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Despite the availability of guidelines, treatment of acute pain after surgery is still a challenge. Although patient-controlled analgesia (PCA) systems represent the gold standard for the systemic administration of opioids, the majority of patients in Italy are treated with continuous intravenous (IV) infusion delivered through elastomeric pumps. Limitations of the currently available IV PCA could be one reason for the poor adherence to the guidelines observed in clinical practice. Recently, the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have approved two new non-invasive pre-programmed PCA systems. The fentanyl iontophoretic transdermal system and the sufentanil sublingual nano tablet system have several potential advantages compared to the currently used PCA devices. In particular, they do not require an intravenous line and eliminate the risk of medication delivery errors typically associated with misprogramming IV PCA pumps. Further studies however are needed to address the potential interindividual variability especially in opioid tolerant patients.

Scoring system for breakthrough-pain likelihood in cancer patients Submission No: 2044 Submission Type: Poster Abstract Submission Aim of Investigation: Breakthrough pain (BTP) shows variable prevalence in different clinical contexts of cancer patients. BTP diagnostic tools with demonstrated reliability, validation and prognostic capability are lacking. We report the preliminary results of an ongoing impact study following the development of a diagnostic/prognostic tool, the IQ-BTP, for BTP recognition and its likelihood among cancer patients. Methods: A sample of 120 chronic pain patients was used as a learning set. An univariate analysis was conducted in order to select the variables associated with the variable of interest (likelihood level of BTP); these have been employed in the planning of a Naive Bayes classifier; a set of scores for each predictor was computed, by extending the approach usually used for binary classification to the case of three likelihood classes of BTP (High, Low, None). The developed BTP-likelihood scoring system, under the form of a questionnaire (IQ-BTP), recently validated, is now used in a multicenter impact study. The study was authorized by the hospital Ethics Committee, and conducted according to the Helsinki declaration and IASP's guidelines for pain research in animals and humans. Results: The scoring system analysis showed that two thirds of the patients may be correctly classified as potentially having (or not having) BTP; proportions of correct classification for BTP likelihood classes "High" and "No BTP" was greater than 80%: most of the patients satisfying the criteria for having BTP were correctly recognized. Conclusions: The IQ-BTP with its peculiar scoring system and with adequate feasibility may enable, in cancer patients, the detection of potential-BTP and its likelihood. The latter may have significant relevance to BTP epidemiology and management.

INTRODUZIONE Il Breakthrough pain (BTP) è un’esacerbazione transitoria del dolore che si verifica dal 51% al 95% dei pazienti che presentano dolore cronico di base (background pain), moderato-severo, cancro correlato, ben controllato con oppiacei. I pazienti oncologici con BTP presentano in genere, dolore più intenso, una maggiore compromissione funzionale, una minore qualità di vita e più importanti distress psicologici, rispetto a quelli senza BTP. (1) Inoltre il BTP, presente anche nei pazienti non oncologici, determina un maggiore impatto socio-economico in termini di ricoveri ospedalieri, visite in pronto soccorso e visite ambulatoriali. (2) Lo scopo dello studio è la validazione di un questionario diagnostico del BTP, attraverso il quale si potrebbe sia quantificare il fenomeno che perfezionare coerentemente l’analgesia. METODI Il q-BTP, composto da 12 quesiti, è stato costruito ad hoc sul modello proposto da Portenoy. Sono stati arruolati nello studio pilota (2^ settimana del mese di Giugno 2010) pazienti con dolore cronico moderato-severo trattati con oppiacei. La somministrazione del q-BTP avveniva durante la prima visita in regime di consulenza intra-ospedaliera oppure presso l’Ambulatorio di Terapia Antalgica. RISULTATI Tra le n=28 nuove visite effettuate nel periodo considerato, n=9 pazienti sono stati arruolati nello studio. L’età media del campione era 62,4 (±9,6) anni; n=6 era di sesso femminile e n=7 presentava patologia neoplastica. In base al q-BTP, n=7 pazienti presentavano dolore episodico intenso. L’intensità media del BTP era moderata-forte. DISCUSSIONE E NOTE CONCLUSIVE Il BTP è un fenomeno clinico complesso (3) che richiede un'accurata diagnosi. Il q-BTP si è rivelato di facile applicazione e di alta specificità. Somministrato sottoforma d’intervista, aiuta il medico nella diagnosi di dolore episodico intenso e facilita l’adeguamento della terapia antalgica nei pazienti neoplastici e non. Il questionario indaga sulla presenza di esacerbazioni transitorie di dolore, sulla loro frequenza, sede e durata. Il q-BTP ha permesso di evidenziare un’elevata prevalenza del BTP nel campione studiato. In seguito a questo studio pilota è prevista l’estensione dello studio su un campione maggiore. BIBLIOGRAFIA: 1. Portenoy RK, Paine D, Jacobsen P. Breakthrough pain: characteristics and impact in patient with cancer pain. Pain 1999;81:129-134 2. Portenoy RK, Hagen NA. Breakthrou pain:definition, prevalence and characteristics pain.1990;41:273-281 3. Caraceni A, Martini C, Zecca E, et al; Working Group ofan IASP Task Force on Cancer Pain. Breakthrough pain characteristics and syndromes in patients with cancer pain.An international survey. Palliat Med. 2004;18:177-183.

