Subscribe to this journal
Advanced Search
 array:25 [
  "pii" => "S2254887419301195"
  "issn" => "22548874"
  "doi" => "10.1016/j.rceng.2019.03.026"
  "estado" => "S300"
  "fechaPublicacion" => "2019-10-01"
  "aid" => "1666"
  "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)"
  "copyrightAnyo" => "2019"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "edi"
  "cita" => "Rev Clin Esp. 2019;219:398-400"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0014256519301079"
      "issn" => "00142565"
      "doi" => "10.1016/j.rce.2019.03.012"
      "estado" => "S300"
      "fechaPublicacion" => "2019-10-01"
      "aid" => "1666"
      "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "edi"
      "cita" => "Rev Clin Esp. 2019;219:398-400"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 56
        "formatos" => array:2 [
          "HTML" => 30
          "PDF" => 26
        ]
      ]
      "es" => array:10 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>"
        "titulo" => "Hacia un uso juicioso de los opioides en Espa&#241;a"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "398"
            "paginaFinal" => "400"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Towards the judicious use of opioids in Spain"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "A&#46; Fern&#225;ndez-L&#243;pez, F&#46;J&#46; Medrano"
            "autores" => array:2 [
              0 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "Fern&#225;ndez-L&#243;pez"
              ]
              1 => array:2 [
                "nombre" => "F&#46;J&#46;"
                "apellidos" => "Medrano"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2254887419301195"
          "doi" => "10.1016/j.rceng.2019.03.026"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419301195?idApp=WRCEE"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519301079?idApp=WRCEE"
      "url" => "/00142565/0000021900000007/v1_201909260755/S0014256519301079/v1_201909260755/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2254887419300931"
    "issn" => "22548874"
    "doi" => "10.1016/j.rceng.2019.03.019"
    "estado" => "S300"
    "fechaPublicacion" => "2019-10-01"
    "aid" => "1650"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "edi"
    "cita" => "Rev Clin Esp. 2019;219:401-2"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>"
      "titulo" => "Reduction in the number of inadequate prescriptions&#58; Pharmacy-prescriber communication"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "401"
          "paginaFinal" => "402"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Reducci&#243;n del n&#250;mero de prescripciones inadecuadas&#58; comunicaci&#243;n farmacia-prescriptor"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "J&#46; Ena"
          "autores" => array:1 [
            0 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Ena"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0014256519300815"
        "doi" => "10.1016/j.rce.2019.03.001"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519300815?idApp=WRCEE"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419300931?idApp=WRCEE"
    "url" => "/22548874/0000021900000007/v1_201912172116/S2254887419300931/v1_201912172116/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2254887419301146"
    "issn" => "22548874"
    "doi" => "10.1016/j.rceng.2019.03.024"
    "estado" => "S300"
    "fechaPublicacion" => "2019-10-01"
    "aid" => "1660"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "edi"
    "cita" => "Rev Clin Esp. 2019;219:396-7"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>"
      "titulo" => "When should pre-exposure prophylaxis against HIV be implemented in Spain&#63;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "396"
          "paginaFinal" => "397"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "&#191;Para cu&#225;ndo la implantaci&#243;n de la profilaxis pre-exposici&#243;n frente al VIH en Espa&#241;a&#63;"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "L&#46; Mart&#237;n-Carbonero, M&#46;L&#46; Montes"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "L&#46;"
              "apellidos" => "Mart&#237;n-Carbonero"
            ]
            1 => array:2 [
              "nombre" => "M&#46;L&#46;"
              "apellidos" => "Montes"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0014256519301018"
        "doi" => "10.1016/j.rce.2019.03.010"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519301018?idApp=WRCEE"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419301146?idApp=WRCEE"
    "url" => "/22548874/0000021900000007/v1_201912172116/S2254887419301146/v1_201912172116/en/main.assets"
  ]
  "asociados" => array:1 [
    0 => array:19 [
      "pii" => "S2254887419300815"
      "issn" => "22548874"
      "doi" => "10.1016/j.rceng.2019.03.015"
      "estado" => "S300"
      "fechaPublicacion" => "2019-10-01"
      "aid" => "1643"
      "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "fla"
      "cita" => "Rev Clin Esp. 2019;219:367-74"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:1 [
        "total" => 0
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
        "titulo" => "Opioid consumption in the Community of Madrid &#40;Spain&#41; between 2004 and 2014"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "es"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "367"
            "paginaFinal" => "374"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "es" => array:1 [
