European Pain Federation position paper on appropriate opioid use in chronic pain management

Unraveling the Hippocampal Molecular and Cellular Alterations behind Tramadol and Tapentadol Neurobehavioral Toxicity

Tramadol and tapentadol are chemically related opioids prescribed for the analgesia of moderate to severe pain. Although safer than classical opioids, they are associated with neurotoxicity and behavioral dysfunction, which arise as a concern, considering their central action and growing misuse and abuse. The hippocampal formation is known to participate in memory and learning processes and has been documented to contribute to opioid dependence. Accordingly, the present study assessed molecular and cellular alterations in the hippocampal formation of Wistar rats intraperitoneally administered with 50 mg/kg tramadol or tapentadol for eight alternate days. Alterations were found in serum hydrogen peroxide, cysteine, homocysteine, and dopamine concentrations upon exposure to one or both opioids, as well as in hippocampal 8-hydroxydeoxyguanosine and gene expression levels of a panel of neurotoxicity, neuroinflammation, and neuromodulation biomarkers, assessed through quantitative real-time polymerase chain reaction (qRT-PCR). Immunohistochemical analysis of hippocampal formation sections showed increased glial fibrillary acidic protein (GFAP) and decreased cluster of differentiation 11b (CD11b) protein expression, suggesting opioid-induced astrogliosis and microgliosis. Collectively, the results emphasize the hippocampal neuromodulator effects of tramadol and tapentadol, with potential behavioral implications, underlining the need to prescribe and use both opioids cautiously.

Acceptability of a proposed practice pharmacist-led review for opioid-treated patients with persistent pain: A qualitative study to inform intervention development

Introduction

Regular review of patients prescribed opioids for persistent non-cancer pain (PCNP) is recommended but not routinely undertaken. The PROMPPT (Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by clinical Pharmacists in primary care Teams) research programme aims to develop and test a pharmacist-led pain review (PROMPPT) to reduce inappropriate opioid use for persistent pain in primary care. This study explored the acceptability of the proposed PROMPPT review to inform early intervention development.

Methods

Interviews (n = 15) and an online discussion forum (n = 31) with patients prescribed opioids for PCNP and interviews with pharmacists (n = 13), explored acceptability of a proposed PROMPPT review. A prototype PROMPPT review was then tested and refined through 3 iterative cycles of in-practice testing (IPT) (n = 3 practices, n = 3 practice pharmacists, n = 13 patients). Drawing on the Theoretical Framework of Acceptability (TFA), a framework was generated (including a priori TFA constructs) allowing for deductive and inductive thematic analysis to identify aspects of prospective and experienced acceptability.

Results

Patients felt uncertain about practice pharmacists delivering the proposed PROMPPT review leading to development of content for the invitation letter for IPT (introducing the pharmacist and outlining the aim of the review). After IPT, patients felt that pharmacists were suited to the role as they were knowledgeable and qualified. Pharmacists felt that the proposed reviews would be challenging. Although challenges were experienced during delivery of PROMPPT reviews, pharmacists found that they became easier to deliver with time, practise and experience. Recommendations for optimisations after IPT included development of the training to include examples of challenging consultations.

Conclusions

Uptake of new healthcare interventions is influenced by perceptions of acceptability. Exploring prospective and experienced acceptability at multiple time points during early intervention development, led to mini-optimisations of the prototype PROMPPT review ahead of a non-randomised feasibility study.

Role of antioxidants in the neurobiology of drug addiction: An update

Relationships between protective enzymatic and non-enzymatic pro-antioxidant mechanisms and addictive substances use disorders (SUDs) are analyzed here, based on the results of previous research, as well as on the basis of our current own studies. This review introduces new aspects of comparative analysis of associations of pro-antixidant and neurobiological effects in patients taking psychoactive substances and complements very limited knowledge about relationships with SUDs from different regions, mainly Europe. In view of the few studies on relations between antioxidants and neurobiological processes acting in patients taking psychoactive substances, this review is important from the point of view of showing the state of knowledge, directions of diagnosis and treatment, and further research needed explanation. We found significant correlations between chemical elements, pro-antioxidative mechanisms, and lipoperoxidation in the development of disorders associated with use of addictive substances, therefore elements that show most relations (Pr, Na, Mn, Y, Sc, La, Cr, Al, Ca, Sb, Cd, Pb, As, Hg, Ni) may be significant factors shaping SUDs. The action of pro-antioxidant defense and lipid peroxidation depends on the pro-antioxidative activity of ions. We explain the strongest correlations between Mg and Sb, and lipoperoxidation in addicts, which proves their stimulating effect on lipoperoxidation and on the induction of oxidative stress. We discussed which mechanisms and neurobiological processes change susceptibility to SUDs. The innovation of this review is to show that addicted people have lower activity of dismutases and peroxidases than healthy ones, which indicates disorders of antioxidant system and depletion of enzymes after long-term tolerance of stressors. We explain higher level of catalases, reductases, ceruloplasmin, bilirubin, retinol, α-tocopherol and uric acid of addicts. In view of poorly understood factors affecting addiction, analysis of interactions allows for more effective understanding of pathogenetic mechanisms leading to formation of addiction and development the initiation of directed, more effective treatment (pharmacological, hormonal) and may be helpful in the diagnosis of psychoactive changes.

Targeting Pannexin-1 Channels: Addressing the 'Gap' in Chronic Pain

Chronic pain complicates many diseases and is notoriously difficult to treat. In search of new therapeutic targets, pannexin-1 (Panx1) channels have sparked intense interest as a key mechanism involved in a variety of chronic pain conditions. Panx1 channels are transmembrane proteins that release ions and small molecules, such as adenosine triphosphate (ATP). They are expressed along important nodes of the pain pathway, modulating activity of diverse cell types implicated in the development and progression of chronic pain caused by injury or pathology. This review highlights advances that have unlocked the core structure and machinery controlling Panx1 function with a focus on understanding and treating chronic pain.

Opioid Treatment in Primary Care: Knowledge and Practical Use of Opioid Therapy

BACKGROUND

Primary care physicians play a key role in initiating opioid therapy. However, knowledge gaps in opioid use and pain management are significant barriers to providing optimal care. This research study aims to investigate the educational needs of primary care physicians regarding opioid therapy and opioid use in pain management.

METHODS

A computer-assisted web interview (CAWI) protocol was used to collect data from primary care physicians. Drug selection criteria, knowledge of opioid substitutes and dosage, and practical use of opioid therapy were evaluated.

RESULTS

While 84% of participating physicians (724 respondents) reported initiating opioid treatment, only a minority demonstrated accurate opioid dosage calculations. Significant discrepancies between physicians' self-perceived knowledge and their clinical skills in opioid prescribing and pain management were observed. In total, 41% of physicians incorrectly indicated dose conversion rates for tramadol (the most frequently used drug according to 65% of responders).

CONCLUSIONS

Targeted educational programs are essential to bridge the knowledge gap and increase physicians' competence in pain management. The proper self-assessment of one's own skills may be the key to improvement. Further research should focus on developing specialized educational courses and decision-support tools for primary care physicians and examining the impact of interprofessional pain management teams on patient outcomes.

Trends in the prescription of opioids and gabapentinoids in patients with failed back surgery syndrome in Korea: a population-based study

Background

Failed back surgery syndrome (FBSS) is a chronic condition that is characterized by persistent back pain following one or more spinal surgeries. Pharmacological interventions, such as the use of opioids and gabapentinoids, are frequently used in the treatment of FBSS. However, prolonged and excessive use of these medications can lead to dependence and adverse effects. This study investigates trends in opioid and gabapentinoid prescriptions among patients with FBSS in Korea from 2016 to 2020.

Methods

Data from the Health Insurance and Review Agency were analyzed, and claims listing FBSS were selected for the study. Prescription patterns of opioids and gabapentinoids were classified based on the number of days prescribed per year.

Results

Of the 390,095 patients diagnosed with FBSS, 41.6% of the patients were prescribed gabapentinoids, and 42.0% of them were prescribed opioids, while 10.6% of the patients were classified as long-term gabapentinoid users, 11.4% as long-term opioid users, and 7.4% of the patients were found to have long-term prescriptions for both drugs. The proportion of patients who received both gabapentinoid and opioid prescriptions increased annually. The doses of opioids prescribed have also increased along with the increase in the number of patients receiving opioid prescriptions.

Conclusions

The prescription rates of opioids and gabapentinoids among patients with FBSS in Korea continue to increase steadily, posing potential risks of addiction and adverse effects. Further research is needed to better understand the actual status of addiction in patients with FBSS.

