Oral transmucosal fentanyl citrate for the treatment of breakthrough pain in cancer patients: an overview of its pharmacological and clinical characteristics

Strong π-Metal Interaction Enables Liquid Interfacial Nanoarray-Molecule Co-assembly for Raman Sensing of Ultratrace Fentanyl Doped in Heroin, Ketamine, Morphine, and Real Urine

Toward the challenge on reliable determination of trace fentanyl to avoid opioid overdose death in drug crisis, here we realize rapid and direct detection of trace fentanyl in real human urine without pretreatment by a portable surface enhanced Raman spectroscopy (SERS) strategy on liquid/liquid interfacial (LLI) plasmonic arrays. It was observed that fentanyl could interact with the gold nanoparticles (GNPs) surface, facilitate the LLI self-assembly, and consequently amplify the detection sensitivity with a limit of detection (LOD) as low as 1 ng/mL in aqueous solution and 50 ng/mL spiked in urine. Furthermore, we achieve multiplex blind sample recognition and classification of ultratrace fentanyl doped in other illegal drugs, which has extremely low LODs at mass concentrations of 0.02% (2 ng in 10 μg of heroin), 0.02% (2 ng in 10 μg of ketamine), and 0.1% (10 ng in 10 μg of morphine). A logic circuit of the AND gate was constructed for automatic recognition of illegal drugs with or without fentanyl doping. The data-driven analog soft independent modeling model could quickly distinguish fentanyl-doped samples from illegal drugs with 100% specificity. Molecular dynamics (MD) simulation elucidates the underlying molecular mechanism of nanoarray-molecule co-assembly through strong π-metal interactions and the differences in the SERS signal of various drug molecules. It paves a rapid identification, quantification, and classification strategy for trace fentanyl analysis, indicating broad application prospects in response to the opioid epidemic crisis.

Rapid SERS Quantification of Trace Fentanyl Laced in Recreational Drugs with a Portable Raman Module

Rapid identification and quantification of opioid drugs are of significant importance and an urgent need in drug regulation and control, considering the serious social and economic impact of the opioid epidemic in the United States. Unfortunately, techniques for accurate detection of these opioids, particularly for fentanyl, an extremely potent synthetic drug of abuse and a main perpetrator in the opioid crisis, are often not readily accessible. Therefore, a fast, highly sensitive, and preferably quantitative technique, with excellent portability, is highly desirable. Such a technique can potentially offer timely and crucial information for drug control officials, as well as health professionals, about drug distribution and overdose prevention. We therefore propose a portable surface-enhanced Raman scattering (SERS) approach by pairing an easy to perform yet reliable SERS protocol with a compact Raman module suitable for rapid, on-site identification and quantification of trace fentanyl. Fentanyl spiked in urine control was successfully detected at concentrations as low as 5 ng/mL. Portable SERS also enabled detection of trace fentanyl laced in recreational drugs at mass concentrations as low as 0.05% (5 ng in 10 μg total) and 0.1% (10 ng in 10 μg total) in heroin and tetrahydrocannabinol (THC), respectively. Drug interaction with the nanoparticle surface was simulated through molecular dynamics to investigate the molecular adsorption mechanism and account for SERS signal differences observed for opioid drugs. Furthermore, resolution of fentanyl in binary and ternary opioid mixtures was readily achieved with multivariate data analysis. In sum, we developed a rapid, highly sensitive, and reliably quantitative method for trace fentanyl analysis by synergizing a streamlined SERS procedure and a portable Raman module at low cost.

