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Huang TL, Huang YM, Hou MM, Lu CH, Chao TY, Chiu TJ, Chang YS, Lin SH, Lin CH, Chen YH, Wang CH, Chen JS, Shen WC. Safety and effectiveness of transdermal buprenorphine in cancer pain: An observational study in Taiwan (SOOTHE). Asia Pac J Clin Oncol 2022; 19:e45-e53. [PMID: 35604203 DOI: 10.1111/ajco.13772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 11/26/2022]
Abstract
AIM Buprenorphine is one of the strongest opioids used for the relief of cancer pain. This study aims to evaluate the real-world clinical experiences of transdermal buprenorphine used in moderate to severe cancer pain in the Asian population. METHODS This is an open-labeled, multicenter, 4-week observational study. Stable cancer pain patients who decided to switch the previous opioid to transdermal buprenorphine will be enrolled in this study. The safety and effectiveness were observed and collected. Pain assessment was performed using a numerical rating scale by the investigators and the Brief Pain Inventory Short Form (BPI-SF) by the patient. The safety profiles included concomitant medications and adverse events (AEs). RESULTS A total of 83 patients were enrolled in this study. The global pain scores in the BPI, as well as the four individual pain parameters (worst, least, average, and right now), showed a continued decrease (p < .05) from week 2 to week 4. Significant improvements were observed in normal work activities, relations with other people, sleep, enjoyment of life, and global BPI pain interference score on week 4. Pain assessments conducted by investigators demonstrated significant, continuous improvements during the study periods. In addition, transdermal buprenorphine demonstrated good safety/tolerability with limited drug-related AEs in the Asian population with cancer pain. CONCLUSION This study demonstrated that transdermal buprenorphine in the Asian population has good safety profiles and continued improvements in pain relief, sleep, and pain interferences. Transdermal buprenorphine can be an effective and convenient option as a transdermal opioid for patients with moderate to severe cancer pain in Taiwan. (NCT Number: NCT04315831).
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Affiliation(s)
- Tai-Lin Huang
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Yen-Min Huang
- Division of Hematology-Oncology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Min-Mo Hou
- Division of Hematology-Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Chang-Hsien Lu
- Division of Hematology-Oncology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Tsu-Yi Chao
- Department of Hematology/Oncology, Shuang Ho Hospital, Zhonghe District, New Taipei City, 235, Taiwan
| | - Tai-Jan Chiu
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Yueh-Shih Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Sheng-Hao Lin
- Department of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Ching-Hsiung Lin
- Department of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Yen-Hao Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Cheng-Hsu Wang
- Division of Hematology-Oncology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
| | - Wen-Chi Shen
- Division of Hematology-Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, 333, Taiwan
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Pergolizzi JV, Magnusson P, LeQuang JA, Breve F, Mitchell K, Chopra M, Varrassi G. Transdermal Buprenorphine for Acute Pain in the Clinical Setting: A Narrative Review. J Pain Res 2021; 14:871-879. [PMID: 33833565 PMCID: PMC8020131 DOI: 10.2147/jpr.s280572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022] Open
Abstract
Transdermal buprenorphine is indicated for chronic pain management, but as its role in the clinical management of acute pain is less clear, this narrative review examines studies of the patch for acute pain, mainly in the postoperative setting. Although perhaps better known for its role in opioid rehabilitation programs, buprenorphine is also an effective analgesic that is a Schedule III controlled substance. Although buprenorphine is a partial agonist at the μ-opioid receptor, it is erroneous to think of the agent as a partial analgesic; it has full analgesic efficacy and unique attributes among opioids, such as a ceiling for respiratory depression and low “drug likeability” among those who take opioids for recreational purposes. Transdermal buprenorphine has been most thoroughly studied for acute pain control in postoperative patients. Postoperative pain follows a distinct and predictable trajectory depending on the type of surgery and patient characteristics. Overall, when the patch is applied prior to surgery and left in place for the prescribed seven days, it was associated with reduced postoperative pain, lower consumption of other analgesics, and patient satisfaction. Transdermal buprenorphine has been evaluated in clinical studies of patients undergoing gynecological surgery, hip fracture surgery, knee or hip arthroscopy/arthroplasty, shoulder surgery, and spinal surgery. Transdermal buprenorphine may also be appropriate pain medication for controlling pain during postsurgical orthopedic rehabilitation programs. Transdermal buprenorphine may result in typical opioid-associated side effects but with less frequency than other opioids. Despite clinical reservations about transdermal buprenorphine and its potential role in acute pain management in the clinical setting, clinical acceptance may be hampered by the fact that it is off-label and buprenorphine is better known as an opioid maintenance agent rather than an analgesic.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research and Development, Region Gävleborg/Uppsala University, Gävle, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet, Stockholm, Sweden
