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Le Cornec C, Le Pottier M, Broch H, Marguinaud Tixier A, Rousseau E, Laribi S, Janière C, Brenckmann V, Guillerm A, Deciron F, Kabbaj A, Jenvrin J, Péré M, Montassier E. Ketamine Compared With Morphine for Out-of-Hospital Analgesia for Patients With Traumatic Pain: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2352844. [PMID: 38285446 PMCID: PMC10825723 DOI: 10.1001/jamanetworkopen.2023.52844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024] Open
Abstract
Importance Pain is a common out-of-hospital symptom among patients, and opioids are often prescribed. Research suggests that overprescribing for acute traumatic pain is still prevalent, even when limits restricting opioid prescriptions have been implemented. Ketamine hydrochloride is an alternative to opioids in adults with out-of-hospital traumatic pain. Objective To assess the noninferiority of intravenous ketamine compared with intravenous morphine sulfate to provide pain relief in adults with out-of-hospital traumatic pain. Design, Setting, and Participants The Intravenous Subdissociative-Dose Ketamine Versus Morphine for Prehospital Analgesia (KETAMORPH) study was a multicenter, single-blind, noninferiority randomized clinical trial comparing ketamine hydrochloride (20 mg, followed by 10 mg every 5 minutes) with morphine sulfate (2 or 3 mg every 5 minutes) in adult patients with out-of-hospital trauma and a verbal pain score equal to or greater than 5. Enrollment occurred from November 23, 2017, to November 26, 2022, in 11 French out-of-hospital emergency medical units. Interventions Patients were randomly assigned to ketamine (n = 128) or morphine (n = 123). Main Outcomes and Measures The primary outcome was the between-group difference in mean change in verbal rating scale pain scores measured from the time before administration of the study drug to 30 minutes later. A noninferiority margin of 1.3 was chosen. Results A total of 251 patients were randomized (median age, 51 [IQR, 34-69] years; 111 women [44.9%] and 140 men [55.1%] among the 247 with data available) and were included in the intention-to-treat population. The mean pain score change was -3.7 (95% CI, -4.2 to -3.2) in the ketamine group compared with -3.8 (95% CI, -4.2 to -3.4) in the morphine group. The difference in mean pain score change was 0.1 (95% CI, -0.7 to 0.9) points. There were no clinically meaningful differences for vital signs between the 2 groups. The intravenous morphine group had 19 of 113 (16.8% [95% CI, 10.4%-25.0%]) adverse effects reported (most commonly nausea [12 of 113 (10.6%)]) compared with 49 of 120 (40.8% [95% CI, 32.0%-49.6%]) in the ketamine group (most commonly emergence phenomenon [24 of 120 (20.0%)]). No adverse events required intervention. Conclusions and Relevance In the KETAMORPH study of patients with out-of-hospital traumatic pain, the use of intravenous ketamine compared with morphine showed noninferiority for pain reduction. In the ongoing opioid crisis, ketamine administered alone is an alternative to opioids in adults with out-of-hospital traumatic pain. Trial Registration ClinicalTrials.gov Identifier: NCT03236805.
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Affiliation(s)
- Clément Le Cornec
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | | | - Hélène Broch
- Urgences Service Mobile d’Urgence et de Réanimation (SMUR), Centre Hospitalier Chateaubriant, Chateaubriant, France
| | - Alexandre Marguinaud Tixier
- Pôle Urgences Adultes–Service d’Aide Médicale Urgente (SAMU), Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | | | - Said Laribi
- Centre Hospitalier Régional et Universitaire Tours Urgences SAMU 37 SMUR de Tours, Tours, France
| | - Charles Janière
- SAMU85 Centre Hospitalier Départemental Vendée la Roche sur Yon, la Roche sur Yon, France
| | | | | | - Florence Deciron
- Centre Hospitalier Le Mans SAMU 72 SMUR du Mans, Le Mans, France
| | - Amine Kabbaj
- Centre Hospitalier Saint Nazaire Urgences SMUR de Saint Nazaire, Saint Nazaire, France
| | - Joël Jenvrin
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Morgane Péré
- Plateforme de Méthodologie et Biostatistique, CHU Nantes, Nantes, France
| | - Emmanuel Montassier
- Department of Emergency Medicine, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
- Center for Research in Transplantation and Translational Immunology, Unité Mixte de Recherche 1064, Nantes Université, CHU Nantes, Institut National de la Santé et de la Recherche Médicale, Nantes, France
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Althagafi SM, Hughes JA. Identifying the relationship between patient-reported outcomes and treatment with opiates in the adult emergency department - A cross-sectional study. Int Emerg Nurs 2022; 62:101152. [PMID: 35245729 DOI: 10.1016/j.ienj.2022.101152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/09/2022] [Accepted: 01/31/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Suhair M Althagafi
- School of Nursing, Queensland University of Technology, Brisbane, Australia; College of Nursing, Umm AlQura University, Makkah, Saudi Arabia
| | - James A Hughes
- School of Nursing, Queensland University of Technology, Brisbane, Australia.
