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Rana D, Salave S, Benival D. Emerging trends in Abuse-Deterrent Formulations: Technological insights and Regulatory considerations. Curr Drug Deliv 2021; 19:846-859. [PMID: 34879799 DOI: 10.2174/1567201818666211208101035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/21/2021] [Accepted: 09/15/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Opioid medications are an integral part in the management of acute and chronic severe pain. However, non-medical practice of these prescription drug products is emerging as a serious public health problem. To control this opioid epidemic, USFDA is encouraging pharmaceutical companies to develop Abuse Deterrent Formulations (ADFs). Abuse Deterrent Formulations are much more difficult to manipulate and abuse when compared to their conventional formulations. This feature of ADFs is due to their ability to incumber extraction of active ingredients, to prevent administration through alternative routes and making abuse of altered product less rewarding. OBJECTIVE The main objective of this review is to abridge different ADFs and various laboratory-based in vitro manipulation and extraction studies, demonstrating that these approved ADFs have capabilities to deter abuse. METHODS The method includes collection of data from different search engines like PubMed, FDA guidance documents, ScienceDirect, Google Patents to get coverage of literature in order to get appropriate information regarding ADFs. RESULTS Various in vitro studies demonstrate that ADFs are effective in minimizing opioid drug abuse including opioid overdose. However, real impact of these ADFs on reducing the drug abuse can be concluded only after receiving the post marketing data. CONCLUSION ADFs are embracing fundamentally different paradigm in management of severe pain. We believe that development of abuse deterrent technologies would shift the architype, deterring multipill abuse and can prove as a breakthrough strategy in controlling this opioid epidemic menace.
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Affiliation(s)
- Dhwani Rana
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A). India
| | - Sagar Salave
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A). India
| | - Derajram Benival
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A). India
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2
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Anderson N, Gillman AG, Wasan AD. Use of a Long-Acting Opioid Microsphere Formulation to Overcome Difficulties in Swallowing Pain Medication. J Pain Res 2020; 13:955-960. [PMID: 32440201 PMCID: PMC7212775 DOI: 10.2147/jpr.s249592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/17/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Xtampza ER® (XER) is a long-acting oxycodone formulation which was designed to be abuse-deterrent and to overcome capsule-swallowing issues. This pilot study evaluated the effectiveness of XER at reducing swallowing difficulty while providing effective analgesia in the setting of chronic pain. Subjects and Methods Eleven subjects with chronic pain who reported pill-swallowing difficulty were enrolled in a 6-week uncontrolled open-label pilot study in which their prescribed daily opioid medication was converted to XER. Swallowing difficulty, pain intensity, opioid satisfaction, and secondary indicators of pain response were recorded for subjects throughout the study. Results Both swallowing difficulty and opioid satisfaction (XER vs baseline opioid) improved significantly over the 6-week study period (p < 0.05), while pain intensity ratings demonstrated no significant change. No significant change was noted in any of the secondary pain, mental health, or physical function measures after conversion to XER compared to baseline. Conclusion Subjects experienced improvement in both swallowing and opioid medication satisfaction after conversion to XER with no significant change in pain intensity and related measures.
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Affiliation(s)
- Nathan Anderson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrea G Gillman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Pain Medicine, Pittsburgh, PA, USA
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3
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Park K, Otte A. Prevention of Opioid Abuse and Treatment of Opioid Addiction: Current Status and Future Possibilities. Annu Rev Biomed Eng 2019; 21:61-84. [PMID: 30786212 DOI: 10.1146/annurev-bioeng-060418-052155] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prescription opioid medications have seen a dramatic rise in misuse and abuse, leading regulators and scientists to develop policies and abuse-deterrent technologies to combat the current opioid epidemic. These abuse-deterrent formulations (ADFs) are intended to deter physical and chemical tampering of opioid-based products, while still providing safe and effective delivery for therapeutic purposes. Even though formulations with varying abuse-deterrent technologies have been approved, questions remain about their effectiveness. While these formulations provide a single means to combat the epidemic, a greater emphasis should be placed on formulations for treatment of addiction and overdose to help those struggling with opioid dependence. This article analyzes various ADFs currently in clinical use and explores potential novel systems for treatment of addiction and prevention of overdose.
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Affiliation(s)
- Kinam Park
- Weldon School of Biomedical Engineering and College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, USA
| | - Andrew Otte
- Weldon School of Biomedical Engineering and College of Pharmacy, Purdue University, West Lafayette, Indiana 47907, USA
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4
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Sarabu S, Bandari S, Kallakunta VR, Tiwari R, Patil H, Repka MA. An update on the contribution of hot-melt extrusion technology to novel drug delivery in the twenty-first century: part II. Expert Opin Drug Deliv 2019; 16:567-582. [PMID: 31046479 DOI: 10.1080/17425247.2019.1614912] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Interest in hot-melt extrusion (HME) technology for novel applications is growing day by day, which is evident from several hundred publications within the last 5 years. HME is a cost-effective, solvent free, 'green' technology utilized for various formulations with low investment costs compared to conventional technologies. HME has also earned the attention of the pharmaceutical industry by the transformation of this technology for application in continuous manufacturing. AREAS COVERED Part II of the review focuses on various novel opportunities or innovations of HME such as multiple component systems (co-crystals, co-amorphous systems and salts), twin-screw granulation, semi-solids, co-extrusion, abuse deterrent formulations, solid self-emulsifying drug delivery systems, chronotherapeutic drug delivery systems, and miscellaneous applications. EXPERT OPINION HME is being investigated as an alternative technology for preparation of multicomponent systems such as co-crystals and co-amorphous techniques. Twin-screw granulation has gained increased interest in preparation of granules via twin-screw melt granulation or twin-screw dry granulation. This novel application of the HME process provides a promising alternate approach in the formulation of granules and solid dosage forms. However, this technology may need to be further investigated for scalability aspects of these novel applications for industrial production.
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Affiliation(s)
- Sandeep Sarabu
- a Department of Pharmaceutics and Drug Delivery , The University of Mississippi, University , MS , USA
| | - Suresh Bandari
- a Department of Pharmaceutics and Drug Delivery , The University of Mississippi, University , MS , USA
| | - Venkata Raman Kallakunta
- a Department of Pharmaceutics and Drug Delivery , The University of Mississippi, University , MS , USA
| | - Roshan Tiwari
- a Department of Pharmaceutics and Drug Delivery , The University of Mississippi, University , MS , USA
| | - Hemlata Patil
- a Department of Pharmaceutics and Drug Delivery , The University of Mississippi, University , MS , USA
| | - Michael A Repka
- a Department of Pharmaceutics and Drug Delivery , The University of Mississippi, University , MS , USA.,b Pii Center for Pharmaceutical Technology , The University of Mississippi, University , MS , USA
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Abstract
PURPOSE OF REVIEW The primary cause of overdose death in the United States is related to pharmaceutical opioids. A few particular populations that struggle with adverse outcomes related to opioid abuse are those in palliative care, those with chronic pain, and those receiving pain treatments secondary to cancer or chemotherapy. RECENT FINDINGS There have been massive efforts to decrease the use of opioid abuse in patient care in a gestalt manner, but palliative care provides unique challenges in applying these reduction tactics used by other specialties. SUMMARY We explore behavioral interventions, provider education, alternative pain management techniques, postmarketing surveillance, and abuse-deterrent formulas as emerging methods to counteract opioid abuse in these populations.