            "titulo" => "Consumo de opioides en la Comunidad de Madrid &#40;Espa&#241;a&#41; entre 2004 y 2014"
          ]
        ]
        "contieneResumen" => array:2 [
          "en" => true
          "es" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figure 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1129
                "Ancho" => 2453
                "Tamanyo" => 121155
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Total consumption of WHO step II and step III opioids in the Community of Madrid between 2004 and 2014&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; CM&#44; Community of Madrid&#59; DID&#44; defined daily doses&#47;1000 inhabitants&#47;day&#59; WHO&#44; World Health Organization&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "D&#46; Ruiz-L&#243;pez, A&#46; Alonso-Babarro"
            "autores" => array:2 [
              0 => array:2 [
                "nombre" => "D&#46;"
                "apellidos" => "Ruiz-L&#243;pez"
              ]
              1 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "Alonso-Babarro"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "es" => array:9 [
          "pii" => "S0014256519300712"
          "doi" => "10.1016/j.rce.2019.02.002"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "es"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519300712?idApp=WRCEE"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419300815?idApp=WRCEE"
      "url" => "/22548874/0000021900000007/v1_201912172116/S2254887419300815/v1_201912172116/en/main.assets"
    ]
  ]
  "en" => array:12 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>"
    "titulo" => "Towards the judicious use of opioids in Spain"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "398"
        "paginaFinal" => "400"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "A&#46; Fern&#225;ndez-L&#243;pez, F&#46;J&#46; Medrano"
        "autores" => array:2 [
          0 => array:3 [
            "nombre" => "A&#46;"
            "apellidos" => "Fern&#225;ndez-L&#243;pez"
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#9674;</span>"
                "identificador" => "fn0005"
              ]
            ]
          ]
          1 => array:4 [
            "nombre" => "F&#46;J&#46;"
            "apellidos" => "Medrano"
            "email" => array:1 [
              0 => "medrano@cica.es"
            ]
            "referencia" => array:6 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
              3 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
              4 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#9674;</span>"
                "identificador" => "fn0005"
              ]
              5 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:6 [
          0 => array:3 [
            "entidad" => "Servicio de Medicina Interna&#44; Equipo de soporte domiciliario&#44; Hospital Universitario Virgen del Roc&#237;o&#44; Sevilla&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Direcci&#243;n del Plan Andaluz de Cuidados Paliativos&#44; Sevilla&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Medicina Interna&#44; Hospital Universitario Virgen del Roc&#237;o&#44; Sevilla&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Instituto de Biomedicina de Sevilla&#44; Sevilla&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Centro de Investigaci&#243;n Biom&#233;dica en Red de Epidemiolog&#237;a y Salud P&#250;blica &#40;CIBERESP&#41;&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Departamento de Medicina&#44; Universidad de Sevilla&#44; Sevilla&#44; Spain"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Hacia un uso juicioso de los opioides en Espa&#241;a"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pain is the most common reason for medical visits in the adult population and the main problem related to patients&#8217; quality of life&#46; According to the latest 2017 Spanish National Health Survey&#44; almost 45&#37; of Spaniards older than 15<span class="elsevierStyleHsp" style=""></span>years have experienced pain in the past month&#46; Nine percent of the population and 20&#37; of individuals older than 75<span class="elsevierStyleHsp" style=""></span>years perceived the pain as severe or extreme&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> According to a number of epidemiological studies&#44; chronic pain &#40;defined as that which persists for more than 3<span class="elsevierStyleHsp" style=""></span>months&#41; affects 24&#37; of the general Spanish adult population&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Opioids are the drugs of choice for treating intense or severe pain and are widely used for acute and chronic oncologic and nononcologic pain&#46; The World Health Organization &#40;WHO&#41; considers that a country&#39;s mean opioid consumption is a good indicator of the quality of the clinical management of pain&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The available information on the use of opioids in Spain has been scarce to date&#46; Studies on the use of drugs express the consumption of drugs in daily defined doses &#40;DDD&#41; per 1000 inhabitants and day &#40;DID&#41;&#46; DDD is the maintenance dosage established by the World Health Organization for an active ingredient in the primary indication for a specified administration route in adults&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The results of the interesting study by Ruiz-Lopez and