[Chronic non-cancer-related pain. Long-term treatment with rapid-release and short-acting opioids in the context of misuse and dependency]

Annually published data show a continual increase in the volume of opioid prescriptions in Germany, thus indicating an intensification of opioid therapy. The majority of opioids are prescribed to treat chronic non-cancer-related pain. On the basis of current guidelines, as well as in terms of the lack of data regarding long-term use of opioids and their effectiveness beyond a period of 3 months, this development must be viewed critically. With reference to four case reports, we discuss and evaluate opioid therapy in relation to medication misuse and the development of drug dependency. Particular emphasis is placed on the administration of rapid-release and short-acting opioid preparations, which we consider to be particularly problematic.

[The transdermal 7-day buprenorphine patch--an effective and safe treatment option, if tramadol or tilidate/naloxone is insufficient. Results of a non-interventional study]

The transdermal 7-day buprenorphine matrix patch provides a constant and user-friendly pain management when chronic musculoskeletal pain requires opioids. This analysis of clinical routine data evaluated the benefit of this treatment for patients previously receiving oral long-term treatment with weak opioids alone. Data of 310 patients previously treated with tramadol or tildate/naloxone and part of a multicentre observational study with 3295 patients were analyzed. In 89.7% of the 310 patients oral treatment with weak opioids was replaced by the 7-day buprenorphine patch due to insufficient analgesia. During treatment with the 7-day buprenorphine patch there was a clinically significant decrease of the mean pain intensity at rest during the day from 5.7 to 2.9, on physical effort during the day from 7.3 to 3.8 and at night from 5.2 to 2.3 (11-point NRS scale, p < or = 0.001). In addition, quality of life aspects such as mobility, self-reliance and quality of sleep improved, which are relevant for individual patient satisfaction with pain management. For patients with previous long-term tramadol or tilidate/naloxone treatment the switch to the 7-day buprenorphine matrix patch proved to be effective and safe for the management of chronic pain. The user-friendly 7-day application interval contributes to improving compliance and a reducing exposure to tablets.

[Postoperative pain therapy with tilidin and tilidin retard as an oral patient-controlled analgesia after uncomplicated myocardial revascularization]

OBJECTIVE

The purpose of this study was to evaluate whether or not the combination of tilidin and tilidin retard as oral patient-controlled analgesia provide a suitable pain management in patients after uncomplicated myocardial revascularization.

METHODS

We conducted a randomised phase IV study to evaluate the effectiveness of postoperative analgesia with tilidin and tilidin retard. Patients with a baseline tilidin retard and tilidin liquid demand medication (group B, 42 patients) were compared with a base line paracetamol and tramadol-HCl liquid demand medication (group A, 44 patients). All patients received the first dose of study medication at the second postoperative day after evaluation of the individual pain score using NRS (numeric rating scale).

RESULTS

Pain relief in group B was significantly better only at the second postoperative day (NRS 1,8 compared to 3,3 in group A), associated with tolerable side effects and comfortable handling.

CONCLUSION

The combination of sustained release with immediate release drugs as a patient controlled analgesia provides suitable and comfortable analgesia after myocardial bypass surgery.

[Tilidine/naloxon retard in long-term administration in chronic pain and multimorbidity. Multicenter study of long-term tolerance and effectiveness in 2 years observation]

BACKGROUND AND METHOD

335 patients (51% female, 49% male, mean age 56 years) with chronic pain and multimorbidity have been included in a multi-center 2-years' study with slow release Tilidine/Naloxone for efficacy and safety which included detailed laboratory examinations. 316 patients had already been treated with analgesics. 159 patients (47.5%) finished the study as planned, 176 patients finished the study earlier.

RESULTS

Parameters of quality of life such as persistent pain, sleep, mood and activity have improved. Tolerance has not been observed. In 85 patients (25%) adverse events had occurred (nausea, vomiting, dizziness) which are related to the study-medication. Constipation was documented in only 4 patients. After 2 years of therapy with Tilidine/Naloxone there has been no relevant changes in laboratory findings. There has been no sign of organ damage or interactions with concomitant medication.

CONCLUSION

Tilidine/Naloxone is an effective and safe analgesic (WHO II) suitable for the longterm treatment of patients with chronic pain.

