Opioids Prescribed at Discharge or Given During Emergency Department Visits Among Adults in the United States, 2016

Opioid analgesics are primarily used to treat chronic and acute pain and, when used appropriately, can be an important part of treatment (1). Pain is a major symptom of patients visiting the emergency department (ED), with up to 42% of ED visits being related to pain (2). Opioids may either be administered in the ED as part of treatment, provided post-treatment in the form of a prescription, or both (3). This report compares rates and percentages of ED visits by adults at which opioids were only given in the ED, only prescribed at discharge, or both, by selected characteristics.

Consumption trends and prescription patterns of opioids from 2011 to 2016: a survey in a Chinese city

OBJECTIVE

Opioid consumption in China has been very less and has varied widely since 1995. The representatively high level of consumption in Mainland China has never been reported. Our aim was to describe the consumption trends and prescription patterns of opioids in Nanjing, a highly developed city of Mainland China, and compare the results with selected worldwide regions.

METHODS

Application data of opioids in 2011-2016 were extracted from the Jiangsu Medicine Information Institute. Six opioids were included. Consumption was expressed in terms of defined daily doses (DDDs), morphine equivalents (MEs) and expenditure. The correlation between consumption of opioids and gross domestic product (GDP), Human Development Index (HDI) and cancer incidence was analysed by Pearson's correlation test.

RESULTS

DDDs, expenditure and MEs of opioids were, respectively, 256.04, $599.24 and 13.07 g in 2011, and increased to 361.27, $1041.79 and 18.09 g in 2016. DDDs in Nanjing were 2.80-fold that in Mainland China, 1.42-fold that in East and South-East Asia, but only equivalent to 8.89% of the worldwide average level. From 2011 to 2016, the consumption had a linear correlation with GDP, HDI and cancer incidence (p<0.05). However, DDDs varied greatly in countries with similar GDP or HDI. Within 45 Asian countries, the GDP only contributed to 10.47% of change in DDDs, while the HDI contributed to 20.32%. Consumption of non-intravenous opioids or strong opioids always comprised majority of the total consumption. The opioids prescribed predominantly were fentanyl, oxycodone and morphine. Fentanyl and oxycodone account for most of the increase in consumption.

CONCLUSION

Opioid consumption has increased >40% from 2011 to 2016, with consumption of fentanyl and oxycodone accounting for most of that increase. The consumption in Nanjing was higher than the average Chinese level, but lower than the global average. An increase in pain control services might be needed, but this need should be highly regulated.

Assessment of Changes in the Geographical Distribution of Opioid-Related Mortality Across the United States by Opioid Type, 1999-2016

Importance

As the opioid epidemic evolves, it is vital to identify changes in the geographical distribution of opioid-related deaths, and the specific opioids to which those deaths are attributed, to ensure that federal and state public health interventions remain appropriately targeted.

Objective

To identify changes in the geographical distribution of opioid-related mortality across the United States by opioid type.

Design, Setting, and Participants

Cross-sectional study using joinpoint modeling and life table analysis of individual-level data from the National Center for Health Statistics on 351 630 US residents who died from opioid-related causes from January 1, 1999, to December 31, 2016, for all of the United States and the District of Columbia. The analysis was conducted from September 6 to November 23, 2018.

Exposures

Deaths involving any opioid, heroin, synthetic opioids, and natural and semisynthetic opioids.

Main Outcomes and Measures

Opioid-related mortality rate, annual percent change in the opioid-related mortality rate, and life expectancy lost at age 15 years by state and opioid type.

Results

From 1999 to 2016, a total of 231 264 men and 120 366 women died from opioid-related causes across the whole United States. Sixty-six observations were removed owing to missing data on age; therefore, 351 564 US residents were included in this study. The mean (SD) age at death was 39.8 (12.5) years for men and was 43.5 (12.9) years from women. Opioid-related mortality rates, especially from synthetic opioids, rapidly increased in all of the eastern United States. In most states, mortality associated with natural and semisynthetic opioids (ie, prescription painkillers) remained stable. In contrast, 28 states had mortality rates from synthetic opioids that more than doubled every 2 years (ie, annual percent change, ≥41%), including 12 with high mortality rates from synthetic opioids (>10 per 100 000 people). Among these 28 states, the mortality rate from natural and semisynthetic opioids ranged from 2.0 to 18.7 per 100 000 people (with a mean mortality rate of 6.0 per 100 000 people). The District of Columbia had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013 (annual percent change, 228.3%; 95% CI, 169.7%-299.6%; P < .001), and a high mortality rate from synthetic opioids in 2016 (18.8 per 100 000 people); the mortality rate from natural and semisynthetic opioids was 6.9 per 100 000 people. Nationally, overall opioid-related mortality resulted in 0.36 years of life expectancy lost in 2016, which was 14% higher than deaths due to firearms and 18% higher than deaths due to motor vehicle crashes; 0.17 years of the life expectancy lost was due specifically to synthetic opioids. In 2016, New Hampshire and West Virginia lost more than 1 year of life expectancy due to opioid-related mortality.

Conclusions and Relevance

Opioid-related mortality, particularly mortality associated with synthetic opioids, has increased in the eastern United States. These findings indicate that policies focused on reducing opioid-related deaths may need to prioritize synthetic opioids and rapidly expanding epidemics in northeastern states and consider the potential for synthetic opioid epidemics outside of the heroin supply.

