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Woodcock C, Cornwall N, Dikomitis L, Harrisson SA, White S, Helliwell T, Knaggs R, Hodgson E, Pincus T, Santer M, Mallen C, Ashworth J, Jinks C. Designing a primary care pharmacist-led review for people treated with opioids for persistent pain: a multi-method qualitative study. BJGP Open 2024:BJGPO.2023.0221. [PMID: 38631722 DOI: 10.3399/bjgpo.2023.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Opioids are frequently prescribed for persistent non-cancer pain despite limited evidence of long-term effectiveness and risk of harm. Evidence-based interventions to address inappropriate opioid prescribing are lacking. AIM To explore perspectives of people living with persistent pain to understand barriers and facilitators in reducing opioids in the context of a pharmacist-led primary care review, and identify review components and features for optimal delivery. DESIGN & SETTING Primary care multi-method qualitative study. METHOD Adults with experience of persistent pain and taking opioids participated in semi-structured interviews (n=15, 73% female) and an online discussion forum (n=31). The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis, involving deductive analysis to TDF domains, inductive analysis within-domains to generate subthemes, and subtheme comparison to form across-domain overarching themes. The behaviour change technique taxonomy v.1 and motivational behaviour change technique classification system were used to systematically map themes to behaviour change techniques to identify potential review components and delivery features. RESULTS 32 facilitator and barrier subthemes for patients reducing opioids were identified across 13 TDF domains. These combined into six overarching themes: learning to live with pain, opioid reduction expectations, assuming a medical model, pharmacist-delivered reviews, pharmacist-patient relationship and patient engagement. Subthemes mapped to 21 unique behaviour change techniques, yielding 17 components and five delivery features for the proposed PROMPPT review. CONCLUSION This study generated theoretically-informed evidence for design of a practice pharmacist-led PROMPPT review. Future research will test the feasibility and acceptability of the PROMPPT review and pharmacist training.
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Affiliation(s)
- Charlotte Woodcock
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
| | - Nicola Cornwall
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
| | - Lisa Dikomitis
- Centre for Health Services Studies and Kent and Medway Medical School, University of Kent, Canterbury, United Kingdom
| | - Sarah A Harrisson
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, United Kingdom
| | - Toby Helliwell
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Roger Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
- Primary Integrated Community Services Ltd, Nottingham, United Kingdom
| | | | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, United Kingdom
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, United Kingdom
| | - Christian Mallen
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Julie Ashworth
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Clare Jinks
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
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Lindberg HB, Steindal SA, Kvande ME. Critical care nurses' experiences of caring for patients with iatrogenic opioid withdrawal in the intensive care unit: A qualitative study. Intensive Crit Care Nurs 2023; 78:103452. [PMID: 37178587 DOI: 10.1016/j.iccn.2023.103452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To explore critical care nurses' experiences of caring for adult patients experiencing iatrogenic opioid withdrawal in the intensive care unit. RESEARCH METHODOLOGY/DESIGN A qualitative study with an explorative and descriptive design was conducted. Data were collected through semi-structured interviews and systematic text condensation was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research checklist. SETTING AND PARTICIPANTS Ten critical care nurses, working at three different intensive care units in two university hospitals in Norway. FINDINGS Three categories were identified in the data analysis. "Subtle signs and symptoms of opioid withdrawal", lack of a systematic approach to opioid withdrawal, and the prerequisites for appropriate management of opioid withdrawal. Critical care nurses experienced challenges in identifying opioid withdrawal due to subtle and vague signs and symptoms, especially when not knowing their patient or when difficulties were encountered with patient communication. A systematic approach to opioid withdrawal and increased knowledge, definitive plans for weaning, as well as interdisciplinary unity and collaboration, could improve the management of opioid withdrawal. CONCLUSION Validated assessment tools, systematic strategies, and guidelines are essential for the management of opioid withdrawal in opioid naïve patients in intensive care units. The prerequisites for an appropriate management of opioid withdrawal are an accurate and effective communication among critical care nurses and other healthcare professionals involved in patient care. IMPLICATIONS FOR CLINICAL PRACTICE There is a need for a validated assessment tool, systematic strategies, and guidelines for the management of opioid withdrawal in opioid naïve patients in intensive care units. Increased emphasis needs to be placed on the process of identifying iatrogenic opioid withdrawal and improving opioid withdrawal management in the education system and clinical practice.
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Affiliation(s)
- Hedda Bekken Lindberg
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.
| | - Simen A Steindal
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Faculty of Health Studies, VID Specialized University, Oslo, Norway.
| | - Monica Evelyn Kvande
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Anaesthesiology and Surgery, University Hospital of North Norway, Tromsø, Norway.
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Thakur D, Ravupalli S, Rao S, Ukey V, Pandit M, Aftab A. Efficacy of Fentanyl Transdermal Patch in Impacted Mandibular Third Molar Surgery-A Comparative Study. J Maxillofac Oral Surg 2023; 22:609-613. [PMID: 37534350 PMCID: PMC10390443 DOI: 10.1007/s12663-022-01820-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 11/06/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Removal of mandibular third molars surgically is one of the most frequently performed oral surgical procedures which are often accompanied with post-operative pain, swelling and trismus. Despite general progress in pain management, moderate to severe acute post-operative pain after removal of lower third molars remains a problem. Fentanyl is an extremely effective drug in the treatment of severe chronic pain such as cancer pain and post-operative pains which acts by increasing patient's tolerance to pain. Fentanyl Transdermal System (FTS) is a rectangular transdermal patch which contains high concentration of fentanyl, a potent short-acting Schedule II opiate. In this study the efficacy of transdermal fentanyl for management of post-operative pain after impacted mandibular 3rd molar surgery is evaluated. Methods 20 patients within the age group of 18-40 years with asymptomatic impacted mandibular third molars were equally divided into 2 groups as group A & group B which underwent surgery in Local Anaesthesia. In every patient one side belonged to group A and other side belonged to group B. 50 μg FTS was applied in group A while placebo patch was applied in group B. Results Patients in group A performed significantly better than group B in terms of mean pain intensity scores assessed by VAS and VRS along with minimum need of post-operative rescue analgesics. Conclusion It was found that FTS resulted in significantly better pain relief, longer pain-free intervals, and lesser post-operative analgesic consumption.