Alonso-Babarro<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> on opioid consumption between 2004 and 2014 in Madrid &#40;Spain&#41;&#44; published in this issue of <span class="elsevierStyleItalic">Revista Cl&#237;nica Espa&#241;ola&#44;</span> and those of a recent report &#40;13 March 2019&#41; from the Spanish Ministry of Health that analyzed data on the national level between 2010 and 2017<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> help to determine the present situation in Spain&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Firstly&#44; both studies have shown significant growth in the overall use of opioids&#44; which has tripled in the Community of Madrid during 2004&#8211;2014 &#40;the overall DID increased from 2&#46;7 to 8&#46;1&#41; and doubled in Spain between 2010 and 2017 &#40;the overall DID increased from 9&#46;9 to 17&#46;4&#41;&#44; although Spanish consumption was still much lower than that of North America and northern European countries&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Secondly&#44; the studies have shown a change in the pattern of consumption for the various drug groups&#46; Step II opioids are still of the most prescribed&#44; with almost 71&#37; of the overall opioid consumption in 2017 and a significant increase in the use of tramadol &#40;especially in combination with paracetamol&#41; and a simultaneous reduction in the use of codeine&#44; which in 2017 represented only 7&#37; of the market share&#46; In terms of major or step III opioids&#44; the most widely used were fentanyl &#40;14&#46;4&#37; of the total opioids in 2017&#41; and buprenorphine &#40;4&#46;4&#37;&#41;&#44; although their prescription progressively declined during 2010&#8211;2017 due to the significant increase in the consumption of new-generation drugs &#40;introduced in Spain in 2010&#41;&#44; such as tapentadol and oxycodone-naloxone&#44; which currently represent 4&#46;3&#37; and 3&#46;3&#37; of the total prescribed opioids&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Morphine consumption in Spain is residual&#44; and its use did not reach 2&#37; of the overall prescriptions&#44; being restricted almost entirely to the hospital and palliative care setting&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The reasons for the increase in opioid consumption are numerous and include cultural changes in the society&#44; a lower pain tolerance&#44; sociodemographic and healthcare factors&#44; increased survival of patients with oncologic and nononcologic conditions with chronic diseases&#44; increased use of opioids in chronic nononcologic pain&#44; increased sensitivity and training of healthcare practitioners in pain management &#40;which has helped overcome the paradigm of morphine phobia&#41;&#44; the development of new active ingredients other than morphine that provide advantages in terms of use and adverse effects and&#44; possibly&#44; increased accessibility provided by the widespread use in Spain of electronic prescriptions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In terms of the usage patterns&#44; there is a noteworthy lack of morphine use&#44; which is the opioid of choice in most clinical practice guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> This fact is probably related to the advantages in terms of the use and adverse effects provided by the new synthetic opioids such as fentanyl&#44; which&#44; in its transdermal form&#44; can be employed for patients with nausea and&#47;or upper gastrointestinal tract symptoms &#40;which are common with advanced neoplasia&#41;&#46; Fentanyl can also be administered on a 72-h basis&#44; thereby avoiding reminding patients with cancer about their cancer&#46; Another factor to consider in the change in opioid usage patterns is the recent development in Spain of palliative care units&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The WHO&#44; in its 2002 definition of palliative care&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> recommends early intervention in the care of patients who are candidates for palliative care&#44; which should be performed based more on the patient&#39;s psychological&#44; physical&#44; emotional&#44; social and spiritual needs than on the vital prognosis&#46; The present objective is to start comprehensive and multidisciplinary care in earlier phases concomitantly with other active treatments against oncologic and nononcologic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">This situation increases the number of patients who are candidates for opioid treatment and extends the duration of their use&#44; which encourages improper usage conditions&#46; This is especially true for chronic nononcologic pain&#44; in which despite the opioids&#8217; demonstrated efficacy in controlling pain during the first 3<span class="elsevierStyleHsp" style=""></span>months of treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> the rates of severe adverse effects in longer treatments is very high &#40;7&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> Opioids have also started to be employed in unaccepted indications such as fibromyalgia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the past decade&#44; there has been an exponential increase in opioid consumption&#44; especially in the US&#44; Canada and&#44; to a lesser extent&#44; Europe&#44; with the number of deaths due to analgesic opioid overdosing quadrupling in the US &#40;16&#44;651 in 