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Wang A, Murphy J, Shteynman L, Daksla N, Gupta A, Bergese S. Novel Opioids in the Setting of Acute Postoperative Pain: A Narrative Review. Pharmaceuticals (Basel) 2023; 17:29. [PMID: 38256863 PMCID: PMC10819619 DOI: 10.3390/ph17010029] [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: 10/25/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Although traditional opioids such as morphine and oxycodone are commonly used in the management of acute postoperative pain, novel opioids may play a role as alternatives that provide potent pain relief while minimizing adverse effects. In this review, we discuss the mechanisms of action, findings from preclinical studies and clinical trials, and potential advantages of several novel opioids. The more established include oliceridine (biased ligand activity to activate analgesia and downregulate opioid-related adverse events), tapentadol (mu-opioid agonist and norepinephrine reuptake inhibitor), and cebranopadol (mu-opioid agonist with nociceptin opioid peptide activity)-all of which have demonstrated success in the clinical setting when compared to traditional opioids. On the other hand, dinalbuphine sebacate (DNS; semi-synthetic mu partial antagonist and kappa agonist), dual enkephalinase inhibitors (STR-324, PL37, and PL265), and endomorphin-1 analog (CYT-1010) have shown good efficacy in preclinical studies with future plans for clinical trials. Rather than relying solely on mu-opioid receptor agonism to relieve pain and risk opioid-related adverse events (ORAEs), novel opioids make use of alternative mechanisms of action to treat pain while maintaining a safer side-effect profile, such as lower incidence of nausea, vomiting, sedation, and respiratory depression as well as reduced abuse potential.
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Affiliation(s)
- Ashley Wang
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
| | - Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (L.S.)
| | - Lana Shteynman
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (L.S.)
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
| | - Abhishek Gupta
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY 11794, USA
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Mitra B, Roman C, Wu B, Luckhoff C, Goubrial D, Amos T, Bannon-Murphy H, Huynh R, Dooley M, Smit DV, Cameron PA. Restriction of oxycodone in the emergency department (ROXY-ED): A randomised controlled trial. Br J Pain 2023; 17:491-500. [PMID: 38107754 PMCID: PMC10722107 DOI: 10.1177/20494637231189031] [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] [Indexed: 12/19/2023] Open
Abstract
Background The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED). Methods An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18-75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge. Results There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26; 95% CI: 0.21 to 0.33; p < .001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17; 95% CI: 1.71-2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51; 95% CI: 0.39-0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94; 95% CI: 0.86-1.02). Conclusions Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Cristina Roman
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Bertha Wu
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Carl Luckhoff
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Diana Goubrial
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Timothy Amos
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Ronald Huynh
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael Dooley
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - De Villiers Smit
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter A. Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Severtson SG, Gurrola MC, Parrino MW, Ellis MS, Cicero TJ, Iwanicki JL, Dart RC. Abuse of tapentadol compared to other atypical opioids among individuals entering treatment for opioid use disorders. J Opioid Manag 2023; 19:445-453. [PMID: 37968978 DOI: 10.5055/jom.0818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Tapentadol is an atypical opioid analgesic thought to have dual mechanisms of action: µ-receptor agonism and inhibition of norepinephrine reuptake. Unlike other atypical opioids, tapentadol is a schedule II-controlled substance. We compared the prevalence of abuse (use to get high) of tapentadol to other atypical opioids used to treat pain (buprenor-phine and tramadol). DESIGN An observational, serial cross-sectional study. SETTING Individuals enrolling in treatment programs for opioid use disorder in 2019. Each completed a self-administered, paper questionnaire assessing prescription drug abuse and illegal drug use within 1 week of enrollment. MAIN OUTCOME MEASURES Indication of past month abuse of tapentadol or comparator drugs on a self-administered ques-tionnaire. RESULTS There were 6,987 respondents. Unadjusted and utilization-adjusted logistic regression models were used to compare odds of endorsement of tapentadol to tramadol and buprenorphine products indicated for the management of pain. Unadjusted abuse prevalence was 0.20 percent for total tapentadol (0.03 percent for NUCYNTA® and 0.06 percent for NUCYNTA ER). Relative to total tapentadol, the odds of abuse of buprenorphine for pain was 2.9 times greater (95 percent CI: 1.6 to 5.3, p < 0.001), and for tramadol, 43.1 times greater (95 percent CI: 25.3 to 73.3, p < 0.001). Adjusting for prescriptions dispensed, differences in odds of abuse were not statistically significant (odds ratio (OR) = 1.6, 95 per-cent CI: 0.9 to 3.0, p = 0.108 for buprenorphine for pain and OR = 0.7, 95 percent CI: 0.4 to 1.2, p = 0.209 for tramadol). CONCLUSIONS Tapentadol use to get high is less frequent than other atypical opioids. Findings suggest tapentadol is rarely the primary drug abused by an individual.
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Affiliation(s)
- S Geoff Severtson
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Marie C Gurrola
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Mark W Parrino
- American Association for the Treatment of Opioid Dependence (AATOD), New York, New York
| | - Matthew S Ellis
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Theodore J Cicero
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Janetta L Iwanicki
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Richard C Dart
- Rocky Mountain Poison & Drug Safety, Denver Health and Hospital Authority, Denver; Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
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Lam T, Xia T, Biggs N, Treloar M, Cheng O, Kabu K, Stevens JA, Evans JD, da Gama ME, Lubman DI, Nielsen S. Effect of discharge opioid on persistent postoperative opioid use: a retrospective cohort study comparing tapentadol with oxycodone. Anaesthesia 2023; 78:420-431. [PMID: 36535726 DOI: 10.1111/anae.15933] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
Opioid harm can vary by opioid type. This observational study examined the effect of opioid type (oxycodone vs. tapentadol) on rates of persistent postoperative opioid use ('persistence'). We linked hospital and community pharmacy data for surgical patients who were dispensed discharge opioids between 1 January 2016 and 30 September 2021. Patients were grouped by opioid experience ('opioid-naive' having received no opioids in the 3 months before discharge) and formulation of discharge opioid (immediate release only or modified release ± immediate release). Mixed-effects logistic regression models predicted persistence (continued use of any opioid at 90 days after discharge), controlling for key persistence risk factors. Of the 122,836 patients, 2.31% opioid-naive and 27.24% opioid-experienced patients met the criteria for persistence. For opioid-naive patients receiving immediate release opioids, there was no significant effect of opioid type. Tapentadol modified release was associated with significantly lower odds of persistence compared with oxycodone modified release, OR (95%CI) 0.81 (0.69-0.94) for opioid-naive patients and 0.81 (0.71-0.93) for opioid-experienced patients. Among patients who underwent orthopaedic surgery (n = 19,832), regardless of opioid experience or opioid formulation, the odds of persistence were significantly lower for those who received tapentadol compared with oxycodone. This was one of the largest and most extensive studies of persistent postoperative opioid use, and the first that specifically examined persistence with tapentadol. There appeared to be lower odds of persistence for tapentadol compared with oxycodone among key subgroups, including patients prescribed modified release opioids and those undergoing orthopaedic surgery.
