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Macintyre PE, Jamcotchian MA, Stevens JA. Calling time on the use of modified-release opioids for acute pain. Med J Aust 2024. [PMID: 39148471 DOI: 10.5694/mja2.52417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/13/2024] [Indexed: 08/17/2024]
Affiliation(s)
- Pamela E Macintyre
- University of Adelaide, Adelaide, SA
- Royal Adelaide Hospital, Adelaide, SA
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2
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Liu S, Patanwala AE, Naylor JM, Stevens JA, Bugeja B, Begley D, Khor KE, Lau E, Adie S, Penm J. Tapentadol Versus Oxycodone for Opioid-Related Adverse Drug Events and Clinical Outcomes After Inpatient Surgery. THE JOURNAL OF PAIN 2024; 25:466-475. [PMID: 37741523 DOI: 10.1016/j.jpain.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/25/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
Oxycodone is a commonly prescribed opioid for postoperative pain. However, there has been a marked increase in the use of tapentadol over the previous decade due to a perceived superior safety profile of tapentadol compared to oxycodone. There is limited real-world evidence on the safety of tapentadol compared to oxycodone after surgery. The primary objective was to examine the impact of tapentadol compared to oxycodone use on the incidence of opioid-related adverse drug events after surgery. Data for adult surgical patients receiving tapentadol or oxycodone during hospitalization between January 1, 2018, and December 31, 2021, were collected from electronic medical records of 3 tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events. Patients receiving tapentadol or oxycodone were matched using nearest-neighbour propensity score matching. In the matched cohorts (n = 1,530 vs n = 2,775; mean [standard deviation] age 62.3 [17.0] years vs 61.9 [standard deviation 17.9] years; 43% vs 45% male for the tapentadol vs oxycodone groups, respectively), patients given tapentadol experienced a similar incidence of adverse events overall (14.4%, 220/1,530 vs 12.6%, 349/2,775; P = .100; 95% CI -.35% to 3.95%). Secondary outcomes included an increased risk of delirium (2.7%, 41/1,530 vs 1.3%, 37/2,775), arrhythmias (3.4%, 52/1,530 vs 2.2%, 62/2,775), and length of hospital stay (5 [range 1-201] vs 4 [range 1-226] days) compared with oxycodone use. Further real-world studies are warranted to determine the impact of tapentadol use on a broad range of patient outcomes. PERSPECTIVE: This study provides an early signal that tapentadol use may be associated with an increased risk of some adverse events and a longer length of stay. Further research is needed to examine the impact of tapentadol use on a broad range of patient outcomes in clinical practice settings.
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Affiliation(s)
- Shania Liu
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Prince of Wales Hospital, Sydney, Australia
| | - Asad E Patanwala
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute, Sydney, Australia; South Western Sydney School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jennifer A Stevens
- School of Clinical Medicine, University of New South Wales Medicine and Health, St Vincent's Clinical School, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia
| | - Bernadette Bugeja
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia
| | - David Begley
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia
| | - Kok E Khor
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Eric Lau
- Department of Pharmacy, St George Hospital, Sydney, Australia
| | - Sam Adie
- St George and Sutherland Clinical School, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Jonathan Penm
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Prince of Wales Hospital, Sydney, Australia
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Liu S, Patanwala AE, Naylor JM, Levy N, Knaggs R, Stevens JA, Bugeja B, Begley D, Khor KE, Lau E, Allen R, Adie S, Penm J. Impact of modified-release opioid use on clinical outcomes following total hip and knee arthroplasty: a propensity score-matched cohort study. Anaesthesia 2023; 78:1237-1248. [PMID: 37365700 PMCID: PMC10952779 DOI: 10.1111/anae.16070] [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] [Accepted: 05/19/2023] [Indexed: 06/28/2023]
Abstract
Modified-release opioids are often prescribed for the management of moderate to severe acute pain following total hip and knee arthroplasty, despite recommendations against their use due to increasing concerns regarding harm. The primary objective of this multicentre study was to examine the impact of modified-release opioid use on the incidence of opioid-related adverse events compared with immediate-release opioid use, among adult inpatients following total hip or knee arthroplasty. Data for total hip and knee arthroplasty inpatients receiving an opioid analgesic for postoperative analgesia during hospitalisation were collected from electronic medical records of three tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events during hospital admission. Patients who received modified with or without immediate-release opioids were matched to those receiving immediate-release opioids only (1:1) using nearest neighbour propensity score matching with patient and clinical characteristics as covariates. This included total opioid dose received. In the matched cohorts, patients given modified-release opioids (n = 347) experienced a higher incidence of opioid-related adverse events overall, compared with those given immediate-release opioids only (20.5%, 71/347 vs. 12.7%, 44/347; difference in proportions 7.8% [95%CI 2.3-13.3%]). Modified-release opioid use was associated with an increased risk of harm when used for acute pain during hospitalisation after total hip or knee arthroplasty.