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6
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Clauw DJ, Essex MN, Pitman V, Jones KD. Reframing chronic pain as a disease, not a symptom: rationale and implications for pain management. Postgrad Med 2019; 131:185-198. [DOI: 10.1080/00325481.2019.1574403] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Daniel J. Clauw
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Verne Pitman
- Global Medical Affairs, US Medical Affairs, Pfizer Inc, New York, NY, USA
| | - Kim D. Jones
- School of Nursing, Linfield College, Portland, OR, USA
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7
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Schifano F, Chiappini S, Corkery JM, Guirguis A. Assessing the 2004-2018 Fentanyl Misusing Issues Reported to an International Range of Adverse Reporting Systems. Front Pharmacol 2019; 10:46. [PMID: 30774595 PMCID: PMC6367955 DOI: 10.3389/fphar.2019.00046] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/14/2019] [Indexed: 01/15/2023] Open
Abstract
Objective: A recent, global, increase in the use of opioids including the prescribing, highly potent, fentanyl has been recorded. Due its current popularity and the potential lethal consequences of its intake, we aimed here at analyzing the fentanyl misuse, abuse, dependence and withdrawal-related adverse drug reactions (ADRs) identified within the European Medicines Agency (EMA), the United Kingdom Yellow Card Scheme (YCS), and the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) databases. Methods: Descriptive analysis of both ADRs and related cases. Results: The analysis of fentanyl-related misuse, abuse, dependence and withdrawal cases reported during years 2004-2018 to the EMA, the YCS, and the FAERS showed increasing levels overtime, specifically, EMA-related data presented two peaks (e.g., in 2008 and 2015), whilst the FAERS dataset was characterized by a dramatic increase of the ADRs collected over the last 18 months, and particularly from 2016. Some 127,313 ADRs (referring to n = 6,161 patients/single cases) related to fentanyl's misuse/abuse/dependence/withdrawal issues were reported to EMA, with 14,287 being judged by the reporter as "suspect." The most represented ADRs were: "drug dependence "(76.87%), "intentional product misuse" (13.06%), and "drug abuse" (7.45%). Most cases involved adult males and the concomitant use of other prescribing/illicit drugs. A range of idiosyncratic (i.e., ingestion/injection of transdermal patches' fentanyl) and very high-dosage intake cases were here identified. Significant numbers of cases required either a prolonged hospitalization (192/559 = 34.35%) or resulted in death (185/559 = 33.09%). Within the same time frame, YCS collected some 3,566 misuse/abuse/dependence/withdrawal ADRs, corresponding to 1,165 single patients/cases, with those most frequently reported being "withdrawal," "intentional product misuse," and "overdose" ADRs. Finally, FAERS identified a total of 19,145 misuse/abuse/dependence/withdrawal-related cases, being "overdose," withdrawal, and "drug use disorder/drug abuse/drug diversion" the most represented ADRs (respectively, 43.11, 20.80, and 20.29%). Conclusion: Fentanyl abuse may be considered a public health issue with significant implications for clinical practice. Spontaneous pharmacovigilance reporting systems should be considered for mapping new trends of drug abuse.
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Affiliation(s)
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
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Salwan AJ, Hagemeier NE, Harirforoosh S. Abuse-Deterrent Opioid Formulations: A Key Ingredient in the Recipe to Prevent Opioid Disasters? Clin Drug Investig 2018; 38:573-577. [DOI: 10.1007/s40261-018-0651-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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9
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Abstract
Opioid use disorders (OUDs) have long been a global problem, but the prevalence rates have increased over 20 years to epidemic proportions in the US, with concomitant increases in morbidity and all-cause mortality, but especially opioid overdose. These increases are in part attributable to a several-fold expansion in the prescription of opioid pain medications over the same time period. Opioid detoxification and psychosocial treatments alone have each not yielded sufficient efficacy for OUD, but μ-opioid receptor agonist, partial agonist, and antagonist medications have demonstrated the greatest overall benefit in OUD treatment. Buprenorphine, a μ-opioid receptor partial agonist, has been used successfully on an international basis for several decades in sublingual tablet and film preparations for the treatment of OUD, but the nature of formulation, which is typically self-administered, renders it susceptible to nonadherence, diversion, and accidental exposure. This article reviews the clinical trial data for novel buprenorphine delivery systems in the form of subcutaneous depot injections, transdermal patches, and subdermal implants for the treatment of OUD and discusses both the clinical efficacy of longer-acting formulations through increasing consistent medication exposure and their potential utility in reducing diversion. These new delivery systems also offer new dosing opportunities for buprenorphine and strategies for dosing intervals in the treatment of OUD.
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Affiliation(s)
- Richard N Rosenthal
- Department of Psychiatry, Addiction Institute at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York
| | - Viral V Goradia
- Department of Psychiatry, Upstate Medical University, Syracuse, NY, USA
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Jones MR, Carney MJ, Kaye RJ, Prabhakar A, Kaye AD. Drug Formulation Advances in Extended-Release Medications for Pain Control. Curr Pain Headache Rep 2017; 20:36. [PMID: 27084375 DOI: 10.1007/s11916-016-0565-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Prescription opioid abusers frequently tamper with opioid tablets in order to either accelerate the delivery of the euphoria-inducing agent or to alter the route of delivery, such that it may be delivered intranasally or intravenously. As one strategy to combat the opioid epidemic in the USA, drug manufacturers have begun to explore formulations which resist such tampering by abusers. Techniques to prevent tampering consist of physical barriers to crushing, chewing, and drug extraction, or aversive or antagonistic agents, incorporated within the formulation itself. Recent years have seen the development of numerous extended-release opioid agents, which are described in this review. This article provides a comprehensive summary of the pharmacology, benefits, risks, and processes behind the development of currently available extended-release opioid drugs, as well as a glimpse into promising future formulations.
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Affiliation(s)
- Mark R Jones
- Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Rachel J Kaye
- Department of Biochemistry, Bowdoin College, Brunswick, ME, USA
| | - Amit Prabhakar
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA.
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11
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Conaghan PG, Serpell M, McSkimming P, Junor R, Dickerson S. Satisfaction, Adherence and Health-Related Quality of Life with Transdermal Buprenorphine Compared with Oral Opioid Medications in the Usual Care of Osteoarthritis Pain. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2017; 9:359-71. [PMID: 27314487 PMCID: PMC4925685 DOI: 10.1007/s40271-016-0181-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Osteoarthritis (OA) causes substantial pain and reduced health-related quality of life (HRQL). Although opioid analgesics are commonly used, the relative benefits of different opioids are poorly studied. Transdermal buprenorphine (TDB) offers an alternative to oral opioids for the treatment of moderate-to-severe chronic pain. This observational study of people with OA pain assessed satisfaction, HRQL and medication adherence. Methods Patients in the UK with self-reported knee and/or hip OA who had been receiving one or more of TDB, co-codamol (an oral paracetamol/codeine combination) and tramadol for at least 1 month completed an online or telephone questionnaire. Medication satisfaction scores, HRQL scores (Short-Form 36 [SF-36]), medication adherence (Morisky Medication Adherence Scale [MMAS™]), adverse events and treatment discontinuations were recorded. Linear and logistic regression models were used to compare the treatment effect of TDB with co-codamol or tramadol. Results Overall, 966 patients met the inclusion criteria; 701 were taking only one of the target medications (TDB: 85; co-codamol: 373; tramadol: 243). The largest age group was 50–59 years and 76.0 % of patients were female. The TDB group was younger, with more male patients, therefore the statistical models were adjusted for age and sex. Medication satisfaction scores were significantly higher in the TDB group than the other two groups (TDB vs. co-codamol: 3.56, 95 % confidence interval [CI] 1.90–6.68, p < 0.0001; TDB vs. tramadol: 3.22, 95 % CI 1.67–6.20, p = 0.0005). Physical Component Summary scores for HRQL and mean adherence were also higher in the TDB group, while Mental Component Summary HRQL scores were similar across the three groups. Conclusions Patients with knee and/or hip OA pain treated with TDB were more satisfied and more adherent with their medication, and reported higher Physical Component Summary HRQL scores than those treated with co-codamol or tramadol, although demographic differences were observed between groups. Electronic supplementary material The online version of this article (doi:10.1007/s40271-016-0181-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine and National Institute of Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, University of Leeds, Leeds, UK
| | - Michael Serpell
- University Department of Anaesthesia, Gartnavel General Hospital, Glasgow, UK
| | - Paula McSkimming
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Rod Junor
- Napp Pharmaceuticals Limited, Cambridge, UK
| | - Sara Dickerson
- Napp Pharmaceuticals Limited, Cambridge, UK. .,Mundipharma International Limited, Cambridge Science Park, Milton Road, Cambridge, CB4 0GW, UK.
