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Hurtado I, Robles C, García-Sempere A, Llopis-Cardona F, Sánchez-Sáez F, Rodríguez-Bernal C, Peiró S, Sanfélix-Gimeno G. Long-term use of prescription opioids for non-cancer pain and mortality: a population-based, propensity-weighted cohort study. Public Health 2024; 232:4-13. [PMID: 38718737 DOI: 10.1016/j.puhe.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE The objective of this study was to identify factors associated with long-term opioid use and to assess the association between long-term use and death. STUDY DESIGN Retrospective cohort study combining several population-wide databases and covering a population of five million inhabitants, including all adults who were initiated on opioid treatment from 2014 to 2018 for non-cancer pain. METHODS We used logistic regression models to identify factors associated with chronic opioid use and carried out survival analyses using multivariable Cox regression modelling for all-cause mortality during follow-up using inverse probability of treatment weighting (IPTW) and propensity scores based on the probability of using opioids chronically. RESULTS Among 760,006 patients, 82,423 (10.85%) used opioids for 90 days or more after initiation. Initial therapy characteristics associated with higher risk for long-term use were initiating with long- and short-acting opioids (when compared to tramadol, odds ratio [OR]: 2.63, 95% confidence interval [CI]: 2.57, 2.69 and OR: 1.60, 95%CI: 1.46, 1.76, respectively), using higher daily doses (when compared to 50 morphine milligramme equivalent [MME] or less, prescribing 50 to 89 daily MME, OR: 1.76, 95%CI: 1.65, 1.87; 90 to 119 daily MME, OR: 2.44, 95%CI: 1.99, 3.01; and more than 120 daily MME, OR: 1.77, 95%CI: 1.64, 1.91), and overlapping with gabapentinoids (OR: 2.26, 95%CI: 2.20, 2.32), benzodiazepines (OR: 1.32, 95%CI: 1.30, 1.35), and antipsychotics (OR: 1.21, 95%CI: 1.16, 1.26). After IPTW, chronic opioid use was associated with higher risk of all-cause mortality when compared to short-term use (Hazard Ratio (HR): 1.37, 95%CI: 1.32, 1.42). Sensitivity analyses provided similar results. CONCLUSION These findings may help healthcare managers to identify and address patients at higher risk of long-term use and riskier prescription patterns.
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Affiliation(s)
- I Hurtado
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Fisabio, Spain; Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain
| | - C Robles
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Fisabio, Spain; Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain
| | - A García-Sempere
- Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain.
| | - F Llopis-Cardona
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Fisabio, Spain; Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain
| | - F Sánchez-Sáez
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Fisabio, Spain; Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain
| | - C Rodríguez-Bernal
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Fisabio, Spain; Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain
| | - S Peiró
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Fisabio, Spain; Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain
| | - G Sanfélix-Gimeno
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Fisabio, Spain; Spanish Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain
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Shinkai M, Katsumata N, Kawai S, Kuyama S, Sasaki O, Yanagita Y, Yoshida M, Uneda S, Tsuji Y, Harada H, Nishida Y, Sakamoto Y, Himeji D, Arioka H, Sato K, Katsuki R, Shomura H, Nakano H, Ohtani H, Sasaki K, Adachi T. Phase III study of bilayer sustained-release tramadol tablets in patients with cancer pain: a double-blind parallel-group, non-inferiority study with immediate-release tramadol capsules as an active comparator. Support Care Cancer 2023; 32:69. [PMID: 38157081 PMCID: PMC10756890 DOI: 10.1007/s00520-023-08242-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/06/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE We investigated whether twice-daily administration of a bilayer tablet formulation of tramadol (35% immediate-release [IR] and 65% sustained-release) is as effective as four-times-daily IR tramadol capsules for managing cancer pain. METHODS This randomized, double-blind, double-dummy, active-comparator, non-inferiority study enrolled opioid-naïve patients using non-steroidal anti-inflammatory drugs or acetaminophen (paracetamol) to manage cancer pain and self-reported pain (mean value over 3 days ≥ 25 mm on a 100-mm visual analog scale [VAS]). Patients were randomized to either bilayer tablets or IR capsules for 14 days. The starting dose was 100 mg/day and could be escalated to 300 mg/day. The primary endpoint was the change in VAS (averaged over 3 days) for pain at rest from baseline to end of treatment/discontinuation. RESULTS Overall, 251 patients were randomized. The baseline mean VAS at rest was 47.67 mm (range: 25.6-82.7 mm). In the full analysis set, the adjusted mean change in VAS was - 22.07 and - 19.08 mm in the bilayer tablet (n = 124) and IR capsule (n = 120) groups, respectively. The adjusted mean difference was - 2.99 mm (95% confidence interval [CI] - 7.96 to 1.99 mm). The upper 95% CI was less than the predefined non-inferiority margin of 7.5 mm. Other efficacy outcomes were similar in both groups. Adverse events were reported for 97/126 (77.0%) and 101/125 (80.8%) patients in the bilayer tablet and IR capsule groups, respectively. CONCLUSION Twice-daily administration of bilayer tramadol tablets was as effective as four-times-daily administration of IR capsules regarding the improvement in pain VAS, with comparable safety outcomes. CLINICAL TRIAL REGISTRATION JapicCTI-184143/jRCT2080224082 (October 5, 2018).
