Implications of the Parenteral Opioid Shortage for Prescription Patterns and Pain Control Among Hospitalized Patients With Cancer Referred to Palliative Care

Capsaicin-induced Ca2+ overload and ablation of TRPV1-expressing axonal terminals for comfortable tumor immunotherapy

As a common malignancy symptom, cancer pain significantly affects patients' quality of life. Approximately 60%-90% of patients with advanced cancer experience debilitating pain. Therefore, a comprehensive treatment system that combines cancer pain suppression and tumor treatment could provide significant benefits for these patients. Here, we designed a manganese oxide (MnO2)/Bovine serum albumin (BSA)/polydopamine (PDA) composite nanoplatform internally loaded with capsaicin for cancer pain suppression and immunotherapy. MBD&C nanoparticles (NPs) can ablate tumor-innervated sensory nerve fibers via Transient receptor potential vanilloid 1 (TRPV1) channels, thereby reducing the pain caused by various inflammatory mediators. The ablation of TRPV1+ nerve terminals can also decrease the secretion of calcitonin gene-related peptide (CGRP) and substance P (SP) in sensory nerve fibers, thus reducing the tumor pain and inhibit tumor progression. MBD&C can promote calcium influx by activating overexpressed TRPV1 channels on the tumor membrane surface, thereby achieving cancer immunotherapy induced by endogenous Ca2+ overloading. In addition, MnO2 NPs can alleviate tumor hypoxia and mitigate the immunosuppressive tumor microenvironment (TME). Ultimately, this treatment system with dual capabilities of inhibiting tumor growth and relieving cancer pain makes comfortable tumor therapy feasible and paves the way for the development of patient-centered approaches to cancer treatment in the future.

Calcium Carbonate/Polydopamine Composite Nanoplatform Based on TGF-β Blockade for Comfortable Cancer Immunotherapy

Cancer pain seriously reduces the quality of life of cancer patients. However, most research about cancer focuses solely on inhibiting tumor growth, neglecting the issue of cancer pain. Therefore, the development of therapeutic agents with both tumor suppression and cancer pain relief is crucial to achieve human-centered treatment. Here, the work reports curcumin (CUR) and ropivacaine (Ropi) coincorporating CaCO3/PDA nanoparticles (CaPNMCUR+Ropi) that realized efficient tumor immunotherapy and cancer pain suppression. The therapeutic efficiency and mechanism are revealed in vitro and in vivo. The results indicate that CaPNMCUR+Ropi underwent tumor microenvironment-responsive degradation and realized rapid release of calcium ions, Ropi, and CUR. The excessive intracellular calcium triggered the apoptosis of tumor cells, and the transient pain caused by the tumor injection was relieved by Ropi. Simultaneously, CUR reduced the levels of immunosuppressive factor (TGF-β) and inflammatory factor (IL-6, IL-1β, and TNF-α) in the tumor microenvironment, thereby continuously augmenting the immune response and alleviating inflammatory pain of cancer animals. Meanwhile, the decrease of TGF-β leads to the reduction of transient receptor potential vanilloid 1 (TRPV1) expression, thereby alleviating hyperalgesia and achieving long-lasting analgesic effects. The design of the nanosystem provides a novel idea for human-centered tumor treatment in the future.

Adverse drug reaction related to drug shortage: A retrospective study on the French National Pharmacovigilance Database

AIM

Drug shortages are a growing global health issue. The aim of the study was to evaluate the consequences of drug shortages on patient safety based on data recorded in the French National Pharmacovigilance Database.

METHODS

All cases involving drug shortages reported from 1985 to the end of 2019 were extracted from the database.