Trends in Opioid Prescribing and Dispensing by Veterinarians in Pennsylvania

IMPORTANCE

Veterinarians are a subset of opioid prescribers.

OBJECTIVE

To assess the quantity and trends in prescribing and dispensing of several different opioids in the past 11 years in a large veterinary hospital in Philadelphia, Pennsylvania.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study inventoried all opioid tablets and/or patches dispensed or prescribed by veterinarians practicing in a multispecialty academic veterinary teaching hospital in Philadelphia for small animals and species, such as rabbits, birds, and reptiles, from January 1, 2007, through December 31, 2017. Prescribing data were obtained from all veterinarians who wrote a prescription for opioids by reviewing detailed pharmacy records of controlled substances for the study period. Data included all opioids dispensed, or prescribed to animals (patients) undergoing evaluation at the center or being followed up as outpatients by the veterinarians in the hospital. Statewide veterinarian prescribing data were used for comparison. Data were analyzed from December 24, 2017, through May 15, 2018.

MAIN OUTCOMES AND MEASURES

The trend in administration and prescribing of 4 specific opioid analgesics (codeine sulfate, hydrocodone bitartrate, and tramadol hydrochloride tablets as well as fentanyl citrate patch) during the 11-year study period. The individual opioids were converted to morphine milligram equivalents (MME) for comparison.

RESULTS

The study included 134 veterinarians (70.9% women) with 366 468 patient visits. During the study period, the hospital veterinarians prescribed 105 183 689 tablets of tramadol, 97 547 tablets of hydrocodone, 38 939 tablets of codeine, and 3153 fentanyl patches to dogs (73.0%), cats (22.5%), and exotic animals (4.5%). Overall, MME use increased 41.2%, whereas visits increased by 12.8%. The comparison data for Pennsylvania revealed a predominance of hydrocodone use (688 340 tablets prescribed), although data were not available for comparison with tramadol because it is a Schedule IV drug.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that the large, increasing volume of opioids prescribed at 1 veterinary teaching hospital highlights concerns parallel to those about excessive opioid prescribing in humans. The extent to which these data may represent similar volumes of prescriptions from the general veterinary practices and hospitals across the United States is suggested by the accompanying Pennsylvania state data. These findings highlight an opportunity to assess the risk of veterinarian opioid prescriptions to safeguard public health.

Drug Overdose Deaths in the United States, 1999-2017

Deaths from drug overdose continue to be a public health burden in the United States (1-5). This report uses the most recent final mortality data from the National Vital Statistics System (NVSS) to update trends in drug overdose deaths, describe demographic and geographic patterns, and identify shifts in the types of drugs involved.

Schedules of Controlled Substances: Temporary Placement of Cyclopropyl Fentanyl in Schedule I. Temporary amendment; temporary scheduling order

The Administrator of the Drug Enforcement Administration is issuing this temporary scheduling order to schedule the synthetic opioid, -(1-phenethylpiperidin-4-yl)-N-phenylcyclopropanecarboxamide (cyclopropyl fentanyl), and its isomers, esters, ethers, salts, and salts of isomers, esters, and ethers in schedule I. This action is based on a finding by the Administrator that the placement of cyclopropyl fentanyl in schedule I of the Controlled Substances Act is necessary to avoid an imminent hazard to the public safety. As a result of this order, the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule I controlled substances will be imposed on persons who handle (manufacture, distribute, reverse distribute, import, export, engage in research, conduct instructional activities or chemical analysis, or possess), or propose to handle, cyclopropyl fentanyl.

Schedules of Controlled Substances: Placement of MT-45 Into Schedule I. Final order

With the issuance of this final order, the Administrator of the Drug Enforcement Administration places the substance MT-45 (Systematic IUPAC Name: 1-cyclohexyl-4-(1,2-diphenylethyl)piperazine), including its salts, isomers, and salts of isomers into schedule I of the Controlled Substances Act. This scheduling action is pursuant to the Controlled Substances Act and is required in order for the United States to discharge its obligations under the Single Convention on Narcotic Drugs, 1961. This action imposes the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule I controlled substances on persons who handle (manufacture, distribute, import, export, engage in research or conduct instructional activities with, or possess), or propose to handle, MT-45.

Schedules of Controlled Substances: Temporary Placement of ortho-Fluorofentanyl, Tetrahydrofuranyl Fentanyl, and Methoxyacetyl Fentanyl Into Schedule I. Temporary amendment; temporary scheduling order

The Administrator of the Drug Enforcement Administration is issuing this temporary scheduling order to schedule the synthetic opioids, N-(2-fluorophenyl)-N-(1-phenethylpiperidin-4-yl)propionamide (ortho-fluorofentanyl or 2-fluorofentanyl), N-(1-phenethylpiperidin-4-yl)-N-phenyltetrahydrofuran-2-carboxamide (tetrahydrofuranyl fentanyl), and 2-methoxy-N-(1-phenethylpiperidin-4-yl)-N-phenylacetamide (methoxyacetyl fentanyl), into Schedule I. This action is based on a finding by the Administrator that the placement of ortho-fluorofentanyl, tetrahydrofuranyl fentanyl, and methoxyacetyl fentanyl into Schedule I of the Controlled Substances Act is necessary to avoid an imminent hazard to the public safety. As a result of this order, the regulatory controls and administrative, civil, and criminal sanctions applicable to Schedule I controlled substances will be imposed on persons who handle (manufacture, distribute, reverse distribute, import, export, engage in research, conduct instructional activities or chemical analysis, or possess), or propose to handle, ortho-fluorofentanyl, tetrahydrofuranyl fentanyl, and methoxyacetyl fentanyl.

