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Cammarota S, Conti V, Corbi G, Di Gregorio L, Dolce P, Fogliasecca M, Iannaccone T, Manzo V, Passaro V, Toraldo B, Valente A, Citarella A. Predictors of Opioid Prescribing for Non-Malignant Low Back Pain in an Italian Primary Care Setting. J Clin Med 2021; 10:jcm10163699. [PMID: 34441993 PMCID: PMC8397205 DOI: 10.3390/jcm10163699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 11/16/2022] Open
Abstract
This study explores which patient characteristics could affect the likelihood of starting low back pain (LBP) treatment with opioid analgesics vs. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in an Italian primary care setting. Through the computerized medical records of 65 General Practitioners, non-malignant LBP subjects who received the first pain intensity measurement and an NSAID or opioid prescription, during 2015–2016, were identified. Patients with an opioid prescription 1-year before the first pain intensity measurement were excluded. A multivariable logistic regression model was used to determine predictive factors of opioid prescribing. Results were reported as Odds Ratios (ORs) with a 95% confidence interval (CI), with p < 0.05 indicating statistical significance. A total of 505 individuals with LBP were included: of those, 72.7% received an NSAID prescription and 27.3% an opioid one (64% of subjects started with strong opioid). Compared to patients receiving an NSAID, those with opioid prescriptions were younger, reported the highest pain intensity (moderate pain OR = 2.42; 95% CI 1.48–3.96 and severe pain OR = 2.01; 95% CI 1.04–3.88) and were more likely to have asthma (OR 3.95; 95% CI 1.99–7.84). Despite clinical guidelines, a large proportion of LBP patients started with strong opioid therapy. Asthma, younger age and pain intensity were predictors of opioid prescribing when compared to NSAIDs for LBP treatment.
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Affiliation(s)
- Simona Cammarota
- LinkHealth Health Economics, Outcomes & Epidemiology s.r.l., 80143 Naples, Italy; (M.F.); (A.C.)
- Correspondence: ; Tel.: +39-333-532-0054
| | - Valeria Conti
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84084 Salerno, Italy; (V.C.); (T.I.); (V.M.)
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy;
| | - Graziamaria Corbi
- Department of Medicine and Health Sciences, “Vincenzo Tiberio”, University of Molise, 86100 Campobasso, Italy;
- Italian Society of Gerontology and Geriatrics (SIGG), 50122 Florence, Italy
| | - Luigi Di Gregorio
- Parmenide Medical Cooperative, 84084 Salerno, Italy; (L.D.G.); (V.P.)
| | - Pasquale Dolce
- Department of Public Health, University of Naples “Federico II”, 80138 Naples, Italy;
| | - Marianna Fogliasecca
- LinkHealth Health Economics, Outcomes & Epidemiology s.r.l., 80143 Naples, Italy; (M.F.); (A.C.)
| | - Teresa Iannaccone
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84084 Salerno, Italy; (V.C.); (T.I.); (V.M.)
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy;
| | - Valentina Manzo
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84084 Salerno, Italy; (V.C.); (T.I.); (V.M.)
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy;
| | - Vincenzo Passaro
- Parmenide Medical Cooperative, 84084 Salerno, Italy; (L.D.G.); (V.P.)
| | | | - Alfredo Valente
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy;
| | - Anna Citarella
- LinkHealth Health Economics, Outcomes & Epidemiology s.r.l., 80143 Naples, Italy; (M.F.); (A.C.)
