Abuse of immediate-release opioids and current approaches to reduce misuse, abuse, and diversion

Abuse and misuse of tramadol in patients with non-oncologic pain in a region of Southern Europe

Background

Tramadol can cause dependence even within the recommended dose range. Its use has increased recently, especially in patients with chronic pain, and although a growing body of literature identifies a non-therapeutic use, patterns of misuse of tramadol is so far limited.

Methods

Two-year observational and cross-sectional study (January 2020 - December 2021) was conducted in 75 community pharmacies from Catalonia. To estimate the potential abuse and misuse of tramadol by patients visiting community pharmacy, and to establish the demographic characteristics of the tramadol users, a validated questionnaire based on the Finch criteria was designed. A total of 251 cases were registered.

Results

Data show that women were more involved (56.6%) and the highest proportion was found in the age interval of 46-65 years (42.6%). The combination of tramadol and paracetamol was reported in 54.6% of the cases and 73.7% corresponded to immediate-release tablets. In 93.6% of the cases, the request was preceded by previous use. Conversely, young men showed a higher non-prescription request for tramadol, reporting acute pain (p < 0.05). These results indicate that there is non-therapeutic use among patients who visit community pharmacies for information on two profiles.

Conclusion

This study shows that being an aged woman and suffering from chronic pain seems to involve a risk of generating dependence on tramadol. Likewise, a suspicion of recreational use of tramadol by young people has also been identified. There is a need to investigate how to manage chronic pain, given its complexity and take into account the risk of misuse that may come with tramadol. The involvement of characteristics such as gender as well as the pharmaceutical form in the development of tramadol misuse also needs to be analysed deeply. It is mandatory to evaluate the criteria for prescribing tramadol and initiatives to improve the knowledge of the health professionals and the population.

Medication safety education in nursing research: Text network analysis and topic modeling

OBJECTIVES

This study aimed to identify the knowledge structure of medication safety nursing education literature by developing schematic diagrams of the relationship between keywords from a macro perspective. This study also identifies the research topics and trends over time.

DESIGN

This quantitative content study used text network analysis to explore keywords and research topics using topic modeling within the medication safety nursing education literature.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were used to search for the medication safety nursing education literature published until December 2021.

METHODS

Keywords from 2085 articles were examined using text network analysis and topic modeling with NetMiner 4.4.3.

RESULTS

The keywords with the most frequency and the highest networking degree in centrality were "patient," "medication," "program," "nurse," and "care." The emerging keywords assessed by time periods were identified; the first phase ("heart failure," "insulin," "chemotherapy," and "infusion"), the second phase ("medication errors," "staff," and "information"), the third phase ("program," "management," and "data"). The results of topic modeling were as follows: safe medication administration, safe medication reconciliation process, medication education for patients, medication errors in nursing practice, and multidisciplinary teamwork for medication safety.

CONCLUSION

These findings will help nursing researchers and educators to understand the trends and insights for medication safety education and educate future nurses to provide safer nursing care.

Tapentadol: A Review of Experimental Pharmacology Studies, Clinical Trials, and Recent Findings

Tapentadol is an analgesic compound that acts centrally to attenuate pain. Previous studies have shown that tapentadol has dual mechanisms of action as a mu-opioid receptor agonist and noradrenaline re-uptake inhibition. Therefore, tapentadol provides a great advantage over classic opioids in pain management from nociceptive to neuropathic. Cumulative evidence from in vitro data suggests that tapentadol effect of norepinephrine re-uptake could be a new target that overcomes other classic opioids in chronic neuropathic pain. Compared to tramadol and other opioids, tapentadol is associated with fewer adverse effects than tramadol. Tapentadol is a new alternative to treat acute, chronic, and neuropathic pain. Thus, this review article was focused on understanding the studies that led to the development of tapentadol as a novel analgesic drug and its advantages over conventional opioids. Thus, tapentadol is a good alternative with fewer adverse effects and is available for human use.

Safe Opioid Storage and Disposal: A Survey of Patient Beliefs and Practices

Objective

To evaluate knowledge, practices, and beliefs of US patients receiving prescription opioids regarding opioid storage, disposal, and diversion.

Design

Internet-based, cross-sectional survey conducted between September and October 2018. Fisher’s exact tests and Kendall’s Tau-c were used to assess associations with storage and disposal outcomes.

