Assessing Abuse Potential of New Analgesic Medications Following Market Release: An Evaluation of Internet Discussion of Tapentadol Abuse

Adverse effects from counterfeit and mislabeled medicine containing tapentadol and carisoprodol

When self-administration with counterfeit or mislabeled medicine is suspected, comprehensive laboratory analysis should be preferred over immunoassay screening to avoid false negative results. Carisoprodol, which was formerly a popular muscle relaxant drug in many countries, has reappeared on illegal drug markets, and may cause an itching, purple-colored rash, even after a single dose.

Exploring Twitter chatter to assess the type and availability of cannabis-related products in Thailand

Cannabis-related tweets were collected between January and April 2022 to estimate the availability and characteristics of cannabis products advertised on Twitter amid the legalization of recreational cannabis in Thailand. The Twitter API was called using the tweepy Python library to collect cannabis-related tweets in the Thai language. A total of 185,558 unique tweets were collected over the duration of the data collection period based on 83 search terms. Twenty thousand random tweets were manually coded by four Thai native speakers to assess the volume and characteristics of tweets proposing cannabis. 72.6% of collected tweets from the 20,000 random samples were coded as relevant to the study. 54.6% of relevant tweets were advertising cannabis products, 29.8% were personal communications, and 15.6% were related to news or media content. Among the tweets that advertised cannabis products, 94.4% proposed cannabis flower, 2.4% cannabis edibles and 1.8% cannabis concentrates. Consumption of potent forms of cannabis such as cannabis edibles and concentrates increase the risk of harmful side-effects, especially in a population with limited knowledge about these products. Our findings call for additional monitoring efforts and for increasing the public awareness on potent cannabis products emerging in Thailand.

Increased incidence of mixed drug toxicity deaths involving tapentadol - A forensic study

Tapentadol is a relatively new synthetic opioid analgesic prescribed for the management of moderate to severe pain. While tapentadol has been shown to be more effective than traditional opioid analgesics, it still carries the risk of addiction, abuse, and misuse. In Australia, tapentadol has become one of the top five most commonly prescribed opioid drugs, with prescriptions increasing by approximately 150,000 each year since it first became available. The rapid increase in tapentadol prescriptions has occurred in parallel to an increasing number of post-mortem tapentadol detections in South Australia (SA). While the number of deaths in SA related to tapentadol use was low in the current study, findings suggest that an increasing trend of deaths involving tapentadol will continue in parallel to a rapidly increasing number of prescriptions, mirroring trends associated with traditional opioids in SA. As a comparatively new opioid analgesic, monitoring future trends will be important to determine if additional prescribing education, intervention, or restrictions are required.

Characterizing the Experience of Tapentadol Nonmedical Use: Mixed Methods Study

Background

The prevalence of abuse, diversion, and web-based endorsement of tapentadol (extended-release [ER], immediate-release [IR]) has been characterized as low compared with other prescription opioids. Little is known about individual experience with tapentadol nonmedical use (NMU).

Objective

This study aims to pilot web-based survey technologies to investigate the motivation for tapentadol NMU, sources of procurement, routes of administration, tampering methods, doses used, and impressions of tapentadol products (Nucynta and Nucynta ER).

Methods

Recruitment flyers and banner advertisements were placed on the Bluelight website [DragonByte Technologies Ltd] with a link to a web-based survey (Qualtrics) designed to query about individuals’ lifetime tapentadol NMU. This web-based survey was followed by an interactive web-based chat (Cryptocat) with respondents who were willing to be contacted. Respondents were queried about sources for obtaining tapentadol, motives for use, routes of administration, tampering methods, drugs used in combination, tablet strengths and dosages, and reasons for continued or discontinued use. Desirability and attractiveness for NMU was rated.

