1
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Kraft KVL, Backmund T, Eberhart L, Schubert AK, Dinges HC, Hagen MK, Gehling M. Does opioid therapy enhance quality of life in patients suffering from chronic non-malignant pain? A systematic review and meta-analysis. Br J Pain 2024; 18:227-242. [PMID: 38751560 PMCID: PMC11092930 DOI: 10.1177/20494637231216352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Background and objective Chronic pain is associated with a poor health-related quality of life (HRQL). Whereas the prescription rate of opioids increased during the last decades, their use in chronic non-malignant pain remains unclear. However, there is currently no clinical consensus or evidence-based guidelines that consider the long-term effects of opioid therapy on HRQL in patients with chronic non-cancer pain. This systematic review aims to address the question of whether opioid therapy improves HRQL in patients with chronic non-malignant pain and provide some guidance to practitioners. Databases and data treatment PubMed, EMBASE and CENTRAL were searched in June 2020 for double-blind, randomized trials (RCTs), comparing opioid therapy to placebo and assessed a HRQL questionnaire. The review comprises a qualitative vote counting approach and a meta-analysis of the Short Form Health Survey (SF-36), EQ-5D questionnaire and the pain interference scale of the Brief pain inventory (BPI). Results 35 RCTs were included, of which the majority reported a positive effect of opioids for the EQ-5D, the BPI and the physical component score (PCS) of the SF-36 compared to placebo. The meta-analysis of the PCS showed a mean difference of 1.82 [confidence interval: 1.32, 2.32], the meta-analysis of the EQ-5D proved a significant advantage of 0.06 [0.00, 0.12]. In the qualitative analysis of the mental component score (MCS) of the SF-36, no positive or negative trend was seen. No significant differences were seen in the MCS (MD: 0.65 [-0.43, 1.73]). A slightly higher premature dropout rate was found in the opioid group (risk difference: 0.04 [0.00, 0.07], p = .07). The body of evidence is graded as low to medium. Conclusion Opioids have a statistically significant, but small and clinical not relevant effect on the physical dimensions of HRQL, whereas there is no effect on mental dimensions of HRQL in patients with chronic non-malignant pain during the initial months of treatment. In clinical practice, opioid prescriptions for chronic non-cancer pain should be individually assessed as their broad efficacy in improving quality of life is not confirmed. The duration of opioid treatment should be determined carefully, as this review primarily focuses on the initial months of therapy.
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Affiliation(s)
- Karl V. L. Kraft
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Teresa Backmund
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Leopold Eberhart
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Ann-Kristin Schubert
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Hanns-Christian Dinges
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Maria K. Hagen
- Department of Physics and Material Sciences Center, Philipps-University Marburg, Marburg, Germany
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2
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Erlenwein J, Tavernini T, Kästner A, Petzke F. [Dealing with "complex" pain patients in eye surgery : Perioperative management of patients with pre-existing chronic pain, opioid consumption and opioid use disorder]. DIE OPHTHALMOLOGIE 2023; 120:1204-1215. [PMID: 37930369 DOI: 10.1007/s00347-023-01949-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
The quality of postoperative pain management is still considered insufficient in many cases, also in surgical ophthalmology. Complex constellations and comorbidities, such as pre-existing chronic pain, opioid consumption and opioid use disorders represent a special challenge due to psychosocial influencing factors and sometimes psychological and psychiatric comorbidities but also due to pharmacological effects, such as the development of opioid tolerance, the opioid-induced hyperalgesia. This review article aims to impart knowledge on aspects of these comorbidities and the perioperative management to improve the treatment skills of ophthalmologists in the management of pain in these complex patients.
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Affiliation(s)
- Joachim Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - Tabea Tavernini
- Interdisziplinäres Schmerzzentrum, DIAKOVERE Friederikenstift, Hannover, Deutschland
| | - Anne Kästner
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Frank Petzke
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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3
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Wegwarth O, Spies C, Ludwig WD, Donner-Banzhoff N, Jonitz G, Hertwig R. Educating physicians on strong opioids by descriptive versus simulated-experience formats: a randomized controlled trial. BMC MEDICAL EDUCATION 2022; 22:741. [PMID: 36289483 PMCID: PMC9607791 DOI: 10.1186/s12909-022-03797-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/06/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Long-term prescriptions of strong opioids for chronic noncancer pain-which are not supported by scientific evidence-suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Because risk perceptions and behaviors can differ depending on whether people learn about risks through description or experience, we investigated the effects of descriptive versus simulated-experience educative formats on physicians' risk perceptions of strong opioids and their prescription behavior for managing chronic noncancer pain. METHODS Three hundred general practitioners and 300 pain specialists in Germany-enrolled separately in two independent exploratory randomized controlled online trials-were randomly assigned to either a descriptive format (fact box) or a simulated-experience format (interactive simulation). PRIMARY ENDPOINTS Objective risk perception (numerical estimates of opioids' benefits and harms), actual prescriptions of seven therapy options for managing chronic pain. SECONDARY ENDPOINT Implementation of intended prescriptions of seven therapy options for managing chronic pain. RESULTS Both formats improved the proportion of correct numerical estimates of strong opioids' benefits and harms immediately after intervention, with no notable differences between formats. Compared to description, simulated experience led to significantly lower reported actual prescription rates for strong and/or weak opioids, and was more effective at increasing prescription rates for non-drug-based therapies (e.g., means of opioid reduction) from baseline to follow-up for both general practitioners and pain specialists. Simulated experience also resulted in a higher implementation of intended behavior for some drug-based and non-drug-based therapies. CONCLUSIONS The two formats, which recruit different cognitive processes, may serve different risk-communication goals: If the goal is to improve exact risk perception, descriptive and simulated-experience formats are likely to be equally suitable. If, however, the goal is to boost less risky prescription habits, simulated experience may be the better choice. TRIAL REGISTRATION DRKS00020358 (German Clinical Trials Register, first registration: 07/01/2020).
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Affiliation(s)
- Odette Wegwarth
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Lentzeallee 94, 14195, Berlin, Germany.
- Heisenberg Chair for Medical Risk Literacy and Evidence-Based Decisions, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Ralph Hertwig
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Lentzeallee 94, 14195, Berlin, Germany
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4
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Schrader NF, Niemann A, Speckemeier C, Abels C, Blase N, Giebel GD, Riederer C, Nadstawek J, Straßmeir W, Wasem J, Neusser S. Prescription of opioid analgesics for non-cancer pain in Germany: study protocol for a mixed methods analysis. J Public Health (Oxf) 2022. [DOI: 10.1007/s10389-022-01748-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Abstract
Aim
Long-term therapy with opioid analgesics bears the risk of complications, such as misuse, abuse, and dependence. An evidence-based guideline addresses the long-term use of opioid analgesics for non-cancer pain. Recent studies observed an increase in opioid prescriptions over the past two decades in Germany. However, the exact circumstances of this increase and if long-term therapy adheres to these guidelines in practice remains unknown. Therefore, this study aimed to evaluate the provision of opioid analgesics for adults with non-cancer pain from patients’ and physicians’ perspectives. Based on the results, recommendations for care strategies for the patient groups at risk of misuse, abuse, and dependence were developed.
Methods
Built on a mixed methods approach, this evaluation combines (i) interviews with primary care physicians and specialists, (ii) surveys of patients and physicians, (iii) analyses based on administrative claims data from a German statutory health insurance provider. Proceeding from the analysis of the evaluation results, the development of care strategies included (iv) semi-structured interviews with stakeholders and (v) expert workshops.
Conclusion
To our knowledge, this is the first attempt to analyze opioid prescriptions from the combined perspectives of patients and practitioners in Germany. The results are intended to facilitate the development of target group-specific care strategies and recommendations to establish a general framework for the implementation of care strategies.
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5
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Engi Z, Benkő R, Soós G, Szok D, Csenki M, Csüllög E, Balog A, Csupor D, Viola R, Doró P, Matuz M. Trends in Opioid Utilisation in Hungary, 2006-2020: A Nationwide Retrospective Study with Multiple Metrics. Eur J Pain 2022; 26:1896-1909. [PMID: 35848717 PMCID: PMC9541344 DOI: 10.1002/ejp.2011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/01/2022] [Accepted: 07/16/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Opioid use is well-documented in several countries: some countries struggle with overuse while others have almost no access to opioids. For Europe, limited data are available. This study analysed Hungarian opioid utilisation in ambulatory care between 2006 and 2020. METHODS We obtained national drug utilization data on reimbursed opioid analgesics (ATC code: N02A) from a national health insurance database for a 15-year period. We investigated utilisation trends, using three volume-based metrics (defined daily dose per 1000 inhabitants per day (DID), oral morphine equivalent per 1000 inhabitants per day, packages dispensed per 1000 inhabitants per year). We stratified data based on administration routes, analgesic potency and reimbursement categories. RESULTS Total opioid utilisation increased during the study period according to all three metrics (74% in DID) and reached 5.31 DID by 2020. Upward trends were driven by an increase both in weak and strong opioid use (79% vs. 53%). The most commonly used opioids were fentanyl (in the strong category; 0.76 DID in 2020) and tramadol (in the weak category; 2.62 DID in 2020). Overall, tramadol was also the most commonly used opioid throughout the study period. Oral administration of opioid medications was dominant. Based on reimbursement categories, musculoskeletal pain was becoming a more frequent indication for opioid use (1552% increase in DID), while opioid use for cancer pain declined significantly during the study period (-33% in DID). CONCLUSIONS Our low utilisation numbers might indicate underuse of opioid analgesia, especially for cancer pain.
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Affiliation(s)
- Z Engi
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725, Szeged, Hungary
| | - R Benkő
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725, Szeged, Hungary.,Central Pharmacy Department, Albert Szent-Györgyi Health Center, University of Szeged, 6725, Szeged, Hungary.,Emergency Department, Albert Szent-Györgyi Health Center, University of Szeged, 6725, Szeged, Hungary
| | - G Soós
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725, Szeged, Hungary
| | - D Szok
- Department of Neurology, Albert Szent-Györgyi Health Center, University of Szeged, 6725, Szeged, Hungary
| | - M Csenki
- Department of Oncotherapy, Albert Szent-Györgyi Health Center, University of Szeged, 6725, Szeged, Hungary
| | - E Csüllög
- Department of Anesthesiology and Intensive Care, Albert Szent-Györgyi Health Center, 6725, University of Szeged, Szeged, Hungary
| | - A Balog
- Department of Rheumatology and Immunology, Albert Szent-Györgyi Health Center, University of Szeged, 6725, Szeged, Hungary
| | - D Csupor
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725, Szeged, Hungary.,Institute for Translational Medicine, Medical School, University of Pécs, 7624, Pécs, Hungary
| | - R Viola
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725, Szeged, Hungary
| | - P Doró
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725, Szeged, Hungary
| | - M Matuz
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725, Szeged, Hungary.,Central Pharmacy Department, Albert Szent-Györgyi Health Center, University of Szeged, 6725, Szeged, Hungary
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6
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Wegwarth O, Ludwig WD, Spies C, Schulte E, Hertwig R. The role of simulated-experience and descriptive formats on perceiving risks of strong opioids: A randomized controlled trial with chronic noncancer pain patients. PATIENT EDUCATION AND COUNSELING 2022; 105:1571-1580. [PMID: 34696941 DOI: 10.1016/j.pec.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/30/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Opioid prescription rates worldwide suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Findings from cognitive science show that risk perceptions can differ systematically depending on whether people learn about risks by description or experience. We investigated the effects of descriptive and simulated experience risk formats on patients' risk perceptions and behavior regarding long-term strong opioid use. METHODS 300 German patients with chronic noncancer pain were randomly assigned in an exploratory randomized controlled trial to either a descriptive format (fact box) or a simulated experience format (interactive simulation). Primary endpoints were subjective and objective risk perceptions and intended intake behavior. RESULTS Both formats significantly improved patients' objective risk perception; patients who saw the fact box estimated some outcomes more accurately (p = .031). Formats were equally effective in improving patients' subjective risk perception in terms of opioids' harms; however, patients receiving the simulation showed a greater reduction and termination of their opioid intake (p = .030) and a higher uptake of alternative therapies. CONCLUSIONS Descriptive and simulated experience risk formats improve risk perceptions and behavior regarding potent but highly risky drugs. PRACTICE IMPLICATIONS To eliminate risky behavior, simulated experience formats may be superior to descriptive formats.