2010&#41; and Europe &#40;6800 in 2014&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Therefore&#44; the abuse and misuse of this drug group has become a public health problem in North America&#46; In Europe&#44; this situation has become a reason for concern because&#44; although the sociocultural and healthcare context is different&#44; the neurobiological substrate for developing these behaviors is common&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Opioid-induced aberrant behaviors &#40;OIABs&#41; can include chemical coping&#44; addiction or other opioid-related conditions such as pseudoaddiction&#44; dependence&#44; tolerance&#44; hyperalgesia and criminal intent&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> The term chemical coping has been recently defined by an expert consensus as &#8220;the use of opioids to cope with emotional distress&#44; characterized by inappropriate and&#47;or excessive opioid use&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Chemical coping in its most severe form becomes an addiction characterized by behavior that includes one or more of the following&#58; loss of control over the use of the drug&#44; compulsive use&#44; continued use despite damage and compulsive need&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">All patients undergoing treatment with opioids can develop OIABs&#44; from chemical coping to addiction&#59; practitioners should therefore be familiar with detecting and addressing these behaviors&#46; It is therefore important to identify the risk factors for developing these behaviors such as alcohol and drug abuse&#44; tobacco use&#44; young age&#44; good functional status&#44; lower scores on the Edmonton Symptom Assessment System scale &#40;a validated reference instrument for assessing the symptoms of patients with advanced cancer&#41;&#44; high doses of morphine&#44; concomitant use of benzodiazepines and other sedatives&#44; psychiatric or psychological comorbidity and a history of sexual abuse&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">If we cannot detect these behaviors early on&#44; we will be increasing the patient&#39;s suffering and risk of adverse effects and ineffectively managing their pain&#46; N&#250;&#241;ez-Olarte et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> recently published the results of a clinical audit of their &#8220;early palliative care&#8221; activity in 100 patients with advanced cancer undergoing long-term opioid treatment&#44; in which 19&#46;2&#37; of the patients presented aberrant behaviors&#44; and 7&#46;7&#37; presented addiction&#46; These data are merely indicative of an emerging phenomenon in Spain&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Our reflections do not question the undoubtedly beneficial role of opioids in controlling pain and should not lead to a decreased use for fear of expanding aberrant behaviors&#44; but rather we attempt to promote appropriate and judicious consumption of this group of drugs&#46; In any case&#44; we need to improve our still highly limited understanding of OIABs to implement more appropriate follow-up and treatment strategies for the individual profile of each patient with severe pain&#46;</p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "NotaPie" => array:2 [
      0 => array:3 [
        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Both authors have contributed equally &#40;&#8220;joint first authors&#8221;&#41;&#46;</p>"
        "identificador" => "fn0005"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fern&#225;ndez-L&#243;pez A&#44; Medrano FJ&#46; Hacia un uso juicioso de los opioides en Espa&#241;a&#46; Rev Clin Esp&#46; 2019&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.rce.2019.03.012">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;rce&#46;2019&#46;03&#46;012</span></p>"
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Encuesta Nacional de Sanidad 2017&#46; Instituto Nacional de Estad&#237;stica&#46; Available from&#58; <a target="_blank" href="https://www.ine.es/dynt3/inebase/es/index.htm?type=pcaxis%26path=/t15/p419/a2017/p04/%26file=pcaxis">https&#58;&#47;&#47;www&#46;ine&#46;es&#47;dynt3&#47;inebase&#47;es&#47;index&#46;htm&#63;type&#61;pcaxis&#38;path&#61;&#47;t15&#47;p419&#47;a2017&#47;p04&#47;&#38;file&#61;pcaxis</a> &#91;accessed 19&#46;03&#46;19&#93;&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of pain in the Spanish population&#58; telephone survey in 5000 homes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46; Catal&#224;"
                            1 => "E&#46; Reig"
                            2 => "M&#46; Art&#233;s"
                            3 => "L&#46; Aliaga"
                            4 => "J&#46;S&#46; L&#243;pez"
                            5 => "J&#46;L&#46; Seg&#250;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/eujp.2001.0310"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Pain"
                        "fecha" => "2002"
                        "volumen" => "6"
                        "paginaInicial" => "133"
                        "paginaFinal" => "140"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11900473"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization&#46; Achieving balance in national opioids control policy&#46; Guidelines for assessment&#46; Available from&#58; <a target="_blank" href="http://www.whocancerpain.wisc.edu/engpublishers/Spanish.html">http&#58;&#47;&#47;www&#46;whocancerpain&#46;wisc&#46;edu&#47;engpublishers&#47;Spanish&#46;html</a> &#91;accessed 18&#46;03&#46;19&#93;&#46;"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Consumo de opioides en la Comunidad de Madrid &#40;Espa&#241;a&#41; entre 2004 y 2014"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Ruiz-L&#243;pez"
