Oral transmucosal fentanyl citrate in the management of breakthrough pain in cancer: an open, multicentre, dose-titration and long-term use study

Comparison of analgesia, adverse effects, and quality of life in cancer patients during treatment of procedural pain with intravenous morphine, fentanyl nasal spray, and fentanyl buccal tablets

Aim

Comparison of analgesia, adverse effects, and quality of life (QoL) of cancer patients in the treatment of procedural pain induced by nursing procedures with the use of intravenous morphine, fentanyl nasal spray, and fentanyl buccal tablets.

Methods

In adults with cancer with opioid tolerance and suffering procedural pain, intravenous morphine was used at an inpatient palliative medicine unit (20 patients) and fentanyl by intranasal (15 patients) and buccal routes (nine patients) at home. Five procedural pain episodes were examined: the Mini-Mental State Examination was used to assess cognitive function, the Brief Pain Inventory – short form (BPI-SF) to assess intensity and impact of pain on daily activities, a pain and adverse-effect questionnaire to assess the intensity of pain and adverse effects, and the European Organisation for Research and Treatment of Cancer QLQ-C15-PAL to assess QoL.

Results

All five procedural pain episodes were completed by 32 patients. Twelve patients stopped treatment due to death or referral to the hospital (four patients in each group), changes in the treatment of background pain (three patients), and intense drowsiness (one patient). Similar beneficial analgesic effects were observed in all patient groups. During fentanyl therapy, a smaller negative effect of pain on patients’ activity, walking, and work (BPI-SF) was observed. Among adverse effects, fewer breaths (10–14 per minute) were observed in 17 patients and slight disturbances of consciousness in seven. For QoL, an improvement in emotional functioning, overall QoL, and fatigue was observed. Patients treated with intranasal and buccal fentanyl had higher physical functioning and were more active.

Conclusion

In the treatment of procedural pain induced by nursing procedures in cancer patients, intravenous morphine and rapid-onset fentanyl show similarly high analgesic efficacy, with good tolerance of treatment and improvement in QoL.

Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis

Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient.

A comparative study between intrathecal dexmedetomidine and fentanyl as adjuvant to intrathecal bupivacaine in lower abdominal surgeries: A randomized trial

Context:

Spinal anesthesia is preferred choice of anesthesia in lower abdominal surgeries since long time. However problem with this is limited duration of action, so for long duration surgeries alternative are required. Dexmedetomidine is a highly selective alpha-2-adrenergic agonist has property to potentiate the action of local anesthetic used in spinal anesthesia. Fentanyl is an opioid and it has also the same property.

Aims:

To compare the efficacy, analgesic effects, and side-effects of dexmedetomidine and fentanyl as adjuvant to bupivacaine for lower abdominal surgery.

Settings and Design:

The type of this study was double-blind randomized trial.

Subjects and Methods:

A total of 80 patients were randomly allocated in two Group D and Group F. Group D were injected injection bupivacaine 0.5% heavy × 3.0 ml + 0.5 ml of preservative free normal saline containing 5 μg dexmedetomidine. Group F were received injection bupivacaine 0.5% heavy × 3.0 ml + 0.5 ml fentanyl equivalent to 25 μg.

Statistical Analysis Used:

The statistical analysis was performed using SPSS (Statistical Package for Social Sciences) version 15.0 statistical analysis software.

Results:

The results show that highest sensitivity level of T6 and T8 was achieved by higher proportion of subjects from Group D when compared to Group F and sensitivity level T7 was achieved by higher proportion of subjects of Group F when compared to Group D. Duration of analgesic properties was significantly higher in Group D when compared to Group F.

Conclusion:

The findings in the present study suggested that intrathecal adjuvant use of dexmedetomidine as compared to fentanyl provides a longer sensory and motor blockade and also prolongs the postoperative analgesic effect.

The use of Instanyl® in the treatment of breakthrough pain in cancer patients: a 3-month observational, prospective, cohort study

PURPOSE

Instanyl® (intranasal fentanyl spray) is a novel treatment for breakthrough pain (BTP) in cancer patients. It has shown a rapid onset of pain relief in clinical trials. This study examines the use of Instanyl® in real-life settings.

METHODS

A 3-month observational, prospective, cohort study of cancer patients with BTP receiving Instanyl® (50, 100, or 200 μg) under routine clinical practice. Data were collected at three time points corresponding with routine clinic visits - baseline, Week 4, and Week 13.

PRIMARY OUTCOMES

success of titration and maintenance dose after titration.

SECONDARY OUTCOMES

change in maintenance dose of Instanyl® and level of background pain medication; Brief Pain Inventory--Short Form (BPI-SF) and Patient Treatment Satisfaction Scale (PTSS) scores; adverse drug reactions (ADRs).

