Patients with chronic pain and dysphagia (CPD): unmet medical needs and pharmacologic treatment options

Surveying the International Prevalence and Nature of Eating, Drinking and Swallowing Difficulties in Adults Presenting with Fibromyalgia

Fibromyalgia is a centralized pain syndrome characterized by widespread pain, fatigue, sleep and sensory issues. Fibromyalgia is present in up to 8% of the global population, disproportionally affecting females. Research acknowledges that patients with similar rheumatic/neurological disorders experience eating, drinking and swallowing difficulties. There are also anecdotal reports regarding dysphagia among the fibromyalgia community. However, there is limited research exploring these issues, with potential impact on care delivery and patient outcomes. This study investigated the nature and prevalence of dysphagia in an international sample of adults with fibromyalgia. An online cross-sectional survey design was used to gather data. Questions were adapted from a criterion-based assessment and available evidence. The survey focused on demographics, dysphagia symptoms, and symptom experiences. Results were analyzed using descriptives and correlational analysis. 1983 individuals participated (age range: 18-94), located: Australia (n = 18), Ireland (n = 63), Canada (n = 174), New Zealand (n = 253), the UK (n = 434) and the USA (n = 1024). Many eating, drinking and swallowing symptoms were reported, including food sticking in the throat during swallowing (89%), and pills taking extra effort to swallow (88%), and dry mouth (85%). This study identified previously under-explored eating, drinking and swallowing difficulties among adults with fibromyalgia. These difficulties were self-reported across age, gender, and location, highlighting the potential prevalence of these concerns among a wide range of people, despite having not been explored in depth in previous studies. Timely and accurate dysphagia identification is vital given the its' potential impact on nutrition, prognosis and quality of life. This study highlighted the importance of honoring patient experiences in fibromyalgia management while also recommending input from allied health professionals such as SLTs and dietitians to improve therapeutic relationships and clinical outcomes. As such, continued research into the cause, implications, and management of these issues beyond is required to inform and optimise future patient-centred service delivery and care provision.

Drug Information Needs of Health Care Professionals in Palliative Care: A Retrospective Evaluation of a Palliative Care Drug Information Service

CONTEXT

Drug therapy is an integral part of palliative care but pharmacotherapy can be challenging for health care professionals. Access to information is essential for health care providers to choose the best drug treatment for an individual patient. A drug information service can support health care professionals to obtain appropriate, unbiased information.

OBJECTIVES

To describe the enquiries to a palliative care drug information service. Objectives are to determine the information needs (including off-label use) of different professional groups and areas of care, to identify subject areas and drug substances for which there is a high need for information.

METHODS

Retrospective evaluation of all enquiries to a palliative care drug information service within 24 months from July 2017 to June 2019.

RESULTS

During the study period, 477 enquiries reached the drug information service, mostly from physicians (59%), followed by pharmacists (31%). Ketamin was the most discussed drug (11%), in general enquiries or corresponding replies mostly contained drugs targeting the nervous system, such as analgesics. Application techniques (26%) was the most relevant category, cancer pain (24%) was the most frequently addressed symptom. About half of the enquiries (48%) dealt with off-label us, regarding an application mode outside the license.

CONCLUSION

The information needs on palliative care pharmacotherapy seem to be particularly high among physicians. The demand for information in the area of application technology is particularly apparent and demonstrates a therapeutic gap in terms of availability of suitable preparations as well as necessary information.

[Pain in old age]

The prevalence of chronic pain increases with increasing age. Multimorbidity increases the risk of disease-related pain. Addressing the problem of pain in higher age is concerned with an increasing problem of care. The multimorbidity and the resulting multimedication are important for the medical care of pain. The therefore necessary physician-patient verbal communication can hardly be remunerated and carried out in the current care landscape. Existing resources must be bundled. The quality of life of older people and not the absence of pain, must be emphasized. Particularly problematic is the recognition and treatment of pain in patients with dementia. Pain in dementia patients is more rarely detected. In addition to questioning relatives and caregivers, a structured pain interview is necessary. The pharmacology of chronic pain is concerned above all with the prevention of iatrogenic risks through interactions and pharmacological complications. The patient-related treatment priorities must be checked and adjusted during the course of treatment. To be considered are age-related altered metabolic pathways. A sensible therapy option is the training of physical activity with a positive effect on the entire pain experience. Behavioral medical treatment procedures are other important building blocks in pain therapy. In addition to the multimodal therapeutic approaches, a stronger interdisciplinary collaboration of special pain medicine and geriatrics is necessary.