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Affiliation(s)
- Deepak Thakur
- Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhilai, India
| | - Shashikant Ravupalli
- Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhilai, India
| | - Sruthi Rao
- Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhilai, India
- V Y Institute of Medical Sciences, VY Hospital, Raipur, India
| | - Viplove Ukey
- Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhilai, India
| | - Manish Pandit
- Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhilai, India
| | - Aafreen Aftab
- Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhilai, India
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Larochelle MR, Jones CM, Zhang K. Change in opioid and buprenorphine prescribers and prescriptions by specialty, 2016-2021. Drug Alcohol Depend 2023; 248:109933. [PMID: 37267746 DOI: 10.1016/j.drugalcdep.2023.109933] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Safer opioid analgesic prescribing and increasing use of medications for opioid use disorder, including buprenorphine, are strategies prioritized to reduce opioid overdose deaths in the United States. Specialty-specific trends in the number of prescribers and prescriptions for opioid analgesics and buprenorphine are not well characterized. METHODS We used data from the IQVIA Longitudinal Prescription database for January 1, 2016 through December 31, 2021. We identified opioid and buprenorphine prescriptions based on NDC codes. We classified prescribers into one of 14 mutually exclusive specialty groups. We calculated the number of prescribers and number of prescriptions for opioids and buprenorphine by specialty and year. RESULTS From 2016 to 2021, the total number of opioid analgesic prescriptions dispensed decreased by 32% to 121,693,308 and the number of unique opioid analgesic prescribers decreased 7% to 966,369. Over the same time period, the number of buprenorphine prescriptions dispensed increased 36% to 13,909,724 and unique number of buprenorphine prescribers increased 86% to 59,090. Across most specialties we identified a contraction in the number of opioid prescriptions dispensed and opioid prescribers and an expansion in the number of buprenorphine prescriptions dispensed. Among high-volume opioid prescribing specialties, the largest decrease in opioid prescribers was 32% among Pain Medicine clinicians. By 2021, Advanced Practice Practitioners overtook Primary Care clinicians as the highest volume buprenorphine prescribers. CONCLUSIONS More work is needed to understand the impact of clinicians who stop prescribing opioids. While the trend in buprenorphine prescribing is encouraging, further expansion is warranted to meet the underlying need.
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Affiliation(s)
- Marc R Larochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.
| | - Christopher M Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kun Zhang
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Jones KF, Abdulhay LB, Orris SR, Merlin JS, Schenker Y, Bulls HW. The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness. J Pain Symptom Manage 2022; 64:89-99. [PMID: 35561937 DOI: 10.1016/j.jpainsymman.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness. OBJECTIVE To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness. METHODS Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea). RESULTS Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness. DISCUSSION The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing (K.F.J.), Boston College, Chestnut Hill, Massachusetts, USA.
| | - Lindsay Bell Abdulhay
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steve R Orris
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W Bulls
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Lavergne J, Debin M, Blanchon T, Colizza V, Dassieu L, Gimenez L, Kengne-Kuetche C, Lapeyre-Mestre M, Dupouy J. Perceived risk of opioid use disorder secondary to opioid analgesic medication use by the general population in France. Eur J Pain 2021; 26:729-739. [PMID: 34958720 DOI: 10.1002/ejp.1901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/15/2021] [Accepted: 12/19/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND In Europe and France, the use of opioid analgesic drugs has become widespread as an option for pain management. However, their use can lead to nonmedical use and/or opioid use disorder (OUD). This work aimed to assess the perceived risk of OUD secondary to opioid analgesic drugs use by the general population. METHODS We conducted a cross-sectional observational study using the GrippeNet web-based cohort, comprising about 10,000 French volunteers from the general population, using a self-administered questionnaire. The main outcome was the perceived risk of OUD secondary to opioid analgesic drugs use, assessed by a 4-item scale and modeled using logistic regression (backward procedure). RESULTS Among 5,046 French respondents, after adjustment, 65% believed that the use of analgesic drugs could likely or very likely lead to OUD. Factors associated with perception of a higher risk were being over 50 and having heard about opioids in the media. Previous opioid use and a high level of education decreased the perception of the risk. Among those having used opioids in the past two years (N = 1770), 71.1% reported being not at all concerned by this risk. The majority of the sample perceived the risk of OUD but those having already used opioid analgesics drugs expressed no concern about this risk for themselves. CONCLUSIONS This finding highlight the need to reinforce warning on the package insert documents, therapeutic education and collaborative care between the prescribing general practitioners and pharmacists to increase awareness of opioid medications users on the risk of OUD.
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Affiliation(s)
- Justine Lavergne
- Département Universitaire de Médecine Générale, Université de Toulouse; Faculté de Médecine, 133 route de Narbonne, 31063, Toulouse, France
| | - Marion Debin
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Thierry Blanchon
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Vittoria Colizza
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Lise Dassieu
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, 850 rue Saint Denis, Montréal, QC, H2X0A9, Canada
| | - Laetitia Gimenez
- Département Universitaire de Médecine Générale, Université de Toulouse; Faculté de Médecine, 133 route de Narbonne, 31063, Toulouse, France.,CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Charly Kengne-Kuetche
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Maryse Lapeyre-Mestre
- CEIP-Addictovigilance, CIC 1436, Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France
| | - Julie Dupouy
- Département Universitaire de Médecine Générale, Université de Toulouse; Faculté de Médecine, 133 route de Narbonne, 31063, Toulouse, France.,CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
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Hammer GB, Khanna AK, Michalsky C, Wase L, Demitrack MA, Little R, Fossler MJ, Ayad S. Oliceridine Exhibits Improved Tolerability Compared to Morphine at Equianalgesic Conditions: Exploratory Analysis from Two Phase 3 Randomized Placebo and Active Controlled Trials. Pain Ther 2021; 10:1343-53. [PMID: 34351590 DOI: 10.1007/s40122-021-00299-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/19/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION In the management of postoperative acute moderate-to-severe pain, opioids remain an important component. However, conventional opioids have a narrow therapeutic index and are associated with dose-limiting opioid-related adverse events (ORAEs) that can result in worse patient outcomes. Oliceridine, a new intravenous µ-opioid receptor agonist, is shown in nonclinical studies to be biased for G protein signaling (achieving analgesia) with limited recruitment of β-arrestin (associated with ORAEs). In two phase 3 randomized controlled studies of patients with moderate-to-severe acute pain following hard or soft tissue surgery, in which analgesia was measured using Sum of Pain Intensity Differences (SPID) from baseline over 48 and 24 h (SPID-48 and -24 respectively, oliceridine at demand doses of 0.1, 0.35, or 0.5 mg was highly effective compared to placebo, with a favorable safety profile compared to morphine. This exploratory analysis was conducted to determine whether the safety benefits seen with oliceridine persisted when adjusted for equal levels of analgesia compared to morphine. METHODS Presence of at least one treatment-emergent ORAE (based on Medical Dictionary for Regulatory Activities [MedDRA]-coded events: hypoxemia, nausea, vomiting, sedation, pruritus, or dizziness) was used as the composite safety endpoint. A logistic regression model was utilized to compare oliceridine (pooled regimens) versus morphine, after controlling for analgesia (using SPID-48 or SPID-24 with pre-rescue scores carried forward 6 h). This analysis excluded patients receiving placebo and was repeated for each study and for pooled data. RESULTS At a given level of SPID-48 or SPID-24, patients receiving oliceridine were less likely to experience the composite safety endpoint. Although not statistically significant at the 0.05 level in the soft tissue model, the odds ratio (OR) showed a consistent numerical trend for oliceridine, being approximately half that observed with morphine in both the hard (OR 0.499; 95% confidence interval [CI] 0.255, 0.976; p = 0.042) and soft (OR 0.542; 95% CI 0.250, 1.175; p = 0.121) tissue studies. Results from the pooled data were consistent with those observed in the individual studies (OR 0.507; 95% CI 0.304, 0.844; p = 0.009). CONCLUSION Findings from this exploratory analysis suggest that at comparable levels of analgesia, patients receiving oliceridine were less likely to experience the composite safety endpoint consisting of ORAEs compared to patients treated with morphine. Oliceridine Exhibits Improved Tolerability Compared to Morphine at Equianalgesic Conditions: Exploratory Analysis from Two Phase 3 Randomized Placebo and Active Controlled Trials- A Video (MP4 99188 kb).