Results

Web-based recruitment successfully attracted difficult-to-find study participants. A total of 78 participants reported that tapentadol was obtained from friends and family (ER 11/30, 37%; IR 18/67, 27%), the internet (ER 11/30, 37%; IR 12/67, 18%) or participants’ own prescriptions from a doctor (ER 9/30, 30%; IR 17/67, 25%). It was used nonmedically for pain relief (ER 18/30, 60%; IR 33/67, 49%) and multiple psychotropic effects, including relaxation (ER 13/30, 43%; IR 29/67, 43%), reduction in depression or anxiety (ER 7/30, 23%; IR 30/67, 45%), or getting high (ER 12/30, 40%; IR 33/67, 49%). Tapentadol was primarily swallowed (ER 22/30, 73%; IR 55/67, 82%), although snorting (ER 2/30, 7%; IR 8/67, 12%) and injection (ER 2/30, 7%; IR 5/67, 8%) were also reported. The preferred dose for NMU was 100 mg (both ER and IR). The participants reported tapentadol use with benzodiazepines (ER 12/21, 57%; IR 28/47, 60%). Most participants had discontinued tapentadol NMU at the time of survey completion (ER 22/30, 73%; IR 55/67, 82%). Reasons for discontinued ER NMU included side effects (10/22, 46%) and lack of effective treatment (10/22, 46%). Reasons for discontinued IR NMU included lack of access (26/55, 47%) and better NMU options (IR 21/55, 38%). Few individuals were willing to divulge identifying information about themselves for the interactive chat (8/78, 10%), demonstrating the strength of anonymous, web-based surveys. Interactive chat supported the survey findings. A subgroup of participants (4/78, 5%) reported hallucinogenic side effects with high doses.

Conclusions

Web-based surveys can successfully recruit individuals who report drug NMU and those who are difficult to find. Tapentadol NMU appears to occur primarily for pain relief and for its psychotropic effects. Although it was liked by some, tapentadol did not receive a robust pattern of endorsement for NMU.

Evaluation of Abuse and Route of Administration of Extended-Release Tapentadol Among Treatment-Seeking Individuals, as Captured by the Addiction Severity Index-Multimedia Version (ASI-MV)

Background

Tapentadol is a molecule incorporating mu opioid receptor agonism and norepinephrine reuptake inhibition to provide analgesia, with the potential for a lower incidence of gastrointestinal side effects than full mu opioid agonists. Postmarketing surveillance of tapentadol as an active pharmaceutical ingredient has consistently revealed low levels of abuse and diversion.

Objective

The purpose of the present study was to further characterize the abuse liability of tapentadol extended-release (ER) by evaluating the prevalence of past 30-day tapentadol ER abuse and reported routes of administration as compared with ER opioids with Food and Drug Administration (FDA) abuse-deterrent labeling (“ADF opioids”) and ER opioids without FDA abuse-deterrent labeling (“non-ADF opioids”).

Methods

Data were collected from January 2014 through December 2017 from 776 centers located in 43 states throughout the United States using the Addiction Severity Index–Multimedia Version (ASI-MV), an instrument that is integral to the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO, Inflexxion, an IBH Company, Costa Mesa, CA, USA).

Results

Tapentadol ER had lower rates of past 30-day abuse than ADF ER and non-ADF ER opioid comparators, both at a population level and when adjusted for drug utilization. Tapentadol ER was primarily abused orally, although it was also abused through alternate routes of administration. Cumulative rates of tapentadol ER abuse by alternative routes of administration were lower than both ADF and non-ADF ER opioid comparators, although large confidence intervals resulting from the small sample size of reported tapentadol ER use limit firm conclusions.

Conclusions

In summary, tapentadol ER was found to have lower rates of both past 30-day abuse and use via alternate routes of administration, specifically snorting and smoking, than ADF and non-ADF ER comparators.

Mining social media for prescription medication abuse monitoring: a review and proposal for a data-centric framework

Objective

Prescription medication (PM) misuse and abuse is a major health problem globally, and a number of recent studies have focused on exploring social media as a resource for monitoring nonmedical PM use. Our objectives are to present a methodological review of social media–based PM abuse or misuse monitoring studies, and to propose a potential generalizable, data-centric processing pipeline for the curation of data from this resource.