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Tapentadol Versus Tramadol: A Narrative and Comparative Review of Their Pharmacological, Efficacy and Safety Profiles in Adult Patients. Drugs 2021; 81:1257-1272. [PMID: 34196947 PMCID: PMC8318929 DOI: 10.1007/s40265-021-01515-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 02/07/2023]
Abstract
We conducted a narrative review of the literature to compare the pharmacological, efficacy and safety profiles of tapentadol and tramadol, and to assess the clinical interest of tapentadol in adult patients. Tapentadol and tramadol share a mixed mechanism of action, including both mu-agonist and monoaminergic properties. Tapentadol is approximately two to three times more potent than tramadol and two to three times less potent than morphine. It has no identified analgesically active metabolite and is not significantly metabolised by cytochrome P450 enzymes, thus overcoming some limitations of tramadol, including the potential for pharmacokinetic drug-drug interactions and interindividual variability due to genetic polymorphisms of cytochrome P450 enzymes. The toxicity profiles of tramadol and tapentadol are similar; however tapentadol is likely to result in less exposure to serotoninergic adverse effects (nausea, vomiting, hypoglycaemia) but cause more opioid adverse effects (constipation, respiratory depression, abuse) than tramadol. The safety of tapentadol in real-world conditions remains poorly documented, particularly in at-risk patient subgroups and also in the ability to assess the risk associated with its residual serotonergic activity (serotonin syndrome, seizures). Because of an earlier market introduction, more real-world safety data are available for tramadol, including data from at-risk patient subgroups. The level of evidence on the efficacy of both tramadol and tapentadol for the treatment of chronic pain is globally low. The trials published to date show overall that tapentadol does not provide a clinically significant analgesic improvement compared to existing treatments, for which the safety profile is much better known. In conclusion, tapentadol is not a first-line opioid but represents an additional analgesic in the therapeutic choices, which some patients may benefit from after careful examination of their clinical situation, co-morbidities and co-medications.
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Abstract
Aim: The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people. Background: Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group. Methods: This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends. Findings: A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA. Conclusions: A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.
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Olesen AE, Henriksen JN, Nielsen LP, Knudsen P, Poulsen BK. Patient safety incidents involving transdermal opioids: data from the Danish Patient Safety Database. Int J Clin Pharm 2020; 43:351-357. [PMID: 32430881 DOI: 10.1007/s11096-020-01057-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
Abstract
Background Transdermal opioids are widely used among elderly adults with chronic pain. However, transdermal patches may be involved in a significant proportion of opioid-related patient safety incidents, as the application process includes several subprocesses, each associated with an individual risk of error. Objective The aim was to obtain specific knowledge on patient safety incidents related to transdermal opioid treatment within both the primary care sector and the hospital sector in Denmark. Setting The study is descriptive with data provided by the Danish Patient Safety Database. Methods We manually retrieved all patient safety incidents concerning transdermal opioids reported for 2018 from (1) the hospital sector and (2) the primary care sector. Study data were collected and managed using REDCap electronic data capture tools. Main outcome measure The available information for each incident was sorted into the following categories: location, medication process, type of problem, outcome at time of reporting, and outcome classification. Results A total of 866 patient safety incidents involving transdermal opioids were reported to the Danish Patient Safety Database in 2018. No fatal incidents were present in the database. In 386 cases, the incidents were reported as harmful, and these 386 cases were analysed. Most reports came from the primary care sector (nursing home, home care or social housing). The majority of incidents were related to the administration of the patch in the medication process, and the most prevalent problem was the omission of doses. Conclusion This study has demonstrated that the administration of transdermal opioids is challenging and may cause harm, particularly in the primary care sector. To improve patient safety, optimized systems, including guidelines on drug management and the continuing education of healthcare personnel in transdermal opioid management, are necessary. These guidelines should preferably incorporate reminders and checklists, since the omission of doses was the most reported problem.