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Voronkov M, Nikonov G, Naumov R, Abernethy J, Isakulyan L. NB-33, a bioreversible opioid derivative of Nalbuphine, shows enhanced pharmacodynamics. Eur J Pharm Sci 2021; 159:105734. [PMID: 33515698 DOI: 10.1016/j.ejps.2021.105734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 11/22/2022]
Abstract
Developing non-addictive and safer opioids for pain management is unmet medical need. Among a number of bioreversible derivatives of Nalbuphine - an equipotent to morphine opioid without serious side effects - NB-33 was identified in silico and confirmed in vivo as a superior analgesic agent. Apart from enhanced pharmacodynamics profile, NB-33 outperformed the parent compound on equimolar bases in cold ethanol tail-flick and mechanical models of pain in rats. With no β-arrestin engagement liability, good stability in simulated gastro-intestinal fluid and slow release of Nalbuphine by plasma NB-33 is being developed as an oral and safer alternative of its parent drug.
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Price-Haywood EG, Burton J, Harden-Barrios J, Bazzano A, Lefante J, Shi L, Jamison RN. Depression, anxiety, pain and chronic opioid management in primary care: Type II effectiveness-implementation hybrid stepped wedge cluster randomized trial. Contemp Clin Trials 2020; 101:106250. [PMID: 33326877 DOI: 10.1016/j.cct.2020.106250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/14/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022]
Abstract
Even though current prescribing trends reveal that high-dose opioid prescribing and opioid prescribing in general has decreased, sustained efforts are needed to help providers adopt and maintain safe prescribing behaviors. The purpose of this four-year type 2 effectiveness-implementation hybrid stepped wedge cluster randomized trial is to: (1) compare the clinical and cost effectiveness of electronic medical record-based clinical decision support [EMR-CDS] versus additional integrated, collaborative behavioral health [EMR-CDS + BHI-CCM] for opioid management of patients with co-morbid chronic non-cancer pain with depression or anxiety; and (2) examine facilitators and barriers to implementing these interventions within 35 primary care clinics in a integrated delivery health system. The EMR-CDS alerts providers to employ opioid risk mitigation and safe prescribing practices at the point of care. The BHI-CCM consists of primary care embedded community health workers for case management; licensed clinical social workers for cognitive behavioral therapy, and a clinical pharmacist for medication management who provide care management via telemedicine (virtual video or audio only visits) under the guidance of a consulting psychiatrist. The primary outcome is reduction in the percentage of patients with average daily opioid dose ≥50 mg morphine equivalent. Secondary outcomes include changes in service utilization, patient reported outcomes and processes of care. The investigators anticipate that study results will elucidate the role of technology versus care team optimization in changing opioid prescribing behaviors. The investigators further anticipate that integrated mental/behavioral health care will increase value-based care and the efficiency with which guideline concordant care is delivered.
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Affiliation(s)
- Eboni G Price-Haywood
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Jeffrey Burton
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Jewel Harden-Barrios
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Alessandra Bazzano
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - John Lefante
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Lizheng Shi
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Robert N Jamison
- Brigham and Women's Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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Beard TL, Michalsky C, Candiotti KA, Rider P, Wase L, Habib AS, Demitrack MA, Fossler MJ, Viscusi ER. Oliceridine is Associated with Reduced Risk of Vomiting and Need for Rescue Antiemetics Compared to Morphine: Exploratory Analysis from Two Phase 3 Randomized Placebo and Active Controlled Trials. Pain Ther 2020; 10:401-413. [PMID: 33210266 PMCID: PMC8119517 DOI: 10.1007/s40122-020-00216-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/28/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Use of parenteral opioids is a major risk factor for postoperative nausea and vomiting. Conventional opioids bind to µ-opioid receptors (MOR), stimulate both the G-protein signaling (achieving analgesia); and the β-arrestin pathway (associated with opioid-related adverse effects). Oliceridine, a next-generation IV opioid, is a G-protein selective MOR agonist, with limited recruitment of β-arrestin. In two randomized, placebo- and morphine-controlled phase 3 studies of patients with moderate-to-severe acute pain following bunionectomy or abdominoplasty, oliceridine at demand doses of 0.1, 0.35, and 0.5 mg provided rapid and sustained analgesia vs. placebo with favorable gastrointestinal (GI) tolerability. In this exploratory analysis, we utilized a clinical endpoint assessing gastrointestinal tolerability, "complete GI response" defined as the proportion of patients with no vomiting and no use of rescue antiemetic to characterize the GI tolerability profile of oliceridine vs. morphine. METHODS A logistic regression model was utilized to compare oliceridine (pooled regimens) vs. morphine, after controlling for analgesia (using the sum of pain intensity difference [SPID]-48/24 [bunionectomy/abdominoplasty] with pre-rescue scores carried forward for 6 h). This analysis excluded patients receiving placebo and was performed for each study separately and for pooled data from both studies. RESULTS In the unadjusted analysis, a significantly greater proportion of patients in the placebo (76.4%), oliceridine 0.1 mg (68.0%), and 0.35 mg (46.2%) demand dose achieved complete GI response vs. morphine 1 mg (30.8%), p ≤ 0.005. In the adjusted analysis, after controlling for analgesia, the odds ratio of experiencing a complete GI response with oliceridine (pooled regimens) vs. morphine was 3.14 (95% CI: 1.78, 5.56; p < 0.0001) in bunionectomy study and 1.92 (95% CI: 1.09, 3.36; p = 0.024) in abdominoplasty study. CONCLUSIONS When controlled for the analgesic effects (constant SPID-48/24), the odds ratio for complete GI response was higher with oliceridine than morphine, suggesting better GI tolerability with oliceridine.
