DOCSLIB.ORG

Long-Acting Narcotic Analgesics Therapeutic Class Review (TCR)

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Long-Acting Narcotic Analgesics Therapeutic Class Review (TCR) Long-Acting Narcotic Analgesics Therapeutic Class Review (TCR) August 13, 2019 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected]. August 2019 Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004–2019 Magellan Rx Management. All rights reserved. FDA-APPROVED INDICATIONS Drug Manufacturer Schedule Indication(s) buprenorphine Biodelivery CIII ▪ Management of pain severe enough to require (Belbuca™)1 Sciences daily, around-the-clock, long-term opioid treatment and for which alternative treatment buprenorphine generic, Purdue CIII options are inadequate (Butrans®)2 fentanyl transdermal generic, Janssen CII (Duragesic®)3 hydrocodone extended-release Purdue CII (Hysingla® ER)4 hydrocodone extended-release Pernix CII (Zohydro® ER)5 hydromorphone extended-release generic, CII (Exalgo®)6 Mallinckrodt methadone generic, West- CII ▪ Management of pain severe enough to require (Dolophine®, Diskets®, Ward/Hikma; daily, around-the-clock, long-term opioid Methadose™)7 Mallinckrodt treatment and for which alternative treatment options are inadequate; ▪ Detoxification and maintenance treatment of opioid addiction morphine sulfate controlled-release generic, Rhodes CII ▪ Management of pain severe enough to require (MS Contin®)8 daily, around-the-clock, long-term opioid morphine sulfate extended-release* Egalet/Zyla CII treatment and for which alternative treatment (Arymo ER™)9 options are inadequate morphine sulfate extended-release† generic, CII (Kadian®)10 Actavis/Allergan morphine sulfate extended-release Daiichi Sankyo CII (Morphabond™ ER)11 morphine sulfate extended-release Pfizer CII and naltrexone (Embeda®)12 oxycodone controlled-release generic‡, Purdue CII (Oxycontin®)13 oxycodone extended-release Collegium CII (Xtampza ER™)14 oxymorphone extended-release§15 generic CII tapentadol extended-release Depomed/ CII ▪ Management of pain severe enough to require (Nucynta® ER)16 Collegium daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate; ▪ Neuropathic pain associated with diabetic peripheral neuropathy (DPN) in adults severe enough to require daily, around-the-clock, long- term opioid treatment and for which alternative treatment options are inadequate Long-Acting Narcotic Analgesics – August 2019 Page 2 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004–2019 Magellan Rx Management. All rights reserved. 4 FDA-Approved Indications (continued) Drug Manufacturer Schedule Indication(s) tramadol extended-release generic, Vertical CIV ▪ Management of pain severe enough to require (Conzip®)17 daily, around-the-clock, long-term opioid treatment and for which alternative treatment tramadol extended-release¶ 18,19 generic CIV options are inadequate * Effective September 28, 2018, Egalet/Zyla announced that they are discontinuing the promotion and manufacture of Arymo ER.20 † Pfizer has discontinued manufacture of Avinza® non-abuse-deterrent extended-release morphine sulfate capsules. Generic products, approved with Avinza as the reference product, are still available. ‡ All generic products of Oxycontin are authorized generics. § In July 2017, Endo announced that they will voluntarily remove Opana® ER (oxymorphone ER) from the market in response to a request from the Food and Drug Administration (FDA) who determined that the product’s risks outweigh its benefits.21,22 Product may remain until supply is depleted. Although Opana ER had abuse-deterrent properties following its reformulation in 2012, it was not considered an abuse-deterrent formulation by the FDA. In addition, oxymorphone extended-release products were approved based on the original formulation of Opana ER (originally approved in 2006), which did not contain abuse-deterrent properties. ¶ Generics were approved as reference products to either Ryzolt® (previously manufactured by Purdue Pharma) or Ultram® ER (previously manufactured by Janssen). Ionsys®, a fentanyl iontophoretic transdermal system for pain management in hospitalized patients only, will not be addressed in this review. OVERVIEW Pain of multiple etiologies remains a substantial problem for many patients presenting in the clinical setting.23 Pain management must be individualized for each of these patients. There are many opioid analgesic products available, differing in specific opioid, dosage form, abuse-deterrent properties, and duration of action. In this review, the terms “narcotic” and “opioid” are used interchangeably. Data from 2012 demonstrated that approximately 11.2% of adults report daily pain, which is greatly misunderstood. Historically, data have suggested that pain may be undertreated, but newer estimates imply that opioid treatment for pain may be overutilized.24 An estimated 20% of patients who presented to outpatient providers with noncancer pain or pain-related diagnoses, whether acute or chronic, received an opioid prescription.25 Caregivers’ misconceptions regarding opiate doses, duration of analgesic effect, and fear of addiction may be responsible for the