RESULTS

Titration with Instanyl® was successful in 84.5 % of 309 patients; most patients were titrated at the lowest dose (50 μg). The majority showed no change in maintenance dose, with little change in the level of background pain medication. BPI-SF and PTSS scores significantly improved from baseline to Week 4. The main reason for terminating Instanyl® was death, as expected due to the underlying disease; incidence of ADRs was low and no fatal ADRs were reported.

CONCLUSIONS

In a real-life group of cancer patients with disease progression, Instanyl® was titrated successfully at doses <200 μg in the majority of patients, requiring only one dose, with no further change in maintenance dose. Pain severity, impact of pain on daily life, and treatment satisfaction significantly improved with Instanyl® treatment. No unexpected ADRs occurred.

A randomized, placebo-controlled study of a new sublingual formulation of fentanyl citrate (fentanyl ethypharm) for breakthrough pain in opioid-treated patients with cancer

BACKGROUND

Oromucosal fentanyl is currently used for the treatment of breakthrough pain (BTP) in opioid-treated cancer patients. Ethypharm developed a sublingual formulation of fentanyl suprabioavailable to oral transmucosal fentanyl citrate with a higher early systemic exposure and a shorter Tmax.

OBJECTIVES

This study evaluated the efficacy and safety profile of fentanyl Ethypharm (FE) in relieving BTP in opioid-treated cancer patients.

METHODS

Opioid-treated adult cancer patients, experiencing 1 to 4 episodes of BTP per day, were included in the study. After an open-label titration period to identify an optimal dose that would provide adequate pain relief for 2 consecutive episodes of BTP with an acceptable level of adverse events, patients were randomly assigned to a double-blind, placebo-controlled, crossover period with 1 of 13 prespecified sequences of 9 tablets (6 tablets of FE of the dose identified during the open-label titration and 3 placebo). Pain intensity and pain relief were recorded at 3, 6, 10, 15, 30, and 60 minutes after study drug administration. Adverse events were recorded. The primary end point was the sum of pain intensity differences (SPID) at 30 minutes.

RESULTS

The distribution of optimal dosages of FE was as follows: 133 µg, 35.9%; 267 µg, 30.8%; 400 µg, 14.1%; 533 µg, 12.8%; and 800 μg, 6.4%. In the modified intention-to-treat population (n = 73), FE significantly improved mean (SE) SPID compared with placebo at 30 minutes (75.0 [49.8] vs 52.5 [52.8]; P < 0.0001). FE significantly improved SPID, pain intensity difference, and pain relief compared with placebo from 6 to 60 minutes' postadministration. Patients with BTP who received placebo required the use of rescue medication more often than those treated with FE (38.4% vs 17.5%; P < 0.0001). A significant improvement in pain scores (>33% and >50% reductions) was also reported for BTP treated with FE. Pain scores for patients with BTP with a neuropathic component (13 patients) were lower with FE than for those receiving placebo, but the difference was not significant. AEs were of mild or moderate severity and typical of opioid drugs.

CONCLUSIONS

This newly developed galenic formulation with a higher early systemic exposure and a shorter Tmax compared with oral transmucosal fentanyl citrate makes FE a particularly suitable formulation for the management of BTP in opioid-treated cancer patients due to the very rapid onset of action. FE provided significant improvement in pain intensity of BTP compared with placebo as early as 6 minutes' postadministration with a sustained effect over 60 minutes. FE was well tolerated by patients. ClinicalTrials.gov identifier: NCT 01842893.

Fentanyl for the treatment of tumor-related breakthrough pain

BACKGROUND

Breakthrough cancer pain (BTCP) is common among cancer patients and markedly lowers their quality of life. The treatment for BTCP episodes that is recommended in current guidelines involves extended-release formulations in combination with rapid-onset and short-acting opioids. In the past few years, several new preparations of fentanyl, an opioid with a very rapid onset, have been approved for this indication. Treating physicians need to be aware of the clinical differences between the newer fentanyl preparations and immediate-release opioids.

METHODS

We searched the PubMed and Embase databases for randomized controlled trials (RCTs) of fentanyl for buccal, sublingual or intranasal administration in comparison with other opioids or a different fentanyl preparation for the treatment of BTCP.

RESULTS

In 6 trials of buccal, sublingual or intranasal fentanyl versus oral immediate-release opioids for the treatment of BTCP episodes, the use of fentanyl was associated with significantly less intense pain. In particular, fentanyl more often lowered the intensity of pain by at least 33% (range between studies: 13% to 57%) or by at least 50% (range between studies: 9% to 38%) within 15 minutes. Please change to "versus" if you agree.] Dose titration should begin at the lowest dose. When one fentanyl preparation is exchanged for another, the effective dose will probably differ.

CONCLUSION

The newer fentanyl preparations extend the treatment options for BTCP. They relieve pain within a short time better than conventional, immediate-release oral opioids do and may therefore be very helpful for patients with suddenly arising, intense, and short-lasting BTCP episodes. Further comparative trials are urgently needed.