The Impact of JWH-133 on Articular Cartilage Regeneration in Osteoarthritis Via Metalloproteinase 13-Dependent Mechanism

Objective: Osteoarthritis (OA) is common degenerative joint disease, mostly characterized by gradual cartilage breakdown. Currently there are no disease-modifying drugs available, therefore, there is an increasing need for basic research to focus on cartilage function in OA. Changes in cannabinoid receptor 2 (CB2) expression were observed in the OA-affected joints, although its action on cartilage chondrocytes remain unclear. We studied the action of dimethylbutyl-deoxy-delta-8-THC (JWH-133), selective CB2 agonist, on chondrocytes metabolism using both in vitro and in vivo studies. Design: Intraarticular (i.a.) injection of monoiodoacetate (MIA) was used to induce OA in rats. OA-related pain symptoms were assessed by pressure application measurements (PAMs). Primary human chondrocytes treated with MIA were used to investigate action of JWH-133 on chondrocytes viability, proliferation, and motility. Cannabinoid system components, inflammatory cytokines and metalloproteinases (MMPs) expression was measured on messenger RNA and protein levels in chondrocytes and animal cartilage. Results: Repeated, i.a. administration of JWH-133 showed antinociceptive potential in PAM, as well as decreased levels of MMPs, which suggests that CB2 agonism may modify degradation of cartilage. JWH-133 administration partially reduced toxicity, increased proliferation, and chondrocytes' migration. Moreover, our data suggest that CB2 agonism leads to alleviation of MMPs expression both in vitro and in vivo. Conclusions: In this study, we demonstrate modifying effect of JWH-133 local administration on cartilage metabolism and MMP13 expression that was shown to be involved in cartilage degradation. CB2 receptors' activation may be of benefit for chondrocytes' proliferation, therefore delaying disease progression. Our results propose direction of studies on OA-modifying treatment that can benefit in management of human OA.

Sodium Leak Channel in Glutamatergic Neurons of the Lateral Parabrachial Nucleus Modulates Inflammatory Pain in Mice

Elevated excitability of glutamatergic neurons in the lateral parabrachial nucleus (PBL) is associated with the pathogenesis of inflammatory pain, but the underlying molecular mechanisms are not fully understood. Sodium leak channel (NALCN) is widely expressed in the central nervous system and regulates neuronal excitability. In this study, chemogenetic manipulation was used to explore the association between the activity of PBL glutamatergic neurons and pain thresholds. Complete Freund's adjuvant (CFA) was used to construct an inflammatory pain model in mice. Pain behaviour was tested using von Frey filaments and Hargreaves tests. Local field potential (LFP) was used to record the activity of PBL glutamatergic neurons. Gene knockdown techniques were used to investigate the role of NALCN in inflammatory pain. We further explored the downstream projections of PBL using cis-trans-synaptic tracer virus. The results showed that chemogenetic inhibition of PBL glutamatergic neurons increased pain thresholds in mice, whereas chemogenetic activation produced the opposite results. CFA plantar modelling increased the number of C-Fos protein and NALCN expression in PBL glutamatergic neurons. Knockdown of NALCN in PBL glutamatergic neurons alleviated CFA-induced pain. CFA injection induced C-Fos protein expression in central nucleus amygdala (CeA) neurons, which was suppressed by NALCN knockdown in PBL glutamatergic neurons. Therefore, elevated expression of NALCN in PBL glutamatergic neurons contributes to the development of inflammatory pain via PBL-CeA projections.

Recommendations for the management of opioid-induced constipation - how to improve usability in clinical practice

INTRODUCTION

Opioid-induced constipation remains undertreated despite effective and safe treatment options exists. Previous guidelines have only been partially effective in improving management, possibly due to their complexity, and studies suggest that a simple setup of concise and behaviorally-orientated steps improves usability.

AREAS COVERED

This article introduces the concept of opioid-induced constipation and provides an overview of existing guidelines in this field. We also propose simplified recommendations for managing opioid-induced constipation, derived from a synthesis of current guidelines and the principles of optimal guideline design theory.

EXPERT OPINION

Despite standard treatment with laxatives and fluid intake in patients with opioid-induced constipation, escalation of treatment is often needed where μ-opioid receptor antagonists or newer medications such as lubiprostone, linaclotide, or prucalopride are used. Previous guidelines have not been used sufficiently and thus management of the condition is often insufficient. We therefore propose simplified recommendations to management, which we believe can come into broader use. It was validated in primary care for credibility, clarity, relevance, usability, and overall benefit. We believe that this initiative can lead to better management of the substantial proportion of patients suffering from side effects of opioids.

Recommendations to standardize patients' follow-up after interventional procedures in chronic pain treatment: A Delphi study

OBJECTIVE

To determine, using the Delphi method, standardized recommendations for the follow-up of patients undergoing an interventional procedure for the treatment of chronic pain in Spain.

METHODS

First, a systematic literature review was performed to identify the literature on the management of patients with chronic pain undergoing interventional techniques; subsequently, a two-round Delphi survey with 108 questions was conducted. The questionnaire was validated by a Scientific Committee (5 experts) and sent to 47 experts specialized in chronic pain. "Consensus" or "intermediate consensus" was determined when ≥ 75% or < 75% to ≥ 65% of the experts selected the same answer for each item, respectively. Then, a face-to-face deliberation process was held with the Scientific Committee to analyze and discuss the results.

RESULTS

The questionnaire was completed by 24 panelists (51%). Consensus was reached on 88.4% of the questions. The panelists identified pain, drug consumption, and quality of life as essential variables in the follow-up of patients with chronic pain. Consensus was reached on most of the scales/questionnaires to be used in measuring outcomes during follow-up, except for psychological status. Regarding the follow-up frequency, in radicular spinal chronic pain, a consensus was reached on the first visit 1-2 months after the intervention, during the first year, at 1, 3, 6, and 12 months, and then every 6 months thereafter. For non-radicular spinal chronic pain, the first visit 1-2 months after surgery was agreed upon, however, there was no consensus on follow-up during the first year. For non-spinal chronic pain, consensus was reached regarding the first visit at 1-2 months after surgery and during the first year at 1, 3, 6, and 12 months. No consensus was reached on follow-up frequency for oncological chronic pain. After receiving a permanent neurostimulator implant for chronic pain, the first visit was agreed upon at 1-3 weeks, during the first year, at 2 weeks, 1, 3, 6, and 12 months, and after, every 6 months. For intrathecal infusion, it was agreed that the first visit should occur during the first month, and thereafter whenever the pump requires a refill.

CONCLUSIONS

These findings provide recommendations in relation to the frequency of follow-up and the scales to be used with chronic pain patients undergoing interventional techniques in Spain.

Barriers Facing Physicians in Opioids Prescribing for the Management of Moderate to Severe Pain in a Tertiary Care Center in Saudi Arabia

Background: Although several interventions are utilized for pain management, opioids remain the most effective intervention for moderate to severe pain. Despite opioids being the most potent analgesics used in different pain settings, several factors impede the optimal prescribing of opioids.Objectives: The study seeks to identify and address the barriers physicians face to prescribing opioids in managing pain.Methods: This study was conducted in a tertiary care center in Riyadh, Saudi Arabia. It involved distributing questionnaires to the participants. The questionnaires sought to identify prescribers' knowledge and current practices as well as obstacles that they face when prescribing opioids. A total of 109 questionnaires were completed by participants.Results: More than half [59.6%] of the respondents thought that opioid use was an optimal way to treat moderate to severe pain. About 33% chose "never" when asked if they fear legal sanctions when prescribing opioids. Fear of side effects limited almost 90% of the respondents from prescribing opioids.Conclusion: The study confirmed the perception that opioids are the most potent pharmacological intervention in treating pain. Several barriers were identified and discussed in this study. Further studies from different settings to understand these barriers are highly recommended.

Opioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare setting

OBJECTIVES

The optimal use of opioids after knee replacement (KR) remains to be determined, given the growing evidence that opioids are no more effective than other analgesics and that their adverse effects can impair quality of life. Therefore, the objective is to examine opioid prescriptions after KR.

DESIGN

In this retrospective study, we used descriptive statistics and estimated the association of prognostic factors using generalised negative binomial models.

SETTING

The study is based on anonymised claims data of patients with mandatory health insurance at Helsana, a leading Swiss health insurance.

PARTICIPANTS

Overall, 9122 patients undergoing KR between 2015 and 2018 were identified.

PRIMARY AND SECONDARY OUTCOME MEASURES

Based on reimbursed bills, we calculated the dosage (morphine equivalent dose, MED) and the episode length (acute: <90 days; subacute: ≥90 to <120 days or <10 claims; chronic: ≥90 days and ≥10 claims or ≥120 days). The incidence rate ratios (IRRs) for postoperative opioids were calculated.

