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Tsuno T, Kawaguchi T, Yanaizumi R, Kondo J, Kojima K, Igarashi T, Inoue M, Miura T, Miyasato A, Azuma K, Hamada H, Saeki T, Mawatari H, Ogura H, Kotani A, Yamaguchi T, Hakamata H. Psychological Barriers to the Use of Opioid Analgesics for Treating Pain in Patients With Advanced Recurrent Cancer: A Multicenter Cohort Study. Palliat Med Rep 2024; 5:43-52. [PMID: 38249830 PMCID: PMC10797307 DOI: 10.1089/pmr.2023.0068] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/23/2024] Open
Abstract
Background We aimed to gain insight into psychological barriers toward initiation of strong opioid analgesic use in patients with advanced recurrent cancer. Methods This study included 46 patients who were prescribed with opioid analgesics for advanced recurrent cancer. The primary outcome was psychological barriers assessed using the Japanese version of the Barriers Questionnaire-II (JBQ-II). The secondary outcomes were psychological changes and pain relief one week after the induction of strong opioid analgesics. Results The mean age of participants was 63.6 years. Furthermore, 26.1% had an Eastern Cooperative Oncology Group (ECOG) performance status of ≥3. The mean JBQ-II total score was 1.97 (95% confidence interval: 1.75-2.19). At the initiation of opioid therapy, there was no difference in the total scores between the baseline and one week later. Nevertheless, there was a significant difference in the subscale "disease progression" score (mean 2.97 vs. 2.59, difference in means 0.38, standard error 0.16, p = 0.026). Personalized Pain Goal (PPG) was achieved in about half of the participants, and a trend toward a higher score in the subscale "harmful effects" (concern about adverse events) was observed in those who did not achieve PPG. Conclusion This study showed that patients with advanced recurrent cancer have psychological barriers to opioid induction. The relationship between the presence of psychological barriers before and after induction of opioid analgesics and the speed of pain improvement was determined. The results may provide fundamental information for prospective intervention studies to develop individualized education programs for patients with psychological barriers to opioids.Clinical Trial Registration Number UMIN000042443.
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Affiliation(s)
- Takehiko Tsuno
- Department of Pharmacy, Yokohama City University Medical Center, Yokohama, Japan
- Department of Analytical Chemistry, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Ryota Yanaizumi
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Junichi Kondo
- Department of Pharmacy, Yokohama City University Medical Center, Yokohama, Japan
| | - Keiko Kojima
- Department of Palliative Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Takashi Igarashi
- Department of Pharmacy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaki Inoue
- Department of Pharmacy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tomofumi Miura
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Akime Miyasato
- Department of Pharmacy, Tokyo Medical University Hospital, Tokyo, Japan
| | - Kanako Azuma
- Department of Pharmacy, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hiroshi Hamada
- Department of Palliative Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Tomoya Saeki
- Department of Pharmacy and Yokohama Minami Kyousai Hospital, Yokohama, Japan
| | - Hironori Mawatari
- Department of Palliative and Supportive Care, Yokohama Minami Kyousai Hospital, Yokohama, Japan
| | - Hiroyuki Ogura
- Department of Pharmacy, Kameda Medical Center, Chiba, Japan
| | - Akira Kotani
- Department of Analytical Chemistry, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideki Hakamata
- Department of Analytical Chemistry, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
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Leiva-Vásquez O, Letelier LM, Rojas L, Viviani P, Castellano J, González A, Pérez-Cruz PE. Is Acetaminophen Beneficial in Patients With Cancer Pain Who are on Strong Opioids? A Randomized Controlled Trial. J Pain Symptom Manage 2023; 66:183-192.e1. [PMID: 37207788 DOI: 10.1016/j.jpainsymman.2023.05.002] [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: 02/06/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
CONTEXT Pain is common among cancer patients. The evidence recommends using strong opioids in moderate to severe cancer pain. No conclusive evidence supports the effectiveness of adding acetaminophen to patients with cancer pain who are already using this regime. OBJECTIVES To assess the analgesic efficacy of acetaminophen in hospitalized cancer patients with moderate to severe pain receiving strong opioids. METHODS In this randomized blinded clinical trial, hospitalized cancer patients with moderate or severe acute pain managed with strong opioids were randomized to acetaminophen or placebo. The primary outcome was pain intensity difference between baseline and 48 hours using the Visual Numeric Rating Scales (VNRS). Secondary outcomes included change in morphine equivalent daily dose (MEDD), and patients' perception of improved pain control. RESULTS Among 112 randomized patients, 56 patients received placebo, 56 acetaminophen. Mean (standard deviation [SD]) decrease in pain intensity (VNRS) at 48 hours were 2.7 (2.5) and 2.3 (2.3), respectively (95% Confidence Interval (CI) [-0.49; 1.32]; P = 0.37). Mean (SD) change in MEDD was 13.9 (33.0) mg/day and 22.4 (57.7), respectively (95% CI [-9.24; 26.1]; P = 0.35). The proportion of patients perceiving pain control improvement after 48 hours was 82% in the placebo and 80% in the acetaminophen arms (P = 0.81). CONCLUSION Among patients with cancer pain on strong opioid regime, acetaminophen may not improve pain control, or decrease total opioid use. These results add to the current evidence available suggesting not to use acetaminophen as an adjuvant for advanced cancer patients with moderate to severe cancer pain who are on strong opioids.