                            1 => "A&#46; Alonso-Babarro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2019.02.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2019"
                        "volumen" => "219"
                        "paginaInicial" => "367"
                        "paginaFinal" => "374"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30914142"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Observatorio de Uso de Medicamentos&#46; Ministerio de Sanidad&#44; Consumo y Bienestar Social&#46; Utilizaci&#243;n de medicamentos opioides en Espa&#241;a durante el periodo 2010&#8211;2017&#46; Available from&#58; <a target="_blank" href="https://www.aemps.gob.es/medicamentosUsoHumano/observatorio/informes-publicados/informes-opioides-espana-2010-2017.htm">https&#58;&#47;&#47;www&#46;aemps&#46;gob&#46;es&#47;medicamentosUsoHumano&#47;observatorio&#47;informes-publicados&#47;informes-opioides-espana-2010-2017&#46;htm</a> &#91;accessed 15&#46;03&#46;19&#93;&#46;"
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An epidemic of the use&#44; misuse and overdose of opioids and deaths due to overdose&#44; in the United States and Canada&#58; is Europe next&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46;T&#46; Helmerhorst"
                            1 => "T&#46; Teunis"
                            2 => "S&#46;J&#46; Janssen"
                            3 => "D&#46; Ring"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1302/0301-620X.99B7.BJJ-2016-1350.R1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Bone Joint J"
                        "fecha" => "2017"
                        "volumen" => "99-B"
                        "paginaInicial" => "856"
                        "paginaFinal" => "864"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28663389"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Uso seguro de opioides en pacientes de situaci&#243;n terminal&#58; gu&#237;a de pr&#225;ctica cl&#237;nica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Guerra de Hoyos"
                            1 => "R&#46; Reyes Sanz-Amores"
                            2 => "M&#46; Espinosa Bosch"
                            3 => "A&#46; Fern&#225;ndez L&#243;pez"
                            4 => "F&#46;J&#46; Galindo Oca&#241;a"
                            5 => "F&#46; Garc&#237;a Mart&#237;nez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2010"
                        "editorial" => "Consejer&#237;a de Salud"
                        "editorialLocalizacion" => "Sevilla"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization&#46; WHO definition of palliative care&#46; Available from&#58; <a target="_blank" href="https://www.who.int/cancer/palliative/definition/en/">https&#58;&#47;&#47;www&#46;who&#46;int&#47;cancer&#47;palliative&#47;definition&#47;en&#47;</a> &#91;accessed 19&#46;03&#46;19&#93;&#46;"
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Estrategia en cuidados paliativos del Sistema Nacional de Salud"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2007"
                        "editorial" => "Ministerio de Sanidad y Consumo"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of opioids versus placebo in chronic pain&#58; a systematic review and meta-analysis of enriched enrollment randomized withdrawal trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46;S&#46; Meske"
                            1 => "O&#46;D&#46; Lawal"
                            2 => "H&#46; Elder"
                            3 => "V&#46; Langberg"
                            4 => "F&#46; Paillard"
                            5 => "N&#46; Katz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2147/JPR.S160255"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pain Res"
                        "fecha" => "2018"
                        "volumen" => "11"
                        "paginaInicial" => "923"
                        "paginaFinal" => "934"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29765246"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain&#58; an overview of Cochrane Reviews"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Els"
                            1 => "T&#46;D&#46; Jackson"
                            2 => "D&#46; Kunyk"
                            3 => "V&#46;G&#46; Lappi"
                            4 => "B&#46; Sonnenberg"
                            5 => "R&#46; Hagtvedt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD012509.pub2"
                      "Revista" => array:5 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2017"
                        "volumen" => "10"
                        "paginaInicial" => "CD012509"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29084357"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Compensaci&#243;n qu&#237;mica y adicci&#243;n a opioides&#58; evidencia&#44; valoraci&#243;n de riesgo y manejo en pacientes con cuidados paliativos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;C&#46; G&#243;mez del Valle"
                            1 => "T&#46; Zertuche-Maldonado"
                            2 => "E&#46; Bruera"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Paliat"