Transmucosal drug administration as an alternative route in palliative and end-of-life care during the COVID-19 pandemic

The Coronavirus disease 2019 (COVID-19) pandemic has led to a surge in need for alternative routes of administration of drugs for end of life and palliative care, particularly in community settings. Transmucosal routes include intranasal, buccal, sublingual and rectal. They are non-invasive routes for systemic drug delivery with the possibility of self-administration, or administration by family caregivers. In addition, their ability to offer rapid onset of action with reduced first-pass metabolism make them suitable for use in palliative and end-of-life care to provide fast relief of symptoms. This is particularly important in COVID-19, as patients can deteriorate rapidly. Despite the advantages, these routes of administration face challenges including a relatively small surface area for effective drug absorption, small volume of fluid for drug dissolution and the presence of a mucus barrier, thereby limiting the number of drugs that are suitable to be delivered through the transmucosal route. In this review, the merits, challenges and limitations of each of these transmucosal routes are discussed. The goals are to provide insights into using transmucosal drug delivery to bring about the best possible symptom management for patients at the end of life, and to inspire scientists to develop new delivery systems to provide effective symptom management for this group of patients.

The use of fentanyl in pain management in head and neck cancer patients: a narrative review

Background

Head and neck (H&N) cancers account for about 5% of all malignant tumours. Pain is one of the most feared consequences of H&N neoplasms and is experienced by up to 80% of patients and worsens their quality of life inhibiting speaking, eating, drinking or swallowing. Nevertheless, pain is still often underestimated and undertreated.

Objectives

The role of opioids in cancer pain has been well established but evidences about the role and the relative effectiveness of opioids such as fentanyl in the context of H&N cancer pain remains unclear.

Methods

A literature review based on the guidance of the Centre for Reviews and Dissemination was conducted. An iterative approach was used starting with an electronic search in the MEDLINE database. The search terms (('Neoplasms'[Mesh]) AND 'Head and Neck Neoplasms'[Mesh]) AND 'Fentanyl'[Mesh] were used.

Results

A total of 18 publications were found by the first performed search on PubMed. Other publications concordant with our aim were found by cross-reference. Considering inclusion and exclusion criteria for our review, eight papers resulted eligible for analysis.

Conclusion

Fentanyl transdermal therapeutic system (TTS) seems to be an important option, thanks to the way of administration, the good safety and tolerability profiles to control baseline pain. For breakthrough cancer pain (BTcP), several formulations of transmucosal fentanyl are available. All the formulations seem to be active and safety but we lack head-to-head studies of fentanyl versus other strong opioids, as well as with different formulation of fentanyl, particularly for BTcP where H&N cancer population is very poorly represented.

Characteristics and Treatment of Breakthrought Pain (BTcP) in Palliative Care

INTRODUCTION

This research was to follow characteristics of breakthrough pain caused by cancer (BTcP) and other most common sympthoms (ESAS) at patients in advanced stage of cancer disease in palliative care.

PATIENTS AND METHODS

Prospective study included 433 patients which were treated in Palliative Care Centre in UKC Tuzla, Bosnia and Herzegovina. Group 1 was consisted of 353 patients whose basal cancer pain of intensity 4-7 NRS was treated weak opiates (basal analgetic- fixed combination of tramadol/paracetamol (37.5 mg/325 mg) in initial dose 3x1tbl for pain intensity 4, to 4x2tbl (for pain intensity 7). In Group 2 (80 patients) basal pain of intensity 8-10 was treated strong opiates as basal analgetic (oral morphine and transdermal fentanil). If the previous day were 2 or more breakthrough pain that required ''rescue dose'' of analgetics (tramadol 50-100 mg orally in group 1 ie. Oral morphine 8-12 mg in the group 2), the dose of basal analgetic was increased.

RESULTS

The total number of reported breakthrough pain in all 433 patients for 10 days of treatment was 3 369 (0.78 BTcP /per patient/day), where at Group 1 patients showed significantly lower BTcP (0.56 BTcP/patient/day). The average intensity of BTcP was 5.91 where in the Group1 was 4.51 while in the Group 2 8.04. 582 (17.28%) was rated grade 7, of which 539 were successfully coupled by strong and 43 (7.39%) successfully coupled by weak opiates. From 556 BTcP who were rated with 8, 540 of them were coupled strong and only 16 successfully coupled by weak opiates. 1967 (58.39 %) of breakthrough pain has occured in the evening hours (18-06 h), while 1402 (41.62%) BTCP occured during day hours (06-18h). Most (1290 or 38.29%) of breakthrough pain lasted less than 10 minutes, 882 (26.18%) between 16 and 20 minutes, 752 (22.32%) between 11 and 15 minutes, 407 (12.8%) between 21 and 30 minutes and 38 (1.13%) lasted longer than 20 minutes.