Schedules of Controlled Substances: Temporary Placement of Acryl Fentanyl Into Schedule I. Temporary scheduling order

The Administrator of the Drug Enforcement Administration is issuing this temporary scheduling order to schedule the synthetic opioid, N-(1-phenethylpiperidin-4-yl)-N-phenylacrylamide (acryl fentanyl or acryloylfentanyl), and its isomers, esters, ethers, salts and salts of isomers, esters, and ethers, into Schedule I. This action is based on a finding by the Administrator that the placement of acryl fentanyl into Schedule I of the Controlled Substances Act is necessary to avoid an imminent hazard to the public safety. As a result of this order, the regulatory controls and administrative, civil, and criminal sanctions applicable to Schedule I controlled substances will be imposed on persons who handle (manufacture, distribute, reverse distribute, import, export, engage in research, conduct instructional activities or chemical analysis, or possess), or propose to handle, acryl fentanyl.

Schedules of Controlled Substances: Temporary Placement of Furanyl Fentanyl Into Schedule I. Final order

The Administrator of the Drug Enforcement Administration is issuing this final order to temporarily schedule the synthetic opioid, N-(1-phenethylpiperidin-4-yl)-N-phenylfuran-2-carboxamide (furanyl fentanyl), and its isomers, esters, ethers, salts and salts of isomers, esters and ethers, into schedule I pursuant to the temporary scheduling provisions of the Controlled Substances Act. This action is based on a finding by the Administrator that the placement of furanyl fentanyl into schedule I of the Controlled Substances Act is necessary to avoid an imminent hazard to the public safety. As a result of this order, the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule I controlled substances will be imposed on persons who handle (manufacture, distribute, reverse distribute, import, export, engage in research, conduct instructional activities or chemical analysis, or possess), or propose to handle, furanyl fentanyl.

Schedules of Controlled Substances: Temporary Placement of U-47700 Into Schedule I. Final order

The Administrator of the Drug Enforcement Administration is issuing this final order to temporarily schedule the synthetic opioid, 3,4-dichloro-N-[2-(dimethylamino)cyclohexyl]-N-methylbenzamide (also known as U-47700), and its isomers, esters, ethers, salts and salts of isomers, esters and ethers, into schedule I pursuant to the temporary scheduling provisions of the Controlled Substances Act. This action is based on a finding by the Administrator that the placement of U-47700 into schedule I of the Controlled Substances Act is necessary to avoid an imminent hazard to the public safety. As a result of this order, the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule I controlled substances will be imposed on persons who handle (manufacture, distribute, reverse distribute, import, export, engage in research, conduct instructional activities or chemical analysis, or possess), or propose to handle, U-47700.

Schedules of Controlled Substances: Placement of Thiafentanil Into Schedule II. Interim final rule with request for comments

The Drug Enforcement Administration is placing the substance thiafentanil (4-(methoxycarbonyl)-4-(N-phenmethoxyacetamido)-1-[2-(thienyl)ethyl]piperidine), including its isomers, esters, ethers, salts and salts of isomers, esters and ethers as possible, into schedule II of the Controlled Substances Act. This scheduling action is pursuant to the Controlled Substances Act, as revised by the Improving Regulatory Transparency for New Medical Therapies Act which was signed into law on November 25, 2015.

Schedules of Controlled Substances: Temporary Placement of Butyryl Fentanyl and Beta-Hydroxythiofentanyl Into Schedule I. Final order

The Administrator of the Drug Enforcement Administration is issuing this final order to temporarily schedule the synthetic opioids, N-(1-phenethylpiperidin-4-yl)-N-phenylbutyramide, also known as N-(1-phenethylpiperidin-4-yl)-N-phenylbutanamide, (butyryl fentanyl) and N-[1-[2-hydroxy-2-(thiophen-2-yl)ethyl]piperidin-4-yl]-N-phenylpropionamide, also known as N-[1-[2-hydroxy-2-(2-thienyl)ethyl]-4-piperidinyl]-N-phenylpropanamide, (beta-hydroxythiofentanyl), and their isomers, esters, ethers, salts and salts of isomers, esters and ethers, into schedule I pursuant to the temporary scheduling provisions of the Controlled Substances Act. This action is based on a finding by the Administrator that the placement of butyryl fentanyl and beta-hydroxythiofentanyl into schedule I of the Controlled Substances Act is necessary to avoid an imminent hazard to the public safety. As a result of this order, the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule I controlled substances will be imposed on persons who handle (manufacture, distribute, reverse distribute, import, export, engage in research, conduct instructional activities or chemical analysis, or possess), or propose to handle, butyryl fentanyl and beta-hydroxythiofentanyl.

