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Arora I, Mal P, Arora P, Paul A, Kumar M. GABAergic implications in anxiety and related disorders. Biochem Biophys Res Commun 2024; 724:150218. [PMID: 38865810 DOI: 10.1016/j.bbrc.2024.150218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/05/2024] [Accepted: 06/02/2024] [Indexed: 06/14/2024]
Abstract
Evidence indicates that anxiety disorders arise from an imbalance in the functioning of brain circuits that govern the modulation of emotional responses to possibly threatening stimuli. The circuits under consideration in this context include the amygdala's bottom-up activity, which signifies the existence of stimuli that may be seen as dangerous. Moreover, these circuits encompass top-down regulatory processes that originate in the prefrontal cortex, facilitating the communication of the emotional significance associated with the inputs. Diverse databases (e.g., Pubmed, ScienceDirect, Web of Science, Google Scholar) were searched for literature using a combination of different terms e.g., "anxiety", "stress", "neuroanatomy", and "neural circuits", etc. A decrease in GABAergic activity is present in both anxiety disorders and severe depression. Research on cerebral functional imaging in depressive individuals has shown reduced levels of GABA within the cortical regions. Additionally, animal studies demonstrated that a reduction in the expression of GABAA/B receptors results in a behavioral pattern resembling anxiety. The amygdala consists of inhibitory networks composed of GABAergic interneurons, responsible for modulating anxiety responses in both normal and pathological conditions. The GABAA receptor has allosteric sites (e.g., α/γ, γ/β, and α/β) which enable regulation of neuronal inhibition in the amygdala. These sites serve as molecular targets for anxiolytic medications such as benzodiazepine and barbiturates. Alterations in the levels of naturally occurring regulators of these allosteric sites, along with alterations to the composition of the GABAA receptor subunits, could potentially act as mechanisms via which the extent of neuronal inhibition is diminished in pathological anxiety disorders.
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Affiliation(s)
- Indu Arora
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Pankaj Mal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Poonam Arora
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Anushka Paul
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Manish Kumar
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
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Ali R, Van Hout MC, Al-Mahaireh M, Wazaify M. Community pharmacists' experience of gabapentin misuse and abuse: A quantitative study from Jordan. J Ethn Subst Abuse 2024:1-17. [PMID: 38967590 DOI: 10.1080/15332640.2024.2361338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
Gabapentin is an anticonvulsant that has an abuse potential. The aim of this study was to investigate the misuse and abuse of gabapentin in Jordan from the perspective of community pharmacists. A cross-sectional survey using a self-reported structured questionnaire was used with a convenience sample of pharmacists employed by various independent and chain community pharmacies. An online technique was used in this study using Google forms. A total of 215 questionnaires were completed, with 200 respondents (93%) reporting awareness of cases of gabapentin abuse in their pharmacies. Less than half of the respondents (n = 94; 43.7%) indicated that gabapentin requests were not accompanied by prescriptions. Almost two-thirds of respondents (63.6%) noticed an increased pattern of gabapentin abuse/misuse during the last 6 months. The study underscores the need for regulatory efforts and pharmacovigilance to manage potential gabapentin abuse, along with pharmacist and patient education at the community pharmacy, regarding potential abuse of gabapentin.
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Affiliation(s)
- Russul Ali
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan
| | | | | | - Mayyada Wazaify
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan
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Mathieson S, Collie A, Maher CG, Abdel Shaheed C, Xia T, Gilbert S, Ferreira GE, Di Donato MF. Secular trends in gabapentinoid dispensing by compensated workers with low back pain: a retrospective cohort study. Occup Environ Med 2024; 81:245-251. [PMID: 38782576 PMCID: PMC11187357 DOI: 10.1136/oemed-2023-109369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES The increase in gabapentinoid prescribing is paralleling the increase in serious harms. To describe the low back pain workers compensation population whose management included a gabapentinoid between 2010 and 2017, and determine secular trends in, and factors associated with gabapentinoid use. METHODS We analysed claim-level and service-level data from the Victorian workers' compensation programme between 1 January 2010 and 31 December 2017 for workers with an accepted claim for a low back pain injury and who had programme-funded gabapentinoid dispensing. Secular trends were calculated as a proportion of gabapentinoid dispensings per year. Poisson, negative binomial and Cox hazards models were used to examine changes over time in incidence and time to first dispensing. RESULTS Of the 17 689 low back pain claimants, one in seven (14.7%) were dispensed at least one gabapentinoid during the first 2 years (n=2608). The proportion of workers who were dispensed a gabapentinoid significantly increased over time (7.9% in 2010 to 18.7% in 2017), despite a reduction in the number of claimants dispensed pain-related medicines. Gabapentinoid dispensing was significantly associated with an opioid analgesic or anti-depressant dispensing claim, but not claimant-level characteristics. The time to first gabapentinoid dispensing significantly decreased over time from 311.9 days (SD 200.7) in 2010 to 148.2 days (SD 183.1) in 2017. CONCLUSIONS The proportion of claimants dispensed a gabapentinoid more than doubled in the period 2010-2017; and the time to first dispensing halved during this period.
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Affiliation(s)
- Stephanie Mathieson
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alex Collie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Stephen Gilbert
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Giovanni E Ferreira
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael F Di Donato
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Moyo P, Merlin JS, Gairola R, Girard A, Shireman TI, Trivedi AN, Marshall BDL. Association of Opioid Use Disorder Diagnosis with Management of Acute Low Back Pain: A Medicare Retrospective Cohort Analysis. J Gen Intern Med 2024:10.1007/s11606-024-08799-3. [PMID: 38829451 DOI: 10.1007/s11606-024-08799-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 05/06/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Practice guidelines recommend nonpharmacologic and nonopioid therapies as first-line pain treatment for acute pain. However, little is known about their utilization generally and among individuals with opioid use disorder (OUD) for whom opioid and other pharmacologic therapies carry greater risk of harm. OBJECTIVE To determine the association between a pre-existing OUD diagnosis and treatment of acute low back pain (aLBP). DESIGN Retrospective cohort study using 2016-2019 Medicare data. PARTICIPANTS Fee-for-service Medicare beneficiaries with a new episode of aLBP. MAIN MEASURES The main independent variable was OUD diagnosis measured prior to the first LBP claim (i.e., index date). Using multivariable logistic regressions, we assessed the following outcomes measured within 30 days of the index date: (1) nonpharmacologic therapies (physical therapy and/or chiropractic care), and (2) prescription opioids. Among opioid recipients, we further assessed opioid dose and co-prescription of gabapentin. Analyses were conducted overall and stratified by receipt of physical therapy, chiropractic care, opioid fills, or gabapentin fills during the 6 months before the index date. KEY RESULTS We identified 1,263,188 beneficiaries with aLBP, of whom 3.0% had OUD. Two-thirds (65.8%) did not receive pain treatments of interest at baseline. Overall, nonpharmacologic therapy receipt was less prevalent and opioid and nonopioid pharmacologic therapies were more common among beneficiaries with OUD than those without OUD. Beneficiaries with OUD had lower odds of receiving nonpharmacologic therapies (aOR = 0.62, 99%CI = 0.58-0.65) and higher odds of prescription opioid receipt (aOR = 2.24, 99%CI = 2.17-2.32). OUD also was significantly associated with increased odds of opioid doses ≥ 90 morphine milligram equivalents/day (aOR = 2.43, 99%CI = 2.30-2.56) and co-prescription of gabapentin (aOR = 1.15, 99%CI = 1.09-1.22). Similar associations were observed in stratified groups though magnitudes differed. CONCLUSIONS Medicare beneficiaries with aLBP and OUD underutilized nonpharmacologic pain therapies and commonly received opioids at high doses and with gabapentin. Complementing the promulgation of practice guidelines with implementation science could improve the uptake of evidence-based nonpharmacologic therapies for aLBP.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Jessica S Merlin
- Division of General Internal Medicine, Challenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richa Gairola
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Anthony Girard
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Theresa I Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Amal N Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Novotny M, Bulla J, Hubl D, Fischer SKM, Grosshans M, Gutzeit A, Bilke-Hentsch O, Seifritz E, Mutschler J. Pregabalin use in forensic hospitals and prisons in German speaking countries-a survey study of physicians. Front Public Health 2024; 11:1309654. [PMID: 38259798 PMCID: PMC10800468 DOI: 10.3389/fpubh.2023.1309654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Background Pregabalin is a gamma-aminobutyric acid (GABA) analog that was approved in the EU in 2004 for the treatment of neuropathic pain, generalized anxiety disorder and epilepsy. Since its introduction, pregabalin abuse and misuse has increased significantly. In Switzerland, clinical reports suggest that pregabalin misuse is common among patients in forensic hospitals and prisons. However, data on pregabalin use is scarce, especially in these settings. Therefore, we conducted a study to explore patterns of pregabalin use among prison and forensic patients. Methods We used a questionnaire to survey physicians working in prison and forensic medicine in German-speaking countries. A total of 131 responses were received. Results According to the physicians' subjective assessment, 82.5% of them had observed a recent increase in pregabalin use by their patients and 89.1% of them reported that their patients requested pregabalin without a clear medical indication. Patients misusing pregabalin in combination with other illicit substances were observed by 93.3% of the physicians surveyed. According to 73.5% of the physicians surveyed, they had already encountered patients on pregabalin doses of more than 600 mg/day (the maximum recommended daily dose); the highest dose reported was 4,200 mg/day. According to 85.0% of physicians surveyed, they have observed patients experiencing withdrawal symptoms from pregabalin, with the most commonly reported symptoms being displeasure and high aggression. Regarding the nationality of pregabalin-misusing patients, 58.3% of the interviewed physicians reported to be rather in contact with foreign patients, mainly from Northwest Africa (Maghreb). Only 45.0% of the surveyed physicians prescribe pregabalin. Among patients who developed behavioral problems while taking pregabalin, none of the physicians (0.0%) showed a tendency to continue pregabalin at the same dose; all respondents chose to reduce/substitute/discontinue. Conclusion Our study has provided confirmatory evidence that the use of pregabalin presents a significant issue in forensic and prison medicine across German-speaking countries. Prescribing pregabalin in this field can compound use disorder problems and exacerbate challenges in daily life for those in forensic institutions or prisons. It is necessary that all physicians who prescribe pregabalin are clearly informed about the management (including the risks) of this drug.
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Affiliation(s)
- Michal Novotny
- Private Clinic Meiringen, Willigen, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Jan Bulla
- Clinic of Forensic Psychiatry and Psychotherapy, Reichenau Centre of Psychiatry, Reichenau, Germany
| | - Daniela Hubl
- Center of Forensic Psychiatry and Psychology, Universitäre Psychiatrische Dienste Bern (UPD), Bern, Switzerland
| | | | - Martin Grosshans
- Department of Global Health, Safety and Well-Being, Systemanalyse Programmentwicklung Societas Europaea (SAP SE), Walldorf, Germany
| | - Andreas Gutzeit
- Department of Radiology, Paracelsus Medical University, Salzburg, Austria
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Institute of Radiology and Nuclear Medicine and Breast Center St. Anna, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | | | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
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Oh J, Yeo J. Trends in the prescription of opioids and gabapentinoids in patients with failed back surgery syndrome in Korea: a population-based study. Korean J Pain 2024; 37:73-83. [PMID: 38130090 PMCID: PMC10764216 DOI: 10.3344/kjp.23246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
Background Failed back surgery syndrome (FBSS) is a chronic condition that is characterized by persistent back pain following one or more spinal surgeries. Pharmacological interventions, such as the use of opioids and gabapentinoids, are frequently used in the treatment of FBSS. However, prolonged and excessive use of these medications can lead to dependence and adverse effects. This study investigates trends in opioid and gabapentinoid prescriptions among patients with FBSS in Korea from 2016 to 2020. Methods Data from the Health Insurance and Review Agency were analyzed, and claims listing FBSS were selected for the study. Prescription patterns of opioids and gabapentinoids were classified based on the number of days prescribed per year. Results Of the 390,095 patients diagnosed with FBSS, 41.6% of the patients were prescribed gabapentinoids, and 42.0% of them were prescribed opioids, while 10.6% of the patients were classified as long-term gabapentinoid users, 11.4% as long-term opioid users, and 7.4% of the patients were found to have long-term prescriptions for both drugs. The proportion of patients who received both gabapentinoid and opioid prescriptions increased annually. The doses of opioids prescribed have also increased along with the increase in the number of patients receiving opioid prescriptions. Conclusions The prescription rates of opioids and gabapentinoids among patients with FBSS in Korea continue to increase steadily, posing potential risks of addiction and adverse effects. Further research is needed to better understand the actual status of addiction in patients with FBSS.