historical undertreatment of pain, and some of the historical increase in opioid use is thought to be related to prescribers worrying they are undertreating their patients’ pain.26,27 Unfortunately, approximately 70,237 people have died from overdoses related to opioid pain medications in the United States (US) in 2017.28 Likewise, drug related deaths have tripled from 1999 to 2015, and during 2015 alone 33,091 persons in the US died from opioid related overdoses.29 Opioid related overdose was higher among males (13.7%) in comparison to females (7.1%).30 In 2017, 17.4% of the US population received ≥ 1 opioid prescription. Annually from 2010, there has been a continued decreased in opioid prescribing.31 Likewise, per capita opioid prescriptions have subsequently decreased by 19.1% from 2006 to 2017. Regardless, persistent pain that is uncontrolled may have clinical, psychological, and social consequences; thus, it is critical to weigh the risks and benefits of opioid use and reevaluate patients routinely for appropriate dose, duration, and treatment choice, including both pharmacologic and nonpharmacologic modalities. Long-Acting Narcotic Analgesics – August 2019 Page 3 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004–2019 Magellan Rx Management. All rights reserved. 4 Different management techniques are utilized for acute and chronic pain. When properly used, long- acting opioids decrease administration frequency, decrease the incidence of adverse effects, and increase periods of consistent pain control. While definitions vary, chronic pain is generally defined as pain lasting > 3 months or past the time required for normal tissue healing. It has various etiologies, including injury, inflammation, and underlying medical conditions.32 Treatment Guidelines The World Health Organization’s (WHO) guidelines for cancer pain management, long recognized as the foundation of cancer pain relief, recommend a 3-stepped approach with consideration for the type of pain and response to therapy.33 Initial therapy should include non-opioid analgesics, such as non- steroidal anti-inflammatory drugs (NSAIDs). For mild to moderate pain, oral combinations of acetaminophen and NSAIDs with opioids are recommended. For moderate to severe pain, opioid analgesics are the treatment of choice. The American Pain Society does not distinguish amongst the available products in their 2009 clinical guidelines for the use of chronic opioid therapy for the treatment of chronic non-cancer pain.34 Titration of dose and frequency should be individualized to the patient’s response and experience of adverse effects. In 2016, the American Society of Clinical Oncology (ASCO) published guidelines for chronic pain management in adult cancer survivors.35 For pharmacologic treatment, systemic non-opioid analgesics and adjuvant analgesics are suggested for chronic pain and to improve function. They state that opioids may be used in those who do not respond to more conservative management.
Load more

Recommended publications
  • Methadone Hydrochloride Tablets, USP) 5 Mg, 10 Mg Rx Only
    ROXANE LABORATORIES, INC. Columbus, OH 43216 DOLOPHINE® HYDROCHLORIDE CII (Methadone Hydrochloride Tablets, USP) 5 mg, 10 mg Rx Only Deaths, cardiac and respiratory, have been reported during initiation and conversion of pain patients to methadone treatment from treatment with other opioid agonists. It is critical to understand the pharmacokinetics of methadone when converting patients from other opioids (see DOSAGE AND ADMINISTRATION). Particular vigilance is necessary during treatment initiation, during conversion from one opioid to another, and during dose titration. Respiratory depression is the chief hazard associated with methadone hydrochloride administration. Methadone's peak respiratory depressant effects typically occur later, and persist longer than its peak analgesic effects, particularly in the early dosing period. These characteristics can contribute to cases of iatrogenic overdose, particularly during treatment initiation and dose titration. In addition, cases of QT interval prolongation and serious arrhythmia (torsades de pointes) have been observed during treatment with methadone. Most cases involve patients being treated for pain with large, multiple daily doses of methadone, although cases have been reported in patients receiving doses commonly used for maintenance treatment of opioid addiction. Methadone treatment for analgesic therapy in patients with acute or chronic pain should only be initiated if the potential analgesic or palliative care benefit of treatment with methadone is considered and outweighs the risks. Conditions For Distribution And Use Of Methadone Products For The Treatment Of Opioid Addiction Code of Federal Regulations, Title 42, Sec 8 Methadone products when used for the treatment of opioid addiction in detoxification or maintenance programs, shall be dispensed only by opioid treatment programs (and agencies, practitioners or institutions by formal agreement with the program sponsor) certified by the Substance Abuse and Mental Health Services Administration and approved by the designated state authority.
