Non-prescription (OTC) oral analgesics for acute pain - an overview of Cochrane reviews

Safety of metamizole (dipyrone) for the treatment of mild to moderate pain-an overview of systematic reviews

Metamizole, as known as dipyrone or novaminsulfone is widely used, especially in Latin America, for its analgesic and antipyretic function. However, several countries have banned it due to the risk of agranulocytosis, skin necrosis, and other serious adverse effects. To assess the safety of metamizole compared to other commonly used non-opioid analgesics (paracetamol, ibuprofen, and acetylsalicylic acid). An overview of systematic reviews. The searches were performed in the PubMed, Cochrane Library, Embase, Scopus and LILACS databases. Systematic reviews of randomized and nonrandomized clinical trials with adult patients with mild to moderate pain that assessed the adverse effects of metamizole were included. A methodological quality assessment was performed through ROBIS. The protocol of this systematic review was submitted to the International Prospective Register of Systematic Reviews (Prospero, CRD42021295272). Of 387 identified studies, four were included, with a total of 20,643 participants, all submitted to a single dose by oral, intramuscular, or intravenous route. No study reported a serious adverse effect. However, 60 of 778 patients (7.7%) who used metamizole; 120/828 (14.5%) who used acetylsalicylic acid; 56/443 (12.6%) who used paracetamol; and 27/213 (12.7%) who used ibuprofen had mild adverse effects. A complementary statistical analysis showed that metamizole, at any dose, has a 38.8% lower chance of adverse effects compared to paracetamol and 46.8% compared to acetylsalicylic acid. The results shows that metamizole is a safe drug with evidence of a lower incidence of adverse effects compared to paracetamol and acetylsalicylic acid.

A real-world disproportionality analysis of the FDA adverse event reporting system events for ibuprofen

INTRODUCTION

Ibuprofen is commonly used as an over-the-counter (OTC) antipyretic and analgesic. As the frequency of its use has increased, there has been a corresponding increase in reports of associated adverse events (AEs). However, these events have not been systematically reported in the literature. Meanwhile, the importance of effective pharmacovigilance in evaluating the benefits and risks of drugs is being recognized.

METHODS

The data was obtained indirectly from FAERS using the OpenVigil 2 database, lexically mapped using software such as MySQL, Microsoft Excel, and the R language, and then subjected to four more rigorous algorithms to detect risk signals associated with ibuprofen AEs.

RESULTS

By analyzing data from the past 18 years, 878 ibuprofen-related AEs were identified as primary AEs. Notably, unexpected reproductive system and breast diseases, etc., which were unexpected, were observed as important system organ classes (SOCs) associated with ibuprofen. Among the 651 preferred terms (PTs) that simultaneously satisfy the four arithmetic methods, renal tubular acidosis and lip oedema are proposed as new signals for ibuprofen AEs.

CONCLUSION

This study explores the important and valuable potential AEs and ADRs of ibuprofen at the SOC and PT levels, respectively. To provide a reference on decision-making for ibuprofen to promote rational clinical dosing.

[Analgesic use in Germany : Survey of the years 2008 to 2019]

BACKGROUND

There are previously published data on the per capita use of analgesics in Germany, but only to 2005. In the present analysis, data for the years 2008-2019 were evaluated. The use of prescription and nonprescription analgesics was investigated and possible influencing factors were discussed.

MATERIALS AND METHODS

The per capita use of prescription and nonprescription analgesics was determined based on data on prescriptions and cash purchases in pharmacies (IMS Pharmascope®, Wiener Neudorf, Austria). Moreover, an evaluation according to active substances was performed for nonprescription drugs. In addition, pharmaceutical manufacturers' advertising expenditures and changes in distribution channels were analyzed as possible influencing factors.

RESULTS

During the observation period 2008-2019, the use of prescription analgesics in Germany increased, while the use of nonprescription analgesics decreased. Single-agent drugs constitute the majority of sales of nonprescription analgesics. The share of combination drugs has decreased in recent years.

CONCLUSION

The use of nonprescription analgesics in Germany decreased between 2008 and 2019. The trend as of 1995, which was observed in a previous investigation, is therefore continuing. External factors, such as the increase in advertising expenses or easier access via mail-order pharmacies, do not appear to influence use.

Pain management following dental trauma and surgical procedures

Surgical procedures and post-traumatic management of dental patients require effective pain management during treatment, but being considerably more invasive than conservative treatments, pain management is required into the postoperative period. Clinical trials on pain intensity following dental surgical procedures (e.g., 3rd molar extraction, implant placement, periodontal, and endodontic surgery) have shown that pain is most intense approximately 5-6 h after completion of the procedure, reaching its peak levels during the first postoperative day. Greatest consumption of analgesics occurs during the first 48-72 h after 3rd molar extraction. For the management of perioperative pain associated with either conservative or surgical dental treatment, the local anesthetics articaine, lidocaine, mepivacaine, and prilocaine are preferred. These drugs, with a vasoconstrictor, provide a rapid onset and a duration of pulpal anesthesia adequate to complete most dental and surgical procedures painlessly. For management of post-traumatic and postsurgical pain, bupivacaine-administered by an appropriate nerve block-near the conclusion of a surgical procedure, can provide the patient with a pain-free period of up to 12 h. Nonsteroidal anti-inflammatory drugs represent the most effective drugs for the management of dental postsurgical pain. NSAIDs, as a group in therapeutic doses, have numbers needed to treat (NNTs) ranging from 2 to 3, while opioid analgesics do not approach those for NSAIDs. A protocol for management of pain following surgical procedures and traumatic injuries is discussed in this paper and includes preemptive NSAID; perioperative pain management; postoperative pain management-local anesthesia; postoperative pain management-analgesics; postoperative telephone call.

