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Mercadante S. Opioid dose titration for cancer pain. Eur J Pain 2024; 28:359-368. [PMID: 37947151 DOI: 10.1002/ejp.2194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Opioid dose titration is a fundamental process of opioid therapy in cancer pain. AIMS To assess data opioid dose titration. METHODS The principal opioid dose titration methods, outcomes, and modalities of administration regarding the different opioid preparations were examined in different clinical contexts. RESULTS Most studies suggested that opioid-naive patients should be started at doses of 15-30 mg/day of oral morphine equivalents. Opioid-tolerant patients may receive low or higher doses of oral morphine equivalents, depending on the level of opioid tolerance. Generally, dose increments of 30%-50% seem to be indicated to start dose titration. Some patients with severe excruciating cancer pain may present as an emergency requiring a rapid application of powerful analgesic strategies. The intravenous use of opioids may circumvent this problem providing a faster pain relief, due to the large availability and rapid achievement of effective plasma concentrations. DISCUSSION Opioid dose titration is a delicate passage in patients with cancer pain. This approach may be different according to different clinical conditions. Opioid dose titration requires expertise to optimize cancer pain management while minimizing the development of adverse effects. CONCLUSION While most approaches are meaningful and partially supported by existing literature, more studies are necessary to establish advantages and disadvantages in different clinical conditions. Optimization of opioid dose titration is of paramount importance. SIGNIFICANCE This review provides the most recent insights on the different modalities of opioid dose titration in cancer pain management.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
- Regional Home Care Program, SAMOT, Palermo, Italy
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Shalev D, Brenner K, Carlson RL, Chammas D, Levitt S, Noufi PE, Robbins-Welty G, Webb JA. Palliative Care Psychiatry: Building Synergy Across the Spectrum. Curr Psychiatry Rep 2024; 26:60-72. [PMID: 38329570 DOI: 10.1007/s11920-024-01485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/09/2024]
Abstract
PURPOSE OF REVIEW Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry. RECENT FINDINGS PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.
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Affiliation(s)
- Daniel Shalev
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 East 68thStreet, Box 39, New York, NY, 10065, USA.
| | - Keri Brenner
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Rose L Carlson
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 East 68thStreet, Box 39, New York, NY, 10065, USA
| | - Danielle Chammas
- Department of Medicine, University of California: San Francisco, San Francisco, CA, USA
| | - Sarah Levitt
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Paul E Noufi
- Department of Medicine, Georgetown University, Baltimore, MD, USA
| | | | - Jason A Webb
- Department of Medicine, Oregon Health and Sciences University, Portland, OR, USA
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Mercadante S, Ferrera P, Lo Cascio A, Casuccio A. Pain Catastrophizing in Cancer Patients. Cancers (Basel) 2024; 16:568. [PMID: 38339319 PMCID: PMC10854960 DOI: 10.3390/cancers16030568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Pain catastrophizing is a group of negative irrational cognitions in the context of anticipated or actual pain. The aim of this study was to decipher the possible role of catastrophism on pain expression and outcomes after a comprehensive palliative care treatment. METHODS A consecutive sample of patients with uncontrolled pain was assessed. Demographic characteristics, symptom intensity included in the Edmonton symptom assessment system (ESAS), and opioid drugs used were recorded at admission (T0). The Pain Catastrophizing Scale (PCS) was measured for patients. Patients were also asked about their personalized symptom goal (PSG) for each symptom of ESAS. One week after a comprehensive palliative care treatment (T7), ESAS and opioid doses used were recorded again, and the number of patients who achieved their PSG (PSGR) were calculated. At the same interval (T7), Minimal Clinically Important Difference (MCID) was calculated using patient global impression (PGI). RESULTS Ninety-five patients were eligible. A significant decrease in symptom intensity was reported for all ESAS items. PGI was positive for all symptoms, with higher values for pain, poor well-being, and poor sleep. Only the rumination subscale of catastrophism was significantly associated with pain at T0 (B = 0.540; p = 0.034). CONCLUSIONS Catastrophism was not associated with the levels of pain intensity, PSG, PSGR, and PGI for pain, except the rumination subscale that was associated with pain intensity at T0. A comprehensive palliative care management provided the relevant changes in symptom burden, undoing the pain expression associated with rumination.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy (A.L.C.)
| | - Patrizia Ferrera
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy (A.L.C.)
| | - Alessio Lo Cascio
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy (A.L.C.)