Schedules of Controlled Substances: Temporary Placement of Acetyl Fentanyl Into Schedule I. Final order

The Administrator of the Drug Enforcement Administration is issuing this final order to temporarily schedule the synthetic opioid, N-(1-phenethylpiperidin-4-yl)-N-phenylacetamide (acetyl fentanyl), and its optical, positional, and geometric isomers, salts and salts of isomers, into schedule I pursuant to the temporary scheduling provisions of the Controlled Substances Act. This action is based on a finding by the Administrator that the placement of this opioid substance into schedule I of the Controlled Substances Act is necessary to avoid an imminent hazard to the public safety. As a result of this order, the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule I controlled substances will be imposed on persons who handle (manufacture, distribute, import, export, engage in research, or possess), or propose to handle, acetyl fentanyl.

Opioid prescriptions before and after high-energy trauma

OBJECTIVE

To describe the legal use of opioids in adult patients before and after high-energy trauma.

DESIGN

The study was a retrospective database study.

SETTING

Clinical care outside hospitals.

PATIENTS

All patients who suffered high-energy trauma and were brought to Odense University Hospital (OUH), Denmark, in 2007 and 2008 were retrieved from the trauma database. These patients were linked with data on opioid use from the regional prescription database. In all, 938 patients were included.

MAIN OUTCOME MEASURE

Redemption of opioid prescription during the 6 months prior to a multitrauma or redemption of two or more prescriptions for opioids 6 months or later after a multitrauma.

RESULTS

Of the 938 patients brought to OUH with severe trauma within the study period, 61 patients died (7 percent) and six of these had redeemed prescriptions for opioids within 6 months prior to the trauma (10 percent) compared to 65 patients of the 877 survivors (7 percent) (odds ratio 1.4, nonsignificant). In all, 62 patients (7 percent) redeemed opioid prescriptions later than 6 months after their trauma and in a multivariable analysis, severe injury itself and severe injuries of the lower extremities were associated with redemption of opioid prescription after the trauma.

CONCLUSIONS

The authors did not find any correlation between death by trauma and redemption of opioid prescriptions within the 6 months before the trauma. More severe traumas and especially severe traumas to the lower extremities were associated with redemption of opioid prescriptions after multitrauma.

On subclasses of opioid analgesics

BACKGROUND

The history of discovery of analgesic drugs has followed a trajectory from original serendipitous discovery of plant-derived substances to laboratory creation of customized molecules that are intentionally designed to interact with specific receptors of neurotransmitters involved in either the transmission of the pain signal or the attenuation of such a signal. The drugs most recently developed have been designed to provide incremental greater separation between pain relief and adverse effects. The result has been drugs that have individualized pharmacodynamic and pharmacokinetic characteristics that represent specific advances in basic science and translate into unique clinical profiles. Several of the drugs include non-opioid components. They retain some of the features of opioids, but have distinct clinical characteristics that differentiate them from traditional opioids. Thus they defy simple classification as opioids.

SCOPE

A summary is provided of the development of the modern view of multi-mechanistic pain and its treatment using analgesics that have multi-mechanisms of action (consisting of both opioid and non-opioid components). Descriptions of examples of such current analgesics and of those that have pharmacokinetic characteristics that result in atypical opioid clinical profiles are given.

FINDINGS

By serendipity or design, several current strong analgesics have opioid components of action, but have an additional non-opioid mechanism of action or some pharmacokinetic feature that gives them an atypical opioid clinical profile and renders them not easily classified as classical opioids.

CONCLUSION

An appreciation that there are now opioid analgesics that differentiate from classical opioids in ways that defy their simplistic classification as opioids suggests that recognition of subclasses of opioid analgesics would be more accurate scientifically and would be more informative for healthcare providers and regulators. This would likely lead to positive outcomes for the clinical use and regulatory control of the current drugs, and provide direction/strategy for the discovery of new drugs.

Trends in high-dose opioid prescribing in Canada

OBJECTIVE

To describe trends in rates of prescribing of high-dose opioid formulations and variations in opioid product selection across Canada.

DESIGN

Population-based, cross-sectional study.

SETTING

Canada.

PARTICIPANTS

Retail pharmacies dispensing opioids between January 1, 2006, and December 31, 2011.

MAIN OUTCOME MEASURES

Opioid dispensing rates, reported as the number of units dispensed per 1000 population, stratified by province and opioid type.

RESULTS

The rate of dispensing high-dose opioid formulations increased 23.0%, from 781 units per 1000 population in 2006 to 961 units per 1000 population in 2011. Although these rates remained relatively stable in Alberta (6.3% increase) and British Columbia (8.4% increase), rates in Newfoundland and Labrador (84.7% increase) and Saskatchewan (54.0% increase) rose substantially. Ontario exhibited the highest annual rate of high-dose oxycodone and fentanyl dispensing (756 tablets and 112 patches per 1000 population, respectively), while Alberta's rate of high-dose morphine dispensing was the highest in Canada (347 units per 1000 population). Two of the highest rates of high-dose hydromorphone dispensing were found in Saskatchewan and Nova Scotia (258 and 369 units per 1000 population, respectively). Conversely, Quebec had the lowest rate of high-dose oxycodone and morphine dispensing (98 and 53 units per 1000 population, respectively).