An Updated Review on the Metabolite (AM404)-Mediated Central Mechanism of Action of Paracetamol (Acetaminophen): Experimental Evidence and Potential Clinical Impact

Paracetamol remains the recommended first-line option for mild-to-moderate acute pain in general population and particularly in vulnerable populations. Despite its wide use, debate exists regarding the analgesic mechanism of action (MoA) of paracetamol. A growing body of evidence challenged the notion that paracetamol exerts its analgesic effect through cyclooxygenase (COX)-dependent inhibitory effect. It is now more evident that paracetamol analgesia has multiple pathways and is mediated by the formation of the bioactive AM404 metabolite in the central nervous system (CNS). AM404 is a potent activator of TRPV₁, a major contributor to neuronal response to pain in the brain and dorsal horn. In the periaqueductal grey, the bioactive metabolite AM404 activated the TRPV₁ channel-mGlu5 receptor-PLC-DAGL-CB1 receptor signaling cascade. The present article provides a comprehensive literature review of the centrally located, COX-independent, analgesic MoA of paracetamol and relates how the current experimental evidence can be translated into clinical practice. The evidence discussed in this review established paracetamol as a central, COX-independent, antinociceptive medication that has a distinct MoA from non-steroidal anti-inflammatory drugs (NSAIDs) and a more tolerable safety profile. With the establishment of the central MoA of paracetamol, we believe that paracetamol remains the preferred first-line option for mild-to-moderate acute pain for healthy adults, children, and patients with health concerns. However, safety concerns remain with the high dose of paracetamol due to the NAPQI-mediated liver necrosis. Centrally acting paracetamol/p-aminophenol derivatives could potentiate the analgesic effect of paracetamol without increasing the risk of hepatoxicity. Moreover, the specific central MoA of paracetamol allows its combination with other analgesics, including NSAIDs, with a different MoA. Future experiments to better explain the central actions of paracetamol could pave the way for discovering new central analgesics with a better benefit-to-risk ratio.

S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial

BACKGROUND

Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery.

METHODS

Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis.

RESULTS

Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires).

CONCLUSION

Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.

The Quality of Counseling for Headache OTC Medications in German Community Pharmacies Using a Simulated Patient Approach: Are There Differences between Self-Purchase and Purchase for a Third Party?

Background

In Germany—as worldwide—headache is one of the most frequent causes of self-medication. The dispensing of over-the-counter (OTC) medications may only be carried out by community pharmacies (CPs). In doing so, CPs have to ensure “adequate” counseling, for both self-purchase and purchase for a third party, which also occurs in everyday pharmacy practice. The aim of this study was to evaluate the quality of counseling for headache OTC medications in German CPs and, as the first study worldwide, to analyze whether and to what extent there are differences in counseling between self-purchase and purchase for a third party.

Methods

A cross-sectional study was carried out using the covert simulated patient methodology (SPM) in all 42 CPs in the German big city Potsdam. With the help of 8 trained simulated patients (SPs), each CP was visited four times by a different SP. The SPs simulated in each CP two scenarios two times with the demand for an OTC medication against headache, which differed only in whether the demand was for themselves or for their boyfriend/girlfriend.

Results

All 168 planned pharmacy visits (84 visits per scenario) were successfully carried out. Overall, the median counseling score was 3.0 out of 9 points (interquartile range [IQR 2.0]). There were no significant differences between the two scenarios (Wilcoxon signed-rank test; p=0.495, r = 0.053). In a multivariate binary logistic regression analysis, the counseling level and the different scenarios were not significantly associated (adjusted odds ratio [AOR] = 1.635, 95% CI = 0.673–3.972, p=0.278).

Conclusions

Due to the partly considerable deficits in counseling of German CPs, policy-makers and the regional chambers of pharmacists are called upon to take appropriate measures to improve the quality of counseling. It is positive that no differences in counseling between self-purchase and purchase for a third party were found, but further verifying studies with a modified methodology are recommended.

The Opioid Analgesic Reduction Study (OARS)-a comparison of opioid vs. non-opioid combination analgesics for management of post-surgical pain: a double-blind randomized clinical trial

Background

Everyday people die unnecessarily from opioid overdose-related addiction. Dentists are among the leading prescribers of opioid analgesics. Opioid-seeking behaviors have been linked to receipt of initial opioid prescriptions following the common dental procedure of third molar extraction. With each opioid prescription, a patient’s risk for opioid misuse or abuse increases. With an estimated 56 million tablets of 5 mg hydrocodone annually prescribed after third molar extractions in the USA, 3.5 million young adults may be unnecessarily exposed to opioids by dentists who are inadvertently increasing their patient’s risk for addiction.

Methods

A double-blind, stratified randomized, multi-center clinical trial has been designed to evaluate whether a combination of over-the-counter non-opioid-containing analgesics is not inferior to the most prescribed opioid analgesic. The impacted 3rd molar extraction model is being used due to the predictable severity of the post-operative pain and generalizability of results. Within each site/clinic and gender type (male/female), patients are randomized to receive either OPIOID (hydrocodone/acetaminophen 5/300 mg) or NON-OPIOID (ibuprofen/acetaminophen 400/500 mg). Outcome data include pain levels, adverse events, overall patient satisfaction, ability to sleep, and ability to perform daily functions. To develop clinical guidelines and a clinical decision-making tool, pain management, extraction difficulty, and the number of tablets taken are being collected, enabling an experimental decision-making tool to be developed.

Discussion

The proposed methods address the shortcomings of other analgesic studies. Although prior studies have tested short-term effects of single doses of pain medications, patients and their dentists are interested in managing pain for the entire post-operative period, not just the first 12 h. After surgery, patients expect to be able to perform normal daily functions without feeling nauseous or dizzy and they desire a restful sleep at night. Parents of young people are concerned with the risks of opioid use and misuse, related either to treatments received or to subsequent use of leftover pills. Upon successful completion of this clinical trial, dentists, patients, and their families will be better able to make informed decisions regarding post-operative pain management.