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Affiliation(s)
- Odette Wegwarth
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany; Institute for Medical Sociology & Rehabilitation Science, Charité - University Hospital Berlin, Berlin, Germany; Center for Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Germany.
| | | | - Claudia Spies
- Center for Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Germany
| | - Erika Schulte
- Center for Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Germany
| | - Ralph Hertwig
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
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7
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Kalkman GA, van den Brink W, Pierce M, Atsma F, Vissers KCP, Schers HJ, van Dongen RTM, Kramers C, Schellekens AFA. Monitoring Opioids in Europe: The Need for Shared Definitions and Measuring Drivers of Opioid Use and Related Harms. Eur Addict Res 2022; 28:231-240. [PMID: 35196659 DOI: 10.1159/000521996] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 01/14/2022] [Indexed: 11/19/2022]
Abstract
The past 20 years, the USA is facing a serious opioid crisis initiated by an increase in prescription opioid use. Europe has also seen an increase in prescription opioid use, but the extent of related harm is still largely unknown. Given the impact of the US opioid epidemic, it is important to closely monitor signs of emerging opioid-related problems to guarantee early warnings and timely actions. Shared and meaningful definitions for opioid use and related harms, and relevant information about specific drivers for opioid use and related problems are needed for an adequate policy response. In this commentary, we discuss these definitions, the need to know more about the specific drivers for increased opioid use, its related harm, and proposals for strategies to move forward. Policy recommendations include making a distinction between licit and illicit opioids when monitoring and reporting on opioid-related harm, and using oral morphine equivalents to quantify prescription opioid use in a clinically relevant and comparable manner. A major topic of further research is exploring unique and universal drivers of prescription opioid (mis)use across Europe, in particular the role of opioid diversion.
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Affiliation(s)
- Gerard A Kalkman
- Department of Clinical Pharmacy, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Pharmacology-Toxicology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Wim van den Brink
- Amsterdam UMC, Location AMC, Department of Psychiatry, University of Amsterdam, Amsterdam, The Netherlands
| | - Mimi Pierce
- Amsterdam UMC, Location AMC, Department of Psychiatry, University of Amsterdam, Amsterdam, The Netherlands
| | - Femke Atsma
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert T M van Dongen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pain Management and Palliative Care, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Pharmacology-Toxicology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands.,Radboud University Medical Centre, Donders Institute for Clinical Neuroscience, Nijmegen, The Netherlands.,Nijmegen Institute for Science Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
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8
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Rautalin I, Kallio M, Korja M. In-hospital postoperative opioid use and its trends in neurosurgery between 2007 and 2018. Acta Neurochir (Wien) 2022; 164:107-116. [PMID: 34664095 PMCID: PMC8761135 DOI: 10.1007/s00701-021-05021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/02/2021] [Indexed: 12/01/2022]
Abstract
Background Postoperative opioid use plays an important role in the global opioid crisis, but little is known about in-hospital opioid use trends of large surgical units. We investigated whether postoperative in-hospital opioid consumption changed in a large academic neurosurgical unit between 2007 and 2018. Methods We extracted the data of consumed opioids in the neurosurgical intensive care unit and two bed wards between 2007 and 2018. Besides overall consumption, we analyzed the trends for weak (tramadol and codeine), strong, and the most commonly used opioids. The use of various opioids was standardized using the defined daily doses (DDDs) of each opioid agent. A linear regression analysis was performed to estimate annual treatment day-adjusted changes with 95% confidence intervals. Results Overall, 121 361 opioid DDDs were consumed during the 196 199 treatment days. Oxycodone was the most commonly used postoperative opioid (49% of all used opioids) in neurosurgery. In the bed wards, the use of oral oxycodone increased 375% (on average 13% (9–17%) per year), and the use of transdermal buprenorphine 930% (on average 26% (9–45%) per year) over the 12-year period. Despite the increased use of strong opioids in the bed wards (on average 3% (1–4%) per year), overall opioid use decreased 39% (on average 6% (4–7%) per year) between 2007 and 2018. Conclusions Due to the increase of strong opioid use in the surgical bed wards, we encourage other large teaching hospitals and surgical units to investigate whether their opioid use trends are similarly worrisome and whether the opioid consumption changes in the hospital setting are transferred to opioid use patterns or opioid-related harms after discharge. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05021-9.
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Affiliation(s)
- Ilari Rautalin
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, P.O. Box 266, 00029, Helsinki, Finland.
| | - Miia Kallio
- HUS Pharmacy, Hospital Pharmacy of Helsinki University Hospital (HUS), P.O. Box 440, 00029, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, P.O. Box 266, 00029, Helsinki, Finland
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9
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Rauschert C, Seitz NN, Olderbak S, Pogarell O, Dreischulte T, Kraus L. Subtypes in Patients Taking Prescribed Opioid Analgesics and Their Characteristics: A Latent Class Analysis. Front Psychiatry 2022; 13:918371. [PMID: 35873263 PMCID: PMC9304960 DOI: 10.3389/fpsyt.2022.918371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/01/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Owing to their pharmacological properties the use of opioid analgesics carries a risk of abuse and dependence, which are associated with a wide range of personal, social, and medical problems. Data-based approaches for identifying distinct patient subtypes at risk for prescription opioid use disorder in Germany are lacking. OBJECTIVE This study aimed to identify distinct subgroups of patients using prescribed opioid analgesics at risk for prescription opioid use disorder. METHODS Latent class analysis was applied to pooled data from the 2015 and 2021 Epidemiological Survey of Substance Abuse. Participants were aged 18-64 years and self-reported the use of prescribed opioid analgesics in the last year (n = 503). Seven class-defining variables based on behavioral, mental, and physical health characteristics commonly associated with problematic opioid use were used to identify participant subtypes. Statistical tests were performed to examine differences between the participant subtypes on sociodemographic variables and prescription opioid use disorder. RESULTS Three classes were extracted, which were labeled as poor mental health group (43.0%, n = 203), polysubstance group (10.4%, n = 50), and relatively healthy group (46.6%, n = 250). Individuals within the poor mental health group (23.2%, n = 43) and the polysubstance group (31.1%, n = 13) showed a higher prevalence of prescription opioid use disorder compared to those of the relatively healthy group. CONCLUSION The results add further evidence to the knowledge that patients using prescribed opioid analgesics are not a homogeneous group of individuals whose needs lie in pain management alone. Rather, it becomes clear that these patients differ in their individual risk of a prescription opioid use disorder, and therefore identification of specific risks plays an important role in early prevention.
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Affiliation(s)
- Christian Rauschert
- Department of Epidemiology and Diagnostics, IFT Institut Für Therapieforschung, Munich, Germany
| | - Nicki-Nils Seitz
- Department of Epidemiology and Diagnostics, IFT Institut Für Therapieforschung, Munich, Germany
| | - Sally Olderbak
- Department of Epidemiology and Diagnostics, IFT Institut Für Therapieforschung, Munich, Germany.,Department of Psychology, University of Arizona, Tucson, AZ, United States
| | - Oliver Pogarell
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität, Munich, Germany
| | - Tobias Dreischulte
- Department of General Practice and Family Medicine, Ludwig-Maximilians-Universität, Munich, Germany
| | - Ludwig Kraus
- Department of Epidemiology and Diagnostics, IFT Institut Für Therapieforschung, Munich, Germany.,Department of Public Health Sciences, Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
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10
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Wegwarth O, Wind S, Goebel E, Spies C, Meerpohl JJ, Schmucker C, Schulte E, Neugebauer E, Hertwig R. Educating Pharmacists on the Risks of Strong Opioids With Descriptive and Simulated Experience Risk Formats: A Randomized Controlled Trial. MDM Policy Pract 2021; 6:23814683211042832. [PMID: 34604531 PMCID: PMC8482350 DOI: 10.1177/23814683211042832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives. High opioid prescription rates in the United States and
Europe suggest miscalibrated risk perceptions among those who prescribe,
dispense, and take opioids. Findings from cognitive decision science suggest
that risk perceptions and behaviors can differ depending on whether people learn
about risks by experience or description. This study investigated effects of a
descriptive versus an experience-based risk education format on pharmacists’
risk perceptions and counseling behavior in the long-term administration of
strong opioids to patients with chronic noncancer pain. Methods. In
an exploratory, randomized controlled online trial, 300 German pharmacists were
randomly assigned to either a descriptive format (fact box) or a simulated
experience format (interactive simulation). Primary Outcome
Measures. 1) Objective risk perception, 2) subjective risk
perception, and 3) intended and 4) actual counseling behavior.
Results. Both risk formats significantly improved pharmacists’
objective risk perception, but pharmacists exposed to the fact box estimated the
benefit-harm ratio more accurately than those exposed to the simulation. Both
formats proved equally effective in adjusting pharmacists’ subjective risk
perception toward a better recognition of opioids’ harms; however, pharmacists
receiving the simulation showed a greater change in their actual counseling
behavior and higher consistency between their intended and actual counseling
than pharmacists receiving the fact box. Conclusion. The simulated
experience format was less effective than the descriptive format in improving
pharmacists’ objective risk perception, equally effective in motivating
pharmacists to counsel patients on less risky treatment alternatives and more
effective in changing the reported actual counseling behavior.
Implications. These exploratory findings provide important
insights into the relevance of the description-experience gap for drug safety
and raise questions for future research regarding the specific mechanisms at
work.
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Affiliation(s)
- Odette Wegwarth
- Max Planck Institute for Human Development, Center for Adaptive Rationality, Berlin, Germany
| | - Stefan Wind
- Berlin Chamber of Pharmacists, Berlin, Germany
| | - Eva Goebel
- Berlin Chamber of Pharmacists, Berlin, Germany
| | - Claudia Spies
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany
| | - Joerg J Meerpohl
- University of Freiburg, Faculty of Medicine & Medical Center, Institute for Evidence in Medicine (for Cochrane Germany Foundation), Freiburg, Germany
| | - Christine Schmucker
- University of Freiburg, Faculty of Medicine & Medical Center, Institute for Evidence in Medicine (for Cochrane Germany Foundation), Freiburg, Germany
| | - Erika Schulte
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany
| | | | - Ralph Hertwig
- Max Planck Institute for Human Development, Center for Adaptive Rationality, Berlin, Germany
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11
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Erlenwein J, Petzke F. [Pain Management in Non-surgical Inpatients - Treatment Approaches and Competence for Pain Services]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:614-627. [PMID: 34507384 DOI: 10.1055/a-1531-0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The number of non-surgical patients in the hospital setting with pain due to medical conditions or comorbidities and/or invasive procedures or treatments is high. Compared to perioperative pain management, the portion of patients and/or conditions that require more than an approach focused on pharmacological treatment of nociceptive pain is considerably higher. Rather, treatment often requires the differentiated use of co-analgesics, non-pharmacological treatments, physiotherapy, occupational therapy, psychological assessment and interventsions and educational approaches, ideally in the form of closely coordinated interdisciplinary treatment. The assessment and treatment of acute and especially chronic pain should follow the biopsychosocial concept of pain, especially if risk factors for chronification have been identified, if patients receive high-dose therapy with analgesics or have preexisting a chronic pain disorder.