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Affiliation(s)
- Ofelia Leiva-Vásquez
- Sección Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Católica de Chile (O.L.V., P.E.P.), Santiago, Chile
| | - Luz M Letelier
- Departamento Medicina Interna, Facultad de Medicina (L.M.L., L.R.), Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Rojas
- Departamento Medicina Interna, Facultad de Medicina (L.M.L., L.R.), Pontificia Universidad Católica de Chile, Santiago, Chile; Programa de Farmacología y Toxicología, Facultad de Medicina, Pontificia Universidad Católica de Chile (L.R., J.C., A.G.), Santiago, Chile
| | - Paola Viviani
- Departamento de Salud Pública, Facultad de Medicina (P.V.), Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joel Castellano
- Programa de Farmacología y Toxicología, Facultad de Medicina, Pontificia Universidad Católica de Chile (L.R., J.C., A.G.), Santiago, Chile
| | - Antonio González
- Programa de Farmacología y Toxicología, Facultad de Medicina, Pontificia Universidad Católica de Chile (L.R., J.C., A.G.), Santiago, Chile; Departamento de Hematología Oncología, Facultad de Medicina (A.G.), Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pedro E Pérez-Cruz
- Sección Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Católica de Chile (O.L.V., P.E.P.), Santiago, Chile.
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Oliva A, González de Chavez P, Dévora S, Abdala S. Opioid prescription patterns in the province of Las Palmas, Canary Islands, Spain (2016-2020): differences between urban and rural areas. Front Pharmacol 2023; 14:1184457. [PMID: 37533632 PMCID: PMC10390770 DOI: 10.3389/fphar.2023.1184457] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023] Open
Abstract
Introduction: The use of opioids has increased markedly in the past decades in European countries, especially for treatment of non-cancer pain including painful chronic musculoskeletal conditions. However, there are some notable differences in the relative levels of use between geographical areas and some distinct, context-specific patterns of weak and strong opioid use. The aim of this work is to describe real world trends in dosage forms and population exposure in the prescription opioid use on isolated geographically area: The Canary Islands of Gran Canaria, Lanzarote and Fuerteventura, Spain. For this, several factors such as living in a rural or urban area, population over 65 years of age, population density or socioeconomic status were analyzed. Methods: Data were extracted from the wholesalers who supply the community pharmacies at the population level. Prescription opioid use was measured as defined daily doses (DDD) per 1,000 inhabitants per day. A model based on covariance analysis with two nested fixed factors and one co-variable was used for contrast analysis at different level. Results: The overall DDD per 1000 inhabitants per day and year variation rate in Spain was very similar to that obtained for Gran Canaria and Fuerteventura (0.967 vs. 1.006), although the levels of dispensation were different (14.75 versus 18.24 for Gran Canaria and 12.7 for Fuerteventura, respectively). Lanzarote is completely different in all issues, where the opioid consumption rate remained stable during the study period, but with a decreasing tendency. The dispensation level of strong opioids varied between islands, from 56.41% for Fuerteventura vs. 17.61% for Gran Canaria, although these values remained stable. Tramadol with acetaminophen and Tramadol in monotherapy were the most consumed forms of the weak opioids, whereas Buprenorphine was the most used strong opioid followed by Fentanyl, although demand for it varied between islands, the transdermal formulations were the most frequent pharmaceutical preparation. Conclusion: The differences in prescription opioid use are most likely explained by the opioid prescribing practices in each island, whereas factors such urbanicity level, population age, population density and status socioeconomic does not help to explain the differences in prescription opioid use across rural and urban areas.