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Affiliation(s)
- A E Olesen
- Department of Clinical Pharmacology, Aalborg University Hospital, Gartnerboligen, ground floor Mølleparkvej 8a, 9000, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - J N Henriksen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | - L P Nielsen
- Department of Clinical Pharmacology, Aalborg University Hospital, Gartnerboligen, ground floor Mølleparkvej 8a, 9000, Aalborg, Denmark.,Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | - P Knudsen
- Division of Knowledge and Learning, The Danish Patient Safety Authority, Copenhagen, Denmark
| | - B K Poulsen
- Department of Clinical Pharmacology, Aalborg University Hospital, Gartnerboligen, ground floor Mølleparkvej 8a, 9000, Aalborg, Denmark
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Incident opioid use and risk of hip fracture among persons with Alzheimer disease: a nationwide matched cohort study. Pain 2018; 160:417-423. [DOI: 10.1097/j.pain.0000000000001412] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Erdal A, Flo E, Aarsland D, Ballard C, Slettebo DD, Husebo BS. Efficacy and Safety of Analgesic Treatment for Depression in People with Advanced Dementia: Randomised, Multicentre, Double-Blind, Placebo-Controlled Trial (DEP.PAIN.DEM). Drugs Aging 2018; 35:545-558. [PMID: 29725986 PMCID: PMC5999156 DOI: 10.1007/s40266-018-0546-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Chronic pain and depression often co-occur, and pain may exacerbate depression in people with dementia. Objective The objective of this study was to assess the efficacy and safety of analgesic treatment for depression in nursing home patients with advanced dementia and clinically significant depressive symptoms. Methods We conducted a multicentre, parallel-group, double-blind, placebo-controlled trial in 47 nursing homes, including 162 nursing home patients aged ≥ 60 years with dementia (Mini-Mental State Examination ≤ 20) and depression (Cornell Scale for Depression in Dementia ≥ 8). Patients were randomised to receive active analgesic treatment (paracetamol or buprenorphine transdermal system) or identical placebo for 13 weeks. The main outcome measure was the change in depression (Cornell Scale for Depression in Dementia) from baseline to 13 weeks, assessed using linear mixed models with fixed effects for time, intervention and their interaction in the models. Secondary outcomes were to assess whether any change in depression was secondary to change in pain (Mobilisation-Observation-Behaviour-Intensity-Dementia-2 Pain Scale) and adverse events. Results The mean depression change was − 0.66 (95% confidence interval − 2.27 to 0.94) in the active group (n = 80) and − 3.30 (− 4.68 to −1.92) in the placebo group (n = 82). The estimated treatment effect was 2.64 (0.55–4.72, p = 0.013), indicating that analgesic treatment had no effect on depressive symptoms from baseline to 13 weeks while placebo appeared to ameliorate depressive symptoms. There was no significant reduction in pain in the active treatment group (paracetamol and buprenorphine combined) vs. placebo; however, a subgroup analysis demonstrated a significant reduction in pain for paracetamol vs. placebo [by − 1.11 (− 2.16 to − 0.06, p = 0.037)] from week 6 to 13 without a change in depression. Buprenorphine did not have significant effects on depression [3.04 (− 0.11 to 6.19), p = 0.059] or pain [0.47 (− 0.77 to 1.71), p = 0.456] from 0 to 13 weeks. Thirty-five patients were withdrawn from the study because of adverse reactions, deterioration or death: 25 (31.3%) during active treatment [23 (52.3%) who received buprenorphine], and ten (12.2%) in the placebo group. The most frequently occurring adverse events were psychiatric (17 adverse reactions) and neurological (14 adverse reactions). Conclusion Analgesic treatment did not reduce depression while placebo appeared to improve depressive symptoms significantly by comparison, possibly owing to the adverse effects of active buprenorphine. The risk of adverse events warrants caution when prescribing buprenorphine for people with advanced dementia. Trial registration ClinicalTrials.gov NCT02267057 (registered 7 July, 2014) and Norwegian Medicines Agency EudraCT 2013-002226-23. Electronic supplementary material The online version of this article (10.1007/s40266-018-0546-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ane Erdal
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.
| | - Elisabeth Flo
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Dag Aarsland
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Dagrun D Slettebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway.,Department of Health and Care, Municipality of Bergen, Bergen, Norway
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Olivência SA, Barbosa LGM, Cunha MRD, Silva LJD. Pharmacological treatment of chronic non-malignant pain among elderly persons: an integrative review. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2018. [DOI: 10.1590/1981-22562018021.170179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Objective: The objective of the present study was to perform an integrative review of proposed pharmacological treatments for chronic non-malignant pain in elderly patients. Method: An integrative review was carried out. The search of literature included papers about the treatment of chronic pain among the elderly, published from 2007 to 2017 and available in Portuguese or English. Searches were conducted on the LILACS and MEDLINE electronic databases using the key words “chronic pain”, “treatment” and “elderly” combined with the Boolean operator “AND”. To analyse methodological quality, the adapted Critical Appraisal Skill Program (CASP) was used. Results: Of a total of 303 studies found, 32 were included. The articles selected included 20 reviews, five observational studies, five clinical trials, one case series and one retrospective study. A total of 75% of the articles were published in the last five years, of which one was in Portuguese and 31 in English. Conclusion :The results demonstrate a variety of treatments for chronic pain among the elderly population, highlighting the role of opioids which, according to more recent evidence, can be carefully used in treatment. Several drugs, however, have not been specifically tested for the elderly population. A number of factors are relevant in pain management of elderly patients, including comorbidities, polypharmacy and patient functionality. An individualized approach should be applied to elderly patients to improve outcomes and reduce side effects.
