Diversion and Illicit Sale of Extended Release Tapentadol in the United States

Abuse of tapentadol compared to other atypical opioids among individuals entering treatment for opioid use disorders

OBJECTIVE

Tapentadol is an atypical opioid analgesic thought to have dual mechanisms of action: µ-receptor agonism and inhibition of norepinephrine reuptake. Unlike other atypical opioids, tapentadol is a schedule II-controlled substance. We compared the prevalence of abuse (use to get high) of tapentadol to other atypical opioids used to treat pain (buprenor-phine and tramadol).

DESIGN

An observational, serial cross-sectional study.

SETTING

Individuals enrolling in treatment programs for opioid use disorder in 2019. Each completed a self-administered, paper questionnaire assessing prescription drug abuse and illegal drug use within 1 week of enrollment.

MAIN OUTCOME MEASURES

Indication of past month abuse of tapentadol or comparator drugs on a self-administered ques-tionnaire.

RESULTS

There were 6,987 respondents. Unadjusted and utilization-adjusted logistic regression models were used to compare odds of endorsement of tapentadol to tramadol and buprenorphine products indicated for the management of pain. Unadjusted abuse prevalence was 0.20 percent for total tapentadol (0.03 percent for NUCYNTA® and 0.06 percent for NUCYNTA ER). Relative to total tapentadol, the odds of abuse of buprenorphine for pain was 2.9 times greater (95 percent CI: 1.6 to 5.3, p < 0.001), and for tramadol, 43.1 times greater (95 percent CI: 25.3 to 73.3, p < 0.001). Adjusting for prescriptions dispensed, differences in odds of abuse were not statistically significant (odds ratio (OR) = 1.6, 95 per-cent CI: 0.9 to 3.0, p = 0.108 for buprenorphine for pain and OR = 0.7, 95 percent CI: 0.4 to 1.2, p = 0.209 for tramadol).

CONCLUSIONS

Tapentadol use to get high is less frequent than other atypical opioids. Findings suggest tapentadol is rarely the primary drug abused by an individual.

Characterizing the Experience of Tapentadol Nonmedical Use: Mixed Methods Study

Background

The prevalence of abuse, diversion, and web-based endorsement of tapentadol (extended-release [ER], immediate-release [IR]) has been characterized as low compared with other prescription opioids. Little is known about individual experience with tapentadol nonmedical use (NMU).

Objective

This study aims to pilot web-based survey technologies to investigate the motivation for tapentadol NMU, sources of procurement, routes of administration, tampering methods, doses used, and impressions of tapentadol products (Nucynta and Nucynta ER).

Methods

Recruitment flyers and banner advertisements were placed on the Bluelight website [DragonByte Technologies Ltd] with a link to a web-based survey (Qualtrics) designed to query about individuals’ lifetime tapentadol NMU. This web-based survey was followed by an interactive web-based chat (Cryptocat) with respondents who were willing to be contacted. Respondents were queried about sources for obtaining tapentadol, motives for use, routes of administration, tampering methods, drugs used in combination, tablet strengths and dosages, and reasons for continued or discontinued use. Desirability and attractiveness for NMU was rated.

Results

Web-based recruitment successfully attracted difficult-to-find study participants. A total of 78 participants reported that tapentadol was obtained from friends and family (ER 11/30, 37%; IR 18/67, 27%), the internet (ER 11/30, 37%; IR 12/67, 18%) or participants’ own prescriptions from a doctor (ER 9/30, 30%; IR 17/67, 25%). It was used nonmedically for pain relief (ER 18/30, 60%; IR 33/67, 49%) and multiple psychotropic effects, including relaxation (ER 13/30, 43%; IR 29/67, 43%), reduction in depression or anxiety (ER 7/30, 23%; IR 30/67, 45%), or getting high (ER 12/30, 40%; IR 33/67, 49%). Tapentadol was primarily swallowed (ER 22/30, 73%; IR 55/67, 82%), although snorting (ER 2/30, 7%; IR 8/67, 12%) and injection (ER 2/30, 7%; IR 5/67, 8%) were also reported. The preferred dose for NMU was 100 mg (both ER and IR). The participants reported tapentadol use with benzodiazepines (ER 12/21, 57%; IR 28/47, 60%). Most participants had discontinued tapentadol NMU at the time of survey completion (ER 22/30, 73%; IR 55/67, 82%). Reasons for discontinued ER NMU included side effects (10/22, 46%) and lack of effective treatment (10/22, 46%). Reasons for discontinued IR NMU included lack of access (26/55, 47%) and better NMU options (IR 21/55, 38%). Few individuals were willing to divulge identifying information about themselves for the interactive chat (8/78, 10%), demonstrating the strength of anonymous, web-based surveys. Interactive chat supported the survey findings. A subgroup of participants (4/78, 5%) reported hallucinogenic side effects with high doses.