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Affiliation(s)
- T Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - T Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - N Biggs
- NostraData, Kew, VIC, Australia
| | | | - O Cheng
- IQVIA, St Leonards, NSW, Australia
| | - K Kabu
- IQVIA, St Leonards, NSW, Australia
| | - J A Stevens
- St Vincent's Clinical School, UNSW Medicine, Darlinghurst, NSW, Australia
| | - J D Evans
- Slade Pharmacy, Mount Waverley, VIC, Australia
| | | | - D I Lubman
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
| | - S Nielsen
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
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Alshehri FS. Tapentadol: A Review of Experimental Pharmacology Studies, Clinical Trials, and Recent Findings. Drug Des Devel Ther 2023; 17:851-861. [PMID: 36974332 PMCID: PMC10039632 DOI: 10.2147/dddt.s402362] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Tapentadol is an analgesic compound that acts centrally to attenuate pain. Previous studies have shown that tapentadol has dual mechanisms of action as a mu-opioid receptor agonist and noradrenaline re-uptake inhibition. Therefore, tapentadol provides a great advantage over classic opioids in pain management from nociceptive to neuropathic. Cumulative evidence from in vitro data suggests that tapentadol effect of norepinephrine re-uptake could be a new target that overcomes other classic opioids in chronic neuropathic pain. Compared to tramadol and other opioids, tapentadol is associated with fewer adverse effects than tramadol. Tapentadol is a new alternative to treat acute, chronic, and neuropathic pain. Thus, this review article was focused on understanding the studies that led to the development of tapentadol as a novel analgesic drug and its advantages over conventional opioids. Thus, tapentadol is a good alternative with fewer adverse effects and is available for human use.
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Affiliation(s)
- Fahad S Alshehri
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
- Correspondence: Fahad S Alshehri, Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al‑ Qura University, Makkah, 24382, Saudi Arabia, Email
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Vosburg SK, Dailey-Govoni T, Beaumont J, Butler SF, Green JL. Characterizing the Experience of Tapentadol Nonmedical Use: Mixed Methods Study. JMIR Form Res 2022; 6:e16996. [PMID: 35687397 PMCID: PMC9233245 DOI: 10.2196/16996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/19/2022] [Accepted: 04/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background The prevalence of abuse, diversion, and web-based endorsement of tapentadol (extended-release [ER], immediate-release [IR]) has been characterized as low compared with other prescription opioids. Little is known about individual experience with tapentadol nonmedical use (NMU). Objective This study aims to pilot web-based survey technologies to investigate the motivation for tapentadol NMU, sources of procurement, routes of administration, tampering methods, doses used, and impressions of tapentadol products (Nucynta and Nucynta ER). Methods Recruitment flyers and banner advertisements were placed on the Bluelight website [DragonByte Technologies Ltd] with a link to a web-based survey (Qualtrics) designed to query about individuals’ lifetime tapentadol NMU. This web-based survey was followed by an interactive web-based chat (Cryptocat) with respondents who were willing to be contacted. Respondents were queried about sources for obtaining tapentadol, motives for use, routes of administration, tampering methods, drugs used in combination, tablet strengths and dosages, and reasons for continued or discontinued use. Desirability and attractiveness for NMU was rated. Results Web-based recruitment successfully attracted difficult-to-find study participants. A total of 78 participants reported that tapentadol was obtained from friends and family (ER 11/30, 37%; IR 18/67, 27%), the internet (ER 11/30, 37%; IR 12/67, 18%) or participants’ own prescriptions from a doctor (ER 9/30, 30%; IR 17/67, 25%). It was used nonmedically for pain relief (ER 18/30, 60%; IR 33/67, 49%) and multiple psychotropic effects, including relaxation (ER 13/30, 43%; IR 29/67, 43%), reduction in depression or anxiety (ER 7/30, 23%; IR 30/67, 45%), or getting high (ER 12/30, 40%; IR 33/67, 49%). Tapentadol was primarily swallowed (ER 22/30, 73%; IR 55/67, 82%), although snorting (ER 2/30, 7%; IR 8/67, 12%) and injection (ER 2/30, 7%; IR 5/67, 8%) were also reported. The preferred dose for NMU was 100 mg (both ER and IR). The participants reported tapentadol use with benzodiazepines (ER 12/21, 57%; IR 28/47, 60%). Most participants had discontinued tapentadol NMU at the time of survey completion (ER 22/30, 73%; IR 55/67, 82%). Reasons for discontinued ER NMU included side effects (10/22, 46%) and lack of effective treatment (10/22, 46%). Reasons for discontinued IR NMU included lack of access (26/55, 47%) and better NMU options (IR 21/55, 38%). Few individuals were willing to divulge identifying information about themselves for the interactive chat (8/78, 10%), demonstrating the strength of anonymous, web-based surveys. Interactive chat supported the survey findings. A subgroup of participants (4/78, 5%) reported hallucinogenic side effects with high doses. Conclusions Web-based surveys can successfully recruit individuals who report drug NMU and those who are difficult to find. Tapentadol NMU appears to occur primarily for pain relief and for its psychotropic effects. Although it was liked by some, tapentadol did not receive a robust pattern of endorsement for NMU.
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Affiliation(s)
- Suzanne K Vosburg
- Inflexxion, An Uprise Health | IBH Company, Irvine, CA, United States
| | | | - Jared Beaumont
- Inflexxion, An Uprise Health | IBH Company, Irvine, CA, United States
| | - Stephen F Butler
- Inflexxion, An Uprise Health | IBH Company, Irvine, CA, United States
| | - Jody L Green
- Inflexxion, An Uprise Health | IBH Company, Irvine, CA, United States
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7
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Lam T, Biggs N, Xia T, Evans J, Stevens J, da Gama M, Lubman DI, Nielsen S. Comparing opioid types in the persistence of opioid use following surgical admission: a study protocol for a retrospective observational linkage study comparing tapentadol and oxycodone in Australia. BMJ Open 2022; 12:e060151. [PMID: 35418442 PMCID: PMC9014068 DOI: 10.1136/bmjopen-2021-060151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Each year, an estimated two million Australians commence opioids, with 50 000 developing longer-term (persistent) opioid use. An estimated 3%-10% of opioid-naïve patients prescribed opioids following surgery develop persistent opioid use. This study will compare rates of persistent opioid use between two commonly used postoperative opioids, oxycodone and tapentadol, to understand if initial postoperative opioid type is important in determining longer-term outcomes. METHODS AND ANALYSIS A retrospective data linkage study that analyses administrative data from hospital and community pharmacies. Data will be obtained from at least four pharmacies that service large hospitals with comparable supplies of oxycodone and tapentadol. The study will include at least 6000 patients who have been dispensed a supply of oxycodone or tapentadol to take home following their discharge from a surgical ward. The primary outcome measure will be persistent opioid use at 3 months postdischarge for opioid naïve people who receive either immediate release tapentadol or immediate release oxycodone. Hierarchical logistic regression models will be used to predict persistent opioid use, controlling for covariates including comorbidities. ETHICS AND DISSEMINATION Ethics approval has been obtained through the Monash University Human Research Ethics Committee (29977). We will present project findings in a peer-reviewed journal article, in accordance with the REporting of studies Conducted using Observational Routinely-collected health Data statement.