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Veal F, Williams M, Bereznicki L, Cummings E, Thompson A, Peterson G, Winzenberg T. Barriers to Optimal Pain Management in Aged Care Facilities: An Australian Qualitative Study. Pain Manag Nurs 2017; 19:177-185. [PMID: 29153298 DOI: 10.1016/j.pmn.2017.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 08/22/2017] [Accepted: 10/02/2017] [Indexed: 02/03/2023]
Abstract
Up to 80% of residents in aged care facilities (ACFs) experience pain, which is often suboptimally managed. The purpose of this study was to characterize pain management in ACFs and identify the barriers to optimal pain management. This exploratory descriptive qualitative study used semistructured interviews in five Southern Tasmania, Australian ACFs. Interviewees included 23 staff members (18 nurses and 5 facility managers) and were conducted from September to November 2015. Interviews included questions about how pain was measured or assessed, what happened if pain was identified, barriers to pain management, and potential ways to overcome these barriers. Interviewees noted that there were no formal requirements regarding pain assessment at the ACFs reviewed; however, pain was often informally assessed. Staff noted the importance of adequate pain management for the residents' quality of life and employed both nonpharmacologic and pharmacologic techniques to reduce pain when identified. The barriers to optimal pain management included difficulty identifying and assessing pain, residents' resistance to reporting pain and/or taking medications, and communication barriers between the nursing staff and GPs. Staff interviewed were dedicated to managing residents' pain effectively; however, actions in a number of areas could improve resident outcomes. These include a more consistent approach to documenting pain in residents' progress notes and improving nurse-GP communications to ensure that new or escalating pain is identified and expedient changes can be made to the resident's management. Additionally, resident, family, nurse, and carer education, conducted within the facilities on a regular basis, could help improve the pain management of residents.
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Affiliation(s)
- Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia.
| | - Mackenzie Williams
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
| | - Luke Bereznicki
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
| | - Elizabeth Cummings
- Nursing and Midwifery Department, School of Health Sciences, University of Tasmania, Hobart, Australia
| | - Angus Thompson
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
| | - Gregory Peterson
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
| | - Tania Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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Tevik K, Selbæk G, Engedal K, Seim A, Krokstad S, Helvik AS. Use of alcohol and drugs with addiction potential among older women and men in a population-based study. The Nord-Trøndelag Health Study 2006-2008 (HUNT3). PLoS One 2017; 12:e0184428. [PMID: 28886172 PMCID: PMC5590962 DOI: 10.1371/journal.pone.0184428] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 08/23/2017] [Indexed: 02/06/2023] Open
Abstract
Background Little is known about the consumption habits of older adults in Norway with respect to alcohol and the use of drugs with addiction potential, such as benzodiazepines, z-hypnotics and opioids, among regular drinkers. We studied the prevalence of self-reported consumption of alcohol on a regular basis in community-living older men and women (≥ 65 years). Furthermore, we investigated the prevalence of dispensed prescribed drugs with addiction potential in older men and women who were regular drinkers. Methods We used data from the Nord-Trøndelag Health Study 2006–2008 (HUNT3). Of 12,361 older adults in the HUNT3 study, 11,545 had answered the alcohol consumption item and were included in our study. Regular drinkers were defined as consuming alcohol one or more days a week. Data on dispensed drugs with addiction potential were drawn from the Norwegian Prescription Database. Addiction potential was defined as at least one prescription for benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years. Results In total 28.2% of older Norwegian adults were regular drinkers. Men in the study were more likely to be regular drinkers than women. Drugs with addiction potential were used by 32.4% of participants, and were more commonly used by women. Nearly 12% of participants used benzodiazepines, 19% z-hypnotics and 12.4% opioids. Among regular drinkers, 29% used drugs with addiction potential, which was also more common among women. Adjusted for age, gender and living situation, use of z-hypnotics was associated with regular alcohol intake, while use of opioids was associated with no regular alcohol intake. Conclusion The prevalence of the use of drugs with addiction potential was high in a Norwegian population of older adults who reported regular consumption of alcohol. Strategies should be developed to reduce or prevent alcohol consumption among older adults who use drugs with addiction potential.