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12
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Vadivelu N, Chang D, Lumermann L, Suchy T, Burg MM, Fontes ML. Management of Patients on Abuse-Deterrent Opioids in the Ambulatory Surgery Setting. Curr Pain Headache Rep 2017; 21:10. [DOI: 10.1007/s11916-017-0612-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Stanos S, Brodsky M, Argoff C, Clauw DJ, D'Arcy Y, Donevan S, Gebke KB, Jensen MP, Lewis Clark E, McCarberg B, Park PW, Turk DC, Watt S. Rethinking chronic pain in a primary care setting. Postgrad Med 2017; 128:502-15. [PMID: 27166559 DOI: 10.1080/00325481.2016.1188319] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic pain substantially impacts patient function and quality of life and is a burden to society at large in terms of increased health care utilization and loss of productivity. As a result, there is an increasing recognition of chronic pain as a public health crisis. However, there remains wide variability in clinical practices related to the prevention, assessment, and treatment of chronic pain. Certain fundamental aspects of chronic pain are often neglected including the contribution of the psychological, social, and contextual factors associated with chronic pain. Also commonly overlooked is the importance of understanding the likely neurobiological mechanism(s) of the presenting pain and how they can guide treatment selection. Finally, physicians may not recognize the value of using electronic medical records to systematically capture data on pain and its impact on mood, function, and sleep. Such data can be used to monitor onset and maintenance of treatments effects at the patient level and evaluate costs at the systems level. In this review we explain how these factors play a critical role in the development of a coordinated, evidence-based treatment approach tailored to meet specific needs of the patient. We also discuss some practical approaches and techniques that can be implemented by clinicians in order to enhance the assessment and management of individuals with chronic pain in primary care settings.
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Affiliation(s)
- Steven Stanos
- a Swedish Pain Services , Swedish Health System , Seattle , WA , USA
| | - Marina Brodsky
- b Global Medical Affairs , Pfizer Inc ., New York , NY , USA
| | - Charles Argoff
- c Department of Neurology , Albany Medical Center , Albany , NY , USA
| | - Daniel J Clauw
- d Department of Anesthesiology , The University of Michigan , Ann Arbor , MI , USA
| | | | - Sean Donevan
- b Global Medical Affairs , Pfizer Inc ., New York , NY , USA
| | - Kevin B Gebke
- f Department of Family Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Mark P Jensen
- g Department of Rehabilitation Medicine , University of Washington , Seattle , WA , USA
| | - Evelyn Lewis Clark
- h Warrior Centric Health, LLC , Rutgers Robert Wood Johnson Medical School , New Brunswick , NJ , USA
| | - Bill McCarberg
- i University of California San Diego , San Diego , CA , USA
| | - Peter W Park
- b Global Medical Affairs , Pfizer Inc ., New York , NY , USA
| | - Dennis C Turk
- j Department of Anesthesiology and Pain Medicine , University of Washington , Seattle , WA , USA
| | - Stephen Watt
- b Global Medical Affairs , Pfizer Inc ., New York , NY , USA
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14
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Kovaliov M, Li S, Korkmaz E, Cohen-Karni D, Tomycz N, Ozdoganlar OB, Averick S. Extended-release of opioids using fentanyl-based polymeric nanoparticles for enhanced pain management. RSC Adv 2017. [DOI: 10.1039/c7ra08450a] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fentanyl-terminated polyesters provide linear release of therapeutics with an effective antinociceptive effect in vivo.
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Affiliation(s)
- Marina Kovaliov
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
| | - Shaohua Li
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
| | - Emrullah Korkmaz
- Department of Mechanical Engineering
- Carnegie Mellon University
- Pittsburgh
- USA
| | - Devora Cohen-Karni
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
| | - Nestor Tomycz
- Neuroscience Institute
- Allegheny Health Network
- Allegheny General Hospital
- Pittsburgh
- USA
| | - O. Burak Ozdoganlar
- Department of Mechanical Engineering
- Carnegie Mellon University
- Pittsburgh
- USA
- Department of Biomedical Engineering
| | - Saadyah Averick
- Neuroscience Disruptive Research Lab
- Allegheny Health Network Research Institute
- Allegheny General Hospital
- Pittsburgh
- USA
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Alford DP, Zisblatt L, Ng P, Hayes SM, Peloquin S, Hardesty I, White JL. SCOPE of Pain: An Evaluation of an Opioid Risk Evaluation and Mitigation Strategy Continuing Education Program. PAIN MEDICINE 2016; 17:52-63. [PMID: 26304703 PMCID: PMC4718419 DOI: 10.1111/pme.12878] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioid analgesics to fund continuing education based on a FDA Blueprint. This article describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program, an ER/LA opioid analgesic REMS program, and its impact on clinician knowledge, confidence, attitudes, and self-reported clinical practice. METHOD Participants of the 3-h SCOPE of Pain training completed pre-, immediate post- and 2-month post-assessments. SUBJECTS The primary target group (n = 2,850), and a subset (n = 476) who completed a 2-month post-assessment, consisted of clinicians licensed to prescribe ER/LA opioid analgesics, who care for patients with chronic pain and who completed the 3-h training between February 28, 2013 and June 13, 2014. RESULTS Immediately post-program, there was a significant increase in correct responses to knowledge questions (60% to 84%, P ≤ 0.02) and 87% of participants planned to make practice changes. At 2-months post-program, there continued to be a significant increase in correct responses to knowledge questions (60% to 69%, P ≤ 0.03) and 67% reported increased confidence in applying safe opioid prescribing care and 86% reported implementing practice changes. There was also an improvement in alignment of desired attitudes toward safe opioid prescribing. CONCLUSIONS The SCOPE of Pain program improved knowledge, attitudes, confidence, and self-reported clinical practice in safe opioid prescribing. This national REMS program holds potential to improve the safe use of opioids for the treatment of chronic pain.
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Affiliation(s)
- Daniel P. Alford
- *The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lara Zisblatt
- *The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Pamela Ng
- Performance Improvement Division, AXDEV Group Inc., Brossard, Quebec, Canada
| | - Sean M. Hayes
- Performance Improvement Division, AXDEV Group Inc., Brossard, Quebec, Canada
| | - Sophie Peloquin
- Performance Improvement Division, AXDEV Group Inc., Brossard, Quebec, Canada
| | - Ilana Hardesty
- *The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julie L. White
- *The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
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16
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Hale ME, Moe D, Bond M, Gasior M, Malamut R. Abuse-deterrent formulations of prescription opioid analgesics in the management of chronic noncancer pain. Pain Manag 2016; 6:497-508. [DOI: 10.2217/pmt-2015-0005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Misuse, abuse and diversion of prescription opioid analgesics represent a global public health concern. The development of abuse-deterrent formulations (ADFs) of prescription opioid analgesics is an important step toward reducing abuse and diversion of these medications, as well as potentially limiting medical consequences when misused or administered in error. ADFs aim to hinder extraction of the active ingredient, prevent administration through alternative routes and/or make abuse of the manipulated product less attractive, less rewarding or aversive. However, opioid ADFs may still be abused via the intended route of administration by increasing the dose and/or dosing frequency. The science of abuse deterrence and the regulatory landscape are still relatively new and evolving. This paper reviews the current status of opioid ADFs, with particular focus on different approaches that can be used to deter abuse, regulatory considerations and implications for clinical management.