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Phaugat P, Nishal S, Dhiman R. Abuse Deterrent Formulations in Constraining the Abuse Potential of Prescription Medicines: A Myth or Truth. Curr Drug Deliv 2021; 19:466-478. [PMID: 34353262 DOI: 10.2174/1567201818666210805145819] [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: 12/19/2020] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diverse pain killers used for the management of varied categories of pain are being misused in order to have extreme pleasant effect by a large number of populations. To overcome the misuse of prescription drugs, regulatory bodies have given stress on development of abuse resistance. METHODS We studied numerous literatures: (1) Research and review papers including the guidelines for pain management, abuse, and abuse deterrence; (2) Description and categorization of pain along with the management approaches; (3) advantages and disadvantages of the abuse deterrent formulations were described. RESULTS Abuse deterrent formulations are the contemporary remedial treatment for pain with reduced prospects of being abused. But these comprise the huge expense in contrast to the generic drugs as well as the non-deterrent branded equivalents. CONCLUSION Many challenges are faced throughout the development of abuse deterrent formulations. These formulations displayed substantial drop in abuse incidences but it may lead to other modes of abuse which may prove more harmful for the users.
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Affiliation(s)
- Parmita Phaugat
- Drug Safety Associate; Pharmacovigilance, Parexel International. India
| | - Suchitra Nishal
- College of Pharmacy, University of Health Sciences Rohtak. India
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Smolev ET, Rolf L, Zhu E, Buday SK, Brody M, Brogan DM, Dy CJ. "Pill Pushers and CBD Oil"-A Thematic Analysis of Social Media Interactions About Pain After Traumatic Brachial Plexus Injury. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 3:36-40. [PMID: 33537664 PMCID: PMC7853657 DOI: 10.1016/j.jhsg.2020.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose Brachial plexus injury (BPI) patients use on-line groups for peer support, often seeking information from Facebook groups devoted to BPI. We hypothesized that a qualitative thematic analysis of posts from BPI Facebook groups would demonstrate the areas in which patients were seeking information regarding treatment of BPI and reveal potential sources of misinformation that patients may encounter. Methods We identified the 2 most popular public Facebook groups for BPI by searching key words “traumatic brachial plexus injury.” We selected posts containing comments regarding BPI from November 1, 2018 through October 31, 2019. We excluded posts regarding brachial plexus birth injury. We used iterative inductive and deductive thematic analysis for the qualitative data to identify recurring topics, knowledge gaps, potential roles of patient educational interventions, and patient interaction dynamics. Two investigators independently coded all posts and resolved discrepancies by discussion. Results A total of 7,694 posts from 2 leading Facebook support groups were analyzed. Three themes emerged: (1) When discussing pain management, there was recurring anti-opioid sentiment. Posters who currently used opioids or supported those who did discussed perceived effects of the opioid epidemic on their treatment, on their relationships with care providers, and on availability of the medication. (2) Posters advocated for alternatives to traditional approaches to pain management, referring to prescribers as pill pushers and touting cannabinoids as a safer and more effective replacement. (3) There was strong anti-gabapentinoid sentiment owing to reported adverse effects and a perceived lack of efficacy, despite its role as a first-line treatment for neuropathic pain. Conclusions Examination of posts from Facebook support groups for BPI revealed recurring themes, questions, misinformation, and opinions from posters with regard to treatment of neuropathic pain. These findings can help clinicians who care for BPI patients identify areas to focus on during patient encounters to address neuropathic pain that commonly occurs with BPI. Clinical relevance Brachial plexus injury surgeons should be aware of information, misinformation, and opinions on social media, because these may influence patient–surgeon interactions.