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Affiliation(s)
- Jinyoung Oh
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyunpook National University Chilgok Hospital, Daegu, Korea
| | - Jinseok Yeo
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyunpook National University Chilgok Hospital, Daegu, Korea
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Syed O, Jancic P, Fink AB, Knezevic NN. Drug Safety and Suicidality Risk of Chronic Pain Medications. Pharmaceuticals (Basel) 2023; 16:1497. [PMID: 37895968 PMCID: PMC10609967 DOI: 10.3390/ph16101497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/13/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023] Open
Abstract
Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.
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Affiliation(s)
- Osman Syed
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL 60515, USA
| | - Predrag Jancic
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
| | - Adam B. Fink
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Harborview Medical Center, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA
| | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center, Department of Anesthesiology, Chicago, IL 60657, USA; (O.S.); (P.J.); (A.B.F.)
- Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
- Department of Surgery, University of Illinois, Chicago, IL 60612, USA
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Polat CS, Konak HE, Akıncı MG, Onat SS, Altas EU. Misuse of gabapentinoids (pregabalin and gabapentin) in patients with neuropathic pain related to spinal cord injury. J Spinal Cord Med 2023; 46:859-864. [PMID: 35108174 PMCID: PMC10446779 DOI: 10.1080/10790268.2021.2024709] [Citation(s) in RCA: 1] [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: 10/19/2022] Open
Abstract
OBJECTIVE To investigate the misuse of gabapentinoids (pregabalin and gabapentin) in patients with neuropathic pain related to spinal cord injury. STUDY DESIGN Cross-sectional study. SETTING Outpatient clinic in a physical therapy and rehabilitation hospital. PARTICIPANTS 127 patients, aged 18-70 years, who had neuropathic pain related to spinal cord injury (SCI) and disease duration of at least 12 months. OUTCOME MEASURES Gabapentinoid use disorder of the patients was determined based on the DSM-5 diagnostic criteria for substance-related disorders. Patients were divided into 2 groups as those with drug misuse and those without drug misuse. Demographic and clinical information of the patients were compared between the groups. Factors associated with drug misuse were analyzed. RESULTS The misuse rate was 81.9% in patients using pregabalin and 69.69% in patients using gabapentin. Duration of disease and the Leeds assessment of neuropathic symptoms and signs (LANSS) score were statistically significantly higher in the drug misuse group. A statistically significant difference was found between the groups in terms of marital status, education and income level, and smoking and alcohol use. A statistically significant relationship was observed between drug misuse and duration of disease and LANSS score. CONCLUSION Misuse of gabapentinoids is prevalent in patients with neuropathic pain related to spinal cord injury. The duration of disease and the severity of NP are associated with misuse. Clinicians should exercise caution when prescribing gabapentinoids to patients with SCI.
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Affiliation(s)
- Cemile Sevgi Polat
- Ankara Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Hatice Ecem Konak
- Ankara Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Meltem Günes Akıncı
- Ankara Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Sule Sahin Onat
- Ankara Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Elif Umay Altas
- Ankara Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey
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Behmer Hansen RA, Behmer Hansen RT, Noureddine C, Behmer VA, Opler D. Reasons for use and experiences of using phenibut, a mixed methods analysis of online reports. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:458-469. [PMID: 37184879 DOI: 10.1080/00952990.2023.2204510] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 05/16/2023]
Abstract
Background: Phenibut is a drug similar in structure to gabapentin and pregabalin. It is available online without prescription, often marketed as a dietary supplement or amino acid derivative. Little is known about phenibut use despite its increased popularity in the United States over the last decade.Objective: To clarify reasons for taking phenibut, circumstances, and effects of use.Methods: Reports of phenibut, gabapentin, and pregabalin use were downloaded from a publicly-available database, Erowid.org. A mixed methods approach utilizing qualitative content analysis was used.Results: Of 229 reports, 211 were from male authors. People usually purchased phenibut online and reportedly used it for recreation, to manage a medical or psychiatric problem (primarily insomnia, anxiety), as a substitute for other drugs (especially benzodiazepines), to manage withdrawal from another substance (including benzodiazepines, opioids), and/or for performance enhancement. While it shared many reported effects with pregabalin and gabapentin such as anxiolysis, increased talkativeness, and impaired motor coordination, reports of gastrointestinal distress and sedation were more commonly attributed to phenibut. Several people reported difficulty in restricting their use and managing withdrawal.Conclusions: Phenibut reports suggest that phenibut may have some benefits for some people. Use also, however, carries risks of adverse effects, a potentially dangerous withdrawal syndrome, and addiction. Not dissimilar to unprescribed gabapentin or pregabalin, self-medication is a common motive for phenibut use. Physicians should continue to ask their patients about use of any non-prescribed medications, dietary supplements, or "amino acid derivatives."Abbreviation: PWUPh: people who use phenibut; PWUG: people who use gabapentin; PWUPr: people who use pregabalin.
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Affiliation(s)
| | | | - Chaden Noureddine
- Department of Psychiatry, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Virginia A Behmer
- Department of Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Douglas Opler
- Department of Psychiatry, Rutgers New Jersey Medical School, Newark, NJ, USA
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Janetzki JL, Pratt NL, Ward MB, Sykes MJ. Application of an Integrative Drug Safety Model for Detection of Adverse Drug Events Associated With Inhibition of Glutathione Peroxidase 1 in Chronic Obstructive Pulmonary Disease. Pharm Res 2023; 40:1553-1568. [PMID: 37173537 PMCID: PMC10338407 DOI: 10.1007/s11095-023-03516-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease is characterised by declining lung function and a greater oxidative stress burden due to reduced activity of antioxidant enzymes such as Glutathione Peroxidase 1. OBJECTIVES The extent to which drugs may contribute to this compromised activity is largely unknown. An integrative drug safety model explores inhibition of Glutathione Peroxidase 1 by drugs and their association with chronic obstructive pulmonary disease adverse drug events. METHODS In silico molecular modelling approaches were utilised to predict the interactions that drugs have within the active site of Glutathione Peroxidase 1 in both human and bovine models. Similarities of chemical features between approved drugs and the known inhibitor tiopronin were also investigated. Subsequently the Food and Drug Administration Adverse Event System was searched to uncover adverse drug event signals associated with chronic obstructive pulmonary disease. RESULTS Statistical and molecular modelling analyses confirmed that the use of several registered drugs, including acetylsalicylic acid and atenolol may be associated with inhibition of Glutathione Peroxidase 1 and chronic obstructive pulmonary disease. CONCLUSION The integration of molecular modelling and pharmacoepidemological data has the potential to advance drug safety science. Ongoing review of medication use and further pharmacoepidemiological and biological analyses are warranted to ensure appropriate use is recommended.
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Affiliation(s)
- Jack L. Janetzki
- UniSA: Clinical and Health Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, GPO Box 2471, Adelaide, SA 5001 Australia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, GPO Box 2471, Adelaide, SA 5001 Australia
| | - Michael B. Ward
- UniSA: Clinical and Health Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, GPO Box 2471, Adelaide, SA 5001 Australia
| | - Matthew J. Sykes
- UniSA: Clinical and Health Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
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Abstract
OBJECTIVE This article informs and updates the practicing neurologist on the current landscape of known neurologic injuries linked to the use of illicit drugs, focusing on emerging agents. LATEST DEVELOPMENTS Synthetic opioids such as fentanyl and similar derivatives have exploded in prevalence, becoming the leading cause of overdose fatalities. The higher potency of synthetic opioids compared with semisynthetic and nonsynthetic opiates poses an increased risk for unintentional overdose when found as an adulterant in other illicit drug supplies such as heroin. Conversely, misinformation about the risk of symptomatic exposure to fentanyl through casual contact with the skin and ambient air has led to misdirected fear and stigma that threatens to impede valid harm-reduction measures for fentanyl users at risk of actual overdose. Finally, during the COVID-19 pandemic, overdose rates and deaths continued to climb, especially among those who use opioids and methamphetamine. ESSENTIAL POINTS A variety of potential neurologic effects and injuries can occur with illicit drug use owing to the diverse properties and mechanisms of action of the various classes. Many high-risk agents are not detected on standard drug screens, including so-called designer drugs, and the practicing neurologist is best served by recognizing the clinical features of the traditional toxidrome and other potential idiosyncratic effects of various illicit agents.
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Patterns and Trends in Pharmacological Treatment for Outpatients with Postherpetic Neuralgia in Six Major Areas of China, 2015-2019. Healthcare (Basel) 2023; 11:healthcare11050764. [PMID: 36900769 PMCID: PMC10000853 DOI: 10.3390/healthcare11050764] [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: 12/12/2022] [Revised: 02/23/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
The aim of this study was to assess the patterns and trends of pharmacological treatment for outpatients with postherpetic neuralgia (PHN) in China in the period 2015-2019. Prescription data for outpatients with PHN were extracted from the database of the Hospital Prescription Analysis Program of China according to the inclusion criteria. The trends in yearly prescriptions and corresponding costs were analyzed and stratified by drug class and specific drugs. A total of 19,196 prescriptions from 49 hospitals in 6 major regions of China were included for analysis. The yearly prescriptions increased from 2534 in 2015 to 5676 in 2019 (p = 0.027), and the corresponding expenditures increased from CNY 898,618 in 2015 to CNY 2,466,238 in 2019 (p = 0.027). Gabapentin and pregabalin are the most commonly used drugs for PHN, and more than 30% of these two drugs were combined with mecobalamin. Opioids were the second most frequently prescribed drug class, and oxycodone accounted for the largest share of the cost. Topical drugs and TCAs are rarely used. The frequent use of pregabalin and gabapentin was in accordance with current guidelines; however, the use of oxycodone raised concerns about rationality and economic burden. The results of this study may benefit the allocation of medical resources and management for PHN in China and other countries.
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Bensen GP, Rogers AC, Leifer VP, Edwards RR, Neogi T, Kostic AM, Paltiel AD, Collins JE, Hunter DJ, Katz JN, Losina E. Does gabapentin provide benefit for patients with knee OA? A benefit-harm and cost-effectiveness analysis. Osteoarthritis Cartilage 2023; 31:279-290. [PMID: 36414225 PMCID: PMC9892279 DOI: 10.1016/j.joca.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/25/2022] [Accepted: 07/08/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Gabapentin can treat neuropathic pain syndromes and has increasingly been prescribed to treat nociplastic pain. Some patients with knee osteoarthritis (OA) suffer from both nociceptive and nociplastic pain. We examined the cost-effectiveness of adding gabapentin to knee OA care. METHOD We used the Osteoarthritis Policy Model, a validated Monte Carlo simulation of knee OA, to examine the value of gabapentin in treating knee OA by comparing three strategies: 1) usual care, gabapentin sparing (UC-GS); 2) targeted gabapentin (TG), which provides gabapentin plus usual care for those who screen positive for nociplastic pain on the modified PainDETECT questionnaire (mPD-Q) and usual care only for those who screen negative; and 3) universal gabapentin plus usual care (UG). Outcomes included cumulative quality-adjusted life years (QALYs), lifetime direct medical costs, and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. We derived model inputs from published literature and national databases and varied key input parameters in sensitivity analyses. RESULTS UC-GS dominated both gabapentin-containing strategies, as it led to lower costs and more QALYs. TG resulted in a cost increase of $689 and a cumulative QALY reduction of 0.012 QALYs. UG resulted in a further $1,868 cost increase and 0.036 QALY decrease. The results were robust to plausible changes in input parameters. The lowest TG strategy ICER of $53,000/QALY was reported when mPD-Q specificity was increased to 100% and AE rate was reduced to 0%. CONCLUSION Incorporating gabapentin into care for patients with knee OA does not appear to offer good value.
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Affiliation(s)
- G P Bensen
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - A C Rogers
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - V P Leifer
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - R R Edwards
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA.
| | - T Neogi
- Boston University School of Medicine, Boston, MA, USA.
| | - A M Kostic
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - A D Paltiel
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT, USA.
| | - J E Collins
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - D J Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia.
| | - J N Katz
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - E Losina
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.
