Latin-American guidelines for opioid use in chronic nononcologic pain

Opioids Prescribing Among Patients with Zoster-Related Pain in Real-Life: A Retrospective, Cohort Study Based on the Clinical Database

Purpose

The aim of this study was to analysis of the opioid use of opioid native zoster-related pain (ZRP) patients to evaluate the impact of opioid use on pain control and quality of life improvement based on the clinical database.

Patients and Methods

We conducted a retrospective cohort study to identify opioid native patients who were hospitalized in the pain department between May 1, 2020, and May 1, 2021. The primary outcomes were persistent opioid use after discharge, visual analogue scale (VAS) at the admission, VAS remission rate during hospitalization, VAS score and quality of life at follow-up. Then, we assessed patient-level risk factors for persistent opioid use after the discharge.

Results

A total of 350 patients met the inclusion criteria. Of those patients, 255 (72.9%) were administered with opioid during hospitalization, and 95 (27.1%) patients were not. Opioid prescription during hospitalization was independently associated with increased odds of persistent use after the discharge (adjusted odds ratio, 20.74; 95% CI, 4.504-95.474; P < 0.01). In the two groups, the VAS score at admission and the VAS score at follow-up were different. In the group with opioids during hospitalization, the persistent opioid use after discharge was more common (38% vs 2.1%) compared to patients without opioids, and VAS remission rate during hospitalization was less, restrictions on daily life, work or housework, and social activities were more common, and mood, diet and sleep were worse, respectively.

Conclusion

Opioids prescription during hospitalization might increase the risk of chronic opioid use in opioid native ZRP patients, and it has limited benefits in pain control and quality of life improvement. Even though PHN was painful and intractable, the use of opioids should also be more cautious, and strict follow-up, management in this population.

Appropriate use of tapentadol: focus on the optimal tapering strategy

OBJECTIVE

Due to its opioid and non-opioid mechanism of action, tapentadol is considered an atypical opioid with improved gastrointestinal tolerability versus traditional opioids. As for all opioid analgesics it is important to understand how to discontinue a treatment when it is not needed anymore. The aim of this article was to provide an overview of opioid therapy in non-cancer pain, with a specific focus on tapering of tapentadol in patients with chronic non-cancer pain, and suggestions on how to achieve tapering.

METHODS

Studies for this narrative review were identified via PubMed using a structured search strategy, focusing on management of chronic non-cancer pain with opioids, and the efficacy, tolerability, and pharmacology of tapentadol prolonged release. Publications were limited to English-language articles published within the last ∼10 years.

RESULTS

The review discusses the use and discontinuation of opioids in general, as well clinical data on discontinuation of tapentadol specifically. We provide a flow chart, which can be used by clinicians in the context of their own clinical experience to appropriately taper tapentadol in patients with chronic non-cancer pain. The flow chart can be easily tailored to individual patient characteristics, duration of tapentadol treatment, response to progressive dosage reduction, and likelihood of withdrawal symptom occurrence.

CONCLUSIONS

While tapentadol is associated with a low frequency of opioid withdrawal symptoms after abrupt discontinuation, use of a tapering strategy is prudent. Tapering strategies developed for opioids in general can potentially be safely individualized in tapentadol-treated patients, although research on tapering strategies for tapentadol is required.

Pain Control in Latin America: The Optimized Role of Buprenorphine in the Treatment of Cancer and Noncancer Pain

Pain is a terrible health problem that transcends borders and nationalities, although there may be significant differences among regions regarding pain management. In Latin America (LatAm, composed of the many nations of Central America, South America, Mexico, and the Caribbean), access to healthcare, pain management, and opioid analgesics can vary. Despite an international U.S.-led trend toward greater control in opioid prescribing, the role of opioids in the management of severe pain in LatAm is probably smaller than it should be, as opioid consumption in LatAm overall is low. Buprenorphine is a strong opioidwith certain characteristics that make it a potentially useful analgesic agent in LatAm: it has a unique pharmacology that allows for transdermal administration and a favorable safety profile with a ceiling effect for respiratory depression. It has a well-studied low risk potential for misuse, and there is strong evidence for its safety and efficacy in managing both cancer and noncancer pain in adults. Caregivers and policy makers in LatAm may learn from the U.S. experience with opioids in order to develop protocols to better and safely manage pain, and it is possible that buprenorphine will play a key role.