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Affiliation(s)
- Timothy L Beard
- Department of Surgery and Clinical Research, Summit Medical Group, Bend Memorial Clinic, Bend, OR, USA.
| | | | - Keith A Candiotti
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Paul Rider
- Department of Surgery, University of South Alabama Medical Center, Mobile, AL, USA
| | | | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | | | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Ghimire A, Subedi A, Bhattarai B, Sah BP. The effect of intraoperative lidocaine infusion on opioid consumption and pain after totally extraperitoneal laparoscopic inguinal hernioplasty: a randomized controlled trial. BMC Anesthesiol 2020; 20:137. [PMID: 32493276 PMCID: PMC7268281 DOI: 10.1186/s12871-020-01054-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND As a component of multimodal analgesia, the administration of systemic lidocaine is a well-known technique. We aimed to evaluate the efficacy of lidocaine infusion on postoperative pain-related outcomes in patients undergoing totally extraperitoneal (TEP) laparoscopies inguinal hernioplasty. METHODS In this randomized controlled double-blind study, we recruited 64 patients to receive either lidocaine 2% (intravenous bolus 1.5 mg. kg - 1 followed by an infusion of 2 mg. kg- 1. h- 1), or an equal volume of normal saline. The infusion was initiated just before the induction of anesthesia and discontinued after tracheal extubation. The primary outcome of the study was postoperative morphine equivalent consumption up to 24 h after surgery. Secondary outcomes included postoperative pain scores, nausea/vomiting (PONV), sedation, quality of recovery (scores based on QoR-40 questionnaire), patient satisfaction, and the incidence of chronic pain. RESULTS The median (IQR) cumulative postoperative morphine equivalent consumption in the first 24 h was 0 (0-1) mg in the lidocaine group and 4 [1-8] mg in the saline group (p < 0.001). Postoperative pain intensity at rest and during movement at various time points in the first 24 h were significantly lower in the lidocaine group compared with the saline group (p < 0.05). Fewer patients reported PONV in the lidocaine group than in the saline group (p < 0.05). Median QoR scores at 24 h after surgery were significantly better in the lidocaine group (194 (194-196) than saline group 184 (183-186) (p < 0.001). Patients receiving lidocaine were more satisfied with postoperative analgesia than those receiving saline (p = 0.02). No difference was detected in terms of postoperative sedation and chronic pain after surgery. CONCLUSIONS Intraoperative lidocaine infusion for laparoscopic TEP inguinal hernioplasty reduces opioid consumption, pain intensity, PONV and improves the quality of recovery and patient satisfaction. TRIAL REGISTRATION ClinicalTrials.gov- NCT02601651. Date of registration: November 10, 2015.
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Affiliation(s)
- Anup Ghimire
- Department of Anesthesiology, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Asish Subedi
- Department of Anesthesiology & Critical Care Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Balkrishna Bhattarai
- Department of Anesthesiology & Critical Care Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Birendra Prasad Sah
- Department of Anesthesiology & Critical Care Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
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Sung HG, Li J, Nam JH, Won DY, Choi B, Shin JY. Concurrent use of benzodiazepines, antidepressants, and opioid analgesics with zolpidem and risk for suicide: a case-control and case-crossover study. Soc Psychiatry Psychiatr Epidemiol 2019; 54:1535-1544. [PMID: 31037540 DOI: 10.1007/s00127-019-01713-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 04/19/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate whether the concurrent use of benzodiazepines, antidepressants, and opioid analgesics with zolpidem increases the risk of suicide or triggers suicide compared with the use of zolpidem alone. METHODS We conducted a case-control and case-crossover study using the Korean National Health Insurance Service-National Sample Cohort database. Cases were older than 20 years with a suicide record (International Codes of Disease 10th Revision codes: X-60-X84 and Y87.0 intentional self-harm) between January 1, 2004, and December 31, 2013. For case-control design, ten controls were matched to each case by age, sex, index year, region, income, and health insurance type. For case-crossover analysis, we set hazard period to 60 days and assigned five corresponding sets of control periods of equal length. Exposure was assessed during 60 days before suicide for combinations of benzodiazepines, antidepressants, opioid analgesics with zolpidem against zolpidem alone. We conducted a conditional logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals (CIs). RESULTS In the case-control study, the risk of suicide was 2.80-fold higher in cases taking benzodiazepines and antidepressants with zolpidem than in those taking zolpidem alone (adjusted OR [aOR], 2.80; 95% CI, 1.38-5.70). However, in the case-crossover study, suicide risk showed no significant difference (crude OR [cOR], 0.92; 95% CI, 0.55-1.52) and was underpowered. CONCLUSIONS The results of the traditional case-control study confirmed that the concurrent use of benzodiazepines and antidepressants with zolpidem was associated with an increased risk of suicide compared with the use of zolpidem alone. However, there was no significant difference in the magnitude of risk in the within-person comparison design.
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Affiliation(s)
- Hi Gin Sung
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon, Gyeong gi-do, South Korea
| | - Junquing Li
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon, Gyeong gi-do, South Korea
| | - Jin Hyun Nam
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon, Gyeong gi-do, South Korea
| | - Dae Yeon Won
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon, Gyeong gi-do, South Korea
| | - BongKyoo Choi
- Department of Medicine and Program in Public Heath, University of California, Irvine, CA, USA
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, 2066 Seobu-ro, Jangan-gu, Suwon, Gyeong gi-do, South Korea.
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Tuazon E, Kunins HV, Allen B, Paone D. Examining opioid-involved overdose mortality trends prior to fentanyl: New York City, 2000-2015. Drug Alcohol Depend 2019; 205:107614. [PMID: 31689642 DOI: 10.1016/j.drugalcdep.2019.107614] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/23/2019] [Accepted: 08/27/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rates of overdose death in New York City (NYC) increased 26% from 2000 to 2015, with a notable decrease in rate from 2006 to 2010. Beginning in 2016, the synthetic opioid fentanyl entered the NYC illicit drug market and has been associated with large increases in overdose death. This study assessed NYC trends in opioid-involved overdose death prior to fentanyl to understand the contribution of specific opioids and inform overdose prevention strategies. METHODS Data were derived from death certificates linked to postmortem toxicology testing. We stratified cases into three mutually exclusive groups: (1) heroin without opioid analgesics (OAs); (2) OAs without heroin; and (3) the combination of heroin and OAs. We calculated mortality rates by year, and compared rates by the demographic characteristics age, sex, and race/ethnicity. Joinpoint regression identified junctures in trends between 2000 and 2015. RESULTS Rates of overdose death involving heroin without OAs decreased from 2006 to 2010, then increased from 2010 to 2015 among males, persons age 15 to 54, and Blacks and Whites. Rates of overdose death involving OAs with and without heroin increased from 2000 to 2015 across all demographic subgroups. CONCLUSIONS The identified trends in overdose death are suggestive of demographic shifts in drug use. In particular, the tamper-resistant reformulation of oxycodone 80 mg may have increased the use of heroin among primary OA users. Notably, older adults may have had established heroin use practices prior to the proliferation of OAs and thus may have been less likely to modify drug use practices.