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Affiliation(s)
- S. Liu
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
- Department of PharmacyPrince of Wales HospitalRandwickNWSAustralia
| | - A. E. Patanwala
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
- Pharmacy DepartmentRoyal Prince Alfred HospitalCamperdownNSWAustralia
| | - J. M. Naylor
- Orthopaedic Department, Whitlam Orthopaedic Research CentreLiverpool HospitalLiverpoolNSWAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNSWAustralia
| | - N. Levy
- Department of Anaesthesia and Peri‐operative MedicineWest Suffolk HospitalBury St. EdmundsUK
| | - R. Knaggs
- School of PharmacyUniversity of Nottingham and Primary Integrated Community ServicesNottinghamUK
| | - J. A. Stevens
- School of Clinical Medicine, St Vincent's Clinical CampusUniversity of New South WalesSydneyNSWAustralia
- School of MedicineUniversity of Notre DameSydneyNSWAustralia
| | - B. Bugeja
- Department of Pain ManagementPrince of Wales HospitalSydneyNSWAustralia
| | - D. Begley
- Department of Pain ManagementPrince of Wales HospitalSydneyNSWAustralia
| | - K. E. Khor
- Department of Pain ManagementPrince of Wales HospitalSydneyNSWAustralia
- Prince of Wales Clinical SchoolUniversity of New South Wales Medicine and HealthSydneyNSWAustralia
| | - E. Lau
- Department of PharmacySt George HospitalKogarahNSWAustralia
| | - R. Allen
- Pain Management UnitSt George HospitalKogarahNSWAustralia
| | - S. Adie
- St George and Sutherland Clinical SchoolUniversity of New South WalesSydneyNSWAustralia
| | - J. Penm
- Department of PharmacyPrince of Wales HospitalRandwickNWSAustralia
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
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Liu S, Athar A, Quach D, Patanwala AE, Naylor JM, Stevens JA, Levy N, Knaggs RD, Lobo DN, Penm J. Risks and benefits of oral modified-release compared with oral immediate-release opioid use after surgery: a systematic review and meta-analysis. Anaesthesia 2023; 78:1225-1236. [PMID: 37415284 PMCID: PMC10952256 DOI: 10.1111/anae.16085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/08/2023]
Abstract
Prescription of modified-release opioids for acute postoperative pain is widespread despite evidence to show their use may be associated with an increased risk of adverse effects. This systematic review and meta-analysis aimed to examine the available evidence on the safety and efficacy of modified-release, compared with immediate-release, oral opioids for postoperative pain in adults. We searched five electronic databases from 1 January 2003 to 1 January 2023. Published randomised clinical trials and observational studies on adults who underwent surgery which compared those who received oral modified-release opioids postoperatively with those receiving oral immediate-release opioids were included. Two reviewers independently extracted data on the primary outcomes of safety (incidence of adverse events) and efficacy (pain intensity, analgesic and opioid use, and physical function) and secondary outcomes (length of hospital stay, hospital readmission, psychological function, costs, and quality of life) up to 12 months postoperatively. Of the eight articles included, five were randomised clinical trials and three were observational studies. The overall quality of evidence was low. Modified-release opioid use was associated with a higher incidence of adverse events (n = 645, odds ratio (95%CI) 2.76 (1.52-5.04)) and worse pain (n = 550, standardised mean difference (95%CI) 0.2 (0.04-0.37)) compared with immediate-release opioid use following surgery. Our narrative synthesis concluded that modified-release opioids showed no superiority over immediate-release opioids for analgesic consumption, length of hospital stay, hospital readmissions or physical function after surgery. One study showed that modified-release opioid use is associated with higher rates of persistent postoperative opioid use compared with immediate-release opioid use. None of the included studies reported on psychological function, costs or quality of life.
