Buprenorphine Transdermal System Improves Sleep Quality and Reduces Sleep Disturbance in Patients with Moderate‐to‐Severe Chronic Low Back Pain: Results from Two Randomized Controlled Trials

Impact of physical therapy techniques and common interventions on sleep quality in patients with chronic pain: A systematic review

This systematic review aims to find effectful healthcare strategies, with special focus on drug-free interventions and physical therapy, as part of the treatment for sleep in patients with chronic musculoskeletal pain. Data search was conducted across seven scientific databases. This review is deposited in the Prospero International prospective register of systematic reviews (CRD42023452574). Seventeen RCTs from different healthcare fields complied with our inclusion criteria. Two RCTs investigated manual therapy, five RCTs therapeutic exercise, one RCT Fu's subcutaneous needling, two RCTs physical agents (one on balneotherapy and one on cryo-stimulation), two RCTs cognitive-behavioral therapy, and four RCTs pharmacological therapy and their effect on sleep quality and/or quantity in patients suffering from chronic pain. We included the four RCT's in this systematic review with the purpose to be able to compare natural interventions with allopathic ones. As allopathic interventions are more prone to have secondary negative effects than physical therapy, compare the two types of interventions could be in favor of choosing the most effective treatment with the least secondary negative effects. Additionally, two RCTs on neurofeedback and limbic neuromodulation were also included. The results of the included studies suggest that strategies such as manual therapy, therapeutic exercise, Fu's subcutaneous needling, balneotherapy, cryo-stimulation, neurofeedback, limbic neuromodulation, cognitive-behavioral therapy, and pharmacological therapies have positive effects on patients suffering from chronic pain and sleep disturbances, especially when they suffer musculoskeletal pain. Secondary negative effects were found for the possible overuse of certain medicines such as morphine, a huge problem in the United States. Sleep deficiency is an independent risk factor for many diseases, including chronic pain syndrome and therefore more studies are needed to find non-toxic interventions for people suffering sleep disorders associated with systemic diseases and pain.

Methadone and Buprenorphine in the Perioperative Setting: A Review of the Literature

PURPOSE OF REVIEW

The purpose of this review is to highlight the most recent literature and guidelines regarding perioperative methadone and buprenorphine use.

RECENT FINDINGS

Surgical patients taking methadone and buprenorphine are being encountered more frequently in the perioperative period, and providers are becoming more familiar with their pharmacologic properties, benefits as well as precautions. Recommendations pertaining to buprenorphine therapy in the perioperative settings have changed in recent years, owing to more clinical and basic science research. In addition to their use in chronic pain and opioid use disorders, they can also be initiated for acute postoperative pain indications, in select patients and situations. Methadone and buprenorphine are being more commonly prescribed for pain management and opioid use disorder, and their continuation during the perioperative period is generally recommended, to reduce the risk of opioid withdrawal, relapse, or inadequately controlled pain. Additionally, both may be initiated safely and effectively for acute pain management during and after the operating room period.

Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials

STUDY OBJECTIVES

To investigate the extent to which sleep measures are reported in intervention trials for chronic low back pain.

METHODS

A systematic scoping review was conducted. Ovid MEDLINE, Cochrane CENTRAL, and CINAHL were queried for trials published between January 2010 and December 2022 using keywords related to chronic low back pain. Two reviewers screened and reviewed abstracts and full texts for eligibility criteria and extracted data. Randomized intervention trials with the aim to treat pain or disability related to chronic low back pain in adults were included. Data were pooled and synthesized from trials that included a measure of sleep.

RESULTS

Two hundred eighty-two trials conducted in 40 different countries were included in the final review. Twenty-six trials (9.2%) assessed any sleep measure, and 13 (4.6%) collected a formal sleep disturbance measure at multiple time points. Three trials analyzed the mediating effects of sleep disturbance on pain. Reporting of sleep measures was no better in more recently published trials; trials published in 2010 (22%; n = 2/9) and 2022 (23%; n = 3/13) had the highest reporting rates.

CONCLUSIONS

The poor adherence to guideline recommendations for capturing measures of sleep quality or disturbance limits clinicians' and researchers' understanding of how sleep may influence treatment effects for chronic low back pain. There is an opportunity to improve the understanding of the relationship between sleep and pain with improved collection and reporting of sleep disturbance measures.

CITATION

Neilson BD, Dickerson C, Young JL, Shepherd MH, Rhon DI. Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials. J Clin Sleep Med. 2023;19(11):1961-1970.

Transdermal buprenorphine improves overall quality of life and symptom severity in cancer patients with pain

AIM AND OBJECTIVES

This study explored the effect of transdermal buprenorphine on quality of life and six symptoms in cancer patients with pain.

