الفهرس 
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Abstract
chronic pain is a clinical challenge for the practicing physician. Pain is a subjective experience, influenced by a host of non medical factors, including age, sex, culture, communication style and fear of addiction, these demographic and behavioral barriers must be considered in assessment and in treatment.
Neuropathic pain, a major factor of difficult pain problems, it is refractory to treatment. The main problem with treating neuropathic pain is that the standard array of non narcotic analgesics, but no treatment is universally successful.
Over the past 15 years a marked shift has occurred from an extreme position of no place for opioids in the treatment of neuropathic pain to a middle position of opioids may be appropriate for selected patients with chronic neuropathic pain. Opioids are the most powerful analgesics, but politics, prejudice and continuing ignorance still impede optimum prescribing.
Morphine is considered the reference standard for opioid analgesics. It is usually prescribed in sustained release oral formulation for the treatment of chronic pain. Sever constipation, a persistent complication of oral opioid, may affect some patients׳ quality of life more than their pain.
Fentanyl, a lipid soluble synthetic opioid, is available as a sustained release opioid analgesic administered through the skin via controlled release formulation, providing continuous, controlled systemic delivery up to 72 hours.
By this work we aimed at comparing the analgesic efficacy of transdermal fentanyl patch with sustained release oral morphine tablets in the management of chronic neuropathic pain. To assess if opioid therapy would result in functional improvement in activity level in patient with neuropathic pain.
The study included 40 patients of both sex. Their age ranged from 18 to 60 years old. All patients were suffering from chronic neuropathic pain based on history and clinical examination. All patients fulfilled inclusion criteria of the study. They were presented with persistent post amputation pain or characteristic feature of complex regional pain syndrome. All patients included in the study were suffering from pain persisting for more than three months with intensity of more than three based on numerical rating scale. After initial visit follow up and maintenance will continue for two to three months. Patients were randomly allocated to one of two equal groups; 20 patients each, group F and group M. Group F, consisted of 20 patients who received transdermal fentanyl patch releasing 25, 50 and 75µg/h. Different concentration of durogesic patches were used according to patients׳ response to treatment. Group M, consisted of 20 patients who received sustained release oral morphine tablets as 30 mg tablets. Dose increased upon to patients׳ response to treatment. Side effect chick list fulfilled by all patients. Suitable medication was used. Persistent symptoms required patients withdrawal from the study. Informed consent was obtained. Patients instructed to visit the clinic twice a week for follow up and for receiving their medication.
Initial assessment included;Pain intensity was carried out by mean of numerical rating scale. Pain relief was carried out by mean of pain relief categorical scale. Measurement of interference/impairment of function was carried out by mean of multidimensional pain inventory. Measurement of cognition was carried by mean of Digit-Symbol and Manual Dexterity. Measurement of affect was carried by mean of Beck Depression Inventory(BDI). By the end of the study each patient completed a satisfaction and drug preference scale.
In our study it was clear that, patients treated with transdermal fentanyl patches had lower pain intensity scales and reported better pain control than those treated with sustained release oral morphine tablets. In spite of this, there was no significant difference between the two studied groups as regard reduction in pain intensity scales or pain relief scales by the end of the titration period and during the follow up visits till the end of the program. Our finding confirmed that potent opioids can provide satisfactory pain relief for the difficult clinical problem of chronic non malignant pain. The improvement in pain complain was associated with significant improvement in functioning as well as activity level in the two studied groups. All patients reported marked improvement in their satisfaction of functioning and activity level including social, occupational and recreational activities. Although better scores were reported in transdermal fentanyl group and these scores were correlated with better pain control in this group, but still there was no significant difference in comparison to sustained release oral morphine group.
By the end of the study mood profile in the two studied groups represented dramatic change; in fentanyl group twelve patients reported mild to moderate depression and two patients reported sever depression. The same results were obtained in morphine group where; eleven patients reported mild to moderate depression and three patients reported sever depression. This improvement in mood profile was highly significant in comparison to baseline assessment. Still, there was no significant difference between the two studied groups. Mood assessment was very confusing task and need further investigation and more collaboration with psychiatry department due to the multifactorial nature of depression in these populations.
The data collected from Digiti-symbol and Manual Dexterity assured that, cognitive function was preserved till the end of the program. The preservation of cognitive, vigilance and psychomotor function was clear in the two studied groups.