Trial registration

ClinicalTrials.govNCT04452344. Registered on June 20, 2020

Abuse of Non-opioid Analgesics in Germany: Prevalence and Associations Among Self-Medicated Users

BACKGROUND

Abuse of non-opioid analgesics (NOA) is associated with serious health consequences. However, due to inconsistent definitions of NOA abuse, prevalence estimates for the German population are unclear.

OBJECTIVES

This study aimed to estimate the 12-month prevalence of NOA abuse among self-medicated users of these drugs in the general German population and to identify risk factors.

METHODS

Data are from the 2015 Epidemiological Survey of Substance Abuse, a nationally representative sample with 9,204 individuals aged 18-64 years. Classification of NOA abuse was based on self-reported information according to the definition of the ICD-10-GM diagnosis F55.2 abuse of non-dependence producing substances. Multiple logistic regression was performed to examine associations between NOA abuse and sociodemographic, behavioral, and health-related variables.

RESULTS

The weighted 12-month prevalence of NOA abuse was 14.6% (95%-CI [13.2- 16.0]) among self-medicated users of these drugs. Extrapolation of the proportion of individuals abusing NOA to the German population aged 18 to 64 is 3,243,396 individuals or 6.4% (95%-CI [5.7- 7.1]). Inexplicable physical pain, being underweight, depression, hazardous alcohol use, daily smoking, illegal drug use, and frequent use of NOA (one or more times per week and daily use) were associated with an increased probability of NOA abuse. The use of cannabis was associated with a lower probability of NOA abuse.

CONCLUSION

Abuse of NOA is highly prevalent in the German population. Against the background of increasing self-medication of NOA, healthcare providers need to be aware of potential risk factors of abuse to better identify and prevent this problem.

Pain relief with combination acetaminophen/codeine or ibuprofen following third-molar extraction: A systematic review and meta-analysis

OBJECTIVE

The purpose of our study was to perform a systematic review and meta-analysis of randomized, blinded, placebo-controlled studies that, following third-molar extraction, utilized either a combination of acetaminophen (600 mg) with codeine (60 mg) or ibuprofen (400 mg) for pain management.

DESIGN

We searched PubMed, and the trial registry ClinicalTrials.gov databases with the keywords "molar or molars", "tooth or teeth", "extraction" and "pain". Selected studies were: (1) randomized, blinded, placebo controlled, (2) utilized either a single-dose combination acetaminophen (600 mg) with codeine (60 mg) (A/C) or ibuprofen, and (3) recorded standardized pain relief (PR) at 6 hours, or summed total pain relief over 6 hours (TOTPAR6). Of the 2,949 articles that were identified, 79 were retrieved for full-text analysis, and 20 of these studies met our inclusion criteria.

RESULTS

For A/C, the weighted, standardized mean difference (SMD) for TOTPAR6 was 0.796 (0.597-0.995, 95% confidence interval), P < 0.001, and for PR at 6 h, the SMD was 0.0186 (0.007 to 0.378; P = 0.059), whereas for ibuprofen the SMD for TOTPAR6 was 3.009 (1.283 to 4.735; P = 0.001), and for PR at 6 h, the SMD was 0.854 (95% CI, 0.712 to 0.996; P < 0.001). A SMD of 0.8 or larger is indicative of a large effect.

CONCLUSIONS

Our data indicate that single dose of ibuprofen (400 mg) is an effective pain reducer for post third molar extraction pain.

Patient, Provider Type, and Procedure Type Factors Associated with Opioid Prescribing by Dentists in a Health Care System

Introduction

Reports examining opioid prescribing for dental conditions are limited and do not examine patient-level factors. This study examines the association of patient age, sex, race, ethnicity, Medicaid coverage, and the need for an interpreter in addition to procedure type and dental provider type with receipt of an opioid prescription in dental care settings within a large health system.

Materials and Methods

This study was conducted utilizing data from the electronic health record of HealthPartners, a large dental practice embedded within a health care system. The analytic sample consisted of all 169,173 encounters from 90,487 patients undergoing a dental procedure in the baseline period (9/1/2018 to 8/30/2019), prior to implementing a clinical trial to de-implement opioids in dentistry.

Results

Opioids were prescribed at 1.9% of all 169,173 encounters and rates varied by patient factors, procedure category, and provider type. Opioid prescriptions were most likely for extraction encounters (25.9%). In a multivariable analysis of 8760 extraction encounters, all patient age groups were more likely than those age 66+ to receive an opioid prescription, particularly those age 18–25 (OR=6.94). Patients having a complex rather than simple extraction were more likely to receive an opioid prescription (OR=6.31) and those seen by an oral surgeon rather than a general dentist (OR=9.11) were more likely to receive an opioid prescription. Among 108,748 encounters with a diagnostic procedure, opioid prescribing was more likely among male than female patients (OR=1.20), Black patients relative to White (OR=1.69), patients with Medicaid coverage (OR=1.86), and patients seeing an oral surgeon rather than a general dentist (OR=27.81).

Conclusion

Opioid prescribing rates vary considerably depending on procedure type. Patterns of associations between patient factors and opioid prescribing also vary considerably across procedure type. To understand which patient groups are more at risk of being prescribed opioids, it is essential to consider the procedures they are receiving.

Caffeine Intoxication Due to Antipyretic Analgesic Overdose in an Adolescent

Recently, high concentrations of caffeine present in energy drinks and over-the-counter (OTC) drugs have become a concern worldwide. Several deaths due to caffeine intoxication have been reported, necessitating caution. Typically, supportive care is used to treat caffeine intoxication. However, in severe cases of caffeine intoxication, hemodialysis may be used. For adults, a lethal blood caffeine concentration is at least 80 µg/mL, whereas lethal blood caffeine concentration is unknown for children. In the present case, a 15-year-old girl took a large dose of an OTC antipyretic analgesic to commit suicide, resulting in caffeine intoxication. In this case, even though blood caffeine concentration was higher than the adult lethal dose, the patient recovered through a simple treatment with intravenous infusion of extracellular fluid.