                        "fecha" => "2018"
                        "volumen" => "25"
                        "paginaInicial" => "281"
                        "paginaFinal" => "290"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of opioid use disorders&#58; a national clinical practice guideline"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Bruneau"
                            1 => "K&#46; Ahamad"
                            2 => "M&#46;C&#46; Goyer"
                            3 => "G&#46; Poulin"
                            4 => "P&#46; Selby"
                            5 => "B&#46; Fischer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1503/cmaj.170958"
                      "Revista" => array:6 [
                        "tituloSerie" => "CMAJ"
                        "fecha" => "2018"
                        "volumen" => "190"
                        "paginaInicial" => "E247"
                        "paginaFinal" => "E257"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29507156"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chemical coping versus pseudoaddiction in patients with cancer pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;H&#46; Kwon"
                            1 => "K&#46; Tanco"
                            2 => "D&#46; Hui"
                            3 => "A&#46; Reddy"
                            4 => "E&#46; Bruera"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1017/S1478951513001351"
                      "Revista" => array:6 [
                        "tituloSerie" => "Palliat Support Care"
                        "fecha" => "2014"
                        "volumen" => "12"
                        "paginaInicial" => "413"
                        "paginaFinal" => "417"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24524251"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Manejo de conductas aberrantes inducidas por opioides en una consulta externa de &#171;cuidados paliativos precoces&#187;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; N&#250;&#241;ez-Olarte"
                            1 => "F&#46; L&#243;pez"
                            2 => "M&#46; Conti-Jim&#233;nez"
                            3 => "I&#46;M&#46; S&#225;nchez"
                            4 => "C&#46; P&#233;rez-Aznar"
                            5 => "M&#46;L&#46; Solano- Garz&#243;n"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Paliat"
                        "fecha" => "2018"
                        "volumen" => "25"
                        "paginaInicial" => "175"
                        "paginaFinal" => "183"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/22548874/0000021900000007/v1_201912172116/S2254887419301195/v1_201912172116/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "72714"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Editorials"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021900000007/v1_201912172116/S2254887419301195/v1_201912172116/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419301195?idApp=WRCEE"
]
Share
Current Issue
Journal Information
Previous article | Next article
Lee este artículo en Español
Export reference
Share
Share
Print
Download PDF
More article options
Statistics
Editorial
DOI: 10.1016/j.rceng.2019.03.026
Towards the judicious use of opioids in Spain
Hacia un uso juicioso de los opioides en España
Download PDF
A. Fernández-Lópeza,b,◊, F.J. Medranoc,d,e,f,◊,
Corresponding author
medrano@cica.es

Corresponding author.
a Servicio de Medicina Interna, Equipo de soporte domiciliario, Hospital Universitario Virgen del Rocío, Sevilla, Spain
b Dirección del Plan Andaluz de Cuidados Paliativos, Sevilla, Spain
c Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain
d Instituto de Biomedicina de Sevilla, Sevilla, Spain
e Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain
f Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain
Related content
Opioid consumption in the Community of Madrid (Spain) between 2004 and 2014
Rev Clin Esp. 2019;219:367-7410.1016/j.rceng.2019.03.015
D. Ruiz-López, A. Alonso-Babarro

Purchase article

For the purchase of this article it is necessary to fill in the following form:

Afganistan
Albania
Alemania
Andorra
Angola
Anguilla
Antartica
Antigua and barbuda
Antillas holandesas
Arabia saudita
Argelia
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgica
Belice
Benin
Bermudas/antillas britanicas
Bhutan
Bolivia
Bosnia y herzegowina
Botswana
Brasil
Brunei darussalam
Bulgaria
Burkina faso
Burundi
Cabo verde
Camboya
Camerun
Canada
Chad
Chile
China
Chipre
Colombia
Comoros
Corea
Costa rica
Cote d´ivoire
Croacia
Cuba
Dinamarca
Djibouti
Dominica
East timor
Ecuador
Egipto
El salvador
Emiratos arabes unidos
Eritrea
Escocia
Eslovaquia
Eslovenia
España
Estados federados de micronesia
Estados unidos
Estonia
Etiopia
Fiji
Filipinas
Finlandia
Francia
Gabon
Gambia
Georgia
Ghana
Gibraltar
Grecia
Grenada
Groenlandia
Guadalupe
Guam
Guatemala
Guayana britanica
Guinea
Guinea ecuatorial
Guinea francesa
Guinea-bissau
Haiti
Holanda
Honduras
Hong kong
Hungria
India
Indonesia
Irak
Iran
Irlanda
Isla bouvet
Isla cocos (keeling)
Isla cook
Isla mauricio
Isla navidad
Isla norfolk
Islandia
Islas caiman
Islas falkland (malvinas)
Islas faroe
Islas georgia del sur y sandwich
Islas heard and mc donald
Islas marshall
Islas northern mariana
Islas salomon
Islas svalbard and jan mayen
Islas turks and caicos
Islas united states minor outlyi
Islas virgenes (britanicas)
Islas virgenes (u.s.a.)