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Affiliation(s)
| | - Derek Moe
- CIMA Labs Inc., Brooklyn Park, MN, USA
| | - Mary Bond
- TEVA Pharmaceuticals, Frazer, PA, USA
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17
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Hartman L, Barnes E, Bachmann L, Schafer K, Lovato J, Files DC. Opiate Injection-associated Infective Endocarditis in the Southeastern United States. Am J Med Sci 2016; 352:603-608. [PMID: 27916215 DOI: 10.1016/j.amjms.2016.08.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/08/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Opiate pain reliever (OPR) misuse by injection is increasing in the United States. Infective endocarditis (IE), a devastating complication of injection OPR use, has been understudied. METHODS We conducted a retrospective chart review of IE cases at an academic tertiary care hospital in North Carolina. Hospital admissions from 2009-2014 were screened for cases of definite IE. Subjects reporting injection drug use (IDU) were classified as IDU-IE, and compared to those without reported IDU, classified as No IDU-IE. Rates of IDU-IE and No IDU-IE, patient demographics, microbiologic data and outcomes were compared between the groups. RESULTS A total of 127 incident admissions for IE were identified, 48 (37.8%) were classified as IDU-IE and 79 (62.2%) as No IDU-IE. IDU-IE cases increased from 14% of hospitalizations for IE in 2009 to 56% in 2014; reporting of OPR injection increased in 2012 and continued through the study period. IDU-IE subjects were younger (32.6 ± 11.7 versus 54.4 ± 13.1, P < 0.0001), more likely to be single (n = 33 [68.8%] versus n = 23 [29.1%], P < 0.0001) and to reside in rural communities (n = 36 [75.0%] versus n = 25 [31.6%], P < 0.0001) than No IDU-IE subjects. Hospital length of stay (26 days versus 12 days, P < 0.0001) and intensive care unit length of stay (2 days versus 1 day, P = 0.04) were longer for IDU-IE patients and hospital mortality did not differ (10.4% IDU-IE versus 8.9% No IDU-IE, P = 0.77). CONCLUSIONS IDU-IE rates increased over time, and OPR injection use in rural communities appears to be a major contributor. Interventions to reduce IDU-IE and OPR misuse are needed to halt this growing epidemic in at-risk rural communities.
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Affiliation(s)
- Lauren Hartman
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Erin Barnes
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Infectious Disease, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Laura Bachmann
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Infectious Disease, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Katherine Schafer
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Infectious Disease, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Lovato
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel Clark Files
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC; Department of Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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Abstract
Opioids are the mainstay for treatment of acute pain and cancer pain, and also have a role in the treatment of chronic non-malignant pain. There has been, however, a growing public health problem stemming from the misuse of opioid analgesics leading to serious consequences. To deter abuse, new formulations of extended-release opioid analgesics and tamper-resistant opioids have recently been developed. The concept of abuse-deterrent extended-release opioids is relatively new and, although abuse may not be completely prevented, the utilization of such abuse-deterrent extended-release opioids could reduce this risk. Extended-release abuse-deterrent opioids have been found to have important clinical applications in cancer, acute pain, and chronic non-malignant pain for analgesia control with decreased incidence of tampering and abuse. In this review, different extended-release formulations of opioids available for clinical applications are presented with descriptions of the formulations, their physical properties, and the clinical studies performed to provide physicians with a better understanding of their uses.
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Webster LR, Kopecky EA, Smith MD, Fleming AB. A Randomized, Double-Blind, Double-Dummy Study to Evaluate the Intranasal Human Abuse Potential and Pharmacokinetics of a Novel Extended-Release Abuse-Deterrent Formulation of Oxycodone. PAIN MEDICINE (MALDEN, MASS.) 2016; 17:1112-30. [PMID: 26814256 PMCID: PMC4894244 DOI: 10.1093/pm/pnv020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/21/2015] [Accepted: 09/06/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Evaluate the human abuse potential (HAP) of an experimental, microsphere-in-capsule formulation of extended-release oxycodone (oxycodone DETERx®) (herein "DETERx"). DESIGN Randomized, double-blind, double-dummy, positive- and placebo-controlled, single-dose, four-phase, four-treatment, crossover study. SETTING Clinical research site. SUBJECTS There were 39 qualifying subjects (72% male, 85% white, mean age of 27 years) with 36 completing all four Double-blind Treatment Periods. METHODS The four phases encompassed: 1) Screening; 2) Drug Discrimination; 3) Double-blind Treatment; and 4) Follow-up. Drug Discrimination tests ensured that subjects could distinguish placebo from opioid. The four Double-blind Treatments compared DETERx-administered as either a crushed intranasal (IN) or an intact oral (PO) preparation-with immediate-release oxycodone IN (OXY-IR IN) and with an intact IN and PO placebo DETERx control. RESULTS For primary pharmacokinetic (PK) assessments, abuse quotient (Cmax/Tmax) was lower with DETERx IN than DETERx PO; both treatments were substantially lower than OXY-IR IN (6.24, 8.60, and 69.6 ng/mL/h, respectively). For drug liking, the primary subjective pharmacodynamic (PD) endpoint, both DETERx IN and DETERx PO produced significantly lower scores than OXY-IR IN (P ≤ 0.0001 for each); DETERx IN was less liked than DETERx PO (P ≤ 0.05), mirroring the PK relationships. Objectively assessed pupillometry corroborated the more rapid and significantly greater effect of OXY-IR IN than either DETERx IN or DETERx PO (P ≤ 0.007 for each). Overall safety profiles of DETERx and OXY-IR were comparable and both were well tolerated. CONCLUSIONS Pharmacokinetic and pharmacodynamic outcomes suggest that DETERx IN has relatively low HAP; continued research in larger populations is suggested.
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Affiliation(s)
- Lynn R Webster
- *Early Development Services, Scientific Affairs, PRA Health Sciences, Salt Lake City, Utah, USA;
| | | | - Michael D Smith
- *Early Development Services, Scientific Affairs, PRA Health Sciences, Salt Lake City, Utah, USA
| | - Alison B Fleming
- Product Development, Collegium Pharmaceutical Inc., Canton, Massachusetts, USA
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Webster LR, Brennan MJ, Kwong LM, Levandowski R, Gudin JA. Opioid abuse-deterrent strategies: role of clinicians in acute pain management. Postgrad Med 2015; 128:76-84. [DOI: 10.1080/00325481.2016.1113841] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Peacock A, Degenhardt L, Larance B, Cama E, Lintzeris N, Ali R, Bruno R. A typology of people who tamper with pharmaceutical opioids: responses to introduction of a tamper-resistant formulation of controlled-release oxycodone. Pharmacoepidemiol Drug Saf 2015; 24:1321-33. [PMID: 26419615 DOI: 10.1002/pds.3883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/10/2015] [Accepted: 09/06/2015] [Indexed: 11/07/2022]
Abstract
PURPOSE In April 2014, a tamper-resistant controlled-release oxycodone formulation was released in Australia. We aimed to determine whether there are latent classes of people who tamper with pharmaceutical opioids based on frequency of opioid and illicit drug use, the demographic and clinical profiles of these groups, and if there were changes in use and harms following the introduction. METHODS A prospective cohort of 606 people who regularly tamper with pharmaceutical opioids was interviewed January to March 2014 (Wave 1) and May to August 2014 (Wave 2). Latent class analysis identified groups based on non-prescribed opioid, illicit drug and prescribed opioid substitution therapy (OST) use at Wave 1. Regression models examined whether group membership predicted use and harms at Wave 2. RESULTS Four groups were identified: frequent OST group (39%), mixed OST/heroin group (7%), infrequent pharmaceutical opioid and heroin group (44%) and frequent oxycodone group (25%). Compared with the frequent OST group, the infrequent pharmaceutical opioid/heroin group was more likely to report non-everyday pain and risky alcohol use, and the frequent oxycodone group had higher odds of homelessness. At Wave 2, oxycodone use decreased across groups (odds ratios (OR) ≤ 0.18, p < 0.001, particularly for the frequent oxycodone group: OR ≤ 0.05, p < 0.001), with reductions in days of use (g ≥ 0.35, p < 0.050). Non-prescribed pharmaceutical opioid use, illicit drug use and harms remained stable or decreased. CONCLUSIONS Despite heterogeneity among people who tamper with pharmaceutical opioids, the tamper-resistant formulation was followed by reductions in oxycodone tampering among high-frequency and low-frequency users. There was no evidence of increased use of other opioids or illicit drugs.