RESULTS

Of all patients, 3445 (37.8%) received opioids in the postoperative year. A large majority had acute episodes (3067, 89.0%), 2211 (65.0%) had peak MED levels above 100 mg/day and most patients received opioids in the first 10 postoperative weeks (2881, 31.6%). Increasing age (66-75 and >75 vs 18-65) was associated with decreased IRR (0.776 (95% CI 0.7 to 0.859); 0.723 (95% CI 0.649 to 0.805)), whereas preoperative non-opioid analgesics and opioids were associated with higher IRR (1.271 (95% CI 1.155 to 1.399); 3.977 (95% CI 4.409 to 3.591)).

CONCLUSION

The high opioid demand is unexpected given that current recommendations advise using opioids only when other pain therapies are ineffective. To ensure medication safety, it is important to consider alternative treatment options and ensure that benefits outweigh potential risks.

Appropriate use of tapentadol: focus on the optimal tapering strategy

OBJECTIVE

Due to its opioid and non-opioid mechanism of action, tapentadol is considered an atypical opioid with improved gastrointestinal tolerability versus traditional opioids. As for all opioid analgesics it is important to understand how to discontinue a treatment when it is not needed anymore. The aim of this article was to provide an overview of opioid therapy in non-cancer pain, with a specific focus on tapering of tapentadol in patients with chronic non-cancer pain, and suggestions on how to achieve tapering.

METHODS

Studies for this narrative review were identified via PubMed using a structured search strategy, focusing on management of chronic non-cancer pain with opioids, and the efficacy, tolerability, and pharmacology of tapentadol prolonged release. Publications were limited to English-language articles published within the last ∼10 years.

RESULTS

The review discusses the use and discontinuation of opioids in general, as well clinical data on discontinuation of tapentadol specifically. We provide a flow chart, which can be used by clinicians in the context of their own clinical experience to appropriately taper tapentadol in patients with chronic non-cancer pain. The flow chart can be easily tailored to individual patient characteristics, duration of tapentadol treatment, response to progressive dosage reduction, and likelihood of withdrawal symptom occurrence.

CONCLUSIONS

While tapentadol is associated with a low frequency of opioid withdrawal symptoms after abrupt discontinuation, use of a tapering strategy is prudent. Tapering strategies developed for opioids in general can potentially be safely individualized in tapentadol-treated patients, although research on tapering strategies for tapentadol is required.

A nationwide study on consumption of opioid analgesics in Iran from 2000 to 2018

BACKGROUND

Opioid analgesics play a unique role in pain management. National opioid consumption studies could provide indirect evidence of pain management in a country. National, regional, and global opioid consumption have been studied in other countries so far; however, conducting a focused study to illuminate the consumption of opioid analgesics over the past decades in Iran seemed necessary.

AIM

The main objective of this study was to determine the consumption of opioid analgesics and explore the trend of their use during 19 years in Iran.

METHOD

Iran pharmaceutical wholesale data were used to extract the annual consumption figures of the opioid analgesics in group N02A of the World Health Organization (WHO) Anatomical Therapeutic Chemical classification and were available in Iran (morphine, fentanyl, pethidine, and oxycodone as strong opioids and, tramadol and pentazocine as weak opioids), from 2000 to 2018. Using Defined Daily Dose (DDD) by WHO and Oral Morphine Equivalent (OMEQ), the amount of annual consumption was determined in DDD/1000 inhabitants/Day (DID) and OMEQ (mg)/1000 inhabitants/Day (OID).

RESULTS

Total opioid analgesic utilization based on DID and OID increased 31.12-fold (from 0.0196 to 0.61) and 21.06-fold (from 1.97 to 41.5 mg) over 19 years, respectively with a significant sharp increase from 2003 to 2006 (ß = 1.78 (DID), P value < 0.001). Medications that constituted 70% of annual opioid analgesics utilization were morphine in 2000, compared to tramadol in 2018. The annual weak and strong opioids share were 86.7% and 13.2% in 2018, respectively.

CONCLUSION

Despite considerable growth in the consumption of opioid analgesics in Iran over nearly two decades, the consumption amount remained low, which might signal sub-optimal pain management. On the other hand, misuse and abuse seem to be the main reason behind significant increases in the consumption of opioid analgesics with less controlled distribution.

Knowing the Enemy Is Halfway towards Victory: A Scoping Review on Opioid-Induced Hyperalgesia

Opioid-induced hyperalgesia (OIH) is a paradoxical effect of opioids that is not consensually recognized in clinical settings. We conducted a revision of clinical and preclinical studies and discuss them side by side to provide an updated and renewed view on OIH. We critically analyze data on the human manifestations of OIH in the context of chronic and post-operative pain. We also discuss how, in the context of cancer pain, though there are no direct evidence of OIH, several inherent conditions to the tumor and chemotherapy provide a substrate for the development of OIH. The review of the clinical data, namely in what concerns the strategies to counter OIH, emphasizes how much OIH rely mechanistically on the existence of µ-opioid receptor (MOR) signaling through opposite, inhibitory/antinociceptive and excitatory/pronociceptive, pathways. The rationale for the maladaptive excitatory signaling of opioids is provided by the emerging growing information on the functional role of alternative splicing and heteromerization of MOR. The crossroads between opioids and neuroinflammation also play a major role in OIH. The latest pre-clinical data in this field brings new insights to new and promising therapeutic targets to address OIH. In conclusion, although OIH remains insufficiently recognized in clinical practice, the appropriate diagnosis can turn it into a treatable pain disorder. Therefore, in times of scarce alternatives to opioids to treat pain, mainly unmanageable chronic pain, increased knowledge and recognition of OIH, likely represent the first steps towards safer and efficient use of opioids as analgesics.

Actual situation and prescribing patterns of opioids by pain physicians in South Korea

Background

Use of opioids for chronic intractable pain is increasing globally, and their proper use can improve patients’ quality of life. In contrast, opioid use disorders, such as abuse or addiction, caused by prescribing opioids, are a worldwide issue. This study aimed to understand current opioid prescribing patterns and pain physicians’ experiences with opioid use in South Korea.

Methods

Pain physicians in 42 university hospitals in South Korea were asked to complete anonymous questionnaires regarding opioid prescriptions.

Results

A total of 69 surveys were completed. Most pain physicians started prescribing opioids at a pain score of 7/10 and aimed to reduce pain by 50%. Most physicians (73.1%) actively explained the prescribed medications and possible side effects, and 61.2% of physicians preferred the prescription interval of 4 weeks. Immediate-release opioids were the most popular treatment for breakthrough pain (92.6%). The most common side effect encountered by physicians was constipation (43.3%), followed by nausea/vomiting (34.3%). Of the physicians, 56.5% replied that addiction and misuse prevalences were less than 5%. However, the most concerning side effect was addiction (33.0%).

Conclusions

The survey results showed that the prescribing patterns of pain physicians generally followed Korean guidelines. Physicians were most interested in the safety and effectiveness of opioid prescriptions. They were most concerned about respiratory depression and abuse or addiction. A significant number of physicians agreed that the NHIS regulations needed improvement for patient convenience and safe and effective treatment, though there were pros and cons of the NHIS restrictions on prescription conditions.

Prevention, diagnosis, and treatment of opioid use disorder under the supervision of opioid stewardship programs: it's time to act now

The third opium war may have already started, not only due to illicit opioid trafficking from the Golden Crescent and Golden Triangle on the international front but also through indiscriminate opioid prescription and opioid diversion at home. Opioid use disorder (OUD), among unintentional injuries, has become one of the top 4 causes of death in the United States (U.S.). An OUD is defined as a problematic pattern of opioid use resulting in clinically significant impairment or distress, consisting of 2 or more of 11 problems within 1 year, as described by the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Observation of aberrant behaviors of OUD is also helpful for overworked clinicians. For the prevention of OUD, the Opioid Risk Tool and the Current Opioid Misuse Measure are appropriate screening tests before and during opioid administration, respectively. Treatment of OUD consists of 3 opioid-based U.S. Food and Drug Administration-approved medications, including methadone, buprenorphine, and naltrexone, and non-opioid-based symptomatic medications for reducing opioid withdrawal syndromes, such as α2 agonists, β-blockers, antidiarrheals, antiemetics, non-steroidal anti-inflammatory drugs, and benzodiazepines. There are at least 6 recommendable guidelines and essential terms related to OUD. Opioid stewardship programs are now critical to promoting appropriate use of opioid medications, improving patient outcomes, and reducing misuse of opioids, influenced by the successful implementation of antimicrobial stewardship programs. Despite the lack of previous motivation, now is the critical time for trying to reduce the risk of OUD.