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Antunovic M, Vucinic S, Kotur-Stevuljevic J, Krstic K, Jovic-Stosic J, Kilibarda V, Perkovic-Vukcevic N, Djordjevic S. Rise of Pregabalin Poisoning and Abuse Cases in Serbia: A Ten-Year Retrospective Study. Int J Gen Med 2023; 16:1239-1250. [PMID: 37065979 PMCID: PMC10094400 DOI: 10.2147/ijgm.s405616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023] Open
Abstract
Purpose The aim of this study was to analyze data on gabapentinoid-related attendances to the National Poison Control Center of Serbia (NPCC), particularly abuse cases; to estimate its changes and to compare it with trends in national consumption rates of these drugs. We also aimed to analyze the main characteristics of the study population and to investigate the major clinical effects in poisoned patients. Patients and Methods This is a retrospective study of patients admitted to the NPCC for acute poisoning involving gabapentinoids from 1 May 2012 to 1 October 2022. Results There were 357 (95.5%) pregabalin-related and 17 (4.5%) gabapentin-related poisoning cases in 302 patients. Abuse of pregabalin was detected in 27.8% (84/302), while gabapentin abuse occurred in 0.7% (2/302) of all patients. A steady increase in rates of pregabalin poisoning and abuse cases strongly correlated with the increase in overall consumption of this drug, while there were no significant changes in rates of gabapentin consumption, poisoning and abuse rate during the study period. Most patients who abused pregabalin pregabalin were males (84.5%) and the median age was 26 years (range: 15-45 years). Almost 60% of patients who abused pregabalin (48/84) belonged to the migrant population. Co-ingestions occurred in 89.4% of pregabalin-related cases (319/357), resulting in more severe poisoning. The most often co-ingested drugs were benzodiazepines and among them clonazepam was detected in the largest number of cases. Conclusion The poisoning and abuse cases involving pregabalin are on the rise in Serbia, which coincided with an increase in its overall consumption during the study period. Isolated pregabalin ingestions resulted in mild poisoning, although severe symptoms such as coma and bradycardia were recorded. When prescribing pregabalin to patients at risk of abuse caution is needed. Strengthening the measures for dispensing of pregabalin may reduce the risks associated with its abuse.
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Affiliation(s)
- Marko Antunovic
- Medical Faculty Military Medical Academy, University of Defense, Belgrade, Serbia
- National Poison Control Center, Military Medical Academy, Belgrade, Serbia
- Correspondence: Marko Antunovic, National Poison Control Center, Military Medical Academy, Crnotravska 17, Belgrade, 11040, Serbia, Tel +381 11 3608 264, Fax +381 11 367 21 87 264, Email
| | - Slavica Vucinic
- Medical Faculty Military Medical Academy, University of Defense, Belgrade, Serbia
- National Poison Control Center, Military Medical Academy, Belgrade, Serbia
| | - Jelena Kotur-Stevuljevic
- Department of Medical Biochemistry, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Kristijan Krstic
- Department of Physical Medicine and Rehabilitation, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Jasmina Jovic-Stosic
- Medical Faculty Military Medical Academy, University of Defense, Belgrade, Serbia
- National Poison Control Center, Military Medical Academy, Belgrade, Serbia
| | - Vesna Kilibarda
- Medical Faculty Military Medical Academy, University of Defense, Belgrade, Serbia
- National Poison Control Center, Military Medical Academy, Belgrade, Serbia
| | - Natasa Perkovic-Vukcevic
- Medical Faculty Military Medical Academy, University of Defense, Belgrade, Serbia
- National Poison Control Center, Military Medical Academy, Belgrade, Serbia
| | - Snezana Djordjevic
- Medical Faculty Military Medical Academy, University of Defense, Belgrade, Serbia
- National Poison Control Center, Military Medical Academy, Belgrade, Serbia
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Billig JI, Gunaseelan V, Yazdanfar M, Sears ED, Iwashyna TJ, Chang T, Waljee JF. Gabapentinoid Prescribing for Carpal Tunnel Syndrome. Hand (N Y) 2023; 18:106S-113S. [PMID: 35225033 PMCID: PMC9896291 DOI: 10.1177/15589447211063544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gabapentinoids, including gabapentin and pregabalin, are commonly prescribed for neuropathic pain, but robust evidence recommends against using gabapentinoids for the treatment of carpal tunnel syndrome (CTS). We aimed to quantify national prescribing patterns of gabapentinoids for CTS. METHODS We performed a retrospective population-based cohort study using claims data of gabapentinoid-naïve patients with a new diagnosis of CTS (2009-2016). Our primary outcome was a new gabapentinoid fill for CTS. We assessed temporal trends and characteristics associated with a gabapentinoid fill. Multivariable logistic regression was used to evaluate the association between patient-level factors and a new gabapentinoid fill for CTS. RESULTS Of the 248 324 previously gabapentinoid-naïve patients with CTS, 9589 patients (4%) filled a gabapentinoid prescription. Sixty-one percent were prescribed by primary care providers or medical subspecialists. Patients with a history of neck pain (odds ratio [OR]: 1.31, 95% confidence interval [CI], 1.25-1.38), back pain (OR: 1.25, 95% CI, 1.20-1.31), arthritis (OR: 1.25, 95% CI, 1.18-1.31), and other pain conditions (OR: 1.26, 95% CI, 1.20-1.31) were associated with an increased odds of a new gabapentinoid fill. In addition, patients with a history of alcohol or substance use disorder were significantly associated with a new gabapentinoid prescription fill (OR: 1.33, 95% CI, 1.20-1.47). CONCLUSIONS Despite evidence recommending against the use of gabapentinoids for CTS, gabapentinoids were frequently initiated among those with higher risk for misuse, including substance use disorders. Given the effectiveness of bracing or surgery for CTS and the risks associated with gabapentinoids, efforts aimed at disseminating evidence-based treatment for CTS are critical to minimize the harms of gabapentinoid misuse.
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Affiliation(s)
| | | | | | - Erika D. Sears
- University of Michigan, Ann Arbor,
USA
- VA Ann Arbor Healthcare System, MI,
USA
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Early Drug Prescription Patterns as Predictors of Final Workers Compensation Claim Costs and Closure: An Updated Analysis on an Expanded Cohort. J Occup Environ Med 2022; 64:1046-1052. [PMID: 35902352 DOI: 10.1097/jom.0000000000002636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of the study is to determine the associations of workers' compensation claim costs and return to work with drugs prescribed for early symptom management. METHODS Claims filed from 1998 to 2007 were followed for 10 years from the injury date. Drugs analyzed included gabapentin, pregabalin, antipsychotics, antidepressants, sedatives, benzodiazepines, carisoprodol, and opioids, controlling for initial reserve, sex, age, physical therapy, attorney involvement, and surgery. RESULTS Gabapentin, antipsychotics, antidepressants, and sedatives used in the first 3 months after injury were significantly associated with higher claim cost (≥$100,000). All opioid morphine equivalent doses greater than or equal to 5 mg/d for the first 6 months was significantly associated with higher cost (≥$100,000) and not being released to work at end of third year after injury with dose-response relationships. CONCLUSIONS Prescription patterns in the first 3 months or first 6 months of workers' compensation claim development may be used as predictors of claim outcomes.
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Structural Model Based on Genetic Algorithm for Inhibiting Fatty Acid Amide Hydrolase. AI 2022. [DOI: 10.3390/ai3040052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The fatty acid amide hydrolase (FAAH) is an enzyme responsible for the degradation of anandamide, an endocannabinoid. Pharmacologically blocking this target can lead to anxiolytic effects; therefore, new inhibitors can improve therapy in this field. In order to speed up the process of drug discovery, various in silico methods can be used, such as molecular docking, quantitative structure–activity relationship models (QSAR), and artificial intelligence (AI) classification algorithms. Besides architecture, one important factor for an AI model with high accuracy is the dataset quality. This issue can be solved by a genetic algorithm that can select optimal features for the prediction. The objective of the current study is to use this feature selection method in order to identify the most relevant molecular descriptors that can be used as independent variables, thus improving the efficacy of AI algorithms that can predict FAAH inhibitors. The model that used features chosen by the genetic algorithm had better accuracy than the model that used all molecular descriptors generated by the CDK descriptor calculator 1.4.6 software. Hence, carefully selecting the input data used by AI classification algorithms by using a GA is a promising strategy in drug development.
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Olopoenia A, Camelo-Castillo W, Qato DM, Adekoya A, Palumbo F, Sera L, Simoni-Wastila L. Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study. LANCET REGIONAL HEALTH. AMERICAS 2022; 13:100302. [PMID: 36777316 PMCID: PMC9904085 DOI: 10.1016/j.lana.2022.100302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Gabapentin, opioids, and/or benzodiazepines are commonly prescribed for a variety of pain and psychiatric conditions. Despite the high likelihood of co-prescription of these medications, little is known about co-utilization of gabapentin (GABA), opioids (OP), and benzodiazepines (BZD) and associated public health outcomes. Methods Using Medicare CCW Data, 2013-2016, we conducted a nested case-control study to examine the association between concurrent utilization of GABA, OP, and BZD and respiratory depression, opioid, and substance-related overdose among Medicare disabled beneficiaries. Cases and controls were Fee-for-service disabled beneficiaries who had a diagnosis of acute pain (AP), chronic pain (CP) or mental health conditions (MH) and received GABA, OP or BZD. Cases with respiratory depression, opioid or substance-related overdose were matched with up to 4 controls on socio-demographics, year of cohort entry and disease risk score. Primary exposure was concurrent medication utilization defined as an overlap of at least one day in prescriptions for GABA, OP and BZD. Findings Across all cohorts, the majority of cases and controls were under 65, female, dually eligible and had prior histories of pain and mental health conditions. GABA+OP+BZD use was associated with increased odds of respiratory depression [AOR(95%CI)-AP: 1.35 (1.19-1.52), CP:1.24 (1.11-1.38) and MH: 1.16 (1.02-1.32) vs. OP only], opioid-related overdose [AP: 1.43 (1.04-1.98), CP: 1.47 (1.07-2.00) and MH: 1.44 (1.04-2.00) vs. OP only], and substance-related overdose [AP: 1.77 (1.26-2.50), CP: 1.70 (1.24-2.34) and MH: 1.92 (1.31-2.82) vs. GABA only]. While there were cohort differences in the association between GABA+OP and both respiratory depression and opioid-related overdose, GABA+OP and GABA+BZD use were associated with significantly higher odds of substance-related overdose across all clinical cohorts. Interpretation Among Medicare disabled beneficiaries, concurrent utilization of gabapentin, opioids, and benzodiazepines is associated with multiple adverse outcomes. Given this, it is imperative that the benefits and risks of co-prescribing these medications be comprehensively examined. Funding None.
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Affiliation(s)
- Abisola Olopoenia
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,Corresponding author at: 2671 Avenir Pl, Vienna, VA, 22180.
| | - Wendy Camelo-Castillo
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA
| | - Danya M. Qato
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,School of Medicine, University of Maryland Baltimore, Baltimore, MD, USA
| | - Adepeju Adekoya
- Johns Hopkins Medicine, Department of Anesthesiology & Critical Care Medicine, Division of Chronic Pain Medicine, Baltimore, MD, USA
| | - Frank Palumbo
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA
| | - Leah Sera
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | - Linda Simoni-Wastila
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore, Baltimore, MD, USA
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Fernández-Liz E, Barceló-Colomer ME, Gómez-Ganda L, Varon-Galcera C, Lalueza-Broto P, Medel-Rebollo FJ, Hortelano-García MA, Martín-Gracia E. Prevalence of Gabapentinoids and Central Nervous System Depressant Drugs, and Their Association with Risk Factors for Respiratory Depression in Primary Care Patients. Clin Drug Investig 2022; 42:417-426. [PMID: 35446006 DOI: 10.1007/s40261-022-01144-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Warnings have been published regarding an increased risk of severe respiratory depression in patients receiving gabapentinoids either alone or in combination with opioids and/or anxiolytics/hypnotics, especially in individuals with a respiratory risk factor. The aim is to report the prevalence of the use of gabapentinoids alone and associated with central nervous system depressant drugs, and possible associated risk factors for respiratory depression, in order to identify the most fragile population and establish intervention strategies. METHODS We performed a cross-sectional study using computerized prescription records from the northern area of Barcelona at Catalan Institute of Health for 363,007 inhabitants registered during 2021. Patients aged ≥ 18 years with one or more gabapentinoid prescription were included. Age, gender, polypharmacy, adjusted morbidity groups, quantity of chronic diseases, and the number of consultations per year were independent variables. Four age categories were defined (18-64 years, then 64-74, 75-84, and those aged 85 years or older). Descriptive and inferential statistics were employed. Level of statistical significance was 5% (p ≤ 0.05). For the analysis, the SPSS program (version 22) was employed. RESULTS Of the study sample, 9218 were prescribed gabapentidoids. Overall prevalence of use was 3.0% (women 3.6%, men 2.4%). On the whole, women used more drugs than men. In contrast to their younger counterparts, consumption increased 2.6 times, 3.8 times, and 4.0 times in the 65-74 age group, 75-84 age group, and those aged ≥ 85 years, respectively. Mean age was 65.59 (±15.80) years. Polypharmacy (5-9 drugs) was present in 41.7% of the patients and extreme polypharmacy (≥ 10 drugs) was present in 39.3% of the patients. Regarding renal function, 2396 patients (25.9%) had glomerular filtration that required dose adjustment (76.1% with gabapentin and 23.8% with pregabalin). In 141 patients (5.9%), a total daily dose higher than that authorized (109 with gabapentin, 29 with pregabalin) had been prescribed. The prescription of gabapentinoids combined with opioids and/or anxiolytics/hypnotics was significantly associated with (i) polypharmacy (5-9 drugs, OR: 3.42 [95% CI 3.00-3.88]; ≥ 10 drugs, OR 8.72 [95% CI 7.42-10.25]); (ii) quantity of chronic diseases, OR: 1.14 (95% CI 1.11-1.17); (iii) augmented number of consultations/year, OR: 1.01 (95% CI 1.00-1.01); (iv) female gender, OR: < 1 for men, OR: 0.66 (95% CI 0.60-0.73); (v) being elderly: 65-74 years, OR: 0.71 (95% CI 0.62-0.81); 75-84 years, OR: 0.62 (95% CI 0.54-0.71); ≥85 years, OR: 0.68 (95% CI 0.58-0.81); and (vi) adjusted morbidity groups, OR: 0.90 (95% CI 0.88-0.92), (p < 0.0001). CONCLUSION Exposure to gabapentinoids occurs in a non-negligible percentage of the population. Greater numbers of combinations of gabapentinoids and opioids and/or anxiolytics/hypnotics were associated with polypharmacy, quantity of chronic diseases, and augmented number of consultations, but not with male gender, older age, and adjusted morbidity groups.