Conclusions

Web-based surveys can successfully recruit individuals who report drug NMU and those who are difficult to find. Tapentadol NMU appears to occur primarily for pain relief and for its psychotropic effects. Although it was liked by some, tapentadol did not receive a robust pattern of endorsement for NMU.

Web-Based Discussion and Illicit Street Sales of Tapentadol and Oxycodone in Australia: Epidemiological Surveillance Study

Background

Opioid use disorder and its consequences are a persistent public health concern for Australians. Web activity has been used to understand the perception of drug safety and diversion of drugs in contexts outside of Australia. The anonymity of the internet offers several advantages for surveilling and inquiring about specific covert behaviors, such as diversion or discussion of sensitive subjects where traditional surveillance approaches might be limited.

Objective

This study aims to characterize the content of web posts and compare reports of illicit sales of tapentadol and oxycodone from sources originating in Australia. First, post content is evaluated to determine whether internet discussion encourages or discourages proper therapeutic use of the drugs. Second, we hypothesize that tapentadol would have lower street price and fewer illicit sales than oxycodone.

Methods

Web posts originating in Australia between 2017 and 2019 were collected using the Researched Abuse, Diversion, and Addiction-Related Surveillance System Web Monitoring Program. Using a manual coding process, unstructured post content from social media, blogs, and forums was categorized into topics of discussion related to the harms and behaviors that could lead to harm. Illicit sales data in a structured format were collected through a crowdsourcing website between 2016 and 2019 using the Researched Abuse, Diversion, and Addiction-Related Surveillance System StreetRx Program. In total, 2 multivariable regression models assessed the differences in illicit price and number of sales.

Results

A total of 4.7% (28/600) of tapentadol posts discussed an adverse event, whereas 10.27% (95% CI 9.32-11.21) of oxycodone posts discussed this topic. A total of 10% (60/600) of tapentadol posts discussed unsafe use or side effects, whereas 20.17% (95% CI 18.92-21.41) of oxycodone posts discussed unsafe use or side effects. There were 31 illicit sales reports for tapentadol (geometric mean price per milligram: Aus $0.12 [US $0.09]) and 756 illicit sales reports for oxycodone (Aus $1.28 [US $0.91]). Models detected no differences in the street price or number of sales between the drugs when covariates were included, although the potency of the pill significantly predicted the street price (P<.001) and availability predicted the number of sales (P=.03).

Conclusions

Australians searching the web for opinions could judge tapentadol as safer than oxycodone because of the web post content. The illicit sales market for tapentadol was smaller than that of oxycodone, and drug potency and licit availability are likely important factors influencing the illicit market.

Assessing open science and citizen science in addictions and substance use research: A scoping review

BACKGROUND

The EU promotes 'Open Science' as a public good. Complementary to its implementation is Citizen Science, which redefines the relationship between the scientific community, civic society and the individual. Open Science and Citizen Science poses challenges for the substance use and addictions research community but may provide positive opportunities for future European addiction research. This paper explores both current barriers and potential facilitators for the implementation of Open Science and Citizen Science in substance use and addictions research.

METHODOLOGY

A scoping review was used to examine barriers and facilitators identified in the substance use and addiction research literature for the adoption of Open Science and Citizen Science.

RESULTS

'Technical' facilitators included the pre-registration of study protocols; publication of open-source datasets; open peer review and online tools. 'Motivational' facilitators included enhanced reputation; embracing co-creation; engaged citizenship and gamification. 'Economic' facilitators included the use of free tools and balanced remuneration of crowdworkers. 'Political' facilitators included better informed debates through the 'triple helix' approach and trust-generating transparency. 'Legal' facilitators included epidemiologically informed law enforcement; better policy surveillance and the validation of other datasets. 'Ethical' facilitators included the 'democratisation of science' and opportunities to explore new concepts of ethics in addiction research.