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Affiliation(s)
- Emma T Smolev
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St Louis, MO
| | - Liz Rolf
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO
| | - Eric Zhu
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St Louis, MO
| | - Sarah K Buday
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Madison Brody
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St Louis, MO
| | - David M Brogan
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St Louis, MO
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St Louis, MO.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO
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5
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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: 3.4] [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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Le Cornec C, Lariby S, Brenckmann V, Hardouin JB, Ecoffey C, Le Pottier M, Fradin P, Broch H, Kabbaj A, Auffret Y, Deciron F, Longo C, Javaudin F, Le Bastard Q, Jenvrin J, Montassier E. Is intravenously administered, subdissociative-dose KETAmine non-inferior to MORPHine for prehospital analgesia (the KETAMORPH study): study protocol for a randomized controlled trial. Trials 2018; 19:260. [PMID: 29716637 PMCID: PMC5930801 DOI: 10.1186/s13063-018-2634-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 04/10/2018] [Indexed: 04/18/2023] Open
Abstract
Background Acute pain is a common condition among prehospital patients and prompt management is pivotal. Opioids are the most frequently analgesics used in the prehospital setting. However, opioids are highly addictive, and some patients may develop opioid dependence, even when they are exposed to brief opioid treatments. Therefore, alternative non-opioid analgesia should be developed to manage pain in the prehospital setting. Used at subdissociative doses, ketamine, a noncompetitive N-methyl-D-aspartate and glutamate receptor antagonist, provides analgesic effects accompanied by preservation of protective airway reflexes. In this context, we will carry out a randomized controlled, open-label, multicenter trial to compare a subdissociative dose of ketamine to morphine to provide pain relief in the prehospital setting, in patients with traumatic and non-traumatic pain. Methods/design This will be a multicenter, single-blind, randomized controlled trial. Consecutive adults will be enrolled in the prehospital setting if they experience moderate to severe, acute, non-traumatic and traumatic pain, defined as a numeric rating scale score greater or equal to 5. Patients will be randomized to receive ketamine or morphine by intravenous push. The primary outcome will be the between-group difference in mean change in numeric rating scale pain scores measured from the time before administration of the study medication to 30 min later. Discussion This upcoming randomized clinical trial was design to assess the efficacy and safety of ketamine, an alternative non-opiate analgesia, to manage non-traumatic and traumatic pain in the prehospital setting. We aim to provide evidence to change prescribing practices to reduce exposition to opioids and the subsequent risk of addiction. Trial registration ClinicalTrials.gov, ID: NCT03236805. Registered on 2 August 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2634-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clément Le Cornec
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
| | - Said Lariby
- Tours University Hospital, Emergency Medicine Department, Tours, France
| | - Vivien Brenckmann
- Emergency Department and Mobile Intensive Care Unit, CHU Grenoble Alpes, 38043, Grenoble Cedex 09, France
| | - Jean Benoit Hardouin
- SPHERE U1246, Inserm, université de Nantes-université de Tours, 44000, Nantes, France
| | - Claude Ecoffey
- Department of Anaesthesia-Emergencies-Intensive Care and Internal Medicine and Geriatrics, Hôpital Pontchaillou, Université de Rennes 1, 2 Rue Henri Le Guilloux, 35033, Rennes Cedex, France
| | - Marion Le Pottier
- Emergency Department, Centre Hospitalier Universitaire Angers, Angers, France
| | - Philippe Fradin
- Emergency Department, La Roche sur Yon Hospital, La Roche Sur Yon, France
| | - Hélène Broch
- Emergency Department, Châteaubriant Hospital, Châteaubriant, France
| | - Amine Kabbaj
- Emergency Department, Saint Nazaire Hospital, Saint Nazaire, France
| | - Yannick Auffret
- Quimper Hospital CHIC, Emergency Department SAMU, 29000, Quimper, France
| | | | - Céline Longo
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
| | - François Javaudin
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
| | | | - Joël Jenvrin
- Emergency Department, Nantes University Hospital, 44000, Nantes, France
