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Opioids in non-cancer pain
Abstracts (841) One-year assessment of opioid use and dose adjustments in patients with chronic non-cancer pain E. Hamed, S. Dogra; University of North Carolina, Chapel Hill, NC Chronic opioid therapy offers many patients improved pain relief and means to return to a more active lifestyle. Frequent dose adjustments and change of opioids may occur before a patient continues on a stable dose. After IRB approval, a prospective cohort of 100 patients with different chronic pain diagnoses that required treatment with different opioids were enrolled, and followed for a period of 12 months to assess their opioid use and the pattern of changes experienced in their regimen. After enrollment, detailed patient demographics were recorded including medical, functional, psychological, and pain data. Follow-up was done every 2 months either by mail or direct contact during their return visits to the pain clinic for a 6-month period. Final data collection was done 12 months after initial contact with the patient for further detailed assessment of any change in their opioids and other adjuvant drug regimen over that period of time. The majority of patients were using methadone, morphine, oxycodone, or transdermal fentanyl patches. The majority of patients required dose adjustments or changes to an alternative opioid during the 12-month period. Only a minority of the patients remained on the same type and dose of opioid. This study evaluated the pattern of opioid rotation and dose adjustment of different opioids over a 12-month period. The opioid therapy was changed on numerous occasions over the 12 months period, based on many factors. Patients on methadone therapy remained the most stable and required the fewest adjustments of their regimen over the study period.
69 (843) Impact of a medication management program on the functionality of individuals with severe chronic nonmalignant pain I. Forster, R. Feroe, P. Jacobs, A. Ohinmaa, D. Van Driesum; LifeMark Health Institute, Edmonton, AB A medication management program was designed to treat complex chronic non-malignant pain patients. All patients were referred by General Practitioners and treated under a publicly funded health care system. GP referral was accepted if there were concerns regarding level of functioning, medication dose, safety or addiction. The referral source agreed to reaccept patient care once concerns were adequately addressed and medications stabilized. A multidisciplinary pain clinic in Edmonton, Canada. The study period was from March 2000 to April 2003. There were no exclusion criteria except patients must be ⬎18 years of age. Patients with co-morbid conditions such as addiction and psychiatric illness were included. Following physician assessment a treatment plan was developed by the management team. The team consisted of an addiction medicine consultant, internist, pharmacist, and registered nurse. All patients were managed with substitution or institution of long acting or continuous release opioids. Medication was titrated to function. Short acting opioids for break through pain were minimized. When addiction and psychiatric screening identified co-morbidities, additional appropriate therapies were started. Urine screens were done on each patient and monitored according to risk factors. A 15 dimensional HRQOL instrument (15D) measured the functional outcome of the program. Emergency Room (ER) utilization was assessed via faxed updates from local ER‘s. Of 58 patients, 57 had complete answers to the 15D. Functional improvement was statistically and clinically significant as measured. ER utilization was controlled or reduced. Patients were successfully transferred back to the referral source 71.5% of the time. The specific pain program significantly improved functionality as measured by the 15D. The functional improvement measured by the 15D was greater than that obtained by a patient undergoing a knee replacement.
(842) Treatment of persistent, moderate to severe pain in long term care
(844) Response to transdermal fentanyl or sustained release oral morphine in chronic low back pain
M. Smith, B. Strunk, T. Hughes, D. Smith; Purdue Pharma, L.P., Stamford, CT The study purpose was to describe the treatment of persistent, moderate to severe pain in elderly long term care residents. We performed a retrospective analysis using 2001-2002 data from the Minimum Data Set (MDS) from residents in 425 skilled nursing facilities (SNFs) throughout 35 U.S. state. Inclusion criteria were: 1) continuous SNF residence for 12⫹ months, and 2) moderate to severe pain over the past 7 days. Of the 2,101 residents meeting study criteria, the majority were female (73.3%), Caucasian (84.3%), with a mean age of 81.5 years. The most commonly reported pain site was joint-related (hip or other, 48%). 56.8% were receiving no opioid therapy at the time of the index MDS assessment. Of those receiving opioids, most (89.9%) were taking shortacting opioids (SAOs) only. Compared to those not taking opioids, longacting opioid (LAO) recipients had poorer performance on activities of daily living (ADL) (ADL score of 2.1 vs. 2.6 respectively where 0⫽completely independent to 4 ⫽totally dependent), and were more likely to be using a feeding tube (4.2% vs.. 8.7%). At second MDS assessment, 25.7% of non-opioid users, 29.8% of those who had been taking SAOs, and 34.8% of those who had been taking LAOs reported moderate to severe pain over the prior 7 days. Despite published clinical guidelines which recommend the use of opioids for the treatment of moderate to severe persistent pain, most SNF residents with such pain were not receiving any opioid therapy. Residents who were more functionally dependent and in poorer health were more likely to be prescribed LAO than those not receiving opioids for their pain.