| | | | - Frank Breve
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, USA
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Webster L, Gudin J, Raffa RB, Kuchera J, Rauck R, Fudin J, Adler J, Mallick-Searle T. Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:714-723. [PMID: 31917418 PMCID: PMC7139205 DOI: 10.1093/pm/pnz356] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor agonist indicated for chronic pain. The panel also provided clinical recommendations on the appropriate use of buprenorphine and conversion strategies for switching to buprenorphine from a full µ-opioid receptor agonist for chronic pain management. METHODS The consensus panel met on March 25, 2019, to discuss relevant literature and provide recommendations on interpreting buprenorphine as a partial µ-opioid receptor agonist, prescribing buprenorphine before some Schedule II, III, or IV options, perioperative/trauma management of patients taking buprenorphine, and converting patients from a full µ-opioid receptor agonist to buprenorphine. RESULTS The panel recommended that buprenorphine's classification as a partial µ-opioid receptor agonist not be clinically translated to mean partial analgesic efficacy. The panel also recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability and that buprenorphine be continued during the perioperative/trauma period. In addition, switching patients from a full µ-opioid receptor agonist to buprenorphine should be considered with no weaning period at starting doses that are based on the previous opioid dose. CONCLUSIONS These recommendations provide a framework for clinicians to address most clinical scenarios regarding buprenorphine use. The overall consensus of the panel was that buprenorphine is a unique Schedule III opioid with favorable pharmacologic properties and a safety profile that may be desirable for chronic pain management.
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Affiliation(s)
| | - Jeffrey Gudin
- Department of Anesthesiology and Pain Management, Englewood Hospital and Medical Center, Englewood, New Jersey; Rutgers New Jersey Medical School, Newark, New Jersey
| | - Robert B Raffa
- College of Pharmacy, The University of Arizona Health Sciences, Tucson, Arizona
- Temple University School of Pharmacy, Philadelphia, Pennsylvania; Neumentum Inc, Palo Alto, California
| | - Jay Kuchera
- Resolute Pain Solutions, Okeechobee, Florida
| | - Richard Rauck
- Carolinas Pain Institute, Winston-Salem, North Carolina
| | - Jeffrey Fudin
- Remitigate LLC, Delmar, New York; Western New England University College of Pharmacy, Springfield, Massachusetts
- Albany College of Pharmacy & Health Sciences, Albany, New York
| | - Jeremy Adler
- Pacific Pain Medicine Consultants, Encinitas, California
| | - Theresa Mallick-Searle
- Division of Pain Medicine, Stanford Medicine Outpatient Center, Redwood City, California, USA
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4
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Abstract
Opioid analgesia continues to be the primary pharmacologic intervention for managing acute pain and malignant pain in both hospitalized and ambulatory patients. The increasing use of opioids in chronic nonmalignant pain is more problematic. Opioid treatment is complicated with the risks raised by adverse effects, especially cognitive disturbance, respiratory depression but also the risk of tolerance, opioid abuse and drug-disease interactions. Despite the growing number of available opioids within the last years, adequate trials of opioid rotation are lacking and most of the information is anecdotal. This article reviews the clinical evidence surrounding the switch from transdermal buprenorphine to tapentadol in malignant and non-malignant pain. Tapentadol acts on both the μ-opioid receptors (MOR) and on the neuronal reuptake of noradrenaline with a limited usefulness in acute pain management while buprenorphine is a mixed agonist-antagonist, and both present some advantages over other opioids. Both drugs show particular pharmacodynamic and pharmacokinetic properties which reduce the risks of development of tolerance, opioid abuse, diversion and determine fewer hormone changes than the "classical opioids" making these opioids more attractive than other opioids in long term opioid treatment. However, in the absence of powered clinical trials, the evidence to support the method used for transdermal buprenorphine rotation to tapentadol is weak.