CONCLUSION

Open Science and Citizen Science in substance use and addictions research may provide a range of benefits in relation to the democratisation of science; transparency; efficiency and the reliability/validity of data. However, its implementation raises a range of research integrity and ethical issues that need be considered. These include issues related to participant recruitment; privacy; confidentiality; security; cost and industry involvement. Progressive journal policies to support Open Science practices; a shift in researcher norms; the use of free tools and the greater availability of methodological and ethical standards are likely to increase adoption in the field.

The opioid epidemic from the acute care hospital front line

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.

Evaluation of Abuse and Route of Administration of Extended-Release Tapentadol Among Treatment-Seeking Individuals, as Captured by the Addiction Severity Index-Multimedia Version (ASI-MV)

Background

Tapentadol is a molecule incorporating mu opioid receptor agonism and norepinephrine reuptake inhibition to provide analgesia, with the potential for a lower incidence of gastrointestinal side effects than full mu opioid agonists. Postmarketing surveillance of tapentadol as an active pharmaceutical ingredient has consistently revealed low levels of abuse and diversion.

Objective

The purpose of the present study was to further characterize the abuse liability of tapentadol extended-release (ER) by evaluating the prevalence of past 30-day tapentadol ER abuse and reported routes of administration as compared with ER opioids with Food and Drug Administration (FDA) abuse-deterrent labeling (“ADF opioids”) and ER opioids without FDA abuse-deterrent labeling (“non-ADF opioids”).

Methods

Data were collected from January 2014 through December 2017 from 776 centers located in 43 states throughout the United States using the Addiction Severity Index–Multimedia Version (ASI-MV), an instrument that is integral to the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO, Inflexxion, an IBH Company, Costa Mesa, CA, USA).

Results

Tapentadol ER had lower rates of past 30-day abuse than ADF ER and non-ADF ER opioid comparators, both at a population level and when adjusted for drug utilization. Tapentadol ER was primarily abused orally, although it was also abused through alternate routes of administration. Cumulative rates of tapentadol ER abuse by alternative routes of administration were lower than both ADF and non-ADF ER opioid comparators, although large confidence intervals resulting from the small sample size of reported tapentadol ER use limit firm conclusions.

Conclusions

In summary, tapentadol ER was found to have lower rates of both past 30-day abuse and use via alternate routes of administration, specifically snorting and smoking, than ADF and non-ADF ER comparators.

Leveraging black-market street buprenorphine pricing to increase capacity to treat opioid addiction, 2010-2018

Increasing capacity to provide buprenorphine, a treatment for opioid addiction, can help mitigate the opioid epidemic in the United States. This study models black-market pricing of buprenorphine to better understand supply and demand for opioid addiction treatment. A mixed effects linear model was used to quantify the effect of county-level racial composition, health insurance coverage, and drug characteristics on price variation. From November 2010 to June 2018, there were 2481 submissions for street buprenorphine transactions in the StreetRx dataset. The mean price was $3.95/mg (SD = $23.12/mg). Price decreased 3.05% each year and was highest in the summer and spring. Brand name buprenorphine was on average 11.18% more expensive than generic buprenorphine. Buprenorphine/naloxone combinations were on average 19.75% less expensive than pure buprenorphine. Purchases in bulk were on average 10.51% cheaper than purchases not in bulk. Street buprenorphine in film form was on average 14.34% more expensive than in pill/tablet form. Buprenorphine street price was 17.12% higher in spring and 22.26% higher in summer compared to fall. For every percentage point increase in percent white, buprenorphine sold for 0.88% higher price. For every percentage point increase in health insurance coverage, street buprenorphine sold for 0.02% lower price. Findings demonstrate that geographic, demographic, and socioeconomic factors shape the diversion of opioid addiction treatment to the black-market. Buprenorphine street pricing can help estimate public need, gaps in care and emerging public health priorities.

Interpol review of controlled substances 2016-2019

This review paper covers the forensic-relevant literature in controlled substances from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20Papers%202019.pdf.

Tapentadol abuse and dependence in India

BACKGROUND

Tapentadol is a synthetic opioid analgesic available in India since 2011. International evidence suggests a low risk of abuse and diversion. Our study aims to question this perception in Indian context.

