Toward more focused multimodal and multidisciplinary approaches for pain management in Parkinson’s disease

Figures & data

Table 1 Study results pain I Parkinson’s disease

Authors	Number patients/controls	Type of study	Prevalence in patients (%)	Prevalence in controls (%)	Assessment tool
Quittenbaum et al, 2004^Citation11	57/95	Cross sectional	68.4	52,6	HRQL SF-36, item 7
Chaudhuri et al, 2006^Citation13	123/96	Cross sectional	27	30	NMS Quest
Etchepare et al, 2006^Citation16	100/100	Cross sectional Consecutive patients	60	23	Back Pain Self Questionnaire
Broetz et al, 2007^Citation17	101/132	Cross sectional	74	27	Back Pain Self Questionnaire
Negres-Pages et al, 2008^Citation5	450/98	Cross sectional	61.8	58	Brief Pain Inventory; McGillPain Questionnaire
Defazio et al, 2008^Citation18	402/317	Cross sectional Consecutive patients	69.9	63	Interview
Beiske et al, 2009^Citation10	176/Norway population data	Cross sectional	83	30	Brief Pain Inventory; HRQL SF-36, item 7
Ehrt et al, 2009^Citation19	227/100	Cross sectional	67	39	Nottingham Health Profile
Madden and Hall, 2010^Citation12	25/25	Cross sectional Consecutive patients	80	40	Shoulder Pain Interview
Kubo et al, 2016^Citation20	324/308	Cross sectional	78.6	40,9	HRQL SF-36, item 7

Figure 1 Pain management in Parkinson’s disease. The first pain assessment is generally performed by the GP or by a neurologist, and it allows to distinguish persistent/recurrent chronic pain from acute pain (eg, painful exacerbation of chronic diseases, or acute pain unrelated to PD). Acute pain is addressed according to the underlying pathology (eg, analgesic medications and surgery for cholelithiasis). In case of persistent/recurrent chronic pain, the pain evaluation is performed by a neurologist who identifies the precise pain category (ie, musculoskeletal, neuropathic, central, and dystonic pain). According to pain diagnosis, the patient care may involve different professionals (1st clinical course). Although re-evaluation of PD therapy is helpful against central, or dystonic pain, therapeutic approaches for musculoskeletal, or neuropathic pain may require the expertise of other specialists, such as pain therapists, orthopedics/physiatrists, rheumatologists, or neurosurgeons (2nd opinion).

Abbreviations: PD, Parkinson’s disease; GP, general practitioner.

Table 2 Selected analgesic opioid drugs

	Duration of action (h)	Half-life (h)	Dosage forms (mg)	Onset time
ORAL USE Full Agonists
Codeine	3–6	2–3	30^a	30 mins
Tramadol ER^b,c	4–6		50, 100	30 mins
Tramadol CR^b,c	12		100, 150, 200	60–120 mins
Oxycodone IR	3–6	2–3	5, 10, 20	40 mins
Tapentadol	12	4	50, 100, 150, 200, 250	60 mins
Oxycodone CR	12	2–3	5, 10, 20, 40, 80	40 mins
Hydromorphone	24	12–15	4, 8, 16, 32	60 mins
Morphine IR	4–6	2–3	10, 30, 60, 100	30 mins
Morphine CR	12	2–3	10, 30, 60, 100	60–120 mins
Methadone^c	4–8	12–57	1 mg/mL; 5 mg/mL	60 min
ROOs^e	2		50, 100, 200, 400, 800, 1200, 1600 µg	5–15 mins
Partial agonists
Buprenorphine sublingual	6–8	2–5	0.2	30 mins
TRANSDERMAL USE full agonists
Fentanyl transdermal	60–72	24–40	12, 25, 50, 75, 100 µg/h	6–12 hrs^d
Partial agonists
Buprenorphine transdermal	72	25–36	35, 52.5, 70 µg/h	12–24 hrs^d

Notes: ^aCombined with acetaminophen 500 mg; ^bMay induce tramadol-induced parkinsonism; ^cTo be avoided in patients receiving selegiline, rasagiline, or safinamide; ^dDepending on the dose (high dosages shorten the onset); ^eApproved and released for oncologic use only.

Abbreviations: ER, extended release; CR, controlled release; IR, immediate release; ROOs, rapid onset opioids.

Table 3 Practical suggestions for managing pain in Parkinson’s disease

Exclude possible sources of acute/chronic pain causes other than PD

The first pain assessment is generally made by the neurologist

Subgroups of PRP types must be defined

Refer to a multidisciplinary team

Use multimodal approaches through a combination of pharmacological agents with non-pharmacological strategies

Optimization of PD therapy may solve most painful episodes

The effects of acetaminophen and NSAIDs for pain relief in PD by are not negligible, but consider their limited effects in subgroups of PRP types (eg, central pain or neuropathic pain)

Because in a minority of patients pain is severe and intractable, consider opioids use as pharmacological treatment

Manage opioids under the supervision of a pain therapist

The dynamics of pain, over time, and the correlation with PD on/off symptomatology should be carefully evaluated

Consider potential interference of pain treatment with antiparkinson medicaments

Patient self-reported changes with regard to pain experiences should be considered (re-assessment)

Limit invasive approaches to selected cases

Abbreviations: PD, Parkinson’s disease; PRP, Parkinson-related pain.

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