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Affiliation(s)
- Tina Lam
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
| | | | - Ting Xia
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
| | - John Evans
- Slade Pharmacy, Mount Waverley, Victoria, Australia
| | - Jennifer Stevens
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | | | - Dan I Lubman
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
- Turning Point, Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
- Turning Point, Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
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Darke S, Duflou J, Peacock A, Farrell M, Lappin J. Characteristics of fatal tapentadol-related toxicity in Australia. Drug Alcohol Rev 2022; 41:1071-1077. [PMID: 35301769 DOI: 10.1111/dar.13462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Tapentadol is a centrally acting opioid analgesic prescribed for the treatment of moderate to severe pain. The study aimed to determine the characteristics of Australian toxicity deaths related to tapentadol. METHODS All cases in which tapentadol use was coded contributory to death (n = 159) were retrieved from the National Coronial Information System (1 July 2000-31 December 2020). RESULTS The mean age was 48.5 (18-81) and 56% were female. Documented histories of problems with chronic pain (66%), mental health (60.4%), substance use (44%) and injecting drug use (23.3%) were common. The majority of deaths were deemed unintentional (76.1%) and in 18.9% pre-existing disease was co-contributory. The median peripheral blood tapentadol concentration was 1.00 mg L-1 (0.02-47.00), and the median aortic concentration was 2.05 mg L-1 (0.10-30.00). In all cases, psychoactive drugs other than tapentadol were also detected, most commonly antidepressants (72.3%), opioids (66.7%), hypnosedatives (64.2%) and gabapentinoids (43.4%). Of cases where autopsies were conducted, 27.7% were diagnosed with cardiomegaly and 18.5% with severe coronary artery stenosis. Pulmonary oedema (68.1%), aspiration of vomitus (39.5%) and acute pneumonia (26.9%) were common. DISCUSSION AND CONCLUSIONS The typical tapentadol-related toxicity death involved unintentional death in the presence of multiple drugs, although a notable minority were intentional self-harm. Multiple morbidities were common. The identification and characteristics of these cases indicate that the adverse event profile of tapentadol needs to be considered in the setting of polypharmacy.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Julia Lappin
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
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Macintyre PE, Quinlan J, Levy N, Lobo DN. Current Issues in the Use of Opioids for the Management of Postoperative Pain: A Review. JAMA Surg 2022; 157:158-166. [PMID: 34878527 DOI: 10.1001/jamasurg.2021.6210] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Uncontrolled and indiscriminate prescribing of opioids has led to an opioid crisis that started in North America and spread throughout high-income countries. The aim of this narrative review was to explore some of the current issues surrounding the use of opioids in the perioperative period, focusing on drivers that led to escalation of use, patient harms, the move away from using self-reported pain scores alone to assess adequacy of analgesia, concerns about the routine use of controlled-release opioids for the management of acute pain, opioid-free anesthesia and analgesia, and prescription of opioids on discharge from hospital. Observations The origins of the opioid crisis are multifactorial and may include good intentions to keep patients pain free in the postoperative period. Assessment of patient function may be better than unidimensional numerical pain scores to help guide postoperative analgesia. Immediate-release opioids can be titrated more easily to match analgesic requirements. There is currently no good evidence to show that opioid-free anesthesia and analgesia affects opioid prescribing practices or the risk of persistent postoperative opioid use. Attention should be paid to discharge opioid prescribing as repeat and refill prescriptions are risk-factors for persistent postoperative opioid use. Opioid stewardship is paramount, and many governments are passing legislation, while statutory bodies and professional societies are providing advice and guidance to help mitigate the harm caused by opioids. Conclusions and Relevance Opioids remain a crucial part of many patients' journey from surgery to full recovery. The last few decades have shown that unfettered opioid use puts patients and societies at risk, so caution is needed to mitigate those dangers. Opioid stewardship provides a multilayered structure to allow continued safe use of opioids as part of broad pain management strategies for those patients who benefit from them most.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
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Mukau L, Wormley K, Tomaszewski C, Ahmad B, Vohra R, Herring A. Buprenorphine for High-dose Tramadol Dependence: A Case Report of Successful Outpatient Treatment. Clin Pract Cases Emerg Med 2022; 6:71-74. [PMID: 35226854 PMCID: PMC8885221 DOI: 10.5811/cpcem.2021.12.54602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/27/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction During the coronavirus disease 2019 pandemic caused by the severe acute
respiratory syndrome coronavirus 2, deaths from opiate drug overdoses
reached their highest recorded annual levels in 2020. Medication-assisted
treatment for opiate use disorder has demonstrated efficacy in reducing
opiate overdoses and all-cause mortality and improving multiple other
patient-centered outcomes. Treatment of tramadol dependence in particular
poses unique challenges due to its combined action as opioid agonist and
serotonin-norepinephrine reuptake inhibitor. Tramadol puts patients with
dependence at risk for atypical withdrawal syndromes when attempting to
reduce use. Little evidence is available to guide treatment of tramadol
dependence. Case Report We present a case of high-dose tramadol addiction that began with misuse of
medically prescribed tramadol for treatment of musculoskeletal back pain.
The patient’s use reached oral consumption of 5000–6000
milligrams of illicit tramadol daily. She complained of common complications
of tramadol use disorder including memory impairment, excessive sedation,
and tramadol-induced seizures. The patient was referred to the emergency
department in a withdrawal crisis seeking treatment where she was
successfully managed with buprenorphine and phenobarbital and then linked to
ongoing outpatient treatment. Conclusion Our report adds to the limited guidance currently available on the acute
management of tramadol withdrawal and treatment of tramadol use disorder.
Our case suggests the initiation of high-dose buprenorphine may be an
effective and feasible option for emergency clinicians.
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Affiliation(s)
- Leslie Mukau
- University of California, San Diego, Department of Emergency Medicine, San Diego, California; El Centro Regional Medical Center, Department of Emergency Medicine, El Centro, California
| | - Kadia Wormley
- Highland Hospital – Alameda Health System, Department of Emergency Medicine, Oakland, California
| | - Christian Tomaszewski
- University of California, San Diego, Department of Emergency Medicine, San Diego, California; El Centro Regional Medical Center, Department of Emergency Medicine, El Centro, California
| | - Bushra Ahmad
- Imperial County Behavioral Health Services, Division of Substance Use Disorder Treatment Program, El Centro, California
| | - Rais Vohra
- University of California, San Francisco-Fresno, Department of Emergency Medicine, Fresno, California
| | - Andrew Herring
- Highland Hospital – Alameda Health System, Department of Emergency Medicine, Oakland, California; University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
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Price R, Smith D, Franklin G, Gronseth G, Pignone M, David WS, Armon C, Perkins BA, Bril V, Rae-Grant A, Halperin J, Licking N, O'Brien MD, Wessels SR, MacGregor LC, Fink K, Harkless LB, Colbert L, Callaghan BC. Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee. Neurology 2022; 98:31-43. [PMID: 34965987 DOI: 10.1212/wnl.0000000000013038] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/15/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To update the 2011 American Academy of Neurology (AAN) guideline on the treatment of painful diabetic neuropathy (PDN) with a focus on topical and oral medications and medical class effects. METHODS The authors systematically searched the literature from January 2008 to April 2020 using a structured review process to classify the evidence and develop practice recommendations using the AAN 2017 Clinical Practice Guideline Process Manual. RESULTS Gabapentinoids (standardized mean difference [SMD] 0.44; 95% confidence interval [CI], 0.21-0.67), serotonin-norepinephrine reuptake inhibitors (SNRIs) (SMD 0.47; 95% CI, 0.34-0.60), sodium channel blockers (SMD 0.56; 95% CI, 0.25-0.87), and SNRI/opioid dual mechanism agents (SMD 0.62; 95% CI, 0.38-0.86) all have comparable effect sizes just above or just below our cutoff for a medium effect size (SMD 0.5). Tricyclic antidepressants (TCAs) (SMD 0.95; 95% CI, 0.15-1.8) have a large effect size, but this result is tempered by a low confidence in the estimate. RECOMMENDATIONS SUMMARY Clinicians should assess patients with diabetes for PDN (Level B) and those with PDN for concurrent mood and sleep disorders (Level B). In patients with PDN, clinicians should offer TCAs, SNRIs, gabapentinoids, and/or sodium channel blockers to reduce pain (Level B) and consider factors other than efficacy (Level B). Clinicians should offer patients a trial of medication from a different effective class when they do not achieve meaningful improvement or experience significant adverse effects with the initial therapeutic class (Level B) and not use opioids for the treatment of PDN (Level B).