Chronic low back pain: a mini-review on pharmacological management and pathophysiological insights from clinical and pre-clinical data

Globally, low back pain (LBP) is one of the most common health problems affecting humans. The lifetime prevalence of non-specific LBP is approximately 84%, with the chronic prevalence at about 23%. Chronic LBP in humans is defined as LBP that persists for more than 12 weeks without a significant pain improvement. Although there are numerous evidence-based guidelines on the management of acute LBP, this is not the case for chronic LBP, which is regarded as particularly difficult to treat. Research aimed at discovering new drug treatments for alleviation of chronic mechanical LBP is lacking due to the paucity of knowledge on the pathobiology of this condition, despite its high morbidity in the affected adult population. For a debilitating condition such as chronic LBP, it is necessary to assess the sustained effects of pharmacotherapy of various agents spanning months to years. Although many rodent models of mechanical LBP have been developed to mimic the human condition, some of the major shortcomings of many of these models are (1) the presence of a concurrent neuropathic component that develops secondary to posterior intervertebral disc puncture, (2) severe model phenotype, and/or (3) use of behavioural endpoints that have yet to be validated for pain. Hence, there is a great, unmet need for research aimed at discovering new biological targets in rodent models of chronic mechanical LBP for use in drug discovery programs as a means to potentially produce new highly effective and well-tolerated analgesic agents to improve relief of chronic LBP. On a cautionary note, it must be borne in mind that because humans and rats display orthograde and pronograde postures, respectively, the different mechanical forces on their spines add to the difficulty in translation of promising rodent data to humans.

Tolerability, Safety, and Effectiveness of Oxycodone DETERx in Elderly Patients ≥65 Years of Age with Chronic Low Back Pain: A Randomized Controlled Trial

Trial Design

This was a phase III, randomized withdrawal, double-blind, placebo-controlled, enriched enrollment, parallel-group, multicenter study intended to demonstrate the safety, tolerability, and analgesic efficacy of oxycodone DETERx^® (Xtampza™ ER) compared with matching placebo.

Methods

This post hoc analysis was performed using data from a subpopulation of enrolled patients who were ≥65 years of age. The study enrolled male and female patients with a clinical diagnosis of moderate-to-severe chronic low back pain for a minimum of 6 months prior to screening who required around-the-clock opioid therapy. To be eligible for enrollment, patients were required to have an average 24-h pain intensity score of ≥5 and ≤9 on an 11-point (0–10) Pain Intensity—Numerical Rating Scale at the screening visit. The study enrolled both opioid-experienced and opioid-naïve patients. The study consisted of an open-label titration phase followed by a 12-week double-blind maintenance phase. The dose range was 40–160 mg oxycodone hydrochloride equivalent per day. This post hoc analysis evaluated the safety, tolerability, and effectiveness of oxycodone DETERx among patients ≥65 years of age. The effectiveness of oxycodone DETERx was evaluated based on average pain intensity scores, Patient Global Impression of Change, responder analysis, and Kaplan–Meier survival analysis. The safety and tolerability of oxycodone DETERx were also evaluated. Patients were randomized to either oxycodone DETERx or placebo using a blocked randomization scheme in a 1:1 ratio. Randomization was stratified by previous opioid use (naïve or experienced). The study drug was coded in a manner that maintained the blinding. Study personnel and patients remained blinded to the assigned treatments throughout the study.

Results

For this post-hoc analysis, the intent-to-treat and randomized safety populations included 52 patients ≥65 years old, 26 each in the oxycodone DETERx and placebo groups, who participated in the study during the titration phase and were randomized to the double-blind maintenance phase. Clinically important pain reduction from screening was achieved with oxycodone DETERx, with the median pain intensity score decreasing from 7.50 at screening to 2.69 at Week 12. A clinically meaningful treatment difference of −0.9 in pain score between oxycodone DETERx and placebo was observed. All 18 elderly patients who completed the study reported improvement in pain, with 62% showing ≥30% improvement and 54% showing ≥50% improvement in pain intensity compared with patients on placebo (p = 0.0128 and p = 0.0501, respectively). Patients on oxycodone DETERx remained in the study longer than those on placebo. Of the 26 patients ≥65 years old randomized to continue oxycodone DETERx during the double-blind maintenance phase, 18 (69%) completed the study; only two patients (8%) in the oxycodone DETERx group discontinued due to adverse events. The safety and tolerability profiles showed no new or unexpected safety concerns. The adverse event profiles were similar between the titration and double-blind maintenance phases.