Islas wallis and futuna
Israel
Italia
Jamaica
Japon
Jordania
Kazakhstan
Kenia
Kiribati
Kuwait
Kyrgyzstan
Lesoto
Letonia
Libano
Liberia
Libia arab jamahiriya
Liechtenstein
Lituania
Luxemburgo
Macao
Macedonia
Madagascar
Malasia
Malawi
Maldives
Mali
Malta
Marruecos
Martinica
Mauritania
Mayotte
Mexico
Monaco
Mongolia
Monserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Nicaragua
Niger
Nigeria
Niue
Noruega
Nueva caledonia
Nueva zelanda
Oman
Pakistan
Palau
Panama
Papua new guinea
Paraguay
Peru
Pitcairn
Polinesia francesa
Polonia
Portugal
Posesiones gran bretaña
Posesiones u.s.a.
Puerto rico
Qatar
Reino unido
Republica checa
Republica de africa central
Republica de cabo verde
Republica de congo
Republica de corea
Republica de moldova
Republica democratica de laos
Republica democratica del congo
Republica dominicana
Reunion
Ruanda
Rumania
Rusia
Sahara occidental
Saint kitts and nevis
Samoa
Samoa americana
San marino
San tomas y principe
San vincent and the grenadines
Santa lucia
Senegal
Serbia
Seychelles
Sierra leona
Singapur
Siria
Somalia
Sri lanka
St. helena
St. pierre and miquelon
Sudafrica
Sudan
Suecia
Suiza
Surinam
Swaziland
Tailandia
Taiwan republica de china
Tajikistan
Tanzania
Territorio de indias britanicas
Togo
Tokelau
Tonga
Trinidad and tobago
Tunisia
Turkmenistan
Turquia
Tuvalu
Ucrania
Uganda
Uruguay
Uzbekistan
Vanuatu
Vaticano
Venezuela
Vietnam
Yemen
Yugoslavia
Zambia
Zimbawe
Lebanon
Paises bajos
A coruña
Alava
Albacete
Alicante
Almeria
Asturias
Avila
Badajoz
Balears
Barcelona
Bizkaia
Burgos
Caceres
Cadiz
Cantabria
Castellon
Ceuta
Ciudad real
Cordoba
Cuenca
Girona
Granada
Guadalajara
Guipuzcoa
Huelva
Huesca
Jaen
La rioja
Las palmas
Leon
Lleida
Lugo
Madrid
Malaga
Melilla
Murcia
Navarra
Ourense
Palencia
Pontevedra
Salamanca
Segovia
Sevilla
Soria
Tarragona
Tenerife
Teruel
Toledo
Valencia
Valladolid
Zamora
Zaragoza
-- Not applicable --
I accept to receive information about Elsevier's special products and promotions by email
I accept to receive information about products and special promotions from Elsevier partners by email
I have read and understand the Privacy Policy and Terms and conditions and agree to be bound by all of its terms.
* Required fields
In addition to temporary access to the article, it will be sent by email.
Customer Support
Phone
Calls from Spain
932 415 960
Calls from abroad
+34 932 415 960
Hours from 9 a.m. to 6 p.m. except the months of July and August, which will be from 9 am to 3 pm.

Subscribe to our newsletter

Highlighted articles
Publish in
Revista Clínica Española
Free access articles
The value of multi-modal ultrasound in the assessment of...
Rev Clin Esp. 2024;224:437-44
Adverse cardiovascular, obstetric and perinatal events...
Rev Clin Esp. 2024;224:337-45
How to detect non-institutionalized older patients at risk...
Rev Clin Esp. 2024;224:217-24
Revista Clínica Española (English Edition) is a member and subscribes the principles of, the Committee on Publication Ethics (COPE)
www.publicationethics.org.
Idiomas
Revista Clínica Española (English Edition)
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?