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[Critical discussion of new data regarding prevalence of opioid use disorder in patients with chronic pain in Germany]. Schmerz 2021; 36:13-18. [PMID: 34505947 PMCID: PMC8821065 DOI: 10.1007/s00482-021-00582-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/03/2022]
Abstract
Hintergrund Es gibt keine Opioidkrise in Deutschland. Neue Studien mit Nichttumorpatienten mit chronischen Schmerzen (CNTS) in Deutschland zeigen jedoch eine unerwartet hohe Prävalenz von Opioidgebrauchsstörungen nach Diagnostic and Statistical Manual for Psychiatric Diseases 5 (DSM-5). Ziel der Arbeit Kritische Diskussion neuer Studienergebnisse zur Prävalenz von Opioidgebrauchsstörungen bei Schmerzpatienten in Deutschland. Material und Methoden Selektive Literaturrecherche und multiprofessionelle Einordnung der Ergebnisse durch Expertenrunde (Schmerztherapie, Neurologie, Psychiatrie, Palliativmedizin, Allgemeinmedizin und Suchttherapie). Ergebnisse Die Kriterien für die Diagnose „Opioidgebrauchsstörung“ des DSM‑5 sind auf Patienten mit CNTS nur eingeschränkt anwendbar, können aber für problematisches Verhalten sensibilisieren. Hierbei ist die Diagnose Opioidgebrauchsstörung nicht mit der Diagnose einer Substanzabhängigkeit nach ICD-10 gleichzusetzen, da die Diagnose nach DSM‑5 ein deutlich breiteres Spektrum abdeckt (mild, moderat, schwer). Risikofaktoren für eine Opioidgebrauchsstörung sind jüngeres Alter, depressive Störungen, somatoforme Störungen und hohe Opioidtagesdosen. Die interdisziplinäre Leitlinie zur Langzeitanwendung von Opioiden bei chronischen nichttumorbedingten Schmerzen (LONTS) enthält Empfehlungen, welche das Risiko für eine Opioidgebrauchsstörung reduzieren sollen. Diskussion Eine Anpassung der DSM-5-Diagnosekriterien der Opioidgebrauchsstörung an die besondere Situation von Patienten mit CNTS und eine Validierung dieser Kriterien könnte helfen, in der Zukunft genauere Daten zu Opioidgebrauchsstörungen von Patienten mit chronischen Schmerzen in Deutschland zu erheben. Verordner sollten für diese Problematik sensibilisiert werden, ohne die Patienten zu pathologisieren oder gar zu stigmatisieren. Weitere Forschung zur Einordnung dieses bisher unterschätzten Phänomens ist notwendig.
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Wouldes TA, Crawford A, Stevens S, Stasiak K. Evidence for the Effectiveness and Acceptability of e-SBI or e-SBIRT in the Management of Alcohol and Illicit Substance Use in Pregnant and Post-partum Women. Front Psychiatry 2021; 12:634805. [PMID: 34025470 PMCID: PMC8131659 DOI: 10.3389/fpsyt.2021.634805] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/17/2021] [Indexed: 12/12/2022] Open
Abstract
Alcohol and illicit psychoactive drug use during pregnancy have increased worldwide, putting women and their children's health and development at risk. Multiple drug use, comorbid psychiatric disorders, sexual and physical abuse are common in women who use alcohol and drugs during pregnancy. The effects on the mother include poor reproductive and life-long health, legal, family, and social problems. Additionally, the exposed child is at increased risk of long-term physical health, mental health, and developmental problems. The stigma associated with substance use during pregnancy and some clinicians' reticence to inquire about substance use means many women are not receiving adequate prenatal, substance abuse, and mental health care. Evidence for mHealth apps to provide health care for pregnant and post-partum women reveal the usability and effectiveness of these apps to reduce gestational weight gain, improve nutrition, promote smoking cessation and manage gestational diabetes mellitus, and treat depression and anxiety. Emerging evidence suggests mHealth technology using a public health approach of electronic screening, brief intervention, or referral to treatment (e-SBIRT) for substance use or abuse can overcome the typical barriers preventing women from receiving treatment for alcohol and drug use during pregnancy. This brief intervention delivered through a mobile device may be equally effective as SBIRT delivered by a health care professional in preventing maternal drug use, minimizing the effects to the exposed child, and providing a pathway to therapeutic options for a substance use disorder. However, larger studies in more diverse settings with women who have co-morbid mental illness and a constellation of social risk factors that are frequently associated with substance use disorders are needed.
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Affiliation(s)
- Trecia A Wouldes
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Andi Crawford
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
- Te Ara Manapou, Parenting and Pregnancy Service, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Suzanne Stevens
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Karolina Stasiak
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
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Hurtado I, García-Sempere A, Peiró S, Sanfélix-Gimeno G. Increasing Trends in Opioid Use From 2010 to 2018 in the Region of Valencia, Spain: A Real-World, Population-Based Study. Front Pharmacol 2020; 11:612556. [PMID: 33362564 PMCID: PMC7759684 DOI: 10.3389/fphar.2020.612556] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/19/2020] [Indexed: 12/14/2022] Open
Abstract
Background: The opioid epidemic has been extensively documented in the United States and Canada, but fewer data are available for Europe. Aim: To describe the trends in opioid use-volume of prescriptions, dosage and number of patients treated-in a Spanish population with more than 4.2 million inhabitants aged 18 years and older. Patients and Methods: Population-based cross-sectional analysis of opioid prescription in adults (≥18 years) from January 1, 2010 to December 31, 2018 in the region of Valencia, Spain. Outcomes were estimated on an annual basis: number of prescriptions, prescription rate per 100 inhabitants, dosage per capita (morphine mg equivalents, MME/c) and volume of patients treated (overall and by drug). Results: Over the study period, 2,107,756 unique patients were prescribed more than 35 million total treatments. The yearly number of treatments doubled, and total MME/c showed almost a threefold increase. Fentanyl MME/c more than tripled, accounting for 34.4% of the total MME/c in 2018. Oxycodone MME/c showed a 10-fold increase, while tapentadol, launched in 2011, showed the highest growth rates. The annual number of patients receiving at least one opioid prescription more than doubled, from 335,379 in 2010 to 722,838 in 2018. Conclusions: Even if proportions still seem far from epidemic, urgent research is warranted on the observed patterns of use, their appropriateness and their association with health and safety outcomes, especially for high-use and high-strength drugs.
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Affiliation(s)
- Isabel Hurtado
- Fundación Para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), València, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), València, Spain
| | - Aníbal García-Sempere
- Fundación Para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), València, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), València, Spain
| | - Salvador Peiró
- Fundación Para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), València, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), València, Spain
| | - Gabriel Sanfélix-Gimeno
- Fundación Para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), València, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), València, Spain
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Verthein U, Buth S, Daubmann A, Martens MS, Schulte B. Trends in risky prescriptions of opioid analgesics from 2011 to 2015 in Northern Germany. J Psychopharmacol 2020; 34:1210-1217. [PMID: 32674662 PMCID: PMC7605054 DOI: 10.1177/0269881120936544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Due to their euphoric and sedative effects, opioid analgesics have high potential for abuse and dependence. In the last decade in the USA and many Western European Countries the prescription rates of opioid analgesics have steadily increased. OBJECTIVE This study describes 5-year trends in the prescription of opioid analgesics and risk indicators such as duration, dose and 'doctor shopping' in Northern Germany. METHODS The annual rates of opioid analgesic prescriptions have been analysed for patients with statutory health insurance processed by the North German Pharmacy Data Center for the years 2011-2015. A distinction was made between non-cancer patients and cancer patients, and different groups according to prescription duration and dose level. RESULTS Between 2011 and 2015, the annual number of patients with opioid analgesic prescriptions increased from 500,000 to 550,000. About half of non-cancer-patients (85% of the total sample) and cancer patients received opioid analgesics for 90 days or less. The rates for long-term prescriptions (⩾9 months) ranged between 6-7% for non-cancer patients and 7-8% for cancer patients. Between 1.2-1.8% received opioid analgesics in doses of more than two defined daily doses. The majority of non-cancer patients with opioid analgesic prescriptions were female. The average age of non-cancer patients was 66 years. About 80% of non-cancer patients with first opioid analgesic prescription received World Health Organization step II medication. CONCLUSION For the first time, this study provides comprehensive patient-related analyses of opioid analgesic prescriptions in Germany over a 5-year period. Despite a slight increase in the overall number of opioid analgesic prescriptions, an epidemic spread of opioid analgesics cannot be observed.
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Affiliation(s)
- Uwe Verthein
- Centre for Interdisciplinary Addiction Research of Hamburg University (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven Buth
- Centre for Interdisciplinary Addiction Research of Hamburg University (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Daubmann
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus-Sebastien Martens
- Centre for Interdisciplinary Addiction Research of Hamburg University (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Schulte
- Centre for Interdisciplinary Addiction Research of Hamburg University (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Gallien Y, Martin A, Caserio-Schönemann C, Le Strat Y, Thiam MM. Epidemiological study of opioid use disorder in French emergency departments, 2010-2018 from OSCOUR database. BMJ Open 2020; 10:e037425. [PMID: 33127629 PMCID: PMC7604823 DOI: 10.1136/bmjopen-2020-037425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Opioid consumption in France has remained stable over the last 15 years, with much lower levels than in the USA. However, few data are available on patients who consume opioids and their use of the health system. Emergency department (ED) data has never been used as a source to investigate opioid use disorder (OUD) in France. DESIGN/SETTINGS/PARTICIPANTS We used the OSCOUR national surveillance network, collecting daily ED data from 93% of French ED, to select and describe visits and hospitalisations after an OUD-related ED visit between 2010 and 2018 using International Classification of Diseases, version 10 (ICD10) codes. We described the population of interest and used binomial negative regressions to identify factors significantly associated with OUD such as gender, age, administrative region, year of admission and ICD10 codes. We also analysed the related diagnoses. PRIMARY OUTCOME MEASURE Trend in ED visits for an OUD-related ED visit. RESULTS We recorded 34 362 OUD-related visits out of 97 892 863 ED visits (36.1/100 000 visits). OUD-related visits decreased from 39.2/100 000 visits in 2010 to 32.9/100 000 visits in 2018, resulting in an average yearly decrease of 2.1% (95% CI 1.5% to 2.7%) after multivariate analysis. We recorded 15 966 OUD-related hospitalisations out of 20 359 574 hospitalisations after ED visits (78.4/100 000 hospitalisations) with an increase from 74.0/100 000 hospitalisations in 2010 to 81.4/100 000 hospitalisations in 2018. The analysis of related diagnoses demonstrated mostly polydrug abuse in this population. CONCLUSIONS While the proportion of OUD visits decreased in the time frame, the hospitalisation proportion increased. The implementation of a nationwide surveillance system for OUD in France using ED visits would provide prompt detection of changes over time.
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Affiliation(s)
- Yves Gallien
- Data Science Division, Santé publique France, Saint-Maurice, France
- SBIM, APHP, Paris, France
| | - Adrien Martin
- Data Science Division, Santé publique France, Saint-Maurice, France
| | | | - Yann Le Strat
- Data Science Division, Santé publique France, Saint-Maurice, France
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Jobski K, Dörks M, Bantel C, Hoffmann F. Regional Differences in Opioid Prescribing in Germany - Results of an Analysis of Health Insurance Data of 57 Million Adult People. J Pain Res 2020; 13:2483-2492. [PMID: 33116790 PMCID: PMC7548317 DOI: 10.2147/jpr.s259009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Regional variations of opioid use have been reported from many countries. The objective of this study was to examine opioid prescribing patterns in Germany including low- and high-potency opioids (LPO and HPO) focusing on regional differences. Methods Data source was the "Information system for health care data" comprising statutory health insurance funds data for about 70 million Germans of all ages. For 2010, we received aggregated data (by age, sex, federal state and district) of Germans (18+) who had been prescribed at least one opioid including the number of prescribed packages. For each stratum, we further received the number of insured persons. We calculated LPO and HPO prevalences and the mean number of prescribed packages. Results Among 57 million adult Germans (mean age: 50.2 years, 53.8% female), opioid prevalences were 38.7 per 1000 persons for LPOs and 12.8 for HPOs. Prevalences rose with increasing age and were higher in women than in men. On average, LPO users were prescribed fewer packages than HPO users (3.5 vs 7.0). LPO use was highest in the eastern states ranging from 32.9 per 1000 persons (Hamburg) to 47.2 (Saxony-Anhalt). HPOs were most often prescribed in the North and in the East with prevalences varying between 10.6 per 1000 persons (Baden-Württemberg) and 16.9 (Mecklenburg-Western Pomerania). On the district level, prevalences varied by the factors 2.6 and 3.2 for LPOs and HPOs, respectively. Conclusion We found large regional variations in opioid prescribing which probably cannot only be attributed to differences in patient characteristics.