Materials and Methods

We identified studies involving social media, PMs, and misuse or abuse (inclusion criteria) from Medline, Embase, Scopus, Web of Science, and Google Scholar. We categorized studies based on multiple characteristics including but not limited to data size; social media source(s); medications studied; and primary objectives, methods, and findings.

Results

A total of 39 studies met our inclusion criteria, with 31 (∼79.5%) published since 2015. Twitter has been the most popular resource, with Reddit and Instagram gaining popularity recently. Early studies focused mostly on manual, qualitative analyses, with a growing trend toward the use of data-centric methods involving natural language processing and machine learning.

Discussion

There is a paucity of standardized, data-centric frameworks for curating social media data for task-specific analyses and near real-time surveillance of nonmedical PM use. Many existing studies do not quantify human agreements for manual annotation tasks or take into account the presence of noise in data.

Conclusion

The development of reproducible and standardized data-centric frameworks that build on the current state-of-the-art methods in data and text mining may enable effective utilization of social media data for understanding and monitoring nonmedical PM use.

An evaluation of online discussion relating to nonmedical use of prescription opioids within the UK

AIM

To identify and describe the nature of online discussion relating to prescription opioids within the UK.

METHODS

We performed analysis of posts originating in the UK related to buprenorphine, hydrocodone, oxycodone and tramadol using Social Studio, a web-monitoring platform. The study included posts published between January 2014 and December 2016. The data were cleaned to produce a final dataset consisting only of substantive mentions, which were then categorised by defined themes.

RESULTS

The final dataset included a total of 17 361 substantive mentions (2936 buprenorphine, 2894 hydrocodone, 3826 oxycodone and 7705 tramadol). The most common theme for all 4 drugs was sharing experience or opinion comprising over 90% of mentions for each drug, while discussion related to polysubstance use was present in >1/4 of mentions across drug substances. Mentions related to diversion were more common for hydrocodone and oxycodone (8.1% [6.3-10.1 95% confidence interval] and 7.8% [6.5-9.2], respectively) than buprenorphine or tramadol (4.1 and 3.9% [3.5-4.3], respectively).

CONCLUSION

This investigation shows that there is substantial online discussion relating to a variety of nonmedical use (NMU) behaviours of prescription opioids within the UK, including for hydrocodone, which is not medically available. Web monitoring provides useful data and merits future investigation; this could include expansion to other categories of drugs and a more in-depth analysis of motivations behind NMU, both of which could add timely evidence regarding the current situation in the UK and help inform public health interventions for NMU of prescription drugs.

How Motivations for Using Buprenorphine Products Differ From Using Opioid Analgesics: Evidence from an Observational Study of Internet Discussions Among Recreational Users

BACKGROUND

Opioid use disorder (OUD) poses medical and societal concerns. Although most individuals with OUD in the United States are not in drug abuse treatment, buprenorphine is considered a safe and effective OUD treatment, which reduces illicit opioid use, mortality, and other drug-related harms. However, as buprenorphine prescriptions increase, so does evidence of misused, abused, or diverted buprenorphine. Users' motivations for extratreatment use of buprenorphine (ie, misuse or abuse of one's own prescription or use of diverted medication) may be different from the motivations involved in analgesic opioid products. Previous research is based on small sample sizes and use surveys, and none directly compare the motivations for using buprenorphine products (ie, tablet or film) with other opioid products having known abuse potential.

OBJECTIVE

The aim of the study was to describe and compare the motivation-to-use buprenorphine products, including buprenorphine/naloxone (BNX) sublingual film and oxycodone extended-release (ER), as discussed in online forums.

METHODS

Web-based posts from 2012 to 2016 were collected from online forums using the Web Informed Services internet monitoring archive. A random sample of posts was coded for motivation to use. These posts were coded into the following motivation categories: (1) use to avoid withdrawal, (2) pain relief, (3) tapering from other drugs, (4) opioid addiction treatment, (5) recreational use (ie, to get high), and (6) other use. Oxycodone ER, an opioid analgesic with known abuse potential, was selected as a comparator.