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Affiliation(s)
- S. Liu
- Faculty of Medicine and HealthSchool of Pharmacy, University of SydneySydneyNSWAustralia
- Department of PharmacyPrince of Wales Hospital, RandwickSydneyNSWAustralia
| | - A. Athar
- Faculty of Medicine and Health, School of MedicineUniversity of Notre DameSydneyNSWAustralia
| | - D. Quach
- Faculty of Medical and Health Sciences, School of PharmacyUniversity of AucklandAucklandNew Zealand
| | - A. E. Patanwala
- Faculty of Medicine and Health, School of PharmacyUniversity of SydneySydneyNSWAustralia
- Department of PharmacyRoyal Prince Alfred HospitalCamperdownNSWAustralia
| | - J. M. Naylor
- Whitlam Orthopaedic Research Centre, Orthopaedic Department, Liverpool HospitalLiverpoolNSWAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNSWAustralia
| | - J. A. Stevens
- School of Clinical Medicine, St VincentTable s Clinical CampusUniversity of New South WalesSydneyNSWAustralia
- University of Notre DameSydneyNSWAustralia
| | - N. Levy
- Department of Anaesthesia and Perioperative MedicineWest Suffolk HospitalBury St. EdmundsUK
| | - R. D. Knaggs
- School of PharmacyUniversity of Nottingham, and Primary Integrated Community ServicesNottinghamUK
| | - D. N. Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals and University of Nottingham, Queen's Medical CentreNottinghamUK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing ResearchSchool of Life SciencesUniversity of Nottingham, Queen's Medical CentreNottinghamUK
| | - J. Penm
- Department of PharmacyPrince of Wales Hospital, RandwickSydneyNSWAustralia
- Faculty of Medicine and Health, School of PharmacyUniversity of SydneySydneyNSWAustralia
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Baumann L, Bello C, Georg FM, Urman RD, Luedi MM, Andereggen L. Acute Pain and Development of Opioid Use Disorder: Patient Risk Factors. Curr Pain Headache Rep 2023; 27:437-444. [PMID: 37392334 PMCID: PMC10462493 DOI: 10.1007/s11916-023-01127-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE OF REVIEW Pharmacological therapy for acute pain carries the risk of opioid misuse, with opioid use disorder (OUD) reaching epidemic proportions worldwide in recent years. This narrative review covers the latest research on patient risk factors for opioid misuse in the treatment of acute pain. In particular, we emphasize newer findings and evidence-based strategies to reduce the prevalence of OUD. RECENT FINDINGS This narrative review captures a subset of recent advances in the field targeting the literature on patients' risk factors for OUD in the treatment for acute pain. Besides well-recognized risk factors such as younger age, male sex, lower socioeconomic status, White race, psychiatric comorbidities, and prior substance use, additional challenges such as COVID-19 further aggravated the opioid crisis due to associated stress, unemployment, loneliness, or depression. To reduce OUD, providers should evaluate both the individual patient's risk factors and preferences for adequate timing and dosing of opioid prescriptions. Short-term prescription should be considered and patients at-risk closely monitored. The integration of non-opioid analgesics and regional anesthesia to create multimodal, personalized analgesic plans is important. In the management of acute pain, routine prescription of long-acting opioids should be avoided, with implementation of a close monitoring and cessation plan.