CONCLUSION

We found marked interprovincial variation in the dispensing of high-dose opioid formulations in Canada, emphasizing the need to understand the reasons for these differences, and to consider developing a national strategy to address opioid prescribing.

Schedule of controlled substances: placement of tramadol into schedule IV. Final rule

With the issuance of this final rule, the Deputy Administrator of the Drug Enforcement Administration places the substance 2-[(dimethylamino)methyl]-1-(3-methoxyphenyl)cyclohexanol (tramadol), including its salts, isomers, and salts of isomers, into schedule IV of the Controlled Substances Act. This scheduling action is pursuant to the Controlled Substances Act which requires that such actions be made on the record after opportunity for a hearing through formal rulemaking. This action imposes the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule IV controlled substances on persons who handle (manufacture, distribute, dispense, import, export, engage in research, conduct instructional activities with, or possess) or propose to handle tramadol.

[Treatment of nociceptive pain in primary care setting]

The pharmacological treatment of chronic pains induced by an excess of nociception is mainly based on analgesics which are classified according to their pharmacological nature (not opioid/opioid) and to their power according to the three World Health Organization steps. Their use is founded on a strategy which differs from the nature of pain (cancer pain vs no cancer pain), in particular with regard to the use of the strong opioids.

New insights into the neuroanatomical distribution and phylogeny of opioids and POMC-derived peptides in fish

This review re-evaluates the use of immunological probes to map enkephalinergic, dynorphinergic, and endorphinergic circuits in the CNS of lobe-finned fishes, ray-finned fishes, and cartilaginous fishes in light of the characterization of proenkephalin, prodynorphin, and POMC sequences from representatives of these groups of fish over the past 20 years. The use of α-MSH specific antisera is a reliable method for detecting POMC immunopositive cell bodies and fibers. Since α-MSH and β-endorphin are co-localized in the same neurons, these studies also reveal the distribution of endorphinergic networks. Met-enkephalin specific antisera can be used to detect enkephalinergic circuits in the CNS of gnathostomes because of the ubiquitous presence of this pentapeptide in the proenkephalin sequences of gnathostomes. However, the use of leu-enkephalin specific antisera to detect enkephalinergic networks is more problematic. While this immunological probe is appropriate for analyzing enkephalinergic networks in mammals and perhaps teleosts, for the lungfishes and cartilaginous fishes this probe is more likely able to detect dynorphinergic circuits. In this regard, there is a need to re-examine dynorphinergic networks in non-mammalian gnathostomes by using species specific antisera directed against dynorphin end-products.

REGIONAL ANALGESIA FOR POST-OPERATIVE PAIN MANAGEMENT--INITIAL EXPERIENCE IN A LOW RESOURCE SETTING

OBJECTIVE

The aim of this study is to demonstrate the use of some regional anaesthetic techniques in effective postoperative pain control in a low resource setting. We also wanted to find out the potential benefits and prospects of regional techniques to achieve effective postoperative analgesia.

DESIGN

This study was a prospective observational study in which 25 patients presenting for various orthopaedic and general surgical procedures were recruited randomly.

SETTING

Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria from December, 2008 to May, 2009.

SUBJECTS

Eligible patients were males and females aged 21-55 years. These included emergency and elective cases.

RESULTS

The age range was 21-55 years with a mean age of 34 years. Of the 25 patient studied, 14 of them were men and 11 women constituting 56% and 44% respectively. Our study shows that Hausa/Fulani ethnic group made up 75% of the study population. Intraoperatively, the anaesthetic techniques used were general anaesthesia (only) in 13 patients (52%), Regional techniques consisting of spinals, epidurals, combined spinals and epidurals and brachial plexus blocks in nine patients (36%) and three (12%) of the patients had a combination of general anaesthesia (GA) and regional anaesthesia (RA). For post-operative pain management, nine patients (36%) had continuous brachial plexus block using intermittent injections, 13 (52%) patients had epidural catheters with intermittent top-up injections and three (12%) patients received combined spinal and epidural with an epidural catheter left in-situ for intermittent top-ups. The drugs used for top-ups included 0.125% plain bupivacaine (15 patients), 0.125% plain bupivacaine + 2.5 mcgs/ml Fentanyl (10 patients) in 10 ml aliquots. The outcome was good in most patients with 19 patients (82.4%) experiencing only mild pain (numeric pain score 0-3). Onset of post-operative pain was 13-18 hours in most (52%) of patients with majority of patients (80%) requiring only a single dose of opioid in 24 hours. There was no incidence of infection at site of catheter insertion one week after the procedure.

CONCLUSION

Regional techniques if used properly can provide superior pain control in the post-operative period. There is reduction in the requirements of opioids in the immediate post-operative when regional techniques are used for pain management. We need to encourage the use of these techniques especially in our setting where resources are sparse and potent analgesics are not always available.

Prescriptions for schedule II opioids and benzodiazepines increase after the introduction of computer-generated prescriptions

BACKGROUND

Prescriptions for controlled substances decrease when regulatory barriers are put in place. The converse has not been studied.

OBJECTIVES

The objective was to determine whether a less complicated prescription writing process is associated with a change in the prescribing patterns of controlled substances in the emergency department (ED).

