To develop this comparison between short-acting opioids (SAOs) and long-acting opioids . In studies lasting from 2 to 30 weeks, LAOs, including ER morphine, ER .. They also note that sedation tends to wane over time and conclude that pain who are prescribed SAOs, a change to LAOs shortly after titration to effective . pain services and primary care providers confront daily as they try to balance the 2. Providers may engage in tapering an opioid due to safety concerns. practice to replace short-acting opioids with extended release products (e.g., MS . This is not intended to replace the independent medical or professional judgment of . short-acting opioid at % of long-acting dose every 2 to 4 hours . A. If upon pre-operative evaluation it is determined the patient will require either a.
Acting Replace Short Opioids They 2.
These results suggest that select cancer patients might prefer OTFC over immediate-release morphine. Breakthrough pain is a transient increase in pain intensity over background pain. Breakthrough pain usually is related to background pain; typically it is of rapid onset, severe in intensity, and self-limiting, with an average duration of 30 minutes.
One approach to managing breakthrough pain is using supplemental analgesia also known as rescue medication at a dose proportional to the total around-the-clock opioid dosage. This review explores and assesses the evidence for the use of opioids in the management of breakthrough pain in patients with cancer. Hand searching of medical journals and references from key textbooks was undertaken, and drug companies were contacted for unpublished data. There were no language restrictions. Date of most recent search: Randomized controlled trials of opioids used as rescue medication against active or placebo comparator in patients with cancer pain were included.
Outcome measures sought were reduction in pain intensity measured by an appropriate scale, adverse effects, attrition, patient satisfaction, and quality of life.
Data Collection and Analysis: Eligible studies were selected and examined independently by the two reviewers. Full text was retrieved if any uncertainty about eligibility remained. Non-English texts were screened. Quality assessment and data extraction were conducted using standardized data forms.
Drug and placebo dose, titration, route, and formulation were compared, and details of all outcome measures if available were recorded. Four studies participants met the inclusion criteria. All were concerned with the use of oral transmucosal fentanyl citrate OTFC [Actiq] in the management of breakthrough pain. OTFC was shown to be an effective treatment for breakthrough pain. In comparisons with placebo or morphine, participants gave lower pain intensity scores and higher pain relief scores for OTFC at all time points.
Global assessment scores also favored OTFC. There is evidence that OTFC is an effective treatment in the management of breakthrough pain. The randomized trial literature for the management of breakthrough pain is small, and no trials were found for other opioids. Given the importance of this subject, more trials need to be undertaken.
These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the originalreviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minorediting changes have been made to the text http: A secondary objective of the review was to find evidence supporting the expert opinion of the European Association of Palliative Care EAPC that short-acting opioids for breakthrough cancer pain should be given in proportion to the amount of long-acting opioid being taken by the patient.
Rapid-acting oral opioids can cause a variety of adverse effects, including respiratory arrest in patients who have not previously used opioids. In Brazil, due to lack of immediate release opioid for oxycodone and hydromorphone, escapes are empirically done with morphine.
However, the pharmacological association of agents acting on the same type of receptor is not recommended. For methadone, remember that there is inter-individual pharmacokinetic variation, as well as potential to induce late toxicity due to its half-life, which varies from eight to 59 hours. Methadone build-up during treatment days or weeks may be life threatening, due to respiratory depression, especially during sleep.
On the other hand, this initial dose may be hazardous for slow methadone acethylators or patients with sleep apnea. In addition, there are reports on cardiotoxicity increased QT interval and torsades de points rhythm with sudden death. So, the equianalgesic ratio may vary from Conversion rate of 5: On the other hand, If the reason for rotation is pain, this rate may be decreased to 5: Morphine requisition is inversely proportional to age, but for methadone this relationship is independent.
Some authors have also not correlated dose equivalence in the conversion of morphine to methadone to gender, cancer and its treatment features, biochemical or hematological parameters. On the other hand, there are few studies on the transition of methadone to a different opioid. Other authors suggest that 10mg methadone would be equivalent to 20, 33 or This broad variation in the literature, in addition to methadone pharmacokinetic and pharmacodynamic characteristics, suggests that methadone should be gradually withdrawn until the complete introduction of the new agent 25, To monitor patients under long term opioids it is necessary to: Treatment includes opioid rotation, decrease the dose and use psychic stimulants.
On the other hand, opioids may alter sleep and wake ratio, decreasing total sleep time, sleep efficiency, delta waves and REM sleep, and may cause fatigue along time; 18 consider that the ability to handle heavy pieces of equipment or drive cars may be impaired. Remember that driving under the influence of any psychoactive substance is considered very severe violation according to the Brazilian Traffic Code, Law , Art.