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Affiliation(s)
- Livia Baumann
- Department of Anaesthesiology and Pain Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Corina Bello
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Filipovic Mark Georg
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Markus M Luedi
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St, Gallen, St. Gallen, Switzerland
| | - Lukas Andereggen
- Faculty of Medicine, University of Bern, Bern, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
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Lam T, Stevens J, Nielsen S. A call to action: how can we better implement recommendations for non-routine use of modified-release opioid formulations? Anaesthesia 2023; 78:660-661. [PMID: 36756701 DOI: 10.1111/anae.15979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 02/10/2023]
Affiliation(s)
- T Lam
- Monash Addiction Research Centre, Monash University, Frankston, Australia
| | - J Stevens
- St Vincent's Clinical School, UNSW Sydney, Darlinghurst, Australia
| | - S Nielsen
- Monash Addiction Research Centre, Monash University, Frankston, Australia
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Liu S, Patanwala AE, Naylor JM, Penm J. Effect of discharge opioid use on persistent postoperative opioid use. Anaesthesia 2023; 78:659. [PMID: 36716347 DOI: 10.1111/anae.15974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Affiliation(s)
- S Liu
- University of Sydney, Sydney, Australia
| | | | - J M Naylor
- University of New South Wales, Sydney, Australia
| | - J Penm
- University of Sydney, Sydney, Australia
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Quinlan J, Levy N, Lobo DN, Macintyre PE. No place for routine use of modified-release opioids in postoperative pain management. Br J Anaesth 2022; 129:290-293. [PMID: 35843745 DOI: 10.1016/j.bja.2022.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/10/2022] [Accepted: 06/17/2022] [Indexed: 11/19/2022] Open
Abstract
Modified-release opioid tablets were introduced into surgical practice in the belief that they provided superior pain relief and reduced nursing workload, and they rapidly became embedded into many perioperative pathways. Although national and international guidelines for the management of postoperative pain now advise against the use of modified-release opioids, they continue to be prescribed in many centres. Recognition that modified-release opioids show lack of benefit and increased risk of harm compared with immediate-release opioids in the acute, postoperative setting has become clear. Their slow onset and offset make rapid and safe titration of these opioids impossible, including down-titration as the patient recovers; pain relief may be less effective; they have been associated with an increased incidence of opioid-related adverse drug events, increased length of hospital stay, and higher readmission rates; and they lead to higher rates of opioid-induced ventilatory impairment and persistent postoperative opioid use. Evidence indicates that modified-release opioids should not be used routinely in the postoperative period.
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Affiliation(s)
- Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
| | - Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia; Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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Stevens JA, Findlay BR. How to close the gaps between evidence and practice for perioperative opioids. Anaesth Intensive Care 2022; 50:44-51. [PMID: 35170349 DOI: 10.1177/0310057x211065041] [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]
Abstract
Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period, including the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. While some of the recommendations have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap. We must also remain mindful that while education is essential, it is on the lowest rung of implementation efficacy and, on its own, is a poor driver of behaviour change. Ongoing structural nudges and the use of local procedure-specific analgesic pathways will also be helpful in addressing the gap between evidence-based recommendations and practice.
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Affiliation(s)
- Jennifer A Stevens
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia.,School of Medicine, University of Notre Dame, Sydney, Australia.,Brian Dwyer Department of Anaesthesia, St Vincent's Hospital, Sydney, Australia
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Levy N, Raghunathan K, Lobo DN. De-implementation of extended-release opioids from peri-operative pathways. Anaesthesia 2021; 76:1559-1562. [PMID: 33891306 DOI: 10.1111/anae.15487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 12/20/2022]
Affiliation(s)
- N Levy
- Department of Anaesthesia, West Suffolk Hospital, Bury St. Edmunds, UK
| | - K Raghunathan
- Department of Anesthesiology and Population Health, Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - D N Lobo
- Department of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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