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Cancer incidence in Latin America is lower than in Europe or the United States but morbidity and mortality rates are disproportionately high. A barrier to adequate pain control is inadequate pain assessment, which is a relatively easy and inexpensive metric. The objective of this narrative review is to describe pain assessment for cancer patients in Latin America. Cultural factors may influence pain perception, including contextualizing pain as noble or natural suffering and aspects of what is now called "spiritual pain." Unlike other painful conditions, cancer pain may be strongly associated with existential fear, psychosocial distress, anxiety, and spiritual concerns. Pain assessment allows not just quantification of pain intensity but may elucidate pain mechanisms involved or psychosocial aspects that may color the pain. Many current pain assessment instruments capture only pain intensity, which is but one aspect of the pain experience; some have expanded to include functional assessments, mental health status evaluations, and quality of life metrics. A quality-of-life assessment may be appropriate for cancer patients since chronic pain can severely impact function, which can in turn create a vicious cycle by exacerbating pain. The incidence of cancer in Latin America is expected to increase in the ensuing years. Better pain assessment and clinician education are needed to help manage pain in this large and growing patient population.

Atypical opioids such as tramadol, tapentadol, and cebranopadol combine two complementary mechanisms of action into a single molecule, creating novel analgesic agents. These are synthetic small molecules: cebranopadol is not yet market released; tramadol and tapentadol are commercially available and have immediate-release (IR) and extended-release (ER) formulations. Tramadol has been widely used in the United States in recent years and works as a prodrug in that its metabolites are active in inhibiting serotonin and norepinephrine reuptake. Tapentadol is a direct-acting agent with a faster onset of action and is a muopioid-receptor agonist and also inhibits noradrenaline reuptake. Cebranopadol is the newest of these drugs, a first-in-class atypical analgesic that combines mu-opioid receptor (MOR) agonism with activity at the nociception/orphanin (NOP) FQ petide receptors. Cebranopadol may be considered a partial kappaopioid receptor agonist as well. The pharmacology of these unique single-entity agents allows them to offer analgesic benefit with fewer side effects and risks. Clinical studies have demonstrated the safety and efficacy of tramadol and tapentadol, and promising but limited studies for cebranopadol show good analgesic effect and safety. Serotonin toxicity or 'serotonin syndrome' may occur with accumulation of serotonin with tramadol. While the misuse of these agents is limited in the United States, tramadol misuse is prevalent in Iran and parts of Africa. Patients have been successfully rotated from one of these agents to another. All three agents show promise in the treatment of cancer and non-cancer pain and their unique formulation in a single molecule reduces the pill burden.

Introduction The definition of nociplastic pain in 2016 has changed the way maladaptive chronic pain is viewed in that it may emerge without neural lesions or neural disease. Many endogenous and pharmacologic substances are being investigated for their role in treating the pain associated with neuronal plasticity. Areas Covered The authors review promising pharmacologic agents for the treatment of pain associated with maladaptive neuronal plasticity. The authors then provide the reader with their expert opinion and provide their perspectives for the future. Expert opinion An imbalance between the amplification of ascending pain signals and the poor activation of descending inhibitory signals may be at the root of many chronic pain syndromes. The inhibitory activity of noradrenaline reuptake may play a role in neuropathic and nociplastic analgesia. A better understanding of the brain's pain matrix, its signaling cascades, and the complex bidirectional communication between the immune system and the nervous system may help meet the urgent and unmet medical need for safe, effective chronic pain treatment, particularly for pain with a neuropathic and/or nociplastic component.

Flaminia Coluzzi,1,2 Domenico Alvaro,3 Augusto Tommaso Caraceni,4 Walter Gianni,5 Franco Marinangeli,6 Giuseppe Massazza,7 Carmine Pinto,8 Giustino Varrassi,9 Fabio Lugoboni10 1Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, LT, Italy; 2Anesthesiology, Intensive Care, and Pain Medicine Unit, Sant’Andrea University Hospital, Rome, RM, Italy; 3Department of Translational and Precision Medicine, Gastroenterology Division, Sapienza University of Rome, Rome, RM, Italy; 4Palliative Care, Pain Therapy, and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, MI, Italy; 5Department of Internal Medicine and Geriatric Medicine, University Hospital Policlinico Umberto I, Rome, RM, Italy; 6Department of Anesthesiology, Pain Medicine, and Palliative care, University of L’Aquila, L’Aquila, AQ, Italy; 7Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin and “Città della Salute e della Scienza” University Hospital, Torino, TO, Italy; 8Medical Oncology Unit, Clinical Cancer Center, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, RE, Italy; 9Fondazione Paolo Procacci, Rome, RM, Italy; 10Department of Medicine, Addiction Unit, University Hospital of Verona, Verona, VR, ItalyCorrespondence: Flaminia ColuzziDepartment of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Latina, Corso della Repubblica 79, Latina, LT, 04100, ItalyTel +39 06 33775673Email flaminia.coluzzi@uniroma1.itBackground: Opioid-induced constipation (OIC) remains an important clinical obstacle despite the availability of several guidelines and pharmacological options for its management. Here, we surveyed common practices and perceptions about OIC among physicians who prescribe opioids in Italy.Methods: The online survey included 26 questions about OIC. Responses were analyzed descriptively and aggregated by physician specialty.Results: A tot

Pietro Persiani,1 Daniele De Meo,1 Elettra Giannini,1 Valeria Calogero,1 Tommaso Speziale Varsamis,1 Armando Ugo Cavallo,2 Lorena Martini,1 Gianluca Cera,1 Flaminia Coluzzi,3 Ciro Villani1 1Department of Orthopaedic and Traumatology, Policlinico Umberto I Hospital, Sapienza University of Rome, Rome, 00185, Italy; 2Department of Biomedicine and Prevention, Tor Vergata University, Rome, 00133, Italy; 3Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, 00185, ItalyCorrespondence: Daniele De MeoDepartment of Orthopaedic and Traumatology, Policlinico Umberto I Hospital, Sapienza University of Rome, Piazzale A. Moro 3, Rome, 00185, ItalyTel +39 3338745373Email daniele.demeo@uniroma1.itPurpose: Following the 2019 coronavirus (COVID-19) pandemic, many reports have investigated the psychosocial effects of the lockdown. The aim of our study was to investigate the effects of the lockdown on the daily life habits of orthopaedic patients.Patients and Methods: Around 30 days after the start of the Italian lockdown, from April 17th to the end of the containment measures on May 18th, the Sapienza University of Rome carried out a 19-item survey on the effects the lockdown caused in patients suffering from an orthopaedic pathology (with regard to changes in lifestyle, pain, treatment) by stratifying the sample by age, sex, profession, pain location, pathogenesis and prior surgeries.Results: A total of 292 subjects with orthopaedic pathologies took part in the survey. Taking into consideration the totality of the sample, physical activity was significantly reduced (p < 0.001). The increase of a sedentary lifestyle was statistically significant (p < 0.001), as well as an increase in pain (p < 0.001) and the need to adjust the pharmacological treatment (p < 0.001). The increase in pain was particularly significant in the 50– 70 age group, among workers, and in polyarthralgic patients. About 55.48% sta