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Affiliation(s)
- Eladio Fernández-Liz
- Primary Health Care Barcelona, Gerència Territorial de Barcelona, Catalan Institute of Health, CAP Poble Nou. Carrer Lope de Vega 138, 6a planta, 08005, Barcelona, Spain.
| | - Maria Estrella Barceló-Colomer
- Primary Health Care Barcelona, Gerència Territorial de Barcelona, Catalan Institute of Health, CAP Poble Nou. Carrer Lope de Vega 138, 6a planta, 08005, Barcelona, Spain
| | - Laura Gómez-Ganda
- Pharmacy Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Carlota Varon-Galcera
- Pharmacy Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Pilar Lalueza-Broto
- Pharmacy Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Francisco Javier Medel-Rebollo
- Pain Unit, Anaesthesia, Resuscitation and Pain Management Department, Vall d'Hebron Hospital Universari, Vall d'Hebron Barcelona Hospital Campus, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain
| | - Maria Angeles Hortelano-García
- Primary Health Care Center Chafarinas, Gerencia Territorial de Barcelona, Catalan Institute of Health, Carrer Chafarinas, 2-8, 08033, Barcelona, Spain
| | - Elisabeth Martín-Gracia
- Primary Health Care Service Muntanya, Gerència Territorial de Barcelona, Catalan Institute of Health, Avenida Meridiana, 428, 08030, Barcelona, Spain
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Kalk NJ, Chiu CT, Sadoughi R, Baho H, Williams BD, Taylor D, Copeland CS. Fatalities associated with gabapentinoids in England (2004-2020). Br J Clin Pharmacol 2022; 88:3911-3917. [PMID: 35435281 PMCID: PMC9543893 DOI: 10.1111/bcp.15352] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
The gabapentinoids were reclassified as Schedule II medications and Class C drugs in the UK in 2019 due to their potential misuse. In this study we examined deaths following gabapentinoid use in England reported to the National Programme on Substance Abuse Deaths. A total of 3051 deaths were reported (gabapentin: 913 cases; pregabalin: 2322 cases [both detected in 184 cases]). Prescribed and illicitly obtained gabapentinoids accounted for similar proportions of deaths (gabapentin illicit 38.0%, prescribed 37.1%; pregabalin illicit 41.0%, prescribed 34.6%). Opioids were co‐detected in most cases (92.0%), and co‐prescribed in a quarter (25.3%). Postmortem blood gabapentinoid concentrations were commonly (sub)therapeutic (65.0% of gabapentin cases; 50.8% of pregabalin cases). In only two cases was gabapentinoid toxicity alone attributed in causing death. Gabapentinoids alone rarely cause death. Clinically relevant doses can, however, prove fatal, possibly by reducing tolerance to opioids. Doctors and patients should be aware of this interaction. Gabapentinoid–opioid co‐prescribing needs urgent revision.
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Affiliation(s)
- Nicola J Kalk
- Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, KCH Alcohol Care Team, London, UK
| | - Ching-Ting Chiu
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical. Science, King's College London, London, UK
| | - Rasa Sadoughi
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heli Baho
- Population Health Research Institute, St George's, University of London, London, UK
| | | | - David Taylor
- South London and Maudsley NHS Foundation Trust, KCH Alcohol Care Team, London, UK.,Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical. Science, King's College London, London, UK
| | - Caroline S Copeland
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical. Science, King's College London, London, UK.,Population Health Research Institute, St George's, University of London, London, UK
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Hill R, Conibear A, Dewey W, Kelly E, Henderson G. Role of Acetaldehyde in Ethanol Reversal of Tolerance to Morphine-Induced Respiratory Depression in Mice. ADVANCES IN DRUG AND ALCOHOL RESEARCH 2022; 1. [PMID: 35909497 PMCID: PMC7613180 DOI: 10.3389/adar.2021.10143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Opioid users regularly consume other drugs such as alcohol (ethanol). Acute administration of ethanol rapidly reverses tolerance to morphine-induced respiratory depression. However, recent research has suggested that the primary metabolite of ethanol, acetaldehyde, may play a key role in mediating the CNS effects seen after ethanol consumption. This research investigated the role of acetaldehyde in ethanol reversal of tolerance to morphine-induced respiratory depression.Methods: Tolerance was induced in mice by 6-days implantation of a 75 mg morphine pellet with control mice implanted with a placebo pellet. Tolerance was assessed by acute morphine administration on day 6 and respiration measured by plethysmography. Levels of acetaldehyde were inhibited or enhanced by pre-treatments with the acetaldehyde chelator D-penicillamine and the inhibitor of acetaldehyde dehydrogenase disulfiram respectively.Results: Morphine pellet implanted mice displayed tolerance to an acute dose of morphine compared to placebo pellet implanted controls. Acute acetaldehyde administration dose-dependently reversed tolerance to morphine respiratory depression. As previously demonstrated, ethanol reversed morphine tolerance, and this was inhibited by D-penicillamine pre-treatment. An acute, low dose of ethanol that did not significantly reverse morphine tolerance was able to do so following disulfiram pre-treatment.Conclusion: These data suggest that acetaldehyde, the primary metabolite of ethanol, is responsible for the reversal of morphine tolerance observed following ethanol administration.
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Affiliation(s)
- Rob Hill
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom
- Correspondence: Rob Hill,
| | - Alexandra Conibear
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom
| | - William Dewey
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - Eamonn Kelly
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Graeme Henderson
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom
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22
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Cakici OU, Kaya C, Sanci A, Gencler OS, Mammadkhanli O, Cindas A. Gabapentin add-on therapy for patients with spinal cord injury associated neurogenic overactive detrusors that are unresponsive to combined anticholinergic and beta-3 adrenergic therapy. Cent European J Urol 2022; 74:547-551. [PMID: 35083075 PMCID: PMC8771127 DOI: 10.5173/ceju.2021.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Spinal cord injury is a major cause of lifelong morbidity and functional micturition problems. Some patients are refractory to the available therapeutics, even when used in combination. In this paper we report our results of using gabapentin as an add-on treatment in refractory overactive detrusor cases secondary to spinal cord injury. Material and methods A total of 27 patients who had a spinal cord injury between the levels of the second thoracic and fourth lumbar vertebrae and had an overactive detrusor in urodynamic studies were included in this retrospective study. The patients were selected due to the fact that they also had not responded to a combination of an anticholinergic and mirabegron and had neuropathic pain. Gabapentin treatment was added to the previous therapy. Demographics, previous treatments, chronic conditions, urodynamic findings, clinical and urodynamic responses are reported in this paper. Results We observed a response to treatment in the urodynamic studies of 11 patients (40.17%), in terms of decreased detrusor contractions, maximal detrusor pressure, and the number of incontinence episodes. Sixteen patients did not respond to the gabapentin add-on therapy and were referred for Botulinum toxin injections to the bladder. Conclusions Gabapentin add-on therapy can be considered as a third or further option, before Botulinum toxin injection, for patients with neurogenic overactive detrusor who did not respond to the combination of anticholinergics and mirabegron. The approved usage of gabapentin for neurogenic pain justifies its usage in this area. In our selected patient group, who had not responded to the combination therapy, we observed a clinical benefit in one-third of the patients.
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Affiliation(s)
- Ozer Ural Cakici
- Department of Urology, Yuksek Ihtisas University affiliated Medical Park Ankara Hospital, Ankara, Turkey
| | - Coskun Kaya
- Department of Urology, Eskisehir State Hospital, Eskisehir, Turkey
| | - Adem Sanci
- Department of Urology, Ankara University, Ankara, Turkey
| | - Onur Serdar Gencler
- Department of Neurology, Yuksek Ihtisas University affiliated Medical Park Ankara Hospital, Ankara, Turkey
| | - Orkhan Mammadkhanli
- Department of Neurosurgery, Yuksek Ihtisas University affiliated Medical Park Ankara Hospital, Ankara, Turkey
| | - Abdullah Cindas
- Department of Physical Therapy and Rehabilitation, Yuksek Ihtisas University affiliated Medical Park Ankara Hospital, Ankara, Turkey
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23
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Vincent K, Horne AW, Daniels JP. Letter to the Editor Regarding "Gabapentin has Longer-Term Efficacy for the Treatment of Chronic Pelvic Pain in Women: A Systematic Review and Pilot Meta-analysis". Pain Ther 2022; 11:317-319. [PMID: 35044640 PMCID: PMC8861220 DOI: 10.1007/s40122-021-00351-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/21/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Katy Vincent
- Nuffield Department of Women's and Reproductive Health, John Radcliffe Hospital, University of Oxford, Headley Way, Oxford, OX3 9DU, UK.
| | - Andrew W Horne
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD, UK
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24
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Schoedel KA, Kolly C, Gardin A, Neelakantham S, Shakeri-Nejad K. Abuse and dependence potential of sphingosine-1-phosphate (S1P) receptor modulators used in the treatment of multiple sclerosis: a review of literature and public data. Psychopharmacology (Berl) 2022; 239:1-13. [PMID: 34773483 PMCID: PMC8770388 DOI: 10.1007/s00213-021-06011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 10/18/2021] [Indexed: 12/05/2022]
Abstract
Abuse and misuse of prescription drugs remains an ongoing concern in the USA and worldwide; thus, all centrally active new drugs must be assessed for abuse and dependence potential. Sphingosine-1-phosphate (S1P) receptor modulators are used primarily in the treatment of multiple sclerosis. Among the new S1P receptor modulators, siponimod, ozanimod, and ponesimod have recently been approved in the USA, European Union (EU), and other countries. This review of literature and other public data has been undertaken to assess the potential for abuse of S1P receptor modulators, including ozanimod, siponimod, ponesimod, and fingolimod, as well as several similar compounds in development. The S1P receptor modulators have not shown chemical or pharmacological similarity to known drugs of abuse; have not shown abuse or dependence potential in animal models for subjective effects, reinforcement, or physical dependence; and do not have adverse event profiles demonstrating effects of interest to individuals who abuse drugs (such as sedative, stimulant, mood-elevating, or hallucinogenic effects). In addition, no reports of actual abuse, misuse, or dependence were identified in the scientific literature for fingolimod, which has been on the market since 2010 (USA) and 2011 (EU). Overall, the data suggest that S1P receptor modulators are not associated with significant potential for abuse or dependence, consistent with their unscheduled status in the USA and internationally.