    [Show full text]
  • Medications to Treat Opioid Use Disorder Research Report
    Research Report Revised Junio 2018 Medications to Treat Opioid Use Disorder Research Report Table of Contents Medications to Treat Opioid Use Disorder Research Report Overview How do medications to treat opioid use disorder work? How effective are medications to treat opioid use disorder? What are misconceptions about maintenance treatment? What is the treatment need versus the diversion risk for opioid use disorder treatment? What is the impact of medication for opioid use disorder treatment on HIV/HCV outcomes? How is opioid use disorder treated in the criminal justice system? Is medication to treat opioid use disorder available in the military? What treatment is available for pregnant mothers and their babies? How much does opioid treatment cost? Is naloxone accessible? References Page 1 Medications to Treat Opioid Use Disorder Research Report Discusses effective medications used to treat opioid use disorders: methadone, buprenorphine, and naltrexone. Overview An estimated 1.4 million people in the United States had a substance use disorder related to prescription opioids in 2019.1 However, only a fraction of people with prescription opioid use disorders receive tailored treatment (22 percent in 2019).1 Overdose deaths involving prescription opioids more than quadrupled from 1999 through 2016 followed by significant declines reported in both 2018 and 2019.2,3 Besides overdose, consequences of the opioid crisis include a rising incidence of infants born dependent on opioids because their mothers used these substances during pregnancy4,5 and increased spread of infectious diseases, including HIV and hepatitis C (HCV), as was seen in 2015 in southern Indiana.6 Effective prevention and treatment strategies exist for opioid misuse and use disorder but are highly underutilized across the United States.
    [Show full text]
  • The Opioid Epidemic: What Labs Have to Do with It?
    The Opioid Epidemic: What labs have to do with it? Ewa King, Ph.D. Associate Director of Health RIDOH State Health Laboratories Analysis. Answers. Action. www.aphl.org Overview • Overdose trends • Opioids and their effects • Analytical testing approaches • Toxicology laboratories Analysis. Answers. Action. www.aphl.org Opioid overdose crisis 1 Analysis. Answers. Action. www.aphl.org Opioid overdose crisis 2 Analysis. Answers. Action. www.aphl.org Opiates and Opioids • Opiates vs. Opioids • Opiates: Naturally occurring, derived from the poppy plant • Opioids: “Opiate-like” drugs in effects, not chemical structure Includes opiates • Narcotic analgesics • CNS depressants • DEA Schedule I or II controlled substances • Additive effect with other CNS depressant drugs Analysis. Answers. Action. www.aphl.org Efficacy of Opioids • How do opioids work? • Bind with opioid receptors • Brain, spinal cord, GI tract, and throughout the body • Pain, emotion, breathing, movement, and digestion Opioid Receptor Analysis. Answers. Action. www.aphl.org Effects of Opioids Physiological Psychological • Pain relief • Drowsiness/ sedation • Cough suppression • Mental confusion • GI motility • Loss of memory • Respiratory depression • Lethargy/ apathy • Pupillary constriction • Euphoria/ tranquility • Itching • Mood swings • Constipation • Depression • Dependence • Withdrawal • Dependence Analysis. Answers. Action. www.aphl.org Opiates 1 Opiates • Naturally occurring alkaloids Opium • Latex from the opium poppy plant Codeine: • Mild to moderate pain • Antitussive Morphine: • Severe pain • Metabolite of codeine and heroin Analysis. Answers. Action. www.aphl.org Opiates 2 Semi-synthetic Opiates: • Synthesized from a natural opiate Heroin: • Schedule I narcotic Hydrocodone (Vicodin): • Mild to moderate pain • Metabolizes to hydromorphone (Dilaudid) Oxycodone (Oxycontin/Percocet): • Moderate to severe pain • Metabolizes to oxymorphone (Opana) Analysis. Answers. Action.