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Affiliation(s)
- Amy Peacock
- School of Medicine (Psychology), University of Tasmania, Hobart, Tasmania, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Elena Cama
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, Faculty of Medicine, Sydney University, Sydney, New South Wales, Australia.,The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Sydney, New South Wales, Australia
| | - Robert Ali
- University of Adelaide, Adelaide, South Australia, Australia
| | - Raimondo Bruno
- School of Medicine (Psychology), University of Tasmania, Hobart, Tasmania, Australia
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Morton TL, Devarakonda K, Kostenbader K, Montgomery J, Barrett T, Webster L. Correlation of Subjective Effects with Systemic Opioid Exposure from Fixed-Dose Combinations of Oxycodone/Acetaminophen in Recreational Users of Prescription Drugs. PAIN MEDICINE 2015; 17:539-550. [PMID: 26304767 DOI: 10.1111/pme.12884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To correlate abuse-related pharmacodynamic measures and pharmacokinetic measures after administering immediate-release/extended-release and immediate-release oxycodone/acetaminophen fixed-dose combination analgesicsDesign. Randomized, double-blind, active- and placebo-controlled, 7-way crossover studySetting. Contract research organizationSubjects. Nondependent recreational users of prescription opioids. METHODS Participants received single doses of intact immediate-release/extended-release and immediate-release oxycodone/acetaminophen 15/650 mg, intact immediate-release/extended-release and immediate-release oxycodone/acetaminophen 30/1,300 mg, crushed immediate-release/extended-release and immediate-release oxycodone/acetaminophen 30/1,300 mg, and placebo. Measures of pharmacodynamics (pupillometry, drug liking, drug high, good drug effects) and pharmacokinetics were assessed predose and up to 24 hours postdose, and correlations between pharmacokinetic parameters and pharmacodynamic data were explored. RESULTS Of 61 participants, 55 completed all 7 treatments. Intact immediate-release/extended-release oxycodone/acetaminophen produced 50% lower oxycodone peak plasma concentration (Cmax) than immediate-release oxycodone/acetaminophen. Median oxycodone time to Cmax (tmax) was significantly longer (P<0.001) for intact immediate-release/extended-release oxycodone/acetaminophen than immediate-release oxycodone/acetaminophen. The pharmacokinetics of crushed immediate-release/extended-release and immediate-release oxycodone/acetaminophen (30/1,300 mg) followed a similar pattern. Crushing did not shorten the median oxycodone tmax for immediate-release/extended-release oxycodone/acetaminophen (30/1,300 mg). Strong correlations were observed between oxycodone Cmax and area under the curve from time 0 to time x peak effects and area under the subjective effect curve from time 0 to time x for all subjective effects (R2=0.711-0.997). CONCLUSION Immediate-release/extended-release oxycodone/acetaminophen produced lower oxycodone Cmax and longer tmax than immediate-release oxycodone/acetaminophen. Lower oxycodone concentrations, particularly at earlier time points, were strongly correlated with lesser positive subjective drug effects.
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Affiliation(s)
| | | | | | - Jeannie Montgomery
- Clinical Trial Manager, Clinical Affairs and Program Management, Mallinckrodt Pharmaceuticals, Hazelwood, Missouri, USA
| | - Thomas Barrett
- Clinical Trial Manager, Clinical Affairs and Program Management, Mallinckrodt Pharmaceuticals, Hazelwood, Missouri, USA
| | - Lynn Webster
- Scientific Affairs, PRA Health Sciences, Salt Lake City, Utah, USA
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MacDonald LE, Onsrud JE, Mullins-Hodgin R. Acute Sensorineural Hearing Loss After Abuse of an Inhaled, Crushed Oxymorphone Extended-Release Tablet. Pharmacotherapy 2015; 35:e118-21. [DOI: 10.1002/phar.1605] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Lisa E. MacDonald
- Novant Health Forsyth Medical Center; Winston-Salem North Carolina and Novant Health Kernersville Medical Center Kernersville North Carolina
| | - Jennifer E. Onsrud
- Novant Health Forsyth Medical Center; Winston-Salem North Carolina and Novant Health Kernersville Medical Center Kernersville North Carolina
| | - Rita Mullins-Hodgin
- Novant Health Forsyth Medical Center; Winston-Salem North Carolina and Novant Health Kernersville Medical Center Kernersville North Carolina
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Colucci SV, Perrino PJ, Shram M, Bartlett C, Wang Y, Harris SC. Abuse potential of intravenous oxycodone/naloxone solution in nondependent recreational drug users. Clin Drug Investig 2015; 34:421-9. [PMID: 24756361 PMCID: PMC4026623 DOI: 10.1007/s40261-014-0192-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Abuse of opioid analgesics has become a public health issue. Some opioid abusers use intravenous administration to increase the magnitude of positive reinforcing effects. Intravenous co-administration of oxycodone with naloxone, an opioid antagonist, may reduce these rewarding effects and discourage abuse. A 2:1 oxycodone:naloxone (OXN) tablet formulation has been studied in the USA for the management of moderate-to-severe chronic pain. Intravenous administration of a 2:1 oxycodone:naloxone solution (sOXN) reflects the oxycodone:naloxone ratio found in laboratory studies of OXN following tampering for intravenous administration. The objective of this study was to characterize abuse-deterrent properties of sOXN. METHODS This single-center, double-blind, randomized, placebo-controlled, active-controlled, crossover study enrolled nondependent recreational opioid users with experience using multiple (two or more) routes of administration. Following demonstration that subjects could discern between placebo and oxycodone, 24 eligible male and female subjects were randomized to receive intravenous injections of 0.07 mg/kg oxycodone (OXY), 0.07 mg/kg oxycodone and 0.035 mg/kg naloxone solution (sOXN), or matching placebo over three visits. Pharmacokinetics, pharmacodynamics, safety, and tolerability were assessed at scheduled times up to 8 h post-dose. Parameters were computed and statistically compared among treatments. RESULTS Pharmacokinetics were similar between OXY and sOXN. Subjects reported significantly fewer rewarding effects with sOXN compared with OXY; differences between sOXN and placebo were generally not significant. sOXN was well tolerated. CONCLUSIONS Significant reductions in drug liking and other subjective effects following administration of sOXN compared with OXY indicate that naloxone concentrations were sufficient to antagonize the effects of oxycodone when abused by the intravenous route of administration in opioid-experienced drug users.
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Affiliation(s)
- Salvatore V Colucci
- Purdue Pharma L.P., One Stamford Forum, 201 Tresser Blvd, Stamford, CT, 06901, USA
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Gould HJ, Paul D. Hydrocodone extended-release: Pharmacodynamics, pharmacokinetics and behavioral pharmacology of a controversy. Pharmacol Res 2015; 91:99-103. [DOI: 10.1016/j.phrs.2014.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 09/24/2014] [Accepted: 09/24/2014] [Indexed: 01/30/2023]
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Abstract
Pain remains a serious consequence of cancer and its treatment. Although significant advances have been made in providing effective cancer pain control, barriers persist. Lack of knowledge, limited time, financial restrictions, and diminished availability of necessary medications serve as significant obstacles. Safe and effective opioid use in a patient with cancer requires skill to overcome these challenges. Understanding the mechanism of action, along with the pharmacokinetics and pharmacodynamics, of opioids will lead to appropriate selection, dosing, and titration of these agents. Rotation from one opioid or route to another is an essential proficiency for oncologists. As opioid-related adverse effects often occur, the oncology team must be expert in preventing and managing constipation, nausea, sedation, and neurotoxicities. An emerging concern is overtreatment-the excessive and prolonged use of opioids in patients when these agents may produce more harm than benefit. This can occur when opioids are used inappropriately to treat comorbid psychologic issues such as anxiety and depression. Recognizing risk factors for overuse along with key components of universal precautions will promote safe use of these medications, supporting adherence and preventing diversion, thereby protecting the patient, the prescriber, and the community. Because substance use disorders are not rare in the oncology setting, attention must be given to the balance of providing analgesia while limiting harm. Caring for patients with substance misuse requires compassionate, multidisciplinary care, with input from supportive oncology/palliative care as well as addiction specialists.
