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Download Article (PDF) CLINICAL PRACTICE Role of Opioid-Involved Drug Interactions in Chronic Pain Management Kevin T. Bain, PharmD, MPH, BCPS, BCGP, CPH; Calvin H. Knowlton, BPharm, MDiv, PhD From Tabula Rasa The use of opioids for chronic pain management is extraordinarily common despite HealthCare. substantial evidence of only modest benefits, when compared with nonopioid Financial Disclosures: None analgesics. Opioid use is also associated with serious risks, including overdose and reported. death. A growing body of evidence suggests that opioids are involved in significant Support: None reported. drug interactions that often go unrecognized in clinical practice. Understanding Address correspondence to opioid-involved drug interactions is of great practical importance for all health care Kevin T. Bain, PharmD, MPH, professionals caring for patients with chronic pain. In this article, we describe the BCPS, BCGP, CPH, Tabula mechanisms of opioid-involved drug interactions and their potential consequences, Rasa HealthCare, 228 Strawbridge Dr, Moorestown, which have major public health implications. Additionally, this article provides prac- NJ 08057-4600. tical strategies to aid health care professionals in avoiding and mitigating opioid- fi Email: [email protected] involved drug interactions in order to obtain a favorable balance in the risk-bene t ratio associated with opioid use. These strategies include using osteopathic princi- ples for chronic pain management, separating the times of administration of the opioid(s) from the nonopioid(s) involved in the interaction, changing the opioid(s) adversely affected by the interaction, changing the nonopioid(s) causing the inter- action, and partnering with pharmacists in clinical practice. J Am Osteopath Assoc. 2019;119(12):839-847 doi:10.7556/jaoa.2019.136 Keywords: addiction, drug-drug interaction, opioid devastating consequence of the surge in opioid prescriptions over the past decade in the United States has been a parallel rise in opioid abuse, misuse, A and death.1,2 In 2013, an estimated 1.9 million persons abused, or were dependent on, prescription opioids.3 In 2016, more than 2.1 million people had an opioid use disorder.4 That year, a reported 11.5 million persons misused prescription opioids, particularly hydrocodone (6.9 million), oxycodone (3.9 million), codeine (2.8 million), and tramadol (1.6 million).4 From 1999 to 2014, there were more than 165,000 reports of opioid-related overdose deaths.2 In 2015, 15,281 persons died of overdoses involving prescription opioids.1 Despite appropriate opioid prescribing, some patients continue to have uncontrolled pain and/or functional impairment.5 According to osteopathic philosophy, sustained levels of persistent pain (ie, >3 months) upset the biopsychosocial balance.6 Clinical, psychological, and social consequences of uncontrolled pain include limitations in daily activities; depression, anxiety, and insomnia; lost work productivity; and reduced quality of life.5,7 Additionally, there are economic consequences of persistently uncontrolled pain. In a series of analyses of opioid users with chronic low back pain and osteoarthritic pain, patients exposed to suboptimal opioid prescribing had significantly greater use of health care resources (eg, outpatient visits, inpatient hospitalizations) and significantly The Journal of the American Osteopathic Association December 2019 | Vol 119 | No. 12 839 CLINICAL PRACTICE higher total health care payments ($700 to $1000) in victim drug). This type of competitive inhibition the 6-month observation period after exposure com- cannot be overcome because substrate affinity for a pared with patients not exposed.8,9 CYP isoenzyme is constant; however, it may be miti- Successful management of chronic pain requires gated by separating times of drug administration. treating the whole person and achieving a fine balance Substrates with similar affinities sharing the same iso- between opioid-related risks and benefits. The individu- enzyme also interact; the substrate with the higher alistic nature of drug interactions has the potential to dose competitively inhibits the substrate with the lower affect the risk-benefit ratio. A growing body of evi- dose. This type of competitive inhibition can be over- dence indicates that opioids are involved in a myriad come by increasing the dose of the victim drug to of drug interactions, with potentially significant clinical surpass the dose of the perpetrator drug.12-14 However, and psychosocial consequences.10 Among opioid users higher opioid doses pose greater risks for opioid use with chronic pain, it has been estimated that 30% are disorders and overdoses. exposed to clinically relevant drug interactions.11 Yet, Substrates of a CYP isoenzyme are potential com- drug