    [Show full text]
  • Opiate/ Heroin Working Group Final Report
    OPIATE/ HEROIN WORKING GROUP FINAL REPORT United States Attorney’s Offices For the Southern and Northern Districts of Mississippi February 28. 2017 HEROIN/OPIATE WORKING GROUP FINAL REPORT Law Enforcement and Data Group Recommendation No. 1: Implement a comprehensive data collection and dissemination program Recommendation No. 2: Heroin (Opiate) Involved Death Investigation Task Force Recommendation No. 3: Greater distribution and training on use of Naloxone Recommendation No. 4: Mandate greater reporting of overdoses and naloxone administration Recommendation No. 5: Expand and advertise availability of the dropbox program Medical Issues Group Recommendation No. 1: Adopt CDC Guidelines Recommendation No. 2: Continuing Medical Education Recommendation No. 3: Upgrades to the Prescription Monitoring Program Recommendation No. 4: Addiction Treatment Education Recommendation No. 5: Review Funding Issues for Alternative Treatments Recommendation No. 6: Limitations on Prescriptions Recommendation No. 7: Mandate increased use of PMP Recommendation No. 8: Change the definition of Pain Management Clinic Recommendation No. 9: IDs for Controlled Substance Prescriptions Treatment and Overdose Prevention Group Recommendation No. 1: More Funding for Treatment Recommendation No. 2: Youth/Juvenile Detention Systems Recommendation No. 3: Expand the availability and use of Vivitrol Recommendation No. 4: Drug Courts and Rentry programs Recommendation No. 5: Public Education and Awareness HEROIN/OPIATE WORKING GROUP FINAL REPORT The United States Attorney’s Offices for the Northern and Southern Districts of Mississippi convened an Opiate/Heroin Working Group in June 2016. At the initial meeting at the Mississippi Bureau of Narcotics (“MBN”) Headquarters, representatives from the medical, pharmaceutical, mental health, law enforcement, judiciary and many other specialties attended a full day symposium to begin the discussion about a comprehensive approach to the opiate and heroin crisis in the nation and in our state.
    [Show full text]
  • Drug Class Review Long-Acting Opioid Analgesics
    Drug Class Review Long-Acting Opioid Analgesics 28:08.08 Opiate Agonists Transdermal Buprenorphine transdermal system (Butrans®) Fentanyl transdermal system (Duragesic®) Oral Buprenorphine oral buccal film (Belbuca®) Hydrocodone ER (Zohydro ER®, Hysingla ER®) Hydromorphone hydrochloride extended-release tablets (Exalgo®) Methadone tablets (Dolophine®) Morphine sulfate controlled-release tablets (MS Contin®, MorphaBond®) Morphine sulfate extended-release capsules (Kadian®) Oxycodone hydrochloride controlled-release tablets (OxyContin®) Oxymorphone hydrochloride extended-release (Opana ER®) Tapentadol extended-release oral tablets (Nucynta ER®) Tramadol hydrochloride extended-release capsule (Conzip, others) Tramadol hydrochloride extended-release tablet (biphasic) (Ultram ER, others) Combination Products Morphine sulfate and naltrexone extended-release capsules (Embeda®) Oxycodone ER/acetaminophen (Xartemis XR®) Final Report March 2016 Review prepared by: Vicki Frydrych, Clinical Pharmacist Melissa Archer, Clinical Pharmacist Justin Tran, PharmD Student Ryan Marcum, PharmD Student University of Utah College of Pharmacy Copyright © 2016 by University of Utah College of Pharmacy Salt Lake City, Utah. All rights reserved. Table of Contents Executive Summary ........................................................................................................................ 3 Introduction ..................................................................................................................................... 5 Table 1. Comparison
    [Show full text]
  • Download an Information Sheet on Opiate Use During Pregnancy
    PARENT/FAMILY EDUCATION OPIATE USE DURING PREGNANCY childrensMN.org OPIATES Medications or drugs known as opiates (or narcotics) are commonly prescribed OPIATE USE DURING for pain. The most common names of these drugs include OxyContin, Percocet, PREGNANCY: HOW DOES IT Vicodin, morphine and methadone. Use of opiates during pregnancy often causes AFFECT MOTHERS AND BABIES? complications for mothers as well as complications for babies exposed to opiates in the womb. Illegal opiates like heroin also cause risks for mother and baby. During pregnancy, everything you eat or drink can have an effect on Prescription opiates can be used illegally, or taken at higher doses than prescribed. your unborn baby. This includes Use of any form of opiate can lead to dependency which has been observed medications, drugs, alcohol and in the rapidly increasing number of