| | - Alessandra Casuccio
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy;
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Coluzzi F, LeQuang JAK, Sciacchitano S, Scerpa MS, Rocco M, Pergolizzi J. A Closer Look at Opioid-Induced Adrenal Insufficiency: A Narrative Review. Int J Mol Sci 2023; 24:ijms24054575. [PMID: 36902007 PMCID: PMC10003084 DOI: 10.3390/ijms24054575] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Among several opioid-associated endocrinopathies, opioid-associated adrenal insufficiency (OIAI) is both common and not well understood by most clinicians, particularly those outside of endocrine specialization. OIAI is secondary to long-term opioid use and differs from primary adrenal insufficiency. Beyond chronic opioid use, risk factors for OIAI are not well known. OIAI can be diagnosed by a variety of tests, such as the morning cortisol test, but cutoff values are not well established and it is estimated that only about 10% of patients with OIAI will ever be properly diagnosed. This may be dangerous, as OIAI can lead to a potentially life-threatening adrenal crisis. OIAI can be treated and for patients who must continue opioid therapy, it can be clinically managed. OIAI resolves with opioid cessation. Better guidance for diagnosis and treatment is urgently needed, particularly in light of the fact that 5% of the United States population has a prescription for chronic opioid therapy.
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Affiliation(s)
- Flaminia Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, 04100 Latina, Italy
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
- Correspondence:
| | | | - Salvatore Sciacchitano
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00189 Rome, Italy
- Laboratory of Biomedical Research, Niccolò Cusano University Foundation, 00166 Rome, Italy
| | - Maria Sole Scerpa
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
| | - Monica Rocco
- Unit of Anaesthesia, Intensive Care, and Pain Medicine, Sant’Andrea University Hospital, 00189 Rome, Italy
- Department of Surgical and Medical Science and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
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Mercadante S, Grassi Y, Cascio AL, Restivo V, Casuccio A. Characteristics of Untreated Cancer Patients Admitted to an Acute Supportive/Palliative Care Unit. J Pain Symptom Manage 2023; 65:e677-e682. [PMID: 36709007 DOI: 10.1016/j.jpainsymman.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Abstract
BACKGRUND The characteristics of patients who had never received anticancer treatments at admission of an acute supportive palliative care unit (ASPCU) have never been explored. MEASURES From a consecutive sample of 422 advanced cancer patients, 62 patients with no previous anticancer therapy were selected and compared with a random sample of patients who had received anticancer treatments. Age, gender, primary tumor, Karnofsky status, characteristics of admission, the level of education, economic status, awareness of disease, the presence of cachexia, and comorbidities and palliative prognostic score, symptom intensity, opioid drugs used at admission, reasons for admission to APSCU were recorded in both groups. At time of discharge, ESAS and analgesic drugs used were recorded again. Discharge modalities were also recorded. One month after the end of recruitment period (the last patient enrollment), a follow-up was performed by phone contacts with relatives to assess survival at three months after discharge. OUTCOMES Patients without previous anticancer therapy (14.7%) were mainly admitted to ASPCU for a low Karnofsky level and high symptom burden, often waiting for or needing a histological diagnosis to make a decision for the next therapeutic steps. This group of patients were older (P<0.0005), more frequently males (P=0.007), and had more comorbidities (P<0.0005) in comparison with treated patients. Twenty-four per cent of these patients started chemotherapy subsequently. Treatment-naive patients had a higher level of symptom burden, which was less responsive to a comprehensive palliative and more frequently died within three months in comparison with treated patients. DISCUSSION Treatment-naive patients showed a higher level of symptom burden, which was less responsive to a comprehensive palliative treatment. In addition they more frequently died within three months in comparison with treated patients.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center for Pain relief and palliative care Unit, La Maddalena Cancer Center (S.M., Y.G., A.L.C., V.R.), Palermo, Italy.