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Affiliation(s)
- Kjerstin Tevik
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- * E-mail:
| | - Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Research Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Knut Engedal
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Arnfinn Seim
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Steinar Krokstad
- HUNT Research Centre, Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Levanger, Norway
- Psychiatric Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Anne-S. Helvik
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- St. Olavs University Hospital, Trondheim, Norway
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A Nationwide Retrospective Study of Opioid Management Patterns in 2,468 Patients with Spinal Pain in Korea. Asian Spine J 2016; 10:1122-1131. [PMID: 27994790 PMCID: PMC5165004 DOI: 10.4184/asj.2016.10.6.1122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/18/2016] [Accepted: 11/18/2016] [Indexed: 12/22/2022] Open
Abstract
STUDY DESIGN Retrospective patient data collection and investigator survey. PURPOSE To investigate patterns of opioid treatment for pain caused by spinal disorders in Korea. OVERVIEW OF LITERATURE Opioid analgesic prescription and adequacy of consumption measures in Korea have markedly increased in the past decade, suggesting changing patterns in pain management practice; however, there is lack of integrated data specific to Korean population. METHODS Patient data were collected from medical records at 34 university hospitals in Korea. Outpatients receiving opioids for pain caused by spinal disorders were included in the study. Treatment patterns, including opioid types, doses, treatment duration, outcomes, and adverse drug reactions (ADRs), were evaluated. Investigators were interviewed on their perceptions of opioid use for spinal disorders. RESULTS Among 2,468 analyzed cases, spinal stenosis (42.8%) was the most common presentation, followed by disc herniation (24.2%) and vertebral fracture (17.5%). In addition, a greater proportion of patients experienced severe pain (73.9%) rather than moderate (19.9%) or mild (0.7%) pain. Oxycodone (51.9%) and fentanyl (50.8%) were the most frequently prescribed opioids; most patients were prescribed relatively low doses. The median duration of opioid treatment was 84 days. Pain relief was superior in patients with longer treatment duration (≥2 months) or with nociceptive pain than in those with shorter treatment duration or with neuropathic or mixed-type pain. ADRs were observed in 8.6% of cases. According to the investigators' survey, "excellent analgesic effect" was a perceived advantage of opioids, while safety concerns were a disadvantage. CONCLUSIONS Opioid usage patterns in patients with spinal disorders are in alignment with international guidelines for spinal pain management. Future prospective studies may address the suitability of opioids for spinal pain treatment by using appropriate objective measurement tools.
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Deeks ED, Lyseng-Williamson KA. Oxycodone prolonged release: a guide to its use in the EU. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0326-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Do nurses in acute care settings administer PRN analgesics equally to patients with dementia compared to patients without dementia? Collegian 2016. [DOI: 10.1016/j.colegn.2015.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Hall T. Management of persistent pain in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2016. [DOI: 10.1002/jppr.1194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Tony Hall
- Advanced Pharmacist in Persistent Pain and Senior Lecturer; School of Clinical Sciences; Queensland University of Technology; Brisbane Queensland Australia
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Abstract
Persistent pain affects the elderly disproportionally, occurring in 50% of elderly community-dwelling patients and 80% of aged care residents. The management of pain in the elderly and frail patient is complicated because of the risks posed by changes in pharmacokinetics and pharmacodynamics, polypharmacy, and drug-disease interactions. Trials evaluating the efficacy of analgesics have often excluded elderly patients and universally excluded frail patients; therefore, the true efficacy and side-effect profiles in these population groups are largely unknown, especially for long-term use. A stepwise approach is recommended to managing pain, commencing with paracetamol and adding on opioids when needed to manage pain. However, because of the short duration of clinical trials, exclusion of frail patients, and minimal inclusion of elderly patients, the decision as to which opioid should be added on to paracetamol is a difficult one. This article reviews the evidence surrounding a newer opioid, tapentadol. Tapentadol acts on both the mu receptors and on neuronal reuptake of noradrenaline, and has no significant analgesically active metabolites, which theoretically presents some advantages, particularly in comparison with tramadol. However, the evidence to support tapentadol is weak and the trials were often methodologically poor and sponsored almost universally by the drug company. Currently, there is insufficient evidence to support the use of tapentadol over other opioids, which have been on the market longer, are less expensive, and have better established safety profiles. As a first-line agent after the failure of paracetamol alone, morphine, oxycodone, fentanyl, or buprenorphine are still the preferred evidence-based choices for add-on opioid therapy for elderly or frail patients.
