a characteristic feature of pain is a sensation which enables the location and response to perceived pain stimulus .
it is assumed that chronic pain is pain lasting longer than 3 months and affects 30% of patients diagnosed with cancer and about 7080% of patients with advanced cancer [ 14 ] . in the epic ( european pain in cancer ) study 6667% of patients identified pain associated with cancer as very stressful and significantly affecting their professional activity and social life .
it should be noted that pain is responsible for the need to resign from work or limit professional activity and decreases the quality of work performed by an active employee .
the basis of analgesic therapy is the three - step analgesic ladder on the top of which are the drugs belonging to the group of strong opioids .
opioids are the basis of treatment of moderate to severe pain . about 60% of patients in the usa and
about 43% in europe have used weak or strong opioids for pain control [ 211 ] .
it was demonstrated that opioids act effectively as analgesics but they also cause a number of side effects , among which the most common is constipation . they concern 4080% of patients treated with opioids and the risk of occurrence increases further in patients with end - stage cancer [ 5 , 12 , 13 ] .
the working group of the polish society of palliative medicine in the recommendations entitled  therapeutic management of patients with constipation in palliative care  defined constipation as a decreased frequency of bowel movements ( to less than 3 per week ) or subjective patient 's complaints , such as : difficulty in defecation , hard stools , straining or incomplete bowel movements .
opioid - induced constipation is part of a broader syndrome  opioid - induced bowel dysfunction ( oibd ) .
it results from the mode of action of these drugs . on the one hand , it is caused by activation of opioid receptors in neurons of the spinal cord that results in a slowdown of intestinal transit and reduced secretory function [ 1517 ] . on the other hand ,
it is caused by the effects of opioids on the enteric autonomic nervous system ( ens ) .
it functions independently of the central nervous system with the involvement of auerbach 's plexus and meissner 's plexus , which are responsible for the motility of the intestine .
inhibition of peristalsis is regulated by the activation of  and  receptors , while the  receptor does not participate in this mechanism [ 1822 ] .
opioids act by inhibiting kinetics of the stomach and propulsion of the small intestine resulting in prolongation of gastrocaecal transit time .
rectal sensitivity to stretching decreases while the tension of rectal sphincter increases [ 17 , 21 , 23 , 24 ] .
the oibd should be recognized as the cause of constipation regardless of the co - occurrence of risk factors such as general condition , conditions of care , dietary factors , mechanical or functional obstacles in the digestive system , metabolic and hormonal disorders , and neurological or psychiatric disease .
the oibd syndrome is accompanied by discomfort and pain in the abdomen as well as gastro - oesophageal reflux . with the use of opioids to prevent adverse effects mentioned above
it is necessary to use prophylactic administration of laxatives [ 22 , 24 , 25 ] .
the european data show that 25% of patients do not receive a prescription for such medication , and only a small proportion of them decide to buy these drugs without a prescription .
constipation significantly decreases the quality of life , making effective pain control difficult . in a study conducted in sweden
it was demonstrated that the degree of satisfaction with analgesic therapy and quality of life of patients show a negative correlation with the degree of severity of the oibd symptoms .
constipation is the most important and most common adverse event observed in the opioid therapy [ 13 , 20 , 21 ] .
economic analyses evaluating differences in the cost of treatment of patients suffering from oibd and patients free from this syndrome showed a higher cost of therapy of patients suffering from oibd . patients with oibd require more attention from the medical staff and are more often hospitalized , and the cost of palliative care is increased [ 17 , 23 , 27 ] .
the study concerns a 45-year - old man , treated in an outpatient palliative care clinic because of cancer pain in the abdominal cavity with radiation of pain to the area of the sacro - lumbar spine ( visceral pain with neuropathic component ) .
when taken to hospital the patient was experiencing breakthrough pain ( nrs scale 89 ) , vomiting , no pain control as well as weaken of bowel prokinetic , constipation and lack of appetite due to obstructive jaundice the patient had a ct of the abdominal cavity and the small pelvis .
therefore it was decided to perform surgery , which was done in march 2011 . during exploratory laparotomy
the patient was taking ketoprofen 50 mg on an ad hoc basis for pain in the upper abdomen . in view of the reported pain a decision was made to perform an abdominal ct scan , which was done in august 2011 .
the exam revealed a tumour of the head of the pancreas reaching to the root of the mesentery , causing infiltration of the duodenum , enlarged lymph nodes in the retroperitoneal space and metastases in both lobes of the liver .