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Affiliation(s)
- Ellenie Tuazon
- Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street, 19th Floor, Queens, NY 11101, United States.
| | - Hillary V Kunins
- Division of Mental Hygiene, New York City Department of Health and Mental Hygiene, 42-09 28th Street, 19th Floor, Queens, NY 11101, United States.
| | - Bennett Allen
- Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street, 19th Floor, Queens, NY 11101, United States.
| | - Denise Paone
- Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street, 19th Floor, Queens, NY 11101, United States.
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Liang RJ, Lai YH, Kao YT, Yang TH, Chen YL, Wang HJ. A novel finding of nalbuphine-6-glucuronide, an active opiate metabolite, possessing potent antinociceptive effects: Synthesis and biological evaluation. Eur J Med Chem 2019; 178:544-551. [PMID: 31212133 DOI: 10.1016/j.ejmech.2019.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/22/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
Nalbuphine, a partial agonist/antagonist opioid analgesic, is structurally related to morphine. It is equipotent to morphine and has no serious side effects. In the past few decades, studies focusing on morphine metabolism have indicated that one of its sugar-conjugated metabolites, morphine-6-glucuronide, exerts a higher analgesic effect than its parent drug. Considering that nalbuphine is a morphine analog that follows a similar metabolic scheme, nalbuphine glucuronides were synthesized in this study and their potential analgesic effects were assessed. Nalbuphine-3-glucuronide (N3G) and nalbuphine-6-glucuronide (N6G) were synthesized based on Schmidt's glycosylation with OPiv protections on the glycosyl donor. In a pharmacodynamic study, paw pressure and cold-ethanol tail-flick tests were conducted in rats to evaluate the analgesic response after intracisternal and intraperitoneal administrations of nalbuphine, N3G, or N6G. The antinociceptive response was evaluated for each compound by calculating the area under the curve and the duration spent at greater than 50% maximum possible analgesia. In conclusion, intracisternal administration of N6G exhibited a stronger analgesic response than nalbuphine in the pain tests after both cold and mechanical stimuli, but N3G had no obvious effect. Similar to that of morphine, the glucuronide metabolite of nalbuphine at the 6-O-position exerted at least three-fold higher antinociceptive potency and five-fold longer analgesic duration than nalbuphine.
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Affiliation(s)
- Ren-Jong Liang
- Medical Supplies and Maintenance, Hualien Armed Forces General Hospital, Hualien, Taiwan, ROC
| | - Yen-Hsun Lai
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Yu-Ting Kao
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ting-Hsuan Yang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yen-Lun Chen
- Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Hong-Jaan Wang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC; Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan, ROC.
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15
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Ali MM, Tehrani AB, Mutter R, Henke RM, O'Brien M, Pines JM, Mazer-Amirshahi M. Potentially Problematic Opioid Prescriptions Among Individuals With Private Insurance and Medicaid. Psychiatr Serv 2019; 70:681-688. [PMID: 31056003 DOI: 10.1176/appi.ps.201800555] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Opioid analgesics can be safe and effective when used properly. Reducing prescriptions that increase adverse outcomes is a focus for addressing the opioid crisis. In this study, the rate of potentially problematic opioid prescriptions was examined over 11 years in a large sample of U.S. patients. METHODS Claims from the IBM MarketScan commercial database (about 45 million) and multistate Medicaid database (about 7 million) from 2005 to 2015 were used to calculate rates of the following potentially problematic prescription practices: prescriptions for high-dose opioids for 90 days or more, prescriptions from multiple providers, prescriptions of long-acting or extended-release opioids for acute pain, overlap between prescriptions for opioids, and overlap between prescriptions for opioids and benzodiazepines. RESULTS Among patients with an opioid prescription, about 8% of those with private insurance and about 14% of those with Medicaid coverage had at least two incidents of potentially problematic prescriptions per year. Over the study period, rates increased for some practices (opioid-benzodiazepine overlap) and decreased for others (prescriptions from multiple providers). Receipt of potentially problematic prescriptions was higher among older patients, female patients with private insurance, and whites and male patients covered by Medicaid. CONCLUSIONS A significant percentage of patients who are prescribed opioids experience problematic prescription practices. Targeted policy and clinical interventions that reduce potentially problematic prescription could be a focus for addressing the U.S. opioid crisis.