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Affiliation(s)
- Raymond Price
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Don Smith
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Gary Franklin
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Gary Gronseth
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Michael Pignone
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - William S David
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Carmel Armon
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Bruce A Perkins
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Vera Bril
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Alexander Rae-Grant
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - John Halperin
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Nicole Licking
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Mary Dolan O'Brien
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Scott R Wessels
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor.
| | - Leslie C MacGregor
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Kenneth Fink
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Lawrence B Harkless
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Lindsay Colbert
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Brian C Callaghan
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
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Macintyre PE. The opioid epidemic from the acute care hospital front line. Anaesth Intensive Care 2021; 50:29-43. [PMID: 34348484 DOI: 10.1177/0310057x211018211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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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: 19] [Impact Index Per Article: 6.3] [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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Geoffrey Severtson S, Kreider SED, Amioka EC, Margolin ZR, Iwanicki JL, Dart RC. Postmarketing Analysis of Misuse, Abuse, and Diversion of Xtampza ER. PAIN MEDICINE 2021; 21:3660-3668. [PMID: 33094329 PMCID: PMC7770232 DOI: 10.1093/pm/pnaa272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objective To evaluate abuse, misuse, and diversion of Xtampza ER, an extended-release (ER) abuse-deterrent formulation (ADF) of oxycodone. Methods Abuse, misuse, and diversion of Xtampza ER were assessed using Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System data sources. Xtampza ER was compared with immediate-release (IR) oxycodone, other ADF ER products combined, and non-ADF ER products combined. Results Xtampza ER prescriptions increased 50-fold during the study period. In contrast, cases from poison centers, substance abuse treatment centers, and diversion were infrequent and did not increase. Adjusted for prescriptions dispensed, poison center exposures were greater for IR oxycodone (rate ratio [RR] = 2.3, P = 0.008), other ADF ER opioids (RR = 5.2, P < 0.001), and non-ADF ER opioids (RR = 2.5, P = 0.004) than for Xtampza ER. In Treatment Center Programs Combined, past-month abuse prevalence for other ADF ER opioids (odds ratio [OR] = 7.4, P < 0.001) and non-ADF ER opioids (OR = 2.0, P = 0.002) was greater than Xtampza ER; IR oxycodone was not significantly different (OR = 1.2, P = 0.349). In the Drug Diversion Program, rates for IR oxycodone (RR = 3.7, P = 0.003), other ADF ER opioids (RR = 4.2, P = 0.002), and non-ADF ER opioids (RR = 3.4, P = 0.007) were greater than Xtampza ER. Adjustment using morphine equivalents provided similar results, except that IR oxycodone in Treatment Center Programs Combined became higher than Xtampza ER. Nonoral abuse cases involving Xtampza ER were infrequent; Web monitoring data support findings that Xtampza ER is difficult to abuse nonorally. Conclusion Xtampza ER abuse, misuse, and diversion and tampering are low relative to other prescription opioid analgesics. Abuse and diversion did not increase over the study period.
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Affiliation(s)
| | - Scott E D Kreider
- Rocky Mountain Poison & Drug Safety (RMPDS), A Division of Denver Health, Denver, Colorado, USA
| | - Elise C Amioka
- Rocky Mountain Poison & Drug Safety (RMPDS), A Division of Denver Health, Denver, Colorado, USA
| | - Zachary R Margolin
- Rocky Mountain Poison & Drug Safety (RMPDS), A Division of Denver Health, Denver, Colorado, USA
| | - Janetta L Iwanicki
- Rocky Mountain Poison & Drug Safety (RMPDS), A Division of Denver Health, Denver, Colorado, USA
| | - Richard C Dart
- Rocky Mountain Poison & Drug Safety (RMPDS), A Division of Denver Health, Denver, Colorado, USA
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15
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Vosburg SK, Beaumont J, Dailey-Govoni ST, Butler SF, Green JL. Evaluation of Abuse and Route of Administration of Extended-Release Tapentadol Among Treatment-Seeking Individuals, as Captured by the Addiction Severity Index-Multimedia Version (ASI-MV). PAIN MEDICINE 2021; 21:1891-1901. [PMID: 31617931 PMCID: PMC7553020 DOI: 10.1093/pm/pnz250] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Tapentadol is a molecule incorporating mu opioid receptor agonism and norepinephrine reuptake inhibition to provide analgesia, with the potential for a lower incidence of gastrointestinal side effects than full mu opioid agonists. Postmarketing surveillance of tapentadol as an active pharmaceutical ingredient has consistently revealed low levels of abuse and diversion. Objective The purpose of the present study was to further characterize the abuse liability of tapentadol extended-release (ER) by evaluating the prevalence of past 30-day tapentadol ER abuse and reported routes of administration as compared with ER opioids with Food and Drug Administration (FDA) abuse-deterrent labeling (“ADF opioids”) and ER opioids without FDA abuse-deterrent labeling (“non-ADF opioids”). Methods Data were collected from January 2014 through December 2017 from 776 centers located in 43 states throughout the United States using the Addiction Severity Index–Multimedia Version (ASI-MV), an instrument that is integral to the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO, Inflexxion, an IBH Company, Costa Mesa, CA, USA). Results Tapentadol ER had lower rates of past 30-day abuse than ADF ER and non-ADF ER opioid comparators, both at a population level and when adjusted for drug utilization. Tapentadol ER was primarily abused orally, although it was also abused through alternate routes of administration. Cumulative rates of tapentadol ER abuse by alternative routes of administration were lower than both ADF and non-ADF ER opioid comparators, although large confidence intervals resulting from the small sample size of reported tapentadol ER use limit firm conclusions. Conclusions In summary, tapentadol ER was found to have lower rates of both past 30-day abuse and use via alternate routes of administration, specifically snorting and smoking, than ADF and non-ADF ER comparators.