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Affiliation(s)
- Alexis Oliva
- Departamento de Ingeniería Química y Tecnología Farmacéutica, Facultad de Farmacia, Universidad de La Laguna, Tenerife, Spain
| | - Patricia González de Chavez
- Departamento de Medicina Física y Farmacología, Facultad de Farmacia, Universidad de La Laguna, Tenerife, Spain
| | - Sandra Dévora
- Departamento de Medicina Física y Farmacología, Facultad de Farmacia, Universidad de La Laguna, Tenerife, Spain
| | - Susana Abdala
- Departamento de Medicina Física y Farmacología, Facultad de Farmacia, Universidad de La Laguna, Tenerife, Spain
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Crush J, Levy N, Knaggs RD, Lobo DN. The pitfalls of labelling opioids as weak or strong. Response to Br J Anaesth 2022; 129:e150-e153. Br J Anaesth 2023; 130:e16-e17. [PMID: 36939496 DOI: 10.1016/j.bja.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jos Crush
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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Quinlan J, Macintyre PE. The pitfalls of labelling opioids as weak or strong. Comment on Br J Anaesth 2022; 129: 137-42. Br J Anaesth 2022; 129:e150-e153. [PMID: 36182559 DOI: 10.1016/j.bja.2022.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/05/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, Australia
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6
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Crush J, Levy N, Knaggs RD, Lobo DN. Misappropriation of the 1986 WHO analgesic ladder: the pitfalls of labelling opioids as weak or strong. Br J Anaesth 2022; 129:137-142. [PMID: 35397880 DOI: 10.1016/j.bja.2022.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 12/18/2022] Open
Abstract
Opioids have a vital role in alleviating pain from cancer and surgery. Despite good intentions, it is now recognised that the original WHO Cancer Pain Relief guidance from 1986, in which opioids were classified as either weak or strong, has been both inadvertently and purposefully misused, thereby contributing to harm from opioid use and misuse. However, the recommendation in the 2018 update of the WHO analgesic ladder that a combination of a high-potency opioid with simple analgesics is better than alternative analgesics for the maintenance of pain relief is also applicable to patients who require short-term opioids. Furthermore, because potential harm through opioid use and misuse is intrinsic to all opioids, whether weak or strong, we argue that the arbitrary classification of opioids either as weak or strong should be discontinued, as this description is not helpful to either prescribers or consumers.
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Affiliation(s)
- Jos Crush
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St. Edmunds, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St. Edmunds, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, UK; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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7
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Mattia C, Luongo L, Innamorato M, Melis L, Sofia M, Zappi L, Puntillo F. An Italian Expert Consensus on the Use of Opioids for the Management of Chronic Non-Oncological Pain in Clinical Practice: Focus on Buprenorphine. J Pain Res 2021; 14:3193-3206. [PMID: 34675646 PMCID: PMC8519776 DOI: 10.2147/jpr.s314206] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of the present work was to evaluate the knowledge and prescriptive habits of clinicians involved in the management of chronic non cancer pain (CNCP), with a special focus on the use of opioids. Methods A Delphi method was used. A Board of specialists elaborated and discussed a series of statements, based on available literature and personal clinical expertise, about particularly controversial topics on pain pathophysiology and treatment. A Panel of experts in the field of pain management, selected by the Board, was invited to vote the proposed statements, indicating the level of agreement on a 5-point Likert scale (1: strongly disagree; 2: disagree; 3: partially agree; 4: agree; 5: strongly agree). The threshold for consensus was set at minimum 66.6% of the number of respondents with a level of agreement ≥4 (Agree or Strongly agree). Results The Board included 5 pain therapists, 1 pharmacologist and 1 methodology expert and drew up a total of 36 statements (for a total of 40 requested answers)”. A total of 100 clinicians were included in the Expert Panel. Respondents were 89 (89%). Consensus was achieved for 32 out of 40 answers. Most of the lack of consensus was recorded for statements regarding opioids use, and resulted from a low level of agreement (3 on the Likert scale), suggesting a neutral position deriving from a lack of knowledge rather than a strong contrary opinion. Conclusion Most of the proposed items reached consensus, suggesting a generally homogeneous approach to CNCP management. However, the lack of consensus recorded for several items regarding opioid use confirms the need to fill important gaps in the knowledge of available agents. A clear explanation of the peculiar pharmacological properties of drugs associated with potential clinical advantages (such as buprenorphine) will help optimize pain treatment in both primary care and hospital settings and improving pain control in CNCP patients.