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Affiliation(s)
- Adriana Miclescu
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Sweden
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5
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Ahn JS, Lin J, Ogawa S, Yuan C, O'Brien T, Le BH, Bothwell AM, Moon H, Hadjiat Y, Ganapathi A. Transdermal buprenorphine and fentanyl patches in cancer pain: a network systematic review. J Pain Res 2017; 10:1963-1972. [PMID: 28860851 PMCID: PMC5571859 DOI: 10.2147/jpr.s140320] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Treatment of cancer pain is generally based on the three-step World Health Organization (WHO) pain relief ladder, which utilizes a sequential approach with drugs of increasing potency. Goals of pain management include optimization of analgesia, optimization of activities of daily living, minimization of adverse effects, and avoidance of aberrant drug taking. In addition, it is recommended that analgesic regimens are individualized and simplified to help ensure patient compliance and should provide the least invasive, easiest, and safest route of opioid administration to ensure adequate analgesia. Buprenorphine and fentanyl are two opioids available for the relief of moderate-to-severe cancer pain. Available clinical data regarding the transdermal (TD) formulations of these opioids and the extent to which they fulfill the recommendations mentioned earlier are systematically reviewed, with the aim of providing additional information for oncologists and pain specialists regarding their comparative use. Due to lack of studies directly comparing TD buprenorphine with TD fentanyl, data comparing these with other step-3 opioids are also evaluated in a network fashion.
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Affiliation(s)
- Jin Seok Ahn
- Division of Hematology and Oncology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
| | - Johnson Lin
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China
| | - Setsuro Ogawa
- Department of Anesthesiology, Nihon University School of Medicine, Tokyo, Japan
| | - Chen Yuan
- Department of Oncology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Tony O'Brien
- Marymount University Hospital and Hospice.,Cork University Hospital, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Brian Hc Le
- Department of Palliative Care, Royal Melbourne Hospital, Parkville, VIC, Australia
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6
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Mecklenburg J, Patil MJ, Koek W, Akopian AN. Effects of local and spinal administrations of mu-opioids on postoperative pain in aged versus adult mice. Pain Rep 2017; 2:e584. [PMID: 28626834 PMCID: PMC5469295 DOI: 10.1097/pr9.0000000000000584] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 11/28/2016] [Accepted: 11/30/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction Suboptimal management of postoperative pain leads to increased risk of chronic opioid therapy, especially in elderly patients. Objectives Although this age-dependent phenomenon has been observed clinically, basic mechanisms including baseline nociception, postoperative hypersensitivity, and mu-opioid efficiency in aged animals have never been evaluated. Methods We tested these criteria using incision model on adult (3–6 months) and aged (24 months) mice to assess translatability of postoperative animal studies to clinical observations. Results Thermal and mechanical testing revealed lower baseline nociception in aged vs adult mice, while behavioral assays after hind paw plantar incision showed similar hypersensitivity levels for both age groups. Efficiency of local and spinal mu-opioid injections on postoperative pain was assessed next. DAMGO, a pure mu-opioid, was effective in reducing postoperative hypersensitivity in aged and adult mice, although adult mice displayed increased sensitivity to higher doses (50 μg local; 1–15 μg spinal). Buprenorphine, a mixed mu-opioid agonist, produced dose-dependent antihypersensitivity with adult mice more sensitive to lower doses (0.1 μg local; 0.02 μg spinal), and aged mice more sensitive to higher doses (1, 10 μg local; 0.1, 1 μg spinal). Finally, exploratory locomotor activity was used to evaluate the suppression of incision-induced spontaneous pain by DAMGO. Spinal and systemic (intraperitoneal) DAMGO inhibited ongoing pain more in adults compared with aged mice. Conclusion As in humans, baseline nociception was lower in aged vs adult mice, while postoperative hypersensitivity magnitudes were comparable between groups. Unlike in humans, adult mice were more sensitive to mu-opioids, although higher doses of mixed mu-opioids were more effective for postoperative antihypersensitivity in aged mice.
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Affiliation(s)
- Jennifer Mecklenburg
- Department of Endodontics, School of Dentistry, UT Health Science Center, San Antonio, TX, USA
| | - Mayur J. Patil
- Department of Psychiatry, School of Medicine, UT Health Science Center, San Antonio, TX, USA
| | - Wouter Koek
- Department of Psychiatry, School of Medicine, UT Health Science Center, San Antonio, TX, USA
- Department of Pharmacology, UT Health Science Center, San Antonio, TX, USA
| | - Armen N. Akopian
- Department of Endodontics, School of Dentistry, UT Health Science Center, San Antonio, TX, USA
- Department of Pharmacology, UT Health Science Center, San Antonio, TX, USA
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7
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Abstract
Buprenorphine (BUP) is a semisynthetic derivative of the opium alkaloid thebaine found in the poppy Papaver somniferum. Its chemical structure contains the morphine structure but differs by having a cyclopropylmethyl group. Buprenorphine is a potent µ opioid agonist. Buprenorphine undergoes extensive first-pass metabolism in the liver and gut. The development of a transdermal BUP formulation in 2001 led to its evaluation in cancer pain. This article provides the practitioner with an update on the current role of BUP in cancer care. It highlights data suggesting effectiveness in various types of cancer pain. The article reviews pharmacology, routes of administration, adverse effects, drug interactions, and cost considerations.