interactions involving opioids often go unrecog- petitive inhibitors; however, not all inhibitors of a nized as causative or contributing factors to opioid use CYP isoenzyme are substrates. Unlike substrates, inhi- disorders and overdose deaths, suggesting the need for bitors bind to an allosteric site, changing the conform- greater public awareness and action. ational structure of a CYP isoenzyme. As a result, We hypothesize that understanding opioid-involved substrates of the inhibited CYP isoenzyme cannot inter- drug interactions is of great practical importance to all act with that isoenzyme to be metabolized. An inhibitor health care professionals caring for patients with renders the metabolic activity of a CYP isoenzyme non- chronic pain. In this article, we describe the mechan- functional, occurring immediately upon interaction. isms of opioid-involved drug interactions and their This action is known as noncompetitive inhibition, potential consequences. We also provide strategies to which cannot be overcome unless the inhibitor is aid health care professionals in avoiding and mitigating removed. In contrast, inducers bind to certain receptors opioid-involved drug interactions to obtain a favorable and increase the synthesis of a CYP isoenzyme. Unlike balance in the associated risk-benefit ratio. inhibition, induction takes days to weeks to occur.12,15 Drug interactions involving opioids are mediated by the CYP system. The CYP2D6 isoenzyme, in particu- Mechanisms of Opioid-Involved Drug lar, mediates the metabolism of approximately 25% of Interactions drugs used in practice.16 This includes activation of The cytochrome P450 (CYP) system is the principal the prodrug opioids codeine, hydrocodone, oxycodone, phase I metabolic pathway for most drugs.12 The main and tramadol from relatively inert drugs to pharmaco- role of the CYP system is to convert parent drugs to logically active metabolites.17 Altered activity of the inactive metabolites for elimination and to convert pro- CYP2D6 isoenzyme is one of the most studied scenarios drugs to active metabolites for utilization.12 Drugs of genetic variants influencing the CYP system.17-19 For interacting with the CYP system are classified as sub- example, activation of tramadol by the CYP2D6 isoen- strates, inhibitors, or inducers.12,13 Substrates are zyme is a prerequisite for its analgesic effects. Patients further classified as weak, moderate, or strong affinity expressing the poor metabolizer phenotype have little to substrates for a specific CYP isoenzyme.12,13 no CYP2D6 isoenzyme activity, resulting in adequate Substrates sharing the same isoenzyme interact such pain control when using tramadol.20,21 Although that the stronger affinity substrate (or perpetrator drug) CYP3A4 plays a role in metabolizing many opioids, competitively inhibits the weaker affinity substrate (or studies have not consistently linked altered activity of 840 The Journal of the American Osteopathic Association December 2019 | Vol 119 | No. 12 CLINICAL PRACTICE this isoenzyme to a clinically significant response from response.24,26 For example, the m-opioid receptor affin- the prodrug opioids.17,22 We believe relatively few pre- ities of morphine and O-desmethyl-tramadol are scribers are knowledgeable about the impact of altered 200 times greater than the affinities of the parent CYP2D6 activity on response to prodrug opioids. opioids, codeine and tramadol, respectively.24,26 Because a surge in prescriptions for prodrug opioids has Hydromorphone has a 10- to 30-fold greater affinity contributed to the present-day opioid epidemic, under- and oxymorphone has a 40-fold greater affinity for the standing the role of the CYP2D6 isoenzyme in opioid m-opioid receptor than their respective parent metabolism and response is paramount. opioids.26 Therefore, CYP2D6 activity is required to Depicted in Figure 1, the CYP2D6 isoenzyme meta- produce the highly potent m-opioid receptor agonists bolizes the prodrug opioids into active metabolites. of the prodrug opioids. These metabolites are much more potent for the Drug interactions can mimic genetic variants and simi- m-opioid receptor target than the prodrug opioids and larly contribute to variability in opioid response.19,27-29 are primarily responsible for their analgesic For example, patients receiving CYP2D6 inhibitors CYP2D6 UGT2B7 Codeine Morphine Morphine-6-glucuronide UGT1A1 CYP3A4 Norcodeine Morphine-3-glucuronide CYP2D6 UGT2B7 Hydromorphone-6- Hydrocodone Hydromorphone glucuronide CYP3A4 Hydromorphone-3- Norhydrocodone glucuronide CYP2D6 UGT2B7 Oxymorphone-3- Oxycodone Oxymorphone glucuronide CYP3A4 CYP3A4 Noroxycodone Noroxymorphone CYP2D6 CYP2D6 O-desmethyl- UGT2B7 O-desmethyl-tramadol Tramadol tramadol (M1) UGT1A8 glucuroninde CYP3A4 N-desmethyl- CYP2B6 tramadol
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