RESULTS

Among all posts, 0.81% (30,576/3,788,922) discussed motivation to use one of the target products. The examination of query-selected posts revealed significantly greater discussion of buprenorphine products than oxycodone ER (P<.001). The posts mentioning buprenorphine products were more likely than oxycodone ER to discuss treatment for OUD, tapering down use, and/or withdrawal management (P<.001). Buprenorphine-related posts discussed recreational use (375/1020, 36.76%), although much less often than in oxycodone ER posts (425/508, 83.7%). Despite some differences, the overall pattern of motivation to use was similar for BNX sublingual film and other buprenorphine products.

CONCLUSIONS

An analysis of spontaneous, Web-based discussion among recreational substance users who post on online drug forums supports the contention that motivation-to-use patterns associated with buprenorphine products are different from those reported for oxycodone ER. Although the findings presented here are not expected to reflect the actual use of the target products, they may represent the interests and motivations of those posting on the online forums. Buprenorphine-related posts were more likely to discuss treatment for OUD, tapering, and withdrawal management than oxycodone ER. Although the findings are consistent with a purported link between the limited availability of medication-assisted therapies for substance use disorders and use of diverted buprenorphine products for self-treatment, recreational use was a motivation expressed in more than one-third of buprenorphine posts.

Opioid use and harms associated with a sustained-release tapentadol formulation: A post-marketing surveillance study

AIMS

A sustained-release formulation (SRF) of tapentadol has been marketed in Australia since February 2013. This study examined tapentadol SRF extra-medical use, attractiveness for extra-medical use, and associated harms in Australia.

METHODS

This post-marketing study comprises analyses of Australian community sales data (2011-2017) for eleven pharmaceutical opioids (prescription and over-the-counter codeine disaggregated); calls to three poisons information centres (covering five of the eight jurisdictions in Australia) related to pharmaceutical opioids and coded by the centres as 'misuse' or 'abuse' (2011-2017); and interviews with people who inject drugs (n = 888) recruited as part of the Illicit Drug Reporting System (IDRS) from all Australian capital cities (2017).

RESULTS

Population-level availability of tapentadol SRF increased from market launch, comprising the sixth largest market share of all opioid unit sales, and third greatest share in oral morphine equivalent milligrams sold, in December 2017. Lifetime tapentadol SRF use among the IDRS sample (n = 888) was low (1.5%; 95%CI 0.9-2.5), with few reporting past-6 month non-prescribed use or injection. Non-fatal overdose following tapentadol use was self-reported by less than 1% (95%CI 0.1-0.8). Between 2013-2017, 1.1% (n = 25) of pharmaceutical opioid 'misuse/abuse' calls were related to tapentadol, and predominantly the SRF.

CONCLUSIONS

Increasing utilisation of tapentadol sustained-release formulation was observed, along with indications of extra-medical use and harms associated with use, although on a smaller scale relative to other opioids. These findings need to be interpreted in the context of the low level of exposure to tapentadol sustained-release formulation among the sentinel population of people who inject drugs.

Opioid use and harms associated with a sustained-release tapentadol formulation: a postmarketing study protocol

INTRODUCTION

It has been argued that tapentadol may pharmacologically have lower abuse potential than other pharmaceutical opioids currently available. However, there has been no comprehensive triangulation of data regarding use and harms associated with this formulation. A sustained-release formulation (SRF) of tapentadol (Palexia) was released in Australia in 2011 and listed for public subsidy in 2013. We summarise here the methods of a postmarketing study which will measure postintroduction: (1) population level availability, (2) extramedical use and diversion, (3) attractiveness for extramedical use and (4) associated harms, of tapentadol compared against other pharmaceutical opioids.

METHODS AND ANALYSIS

We evaluated key sources on pharmaceutical use and harms in Australia. This review indicateddata from four sources that disaggregate pharmaceutical opioid formulations and capture tapentadol SRF could be triangulated. These data sources comprised: (1) national pharmaceutical opioid community sales data from 2011 to 2017, (2) national pharmaceutical opioid poisonings reported to Poison Information Centres (PICs) from 2011 to 2017, (3) number of vendors on online marketplaces listing pharmaceutical opioids for sale and (4) data on pharmaceutical opioid extramedical use, attractiveness and harms from interviews with people who regularly inject drugs in Australia.