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Affiliation(s)
- Kathrin Jobski
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Michael Dörks
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carsten Bantel
- University Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Klinikum Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Long-term opioid therapy for chronic noncancer pain: second update of the German guidelines. Pain Rep 2020; 5:e840. [PMID: 32904018 PMCID: PMC7447355 DOI: 10.1097/pr9.0000000000000840] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/21/2020] [Accepted: 06/29/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Neither uncritical opioid prescription nor general rejection of opioids is justified in patients with chronic noncancer pain. Responsible application requires consideration of indications, contraindications, and regular assessment. The opioid epidemic in North America challenges national guidelines worldwide to define the importance of opioids for the management of chronic noncancer pain (CNCP).
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Berthold D, Carrasco AJP, Brachvogel S, Sibelius U, Eul B, Dumitrascu R, El-Awad U, Maeder LJ, Hauch H. Changes in Pain Medication Profile among Patients Admitted to Specialized Home Palliative Care in Relation to Referral Source: An Exploratory Study. J Pain Palliat Care Pharmacother 2020; 34:184-191. [PMID: 32521186 DOI: 10.1080/15360288.2020.1765944] [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: 10/24/2022]
Abstract
Pain is a common symptom leading to referrals to specialized home palliative care (SHPC) services and is known to affect patients' quality of life. To date, little is known about the impact of referral source on its management. To assess changes to pain medication profile in the course of SHPC and to identify potential differences in relation to referral source. This exploratory study is a retrospective analysis of 501 electronic medical records of a SHPC team in Germany. This included the assessment of baseline pain medication profiles according to the WHO analgesic ladder and changes to analgesic treatment in the course of SHPC with respect to referral source. At the time of admission, 77.4% of patients referred by a hospital and 78.8% of patients referred by the outpatient sector received a fixed analgesic regimen. In all, 61.9% of the inpatient group versus 62.9% of the outpatient group were treated with opioids, and 79.0% received modifications to pain medication at one point in time following admission. Thereby, patients referred by the outpatient sector received significantly earlier modifications and more supplementations of pain medication. Our study suggests positive development in the prescription of opioid analgesics compared to earlier studies in Germany. On the one hand, it highlights the relevance of thorough assessment and responsive evaluation of pain in SHPC, and on the other hand it reveals possible training needs of referring physicians, particularly those working in the outpatient sector. Our results inspired further research examining more closely the links between referral source and pain management.
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El-Akkad SED, Nolan S, Fairbairn N, Ye M, Wu A, Barrios R, Montaner J, Ti L. The impact of high-dose opioid prescription on mortality rates among people living with HIV: A retrospective cohort study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 78:102705. [PMID: 32143186 PMCID: PMC7302960 DOI: 10.1016/j.drugpo.2020.102705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/25/2019] [Accepted: 02/16/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES High-dose opioid use is associated with increased morbidity, mortality, and healthcare utilization. People living with HIV (PLHIV) are frequently prescribed these medications to manage their pain. However, little is known about the relationship between being prescribed high doses of opioids (> 90 MME/d) and mortality risk among this population. The objective of this study was to examine the trends in mortality and the relationship between high-dose opioid analgesic prescribing and mortality among PLHIV. METHODS Utilizing the STOP HIV/AIDS cohort--a population-level linked database of treatment of PLHIV in British Columbia--we conducted bivariable and multivariable generalized estimating equation (GEE) models with a Poisson distribution to examine the relationship between high-dose opioid prescription and all-cause mortality rates in the study sample. RESULTS Between 1996 and 2015, 9272 PLHIV were included in the study. Age- and sex-adjusted mortality rate (using the 2011 Canadian population as the reference) was 30.99 per 1000 person-years (95% confidence interval [CI]: 28.11-33.88). In a multivariable GEE model with adjustment for various demographic and clinical confounders, there was a positive and independent association between being prescribed high-dose opioids and all-cause mortality rates (adjusted rate ratio [ARR] = 3.01; 95%CI: 2.47-3.66). DISCUSSION We found that mortality rates were significantly higher among PLHIV who were prescribed high-dose opioids compared to those who were prescribed lower doses. Our results highlight the risk associated with the prescribing of high-dose opioids to manage HIV-related pain and emphasize the need to explore non-opioid approaches to pain management.
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Affiliation(s)
- Saif-El-Din El-Akkad
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; Research Scientist & Health Administrative Data Lead, B.C. Centre on Substance Use Assistant Professor, Department of Medicine, University of British Columbia, 400-1045 Howe Street Vancouver, BC, Canada, V6Z 2A9
| | - Nadia Fairbairn
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; Research Scientist & Health Administrative Data Lead, B.C. Centre on Substance Use Assistant Professor, Department of Medicine, University of British Columbia, 400-1045 Howe Street Vancouver, BC, Canada, V6Z 2A9
| | - Monica Ye
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Anthony Wu
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Julio Montaner
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Lianping Ti
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6; Research Scientist & Health Administrative Data Lead, B.C. Centre on Substance Use Assistant Professor, Department of Medicine, University of British Columbia, 400-1045 Howe Street Vancouver, BC, Canada, V6Z 2A9.
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Drakopoulos A, Koszegi Z, Lanoiselée Y, Hübner H, Gmeiner P, Calebiro D, Decker M. Investigation of Inactive-State κ Opioid Receptor Homodimerization via Single-Molecule Microscopy Using New Antagonistic Fluorescent Probes. J Med Chem 2020; 63:3596-3609. [DOI: 10.1021/acs.jmedchem.9b02011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Antonios Drakopoulos
- Pharmaceutical and Medicinal Chemistry, Institute of Pharmacy and Food Chemistry, Julius Maximilian University of Würzburg, 97074 Würzburg, Germany
| | - Zsombor Koszegi
- Institute of Metabolism and Systems Research and Centre of Membrane Proteins and Receptors, College of Medical and Dental Sciences, University of Birmingham, B152TT Birmingham, U.K
| | - Yann Lanoiselée
- Institute of Metabolism and Systems Research and Centre of Membrane Proteins and Receptors, College of Medical and Dental Sciences, University of Birmingham, B152TT Birmingham, U.K
| | - Harald Hübner
- Medicinal Chemistry, Department of Chemistry and Pharmacy, Friedrich-Alexander University of Erlangen-Nürnberg, 91058 Erlangen, Germany
| | - Peter Gmeiner
- Medicinal Chemistry, Department of Chemistry and Pharmacy, Friedrich-Alexander University of Erlangen-Nürnberg, 91058 Erlangen, Germany
| | - Davide Calebiro
- Institute of Metabolism and Systems Research and Centre of Membrane Proteins and Receptors, College of Medical and Dental Sciences, University of Birmingham, B152TT Birmingham, U.K
| | - Michael Decker
- Pharmaceutical and Medicinal Chemistry, Institute of Pharmacy and Food Chemistry, Julius Maximilian University of Würzburg, 97074 Würzburg, Germany
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Erlenwein J, Pfingsten M, Hüppe M, Seeger D, Kästner A, Graner R, Petzke F. [Management of patients with chronic pain in acute and perioperative medicine : An interdisciplinary challenge]. Anaesthesist 2020; 69:95-107. [PMID: 31932857 DOI: 10.1007/s00101-019-00708-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic pain is a frequent comorbidity of patients in hospitals and has an influence on the clinical course and the duration of hospitalization. There is a need to have a better understanding of chronic pain as a comorbidity and it should be considered to a greater extent in understanding diseases, in treatment concepts and hospital structures to ensure a resource-oriented and high-quality care. This begins on admission by identifying pre-existing pain and related risk factors with the medical history and taking these into account in the treatment regimen. A multimodal treatment approach that involves medicinal, educational, psychological and physiotherapeutic expertise is required in these patients. A unimodal approach in the treatment is not effective. A pain physician should be involved in the treatment team as early as possible. Furthermore, psychological joint supervision should be available for these patients as several studies have demonstrated positive perioperative effects of psychological approaches on the treatment in this patient group.
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Affiliation(s)
- J Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - M Pfingsten
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - M Hüppe
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - D Seeger
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - A Kästner
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - R Graner
- Klinik für Psychiatrie und Psychotherapie, Asklepios Fachklinikum Tiefenbrunn, Rosdorf, Deutschland
| | - F Petzke
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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The Trends in Opioid Use in Castile and Leon, Spain: A Population-Based Registry Analysis of Dispensations in 2015 to 2018. J Clin Med 2019; 8:jcm8122148. [PMID: 31817357 PMCID: PMC6947376 DOI: 10.3390/jcm8122148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 01/19/2023] Open
Abstract
Opioids are driving-impairing medicines (DIM). To assess the evolution and trends of opioid analgesics use between 2015 and 2018 in Castile and Leon (Spain), a population-based registry study was conceived. The length of opioid use and its concomitant use with other DIMs were studied. Analyses were done considering age and gender distributions. Adjusted consumption for licensed drivers is also presented. Of the 5 million dispensations recorded between 2015 and 2018, opioid analgesics were dispensed to 11.44% of the general population and 8.72% of vehicle drivers. Increases among daily users (2.6 times higher) and chronic users (1.5% higher) were noted, supporting the overall increase in opioid use (1.5%). The use of multiple drugs including other DIMs was a common finding (mean ± SD, 2.54 ± 0.01). Acute use (5.26%) and chronic use (3.20%) were also frequent. Formulations combining opioid analgesics with nonopioid analgesics were preferred. The use of opioids increased in Spain between 2015 and 2018. Concomitant use with other DIMS especially affects women and the elderly. Frequent use of opioid analgesics with other DIMs is a serious problem for drivers and increases the risk of accidents. Promoting safe driving should be a main objective of health authorities, to be achieved by developing and implementing educational activities for healthcare professionals and patients.
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Patterns of pain medication use associated with reported pain interference in older adults with and without cancer. Support Care Cancer 2019; 28:3061-3072. [PMID: 31637515 DOI: 10.1007/s00520-019-05074-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT Concerns about the adequacy of pain management among older adults are increasing, particularly with restrictions on opioid prescribing. OBJECTIVES To examine associations between prescription pain medication receipt and patient-reported pain interference in older adults with and without cancer. METHODS Using the 2007-2012 Surveillance Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database linked to Medicare Part D prescription claims, we selected MHOS respondents (N = 15,624) aged ≥ 66 years, ≤ 5 years of a cancer diagnosis (N = 9105), or without cancer (N = 6519). We measured receipt of opioids, non-steroidal anti-inflammatory drugs, and antiepileptics, and selected antidepressants within 30 days prior to survey. Patient-reported activity limitation due to pain (pain interference) within the past 30 days was summarized as severe, moderate, or mild/none. Logistic regression using predictive margins estimated associations between pain interference, cancer history, and pain medication receipt, adjusting for socio-demographics, chronic conditions, and Part D low-income subsidy. RESULTS Severe or moderate pain interference was reported by 21.3% and 46.1%, respectively. Pain medication was received by 21.5%, with 11.6% receiving opioids. Among adults reporting severe pain interference, opioid prescriptions were filled by 27.0% versus 23.8% (p = 0.040) with and without cancer, respectively. Over half (56%) of adults reporting severe pain in both groups failed to receive any prescription pain medication. CONCLUSIONS Older adults with cancer were more likely to receive prescription pain medications compared with adults without cancer; however, many older adults reporting severe pain interference did not receive medications. Improved assessment and management of pain among older adults with and without cancer is urgently needed.
