How frequently are contraindicated or warned against combinations of drugs prescribed to patients receiving long-term opioid therapy for chronic pain?

CYP2D6 phenotypes and opioid metabolism: the path to personalized analgesia

INTRODUCTION

Opioids play a fundamental role in chronic pain, especially considering when 1 of 5 Europeans adults, even more in older females, suffer from it. However, half of them do not reach an adequate pain relief. Could pharmacogenomics help to choose the most appropriate analgesic drug?

AREAS COVERED

The objective of the present narrative review was to assess the influence of cytochrome P450 2D6 (CYP2D6) phenotypes on pain relief, analgesic tolerability, and potential opioid misuse. Until December 2021, a literature search was conducted through the MEDLINE, PubMed database, including papers from the last 10 years. CYP2D6 plays a major role in metabolism that directly impacts on opioid (tramadol, codeine, or oxycodone) concentration with differences between sexes, with a female trend toward poorer pain control. In fact, CYP2D6 gene variants are the most actionable to be translated into clinical practice according to regulatory drug agencies and international guidelines.

EXPERT OPINION

CYP2D6 genotype can influence opioids' pharmacokinetics, effectiveness, side effects, and average opioid dose. This knowledge needs to be incorporated in pain management. Environmental factors, psychological together with genetic factors, under a sex perspective, must be considered when you are selecting the most personalized pain therapy for your patients.

Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions

The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.

The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article

Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.

Opioid Management in Older Adults with Chronic Kidney Disease: A Review

Chronic pain, a common comorbidity of chronic kidney disease, is consistently under-recognized and difficult to treat in older adults with nondialysis chronic kidney disease. Given the decreased kidney function associated with aging and chronic kidney disease, these patients are at increased risk for drug accumulation and adverse events. Emerging research has demonstrated the efficacy of opioids in chronic kidney disease patients, but research specifically focusing on older, nondialysis chronic kidney disease patients is scarce. The primary objective of this review is to determine which oral and transdermal opioids are the safest for older, nondialysis chronic kidney disease patients. We discuss the limited existing evidence on opioid prescription in older, nondialysis chronic kidney disease patients and provide recommendations for the management of oral and transdermal opioids in this patient population. Specifically, transdermal buprenorphine, transdermal fentanyl, and oral hydromorphone are the most tolerable opioids in these patients; hydrocodone, oxycodone, and methadone are useful but require careful monitoring; and tramadol, codeine, morphine, and meperidine should be avoided due to risk of accumulation and adverse events. Because older adults with nondialysis chronic kidney disease are at increased risk for adverse events, vigilant monitoring of opioid prescription is critical. Lastly, collaboration among an interprofessional clinical team can ensure safe prescription of opioids in older adults with nondialysis chronic kidney disease.

Inappropriate opioid prescribing practices: A narrative review

Purpose

Results of a literature review to identify indicators of inappropriate opioid prescribing are presented.

Summary

While prescription opioids can be effective for the treatment of acute pain, inappropriate prescribing practices can increase the risk of opioid-related harms, including overdose and mortality. To date, little research has been conducted to determine how best to define inappropriate opioid prescribing. Five electronic databases were searched to identify studies (published from database inception to January 2017) that defined inappropriate opioid prescribing practices. Search terms varied slightly across databases but included opioid, analgesics, inappropriate prescribing, practice patterns, and prescription drug misuse. Gray literature and references of published literature reviews were manually searched to identify additional relevant articles. From among the 4,665 identified articles, 41 studies were selected for data extraction and analysis. Fourteen studies identified high-daily-dose opioid prescriptions, 14 studies identified coadministration of benzodiazepines and opioids, 10 studies identified inappropriate opioid prescribing in geriatric populations, 8 studies identified other patient-specific factors, 4 studies identified opioid prescribing for the wrong indication, and 4 studies identified factors such as initiation of long-acting opioids in opioid-naive patients as indicators of inappropriate opioid prescribing.

Conclusion

A literature review identified various indicators of inappropriate opioid prescribing, including the prescribing of high daily doses of opioids, concurrent benzodiazepine administration, and geriatric-related indicators. Given the significant contribution of inappropriate opioid prescribing to opioid-related harms, identification of these criteria is important to inform and improve opioid prescribing practices among healthcare providers.