young women that have developed opiate tobacco. Certain substances are dependency in the past 10 years. Many people who have become dependent on not safe during pregnancy and you prescription opiates are also at risk of using heroin. should review any medications, drugs (over the counter, prescribed The newborn baby exposed to opiates in the womb may have withdrawal and illegal), supplements, or herbs symptoms after being born. When babies have symptoms of withdrawal, they often that you are taking with your need to stay in the hospital longer and may not be able to stay in their mother’s doctor or midwife. By informing room. Instead, they may need the close observation and care that is given in a your care team about ALL drugs special care nursery.
    [Show full text]
  • Heterodimerization of Μ and Δ Opioid Receptors: a Role in Opiate Synergy
    The Journal of Neuroscience, 2000, Vol. 20 RC110 1of5 Heterodimerization of ␮ and ␦ Opioid Receptors: A Role in Opiate Synergy I. Gomes, B. A. Jordan, A. Gupta, N. Trapaidze, V. Nagy, and L. A. Devi Departments of Pharmacology and Anesthesiology, New York University School of Medicine, New York, New York 10016 Opiate analgesics are widely used in the treatment of severe ␮-selective ligands results in a significant increase in the bind- pain. Because of their importance in therapy, different strate- ing of a ␦ receptor agonist. This robust increase is also seen in gies have been considered for making opiates more effective SKNSH cells that endogenously express both ␮ and ␦ recep- while curbing their liability to be abused. Although most opiates tors. Furthermore, we find that a ␦ receptor antagonist en- exert their analgesic effects primarily via ␮ opioid receptors, a hances both the potency and efficacy of the ␮ receptor signal- number of studies have shown that ␦ receptor-selective drugs ing; likewise a ␮ antagonist enhances the potency and efficacy can enhance their potency. The molecular basis for these find- of the ␦ receptor signaling. A combination of agonists (␮ and ␦ ings has not been elucidated previously. In the present study, receptor selective) also synergistically binds and potentiates we examined whether heterodimerization of ␮ and ␦ receptors signaling by activating the ␮–␦ heterodimer. Taken together, could account for the cross-modulation previously observed these studies show that heterodimers exhibit distinct ligand between these two receptors. We find that co-expression of ␮ binding and signaling characteristics. These findings have im- and ␦ receptors in heterologous cells followed by selective portant clinical ramifications and may provide new foundations immunoprecipitation results in the isolation of ␮–␦ het- for more effective therapies.
    [Show full text]
  • (D-Ala*)Deltorphin II: D,-Dependent Stereotypies and Stimulation of Dopamine Release in the Nucleus Accumbens
    The Journal of Neuroscience, June 1991, 17(6): 1565-l 576 (D-Ala*)Deltorphin II: D,-dependent Stereotypies and Stimulation of Dopamine Release in the Nucleus Accumbens R. Longoni,’ L. Spina,’ A. Mulas,’ E. Carboni,’ L. Garau,’ P. Melchiorri,2 and G. Di Chiaral ‘Institute of Experimental Pharmacology and Toxicology, University of Cagliari, 09100 Cagliari, Italy and 21nstitute of Medical Pharmacology, University of Rome “La Sapienza,” 00185 Rome, Italy In order to investigate the relative role of central 6- and has been implicated in the stimulant actions of systemic opiates. F-opioid receptors in behavior, the effects of (D- Morphine-like opiates stimulate DA release preferentially in the Ala*)cleltorphin II, a natural Gopioid peptide, and PL017, nucleus accumbens (Di Chiara and Imperato, 1988a) and elicit a beta-casomorphin derivative specific for mu receptors, hypermotility sensitive to blockade by the DA D, receptor an- were compared after local intracerebral and intraventricular tagonist SCH 23390 (Longoni et al., 1987a). Intra-accumbens administration. lntracerebral infusion of the two peptides was infusion of opioid peptides elicits motor stimulation, but this done bilaterally in the limbic nucleus accumbens and in the action seems independent from DA, being resistant to classic ventral and dorsal caudate putamen of freely moving rats DA-receptor antagonists (neuroleptics; Pert and Sivit, 1977; Ka- through chronic intracerebral cannulas. After intra-accum- livas et al., 1983). Moreover, the syndrome elicited by intra- bens infusion, the two peptides elicited marked but opposite accumbens opiates is biphasic, as motor stimulation is typically behavioral effects: while (o-Ala2)deltorphin II evoked dose- preceded by motor inhibition and catalepsy (Costa11et al., 1978).
