Not so fast: the reformulation of fentanyl and breakthrough chronic non-cancer pain

[Use of rapid-onset fentanyl preparations beyond indication : A random questionnaire survey among congress participants and pain physicians]

BACKGROUND

Despite publicised advice and warnings, there are only scant data on the non-indicated prescription of rapid-onset preparations of fentanyl (ROF) in non-cancer pain (NCP). Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation.

OBJECTIVE

Initiated by the Working Group Cancer Pain and supported by the German Pain Society, a random sample survey was conducted to assess the non-indicated use of ROF.

METHODS

The survey addressed attendees of pain conferences who were given the option to fill in the questionnaires outside the conference or online. Primary endpoints of the structured questionnaire were quantitative and qualitative items with regard to the prescription of ROF, while secondary endpoints were opioid-induced side effects.

RESULTS

Obtaining a response rate of 44% (132/300) and an additional 51 online questionnaires revealed that 165 (90%) respondents had knowledge of non-indicated prescriptions or were involved in these. Of these, 65% were clinicians and 17% worked in an outpatient capacity. In all, 22% were trained pain or palliative physicians. Approximately 1205 patients were assessed indirectly. The main causes for dispensing ROF included NCP entities such as back pain (44%), neuropathic pain (33%), head or facial pain (12%), and dyspnea (5%) in cancer pain or lack of break-through pain or basic medication (44%). Sedation (32%), nausea/vomiting (31%), constipation (16%) and insufficient analgesia (31%) were the mostly commonly reported adverse effects.

CONCLUSION

Despite the non-ambiguous indication for ROF, physicians often demonstrate inappropriate prescription behaviour. Iatrogenic misuse of ROF should be minimized. The rates of adverse effects of ROF seems to be in line with other opioids.

[Dose-finding for treatment with a transdermal fentanyl patch : Titration with oral transmucosal fentanyl citrate and morphine sulfate]

To date, no studies investigating titration with oral transmucosal fentanyl for the dose-finding of transdermal fentanyl treatment have been published. In an open randomized study 60 patients with chronic malignant (n = 39) or nonmalignant pain (n = 21), who required opioid therapy according to step three of the guidelines of the World Health Organization (WHO), were investigated. In two groups of 30 patients each titration with immediate release morphine (IRM) or oral transmucosal fentanyl citrate (OTFC) was undertaken. For measurement purposes the Brief Pain Inventory (BPI) and Minimal Documentation System (MIDOS) were used. After a 24-h titration phase, in which patients documented the intensity of pain, nausea, and tiredness, treatment with transdermal fentanyl was evaluated over a 10-day period by means of the necessary dose adaptation (responder ≤ 1 dose adaptation; conversion formula 1:1 [OTFC group] vs 100:1 [IRM group]).The pain reduction over the first 24 h (titration phase) did not differ significantly between the groups. The number of responders (17 OTFC vs. 21 IRM) over the 10-day period did not show any difference either. In both groups there was a significant reduction in pain intensity (p < 0.001). Over the course of the study, there were significantly more drop-outs because of adverse effects in the OTFC group than in the IRM group (8 vs 1, p = 0.028).Oral transmucosal fentanyl citrate can be applied for the titration of transdermal fentanyl, but it does not show any clinically relevant advantage. For example, the risk of side effects-induced drop-outs was greater in the present study. Whether the unnecessary opioid switching to treat chronic pain and breakthrough pain is advantageous with regard to minimizing conversion errors cannot be definitively answered within the scope of this study.

Ask The Experts: Critical issues in cancer pain management

Rainer Sabatowski qualified as anesthesiologist in 1995 and as pain specialist in 2003. He was head of a pain clinic at the University of Cologne, Germany, from 2002 to 2007. Since 2007 he has been head of the Comprehensive Pain Center at the University Hospital "Carl Gustav Carus" at the Technical University Dresden (Germany). This is an integrated center with a focus on cancer pain management in cooperation with the Comprehensive Cancer Center (UCC) and multimodal programs for the treatment of chronic noncancer pain patients. He performed several studies on the topic of the impact of opioids on cognitive and psychomotor function and worked as an external consultant of the European Driving under the Influence of Drugs, Alcohol and Medicines (DRUID) project. Currently his team works on - among other topics - spouses' impact on the chronification processes in noncancer pain patients and on the implementation and evaluation of multimodal pain management programs for different pain populations, as well as in different clinical settings. He has spoken at many national and international pain meetings and was scientific chair of the 8th Palliative Care Congress of the German Society of Palliative Care in Dresden in 2010. He has published over 100 papers and book chapters and is on the editorial board of several pain journals. He is also a member of the advisory board of the German IASP chapter and works in several focus groups of this pain society.