Background: Outcome prediction allows patients and professionals to formulate a management plan and to identify risk for poor prognosis. The BPI measures pain and psychosocial outcomes of chronic pain (CP); the Mainz Pain Staging System (MPSS) is a multi-dimensional measure of the CP stage (I-III). Aims: to analyse the association of BPI measures and the MPSS stage and to verify whether the NPSS may predict outcome in Low Back CP. Methods: We enrolled N=242 patients with lumbosacral Pain who were followed for approx. 60 days. Follow up and treatments occurred at 20 days interval being T1 the admission day and T4 the 60th day after admission. The MPSS was administered at T1 while the BPI from T1 to T4. Measures for analysis were patients' demographics, MPSS stage and BPI item scores. Results: Mean age was 65,7 (±15,2) and 75,6% were females; lumbosacral pain was coupled with sciatica syndrome in 79,8%; MPSS stage (I-III) proportions were: 7,9%, 41,3% and 50,8%, respectively. Statistically significant associations were found between MPSS-III category, the female gender and advanced age (66-80 years); and between MPSS-I category and young adults (21-35 years). Among MPSS-II/III patients, pain interference with the patient's mood significantly decreased from T1 to T4 while scores of worst pain in the past 24h significantly decreased only among MPSS-I/II patients. Conclusions: Following Low Back CP treatment, caregiver may expect poor pain relief among MPSS-III patients. However, continuous multidisciplinary approach significantly improves these patient's quality of life. Prediction of prognosis has wide implications for public health initiatives.

Background: Differential diagnosis of low back pain (LBP) is complex and a prominent issue at all health-care levels; guidance may come from patients’ history cues and clinical examination signs. Human and animal studies report that diagnosis of lumbar radicular pain (LRP) may come from evaluating subjective responses of injured lumbar nerves to a strain applied at the buttock. The Buttock Applied Strain (BUAS-test) test may guide the differential diagnosis of LBP. Following an ex-adiuvantibus criterion, clinical improvement of LRP, diagnosed with the BUAS-test and congruently treated, may support this test diagnostic ability. Methods: Among 258 LRP patients, who, upon first visit (V1), tested positive on the BUAS-test (with/without positive Straight Leg Raising Test, SLRT), the effect of gabapentin prescription on painDETECT (PD) questionnaire and Brief Pain Inventory (BPI) outcomes was quantified in the follow-up visit (V2). To support BUAS-test diagnostic ability, we hypothesized that, at V2, >50% of the sample would present negative PD outcome, significant ( t-test) and ⩾2 points V2-V1 differences for each of the BPI-item’s score. We used multinomial logistic regression (MLR) and χ2 analyses to evaluate the PD-V2 outcomes’ dependence upon independent variables. Results: Of the sample, 77% reported a negative PD-V2 outcome. V2-V1 differences of all BPI items were significant and >2 points. PD-V2 outcomes showed significant associations with SLRT-V1 and PD-V1, respectively, but not with gender, age group or pain site. MLR showed a significant relationship between SLRT-V1 and PD-V2 outcomes. Conclusion: Among LRP patients, diagnosed by the BUAS-test and treated with gabapentin, all prespecified endpoints were reached. These results may be considered a piece of ex-adiuvantibus evidence for the BUAS-test ability to diagnose LRP. While positive BUAS-test implies potential LRP, the co-presence with positive SLRT may imply a severer LRP condition. Further prospective research, in different settings and direct clinical measures, is needed.

Introduction: Intravenous (I.V.) morphine administered through a patient-controlled system currently represents the gold standard treatment for moderate to severe acute postoperative pain. To fix the limitations showed by the available I.V. patient-controlled analgesia (PCA) systems that may restrict its use in the clinical practice a needle-free, iontophoretic, fentanyl patient-controlled transdermal system has been developed and recently approved by the United States Food and Drug Administration (FDA) and by the European Medicines Agency (EMA).Areas covered: This review aims at describing the technology, pharmacology and clinical efficacy of fentanyl iontophoretic transdermal system (ITS) in the treatment of acute pain. A literature search was conducted in the PUBMED database using the term fentanyl iontophoretic transdermal system through September 2015 and results from the main clinical trials are discussed.Expert opinion: In 2015, the appropriate treatment of acute pain after surgery is still a challenge and it represents a primary goal in the care of the surgical patient. When regional analgesia techniques are not applicable and systemic analgesia is required, patient controlled systems represent the standard of care for opioid administration. The fentanyl ITS presents several potential advantages compared to the currently used PCA devices. In particular, it does not require intravenous lines and eliminates the potential for drug administration errors, observed with manually programmed standard PCA devices. Nevertheless, further studies are needed to address eventual inter-individual variability especially for opioid tolerant patients.

Biased pain evaluation due to automated heuristics driven by symptom uncertainty may undermine pain treatment; medical evidence moderators are thought to play a role in such circumstances. We explored, in this cross-sectional survey, the effect of such moderators (e.g., nurse awareness of patients’ pain experience and treatment) on the agreement betweenn=862inpatients’ self-reported pain andn=115nurses’ pain ratings using a numerical rating scale. We assessed the mean of absolute difference, agreement (κ-statistics), and correlation (Spearman rank) of inpatients and nurses’ pain ratings and analyzed congruence categories’ (CCs: underestimation, congruence, and overestimation) proportions and dependence upon pain categories for each medical evidence moderator (χ2analysis). Pain ratings agreement and correlation were limited; the CCs proportions were further modulated by the studied moderators. Medical evidence promoted in nurses overestimation of low and underestimation of high inpatients’ self-reported pain. Knowledge of the negative influence of automated heuristics driven by symptoms uncertainty and medical-evidence moderators on pain evaluation may render pain assessment more accurate.