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Opioid prescription patterns in Germany and the global opioid epidemic: Systematic review of available evidence. PLoS One 2019; 14:e0221153. [PMID: 31461466 PMCID: PMC6713321 DOI: 10.1371/journal.pone.0221153] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/30/2019] [Indexed: 01/10/2023] Open
Abstract
Introduction Opioids are one of the most important and effective drug classes in pain medicine with a key role in most medical fields. The increase of opioid prescription over time has led to higher numbers of prescription opioid misuse, abuse and opioid-related deaths in most developed OECD (Organisation for Economic Co-operation and Development) countries around the world. Whilst reliable data on the prevalence of opioid treatment is accessible for many countries, data on Germany specifically is still scarce. Considering Germany being the largest country in the European Union, the lack of evidence-based strategies from long-term studies is crucial. The aim of this work is to review and summarise relevant published literature on the prevalence of opioid prescription in Germany to adequately inform health policy strategies. Methods A systematic review of the epidemiology of opioid prescription in Germany was conducted, searching PubMed and Web of Science. Eligibility criteria were defined prior to conducting the search. Literature concerning Germany, published in English and German was included and the search was replicated by three independent researchers. Two levels of screening were employed. Disagreement was resolved by face-to-face discussion, leading to a consensus judgement. Results Our electronic search yielded 735 articles. Reviewing titles and abstracts yielded 19 relevant articles. Three authors examined each article’s full text more closely and determined that twelve papers should be included. Of the twelve identified studies—with publication dates ranging from 1985 to 2016—six were retrospective cross-sectional studies and six were retrospective repeated-measures cross-sectional studies. Sample sizes ranged from 92,842 to ≈ 11,000,000 participants. Data sources of included studies showed vast heterogeneity. The reviewed literature suggested an increase in the number of patients with opioid prescriptions and defined daily doses of opioids per recipient in Germany over time. The majority of opioid prescriptions was used for patients with non-cancer pain. Opioid use was more common in older people, women and in the north of Germany. Fentanyl was shown to be the most prescribed strong opioid in outpatient settings in Germany, despite not being the first-line choice for chronic pain conditions. All data published before 2000—but none of the more recent studies—suggested an insufficient treatment of pain using opioids. There were no signs for a current opioid epidemic in Germany. Conclusions Despite some limitations of the review and the heterogeneity of studies, it can be stated that the number of opioid prescriptions overall as well as the number of people receiving opioid treatment have increased over time. Most prescriptions were found to be for strong opioids and patients with non-cancer pain. Even though patterns of opioid prescription follow trends observed in other developed countries, there are no signs of an opioid epidemic in Germany. Therefore, this review could currently not find a need for urgent health policy interventions regarding opioid prescription practices. However, critical gaps in the literature remain and more research is needed to make more reliable judgements.
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Abholz HH. Number of Addicts Underestimated. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:459. [PMID: 31431247 PMCID: PMC6712907 DOI: 10.3238/arztebl.2019.0459a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Heinz-Harald Abholz
- *Institut für Allgemeinmedizin (ifam), Universitätsklinikum Düsseldorf und Praxis Elsdorf; Germany
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Abstract
BACKGROUND Opioids are the oldest and most potent drugs for the treatment of severe pain but they are burdened by detrimental side effects, such as respiratory depression, addiction potential, sedation, nausea and constipation. Their clinical application is undisputed in the treatment of acute (e.g. perioperative) and cancer pain but their long-term use in chronic pain has met increasing criticism and has contributed to the current "opioid crisis". OBJECTIVES This article reviews the pharmacological principles and new research strategies aiming at novel opioids with reduced side effects. The basic mechanisms underlying pain and opioid analgesia and other effects of opioids are outlined. To illustrate the clinical situation and medical problems, the plasticity of opioid receptors, intracellular signaling pathways, endogenous and exogenous opioid receptor ligands, central and peripheral sites of analgesic and side effects are discussed. CONCLUSION The epidemic of opioid misuse has shown that there is a lack of fundamental knowledge about the characteristics and management of chronic pain, that conflicts of interest and validity of models must be more intensively considered in the context of drug development and that novel analgesics with less addictive potential are urgently needed. Currently, the most promising perspectives appear to be augmenting endogenous opioid actions and the selective activation of peripheral opioid receptors.
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Affiliation(s)
- C Stein
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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Ho JY. The Contemporary American Drug Overdose Epidemic in International Perspective. POPULATION AND DEVELOPMENT REVIEW 2019; 45:7-40. [PMID: 31123371 PMCID: PMC6527318 DOI: 10.1111/padr.12228] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- Jessica Y Ho
- Leonard Davis School of Gerontology and Department of Sociology, University of Southern California, Los Angeles, California, United States,
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Abstract
BACKGROUND Opioids are the oldest and most potent drugs for the treatment of severe pain but they are burdened by detrimental side effects, such as respiratory depression, addiction potential, sedation, nausea and constipation. Their clinical application is undisputed in the treatment of acute (e.g. perioperative) and cancer pain but their long-term use in chronic pain has met increasing criticism and has contributed to the current "opioid crisis". OBJECTIVES This article reviews the pharmacological principles and new research strategies aiming at novel opioids with reduced side effects. The basic mechanisms underlying pain and opioid analgesia and other effects of opioids are outlined. To illustrate the clinical situation and medical problems, the plasticity of opioid receptors, intracellular signaling pathways, endogenous and exogenous opioid receptor ligands, central and peripheral sites of analgesic and side effects are discussed. CONCLUSION The epidemic of opioid misuse has shown that there is a lack of fundamental knowledge about the characteristics and management of chronic pain, that conflicts of interest and validity of models must be more intensively considered in the context of drug development and that novel analgesics with less addictive potential are urgently needed. Currently, the most promising perspectives appear to be augmenting endogenous opioid actions and the selective activation of peripheral opioid receptors.
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Affiliation(s)
- C Stein
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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Ho JY, Hendi AS. Recent trends in life expectancy across high income countries: retrospective observational study. BMJ 2018; 362:k2562. [PMID: 30111634 PMCID: PMC6092679 DOI: 10.1136/bmj.k2562] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To assess whether declines in life expectancy occurred across high income countries during 2014-16, to identify the causes of death contributing to these declines, and to examine the extent to which these declines were driven by shared or differing factors across countries. DESIGN Demographic analysis using aggregated data. SETTING Vital statistics systems of 18 member countries of the Organisation for Economic Co-operation and Development. PARTICIPANTS 18 countries with high quality all cause and cause specific mortality data available in 2014-16. MAIN OUTCOME MEASURES Life expectancy at birth, 0-65 years, and 65 or more years and cause of death contributions to changes in life expectancy at birth. RESULTS The majority of high income countries in the study experienced declines in life expectancy during 2014-15; of the 18 countries, 12 experienced declines in life expectancy among women and 11 experienced declines in life expectancy among men. The average decline was 0.21 years for women and 0.18 years for men. In most countries experiencing declines in life expectancy, these declines were predominantly driven by trends in older age (≥65 years) mortality and in deaths related to respiratory disease, cardiovascular disease, nervous system disease, and mental disorders. In the United States, declines in life expectancy were more concentrated at younger ages (0-65 years), and drug overdose and other external causes of death played important roles in driving these declines. CONCLUSIONS Most of the countries that experienced declines in life expectancy during 2014-15 experienced robust gains in life expectancy during 2015-16 that more than compensated for the declines. However, the United Kingdom and the United States appear to be experiencing stagnating or continued declines in life expectancy, raising questions about future trends in these countries.
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Affiliation(s)
- Jessica Y Ho
- Leonard Davis School of Gerontology and Department of Sociology, University of Southern California, 3715 McClintock Avenue, Los Angeles, CA 90089, USA
| | - Arun S Hendi
- Office of Population Research and Department of Sociology, Princeton University, Princeton, NJ, USA
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Just JM, Bingener L, Bleckwenn M, Schnakenberg R, Weckbecker K. Risk of opioid misuse in chronic non-cancer pain in primary care patients - a cross sectional study. BMC FAMILY PRACTICE 2018; 19:92. [PMID: 29925323 PMCID: PMC6011396 DOI: 10.1186/s12875-018-0775-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 05/25/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Efforts to improve treatment of pain using opioids have to adequately take into account their therapeutic shortcomings which involve addictiveness. While there are no signs of an "opioid epidemic" in Germany similar to that in the US, there is little data on the prevalence of prescription opioid misuse and addiction. Therefore, our objective was to screen primary care patients on long-term opioid therapy for signs of misuse of prescription opioids. METHODS We recruited 15 GPs practices and asked all patients on long-term opioid therapy (> 6 months) to fill out a questionnaire including the "Current Opioid Misuse Measure" (COMM®), a self-report questionnaire. Patients with a malignant disease were excluded. RESULTS N = 91 patients participated in the study (response rate: 75.2%). A third (31.5%) showed a positive COMM® - Score which represents a high risk of aberrant drug behaviour. A positive COMM® - Score showed a statistically significant correlation with a lifetime diagnosis of depression and neck pain. CONCLUSIONS While Germany does not face an "opioid eoidemic", addictiveness of opioids should be considered when using them in chronic non-tumor pain. In our study population, almost every third patient was at risk and should therefore be followed up closely. Co-prevalence of depression is a significant issue and should always be screened for in patients with chronic pain, especially thus with aberrant drug behaviour.
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Affiliation(s)
- Johannes Maximilian Just
- Institute of General Practice and Family Medicine, Bonn University Clinic, Sigmund-Freud-Street 25, 53127, Bonn, Germany.
| | - Linda Bingener
- Institute of General Practice and Family Medicine, Bonn University Clinic, Sigmund-Freud-Street 25, 53127, Bonn, Germany
| | - Markus Bleckwenn
- Institute of General Practice and Family Medicine, Bonn University Clinic, Sigmund-Freud-Street 25, 53127, Bonn, Germany
| | - Rieke Schnakenberg
- Institute of General Practice and Family Medicine, Bonn University Clinic, Sigmund-Freud-Street 25, 53127, Bonn, Germany.,Department for Health Services Research, Carl von Ossietzky Universität Oldenburg, Post office box 2503, 26111, Oldenburg, Germany
| | - Klaus Weckbecker
- Institute of General Practice and Family Medicine, Bonn University Clinic, Sigmund-Freud-Street 25, 53127, Bonn, Germany
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Shipton EA, Shipton EE, Shipton AJ. A Review of the Opioid Epidemic: What Do We Do About It? Pain Ther 2018; 7:23-36. [PMID: 29623667 PMCID: PMC5993689 DOI: 10.1007/s40122-018-0096-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Indexed: 01/24/2023] Open
Abstract
The opioid epidemic, with its noticeable increase in opioid prescriptions and related misuse, abuse and resultant deaths in the previous 12 years, is a particularly North American phenomenon. Europe, and particularly low- and middle-income countries, appear to be less influenced by this problem. There is undisputable value in using opioids not only in the treatment of acute pain, but in cancer pain as well. However, opioids are progressively being prescribed more and more for chronic non-cancer pain, despite inadequate data on their efficacy. In this paper, we describe the current prevalence of opioid misuse in a number of countries and the rationale for the commencement of opioid therapy. The safe initiation and monitoring of opioid therapy as well as the need for concurrent use of interdisciplinary multimodal therapy is discussed. The possible consequences of long-term use and predictors of high opioid use and overdose are presented. In particular, the management of opioid use disorders and the prevention of opioid abuse and dependence in the young, the old and the pregnant are discussed. Measures to prevent overprescribing and to alleviate risk are described, including the tapering of opioids and the use of opioid deterrents. Finally, the paper looks at the future development of pioneering medications and technologies to potentially treat abuse. In those parts of the world with an opioid epidemic, coroners and medical examiners, private and public health agencies, and agencies that enforce the law need to cooperate in an effort to slow down and reverse the indiscriminate use of prescribing opioids in the long-term for chronic non-cancer pain. Ongoing research is needed to create ways to minimise risks of opioid use, and to provide evidence for effective strategies for treating chronic pain.