Prospective Cross-Sectional Study of the Uses of Non-prescription Analgesics among Hail Residents

<p>The aim of this paper was to describe the general status of the use of non-prescription analgesics (NPA) among the residents of Hail city to ensure the safe use of non-prescription analgesics.  One hundred participants with different diseases were studied consecutively from January to March 2020. Data were collected with an online, semi-structured questionnaire; the obtained data were converted into statistical data using Microsoft Excel 2013. Most participants were taking a single, non-prescription analgesic (87.5%), while combination analgesic products were used by only 12.5% of participants. Using over-the-counter analgesics is common among residents of Hail, and most of those studied use these products in moderation and do not exceed the recommended dose. Acetaminophen is the most widely used product, but people also use NSAIDs and amphetamine-like products. The use of over-the-counter analgesics is common among residents of Hail, and most of the participants in this study use these products in moderation and do not exceed the recommended dose; therefore, exposure of patients to an increased risk of adverse effects of these products is out of the question, and this indicates that a large group of people in this region knows the risk of analgesics overuse. New studies are needed to help improve the approaches to the use of NPA drugs</p>

Paracetamol: A Review of Guideline Recommendations

Musculoskeletal pain conditions are age-related, leading contributors to chronic pain and pain-related disability, which are expected to rise with the rapid global population aging. Current medical treatments provide only partial relief. Furthermore, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in young and otherwise healthy individuals but are often contraindicated in elderly and frail patients. As a result of its favorable safety and tolerability record, paracetamol has long been the most common drug for treating pain. Strikingly, recent reports questioned its therapeutic value and safety. This review aims to present guideline recommendations. Paracetamol has been assessed in different conditions and demonstrated therapeutic efficacy on both acute and chronic pain. It is active as a single agent and is additive or synergistic with NSAIDs and opioids, improving their efficacy and safety. However, a lack of significant efficacy and hepatic toxicity have also been reported. Fast dissolving formulations of paracetamol provide superior and more extended pain relief that is similar to intravenous paracetamol. A dose reduction is recommended in patients with liver disease or malnourished. Genotyping may improve efficacy and safety. Within the current trend toward the minimization of opioid analgesia, it is consistently included in multimodal, non-opioid, or opioid-sparing therapies. Paracetamol is being recommended by guidelines as a first or second-line drug for acute pain and chronic pain, especially for patients with limited therapeutic options and for the elderly.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

Hintergrund

Nichtopioidanalgetika werden bei vielen Patienten zur perioperativen Analgesie eingesetzt. Zu einigen praktischen Fragen beim Einsatz von Nichtopioidanalgetika liegen z. T. nur wenig Informationen aus Studien vor, und in Krankenhäusern existieren häufig keine Konzepte zum Vorgehen, z. B. zur Patientenaufklärung und zum Zeitpunkt der perioperativen Gabe.

Methodik

Eine Expertengruppe der beteiligten Fachgesellschaften hat konsensbasierte Empfehlungen zum perioperativen Einsatz von Nichtopioidanalgetika erarbeitet und in einem strukturierten formalen Konsensusprozess verabschiedet.

Ergebnisse

Die Arbeitsgruppe stimmt überein, dass Nichtopioidanalgetika Bestandteil eines perioperativen multimodalen Analgesiekonzepts sein sollen und Patienten präoperativ über Nutzen, Risiken und alternative Behandlungsmöglichkeiten aufgeklärt werden sollen. Die präoperative Patienteninformation und -edukation soll auch eine Schmerz- und Analgetikaanamnese umfassen und Patienten mit Risikofaktoren für starke Schmerzen und eine Schmerzchronifizierung sollen identifiziert werden. Unter Berücksichtigung von Kontraindikationen können Nichtopioidanalgetika abhängig von der Operationsdauer auch schon prä- oder intraoperativ gegeben werden, um nach Beendigung der Anästhesie ausreichende Plasmakonzentrationen zu erzielen. Nichtopioidanalgetika oder Kombinationen von (Nichtopioid‑)Analgetika sollen nur für einen begrenzten Zeitraum gegeben werden. Ein gemeinsam erarbeiteter abteilungsübergreifender Behandlungsstandard mit dem Nichtopioidanalgetikum erster Wahl, weiteren Therapieoptionen sowie adäquaten Dosierungen, ergänzt durch eingriffsspezifische Konzepte, soll schriftlich hinterlegt werden. Bei Entlassung aus dem Krankenhaus soll der nachbehandelnde Arzt zu perioperativ gegebenen und aktuell noch eingenommenen Analgetika schriftliche Informationen erhalten. Patienten sollen zu möglichen Nebenwirkungen der Analgetika und ihrer Symptome, die auch nach Krankenhausentlassung auftreten können, und die befristete Einnahmedauer informiert werden.

Schlussfolgerung

Die Anwendung von Nichtopioidanalgetika soll als Bestandteil eines perioperativen multimodalen Analgesiekonzepts mit klaren Vorgaben zu Indikationen, Kontraindikationen, Dosierungen und Behandlungsdauer in einem abteilungsübergreifenden Behandlungsstandard schriftlich hinterlegt werden.

Zusatzmaterial online

Die Offenlegung von Interessen ist in der Online-Version dieses Artikels (10.1007/s00104-021-01421-w) enthalten.

Acute Tolerance to the Analgesic Effects of Alcohol

OBJECTIVE

The goal of this study was to determine whether the acute analgesic effects of alcohol intake are moderated by acute alcohol tolerance, characterized by differing subjective and neurobehavioral effects of a given blood alcohol concentration (BAC) depending on whether BAC is rising or falling.