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Abstract
SummaryIn this review we identified cohort and cross-sectional studies that assessed pain in community-dwelling older people (>65 years) reliably characterized as frail. Secondly, we considered biologically plausible mechanisms that may alter pain perception, or contribute to, or exacerbate pain in an older person with frailty. Thirdly, we considered specific implications of pain management for this group of people. From the limited data from the seven included studies, it would appear that the presence of pain is higher in older people with frailty compared with people characterized as pre-frail or not frail. Thus older people reporting pain are more likely to be frail. However, a lack of prospective data precludes inferences about the direction of the relationship: that is whether pain or frailty is the antecedent. Further research is needed to understand the direction of the relationship, and to identify appropriate pain management strategies for older people with frailty.
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Gadzhanova S, Roughead EE, Pont LG. Safety of opioid patch initiation in Australian residential aged care. Med J Aust 2015; 203:298. [DOI: 10.5694/mja15.00174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 07/30/2015] [Indexed: 11/17/2022]
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Comment on “Pain in the Frail or Elderly Patient: Does Tapentadol Have a Role?”. Drugs Aging 2015; 32:871-3. [DOI: 10.1007/s40266-015-0313-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Brallier JW, Deiner S. The Elderly Spine Surgery Patient: Pre- and Intraoperative Management of Drug Therapy. Drugs Aging 2015; 32:601-9. [DOI: 10.1007/s40266-015-0278-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Chang YP, Compton P, Almeter P, Fox CH. The Effect of Motivational Interviewing on Prescription Opioid Adherence Among Older Adults With Chronic Pain. Perspect Psychiatr Care 2015; 51:211-9. [PMID: 25159493 DOI: 10.1111/ppc.12082] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/20/2014] [Accepted: 07/10/2014] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To test the effect of office-based motivational interviewing (MI) on prescription opioid adherence in older adults with chronic pain. DESIGN AND METHODS Pre- and post-design was used. Thirty chronic pain patients participated in a 4-week MI in two outpatient settings. FINDINGS Participants demonstrated a significantly reduced risk of prescription opioid misuse, decreased substance use, increased self-efficacy, increased motivation to change, and decreased depression at both the post-test and 1-month follow-up. PRACTICE IMPLICATION MI can be effectively delivered in outpatient settings for older adults who are at risk for opioid misuse. Clinicians could incorporate MI techniques to enhance prescription opioid adherence.
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Affiliation(s)
- Yu-Ping Chang
- School of Nursing, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Peggy Compton
- School of Nursing and Health Studies, Georgetown University, Washington DC, USA
| | - Pamela Almeter
- School of Nursing, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Chester H Fox
- Department of Family Medicine, University at Buffalo, The State University of New York, New York, New York, USA
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Abstract
Alterations in pharmacokinetics and pharmacodynamics place geriatric patients at an increased risk of experiencing an adverse drug event. The incidence of medication-related adverse events can be decreased with careful selection of agents and appropriate dosage adjustments.
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Affiliation(s)
- Janine Then
- Department of Pharmacy and Therapeutics, University of Pittsburgh, 3501 Terrace St, Pittsburgh, PA 15261, USA
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland, 22 S. Greene St, Baltimore, MD 21201, USA.