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Affiliation(s)
- Edward A Shipton
- Department of Anaesthesia, University of Otago, Christchurch, New Zealand.
| | - Elspeth E Shipton
- Department of Anaesthesia, University of Otago, Christchurch, New Zealand
| | - Ashleigh J Shipton
- Department of Anaesthesia, University of Otago, Christchurch, New Zealand
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Hider-Mlynarz K, Cavalié P, Maison P. Trends in analgesic consumption in France over the last 10 years and comparison of patterns across Europe. Br J Clin Pharmacol 2018. [PMID: 29514410 DOI: 10.1111/bcp.13564] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIMS The aims of the present study were to describe the consumption trends of three groups of analgesics (non-opioids, and mild and strong opioids) between 2006 and 2015 in France, and compare this pattern of use with six European countries in 2015. METHODS Annual drugs sales were extracted from the French national authority's consumption database, and from the IMS Multinational Integrated Data Analysis System and national databases for European countries. RESULTS The use of mild opioids in France was found to have decreased by 53% over the past 10 years, owing to the declining use of dextropropoxyphene combinations, along with an increase in the use of non-opioids and strong opioids (from 72 to 93, and 2 to 2.8 defined daily doses/1000 inhabitants/day, respectively). Paracetamol, the most consumed analgesic, increased over this period, particularly for the adult high dose (+140%). The use of tramadol and codeine combinations also increased, by 62% and 42%, respectively. Morphine remained the most used strong opioid, although there were also large increases in the consumption of oxycodone (+613%) and fentanyl (+263% and +72% for transmucosal and transdermal forms, respectively). A comparison of the patterns of use in Europe in 2015 showed a higher consumption of mild and strong opioids in the UK. France ranked first and third place, respectively, for paracetamol and mild opioid consumption, whereas its use of strong opioids was among the lowest. CONCLUSIONS Paracetamol consumption is clearly highest in France, whereas its use of strong opioids is among the lowest in Europe, although its consumption of oxycodone has increased significantly. Further studies are required specifically to monitor these drugs.
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Affiliation(s)
- Karima Hider-Mlynarz
- French National Agency for Medicines and Health Products Safety, Surveillance Division, Saint-Denis, France
| | - Philippe Cavalié
- French National Agency for Medicines and Health Products Safety, Surveillance Division, Saint-Denis, France
| | - Patrick Maison
- French National Agency for Medicines and Health Products Safety, Surveillance Division, Saint-Denis, France
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Jobski K, Kollhorst B, Garbe E, Schink T. The Risk of Ischemic Cardio- and Cerebrovascular Events Associated with Oxycodone-Naloxone and Other Extended-Release High-Potency Opioids: A Nested Case-Control Study. Drug Saf 2018; 40:505-515. [PMID: 28194654 DOI: 10.1007/s40264-017-0511-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION In Germany, an extended-release (ER) combination of the high-potency opioid (HPO) oxycodone and the antagonist naloxone was approved in 2006. In recent years, the cardio- and cerebrovascular safety of opioid antagonists and of opioids themselves has been discussed. OBJECTIVES The objective of this study was to estimate the risk of major ischemic cardio- and cerebrovascular events in patients receiving ER oxycodone-naloxone compared with those receiving other ER HPOs. METHODS We used the German Pharmacoepidemiological Research Database (GePaRD) to conduct a nested case-control study (2006-2011) within a cohort of ER HPO users. Cases were defined as patients hospitalized for acute myocardial infarction (MI) or ischemic stroke (IS). For each case, up to ten controls were selected by risk-set sampling. Using conditional logistic regression, confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were obtained for the risk of MI/IS associated with (1) current HPO treatment, (2) recent discontinuation, or (3) recent switch of HPO therapy compared with past treatment. RESULTS In 309,936 ER HPO users, 12,384 MI/IS events were detected, resulting in a crude incidence rate of 19.48 (95% CI 19.14-19.82) per 1000 person years. A small but significantly elevated aOR was found for morphine (1.12; 95% CI 1.04-1.22) but not for oxycodone-naloxone. Recent discontinuation and recent switch of any ER HPO also had a significant impact on the outcome (aOR 1.12; 95% CI 1.04-1.21 and 1.25; 95% CI 1.03-1.52, respectively). CONCLUSIONS Our study does not indicate an association between oxycodone-naloxone and ischemic cardio- or cerebrovascular events. However, our findings do suggest that every change in ER HPO therapy should be conducted with caution.
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Affiliation(s)
- Kathrin Jobski
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany. .,Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstrasse 140, 26129, Oldenburg, Germany.
| | - Bianca Kollhorst
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Edeltraut Garbe
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Core Scientific Area 'Health Sciences', University of Bremen, Bremen, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
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Elsesser K, Cegla T. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy. Scand J Pain 2017; 17:87-98. [DOI: 10.1016/j.sjpain.2017.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 06/29/2017] [Accepted: 07/05/2017] [Indexed: 12/17/2022]
Abstract
Abstract
Background and aims
Recent studies reveal high prevalence rates of patients receiving long-term opioids. However, well designed studies assessing effectiveness with longer than 3 months follow-up are sparse. The present study investigated the outcomes of long-term opioid therapy compared to nonopioid treatment in CNCP patients with respect to measures of pain, functional disability, psychological wellbeing, and quality of life (QoL).
Methods
Three hundred and thirty three consecutive patients at our pain clinic were included and divided into patients with continuous opioid treatment for at least 3 months (51%) and patients receiving nonopioid analgesics (49%). Further, outcome of different doses of opioid (<120 mg vs. >120 mg morphine equivalents) and differences between high and low potency opioids were examined.
Results
The opioid and nonopioid groups did not differ with regard to pain intensity or satisfaction with analgesic. Patients with continuous opioids treatment reported higher neuropathic like pain, longer duration of pain disorder, lower functional level, wellbeing, and physical QoL in comparison to patients receiving nonopioid analgesics. Higher opioid doses were associated with male gender, intake of high potency opioids and depression but there were no differences with regard to pain relief or improvement of functional level between high and low doses. Similarly, patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief. Overall, remaining level of pain, functional disability and poor QoL were quite high irrespective of the analgesic used or opioid dosing.
Conclusions
In the long-term no clear advantage of opioid vs. non-opioid analgesics could be revealed. In terms of remaining pain intensity, functional disability and quality of life, treatment with pain medication proved insufficient. Additionally, with higher doses of opioids the benefit to risk relationship becomes worse and patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief.
Implications
Our results raise questions about the long-term effectiveness of analgesic treatment regimens irrespective of analgesics type employed and call for more multidisciplinary treatment strategies.
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Affiliation(s)
- Karin Elsesser
- Sankt Josef Krankenhaus , Clinic of Pain Medicine, Bergstr , 6-12, 42105 Wuppertal , Germany
| | - Thomas Cegla
- Sankt Josef Krankenhaus , Clinic of Pain Medicine, Bergstr , 6-12, 42105 Wuppertal , Germany
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Jensen-Dahm C, Palm H, Gasse C, Dahl JB, Waldemar G. Postoperative Treatment of Pain after Hip Fracture in Elderly Patients with Dementia. Dement Geriatr Cogn Disord 2017; 41:181-91. [PMID: 27045590 DOI: 10.1159/000444704] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/13/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Prior studies have shown that patients with dementia are at risk of receiving insufficient treatment for pain after a hip fracture. We therefore hypothesized that elderly hip fracture patients with dementia received less postoperative pain treatment than those without dementia. METHOD All patients (age ≥65 years) who had been operated on for a hip fracture in the Copenhagen University Hospital region in 2009 were included. Data about analgesic use for the first 72 h after surgery were acquired from the hospitals' electronic medication system and linked with information about dementia, comorbidity, and prior drug use. RESULTS A total of 1,507 patients were included, of which 296 (19.6%) suffered from dementia. Both groups were equally likely to receive paracetamol and opioids. Patients with dementia received lower doses of oral morphine equivalents during the first [dementia vs. no dementia: 29.0 (26.4-31.8) vs. 34.7 (33.1-36.4) mg, p = 0.001] and second [27.8 (25.4-30.5) vs. 31.2 (29.9-32.4) mg, p = 0.019] but not on the third postoperative day (p = 0.10). CONCLUSION The lower doses of opioids may reflect uncertainty about how to treat pain patients with dementia. Further guidance is needed, as inadequate treatment of pain may have adverse consequences.
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Affiliation(s)
- Christina Jensen-Dahm
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
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Meißner W. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:462. [PMID: 28705301 PMCID: PMC5523802 DOI: 10.3238/arztebl.2017.0462b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Analgesic use by ageing and elderly patients with chronic non-malignant pain: a qualitative study. Int J Clin Pharm 2017; 39:798-807. [PMID: 28474305 PMCID: PMC5541120 DOI: 10.1007/s11096-017-0466-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 04/13/2017] [Indexed: 01/05/2023]
Abstract
Background Analgesics are used in the management of chronic non-malignant pain (CNMP), a condition which is highly prevalent among older adults. CNMP may not only be physically distressing but also complicated by psychosocial and economic factors. An individual’s perception and use of analgesics may be influenced by a range of factors such as perceptions of risk or benefits, ability to purchase medication or access to non-pharmacological therapies or specialist care. Objective The aim of this study was to describe the perceptions and experiences of analgesics by ageing and elderly individuals with CNMP and identify factors that influence their use. Setting Telephone interviews with 28 members of Chronic Pain Ireland aged ≥50. Method In-depth semi-structured interviews; audio-recorded, transcribed verbatim, and thematically analysed. Main outcome measure Experiences and perceptions of ageing and elderly individuals with CNMP taking analgesics. Results A combination of factors specific to the patient and arising from outside influences informed perceptions and experiences of analgesics. Pain severity, perceived efficacy of analgesics, occurrence of adverse-effects and concerns about addiction/dependence were identified as internal factors influencing medication use. External factors included views of family members, access to specialised care and the individual’s interaction with healthcare professionals (HCPs). Conclusion Individuals with CNMP regard analgesics as an important method for managing pain and are relied upon when other interventions are difficult to access. HCPs in primary care, who are the main point of contact for patients, need to take into account the various factors that may influence analgesic use when consulting with this patient group.
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Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep 2017; 2:e599. [PMID: 29392214 PMCID: PMC5741305 DOI: 10.1097/pr9.0000000000000599] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION A marked rise in opioid prescriptions for patients with chronic noncancer pain (CNCP) with a parallel increase in opioid abuse/misuse, and resulting deaths was noted in the Unites states in the past decade (opioid epidemic). In response, the US Center of Diseases Control (CDC) developed a guideline for prescribing of opioids for patients with CNCP. OBJECTIVES To assess (1) if there is an opioid epidemic in Australia, Canada, and Germany (2) to compare Australian, Canadian, German, and Center of Diseases Control guidelines recommendations for long-term opioid therapy for CNCP. METHODS National evidence-based guidelines and PubMed were searched for recommendations for opioid prescriptions for CNCP. RESULTS There are signs of an opioid epidemic in Australia and Canada, but not in Germany. Guidelines in all 4 countries provide similar recommendations: opioids are not the first-line therapy for patients with CNCP; regular clinical assessments of benefits and harms are necessary; excessive doses should be avoided (recommended morphine equivalent daily doses range from 50 to 200 mg/d); stopping rules should be followed. All guidelines do not recommend the use of opioids in chronic pain conditions without an established nociceptive or neuropathic cause such as fibromyalgia and primary headache. CONCLUSION Implementation of opioid prescribing guidelines should ensure that physicians prescribe opioids only for appropriate indications in limited doses for selected patients and advice patients on their safe use. These measures could contribute to reduce prescription opioid misuse/abuse and deaths.