BACKGROUND

Transdermal opioids offer advantages over traditional routes of administration. The impact of transdermal buprenorphine on quality of life for patients with cancer in Asian populations is unknown.

DESIGN

This study employed a single-arm observational repeated measures design. Cancer patients with pain were evaluated prior to treatment (baseline). Over a 4-week treatment period, quality of life and symptoms were assessed at 2 and 4 weeks. This study adhered to the recommendations of STROBE guidelines.

METHODS

This multi-site study was conducted in six hospitals located across northern, middle and southern Taiwan. Adult cancer patients whose pain was previously stable with opioid analgesics and, based on clinical judgement, were able to convert to transdermal buprenorphine treatment were invited to participate. Quality of life was measured with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30).

RESULTS

Generalised estimating equations showed participants who completed at least one follow-up measurement (N = 80) over 4-weeks had a significant improvement in overall quality of life. Functional status only improved for social functioning. However, symptom severity decreased significantly for nausea/vomiting, pain, insomnia and constipation.

CONCLUSIONS

The study provides initial evidence supporting transdermal buprenorphine for providing beneficial effects of improving quality of life and reducing severity of symptoms in Asian patients with cancer.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can inform the clinical practice that the use of transdermal buprenorphine in cancer patients with pain may also reduce the severity of other symptoms and improve overall quality of life.

TRIAL REGISTRATION DETAILS

This study was registered in ClinicalTrials.gov. Identifier: NCT04315831.

Are Changes in Sleep Quality/Quantity or Baseline Sleep Parameters Related to Changes in Clinical Outcomes in Patients With Nonspecific Chronic Low Back Pain?: A Systematic Review

OBJECTIVES

Sleep disturbance is prevalent among patients with chronic low back pain (CLBP). This systematic review aimed to summarize the evidence regarding the: (1) temporal relations between changes in sleep quality/quantity and the corresponding changes in pain and/or disability; and (2) role of baseline sleep quality/quantity in predicting future pain and/or disability in patients with CLBP.

METHODS

Four databases were searched from their inception to February 2021. Two reviewers independently screened the abstract and full text, extracted data, assessed the methodological quality of the included studies, and evaluated the quality of evidence of the findings using the Grading of Recommendations Assessment Development and Evaluation (GRADE).

RESULTS

Of 1995 identified references, 6 articles involving 1641 participants with CLBP were included. Moderate-quality evidence substantiated that improvements in self-reported sleep quality and total sleep time were significantly correlated with the corresponding LBP reduction. Low-quality evidence showed that self-reported improvements in sleep quality were related to the corresponding improvements in CLBP-related disability. There was conflicting evidence regarding the relation between baseline sleep quality/quantity and future pain/disability in patients with CLBP.

DISCUSSION

This is the first systematic review to accentuate that improved self-reported sleep quality/quantity may be associated with improved pain/disability, although it remains unclear whether baseline sleep quality/quantity is a prognostic factor for CLBP. These findings highlight the importance of understanding the mechanisms underlying the relation between sleep and CLBP, which may inform the necessity of assessing or treating sleep disturbance in people with CLBP.

Buprenorphine for Chronic Pain: A Safer Alternative to Traditional Opioids

With the ongoing public health crisis with prescription opioids, there is a need for safer alternatives for medication management in chronic pain patients. Buprenorphine is a partial mu-opioid agonist which is commonly utilized to treat patients with opioid-use disorders. The purpose of this review is to discuss the potential use of this medication for the treatment of chronic pain instead of resorting to more traditional Schedule II opioids. Buprenorphine offers a safer alternative for patients who require opioids to manage chronic pain, given the unique pharmacological properties that allow it to provide adequate analgesia with less abuse potential.

Daily associations between sleep and opioid use among adults with comorbid symptoms of insomnia and fibromyalgia

STUDY OBJECTIVES

Disturbed sleep and use of opioid pain medication are common among individuals with chronic pain. Anecdotally, opioids are thought to promote sleep by relieving pain. This study aimed to determine whether opioid use is associated with daily sleep parameters (and vice versa) in adults with comorbid symptoms of insomnia and fibromyalgia.

METHODS

Individuals reporting symptoms of insomnia and opioid use for fibromyalgia (n = 65, 93% women, 79% White) wore wrist actigraphy and completed daily diaries for 14 days (910 observations). Analyses examined daily associations between opioid dose (measured in lowest recommended dosage units) and three sleep parameters (actigraphy/self-reported total wake time and self-reported sleep quality). Multilevel models were used to account for the clustering of daily sleep and opioid assessments (level 1) within individuals (level 2).