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Affiliation(s)
| | | | | | | | - Jody L Green
- Inflexxion, an IBH Company, Costa Mesa, California, USA
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Green JL, Dailey-Govoni T, Butler SF. Real-World Data on Nonmedical Use of Tramadol from Patients Evaluated for Substance Abuse Treatment in the NAVIPPRO Addiction Severity Index-Multimedia Version (ASI-MV ®) Network. Drug Saf 2020; 44:235-244. [PMID: 33175336 PMCID: PMC7847458 DOI: 10.1007/s40264-020-01012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Drug safety studies regarding comparative risk of different opioid compounds are important as providers and regulatory agencies in the United States continue to balance pain management with an ongoing opioid epidemic. OBJECTIVE The aim of this study was to evaluate nonmedical use (NMU) and diversion of tramadol and comparator opioids using real-world data from the Addiction Severity Index-Multimedia Version (ASI-MV®). METHODS A cross-sectional study design was used to evaluate past 30-day tramadol and comparator opioid NMU among adults assessed for substance abuse treatment using the ASI-MV from 2010 to 2018. Population and drug utilization-adjusted rates were studied, as well as patient characteristics, route of administration, and diversion. RESULTS Past 30-day NMU of one or more prescription opioid was reported in 125,048 (22.6%) of ASI-MV assessments (2010-2018); 46.5% reported oxycodone, 43.2% hydrocodone, 8.1% morphine, and 7.2% tramadol. Male respondents ranged from 43.2% in the tramadol group to 51.8% in the oxycodone group. Majority (~ 76%) were Caucasian in all groups, with 86.9% Caucasian in the morphine group. Prevalence of past 30-day tramadol NMU was significantly lower than that of morphine, oxycodone, and hydrocodone for both population and utilization-adjusted rates. Rate of snorting of tramadol was 4-7 times lower than comparator opioids and injection was 14-34 times lower than morphine and oxycodone. Tramadol was most likely to be obtained via the patient's own prescription while the comparator opioids were more often obtained via dealers or family/friends. CONCLUSION Tramadol had a significantly lower rate of NMU than comparator opioids and was less likely to be diverted or used via higher-risk non-oral routes. These findings support previous evaluations by WHO and the United States Drug Enforcement Agency that concluded that tramadol has a low potential for abuse.
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Affiliation(s)
- Jody L Green
- Inflexxion, A Division of Integrated Behavioral Health, Irvine, CA, USA.
| | | | - Stephen F Butler
- Inflexxion, A Division of Integrated Behavioral Health, Irvine, CA, USA
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17
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The Potential Role of Dual Mechanistic Opioids in Combating Opioid Misuse. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00414-5] [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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18
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Knezevic NN, Jovanovic F, Candido KD, Knezevic I. Oral pharmacotherapeutics for the management of peripheral neuropathic pain conditions - a review of clinical trials. Expert Opin Pharmacother 2020; 21:2231-2248. [PMID: 32772737 DOI: 10.1080/14656566.2020.1801635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Epidemiological studies have shown that 6.9-10% of people suffer from neuropathic pain, a complex painful condition which is often undertreated. Data regarding the effectiveness of treatment options for patients with neuropathic pain is inconsistent, and there is no single treatment option that shows cost-effectiveness across studies. AREAS COVERED In this narrative review, the authors present the results of different prospective, randomized controlled trials, systematic reviews and meta-analyses assessing the effects of different oral medications in the management of various peripheral neuropathic pain conditions. The authors discuss the effectiveness of commonly used oral medications such as voltage-gated calcium channels antagonists, voltage-gated sodium channel antagonists, serotonin-norepinephrine reuptake inhibitors, NMDA antagonists, and medications with other mechanisms of action. EXPERT OPINION Most of the presented medications were more effective than placebo; however, when compared to each other, none of them were significantly superior. The heterogeneity of the studies looking into different oral neuropathic conditions has been the major issue that prevents us from making stronger recommendations. There are multiple reasons including high placebo responsiveness, improperly treated underlying comorbidities (particularly anxiety and depression), and inter-patient variability. Different sensory phenotypes should also be taken into consideration when designing future clinical trials for neuropathic pain.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US.,Department of Anesthesiology, College of Medicine, University of Illinois , Chicago, IL, US.,Department of Surgery, College of Medicine, University of Illinois , Chicago, IL, US
| | - Filip Jovanovic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US.,Department of Anesthesiology, College of Medicine, University of Illinois , Chicago, IL, US.,Department of Surgery, College of Medicine, University of Illinois , Chicago, IL, US
| | - Ivana Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US
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Barbosa J, Faria J, Garcez F, Leal S, Afonso LP, Nascimento AV, Moreira R, Queirós O, Carvalho F, Dinis-Oliveira RJ. Repeated Administration of Clinical Doses of Tramadol and Tapentadol Causes Hepato- and Nephrotoxic Effects in Wistar Rats. Pharmaceuticals (Basel) 2020; 13:ph13070149. [PMID: 32664348 PMCID: PMC7407499 DOI: 10.3390/ph13070149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/18/2022] Open
Abstract
Tramadol and tapentadol are fully synthetic and extensively used analgesic opioids, presenting enhanced therapeutic and safety profiles as compared with their peers. However, reports of adverse reactions, intoxications and fatalities have been increasing. Information regarding the molecular, biochemical, and histological alterations underlying their toxicological potential is missing, particularly for tapentadol, owing to its more recent market authorization. Considering the paramount importance of liver and kidney for the metabolism and excretion of both opioids, these organs are especially susceptible to toxicological damage. In the present study, we aimed to characterize the putative hepatic and renal deleterious effects of repeated exposure to therapeutic doses of tramadol and tapentadol, using an in vivo animal model. Male Wistar rats were randomly divided into six experimental groups, composed of six animals each, which received daily single intraperitoneal injections of 10, 25 or 50 mg/kg tramadol or tapentadol (a low, standard analgesic dose, an intermediate dose and the maximum recommended daily dose, respectively). An additional control group was injected with normal saline. Following 14 consecutive days of administration, serum, urine and liver and kidney tissue samples were processed for biochemical, metabolic and histological analysis. Repeated administration of therapeutic doses of both opioids led to: (i) increased lipid and protein oxidation in liver and kidney, as well as to decreased total liver antioxidant capacity; (ii) decreased serum albumin, urea, butyrylcholinesterase and complement C3 and C4 levels, denoting liver synthesis impairment; (iii) elevated serum activity of liver enzymes, such as alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and γ-glutamyl transpeptidase, as well as lipid profile alterations, also reflecting hepatobiliary commitment; (iv) derangement of iron metabolism, as shown through increases in serum iron, ferritin, haptoglobin and heme oxygenase-1 levels. In turn, elevated serum cystatin C, decreased urine creatinine output and increased urine microalbumin levels were detected upon exposure to tapentadol only, while increased serum amylase and urine N-acetyl-β-D-glucosaminidase activities were observed for both opioids. Collectively, these results are compatible with kidney injury. Changes were also found in the expression levels of liver- and kidney-specific toxicity biomarker genes, upon exposure to tramadol and tapentadol, correlating well with alterations in lipid profile, iron metabolism and glomerular and tubular function. Histopathological analysis evidenced sinusoidal dilatation, microsteatosis, mononuclear cell infiltrates, glomerular and tubular disorganization, and increased Bowman's spaces. Although some findings are more pronounced upon tapentadol exposure, our study shows that, when compared with acute exposure, prolonged administration of both opioids smooths the differences between their toxicological effects, and that these occur at lower doses within the therapeutic range.