Health benefits of an adverse events reporting system for chronic pain patients using long-term opioids

BACKGROUND

Safety data from long-term opioid therapy in the real world has been poorly studied in chronic non-cancer pain (CNCP). The aim was to design a pharmacovigilance data recording system and assess whether participation in this recording system improves pain management, enhancing patient's health status.

METHODS

A pharmacovigilance data recording system was conducted during 24 months. Data were self-reported by patients (pain, adverse events [AEs] and healthcare resources use) and physicians (morphine equivalent daily dose [MEDD] prescribed and suspected adverse drug reaction [ADRs]). Outcomes from patients with (case) or without (controls) suspected ADRs and cases follow-up were also compared with Spanish Pharmacovigilance System data.

RESULTS

A total of 753 patients were recruited in 897 visits. Fentanyl and tramadol were the most prescribed opioids, 89% with concomitant drugs, pregabalin being the one with the most potential drug interactions. Cases presented significantly higher pain intensity (VAS 67 ± 26 vs 59 ± 30 mm, P < 0.05), number of AEs (8 ± 6 vs 5 ± 3 AEs/patient, P < 0.01), polypharmacy related to pain (65% vs 34%, P < 0.01) and MEDD (139 ± 130 vs 106 ± 99 mg/d, P < 0.01) than controls. Furthermore, cases presented significant higher changes in pharmacological pain therapy due to pain, unplanned emergency visits and hospital admission than controls. Physicians notified 168 suspected ADRs mostly related to neurological or psychiatric events and 8% of them were previously unknown.

CONCLUSIONS

This data recording system provided important information to achieve a better control of CNCP pharmacological pain therapy, improving patient's health status and reducing costs to the Health System.

Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015)

INTRODUCTION

We assess trends in opioid administration and prescribing from 2005-2015 in older adults in United States (U.S.) emergency departments (ED).

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) survey from 2005 to 2015. ED visits for painful conditions were selected and stratified by age (18-64, 65-74, 75-84, ≥ 85 years). We analyzed trends in opioid administration in the ED and prescribing at discharge to encounters ≥ 65 and assessed predictors of use using survey-weighted chi-square tests and logistic regression. Trends in the use of five commonly prescribed opioids were also explored.

RESULTS

Opioid administration in the ED and prescribing at discharge for encounters with patients ≥ 65 years fell overall, but not significantly. By contrast, opioid administration in the ED and prescribing at discharge significantly declined for adult encounters 18-64 by 20% and 32%, respectively. A similar proportion of adult encounters ≥ 65 were administered opioids in the ED as 18-64, but adult encounters ≥ 85 had the lowest rates of administration. A smaller proportion of adult encounters ≥ 65 years with painful conditions were prescribed opioids at discharge compared to <65. However, this age-related disparity in prescribing narrowed over the study period. There were shifts in the specific types of opioids administered and prescribed in adult encounters ≥ 65 years over the study period, with the most notable being a 76% increase in hydromorphone administration comparing 2005-06 to 2014-15.

CONCLUSION

From 2005-15, 1 in 4 to 1 in 10 ED patients with painful conditions were administered or prescribed an opioid in U.S. EDs. Opioids prescribing increased from 2005-11 and then declined from 2012-15, more so among visits in the 18-64 age group compared to ≥ 65 years. Opioid administrating demonstrated a gradual rise and decline in all adult age groups. Age consistently appears to be an important consideration, where opioid prescribing declines with advancing age. Given the nationwide opioid crisis, ED providers should remain vigilant in limiting opioids, particularly in older adults who are at higher risk for adverse effects.

