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Cancer related pain is prevalent among patients with a cancer diagnosis, occurring from the tumor itself or as a result of treatment. Many patients require opioid therapy to manage pain and providers must balance efficacy with side effects. Transdermal buprenorphine (TDB) has shown promise for pain management, however, the maximum dose available in the US is considered low, resulting in doubts of efficacy. This study set out to assess if the patch strengths available in the US (5-20 mcg/hour) are able to provide analgesia for patients with cancer in a palliative medicine clinic. This retrospective chart review analyzed patient charts for outpatient TDB use within a palliative medicine clinic in the United States. Patients had to have a follow up visit with the clinic in order to be included. Sixty-eight patients were included for analysis with 54 (79%) continuing at least 28 days and 37 (54%) continuing for at least 84 days. The median change in pain score was 0, though 25 (46%) of patients reported a decrease of 1 or more points at the first follow up. TDB is a viable option for cancer related pain for select patients, demonstrated by duration of use and stable reporting of pain.

Context: Treatment-induced mucositis commonly affects cancer patients, and ketamine oral rinse solution has shown efficacy for refractory pain. Although intranasal ketamine as systemic therapy has previously been studied, there are no reports on intranasal ketamine spray for topical pain treatment. Objective: To present the novel use of atomized intravenous ketamine solution for topical treatment of sinonasal mucositis pain. Patient case: A patient with sinonasal undifferentiated carcinoma presented with refractory treatment-related intranasal mucositis pain. Following initiation of atomized ketamine solution delivered topically into the nostrils, pain improved, and opioid use decreased. After dose adjustment for confusion, the patient continued ketamine therapy for several weeks with good effect. Conclusion: Atomized ketamine solution delivered intranasally may be a safe and effective topical treatment for mucositis pain of the sinuses. Interpretation of safety of the initial dosing used was affected by several confounding factors. However, a reduced dose appeared efficacious and was well tolerated.

Opioid tapering is an essential clinical tool to utilize for a variety of reasons, including safety and analgesic optimization. The need for individualized regimens reveals a corresponding need for healthcare providers who can actively manage patients throughout the process. Pharmacists have taken on an integral role for achieving success in opioid tapering. This survey was conducted to describe the current opioid tapering practices of pain and palliative care pharmacists. A Qualtrics survey was offered to the Society of Pain and Palliative Care Pharmacist members. The majority (87%) indicated they specialized in pain management. Almost all respondents (98%) reported providing tapering recommendations and 82% reported being involved with patient monitoring throughout the taper. The majority (multiple responses could be chosen) noted that the indication for initiating an opioid taper was due to abuse/misuse (91%), reduced overall efficacy (89%), and adverse drug reactions (78%). The most common follow-up intervals during tapering were weekly (15%), every 2 weeks (22%), and every 4 weeks (44%). This practice-based survey, though small, showed that pharmacists in pain management and palliative care are actively involved in opioid tapering. This survey will hopefully serve as a foundation for continuing research into opioid tapering and the pharmacist's role therein.

Although constipation and respiratory depression are the adverse effects that clinicians most often associate with opioids, several others can negatively influence palliative care patient experiences and outcomes. For example, pruritus can result in refusal to take opioids, resulting in increased symptom burden. Some palliative care patients will be on long-term opioids, and evidence of long-term adverse effects continue to emerge, including endocrine dysfunction, immunosuppression, and decreased bone mineral density. In this chapter, research into these adverse effects is reviewed along with treatment recommendations. The scarcity of high-quality research studies into these adverse effects has led to limited treatment recommendations and a lack of consensus among palliative specialist.