METHOD

We report the trend and profile of Tapentadol abuse cases that were treated at a tertiary level addiction treatment centre in southern India. We also describe the ease of repurposing oral tablets of Tapentadol into an injection. At the national level, we have examined the temporal and spatial trends of online interest in Tapentadol and compared it with a non-opioid drug Ilaprazole and an opioid drug Tramadol using Google Trends. We have used the National Drug Use Survey 2019 to illustrate the regional data.

RESULTS

23 cases of Tapentadol abuse sought treatment between 01/01/2011 and 30/08/2019. In last one year, the number of cases has more than doubled. A majority (N = 19, 83 %) of cases had intravenous Tapentadol abuse, needle sharing and 60 % were diagnosed with Hepatitis C. Tapentadol is attracting new users (N = 13, 56.5 %) as well as replacing other opioids (N = 10, 43.5 %) amongst drug users. Tapentadol has received more online interest than Ilaprazole. Temporal and spatial trends of online interest in Tapentadol parallel Tramadol. States with high prevalence of opioid users have shown high online interest in both opioid drugs.

CONCLUSION

Tapentadol is being widely abused, and urgent regulatory measures are required.

Opioid use and harms associated with a sustained-release tapentadol formulation: A post-marketing surveillance study

AIMS

A sustained-release formulation (SRF) of tapentadol has been marketed in Australia since February 2013. This study examined tapentadol SRF extra-medical use, attractiveness for extra-medical use, and associated harms in Australia.

METHODS

This post-marketing study comprises analyses of Australian community sales data (2011-2017) for eleven pharmaceutical opioids (prescription and over-the-counter codeine disaggregated); calls to three poisons information centres (covering five of the eight jurisdictions in Australia) related to pharmaceutical opioids and coded by the centres as 'misuse' or 'abuse' (2011-2017); and interviews with people who inject drugs (n = 888) recruited as part of the Illicit Drug Reporting System (IDRS) from all Australian capital cities (2017).

RESULTS

Population-level availability of tapentadol SRF increased from market launch, comprising the sixth largest market share of all opioid unit sales, and third greatest share in oral morphine equivalent milligrams sold, in December 2017. Lifetime tapentadol SRF use among the IDRS sample (n = 888) was low (1.5%; 95%CI 0.9-2.5), with few reporting past-6 month non-prescribed use or injection. Non-fatal overdose following tapentadol use was self-reported by less than 1% (95%CI 0.1-0.8). Between 2013-2017, 1.1% (n = 25) of pharmaceutical opioid 'misuse/abuse' calls were related to tapentadol, and predominantly the SRF.

CONCLUSIONS

Increasing utilisation of tapentadol sustained-release formulation was observed, along with indications of extra-medical use and harms associated with use, although on a smaller scale relative to other opioids. These findings need to be interpreted in the context of the low level of exposure to tapentadol sustained-release formulation among the sentinel population of people who inject drugs.

Scoring the best deal: Quantity discounts and street price variation of diverted oxycodone and oxymorphone

PURPOSE

Diverted prescription opioids are significant contributors to drug overdose mortality. Street price has been suggested as an economic metric of the diverted prescription opioid black market. This study examined variables that may influence the street price of diverted oxycodone and oxymorphone.

METHODS

A cross-sectional study was conducted utilizing data from the previously validated, crowdsourcing website StreetRx. Street price reports of selected oxycodone and oxymorphone products, between August 22, 2014 and June 30, 2016, were considered for analysis. Geometric means and 95% confidence intervals were calculated comparing prices per milligram of drug in US dollars. Univariate and multivariable regressions were used to examine the influence of dosage strength, drug formulation, and bulk purchasing on street price.

RESULTS

A total of 5611 oxycodone and 1420 oxymorphone reports were analyzed. Across various dosages and formulations, geometric mean prices per milligram ranged between $0.12 and $1.07 for oxycodone and $0.73 and $2.90 for oxymorphone. For a 2-fold increase in dosage strength, there is a 24.0% (95% CI: -28.1%, -19.6%, P < 0.001) and a 22.5% (95% CI: -24.2%, -20.8%, P < 0.001) decrease on average in price per milligram for oxycodone and oxymorphone, respectively. Lower potency, high dosage strength, crush-resistant opioids, and those purchased in bulk were significantly cheaper.

CONCLUSION

Street prices for diverted oxycodone and oxymorphone are influenced by multiple factors including potency, dosage, formulation, and bulk purchasing. Buyers who purchase large quantities of low potency, large dosage, crush-resistant formulation prescription opioids can expect to achieve the lowest price.