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Puntillo K, Naidu RK. Measurement of Chronic Pain and Opioid Use Evaluation in Community-Based Persons with Serious Illnesses. J Palliat Med 2018; 21:S43-S51. [PMID: 29091525 PMCID: PMC5756460 DOI: 10.1089/jpm.2017.0457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic pain associated with serious illnesses is having a major impact on population health in the United States. Accountability for high quality care for community-dwelling patients with serious illnesses requires selection of metrics that capture the burden of chronic pain whose treatment may be enhanced or complicated by opioid use. OBJECTIVE Our aim was to evaluate options for assessing pain in seriously ill community dwelling adults, to discuss the use/abuse of opioids in individuals with chronic pain, and to suggest pain and opioid use metrics that can be considered for screening and evaluation of patient responses and quality care. DESIGN Structured literature review. MEASUREMENTS Evaluation of pain and opioid use assessment metrics and measures for their potential usefulness in the community. RESULTS Several pain and opioid assessment instruments are available for consideration. Yet, no one pain instrument has been identified as "the best" to assess pain in seriously ill community-dwelling patients. Screening tools exist that are specific to the assessment of risk in opioid management. Opioid screening can assess risk based on substance use history, general risk taking, and reward-seeking behavior. CONCLUSIONS Accountability for high quality care for community-dwelling patients requires selection of metrics that will capture the burden of chronic pain and beneficial use or misuse of opioids. Future research is warranted to identify, modify, or develop instruments that contain important metrics, demonstrate a balance between sensitivity and specificity, and address patient preferences and quality outcomes.
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Affiliation(s)
- Kathleen Puntillo
- Department of Nursing, University of California, San Francisco, San Francisco, California
| | - Ramana K. Naidu
- Division of Pain Medicine, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
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Muir H, Seymour F. Screening tools to assess risk of opioid abuse in the Canadian primary healthcare setting. Nurse Pract 2017; 42:45-50. [PMID: 28346282 DOI: 10.1097/01.npr.0000508172.41410.3b] [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: 06/06/2023]
Abstract
Opioid therapy for patients with chronic pain is increasing in frequency along with rates of opioid abuse. Many screening tools are available to assess for the risk of opioid abuse. NPs should use screening tools that are cross-validated for use in chronic pain patients in the Canadian primary healthcare setting.
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Affiliation(s)
- Hollie Muir
- Hollie Muir is an NP at the Oromocto Health Centre, Oromocto, N.B., Canada. Fran Seymour is a senior teaching associate and NP at the University of New Brunswick, Frederickton, N.B., Canada
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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: 0.7] [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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Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med 2016; 35:337-341. [PMID: 27802876 DOI: 10.1016/j.ajem.2016.10.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022] Open
Abstract
The United States is currently experiencing a public health crisis of opioid addiction, which has its genesis in an industry marketing effort that successfully encouraged clinicians to prescribe opioids liberally, and asserted the safety of prescribing opioids for chronic non-cancer pain, despite a preponderance of evidence demonstrating the risks of dependence and misuse. The resulting rise in opioid use has pushed drug overdose deaths in front of motor vehicle collisions to become the leading cause of accidental death in the country. Emergency providers frequently treat patients for complications of opioid abuse, and also manage patients with acute and chronic pain, for which opioids are routinely prescribed. Emergency providers are therefore well positioned to both prevent new cases of opioid misuse and initiate appropriate treatment of existing opioid addicts. In opioid-naive patients, this is accomplished by a careful consideration of the likelihood of benefit and harm of an opioid prescription for acute pain. If opioids are prescribed, the chance of harm is reduced by matching the number of pills prescribed to the expected duration of pain and selecting an opioid preparation with low abuse liability. Patients who present to acute care with exacerbations of chronic pain or painful conditions associated with opioid misuse are best managed by treating symptoms with opioid alternatives and encouraging treatment for opioid addiction.