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Affiliation(s)
- Joana Barbosa
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
- UCIBIO, REQUIMTE—Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal;
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- Correspondence: (J.B.); (R.J.D.-O.); Tel.: +351-224-157-216 (J.B.); +351-224-157-216 (R.J.D.-O.)
| | - Juliana Faria
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
- UCIBIO, REQUIMTE—Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal;
| | - Fernanda Garcez
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
| | - Sandra Leal
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
- Department of Biomedicine, Unit of Anatomy, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Luís Pedro Afonso
- Department of Pathology, Portuguese Institute of Oncology of Porto, 4200-072 Porto, Portugal;
| | - Ana Vanessa Nascimento
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
| | - Roxana Moreira
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
| | - Odília Queirós
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
| | - Félix Carvalho
- UCIBIO, REQUIMTE—Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal;
| | - Ricardo Jorge Dinis-Oliveira
- IINFACTS—Institute of Research and Advanced Training in Health Sciences and Technologies, Department of Sciences, University Institute of Health Sciences (IUCS), CESPU, CRL, 4585-116 Gandra, Portugal; (J.F.); (F.G.); (S.L.); (A.V.N.); (R.M.); (O.Q.)
- UCIBIO, REQUIMTE—Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal;
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- Correspondence: (J.B.); (R.J.D.-O.); Tel.: +351-224-157-216 (J.B.); +351-224-157-216 (R.J.D.-O.)
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20
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Wilson J, Lam T, Scott D, Crossin R, Matthews S, Smith K, Lubman DI, Nielsen S. ‘Extreme personal stress’ and ‘a lot of pain’: Exploring the physical, mental and social contexts of extramedical pharmaceutical opioid use in Australian paramedic case descriptions. Drug Alcohol Rev 2020; 39:870-878. [DOI: 10.1111/dar.13118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
- James Wilson
- Turning Point, Eastern Health Melbourne Australia
- Monash Addiction Research Centre, Eastern Health Clinical School Monash University Melbourne Australia
| | - Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical School Monash University Melbourne Australia
| | - Debbie Scott
- Turning Point, Eastern Health Melbourne Australia
- Monash Addiction Research Centre, Eastern Health Clinical School Monash University Melbourne Australia
| | - Rose Crossin
- Turning Point, Eastern Health Melbourne Australia
- Monash Addiction Research Centre, Eastern Health Clinical School Monash University Melbourne Australia
| | - Sharon Matthews
- Turning Point, Eastern Health Melbourne Australia
- Monash Addiction Research Centre, Eastern Health Clinical School Monash University Melbourne Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Australia
- Ambulance Victoria Melbourne Australia
- Department of Community Emergency Health and Paramedic Practice Monash University Melbourne Australia
| | - Dan I. Lubman
- Turning Point, Eastern Health Melbourne Australia
- Monash Addiction Research Centre, Eastern Health Clinical School Monash University Melbourne Australia
| | - Suzanne Nielsen
- Turning Point, Eastern Health Melbourne Australia
- Monash Addiction Research Centre, Eastern Health Clinical School Monash University Melbourne Australia
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Nielsen S, Crossin R, Middleton M, Lam T, Wilson J, Scott D, Martin C, Smith K, Lubman D. Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Victoria, Australia from 2013 to 2018. Addiction 2020; 115:1075-1087. [PMID: 31742765 PMCID: PMC7317708 DOI: 10.1111/add.14896] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/24/2019] [Accepted: 11/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Despite increases in opioid prescribing and related morbidity and mortality, few studies have comprehensively documented harms across opioid types. We examined a population-wide indicator of extramedical pharmaceutical opioid-related harm to determine if the supply-adjusted rates of ambulance presentations, the severity of presentations or other attendance characteristics differed by opioid type. DESIGN Retrospective observational study of coded ambulance patient care records related to extramedical pharmaceutical opioid use, January 2013 to September 2018. SETTING Australia CASES: Primary analyses used Victorian data (n = 9823), with available data from other Australian jurisdictions (n = 4338) used to determine generalizability. MEASUREMENTS We calculated supply-adjusted rates of attendances using Poisson regression, and used multinomial logistic regression to compare demographic, presentation severity, mental health, substance use and other characteristics of attendances associated with seven pharmaceutical opioids. FINDINGS In Victoria, the highest rates of attendance [per 100 000 oral morphine equivalent mg (OME)] were for codeine (0.273/100 000) and oxycodone (0.113/100 000). The lowest rates were for fentanyl (0.019/100 000) and tapentadol (0.005/100 000). Oxycodone-naloxone rates (0.031/100 000) were lower than for oxycodone as a single ingredient (0.113/100 000). Fentanyl-related attendances were associated with the most severe characteristics, most likely to be an accidental overdose, most likely to have naloxone administered and least likely to be transferred to hospital. In contrast, codeine-related attendances were more likely to involve suicidal thoughts/behaviours, younger females and be transported to hospital. Supply-adjusted attendance rates for individual opioids were stable over time. Victorian states were broadly consistent with non-Victorian states. CONCLUSIONS In Australia, rates and characteristics of opioid-related harm vary by opioid type. Supply-adjusted ambulance attendance rates appear to be both stable over time and unaffected by large changes in supply.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
| | - Rose Crossin
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
| | - Melissa Middleton
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
| | - Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
| | - James Wilson
- Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
| | - Debbie Scott
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
| | - Catherine Martin
- Biostatistical Unit, Public Health and Preventative MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Karen Smith
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia,Ambulance VictoriaDoncasterVictoriaAustralia,Department of Community Emergency Health and Paramedic PracticeMonash UniversityFrankstonVictoriaAustralia
| | - Dan Lubman
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
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Peacock A, Gisev N, Memedovic S, Larance B, Brown J, Cairns R, Buckley N, Farrell M, Degenhardt L. Opioid use and harms associated with a sustained-release tapentadol formulation: A post-marketing surveillance study. Drug Alcohol Depend 2020; 206:107697. [PMID: 31869601 DOI: 10.1016/j.drugalcdep.2019.107697] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 10/11/2019] [Accepted: 10/15/2019] [Indexed: 02/06/2023]
Abstract
AIMS A sustained-release formulation (SRF) of tapentadol has been marketed in Australia since February 2013. This study examined tapentadol SRF extra-medical use, attractiveness for extra-medical use, and associated harms in Australia. METHODS This post-marketing study comprises analyses of Australian community sales data (2011-2017) for eleven pharmaceutical opioids (prescription and over-the-counter codeine disaggregated); calls to three poisons information centres (covering five of the eight jurisdictions in Australia) related to pharmaceutical opioids and coded by the centres as 'misuse' or 'abuse' (2011-2017); and interviews with people who inject drugs (n = 888) recruited as part of the Illicit Drug Reporting System (IDRS) from all Australian capital cities (2017). RESULTS Population-level availability of tapentadol SRF increased from market launch, comprising the sixth largest market share of all opioid unit sales, and third greatest share in oral morphine equivalent milligrams sold, in December 2017. Lifetime tapentadol SRF use among the IDRS sample (n = 888) was low (1.5%; 95%CI 0.9-2.5), with few reporting past-6 month non-prescribed use or injection. Non-fatal overdose following tapentadol use was self-reported by less than 1% (95%CI 0.1-0.8). Between 2013-2017, 1.1% (n = 25) of pharmaceutical opioid 'misuse/abuse' calls were related to tapentadol, and predominantly the SRF. CONCLUSIONS Increasing utilisation of tapentadol sustained-release formulation was observed, along with indications of extra-medical use and harms associated with use, although on a smaller scale relative to other opioids. These findings need to be interpreted in the context of the low level of exposure to tapentadol sustained-release formulation among the sentinel population of people who inject drugs.