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Affiliation(s)
| | - Carine Kolly
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Anne Gardin
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Srikanth Neelakantham
- grid.464975.d0000 0004 0405 8189Novartis Institutes for Biomedical Research, Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Kasra Shakeri-Nejad
- grid.419481.10000 0001 1515 9979Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland
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25
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Olopoenia A, Camelo-Castillo W, Qato DM, Adekoya A, Palumbo F, Sera L, Simoni-Wastila L. Patterns of opioid and benzodiazepine use with gabapentin among disabled Medicare beneficiaries - A retrospective cohort study. Drug Alcohol Depend 2022; 230:109180. [PMID: 34847506 DOI: 10.1016/j.drugalcdep.2021.109180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Our goal was to describe specific patterns associated with co-prescriptions of gabapentin, opioids, and benzodiazepines among disabled Medicare beneficiaries. METHODS Using 2013-2015 Medicare data, we conducted a retrospective cohort study among fee-for-service disabled beneficiaries continuously enrolled in Medicare Parts A, B, and D. The index date was defined as the earliest fill date for a gabapentin, opioid, or benzodiazepine prescription. Monotherapy, dual therapy, and tri-therapy were defined as utilization of one, two, and three medication classes, respectively. Augmentation was defined as a prescription for a different medication class in addition to prescription for initial medication; switching referred to a change in prescription for a different medication class with no subsequent fills of initial medication. We used descriptive statistics, Kaplan Meier analyses and Cox proportional hazards to examine the association between initial therapy and monotherapy, dual therapy, tri-therapy, switching and augmentation. RESULTS Among 151,552 disabled beneficiaries, gabapentin initiators were more likely to augment therapy (50.1%) when compared to opioid (28.7%) and benzodiazepine (38.7%) users. When compared to opioid initiators, the risk of augmentation (HR[95%CI]: 1.85[1.82-1.89]) and switching (1.62 [1.51-1.73]) was significantly higher among gabapentin initiators. Risk of augmentation was also significantly higher among beneficiaries with co-morbid pain and mental health conditions (p < 0.01). Overall, the majority of beneficiaries augmented and switched within 2-months and 4-months after initiating therapy, respectively. CONCLUSIONS Given safety concerns associated with gabapentin, opioids, and benzodiazepines, it is imperative that the benefits and risks of co-prescribing these medications be examined comprehensively, especially for those in vulnerable sub-groups.
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Affiliation(s)
- Abisola Olopoenia
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Wendy Camelo-Castillo
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Danya M Qato
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States; University of Maryland, Baltimore, School of Medicine, 655W. Baltimore St, Baltimore, MD 21201, United States.
| | - Adepeju Adekoya
- Johns Hopkins Medicine, Department of Anesthesiology & Critical Care Medicine, Division of Chronic Pain Medicine, United States.
| | - Frank Palumbo
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Leah Sera
- University of Maryland, Baltimore, Department of Pharmacy Practice and Science, United States.
| | - Linda Simoni-Wastila
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States; Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore, Baltimore, United States.
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26
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Lai JY, Kalk N, Roberts E. The effectiveness and tolerability of anti-seizure medication in alcohol withdrawal syndrome: a systematic review, meta-analysis and GRADE of the evidence. Addiction 2022; 117:5-18. [PMID: 33822427 DOI: 10.1111/add.15510] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/11/2021] [Accepted: 03/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Anti-seizure medications (ASMs) have been used historically as treatment options in alcohol withdrawal syndrome (AWS). In the past 10 years, there have been no large-scale meta-analyses comparing ASMs with placebo or the current AWS treatment standard, benzodiazepines. We aimed to evaluate the efficacy and tolerability of ASMs in AWS. METHODS Systematic review and meta-analysis of randomised controlled trials (RCTs) via searching Medline, Embase and PsychINFO from database inception to March 2020 involving adults age >18 years with AWS. We included 24 RCTs reporting on a total of 2223 participants. Efficacy outcomes included the number of participants experiencing AWS related seizures or delirium, Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) score reduction and rescue medication requirements. Tolerability outcomes included adverse event rate and dropout because of adverse events, alongside severe and life-threatening adverse event rates. Quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS There was no evidence of significant improvements in any efficacy outcomes when comparing ASMs with placebo or benzodiazepines. When compared with benzodiazepines, ASMs demonstrated significantly increased odds of requiring rescue medications (OR = 3.50, 95% CI = 1.32, 9.28; P = 0.012). When comparing ASMs with placebo, there were significantly more dropouts because of adverse events (OR = 1.86, 95% CI = 1.05, 3.28; P = 0.034). Most results were of very low quality with the majority of included studies conducted before 2000. CONCLUSIONS This systematic review and meta-analysis found no evidence to support general first line clinical use of anti-seizure medications in alcohol withdrawal syndrome treatment.
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Affiliation(s)
- Jou-Yin Lai
- Department of Child and Adolescent Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital Songde Branch, Taipei City, Taiwan
| | - Nicola Kalk
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and the Maudsley NHS Foundation Trust, London, UK
| | - Emmert Roberts
- National Addiction Centre and the Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and the Maudsley NHS Foundation Trust, London, UK
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27
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Sloan G, Alam U, Selvarajah D, Tesfaye S. The Treatment of Painful Diabetic Neuropathy. Curr Diabetes Rev 2022; 18:e070721194556. [PMID: 34238163 DOI: 10.2174/1573399817666210707112413] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/18/2021] [Accepted: 03/08/2021] [Indexed: 11/22/2022]
Abstract
Painful diabetic peripheral neuropathy (painful-DPN) is a highly prevalent and disabling condition, affecting up to one-third of patients with diabetes. This condition can have a profound impact resulting in a poor quality of life, disruption of employment, impaired sleep, and poor mental health with an excess of depression and anxiety. The management of painful-DPN poses a great challenge. Unfortunately, currently there are no Food and Drug Administration (USA) approved disease-modifying treatments for diabetic peripheral neuropathy (DPN) as trials of putative pathogenetic treatments have failed at phase 3 clinical trial stage. Therefore, the focus of managing painful- DPN other than improving glycaemic control and cardiovascular risk factor modification is treating symptoms. The recommended treatments based on expert international consensus for painful- DPN have remained essentially unchanged for the last decade. Both the serotonin re-uptake inhibitor (SNRI) duloxetine and α2δ ligand pregabalin have the most robust evidence for treating painful-DPN. The weak opioids (e.g. tapentadol and tramadol, both of which have an SNRI effect), tricyclic antidepressants such as amitriptyline and α2δ ligand gabapentin are also widely recommended and prescribed agents. Opioids (except tramadol and tapentadol), should be prescribed with caution in view of the lack of definitive data surrounding efficacy, concerns surrounding addiction and adverse events. Recently, emerging therapies have gained local licenses, including the α2δ ligand mirogabalin (Japan) and the high dose 8% capsaicin patch (FDA and Europe). The management of refractory painful-DPN is difficult; specialist pain services may offer off-label therapies (e.g. botulinum toxin, intravenous lidocaine and spinal cord stimulation), although there is limited clinical trial evidence supporting their use. Additionally, despite combination therapy being commonly used clinically, there is little evidence supporting this practise. There is a need for further clinical trials to assess novel therapeutic agents, optimal combination therapy and existing agents to determine which are the most effective for the treatment of painful-DPN. This article reviews the evidence for the treatment of painful-DPN, including emerging treatment strategies such as novel compounds and stratification of patients according to individual characteristics (e.g. pain phenotype, neuroimaging and genotype) to improve treatment responses.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine and the Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Liverpool University Hospital, NHS Foundation Trust, Liverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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28
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Wilson DL. Preventing Prescription Drug Abuse: A Pharmacy Technician Tool Kit. J Pharm Technol 2021; 36:218-219. [PMID: 34752545 DOI: 10.1177/8755122520939639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The misuse of prescription medications in the United States is a worsening public health problem. Pharmacy technicians are often the first pharmacy staff member to receive newly dropped off prescriptions and to interact with patients in the pharmacy. Having a tool kit of the knowledge and skills needed to distinguish prescriptions that may result in misuse from the legitimate ones and to respond appropriately and professionally to each is essential to pharmacy technicians performing their role and function in the dispensing process.
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29
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Rosano TG, Wood M, Hooten WM, Rumberger JM, Fudin J, Argoff CE. Application and Clinical Value of Definitive Drug Monitoring in Pain Management and Addiction Medicine. PAIN MEDICINE 2021; 23:821-833. [PMID: 34643732 DOI: 10.1093/pm/pnab303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/26/2021] [Accepted: 09/25/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To assess routine application and clinical value of definitive urine drug monitoring (UDM) for drug detection, inconsistent drug use and prescription adherence, along with a comparison to immunoassay screening (IAS). METHODS Direct-to-definitive UDM performance was analyzed retrospectively in 5,000 patient specimens. Drug findings, medication inconsistencies and detection sensitivity were assessed, and definitive UDM versus IAS monitoring was studied. RESULTS Definitive testing resulted in 18,793 drug findings with 28,403 positive drug and metabolite tests. Definitive testing expanded monitoring with 11,396 drug findings that would not be tested by IAS. The opioids accounted for the highest frequency of inconsistent positive drug-use findings, at 12%. Conversely, inconsistent negative drug findings, used as an index of prescription non-adherence, were determined in 1,751 of 15,409 monitored medications and included a high frequency of antidepressants and antipsychotics inconsistencies. Direct comparison of definitive UDM and IAS showed false-positives by IAS as well as a high rate of false-negatives that would be missed using current confirmation protocols. CONCLUSIONS Results from routine application of direct-to-definitive UDM demonstrate the clinical value of drug-use identification and objective evaluation of inconsistencies in drug misuse and medication adherence in pain management and addiction medicine practice. Without conversion to direct-to-definitive UDM, continuing use of IAS will limit the scope of drugs being tested, will result in an indeterminate rate of false negatives and will require confirmation testing to eliminate the reporting of false positive IAS tests. The findings in this study provide evidence-based support for recommended use of a direct-to-definitive drug testing protocol.
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Affiliation(s)
- Thomas G Rosano
- National Toxicology Center, Albany NY, USA.,Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, New York, USA
| | | | - W Michael Hooten
- Pain Medicine, Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester MN
| | | | - Jeffrey Fudin
- Scientific and Clinical Affairs, Remitigate Therapeutics, Delmar, New York.,Albany College of Pharmacy and Health Sciences, Albany NY
| | - Charles E Argoff
- Albany College of Pharmacy and Health Sciences, Albany NY.,Department of Neurology, Albany Medical College, Albany, NY
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30
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Lavin RA, Liu C, Yuspeh L, Kalia N, Leung N, Tsourmas NF, Williams L, Hunt DL, Bernacki EJ, Tao XG. Trends in the Utilization and Dose of Gabapentinoids in Combination With Opioids in an Injured Worker Population Between 2008 and 2018. J Occup Environ Med 2021; 63:e694-e700. [PMID: 34354021 DOI: 10.1097/jom.0000000000002344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine long term (11 year) trends in gabapentin and pregabalin prescribing among workers' compensation claimants at various opioid dose combinations (low, medium, high, and very high) in Louisiana. METHOD A longitudinal study of 18,737 claimants who filled any prescriptions between 2008 and 2018. RESULTS The proportion of claimants prescribed opioids alone at all dose levels decreased dramatically. The proportion claimants prescribed the combination of low dose opioids and low dose gabapentinoids increased (7.7% to 10.9%). Prescribing higher daily doses of gabapentinoids was associated with higher daily doses of opioids. Gabapentinoid prescribing was associated with continued prescribing of medium and high dose opioids as claims matured. CONCLUSIONS Overall opioid prescribing decreased over time, while prescribing low dose opioids with gabapentinoids, increased.
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Affiliation(s)
- Robert A Lavin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland (Dr Lavin); Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Lavin, Mr Yuspeh, Dr Kalia, Dr Leung, Dr Tsourmas, Dr Bernacki, and Dr Tao); Occupational and Environmental Medicine Residency Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Liu); Strategy, Enterprise Risk, and Research, Louisiana Workers' Compensation Corporation, Baton Rouge, Louisiana (Mr Yuspeh); The General Electric Company, Cincinnati, Ohio (Dr Kalia); Texas Mutual: Workers' Compensation Insurance, Austin, Texas (Dr Leung, Dr Tsourmas, and Dr Williams); Corporate Administration Office, AF Group, Lansing, Michigan (Dr Hunt)
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31
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Abstract
This review summarizes current evidence on the abuse and misuse of the gabapentinoids pregabalin and gabapentin. Pharmacovigilance studies, register-based studies, surveys, clinical toxicology studies, and forensic toxicology studies were identified and scrutinized with the goal to define the problem, identify risk factors, and discuss possible methods to reduce the potential for abuse and misuse. Studies found that gabapentinoids are abused and misused and that individuals with a history of psychiatric disorders or substance use disorder seem to be at high risk. Moreover, some evidence supports the notion that patients with opioid use disorders may be at an increased risk of abusing gabapentinoids. Available evidence also suggests that abuse and misuse are more frequent in users of pregabalin compared with users of gabapentin. Health professionals and prescribers should be aware of the risk for misuse of pregabalin and gabapentin, which eventually could lead to abuse, substance dependence, and intoxications. Prescribing to patients belonging to risk populations such as those with psychiatric disorders or substance use disorder should be avoided if possible and, if prescribed, signs of misuse and abuse should be monitored.