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Affiliation(s)
- Reuben J Strayer
- 79-01 Broadway, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst, NY 11373, United States.
| | - Sergey M Motov
- 4802 Tenth Ave, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, United States
| | - Lewis S Nelson
- 185 South Orange Avenue, Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
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Patient Perspectives of Acute Pain Management in the Era of the Opioid Epidemic. Ann Emerg Med 2015; 66:246-252.e1. [DOI: 10.1016/j.annemergmed.2015.03.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/19/2015] [Accepted: 03/23/2015] [Indexed: 11/18/2022]
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12
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McCarberg BH. Pain Management in Primary Care: Strategies to Mitigate Opioid Misuse, Abuse, and Diversion. Postgrad Med 2015; 123:119-30. [DOI: 10.3810/pgm.2011.03.2270] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ahern TL, Herring AA, Anderson ES, Madia VA, Fahimi J, Frazee BW. The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med 2015; 33:197-201. [DOI: 10.1016/j.ajem.2014.11.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 11/05/2014] [Accepted: 11/07/2014] [Indexed: 11/29/2022] Open
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Nalamachu S, Rauck RL, Hale ME, Florete OG, Robinson CY, Farr SJ. A long-term, open-label safety study of single-entity hydrocodone bitartrate extended release for the treatment of moderate to severe chronic pain. J Pain Res 2014; 7:669-78. [PMID: 25473308 PMCID: PMC4247141 DOI: 10.2147/jpr.s71536] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective To evaluate the long-term safety, tolerability, and effectiveness of single-entity extended-release hydrocodone in opioid-experienced subjects with moderate to severe chronic pain not receiving adequate pain relief or experiencing intolerable side effects from their current opioid. Methods This multicenter, open-label study started with a conversion/titration phase (≤6 weeks) where subjects (n=638) were converted to individualized doses (range 20–300 mg) of extended-release hydrocodone dosed every 12 hours, followed by a 48-week maintenance phase (n=424). The primary objective (safety and tolerability) and the secondary objective (long-term efficacy as measured by change in average pain score; 0= no pain, 10= worst imaginable pain) were monitored throughout the study. Results Subjects were treated for a range of chronic pain etiologies, including osteoarthritis, low back pain, and neuropathic and musculoskeletal conditions. The mean hydrocodone equivalent dose at screening was 68.9±62.2 mg/day and increased to 139.5±81.7 mg/day at the start of the maintenance phase. Unlimited dose adjustments were permitted at the investigator’s discretion during the maintenance phase, reflecting typical clinical practice. No unexpected safety issues were reported. Common adverse events during the conversion/titration and maintenance phases, respectively, were constipation (11.3% and 12.5%), nausea (10.7% and 9.9%), vomiting (4.1% and 9.7%), and somnolence (7.7% and 4.2%). Four deaths occurred during the study; all were considered unrelated to treatment. One subject died 13 months after the study ended. From the start to end of the conversion/titration phase, 84% of subjects had a clinically meaningful improvement in average pain score (≥30% improvement), and the mean average pain scores remained stable through the maintenance phase. Conclusion This single-entity, extended-release formulation of hydrocodone was generally safe, well tolerated, and effective in reducing chronic pain for 48 weeks. This formulation provides a new option for patients experiencing chronic pain, especially those who are taking immediate-release hydrocodone and have concerns about liver toxicity due to acetaminophen.
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Affiliation(s)
- Srinivas Nalamachu
- International Clinical Research Institute, Overland Park, KS, USA ; Kansas University Medical Center, Kansas City, KS, USA
| | - Richard L Rauck
- Carolinas Pain Institute, Center for Clinical Research, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Darwish M, Bond M, Tracewell W, Robertson P, Yang R. Pharmacokinetics of Hydrocodone Extended-Release Tablets Formulated with Different Levels of Coating to Achieve Abuse Deterrence Compared with a Hydrocodone Immediate-Release/Acetaminophen Tablet in Healthy Subjects. Clin Drug Investig 2014; 35:13-22. [DOI: 10.1007/s40261-014-0244-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Ahern TL, Herring AA, Stone MB, Frazee BW. Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J Emerg Med 2013; 31:847-51. [PMID: 23602757 DOI: 10.1016/j.ajem.2013.02.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 02/02/2013] [Accepted: 02/04/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain. METHODS This was a prospective observational study of adult patients with severe pain at an urban public hospital. We administered 0.5 mg of intravenous (IV) hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120 minutes using a 10-point verbal numerical rating scale (NRS). Patients were monitored throughout for adverse events. Dissociative side effects were assessed using the side effects rating scale for dissociative anesthetics. RESULTS Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9), 14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain score was 5.0 (SD, 2.8). The summed pain intensity difference and percent summed pain intensity difference scores were 25 (95% confidence interval [CI], 21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50% (95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only weak or modest side effects. Ninety percent of patients reported that they would have the medications again. No significant adverse events occurred. CONCLUSIONS Low-dose ketamine combined with a reduced dose hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain.