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8
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Gram M, Graversen C, Nielsen AK, Arendt-Nielsen T, Mørch CD, Andresen T, Drewes AM. A novel approach to pharmaco-EEG for investigating analgesics: assessment of spectral indices in single-sweep evoked brain potentials. Br J Clin Pharmacol 2014; 76:951-63. [PMID: 23521205 DOI: 10.1111/bcp.12120] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 03/12/2013] [Indexed: 01/29/2023] Open
Abstract
AIMS To compare results from analysis of averaged and single-sweep evoked brain potentials (EPs) by visual inspection and spectral analysis in order to identify an objective measure for the analgesic effect of buprenorphine and fentanyl. METHODS Twenty-two healthy males were included in a randomized study to assess the changes in EPs after 110 sweeps of painful electrical stimulation to the median nerve following treatment with buprenorphine, fentanyl or placebo patches. Bone pressure, cutaneous heat and electrical pain ratings were assessed. EPs and pain assessments were obtained before drug administration, 24, 48, 72 and 144 h after beginning of treatment. Features from EPs were extracted by three different approaches: (i) visual inspection of amplitude and latency of the main peaks in the average EPs, (ii) spectral distribution of the average EPs and (iii) spectral distribution of the EPs from single-sweeps. RESULTS Visual inspection revealed no difference between active treatments and placebo (all P > 0.05). Spectral distribution of the averaged potentials showed a decrease in the beta (12-32 Hz) band for fentanyl (P = 0.036), which however did not correlate with pain ratings. Spectral distribution in the single-sweep EPs revealed significant increases in the theta, alpha and beta bands for buprenorphine (all P < 0.05) as well as theta band increase for fentanyl (P = 0.05). For buprenorphine, beta band activity correlated with bone pressure and cutaneous heat pain (both P = 0.04, r = 0.90). CONCLUSION In conclusion single-sweep spectral band analysis increases the information on the response of the brain to opioids and may be used to identify the response to analgesics.
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Affiliation(s)
- Mikkel Gram
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark; Center for Sensory-Motor Interactions (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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9
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Abstract
Questions from patients about pain conditions, analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. The use of transdermal buprenorphine for chronic pain management is discussed. A brief history of the medication is provided. The use of the medication in opioid maintenance, and withdrawal and other concerns are discussed. Possible side effects are described.
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10
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A double-blind, placebo-controlled study on the effect of buprenorphine and fentanyl on descending pain modulation: a human experimental study. Clin J Pain 2013; 28:623-7. [PMID: 22156892 DOI: 10.1097/ajp.0b013e31823e15cb] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The descending pain inhibitory system is impaired in chronic pain and it is important to know how analgesics interact with this system. The aim of this human experimental pain, double-blind, randomized, placebo-controlled, 3 way cross-over study was to investigate the effect of 2 different opioids on descending pain inhibition using conditioning pain modulation (CPM) as a screening tool. METHODS Twenty-two healthy male volunteers were randomized to 72 hours of treatment with transdermal patches of fentanyl (25 μg/h), buprenorphine (20 μg/h), or placebo. The CPM was induced by immersing the hand into cold (3.0 ± 0.3°C) water and the evoked pain was continuously rated on a visual analogue scale (VAS). The test stimulus [pressure pain tolerance threshold (PPTol)] was applied to the contra-lateral arm. The CPM test was performed at baseline, 24, 48, and 72 hours after application of the patches. RESULTS The opioid treatments did not significantly (F=2.249; P=0.07) modulate the PPTol over the treatment period compared with placebo. The CPM-evoked PPTol increases (percentage increase from what was obtained at the baseline before patch application) were significantly enhanced by buprenorphine (P=0.004) and fentanyl (P=0.005) compared with placebo, with no differences between the 2 active drugs. Fentanyl significantly attenuated the time to cold water-evoked VAS peak compared with placebo (P=0.005), and the same trend was observed for buprenorphine (P=0.06). The VAS pain intensity was not affected. DISCUSSION The opioids buprenorphine and fentanyl significantly potentiate the effect of descending pain inhibition in healthy volunteers.