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Affiliation(s)
- Winfried Häuser
- Department Internal Medicine 1, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Stephan Schug
- Pharmacology, Pharmacy and Anaesthesiology Unit, School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Andrea D Furlan
- Department of Medicine, University of Toronto, Institute for Work & Health, Toronto Rehab-UHN, Toronto, ON, Canada
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Saulle R, Vecchi S, Gowing L. Supervised dosing with a long-acting opioid medication in the management of opioid dependence. Cochrane Database Syst Rev 2017; 4:CD011983. [PMID: 28447766 PMCID: PMC6478186 DOI: 10.1002/14651858.cd011983.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Opioid dependence (OD) is an increasing clinical and public health problem worldwide. International guidelines recommend opioid substitution treatment (OST), such as methadone and buprenorphine, as first-line medication treatment for OD. A negative aspect of OST is that the medication used can be diverted both through sale on the black market, and the unsanctioned use of medications. Daily supervised administration of medications used in OST has the advantage of reducing the risk of diversion, and may promote therapeutic engagement, potentially enhancing the psychosocial aspect of OST, but costs more and is more restrictive on the client than dispensing for off-site consumption. OBJECTIVES The objective of this systematic review is to compare the effectiveness of OST with supervised dosing relative to dispensing of medication for off-site consumption. SEARCH METHODS We searched in Cochrane Drugs and Alcohol Group Specialised Register and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science from inception up to April 2016. Ongoing and unpublished studies were searched via ClinicalTrials.gov (www.clinicaltrials.gov) and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (http://www.who.int/ictrp/en/).All searches included non-English language literature. We handsearched references on topic-related systematic reviews. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs), and prospective controlled cohort studies, involving people who are receiving OST (methadone, buprenorphine) and comparing supervised dosing with dispensing of medication to be consumed away from the dispensing point, usually without supervision. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS Six studies (four RCTs and two prospective observational cohort studies), involving 7999 participants comparing supervised OST treatment with unsupervised treatment, met the inclusion criteria. The risk of bias was generally moderate across trials, but the results reported on outcomes that we planned to consider were limited. Overall, we judged the quality of the evidence from very low to low for all the outcomes.We found no difference in retention at any duration with supervised compared to unsupervised dosing (RR 0.99, 95% CI 0.88 to 1.12, 716 participants, four trials, low-quality evidence) or in retention in the shortest follow-up period, three months (RR 0.94; 95% CI 0.84 to 1.05; 472 participants, three trials, low-quality evidence). Additional data at 12 months from one observational study found no difference in retention between groups (RR 0.94, 95% CI 0.77 to 1.14; n = 300).There was no difference in abstinence at the end of treatment (self-reported drug use) (67% versus 60%, P = 0.33, 293 participants, one trial, very low-quality evidence); and in diversion of medication (5% versus 2%, 293 participants, one trial, very low-quality evidence).Regarding our secondary outcomes, we did not found a difference in the incidence of adverse effects in the supervised compared to unsupervised control group (RR 0.63; 96% CI 0.10 to 3.86; 363 participants, two trials, very low-quality evidence). Data on severity of dependence were very limited (244 participants, one trial) and showed no difference between the two approaches. Data on deaths were reported in two studies. One trial reported two deaths in the supervised group (low-quality evidence), while in the cohort study all-cause mortality was found lower in regular supervision group (crude mortality rate 0.60 versus 0.81 per 100 person-years), although after adjustment insufficient evidence existed to suggest that regular supervision was protective (mortality rate ratio = 1.23, 95% CI = 0.67 to 2.27).No studies reported pain symptoms, drug craving, aberrant opioid-related behaviours, days of unsanctioned opioid use and overdose. AUTHORS' CONCLUSIONS Take-home medication strategies are attractive to treatment services due to lower costs, and place less restrictions on clients, but it is unknown whether they may be associated with increased risk of diversion and unsanctioned use of medication. There is uncertainty about the effects of supervised dosing compared with unsupervised medication due to the low and very low quality of the evidence for the primary outcomes of interest for this review. Data on defined secondary outcomes were similarly limited. More research comparing supervised and take-home medication strategies is needed to support decisions on the relative effectiveness of these strategies. The trials should be designed and conducted with high quality and over a longer follow-up period to support comparison of strategies at different stages of treatment. In particular, there is a need for studies assessing in more detail the risk of diversion and safety outcomes of using supervised OST to manage opioid dependence.
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Affiliation(s)
- Rosella Saulle
- Lazio Regional Health ServiceDepartment of EpidemiologyVia di S. CostanzaRomeItaly00198
| | - Simona Vecchi
- Lazio Regional Health ServiceDepartment of EpidemiologyVia di S. CostanzaRomeItaly00198
| | - Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
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Krause D, Plörer D, Koller G, Martin G, Winter C, Adam R, Canolli M, Al-Iassin J, Musselmann R, Walcher S, Schäfer F, Pogarell O. High Concomitant Misuse of Fentanyl in Subjects on Opioid Maintenance Treatment. Subst Use Misuse 2017; 52:639-645. [PMID: 28157415 DOI: 10.1080/10826084.2016.1246571] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Concomitant opioid misuse is an increasing problem in opioid maintenance treatment as it interferes with treatment success. OBJECTIVE Therefore, the rates of concomitant fentanyl misuse in opioid maintained patients were investigated. METHODS We conducted a cross-sectional study which consisted in collecting data via urine samples and questionnaires in Germany. Urine samples of patients on opioid maintenance treatment were gathered and fentanyl concentrations were measured from 2008 to 2012. An anonymous questionnaire provided data on the consumption of fentanyl as concomitant drug. Data were analyzed with descriptive statistics and group differences were calculated using the Chi-Square test. RESULTS Among the total sample (urine probes of 960 patients), 6.8% opioid maintained patients had positive urine samples for fentanyl and 37.9% reported concomitant fentanyl misuse (401 of these patients filled out the questionnaire). A significant age-related association of concomitant fentanyl misuse was identified in the urine analyses (χ2 = 7.489; p = .024) and also in the questionnaire data (χ2 = 11.899, p = .003), indicating that young age increased the probability of fentanyl consumption. Patients receiving methadone had the highest rates of concomitant fentanyl misuse with 18.4% according to urine analysis. In addition, the results show that patients who are on diamorphine are significantly less likely to misuse fentanyl. CONCLUSIONS Fentanyl is a frequently used concomitant drug. Especially young patients and patients taking methadone are at high risk. Because of the life-threatening consequences of fentanyl overdose, patients taking fentanyl should be intensively medically surveilled.
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Affiliation(s)
- Daniela Krause
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
| | - Diana Plörer
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
| | - Gabriele Koller
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
| | - Gabi Martin
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
| | - Catja Winter
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
| | - Roland Adam
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
| | - Minavere Canolli
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
| | - Jori Al-Iassin
- b Outpatient Clinic for Opioid Substitution , Munich , Germany
| | | | | | | | - Oliver Pogarell
- a Department of Psychiatry and Psychotherapy , Ludwig-Maximilians-University , Munich , Germany
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Jobski K, Luque Ramos A, Albrecht K, Hoffmann F. Pain, depressive symptoms and medication in German patients with rheumatoid arthritis-results from the linking patient-reported outcomes with claims data for health services research in rheumatology (PROCLAIR) study. Pharmacoepidemiol Drug Saf 2017; 26:766-774. [DOI: 10.1002/pds.4202] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/12/2017] [Accepted: 03/05/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Kathrin Jobski
- Department of Health Services Research; Carl von Ossietzky University Oldenburg; Oldenburg Germany
| | - Andres Luque Ramos
- Department of Health Services Research; Carl von Ossietzky University Oldenburg; Oldenburg Germany
| | - Katinka Albrecht
- Epidemiology Unit; German Rheumatism Research Centre; Berlin Germany
| | - Falk Hoffmann
- Department of Health Services Research; Carl von Ossietzky University Oldenburg; Oldenburg Germany
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Schumacher MB, Jongen S, Knoche A, Petzke F, Vuurman EF, Vollrath M, Ramaekers JG. Effect of chronic opioid therapy on actual driving performance in non-cancer pain patients. Psychopharmacology (Berl) 2017; 234:989-999. [PMID: 28190085 DOI: 10.1007/s00213-017-4539-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/16/2017] [Indexed: 12/31/2022]
Abstract
RATIONALE Chronic non-cancer pain (CNCP) is a major health problem. Patients are increasingly treated with chronic opioid therapy (COT). Several laboratory studies have demonstrated that long-term use of opioids does not generally impair driving related skills. But there is still a lack of studies investigating on-the-road driving performance in actual traffic. OBJECTIVES The present study assessed the impact of COT on road-tracking and car-following performance in CNCP patients. METHODS Twenty CNCP patients, long-term treated with stable doses of opioid analgesics, and 19 healthy controls conducted standardized on-the-road driving tests in normal traffic. Performance of controls with a blood alcohol concentration (BAC) of 0.5 g/L was used as a reference to define clinically relevant changes in driving performance. RESULTS Standard Deviation of Lateral Position (SDLP), a measure of road-tracking control, was 2.57 cm greater in CNCP patients than in sober controls. This difference failed to reach statistical significance in a superiority test. Equivalence testing indicated that the 95% CI around the mean SDLP change was equivalent to the SDLP change seen in controls with a BAC of 0.5 g/L and did not include zero. When corrected for age differences between groups the 95% CI widened to include both the alcohol reference criterion and zero. No difference was found in car-following performance. CONCLUSIONS Driving performance of CNCP patients did not significantly differ from that of controls due to large inter-individual variations. Hence in clinical practice determination of fitness to drive of CNCP patients who receive opioid treatments should be based on an individual assessment.
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Affiliation(s)
- Markus B Schumacher
- Federal Highway Research Institute (BASt), Bruederstrasse 53, D-51427, Bergisch Gladbach, Germany.
| | - Stefan Jongen
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Universiteitssingel 40, Maastricht, 6200 MD, The Netherlands
| | - Anja Knoche
- Federal Highway Research Institute (BASt), Bruederstrasse 53, D-51427, Bergisch Gladbach, Germany
| | - Frank Petzke
- Universitaetsmedizin Goettingen, Georg-August-Universitaet, Robert-Koch-Str. 40, D-37075, Goettingen, Germany
| | - Eric F Vuurman
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Universiteitssingel 40, Maastricht, 6200 MD, The Netherlands
| | - Mark Vollrath
- Institut für Psychologie, Ingenieur- und Verkehrspsychologie, Technische Universitaet Braunschweig, Gaussstr. 23, D-38106, Braunschweig, Germany
| | - Johannes G Ramaekers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Universiteitssingel 40, Maastricht, 6200 MD, The Netherlands
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Wertli MM, Reich O, Signorell A, Burgstaller JM, Steurer J, Held U. Changes over time in prescription practices of pain medications in Switzerland between 2006 and 2013: an analysis of insurance claims. BMC Health Serv Res 2017; 17:167. [PMID: 28241764 PMCID: PMC5327558 DOI: 10.1186/s12913-017-2086-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 02/09/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Europe, scant information is available about prescription practices for pain medications. The aim of this research was to assess changes in prescription rates of non-opioid, weak opioid, and strong opioid medications between 2006 and 2013 in the Swiss population. METHODS Using insurance claims data covering one-sixth of the Swiss population, we analyzed the numbers of reimbursed pain medications, the number of reimbursements per persons, and the cumulative dose in milligrams. For opioids, the morphine equivalent dose and treatment days were calculated. Data were extrapolated to the dose per day per 100'000 population stratified by age, gender, and canton. RESULTS In total, 4'746'942 paracetamol, 2'156'620 NSAIDs or Coxibs, 931'129 metamizole, 1'322'272 weak opioid, and 807'835 strong opioid claims were analyzed. Between 2006 and 2013, the increase in claims per 100'000 persons was 32% for paracetamol, 242% for metamizole, 107% for NSAIDS, 86% for Coxibs, 13% for weak opioids, and 121% for strong opioids. For strong opioids the total MED in mg /100'000 increased by 117%, the treatment days /100'000 by 101%. For strong opioids, fentanyl was most frequently used (increase between 2006 and 2013 by 91% for MED/100'000 persons and 94% treatment days / 100'000) followed by buprenorphine and oxycodone. The highest proportional increase in MED / 100'000 was observed for methadone (+1414%) and oxycodone (+313%). Marked geographical variation was detected in the use of metamizole, paracetamole, and strong opioids in different cantons. CONCLUSION The analysis of insurance claims data provides evidence that the prescription rates for pain medications increased in Switzerland within the last ten years, in particular for metamizole and strong opioids. Furthermore, the prescription rates for metamizole, paracetamol, and strong opioids varied substantially between different cantons in Switzerland.