RESULTS

Opioid use did not have a significant daily effect on total wake time or sleep quality, and sleep parameters did not significantly impact opioid use the next day; however, participants reported worse sleep quality and greater doses of opioids on evenings that they experienced greater pain.

CONCLUSIONS

Among adults reporting symptoms of insomnia and opioid use for fibromyalgia pain, opioid use is not reliably associated with wake time or sleep quality that night, and these sleep parameters are not significantly associated with opioid use the next day; however, evening pain has an adverse daily impact on both sleep quality and opioid use. Studies identifying strategies to prevent and manage fibromyalgia pain are needed, especially for individuals reporting comorbid insomnia and opioid use.

The utilization of buprenorphine in chronic pain

Reclassification of chronic pain as a disease may be helpful because patients with chronic pain require significant treatment and rehabilitation with a clear diagnosis. This can help address critical factors including suffering, quality of life, participation, and with family and social life, which continue to become more important in evaluating the quality of the health care we give our patients today. During the past decade of the opioid epidemic, methadone was the primary treatment for opioid addiction until buprenorphine was approved. Buprenorphine's high-affinity partial agonist properties make it a good alternative to methadone due to lower abuse potential and safer adverse effect profile while maintaining significant efficacy. Expanded out-patient prescribing options have allowed physician and physician extenders such as physician assistants and nurse practitioners to treat these patients that otherwise would have been required to utilize methadone. With unique pharmacological properties, buprenorphine is a safe and effective analgesic for chronic pain. The literature for buprenorphine shows great potential for its utilization in the treatment of chronic pain.

Buprenorphine buccal film for chronic pain management

Buprenorphine is a Schedule III opioid with unique pharmacodynamic and pharmacokinetic properties that contribute to effective analgesia and fewer safety risks than other opioids. This review article focuses on the buccal film formulation, which is preferable to other buprenorphine formulations on the basis of bioavailability, safety and efficacy. The clinical studies reviewed here confirm that buprenorphine buccal film offers effective and continuous pain relief that is generally well tolerated, with no cases of respiratory depression reported in any of the studies. On the basis of these clinical data and individual patient risk/benefit assessments, clinicians should consider utilizing buprenorphine buccal film as a first-line opioid treatment for chronic pain over other buprenorphine formulations or other opioids.

Safety And Efficacy Of The Unique Opioid Buprenorphine For The Treatment Of Chronic Pain

BACKGROUND

Chronic pain is associated with decreased quality of life and is one of the most common reasons adults seek medical care, making treatment imperative for many aspects of patient well-being. Chronic pain management typically involves the use of Schedule II full μ-opioid receptor agonists for pain relief; however, the increasing prevalence of opioid addiction is a national crisis that is impacting public health and social and economic welfare. Buprenorphine is a Schedule III partial μ-opioid receptor agonist that is an equally effective but potentially safer treatment option for chronic pain than full μ-opioid receptor agonists. The purpose of this review is to provide an overview of the clinical efficacy and safety of the transdermal and buccal formulations of buprenorphine, which are approved by the Food and Drug Administration for chronic pain, compared with that of extended-release full μ-opioid receptor agonists.

METHODS

Controlled or randomized controlled clinical trial information was retrieved from EMBASE, Medline, and PubMed using the search terms "buprenorphine" AND "chronic" AND "pain."

RESULTS

A total of 33 clinical studies were ultimately used in this review, including 29 (88%) on transdermal buprenorphine and 4 (12%) on buprenorphine buccal film. Although the measure of pain intensity varied among studies, each of these 33 trials demonstrated efficacy for buprenorphine in pain relief. A total of 28 studies also assessed safety, with each concluding that buprenorphine was generally well tolerated.

CONCLUSION

Comparison of current clinical data along with results of responder and safety analyses support the use of buprenorphine over full μ-opioid receptor agonists for effective preferential treatment of chronic pain; however, head-to-head clinical studies are warranted.

Pain Control in Latin America: The Optimized Role of Buprenorphine in the Treatment of Cancer and Noncancer Pain

Pain is a terrible health problem that transcends borders and nationalities, although there may be significant differences among regions regarding pain management. In Latin America (LatAm, composed of the many nations of Central America, South America, Mexico, and the Caribbean), access to healthcare, pain management, and opioid analgesics can vary. Despite an international U.S.-led trend toward greater control in opioid prescribing, the role of opioids in the management of severe pain in LatAm is probably smaller than it should be, as opioid consumption in LatAm overall is low. Buprenorphine is a strong opioidwith certain characteristics that make it a potentially useful analgesic agent in LatAm: it has a unique pharmacology that allows for transdermal administration and a favorable safety profile with a ceiling effect for respiratory depression. It has a well-studied low risk potential for misuse, and there is strong evidence for its safety and efficacy in managing both cancer and noncancer pain in adults. Caregivers and policy makers in LatAm may learn from the U.S. experience with opioids in order to develop protocols to better and safely manage pain, and it is possible that buprenorphine will play a key role.