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11
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Davis MP. Twelve Reasons for Considering Buprenorphine as a Frontline Analgesic in the Management of Pain. ACTA ACUST UNITED AC 2012; 10:209-19. [DOI: 10.1016/j.suponc.2012.05.002] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/14/2012] [Accepted: 05/18/2012] [Indexed: 11/17/2022]
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Defalco FJ, Ryan PB, Soledad Cepeda M. Applying standardized drug terminologies to observational healthcare databases: a case study on opioid exposure. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2012; 13:58-67. [PMID: 23396660 PMCID: PMC3566397 DOI: 10.1007/s10742-012-0102-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 10/02/2012] [Accepted: 10/05/2012] [Indexed: 11/24/2022]
Abstract
Observational healthcare databases represent a valuable resource for health economics, outcomes research, quality of care, drug safety, epidemiology and comparative effectiveness research. The methods used to identify a population for study in an observational healthcare database with the desired drug exposures of interest are complex and not consistent nor apparent in the published literature. Our research evaluates three drug classification systems and their impact on prevalence in the analysis of observational healthcare databases using opioids as a case in point. The standard terminologies compiled in the Observational Medical Outcomes Partnership’s Common Data Model vocabulary were used to facilitate the identification of populations with opioid exposures. This study analyzed three distinct observational healthcare databases and identified patients with at least one exposure to an opioid as defined by drug codes derived through the application of three classification systems. Opioid code sets were created for each of the three classification systems and the number of identified codes was summarized. We estimated the prevalence of opioid exposure in three observational healthcare databases using the three defined code sets. In addition we compared the number of drug codes and distinct ingredients that were identified using these classification systems. We found substantial variation in the prevalence of opioid exposure identified using an individual classification system versus a composite method using multiple classification systems. To ensure transparent and reproducible research publications should include a description of the process used to develop code sets and the complete code set used in studies.
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Affiliation(s)
- Frank J Defalco
- Janssen Pharmaceutical Research & Development, L.L.C. 920 Route 202, Raritan, NJ 08869 USA
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13
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Andresen T, Staahl C, Oksche A, Mansikka H, Arendt-Nielsen L, Drewes AM. Effect of transdermal opioids in experimentally induced superficial, deep and hyperalgesic pain. Br J Pharmacol 2012; 164:934-45. [PMID: 21182491 DOI: 10.1111/j.1476-5381.2010.01180.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND PURPOSE Chronic pain and hyperalgesia can be difficult to treat with classical opioids acting predominately at the µ-opioid receptor. Buprenorphine and its active metabolite are believed to act through µ-, κ- and δ-receptors and may therefore possess different analgesic and anti-hyperalgesic effects compared with pure µ-receptor agonists, for example, fentanyl. Here, we have compared the analgesic and anti-hyperalgesic effects of buprenorphine and fentanyl. EXPERIMENTAL APPROACH Twenty-two healthy volunteers were randomized to treatment with transdermal buprenorphine (20 µg·h(-1), 144 h), fentanyl (25 µg·h(-1), 72 h) or placebo patches in a double-blind, cross-over experimental pain study. The experimental pain tests (phasic pain, sensitization) involved pressure at the tibial bone, cutaneous electrical and thermal stimulation, intramuscular nerve growth factor, UVB light burn injury model and intradermal capsaicin-induced hyperalgesia. Pain testing was carried out at baseline, 24, 48, 72 and 144 h after application of the drugs. KEY RESULTS Compared with placebo, buprenorphine, but not fentanyl, significantly attenuated pressure at the tibial bone as well as pressure pain in the primary hyperalgesic area induced by UVB light The two drugs were equipotent and better than placebo against cutaneous thermal pain stimulation), but failed to show significant analgesic effect to cutaneous electrical stimulation, nerve growth factor-induced muscle soreness and to capsaicin-induced hyperalgesia. CONCLUSIONS AND IMPLICATIONS Buprenorphine, but not fentanyl, showed analgesic effects against experimentally induced, bone-associated pain and primary hyperalgesia compared with placebo. These tissue- and modality-differentiated properties may reflect the variable effects of opioid drugs observed in individual patients.