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Affiliation(s)
- Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia; School of Medicine, University of Tasmania, TAS, Australia.
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Sonja Memedovic
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia; School of Psychology, University of Wollongong, NSW, Australia
| | - Jared Brown
- NSW Poisons Information Centre, The Children's Hospital at Westmead, NSW, Australia
| | - Rose Cairns
- NSW Poisons Information Centre, The Children's Hospital at Westmead, NSW, Australia; School of Medical Sciences, University of Sydney, NSW, Australia
| | - Nicholas Buckley
- NSW Poisons Information Centre, The Children's Hospital at Westmead, NSW, Australia; School of Medical Sciences, University of Sydney, NSW, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
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Zah V, Brookfield RB, Imro M, Tatovic S, Pelivanovic J, Vukicevic D. Healthcare Costs And Resource Utilization In Chronic Pain Patients Treated With Extended-Release Formulations Of Tapentadol, Oxycodone, Or Morphine Stratified By Type Of Pain: A Retrospective Claims Analysis, 2012-2016. J Pain Res 2019; 12:3037-3048. [PMID: 31819597 PMCID: PMC6850678 DOI: 10.2147/jpr.s222617] [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: 07/10/2019] [Accepted: 10/19/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Chronic pain treatment imposes a substantial economic burden on US society. Treatment costs may vary across subgroups of patients with different types of pain. The aim of our study was to compare healthcare costs (HC) and resource utilization in musculoskeletal (MP), neuropathic (NP), and cancer pain (CaP) patients treated with long-acting opioids (LAO), using real-world evidence. Patients and methods We compared total HC and resource utilization in subgroups of chronic pain patients (MP, NP or CaP) treated with three LAO alternatives: morphine-sulfate extended-release (MsER), oxycodone ER (OxnER) and tapentadol ER (TapER). Retrospective claims data were analyzed in the IBM Truven Health MarketScan® Commercial Claims Database (October 2012 through March 2016). All patients were continuously health plan enrolled for at least 12 months before the index date (first LAO prescription date) and during the LAO-treatment period. The cohorts were propensity-score matched. Results A total of 2824 TapER-treated patients were matched to 16,716 OxnER-treated patients, while 2827 TapER patients were matched to 16,817 MsER patients. The average monthly total HC were lower in the TapER than in the OxnER cohort ($2510 vs. $3720, p<0.001), reflecting significantly lower outpatient, inpatient and emergency department visit rates in the TapER cohort. Similarly, the TapER cohort exhibited a lower average monthly total HC ($2520 vs. $2900, p<0.05) than MsER cohort, with significantly fewer inpatient and outpatient visits in the TapER cohort. TapER demonstrated significantly lower total HC than OxnER in patients with NP and MP, and similar to OxnER in CaP patients. TapER costs were similar to MsER costs in all pain-type subpopulations. Conclusion Based on real-world evidence, the TapER treatment for chronic pain was associated with significantly lower HC compared with MsER or OxnER. When categorized by type of pain, TapER remained a less costly strategy in comparison with OxnER for MP and NP.
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Affiliation(s)
- Vladimir Zah
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc, Mississauga, Ontario, Canada
| | | | - Martina Imro
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc, Mississauga, Ontario, Canada
| | - Simona Tatovic
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc, Mississauga, Ontario, Canada
| | - Jovana Pelivanovic
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc, Mississauga, Ontario, Canada
| | - Djurdja Vukicevic
- Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc, Mississauga, Ontario, Canada
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Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Tapentadol prolonged release (tapentadol PR) [Palexia® SR in EU] is a long-acting tablet formulation of the strong central analgesic tapentadol, which acts as both a μ-opioid receptor (MOR) agonist and a noradrenaline reuptake inhibitor. Tapentadol PR is approved for chronic pain in various countries, with its EU indication (severe chronic pain manageable only with opioid analgesics) being the focus here. Well-designed trials and clinical practice data support tapentadol PR use in this setting. Short term, tapentadol PR was an effective and generally well tolerated analgesic for moderate to severe pain of varying aetiologies, including neuropathic pain. It provided analgesia at least as good as that of conventional strong opioids and appeared more favourable in terms of gastrointestinal tolerability, likely due to less potent MOR binding. Severe back pain with a neuropathic component responded well to moderate-dose tapentadol PR in some patients, while for others, an increase to the maximum recommended tapentadol PR dosage provided analgesia at least as good as that of moderate-dose tapentadol PR plus pregabalin and appeared to have some CNS tolerability benefits. Data also support the use of tapentadol PR in opioid rotation, including when conventional opioids are intolerable. Longer-term data in musculoskeletal pain conditions indicate continued benefit over up to 2 years’ treatment with tapentadol PR with no evidence of tolerance. Thus, tapentadol PR is a useful option for the management of severe chronic pain.
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Affiliation(s)
- Emma D Deeks
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Arthur J, Bruera E. Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer. Nat Rev Clin Oncol 2019; 16:213-226. [PMID: 30514978 DOI: 10.1038/s41571-018-0143-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The current opioid crisis has brought renewed attention and scrutiny to opioid prescriptions. When patients receiving opioid therapy for pain engage in nonmedical opioid use (NMOU) or diversion, untoward consequences can occur. New evidence suggests that patients with cancer might be at a higher risk of NMOU than was previously thought, but clinical evidence still supports the use of opioid analgesics as the gold standard to treat cancer-related pain, creating a dilemma in patient management. Clinicians are encouraged to adopt a universal precautions approach to patients with cancer receiving opioids, which includes screening all patients; discussing the risks, benefits, adverse effects and alternatives of opioid therapy; and providing education on safe use, storage and disposal. Use of urine drug tests, prescription drug monitoring programmes and close observation of behaviours related to opioid use help to ensure treatment adherence, detect NMOU and support therapeutic decision-making. These measures can optimize the risk-benefit ratio while supporting safe opioid use. In this Review, we examine the role of opioids in cancer pain, the risk of substance use disorder and methods to achieve the right balance between the two in order to ensure safe opioid use.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA.