[Rapid release fentanyl administration forms. Comments of the Working Group on Tumor Pain of the German Pain Society]

The spectrum of indications for rapid release fentanyl preparations is controversial. For this reason the Working Group on Tumor Pain will formulate comments on how to deal with these substances. Breakthrough pain should receive individualized therapy; therefore, the use of opioids of various galenic formulations seems to be advisable. New rapid release fentanyl preparations are suitable for alleviating spontaneous breakthrough pain in tumor patients due to a rapid but short-acting effect. However, a prior optimization of the analgesic basis medication is absolutely necessary. Uncontrolled prescription for non-cancer pain must be criticized due to the problem of addiction. The medical profession should be informed about the benefits of rapid release fentanyl preparations but must also be made aware of the risk of a rapid development of addiction and tolerance. A self-commitment of the pharmaceutical industry to waive advertising for the dangerous off-label use would be desirable. In the opinion of the Working Group on Tumor Pain the use of fentanyl should be openly discussed and further scientific investigations are imperative with the aim of formulating clear recommendations.

[Chronic non-cancer-related pain. Long-term treatment with rapid-release and short-acting opioids in the context of misuse and dependency]

Annually published data show a continual increase in the volume of opioid prescriptions in Germany, thus indicating an intensification of opioid therapy. The majority of opioids are prescribed to treat chronic non-cancer-related pain. On the basis of current guidelines, as well as in terms of the lack of data regarding long-term use of opioids and their effectiveness beyond a period of 3 months, this development must be viewed critically. With reference to four case reports, we discuss and evaluate opioid therapy in relation to medication misuse and the development of drug dependency. Particular emphasis is placed on the administration of rapid-release and short-acting opioid preparations, which we consider to be particularly problematic.

[Dependency syndrome and hyperalgesia due to an opioid therapy for curative treatable pain. Case report of an apparent palliative patient]

Opioids are an essential part of cancer pain management but particularly in this patient group physicians could misinterpret opioid-induced potentially life-threatening side effects within the central nervous system (CNS) or hyperalgesia as a consequence of tumor progression. In this case increasing the opioid dose or switching to rapidly acting opioids may trigger a vicious circle. We describe a case report of a male patient who was treated with high doses of transdermal and endonasal fentanyl 2 years after pancreatomy due to cancer. The patient was referred to the palliative care unit presenting with delirious behavior and 30-40 severe abdominal pain attacks/day. After withdrawal of the opioid medication all CNS symptoms disappeared. Further diagnostics revealed multiple incisional hernia as the reason of the pain syndrome. The patient recovered after herniotomy and has now been pain free without any pain medication for more than 16 months. This case report underlines again the necessity of pain diagnostics also in assumed palliative patients with the risks of high dose opioid treatment.

Barriers to pain management: focus on opioid therapy

Despite the availability of effective pain treatments, there are numerous barriers to effective management resulting in a large proportion of patients not achieving optimal pain control. Chronic pain is inadequately treated because of a combination of cultural, societal, educational, political and religious constraints. The consequences of inadequately treated pain are physiological and psychological effects on the patient, as well as socioeconomic implications. Unreasonable failure to treat pain is viewed as unethical and an infringement of basic human rights. The numerous barriers to the clinical management of pain vary depending on whether they are viewed from the standpoint of the patient, the physician, or the institution. Identification and acknowledgement of the barriers involved are the first steps to overcoming them. Successful initiatives to overcome patient, physician and institutional barriers need to be multifaceted in their approach. Multidisciplinary initiatives to improve pain management include dissemination of community-based information, education and awareness programmes to attempt to change attitudes towards pain treatment. A better awareness and insight into the problems caused by unrelieved pain and greater knowledge about the efficacy and tolerability of available pain management options should enable physicians to seek out and adhere to treatment guidelines, and participate in interventional and educational programmes designed to improve pain management, and for institutions to implement the initiatives required. Although much work is underway to identify and resolve the issues in pain management, many patients still receive inadequate treatment. Continued effort is required to overcome the known barriers to effective pain management.