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Affiliation(s)
- Staffan Hägg
- Futurum, Jönköping, Region Jönköping County and Department of Biomedicine and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Futurum, Hus B4, Ryhov Hospital, S-551 85, Jönköping, Sweden.
| | - Anna K Jönsson
- Division of Drug Research, Department of Biomedicine and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Chemistry, National Board of Forensic Medicine, Linköping, Sweden
| | - Johan Ahlner
- Division of Drug Research, Department of Biomedicine and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Chemistry, National Board of Forensic Medicine, Linköping, Sweden
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32
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Evoy KE, Peckham AM, Covvey JR, Tidgewell KJ. Gabapentinoid Pharmacology in the Context of Emerging Misuse Liability. J Clin Pharmacol 2021; 61 Suppl 2:S89-S99. [PMID: 34396549 DOI: 10.1002/jcph.1833] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/13/2021] [Indexed: 12/15/2022]
Abstract
This article will review the epidemiology and pharmacology of gabapentinoids (gabapentin and pregabalin) relevant to their emerging misuse potential and provide guidance for clinical and regulatory management. Gabapentinoids are γ-aminobutyric acid analogues that produce their therapeutic effects by inhibiting voltage-gated calcium channels and decreasing neurotransmitter release. Recently gabapentinoid prescribing and use have increased tremendously. Although traditionally thought to possess a favorable safety profile, gabapentinoid misuse has also risen significantly. Gabapentinoid misuse generally occurs in combination with other substances, most notably opioids, and may be for purposes of eliciting euphoric effects, enhancing the effects of other substances, or self-treating conditions such as withdrawal, pain, anxiety, or insomnia. Given its faster onset, increased bioavailability and potency, and nonsaturable absorption, pregabalin's pharmacokinetics theoretically enhance its misuse liability versus gabapentin. However, gabapentin can produce similar euphoric effects, and epidemiologic studies have identified higher rates of gabapentin misuse in the United States, likely because of greater availability and less regulated prescribing. Although adverse events of gabapentinoid-only ingestion are relatively benign, a growing body of evidence indicates that gabapentinoids significantly increase opioid-related morbidity and mortality when used concomitantly. In addition, significant withdrawal effects may occur on abrupt discontinuation. As a result of these trends, several US states have begun to further regulate gabapentinoid prescribing, reclassifying it as a controlled substance or mandating reporting to local prescription drug-monitoring programs. Although increased regulation of gabapentin prescribing may be warranted, harm reduction efforts and increased patient and provider education are necessary to mitigate this concerning gabapentinoid misuse trend.
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Affiliation(s)
- Kirk E Evoy
- The University of Texas at Austin College of Pharmacy, Austin, Texas, USA.,University Health System, San Antonio, Texas, USA
| | - Alyssa M Peckham
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jordan R Covvey
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kevin J Tidgewell
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
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33
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Jamison RN, Edwards RR, Curran S, Wan L, Ross EL, Gilligan CJ, Gozani SN. Effects of Wearable Transcutaneous Electrical Nerve Stimulation on Fibromyalgia: A Randomized Controlled Trial. J Pain Res 2021; 14:2265-2282. [PMID: 34335055 PMCID: PMC8318714 DOI: 10.2147/jpr.s316371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/13/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose Fibromyalgia is a chronic condition characterized by widespread pain and interference with daily activities. The aim of this study is to assess the benefit of transcutaneous electrical nerve stimulation (TENS) for persons diagnosed with fibromyalgia. Patients and Methods Adults meeting diagnostic criteria for fibromyalgia were randomized in a double-blind trial to receive either an active (n=62) or sham (n=57) wearable TENS device for 3-months. Subjects were classified as having lower or higher pain sensitivity by Quantitative Sensory Testing (QST). Patient Global Impression of Change (PGIC, primary outcome) and secondary efficacy measures including Fibromyalgia Impact Questionnaire (FIQR), Brief Pain Inventory (BPI) and painDETECT questionnaire (PDQ) were assessed at baseline, 6-weeks and 3-months. Treatment effects were determined by a mixed model for repeated measures (MMRM) analysis of the intention-to-treat (ITT) population (N=119). A pre-specified subgroup analysis of pain sensitivity was conducted using an interaction term in the model. Results No differences were found between active and sham treatment on PGIC scores at 3-months (0.34, 95% CI [−0.37, 1.04], p=0.351) in the ITT population. However, in subjects with higher pain sensitivity (n=60), PGIC was significantly greater for active treatment compared to sham (1.19, 95% CI [0.24, 2.13], p=0.014). FIQR total score (−7.47, 95% CI [−12.46, −2.48], p=0.003), FIQR pain item (−0.62, 95% CI [−1.17, −0.06], p=0.029), BPI Interference (−0.70, 95% CI [−1.30, −0.11], p=0.021) and PDQ (−1.69, 95% CI [−3.20, −0.18], p=0.028) exhibited significant improvements for active treatment compared to sham in the ITT population. Analgesics use was stable and comparable in both groups. Conclusion This study demonstrated modest treatment effects of reduced disease impact, pain and functional impairment from wearable TENS in individuals with fibromyalgia. Subjects with higher pain sensitivity exhibited larger treatment effects than those with lower pain sensitivity. Wearable TENS may be a safe treatment option for people with fibromyalgia. Clinicaltrials.gov Registration NCT03714425.
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Affiliation(s)
- Robert N Jamison
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, MA, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, MA, USA
| | - Samantha Curran
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, MA, USA
| | - Limeng Wan
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, MA, USA
| | - Edgar L Ross
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, MA, USA
| | - Christopher J Gilligan
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, MA, USA
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Chiappini S, Schifano F, Corkery JM, Guirguis A. Beyond the 'purple drank': Study of promethazine abuse according to the European Medicines Agency adverse drug reaction reports. J Psychopharmacol 2021; 35:681-692. [PMID: 33427017 PMCID: PMC8278560 DOI: 10.1177/0269881120959615] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Promethazine is a medicinal product, available on its own or in combination with other ingredients including dextromethorphan, paracetamol and/or expectorants. Anecdotal reports have however indicated that promethazine may have a misuse potential, especially in adolescents. OBJECTIVE We here aimed at studying how this phenomenon has been reported to the European Monitoring Agency Adverse Drug Reactions database. METHODS After a formal request to the European Monitoring Agency, the promethazine-specific dataset has been studied, performing a descriptive analysis of misuse/abuse/dependence-related adverse drug reaction reports. The study was approved by the University of Hertfordshire (LMS/PGR/UH/03234). RESULTS The analysis of promethazine data showed increasing levels of misuse/abuse/ dependence issues over time (2003-2019). Out of a total number of 1543 cases of adverse drug reactions, the abuse/misuse/dependence-related cases reported were 557, with 'drug abuse' (300/557: 53.8%) and 'intentional product misuse' (117/557: 21.0%). being the most represented adverse drug reactions. A high number of fatalities were described (310/557: 55.6%), mostly recorded as 'drug toxicity/drug abuse' cases, with opiates/opioids having been the most commonly reported concomitant drugs used. CONCLUSION Anecdotal promethazine misuse/abuse reports have been confirmed by European Monitoring Agency data. Promethazine misuse/abuse appears to be an alarming issue, being associated with drug-related fatalities. Thus, healthcare professionals should be warned about a possible misuse of promethazine and be vigilant, as in some countries medicinal products containing promethazine can be purchased over the counter. Since promethazine is often available in association with opioids, its abuse may be considered a public health issue, with huge implications for clinical practice.
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Affiliation(s)
- Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield, UK
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield, UK,Fabrizio Schifano, Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, Hertfordshire AL10 9AB, UK.
| | - John Martin Corkery
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield, UK
| | - Amira Guirguis
- Swansea University Medical School, Institute of Life Sciences 2, Swansea University, Swansea, UK
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Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD, Iosifescu DV. Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:222-242. [PMID: 34690588 PMCID: PMC8475923 DOI: 10.1176/appi.focus.19203] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
(Appeared originally in Frontiers in Psychiatry 2020 Dec 23; 11:595584)
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Dimethyl Trisulfide Diminishes Traumatic Neuropathic Pain Acting on TRPA1 Receptors in Mice. Int J Mol Sci 2021; 22:ijms22073363. [PMID: 33806000 PMCID: PMC8036544 DOI: 10.3390/ijms22073363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 12/20/2022] Open
Abstract
Pharmacotherapy of neuropathic pain is still challenging. Our earlier work indicated an analgesic effect of dimethyl trisulfide (DMTS), which was mediated by somatostatin released from nociceptor nerve endings acting on SST4 receptors. Somatostatin release occurred due to TRPA1 ion channel activation. In the present study, we investigated the effect of DMTS in neuropathic pain evoked by partial ligation of the sciatic nerve in mice. Expression of the mRNA of Trpa1 in murine dorsal-root-ganglion neurons was detected by RNAscope. Involvement of TRPA1 ion channels and SST4 receptors was tested with gene-deleted animals. Macrophage activity at the site of the nerve lesion was determined by lucigenin bioluminescence. Density and activation of microglia in the spinal cord dorsal horn was verified by immunohistochemistry and image analysis. Trpa1 mRNA is expressed in peptidergic and non-peptidergic neurons in the dorsal root ganglion. DMTS ameliorated neuropathic pain in Trpa1 and Sstr4 WT mice, but not in KO ones. DMTS had no effect on macrophage activity around the damaged nerve. Microglial density in the dorsal horn was reduced by DMTS independently from TRPA1. No effect on microglial activation was detected. DMTS might offer a novel therapeutic opportunity in the complementary treatment of neuropathic pain.
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Evoy KE, Sadrameli S, Contreras J, Covvey JR, Peckham AM. Authors' Reply to Bonnet et al. "Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update". Drugs 2021; 81:615-617. [PMID: 33738758 DOI: 10.1007/s40265-021-01495-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Kirk E Evoy
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA. .,University Health System, San Antonio, TX, USA. .,The University of Texas Health San Antonio School of Medicine, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA.
| | - Sarvnaz Sadrameli
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA.,University Health System, San Antonio, TX, USA.,University of Illinois at Chicago, 833 South Wood St., Chicago, IL, 60612, USA
| | - Jillian Contreras
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA.,University Health System, San Antonio, TX, USA
| | - Jordan R Covvey
- School of Pharmacy, Duquesne University, 600 Forbes Avenue, 418D Mellon Hall, Pittsburgh, PA, 15282, USA
| | - Alyssa M Peckham
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA.,School of Pharmacy, Northeastern University, 140 The Fenway, Boston, MA, 02115, USA
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Bargel S, Becam J, Chanu L, Lanot T, Martin M, Vaucel J, Willeman T, Fabresse N. Les gabapentinoïdes : une revue de la littérature. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2021. [DOI: 10.1016/j.toxac.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ibiloye EA, Barner JC, Lawson KA, Rascati KL, Evoy KE, Peckham AM. Prevalence of and Factors Associated with Gabapentinoid Use and Misuse Among Texas Medicaid Recipients. Clin Drug Investig 2021; 41:245-253. [PMID: 33580482 DOI: 10.1007/s40261-021-01009-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Gabapentin and pregabalin have been considered relatively safe opioid-sparing adjuncts for pain management. However, rising prescribing trends, presence of gabapentinoids in opioid-related overdoses, and the growing body of evidence regarding gabapentinoid misuse and abuse, have caused gabapentinoids to emerge as a drug class of public health concern. This study aimed to assess the prevalence of, and factors associated with gabapentinoid use and misuse. METHODS This retrospective study of Texas Medicaid data from 1/1/2012 to 30/8/2016 included patients aged 18-63 years at index date, with ≥ 1 gabapentinoid prescription, and continuously enrolled 6 months pre-index and 12 months post-index. Gabapentinoid misuse was defined as ≥ 3 claims exceeding daily doses of 3600 mg for gabapentin and 600 mg for pregabalin. Age, gender, concurrent opioid use, neuropathic pain diagnoses and gabapentinoid type were independent variables. Descriptive and inferential statistics were used. RESULTS Of included subjects (N = 39,000), 0.2% (N = 81) met study criteria for gabapentinoid misuse. Overall, the majority (76.4%) of gabapentinoid users were aged 41-63 years with a mean ± SD age of 48.2 ± 10.7 years. Those patients meeting the study criteria for gabapentinoid misuse were significantly younger (45.1 ± 11.0 vs 48.2 ± 10.7, p = 0.0084). Majority of the study sample was female (68.1%). However, a significantly higher proportion of males met the study criteria for gabapentinoid misuse compared to females (0.3% vs 0.2%, p = 0.0079). Approximately one-half (51.9%) of the study sample had neuropathic pain, and gabapentinoid misuse was significantly higher in neuropathic pain patients compared to those without neuropathic pain (0.3% vs 0.1%, p = 0.0078). Over three-quarters (77.4%) of patients were using gabapentin; however, gabapentinoid misuse was significantly higher among pregabalin users (0.4% vs 0.2%, p = 0.0003). Approximately 20% (17.3%) of gabapentinoid users had ≥ 90 days of concurrent opioid use. However, there was no significant difference in gabapentinoid misuse among patients with concurrent opioid use compared to patients without (0.3% vs 0.2%, p = 0.1440). Factors significantly associated with misuse included: male sex (odds ratio [OR] 0.486; 95% confidence interval [CI] 0.313-0.756; p = 0.0013); neuropathic pain (OR 2.065; 95% CI 1.289-3.308; p = 0.0026); and pregabalin versus gabapentin use (OR 2.337, 95% CI 1.492-3.661; p = 0.0002). Concurrent opioid use was not significantly associated with gabapentinoid misuse (OR 1.542, 95% CI 0.920-2.586; p = 0.1006). CONCLUSION Prevalence of gabapentinoid misuse was low (0.2%) among Texas Medicaid recipients. Younger age, male gender, neuropathic pain diagnosis and pregabalin use were significantly associated with higher levels of gabapentinoid misuse.