ETHICS AND DISSEMINATION

Ethics approval is not required for use of pharmaceutical sales data. Ethics approval has been obtained for use of national pharmaceutical opioid poisonings reported to PICs (LNR/16/SCHN/44) and for use of online marketplace data and interview data from people who inject drugs (HC12086). Key findings will be published mid-2018 in a peer-reviewed academic journal, and presented at various conferences and professional meetings.

Comparative pharmacology and toxicology of tramadol and tapentadol

Moderate-to-severe pain represents a heavy burden in patients' quality of life, and ultimately in the society and in healthcare costs. The aim of this review was to summarize data on tramadol and tapentadol adverse effects, toxicity, potential advantages and limitations according to the context of clinical use. We compared data on the pharmacological and toxicological profiles of tramadol and tapentadol, after an extensive literature search in the US National Library of Medicine (PubMed). Tramadol is a prodrug that acts through noradrenaline and serotonin reuptake inhibition, with a weak opioid component added by its metabolite O-desmethyltramadol. Tapentadol does not require metabolic activation and acts mainly through noradrenaline reuptake inhibition and has a strong opioid activity. Such features confer tapentadol potential advantages, namely lower serotonergic, dependence and abuse potential, more linear pharmacokinetics, greater gastrointestinal tolerability and applicability in the treatment of chronic and neuropathic pain. Although more studies are needed to provide clear guidance on the opioid of choice, tapentadol shows some advantages, as it does not require CYP450 system activation and has minimal serotonergic effects. In addition, it leads to less side effects and lower abuse liability. However, in vivo and in vitro studies have shown that tramadol and tapentadol cause similar toxicological damage. In this context, it is important to underline that the choice of opioid should be individually balanced and a tailored decision, based on previous experience and on the patient's profile, type of pain and context of treatment.

SIGNIFICANCE

This review underlines the need for a careful prescription of tramadol and tapentadol. Although both are widely prescribed synthetic opioid analgesics, their toxic effects and potential dependence are not completely understood yet. In particular, concerning tapentadol, further research is needed to better assess its toxic effects.

Using Social Listening Data to Monitor Misuse and Nonmedical Use of Bupropion: A Content Analysis

Background

The nonmedical use of pharmaceutical products has become a significant public health concern. Traditionally, the evaluation of nonmedical use has focused on controlled substances with addiction risk. Currently, there is no effective means of evaluating the nonmedical use of noncontrolled antidepressants.

Objective

Social listening, in the context of public health sometimes called infodemiology or infoveillance, is the process of identifying and assessing what is being said about a company, product, brand, or individual, within forms of electronic interactive media. The objectives of this study were (1) to determine whether content analysis of social listening data could be utilized to identify posts discussing potential misuse or nonmedical use of bupropion and two comparators, amitriptyline and venlafaxine, and (2) to describe and characterize these posts.

Methods

Social listening was performed on all publicly available posts cumulative through July 29, 2015, from two harm-reduction Web forums, Bluelight and Opiophile, which mentioned the study drugs. The acquired data were stripped of personally identifiable identification (PII). A set of generic, brand, and vernacular product names was used to identify product references in posts. Posts were obtained using natural language processing tools to identify vernacular references to drug misuse-related Preferred Terms from the English Medical Dictionary for Regulatory Activities (MedDRA) version 18 terminology. Posts were reviewed manually by coders, who extracted relevant details.

Results

A total of 7756 references to at least one of the study antidepressants were identified within posts gathered for this study. Of these posts, 668 (8.61%, 668/7756) referenced misuse or nonmedical use of the drug, with bupropion accounting for 438 (65.6%, 438/668). Of the 668 posts, nonmedical use was discouraged by 40.6% (178/438), 22% (22/100), and 18.5% (24/130) and encouraged by 12.3% (54/438), 10% (10/100), and 10.8% (14/130) for bupropion, amitriptyline, and venlafaxine, respectively. The most commonly reported desired effects were similar to stimulants with bupropion, sedatives with amitriptyline, and dissociatives with venlafaxine. The nasal route of administration was most frequently reported for bupropion, whereas the oral route was most frequently reported for amitriptyline and venlafaxine. Bupropion and venlafaxine were most commonly procured from health care providers, whereas amitriptyline was most commonly obtained or stolen from a third party. The Fleiss kappa for interrater agreement among 20 items with 7 categorical response options evaluated by all 11 raters was 0.448 (95% CI 0.421-0.457).