Buprenorphine/naloxone versus methadone opioid rotation in patients with prescription opioid use disorder and chronic pain: study protocol for a randomized controlled trial

Background

Opioids are effective in pain-management, but long-term opioid users can develop prescription opioid use disorder (OUD). One treatment strategy in patients with OUD is rotating from a short-acting opioid to a long-acting opioid (buprenorphine/naloxone (BuNa) or methadone). Both BuNa and methadone have been shown to be effective strategies in patients with OUD reducing opioid misuse, however data on head-to-head comparison in patients with chronic non-malignant pain and prescription OUD are limited.

Methods

This two-armed open-label, randomized controlled trial aims to compare effectiveness between BuNa and methadone in patients with chronic non-malignant with prescription OUD (n = 100). Participants receive inpatient rotation to either BuNa or methadone with a flexible dosing regimen. The primary outcome is opioid misuse 2 months after rotation. Secondary outcomes include treatment compliance, side effects, analgesia, opioid craving, quality of life, mood symptoms, cognitive and physical functioning over 2- and 6 months follow-up. Linear mixed model analysis will be used to evaluate change in outcome parameters over time between the treatment arms.

Discussion

This is one of the first studies comparing buprenorphine/naloxone and methadone for treating prescription OUD in a broad patient group with chronic non-malignant pain. Results may guide future treatment for patients with chronic pain and prescription OUD.

Trial registrationhttps://www.trialregister.nl/, NL9781

Bioequivalence, Drugs with Narrow Therapeutic Index and the Phenomenon of Biocreep: A Critical Analysis of the System for Generic Substitution

The prescription of generic drugs represents one of the main cost-containment strategies of health systems, aimed at reducing pharmaceutical expenditure. In this context, most regulatory authorities encourage or obligate dispensing generic drugs because they are far less expensive than their brand-name alternatives. However, drug substitution can be critical in particular situations, such as the use of drugs with a narrow therapeutic index (NTI). Moreover, generics cannot automatically be considered bioequivalent with each other due to the biocreep phenomenon. In Italy, the regulatory authority has established the Transparency Lists which include the medications that will be automatically substituted for brand-name drugs, except in exceptional cases. This is a useful tool to guide prescribers and guarantee pharmaceutical sustainability, but it does not consider the biocreep phenomenon.

Quantitative Systems Pharmacology and Biased Agonism at Opioid Receptors: A Potential Avenue for Improved Analgesics

Chronic pain is debilitating and represents a significant burden in terms of personal and socio-economic costs. Although opioid analgesics are widely used in chronic pain treatment, many patients report inadequate pain relief or relevant adverse effects, highlighting the need to develop analgesics with improved efficacy/safety. Multiple evidence suggests that G protein-dependent signaling triggers opioid-induced antinociception, whereas arrestin-mediated pathways are credited with modulating different opioid adverse effects, thus spurring extensive research for G protein-biased opioid agonists as analgesic candidates with improved pharmacology. Despite the increasing expectations of functional selectivity, translating G protein-biased opioid agonists into improved therapeutics is far from being fully achieved, due to the complex, multidimensional pharmacology of opioid receptors. The multifaceted network of signaling events and molecular processes underlying therapeutic and adverse effects induced by opioids is more complex than the mere dichotomy between G protein and arrestin and requires more comprehensive, integrated, network-centric approaches to be fully dissected. Quantitative Systems Pharmacology (QSP) models employing multidimensional assays associated with computational tools able to analyze large datasets may provide an intriguing approach to go beyond the greater complexity of opioid receptor pharmacology and the current limitations entailing the development of biased opioid agonists as improved analgesics.

Contrasting opioid use for pain management in microvascular head and neck reconstruction: an international study

Opioids are often the mainstay of postoperative pain management, despite strong evidence of their ill effects and potential for long-term addiction. The goal of this study was to quantify opioid use and contrast pain management strategies of multiple international institutions performing fibula free flap reconstruction. A retrospective multicenter cohort study was designed, including five international centers. For inclusion, the patients had to have undergone a primary fibula free flap reconstruction of the mandible. A total of 185 patients were included. The median opioid use across all centers at 72 hours was 133 oral morphine equivalents. The highest utilization was in the USA (P < 0.001), which was approximately six times that of Italy, four times that of Argentina, and twice that of India, despite all centers performing a similar procedure. Based on this study there are clear differences in prescribing practices and ideologies among surgeons from different countries.

Persistent Use of Prescription Opioids Following Lumbar Spine Surgery: Observational Study with Prospectively Collected Data From Two Norwegian Nationwide Registries

STUDY DESIGN

Prospective pharmacoepidemiological study.

OBJECTIVE

To investigate the use of prescription opioids 2 years following degenerative lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

There are limited data providing details to evaluate patterns of opioid use. The number of patients is often limited and data on opioid use following some of the most common surgical procedures are lacking.

METHODS

Data from the Norwegian Registry for Spine Surgery and the Norwegian Prescription Database were linked on an individual level. The primary outcome measure was persistent opioid use the second year after surgery. Functional disabilitywas measured with the Oswestry disability index (ODI). Study participants were operated between 2007 and 2017.

RESULTS

Among 32,886 study participants, 2754 (8.4%) met criteria for persistent opioid use the second year after surgery. Among persistent opioid users in the second year after surgery, 64% met the criteria for persistent opioid use the year preceding surgery. Persistent opioid use the year preceding surgery (odds ratio [OR] 31.10, 95% confidence interval [CI] 26.9-36.0, P  = 0.001), use of high doses of benzodiazepines (OR 1.62, 95% CI 1.30-2.04, P  = 0.001), and use of high doses of z-hypnotics (OR 1.90, 95% CI 1.58-2.22, P  = 0.001) the year before surgery were associated with increased risk of persistent opioid use the second year after surgery. A higher ODI score at 1 year was observed in persistent opioid users compared with non-persistent users (41.5 vs. 18.8 points) and there was a significant difference in ODI change (-13.7 points). Patients with persistent opioid use in the year preceding surgery were less likely to achieve a minimal clinically important ODI change at 1 year compared with non-persistent users (37.7% vs. 52.6%, P  = 0.001).

CONCLUSION

Patients with or at risk of developing persistent opioid should be identified and provided counseling and support to taper off opioid treatment.Level of Evidence: 2.

Opioid prescribing in out-of-hours primary care in Flanders and the Netherlands: A retrospective cross-sectional study

Background

Increased opioid prescribing has raised concern, as the benefits of pain relief not always outweigh the risks. Acute and chronic pain is often treated in a primary care out-of-hours (OOH) setting. This setting may be a driver of opioid use but the extent to which opioids are prescribed OOH is unknown. We aimed to investigate weak and strong opioid prescribing at OOH primary care services (PCS) in Flanders (Northern, Dutch-speaking part of Belgium) and the Netherlands between 2015 and 2019.

Methods

We performed a retrospective cross sectional study using data from routine electronic health records of OOH-PCSs in Flanders and the Netherlands (2015–2019). Our primary outcome was the opioid prescribing rate per 1000 OOH-contacts per year, in total and for strong (morphine, hydromorphone, oxycodone, oxycodone and naloxone, fentanyl, tapentadol, and buprenorphine and weak opioids (codeine combinations and tramadol and combinations) and type of opioids separately.

Results

Opioids were prescriped in approximately 2.5% of OOH-contacts in both Flanders and the Netherlands. In Flanders, OOH opioid prescribing went from 2.4% in 2015 to 2.1% in 2017 and then increased to 2.3% in 2019. In the Netherlands, opioid prescribing increased from 1.9% of OOH-contacts in 2015 to 2.4% in 2017 and slightly decreased thereafter to 2.1% of OOH-contacts. In 2019, in Flanders, strong opioids were prescribed in 8% of the OOH-contacts with an opioid prescription. In the Netherlands a strong opioid was prescribed in 57% of these OOH-contacts. Two thirds of strong opioids prescriptions in Flanders OOH were issued for patients over 75, in the Netherlands one third was prescribed to this age group.

Conclusion

We observed large differences in strong opioid prescribing at OOH-PCSs between Flanders and the Netherlands that are likely to be caused by differences in accessibility of secondary care, and possibly existing opioid prescribing habits. Measures to ensure judicious and evidence-based opioid prescribing need to be tailored to the organisation of the healthcare system.