CONCLUSION

Duriong our study, we noted a relatively large number of breakthrough pain with lower intensity (3-6) in patients treated with weak opiates, which are also adversely affected patients satisfaction with pain treatment and required additional doses of analgetics. In the small percentage is possible the breakthrough pain of stronger intensity (7-8) treat by maximum doses of weak opiates.

A comparative study between intrathecal dexmedetomidine and fentanyl as adjuvant to intrathecal bupivacaine in lower abdominal surgeries: A randomized trial

Context:

Spinal anesthesia is preferred choice of anesthesia in lower abdominal surgeries since long time. However problem with this is limited duration of action, so for long duration surgeries alternative are required. Dexmedetomidine is a highly selective alpha-2-adrenergic agonist has property to potentiate the action of local anesthetic used in spinal anesthesia. Fentanyl is an opioid and it has also the same property.

Aims:

To compare the efficacy, analgesic effects, and side-effects of dexmedetomidine and fentanyl as adjuvant to bupivacaine for lower abdominal surgery.

Settings and Design:

The type of this study was double-blind randomized trial.

Subjects and Methods:

A total of 80 patients were randomly allocated in two Group D and Group F. Group D were injected injection bupivacaine 0.5% heavy × 3.0 ml + 0.5 ml of preservative free normal saline containing 5 μg dexmedetomidine. Group F were received injection bupivacaine 0.5% heavy × 3.0 ml + 0.5 ml fentanyl equivalent to 25 μg.

Statistical Analysis Used:

The statistical analysis was performed using SPSS (Statistical Package for Social Sciences) version 15.0 statistical analysis software.

Results:

The results show that highest sensitivity level of T6 and T8 was achieved by higher proportion of subjects from Group D when compared to Group F and sensitivity level T7 was achieved by higher proportion of subjects of Group F when compared to Group D. Duration of analgesic properties was significantly higher in Group D when compared to Group F.

Conclusion:

The findings in the present study suggested that intrathecal adjuvant use of dexmedetomidine as compared to fentanyl provides a longer sensory and motor blockade and also prolongs the postoperative analgesic effect.

Transmucosal Immediate-Release Fentanyl for Breakthrough Cancer Pain: Opportunities and Challenges for Use in Palliative Care

Opioids are used to treat breakthrough cancer pain (BTCP) and can be classified by relative duration and onset of action. Regulatory approvals of numerous transmucosal immediate-release fentanyl (TIRF) formulations provide alternative options to palliative care-trained providers in the management of BTCP. TIRFs have been formulated as a sublingual tablet, sublingual spray, intranasal spray, pectin-based nasal spray, buccal tablet, and buccal soluble film. Differences exist between TIRFs regarding formulation design and dosing to treat BTCP. Opportunities for use include palliation of BTCP in head and neck cancer and/or radiation-induced mucositis. The purpose of this review is to discuss TIRF formulation and dosing, pharmacokinetics, clinical efficacy, patient acceptability, and safety/tolerability. In addition, barriers to TIRF utilization will be discussed.

Highlights in opioid agonists and antagonists

This review highlights new insights in to opioid agonists and antagonists, focusing on their mechanism of action with spinal and systemic administration, chronic use and main adverse effects. Short-cuts on some opioid agonists and antagonists of clinical interest are also presented, revealing potential clinical implications and future clinical directions as part of multimodal analgesia.