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Affiliation(s)
- T Andresen
- Mech-Sense, Department of Gastroenterology, Aalborg Hospital, Aarhus University, Denmark
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14
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Gastrointestinal symptoms under opioid therapy: A prospective comparison of oral sustained-release hydromorphone, transdermal fentanyl, and transdermal buprenorphine. Eur J Pain 2012; 13:737-43. [DOI: 10.1016/j.ejpain.2008.09.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 08/18/2008] [Accepted: 09/07/2008] [Indexed: 01/08/2023]
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15
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Andresen T, Upton RN, Foster DJR, Christrup LL, Arendt-Nielsen L, Drewes AM. Pharmacokinetic/pharmacodynamic relationships of transdermal buprenorphine and fentanyl in experimental human pain models. Basic Clin Pharmacol Toxicol 2010; 108:274-84. [PMID: 21138531 DOI: 10.1111/j.1742-7843.2010.00649.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pharmacokinetic/pharmacodynamic (PK/PD) modelling can be used to characterize the relationship between dose regimen of opioids, plasma concentration and effect of opioids, which in turn can lead to more rational treatment regimens of pain. The aim of this study was to investigate the concentration-effect relationship for transdermal buprenorphine and fentanyl in experimentally induced pain. Twenty-two healthy volunteers were randomized to receive transdermal patches with fentanyl (25 μg/hr, 72 hr), buprenorphine (20 μg/hr, 144 hr) or placebo. The experimental pain tests were pressure at the tibial bone, cutaneous thermal stimulation, cold pressor test (conditioning stimulus (3 ± 0.3°C cold water), nerve growth factor-induced muscle soreness and intradermal capsaicin-induced hyperalgesia and allodynia. Experiments were carried out at baseline, 24, 48, 72 and 144 hr after application of patches. Time-course of placebo was described first and was afterwards added to the description of the time-courses of buprenorphine and fentanyl. This was either described by zero (no drug effect), linear or E(max) model concentration-effect relationships. Time-dependent changes in pain measures in the placebo arm were described by linear or quadratic functions. The time-course of fentanyl and buprenorphine plasma concentrations was complex but could be represented by cubic spline interpolation in the models. Buprenorphine significantly attenuated bone-associated pain, heat pain, nerve growth factor-induced soreness and cold pressor pain. Fentanyl significantly attenuated cold pressor pain for the administered dose regimens. Although the PK/PD relationship for both drugs could be described with similar models, tissue-differentiated analgesic effects between buprenorphine and fentanyl was shown.
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Affiliation(s)
- Trine Andresen
- Mech-Sense, Department of Gastroenterology, Aalborg Hospital, Aarhus University Hospital, Denmark
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Gatti A, Dauri M, Leonardis F, Longo G, Marinangeli F, Mammucari M, Sabato AF. Transdermal Buprenorphine in Non-Oncological Moderate-to-Severe Chronic Pain. Clin Drug Investig 2010; 30 Suppl 2:31-8. [DOI: 10.2165/1158409-s0-000000000-00000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Hass B, Lungershausen J, Hertel N, Poulsen Nautrup B, Kotowa W, Liedgens H. Cost-effectiveness of strong opioids focussing on the long-term effects of opioid-related fractures: a model approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2009; 10:309-21. [PMID: 19101743 DOI: 10.1007/s10198-008-0134-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 10/24/2008] [Indexed: 05/16/2023]
Abstract
Opioid analgesics are known to impact on the central nervous system (CNS). These CNS side effects, such as dizziness and confusion, have been shown to lead to an increased risk of falling with subsequent fractures in elderly patients being treated with opioids. The risk of experiencing fractures has been shown to be dependent on the substance administered. Therefore, a health economic model was developed to investigate the cost-effectiveness of the most commonly used strong opioids in Germany, focussing on opioid-related fractures. By means of a Markov model, the consequences of hip, spine and forearm fractures due to the prior administration of transdermal (TD) buprenorphine, TD fentanyl, oral oxycodone as well as oral morphine were assessed from the perspectives of the German statutory health insurance (SHI) and the German social security (GSS) system over a time horizon of 6 years. The most frequently prescribed strength/package-size combinations of these opioids were taken into consideration, including generics where available. The results of the present analysis predict that TD buprenorphine is dominant compared to TD fentanyl and oxycodone by showing better effects [life years gained/quality adjusted life years (QALY) gained] at lower cost. From the SHI perspective, the incremental cost-effectiveness ratio (ICER) compared to morphine is <euro> 6,801.61 per life year gained, and <euro> 7,766.11 per QALY gained. From the GSS perspective, the ICER is <euro> 2,496.77 per life year gained and <euro> 2,850.83 per QALY gained. The model is robust regarding probabilistic variations of all parameters in the sensitivity analyses. Focussing on fractures due to the prior administration of strong opioids, TD buprenorphine is less costly and more effective than TD fentanyl and oxycodone and represents a cost-effective treatment option versus morphine in patients with chronic pain from both the SHI and GSS perspective in Germany.
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Affiliation(s)
- Bastian Hass
- Health Economics and Outcomes Research, IMS HEALTH GmbH & Co. OHG, 90402, Nuremberg, Germany.