METHODS

The authors conducted a retrospective nonconcurrent cohort study of all patients seen in an adult ED between April 19, 2005, and April 18, 2007, who were discharged with a prescription. Prior to April 19, 2006, a specialized prescription form stored in a locked cabinet was obtained from the nursing staff to write a prescription for benzodiazepines or Schedule II opioids. After April 19, 2006, New York State mandated that all prescriptions, regardless of schedule classification, be generated on a specialized bar-coded prescription form. The main outcome of the study was to compare the proportion of Schedule III-V opioids to Schedule II opioids and benzodiazepines prescribed in the ED before and after the introduction of a less cumbersome prescription writing process.

RESULTS

Of the 26,638 charts reviewed, 2.1% of the total number of prescriptions generated were for a Schedule II controlled opioid before the new system was implemented compared to 13.6% after (odds ratio [OR] = 7.3, 95% confidence interval [CI] = 6.4 to 8.4). The corresponding percentages for Schedule III-V opioids were 29.9% to 18.1% (OR = 0.52, 95% CI = 0.49 to 0.55) and for benzodiazepines 1.4% to 3.9% (OR = 2.8, 95% CI = 2.4 to 3.4).

CONCLUSIONS

Patients were more likely to receive a prescription for a Schedule II opioid or a benzodiazepine after a more streamlined computer-generated prescription writing process was introduced in this ED.

[The role of strong opioids in the treatment of the chronic musculoskeletal pain]

This article concentrates on recent evidence about opioid analgesics for persistent musculoskeletal pain. Chronic musculoskeletal pain is a major health problem for which opioids provide one treatment option. Pain is an experience that affects all aspects of a patient's life and effective pain management with strong opioids may help the patient to focus on the positive aspects of life, decreasing the focus on pain. This therapy should be reserved for patients who fail to respond to other lower-risk options and only after proper consideration is given to the long-term consequences of strong opioid use according to the WHO three-step ladder. Several reviews and our experience have shown that opioids are typically reserved for moderate to severe musculoskeletal pain that cannot be relieved by other drugs. In this article are presented the strong opioid drugs, routes of administration, dosage guidelines and potential adverse effects. The management of patients with chronic musculoskeletal pain is a common clinical challenge.

[Efficacy comparison between morphine sulfate controlled-released tablet and morphine hydrochloride sustained-released tablet in treating cancer pain]

BACKGROUND & OBJECTIVE

Morphine sulfate controlled-released tablet and morphine hydrochloride sustained-released tablet are preferred medicines for treating moderate-severe cancer pain. There are some differences between the two medicines in their efficacy, metabolism and adverse events. This study was to compare the efficacy and toxicities between morphine sulfate controlled-released tablet and morphine hydrochloride sustained-released tablet in treating moderate-severe cancer pain.

METHODS

A total of 121 patients with moderate-severe cancer pain were randomized into two groups: 61 were treated with morphine sulfate controlled-released tablet and 60 were treated with morphine hydrochloride sustained-released tablet. Analgesic efficacy and toxicities of the two medicines were observed.

RESULTS

Of the 61 patients treated with morphine sulfate controlled-released tablet, 12 had moderate pain, 49 had severe pain; the total response rate was 91.80%. Of the 60 patients treated with morphine hydrochloride sustained-released tablet, 13 had moderate pain, 47 had severe pain; the total response rate was 91.67%. There was no significant difference in the efficacy between the two medicines. Digestive system adverse events, including nausea, vomiting and constipation, were more common in morphine hydrochloride sustained-released tablet group than in morphine sulfate controlled-released tablet group (66.66% vs. 34.43%, P<0.05).

CONCLUSIONS

Both morphine sulfate controlled-released tablet and morphine hydrochloride sustained-released tablet are safety in treating moderate-severe cancer pain and the toxicities are tolerable. We recommend to take morphine sulfate controlled-released tablet for older patients and the patients with digestive disorders.

Internet surveillance: content analysis and monitoring of product-specific internet prescription opioid abuse-related postings

OBJECTIVES

This study describes the development of a systematic approach to the analysis of Internet chatter as a means of monitoring potentially abusable opioid analgesics.

METHODS

Message boards dedicated to drug abuse were selected using specific inclusion criteria. Threaded discussions containing 48,293 posts were captured. A coding system was created to compare content of posts related to 3 opioid analgesics: Kadian, Vicodin, and OxyContin.

RESULTS

The number of posts containing mentions of the target drugs were significantly different [OxyContin (1813)>Vicodin (940)>Kadian (27), P<0.001]. Analyses revealed that these differences were not simply a reflection of the availability of each product (ie, number of prescriptions written). Reliability tests indicated that the content coding system achieved good interrater reliability coefficients (average kappa across all categories=0.76, range=0.52 to 1.0). Content analysis of a sample of 234 randomly selected posts indicated that the proportion of Internet posts endorsing abuse of Kadian was statistically significantly less than OxyContin (45.5% vs. 68.4%, P=0.036, not adjusted for multiple comparisons).

DISCUSSION

These results suggest that a systematic approach to postmarketing surveillance of Internet chatter related to pharmaceutical products is feasible and yields reliable information about the quantity of discussion of specific products and qualitative information regarding the nature of the discussions. Kadian was associated with fewer Internet mentions than either OxyContin or Vicodin. This investigation stands as a first attempt to establish systematic methods for conducting Internet surveillance.