Pharmacokinetics of nortilidine and naloxone after administration of tilidine/naloxone solution or tilidine/naloxone sustained release tablets

Valoron N is a compound which consists of the prodrug tilidine (CAS 20380-58-9), from which the active metabolite nortilidine is formed by demethylation in the liver, and the opiate antagonist naloxone (CAS 465-65-6), which prevents the abuse of the analgesic by opiate dependents. The pharmacokinetics of nortilidine and naloxone were studied in 18 male healthy subjects after oral application of tilidine/naloxone solution or tilidine/naloxone retard tablets, respectively. The following report gives the results on investigations of a) dose linearity after application of 25 mg, 50 mg and 100 mg Valoron N solution, b) dose equivalence of Valoron N solution (4 x 50 mg tilidine) and Valoron N retard tablets (2 x 100 mg tilidine) under steady state conditions, and c) the equivalence of different dose strengths of Valoron N retard tablets (50 mg, 100 mg, 200 mg tilidine/tablet). The results obtained in these studies demonstrate a dose linear kinetic for nortilidine after the application of 25 mg to 100 mg tilidine. Furthermore, there is dose equivalence between the tilidine/naloxone solution and tilidine/naloxone retard tablets, which permits the replacing of the solution with the retard tablets. Because of the equivalence of different dose strengths of Valoron N tablets, patients are able to exchange low dosed Valoron N retard tablets for higher-dosed ones (50 mg, 100 mg and 200 mg tilidine/tablet), if necessary. With their constant release of tilidine and the possibility for individual dosage, the retard tablets are efficient analgesics that improve pain therapy considerably for patients with chronic pain.

Adverse effects of opioid analgesic treatment are correlated with a significant elevation in plasma epinephrine in healthy humans

OBJECTIVE

The purpose of this study was to elucidate the relationship of plasma catecholamine concentrations with experienced pain intensity and analgesic effects in the setting of an experimental pain study with human volunteers.

METHODS

Plasma norepinephrine and epinephrine concentrations of 12 healthy human volunteers were analysed before and during painful electrical tooth-pulp stimulation under medication using the highly potent opioid analgesic tilidine in a fixed tilidine/naloxone combination and with the non-steroidal anti-inflammatory agent bromfenac. Catecholamine levels were compared with pharmacodynamic effects and reported adverse effects.

RESULTS

Catecholamine levels revealed a statistically significant increase in plasma epinephrine concentrations (but not norepinephrine concentrations) 60-90 min after administration of tilidine/naloxone. This was correlated with the onset of adverse effects involving vertigo episodes in all reported cases. In contrast, there was no obvious correspondence of epinephrine or norepinephrine plasma concentrations to the experience of pain and analgesia. For comparison, under medication with the non-opioid analgesic bromfenac, only one mild adverse effects were noted, and no changes in plasma epinephrine or norepinephrine could be determined during the experimental sessions.

CONCLUSIONS

It is proposed that elevated plasma epinephrine concentrations are a newly determined response to opioid-induced vertigo; this has possible clinical implications.

Effects of tramadol and tilidine/naloxone on oral-caecal transit and pupillary light reflex

As has been demonstrated in binding studies the two opioids tilidine (CAS 27107-79-7)/naloxone (CAS 357-08-4) and tramadol (CAS 36282-47-0) differ in regard to their affinities to the opioid receptor site. Therefore it is of interest to evaluate whether such a difference in opioid affinity is also seen in the pharmacological effects of clinically relevant doses in man. Following institutional approval by the local ethical committee and informed consent, 12 volunteers received oral doses of tramadol (100 mg), tilidine/naloxone (100 mg) and placebo, respectively, in a randomized, double-blind cross-over design. In order to determine the degree of constipation, oral-caecal transit time was measured using the H2-exhalation test. Additionally, in order to evaluate a centrally mediated effect, the response of the pupil to light was quantified using the pupillary light reflex technique. Both, peripheral and central mediated effects were compared to placebo. Tramadol as well as tilidine/naloxone induced a significant (p < 0.05) prolongation of oral-caecal transit when compared to placebo. However, prolongation of oral-caecal transit was significantly longer in the tilidine/naloxone (p < 0.05) than in the tramadol group. Compared to tramadol, the pronounced constipating effect of tilidine/naloxone is likely to be due to the 10 fold higher affinity of that drug to the peripheral opioid receptor sites in the intestinal tract, which are responsible for normal propulsion. Such difference in binding is underlined by a central effect, the pupillary light reflex response. The amount of constriction of the iris to light was reduced after both opioids. Again, tilidine/naloxone significantly reduced (p < 0.001) the pupillary light reflex when compared to tramadol. Other side effects such as tiredness, nausea, emesis and dry mouth were more often reported after tilidine/naloxone than after tramadol (40% versus 15%; p < 0.05). Vertigo and perspiration were more often reported after tramadol than after after tilidine/naloxone (58% and 78% versus 8%; p < 0.01). All these data support the findings that while tramadol is considered an opioid, it does not mediate its main clinical relevant properties via binding at the opioid receptor. More likely, due to its monoaminergic reuptake mechanism, to a lesser extent opioid-like effects are induced.