RESULTS

Following the selection process, 462 cases were included. The number of cases increased significantly from 2004 to 2019. Cases mainly involved drugs from the nervous system (22.1%, 95% confidence interval [CI] 17.5-27.0%), the cardiovascular system (16.4%, 95% CI 11.9-21.4%) and anti-infectives for systemic use (14.3%, 95% CI 9.7-19.2%) ATC classes. Most of the cases reported an adverse drug reaction (ADR) belonging to the SOC nervous system (21%, 95% CI 18-24%), skin and subcutaneous (14%, 95% CI 11-17%), general (13%, 95% CI 10-17%) and gastrointestinal (8%, 95% CI 5-11%) disorders. Disease worsening was observed in 15.9% of the cases, mostly related to a lack of efficacy of the replacement drug. Half of the cases were considered as serious. Evolution was favourable in 79.4% of the cases. Death and/or life-threatening situations were reported in 5.8% of the cases. Medication errors (MEs) were identified in 51 cases (11%), mostly occurring at the administration step and involving a human factor.

CONCLUSION

This study emphasizes the clinical impact of drug shortage in terms of ADRs, ME and inefficiency. These observations underline the importance of a global health policy programme to limit the occurrence of drug shortages and to reinforce the information provided to patients and health care professionals in this context to limit risk.

The Affordable Care Act's young adult mandate was associated with a reduction in pain prevalence

ABSTRACT

Pain is a major health problem among U.S. young adults. The passage of the Affordable Care Act's young adult mandate in 2010 allowed individuals to remain on their parents' health insurance until age 26. Although studies have documented the positive effects of this mandate on various health outcomes, less is known about its association with self-reported pain among young adults. Using the 2002 to 2018 National Health Interview Survey (N = 48,053) and a difference-in-differences approach, we compared the probabilities of reporting pain at 5 sites (low back, joint, neck, headache/migraine, and facial/jaw) and the number of pain sites between mandate eligible (ages 20-25) and ineligible (ages 26-30) adults before and after the mandate. In fully adjusted models, the mandate was associated with a decline of 2 percentage points in the probability of reporting pain at any site (marginal effect, -0.02; 95% confidence interval [CI], -0.05 to -0.002; weighted sample proportion, 0.37) and in the number of pain sites (coefficient, -0.07; 95% CI, -0.11 to -0.01; weighted sample average, 0.62). These results were primarily driven by the association between the mandate and the probability of reporting low back pain (marginal effect, -0.03; 95% CI, -0.05 to -0.01; weighted sample proportion, 0.20). Additional analyses revealed that the mandate was associated with improvements in access to care and reductions in risk factors for pain-including chronic conditions and risky health behaviors. To the extent that the results are generalizable to other health insurance programs, removing financial barriers to medical care may help reduce pain prevalence.

Drug Shortage: Causes, Impact, and Mitigation Strategies

Drug shortage is a global issue affecting low, middle, and high-income countries. Many countries have developed various strategies to overcome the problem, while the problem is accelerating, affecting the whole world. All types of drugs, such as essential life-saving drugs, oncology medicines, antimicrobial drugs, analgesics, opioids, cardiovascular drugs, radiopharmaceutical, and parenteral products, are liable to the shortage. Among all pharmaceutical dosage forms, sterile injectable products have a higher risk of shortage than other forms. The causes of shortage are multifactorial, including supply issues, demand issues, and regulatory issues. Supply issues consist of manufacturing problems, unavailability of raw materials, logistic problems, and business problems. In contrast, demand issues include just-in-time inventory, higher demand for a product, seasonal demand, and unpredictable demand. For regulatory issues, one important factor is the lack of a unified definition of drug shortage. Drug shortage affects all stakeholders from economic, clinical, and humanistic aspects. WHO established global mitigation strategies from four levels to overcome drug shortages globally. It includes a workaround to tackle the current shortage, operational improvements to reduce the shortage risk and achieve early warning, changes in governmental policies, and education and training of all health professionals about managing shortages.

Management of a parenteral opioid shortage using ASHP guidelines

PURPOSE

Management of an acute shortage of parenteral opioid products at a large hospital through prescribing interventions and other guideline-recommended actions is described.

