chronic-pain-opioid-treatment-report-140929

Key Question 3cIn patients with chronic pain, what is the comparative effectiveness ofdifferent long-acting opioids on outcomes related to pain, function, andquality of life; and risk of overdose, addiction, abuse, or misuse?Key Points• Three randomized, head-to-head trials of various long-acting opioids found nodifferences in long-term outcomes related to pain or function (SOE: Low).• No trial was designed to assess risk of overdose, addiction, abuse, or misuse (SOE:Insufficient).• One cohort study found sustained-release methadone to be associated with lowermortality risk (presumably related to accidental overdose) as compared to morphine in apropensity-adjusted analysis (SOE: Low).• Another cohort study found some differences between long-acting opioids in rates ofadverse outcomes related to abuse, but outcomes were nonspecific for opioid-related adverseevents, precluding reliable conclusions (SOE: Insufficient).Detailed SynthesisThe APS review included one fair-quality, open-label randomized trial (n=680) of transdermalfentanyl versus sustained-release morphine in patients with chronic low back pain that evaluatedoutcomes through 13 months 43 (Table 2 below; Appendix E8a, E8b, and F4). The study found nodifferences between these long-acting opioids in pain relief, pain intensity, use of supplementalanalgesic medications, work loss, and quality of life. The study was not designed to assessoverdose and addiction or related outcomes, and no cases of these outcomes were reported. TheAPS review also included a fair-quality retrospective cohort study based on Oregon Medicaidadministrative data (n=5,684) that evaluated abuse and other related outcomes in patients withcancer or noncancer pain and at least one new 28-day prescription of methadone, sustainedreleaseoxycodone, sustained-release morphine, or transdermal fentanyl over a 4-yeartimeframe. 95 Adverse events were based on clinical encounters and ICD-9 codes and defined asemergency department (ED) visits or hospitalization for opioid-related events, all-cause ED visitsor hospitalizations, opioid poisoning, overdose symptoms, and death. After adjusting for opioiddose, co-morbidities, concomitant medications, and other potential confounders, sustained-releaseoxycodone was associated with lower risk than sustained-release morphine of an ED encounter orhospitalization involving an opioid-related adverse event (HR 0.45, 95 percent CI 0.26 to 0.77) ordeath (HR 0.71, 95 percent CI 0.54 to 0.94). Among patients with noncancer pain, compared withsustained-release morphine, fentanyl was associated with higher risk of ED encounters (HR 1.27,95 percent CI 1.02 to 1.59) and methadone was associated with greater risk of overdosesymptoms (HR 1.57, 95 percent CI 1.03 to 2.40). There were no significant differences betweenmethadone and long-acting morphine in risk of death (adjusted HR 0.71, 95 percent CI 0.46 to1.08) or overdose symptoms. Some limitations of this study include large, statistically significantdifferences in baseline characteristics between patients prescribed different long-acting opioidsand analysis of outcomes not specific for opioid-related adverse events. For example, overdosesymptoms were defined as alteration of consciousness, malaise, fatigue, lethargy, or respiratoryfailure.30