Comparison of tilidine/naloxone, tramadol and bromfenac in experimental pain: a double-blind randomized crossover study in healthy human volunteers

AIM

The analgesic efficacy and safety of single oral doses of two centrally acting compounds, the combination of 50 mg tilidine and 4 mg naloxone (Valoron N) and 50 mg tramadol (Tramal), were compared to 25, 50 and 75 mg of the non-steroidal antiinflammatory bromfenac in experimental pain.

SUBJECTS AND METHODS

It was a placebo-controlled double-blind 6-way crossover study design with 12 human volunteers. Acute pain was generated by electrical tooth pulp stimulation. Treatment effects were determined by recording somatosensory-evoked potentials and by subjective pain rating.

RESULTS

The tilidine/naloxone combination clearly was the most potent medication in this study, followed by bromfenac 75 mg, which produced an early pain relief. Tramadol produced poor analgesia, as did bromfenac 25 and 50 mg. There was no dose-response relationship for bromfenac. Control of plasma levels revealed pronounced interindividual differences in peak plasma concentrations for bromfenac, but not for tramadol. Tilidine/naloxone exerted adverse effects in 9, tramadol in 3 volunteers. Under medication with 25 and 50 mg bromfenac, respectively, only one subject reported adverse effects. No adverse effects were experienced with 75 mg bromfenac or placebo.

CONCLUSION

The results support previous conclusions about the analgesic efficacy of tilidine/naloxone and tramadol in experimental pain. Moreover, the findings suggest that 75 mg bromfenac might be suitable for fast but short relief of pain of non-inflammatory genesis.

[Long-term treatment of chronic pain with tilidine-naloxone. An analysis of 50 patients with chronic pain conditions of non-malignant origin]

METHOD

50 patients with incurable chronic pain states were treated for a period of between six months and 14 years (median: 31 months) with tilidine-naloxone, and the results of tumor recorded. Amelioration of pain was achieved in an average of 60.7% of the cases. The 16 patients of this series suffering from neuropathic pain who received a somewhat lower dose responded equally as well (60.3% amelioration) as the overall group. In 24 patients suffering from pain, the daily dose remained unchanged throughout the course of treatment, had to be increased in 19, and was reduced in seven patients. In two patients, acceptable side-effects were indicated; in no case were there any signs of drug-induced organic damage.

CONCLUSIONS

The results show that tilidine-naloxone is a highly effective opioid analgesic with a remarkably favorable benefit-risk ratio for use in long-term treatment.

[Comparison of diflunisal and tilidine in tumor pain]

In an open study in patients with tumour-induced pain the analgetic effects of the prostaglandin-inhibiting compound diflunisal and the centrally-acting analgetic tilidine N were compared. A dosage of 1 g diflunisal was found to be equivalent to 50 drops of tilidine N and to be subjectively well-tolerated. In the pain-relieving therapy of tumour patients diflunisal appears to offer a genuine alternative to centrally-acting analgetics.

A comparison of tilidine hydrochloride and morphine in the treatment of postoperative pain

Intramuscular injections of 10 mg morphine or 100 mg tilidine hydrochloride were administered in a double-blind fashion and in random order to 40 patients after minor surgical operations. The therapeutic effect of each analgesic was assessed by comparing the severity of pain immediately postoperatively with that 1, 2, 3 and 4 hours after injection of the relevant analgesic. Tilidine and morphine relieved pain to a similar degree. Within the limits of the protocol followed, morphine appeared superior to tilidine in some tests. No major side-effects occurred.

Action of tilidine hydrochloride and morphine hydrochloride on ventilatory control in normal subjects

The action of tilidine hydrochloride and morphine hydrochloride on the ventilatory response to inhaled carbon dioxide has been assessed in 10 normal volunteers. In doses of 50 mg and 100 mg given intravenously, tilidine hydrochloride induced less respiratory depression than 10 mg of morphine given intravenously. Side effects were not different or troublesome with either drug. Depending on its relative pain-relieving property, tilidine hydrochloride may have advantages over morphine as an analgesic.