Distinct effects of individual opioids on the morphology of spines depend upon the internalization of mu opioid receptors

This study has examined the relationship between the effects of opioids on the internalization of mu opioid receptors (MORs) and the morphology of dendritic spines. Several opioids (morphine, etorphine, DAMGO or methadone) were applied to cultured hippocampal neurons. Live imaging and biochemical techniques were used to examine the dynamic changes in MOR internalization and spine morphology. This study reveals that MOR internalization can regulate opioid-induced morphological changes in dendritic spines: (1) Chronic treatment with morphine, which induced minimal receptor internalization, caused collapse of dendritic spines. In contrast, "internalizing" opioids such as DAMGO and etorphine induced the emergence of new spines. It reveals that opioid-induced changes in spines vary greatly depending on how the applied opioid agonist affects MOR internalization. (2) The blockade of receptor internalization by dominant negative mutant of dynamin, K44E, reversed the effects of DAMGO and etorphine. It indicates that receptor internalization is necessary for the distinct effects of DAMGO and etorphine on spines. (3) In neurons that were cultured from MOR knock-out mice and had been co-transfected with DsRed and MOR-GFP, morphine caused collapse of spines whereas DAMGO induced emergence of new spines, indicating that opioids can alter the structure of spines via postsynaptic MORs. (4) Methadone at a low concentration induced minimal internalization and had effects that were similar to morphine. At a high concentration, methadone induced robust internalization and had effects that are opposite to morphine. The concentration-dependent opioid-induced changes in dendritic spines might also contribute to the variation in the effects of individual opioids.

Rational Use of Sublingual Opioids in Palliative Medicine

The sublingual administration of opioid analgesics has been a mainstay in the pain management of homebound dying hospice patients who are no longer able to swallow. It is also a potentially useful route of administration in other situations in which the oral route is not available and other routes are impractical or inappropriate. Potential advantages of the sublingual route include rapid analgesic onset and avoidance of hepatic first-pass metabolism. Pharmacokinetic and pharmacodynamic studies have yielded widely disparate data on sublingual morphine. Other opioids have been less studied. Available data suggests limited sublingual availability of hydrophilic opioids (e.g., morphine, oxycodone, and hydromorphone) and superior absorption of the lipophilic opioids (e.g., methadone and the fentanils). Buprenorphine, a potent, lipophilic, partial mu-opioid receptor agonist, appears promising but awaits further study.

Pharmacogenetics of Opioids

Opioids are used for acute and chronic pain and dependency. They have a narrow therapeutic index and large interpatient variability in response. Genetic factors regulating their pharmacokinetics (metabolizing enzymes, transporters) and pharmacodynamics (receptors and signal transduction elements) are contributors to such variability. The polymorphic CYP2D6 regulates the O-demethylation of codeine and other weak opioids to more potent metabolites with poor metabolizers having reduced antinociception in some cases. Some opioids are P-glycoprotein substrates, whereas, ABCB1 genotypes inconsistently influence opioid pharmacodynamics and dosage requirements. Single-nucleotide polymorphisms in the mu opioid receptor gene are associated with increasing morphine, but not methadone dosage requirements and altered efficacy of mu opioid agonists and antagonists. As knowledge regarding the interplay between genes affecting opioid pharmacokinetics including cerebral kinetics and pharmacodynamics increases, our understanding of the role of pharmacogenomics in mediating interpatient variability in efficacy and side effects to this important class of drugs will be better informed. Opioid drugs as a group have withstood the test of time in their ability to attenuate acute and chronic pain. Since the isolation of morphine in the early 1800s by Friedrich Sertürner, a large number of opioid drugs beginning with modification of the 4,5-epoxymorphinan ring structure were developed in order to improve their therapeutic margin, including reducing dependence and tolerance, ultimately without success.

Adverse effects of opioids on the central nervous systems of palliative care patients

Opioids, defined as drugs that stimulate opioid receptors, are primarily used in the treatment of moderate to severe pain. They induce central nervous system (CNS) adverse effects which can be divided into three groups. The first group includes effects that lower the level of consciousness-sedation, drowsiness and sleep disturbance. The second group affects the thinking process and the ability to react-cognitive impairment, psychomotor impairment, delirium, hallucinations, dreams and nightmares. The third group is of the direct toxic effects of opioids on neurons and includes myoclonus (perhaps), hyperalgesia and tolerance. This review addresses the incidence, possible mechanisms, and treatment of each of these groups of opioid-induced adverse effects.

Incomplete Recovery of Prescription Opioids in Urine using Enzymatic Hydrolysis of Glucuronide Metabolites

Confirmation of opioids in urine samples of clinical patients requires liberation of opioids from their glucuronide conjugates. Both acid hydrolysis and enzyme hydrolysis using beta-glucuronidase from various sources have been reported, with the latter approach prevailing in most clinical toxicology laboratories. The goal of this study was to compare the efficiency of acid versus different enzyme hydrolysis methods in recovering morphine and common semisynthetic opioids from glucuronide standards and 78 patient urine samples that were screened positive for opioids as a class. Specimens were analyzed with a validated gas chromatography-mass spectrometry (GC-MS) procedure. With the exception of oxycodone, the results indicated that the majority of opioids tested were extensively glucuronide-conjugated in urine. Significantly, acid hydrolysis liberated > 90% of morphine and hydromorphone from their glucuronide standards but enzyme hydrolysis had lower and variable efficiency, depending on the opiate type and the enzyme source. In patient specimens, much higher concentrations of free codeine, morphine, hydromorphone, and oxymorphone were obtained with acid hydrolysis than with various enzyme methods. Incomplete hydrolysis using beta-glucuronidase could lead to false-negative results for many opioids when urine is tested for drugs of abuse. We conclude that acid hydrolysis is the method of choice for GC-MS confirmation of urine opioids.