Grading clinical guidelines for the use of transmucosal immediate-release fentanyl products in breakthrough pain

Pain is a complex symptom that is commonly feared in palliative care owing to its significant effects on patients' quality of life (QoL), and is directly associated with morbidity. More specifically, the management of breakthrough pain (BTP) is particularly important. Opioids play a major part in the management of BTP, and the various transmucosal immediate-release fentanyl (TIRF) products are a common treatment choice. This paper considers the strength of the evidence underlying recommendations regarding the use of TIRF. Failure to consider the quality of evidence in practice can lead to misguided recommendations. Guidelines should therefore be used to inform clinicians of the quality of the underlying evidence and whether recommendations are strong or weak. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach is increasingly being adopted worldwide as it provides a system for rating quality of evidence and strength of recommendations that is clear, comprehensive, transparent, and practical. This paper adopts the GRADE approach to assess the strength of recommendations made in a 2011 review by Zeppetella in order to develop guidelines for the use of TIRF. The recommendations include that TIRF products can be considered for first-line treatment and that they should be individualised to patients who are on a background opioid.

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).

Oral trasmucosal fentanyl citrate for breakthrough pain treatment in cancer patients

INTRODUCTION

Breakthrough cancer pain has been defined as a transitory increase in pain intensity that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. The availability of supplemental doses of oral opioids, in addition to the continuous analgesic medication, is the main treatment suggested to manage pain flares.

AREAS COVERED

Oral transmucosal fentanyl citrate (OTFC) is the first product of a new generation of delivery systems, named rapid-onset opioids (ROOs), characterized by rapidity of effect and the short duration of analgesia. Controlled studies and long-term experience have shown that OTFC is an effective treatment for breakthrough pain management and its use should be considered in any patient experiencing breakthrough pain related to cancer.

EXPERT OPINION

The onset of action of OTFC - demonstrated to start within 15 min - and the short time to maximum concentration make it a useful indication for breakthrough pain; dose titration is commonly recommended. However, it is likely that patients receiving high doses of opioids for background analgesia will not be candidates for titration with minimal initial doses of OTFC, as they are opioid tolerant and the process would be time consuming.

Fentanyl for breakthrough pain: a systematic review

The purpose of this article is to systematically review the use of fentanyl as an analgesic for breakthrough pain. This article found that the oral transmucosal fentanyl (OTFC) had a quicker onset to analgesia than oral immediate-release opioids. Intranasal fentanyl (INFS) had a quicker onset to analgesia than buccal tablets, which in turn had a quicker onset to analgesia than OTFC. Patient acceptance and global rating of efficacy were greater for INFS than for buccal fentanyl. OTFC and INFS have been used effectively to reduce acute pain in children who are opioid-naive. Abuse and addiction to OTFC, fentanyl buccal tablets and INFS was low, owing to patient selection.

Integrated strategies for the successful management of breakthrough cancer pain

PURPOSE OF REVIEW

To highlight the significant impact breakthrough cancer pain (BTcP) can have on patients' quality of life and to discuss potential management strategies that could improve pain control in clinical practice as well as effective strategies to manage risk.

RECENT FINDINGS

BTcP can place a significant physical, psychological and economic burden on patients. Despite advances in the management of cancer pain, through the application of modern, evidence-based, multimodality management and the availability of new treatment options, recent European surveys have indicated that the diagnosis and treatment of BTcP is still suboptimal. A general lack of consensus on its definition alongside poor recognition and inadequate assessment may often lead to undertreatment and poor patient outcomes. Fentanyl preparations that have been developed and licensed specifically for the treatment of BTcP have been shown to work more rapidly and be preferred by patients to traditional rescue medication, such as normal-release oral opioids.

SUMMARY

Optimizing the management of BTcP requires an integrated approach, including independent assessment and better use of available treatments while taking into consideration risk management strategies, which will ultimately lead to improved outcomes and quality of life for patients.

The management of cancer pain

The experience of pain in cancer is widely accepted as a major threat to quality of life, and the relief of pain has emerged as a priority in oncology care. Pain is associated with both the disease as well as treatment, and management is essential from the onset of early disease through long-term survivorship or end-of-life care. Effective relief of pain is contingent upon a comprehensive assessment to identify physical, psychological, social, and spiritual aspects and as a foundation for multidisciplinary interventions. Fortunately, advances in pain treatment and in the field of palliative care have provided effective treatments encompassing pharmacological, cognitive-behavioral, and other approaches. The field of palliative care has emphasized that attention to symptoms such as pain is integral to quality cancer care.

The efficacy and safety of fentanyl buccal tablet compared with immediate-release oxycodone for the management of breakthrough pain in opioid-tolerant patients with chronic pain

BACKGROUND

Current clinical guidelines have identified the need for studies comparing the effect of different short-acting or rapid-onset opioids for the treatment of breakthrough pain (BTP). In this study we evaluated the efficacy and safety of treatment with fentanyl buccal tablet (FBT) in comparison with immediate-release oxycodone in alleviating BTP in opioid-tolerant patients with chronic pain.

