Is actiq use in noncancer-related pain really "a recipe for success"?

Adverse Drug Reactions to Opioids: A Study in a National Pharmacovigilance Database

INTRODUCTION

Opioids are commonly used as analgesics; however, like any medicine, they can produce adverse drug reactions (ADRs), including nausea, constipation, dependence, and respiratory depression, that result in harmful and fatal events. Therefore, it is essential to monitor the safety of these drugs in clinical practice.

OBJECTIVE

This study aimed to characterize the safety profile of opioids by conducting a descriptive study based on a spontaneous reporting system (SRS) for ADRs in The Netherlands, focusing on abuse, misuse, medication errors, and differences between sexes.

METHODS

Reports submitted to the Netherlands Pharmacovigilance Centre Lareb from January 2003 to December 2021 with an opioid drug as the suspected/interacting medicine were analyzed. Reporting odds ratios (RORs) for drug-ADR combinations were calculated, analyzed, and corrected for sex and drug utilization (expenditure) for the Dutch population.

RESULTS

A total of 8769 reports were analyzed. Tramadol was the opioid with the most reports during the period (n = 2746), while oxycodone or tramadol had the highest number of reports per year in the study period. The most reported ADRs from opioid use were nausea, followed by dizziness and vomiting, independent of sex, and all of them were more often reported in women. Vomiting associated with tramadol (ROR females/males = 2.17) was significantly higher in women. Buprenorphine was responsible for most ADRs when corrected for expenditure, with high RORs observed with application site hypersensitivity, application site reaction, and application site rash. Fentanyl gave rise to most of the reports of ADRs concerning abuse, misuse, and medication errors.

CONCLUSION

Patients treated with opioids experienced ADRs, primarily nausea, dizziness, and vomiting. For those groups of drugs, no significant differences were found between the sexes, except for the vomiting associated with tramadol. In general, ADRs related to opioids presented higher RORs when uncorrected and corrected for sexes and expenditure than other drugs. There was more disproportionate reporting for ADRs concerning abuse, misuse, and medication errors for opioids than other drugs in the Dutch SRS.

[Use of rapid-onset fentanyl preparations beyond indication : A random questionnaire survey among congress participants and pain physicians]

BACKGROUND

Despite publicised advice and warnings, there are only scant data on the non-indicated prescription of rapid-onset preparations of fentanyl (ROF) in non-cancer pain (NCP). Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation.

OBJECTIVE

Initiated by the Working Group Cancer Pain and supported by the German Pain Society, a random sample survey was conducted to assess the non-indicated use of ROF.

METHODS

The survey addressed attendees of pain conferences who were given the option to fill in the questionnaires outside the conference or online. Primary endpoints of the structured questionnaire were quantitative and qualitative items with regard to the prescription of ROF, while secondary endpoints were opioid-induced side effects.

RESULTS

Obtaining a response rate of 44% (132/300) and an additional 51 online questionnaires revealed that 165 (90%) respondents had knowledge of non-indicated prescriptions or were involved in these. Of these, 65% were clinicians and 17% worked in an outpatient capacity. In all, 22% were trained pain or palliative physicians. Approximately 1205 patients were assessed indirectly. The main causes for dispensing ROF included NCP entities such as back pain (44%), neuropathic pain (33%), head or facial pain (12%), and dyspnea (5%) in cancer pain or lack of break-through pain or basic medication (44%). Sedation (32%), nausea/vomiting (31%), constipation (16%) and insufficient analgesia (31%) were the mostly commonly reported adverse effects.

CONCLUSION

Despite the non-ambiguous indication for ROF, physicians often demonstrate inappropriate prescription behaviour. Iatrogenic misuse of ROF should be minimized. The rates of adverse effects of ROF seems to be in line with other opioids.

[Rapid release fentanyl administration forms. Comments of the Working Group on Tumor Pain of the German Pain Society]

The spectrum of indications for rapid release fentanyl preparations is controversial. For this reason the Working Group on Tumor Pain will formulate comments on how to deal with these substances. Breakthrough pain should receive individualized therapy; therefore, the use of opioids of various galenic formulations seems to be advisable. New rapid release fentanyl preparations are suitable for alleviating spontaneous breakthrough pain in tumor patients due to a rapid but short-acting effect. However, a prior optimization of the analgesic basis medication is absolutely necessary. Uncontrolled prescription for non-cancer pain must be criticized due to the problem of addiction. The medical profession should be informed about the benefits of rapid release fentanyl preparations but must also be made aware of the risk of a rapid development of addiction and tolerance. A self-commitment of the pharmaceutical industry to waive advertising for the dangerous off-label use would be desirable. In the opinion of the Working Group on Tumor Pain the use of fentanyl should be openly discussed and further scientific investigations are imperative with the aim of formulating clear recommendations.

[Dependency syndrome and hyperalgesia due to an opioid therapy for curative treatable pain. Case report of an apparent palliative patient]

Opioids are an essential part of cancer pain management but particularly in this patient group physicians could misinterpret opioid-induced potentially life-threatening side effects within the central nervous system (CNS) or hyperalgesia as a consequence of tumor progression. In this case increasing the opioid dose or switching to rapidly acting opioids may trigger a vicious circle. We describe a case report of a male patient who was treated with high doses of transdermal and endonasal fentanyl 2 years after pancreatomy due to cancer. The patient was referred to the palliative care unit presenting with delirious behavior and 30-40 severe abdominal pain attacks/day. After withdrawal of the opioid medication all CNS symptoms disappeared. Further diagnostics revealed multiple incisional hernia as the reason of the pain syndrome. The patient recovered after herniotomy and has now been pain free without any pain medication for more than 16 months. This case report underlines again the necessity of pain diagnostics also in assumed palliative patients with the risks of high dose opioid treatment.

Increase in opiate prescription in Germany between 2000 and 2010: a study based on insurance data

BACKGROUND

Insufficient data have been available to date on the prevalence of opioid treatment in Germany, physicians' prescribing habits, and the percentages of cancer patients and non-cancer patients among those receiving opioids for an evaluation of the quality of care and an assessment of possible underuse or misuse.

METHODS

The data analyzed in this study were derived from the statutory health insurance sample of the AOK health insurance company in the German state of Hesse / ASHIP Hesse for the years 2000-2010. For the purpose of this study, prevalence was defined as the percentage of insurees who received at least one outpatient prescription of an opioid (ATC N02A, excluding codeine, levomethadone and methadone). In order to control for population aging, the prevalence was standardized to the German population on December 31(st) of the preceding year and to the age-structure of the population as it was in 1999. Opioid prescribing for cancer was assumed when a cancer diagnosis was documented in the same year in which the opioid prescription was issued.

RESULTS

The percentage of insurees receiving at least one opioid prescription rose over the period of the study from 3.31% in 2000 to 4.53% in 2010, a relative gain of 37%. Opioids were mostly prescribed to patients with non-cancer pain (2010: about 77% of opioid recipients). The percentage of non-cancer patients receiving long-term opioid treatment has also increased over the period of the study.

CONCLUSION

As opioids are frequently prescribed for non-cancer pain, it cannot be inferred from the observed increase in opioid prescribing that cancer patients are now receiving better opioid treatment than they were before. Further issues of concern are the observed increases in the prescribing of potent immediate release opioids and in the long-term opioid treatment for non-cancer patients, the benefit of which is currently debated.