Considerations in selecting rapid-onset opioids for the management of breakthrough pain

Breakthrough pain (BTP) is a transitory pain that occurs despite the use of long-term, around-the-clock analgesia. It is highly prevalent in certain populations and places a significant burden on patients, their families, caregivers, and health-care systems. Despite its prevalence and impact, BTP is sometimes unrecognized and often undertreated. Various formulations of fentanyl – a rapid-onset opioid with short duration of action – are available for the management of BTP. The efficacy of formulations using transmucosal, transbuccal, sublingual, and intranasal administration routes has been demonstrated for BTP treatment in clinical trials. However, a lack of head-to-head trials evaluating their relative efficacy makes it challenging for physicians to reach informed decisions on the most efficacious intervention for individual patients. In the absence of clear data on the relative efficacy of fentanyl formulations, prescribing decisions need to be based on physician understanding and experience and product cost and availability, taking into account the individual patient’s needs, the ability of the patient or caregivers to administer medication, and the patient’s wishes. This review evaluates current pharmacologic methods of alleviating BTP and discusses factors that should be considered when selecting the most appropriate formulation for individual patients. With the range of fentanyl formulations available, it is now possible to successfully address BTP in the majority of patients.

A comprehensive review of rapid-onset opioids for breakthrough pain

Breakthrough pain (BTP) is a transitory pain (reaching maximum severity in ~15 minutes and lasting ~60 minutes in patients with cancer) that occurs despite the management of chronic pain with long-term around-the-clock analgesia. BTP occurs in 33-65% of patients with chronic cancer pain and in ~70% of patients with chronic noncancer pain. BTP has historically been managed with short-acting opioids; however, these medications have a pharmacokinetic profile that does not correlate with the sudden onset and short time to maximum severity of BTP. Interest in rapid-onset opioids to relieve BTP has therefore been growing. This comprehensive review aims to summarize the currently available clinical data for the approved rapid-onset opioids, which comprise different formulations of fentanyl, a μ-opioid receptor agonist with anaesthetic and analgesic properties. Administration routes for fentanyl in the management of BTP currently include the transmucosal and intranasal routes; an intrapulmonary formulation is also in development. The findings of this review suggest that the efficacy and safety of the approved rapid-onset opioids are comparable.

Topical fentanyl in a randomized, double-blind study in patients with corneal damage

OBJECTIVES

Corneal damage causes severe pain. This study investigated whether peripheral opioid receptors are present in the human cornea and assessed the efficacy of topical fentanyl in patients with corneal erosion.

METHODS

Immunohistochemical staining experiments were performed to examine the presence of both mu and delta-receptors on peripheral nerve fibers within human corneal tissue. In a randomized, double-blind clinical trial dexpanthenol (n=20) or dexpanthenol plus 10 microg fentanyl (n=20) were topically applied every 4 hours to the eye of patients with a surgical intervention of corneal damage and subjective pain intensity was determined by a numerical rating scale.

RESULTS

Immunohistochemical staining identified peripheral nerve fibers in human cornea expressing both mu and delta-opioid receptors. In patients with corneal damage the ophthalmic intervention in local anesthesia decreased the subjective pain intensity significantly. At 4-hour intervals after the ophthalmic intervention, moderate pain intensity levels were not altered by the application of dexpanthenol with or without fentanyl. At 24 hours pain intensity dropped significantly, most likely owing to a natural decrease in pain, because the erosion was almost healed.

DISCUSSION

Both mu and delta-receptors are localized on nerve fibers within the cornea, which are accessible for topical opioid treatment. However, our formulation and dose of topical fentanyl in combination with dexpanthenol did not show any benefit in relieving pain from corneal erosion. Future studies are planned to determine the optimal protocol and dose of topical opioid treatment.