METHODS

In this cross-over design study, opioid-tolerant patients were randomized to open-label titration with FBT (200, 400, 600, 800 μg) followed by oxycodone (15, 30, 45, 60 mg) or vice versa for the management of BTP. After titration to a successful dose of both study drugs, patients were rerandomized to double-blind treatment for 10 BTP episodes with 1 of the already identified successful doses of study drug followed by cross-over to double-blind treatment for 10 BTP episodes with the other study drug. The primary efficacy measure was the difference in pain intensity (based on an 11-point numerical scale) 15 minutes after administration of study drug (PID(15)). Other efficacy measures included PID at other time points postdose (5 through 60 minutes), the sum of pain intensity differences (SPID) at 30 and 60 minutes postdose, pain relief (5 through 60 minutes), proportion of BTP episodes for which patients experienced meaningful reduction in pain intensity, and patient preference for BTP medication. Adverse events were also recorded.

RESULTS

Of the 323 patients enrolled, 203 achieved a successful dose of both study drugs, 191 completed the titration phase, and 180 completed the double-blind phase. PID(15) was significantly greater after FBT versus oxycodone (mean [SD], 0.82 [1.12] vs. 0.60 [0.88]; 95% confidence interval [CI] = 0.18, 0.29; P < 0.0001). Secondary efficacy measures favored FBT and showed differences versus oxycodone from 5 minutes postdose for PID and 10 minutes postdose for pain relief. SPID(30) and SPID(60) were greater with FBT than with oxycodone (P < 0.0001 for both measures). A ≥33% improvement in pain intensity occurred in a larger proportion of FBT-treated episodes versus oxycodone beginning 15 through 45 minutes postdose (P < 0.05). FBT was preferred by 52% of patients, oxycodone by 33%. Adverse events with both study drugs were generally typical of opioids, and the majority occurred during titration. Two serious adverse events (pneumonia) were reported in 1 patient; both occurrences were considered unrelated to study drug.

CONCLUSION

FBT resulted in more rapid onset of analgesia and was generally well tolerated in comparison with oxycodone for the treatment of BTP in opioid-tolerant patients.

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.

Formulations of fentanyl for the management of pain

Fentanyl is an opioid initially developed for parenteral administration. While oral administration is not an option due to a high first-pass metabolism, its high potency and lipophilicity have made a number of new routes of administration feasible. The transdermal therapeutic system offers an excellent option for long-term treatment of cancer and chronic pain, achieving stable plasma concentrations over the treatment period. The recent change from reservoir to matrix systems has made these systems more convenient to wear and safer to use, while being bioequivalent. In contrast, the patient-controlled iontophoretic transdermal system has been developed to enable on-demand delivery of transdermal bolus doses of fentanyl to treat postoperative pain. It offers a needle-free system to provide patient-controlled analgesia otherwise offered by intravenous pumps. However, due to technical difficulties the system is currently not clinically available. Oral transmucosal fentanyl utilizes the rapid uptake through the buccal mucosa to achieve high plasma concentrations rapidly and is indicated to treat breakthrough pain in patients who are not opioid-naive. The recently introduced fentanyl buccal tablets offer slightly better pharmacokinetics for the same indication. The intranasal route is another option to achieve rapid uptake of fentanyl, and is currently being investigated to provide acute and breakthrough pain relief. Transpulmonary administration of fentanyl remains experimental and this route of administration is not yet in clinical use. Overall, the specific pharmacological and physicochemical properties of fentanyl have made this compound highly suitable for novel routes of administration in a range of clinical indications.

Evaluation of the single- and multiple-dose pharmacokinetics of fentanyl buccal soluble film in normal healthy volunteers

Fentanyl buccal soluble film (FBSF) is a rapidly absorbed transmucosal formulation of fentanyl for the management of breakthrough pain in opioid-tolerant patients with cancer. This open-label, 3-period, sequential dose study evaluated the dose-to-dose reproducibility of the pharmacokinetics of fentanyl following the administration of 600- or 1800-microg doses of FBSF in 12 naltrexone-blocked, healthy adult volunteers. Subjects received 3 study treatments: single doses of 600 microg of FBSF on day 1 and day 4 and three 600-microg doses administered at 1-hour intervals on day 7. Plasma fentanyl concentrations were measured over a 48-hour period after each single dose of FBSF and 72 hours after the 3-dose regimen. Peak plasma concentrations (mean C(max) = 1.08 and 1.01 ng/mL) and overall exposure (mean AUC(0-12) = 6.3 and 6.2 h.ng/mL; mean AUC(inf) = 9.14 and 9.60 h.ng/mL) were nearly identical after the 2 single doses (P >or= .1, all comparisons). C(max) and overall fentanyl exposure (AUC(inf)) increased approximately 3-fold with the 3-dose regimen compared with the single-dose periods. Fentanyl plasma concentrations following single doses of FBSF were reproducible, and 3 doses administered 1 hour apart produced a tripling in exposure and maximal concentration compared with a single dose.