Conclusions

Oxycodone DETERx was efficacious and generally well tolerated in patients ≥65 years old.

Trial Registration

The study was registered with ClinicalTrials.gov (NCT01685684).

Options for Treating Pain in Cancer Patients with Dysphagia

Patients with chronic pain often develop dysphagia during the course of an advanced disease such as cancer. Opioids are the cornerstone of the management of cancer pain and are commonly administered orally. However, the oral route does not suit patients with dysphagia, who require alternative methods to administer analgesic drugs. Opioids given by parenteral or transdermal routes provide adequate pain control, being at least as efficacious as the oral route, but knowledge and experience in conversion ratios are mandatory when using these routes of administration. For breakthrough pain, transmucosal fentanyl preparations should be the preferred option and these can be given as needed due to the route of absorption. In addition, a new class of opioid formulations has been developed for use in dysphagic patients that are administered via nasogastric or enteral tubes while maintaining their sustained-release properties.

Oxycodone DETERx®: A Novel Abuse-Deterrent, Extended-Release Analgesic Option for the Treatment of Patients with Chronic Pain

BACKGROUND

Extended-release (ER) opioid analgesics are commonly used to provide safe and effective pain relief to treat pain severe enough to require around-the-clock, long-term dosing. These ER opioid formulations usually contain more drug per dosage unit than immediate-release (IR) agents, and therefore bring with them challenges related to both opioid abuse and misuse, often through manipulation of the dosage form. Oxycodone DETERx® (Xtampza® ER, Collegium Pharmaceutical, Inc.) is a novel abuse-deterrent, ER formulation developed to deter common methods of manipulation. In addition to having abuse-deterrent properties, oxycodone DETERx was developed to provide alternative modes of administration for patients with chronic pain and difficulty swallowing.

SCOPE

Using published articles, abstracts, and prescribing information, data supporting the use of oxycodone DETERx are reviewed.

FINDINGS

Oxycodone DETERx was effective at reducing chronic pain in patients enrolled in a pivotal clinical trial, and had a tolerability profile expected of opioids. In addition to administration of the intact capsule, oxycodone DETERx can also be administered by sprinkling directly into the mouth from a dosing cup, onto soft foods, or through nasogastric or gastrostomy tubes, thus providing flexible dosing options for patients who have difficulty swallowing. In vitro studies demonstrated the reduced ability of oxycodone DETERx to be manipulated by common techniques used by abusers to defeat the ER characteristics or prepare the formulation for injection. Pharmacokinetic studies demonstrated that the ER characteristics of oxycodone DETERx are maintained if chewed or crushed. As a result, oxycodone DETERx is currently the only ER-formulated opioid without a boxed warning against crushing or chewing. Human abuse-potential studies conducted in a population of recreational opioid users demonstrated lower drug-liking scores for oxycodone DETERx administered intranasally and orally when compared with IR oxycodone.

FUNDING

Collegium Pharmaceutical, Inc.

An abuse-deterrent, microsphere-in-capsule formulation of extended-release oxycodone: alternative modes of administration to facilitate pain management in patients with dysphagia

BACKGROUND

Patients with chronic pain may experience difficulty swallowing, in part due to worsening disease, comorbid conditions, iatrogenic etiology, or age. Patients or caregivers may manipulate extended-release (ER) opioid formulations to facilitate oral dosing due to a lack of therapeutic options that allow for sprinkle or enteral feeding tube administration. If crushed or broken, current oral ER opioids can be associated with adverse sequelae, including risk of potentially fatal overdose.

OBJECTIVE

To review the safety, in vitro dissolution data, and in vivo pharmacokinetic data that support alternative modes of administration of oxycodone DETERx (Xtampza ER) via sprinkling onto soft foods for oral ingestion or via enteral feeding tubes.