Mapping of Crowdsourcing in Health: Systematic Review

Background

Crowdsourcing involves obtaining ideas, needed services, or content by soliciting Web-based contributions from a crowd. The 4 types of crowdsourced tasks (problem solving, data processing, surveillance or monitoring, and surveying) can be applied in the 3 categories of health (promotion, research, and care).

Objective

This study aimed to map the different applications of crowdsourcing in health to assess the fields of health that are using crowdsourcing and the crowdsourced tasks used. We also describe the logistics of crowdsourcing and the characteristics of crowd workers.

Methods

MEDLINE, EMBASE, and ClinicalTrials.gov were searched for available reports from inception to March 30, 2016, with no restriction on language or publication status.

Results

We identified 202 relevant studies that used crowdsourcing, including 9 randomized controlled trials, of which only one had posted results at ClinicalTrials.gov. Crowdsourcing was used in health promotion (91/202, 45.0%), research (73/202, 36.1%), and care (38/202, 18.8%). The 4 most frequent areas of application were public health (67/202, 33.2%), psychiatry (32/202, 15.8%), surgery (22/202, 10.9%), and oncology (14/202, 6.9%). Half of the reports (99/202, 49.0%) referred to data processing, 34.6% (70/202) referred to surveying, 10.4% (21/202) referred to surveillance or monitoring, and 5.9% (12/202) referred to problem-solving. Labor market platforms (eg, Amazon Mechanical Turk) were used in most studies (190/202, 94%). The crowd workers’ characteristics were poorly reported, and crowdsourcing logistics were missing from two-thirds of the reports. When reported, the median size of the crowd was 424 (first and third quartiles: 167-802); crowd workers’ median age was 34 years (32-36). Crowd workers were mainly recruited nationally, particularly in the United States. For many studies (58.9%, 119/202), previous experience in crowdsourcing was required, and passing a qualification test or training was seldom needed (11.9% of studies; 24/202). For half of the studies, monetary incentives were mentioned, with mainly less than US $1 to perform the task. The time needed to perform the task was mostly less than 10 min (58.9% of studies; 119/202). Data quality validation was used in 54/202 studies (26.7%), mainly by attention check questions or by replicating the task with several crowd workers.

Conclusions

The use of crowdsourcing, which allows access to a large pool of participants as well as saving time in data collection, lowering costs, and speeding up innovations, is increasing in health promotion, research, and care. However, the description of crowdsourcing logistics and crowd workers’ characteristics is frequently missing in study reports and needs to be precisely reported to better interpret the study findings and replicate them.

Comparative pharmacology and toxicology of tramadol and tapentadol

Moderate-to-severe pain represents a heavy burden in patients' quality of life, and ultimately in the society and in healthcare costs. The aim of this review was to summarize data on tramadol and tapentadol adverse effects, toxicity, potential advantages and limitations according to the context of clinical use. We compared data on the pharmacological and toxicological profiles of tramadol and tapentadol, after an extensive literature search in the US National Library of Medicine (PubMed). Tramadol is a prodrug that acts through noradrenaline and serotonin reuptake inhibition, with a weak opioid component added by its metabolite O-desmethyltramadol. Tapentadol does not require metabolic activation and acts mainly through noradrenaline reuptake inhibition and has a strong opioid activity. Such features confer tapentadol potential advantages, namely lower serotonergic, dependence and abuse potential, more linear pharmacokinetics, greater gastrointestinal tolerability and applicability in the treatment of chronic and neuropathic pain. Although more studies are needed to provide clear guidance on the opioid of choice, tapentadol shows some advantages, as it does not require CYP450 system activation and has minimal serotonergic effects. In addition, it leads to less side effects and lower abuse liability. However, in vivo and in vitro studies have shown that tramadol and tapentadol cause similar toxicological damage. In this context, it is important to underline that the choice of opioid should be individually balanced and a tailored decision, based on previous experience and on the patient's profile, type of pain and context of treatment.

SIGNIFICANCE

This review underlines the need for a careful prescription of tramadol and tapentadol. Although both are widely prescribed synthetic opioid analgesics, their toxic effects and potential dependence are not completely understood yet. In particular, concerning tapentadol, further research is needed to better assess its toxic effects.