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Affiliation(s)
- Mir M Ali
- Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (DHHS), Washington, D.C. (Ali); Real World Analytics and Alliances, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey (Tehrani); Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office (CBO), Washington, D.C. (Mutter); IBM Watson Health, Cambridge, Massachusetts (Henke, O'Brien); U.S. Acute Care Solutions, Canton, Ohio (Pines); MedStar Washington Hospital Center, Washington, D.C. (Mazer-Amirshahi)
| | - Ali B Tehrani
- Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (DHHS), Washington, D.C. (Ali); Real World Analytics and Alliances, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey (Tehrani); Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office (CBO), Washington, D.C. (Mutter); IBM Watson Health, Cambridge, Massachusetts (Henke, O'Brien); U.S. Acute Care Solutions, Canton, Ohio (Pines); MedStar Washington Hospital Center, Washington, D.C. (Mazer-Amirshahi)
| | - Ryan Mutter
- Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (DHHS), Washington, D.C. (Ali); Real World Analytics and Alliances, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey (Tehrani); Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office (CBO), Washington, D.C. (Mutter); IBM Watson Health, Cambridge, Massachusetts (Henke, O'Brien); U.S. Acute Care Solutions, Canton, Ohio (Pines); MedStar Washington Hospital Center, Washington, D.C. (Mazer-Amirshahi)
| | - Rachel Mosher Henke
- Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (DHHS), Washington, D.C. (Ali); Real World Analytics and Alliances, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey (Tehrani); Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office (CBO), Washington, D.C. (Mutter); IBM Watson Health, Cambridge, Massachusetts (Henke, O'Brien); U.S. Acute Care Solutions, Canton, Ohio (Pines); MedStar Washington Hospital Center, Washington, D.C. (Mazer-Amirshahi)
| | - Margaret O'Brien
- Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (DHHS), Washington, D.C. (Ali); Real World Analytics and Alliances, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey (Tehrani); Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office (CBO), Washington, D.C. (Mutter); IBM Watson Health, Cambridge, Massachusetts (Henke, O'Brien); U.S. Acute Care Solutions, Canton, Ohio (Pines); MedStar Washington Hospital Center, Washington, D.C. (Mazer-Amirshahi)
| | - Jesse M Pines
- Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (DHHS), Washington, D.C. (Ali); Real World Analytics and Alliances, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey (Tehrani); Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office (CBO), Washington, D.C. (Mutter); IBM Watson Health, Cambridge, Massachusetts (Henke, O'Brien); U.S. Acute Care Solutions, Canton, Ohio (Pines); MedStar Washington Hospital Center, Washington, D.C. (Mazer-Amirshahi)
| | - Maryann Mazer-Amirshahi
- Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (DHHS), Washington, D.C. (Ali); Real World Analytics and Alliances, Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey (Tehrani); Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office (CBO), Washington, D.C. (Mutter); IBM Watson Health, Cambridge, Massachusetts (Henke, O'Brien); U.S. Acute Care Solutions, Canton, Ohio (Pines); MedStar Washington Hospital Center, Washington, D.C. (Mazer-Amirshahi)
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Holgado D, Zandonai T, Zabala M, Hopker J, Perakakis P, Luque-Casado A, Ciria L, Guerra-Hernandez E, Sanabria D. Tramadol effects on physical performance and sustained attention during a 20-min indoor cycling time-trial: A randomised controlled trial. J Sci Med Sport 2017; 21:654-660. [PMID: 29128419 DOI: 10.1016/j.jsams.2017.10.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/19/2017] [Accepted: 10/31/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the effect of tramadol on performance during a 20-min cycling time-trial (Experiment 1), and to test whether sustained attention would be impaired during cycling after tramadol intake (Experiment 2). DESIGN Randomized, double-blind, placebo controlled trial. METHODS In Experiment 1, participants completed a cycling time-trial, 120-min after they ingested either tramadol or placebo. In Experiment 2, participants performed a visual oddball task during the time-trial. Electroencephalography measures (EEG) were recorded throughout the session. RESULTS In Experiment 1, average time-trial power output was higher in the tramadol vs. placebo condition (tramadol: 220W vs. placebo: 209W; p<0.01). In Experiment 2, no differences between conditions were observed in the average power output (tramadol: 234W vs. placebo: 230W; p>0.05). No behavioural differences were found between conditions in the oddball task. Crucially, the time frequency analysis in Experiment 2 revealed an overall lower target-locked power in the beta-band (p<0.01), and higher alpha suppression (p<0.01) in the tramadol vs. placebo condition. At baseline, EEG power spectrum was higher under tramadol than under placebo in Experiment 1 while the reverse was true for Experiment 2. CONCLUSIONS Tramadol improved cycling power output in Experiment 1, but not in Experiment 2, which may be due to the simultaneous performance of a cognitive task. Interestingly enough, the EEG data in Experiment 2 pointed to an impact of tramadol on stimulus processing related to sustained attention. TRIAL REGISTRATION EudraCT number: 2015-005056-96.
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Affiliation(s)
- Darías Holgado
- Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, Spain; Mind, Brain, and Behaviour Research Centre, University of Granada, Spain.
| | - Thomas Zandonai
- Mind, Brain, and Behaviour Research Centre, University of Granada, Spain; Department of Experimental Psychology, Faculty of Psychology, University of Granada, Spain
| | - Mikel Zabala
- Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, Spain
| | - James Hopker
- Endurance Research Group, School of Sport and Exercise Sciences, University of Kent, UK
| | - Pandelis Perakakis
- Mind, Brain, and Behaviour Research Centre, University of Granada, Spain; Universidad Loyola Andalucía, Departamento de Psicología, Campus de Palmas Altas, Sevilla, España
| | - Antonio Luque-Casado
- Mind, Brain, and Behaviour Research Centre, University of Granada, Spain; Department of Physical Activity and Sport, "San Isidoro" University Center (Pablo de Olavide University), Spain
| | - Luis Ciria
- Mind, Brain, and Behaviour Research Centre, University of Granada, Spain; Department of Experimental Psychology, Faculty of Psychology, University of Granada, Spain
| | | | - Daniel Sanabria
- Mind, Brain, and Behaviour Research Centre, University of Granada, Spain; Department of Experimental Psychology, Faculty of Psychology, University of Granada, Spain.
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Mathieson S, Valenti L, Maher CG, Britt H, Li Q, McLachlan AJ, Lin CWC. Worsening trends in analgesics recommended for spinal pain in primary care. Eur Spine J 2017. [PMID: 28639074 DOI: 10.1007/s00586-017-5178-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE Limited evidence exists on secular trends of analgesics for spinal pain. We investigated general practitioner's (GP) recommendations of analgesic medicines for spinal pain and investigated characteristics associated with their recommendation. METHODS We accessed data on spinal pain consultations from the Bettering the Evaluation and Care of Health (BEACH) database, a nationally representative database on GP activity in Australia. Data extracted included consultation details and management provided. Medicines recommended were grouped as simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics or neuropathic pain medicines. Multivariate logistic regression determined if patient characteristics and GP characteristics were associated with medication recommendations. RESULTS We analysed BEACH data for 9100 GPs who managed 39,303 patients with spinal pain between 2004 and 2014. Over the decade, analgesic recommendations increased. After accounting for patient and GP characteristics, there was a significant increase in the rate single-ingredient opioid analgesics [annual relative increase of 6% (RR 1.06 (95% CI 1.05-1.07), P < 0.001)] and neuropathic pain medicines [annual relative increase of 19% (RR 1.19 (95% CI 1.16-1.22), P < 0.001)] were recommended; and a significant decrease in the rate NSAIDs were recommended [annual relative decrease of 4% (RR 0.96 (95% CI 0.95-0.97), P < 0.001)]. Logistic regression identified several patient and GP characteristics associated with medicine recommendations, e.g. stronger opioids were less likely recommended for Indigenous patients [odds ratio 0.15 (95% CI 0.04-0.56)]. CONCLUSIONS GP's analgesic recommendations for spinal pain have become increasingly divergent from guideline recommendations over time.