SUMMARY

In early 2018, many hospitals were faced with a shortage of parenteral opioids that was predicted to last an entire year. The American Society of Health-System Pharmacists (ASHP) has published guidelines on managing drug product shortages. This article describes the application of these guidelines to manage the parenteral opioid shortage and the impact on opioid dispensing that occurred in 2018. Our approach paralleled that recommended in the ASHP guidelines. Daily dispensing reports generated from automated dispensing cabinets and from the electronic health record were used to capture dispenses of opioid medications. Opioid prescribing and utilization data were converted to morphine milligram equivalents (MME) to allow clinical leaders and hospital administrators to quickly evaluate opioid inventories and consumption. Action steps included utilization of substitute opioid therapies and conversion of opioid patient-controlled analgesia (PCA) and opioid infusions to intravenous bolus dose administration. Parenteral opioid supplies were successfully rationed so that surgical and elective procedures were not canceled or delayed. During the shortage, opioid dispensing decreased in the inpatient care areas from approximately 2.0 million MME to 1.4 million MME and in the operating rooms from 0.56 MME to 0.29 million MME. The combination of electronic health record alerts, increased utilization of intravenous acetaminophen and liposomal bupivacaine, and pharmacist interventions resulted in a 67% decline in PCA use and a 65% decline in opioid infusions.

CONCLUSION

A multidisciplinary response is necessary for effective management of drug shortages through implementation of strategies and practices for notifying clinicians of shortages and identifying optimal alternative therapies.

Impact of Opioid Restrictions During a Critical Drug Shortage Period: Interrupted Time Series for Institutional Opioid Utilization

OBJECTIVES

This study aimed to evaluate the impact of intravenous opioid product restrictions at an academic medical institution in an urban setting during the time of critical opioid shortages. We assessed the effect of ordering restrictions on inpatient opioid utilization measured by 1) changes in intermittent oral and injectable opioid product administration; 2) changes in total institutional opioid administration; and 3) changes in the utilization of individual restricted opioid agents.

METHODS

This study is a single-center retrospective analysis by interrupted time series of institutional opioid utilization from 07/2017 to 06/2018. Utilization was quantified using milligrams of intravenous morphine equivalent administered or dispensed per admitted patient. Restrictions were grouped into 10 distinct phases, which informed the interruptions in linear regression models.

RESULTS

Sequential restrictions during the study period led to shifts in use of individual agents but did not have a significant impact on overall total opioid utilization. "Soft" restrictions did not have a direct, statistically significant impact on medication use but did decrease utilization over time. In situations where a product was restricted with a "soft stop" followed by a "hard stop," the "hard stop" directly reduced usage.

CONCLUSIONS

Targeted ordering restrictions allowed the institution to redirect drug use according to clinical need without affecting the overall utilization. Clinical decision support led providers to choose therapeutically equivalent alternatives. The demonstrated effect of restrictions will guide institutions in the selection of "hard stop" or "soft stop" restrictions in response to future shortages.

Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain

INTRODUCTION

Nonmedical opioid use (NMOU) in patients with cancer is a term covering a spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death.

OBJECTIVES

The objectives of this study were to (A) evaluate current literature regarding management of NMOU in patients with cancer-related pain; (B) provide best practice recommendations based on evidence; and (C) integrate practices derived from the management of noncancer pain, where clinically appropriate or when the oncology literature is limited.

METHODS

This study is a narrative review.

IMPLICATIONS

Although harm from NMOU was thought to be rare among oncology patients, about one in five patients with cancer is at risk of adverse outcomes including prolonged opioid use, high opioid doses, and increased health care utilization. The management of NMOU can be challenging because pain is a multidimensional experience encompassing physical, psychological, and spiritual domains. An interdisciplinary team approach is most effective, and management strategies may include (A) education of patients and families; (B) harm reduction, including opioid switching, decreasing the overall daily dose, avoiding concurrent sedative use, and using adjuvant medications for their opioid-sparing potential; (C) managing psychological and spiritual distress with an interdisciplinary team and techniques such as brief motivational interviewing; and (D) risk mitigation by pill counts, frequent clinic visits, and accessing statewide prescription drug monitoring plans.