Considering tapentadol as a first-line analgesic: 14 questions

Tapentadol is the newest centrally acting analgesic to be approved by the US FDA and regulatory bodies in other countries. It has been called the first-in-class of a novel-acting analgesic mechanism of action that combines µ-opioid receptor agonist activity with neuronal norepinephrine-reuptake inhibition in a single molecule. This duality of action should combine inhibition of ascending (afferent) pain-transmitting signals with activation of descending (efferent) pain-attenuating systems (e.g., diffuse noxious inhibitory controls). However, not all novel mechanisms of action impart the characteristics needed for an analgesic to be considered for first-line therapy. These key questions may help inform clinical decision making.

Health Care Utilization and Costs Associated with Nausea and Vomiting in Patients Receiving Oral Immediate-Release Opioids for Outpatient Acute Pain Management

Introduction

Nausea and vomiting (NV) are common side effects of opioid use and limiting factors in pain management. This study sought to quantify the frequency of antiemetic prescribing and the impact of NV on health care resource utilization and costs in outpatients prescribed opioids for acute pain. The perspective was that of a commercial health plan.

Methods

Medical and pharmacy claims from IMS PharMetrics Plus were used to identify patients initiating opioid therapy with a prescription for an oxycodone-, hydrocodone- or codeine-containing immediate-release product for acute use (≤15-day supply) between October 1, 2013 and September 30, 2014. Patients with a medical claim for NV (International Classification of Diseases, Ninth Revision, Clinical Modification codes 787.0x), with or without an antiemetic prescription fill, were compared with patients with no NV claim or antiemetic prescription fill to assess differences in all-cause health care utilization and costs over 1 month. Propensity score matching (PSM) was used to adjust for between-group differences in baseline patient characteristics.

Results

The co-prescribing of opioids with antiemetic agents was 10.2%. After PSM (n = 45,790 per group), patients with NV claims had significantly more hospitalizations (11.5% vs 4.2%), emergency department visits (65.0% vs 12.1%), and physician office visits (85.2% vs 64.5%) compared with patients with no NV claims (all P < 0.0001). Mean total health care costs were higher among patients with a NV claim versus those without evidence of the side effect ($6290 vs $2309; P < 0.0001). Among patients with a recent hospitalization, patients with NV claims had higher rates of 30-day rehospitalization than those with no NV claims (24.4% vs 3.0%; P < 0.0001).

Conclusions

Among outpatients prescribed opioids for management of acute pain, co-prescribing with antiemetics was low, and the economic burden associated with NV was high. Efforts to prevent NV in patients receiving opioid therapy may improve patient outcomes and provide cost savings to the health care system.

Funding

Daiichi Sankyo, Inc.

Electronic supplementary material

The online version of this article (doi:10.1007/s40122-016-0057-y) contains supplementary material, which is available to authorized users.

Tapentadol: Can It Kill Two Birds with One Stone without Breaking Windows?

Tapentadol is a novel oral analgesic with a dual mode of action as an agonist of the µ-opioid receptor (MOR), and as a norepinephrine reuptake inhibitor (NRI) all in a single molecule. Immediate release (IR) tapentadol shows its analgesic effect quickly, at around 30 minutes. Its MOR agonistic action produces acute nociceptive pain relief; its role as an NRI brings about chronic neuropathic pain relief. Absorption is rapid, with a mean maximal serum concentration at 1.25-1.5 h after oral intake. It is present primarily in the form of conjugated metabolites after glucuronidation, and excretes rapidly and completely via the kidneys. The most common adverse reactions are nausea, dizziness, vomiting, and somnolence. Constipation is more common in use of the ER formulation. Precautions against concomitant use of central nervous system depressants, including sedatives, hypnotics, tranquilizers, general anesthetics, phenothiazines, other opioids, and alcohol, or use of tapentadol within 14 days of the cessation of monoamine oxidase inhibitors, are advised. The safety and efficacy have not been established for use during pregnancy, labor, and delivery, or for nursing mothers, pediatric patients less than 18 years of age, and cases of severe renal impairment and severe hepatic impairment. The major concerns for tapentadol are abuse, addiction, seeking behavior, withdrawal, and physical dependence. The presumed problem for use of tapentadol is to control the ratio of MOR agonist and NRI. In conclusion, tapentadol produces both nociceptive and neuropathic pain relief, but with worries about abuse and dependence.