METHODS

A review of oxycodone DETERx data from in vitro and in vivo studies was conducted to demonstrate support for alternative routes and modes of administration.

RESULTS

There was no difference in the dissolution profile when administered with various soft foods or when mixed with various liquid vehicles and administered via nasogastric (NG) or gastrostomy (G) tubes, based on in vitro studies. When sprinkled onto applesauce and administered orally, the microspheres were bioequivalent to the intact oxycodone capsules. When crushed or chewed, the formulation maintained its pharmacokinetic profile; no bolus dose of opioid was released. The sprinkle-dose study was limited by the single-dose study design, as well as the small sample size.

CONCLUSIONS

Oxycodone DETERx is the first ER oxycodone formulation that can be administered either intact, sprinkled onto soft foods, or via NG/G tubes, thereby providing options for treating pain in patients who have difficulty swallowing.

The value of oxybutynin in transdermal patches for treating overactive bladder

CONTEXT

There is currently a broad therapeutic arsenal of drugs for treating overactive bladder syndrome (OAB). However, there is still a need for new compounds and for improving known drugs in terms of efficacy, compliance and tolerability.

OBJECTIVE

To report the scientific evidence on the safety and efficacy of transdermal oxybutynin (OXY-TDS) for treating OAB.

MATERIAL AND METHODS

A systematic review without time restrictions was conducted until May 2015 in the MEDLINE/PubMed database. We also performed a manual review of abstracts published in international urogynaecology congresses.

RESULTS

The evaluated studies show that patients treated with OXY-TDS experience a significant reduction in urinary incontinence episodes compared with placebo, which is comparable to that observed in patients treated with oral oxybutynin or with tolterodine. In all of the studies, we observed improvements in symptoms from the second or third week of treatment and in a sustained manner until the end of treatment (6, 12 or 24 weeks). The clinical practice study also showed improved quality of life, achieving benefits in numerous patient profiles, with an efficacy independent of previous treatments. The safety of the drug was demonstrated in the various patient profiles.

CONCLUSIONS

OXY-TDS represents an effective alternative for the symptomatic treatment of adult patients with OAB, which, thanks to its pharmacokinetic profile, better tolerability, different administration method and dosage, could represent an added value in treating special populations.

Comparing the Effect of Tampering on the Oral Pharmacokinetic Profiles of Two Extended-Release Oxycodone Formulations with Abuse-Deterrent Properties

OBJECTIVE

Oxycodone DETERx® is an extended-release (ER), microsphere-in-capsule abuse-deterrent-formulation designed to retain its extended-release properties following tampering or misuse (e.g., chewing, crushing). This study assessed the safety and pharmacokinetics of orally administered intact and crushed Oxycodone DETERx® capsules compared with intact and crushed reformulated OxyContin® tablets and crushed immediate-release oxycodone tablets (IR oxycodone).

METHODS

This was a randomized, open-label, active-controlled, cross-over study. Healthy subjects received five oxycodone treatments (40 mg) with a standardized high-fat, high-calorie meal: Oxycodone DETERx® (intact or crushed), OxyContin® (intact or crushed), and IR oxycodone (crushed). Blood samples were collected for assessment of oxycodone plasma concentrations.

RESULTS

Thirty-eight subjects completed the study. Both crushed and intact Oxycodone DETERx® resulted in lower peak plasma concentrations when compared with IR oxycodone. Crushed Oxycodone DETERx® was bioequivalent to intact Oxycodone DETERx® and exhibited a numerically lower Cmax . Also, median Tmax was unchanged by crushing. In contrast, mean peak plasma oxycodone concentrations for crushed OxyContin® were significantly higher compared with intact OxyContin® and were bioequivalent to IR oxycodone. Median Tmax for crushed OxyContin® was the same as IR oxycodone and 3.25 hours shorter than intact OxyContin®.

CONCLUSIONS

These data demonstrate that when crushed and taken orally, Oxycodone DETERx® maintains its EXTENDED-release profile, while crushed OxyContin® shows a pharmacokinetic profile similar to an immediate-release product. These results suggest that Oxycodone DETERx® may be less attractive to illicit drug users compared with existing abuse-deterrent-formulations, while providing a safer option for patients who may unknowingly crush their medication such as those who have difficulty swallowing.