Recent advances in the pharmacological management of pain

Pain is an unpleasant sensation that originates from ongoing or impending tissue damage. Management of different types of pain (acute, postoperative, inflammatory, neuropathic or cancer) is the most frequent issue encountered by clinicians and pharmacological therapy is the first line of approach for the treatment of pain. This review presents and discusses recent clinical advances regarding both the improvements in delivery of analgesic drugs and improvements in the design of analgesic molecules. The new modalities of administration of analgesics used in the clinic are reviewed, including skin patches, oral and mucosal sprays, transdermal delivery systems and intranasal administration. New insights are then presented on standard drugs used to relieve pain, such as opioids (including tramadol), NSAIDs including selective cyclo-oxygenase-2 inhibitors, paracetamol (acetaminophen), local anaesthetics and adjuvant analgesics such as antidepressants, anticonvulsants (gabapentin and pregabalin), cannabinoids, ketamine and others (e.g. nefopam). Although the understanding of pain mechanisms has improved significantly recently, much more is yet to be discovered and awaited. Broadening of our knowledge is needed to improve basic and clinical research in this field in order to better alleviate pain in millions of people.

Oral transmucosal fentanyl citrate in cancer pain management: a practical application of nanotechnology

Pain is experienced by most cancer patients and represents an important issue in the clinical setting. Breakthrough pain is a transitory flare of pain that occurs in most cancer patients on a background of otherwise controlled persistent pain. Treatment of breakthrough pain is a challenging phenomenon. Oral transmucosal fentanyl citrate (OTFC; Actiq, Cephalon, UK), a new opioid formulation with a unique delivery system, utilizing the advantages that nanotechnology offers, reflects the characteristics of breakthrough pain (rapid onset of action and short duration), which makes it an effective treatment to cancer patients who are already receiving opioids and continue to experience such flares of pain. Oral transmucosal fentanyl citrate is specifically developed and approved for the management of breakthrough pain in cancer patients and it has the potential to be a useful tool for clinicians.

The Treatment of Breakthrough Pain

OBJECTIVE

To review strategies for treating patients with breakthrough pain (BTP).

DESIGN

This review is based on expert consensus recommendations for treating BTP and is supplemented by recent clinical studies and the author's clinical experience.

RESULTS

Breakthrough pain is severe or excruciating pain of rapid onset that can disable or even immobilize the patient. Patients with BTP should be assessed after baseline persistent pain has been stabilized with around-the-clock (ATC) analgesics. Clues about the cause and pattern of BTP may be identified from a patient history, preferably including a pain diary. Effective treatment can greatly improve the patient's quality of life and should be tailored for each patient, taking into consideration the cause and type of the BTP episodes. Short-acting opioid analgesics are the primary treatment. The absorption characteristics, onset of action, and duration of effect vary among the available opioid compounds based on their lipophilicity. The dose and/or dosing frequency of the ATC analgesic should be adjusted for patients with end-of-dose BTP. Short-acting oral opioids are useful when given preemptively in patients with predictable incident BTP, while rapid-onset transmucosal lipophilic opioids are most effective for patients with unpredictable incident or idiopathic BTP. Regardless of the subtype of BTP, nonpharmacologic strategies are often helpful in alleviating pain and anxiety and should be used to supplement pharmacologic intervention for BTP.

CONCLUSION

Breakthrough pain can often be successfully treated by tailoring opioid therapy based on the subtype of BTP. These characteristics of BTP will determine the most appropriate opioid compound (i.e., hydrophilic vs lipophilic) and most effective mode of drug delivery.

Oral transmucosal fentanyl citrate for cancer breakthrough pain: a review

PURPOSE/OBJECTIVES

To review the dose titration, efficacy, and safety of oral transmucosal fentanyl citrate (OTFC).

DATA SOURCES

Phase I and II clinical trial abstracts and evidence-based review articles.

DATA SYNTHESIS

OTFC has an onset, peak, and duration of action similar to that of an IV dose of an opioid and has been demonstrated to be effective and well tolerated for the management of breakthrough pain in patients with cancer.

CONCLUSIONS

Studies of OTFC demonstrate that it is easy to use,noninvasive, effective, safe, and acceptable to patients, caregivers, and healthcare providers. However, OTFC is expensive and approved for use only in opioid-tolerant patients with cancer.

IMPLICATIONS FOR NURSING

Breakthrough pain in patients with cancer is a common problem with characteristics that make it difficult to treat. Oncology nurses should familiarize themselves with OTFC's unique characteristics to be able to best help patients manage their therapy.