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Affiliation(s)
- Terence L Ahern
- Department of Emergency Medicine, Alameda County Medical Center, Highland Hospital, Oakland, CA 94602-1018, USA.
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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: 1.7] [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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Rockett IRH, Regier MD, Kapusta ND, Coben JH, Miller TR, Hanzlick RL, Todd KH, Sattin RW, Kennedy LW, Kleinig J, Smith GS. Leading causes of unintentional and intentional injury mortality: United States, 2000-2009. Am J Public Health 2012; 102:e84-92. [PMID: 22994256 PMCID: PMC3477930 DOI: 10.2105/ajph.2012.300960] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2012] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We have described national trends for the 5 leading external causes of injury mortality. METHODS We used negative binomial regression and annual underlying cause-of-death data for US residents for 2000 through 2009. RESULTS Mortality rates for unintentional poisoning, unintentional falls, and suicide increased by 128%, 71%, and 15%, respectively. The unintentional motor vehicle traffic crash mortality rate declined 25%. Suicide ranked first as a cause of injury mortality, followed by motor vehicle traffic crashes, poisoning, falls, and homicide. Females had a lower injury mortality rate than did males. The adjusted fall mortality rate displayed a positive age gradient. Blacks and Hispanics had lower adjusted motor vehicle traffic crash and suicide mortality rates and higher adjusted homicide rates than did Whites, and a lower unadjusted total injury mortality rate. CONCLUSIONS Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Suicide has surpassed motor vehicle traffic crashes as the leading cause of injury mortality. Comprehensive traffic safety measures have successfully reduced the national motor vehicle traffic crash mortality rate. Similar efforts will be required to diminish the burden of other injury.
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Affiliation(s)
- Ian R H Rockett
- Department of Epidemiology, School of Public Health, Robert C. Byrd Health Sciences Center, PO Box 9190, West Virginia University, Morgantown, WV 26506-9190, USA.
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Abstract
BACKGROUND Primary care physicians, nurse practitioners, and nurses are often the first to evaluate patients with pain and many patients depend on these clinicians for pain relief. The growing evidence supporting use of opioids for appropriately selected patients means that primary care practitioners must be knowledgeable regarding ever-evolving pain-management strategies. SCOPE This review summarizes core considerations in opioid prescribing in the primary care setting, the risks of undertreatment of pain, the challenges and barriers associated with prescribing opioids, identifying risk factors that may predict problematic use, and emerging formulation technologies expected to assist clinicians in better achieving effective pain control while minimizing risks for misuse or diversion. RESULTS Primary care physicians face considerable challenges in optimizing pain management while minimizing potential for misuse, abuse and diversion. Opioid treatment decisions are based not only on the type of pain but also the patient's psychosocial history, including a screening for predicting aberrant behaviors and, in some patients, substance abuse. New opioid formulations are available to assist clinicians in achieving adequate patient relief while reducing risk of tampering and abuse. Primary care practitioners need to be aware of these new options and integrate them into clinical treatment decisions. CONCLUSIONS The strategic use of new opioid formulations and better patient assessment may lead to more successful use of opioids in the management of pain, while limiting or lowering the risk of the development of an addiction problem, abuse or diversion.
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Affiliation(s)
- Steven Stanos
- Center for Pain Management, Rehabilitation Institute of Chicago, Chicago, IL 60611, USA.