METHOD

Twenty-nine healthy drinkers (20 women) completed two laboratory sessions in which they consumed a study beverage: active alcohol (target BAC= .08 g/dl) and placebo. Acute alcohol tolerance was assessed by examining the main and interactive effects of beverage condition and assessment limb (ascending vs. descending) on quantitative sensory testing measures collected using slowly ramping heat stimuli and perceived relief ratings at comparable breath alcohol concentrations on the ascending and descending limbs.

RESULTS

BAC limb moderated the effect of condition on pain threshold, such that the threshold was significantly elevated in the alcohol condition on the ascending limb. The alcohol condition produced greater ratings of perceived pain relief than the placebo condition, and pain relief ratings were greater on the ascending versus descending limb of the BAC curve. Alcohol intake did not significantly affect pain tolerance or aftersensation ratings on either BAC limb.

CONCLUSIONS

This study provides initial experimental evidence that alcohol's analgesic and pain-relieving effects are subject to acute tolerance following acute alcohol intake. These findings suggest that self-medicating pain via alcohol intake may be associated with high-risk drinking topography, increasing the risk for alcohol-related consequences. Further research is needed to determine if these effects extend to the context of clinical and chronic pain.

Acute Tolerance to the Analgesic Effects of Alcohol

OBJECTIVE

The goal of this study was to determine whether the acute analgesic effects of alcohol intake are moderated by acute alcohol tolerance, characterized by differing subjective and neurobehavioral effects of a given blood alcohol concentration (BAC) depending on whether BAC is rising or falling.

METHOD

Twenty-nine healthy drinkers (20 women) completed two laboratory sessions in which they consumed a study beverage: active alcohol (target BAC= .08 g/dl) and placebo. Acute alcohol tolerance was assessed by examining the main and interactive effects of beverage condition and assessment limb (ascending vs. descending) on quantitative sensory testing measures collected using slowly ramping heat stimuli and perceived relief ratings at comparable breath alcohol concentrations on the ascending and descending limbs.

RESULTS

BAC limb moderated the effect of condition on pain threshold, such that the threshold was significantly elevated in the alcohol condition on the ascending limb. The alcohol condition produced greater ratings of perceived pain relief than the placebo condition, and pain relief ratings were greater on the ascending versus descending limb of the BAC curve. Alcohol intake did not significantly affect pain tolerance or aftersensation ratings on either BAC limb.

CONCLUSIONS

This study provides initial experimental evidence that alcohol's analgesic and pain-relieving effects are subject to acute tolerance following acute alcohol intake. These findings suggest that self-medicating pain via alcohol intake may be associated with high-risk drinking topography, increasing the risk for alcohol-related consequences. Further research is needed to determine if these effects extend to the context of clinical and chronic pain.

Sex differences in the consumption of over-the-counter analgesics among amateur volleyball players

Background

Compared with the normal adult population, athletes of several sport disciplines, such as endurance sports, ball sports, cycling and swimming, have higher use of over-the-counter analgesics (OTC analgesics). The aim of this study was to describe the epidemiology of OTC analgesic use in volleyball players as a typical competitive sport discipline. One particular focus was placed on the analysis whether the athletes’ use of OTC analgesics was influenced by their performance motivation.

Methods

A cross-sectional survey among amateur volleyball players was carried out using a web-based sports questionnaire. The study included athletes of both sexes, 18 years and older, currently playing in a German volleyball league. The athletes’ sport-related complaints were evaluated regarding the use of OTC analgesics. The use of OTC analgesics by athletes was compared with their performance motivation, based on the „Achievement Motives Scale - Sport” (AMS-Sport) questionnaire.

Results

The analysis of 114 completed questionnaires of amateur athletes revealed that the use of OTC analgesics was sex dependent, with a higher prevalence of use in female players (60%) versus male players (38%). The main reasons for consumption of OTC analgesics were pain in the head, knee and shoulder. The most frequently taken drug was ibuprofen, most often taken at competitions and over a period of 4 years (median). The analysis of the AMS-Sport questionnaire revealed that a logistic regression model for estimating the probability of drug use can be explained by the factors hope of success and years of playing practise in female players but not male players. In females, an increase in the factor hope of success resulted in a lower probability of OTC analgesic use, while an increase in years of playing practise resulted in a higher probability of use.

Conclusion

The average duration that volleyball players in this study took OTC analgesics was higher than that of the German population, and OTC analgesic use was more prevalent in female than male volleyball players. Thus, to reduce the prevalence of OTC analgesic use, educational programs should be implemented in sports teams; and, to reduce direct and indirect social pressure, sports teams should also receive sex-specific psychological support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00273-5.

Oligoanalgesia in the emergency setting - An Indian review

Pain is a result of nociceptive tissue injury and results in acute and chronic impact to patients. Acute pain management is the need of the hour as untreated or under-treated pain may progress to chronic pain. Pain irrespective of its temporality causes a negative impact on the quality of life of the patients. Many Indian emergency settings are not adequately equipped to handle pain due to the heavy load of patients and the lack of awareness about the pain management guidelines. This leads to undertreatment of pain or 'oligoanalgesia'. A pain management protocol can help prevent oligoanalgesia in an emergency setting. Proper utilization of triage systems that incorporate pain as one of the vital signs is necessary. The categorization of pain with the help of a pain scale helps determine the severity of pain and its appropriate management. Pain management is an ongoing process that does not end with the discharge of the patient. Post discharge management of pain is also an important factor to prevent chronic pain. This may involve various modalities for pain management under the preview of multimodal management of pain.

De-Implementing Opioid Use and Implementing Optimal Pain Management Following Dental Extractions (DIODE): Protocol for a Cluster Randomized Trial

Background

Overdose deaths from prescription opioid analgesics are a continuing crisis in the United States. Opioid analgesics are among the most frequently prescribed drugs by dentists. An estimated 5 million people undergo third-molar extractions in the United States each year, resulting in postoperative pain. Studies show that, in most cases, the combination of ibuprofen and acetaminophen is an effective alternative to commonly prescribed opioid analgesics for the management of postextraction pain. Nevertheless, many dentists routinely prescribe opioids after dental extractions.