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Affiliation(s)
- Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "Sapienza" University of Rome, Rome, Italy.,Anesthesia, Intensive Care and Pain Unit, ICOT-Polo Pontino, Latina, Italy
| | - Livio Luongo
- Department of Experimental Medicine, Division of Pharmacology, University of Campania "L. Vanvitelli", Naples, Italy.,NEUROMED, Pozzilli, Italy
| | - Massimo Innamorato
- Pain Therapy Unit, AUSL Romagna, S.M.Croci Hospital Ravenna, Ravenna, Italy
| | | | - Michele Sofia
- Department of Palliative Care and Pain Therapy, ASST Rodhense, Garbagnate Milanese, Itlay
| | - Lucia Zappi
- UOC Antalgic Therapy, Emergency and Acceptance Department, San Martino Polyclinic Hospital, Genoa, Italy
| | - Filomena Puntillo
- Department of Interdisciplinary Medicine, "Aldo Moro" University of Bari, Bari, 70124, Italy.,Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital of Bari, Bari, 70124, Italy
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Wegwarth O, Wind S, Goebel E, Spies C, Meerpohl JJ, Schmucker C, Schulte E, Neugebauer E, Hertwig R. Educating Pharmacists on the Risks of Strong Opioids With Descriptive and Simulated Experience Risk Formats: A Randomized Controlled Trial. MDM Policy Pract 2021; 6:23814683211042832. [PMID: 34604531 PMCID: PMC8482350 DOI: 10.1177/23814683211042832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [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: 06/22/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives. High opioid prescription rates in the United States and
Europe suggest miscalibrated risk perceptions among those who prescribe,
dispense, and take opioids. Findings from cognitive decision science suggest
that risk perceptions and behaviors can differ depending on whether people learn
about risks by experience or description. This study investigated effects of a
descriptive versus an experience-based risk education format on pharmacists’
risk perceptions and counseling behavior in the long-term administration of
strong opioids to patients with chronic noncancer pain. Methods. In
an exploratory, randomized controlled online trial, 300 German pharmacists were
randomly assigned to either a descriptive format (fact box) or a simulated
experience format (interactive simulation). Primary Outcome
Measures. 1) Objective risk perception, 2) subjective risk
perception, and 3) intended and 4) actual counseling behavior.
Results. Both risk formats significantly improved pharmacists’
objective risk perception, but pharmacists exposed to the fact box estimated the
benefit-harm ratio more accurately than those exposed to the simulation. Both
formats proved equally effective in adjusting pharmacists’ subjective risk
perception toward a better recognition of opioids’ harms; however, pharmacists
receiving the simulation showed a greater change in their actual counseling
behavior and higher consistency between their intended and actual counseling
than pharmacists receiving the fact box. Conclusion. The simulated
experience format was less effective than the descriptive format in improving
pharmacists’ objective risk perception, equally effective in motivating
pharmacists to counsel patients on less risky treatment alternatives and more
effective in changing the reported actual counseling behavior.
Implications. These exploratory findings provide important
insights into the relevance of the description-experience gap for drug safety
and raise questions for future research regarding the specific mechanisms at
work.