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Pergolizzi JV, Mercadante S, Echaburu AV, Van den Eynden B, Fragoso RMDF, Mordarski S, Lybaert W, Beniak J, Orońska A, Slama O. The role of transdermal buprenorphine in the treatment of cancer pain: an expert panel consensus. Curr Med Res Opin 2009; 25:1517-28. [PMID: 19435402 DOI: 10.1185/03007990902920731] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The semi-synthetic opioid, buprenorphine, has the general structure of morphine but differs from it in significant ways, both pharmacologically and clinically. A number of long-term studies have shown effective, long-lasting analgesia in moderate to severe cancer and non-cancer pain, including neuropathic pain, with a low incidence of constipation, nausea, dizziness and tiredness. The treatment of moderate to severe chronic pain has improved as a result of the development of new methods of administration of this substance, particularly the introduction of the transdermal drug delivery system, which offers a number of advantages over the usual oral and parenteral routes. SCOPE A panel of experts specialising in palliative care and pain treatment was convened in November 2007 to discuss their clinical experiences with transdermal buprenorphine and other analgesics. The aim was to provide practical guidance on the treatment of cancer pain with transdermal buprenorphine, particularly when there is a need for increasing pain relief leading to high and increasing doses. A literature search on the use of transdermal buprenorphine was carried out for the panel meeting (based on a search of PubMed to November 2007 - since updated by an additional search for the period to February 2009) and a number of case histories were presented and discussed. This commentary article presents this evidence and the consensus findings of the expert panel. FINDINGS The Panel reached consensus that transdermal buprenorphine was a valuable treatment for chronic cancer pain, including its neuropathic components. A number of general recommendations were made. Large-scale, randomised clinical studies are needed to provide product comparisons on the use of analgesics in the treatment of neuropathic pain although it was recognised that such studies may not be practicable. Data on the treatment of acute and chronic pain should be kept separate in general. Physicians should be made more aware of the problem of hyperalgesic effects of some opioids in long term use. Buprenorphine in contrast has been described to exert an antihyperalgesic effect. The development of analgesic tolerance with some opioids in long term use and the lack of it with buprenorphine requires further studies. The registered dose range of 35-140 microg/h was considered adequate to achieve sufficient pain relief in most patients although some members of the panel presented data showing that increases beyond this dose range provided improved pain relief if slow titration is used. However, it was generally felt that more evidence was needed before this could become generally acceptable. CONCLUSION The consensus was that transdermal buprenorphine has a valuable role to play in the treatment of chronic cancer pain because of its efficacy and good safety and tolerability profile, including a low risk of respiratory depression, a lack of immunosuppression and a lack of accumulation in patients with impaired renal function.
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Vadivelu N, Hines RL. Management of chronic pain in the elderly: focus on transdermal buprenorphine. Clin Interv Aging 2008; 3:421-30. [PMID: 18982913 PMCID: PMC2682375 DOI: 10.2147/cia.s1880] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic pain in the elderly is a significant problem. Pharmacokinetic and metabolic changes associated with increased age makes the elderly vulnerable to side effects and overdosing associated with analgesic agents. Therefore the management of chronic cancer pain and chronic nonmalignant pain in this growing population is an ongoing challenge. New routes of administration have opened up new treatment options to meet this challenge. The transdermal buprenorphine matrix allows for slow release of buprenorphine and damage does not produce dose dumping. In addition the long-acting analgesic property and relative safety profile makes it a suitable choice for the treatment of chronic pain in the elderly. Its safe use in the presence of renal failure makes it an attractive choice for older individuals. Recent scientific studies have shown no evidence of a ceiling dose of analgesia in man but only a ceiling effect for respiratory depression, increasing its safety profile. It appears that transdermal buprenorphine can be used in clinical practice safely and efficaciously for treating chronic pain in the elderly.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology,Yale University School of Medicine, New Haven 06520, USA.