Objective

We describe the rationale, design, and methods for a randomized trial of interventions designed to de-implement opioid prescribing by dentists while implementing effective nonopioid analgesics following dental extractions.

Methods

Using a prospective, 3-arm, cluster randomized trial design with dentists as the unit randomized and patient-level prescribing data as the primary outcome, we will compare different strategies to reduce the reliance on opioids and increase the use of alternative pain management approaches utilizing information support tools aimed at both providers and their patients. The study will test the efficacy of 2 interventions to decrease opioid prescribing following dental extractions: clinical decision support with (CDS-E) and without patient education (CDS). Providers will be randomized to CDS, CDS-E, or standard practice. Patient-level outcomes will be determined via review of comprehensive electronic health records. We will compare study arms on differential change in prescribing patterns from pre- to postimplementation of the intervention. The primary outcome of interest is a binary indicator of whether or not the patient received an opioid prescription on the day of the extraction encounter. We will also examine recommendations or prescriptions for nonopioid analgesics, patients’ perceptions of shared decision making, and patients’ pain experiences following the extraction.

Results

The HealthPartners Institutional Review Board approved the study. All study materials including the CDS and patient education materials have been developed and pilot tested, and the protocol has been approved by the National Institute of Dental and Craniofacial Research. The intervention was implemented in February 2020, with 51 dentists who were randomized to 1 of the 3 arms.

Conclusions

If the intervention strategies are shown to be effective, they could be implemented more broadly in dental settings with high levels of opioid prescribing.

Trial Registration

ClinicalTrials.gov NCT03584789, https://clinicaltrials.gov/ct2/show/NCT03584789

International Registered Report Identifier (IRRID)

DERR1-10.2196/24342

Evaluation of Fixed-Dose Combinations of Ibuprofen and Acetaminophen in the Treatment of Postsurgical Dental Pain: A Pilot, Dose-Ranging, Randomized Study

Introduction

Ibuprofen and acetaminophen provide analgesia via different mechanisms of action and do not exhibit drug–drug interactions; therefore, combining low doses of each may provide greater efficacy without compromising safety.

Objectives

The present study assessed the analgesic efficacy of fixed-dose combinations (FDCs) of ibuprofen/acetaminophen (IBU/APAP) compared with ibuprofen 400 mg and placebo.

Methods

This 12-h, double-blind, proof-of-concept study compared three FDCs of IBU/APAP (200 mg/500 mg, 250 mg/500 mg, and 300 mg/500 mg) with ibuprofen 400 mg and placebo in patients with moderate-to-severe pain following third molar extraction. The primary endpoint was the time-weighted sum of pain relief and pain intensity difference scores from 0 to 8 h after dosing (SPRID[4]_0–8). Time to meaningful pain relief (TMPR), duration of pain relief, and adverse events (AEs) were also assessed.

Results

In total, 394 patients were randomized. All active treatments were superior to placebo for SPRID[4]_0–8 (all p < 0.001) but not significantly different from ibuprofen 400 mg. Median TMPR with FDCs and ibuprofen (44.5–54.1 and 56.2 min, respectively) was faster than with placebo (> 720 min; all p < 0.001 vs. placebo). Duration of pain relief was similar with the FDCs and ibuprofen 400 mg (9.7 –11.1 h) and longer than with placebo (1.6 h; all p < 0.001). AE incidence was comparable with all treatments.

Conclusion

Each IBU/APAP FDC provided analgesic efficacy comparable to that with ibuprofen 400 mg and superior to that with placebo. Each FDC provided MPR in < 1 h, duration of pain relief > 9 h, and tolerability similar to that with ibuprofen and placebo.

ClinicalTrials.gov Registration

NCT01559259

Electronic supplementary material

The online version of this article (10.1007/s40268-020-00310-7) contains supplementary material, which is available to authorized users.

Analgesics for Dental Implants: A Systematic Review

Postsurgical pain is commonly associated with dental and oral surgery, and the use of analgesics has been investigated in the management of postoperative pain. This systematic review summarizes available evidence on analgesics used to manage dental implant surgery postoperative pain, to identify best therapeutic protocols and knowledge gap. A comprehensive search was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov, and the Cochrane Database of Systematic Reviews through May 2020. Only randomized controlled trials were included. PRISMA guidelines were followed, and risk of bias was appraised using Cochrane RoB2 tool. Eleven trials (762 patients overall) were included. Some aspects limited the feasibility of a meaningful meta-analysis; thus, a narrative synthesis was conducted. Risk of bias was low in four studies and high in two studies, while five studies raised some concerns due to the randomization process. Analgesic use seemed to be associated with improved postoperative outcomes (pain, patient's satisfaction, and need for rescue medication) when compared to placebo. Overall, this review suggests that the administration of analgesics may provide some advantages in the management of postoperative outcomes after dental implant placement, while indications about the best analgesics cannot be provided.

Ibuprofen Arginate for Rapid-Onset Pain Relief in Daily Practice: A Review of Its Use in Different Pain Conditions

Ibuprofen is one of the most frequently used analgesics. One of the concerns related with the oral administration of conventional ibuprofen is the relatively slow absorption, which is clinically a relative inconvenience when rapid-onset analgesic effect is required in patients suffering from acute moderate/severe pain. A new oral dosage formulation of ibuprofen containing the L-arginine salt of ibuprofen (ibuprofen arginate) has been commercialized for more than two decades, but data reported in the literature are relatively scarce. This article presents salient findings on pharmacokinetics, pharmacological activity, clinical efficacy and tolerability of ibuprofen arginate, with the purpose to provide clinicians with a summary overview of some frequent acute pain conditions, such as dental pain, dysmenorrhea, headache or postoperative pain in which ibuprofen arginate may be considered the drug of choice in individual patients.