    [Show full text]
  • 1 Depodur (Morphine Sulfate Extended-Release Liposome Injection)
    DepoDur® (morphine sulfate extended-release liposome injection) CII Rx Only DESCRIPTION DepoDur (morphine sulfate extended-release liposome injection) is a sterile suspension of multivesicular liposomes containing morphine sulfate, intended for epidural administration. Chemically, morphine sulfate is 7, 8-didehydro-4, 5α-epoxy-17-methylmorphinan-3, 6α -diol sulfate (2:1) (salt) pentahydrate with a molecular weight of 758. Morphine sulfate pentahydrate has the following structural formula: Morphine base has a pKa of 7.9, with an octanol/water partition coefficient of 1.42 at physiologic pH 7.4. At this pH, morphine’s tertiary amino group is mostly ionized, making the molecule water-soluble. DepoDur is a sterile, non-pyrogenic, white to off-white, preservative-free suspension of multivesicular lipid-based particles containing Morphine Sulfate, USP. The median diameter of the liposome particles is in the range of 17 to 23 μm. The liposomes are suspended in a 0.9% sodium chloride solution. Each vial contains morphine sulfate (expressed as the pentahydrate) at a nominal concentration of 10 mg/mL. Inactive ingredients and their approximate concentrations are: 1,2-dioleoyl-sn-glycero-3-phosphocholine (DOPC), 4.2 mg/mL; cholesterol, 3.3 mg/mL; 1,2-dipalmitoyl-sn-glycero-3-phospho-rac-(1-glycerol) (DPPG), 0.9 mg/mL; tricaprylin, 0.3 mg/mL; and triolein, 0.1 mg/mL. The pH of DepoDur is in the range of 5.0 to 8.0. After the administration of DepoDur into the epidural space, morphine sulfate is released from the multivesicular liposomes over a period of time. Liposomal encapsulation or incorporation in a lipid complex can substantially affect a drug’s functional properties relative to those of the unencapsulated or nonlipid- associated drug.