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Yadav PN, Chaturvedi K, Howells RD. Inhibition of agonist-induced down-regulation of the delta-opioid receptor with a proteasome inhibitor attenuates opioid tolerance in human embryonic kidney 293 cells. J Pharmacol Exp Ther 2006; 320:1186-94. [PMID: 17159161 DOI: 10.1124/jpet.106.113621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study was designed to test the hypothesis that inhibition of agonist-induced delta-receptor down-regulation would block the development of opioid tolerance in a cell-based model. A human embryonic kidney 293 cell line was established that expressed an epitope-tagged delta-opioid receptor (DOR). Treatment of DOR cells with Tyr-d-Ala-Gly-Phe-d-Leu-enkephalin (DADL) resulted in a time-dependent decrease in the B(max) of delta-opioid receptor binding sites and immunoreactive receptor protein. When cells were coincubated with the proteasome inhibitor N-benzyloxycarbonyl-l-leucyl-l-leucyl-l-leucinal (ZLLL) and DADL, the magnitude of the agonist-induced decrease in B(max) and immunoreactive receptor protein was reduced compared with DADL treatment alone. Acute treatment of DOR cells with DADL caused a 3-fold increase in the level of phosphorylated mitogen-activated protein (MAP) kinase. Prior exposure of DOR cells to DADL completely abrogated the agonist-induced activation of MAP kinase. When DOR cells were coincubated with DADL and ZLLL, the proteasome inhibitor prevented the loss of agonist activation of MAP kinase. Acute treatment of DOR cell membranes with DADL stimulated [(35)S]guanosine 5'-3-O-(thio-)triphosphate (GTPgammaS) binding. When DOR cells were preincubated with DADL, the agonist-induced increase in [(35)S]GTPgammaS binding was attenuated. Coincubation of ZLLL and agonist partially prevented the decreased responsiveness to agonist stimulation. The results of this study demonstrated that inhibition of agonist-induced down regulation with a proteasome inhibitor attenuated opioid tolerance in a cellular model, and suggest that coadministration of a proteasome inhibitor with chronic opioid agonist treatment may be useful for limiting opioid tolerance in vivo.
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Affiliation(s)
- Prem N Yadav
- Department of Biochemistry and Molecular Biology, UMDNJ-New Jersey Medical School, 185 South Orange Ave., Newark, NJ 07103, USA
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Sittl R, Nuijten M, Poulsen Nautrup B. Patterns of Dosage changes with transdermal buprenorphine and transdermal fentanyl for the treatment of noncancer and cancer pain: A retrospective data analysis in Germany. Clin Ther 2006; 28:1144-1154. [PMID: 16982291 DOI: 10.1016/j.clinthera.2006.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Previous studies have suggested that buprenorphine may have a low association with tolerance development compared with other strong opioids. In a previous study by our group, mean cohort and intraindividual dosage increases over an entire course of treatment and on a per-day basis were significantly lower with transdermal (TD) buprenorphine than with TD fentanyl. However, no information concerning the relationship between qualitative and quantitative dose changes is available. OBJECTIVE The aim of this study was to compare TD buprenorphine and TD fentanyl with respect to dosage increases, dosage stability, and the nature of dosage changes. METHODS This retrospective analysis used data from the IMS Disease Analyzer-Mediplus database, which contains patient-related data documented by 400 medical practices in Germany. Data from patients with noncancer or cancer pain treated with TD buprenorphine or TD fentanyl for at least 3 months between May 2002 and April 2005 were analyzed. Daily dosages were directly determined from the prescribed patch strength, taking into account the possibility of multiple patches applied simultaneously. To determine dosage stability, patients were classified based on the type of dosage change (stable, increase, alternating, or decrease) of the prescribed dosages. From the prescribed daily dosages, mean percentage increases were calculated on a per-patient basis for the entire treatment period and per day, and these were assessed in relation to the type of dosage change. RESULTS In total, 631 patients with noncancer pain and 605 patients with cancer pain were included in the analysis (782 women, 454 men; mean age, 76.3 years [range, 29-100 years]). Treatment indications included osteoarthritis, low back pain, osteoporosis (noncancer groups), and neoplasm (cancer groups). Patients had similar analgesic premedication requirements based on steps 1 to 3 of the World Health Organization analgesic ladder. Comedication requirements for breakthrough pain were also similar between the TD buprenorphine and TD fentanyl groups. The mean percentage increases per day were 0.10% (TD buprenorphine) and 0.25% (TD fentanyl) in the noncancer groups and 0.19% (TD buprenorphine) and 0.47% (TD fentanyl) in the cancer groups (both, P < 0.05). A significantly larger proportion of patients receiving TD buprenorphine had stable dosages over the entire treatment period compared with patients receiving TD fentanyl (noncancer groups: 56.9% vs 41.6%; cancer groups: 50.0% vs 26.2% [both, P < 0.05]). Compared with TD buprenorphine, the proportion of patients with alternating dosage changes was significantly greater in patients receiving TD fentanyl (noncancer groups: 22.7% vs 13.1%; cancer groups: 30.6% vs 11.8% [both, P < 0.05]). CONCLUSIONS In this retrospective data analysis, compared with TD buprenorphine, the increase in mean daily dosage was significantly greater in patients treated with TD fentanyl. Also, compared with TD buprenorphine, alternating dosage changes were seen in a significantly greater proportion of patients receiving TD fentanyl. On the other hand, a significantly greater proportion of patients treated with TD buprenorphine had stable dosages over their entire treatment periods.
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