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Affiliation(s)
- Elizabeth A Ibiloye
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA.
| | - Jamie C Barner
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA
| | - Kenneth A Lawson
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA
| | - Karen L Rascati
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA
| | - Kirk E Evoy
- Pharmacotherapy Division, College of Pharmacy, University of Texas at Austin, San Antonio, Texas, USA
- University Health System, San Antonio, Texas, USA
| | - Alyssa M Peckham
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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Liu C, Lavin RA, Yuspeh L, Leung N, Kalia N, Tsourmas NF, Williams L, Bernacki EJ, Tao XG. Gabapentinoid and Opioid Utilization and Cost Trends Among Injured Workers. J Occup Environ Med 2021; 63:e46-e52. [PMID: 33196519 DOI: 10.1097/jom.0000000000002085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To characterize changes in opioid, gabapentin, and pregabalin utilization patterns and cost trends between 2008 and 2018 in a Louisiana workers' compensation claims population and explore the role of gabapentinoids as alternative analgesics during the opioid epidemic. METHOD Filled prescriptions for gabapentinoids and opioids were studied for 11 years in a cohort of 18,737 claimants. RESULTS The proportion of claimants prescribed gabapentin increased 2-fold (8.9% to 18.9%) and average drug cost per claimant decreased 22% ($612 to $480). The proportion of claimants prescribed pregabalin decreased approximately 80% (11.7% to 2.5%) and average drug cost per claim increased 224% ($911 to $2952). Proportion of claimants prescribed opioids decreased 20% (80% to 64.2%) and average drug cost per claim decreased 46% ($691 to $371). CONCLUSIONS Utilization increased substantially for gabapentin and decreased for pregabalin and opioids.
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Affiliation(s)
- Che Liu
- Occupational and Environmental Medicine Residency Program, Johns Hopkins Bloomberg School of Public Health (Dr Liu); Department of Neurology, University of Maryland School of Medicine (Dr Lavin); Assistant Vice President of Strategy, Enterprise Risk, and Research, Louisiana Workers' Compensation Corporation, Louisiana (Mr Yuspeh); Department of Medicine (Mr Yuspeh, Dr Leung, Dr Kalia, Dr Bernacki); Department of Population Health, Dell Medical School, the University of Texas at Austin (Dr Leung, Dr Tsourmas, Dr Bernacki); North America Medical Leader, The Procter and Gamble Company, Cincinnati, Ohio (Dr Kalia); Medical Operations, Policy Holder Services Division, Medical Director, Texas Mutual Insurance (Dr Williams), Austin, Texas; Division of Occupational and Environmental Medicine, Department of Medicine (Dr Tao), Johns Hopkins University School of Medicine, Baltimore, Maryland
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Freynhagen R, Baron R, Kawaguchi Y, Malik RA, Martire DL, Parsons B, Rey RD, Schug SA, Jensen TS, Tölle TR, Ushida T, Whalen E. Pregabalin for neuropathic pain in primary care settings: recommendations for dosing and titration. Postgrad Med 2021; 133:1-9. [PMID: 33423590 DOI: 10.1080/00325481.2020.1857992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pregabalin is one of the first-line treatments approved for the management of neuropathic pain (NeP). While many patients benefit from treatment with pregabalin, they are often treated with suboptimal doses, possibly due to unfamiliarity around prescribing the drug and/or side effects that can occur with up-titration. This narrative review discusses key aspects of initiating, titrating, and managing patients prescribed pregabalin therapy, and addresses concerns around driving and the potential for abuse, as well as when to seek specialist opinion. To ensure that patients derive maximum therapeutic benefit from the drug, we suggest a 'low and slow' dosing approach to limit common side effects and optimize tolerability alongside patients' expectations. When requiring titration to higher doses, we recommend initiating 'asymmetric dosing,' with the larger dose in the evening. Fully engaging patients in order for them to understand the expected timeline for efficacy and side effects (including their resolution), can also help determine the optimal titration tempo for each individual patient. The 'low and slow' approach also recognizes that patients with NeP are heterogeneous in terms of their optimal therapeutic dose of pregabalin. Hence, it is recommended that general practitioners closely monitor patients and up-titrate according to pain relief and side effects to limit suboptimal dosing or premature discontinuation.
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Affiliation(s)
- Rainer Freynhagen
- Center for Anaesthesiology, Intensive Care, Pain Medicine & Palliative Medicine, Benedictus Hospital, Feldafing, Germany
| | - Ralf Baron
- Department of Anaesthesiology, Technische Universtät München, Munich, Germany
| | - Yoshiharu Kawaguchi
- Division of Neurological Pain Research and Therapy, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Rayaz A Malik
- Department of Orthopaedic Surgery, Toyama University Hospital, Toyama, Japan; eWeill Cornell Medicine, Qatar, Doha, Qatar
| | | | | | | | - Stephan A Schug
- Argentine Institute for Neurological Research (IADIN), Buenos Aires, Argentina
| | | | - Thomas R Tölle
- Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Perth, WA, Australia
| | - Takahiro Ushida
- Department of Neurology and Diabetic Neuropathy Consortium, Aarhus University Hospital, Aarhus, Denmark
| | - Ed Whalen
- Department of Neurology, Technische Universität München, Munich, Germany.,Multidisciplinary Pain Center, Aichi Medical University Hospital, Nagakute, Japan
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Evoy KE, Covvey JR, Peckham AM, Reveles KR. Gabapentinoid misuse, abuse and non-prescribed obtainment in a United States general population sample. Int J Clin Pharm 2021; 43:1055-1064. [PMID: 33387188 DOI: 10.1007/s11096-020-01217-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/08/2020] [Indexed: 11/24/2022]
Abstract
Background Reports of gabapentinoid (gabapentin and pregabalin) misuse are on the rise, but few studies have assessed this within the general US population. Objective Describe lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids and descriptive characteristics associated with such actions in a US general population sample. Setting This cross-sectional questionnaire was administered online by Qualtrics® research panel aggregator via quota-based sampling. Methods Data were collected from a sample of respondents that mirrored the general US population aged 18-59 years with regards to age, geographic region, ethnicity, income, and education level, based on most recent census data. Misuse/abuse/non-prescribed obtainment was collectively defined as use of a gabapentinoid for reasons other than a diagnosed medical condition, using with the intention of altering one's state of consciousness, or obtaining without a prescription. A multivariable logistic regression model was created to predict misuse/abuse/non-prescribed obtainment of gabapentinoids, incorporating relevant covariates. Main outcome measure Proportion of sample indicating lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids. Results Among 1,843 respondents, 121 (6.6%) reported gabapentinoid misuse/abuse/non-prescribed obtainment. Specifically, 2.1% (n = 39) and 1.5% (n = 27) of respondents for gabapentin and pregabalin, respectively, met study criteria for abuse. Opioids were the most common medication co-administered with gabapentinoids (among 50-70% of respondents) for misuse/abuse. Previous treatment for addiction (OR: 2.61, 95% CI: 1.32-5.14, p = 0.005) and the total attitudinal risk score (OR: 1.14, 95% CI: 1.09-1.19, p < 0.001) were associated with gabapentinoid misuse/abuse/non-prescribed obtainment. Conclusion Among those surveyed, 6.6% reported previous gabapentinoid misuse/abuse/non-prescribed obtainment, providing one of the first estimates within a nationally distributed, US general population sample.
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Affiliation(s)
- Kirk E Evoy
- The University of Texas At Austin College of Pharmacy, 7703 Floyd Curl Dr. - MC 6220, San Antonio, TX, 78229, USA. .,University Health System, San Antonio, TX, USA. .,The University of Texas Health San Antonio School of Medicine, 7703 Floyd Curl Dr. MC - 6220, San Antonio, TX, 78229, USA.
| | - Jordan R Covvey
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 418 Mellon Hall, Pittsburgh, PA, 15282, USA
| | - Alyssa M Peckham
- School of Pharmacy, Northeastern University, Bouvé College of Health Sciences, 360 Huntington Ave, Boston, MA, R218 TF02115, USA.,Department of Pharmacy, Massachusetts General Hospital, 360 Huntington Ave, Boston, MA, R218 TF02115, USA
| | - Kelly R Reveles
- The University of Texas At Austin College of Pharmacy, 7703 Floyd Curl Dr. - MC 6220, San Antonio, TX, 78229, USA.,The University of Texas Health San Antonio School of Medicine, 7703 Floyd Curl Dr. MC - 6220, San Antonio, TX, 78229, USA
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Papazisis G, Spachos D, Siafis S, Pandria N, Deligianni E, Tsakiridis I, Goulas A. Assessment of the Safety Signal for the Abuse Potential of Pregabalin and Gabapentin Using the FAERS Database and Big Data Search Analytics. Front Psychiatry 2021; 12:640264. [PMID: 34093263 PMCID: PMC8172802 DOI: 10.3389/fpsyt.2021.640264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/02/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The latest decade, an emerging issue has been the abuse potential of the gabapentinoids pregabalin and gabapentin. The aim of our study was to assess this safety signal combining two different methods of surveillance: search analytics big data and the FDA spontaneous reporting system database. Methods: Analysis of big data and the FAERS was used to detect pregabalin's and gabapentin's abuse potential in comparison with two controls, clonazepam and levetiracetam, and further, the correlation between these domains was investigated. Data from the United States between 2007 and 2020Q2 were analyzed. Results: The FAERS analysis revealed the following pattern of signals: clonazepam > pregabalin ≥ gabapentin > levetiracetam, for both the primary term "drug abuse and dependence" and the secondary terms (withdrawal, tolerance, overdose). The Google domain pattern was slightly different: clonazepam ≥ gabapentin ≥ pregabalin≥ levetiracetam. A monotonic correlation was found between FAERS and Google searches for gabapentin (r = 0.558; p < 0.001), pregabalin (r = 0.587; p < 0.001), and clonazepam (r = 0.295; p = 0.030). Conclusion: Our results revealed that there is preliminary evidence of a safety signal for the abuse potential of pregabalin and gabapentin. Analysis of the FAERS database, supplemented by big data search analytics, suggests that there is potential of using these methods as a supplementary tool to detect drug abuse-related safety signals in pharmacovigilance.
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Affiliation(s)
- Georgios Papazisis
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Spachos
- Laboratory of Medical Physics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Spyridon Siafis
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niki Pandria
- Laboratory of Medical Physics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Deligianni
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Tsakiridis
- Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Goulas
- First Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Alsaab HO, Altowairqi E, Alzahrani N, Alzahrani R, Alshehri FS, Almalki AH, Alsanie WF, Gaber A, Alkhalifa T, Almalki A, Shah ZA, Althobaiti YS. Sex differences in pregabalin-seeking like behavior in a conditioned place preference paradigm. Saudi Pharm J 2020; 28:1749-1755. [PMID: 33424265 PMCID: PMC7783229 DOI: 10.1016/j.jsps.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/03/2020] [Indexed: 12/30/2022] Open
Abstract
Substance abuse is a chronic, relapsing disorder characterized by compulsive drug use regardless of negative consequences. Incremental increases in pregabalin abuse have been observed in Saudi Arabia and throughout the world. In previous studies, the potential for pregabalin abuse with escalating doses of the drug (30, 60, 90, and 120 mg/kg) were investigated in male mice. Notably, researchers have argued that women may exhibit a greater tendency to consume drugs without a prescription to alleviate stress and depression. Moreover, female subjects are more prone to impulsivity in drug intake or abuse than their male counterparts. Therefore, in the present study, we compared the potential for pregabalin abuse between male and female mice using a conditioned place preference paradigm. Male and female BALB/c mice were divided into four groups based on the pregabalin dose administered (30, 60, 90, or 120 mg/kg, intraperitoneal). Preference scores were then calculated and compared between male and female mice in each dosage group. Interestingly, preference scores were significantly higher in female mice than in male mice at dosages of 30 and 120 mg/kg. These findings indicate that female mice may be more prone to pregabalin abuse and tolerance than male mice. These results might be helpful to the healthcare providers and policymakers to consider these sex differences in choosing therapeutic plans and consider alternatives to the misused prescription medications.