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Serotonin in anxiety and panic: Contributions of the elevated T-maze. Neurosci Biobehav Rev 2014; 46 Pt 3:397-406. [DOI: 10.1016/j.neubiorev.2014.03.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 02/05/2014] [Accepted: 03/03/2014] [Indexed: 11/21/2022]
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Atkinson TJ, Fudin J, Pandula A, Mirza M. Medication pain management in the elderly: unique and underutilized analgesic treatment options. Clin Ther 2013; 35:1669-89. [PMID: 24161287 DOI: 10.1016/j.clinthera.2013.09.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND By 2030, the US population of adults aged ≥65 years will increase by >80%, and these adults will account for nearly 20% of the US population. In this population, the decline of multiple physiologic processes and diseases collectively influence treatment options. Physiologic changes, drug-drug interactions resulting from polypharmacy, and drug-disease interactions combine to make elderly patients more sensitive to the adverse events (AEs) associated with medications, all of which must be considered in drug selection. OBJECTIVE This article focuses on select underutilized medication options for analgesia that may provide significant advantages in the elderly population above and beyond commonly prescribed conventional choices. METHODS We performed a complete review of the literature using the search terms pain management, elderly, opioids, NSAIDs, topical NSAIDs, levorphanol, buprenorphine transdermal, and tapentadol. Databases searched included PubMed, Google Scholar, Ovid, and Athens. Package inserts were utilized for approval dates, indications, and formulations available. We looked at reviews of agents to identify important studies for consideration that searches may have missed. Pharmacology and pharmacokinetic data were taken from randomized trials focusing in this area. Pivotal Phase III trials were utilized for discussion of clinical trial experience and to summarize efficacy and AEs. For purposes of validity, only peer-reviewed literature was included. RESULTS There were limited data that specifically outlined analgesic drug selection and highlighted safer alternatives for the elderly patient based on polypharmacy risks, end-organ deterioration, and/or drug choices that presented less risk. We focused on unique opioid alternatives: levorphanol, which offers several therapeutic advantages similar to methadone but without the pharmacokinetic and drug-interaction pitfalls associated with methadone; tapentadol, associated with significantly less gastrointestinal distress and constipation; and transdermal buprenorphine, an agonist/antagonist with less risk for the toxicities associated with conventional opioids and with compliance benefits. Topical NSAIDs are discussed as a viable therapeutic option. Specific attention to a more desirable tolerability profile, including avoidance of drug interactions, end-organ dysfunction, and gastrointestinal bleed with topical NSAID agents versus their oral counterparts is discussed, including the ability to achieve superior tissue levels for appropriately selected inflammatory conditions. CONCLUSION It is incumbent that providers consider these options as part of an analgesic armamentarium in an effort to maximize therapeutic benefit and minimize risks in the increasing elderly patient population.
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Harden RN, Kaye AD, Kintanar T, Argoff CE. Evidence-based guidance for the management of postherpetic neuralgia in primary care. Postgrad Med 2013; 125:191-202. [PMID: 23933906 DOI: 10.3810/pgm.2013.07.2690] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This article aims to help primary care physicians negotiate gaps in current guidelines for postherpetic neuralgia (PHN). The objectives of this article are to: 1) briefly review the available guidelines and identify their strengths and weaknesses; 2) review the gaps in the guidelines; 3) review new data that were not included in the most recent guidelines; 4) provide expert opinion on how the new data and current guidelines can be used to make treatment decisions; and 5) review several important dimensions of care (eg, tolerability, dosing) and provide guidance. In general, all guidelines recognize the α2δ ligands, tricyclic antidepressants (TCAs), opioids, and tramadol as efficacious systemic options, with topical lidocaine serving as an efficacious nonsystemic approach for localized PHN treatment. The first-line treatment options typically recommended in the guidelines are α2δ ligands and TCAs, while opioids and tramadol are often recommended as second- or third-line options. Since the latest guidelines were published, newer agents (eg, topical capsaicin [8%] patch and gastroretentive gabapentin) have met the standard as first-line therapy with the publication of ≥ 1 randomized controlled trial. However, gabapentin enacarbil has not met this standard due to a lack of a published randomized controlled trial in PHN.
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Affiliation(s)
- R Norman Harden
- Director, Center for Pain Studies, Rehabilitation Institute of Chicago, IL, USA
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