Spanish Validation of the COMM Scale to Assess the Misuse of Prescription Opioids in Patients with Chronic Noncancer Pain

The Current Opioid Misuse Measure (COMM) is a questionnaire used to identify and monitor chronic pain patients on opioid therapy who may be misusing their prescription opioids. The aim of the present study was to adapt the questionnaire for its use in Spanish-speaking populations. A total of 171 individuals (131 women and 40 men) with nononcological chronic pain participated in this cross-sectional study. The most frequent pain diagnoses in the sample were fibromyalgia, herniated disc, and rheumatoid arthritis. Systematic sampling was used. All individuals were interviewed at their clinic between March 2018 and February 2020. The dimensionality of the COMM-SV items was evaluated using an optimal implementation of parallel analysis (PA) and an exploratory factor analysis. Internal consistency, test-retest reliability, and criterion and convergent validity were calculated. The COMM-SV comprises five factors: problematic interpersonal behaviour, searching for more medication than prescribed, medication misuse and self-injurious thoughts, emergency use, and memory and attention problems. It has good reliability and adequate test-retest stability. The results support its criterion and convergent validity. Given the increasing use and abuse of opioids, a valid and reliable instrument is needed in Spanish settings to identify patients with chronic pain who present aberrant behaviour related to the use of these medications. The COMM-SV enables Spanish clinicians to do that.

Introducing nurse prescribing in Gibraltar: the impact on palliative care

This article critically explores the impact of the introduction of nurse prescribing on palliative care in Gibraltar. A preliminary audit review of the prescriptions issued by the two palliative independent nurse prescribers over their first full calendar year of prescribing (2020) revealed two primary areas of impact: facilitating end-of-life care at home and improving anticipatory prescribing for end-of-life symptom management. These initial findings will be discussed in the context of the challenges and facilitators encountered during the first year of prescribing practice. Challenges were primarily related to the introduction of an advanced nursing role into an existing medical paradigm. Identified facilitators included comprehensive record keeping, collaborative working and the development of local guidelines, as well as the support of management and peers. The article concludes with a recommendation for further audits of prescribing data as a way to measure the impact of the new role and to inform future palliative service development.

An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives

Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.

Opioid use trends in Spain: the case of the island of La Gomera (2016-2019)

This study is an evaluation of prescription opioid use on the island of La Gomera, a mainly rural area, during the period 2016-2019 at various levels. Data were extracted from the wholesalers who supply the community pharmacies at the population level. Prescription opioid use was measured as defined daily doses per 1,000 inhabitants/day (DID) and by the number of units sold per 1,000 inhabitants and year (units sold). This provided an island total of La Gomera's overall prescription of opioids and its rate of change, as well as differences in prescribing at the municipal and health area level. Tramadol with acetaminophen and tramadol in monotherapy were the most consumed by "units sold" parameter, which accounted for 69.48% and 18.59% of the total. The situation was similar for DID, although with lower percentages, but a significant increase was observed in the use of fentanyl and buprenorphine, around 15% in each case. The balance between the uses of weak or strong opioids was different in La Gomera compared to that of Spain as a whole. In Spain, almost 70% of the prescriptions were for weak opioids compared to 58.67% in La Gomera. Fentanyl was the most used strong opioid (16.10%) followed by tapentadol and buprenorphine, around 5% each, whereas in La Gomera, buprenorphine was the most consumed (15.75%) followed by fentanyl (14.87%) and tapentadol (5.82%). These differences in prescription opioid use are most likely explained by prescriber characteristics, whereas the population age, socioeconomic status, or living in rural/urban area are not decisive determinants.

Antinociceptive Effects of Aza-Bicyclic Isoxazoline-Acylhydrazone Derivatives in Different Models of Nociception in Mice

BACKGROUND

In a study recently published by our research group, the compounds isoxazoline-acylhydrazone derivatives R-99 and R-123 presented promising antinociceptive activity. However, the mechanism of action of this compound is still unknown.

OBJECTIVE

This study aimed to assess the mechanisms involved in the antinociceptive activity of these compounds in chemical models of pain.

METHODS

Animals were orally pretreated and evaluated in the acetic acid-, formalin-, capsaicin-, carrageenan- and Complete Freund's Adjuvant (CFA)-induced pain models in mice. The effects of the compounds after pretreatment with naloxone, prazosin, yohimbine, atropine, L-arginine, or glibenclamide were studied, using the acetic acid-induced writhing test to verify the possible involvement of opioid, α1-adrenergic, α2-adrenergic or cholinergic receptors, and nitric oxide or potassium channels pathways, respectively.

RESULTS

R-99 and R-123 compounds showed significant antinociceptive activity on pain models induced by acetic acid, formalin, and capsaicin. Both compounds decreased the mechanical hyperalgesia induced by carrageenan or CFA in mice. The antinociceptive effects of R-99 and R-123 on the acetic acid-induced writhing test were significantly attenuated by pretreatment with naloxone, yohimbine or atropine. R-99 also showed an attenuated response after pretreatment with atropine and glibenclamide. However, on the pretreatment with prazosin, there was no change in the animals' response to both compounds.

CONCLUSION

R-99 and R-123 showed antinociceptive effects related to mechanisms that involve, at least in part, interaction with the opioid and adrenergic systems and TRPV1 pathways. The compound R-99 also interacts with the cholinergic pathways and potassium channels.

Impact and Consequences of Opioid-Induced Constipation: A Survey of Patients

INTRODUCTION

Opioids are a valuable tool to help achieve control of pain. However, opioid-induced constipation (OIC) is an important limitation of treatment with this class of drugs.

METHODS

To better understand the impact of OIC on patient-reported outcomes, we carried out a survey involving patients being treated with opioids. Both ad hoc questions and the PROMIS and PAC-SYM and PAC-QOL scores were used.

RESULTS

Of the 597 participants, 150 (25%) had cancer-related pain, and 447 (75%) had non-cancer pain; 66% experienced OIC. PROMIS pain interference questions indicated that pain is more likely to interfere with a patient's life when they have OIC. PAC-QOL and PAC-SYM revealed that 58% of patients with non-cancer pain and OIC reported at least one "severe" or "very severe" constipation symptom, compared to 83% with cancer-related pain. Younger age and less time on opioids were associated with greater impact of OIC on quality of life. Only 41% of patients were satisfied with how their constipation was managed. Over 50% of those with non-cancer pain said that they modified their opioid regimen due to constipation, vs. 6% of those with cancer pain. Constipation had been discussed with the healthcare provider (HCP) in 48% of non-cancer patients and in 73% of cancer patients. In those with chronic pain and OIC, 24% expressed varying degrees of dissatisfaction with the healthcare system, vs. 37% in those with cancer pain and OIC.

CONCLUSION

Our results provide additional evidence that management of OIC is inadequate in many cases. Moreover, they indicate that there is a definite need for better education about OIC among HCPs.

Personalized Pain Medicine: Turning Theory into Policy

: On the one hand, patients, therapists, policy-makers, business people, and health organization managers need to approach medicine from different perspectives, each perspective being appropriate for each role. On the other hand, a lack of appreciation of the perspectives of the other vested interests diminishes their effectiveness in accomplishing what their respective roles demand. In this article, we explain the main difference between these perspectives along a spectrum ranging from highly individualist to highly collectivist views of medicine. We aim to show the gap between personal (individualistic) and social (collectivist) medicine models. We then present possible ways to close this gap. We argue that these differences need to be reconciled, at least to some extent, if medicine is to evolve along with other disciplines, such as engineering, to create and implement personalized solutions to patients' pains. We conclude by proposing a framework through which patients, practitioners, health organizations, business people, and policy-makers can develop enough of a mutual understanding of each other's perspectives, problems, and solution orientations to be able to work relatively harmoniously toward the common goal of creating bespoke solutions to individuals' pains.

Opioid-induced Hyperalgesia in Patients With Chronic Pain: A Systematic Review of Published Cases

INTRODUCTION

Opioid-induced hyperalgesia (OIH) remains an issue in patients with chronic pain. Multiple cases of OIH in patients with chronic pain exposed to opioids have been reported worldwide. The objective of this systematic review was to summarize the evidence of OIH from clinical reports.

METHODS

We searched the PubMed, Cochrane, EMBASE, and LILACS databases for case reports and case series of OIH published up to December 2020, with the aim to summarize the evidence for OIH in patients with chronic pain from clinical reports and to discuss issues relevant to the clinical diagnosis and management of OIH.