Fentanyl (transmucosal)

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

A physician-driven solution--the Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain medicine

The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.

[Physicians' knowledge and attitudes concerning the use of opioids in the treatment of chronic cancer and non-cancer pain]

INTRODUCTION

The efficacy of opioids has been proved and several guidelines and expert panel-based recommendations regarding the use of opioids in different pain syndromes are available. Nevertheless, undertreatment of pain with strong opioids was reported in previous studies. It was shown that physicians' lack of knowledge, their concerns and misconceptions about the opioid use and the controlled substances regulations that govern the prescriptions of opioids occasionally contribute to insufficient pain treatment. This study was designed to evaluate German physicians' knowledge and their concerns about the use of opioids.

METHOD

During a postgraduate course a questionnaire was completed by German physicians specializing in pain therapy.

RESULTS

A total of 226 physicians completed the questionnaire (response rate 57%). Many of them had poor knowledge of the WHO recommendations for the treatment of cancer pain including the WHO analgesic ladder. Deficiencies in the knowledge of pharmacological aspects and controlled substances regulations were revealed. Many physicians would prescribe strong opioids for non-opioid-sensitive types of pain. The concerns regarding opioid therapy included adverse effects and addiction. In contrast to earlier findings the German controlled substances regulations no longer seem to be a barrier to the prescription of opioids in the treatment of chronic severe pain since they were changed in 1998. As a result, the lack of knowledge and the physicians' concerns about the use of opioids as shown in this survey may likely lead to an insufficient treatment of patients suffering from severe chronic pain.

CONCLUSION

It is necessary to improve the medical students' education and the physicians' postgraduate training regarding principles of pain management such as the WHO guidelines for the treatment of cancer pain. A better knowledge of important pharmacological aspects of opioids should help to reduce physicians' concerns about the use of strong opioids. Nevertheless, improvement of physicians' skills in pain therapy is only one aim in a multidisciplinary concept in order to improve patients' pain therapy.

Treatment of breakthrough pain with fentanyl buccal tablet in opioid-tolerant patients with chronic pain: appropriate patient selection and management

BACKGROUND

Opioids can be a safe and effective option for carefully selected patients with a structured treatment program that includes consistent monitoring. However, the benefits and risks of opioid therapy for patients with chronic pain, and society as a whole, have been sharply debated. A key component of this debate has involved the administration of rapid-onset opioids for the management of breakthrough pain.

OBJECTIVE

Review key aspects of breakthrough pain management with fentanyl buccal tablet, with a focus on minimizing risk to optimize therapeutic outcomes. Recommendations that apply broadly to all rapid-onset opioids are also discussed.

DESIGN

Available fentanyl buccal tablet clinical and post-marketing data were reviewed.

RESULTS

Like other schedule II controlled substances, and because fentanyl buccal tablet is a highly potent opioid, its use is associated with risk of overdose, misuse, and diversion. As with all rapid-onset opioids, particular attention to patient selection and risk assessment is warranted. The inclusion and exclusion criteria in fentanyl buccal tablet clinical studies represent patient selection standards that should be translated to clinical practice, most importantly, that patients are opioid-tolerant before fentanyl buccal tablet initiation. Titration of fentanyl buccal tablet from a low starting dose to a successful dose allows the safe identification of a dose that provides the greatest pain relief without unacceptable adverse events. After initiating fentanyl buccal tablet therapy, all patients should continue to be regularly monitored for response, including analgesia, functioning, tolerability, and aberrant behavior.

CONCLUSIONS

Fentanyl buccal tablet can be an effective and generally safe treatment for breakthrough pain when appropriate patient selection, administration, dosing, and monitoring are applied.

Synthesis and investigations of double-pharmacophore ligands for treatment of chronic and neuropathic pain

Acids 9a-f as possible bivalent ligands designed as a structural combination of opioid mu-agonist (Fentanyl) and NSAID (Indomethacin) activities and produced compounds which were tested as analgesics. The obtained series of compounds exhibits low affinity and activity both at opioid receptors and as cyclooxygenase (COX) inhibitors. One explanation of the weak opioid activity could be stereochemical peculiarities of these bivalent compounds which differ significantly from the fentanyl skeleton. The absence of significant COX inhibitory properties could be explained by the required substitution of an acyl fragment in the indomethacin structure for 4-piperidyl.