    [Show full text]
  • Urine Drug Toxicology and Pain Management Testing
    Urine Drug Toxicology and Pain Management Testing Kara Lynch, PhD, DABCC University of California San Francisco San Francisco, CA Learning Objectives • Describe what chronic pain is, who is affected and how they are commonly treated • Explain the common methodologies used in pain management testing • Interpret urine drug testing results • Create protocols to minimize the occurrence of false positive or false negative results Pain – definition and types • Pain - an unpleasant sensory and emotional experience associated with actual or potential tissue damage • Chronic pain - pain that extends beyond the expected period of healing • Nociceptive Pain – Pain caused by tissue injury – Stimulus-evoked, high intensity – Opioid sensitive • Neuropathic Pain – Caused by nerve injury – Spontaneous activity – Develops in days or month – Opioid insensitive Chronic Pain Patients • Arthritis • Fibromyalgia – Osteoarthritis • Headaches – Rheumatoid arthritis – Migraine – Gout – Tension • Cancer – Cluster • Chronic non-cancer pain • Myofascial pain • Central pain syndrome • Neuropathic pain – CNS damage – Diabetic Peripheral – Multiple Sclerosis Neuropathy – Parkinson’s disease – Postherpetic neuralgia • Chronic abnominal pain • Neck and Back Pain – Intestinal obstructions Chronic Pain Medications • Opiates • Synthetic opioids – Codeine – Fentanyl – Morphine – Methadone • Semi-synthetic opioids – Meperidine – Oxymorphone – Tramadol – Oxycodone – Propoxyphene – Hydromorphone – Levorphanol – Hydrocodone – Tapentadol – Buprenorphine • Anticonvulsant • Muscle
    [Show full text]
  • Overview of Oral Modified-Release Opioid Products for the Management of Chronic Pain
    Pain Management Overview of Oral Modified-Release Opioid Products for the Management of Chronic Pain Celene M Amabile and Bill J Bowman OBJECTIVE: To evaluate pharmaceutical and pharmacotherapeutic differences in oral opioid modified-release products used in the management of chronic pain. DATA SOURCES: Searches of MEDLINE (1966–May 2006) and an extensive review of peer reviewed journals were conducted using the key search terms opioid, morphine, hydromorphone, and oxycodone. Supplemental information was gathered through the American Pain Society, and limited but relevant information was obtained from manufacturers’ labeling. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated. Information deemed relevant was included for this review if it introduced new or well supported concepts or clarified clinical practice issues. DATA SYNTHESIS: The recognition and treatment of pain has become a major focus of healthcare professionals. The Joint Commission on Accreditation of Healthcare Organizations mandates compliance with recommended standards, outcome measures, and other initiatives. A general review of pain management and pharmacokinetic parameters are included. CONCLUSIONS: Oral modified-release products have enabled patients to better maintain pain control due to convenient dosing intervals and sustained blood concentrations. The differences between available oral modified-release products are half-life, cost, and formulation (excipients and drug-release properties). KEY WORDS: hydromorphone, morphine, opioid, oxycodone. Ann Pharmacother 2006;40:1327-35. Published Online, 25 Jul 2006, www.theannals.com, DOI 10.1345/aph.1G259 THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT ACPE UNIVERSAL PROGRAM NUMBER: 407-000-06-017-H01 he recognition and treatment of pain have become a fewest adverse drug effects (ADEs).1,2 However, this dos- Tmajor focus of healthcare professionals.
    [Show full text]
  • Morphine and Heroin Differentially Modulate in Vivo Hippocampal LTP in Opiate-Dependent Rat
    Neuropsychopharmacology (2007) 32, 1738–1749 & 2007 Nature Publishing Group All rights reserved 0893-133X/07 $30.00 www.neuropsychopharmacology.org Morphine and Heroin Differentially Modulate In Vivo Hippocampal LTP in Opiate-Dependent Rat 1,3 2,3 2,3 1,3 1 1 2 ,1 Guobin Bao , Lin Kang , Haohong Li , Yuting Li ,LuPu, Peng Xia , Lan Ma and Gang Pei* 1 Laboratory of Molecular Cell Biology, Institute of Biochemistry and Cell Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of 2 Sciences, Shanghai, People’s Republic of China; Pharmacology Research Center, Shanghai Medical College and Institutes of Brain Science, Fudan University, Shanghai, People’s Republic of China Addictive drugs have been shown to severely influence many neuronal functions, which are considered as the underlying mechanisms for physiological and psychological dependences. We previously showed that in vivo LTP in rat hippocampal CA1 region is significantly reduced during withdrawal following chronic opiates treatment, and the reduced LTP can be restored by re-exposure of animals to corresponding drugs. Here, we further demonstrated that during opiates withdrawal, the re-exposure of morphine either systemically (subcutaneously) or locally (intracerebroventricularly) could restore the reduced LTP in heroin-dependent rats, but heroin could not restore the reduced LTP, in morphine-dependent rats, indicating differential modulations of hippocampal functions by those two opiates. In contrast, DAMGO, a mu-opioid receptor (MOR) agonist, could restore the reduced LTP, and CTOP, a MOR antagonist, could block the restoration in rats dependent on both opiates, showing that MOR is functional under such conditions. However, the upregulation of hippocampal PKA activity during morphine withdrawal could be suppressed by re-exposure of morphine but not that of heroin, suggesting a likely underlying mechanism of the differential modulation of LTP by two opiates.
    [Show full text]