RESULTS

We retrieved and reviewed 41 articles describing 72 cases. Clinical features of OIH were observed in patients of both sexes, all ages, and with various types of pain treated with different classes of opioids. OIH was reported at all doses, but most published studies reported a pattern of OIH following treatment with very high daily doses of opioids (median oral morphine equivalent dose of 850 mg). OIH was diagnosed clinically in all cases. Three different strategies for OIH management were described: opioid rotation, opioid cessation, and the use of adjuvant pharmacotherapies. All had statistically similar success rates for OIH treatment: 72%, 57%, and 79%, respectively. The decrease in pain was achieved rapidly (mean: 8 d; range: 1 to 28 d). Adjuvant therapies resulted in the largest decrease in dose. Ketamine and dexmedetomidine were the most widely used adjuvant drugs.

CONCLUSION

The key finding is that clinical symptoms of OIH can be resolved when this condition is diagnosed and managed.

Tapentadol and Oxycodone/Naloxone Prescribing Patterns in Primary Health Care in Catalonia, Spain: A Cross-Sectional Study

Objective

To characterize the use of tapentadol and the combination oxycodone/naloxone in primary health care. Data on their use and possible misuse will allow the identification of risk factors and to design protocols to reduce and prevent avoidable harm to patients being treated for pain.

Design

A descriptive, cross-sectional and multicenter study was performed.

Setting

Fifty-three primary health care teams, which provides healthcare for 1,300,000 inhabitants.

Patients

A total of 1840 patients had active prescriptions of tapentadol and 985 of oxycodone/naloxone.

Methods

Demographic (age, sex) and clinical (glomerular filtration rate; active liver disease; dosing and duration of treatment), prescribed daily dose (according to age, sex, length of treatment), concomitant analgesic treatment and diagnosis. Patient information was obtained from medical records.

Results

Most of the patients were women (>74.0% in both cases), and the average age was 69.3 years (women: 70.1±13.2; men: 66.7±13.9 years) in the case of tapentadol and 70.6 years (women: 64.0±13.6; men: 72.6±14.3 years) in the case of oxycodone/naloxone. Only 12.2% of patients taking tapentadol and 12.1% taking oxycodone/naloxone had a normal renal function. In both cases, 4.1% of patients had active liver disease. The average length of treatment was 246.4 days in oxycodone/naloxone and 199.0 days in tapentadol. It was recorded that 85.1% of patients in the case of tapentadol and 89.0% in the oxycodone/naloxone had at least another drug prescribed for pain. About 42.2% of patients treated with tapentadol and 34.4% of patients treated with oxycodone/naloxone had associated neuralgia as a diagnosis.

Conclusion

The pattern of use and profile of patients with tapentadol and oxycodone/naloxone had more similarities than differences, and suggested that prescribing practice, and monitoring should be assessed regularly to ensure patient safety and effective management of pain.

Opioid-Induced Constipation in Patients with Cancer Pain in Japan (OIC-J Study): A Post Hoc Analysis

Opioid-induced constipation (OIC) can limit the clinical benefit of opioid treatment. This post-hoc analysis evaluated the association between the Rome IV diagnostic criteria and other measures for OIC, including the Bowel Function Index (BFI), correlation between demographics and OIC onset, impact of OIC on pain treatment, and impact of patient–healthcare professional (HCP) communication on patient satisfaction. Patients recorded bowel habits in paper diaries for 14 days following opioid initiation. Study-specific questionnaires were used to evaluate patient awareness of OIC and satisfaction. Patients were ≥20 years old, initiating strong opioid therapy for cancer pain, had an ECOG PS ≤ 2, and had no constipation (≥3 bowel movements within 7 days of enrollment). A total of 220 patients were enrolled. The sensitivity and specificity of BFI for identifying OIC were 81.2% and 54.7%, respectively. Age <65 versus ≥65 years (odds ratio (OR) = 0.510, 95% confidence interval (CI): 0.267–0.977) and the presence or absence of comorbidities (OR = 0.443, 95% CI: 0.221–0.885) were correlated with OIC onset. The proportion of inpatients with sustainable pain control at week 2 was similar in patients with or without OIC (60.0% vs. 67.2%, respectively). By patient assessment, there was a significant correlation between an adequate level of patient–HCP communication and satisfaction with OIC treatment (OR = 9.538 (95% CI: 1.577–57.681)). Using BFI to screen for OIC represents a valid approach in patients with cancer pain. Patient–HCP communication is essential for effective management of OIC in patients with cancer pain.

Prevalence and risk factors of musculoskeletal pain in patients with chronic obstructive pulmonary disease: A systematic review

OBJECTIVES

This systematic review aimed to discuss the prevalence and the risk factors of the musculoskeletal pain in chronic obstructive pulmonary disease (COPD).

DATA SOURCE AND STUDY SELECTION

Four databases were analysed (Scopus, PubMed, Cochrane and EMBASE). We excluded systematic reviews, meta-analyses, conference abstracts and case reports. Two authors independently checked for the eligibility of the relevant articles. The risk of bias was evaluated using the Newcastle Ottawa Quality Assessment Scale and the Joanna Briggs Institute critical appraisal checklist. The selection and evaluation of studies followed the PRISMA guidelines.

RESULTS

Twenty studies were retrieved, including from 21 to 7952 patients with COPD. The prevalence of pain was highly heterogeneous across studies: 7-89.7%. Pain was mostly reported in the lumbar (7-69%) and cervical spine (11-48.3%) and the chest (44-82.8%). The main risk factors for developing pain were old age, sex (female), level of physical activity (low) and comorbidities.

CONCLUSION

Pain is a very common symptom in patients with COPD. Despite this, few clinical trials have investigated the pain. It appears to be located primarily in the lumbar, cervical and thoracic regions and facilitated by being a female, a low level of physical activity, comorbidity(ies) and old age.

Effects of opioid rotation to buprenorphine/naloxone on pain, pain thresholds, pain tolerance, and quality of life in patients with chronic pain and opioid use disorder

ABSTRACT

Long-term opioid use in patients with chronic noncancer pain (CNCP) can lead to opioid use disorder (OUD) and has been associated with hyperalgesia and reduced quality of life (QoL). Studies suggest antihyperalgesic properties of buprenorphine, and buprenorphine or naloxone (BuNa) has shown beneficial effects on QoL in patients with OUD without CNCP. This study investigated the added value of BuNa in patients with CNCP with OUD on self-reported pain, pain thresholds, pain tolerance, and QoL. In the current study, 43 outpatients with CNCP and OUD were included for inpatient conversion from full μ-receptor agonist opioids to BuNa. Self-reported pain, pain thresholds, pain tolerance, and QoL were determined at baseline and after 2 months of follow-up, using, respectively, a Visual Analogue Scale (VAS-pain and VAS-QoL), quantitative sensory testing, and EuroQol-5 dimensions. In total, 37 participants completed the protocol, and their data were analyzed. The mean VAS-pain score decreased from 51.3 to 37.2 (27.5%, F = 3.3; P = 0.044), whereas the pressure pain threshold and electric pain threshold or tolerance increased after substitution (F = 7.8; P = 0.005 and F = 44.5; P < 0.001, respectively), as well as QoL (EuroQol-5 dimensions questionnaire: F = 10.4; P = 0.003 and VAS-QoL: F = 4.4; P = 0.043). We found that conversion of full μ-receptor agonists to BuNa, in patients with CNCP with OUD, was accompanied with lower self-reported pain, higher pain thresholds, higher pain tolerance, and improved QoL. Despite several study limitations, these data suggest that BuNa might be of value in patients with CNCP with OUD. Future studies should investigate long-term effects of BuNa in randomized trials.

Bone sarcoma: success through interdisciplinary collaboration

PURPOSE

Osteosarcoma and Ewing sarcoma are the most frequent malignant bone tumours of childhood and adolescence. This review summarizes the oncologist's view of these diseases and their treatment.

METHODS

A non-systematic literature review was performed, the personal impressions and experience of the authors is described.

RESULTS

Local therapy and chemotherapy, each on their own, will not cure patients with malignant bone sarcomas. Together, they present a highly efficacious combination. While the most effective drugs were defined decades ago, progress since then has been limited. It is hoped that substances shown to be active in relapsed disease will be forwarded into even more efficacious frontline treatments. Good palliative therapy is necessary when cure is no longer an option.

CONCLUSION

Close interdisciplinary collaboration is the key to successful treatment of bone sarcomas in paediatric patients.