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Ffrench-O'Carroll R, Steinhaeuser H, Duff S, Close J, McNamara J, Ahmed N, Murray M, Rice T, Immanni S. A randomized controlled trial comparing tapentadol with oxycodone in non-breastfeeding women post elective cesarean section. Curr Med Res Opin 2019; 35:975-981. [PMID: 30444145 DOI: 10.1080/03007995.2018.1550059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Tapentadol may allow greater pain relief with reduced "opioid load" compared to oxycodone. Its use has not been studied in the obstetric population. The objective of this study was to compare the efficacy and side effect profile of tapentadol with oxycodone in patients who received spinal anesthesia for elective cesarean section. The trial was registered with EU Clinical Trials Register with CT number 2016-001621-33. METHODS This was a multicenter, randomized controlled trial. Randomized patients (n = 68) received either 50 mg tapentadol or oxycodone 10 mg 12 hourly postoperatively. The primary endpoint was the sum of pain intensity difference over the first 48 hours of treatment (SPID48). Secondary outcomes included time to rescue medications, SPID36, total pain relief (TOTPAR) scores, patient satisfaction scores, sum of total pain relief and pain intensity difference (SPRID) scores, time to rescue medications and side effects experienced. An analysis of covariance model with baseline pain intensity score as a covariate was used for statistical analysis. RESULTS There was no significant difference in the primary endpoint of SPID48 with adjusted mean difference -11.45 (95% CI -35.35, 12.45) p = .34). Oxycodone showed significantly greater SPID36 scores compared to tapentadol with increased time to rescue medication. Side effects experienced were similar between groups. CONCLUSION Tapentadol did not provide superior pain control or improved tolerability compared to oxycodone post cesarean section. Results should be interpreted however with consideration of administration of intrathecal opioids to all patients in this study and debate over the optimal dose of tapentadol for acute pain.
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Affiliation(s)
| | | | - S Duff
- a University Hospital Waterford , Waterford , Ireland
| | - J Close
- a University Hospital Waterford , Waterford , Ireland
| | - J McNamara
- a University Hospital Waterford , Waterford , Ireland
| | - N Ahmed
- b St Luke's General Hospital , Kilkenny , Ireland
| | - M Murray
- a University Hospital Waterford , Waterford , Ireland
| | - T Rice
- c South Tipperary General Hospital , Clonmel , Ireland
| | - S Immanni
- a University Hospital Waterford , Waterford , Ireland
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Arthur J, Reddy A. Opioid Prescribing in an Opioid Crisis: What Basic Skills Should an Oncologist Have Regarding Opioid Therapy? Curr Treat Options Oncol 2019; 20:39. [PMID: 30937544 DOI: 10.1007/s11864-019-0636-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OPINION STATEMENT Although clinical evidence supports the use of opioids for cancer-related pain, doing so amidst the current opioid crisis remains a challenge. A proportion of opioid-related deaths in the USA are attributable to prescription opioids, which implicates health care providers as one of the major contributors. It is therefore even more important now for all clinicians to follow safe and effective opioid prescribing practices. Oncologists are often in the frontline of cancer pain management. They are encouraged to use validated tools to screen all patients receiving opioids for high risk behaviors. Those identified as high risk for potential abuse of opioids should be monitored closely. When aberrant behavior is detected, the clinician will need to openly discuss the issue and its possible implications. Oncologists may then implement measures such as limiting the dose and quantity of opioids prescribed, shortening interval between follow-ups for refills to allow for increased monitoring, setting boundaries/limitations, weaning off opioid analgesics, or/and referring to a pain or palliative medicine or drug addiction expert for co-management when necessary. These efforts may aid oncologists in safely managing cancer pain in the environment of national opioid crisis.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Stewart JE, Tuffin PH, Kay J, Mohamad AHT, Ritchie KL, Muthukuda G, Popielewska A, Schug SA. The effect of guideline implementation on discharge analgesia prescribing (two years on). Anaesth Intensive Care 2019; 47:40-44. [DOI: 10.1177/0310057x18811746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The provision of appropriate discharge analgesia can be challenging and is often prescribed by some of the most junior members of the medical team. Opioid abuse has been considered a growing public health crisis and physician overprescribing is a major contributor. In 2015 an initial audit of discharge analgesia at the Royal Perth Hospital led to the development of discharge analgesia guidelines. Compliance with these guidelines was assessed by a follow-up audit in 2016, which showed improved practice. This audit assesses discharge analgesia prescribing practices two years following guideline implementation. Dispensing data were obtained for analgesic medication over a three-month period from April to July 2017 and 100 unique patients were chosen using computer generated randomisation. Patients’ medical records were assessed against the hospital’s Postoperative Inpatients Discharge Analgesia Guidelines. The data collected were then compared with equivalent data from the previous 2015 and 2016 audits. Overall 83.4% of the 170 discharge analgesia prescriptions written were compliant with guidelines. The highest overall compliance rates were achieved for paracetamol (100%, up from 95.9% in 2016), celecoxib (96%, down from 100% in 2016), and oxycodone immediate release (IR) (74%, down from 88.9% in 2016). The quantity of oxycodone IR given on discharge complied with quantity guidelines in only 56% of cases. Overall there has been a significant and sustained improvement in appropriateness of discharge analgesia prescribing since 2015, though the results from 2017 show less compliance than 2016 and that achieving compliance with quantity guidelines is an ongoing challenge. This demonstrates the challenge of obtaining high adherence to guidelines over a longer time period.
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Affiliation(s)
- Jonathon E Stewart
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Australia
| | - Penelope H Tuffin
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Australia
| | - Judith Kay
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Australia
| | | | - Kara L Ritchie
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Australia
| | - Gihan Muthukuda
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Australia
| | | | - Stephan A Schug
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Australia
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Dalal S, Bruera E. Pain Management for Patients With Advanced Cancer in the Opioid Epidemic Era. Am Soc Clin Oncol Educ Book 2019; 39:24-35. [PMID: 31099619 DOI: 10.1200/edbk_100020] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Use of opioids for the treatment of pain is necessary for the majority of patients with advanced cancer, however its use has become challenging in the face of the opioid epidemic and the emerging evidence that patients with cancer are also at risk for nonmedical opioid use. This article proposes an assessment and treatment plan that incorporates universal screening with monitoring for all patients with cancer who are considered for opioid treatment to assess their risk for opioid misuse and harm. Timely identification with appropriate management, including referral of at-risk patients, will allow oncology professionals to optimize the risk-to-benefit and support the safe use of opioids for patients with cancer.
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Affiliation(s)
- Shalini Dalal
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Ahmad R, Alaei S, Omidian H. Safety and performance of current abuse-deterrent formulations. Expert Opin Drug Metab Toxicol 2018; 14:1255-1271. [DOI: 10.1080/17425255.2018.1546289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Rand Ahmad
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Samaneh Alaei
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Hamid Omidian
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
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Abstract
BACKGROUND Tapentadol is a novel atypical opioid. Anecdotal evidence suggests that tapentadol has a lower toxicity than conventional opioids. OBJECTIVES To evaluate all single-drug mortality due to tapentadol and assess serious adverse events caused by tapentadol. METHODS The Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) reporting guidelines, an evidence-based minimum set of items for reporting in systematic reviews, were followed in this systematic review. RESULTS 24 peer-reviewed papers were identified. They indicate that tapentadol toxicity can cause mortality and serious adverse effects. CONCLUSION(S) At least four confirmed fatalities, and serious adverse effects have been documented for individuals abusing or using tapentadol as prescribed. Serious adverse effects of tapentadol use may include respiratory depression, confusion, coma, hallucination/delusion, seizures, tachycardia, hypertension, agitation, tremor, miosis, hypotension, dyspnea, electrolyte abnormality, atrial fibrillation or severe upper abdominal pain. Tapentadol is unlikely to cause serotonin syndrome. The toxicity of tapentadol is significantly less than pure mu opioids, such as oxycodone.
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Affiliation(s)
- Jessie S Channell
- Medical School, The University of Western Australia, Perth, Western Australia
| | - Stephan Schug
- Medical School, The University of Western Australia, Perth, Western Australia
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