgesia, or toxicity.
World Health Organization: Cancer Pain relief: With a Guide to Opioid Availability. Geneve, Switzerland: World Health Organization, 1996.
Quigley C: Opioid switching to improve pain relief and drug tolerability. Cochrane Database Syst Rev. 2004; (3): CD004847.
Estfan B, LeGrand SB, Walsh D, et al.: Opioid rotation in cancer patients: Pros and cons. Oncology. 2005; 19(4): 511-516.
de Stoutz ND, Bruera E, Suarez-Almazor M: Opioid rotation for toxocity reduction in terminal cancer patients. J Pain Symptom Manage. 1995; 10(5): 378-384.
Raffaeli W, Andruccioli J, Righetti D, et al.: Intraspinal therapy for the treatment of chronic pain: A review of the literature between 1990 and 2005 and suggested protocol for its rational and safe use. Neuromodulation. 2006; 9(4): 290-308.
Boisvert M, Cohen SR: Opioid use in avanced malignant disease: Why different centres use vastly different doses? A plea for standardized reporting. J Pain Symptom Manage. 1995; 10: 632-638.
Donovan KA, Taliaferro LA, Brock CW, et al.: Sex differences in the adequacy of pain management among patients referred to a multidisciplinary cancer pain clinic. J Pain Symptom Manage. 2008; 36(2): 167-172.
Apolone G, Corli O, Caraceni A, et al.: Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group. Br J Cancer. 2009; 100: 1566-1574.
Costantini M, Ripamonti C, Beccaro M, et al.: Prevalence, distress, management, and relief of pain during the last 3 months of cancer patient’s life. Results of an Italian mortality follow-back survey. Ann Oncol. 2009; 20: 729-735.
Villars P, Dodd M, West C, et al.: Differences in the prevalence and severity of side effects based on type of analgesic prescription in patients with chronic cancer pain. J Pain Symptom Manage. 2007; 33: 67-77.
Khan MI, Walsh D, Brito-Dellan N: Opioid and adjuvant analgesics: Compared and contrasted. Am J Hosp Palliat Care. 2011; 28(5): 378-383.
Likar R, Sittl R: Transdermal buprenorphine for treating nociceptive and neuropathic pain: four cases study. Anesth Analg. 2005; 100: 781-785.
Angst MS, Clarck JD: Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology. 2006; 104(3): 570-587.
Shaheen PE, Walsh D, Lasheen W, et al.: Opioid equianalgesic tables: Are they equally dangerous? J Pain Symptom Manage. 2009; 39(3): 409-417.
Riley J, Ross JR, Rutter D, et al.: No pain relief from morphine? Individual variation in sensitivity to morphine and the need to switch to an alternative opioid in cancer patients. Support Care Cancer. 2006; 14: 56-64.
Hyungsuk K, Clark D, Dionne RA: Genetic contribution to clinical pain and analgesia: Avoiding pitfalls in genetic research. J Pain. 2009; 10(7): 663-693.
Raffaeli W, Marconi G, Fanelli G, et al.: Opioid-related side-effects after intrathecal morphine: A prospective, randomized, double-blind dose-response study. Eur J Anaesthesiol. 2006; 23: 605-610.
Pasternak GW: Molecular biology of opioid analgesia. J Pain Symptom Manage. 2005; 29(5S): S2-S9.
O’Connor PG: Methods of detoxification and their role in treating patients with opioid dependence [editorial]. JAMA. 2005; 294: 961-963.
Gold MS: Opiate addiction and the locus coeruleus. The clinical utility of clonidine, naltrexone, methadone, and buprenorphine. Psychiatr Clin North Am. 1993; 16: 61-73.
Woody GE: Research findings on psychotherapy of addictive disorders. Am J Addict. 2003; 12 (Suppl 2): S19-S26.
O’Connor PG, Fiellin DA: Pharmacologic treatment of heroih-dependent patients. Ann Intern Med. 2000; 133: 40-54.
O’Connor PG: Methods of detoxification and their role in treating patients with opioid dependance. JAMA. 2005; 294(8): 961-963.
O’Connor PG, Kosten TR: Rapid and ultrarapid opioid detoxification techniques. JAMA. 1998; 279: 229.
Singh J, Basu D: Ultra-rapid opioid detoxification: Current status and controversies. J Postgrad Med. 2004; 50(3): 227-232.
Raffaeli W, Righetti D, Sarti D, et al.: Ziconotide: A rapid detoxification protocol for the conversion from intrathecal morphine–The Raffaeli Detoxification Model. J Opioid Manage. 2011; 7(1): 21-26.
Handelsman L, Cochrane KJ, Aronson MJ, et al.: Two new rating scales for opiate withdrawal. Am J Alcohol Abuse. 1987; 13: 293-308.
Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP: Validity of four pain intensity rating scales. Pain. 2011; 152: 2399-2404.
Shaheen PE, Legrand SB, Walsh D, et al.: Errors in opioid prescribing: A prospective survey in cancer pain. J Pain Symptom Manage. 2010; 39(4): 702-711.
Anderson R, Saiers JH, Abram S, et al.: Accuracy in equianalgesic dosing: Conversion dilemmas. J Pain Symptom Manage. 2001; 21: 397-406.
Gold MS: Opiate addiction and the locus coeruleus. The clinical utility of clonidine, naltrexone, methadone, and buprenorphine. Psychiatr Clin North Am. 1993; 16(1): 61-73.
Samuels ER, Szabadi E: Functional neuroanatomy of the noradrenergic locus coeruleus: Its roles in the regulation of arousal and autonomic function part I: Principles of functional organisation. Curr Neuropharmacol. 2008; 6(3): 235-253.
Joo DT: Mechanisms on opioid tolerance: Emerging evidence and therapeutic implications. Can J Anaesth. 2007; 54(12): 969-976.
Gatti A. Reale C, Luzi M, et al.: Effects of opioid rotation in chronic pain patients: ORTIBARN study. Clin Drug Investig. 2010; 30 (Suppl 2): 39-47.
Cherny NI: How to deal with difficult pain problems. Ann Oncol. 2005; 16 (Suppl 2): ii79-ii87.
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