L. Allan, E. Kalso; Northwick Park & St Mark‘s NHS Trust, London Patients with chronic low back pain (CLBP) uncontrolled by other analgesics may benefit from strong opioids but there are few rigorous studies, and most involve patients already receiving strong opioids. To compare transdermal fentanyl (TDF) and sustained-release oral morphine (SRM) in patients with CLBP who were not receiving strong opioids. Patients with CLBP requiring continuous strong opioid treatment received TDF (starting dose 25mcg/h) or SRM (starting dose 30mg/12h) for 13 months. Dose was titrated according to response. Prior use of NSAIDs, anticonvulsants, etc. was maintained but concomitant opioid medication was not permitted during the study. Ratings of pain relief and constipation were combined into a composite score. Response rates were compared in a secondary analysis; a response was defined as a change from ‘severe’ pain at baseline to ‘moderate,’ ‘slight’ or ‘none’ at endpoint, or from ‘moderate’ to ‘none’. The last available data point was used for patients who did not complete the study. Data are available from 680 patients (mean age 54 years, mean pain duration 10 years). The mean composite pain relief/constipation score was significantly better for TDF than SRM (141⫾16 versus 88⫾13 respectively, p⫽0.028). The proportion of responders was similar for TDF and SRM: 40% vs 37% for pain at rest, 47% vs 50% for pain on movement, 47% vs 42% for pain during the day, and 53% vs 50% for pain at night. The proportions of patients with endpoint VAS pain score ⬍50mm were similar (TDF 40%, SRM 39%). Apart from constipation, adverse event rates were similar. Both treatments provided comparable pain relief and had acceptable long-term safety profiles. Patients receiving transdermal fentanyl experienced significantly less constipation than those using morphine. Strong opioids should be considered as part of the multimodal management of CLBP. This study was supported by Janssen-Cilag.
69 (843) Impact of a medication management program on the functionality of individuals with severe chronic nonmalignant pain I. Forster, R. Feroe, P. Jacobs, A. Ohinmaa, D. Van Driesum; LifeMark Health Institute, Edmonton, AB A medication management program was designed to treat complex chronic non-malignant pain patients. All patients were referred by General Practitioners and treated under a publicly funded health care system. GP referral was accepted if there were concerns regarding level of functioning, medication dose, safety or addiction. The referral source agreed to reaccept patient care once concerns were adequately addressed and medications stabilized. A multidisciplinary pain clinic in Edmonton, Canada. The study period was from March 2000 to April 2003. There were no exclusion criteria except patients must be ⬎18 years of age. Patients with co-morbid conditions such as addiction and psychiatric illness were included. Following physician assessment a treatment plan was developed by the management team. The team consisted of an addiction medicine consultant, internist, pharmacist, and registered nurse. All patients were managed with substitution or institution of long acting or continuous release opioids. Medication was titrated to function. Short acting opioids for break through pain were minimized. When addiction and psychiatric screening identified co-morbidities, additional appropriate therapies were started. Urine screens were done on each patient and monitored according to risk factors. A 15 dimensional HRQOL instrument (15D) measured the functional outcome of the program. Emergency Room (ER) utilization was assessed via faxed updates from local ER‘s. Of 58 patients, 57 had complete answers to the 15D. Functional improvement was statistically and clinically significant as measured. ER utilization was controlled or reduced. Patients were successfully transferred back to the referral source 71.5% of the time. The specific pain program significantly improved functionality as measured by the 15D. The functional improvement measured by the 15D was greater than that obtained by a patient undergoing a knee replacement.