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Affiliation(s)
| | | | | | - Shoichi Kuyama
- National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | | | | | | | - Shima Uneda
- Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | | | | | | | | | | | | | | | - Ryo Katsuki
- National Hospital Organization Ureshino Medical Center, Saga, Japan
| | - Hiroki Shomura
- Japan Community Health Care Organization Hokkaido Hospital, Hokkaido, Japan
| | - Hideshi Nakano
- Department of Clinical Development, Nippon Zoki Pharmaceutical Co., Ltd., Osaka, Japan
| | - Hideaki Ohtani
- Department of Clinical Development, Nippon Zoki Pharmaceutical Co., Ltd., Osaka, Japan
| | - Kazutaka Sasaki
- Department of Clinical Development, Nippon Zoki Pharmaceutical Co., Ltd., Osaka, Japan
| | - Takeshi Adachi
- Department of Clinical Development, Nippon Zoki Pharmaceutical Co., Ltd., Osaka, Japan
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Weiner SG, Hoppe JA. Contextualising opioid-related risk factors before an initial opioid prescription. BMJ Qual Saf 2023; 33:1-3. [PMID: 37500564 PMCID: PMC10817995 DOI: 10.1136/bmjqs-2023-016336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Scott G Weiner
- Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason A Hoppe
- Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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García-Sempere A, Hurtado I, Robles C, Llopis-Cardona F, Sánchez-Saez F, Rodriguez-Bernal C, Peiró-Moreno S, Sanfélix-Gimeno G. Initial opioid prescription characteristics and risk of opioid misuse, poisoning and dependence: retrospective cohort study. BMJ Qual Saf 2023; 33:13-23. [PMID: 37414557 PMCID: PMC10804034 DOI: 10.1136/bmjqs-2022-015833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/09/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To identify individual and initial prescription-related factors associated with an increased risk for opioid-related misuse, poisoning and dependence (MPD) in patients with non-cancer pain. METHODS Cohort study linking several databases covering 5 million inhabitants of the region of Valencia, Spain, including all adults initiating prescription opioids in the period 2012-2018. To ascertain the association between the characteristics of the initial prescription choice and the risk of opioid MPD, we used shared frailty Cox regression models. We additionally considered death as a competing risk in sensitivity analyses. RESULTS 958 019 patients initiated opioid prescription from 2012 to 2018, of which 0.13% experienced MPD. Most patients were prescribed tramadol as initial opioid (76.7%) followed by codeine (16.3%), long-acting opioids (6.7%), short-acting opioids (0.2%) and ultrafast opioids (0.1%). Initiation with ultrafast (HR 7.2; 95% CI 4.1 to 12.6), short-acting (HR 4.8; 95% CI 2.3 to 10.2) and long-acting opioids (HR 1.5; 95% CI 1.2 to 1.9) were associated with a higher risk of MPD when compared with tramadol. Initial prescriptions covering 4-7 days (HR 1.3; 95% CI 1.0 to 1.8), 8-14 days (HR 1.4; 95% CI 1.0 to 1.9), 15-30 days (HR 1.7; 95% CI 1.2 to 2.3) and more than one a month (HR 1.8; 95% CI 1.3 to 2.5) were associated with more MPD risk than initial prescriptions for 1-3 days. Treatments with >120 daily morphine milligram equivalents (MME) increased MPD risk (vs <50 MME, HR 1.6; 95% CI 1.1 to 2.2). Main individual factors associated with increased risk of MPD risk were male sex (HR 2.4; 95% CI 2.1 to 2.7), younger age (when compared with patients aged 18-44 years, patients aged 45-64 years, HR 0.4; 95% CI 0.4 to 0.5; patients aged 65-74 years, HR 0.4; 95% CI 0.3 to 0.5 and patients aged 75 years old and over, HR 0.7; 95% CI 0.6 to 0.8), lack of economic resources (2.1; 95% CI 1.8 to 2.5) and registered misuse of alcohol (2.9; 95% CI 2.4 to 3.5). Sensitivity analyses yielded overall comparable results. CONCLUSIONS Our study identifies riskier patterns of opioid prescription initiation for non-cancer indications, as well as patient subgroups with higher risk of misuse, poisoning and dependence.
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Affiliation(s)
- Aníbal García-Sempere
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Isabel Hurtado
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Celia Robles
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Fran Llopis-Cardona
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Francisco Sánchez-Saez
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Clara Rodriguez-Bernal
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Salvador Peiró-Moreno
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
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Soyka M, Wild I, Caulet B, Leontiou C, Lugoboni F, Hajak G. Long-term use of benzodiazepines in chronic insomnia: a European perspective. Front Psychiatry 2023; 14:1212028. [PMID: 37599882 PMCID: PMC10433200 DOI: 10.3389/fpsyt.2023.1212028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Chronic insomnia occurs in ~10% of the general population and has numerous negative health effects. The recommended first line treatment of cognitive behavior therapy for insomnia is not widely available for patients in Europe, so pharmacotherapies such as benzodiazepine receptor agonist agents (benzodiazepines and Z-drugs) are commonly used. However, their use is only recommended for ≤4 weeks due to unproven long-term efficacy in treatment of chronic insomnia, and the risk of tolerance, and the potential for dependence and misuse. In Europe, recommendations limiting the use of benzodiazepines (lowest dose and shortest duration) in chronic insomnia are not always followed, likely due to the lack of approved effective alternative therapies. Here we present a recent pilot survey of the pharmacological treatment landscape in chronic insomnia in five European countries (France, Germany, Italy, Spain, and the United Kingdom) and physicians' attitude toward treatment. The results suggest that benzodiazepines and Z-drugs are the most widely used treatments in chronic insomnia and are being used for longer than their recommended duration. Country variations in prescription rates were observed. Due to the known association between long-term benzodiazepine use and potential for developing dependence, further analysis of the literature was performed on the use and misuse of benzodiazepines. The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use of benzodiazepines may increase the risk of opioid use disorder.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - Imane Wild
- Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | | | | | - Fabio Lugoboni
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Göran Hajak
- University of Regensburg, Regensburg, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Bamberg, Germany
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