Tapentadol prolonged release in patients with chronic low back pain: real-world data from the German Pain eRegistry

Aim: Comparison of tapentadol prolonged release (PR) with other oral WHO-III PR opioid analgesics (morphine, oxycodone ± naloxone, hydromorphone) in routine medical care of chronic low back pain. Patients & methods: Noninterventional, retrospective 12-week study using anonymized clinical practice data from the German Pain eRegistry. Six effectiveness, tolerability, and safety criteria were aggregated in a primary composite end point (treatment responder). Propensity scoring matched 2331 datasets per treatment cohort. Results: All six single criteria showed significantly better outcomes for tapentadol PR (all parameters p < 0.001). There were significantly more treatment responders under tapentadol PR (65.7 vs 14.2%; p < 0.001). Conclusion: Tapentadol PR showed significantly better effectiveness and tolerability in severe chronic low back pain unsuccessfully treated with WHO-I/II analgesics compared with the other oral WHO-III PR opioids investigated.

Epigenetic Alterations in Prescription Opioid Misuse: New Strategies for Precision Pain Management

Prescription opioids are used for some chronic pain conditions. However, generally, long-term therapy has unwanted side effects which may trigger addiction, overdose, and eventually cause deaths. Opioid addiction and chronic pain conditions have both been associated with evidence of genetic and epigenetic alterations. Despite intense research interest, many questions about the contribution of epigenetic changes to this typology of addiction vulnerability and development remain unanswered. The aim of this review was to summarize the epigenetic modifications detected in specific tissues or brain areas and associated with opioid prescription and misuse in patients who have initiated prescribed opioid management for chronic non-cancer pain. The review considers the effects of opioid exposure on the epigenome in central and peripheral tissues in animal models and human subjects and highlights the mechanisms in which opioid epigenetics may be involved. This will improve our current understanding, provide the basis for targeted, personalized pain management, and thus balance opioid risks and benefits in managing chronic pain.

Aerobic Physical Exercise for Pain Intensity, Aerobic Capacity, and Quality of Life in Patients With Chronic Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, chronic pain is a disabling condition that is difficult to manage, which generates a high burden on health systems. The objective is to determine the effects of aerobic physical exercise in adults with chronic pain.

METHODS

A systematic review of searches in databases including MEDLINE, LILACS, ScienceDirect, PEDro, OTseeker, The Cochrane Library, EBSCO, and Google Scholar was conducted. The search process was carried out until July 31, 2020, and the study selection process was independently carried out through a criteria analysis for each phase. Outcome measures were chosen: aerobic capacity, physical function, quality of life, and pain.

RESULTS

Twenty-seven studies were included in which aerobic exercise was considered as an option to treat chronic pain. These studies showed significant results compared with other treatment options in terms of pain measurements (-0.22 [-0.42 to -0.03]) and aerobic capacity. For quality of life, there were significant improvements in the physical function component over the mental health component evaluated with the short form health survey-36/12.

CONCLUSION

Aerobic exercise is a nonpharmacological therapeutic option for treatment. Also, aerobic capacity and endurance improved when this type of exercise was prescribed, thus resulting in a substantial improvement in the quality of life of people suffering from chronic pain.

Prescriptions of analgesics during chronic cancer disease trajectories: A complete national cohort study

PURPOSE

Pain management principles vary considerably between chronic noncancer, acute and cancer pain. Cancer patients responding to oncological treatment may live with low tumor burden for years. Opioid treatment should reflect that the ratio between benefits and risks in these patients is different from patients with a rapidly progressive disease. Our study investigated the prescription patterns of analgesics in patients who died 6 to 9 years after cancer diagnosis.

PATIENTS AND METHODS

A pharmaco-epidemiological study based on the Norwegian Prescription Database and Cancer Registry of Norway. The 1-year periodic prevalence of receiving different analgesics and of persistent opioid use were analyzed. Persistent opioid use was defined as >365 Defined Daily Doses or >9000 mg Oral Morphine Equivalents during 365 days with prescriptions in all quarters of the 365 days period. Data were reported for the first 7 years for patients who lived 8-9 years after cancer diagnosis (N = 1502), while for patients who lived 6-7 years (N = 3817) data was reported for the first 5 years after diagnosis.

RESULTS

Compared to age- and gender adjusted general population, the 1-year periodic prevalence of opioid prescription was doubled the first year after diagnosis and remained raised with approximately 50%. The prevalence of persistent opioid use was threefold of the general population. Approximately 55% of patients with persistent opioid use 4 years after a cancer diagnosis were co-medicated with high doses of benzodiazepines and/or benzodiazepine-related hypnotics.

CONCLUSION

The findings of increased opioid use raise concerns regarding whether the benefits outweigh risks and side effects in this population.

The Association of Smoking and Alcohol Abuse on Anxiety and Depression in Patients With Recurrent Acute or Chronic Pancreatitis Undergoing Total Pancreatectomy and Islet Autotransplantation: A Report From the Prospective Observational Study of TPIAT Cohort

OBJECTIVES

Smoking and alcohol use are risk factors for acute and chronic pancreatitis, and their role on anxiety, depression, and opioid use in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT) is unknown.

METHODS

We included adults enrolled in the Prospective Observational Study of TPIAT (POST). Measured variables included smoking (never, former, current) and alcohol abuse or dependency history (yes vs no). Using univariable and multivariable analyses, we investigated the association of smoking and alcohol dependency history with anxiety and depression, opioid use, and postsurgical outcomes.

RESULTS

Of 195 adults studied, 25 were current smokers and 77 former smokers, whereas 18 had a history of alcohol dependency (of whom 10 were current smokers). A diagnosis of anxiety was associated with current smoking (P = 0.005), and depression was associated with history of alcohol abuse/dependency (P = 0.0001). However, active symptoms of anxiety and depression at the time of TPIAT were not associated with smoking or alcohol status. Opioid use in the past 14 days was associated with being a former smoker (P = 0.005).

CONCLUSIONS

Active smoking and alcohol abuse history were associated with a diagnosis of anxiety and depression, respectively; however, at the time of TPIAT, symptom scores suggested that they were being addressed.

Chronic Pancreatitis: Epidemiology, Diagnosis, and Management Updates

Chronic pancreatitis is a clinical entity that results from the progressive inflammation and irreversible fibrosis of the pancreas resulting from the cumulative injury sustained by the pancreas over time. It is an illness with variable presentations that can severely impact quality of life, while its long-term complications such as exocrine pancreatic insufficiency (EPI), diabetes mellitus, and risk of pancreatic cancer can become life threatening. The diagnosis of chronic pancreatitis can be challenging as despite the recent advancements in imaging technology, the radiographic findings do not become prominent until late stages of disease. Thus, the physicians' clinical acumen in obtaining thorough history taking focusing on risk factors, clinical symptoms, in addition to high-quality imaging, often guide to the accurate diagnosis of chronic pancreatitis. Endoscopy also plays a pivotal role in the diagnosis and management of chronic pancreatitis. Endoscopic ultrasound (EUS) is believed to be the most sensitive modality for diagnosing chronic pancreatitis. Despite efforts, however, natural history studies have demonstrated that 61% of individuals with chronic pancreatitis will require at least one endoscopic intervention, while 31% will require a surgical procedure as part of their management strategy. Recent advancements in genomic studies have furthered our understanding of the genetic polymorphisms that are associated with the pathogenesis of chronic pancreatitis. Genetic testing offers the potential to reveal treatable pancreatitis-related disorders, and can inform decision making with regard to radical therapies for persistent or severe disease such as total pancreatectomy with islet autotransplantation (TPIAT). The management of patients suffering from chronic pancreatitis often requires a multi-disciplinary approach, addressing pertinent symptoms as well as the sequelae of chronic inflammation and fibrosis. Abdominal pain is the prevailing symptom and most common complication of chronic pancreatitis, and impairs quality of life. Although heavily dependent on a wide range of analgesia, endoscopic treatment such as endoscopic retrograde cholangiopancreatography (ERCP) and surgical intervention can offer long-lasting relief of symptoms. For EPI, treatment with pancreatic enzyme supplements offers marginal-to-moderate relief. The most feared complication of chronic pancreatitis-the development of pancreatic cancer-has no known prevention measure to date.

Quality of life in chronic pain treated through pulsed radiofrequency therapy: A retrospective study

Anxiety and depression are often symptoms present in people who suffer from chronic pain, compromising the quality of life of these individuals. The objective of this study was to assess whether a pulsed radiofrequency (PRF) treatment, in addition to psychological support intervention, can decrease chronic pain, thereby improving quality of life and restoring psychological well-being.Fifty outpatients with a diagnosis of chronic pain, without any benefit from traditional drug therapies, were selected to perform a PRF treatment in combination with a psychological intervention. They were evaluated before and after the intervention through the Hamilton Anxiety Rating Scale and the Beck Depression Inventory-II for anxiety and depression symptomatology, respectively, the Short Form Health Survey 36 (SF-36) was used to assess the subject's quality of life, and the Numerical Rating Scale was used for pain assessment.The Wilcoxon signed-rank test showed a significant difference in Beck Depression Inventory-II (P < .001), Hamilton Anxiety Rating Scale (P < .01), and Numerical Rating Scale (P = .004). In the SF-36 scores, we observed a significant difference between T0 and T1 in both mental (P < .001) and physical (P < .001) dimensions.This study shows that a chronic pain reduction leads to a decrease of anxiety-depressive symptoms and an improvement in quality of life. PRF seems to be an appropriate method to reduce the chronic pain that influences psychological well-being and quality of life.