Recent advances in the use of opioids for cancer pain

Opioids are the mainstay of treatment for moderate to severe cancer pain. In recent years there have been many advances in the use of opioids for cancer pain. Availability and consumption of opioids have increased and opioids other than morphine (including methadone, fentanyl, oxycodone) have become more widely used. Inter-individual variation in response to opioids has been identified as a significant challenge in the management of cancer pain. Many studies have been published demonstrating the benefits of opioid switching as a clinical maneuver to improve tolerability. Constipation has been recognized as a significant burden in cancer patients on opioids. Peripherally restricted opioid antagonists have been developed for the prevention and management of opioid induced constipation. The phenomenon of breakthrough pain has been characterized and novel modes of opioid administration (transmucosal, intranasal, sublingual) have been explored to facilitate improved management of breakthrough cancer pain. Advances have also been made in the realm of molecular biology. Pharmacogenetic studies have explored associations between clinical response to opioids and genetic variation at a DNA level. To date these studies have been small but future research may facilitate prospective prediction of response to individual drugs.

Efficacy and safety of transdermal fentanyl for treatment of oral mucositis pain caused by chemotherapy

BACKGROUND/OBJECTIVE

We investigated the efficacy and safety of transdermal fentanyl for severe mucositis pain caused by chemotherapy.

METHODS

Thirty-two patients who had moderate to severe pain using the Numeric Rating Scale (NRS) were enrolled in this study. The analgesic effect, quality of life and side effects were evaluated after the administration of transdermal fentanyl.

RESULTS

The median NRS score was reduced from 6 (range 4 - 9) before treatment to 4 (range 0 - 9), 2.5 (range 0 - 8), 2 (range 0 - 8), 2 (range 0 - 6) and 0 (range 0 - 5) on days 3, 5, 7, 10 and 15, respectively, after treatment (p < 0.001). The patients' quality of life also improved significantly (p < 0.01). The side effects of treatment were mild, and disappeared within several days.

CONCLUSIONS

Transdermal fentanyl is an effective, convenient and well-tolerated treatment for severe mucositis pain caused by chemotherapy that can improve patients' quality of life.

A new transmucosal drug delivery system for patients with breakthrough cancer pain: the fentanyl effervescent buccal tablet

Breakthrough pain, a transitory severe pain with the background of otherwise controlled persistent pain has a prevalence between 52% and 67% in outpatients with cancer. Medications for such sudden-onset pain require non-invasive delivery of a potent and short-acting opioid for rapid pain relief. Although oral transmucosal delivery of fentanyl citrate (OTFC) has been shown to provide better pain relief than a typical oral opioid administration such as morphine sulfate immediate release (MSIR) in the management of breakthrough pain in patients with cancer-related pain, newer delivery systems offer a potential for further enhancement of pain relief. The fentanyl effervescent buccal tablet (FBT) formulation employs a novel drug delivery system that relies on an effervescence reaction to improve buccal fentanyl absorption. Using the effervescence reaction results in the production and dissipation of carbon dioxide with a dynamic shift in pH as the tablet dissolves. The induced low pH favors dissolution of fentanyl citrate in saliva (higher water solubility). The subsequent increase in pH thereafter favors the buccal absorption of non-ionized fentanyl across the buccal mucosa. Such a pH “pumping” mechanism increases the permeation of fentanyl into and through the buccal to the vascular system from where the agent is transported to the specific opioid receptor sites in the CNS. Compared with OTFC, data in healthy volunteers show that the effervescence reaction employed in FBT increases the total amount and the speed of absorption of fentanyl being absorbed. Compared with OTFC there is an increase in peak fentanyl blood concentrations, and an enhancement of the amount of buccal delivery of fentanyl. Such favorable data are underlined by the results of clinical studies where the FBT technology was studied in patients with breakthrough pain in chronic malignant pathologies.

Oral Transmucosal Fentanyl Citrate: Overview of Pharmacological and Clinical Characteristics

Oral transmucosal fentanyl citrate (OTFC; brand name Actiq, Cephalon, UT) is a new opioid formulation that incorporates fentanyl into a lozenge and allows drug delivery through the buccal mucosa. This kind of absorption avoids first-pass metabolism, yielding a bioavailability substantially greater than oral administration. OTFC has a rapid onset of action and a short duration of effect. These characteristics, which resemble the course of a typical breakthrough pain episode, resulted in making OTFC the first opioid analgesic formulation specifically developed and approved for control of breakthrough pain in cancer patients. Apart from that, OTFC has been used in a variety of clinical situations of noncancer pain. This review article presents the synthesis; clinical pharmacology; pharmacokinetic and pharmacodynamic properties, toxicity, and clinical efficacy of this novel agent.