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Affiliation(s)
- Eduardo Bruera
- From the The University of Texas MD Anderson Cancer Center, Houston, TX; Feinberg School of Medicine, Northwestern University, Chicago, IL; Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Judith A Paice
- From the The University of Texas MD Anderson Cancer Center, Houston, TX; Feinberg School of Medicine, Northwestern University, Chicago, IL; Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
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Voon P, Callon C, Nguyen P, Dobrer S, Montaner JSG, Wood E, Kerr T. Denial of prescription analgesia among people who inject drugs in a Canadian setting. Drug Alcohol Rev 2014; 34:221-8. [PMID: 25521168 DOI: 10.1111/dar.12226] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 10/05/2014] [Indexed: 01/18/2023]
Abstract
INTRODUCTION AND AIMS Despite the high prevalence of pain among people who inject drugs (PWIDs), clinicians may be reluctant to prescribe opioid-based analgesia to those with a history of drug use or addiction. We sought to examine the prevalence and correlates of PWIDs reporting being denied of prescription analgesia (PA). We also explored reported reasons for and actions taken after being denied PA. DESIGN AND METHODS Using data from two prospective cohort studies of PWIDs, multivariate logistic regression was used to identify the prevalence and correlates of reporting being denied PA. Descriptive statistics were used to characterise reasons for denials and subsequent actions. RESULTS Approximately two-thirds (66.5%) of our sample of 462 active PWIDs reported having ever been denied PA. We found that reporting being denied PA was significantly and positively associated with having ever been enrolled in methadone maintenance treatment (adjusted odds ratio 1.76, 95% confidence interval 1.11-2.80) and daily cocaine injection (adjusted odds ratio 2.38, 95% confidence interval 1.00-5.66). The most commonly reported reason for being denied PA was being accused of drug seeking (44.0%). Commonly reported actions taken after being denied PA included buying the requested medication off the street (40.1%) or obtaining heroin to treat pain (32.9%). DISCUSSION AND CONCLUSIONS These findings highlight the challenges of addressing perceived pain and the need for strategies to prevent high-risk methods of self-managing pain, such as obtaining diverted medications or illicit substances for pain. Such strategies may include integrated pain management guidelines within methadone maintenance treatment and other substance use treatment programs.
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Affiliation(s)
- Pauline Voon
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
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Argoff CE, Kopecky EA. Patients with chronic pain and dysphagia (CPD): unmet medical needs and pharmacologic treatment options. Curr Med Res Opin 2014; 30:2543-59. [PMID: 25244248 DOI: 10.1185/03007995.2014.967388] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND For properly selected patients experiencing chronic pain, extended-release opioid formulations may represent an appropriate pain management choice. For the many adults, elderly, and children who have medical conditions that make swallowing solid, oral-dose formulations difficult (dysphagia) or painful (odynophagia), this option may be limited. The combination of chronic pain with dysphagia (CPD) presents a challenge to physicians and patients alike when oral opioid analgesia is needed to control pain, but patients are unable to swallow solid, oral dosage forms. METHODS A Medline search was performed (1990 to 2013) using the search terms swallowing difficulties, dysphagia, odynophagia, adults, pediatrics, elderly, chronic pain, pain, and opioids. The following websites were searched: American Dysphagia Network, Dysphagia Research Society, World Health Organization, American Pain Society, International Association for the Study of Pain, American Academy of Pain Medicine, and American Society of Interventional Pain Physicians. Chronic pain guidelines from the following professional organizations were searched: American Pain Society, National Comprehensive Cancer Network, American Society of Interventional Pain Physicians, British Geriatric Society, European Society of Medical Oncology, World Health Organization, and the European Association for Palliative Care. FINDINGS There is an unmet medical need for greater recognition of dysphagia, awareness of potential problems with medication administration in these patients, recognition of alternative drug formulations that are available for use in CPD, and an appreciation that there are new, solid, oral-dose, opioid formulations in development that can mitigate these issues associated with swallowing difficulty while still providing practical, effective analgesia. Current pharmacologic treatments have limitations; new, prospective opioid formulations in clinical development may offer physicians and patients with CPD effective treatment options while mitigating accidental exposure and abuse liability. CONCLUSIONS The number of patients with CPD may be larger than is currently anticipated by healthcare providers. Physicians should proactively include a discussion of dysphagia as part of the patient examination. CPD is an unmet medical need. There are novel opioid formulations in clinical development that address the limitations of current opioid treatments. This manuscript reviews the problems associated with dysphagia on medication administration and adherence, currently available treatment options, and opioid analgesic formulations currently in clinical development.
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Voon P, Callon C, Nguyen P, Dobrer S, Montaner J, Wood E, Kerr T. Self-management of pain among people who inject drugs in Vancouver. Pain Manag 2014; 4:27-35. [PMID: 24641341 DOI: 10.2217/pmt.13.62] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
AIMS To evaluate factors and methods associated with self-management of pain among people who inject drugs (IDUs) in Vancouver (Canada). PATIENTS & METHODS This cross-sectional study used bivariate statistics and multivariate logistic regression to analyze self-reported responses among 483 IDUs reporting moderate-to-extreme pain in two prospective cohort studies from 1 December 2012 to 31 May 2013. RESULTS Median age was 49.6 years (interquartile range: 43.9-54.6 years), 33.1% of IDUs were female and 97.5% reported self-management of pain. Variables independently and positively associated with self-managed pain included having been refused a prescription for pain medication (adjusted odds ratio: 7.83; 95% CI: 1.64-37.3) and having ever been homeless (adjusted odds ratio: 3.70; 95% CI: 1.00-13.7). Common methods of self-management of pain included injecting heroin (52.7%) and obtaining diverted prescription pain medication from the street (65.0%). CONCLUSION Self-management of pain was common among IDUs who reported moderate-to-extreme pain in this setting, particularly among those who had been refused a prescription for pain medication and those who had ever been homeless. These data highlight the challenges of adequate pain management among IDUs.
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Affiliation(s)
- Pauline Voon
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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Mastropietro DJ, Omidian H. Abuse-deterrent formulations: Part 2: commercial products and proprietary technologies. Expert Opin Pharmacother 2014; 16:305-23. [DOI: 10.1517/14656566.2014.970175] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David J Mastropietro
- Nova Southeastern University, College of Pharmacy, Department of Pharmaceutical Sciences, 3200 South University Drive, Fort Lauderdale, FL 33328, USA
| | - Hossein Omidian
- Nova Southeastern University, College of Pharmacy, Department of Pharmaceutical Sciences, 3200 South University Drive, Fort Lauderdale, FL 33328, USA
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Correlates and Consequences of Opioid Misuse among High-Risk Young Adults. JOURNAL OF ADDICTION 2014; 2014:156954. [PMID: 25506462 PMCID: PMC4259139 DOI: 10.1155/2014/156954] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/01/2014] [Accepted: 11/01/2014] [Indexed: 11/25/2022]
Abstract
Background. Prescription opioids are the most frequently misused class of prescription drug among young adults aged 18–25, yet trajectories of opioid misuse and escalation are understudied. We sought to model opioid misuse patterns and relationships between opioid misuse, sociodemographic factors, and other substance uses. Methods. Participants were 575 young adults age 16–25 who had misused opioids in the last 90 days. Latent class analysis was performed with models based on years of misuse, recency of misuse, and alternate modes of administration within the past 12 months, 3 months, and 30 days. Results. Four latent classes emerged that were differentially associated with heroin, cocaine, and methamphetamine use, tranquilizer misuse, daily opioid misuse, and opioid withdrawal. Alternate modes of administering opioids were associated with increased risk for these outcomes. Sociodemographic factors, homelessness, prescription history, and history of parental drug use were significantly associated with riskier opioid misuse trajectories. Conclusion. Young adults who reported more debilitating experiences as children and adolescents misused opioids longer and engaged in higher risk alternate modes of administering opioids. Data on decisions both to use and to alter a drug's form can be combined to describe patterns of misuse over time and predict important risk behaviors.