A computational model of liver tissue damage and repair

Drug induced liver injury (DILI) and cell death can result from oxidative stress in hepatocytes. An initial pattern of centrilobular damage in the APAP model of DILI is amplified by communication from stressed cells and immune system activation. While hepatocyte proliferation counters cell loss, high doses are still lethal to the tissue. To understand the progression of disease from the initial damage to tissue recovery or death, we computationally model the competing biological processes of hepatocyte proliferation, necrosis and injury propagation. We parametrize timescales of proliferation (α), conversion of healthy to stressed cells (β) and further sensitization of stressed cells towards necrotic pathways (γ) and model them on a Cellular Automaton (CA) based grid of lattice sites. 1D simulations show that a small α/β (fast proliferation), combined with a large γ/β (slow death) have the lowest probabilities of tissue survival. At large α/β, tissue fate can be described by a critical γ/β* ratio alone; this value is dependent on the initial amount of damage and proportional to the tissue size N. Additionally, the 1D model predicts a minimum healthy population size below which damage is irreversible. Finally, we compare 1D and 2D phase spaces and discuss outcomes of bistability where either survival or death is possible, and of coexistence where simulated tissue never completely recovers or dies but persists as a mixture of healthy, stressed and necrotic cells. In conclusion, our model sheds light on the evolution of tissue damage or recovery and predicts potential for divergent fates given different rates of proliferation, necrosis, and injury propagation.

Phase I Pharmacokinetic Study of Fixed-Dose Combinations of Ibuprofen and Acetaminophen in Healthy Adult and Adolescent Populations

Introduction

A fixed-dose combination (FDC) of ibuprofen and acetaminophen has been developed that provides greater analgesic efficacy than either agent alone at the same doses without increasing the risk for adverse events.

Methods

We report three clinical phase I studies designed to assess the pharmacokinetics (PK) of the FDC of ibuprofen/acetaminophen 250/500 mg (administered as two tablets of ibuprofen 125 mg/acetaminophen 250 mg) in comparison with its individual components administered alone or together, and to determine the effect of food on the PK of the FDC. Two studies in healthy adults aged 18–55 years used a crossover design in which subjects received a single dose of each treatment with a 2-day washout period between each. In the third study, the bioavailability of ibuprofen and acetaminophen from a single oral dose of the FDC was assessed in healthy adolescents aged 12–17 years, inclusive.

Results

A total of 35 and 46 subjects were enrolled in the two adult studies, respectively, and 21 were enrolled in the adolescent study. Ibuprofen and acetaminophen in the FDC were bioequivalent to the monocomponents administered alone or together. With food, the maximum concentration (C_max) for ibuprofen and acetaminophen from the FDC was reduced by 36% and 37%, respectively, and time to C_max (i.e. t_max) was delayed. Overall drug exposure to ibuprofen or acetaminophen in the fed versus fasted states was similar. In adolescents, overall exposure to acetaminophen and ibuprofen was comparable with that in adults, with a slightly higher overall exposure to ibuprofen. Exposure to acetaminophen and ibuprofen in adolescents aged 12–14 years was slightly higher versus those aged 15–17 years. Adverse events were similar across all treatment groups.

Conclusions

The FDC of ibuprofen/acetaminophen 250/500 mg has a PK profile similar to its monocomponent constituents when administered separately or coadministered, indicating no drug–drug interactions and no formulation effects. Similar to previous findings for the individual components, the rates of absorption of ibuprofen and acetaminophen from the FDC were slightly delayed in the presence of food. Overall, adolescents had similar exposures to acetaminophen and ibuprofen as adults, while younger adolescents had slightly greater exposure than older adolescents, probably due to their smaller body size. The FDC was generally well tolerated.

Exploring Australian pharmacists' perceptions and attitudes toward codeine up-scheduling from over-the-counter to prescription only

Objective:

Explore the perceptions, attitudes and experiences of pharmacists relating to the up-scheduling of low dose codeine containing analgesics and the impact on pharmacy practice.

Methods:

A mixed design method was used consisting of an anonymous online questionnaire survey to quantitatively capture broad pre-scheduling change perceptions paired with a series of in-depth post-scheduling semi-structured interviews to provide a qualitative picture of the impact of codeine up-scheduling on pharmacy practice in Australia.

Results:

A total of 191 pharmacists completed the quantitative survey and 10 participated in the in-depth interview. The majority of respondents supported the decision to up-schedule over-the-counter combination products containing codeine to some degree. Three main themes emerged from the data: pharmacists’ perceptions of the codeine up-scheduling decision, preparing for the up-schedule and impact of the up-schedule on pharmacy practice. Pharmacists were concerned about the impact of up-scheduling on the pharmacy business, patient access to pain relief and the diminishment of their professional role.

Conclusions:

There were diverse perceptions, preparedness and impact on practice regarding the up-scheduling of low dose codeine products. Further research should be conducted to gauge if and how these perceptions have changed over time and to identify whether pain is being managed more effectively post codeine up-scheduling.

[Treatment of polyneuropathy: autonomic symptoms and pain]

BACKGROUND

The treatment of polyneuropathy includes symptomatic therapy of sensory, motor and autonomic dysfunctions.

AIM

This article provides an overview of the current treatment recommendations for polyneuropathy, focusing on pain.

METHODS

Current treatment guidelines will be discussed based on a literature research.

RESULTS

Calcium-channel anticonvulsants gabapentin/pregabalin as well as antidepressants duloxetine and amitriptyline are recommended as first line therapeutics. Alternatively, topical therapeutics can be used in the case of localized disorders. In individual cases, opioids or other antidepressants/anticonvulsants may be effective. Pharmacological treatment is often limited due to adverse events, which affect the central nervous system in particular.