it was decided to include tramadol at a dose of 200 mg / day in the treatment .
a good control of the pain was achieved , due to tramadol , with the severity of 23 on the nrs scale .
the patient used ketoprofen at a dose of 50 mg on an ad hoc basis . in september 2011
gastro - intestinal and gastrointestinal - intestinal anastomosis were performed , and specimens of liver metastases were collected .
the result of histopathological examination confirmed malignancy . in view of the good general condition of the patient and normal values of the laboratory parameters ,
the pain was well controlled with tramadol 200 mg / day and the patient used ketoprofen at a dose of 50 mg on an ad hoc basis . in the course of the chemotherapy disease progression occurred .
the imaging studies ( ultrasound and computed tomography of the abdominal cavity ) confirmed progression of the metastatic disease in the liver .
in addition , there was an elevated concentration of the tumour marker , ca19 - 9 antigen  2855.00 u / ml ( 0.0037.00 ) . in october 2011
the patient was referred to the outpatient palliative care clinic due to the pain in the upper abdomen that radiated to the area of the lumbar spine . at the same time
another line of cancer treatment was included ; erlotinib  an inhibitor of the tyrosine kinase receptor for the receptor of the epidermal growth factor ( egfr ) .
on admission to the outpatient palliative care clinic the patient reported a strong breakthrough pain ( 89 on the nrs scale ) , vomiting , positive symptoms of psychosis , lack of control of background pain , weakness , impaired intestinal motility 
the gp prescribed transdermal fentanyl 25 g / h , nsaids and lactulose . in the outpatient palliative care clinic subcutaneous morphine
once the analgesic effect was obtained , taking into account the need for the use of opioids , with constipation present , a recommendation was made to use a combination of oxycodone + naloxone ( targin ) prolonged - release 2  10 mg , and fentanyl for breakthrough pain ( the buccal tablet ) 100 mg on an ad hoc basis . during another visit to the outpatient palliative care clinic which took place a week later
after treatment with targin , constipation , nausea and vomiting disappeared and also the appetite improved .
the recommendation was : targin ( 20 mg oxycodone/10 mg naloxone ) , fentanyl ( buccal tablet ) 200 g on an ad hoc basis .
after another week of taking targin while evaluating the effectiveness of treatment , further , good control of pain and normal and regular bowel movements were recorded .
in the case study described above pain therapy was applied in accordance with the principles of pain management according to the world health organization ( who ) .
the patient was treated in the first phase with a drug from the group of non - steroidal anti - inflammatory drugs ( nsaids ) , which was not the right choice , taking into account the presence of a neuropathic component and the course and diagnosis of the disease .
the patient did not use adjunctive treatment with a medication belonging to the group of tricyclic antidepressants or anticonvulsants . in the second stage of symptomatic treatment tramadol
it is a weak opioid at the second level of the analgesic ladder and an antagonist of the nmda receptor complex .
the patient complained about a feeling of fullness in the abdomen reported two bowel movements per week and after defecation there was a sensation of stool retention that could be potentially life - threatening in case of obstruction .
the use of oxycodone - naloxone prolonged - release combination was a good choice due to the analgesic effect of oxycodone and the impact on normalization of gastrointestinal function by the opioid antagonist  naloxone .
upon oral administration , naloxone prevents binding of oxycodone with receptors in the gut wall , before the two substances reach the liver where approximately 97% of naloxone is metabolized .
50% to 80% of oxycodone reaches the systemic circulation causing analgesia . the use of oxycodone - naloxone combination in the form of targin in the case of a 45-year - old patient turned out to be an effective solution in the treatment of a mixed pain with nociceptive and neuropathic components .
in addition , the use of oxycodone - naloxone combination has been shown to act against constipation , with a minimal emetic effect that is typical for other opioids .
 pain afflicts patients suffering from many chronic diseases and is present in 80% of cases of patients with advanced cancer who suffer from persistent pain . 
 the aim of the pain treatment is to achieve the maximum analgesic effect while minimizing side effects . 
 the main analgesic agent  morphine is unfortunately a therapy associated with gastrointestinal side effects . 
 it appears that the combination of oxycodone and naloxone available as targin ( mundipharma ) is an alternative . 
 the paper presents a case of a 45-year - old patient who was treated effectively with oxycodone / naloxone prolonged - release tablets . 
 this treatment has proven to be effective in providing pain and constipation control . 
Introduction
Case study
Summary
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