Oral abuse of fentanyl patches (Duragesic): seven case reports

In order to increase the understanding regarding the oral abuse and potential toxicity of fentanyl patches seven cases were identified over a 3-year period where fentanyl, either alone or in combination with other factors, contributed to death following the oral abuse of Duragesic patches. The decedents comprised three females and four males with ages ranging from 20 to 51 years. Postmortem blood fentanyl concentrations were determined in all cases and ranged from 7 to 97 ng/mL. Two deaths were classified as a fentanyl overdose, three deaths were classified as a fentanyl and ethanol overdose, one death was considered a mixed drug intoxication and the remaining death was determined to be a combination of fentanyl and medical causes. These cases represent the largest reported series of deaths following the oral administration of transdermal fentanyl patches and provide detailed information on the potential for the abuse of transdermal Duragesic patches via this route. The postmortem blood fentanyl concentrations detected for each of the decedents demonstrate the potentially fatal blood concentrations that can arise after this relatively rare route of administration.

[Oral transmucosal fentanyl citrate for the treatment of breakthrough pain. Results of a non-interventional study (NIS)]

BACKGROUND

In a non-interventional study the efficacy and tolerability of oral transmucosal fentanyl citrate (OTFC) was studied in patients with opioid-treated cancer pain suffering from breakthrough pain.

PATIENTS AND METHODS

The prospective multicenter observational trial included 406 patients. For 3-4 months, efficacy of OTFC treatment for breakthrough pain was documented using a numerical analog pain intensity scale (NAS). Further, OTFC therapy was rated and adverse events were recorded.

RESULTS

With application of oral transmucosal fentanyl citrate median pain intensity fell from NAS 8 points at the beginning to NAS 2 points at the end of the study. The median effective dosage was 400 g. Tolerability was rated as good or very good by 87.5% of the patients.

CONCLUSION

Oral transmucosal fentanyl citrate is a safe and effective treatment for breakthrough pain in chronic cancer-related pain.

Fentanyl buccal tablet for the relief of breakthrough pain in opioid-tolerant adult patients with chronic neuropathic pain: a multicenter, randomized, double-blind, placebo-controlled study

BACKGROUND

Patients with chronic noncancer pain, including neuropathic pain, may have transitory exacerbations of pain (median duration, 60 minutes), termed breakthrough pain (BTP), that may reach peak intensity within minutes. Typical short-acting oral opioids may not provide sufficiently rapid relief (30- to 60-minute onset of analgesia). The fentanyl buccal tablet (FBT) provides a rapid onset of analgesia (10-15 minutes) by enhancing fentanyl absorption across the buccal mucosa.

OBJECTIVE

This study evaluated the efficacy and tolerability of FBT in opioid-tolerant patients with BTP associated with chronic noncancer neuropathic pain.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled study in men and women aged 18 to 80 years who were opioid tolerant; had a >/= 3-month history of chronic persistent neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, traumatic injury, or complex regional pain syndrome; and reported having episodes of BTP. After an open-label titration period to identify an effective FBT dose (the dose at which the patient reported receiving adequate pain relief within 30 minutes after administration of a single tablet of that dose during at least 2 of 3 BTP episodes), patients were randomly assigned to treat 9 consecutive episodes of BTP over the next 21 days with 1 of 3 double-blind dose sequences of FBT and placebo tablets. Pain intensity (PI) (rated on an 11-point pain scale, from 0 = no pain to 10 = worst pain) and other outcomes were assessed before dosing and for 2 hours after dosing. The primary efficacy measure was the sum of PI differences (PIDs) for the first 60 minutes (SPID(60)). Secondary efficacy measures included the proportion of BTP episodes with >/= 33% and >/= 50% improvement in PI from baseline; PID at other time points (5, 10, 15, 30, 45, 60, 90, and 120 minutes after dosing); pain relief (PR) at the same time points (rated on a 5-point Likert scale from 0 = none to 4 = complete); proportion of BTP episodes with meaningful PR; time to meaningful PR; and proportion of BTP episodes in which supplemental medication was required after administration of study drug. Adverse events (AEs) spontaneously reported by the patient or elicited by the investigator were recorded throughout the study.