Pain intensity as a moderator of the association between opioid use and insomnia symptoms among adults with chronic pain

OBJECTIVE

Research documenting the impact of opioid use on sleep among individuals with chronic pain has been mixed. This study aimed to determine if pain intensity moderates the association between opioid use and insomnia symptoms among adults with comorbid symptoms of insomnia and chronic widespread pain.

METHODS

Participants (N = 144; 95% female; mean age = 51.6, SD = 11.4) completed assessments of insomnia symptoms, pain and use of sleep/pain medication. Multiple regression was used to determine if pain intensity moderates the association between opioid use (yes/no) sleep onset latency (SOL), wake after sleep onset (WASO), sleep quality, or time in bed. Analyses controlled for gender, symptoms of sleep apnea, symptoms of depression, use of sleep medication (yes/no), and use of non-opioid pain medication (yes/no).

RESULTS

Stronger pain intensity was associated with longer self-reported WASO and worse sleep quality, independent of opioid use. Conversely, opioid use was associated with longer time in bed, independent of pain intensity. Opioid use and pain intensity interacted in the prediction of SOL, such that opioid use (vs. non-use) was associated with longer SOL in the context of mild but not moderate to severe pain intensity.

CONCLUSIONS

Opioid use was associated with more difficulty falling asleep among adults with chronic pain; however, this cross-sectional effect was only significant among those reporting lower pain intensity. Authors speculate that this effect is masked among those with severe pain because the pain-related sleep debt they acquire throughout the night then facilitates sleep onset the next day.

Transdermal buprenorphine for moderate chronic noncancer pain syndromes

Introduction: Chronic noncancer pain has remained a challenging clinical problem. Opioid analgesics are effective, but they are known to be associated with opioid use disorder and potentially treatment-limiting side effects. Buprenorphine is a Schedule III synthetic opioid in the USA with a chemical structure similar to that of morphine but with a longer duration of action, greater potency, and other unique pharmacological attributes. Its role in treatment of chronic noncancer pain may be broader than currently thought.Areas covered: The pharmacokinetics, pharmacodynamics, clinical efficacy, and safety profile of transdermal buprenorphine in moderate chronic noncancer pain syndromes patients will be discussed.Expert commentary: Buprenorphine offers effective analgesia in the form of a Schedule III drug (rather than Schedule II such as oxycodone or morphine) and transdermal buprenorphine is a convenient, accepted, around-the-clock pain reliever. Its lower potential for abuse should make it a more desirable pain reliever but many payers do not reimburse buprenorphine, driving prescribers and their patients to generic versions of the riskier Schedule II oral opioids such as oxycodone and morphine.

Significant Efficacy of Tramadol/Acetaminophen in Elderly Patients with Chronic Low Back Pain Uncontrolled by NSAIDs: An Observational Study

Chronic low back pain (LBP) is a common condition and is generally treated using non-steroidal anti-inflammatory drug (NSAID); however, chronic NSAID use can decrease renal function. Tramadol, a weak opioid agonist, may improve chronic LBP and disability, while avoiding adverse effects such as gastrointestinal and renal toxicity. However, few studies have evaluated the short-term efficacy of opioids in Asian patients with chronic LBP. In this study, 24 patients with chronic LBP unresponsive to NSAIDs (10 men, 14 women; mean age, 65.1 ± 12.1 years) were prescribed tramadol/acetaminophen (37.5 mg/325 mg; four tablets daily) for 1 month. Then, the following parameters were assessed at baseline and after 1 week and 1 month of treatment: leg pain and LBP (Visual Analog Score [VAS]); activity of daily life (Roland-Morris Disability Questionnaire [RDQ]); and disability (Oswestry Disability Index [ODI]). Leg pain resolved within 1 week (p = 0.00093); however, LBP was relieved only at 1 month (p = 0.00034). The mean RDQ (p = 0.015) and ODI (p = 0.0032) scores were improved at 1 month. A total 41.6% of patients reported nausea and floating sensation beginning tramadol/acetaminophen treatment, and 12.5% (four patients) discontinued treatment as a result. LBP did not improve in 25% of patients administered tramadol/acetaminophen. Because this was an observational study, rather than a comparative study, further investigation is needed to evaluate the long-term efficacy of tramadol/acetaminophen in elderly patients with chronic LBP unresponsive to NSAIDs.