Medical use, non-medical use and use disorders of benzodiazepines and prescription opioids in adults: Differences by insurance status

OBJECTIVES

To report and analyze prevalence's of Benzodiazepines (BZDs) and Prescription Opioids (POs) use by insurance status and to investigate associations between insurance status and BZDs, POs and concurrent medical/non-medical use and use disorders.

METHODS

This study included 81,133 adults ages 18 and older from 2015 and 2016 National Survey on Drug Use and Health. Participants' self-reported past- year medical use, non-medical use and use disorders of BZDs and POs were assessed, along with their insurance status (Private/Military, Medicare, Medicaid, and Uninsured) and demographic characteristics.

RESULTS

In 2015-2016, 12.6% of adults reported using BZDs and 36.9% reported using POs in the past year. Among adults, 8.3% reported past-year use of both BZDs and POs; also, 1.9% and 3.8% reported non-medical use of BZDs and POs, respectively, and 0.9% reported non-medical use of both BZDs and POs. Medicaid-covered respondents had higher risk of BZDs (aRRR = 1.59, 95%CI = [1.45, 1.74]), POs (aRRR = 1.66, 95%CI = [1.54, 1.79]) and concurrent past-year medical use (aRRR = 2.11, 95%CI = [1.87, 2.38]), higher risk of BZDs non-medical use (aRRR = 1.40, 95%CI = [1.17, 1.68]) and BZD Use Disorders (aRRR = 2.60, 95%CI = [1.82, 3.72]), POs non-medical use (aRRR = 1.67, 95%CI = [1.45, 1.92]), PO use Disorders (aRRR = 4.12, 95%CI = [3.33, 5.11]) and concurrent non-medical use (aRRR = 1.52, 95%CI = [1.20, 1.92]) and Use Disorders (aRRR = 3.68, 95%CI = [1.93, 6.78]), compared to those with private insurance.

CONCLUSIONS

Future health policies should focus on reducing individual and co-prescription of BZDs and POs and providing different strategies of pain management.

Pain prevalence and treatment in patients with metastatic bone disease

The accomplishment of successful pain treatment requires evaluation, characterization and quantification. The present study characterized pain and survival in a cohort of patients with cancer with bone metastasis who were treated with intravenous bisphosphonates. A total of 84 patients self-completed the Brief Pain Inventory (BPI) and 36-Item Short Form Survey (SF-36), between November 2010 and March 2011 with a 5-year survival follow-up as a surrogate marker of cancer burden. The median age was 62 years old (34–85), 64% of patients were female and 58% of these females had breast cancer. In the population, self-reported pain was 91.6%, with 29 patients (34.5%) reporting severe pain (score 7–10). Among these patients, only 13 (44.8%) presented a similar report to that of their clinical files and 5 were undergoing treatment with strong opioids (17.2%). A total of 45 patients (46%) had not been prescribed analgesic drugs, of these patients, 32 were treated with a weak opioid, and 13 with a strong opioid. An association was observed between pain records and the prescribed analgesic (P=0.031). BPI maximum pain and overall survival data were analyzed, and a significant association was identified between male patients presenting severe pain and decreased survival (P=0.004). Male survival was associated with severe pain, which is consistent with other data. The results revealed a skeletal-related events (SRE)-free survival (time elapsed from diagnosis of the first bone metastasis to the first SRE) of 9 months (4.39–13.73, 95% CI) with a statistically significant difference between subgroups of time since diagnosis of bone metastasis (P=0.005). The added value of the present study is the suggestion that complete and accurate pain narratives are mandatory and may contribute to the optimization of analgesia, and may help to increase survival rates. Optimal pain management for patients with cancer remains an urgent requirement.