All-Cause and Overdose Mortality Risk Among People Prescribed Opioids: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate all-cause and overdose crude mortality rates and standardized mortality ratios among people prescribed opioids for chronic noncancer pain and risk of overdose death in this population relative to people with similar clinical profiles but not prescribed opioids.

DESIGN

Systematic review and meta-analysis.

METHODS

Medline, Embase, and PsycINFO were searched in February 2018 and October 2019 for articles published beginning 2009. Due to limitations in published studies, we revised our inclusion criteria to include cohort studies of people prescribed opioids, excluding those studies where people were explicitly prescribed opioids for the treatment of opioid use disorder or acute cancer or palliative pain. We estimated pooled all-cause and overdose crude mortality rates using random effects meta-analysis models. No studies reported standardized mortality ratios or relative risks.

RESULTS

We included 13 cohorts with 6,029,810 participants. The pooled all-cause crude mortality rate, based on 10 cohorts, was 28.8 per 1000 person-years (95% CI = 17.9-46.4), with substantial heterogeneity (I2 = 99.9%). The pooled overdose crude mortality rate, based on six cohorts, was 1.1 per 1000 person-years (95% CI = 0.4-3.4), with substantial heterogeneity (I2 = 99.5%), but indications for opioid prescribing and opioid exposure were poorly ascertained. We were unable to estimate mortality in this population relative to clinically similar populations not prescribed opioids.

CONCLUSIONS

Methodological limitations in the identified literature complicate efforts to determine the overdose mortality risk of people prescribed opioids. There is a need for large-scale clinical trials to assess adverse outcomes in opioid prescribing, especially for chronic noncancer pain.

Evaluation of medical students' knowledge of psychoactive substances in the context of their future role in addiction prevention and therapy

This study assesses the knowledge of medical students on the health effects of the use of psychoactive substances, in the context of their future role in prevention and treatment of addictions. The study was conducted using a questionnaire containing questions about classification, symptoms and effects of psychoactive substances, and the existing prevention programs. The study involved 430 students of medicine and allied faculties. Only 20.8% of medicine students and 12.5% of students of other faculties could correctly classify different psychoactive substances. Correct symptoms of drug misuse were mentioned by 20.4% of medicine students and 19.2% of students of other faculties. The overall knowledge of medical students was no greater than the knowledge of students of other allied faculties. Medical students showed insufficient knowledge about psychoactive substances and their effects on the human body, thus indicating the need to introduce into their study programme a more teaching in this area.

European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain

BACKGROUND

Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).

METHODS

The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.

RESULTS

The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation.

CONCLUSIONS

Opioids remain a treatment option for some selected patients with CNCP under careful surveillance.

SIGNIFICANCE

In chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.

Characterization and Associated Costs of Constipation Relating to Exposure to Strong Opioids in England: An Observational Study

PURPOSE

Opioid use is associated with gastrointestinal adverse events, including nausea and constipation. We used a real-world dataset to characterize the health care burden associated with opioid-induced constipation (OIC) with particular emphasis on strong opioids.

METHODS

This retrospective cohort study was conducted using the Clinical Practice Research Datalink, a large UK primary care dataset linked to hospital data. Patients prescribed opioids during 2016 were selected and episodes of opioid therapy constructed. Episodes with ≥84 days of exposure were classified as chronic, with date of first prescription as the index date. The main analysis focused on patients prescribed strong opioids who were laxative naive. Constipation was defined by ≥2 laxative prescriptions during the opioid episode. Patients for whom initial laxative therapy escalated by switch, augmentation, or dose were defined as OIC unstable, and the first 3 lines of OIC escalation were classified. Health care costs accrued in the first 12 months of the opioid episode were aggregated and compared.

FINDINGS

A total of 27,629 opioid episodes were identified; 5916 (21.4%) involved a strong opioid for patients who were previously laxative naive. Of these patients, 2886 (48.8%) were defined as the OIC population; 941 (33.26%) were classified as stable. Of the 1945 (67.4%) episodes classified as unstable, 849 (43.7%), 360 (18.5%), and 736 (37.8%) had 1, 2, and ≥3 changes of laxative prescription, respectively. Patients without OIC had lower costs per patient year (£3822 [US$5160/€4242]) compared with OIC (£4786 [US$6461/€5312]). Costs increased as patients had multiple changes in therapy: £4696 (US$6340/€5213), £4749 (US$6411/€5271), and £4981 (US$6724/€5529) for 1, 2, and ≥3 changes, respectively. The adjusted cost ratio relative to non-OIC was 1.14 (95% CI, 1.09-1.32) for those classified as stable and 1.19 (95% CI, 1.09-1.32) for those with ≥3 laxative changes. Similar patterns were observed for patients taking anyopioid, with costs increased for those classified as having OIC (£3727 [US$5031/€4137] vs £2379 [US$3212 /€2641),and for those patients classified as unstable versus stable (£3931 [US$5307/€4363] vs £3432 [US$4633/€3810). Costs increased with each additional line of therapy from £3701 (US$4996/€4108), £3916 (US$5287/€4347), and £4318 (US$5829/€4793).

IMPLICATIONS

OIC was a common adverse event of opioid treatment and was poorly controlled for a large number of patients. Poor control was associated with increased health care costs. The impact of OIC should be considered when prescribing opioids. These results should be interpreted with consideration of the caveats associated with the analysis of routine data.

Pancreas Cancer-Associated Pain Management

Pain is highly prevalent in patients with pancreas cancer and contributes to the morbidity of the disease. Pain may be due to pancreatic enzyme insufficiency, obstruction, and/or a direct mass effect on nerves in the celiac plexus. Proper supportive care to decrease pain is an important aspect of the overall management of these patients. There are limited data specific to the management of pain caused by pancreatic cancer. Here we review the literature and offer recommendations regarding multiple modalities available to treat pain in these patients. The dissemination and adoption of these best supportive care practices can improve quantity and quality of life for patients with pancreatic cancer. IMPLICATIONS FOR PRACTICE: Pain management is important to improve the quality of life and survival of a patient with cancer. The pathophysiology of pain in pancreas cancer is complex and multifactorial. Despite tumor response to chemotherapy, a sizeable percentage of patients are at risk for ongoing cancer-related pain and its comorbid consequences. Accordingly, the management of pain in patients with pancreas cancer can be challenging and often requires a multifaceted approach.

Opioids: A 'crisis' of too much or not enough - or simply how rich you are and where you live?

The 'Opioid Crisis', which originated in Western countries, has been misrepresented and is misinforming the global public. For 20 years, since the advent of the synthetic opioids, 25,000 Americans, on average, have died annually from opioid-related overdoses. The United States produces and consumes by far the greatest amounts of opioids. National regulations introduced to curb overdoses and restrict opioid availability have condemned many Americans, such as cancer patients or those in need of palliative care, to a life of extreme pain due to lack of access to adequate pain management. As is often the case, US-driven laws have informed and guided international regulations. Worldwide, 83% of countries have low or non-existent access to opioids for pain relief. Over 25 million people are at the end-of-life stage, with eight million people dying annually in unnecessary pain and distress. Ineffectively controlled pain is a global public health issue blighting the lives of billions of people worldwide with immeasurable human and socioeconomic costs. International conventions regulate the trade and use of controlled medications, including many opioids. The goal is to balance widespread access to optimal forms of pain management with restrictions to govern the use and prevent the misuse of controlled substances. Those conventions are failing to meet their goals. International guidelines to inform national legislation have been compromised and withdrawn, thanks to undue interference from US-based opioid manufacturers. The new goal must be to ensure equitable access, for all, to opioids and ensure that optimal pain management becomes a central component of Universal Health Coverage. SIGNIFICANCE: The opioid crisis is, more accurately, a multicomponent global crisis and one that is not fully apparent or well understood. Regulations of the wealthy and powerful to control a surfeit of opioids, which encourages misuse, cannot be allowed to govern legislation in the majority of countries worldwide where citizens have little or no access to opioids to reduce pain and suffering. International conventions must be revised to ensure an optimal balance that allows access to opioids for all those who need them.