| | - Yasmine Grassi
- Main regional center for Pain relief and palliative care Unit, La Maddalena Cancer Center (S.M., Y.G., A.L.C., V.R.), Palermo, Italy
| | - Alessio Lo Cascio
- Main regional center for Pain relief and palliative care Unit, La Maddalena Cancer Center (S.M., Y.G., A.L.C., V.R.), Palermo, Italy
| | - Vincenzo Restivo
- Main regional center for Pain relief and palliative care Unit, La Maddalena Cancer Center (S.M., Y.G., A.L.C., V.R.), Palermo, Italy
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) (A.C.), University of Palermo, Palermo, Italy
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Maddalena Opioid Switching Score in patients with cancer pain. Pain 2023; 164:91-97. [PMID: 35500284 DOI: 10.1097/j.pain.0000000000002669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/20/2022] [Indexed: 01/09/2023]
Abstract
ABSTRACT Evaluation of opioid switching (OS) for cancer pain has not been properly assessed. The aim of this study was to assess an integrated score (Maddalena Opioid Switching Score) as a simple and repeatable tool to evaluate the outcomes of OS, facilitating the interpretation and comparison of studies, and information exchange among researchers. The integrated score took into account pain intensity, intensity of opioid-related symptoms, and cognitive function by using an author's formula. Physical and psychological symptoms were evaluated by the Edmonton Symptom Assessment Scale and Patient Global Impression (PGI) by the minimal clinically important difference. One hundred six patients were analyzed. Ninety-five patients were switched successfully, and 11 patients underwent a further OS and/or an alternative procedure. The Maddalena Opioid Switching Score significantly decreased after OS and was highly correlated to PGI of improvement ( P < 0.0005). In patients with unsuccessful OS, no significant changes in the Maddalena Opioid Switching Score and PGI were observed. A significant reduction in Edmonton Symptom Assessment Scale items intensity was observed after OS. The Maddalena Opioid Switching Score resulted to be a sensitive instrument for measuring the clinical improvement produced by OS.
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Mercadante S, Adile C, Ferrera P, Grassi Y, Cascio AL, Casuccio A. Conversion ratios for opioid switching: a pragmatic study. Support Care Cancer 2022; 31:91. [PMID: 36580152 DOI: 10.1007/s00520-022-07514-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/03/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The final conversion ratios among opioids used for successful switching are unknown. The aim of this study was to determine the initial and final conversion ratios used for a successful opioid switching in cancer patients, and eventual associated factors. METHODS Ninety-five patients who were successfully switched were evaluated. The following data were collected: age, gender, Karnofsky performance score, primary cancer, cognitive function, the presence of neuropathic, and incident pain. Opioids, route of administration, and their doses expressed in oral morphine equivalents used before OS were recorded as well as opioids use for starting opioid switching, and at time of stabilization. Physical and psychological symptoms were routinely evaluated by Edmonton Symptom Assessment Scale. RESULTS No statistical changes were observed between the initial conversion ratios and those achieved at time of stabilization for all the sequences of opioid switching. When considering patients switched to methadone, there was no association between factors taken into considerations. CONCLUSION Opioid switching is a highly effective and safe technique, improving analgesia and reducing the opioid-related symptom burden. The final conversion ratios were not different from those used for starting opioid switching. Patients receiving higher doses of opioids should be carefully monitored for individual and unexpected responses in an experienced palliative care unit, particularly those switched to methadone. Future studies should provide data regarding the profile of patients with difficult pain to be hospitalized.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Yasmine Grassi
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Alessio Lo Cascio
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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The Impact of P-Glycoprotein on Opioid Analgesics: What's the Real Meaning in Pain Management and Palliative Care? Int J Mol Sci 2022; 23:ijms232214125. [PMID: 36430602 PMCID: PMC9695906 DOI: 10.3390/ijms232214125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
Opioids are widely used in cancer and non-cancer pain management. However, many transporters at the blood-brain barrier (BBB), such as P-glycoprotein (P-gp, ABCB1/MDR1), may impair their delivery to the brain, thus leading to opioid tolerance. Nonetheless, opioids may regulate P-gp expression, thus altering the transport of other compounds, namely chemotherapeutic agents, resulting in pharmacoresistance. Other kinds of painkillers (e.g., acetaminophen, dexamethasone) and adjuvant drugs used for neuropathic pain may act as P-gp substrates and modulate its expression, thus making pain management challenging. Inflammatory conditions are also believed to upregulate P-gp. The role of P-gp in drug-drug interactions is currently under investigation, since many P-gp substrates may also act as substrates for the cytochrome P450 enzymes, which metabolize a wide range of xenobiotics and endobiotics. Genetic variability of the ABCB1/MDR1 gene may be accountable for inter-individual variation in opioid-induced analgesia. P-gp also plays a role in the management of opioid-induced adverse effects, such as constipation. Peripherally acting mu-opioid receptors antagonists (PAMORAs), such as naloxegol and naldemedine, are substrates of P-gp, which prevent their penetration in the central nervous system. In our review, we explore the interactions between P-gp and opioidergic drugs, with their implications in clinical practice.