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Affiliation(s)
- Stephanie Mathieson
- Musculoskeletal Health Sydney, School of Public Health, Sydney Medical School, University of Sydney, Sydney, 2050, Australia.
| | - Lisa Valenti
- Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, 2000, Australia
| | - Christopher G Maher
- Musculoskeletal Health Sydney, School of Public Health, Sydney Medical School, University of Sydney, Sydney, 2050, Australia
| | - Helena Britt
- Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, 2000, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy and Centre for Education and Research on Ageing, The University of Sydney and Concord Hospital, Sydney, NSW, 2006, Australia
| | - Chung-Wei Christine Lin
- Musculoskeletal Health Sydney, School of Public Health, Sydney Medical School, University of Sydney, Sydney, 2050, Australia
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Hogan WR, Hanna J, Hicks A, Amirova S, Bramblett B, Diller M, Enderez R, Modzelewski T, Vasconcelos M, Delcher C. Therapeutic indications and other use-case-driven updates in the drug ontology: anti-malarials, anti-hypertensives, opioid analgesics, and a large term request. J Biomed Semantics 2017; 8:10. [PMID: 28253937 PMCID: PMC5335794 DOI: 10.1186/s13326-017-0121-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/24/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The Drug Ontology (DrOn) is an OWL2-based representation of drug products and their ingredients, mechanisms of action, strengths, and dose forms. We originally created DrOn for use cases in comparative effectiveness research, primarily to identify historically complete sets of United States National Drug Codes (NDCs) that represent packaged drug products, by the ingredient(s), mechanism(s) of action, and so on contained in those products. Although we had designed DrOn from the outset to carefully distinguish those entities that have a therapeutic indication from those entities that have a molecular mechanism of action, we had not previously represented in DrOn any particular therapeutic indication. RESULTS In this work, we add therapeutic indications for three research use cases: resistant hypertension, malaria, and opioid abuse research. We also added mechanisms of action for opioid analgesics and added 108 classes representing drug products in response to a large term request from the Program for Resistance, Immunology, Surveillance and Modeling of Malaria in Uganda (PRISM) project. The net result is a new version of DrOn, current to May 2016, that represents three major therapeutic classes of drugs and six new mechanisms of action. CONCLUSIONS A therapeutic indication of a drug product is represented as a therapeutic function in DrOn. Adverse effects of drug products, as well as other therapeutic uses for which the drug product was not designed are dispositions. Our work provides a framework for representing additional therapeutic indications, adverse effects, and uses of drug products beyond their design. Our work also validated our past modeling decisions for specific types of mechanisms of action, namely effects mediated via receptor and/or enzyme binding. DrOn is available at: http://purl.obolibrary.org/obo/dron.owl . A smaller version without NDCs is available at: http://purl.obolibrary.org/obo/dron/dron-lite.owl.
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Affiliation(s)
- William R. Hogan
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Josh Hanna
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Amanda Hicks
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Samira Amirova
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Baxter Bramblett
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Matthew Diller
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Rodel Enderez
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Timothy Modzelewski
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Mirela Vasconcelos
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
| | - Chris Delcher
- Department of Health Outcomes and Policy, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, P.O. Box 100219, Gainesville, FL 32610 USA
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Maughan BC, Hersh EV, Shofer FS, Wanner KJ, Archer E, Carrasco LR, Rhodes KV. Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug Alcohol Depend 2016; 168:328-334. [PMID: 27663358 DOI: 10.1016/j.drugalcdep.2016.08.016] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/11/2016] [Accepted: 08/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Individuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal. METHODS We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fisher's exact p=0.11). CONCLUSION Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery.
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Affiliation(s)
- Brandon C Maughan
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Elliot V Hersh
- Departments of Oral & Maxillofacial Surgery and Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia PA, USA.
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Kathryn J Wanner
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Elizabeth Archer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Lee R Carrasco
- Departments of Oral & Maxillofacial Surgery and Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia PA, USA.
| | - Karin V Rhodes
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Tanco K, Bruera SE, Bruera E. Insurance company denial of payment and enforced changes in the type and dose of opioid analgesics for patients with cancer pain. Palliat Support Care 2014; 12:515-8. [PMID: 26223704 DOI: 10.1017/S1478951514000091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Opioids are the mainstay of treatment for moderate to severe cancer pain. The variations in average monthly cost can make it difficult for most patients to procure them without adequate insurance coverage. There are increasing numbers of denials of payment and statements made by insurance agents and other sources regarding inappropriate opioid use, resulting in severe pain and emotional distress for cancer patients and their families. This case series describes five events where the insurer was a major barrier to opioid access.
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Ohishi A, Chisaki Y, Hira D, Nagasawa K, Terada T. Opioid analgesics increase incidence of somnolence and dizziness as adverse effects of pregabalin: a retrospective study. J Pharm Health Care Sci 2015; 1:30. [PMID: 26819741 PMCID: PMC4729150 DOI: 10.1186/s40780-015-0032-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 10/29/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pregabalin, a gabapentinoid, is an adjuvant analgesic for treatment of neuropathic pain, but it has serious adverse effects such as somnolence and dizziness, particularly in elderly patients. Although decreased renal function is considered to the contributing factor for high frequency of these adverse effects in elder patients, only a few systematic clinical investigations, especially for hospitalized patients, have been performed on factors that might affect the incidence of its adverse effects. In this study, we performed a retrospective study on the effect of concomitant drugs on induction of somnolence and dizziness as adverse effects of pregabalin in hospitalized patients. METHODS The subjects were all pregabalin-administered patients in Shiga University of Medical Science Hospital from September 2010 to September 2012, and the subject number was 195. Multivariate logistic regression analysis was performed to determine predictors of the adverse effects, creatinine clearance, duration of pregabalin therapy, initial and maintenance doses of pregabalin, and concomitant drugs, including hypoglycemic drugs, anti-hypertensive ones, non-steroidal anti-inflammatory ones, opioids and central nervous system depressants, being used as independent variables. RESULTS The median initial doses of pregabalin in each renal function group were the same with the case of the defined dose. Although renal function is a well-known factor for prediction of development of adverse effects of pregabalin, we did not detect significant contribution of it. Alternatively, it was demonstrated that concomitant administration of opioids was the significant factor of the incidence of somnolence and dizziness. The first onset date of the adverse effects was frequently detected in the early days of the pregabalin therapy. CONCLUSIONS The fine tuning of pregabalin dosage schedule based on the renal function appeared to be critical for prevention of development of its adverse effects. Adverse effects tended to develop in the initial phase of pregabalin therapy. Concomitant administration of opioids with pregabalin has the potential to increase the incidence of adverse effects, and thus much more careful attention has to be paid especially in those situations.