Participants

Patients aged ≥18 years with acute (n=250) or chronic noncancer (n=250) pain were prescribed an oral opioid within 90 days of the survey.

Results

Mean (SD) patient age was 48 (14.7) years, 57.2% were female, 82.6% lived with ≥1 person in the home, and 28.0% had remaining/unused pills. One-third of all patients received safe opioid storage (35.2%) and/or disposal (31.4%) counseling from a healthcare provider, while 50.0% received neither storage nor disposal information. Only 27.4% of all patients stored their opioids in a locked location, and 17.9% of those with remaining/unused pills disposed of their medication. Patients who received any opioid counseling were more likely to keep their medication in a locked location compared with those who did not (42.4% vs 12.4%, respectively; P<0.0001), as were those who perceived any risk of opioid diversion in the home compared with those who perceived no risk or were unsure (53.7% vs 24.2%, respectively; P<0.0001). Disposal rates did not differ based on counseling received (20.8% counseled vs 16.1% not counseled; P=0.5011) or perceived diversion risk (27.8% perceived any risk vs 16.4% perceived no risk or unsure; P=0.3166).

Conclusion

The proportion of patients receiving prescription opioids who receive safe storage/disposal counseling from a healthcare provider appears suboptimal. Further research is warranted to develop effective ways to improve patient opioid storage/disposal education and practices.

Abuse-deterrent opioid analgesics: a guide for clinicians

The US FDA has encouraged the development of abuse-deterrent formulations (ADFs) of opioid analgesics as one component in a comprehensive effort to combat prescription opioid abuse. Guidance issued by the FDA outlines three types of premarket studies for evaluating abuse deterrence: laboratory-based in vitro manipulation and extraction studies, pharmacokinetic studies and human abuse potential studies. After approval, postmarket studies are needed to evaluate the impact of an ADF product on abuse in real-world settings. This review summarizes the regulatory issues involved in the development of ADF opioids and clarifies abuse-deterrence claims in product labels, in order to assist clinicians in critically evaluating the available evidence pertaining to the abuse-deterrent features of opioid analgesics.

The Tightrope Walk: Pain Management and Opioid Stewardship

Pain and pain management are a major focus for an orthopedic nurse. However, reliance upon opioid monotherapy creates adverse effects for patients and has contributed to the opioid epidemic across the United States. There have been strategies developed locally and nationally to address the epidemic. Nurses, too, have an ethical and moral obligation to balance the management of pain therapies to alleviate the suffering of their patients, all while being good stewards of opioid medications. Nurses must also take the time to properly educate their patients on good stewardship techniques including proper use and disposal of their opioid medications.

Abuse Deterrent Immediate Release Egg-Shaped Tablet (Egglets) Using 3D Printing Technology: Quality by Design to Optimize Drug Release and Extraction

Opioid abuse is a growing problem and has become a national health crisis over the past decade in the USA. Oral ingestion, snorting, and injection are the most commonly employed routes of abuse for an immediate release product. To circumvent these issues, we have developed an egg-shaped tablet (egglet) using fused deposition modeling (FDM) 3D printing technology. Drug-loaded polymeric filaments (1.5 mm) were prepared using hot melt extrusion (HME) followed by printing into egglets of different sizes and infill densities. Based on printability and crush resistance, polyvinyl alcohol (PVA) was found to be the most suitable polymer for the preparation of abuse deterrent egglets. Further, egglets were evaluated and optimized for mechanical manipulation using household equipment, milling, particle size distribution, solvent extraction, and drug release as per the FDA guidance (November 2017). A multifactorial design was used to optimize egglets for solvent extraction and drug release. Extreme hardness (> 500 N) and very large particle size (> 1 mm) on mechanical manipulation confirmed the snorting deterring property while less than 15% drug extraction in 5 min (% S_ext) demonstrated the deterrence for injection abuse. Quality target product profile D85 < 30 min and % S_ext < 15 was achieved with egglets of 6 mm diameter, 45% infill density, and 15% w/w drug loading. Dose of drug can be easily customized by varying dimension and infill density without altering the composition. HME coupled with FDM 3D printing could be a promising tool in the preparation of patient-tailored, immediate release abuse deterrent formulation.