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Affiliation(s)
- Hashem O. Alsaab
- Addiction and Neuroscience Research Unit, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
- Department of Pharmaceutics and Pharmaceutical Technology, College of Pharmacy, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
| | - Ebtehal Altowairqi
- Department of Pharmacology and Toxicology, College of Pharmacy, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
| | - Nada Alzahrani
- Addiction and Neuroscience Research Unit, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
| | - Reem Alzahrani
- Addiction and Neuroscience Research Unit, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
| | - Fahad S. Alshehri
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Atiah H. Almalki
- Addiction and Neuroscience Research Unit, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
- Department of Pharmaceutical Chemistry, College of Pharmacy, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
| | - Walaa F. Alsanie
- Addiction and Neuroscience Research Unit, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
- Faculty of Applied Medical Sciences, Department of Clinical Laboratories, Taif University, Taif 21974, Saudi Arabia
| | - Ahmed Gaber
- Addiction and Neuroscience Research Unit, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
- Department of Biology, Faculty of Science, Taif University, Taif 21974, Saudi Arabia
| | - Turki Alkhalifa
- General Administration for Precursors and Laboratories, General Directorate of Narcotics Control, Ministry of Interior, Riyadh, Saudi Arabia
| | - Ahmad Almalki
- General Administration for Precursors and Laboratories, General Directorate of Narcotics Control, Ministry of Interior, Riyadh, Saudi Arabia
| | - Zahoor A. Shah
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43614, USA
| | - Yusuf S. Althobaiti
- Addiction and Neuroscience Research Unit, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
- Department of Pharmacology and Toxicology, College of Pharmacy, Taif University, Health Science Campus, Al Haweiah, Taif 21974, Saudi Arabia
- General Administration for Precursors and Laboratories, General Directorate of Narcotics Control, Ministry of Interior, Riyadh, Saudi Arabia
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McAnally H, Bonnet U, Kaye AD. Gabapentinoid Benefit and Risk Stratification: Mechanisms Over Myth. Pain Ther 2020; 9:441-452. [PMID: 32737803 PMCID: PMC7648827 DOI: 10.1007/s40122-020-00189-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Recent years have seen a dramatic escalation of off-label prescribing for gabapentin and pregabalin (gabapentinoids) owing in part to generic versions of each being released over the past two decades, but also in part as a response to increasing calls for multimodal and non-opioid pain management strategies. In this context, several recent articles have been published alleging widespread misuse, with speculations on the unappreciated addictive potential of the gabapentinoid class of drugs. Reports of a 1% population-level abuse prevalence stem from a single internet survey in the UK, and the vanishingly small adverse event outcomes data do not support such frequency. In this targeted narrative review, we aim to disabuse pain physicians and other clinicians, pharmacists, and policymakers of both the positive and negative myths concerning gabapentinoid medications. RESULTS Gabapentinoids inhibit the joint action of voltage-gated calcium channel (VGCC) α2δ subunits in conjunction with the n-methyl-D-aspartate (NMDA) receptor, with subsequent downregulation of VGCC expression and excitatory neurotransmitter release, and possibly synaptogenesis as well, through actions on thrombospondins. These activities reduce the likelihood of central sensitization, which explains in part the efficacy of the gabapentinoids in the management of neuropathic pain. Gabapentinoids also facilitate slow-wave sleep, a relatively rare phenomenon among central nerve system-acting agents, which is also thought to explain some of the therapeutic benefit of the class in conditions such as fibromyalgia. The number needed to treat to see benefit overlaps that of the nonsteroidal anti-inflammatory drugs, but with a considerably improved safety profile. Along these lines, in the context of over 50 million prescriptions per year in the USA alone, the gabapentinoids display remarkably low risk, including risks of misuse, abuse, and dependence. Furthermore, the neurobiology of these agents does not lend plausibility to the allegations, as they have never been shown to elicit dopaminergic activity within the nucleus accumbens, and in addition likely confer a "negative-feedback loop" for habituation and dependence by serving as functional NMDA antagonists, possibly through their actions on thrombospondins. Clinical and epidemiological addictionology studies corroborate the lack of any significant addictive potential of the gabapentinoids, and these drugs are increasingly being used in the treatment of addiction to other substances, with excellent results and no evidence of cross-addiction. However, among individuals with other substance use disorders and, in particular opioid use disorder, there are consistent data showing misuse of gabapentinoids in up to 20% of this population. Although there are allegations of using gabapentinoids to amplify the hedonic effects of opioids, the vast majority of misuse events appear to occur in an attempt to ameliorate opioid withdrawal symptoms. Furthermore, rare but potentially serious respiratory depression may occur, again amplified in the context of opioid or other sedative use. Careful risk:benefit assessment and stratification are warranted when prescription of a gabapentinoid is under consideration, in particular among individuals using opioids. CONCLUSIONS Gabapentinoids remain a vital tool in the pain physician's multimodal armamentarium, but these drugs may not be effective in every clinical situation. Individuals with central sensitization and pain associated with slow-wave sleep deficits and potentially persons with comorbid addictions may benefit the most. The gabapentinoids appear to possess no addictive potential on their own, based on laboratory and clinical data, but they may be abused by persons with opioid use disorders; consequently, cautious risk stratification must take place.
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Affiliation(s)
- Heath McAnally
- Northern Anesthesia and Pain Medicine, LLC, Eagle River, AK, USA.
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Udo Bonnet
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, University of Duisburg/Essen, Castrop-Rauxel, Germany
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Abstract
Generalized anxiety disorder (GAD) is characterized by persistent and excessive worry. Around half of the patients treated for GAD will fail to respond to initial treatment. Treatment-resistant (or refractory) GAD is defined as failure to respond to at least 1 trial of antidepressant therapy at adequate dose and duration. Review of the literature indicates several potential medication classes and individual agents that can be used as augmentation strategies to treat residual symptoms when recommended therapy per clinical practice guidelines fails. A thorough literature search revealed 2 medication classes with the largest amount of data to support their use in treatment-resistant GAD treatment: gamma-aminobutyric acid–related agents and atypical antipsychotics. This article focuses on evidence-based recommendations for the use of these agents as adjunctive therapies for patients with treatment-resistant GAD. Different pharmacologic approaches to use these agents are demonstrated through 2 patient cases in which patients have failed first-line treatment options.
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Abstract
BACKGROUND A 2017 systematic review (SR) identified 59 studies examining gabapentinoid (pregabalin and gabapentin) misuse/abuse. Evidence of gabapentinoid misuse/abuse has since grown substantially. OBJECTIVE Update previous SR and describe new insights regarding gabapentinoid abuse. METHODS A SR of PubMed was conducted to identify studies published from 7/29/2016-8/31/2020. Four searches were performed using the following terms: "gabapentin [MeSH] OR pregabalin [MeSH] OR gabapentinoid" AND one of the following substance misuse/abuse-related terms: "substance-related disorders [MeSH]", "overdose", "abuse", or "misuse". Clinicaltrials.gov and the Cochrane Library database were searched to identify ongoing studies or similar SRs. Reference lists of included studies were reviewed to identify additional literature. All studies with novel data related to pregabalin and/or gabapentin abuse, misuse, or overdose conducted during the study period were included. Articles not written in English, review articles, and animal studies were excluded. RESULTS Fifty-five studies were included (29 [52.7%] from North America, 17 [30.9%] Europe, 6 [10.9%] Asia, and 3 [5.5%] Australia). Forty-six observational studies and 10 case reports/series were included (one manuscript included both). Twenty (36.4%) studied gabapentin only, 18 (32.7%) pregabalin only, and 17 (30.9%) both pregabalin/gabapentin. These studies corroborate findings from the previous SR that gabapentinoids are increasingly abused or misused to self-medicate, that gabapentinoids can produce desirable effects alone but are often used concomitantly with other drugs, and that opioid use disorder is the greatest risk factor for gabapentinoid abuse. While the original SR identified the largest studies having been published in Europe, this review identified several more generalisable US studies that have subsequently been conducted. The most concerning finding was increased evidence of associated patient harm, including increased hospital utilisation and opioid-related overdose mortality risk. CONCLUSION Evidence suggests that gabapentinoid misuse/abuse represents a growing trend that is causing significant patient harm. Prescribers should exercise appropriate caution with use in high-risk populations and monitor for signs of misuse or abuse.
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O’Hare C, Rahman T, Williams NT. Treatment of Chronic Refractory Cough in Adults: Focus on Neuromodulators and Other Therapeutic Modalities. J Pharm Technol 2020. [DOI: 10.1177/8755122520954866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective: To evaluate the literature and educate health care professionals about the different management options for chronic refractory cough (CRC). Data Sources: Searches were performed through MEDLINE (1966 to July 2020) using OVID and EBSCOhost and EMBASE (1947 to July 2020) using OVID. Search terms included chronic cough, neurogenic cough, neuromodulators, chronic cough management, and chronic cough treatment. References of all relevant articles were further used to obtain additional articles. Study Selection and Data Extraction: This review includes articles in the English language and human trial literature. Twenty-three trials explored the use of oral neuromodulators in the management of CRC. Data Synthesis: CRC is a poorly understood disease that may have a complex neuropathic etiology. Oral neuromodulators, such as amitriptyline, baclofen, gabapentin, and pregabalin, continue to be the most commonly used agents for the management of CRC. Alternative pharmacological therapies such as botulinum toxin, anesthetic agents (benzonatate, lidocaine), and narcotic agents have efficacy data, and further research into effective doses and routes of administration is warranted. Alternative nonpharmacologic therapies more commonly used included speech pathology treatment. Conclusion: Several medication and alternative treatment interventions may be effective in managing CRC. Current studies used wide dosing and titration strategies, making it challenging to standardize therapy. No consistent method of assessing cough reflex was used between studies, as well as a lack of consistent randomization and small sample sizes. Additional research is needed to standardize treatment durations, optimum doses, and place in therapy of the available interventions in the management of CRC.
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Affiliation(s)
- Caroline O’Hare
- Southwestern Oklahoma State University, Weatherford, OK, USA
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UZUNER B, KETENCİ S, SALBAŞ E. Diyabetik Nöropatiye Genel Yaklaşım. ACTA MEDICA ALANYA 2020. [DOI: 10.30565/medalanya.788960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Knezevic NN, Jovanovic F, Candido KD, Knezevic I. Oral pharmacotherapeutics for the management of peripheral neuropathic pain conditions - a review of clinical trials. Expert Opin Pharmacother 2020; 21:2231-2248. [PMID: 32772737 DOI: 10.1080/14656566.2020.1801635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Epidemiological studies have shown that 6.9-10% of people suffer from neuropathic pain, a complex painful condition which is often undertreated. Data regarding the effectiveness of treatment options for patients with neuropathic pain is inconsistent, and there is no single treatment option that shows cost-effectiveness across studies. AREAS COVERED In this narrative review, the authors present the results of different prospective, randomized controlled trials, systematic reviews and meta-analyses assessing the effects of different oral medications in the management of various peripheral neuropathic pain conditions. The authors discuss the effectiveness of commonly used oral medications such as voltage-gated calcium channels antagonists, voltage-gated sodium channel antagonists, serotonin-norepinephrine reuptake inhibitors, NMDA antagonists, and medications with other mechanisms of action. EXPERT OPINION Most of the presented medications were more effective than placebo; however, when compared to each other, none of them were significantly superior. The heterogeneity of the studies looking into different oral neuropathic conditions has been the major issue that prevents us from making stronger recommendations. There are multiple reasons including high placebo responsiveness, improperly treated underlying comorbidities (particularly anxiety and depression), and inter-patient variability. Different sensory phenotypes should also be taken into consideration when designing future clinical trials for neuropathic pain.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US.,Department of Anesthesiology, College of Medicine, University of Illinois , Chicago, IL, US.,Department of Surgery, College of Medicine, University of Illinois , Chicago, IL, US
| | - Filip Jovanovic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US.,Department of Anesthesiology, College of Medicine, University of Illinois , Chicago, IL, US.,Department of Surgery, College of Medicine, University of Illinois , Chicago, IL, US
| | - Ivana Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center , Chicago, IL, US
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