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Comprehensive Targeted Treatment for Neuropathic and Nociceptive Pain in Palliative Care Patients. Am J Ther 2022; 29:e512-e519. [PMID: 36049186 DOI: 10.1097/mjt.0000000000001536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain is a common symptom in patients with advanced, metastatic, or terminal cancer. Neuropathic pain and psycho-emotional suffering are factors that increase the difficulty of pain management. Pain control in patients with cancer remains a challenge for medical professionals. STUDY QUESTION What is the evolution of neuropathic/mixed pain compared with nociceptive pain under standardized treatment in patients with cancer? STUDY DESIGN A prospective, longitudinal, open-label, nonrandomized study was conducted on patients with cancer pain. MEASURES AND OUTCOMES Pain type was assessed at admission using the modified Brief Pain Inventory, and pain intensity was assessed daily using the Numerical Rating Scale for 14 days and on days 21 and 28. Screening of depression was performed on days 1, 7, 14, 21, and 28 using the Hamilton Depression Rating Scale. Patients with pain and depression received analgesics with antidepressants, while patients without depression received analgesics or analgesics with an anticonvulsant depending on the pain subtype. RESULTS Of 72 patients, 23 had nociceptive pain and 49 had neuropathic/mixed pain. At admission, pain intensity was higher for patients with neuropathic/mixed pain compared with nociceptive pain (mean values: 7.06 vs. 5.82) with statistical significance (P = 0.001) and remained as such at the end of this study (mean values: 3.77 vs. 2.73). A decrease in the mean pain intensity was observed in all types of pain, but without statistical significance regardless of pain type and treatment protocol used (P = 0.77). If depression was present, antidepressants combined with analgesics decreased pain and depression scores significantly (P = 0.001). CONCLUSIONS Patients with neuropathic/mixed pain have higher levels of pain and lower response to treatment. Identifying psycho-emotional suffering can improve pain control by intervening in the physical and psycho-emotional components of pain.
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Mercadante S, Giuliana F, Bellingardo R, Albegiani G, Di Silvestre G, Casuccio A. Pattern and characteristics of patients admitted to a hospice connected with an acute palliative care unit in a comprehensive cancer center. Support Care Cancer 2021; 30:2811-2819. [PMID: 34842974 PMCID: PMC8628130 DOI: 10.1007/s00520-021-06685-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/07/2021] [Indexed: 12/03/2022]
Abstract
Purpose Information about inpatient hospice activity is limited. No data exist about the pattern and the characteristics of advanced cancer patients admitted to a hospice connected to an acute supportive/palliative care unit (ASPCU). Methods Data of hospice admissions were retrieved from the database where all data were prospectively collected. The Edmonton Symptom Assessment Scale (ESAS) and the use of analgesics and adjuvant were recorded at admission (T0), 1 week (T7), 2 weeks (T14), and the day before death (T-end). The use of palliative sedation and its indication, duration, and drugs end doses used were recorded. The number of hospice deaths, discharges, and hospice staying were recorded. Results One hundred seventy-seven patients were admitted in 13 months. There were significant differences in total ESAS at T0 (P = 0.033), total ESAS being significantly lower in patients admitted from the ASPCU than those referred from other settings. The day before death (T-end), only 48 patients could be evaluated. Patients referred by a palliative care setting were more likely to be prescribed opioids at T0 (P = 0.0007). At T-end, there was a significant increase in the use of morphine and haloperidol (P < 0.05). Seventeen percent of patients died within 48 h. Only a minority of patients could be properly assessed at T-end (25%). Palliative sedation was performed in 10.1% of patients. The mean hospice staying was 16.3 (SD 21.4) days. There were no differences in mean hospice staying between patients who died in hospice or those discharged (P = 0.873). Conclusion The presence of a hospice in a comprehensive cancer center could offer a further opportunity for continuing care. Specialized palliative care may be offered to patients referred from other hospitals, home palliative care, but above all, transfer to hospice may allow a continuity of care for those patients who were initially admitted to an ASPCU for symptom control, to which anticancer therapies were withdrawn or withhold after multidisciplinary consultation. Similarly, after a proper palliative care consultation in other hospital units, patients may be referred to hospice. This process may avoid transfers to external hospices, which can prevent the continuity of care.
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Affiliation(s)
- Sebastiano Mercadante
- Mean Regional Center for Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Fausto Giuliana
- Mean Regional Center for Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Rosanna Bellingardo
- Mean Regional Center for Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Gianluca Albegiani
- Mean Regional Center for Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | | | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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