Taking Control: Emerging Issues in Pain ... - Pharmacy Times

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Equianalgesic Dose Table: Conclusions • Equianalgesic dose table is only starting point for creation of guidelines for opioid rotation • Selection of starting dose of new drug based on table must be followed by dose reduction because of : - Concern about generalizability of relative potency estimate in heterogeneous population - Concern about incomplete cross-tolerance • Uninformed use of table is dangerous Opioid Classification Category Benefits Drugs* Short-acting: for intermittent and breakthrough pain 1 Easier to titrate More rapidly attained steady-state plasma concentrations 2 Morphine sulfate Codeine Hydrocodone Oxycodone Hydromorphone Fentanyl Oxymorphone Levorphanol Extended-Release Opioids May Be Better Suited for Treatment of Chronic Pain • Extended-release opioids may have greater utility than immediate-release opioids in treating chronic pain patients • Fewer peaks = less risk for overmedication, side effects, euphoria • Fewer troughs = less end-of-dose breakthrough pain Long-acting: For treating chronic pain in patients with consistent pain levels 3,4 Makes around-theclock therapy possible Dosing convenience and flexibility Relative steady-state concentrations of opioid concentrations in the blood 3,4 Morphine (sustained-release) Oxycodone (sustained-release) Transdermal fentanyl Hydromorphone (sustained-release) Methadone Oxymorphone Levorphanol 1.NPC/JCAHO. Pain: Current Understanding of Assessment, Management, and Treatments. December 2001. 2. Cherny NI. CA— Serum Level Dose Immediate-release Toxic Pain Relief No Relief Dose Time End-of-dose BTP Serum Level Dose Extended-release Time Toxic Pain Relief No Relief Cancer J Clin. 2000;50:70-116. 3. McCarberg BH, Barkin RL. Am J Ther. 2001;8:181-186. 4. AGS Panel on Chronic Pain in Older McCarberg BH, et al. Am J Ther. 2001;8:181-186. Persons. J Am Geriatr Soc. 1998;46:635-651. Short-Acting vs. Long-Acting Opioids Conventional Practice: Opioid Treatment Advantages Disadvantages Short-Acting Opioids Fast-acting; appropriate for acute pain, breakthrough pain Need for repetitive dosing Long-Acting Opioids May be more appropriate for patients with a constant pain component; analgesic stability Initial delayed onset of action • Role of opioid therapy in chronic pain controversial • Trial of opioid therapy may be considered in all cases of moderate-to-severe pain but decision to proceed requires case-by-case analysis: • Conventional practice • Availability of other therapies with equal or better therapeutic index • Risk of adverse drug effects • Assessed risk of drug abuse, addiction, diversion Fine P, Portenoy RK. Opioid Analgesia. New York: McGraw Hill; 2004.
Conventional Practice: Opioid Treatment (cont.) • Opioid therapy potentially analgesic in all types of acute and chronic pain: • Consensus: Opioid therapy used first-line for severe acute pain • Consensus: Opioid therapy used first-line for moderateto-severe chronic pain related to: o o o Cancer HIV/AIDS Advanced medical illness of any type Opioids for Chronic Pain: Status of Data • Opioids for noncancer pain: • Systematic review of open-label prospective studies through April 2007 • 17 studies (N=3079) of oral, transdermal, or neuraxial opioid for any type of pain • Study duration at least 6 months • Results: • Many patients discontinued treatment due to side effects or poor response (oral, 32.5%; transdermal, 17.5%; neuraxial, 6.3%) • Signs of addiction in 0.05% of patients • Signs of abuse in 0.43% of patients Fine P, Portenoy RK. Opioid Analgesia. New York: McGraw Hill; 2004. Noble M et al. J Pain Symptom Manage. 2008;35:214-228 . • Results: Opioids for Chronic Pain: Status of Data (cont.) • Small but significant pain reduction for oral therapy (mean, 1.99 points) and neuraxial therapy (mean, 1.33 points) • Insufficient data on transdermal therapy • Conclusion: • Many patients discontinue therapy • Among patients who continue therapy, weak evidence on pain relief over time • Insufficient data regarding other long-term outcomes, including function and drug abuse Opioid Treatment of Chronic Pain Patient Assessment Trial of Opioid Therapy Patient Reassessment Other Therapies for Pain Continue Opioid Therapy Exit Strategy Noble M et al. J Pain Symptom Manage. 2008;35:214-228. Prescription Abuse Across the Lifespan Prevalence of Substance Use Disorders – US General Population • 8.7% of general population ≥ age 12 classified with substance dependence or abuse • Alcohol: 15 million • Illicit drugs: 4.2 million • 20.5 million needed treatment but did not receive it • Number of people receiving treatment for nonmedical pain reliever use more than doubled from 2002-2010 Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011.
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