Neuropathic pain (NP) is a chronic condition that affects ~ 1% of the general population globally. Several conditions such as chronic diabetes, herpes zoster (HZ), cancer, HIV, stroke, multiple sclerosis, physical compression or damage of nerves and certain surgical procedures can lead to neuropathy and related pain. The condition is difficult to treat with traditional analgesic drugs. Typically, non-traditional analgesics are used in treating pain in this condition such as antidepressants and antiepileptic drugs. Opioids are useful in some patients, but the risk of addiction and the risk of both short-term and long-term adverse effects make it a low priority drug class in the treatment of NP. In the current review we discuss the pharmacology and pharmaceutical care aspects of various classes of drugs used in the treatment of NP, counselling points for these drug classes, and future prospects in the treatment of NP.

Evidence guiding inpatient management of buprenorphine is lacking-this retrospective cohort study evaluated the clinical impact of hospital continuation versus discontinuation of buprenorphine at an academic medical center. The primary outcome was inpatient oral morphine equivalents (OME). Secondary outcomes included patient pain levels, functional assessment, and hospital length of stay. One hundred thirty-one patients (74 continued buprenorphine, 57 discontinued) were included in the analysis. Median OME were significantly lower among patients continued on buprenorphine versus discontinued (11 mg vs 103 mg

To date, there are no known published studies that prospectively followed hospice patients receiving hydromorphone to evaluate the development of hydromorphone-induced neuroexcitation (HINE). The first objective of this study was to determine the incidence of HINE. The second objective was to identify factors influencing the presence or absence of HINE symptoms in hospice patients.This was a noninterventional, prospective study. This study population included hospice patients 18 years of age or older who were admitted to one of two Nathan Adelson Hospice inpatient units in Las Vegas, Nevada, and were initiated on a scheduled regimen of hydromorphone. A total of 156 patients were enrolled and analyzed in this study. Data collection was performed by the study investigators using a standard data tracking form, including hospice diagnosis, gender, renal function, hydromorphone regimen, and whether or not the patient experienced neuroexcitatory symptoms. Data collection occurred from November 2010 to March 2011.Based on the data collected in this study, it appears that the likelihood of HINE does increase with larger doses, increasing age, increasing serum creatinine, and the presence of malignant neoplasm. However, after adjusting for the variables in the logistic regression model, diagnosis of malignant neoplasm was not a significant predictor of HINE. Future studies may focus on evaluating metabolite levels, such as hydromorphone-3-glucuronide (H3G), in patients developing HINE symptoms. This may help to determine if the metabolites of opioids, such as H3G, are involved in the development of the neurotoxic symptoms.

Opioid medications continue to be an important tool in the treatment of acute and chronic pain. Unfortunately, misuse and abuse of legal and illegal opioids by patients have led to the largest opioid overdose epidemic ever known. Consequently, manufacturers have been encouraged to develop abuse deterrent formulations of opioids that limit the abuse potential of these medications. Accidental overdoses by children also continue to occur with lethal consequences and older, traditional opioids are being abused in different ways and quantities with life threatening sequelae. A comprehensive review of case studies on side effects, adverse drug reactions and toxicity published in 2017 regarding the use of various opioids and opioid antagonists is also included. A literature search was conducted in Google Scholar, Ovid, and PubMed with and without MeSH terms.

To describe the development of an integrated pain and palliative care course and to investigate the long-term effectiveness of the course during doctor of pharmacy (PharmD) students' advanced pharmacy practice experiences (APPEs) and in their practice after graduation.Roseman University College of Pharmacy faculty developed a 3-week elective course in pain and palliative care by integrating relevant clinical and pharmaceutical sciences. Instructional strategies included lectures, team and individual activities, case studies, and student presentations.Students who participated in the course in 2010 and 2011 were surveyed anonymously to gain their perception about the class as well as the utility of the course during their APPEs and in their everyday practice. Traditional and nontraditional assessment of students confirmed that the learning outcomes objectives were achieved.Students taking the integrated course on pain management and palliative care achieved mastery of the learning outcome objectives. Surveys of students and practicing pharmacists who completed the course showed that the learning experience as well as retention was improved with the integrated mode of teaching. Integrating basic and clinical sciences in therapeutic courses is an effective learning strategy.