CONCLUSION

Although many of the management strategies for NMOU in patients with cancer-related pain are modeled on those for chronic non-cancer-related pain, there is emerging evidence that education and harm-reduction initiatives specifically for cancer-related pain are effective.

IMPLICATIONS FOR PRACTICE

Nonmedical opioid use (NMOU) in patients with cancer is a term covering a broad spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. This review evaluates the evidence for best practices in oncology and addresses limitations in the literature with supplemental evidence from noncancer chronic pain. Management recommendations for NMOU are provided, based on a combination of literature-based evidence and best clinical practice. Effective management of NMOU in oncology has the potential to improve quality of life, decrease health utilization, and improve survival.

Factors Associated with Improvement in Uncontrolled Cancer Pain without Increasing the Opioid Daily Dose among Patients Seen by an Inpatient Palliative Care Team

Background: Increasing the total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidimensional and may improve pain control in the absence of opioid dose increase. Objective: The purpose of this study was to determine the proportion of patients referred to our inpatient palliative care (IPC) team who achieved clinically improved pain (CIP) without opioid dose increase. Design: We reviewed consecutive patients referred to our IPC team. Setting/Subjects: Eligibility criteria included (1) taking opioid medication; (2) having ≥2 consecutive visits with the IPC team; and (3) an Edmonton Symptom Assessment Scale (ESAS) pain score ≥4 at consultation. Measurements: We assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, and oral morphine equivalent daily dose [MEDD]), presence of opioid rotation, psychological consultation, changes in adjuvant medications (e.g., corticosteroids; antiepileptics-gabapentin and pregabalin; benzodiazepines; and neuroleptics), and achievement of CIP. Results: Of the 300 patients enrolled, CIP was achieved in 196 (65%) patients. Of CIP patients, 85 (43%) achieved CIP without an increase in MEDD. CIP without MEDD increase was associated with more adjuvant medication changes (p = 0.003), less opioid rotation (p = 0.005), and lower symptom distress scale of ESAS (p = 0.04). Conclusions: Nearly half of the patients achieved CIP without MEDD increase, suggesting that the multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients without the need to increase the opioid dose.

Sufentanil Sublingual Tablet: A New Option for Acute Pain Management

Objective: The purpose of this article is to review the safety and efficacy of sufentanil sublingual tablet (SST) and suggest its place in therapy for managing acute pain in patients requiring intravenous (IV) opioids. Data Sources: A MEDLINE/PubMed search was performed (2010 to April 2019) using the following keywords: sufentanil sublingual tablet, sufentanil, opioid, moderate to severe acute pain. Study Selection and Data Extraction Quantification: We included English language articles evaluating SST pharmacology, pharmacokinetics, efficacy, and safety in humans for the treatment of acute pain. Data Synthesis: SST is Food and Drug Administration approved and considered safe and effective for the treatment of acute pain in Risk Evaluation and Mitigation Strategy–certified and medically supervised health care settings. Phase III clinical trials showed a statistically significant decrease in summed pain intensity score when SST was compared with placebo. Relevance to Patient Care and Clinical Practice: SST can be a useful option in patients requiring a parenteral opioid who do not have IV access, or it may be unnecessary or difficult to obtain. Because of its quick onset and sustained analgesia, SST may also be useful for procedural pain in the critically ill, to expedite discharges for outpatient procedures, in emergency departments (EDs), and in the battlefield. Conclusions: SST can satisfy an unmet need in patients with acute pain, who require parenteral opioids, and either have no IV access or require prolonged time to achieve IV access such as patients in outpatient surgical centers, EDs, and the battlefield. During periods of parenteral opioid shortage, SST may provide another option for adequate analgesia.