RESULTS

Of 102 patients in the open-label titration period, 80 identified an effective dose of FBT and 79 entered the double-blind phase. Of these 79 patients, 77 (97%) completed the study and 75 (95%) were evaluable for efficacy. Of the 79 patients who entered the double-blind phase, 63% were women and 92% were white; their mean (SD) age was 48.3 (10.42) years, and their mean weight was 96.8 (33.42) kg. Baseline demographic and pain characteristics were similar between the overall population and the double-blind population. SPID(60) was significantly greater for BTP episodes treated with FBT compared with those in which placebo was administered (mean [SE], 9.63 [0.75] vs 5.73 [0.72], respectively; P < 0.001). Significant differences between FBT and placebo were seen beginning at 10 minutes for PID (mean, 0.740 [0.149] vs 0.427 [0.081]; P < 0.047) and PR (mean, 0.561 [0.087] vs 0.324 [0.056]; P < 0.001). A >/= 33% improvement in PI from baseline was seen in a greater proportion of BTP episodes treated with FBT compared with placebo from 10 minutes (9% vs 3%; P = 0.008) through 2 hours (66% vs 37%; P < 0.001). Patients were almost 4 times less likely to require supplemental opioids when BTP episodes were treated with FBT compared with placebo (odds ratio = 0.28; 95% Cl, 0.18-0.42). AEs were reported by 64 (63%) of 102 patients. The most commonly reported AEs were those typical of opioids (nausea [13%], dizziness [13%], somnolence [10%], and vomiting [5%]) and occurred more often during the dose-titration phase (55/102 [54%]) than during the double-blind phase (22/79 [28%]).

CONCLUSION

In these opioid-tolerant patients with chronic neuropathic pain who identified an effective FBT dose, FBT had a rapid onset of action and was effective and well tolerated in the treatment of BTP.

Breakthrough pain in children with cancer

The aims of this prospective study were to determine the prevalence, characteristics, and impact of breakthrough pain in children with cancer. Twenty-seven pediatric inpatients with cancer (aged 7-18 years) who had severe pain requiring treatment with opioids and who received care in the Oncology Unit at the Children's Hospital at Westmead, Sydney, Australia participated in this study. The children responded to a structured interview (Breakthrough Pain Questionnaire for Children), designed to characterize breakthrough pain in children. Measures of pain, anxiety, and depressed mood were completed. Fifty-seven percent of the children experienced one or more episodes of breakthrough pain during the preceding 24 hours, each episode lasting seconds to minutes, occurring 3-4 times/d, and most commonly characterized as "sharp" and "shooting" by the children. Younger children (7-12 years) had a significantly higher risk of experiencing breakthrough pain compared to teenagers. No statistical difference could be shown between children with and without breakthrough pain in regard to anxiety and depression. The most effective treatment of an episode of breakthrough pain was a patient-controlled analgesia opioid bolus dose. Further studies of breakthrough pain in children and more effective treatment strategies in this age group are necessary.

Transmucosal fentanyl vs intravenous morphine in doses proportional to basal opioid regimen for episodic-breakthrough pain

The use of supplemental doses of opioids is commonly suggested to manage breakthrough pain. A comparative study of intravenous morphine (IV-MO) and oral transmucosal fentanyl citrate (OTFC) given in doses proportional to the basal opioid regimen was performed in 25 cancer patients receiving stable opioid doses. For each episode, when it occurred and 15 and 30 min after the treatment, pain intensity and opioid-related symptoms were recorded. Fifty-three couples of breakthrough events, each treated with IV-MO and OTFC, were recorded. In episodes treated with IV-MO, pain intensity decreased from a mean of 6.9 to 3.3 and to 1.7 at T1 and T2, respectively. In episodes treated with OTFC, pain intensity decreased from a mean of 6.9 to 4.1 and to 2.4 at T1 and T2, respectively. Statistical differences between the two treatments were found at T1 (P=0.013), but not at T2 (P=0.059). Adverse effects were comparable and were not significantly related with the IV-MO and OTFC doses. Intravenous morphine and OTFC in doses proportional to the scheduled daily dose of opioids were both safe and effective, IV-MO having a shorter onset than OTFC. Future comparative studies with appropriate design should compare titration methods and proportional methods of OTFC dosing.

Barriers to pain management in the rehabilitation of the surgical oncology patient

Virtually every surgical oncology patient faces pain, and it can become a major barrier to rehabilitation and quality of life. Pain must be assessed as to its severity, etiology (somatic, visceral, or neuropathic), causation (directly from malignancy or from treatment side effects), and its impact on daily function. Treatments can include physical modalities, exercise, opioids, adjuvant medications, and interventional techniques. Barriers to treatment may include side effects, finances, and attitudes. New technologies in medication delivery systems, intrathecal pumps, injections, and surgery have greatly strengthened the armamentarium available to manage pain.

Fentanyl buccal tablet (FBT) for relief of breakthrough pain in opioid-treated patients with chronic low back pain: a randomized, placebo-controlled study

BACKGROUND

Short-acting opioids are commonly used to treat breakthrough pain (BTP) and rapid-onset formulations are being developed to improve the effectiveness of this approach. Fentanyl buccal tablet (FBT) is a new formulation of fentanyl that enhances transbuccal drug delivery via an effervescent reaction and may provide relatively rapid-onset analgesia. FBT was evaluated for BTP in opioid-treated patients with chronic low back pain--the first such study in a population with chronic non-cancer pain.