World Opioid and Substance Use Epidemic: A Latin American Perspective

The opioid crisis is a growing social and public health phenomenon, particularly in developed countries such as the United States. Since the 1990s, this crisis has shown a variety of causal processes and consequences and has affected quality of life for millions of individuals, families, and communities across the globe. Although abuse of opioid‐based painkillers appears to have triggered the epidemic in the United States, in this article, the problem is examined with a focus on Latin America, where drug‐associated problems constitute threats to the health and quality of life for large segments of the population. After a review of the history of opium consumption and its consequences in the world and in Latin America, the authors present epidemiological data and information about regional market differences, professional involvement, clinical practices, public health realities, and prevention efforts. Recommendations are made for collaborative efforts to promote prevention policies and measures to improve the situation.

Where Is the Opioid Use Epidemic in Mexico? A Cautionary Tale for Policymakers South of the US-Mexico Border

In North America, opioid use and its harms have increased in the United States and Canada over the past 2 decades. However, Mexico has yet to document patterns suggesting a higher level of opioid use or attendant harms.Historically, Mexico has been a country with low-level use of opioids, although heroin use has been documented. Low-level opioid use is likely attributable to structural, cultural, and individual factors. However, a range of dynamic factors may be converging to increase the use of opioids: legislative changes to opioid prescribing, national health insurance coverage of opioids, pressure from the pharmaceutical industry, changing demographics and disease burden, forced migration and its trauma, and an increase in the production and trafficking of heroin. In addition, harm-reduction services are scarce.Mexico may transition from a country of low opioid use to high opioid use but has the opportunity to respond effectively through a combination of targeted public health surveillance of high-risk groups, preparation of appropriate infrastructure to support evidence-based treatment, and interventions and policies to avoid a widespread opioid use epidemic.

Use of strong opioids for chronic pain in osteoarthritis: an insight into the Latin American reality

INTRODUCTION

Osteoarthritis is the most common cause of arthritis and one of the main causes of chronic pain. Although opioids are frequently employed for chronic pain treatment, their usage for osteoarthritis pain remains controversial due to the associated adverse effects. Most guidelines reserve their use for refractory pain in patients with hip and knee osteoarthritis. The situation is even more complex in Latin America, where the prevalence of insufficient pain treatment is high because of the limited availability and use of strong opioids. Areas covered: In this article we review the epidemiology of osteoarthritis, its socioeconomic burden, its impact as a chronic pain cause and the pharmacological treatment options, giving emphasis to the role of strong opioids, their safety and efficacy, especially in Latin American countries, where restrictions regulate their usage. Expert commentary: Usage of strong opioids is safe and effective in the short-term management of osteoarthritis with moderate to severe pain, when other pharmacological treatments are inadequate and surgery is contraindicated, provided their use adheres to existing guidelines. Educational programs for patients and physicians and further research on treating chronic pain with opioids should be implemented to reduce adverse effects and improve care quality.

The role of tramadol in pain management in Latin America: a report by the Change Pain Latin America Advisory Panel

OBJECTIVE

Change Pain Latin America (CPLA) was created to enhance chronic pain understanding and develop pain management improving strategies in this region. During its seventh meeting (August 2016), the main objective was to discuss tramadol's role in treating pain in Latin America. Furthermore, potential pain management consequences were considered, if tramadol was to become more stringently controlled.

METHODS

Key topics discussed were: main indications for prescribing tramadol, its pharmacological characteristics, safety and tolerability, effects of restrictions on its availability and use, and consequent impact on pain care quality.

RESULTS

The experts agreed that tramadol is used to treat a wide spectrum of non-oncological pain conditions (e.g. post-surgical, musculoskeletal, post-traumatic, neuropathic, fibromyalgia), as well as cancer pain. Its relevance when treating special patient groups (e.g. the elderly) is recognized. The main reasons for tramadol's high significance as a treatment option are: its broad efficacy, an inconspicuous safety profile and its availability, considering that access to strong analgesics - mainly controlled drugs (classical opioids) - is highly restricted in some countries. The CPLA also agreed that tramadol is well tolerated, without the safety issues associated with long-term nonsteroidal anti-inflammatory drug (NSAID) use, with fewer opioid-like side effects than classical opioids and lower abuse risk.

CONCLUSIONS

In Latin America, tramadol is a valuable and frequently used medication for treating moderate to severe pain. More stringent regulations would have significant impact on its availability, especially for outpatients. This could cause regression to older and frequently inadequate pain management methods, resulting in unnecessary suffering for many Latin American patients.