Take-home naloxone treatment for opioid emergencies: a comparison of routes of administration and associated delivery systems

INTRODUCTION

Naloxone reversal of opioid-induced respiratory depression outside of medical facilities has become more prevalent because of the escalating opioid epidemic in the USA. Take-home naloxone for treatment of opioid emergencies is now being recommended by numerous federal, state, and professional organizations. Areas covered: The scope of the opioid overdose epidemic is reviewed along with practical, clinical, regulatory, and usability considerations for take-home naloxone routes of administration currently available and associated delivery systems. Specific opioid-related factors are discussed in detail with emphasis placed on life-threatening respiratory depression and naloxone antagonism. A clinical overview, including pharmacokinetic and FDA approval information for each take-home naloxone product is discussed in detail as well as the impact of take-home naloxone in the community. Finally, given these products are to be used in a panic-stricken, life-threatening opioid emergency, an analysis of available usability data is provided with proposed directions for further study. Expert opinion: Based on the available clinical evidence, auto-injectable naloxone should be the preferred administration route for take-home naloxone treatment until additional safety, efficacy, and comparative outcomes data are available for unconventional routes of administration that unequivocally provide equal or superior results.

The Role of Opioid Analgesics in Geriatric Pain Management

When possible, chronic noncancer pain (CNCP) in older adults should be managed by nonpharmacologic modalities in conjunction with nonopioid analgesics. If moderate-to-severe pain persists despite these approaches, however, nonparenteral opioids may be considered as adjunctive therapy. This article reviews the epidemiology of opioid use and their effectiveness for CNCP in older adults and summarizes important age-related changes in opioid pharmacokinetics and pharmacodynamics that increase the risks of adverse effects in the elderly. Finally, to assist clinicians with selecting appropriate therapy, the article concludes with an evidence-based approach to optimize opioid prescribing in older adults with CNCP.

Trends in Opioid Dosing Among Washington State Medicaid Patients Before and After Opioid Dosing Guideline Implementation

By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In 2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used.

PERSPECTIVE

Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Changes in opioid prescribing for Washington workers' compensation claimants after implementation of an opioid dosing guideline for chronic noncancer pain: 2004 to 2010

An opioid overdose epidemic emerged in the United States following increased opioid prescribing for chronic noncancer pain. In 2007, Washington State agencies implemented an opioid dosing guideline on safe prescribing for chronic noncancer pain. The objective of this population-based observational study was to evaluate opioid use and dosing before and after guideline implementation. We identified 161,283 workers aged 18 to 64 years with ≥1 opioid prescriptions in Washington Workers' Compensation, April 1, 2004, to December 31, 2010. Prevalence and incidence rates of opioid use were assessed. We compared pre- and postguideline chronic and high-dose use (≥120 mg/d) among incident users. The mean monthly prevalence of opioid use declined by 25.6% between 2004 (14.4%) and 2010 (10.7%). Fewer incident users went on to chronic opioid therapy in the postguideline period (4.7%; 95% confidence interval [CI], 4.5-5.0%) than in the preguideline period (6.3%; 95% CI, 6.1-6.6%). Compared with preguideline incident users, postguideline incident users were 35% less likely to receive high doses (adjusted odds ratio = .65; 95% CI, .59-.71). Although the extent to which decreases were due to the guidelines is uncertain, to our knowledge, this is the first report of significant decreases in chronic and high-dose prescription opioid use among incident users.

PERSPECTIVE

Evidence-based strategies for opioid risk management are needed to help abate the epidemic of opioid-related morbidity and mortality. The study findings suggest that opioid dosing guidelines that specify a "yellow flag" dosing threshold may be a useful tool in preventing escalation of doses into ranges associated with increased mortality risk.

Prescribing opioids in older people

People are living to older age. Demographic pressures are driving change. Opiate analgesics are the most powerful known pain relievers. Persistent pain, both cancer and non-cancer types is frequent in older adults. The use of opioid analgesics is appropriate in the treatment of moderate to severe persistent pain. The challenge of prescribing opioids in older adults is to understand the factors involved in making appropriate choices and monitoring the beneficial effects of pain relief while managing the side-effects. This article will review the current concepts, evidence and controversies surrounding opiate use in the elderly. An approach is outlined which involves: pain assessment, screening for substance abuse potential, deciding whether you are able to treat your patient without help, starting treatment, monitoring effectiveness of pain control and managing opioid-associated side-effects. The goal of pain management using opioids is the attainment of improved function and quality of life.