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Affiliation(s)
- Maria M Wertli
- Horten-Centre for patient oriented research and knowledge transfer, University of Zurich, CH-8032, Zurich, Switzerland. .,Department of General Internal Medicine, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
| | - Oliver Reich
- Department of Health Sciences, Helsana, Zürichstrasse 130, CH-8600, Dübendorf, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana, Zürichstrasse 130, CH-8600, Dübendorf, Switzerland
| | - Jakob M Burgstaller
- Horten-Centre for patient oriented research and knowledge transfer, University of Zurich, CH-8032, Zurich, Switzerland
| | - Johann Steurer
- Horten-Centre for patient oriented research and knowledge transfer, University of Zurich, CH-8032, Zurich, Switzerland
| | - Ulrike Held
- Horten-Centre for patient oriented research and knowledge transfer, University of Zurich, CH-8032, Zurich, Switzerland
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Abstract
BACKGROUND Opioids are increasingly used in the elderly. Side effects differ compared to other analgesics. PURPOSE In this review article, special aspects about using opioids for noncancer pain in older people and in geriatric patients are identified. CURRENT SITUATION So far randomized controlled trials for the indication of and comparison between various opioids have been performed in middle-aged patients and not exclusively in geriatric patients or elderly (> 75 years). Furthermore, the evidence for multimorbid elderly patients with respect to side effects is also very poor. RECOMMENDATIONS The indication for opioid therapy should be narrow. The patient and their caregivers must be provided patient information regarding opioid therapy. The principle "start low, go slow" is highly recommended. To reduce the risk of falls, longer acting opioids should be used and short acting opioids should be avoided. Everyday relevant negative effects on cognition are possible in opioid use and have to be observed. As recommended in the recently published German guideline for long-term use of opioids in noncancer pain a critical check after 3 months and in case of dosing over 120 mg morphine equivalents is advisable, especially for older patients. Liver and kidney function and drug interactions have to be taken into consideration like in every age group.
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Affiliation(s)
- M Schuler
- Klinik für Geriatrie und Palliativmedizin, Diakonissenkrankenhaus, Speyerer Str. 91-93, 68163, Mannheim, Deutschland.
| | - N Grießinger
- Schmerzambulanz, Anästhesiologische Klinik, Universitätsklinikum Erlangen, Erlangen, Deutschland
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Häuser W, Bernardy K, Maier C. [Long-term opioid therapy in chronic noncancer pain. A systematic review and meta-analysis of efficacy, tolerability and safety in open-label extension trials with study duration of at least 26 weeks]. Schmerz 2016; 29:96-108. [PMID: 25503691 DOI: 10.1007/s00482-014-1452-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The efficacy and safety of long-term (≥ 6 months) opioid therapy (LtOT) in chronic noncancer pain (CNCP) is under debate. A systematic review with meta-analysis of the efficacy and harms of opioids in open-label extension studies of randomized controlled trials (RCTs) has not been conducted until now. METHODS We screened MEDLINE and clinicaltrials.gov (through to December 2013), as well as reference sections of systematic reviews of long-term RCTs of opioids in CNCP. We included open-label extension trials with a study duration ≥ 26 weeks of RCTs of ≥ 2 weeks duration. Using a random effects model, pooled estimates of event rates for categorical data and standardized mean differences (SMD) for continuous variables were calculated. RESULTS We included 11 open-label extension studies with 2445 participants with nociceptive (low back, osteoarthritis) and neuropathic (radicular, polyneuropathy) pain. Median study duration was 26 (range 26-108) weeks. Four studies tested oxycodone, two studies tramadol and buprenorphine; hydromorphone, morphine, oxymorphone and tapentadol were each tested in one study. Of the patients randomized at baseline, 28.5 % (95 % confidence interval, CI, 17.9-39.2 %) finished the open-label period; 53.5 % (95 % CI 38.1-68.2 %) of patients entering the open-label period finished the open-label period. In sum, the total loss was 71.5 % (95 % CI 60.9-83.1 %) of all patients primarily included into the RCT. A total of 4.9 % (95 % CI 2.9-8.2 %) of patients dropped out due lack of efficacy; 16.8 % (95 % CI 11.0-24.8 %) dropped out to due adverse events (AE) in the open-label period and 0.08 % (95 % CI 0.001-0.05 %) of patients died during the open-label period. Only one study systematically assessed aberrant drug behavior of the patients: 5.7 % (95 % CI 3.4-9.6 %) showed aberrant drug behavior in the opinion of the investigators and 2.6 % (95 % CI 1.2-5.8 %) were judged to show aberrant drug behavior by independent expert assessment. There was no significant change (p = 0.50) in pain intensity between the end of the randomized period and the end of open-label phase (SMD 0.19 [- 0.03, 0.41]; six studies with 1360 participants). CONCLUSION Only a minority of patients selected for opioid therapy at randomization finished the long-term open-label study. However, sustained effects of pain reduction could be demonstrated in these patients. LtOT can be considered in carefully selected and monitored CNCP patients who experience clinically meaningful pain reduction with at least tolerable AE in short-term opioid therapy. The English full-text version of this article is freely available at SpringerLink (under "Supplementary Material").
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Affiliation(s)
- W Häuser
- Innere Medizin I, Klinikum Saarbrücken gGmbH, Winterberg 1, 66119, Saarbrücken, Deutschland,
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[Opioids in chronic noncancer pain-are opioids different? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids of at least four week's duration]. Schmerz 2016; 29:73-84. [PMID: 25376545 DOI: 10.1007/s00482-014-1432-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND We updated a systematic review on the comparative efficacy, tolerability and safety of opioids and of their routes of application in chronic noncancer pain (CNCP). METHODS We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as the reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CNCP. We included randomized head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) of at least 4 week's duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables. The quality of evidence was rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS We included 13 RCTs with 6748 participants. Median study duration was 15 weeks (range 4-56 weeks). Hydromorphone, morphine, oxymorphone and tapentadol were compared to oxycodone; fentanyl to morphine and buprenorphine to tramadol. In pooled analysis, there were no significant differences between the two groups of opioids in terms of mean pain reduction (low-quality evidence), the patient global impression to be much or very much improved outcome (low-quality evidence), physical function (very low-quality evidence), serious adverse events (moderate-quality evidence) or mortality (moderate-quality evidence). There was no significant difference between transdermal and oral application of opioids in terms of mean pain reduction, physical function, serious adverse events, mortality (all low-quality evidence) or dropout due to adverse events (very low-quality). CONCLUSION Pooled head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) provide no rational for preferring one opioid and/or administration route over another in the therapy of patients with CNCP. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").
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Häuser W, Bock F, Engeser P, Hege-Scheuing G, Hüppe M, Lindena G, Maier C, Norda H, Radbruch L, Sabatowski R, Schäfer M, Schiltenwolf M, Schuler M, Sorgatz H, Tölle T, Willweber-Strumpf A, Petzke F. [Recommendations of the updated LONTS guidelines. Long-term opioid therapy for chronic noncancer pain]. Schmerz 2016; 29:109-30. [PMID: 25616996 DOI: 10.1007/s00482-014-1463-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The regular update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003), began in November 2013. METHODS The guidelines were developed by 26 scientific societies and two patient self-help organisations under the coordination of the Deutsche Schmerzgesellschaft (German Pain Society). A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Scopus databases (up until October 2013) was performed. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by multistep formal procedures, in order to reach a consensus according to German Association of the Medical Scientific Societies ("Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften", AWMF) regulations. The guidelines were reviewed by the Drug Commission of the German Medical Association, the Austrian Pain Society and the Swiss Association for the Study of Pain. RESULTS Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-25 weeks) and long-term (≥ 26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches, as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. For all other clinical presentations, a short- and long-term therapy with opioid-containing analgesics should be evaluated on an individual basis. Long-term therapy with opioid-containing analgesics is associated with relevant risks (sexual disorders, increased mortality). CONCLUSION Responsible application of opioid-containing analgesics requires consideration of possible indications and contraindications, as well as regular assessment of efficacy and adverse effects. Neither an uncritical increase in opioid application, nor the global rejection of opioid-containing analgesics is justified in patients with CNCP.
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Affiliation(s)
- W Häuser
- Medizinisches Versorgungszentrum (Schmerztherapie, Palliativmedizin, Psychiatrie, Psychotherapie) Saarbrücken - St. Johann, Saarbrücken, Deutschland,
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Welsch P, Sommer C, Schiltenwolf M, Häuser W. [Opioids in chronic noncancer pain-are opioids superior to nonopioid analgesics? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids versus nonopioid analgesics of at least four week's duration]. Schmerz 2016; 29:85-95. [PMID: 25376546 DOI: 10.1007/s00482-014-1436-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Some leading German pain medicine experts postulate that there is a type of chronic non-cancer pain (CNCP) with an opioid requirement. We tested whether opioids are superior to nonopioid analgesics in the management of CNCP in studies of at least 4 week's duration. METHODS We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as the reference sections of original studies and systematic reviews of randomised controlled trials (RCTs) of opioids in CNCP. We included double-blind RTCs comparing opioids to nonopioid analgesics of at least 4 week's duration. Relative risks differences (RD) of categorical data and standardized mean differences (SMD) of continuous variables were calculated using a random effects model. RESULTS We included 10 RCTs with 3046 participants. Median study duration was 6 weeks (range 4-12 weeks). Five studies compared tramadol with nonsteroidal anti-inflammatory drugs (NSAIDs) in osteoarthritis pain and one trial compared tramadol to flupirtine in low back pain. Morphine was compared to antidepressants (two studies), an anticonvulsant (one study) and an antiarrhythmic (one study) in different neuropathic pain syndromes. There was no significant difference between opioids and nonopioid analgesics in pain reduction (SMD 0.03 [95 % confidence interval, CI - 0.18, 0.24]; p = 0.76). Nonopioid analgesics were superior to opioids in improving physical function (SMD 0.17 [95 % CI 0.02, 0.32]; p = 0.03). Patients dropped out due to adverse events more frequently with opioids than with nonopioid analgesics (RD 0.09 [95 % CI 0.06, 0.13]; p < 0.0001). There was no significant difference between opioids and nonopioid analgesics in terms of serious adverse events or dropout rates due to lack of efficacy. CONCLUSION Nonopioid analgesics are superior to opioids in terms of improvement of physical function and tolerability in short-term (4-12 weeks) therapy of neuropathic, low back and osteoarthritis pain. Our results do not support the concept of an"opioid-requiring" CNCP. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").
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Affiliation(s)
- P Welsch
- Stichting Rugzorg Nederland, Ede, Niederlande
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