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Affiliation(s)
- Odette Wegwarth
- Max Planck Institute for Human Development, Center for Adaptive Rationality, Berlin, Germany
| | - Stefan Wind
- Berlin Chamber of Pharmacists, Berlin, Germany
| | - Eva Goebel
- Berlin Chamber of Pharmacists, Berlin, Germany
| | - Claudia Spies
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany
| | - Joerg J Meerpohl
- University of Freiburg, Faculty of Medicine & Medical Center, Institute for Evidence in Medicine (for Cochrane Germany Foundation), Freiburg, Germany
| | - Christine Schmucker
- University of Freiburg, Faculty of Medicine & Medical Center, Institute for Evidence in Medicine (for Cochrane Germany Foundation), Freiburg, Germany
| | - Erika Schulte
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany
| | | | - Ralph Hertwig
- Max Planck Institute for Human Development, Center for Adaptive Rationality, Berlin, Germany
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Lalic S, Gisev N, Bell JS, Ilomäki J. Transition to high-dose or strong opioids: a population-based study of people initiating opioids in Australia. Addiction 2020; 115:1088-1097. [PMID: 31814212 DOI: 10.1111/add.14926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/05/2019] [Revised: 08/06/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Strong and high-dose opioids are associated with opioid overdose and death. The objective of this study was to determine the rate and predictors of transitioning to high-dose or strong opioids among people initiating opioids. DESIGN Retrospective cohort study. SETTING Australia. PARTICIPANTS People initiating opioid analgesics from July 2013 to January 2018 were identified from a random 10% sample of Australia's Pharmaceutical Benefits Scheme eligible population. MEASUREMENTS Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for the predictors of escalating to ≥ 50 mg oral morphine equivalents (OMEs)/day (cohort 1); ≥ 90 mg OMEs/day (cohort 2) and transitioning from weak opioids to strong opioids (cohort 3) over 12 months of follow-up. Predictors included age, sex, number of comorbidities, history of depression, prior treatment for cancer and selected other medication use. FINDINGS In total, 861 691 people initiated opioids at average doses < 50 mg OMEs/day (cohort 1), 874 401 at < 90 mg OMEs/day (cohort 2) and 603 884 initiated weak opioids (cohort 3). Overall, 1.4% of people escalated to doses ≥ 50 mg OMEs/day, 0.8% to doses ≥ 90 mg OMEs/day and 7.3% transitioned to strong opioids. The strongest predictors of transitioning included prior treatment for cancer [cohort 1: HR = 3.19, 95% CI = 3.00-3.40; cohort 2: HR = 4.19, 95% CI = 3.90-4.51; cohort 3: HR = 2.07, 95% CI = 1.95-2.18] and age ≥ 75 years (cohort 1: HR = 3.04, 95% CI = 2.73-3.38; cohort 2: HR = 2.51, 95% CI = 2.17-2.89; cohort 3: HR = 1.88, 95% CI = 1.80-1.96). Females transitioned to high doses and strong opioids less rapidly than males (cohort 1: HR = 0.79, 95% CI = 0.76-0.82; cohort 2: HR = 0.70, 95% CI = 0.66-0.73; cohort 3: HR = 0.95, 95% CI = 0.93-0.96). CONCLUSIONS In Australia, more than one in every 13 people initiating weak opioids transition to strong opioids. By extrapolation, more than 26 000 Australian adults initiating opioids escalate to high doses each year. People with cancer treatment history, older people and males transition to strong and high-dose opioids more rapidly than others.
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Affiliation(s)
- Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, Australia.,Pharmacy Department, Monash Health, Melbourne, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, Australia
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10
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Gupta A, Parmar B, Arora MH, Miriyala R, Anand N, Ghoshal S. Factors Influencing the Initiation of Strong Opioids in Cancer Patients on Palliative Care: An Audit from a Tertiary Cancer Center in India. Indian J Palliat Care 2020; 26:66-70. [PMID: 32132787 PMCID: PMC7017702 DOI: 10.4103/ijpc.ijpc_89_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/31/2019] [Revised: 08/30/2019] [Accepted: 11/02/2019] [Indexed: 12/25/2022] Open
Abstract
Aim This audit was done to analyze the factors influencing the use of strong opioids in cancer patients receiving comprehensive palliative care from a tertiary institute. Materials and Methods Case records of patients registered for palliative care at our center in 3 months were retrospectively reviewed and followed up throughout the course of their illness. Demographic factors, prior treatments, social support system, analgesic use at registration, and use of radiation and adjuvant analgesics were recorded. Strong opioid use and their time of initiation were evaluated, and multivariate analysis was used to identify the factors correlating with the above. Results After registration, strong opioids were initiated in 16% of the patients. It was observed that patients younger than 55 years and those with visceral metastases and history of use of weak opioids at the time of registration had a higher probability of being started on strong opioids. Factors associated with a significantly longer strong opioid-free interval were having spouse as primary caregiver, presence of skeletal metastases, use of palliative radiotherapy, and low socioeconomic status. Conclusion It is certain that the use of strong opioids for adequate analgesia is a necessity for palliative-care patients. However, optimal utilization of adjunctive analgesic modalities, coupled with good supportive care, can minimize the requirement and duration of strong opioid use, especially in developing countries with limited access to specialist palliative care.