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Stanos SP, Bruckenthal P, Barkin RL. Strategies to reduce the tampering and subsequent abuse of long-acting opioids: potential risks and benefits of formulations with physical or pharmacologic deterrents to tampering. Mayo Clin Proc 2012; 87:683-94. [PMID: 22766088 PMCID: PMC3498428 DOI: 10.1016/j.mayocp.2012.02.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 02/17/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
Increased prescribing of opioid analgesics for chronic noncancer pain may reflect acceptance that opioid benefits outweigh risks of adverse events for a broadening array of indications and patient populations; however, a parallel increase in the abuse, misuse, and diversion of prescription opioids has resulted. There is an urgent need to reduce opioid tampering and subsequent abuse without creating barriers to safe, effective analgesia. Similar to the "magic bullet" concept of antibiotic development (kill the bacteria without harming the patient), the idea behind reformulating opioid analgesics is to make them more difficult to tamper with and abuse by drug abusers but innocuous to the compliant patient. As antibiotics exploit differences in bacterial and human physiology, tamper-resistant formulations depend on differences in the way drug abusers and compliant patients consume opioids. Most opioid abusers tamper with tablets to facilitate oral, intranasal, or intravenous administration, whereas compliant patients usually take intact tablets. Pharmaceutical strategies to deter opioid abuse predominantly focus on tablet tampering, incorporating physical barriers (eg, crush resistance) or embedded chemicals that render tampered tablets inert, unusable, or noxious. Deterring tampering and abuse of intact tablets is more challenging. At present, only a few formulations with characteristics designed to oppose tampering for abuse have received approval by the US Food and Drug Administration, and none has been permitted to include claims of abuse deterrence or tamper resistance in their labeling. This review discusses the potential benefits, risks, and limitations associated with available tamper-resistant opioids and those in development.
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Affiliation(s)
- Steven P Stanos
- Rehabilitation Institute of Chicago, Center for Pain Management, Chicago, IL 60611, USA.
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Rubino D. Experience with an extended-release opioid formulation designed to reduce abuse liability in a community-based pain management clinic. Int J Gen Med 2011; 4:617-26. [PMID: 22069367 PMCID: PMC3206108 DOI: 10.2147/ijgm.s23042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
CONTEXT With the growing public health concern over rising rates of opioid abuse, physicians have a responsibility to incorporate safeguards into their practice to minimize the potential for opioid misuse, abuse, and diversion. Patient-specific treatment regimens should include steps to monitor treatment success with regard to optimal pain management as well as inappropriate use of opioids and other substances. Opioid formulations designed to be less attractive for abuse are also being developed. While future studies are needed to determine the impact of such formulations in addressing the issue of opioid misuse in the community as a whole, the experience of practitioners who have utilized these formulations can highlight the practical steps to incorporate such formulations into the everyday patient-care setting. PURPOSE The purpose of this report is to describe experience in managing patients with chronic, moderate-to-severe pain using morphine sulfate and naltrexone hydrochloride extended release capsules (MS-sNT) (EMBEDA(®), King Pharmaceuticals(®) Inc, Bristol, TN, which was acquired by Pfizer Inc, New York, NY, in March 2011), a formulation designed with features to deter abuse/misuse, in a community-based pain management clinic. CASE PRESENTATIONS Case reports demonstrating a clinical management plan for assessment, initial interview procedures, explanation/discussion of proposed therapies, patients' treatment goals, conversion to MS-sNT, and titration and treatment outcomes are provided. RESULTS The management approach yielded successful outcomes including pain relief, improved quality of life, treatment satisfaction, and patient acceptance of a formulation designed to deter abuse/misuse. DISCUSSION The cases presented demonstrate that the communication accompanying complete pretreatment assessment, goal-setting and expectations, and attention to individual patient needs can enable optimization of pain-related outcomes, resulting in improved quality of life for patients and fostering patient acceptance of formulations designed to help address opioid abuse/misuse issues in the community at large.
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Smith HS. Morphine sulfate and naltrexone hydrochloride extended release capsules for the management of chronic, moderate-to-severe pain, while reducing morphine-induced subjective effects upon tampering by crushing. Expert Opin Pharmacother 2011; 12:1111-25. [DOI: 10.1517/14656566.2011.571205] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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