DESIGN

Randomized, double-blind, placebo-controlled.

PATIENTS AND SETTING

Patients with chronic low back pain receiving long-term opioid therapy at 16 pain treatment centers in the United States.

PROCEDURES

Following open-label titration to identify an effective FBT dose, patients were randomly assigned to one of three double-blind dose sequences (six doses of FBT, three placebo) to treat nine BTP episodes. Pain intensity (PI), measured on an 11-point scale (0 = no pain; 10 = worst pain), and other outcomes were assessed for 2 h after dosing.

DATA ANALYSIS

The primary efficacy measure was the sum of pain intensity differences (PIDs) for the first 60 min (SPID60); secondary efficacy measures included PIDs at other time points, pain relief (PR), meaningful PR, time to meaningful PR, use of supplementary BTP medication, and self/investigator-reported adverse events.

RESULTS

Of the 124 patients screened, 105 patients were enrolled, 84 identified an effective FBT dose, and 77 entered the double-blind phase. SPID60 significantly favored FBT (p < 0.0001). All secondary measures also favored FBT, with PIDs and PR showing significant differences versus placebo as early as 10 and 15 min, respectively. An improvement in PI score of > or = 33% occurred in a significantly larger proportion of FBT-treated episodes versus placebo from 15 min (20% vs. 11%, p < 0.01) through 2 h (65% vs. 28%, p < 0.0001). Patients were approximately four times more likely to require supplemental opioids for BTP episodes following administration of placebo compared with episodes treated with FBT. AEs were typical for opioids, and were mostly reported during dose titration. Limitations of this study may be related to its open-label dose-titration phase (which has the potential to compromise blinding) and the recruitment of patients from pain clinics, which could potentially yield a study population that is not representative of the general population with BTP.

CONCLUSIONS

FBT was efficacious and well tolerated in the treatment of BTP in opioid-treated patients with chronic low back pain.

A Randomized, Placebo-controlled Study of Fentanyl Buccal Tablet for Breakthrough Pain in Opioid-treated Patients With Cancer

OBJECTIVES

Cancer-related breakthrough pain (BTP) is typically managed with a short-acting oral opioid, taken as needed during a fixed-schedule opioid regimen. The conventional approach may not provide the onset of analgesia required for BTP for many patients, because the onset of analgesia with short-acting opioids lags behind the time course of the majority of episodes of BTP. The fentanyl buccal tablet (FBT) employs a novel delivery system that enhances the rate and extent of absorption of fentanyl through the buccal mucosa. This double-blind, randomized, placebo-controlled study evaluated the efficacy, safety, and tolerability of FBT in opioid-treated patients with cancer-related BTP.

METHODS

After an open-label titration (N=123) to identify an effective FBT dose to treat BTP episodes, 77 patients were randomly assigned to 1 of 18 prespecified dose sequences of 10 tablets (7 FBT and 3 placebo). Pain intensity, pain relief (PR), and global performance of the medication were recorded at regular time intervals between 15 and 60 minutes. Pain intensity differences (PID), the summed PID (SPID), and summed total PR were calculated. The SPID at 30 minutes (SPID30) was the primary efficacy variable. Adverse events were reported.

RESULTS

Sixty-five percent (80/123) of patients were titrated to an effective dose. The mean (SE) SPID30 for FBT was 3.0+/-0.12 versus 1.8+/-0.18 for placebo (P<0.0001). Measures of PR, PID, SPID, summed total PR, and patient ratings of global performance of medication significantly favored FBT over placebo at all time points. Adverse events were typical of opioid drugs. Poor oral tolerability was noted in 2 patients.

CONCLUSIONS

FBT is efficacious and safe in the treatment of cancer-related BTP.

Cancer-related breakthrough pain

Breakthrough pain is a common problem in patients with cancer, and is associated with significant morbidity among this group of patients. This review examines the different types of breakthrough pain, and the various options for the management of breakthrough pain.

Pain in children who have life-limiting conditions

Children and adolescents who have life-limiting conditions are vulnerableto acute and chronic pain problems. Many compounding and complicatingfactors often need to be explored in this setting. Barriers to effective painmanagement include poor assessment and measurement of pain anda lack of specialist knowledge. Fears regarding the use of opioids and theirassociation with the end of life must be addressed openly and with clarity.Day-to-day management should include continual appraisal of pain issuesif quality of life is to be maximized. Pain is a complicated phenomenon. The impact of pain and the compli-cated dynamic of suffering in children and young people who have life-lim-iting conditions must not be underestimated. The clinician must be vigilantand take responsibility for all aspects of pain management in these patients.

Endogenous opiates and behavior: 2004

This paper is the 27th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over 30 years of research. It summarizes papers published during 2004 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.