DISCUSSION

In general, treatment for polyneuropathy should follow a multimodal concept and include the treatment of other symptoms. When choosing pain medication, comorbidities, patient's age and adverse events need to be taken into consideration. Phenotype-based stratification may support specialized pain therapy and achieve the best medical treatment.

[Pain therapy for children and adolescents with hemophilia : Recommendations by an expert panel]

BACKGROUND

Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated.

OBJECTIVES

This paper discusses how to improve pain management for children and adolescents (0-18 years) with hemophilia and which specific features in this population should influence decisions in pain management.

MATERIALS AND METHODS

An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience.

RESULT

Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.

Analgesic use among the Brazilian population: Results from the National Survey on Access, Use and Promotion of Rational Use of Medicines (PNAUM)

Purpose

To estimate the prevalence of use of analgesics in Brazil; and to characterize this use, according to sociodemographic and health-related characteristics.

Methods

A cross-sectional population-based study (National Survey on Access, Use and Promotion of Rational Use of Medicines, PNAUM) was conducted between September 2013 and February 2014. A total of 41,433 people of all ages in Brazilian urban households were interviewed. Occasional use (within the last 15 days) and continuous use of non-opioid analgesics, opioid analgesics and non-steroidal anti-inflammatory drugs were investigated, regardless of whether this use occurred through prescription or self-medication. The main outcome was the use of at least one analgesic.

Results

The majority of the individuals were female (52.8%), aged between 20 and 59 years (57.2%), with 1 to 8 years of schooling (45.6%). The overall prevalence of analgesic use was 22.8% [95% CI: 21.4–24.2]. The use of analgesics was significantly higher among women, adults and elderly (20 years or more), highly educated individuals and respondents who referred: diagnosis of one or more chronic diseases, using three or more medications, possession of health insurance and with one or more emergency care admittances or hospitalizations within the last year. Non-opioid analgesics were the agents most used (18.5% of the sample), followed by non-steroidal anti-inflammatory drugs (6.9%) and opioid analgesics (0.5%). The most commonly used drugs were metamizole (37.8% of all analgesics), paracetamol (25.3%) and diclofenac (10.7%). These drugs were used mainly to manage occasional health conditions, particularly pain.

Conclusion

One in five Brazilians used some analgesic, especially non-opioid analgesics, to manage acute health problems such as painful conditions.

Genetic Basis of Delayed Hypersensitivity Reactions to Drugs in Jewish and Arab Populations

Genetic variation can affect drug pharmacokinetics and pharmacodynamics and contribute to variability between individuals in response to medications. Specifically, differences in allele frequencies among individuals and ethnic groups have been associated with variation in their propensity to develop drug hypersensitivity reactions (HSRs). This article reviews the current knowledge on the genetic background of HSRs and its relevance to Jewish and Arab populations. The focus is on human leukocyte antigen (HLA) alleles and haplotypes as predictive markers of HSRs ("immunopharmacogenetics"), but other genes and alleles are described as well. Also discussed is the translation of the pharmacogenetic information to practice recommendations.

A study of medical professionals' perspectives on medicines containing codeine in South Africa

Background

Misuse of codeine available on prescription and over-the-counter (OTC) has been highlighted as a potential problem in South Africa.

Objective

To examine the perceptions of medical professionals regarding codeine use (prescribed and OTC), misuse, dependence and treatment options in South Africa.

Method

Data for the study were obtained using a sample of medical professionals obtained through random and convenience sampling. A quantitative methodology was employed using a structured self-administered questionnaire with closed and open-ended items. Data analysis was conducted using SPSS version 21; 238 medical professionals involved in the prescribing of codeine completed the questionnaire.

Results

Two-thirds of participants stated that they routinely reviewed patients prescribed codeine, and high levels of concern were expressed about the availability of OTC medicine containing codeine in pharmacies (84.9%) and on the internet (71.3%). There was agreement that medicines containing codeine should be regulated to a prescription-only medicine (85.3%). Only 22% of participants agreed that they had suitable screening methods to help with detection of codeine dependence. Eighty per cent indicated that they would welcome the opportunity for greater instruction on prescribing potentially addictive medicines.

Conclusion

There appears to be a need to improve education on consumption and risks associated with codeine use. In addition, screening tools are needed to detect those with codeine dependence. Greater data sources are now needed to examine the sale of and consumption of codeine medicines in the interest of public health.

Medical professionals' perspectives on prescribed and over-the-counter medicines containing codeine: a cross-sectional study

OBJECTIVES

To explore prescribing practitioners' perspectives on prescribed codeine use, their ability to identify dependence and their options for treatment in the UK.

DESIGN

Cross-sectional design using a questionnaire containing closed-ended and open-ended items.

SETTING

A nationally representative sample of prescribing professionals working in the UK.

PARTICIPANTS

300 prescribing professionals working in primary care and pain settings.

RESULTS

Participants stated that they regularly reviewed patients prescribed codeine, understood the risks of dependence and recognised the potential for codeine to be used recreationally. Over half the participants felt patients were unaware of the adverse health consequences of high doses of combination codeine medicines. One-quarter of participants experienced patient resentment when asking about medicines containing codeine. Just under 40% of participants agreed that it was difficult to identify problematic use of codeine without being informed by the patient and did not feel confident in identification of codeine dependence. Less than 45% of all participants agreed that codeine dependence could be managed effectively in general practice. Slow or gradual withdrawal was the most popular suggested treatment in managing dependence. Education and counselling was also emphasised in managing codeine-dependent patients in primary care.

CONCLUSIONS

Communication with patients should involve assessment of patient understanding of their medication, including the risk of dependence. There is a need to develop extra supports for professionals including patient screening tools for identifying codeine dependence. The support structure for managing codeine-dependent patients in primary care requires further examination.