(842) Treatment of persistent, moderate to severe pain in long term care
(844) Response to transdermal fentanyl or sustained release oral morphine in chronic low back pain
M. Smith, B. Strunk, T. Hughes, D. Smith; Purdue Pharma, L.P., Stamford, CT The study purpose was to describe the treatment of persistent, moderate to severe pain in elderly long term care residents. We performed a retrospective analysis using 2001-2002 data from the Minimum Data Set (MDS) from residents in 425 skilled nursing facilities (SNFs) throughout 35 U.S. state. Inclusion criteria were: 1) continuous SNF residence for 12⫹ months, and 2) moderate to severe pain over the past 7 days. Of the 2,101 residents meeting study criteria, the majority were female (73.3%), Caucasian (84.3%), with a mean age of 81.5 years. The most commonly reported pain site was joint-related (hip or other, 48%). 56.8% were receiving no opioid therapy at the time of the index MDS assessment. Of those receiving opioids, most (89.9%) were taking shortacting opioids (SAOs) only. Compared to those not taking opioids, longacting opioid (LAO) recipients had poorer performance on activities of daily living (ADL) (ADL score of 2.1 vs. 2.6 respectively where 0⫽completely independent to 4 ⫽totally dependent), and were more likely to be using a feeding tube (4.2% vs.. 8.7%). At second MDS assessment, 25.7% of non-opioid users, 29.8% of those who had been taking SAOs, and 34.8% of those who had been taking LAOs reported moderate to severe pain over the prior 7 days. Despite published clinical guidelines which recommend the use of opioids for the treatment of moderate to severe persistent pain, most SNF residents with such pain were not receiving any opioid therapy. Residents who were more functionally dependent and in poorer health were more likely to be prescribed LAO than those not receiving opioids for their pain.
L. Allan, E. Kalso; Northwick Park & St Mark‘s NHS Trust, London Patients with chronic low back pain (CLBP) uncontrolled by other analgesics may benefit from strong opioids but there are few rigorous studies, and most involve patients already receiving strong opioids. To compare transdermal fentanyl (TDF) and sustained-release oral morphine (SRM) in patients with CLBP who were not receiving strong opioids. Patients with CLBP requiring continuous strong opioid treatment received TDF (starting dose 25mcg/h) or SRM (starting dose 30mg/12h) for 13 months. Dose was titrated according to response. Prior use of NSAIDs, anticonvulsants, etc. was maintained but concomitant opioid medication was not permitted during the study. Ratings of pain relief and constipation were combined into a composite score. Response rates were compared in a secondary analysis; a response was defined as a change from ‘severe’ pain at baseline to ‘moderate,’ ‘slight’ or ‘none’ at endpoint, or from ‘moderate’ to ‘none’. The last available data point was used for patients who did not complete the study. Data are available from 680 patients (mean age 54 years, mean pain duration 10 years). The mean composite pain relief/constipation score was significantly better for TDF than SRM (141⫾16 versus 88⫾13 respectively, p⫽0.028). The proportion of responders was similar for TDF and SRM: 40% vs 37% for pain at rest, 47% vs 50% for pain on movement, 47% vs 42% for pain during the day, and 53% vs 50% for pain at night. The proportions of patients with endpoint VAS pain score ⬍50mm were similar (TDF 40%, SRM 39%). Apart from constipation, adverse event rates were similar. Both treatments provided comparable pain relief and had acceptable long-term safety profiles. Patients receiving transdermal fentanyl experienced significantly less constipation than those using morphine. Strong opioids should be considered as part of the multimodal management of CLBP. This study was supported by Janssen-Cilag.