A Randomized Controlled Trial

Dextromethorphan as a novel non‐opioid adjunctive agent for pain control in medication abortion: a randomized controlled trial (Clinicaltrials.gov: NCT03480009) University of Pittsburgh 1/17/2019 V4 pg. 1 1 Project Summary 2 Justification of project 3 Medication abortion accounts for approximately one‐third of first trimester abortions and commonly 4 causes severe pain that women experience and manage at home [1‐6]. Currently there are no evidence‐ 5 based recommendations for a medication abortion analgesic regimen. Surveys and literature reviews 6 show that most medication abortion providers recommend a combination of non‐steroidal anti‐ 7 inflammatory drugs and narcotics for pain control [7, 8]. 8 Given the current epidemic of opioid addiction and the frequency of medication abortion in the United 9 States, it is imperative that we seek alternatives to opioid medications to manage pain. By providing 10 outpatient opioid medications to medication abortion patients, we may be contributing to the opioid 11 abuse problem. This study evaluates dextromethorphan, an over‐the‐counter cough suppressant, as a 12 non‐opioid medication adjuvant for pain control in medication abortion. 13 Proposed research 14 This is a four‐arm, double‐blinded, randomized controlled trial. Our primary outcomes are maximum 15 pain scores and total analgesia usage, and our secondary outcomes are differences in mean pain score 16 between interventions as well as patient satisfaction with their pain control during medication abortion. 17 We hypothesize that dextromethorphan administration in conjunction with the current standard 18 regimen (ibuprofen, narcotic by request) will decrease patient pain scores and total analgesic usage 19 compared to placebo in conjunction with the current regimen. Our study will be conducted at Planned 20 Parenthood of Western Pennsylvania, coordinated by the Center for Family Planning Research of the 21 University of Pittsburgh Medical Center. 22 New features 23 This study will be the first to evaluate dextromethorphan for pain control in medication abortion, and 24 one of few to evaluate use of this medication for gynecologic pain control. Dextromethorphan is a 25 promising medication given its long safety record, easy administration and affordability [9]. 26 Problems anticipated 27 We anticipate that there could be difficulty with enrollment, as women presenting for medication 28 abortion may not be receptive to additional information regarding a research study or to the extra 29 burden of time related to enrollment in a research study. However, with this potential challenge in 30 mind, we plan to succinctly inform patients of the potential for direct benefit to them with the goal to 31 overcome their hesitation about participation and allow us to provide them with more detailed 32 information. We also have planned this study to minimize the duration of engagement and burden on 33 participants to enhance feasibility. 34 The medication administration schedule may prove difficult for patient compliance. Participants will be 35 prompted by text message as to when they should use their study medications based on their projected 36 misoprostol administration schedule discussed in clinic. This will allow us to support and encourage 37 medication administration at the correct times relative to misoprostol administration. This active 38 engagement is also designed to support participants with timely data reporting. V4 pg. 2 39 1. Description of Project 40 1.1 Rationale and objectives of the study 41 1.1.1 Rationale 42 Medication abortion using mifepristone and misoprostol is common, accounting for nearly one‐third of 43 first trimester abortions in the United States in 2014 [6]. Although women generally tolerate medication 44 abortion well, pain and bleeding are common and expected with medication abortion [10]. Pain 45 management for medication abortion is challenging since the most acute pain occurs at home rather 46 than under the supervision of medical professionals. 47 Pain experienced with medication abortion can be severe. In a randomized controlled trial utilizing a 48 mifepristone/misoprostol regimen without premedication, women reported mean pain scores of 8/10 49 one hour after misoprostol administration [1]. Wiebe et al. monitored pain after premedication with 50 ibuprofen or acetaminophen with codeine in a methotrexate/misoprostol regimen and found that 23.4% 51 of patients reported severe pain (9‐10/10) in the first 24 hours after misoprostol administration [2]. 