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Affiliation(s)
- Ankita Gupta
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhushan Parmar
- Department of Radiotherapy and Oncology, Pt. JLNGMCH, Chamba, Himachal Pradesh, India
| | - Minni Hurria Arora
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raviteja Miriyala
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neeru Anand
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sushmita Ghoshal
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Zheng D, Narayan SW, Zoega H, Litchfield M, Buckley NA, Pearson SA, Schaffer AL. Anticipating the effects of restricting high-dose preparations of strong opioids in Australia: A population-based analysis to inform the current policy debate. Pharmacoepidemiol Drug Saf 2019; 28:521-527. [PMID: 30790376 DOI: 10.1002/pds.4755] [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: 09/10/2018] [Revised: 12/04/2018] [Accepted: 01/27/2019] [Indexed: 11/07/2022]
Abstract
PURPOSE Countries worldwide are developing a variety of strategies to combat the opioid epidemic, such as restricting access to high-strength opioid formulations. We aimed to examine the dispensing patterns of strong opioids by dose units (DUs), age, and sex. METHODS We used Australian population-level dispensing data from January 2003 to December 2015 and categorised strong opioids by DU: very low, low, moderate, and high, corresponding to total daily doses of less than or equal to 25, 26 to 50, 51 to 100, and greater than 100 morphine milligramme equivalents, respectively. We measured trends in strong opioid use as dispensings/1000 population/year and stratified dispensing in 2015 by patient age and sex. RESULTS From 2003 to 2015, strong opioid dispensing of very low, low, moderate, and high DU increased 6.7-, 6.2-, 2.2-, and 1.8-fold, respectively. The increase in very low and low DU dispensing was driven primarily by oxycodone (5, 10, and 15 mg tablets and capsules) and buprenorphine transdermal patches. In 2015, the number of dispensings/1000 population for very low, low, moderate, and high DU were 180.3, 77.0, 52.7, and 34.8, respectively. Females aged greater than or equal to 85 years had the highest opioid use, ranging from 157.1 dispensings/1000 population for high DU to 2104.5 dispensings/1000 population for very low DU. In contrast, the high DU dispensings in males aged 25 to 64 years exceeded their female counterparts by approximately 1.3-fold. CONCLUSION Relative to moderate and high DU strong opioids, dispensing of very low and low DU strong opioids increased dramatically during the study period in Australia. Future studies investigating opioids use and harms in elderly females and males between 25 to 64 years are warranted.
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Affiliation(s)
- Danni Zheng
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Sujita W Narayan
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Helga Zoega
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia.,Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Melisa Litchfield
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Nicholas A Buckley
- Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia.,Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| | - Andrea L Schaffer
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
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Mercadante S, Bruera E. Methadone as a First-Line Opioid in Cancer Pain Management: A Systematic Review. J Pain Symptom Manage 2018; 55:998-1003. [PMID: 29101087 DOI: 10.1016/j.jpainsymman.2017.10.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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: 09/20/2017] [Revised: 10/24/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
AIM The objective of this review was to assess the existent evidence for the use of methadone as a first-line therapy in cancer pain management. METHODS A systematic literature search on MEDLINE and Embase databases was carried out from each database, setting up the date to August 30, 2017. Studies were included if methadone was a first-line drug as a Step 3 of World Health Organization analgesic ladder, or at low doses (Step 2), if they were conducted in adult patients with cancer pain, and if they contained outcomes on pain- and opioid-related adverse effects. RESULTS The initial search yielded 219 records. Ten articles were considered after the initial screening according to inclusion and exclusion criteria. They included three longitudinal open-label studies. In two studies methadone was initiated at low doses (≤10 mg/day). These studies suggested that methadone was effective in providing analgesia and well tolerated as first opioid at different starting doses and in different conditions and settings. Five additional studies were randomized controlled studies with morphine in patients who had received opioids for moderate pain. Methadone, compared with oral morphine, or transdermal fentanyl, either at low (Step 2 level) or relatively higher doses (Step 3 level), provided similar analgesia with similar adverse effects profile with limited dose escalation in time. CONCLUSION Available data are not sufficient to draw net conclusion. However, open-label and controlled studies have shown that methadone may be effective as first-line drug in the management of cancer pain, providing analgesia and adverse effect profiles similar to those produced by other opioids. The finding that methadone doses tend to remain stable suggests that metabolic characteristics and extraopioid analgesic effects, as its well antihyperalgesic properties may be interesting potential advantages. Further studies should provide information regarding the long-term use of methadone or the need to switch from methadone to other opioids when a loss of analgesic response occurs.