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Morton T, Kostenbader K, Montgomery J, Devarakonda K, Barrett T, Webster L. Comparison of subjective effects of extended-release versus immediate-release oxycodone/acetaminophen tablets in healthy nondependent recreational users of prescription opioids: a randomized trial. Postgrad Med 2014; 126:20-32. [PMID: 25141240 DOI: 10.3810/pgm.2014.07.2780] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prescription opioids have substantial abuse potential. This study compared the positive subjective drug effects of a newly developed extended-release (ER) oxycodone (OC)/acetaminophen (acetyl-para-aminophenol [APAP]) formulation with those of immediate-release (IR) OC/APAP. METHODS This randomized, double-blind, active- and placebo-controlled, 7-way crossover study enrolled healthy volunteers who were recreational prescription opioid users. The protocol was approved by an institutional review board and all participants provided written informed consent. Participants received single doses of intact ER and IR OC/APAP 15/650 mg, intact ER and IR OC/APAP 30/1300 mg, crushed ER and IR OC/APAP 30/1300 mg, and placebo. Peak subjective effects (Emax), time to Emax, and area under the drug-effect curves for drug liking, drug high, and good drug effects were measured using visual analogue scales. Least squares means with 95% confidence interval were compared using analysis of variance. RESULTS Among completers (N = 55), intact ER OC/APAP produced delayed and lower peak effects versus IR OC/APAP. Comparing intact tablets, the drug liking Emax (least squares means [95% confidence interval]) was significantly lower for OC/APAP 30/1300 mg (76.4 [72.8 to 80.0]) than for IR OC/APAP 30/1300 mg (85.6 [81.9 to 89.2]; difference, -9.2 [-13.1 to -5.2]; P < 0.001). Similar results were observed for intact ER and IR OC/APAP (15 mg/650 mg). Crushing ER OC/APAP 30/1300 mg further delayed these effects compared with the same dose of crushed IR OC/APAP and intact ER OC/APAP. CONCLUSIONS Extended-release OC/APAP produced lower subjective drug effects than IR OC/APAP. Crushing ER OC/APAP further delayed onset of subjective effects compared with intact ER OC/APAP. The ER OC/APAP may be less attractive for abuse than IR OC/APAP. CLINICAL TRIAL REGISTRATION This phase 1 study conducted in the United States was not registered.
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Affiliation(s)
- Terri Morton
- Senior Principal Pharmacokinetic Scientist, PRA Healthsciences, Salt Lake City, UT
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Kestenbaum MG, Vilches AO, Messersmith S, Connor SR, Fine PG, Murphy B, Davis M, Muir JC. Alternative routes to oral opioid administration in palliative care: a review and clinical summary. PAIN MEDICINE 2014; 15:1129-53. [PMID: 24995406 DOI: 10.1111/pme.12464] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.
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Abstract
BACKGROUND Buprenorphine/naloxone is an effective medication used to treat opioid dependence. Patients in treatment and those using it illegally without prescriptions have discussed using buprenorphine/naloxone anonymously on Internet discussion boards. Their beliefs about self-treatment and efforts to self-treat are not well known. OBJECTIVES To identify facilitators of self-treatment by online buprenorphine/naloxone users. METHODS A qualitative, retrospective study of discussion board postings from September 2010 to November 2012 analyzed 121 threads from 13 discussion boards using grounded theory. RESULTS Facilitators of self-management themes that emerged included: (1) a ready supply of buprenorphine/naloxone from a variety of sources; (2) distrust of buprenorphine prescribers and pharmaceutical companies; (3) the declaration that buprenorphine/naloxone is a "bad-tasting" medicine; (4) the desire to adopt a different delivery method other than sublingually; and (5) a desire to become completely "substance-free." The sublingual film formulation appears to be an important facilitator in self-treatment because it can more easily be apportioned to extend the medication because of limited supply, cost, or to taper. CONCLUSIONS/IMPORTANCE: The findings indicate a range of self-management activities ranging from altering the amount taken to modifying the physical medication composition or changing the administration route; some of these behaviors constitute problematic extra-medical use. Contributors to discussion boards seem to trust each other more than they trust pharmacists and prescribing physicians. The shared knowledge and behaviors of this understudied online community are important to healthcare providers because of the previously unknown precautions and risks taken to self-treat.
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Affiliation(s)
- Shan-Estelle Brown
- Department of Internal Medicine, Section of Infectious Diseases-AIDS Program, Yale University School of Medicine , New Haven, Connecticut , USA
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Victorri-Vigneau C, Collin C, Messina-Gourlot C, Raffournier C, Mallaret M, Besse J, Courne MA, Richard N, Sébille V, Arnaud P. Designing a tool allowing for a standardized assessment of resistance to drug diversion. Expert Opin Drug Deliv 2014; 11:995-1004. [DOI: 10.1517/17425247.2014.901307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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DePriest AZ, Miller K. Oxycodone/Naloxone: role in chronic pain management, opioid-induced constipation, and abuse deterrence. Pain Ther 2014; 3:1-15. [PMID: 25135384 PMCID: PMC4108020 DOI: 10.1007/s40122-014-0026-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Indexed: 01/31/2023] Open
Abstract
The use of opioids in the treatment of chronic pain is widespread; the prevalence of specific opioids varies from country to country and depends on product availability, national formulary systems, and provider preferences. Patients often receive opioids for legitimate treatment of pain conditions, but on the opposite side of the spectrum, nonmedical use of opioids is a significant public health concern. Opioids are associated with several side effects, and constipation is the most commonly reported and persistent symptom. Unlike some adverse effects associated with opioid use, tolerance does not develop to constipation. Opioid-induced constipation (OIC) is the most prevalent patient complaint associated with opioid use and has been associated with declines in various quality of life measures. OIC can be extremely difficult for patients to tolerate and may prompt patients to decrease or discontinue opioid treatment. Current management strategies for OIC are often insufficient. A prolonged-release formulation of oxycodone/naloxone (OXN) has been investigated for the treatment of nonmalignant and cancer pain and mitigation of OIC, and evidence is largely favorable. Studies have demonstrated the capability of OXN to alleviate OIC while maintaining pain control comparable to oxycodone-only regimens. There is insufficient evidence for OXN efficacy for patients with mild OIC or patients maintained on high doses of opioids, and use in these populations is controversial. The reduction of costs associated with OIC may provide overall cost effectiveness with OXN. Additionally, the presence of naloxone may deter abuse/misuse by those seeking to misuse the formulation by modes of administration other than oral ingestion. Most studies to date have occurred in European countries, and phase 3 trials continue in the United States. This review will include current therapeutic options for pain and constipation, unique characteristics of OXN, evidence related to use of OXN and its place in therapy, discussion of opioid abuse/misuse, and various abuse-deterrent mechanisms, and areas of continuing research.
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Evaluation of the resistance of a geopolymer-based drug delivery system to tampering. Int J Pharm 2014; 465:169-74. [DOI: 10.1016/j.ijpharm.2014.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 02/12/2014] [Accepted: 02/15/2014] [Indexed: 11/20/2022]
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Prevalence of Axis-1 psychiatric (with focus on depression and anxiety) disorder and symptomatology among non-medical prescription opioid users in substance use treatment: systematic review and meta-analyses. Addict Behav 2014; 39:520-31. [PMID: 24333033 DOI: 10.1016/j.addbeh.2013.11.022] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/23/2013] [Accepted: 11/22/2013] [Indexed: 12/17/2022]
Abstract
Non-medical prescription opioid use (NMPOU) constitutes a substantial clinical and public health concern in North America. Although there is evidence of elevated rates of mental health problems among people with NMPOU, the extent of these correlations specifically in treatment samples has not been systematically assessed. A systematic review and meta-analysis were conducted for Axis-1 psychiatric diagnoses and symptoms with a principal focus on depression and anxiety disorders in substance use treatment samples reporting NMPOU at admission to treatment (both criteria within past 30days). 11 unique studies (all from either the United States or Canada) met inclusion criteria and were included in the meta-analysis. The pooled prevalence of 'any' mental health problems (both diagnosis and symptoms) among substance abuse treatment patients reporting NMPOU was 43% (95% CI: 32%-54%; I(2) for inter-study heterogeneity: 99.5%). The pooled prevalence of depression diagnosis among substance abuse treatment patients reporting NMPOU was 27% (95% CI: 9%-45%; I(2): 99.2%); the pooled prevalence of anxiety diagnosis in the sample was 29% (95% CI: 14%-44%; I(2): 98.7%). The prevalence rates of psychiatric problems (both diagnosis and symptoms), depression diagnosis and anxiety diagnosis are disproportionately high in substance use treatment samples reporting NMPOU relative to general population rates. Adequate and effective clinical strategies are needed to address co-occurring NMPOU and mental health in substance use treatment systems, especially given rising treatment demand for NMPOU. Efforts are needed to better understand the temporal and causal relationships among NMPOU, mental health problems, and treatment seeking in order to improve interventions.