Geographic variation in the prescription of schedule II opioid analgesics among outpatients in the United States

OBJECTIVE

To measure geographic variation in opioid use in a large, commercially insured, outpatient population in the United States.

DATA SOURCES

Outpatient prescription drug claims database of a national pharmaceutical benefit manager for 7,873,337 subjects with at least one prescription drug claim in 2000.

STUDY DESIGN

We measured the period prevalence of claims for opioid analgesics and controlled-release oxycodone at the state level. We measured geographic variation using the weighted coefficient of variation and systematic component of variation. In county-level multivariable regression, we explored associations between potential explanatory variables and claims for opioid analgesics and controlled-release oxycodone.

PRINCIPAL FINDINGS

A total of 567,778 (64.2 per 1,000 total claims) were for oral opioid analgesics. Claim rates by state ranged from <20 to >100 claims per 1,000 total claims. States with long-standing prescription monitoring programs had among the lowest rates. In the county-level data, presence of a statewide prescription monitoring program and proportions of the population aged 15-24 and 65 years and older were independently and negatively associated with claim rates for all opioid analgesics. Surgeons per 1,000, proportion of the population reporting illicit drug use, and proportion who were female were independently and positively associated with claim rates for all opioid analgesics. Only the proportion of the population aged 25-34 and number of surgeons per 1,000 were independently and positively associated with claim rates for oxycodone.

CONCLUSIONS

Claim rates for opioid analgesics vary significantly by state. Presence of a statewide prescription monitoring program is associated with lower claim rates at the county level. Future research should use individual-level data to assess whether these findings reflect a reduction in abuse and diversion or suboptimal treatment of pain.

[Clinical pharmacology of analgesics: outlook and risks]

Despite that many drugs are available for pain treatment, many patients are still suffering because of wrong choice or wrong use of analgesics. Both are determined by the degree and the nature of pain to be treated. Non-opioid drugs, especially COX-2-inhibitors are extensively evaluated. If treatment with these drugs is not sufficient, opioids have to be used. Their efficiency is outstanding and their side effects are appropriate. However, doctors and nurses are still reluctant to use opioids because of overestimation of respiratory depression and addiction.

Opioid guidelines in the management of chronic non-cancer pain

BACKGROUND

Opioid abuse has increased at an alarming rate. However, available evidence suggests a wide variance in the use of opioids, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration (DEA).

OBJECTIVES

The objective of these opioid guidelines by the American Society of Interventional Pain Physicians (ASIPP) is to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to bring consistency in opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of drug diversion.

DESIGN

A policy committee evaluated a systematic review of the available literature regarding opioid use in managing chronic non-cancer pain. This resulted in the formulation of the essentials of guidelines, a series of potential evidence linkages representing conclusions, followed by statements regarding relationships between clinical interventions and outcomes.

METHODS

Consistent with the Agency for Healthcare Research and Quality (AHRQ) hierarchical and comprehensive standards, the elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentations, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Evidence was designated based on scientific merit as Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), or Level V (indeterminate).

RESULTS

After an extensive review and analysis of the literature, the authors utilized two systematic reviews, two narrative reviews, 32 studies included in prior systematic reviews, and 10 additional studies in the synthesis of evidence. The evidence was limited.

CONCLUSION

These guidelines evaluated the evidence for the use of opioids in the management of chronic non-cancer pain and recommendations for management. These guidelines are based on the best available scientific evidence and do not constitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a "standard of care."

Opioid dosing trends and mortality in Washington State workers' compensation, 1996-2002

BACKGROUND

The use of opioids for chronic non-cancer pain has increased in the United States since state laws were relaxed in the late 1990s. These policy changes occurred despite scanty scientific evidence that chronic use of opioids was safe and effective.

METHODS

We examined opiate prescriptions and dosing patterns (from computerized databases, 1996 to 2002), and accidental poisoning deaths attributable to opioid use (from death certificates, 1995 to 2002), in the Washington State workers' compensation system.

RESULTS

Opioid prescriptions increased only modestly between 1996 and 2002. However, prescriptions for the most potent opioids (Schedule II), as a percentage of all scheduled opioid prescriptions (II, III, and IV), increased from 19.3% in 1996 to 37.2% in 2002. Among long-acting opioids, the average daily morphine equivalent dose increased by 50%, to 132 mg/day. Thirty-two deaths were definitely or probably related to accidental overdose of opioids. The majority of deaths involved men (84%) and smokers (69%).

CONCLUSIONS

The reasons for escalating doses of the most potent opioids are unknown, but it is possible that tolerance or opioid-induced abnormal pain sensitivity may be occurring in some workers who use opioids for chronic pain. Opioid-related deaths in this population may be preventable through use of prudent guidelines regarding opioid use for chronic pain.