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Affiliation(s)
- Akihiro Ohishi
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga 520-2192 Japan ; Department of Environmental Biochemistry, Kyoto Pharmaceutical University, 5 Nakauchi-cho, Misasagi, Yamashina-ku, Kyoto, 607-8414 Japan
| | - Yugo Chisaki
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga 520-2192 Japan ; Education and Research Center for Clinical Pharmacy, Kyoto Pharmaceutical University, 5 Nakauchi-cho, Misasagi, Yamashina-ku, Kyoto, 607-8414 Japan
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga 520-2192 Japan
| | - Kazuki Nagasawa
- Department of Environmental Biochemistry, Kyoto Pharmaceutical University, 5 Nakauchi-cho, Misasagi, Yamashina-ku, Kyoto, 607-8414 Japan
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga 520-2192 Japan
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Koopmans G, Simpson K, De Andrés J, Lux EA, Wagemans M, Van Megen Y. Fixed ratio (2:1) prolonged-release oxycodone/naloxone combination improves bowel function in patients with moderate-to-severe pain and opioid-induced constipation refractory to at least two classes of laxatives. Curr Med Res Opin 2014; 30:2389-96. [PMID: 25265132 DOI: 10.1185/03007995.2014.971355] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The effects of combined oxycodone/naloxone prolonged release tablets (OXN PR) were investigated in patients with moderate-to-severe chronic cancer-related or non-cancer pain. All patients had opioid-induced constipation (OIC) which persisted despite substantial laxative therapy. RESEARCH DESIGN AND METHODS This pooled analysis included 75 patients with OIC at study entry that was refractory to at least two laxatives with different modes of action. Patients completed randomized, double-blind treatment with OXN PR 20-120 mg/day for either 12 weeks (OXN 9001: non-cancer pain study) or 4 weeks (OXN 2001: cancer-related pain study). Analgesia and bowel function were assessed using the Brief Pain Inventory Short Form and Bowel Function Index (BFI), respectively. Use of laxative medication and safety were assessed throughout the studies. CLINICAL TRIAL REGISTRATION NCT00513656, EudraCT 2005-002398-57, EudraCT 2005-003510-15. RESULTS Statistically and clinically significant improvements in bowel function were observed following double-blind treatment with OXN PR. Mean (SD) reduction in BFI score was 21.2 (28.8) and comparable in patients with cancer-related (19.0 [28.9]) and non-cancer pain (23.3.[29.0]; P ≤ 0.0002). Furthermore, the proportion of patients with a BFI score within normal range (≤28.8) increased from 9.5% at screening to 43.1% at Day 15 of OXN PR. While all patients used ≥2 laxatives of different classes at screening, during study treatment 36% stopped using laxatives (P < 0.001). OXN PR provided effective analgesia, evidenced by stable pain scores during study treatment, and there were no unanticipated adverse events. CONCLUSIONS OXN PR significantly improved bowel function and reduced the use of laxatives in patients with OIC, previously unresponsive to at least two different classes of laxatives. OXN also provided effective analgesia for patients with moderate-to-severe cancer-related pain and non-cancer-related pain.
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Affiliation(s)
- Gineke Koopmans
- Mundipharma Pharmaceuticals BV, Medical Department , Hoevelaken , The Netherlands
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Alexander L, Mannion RO, Weingarten B, Fanelli RJ, Stiles GL. Development and impact of prescription opioid abuse deterrent formulation technologies. Drug Alcohol Depend 2014; 138:1-6. [PMID: 24613631 DOI: 10.1016/j.drugalcdep.2014.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/03/2014] [Accepted: 02/03/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Millions of patients are treated with opioid analgesics (OpAs) to relieve pain. Unfortunately, these medications are subject to abuse and/or unintended misuse. Abuse deterrent formulations (ADFs) represent an intervention strategy to decrease abuse/misuse without affecting patient access. The Food and Drug Administration (FDA) has issued Draft Guidance "Abuse deterrent opioids, Evaluation and Labeling" and is currently actively pursuing scientific input on this issue. METHODS The development of ADF technologies was reviewed using peer reviewed journals describing OpA post marketing studies, web sites containing FDA announcements on product approvals and manufacturer product use profiles. RESULTS Reviewed is the FDA recent approval of a product label describing the abuse deterrent characteristics of OxyContin(®) (physical barrier formulation), and the FDA determination that studies were insufficient for an Opana(®) (physical barrier) ADF label. Additional reviewed marketed OpAs with ADF technologies include: Suboxone(®) and Embeda(®) (opioid agonist/antagonist combinations), Oxecta(®) (aversion technology), and Nucynta(®) (physical barrier). Reviewed ADF technologies currently in development include: new physical barrier and aversion technologies, an innovative extended release formulation as well as novel polymer-opioid conjugates. As ADF technologies are part of a comprehensive intervention strategy to promote safe OpA use, additional components including governmental, community, and educational initiatives are reviewed. CONCLUSIONS The outcomes of the recent ADF labeling applications for OxyContin(®) (Tier 3 approval) and Opana(®) (non-approval) suggest that the threshold for ADF labeling will be appropriately high. The presented findings indicate that ADF technologies can be a critical component of a comprehensive strategy to promote the safe and effective use of OpAs.
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Affiliation(s)
- Louis Alexander
- Department of Risk Management and Epidemiology, Purdue Pharma L.P., United States
| | | | | | | | - Gary L Stiles
- Research and Development, Purdue Pharma L.P., United States
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Bruehl S, Burns JW, Gupta R, Buvanendran A, Chont M, Kinner E, Schuster E, Passik S, France CR. Endogenous opioid function mediates the association between laboratory-evoked pain sensitivity and morphine analgesic responses. Pain 2013; 154:1856-64. [PMID: 23748117 DOI: 10.1016/j.pain.2013.06.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/21/2013] [Accepted: 06/03/2013] [Indexed: 01/12/2023]
Abstract
Predictors of responsiveness to opioid analgesic medications are not well understood. This study tested whether individual differences in endogenous opioid (EO) function are associated with analgesic responsiveness to morphine. In randomized, counterbalanced order over 3 sessions, 45 chronic low back pain participants and 31 healthy controls received an opioid antagonist (8 mg naloxone), morphine (0.08 mg/kg), or placebo. Participants then engaged in 2 laboratory-evoked pain tasks (ischemic and thermal). Outcomes included pain threshold, pain tolerance, and pain ratings. Indexes of EO function and morphine analgesic responsiveness were derived for each measure as the difference in pain responses between the placebo condition and naloxone or morphine condition, respectively. For all 7 pain measures across the 2 laboratory pain tasks, greater EO function was associated with significantly lower morphine analgesic responsiveness (P<0.001-P=0.02). Morphine reduced pain responses of low EO individuals to levels similar to those of high EO individuals receiving placebo. Higher placebo condition-evoked pain sensitivity was associated with significantly greater morphine analgesic responsiveness for 5 of 7 pain measures (P<0.001-P=0.02). These latter associations were significantly mediated by EO function for 4 of these 5 pain outcomes (all P values<0.05). In the laboratory-evoked pain context, opioid analgesic medications may supplement inadequate EO analgesia, with little incremental benefit in those with preexisting high EO function. Implications for personalized medicine are discussed.
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