Conclusions

Social listening, conducted in collaboration with harm-reduction Web forums, offers a valuable new data source that can be used for monitoring nonmedical use of antidepressants. Additional work on the capabilities of social listening will help further delineate the benefits and limitations of this rapidly evolving data source.

"Those edibles hit hard": Exploration of Twitter data on cannabis edibles in the U.S

AIMS

Several states in the U.S. have legalized cannabis for recreational or medical uses. In this context, cannabis edibles have drawn considerable attention after adverse effects were reported. This paper investigates Twitter users' perceptions concerning edibles and evaluates the association edibles-related tweeting activity and local cannabis legislation.

METHODS

Tweets were collected between May 1 and July 31, 2015, using Twitter API and filtered through the eDrugTrends/Twitris platform. A random sample of geolocated tweets was manually coded to evaluate Twitter users' perceptions regarding edibles. Raw state proportions of Twitter users mentioning edibles were ajusted relative to the total number of Twitter users per state. Differences in adjusted proportions of Twitter users mentioning edibles between states with different cannabis legislation status were assesed via a permutation test.

RESULTS

We collected 100,182 tweets mentioning cannabis edibles with 26.9% (n=26,975) containing state-level geolocation. Adjusted percentages of geolocated Twitter users posting about edibles were significantly greater in states that allow recreational and/or medical use of cannabis. The differences were statistically significant. Overall, cannabis edibles were generally positively perceived among Twitter users despite some negative tweets expressing the unreliability of edible consumption linked to variability in effect intensity and duration.

CONCLUSION

Our findings suggest that Twitter data analysis is an important tool for epidemiological monitoring of emerging drug use practices and trends. Results tend to indicate greater tweeting activity about cannabis edibles in states where medical THC and/or recreational use are legal. Although the majority of tweets conveyed positive attitudes about cannabis edibles, analysis of experiences expressed in negative tweets confirms the potential adverse effects of edibles and calls for educating edibles-naïve users, improving edibles labeling, and testing their THC content.

Tapentadol: Can It Kill Two Birds with One Stone without Breaking Windows?

Tapentadol is a novel oral analgesic with a dual mode of action as an agonist of the µ-opioid receptor (MOR), and as a norepinephrine reuptake inhibitor (NRI) all in a single molecule. Immediate release (IR) tapentadol shows its analgesic effect quickly, at around 30 minutes. Its MOR agonistic action produces acute nociceptive pain relief; its role as an NRI brings about chronic neuropathic pain relief. Absorption is rapid, with a mean maximal serum concentration at 1.25-1.5 h after oral intake. It is present primarily in the form of conjugated metabolites after glucuronidation, and excretes rapidly and completely via the kidneys. The most common adverse reactions are nausea, dizziness, vomiting, and somnolence. Constipation is more common in use of the ER formulation. Precautions against concomitant use of central nervous system depressants, including sedatives, hypnotics, tranquilizers, general anesthetics, phenothiazines, other opioids, and alcohol, or use of tapentadol within 14 days of the cessation of monoamine oxidase inhibitors, are advised. The safety and efficacy have not been established for use during pregnancy, labor, and delivery, or for nursing mothers, pediatric patients less than 18 years of age, and cases of severe renal impairment and severe hepatic impairment. The major concerns for tapentadol are abuse, addiction, seeking behavior, withdrawal, and physical dependence. The presumed problem for use of tapentadol is to control the ratio of MOR agonist and NRI. In conclusion, tapentadol produces both nociceptive and neuropathic pain relief, but with worries about abuse and dependence.