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Schatman ME, Darnall BD. A practical and ethical solution to the opioid scheduling conundrum. J Pain Res 2013; 7:1-3. [PMID: 24353439 PMCID: PMC3862644 DOI: 10.2147/jpr.s58148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Beth D Darnall
- Stanford University School of Medicine, Division of Pain Medicine, Palo Alto, CA, USA
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Butler SF, Zacharoff K, Charity S, Lawler K, Jamison RN. Electronic opioid risk assessment program for chronic pain patients: barriers and benefits of implementation. Pain Pract 2013; 14:E98-E105. [PMID: 24279713 DOI: 10.1111/papr.12141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/15/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A preliminary electronic pain assessment program known as Pain Assessment Interview Network, Clinical Advisory System (painCAS), was implemented in 2 pain centers over the course of 10 months to understand the tool's impact on opioid risk assessment documentation and clinical workflow. The program contains validated electronic versions of screeners for opioid misuse risk (SOAPP-R and Current Opioid Misuse Measure). METHODS Charts of patients with an initial and 2 follow-up visits were randomly selected for review of presence of opioid risk assessments before and after implementation of the electronic assessment program. Clinical and administrative staff members were interviewed to gain their perceptions of the impact of the program. RESULTS Significant increases were observed in the documentation of opioid risk assessments between the baseline patient chart reviews before implementation of the program (n = 66) and the postintervention patient chart reviews after the implementation of the program (n = 39), for both initial and follow-up clinic visits (P < 0.001). Specific benefits of the program identified by 7 clinicians and 8 administrators included ease of use, reduced paperwork, completion of the assessment before the clinic visit, and incorporation of information directly into an electronic medical record (EMR). Perceived barriers to implementation included poor patient compliance, changes in administration workflow, and difficulties associated with patients with no email addresses, and limited computer skills. CONCLUSIONS Implementation of an opioid risk electronic pain assessment program significantly increased the likelihood that a risk assessment would be included in the medical record, which has implications for improvement of quality of care.
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Papaseit E, Pérez-Mañá C, Torrens M, Farré M. [Abuse-related adverse drug reactions and abuse deterrent formulations]. Med Clin (Barc) 2013; 141:454-8. [PMID: 24144061 DOI: 10.1016/j.medcli.2013.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/19/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Esther Papaseit
- Grupo de Investigación Clínica en Farmacología Humana y Neurociencias, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Parc de Salut Mar, Barcelona, España; Departamento de Farmacología, de Terapéutica y de Toxicología, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona, España; Departamento de Psiquiatría, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Barcelona, España
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Pappagallo M, Sokolowska M. The implications of tamper-resistant formulations for opioid rotation. Postgrad Med 2013; 124:101-9. [PMID: 23095430 DOI: 10.3810/pgm.2012.09.2588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Because rates of both opioid prescribing and opioid abuse have increased, drug companies have responded by considering strategies to make opioid formulations less attractive for abuse without compromising safety or efficacy for patients with legitimate pain management needs. The emergence of tamper-resistant opioid formulations is intended to deter abuse by creating obstacles to crushing or dissolving opioid tablets and capsules. At present, 2 long-acting and 1 immediate-release (IR) opioids are available in tamper-resistant formulations. Oxycodone controlled-release and oxymorphone extended-release tablets have each been reformulated with a hardened matrix that resists crushing or dissolution in liquids, making them difficult to prepare for nasal insufflation or intravenous use. Oxycodone IR has been reformulated with aversive ingredients that create nasal discomfort if the tablet is crushed and insufflated. Tamper-resistant opioid formulations are likely to be selected for patients who are identified as being at risk for abuse. However, patients vary in their response to individual opioids and may require rotation to a series of alternative opioids before finding one that is effective and sufficiently well tolerated. With only a few tamper-resistant opioid formulations currently available, switching and rotation may become difficult. As a result, patients who do not respond to a tamper-resistant opioid formulation or experience intolerable adverse events may require rotation to a formulation without tampering safeguards. Prescribers will need to be on guard for patients who may make false claims of poor response or adverse events to avoid tamper-resistant opioid formulations. Moreover, prescribers need to be aware of any tamper-resistance mechanisms that may affect efficacy or tolerability in patients with legitimate pain management needs compared with formulations without tampering safeguards.
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Affiliation(s)
- Marco Pappagallo
- Director of Pain Management and Medical Mentoring, The New Medical Home for Chronic Pain, New York, NY 10010, USA.
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Kaye AM, Kaye AD, Lofton EC. Basic concepts in opioid prescribing and current concepts of opioid-mediated effects on driving. Ochsner J 2013; 13:525-532. [PMID: 24358001 PMCID: PMC3865831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Many patients with chronic pain receive substandard analgesic therapy. Incomplete or inadequate care often stems from physician fears of patient addiction and/or drug toxicity. As a result, many chronic pain patients are undertreated and have unrelieved pain that tempts them to overuse or to abuse prescribed pharmacologic treatments. In the last few years, educational efforts have targeted physicians who treat chronic, nonmalignant pain with information to improve prescribing strategies and to appreciate side effects. Additionally, opioid prescribing guidelines and educational programs, including World Health Organization-published guidelines for the management of cancer pain in 1986 and the American Pain Society's promotion of pain as the 5(th) vital sign, have increased the propensity of pharmacists, physicians, and pain specialists to dispense pain treatments. METHODS Controversial and evolving consequences from this explosion of prescription opioid use have emerged and are discussed in this review, including prescribing principles, opioid analgesic side effects, and driving concerns. CONCLUSION With additional appreciation for the untoward effects of chronic analgesia and a better understanding of opioid pharmacology, physicians can utilize pain management treatments in a safer and more effective manner.
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Affiliation(s)
- Adam M. Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA
| | - Alan D. Kaye
- Departments of Anesthesiology and Pharmacology, Louisiana State University School of Medicine, New Orleans, LA
| | - Elise C. Lofton
- Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA
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Lourenço LM, Matthews M, Jamison RN. Abuse-deterrent and tamper-resistant opioids: how valuable are novel formulations in thwarting non-medical use? Expert Opin Drug Deliv 2012; 10:229-40. [PMID: 23252692 DOI: 10.1517/17425247.2013.751095] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION In recent years, attention has been given to the development of abuse-deterrent and tamper-resistant opioid formulations in light of concern over the growing misuse and abuse of opioids prescribed for the treatment of chronic pain. AREAS COVERED This critical review discusses abuse-deterrent and tamper-resistant formulations, which may help to overcome concerns of misuse in using opioids for pain management. The role and utility of these novel formulations in clinical practice are outlined, as well as the risks and benefits associated with formulations that are currently available or under development. EXPERT OPINION Numerous concerns with the integration of these formulations into clinical practice remain, as no product is intended or capable of addressing all types of misuse or abuse. As a result, these formulations should not necessarily be considered preferred agents once available in clinical practice. Moreover, before initiating therapy with abuse-deterrent and tamper-resistant formulations, proper patient assessment to identify risk factors for misuse and abuse should be implemented and optimized. With screening and monitoring in place, it would then be sensible to consider these formulations in patients who appear to be at high risk of misuse, abuse and/or diversion.
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Affiliation(s)
- Laura M Lourenço
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
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Pergolizzi JV. Treatment of Chronic Pain in Older People: Evidence-Based Choice of Strong-Acting Opioids. Drugs Aging 2012; 29:993-5; author reply 997-8. [DOI: 10.1007/s40266-012-0025-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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