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Affiliation(s)
- Sebastiano Mercadante
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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Abstract
AIM The aim of this review was to assess the role of tapentadol given at medium-high doses in opioid-tolerant patients for cancer pain management in place of step-3 analgesics. METHODS AND RESULTS A systematic literature search was performed out of which six studies and one secondary analysis provided data regarding tapentadol used as a step-3 analgesic for this review. Tapentadol, when used at ≥60 mg of oral morphine equivalents in opioid-tolerant patients with cancer pain, or passing from step-2 doses to ≥60 mg of oral morphine equivalents, was well tolerated and effective and could be considered as a flexible drug to be used for the management of moderate-to-severe cancer pain. The limited occurrence of gastrointestinal adverse effects may be a great advantage in the context of a disease like cancer, where multiple causes contribute to nausea, vomiting, or constipation; however, studies of tapentadol given at doses equivalent to step-3 level have some weaknesses, as data from prospective observational studies are poorly generalizable due to a small number of participants, controlled studies do not clearly show a superiority of tapentadol with respect to other opioids, and the sample size is often small. CONCLUSIONS More studies are necessary to confirm the role of tapentadol in cancer patients requiring strong opioids for their pain.
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Affiliation(s)
- Sebastiano Mercadante
- a Anesthesia & Intensive Care and Pain Relief & Palliative Care Unit , La Maddalena Cancer Center , Palermo , Italy
- b Home Palliative Care program , SAMO , Palermo , Italy
- c MD Anderson , University of Texas , Houston , TX , USA
- d University of Palermo , Palermo , Italy
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Ruiz Iban MA, Benavides J, Forero JP, Bittelman S, Martinez R, Mite MA, Diaz Heredia J, Ulloa S, Lizárraga Ferrand MM. Use of strong opioids for chronic pain in osteoarthritis: an insight into the Latin American reality. Expert Rev Clin Pharmacol 2017; 11:47-59. [PMID: 28920710 DOI: 10.1080/17512433.2018.1381556] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Osteoarthritis is the most common cause of arthritis and one of the main causes of chronic pain. Although opioids are frequently employed for chronic pain treatment, their usage for osteoarthritis pain remains controversial due to the associated adverse effects. Most guidelines reserve their use for refractory pain in patients with hip and knee osteoarthritis. The situation is even more complex in Latin America, where the prevalence of insufficient pain treatment is high because of the limited availability and use of strong opioids. Areas covered: In this article we review the epidemiology of osteoarthritis, its socioeconomic burden, its impact as a chronic pain cause and the pharmacological treatment options, giving emphasis to the role of strong opioids, their safety and efficacy, especially in Latin American countries, where restrictions regulate their usage. Expert commentary: Usage of strong opioids is safe and effective in the short-term management of osteoarthritis with moderate to severe pain, when other pharmacological treatments are inadequate and surgery is contraindicated, provided their use adheres to existing guidelines. Educational programs for patients and physicians and further research on treating chronic pain with opioids should be implemented to reduce adverse effects and improve care quality.
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Affiliation(s)
- Miguel Angel Ruiz Iban
- a Shoulder and Elbow Unit, Orthopaedic Surgery and Traumatology Service , Hospital Universitario Ramón y Cajal , Madrid , Spain
| | | | - Juan Pablo Forero
- c Servicios Rehabilitación Organización Sanitas Colombia , Clínica Reina Sofía , Bogotá , Colombia
| | - Sacha Bittelman
- d Orthopaedic Surgery in Hip and Knee Replacement , Hospital Instituto de Seguridad del Trabajo (IST) and Clínica Tabancura, Orthopaedic and traumatology department at the University Diego Portales , Santiago de Chile , Chile
| | - Rafael Martinez
- e Facultad de Medicina , Universidad Finis Terrae, Clínica Avansalud, Clínica Bicentenario, Instituto de Seguridad del Trabajo , Santiago de Chile , Chile
| | - Miguel Angel Mite
- f Orthopaedic and Traumatology department at the University of Guayaquil, Orthopaedic Surgery the Hip and Knee Replacement Team , Hospital IESS Dr. Teodoro Maldonado Carbo , Guayaquil , Ecuador
| | - Jorge Diaz Heredia
- a Shoulder and Elbow Unit, Orthopaedic Surgery and Traumatology Service , Hospital Universitario Ramón y Cajal , Madrid , Spain
| | - Sergio Ulloa
- g Rheumatology Department , Médica Sur. Comité técnico de Funsalud , México D.F , México
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