52 Raymond et al. compared different analgesic regimens of ibuprofen in medication abortion with 53 mifepristone and misoprostol and found mean maximum pain scores of 7.1 and 7.3 for prophylactic 54 versus as‐needed ibuprofen dosing. [5] In trials varying the timing of administration of vaginal 55 misoprostol after mifepristone administration, median pain scores during the abortions ranged from 57‐ 56 64 mm on a Visual Analogue Scale (VAS) [3, 4]. A structured literature review from 2006 of first trimester 57 medication abortions found that approximately three‐quarters of patients use narcotics on the day of 58 prostaglandin administration to manage their pain [7]. A survey of National Abortion Federation clinics 59 in 2008 found that 95% of providers routinely prescribed analgesics for medication abortion: 51% 60 prescribed acetaminophen with codeine and 44% prescribed non‐steroidal anti‐inflammatory drugs [8]. 61 The pain experienced by women during medication abortion is a function of uterine cramping and 62 passage of pregnancy tissue through the cervix. However, the experience of pain is complex and a 63 subjective multifactorial phenomenon. Prior studies have found that younger age, nulliparity and 64 increasing gestational age are predictors for higher reported pain scores during medication abortion [10, 65 11]. Asian race and higher education have been associated with decreased narcotic use during 66 medication abortion [12]. Individual pain history can also be predictive, as women who report more pain 67 during menses consistently also report higher pain scores during medication abortion [10]. Women who 68 suffer from chronic pain syndromes and substance abuse also struggle with acute pain control [13]; 69 however, this has not been specifically studied for medication abortion. 70 Currently there is insufficient evidence to recommend an optimal regimen for pain control in medication 71 abortion and there are concerns surrounding narcotic prescribing and the opiate abuse epidemic. From 72 1999‐2010, opioid overdoses have risen steadily in parallel with opioid prescriptions. In 2015, there 73 were 33,091 opioid‐use related deaths, half of which involved prescribed narcotics [14]. A mixed‐ 74 methods study of patients with a diagnosis of substance use disorder found that approximately half had 75 their first narcotic exposures through use of prescribed medication and this may have contributed to 76 their ultimate addiction [15]. The Society of Family Planning Clinical Guideline on medication abortion 77 recommends “instructions for analgesia with over‐the‐counter medications” and “oral narcotics to use 78 as needed” [16]. Given the current epidemic of opioid addiction and the frequency of medication 79 abortion in the United States, it is imperative that we seek alternatives to opioid medications to manage V4 pg. 3 80 pain. By providing outpatient opioid medications to medication abortion patients, we may be 81 contributing to the opioid abuse problem. 82 Dextromethorphan (DM) has potential to be a safe and effective option for pain control in medication 83 abortion. As a N‐methyl‐D‐aspartate (NMDA) antagonist, dextromethorphan functions by blocking the 84 transmission of pain signals from peripheral nociceptors to the central nervous system. It is not directly 85 anti‐nociceptive, but instead modifies the perception of pain and is largely dependent on the 86 concomitant use of another analgesic. Dextromethorphan has demonstrated synergy with both opioids 87 and nonsteroidal anti‐inflammatory drugs (NSAIDs) [9], and therefore may be useful in optimizing pain 88 control and minimizing or eliminating opioid use. Dextromethorphan may also be an effective 89 preemptive analgesic, reducing pain sensation when administered prior to the insult. This principle has 90 been demonstrated with ketamine administration, another NMDA antagonist, in “Expedited Recovery 91 After Surgery (ERAS)” protocols [17]. Preemptive administration has been shown to decrease both 92 intraoperative and postoperative opioid needs. Dextromethorphan has been studied in acute post‐ 93 operative pain as well as in chronic and neuropathic pain management [9]. Oral, orthopedic and 94 gynecologic surgery studies have all shown attenuation of pain or opioid use by using preoperative 95 dextromethorphan in doses varying from 27 mg‐120 mg [18‐21]. However, several negative studies also 96 exist, though these studies are limited by concerns about adequate dosing or possible confounding by 97 administration with other central pain modifying drugs [22, 23]. 98 Dextromethorphan, the most frequently used cough suppressant in the United States, has a long track 99 record of safety associated with over‐the‐counter use in adults and children since receiving FDA 100 approval in 1958. It is not considered habit‐forming, although there is potential for abuse as large doses 101 cause hallucinations and a dissociative state and has primarily been abused by adolescents aged 13‐15 102 years. Dextromethorphan

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