This fact should be evaluated by the physician during opioid titration period; 19 understand that inadequate pain evaluation and measurement, low expectation with regard to treatment, lack of communication with the health team, fear of adverse effects and dependence may interfere with the results of analgesia and that continuous education of the health team and of patients is needed, explaining any pending issues includes informed consent.
It is important to adequately select patients who will use opioids in the long term; start titration and maintenance evaluating adverse effects and adjusting the dose to each clinical situation; observe when opioid should be withdrawn or rotated, as well as monitor patients in the long term.
Authors of the Specialists group: Non-medical use, abuse and dependence on prescription opioids among U. Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients.
WHO's pain ladder for adults. Interventional treatment of cancer pain: Appropriate when less invasive therapies fail to provide adequate analgesia. Med Clin North Am. A structured evidence-based review. Opioid titration in cancer pain: Canadian guideline for safe and effective use of opioids for chronic noncancer pain: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
A systematic review of randomized trials of long-term opioide management for chronic non-cancer pain. Opioid use in chronic noncancer pain: Evidence-based guidelines on the use of opioids in chronic non-cancer pain--a consensus statement by the Pain Association of Singapore Task Force. Ann Acad Med Singapore. Opioid rotation in clinical practice. Opioid rotation in the management of chronic pain: This preference was seen after the titration phase, during which all patients were taking an SAO and an LAO and were allowed, under supervision, to modify their total daily dose on the basis of pain intensity.
The goals of pain management therapy include not only reductions in pain but also improvements in psychosocial functioning relative to baseline, including emotional well-being and the ability to perform ADLs. The experience of pain is unique for every patient; therefore, treatment goals are tailored to the needs of each patient. For some patients, controlling constant pain with LAOs may be best, if less frequent dosing and sufficient pain relief allow them to resume at least some, if not all, normal activities; other patients may find that an SAO provides them with the same outcome and is more effective than an LAO.
Comorbid pain-related sleep disturbances are reported by The relationship between intensity of pain and quality of sleep. From Curr Med Res Opin , 80 with permission. The LAO formulations may effectively improve sleep in some patients with chronic pain. Objective evidence obtained in a pilot study supports subjective reports that pain control with LAOs can improve sleep quality. This study provides objective data of improved sleep in these patients, supporting the subjective self-reported improvements in sleep of patients with chronic pain undergoing LAO therapy.
In one study, patients with osteoarthritis-associated pain were treated with CR oxycodone twice daily or IR oxycodone-acetaminophen 4 times daily for 4 weeks after a 4-week titration period. The critical determinant in improving sleep in patients with CNCP is effective pain relief, which can be obtained with either SAOs or LAOs in patients selected because of their specific needs and the nature of their pain.
As with all therapies, a careful risk-benefit analysis must be performed to determine the relative merits of opioid therapy.
Although numerous studies have shown opioid therapy to positively affect sleep in patients with CNCP, some patients undergoing long-term opioid therapy may exhibit an increase in sleep disturbances, particularly central sleep apnea.
Patients being treated for CNCP should be monitored for AEs, which may influence the decision to continue, adjust, or discontinue a pharmacological regimen. Moreover, because of response variability to treatment, AE profiles for medications or classes of agents may differ. Hyperalgesia has also been reported to be associated with long-term opioid administration, a possible contributing factor to the development of apparent analgesic tolerance.
Recently published clinical guidelines developed after a systematic review of the available literature regarding the use of long-term opioid therapy in CNCP make the following recommendations regarding opioid-related AEs: They also note that sedation tends to wane over time and conclude that evidence is insufficient to recommend specific medical therapies for ongoing opioid-related sedation.
With respect to the long-term use of opioids while driving or working, these same guidelines specifically recommend the following: Patients should be counseled not to drive or engage in potentially dangerous activities when impaired or if they describe or demonstrate signs of impairment.
This approach allows the physician to obtain information about the pharmacological effects of the drug without causing long periods of discomfort if the drug produces intolerable AEs. Patients with persistent pain are then transitioned to an LAO and are often treated with an equianalgesic daily dose.
Opioid therapy is associated with risks for misuse and abuse. In recent years, an increasing number of Americans have been using prescription pain relievers for nonmedical purposes; 5. Hydrocodone preparations are the most frequently prescribed SAOs for the management of chronic pain 94 and are the most frequently prescribed opioid analgesics in emergency departments.
It is clear that addressing the problem of opioid misuse and abuse is not a simple issue of long- vs short-acting formulations but one of identifying patients at risk for abuse and continually monitoring them for problematic behaviors.
A comprehensive risk assessment to stratify patients according to possible risk for opioid misuse considers their medical, psychiatric, social, and family histories, in addition to findings on physical examination. Such an approach codifies many physician practices already in use and applies them specifically to cases that may present a risk of abuse. It also encourages the evaluation of biological, psychological, and social characteristics that correlate with misuse or abuse potential.
In addition, several validated screening questionnaires eg, Opioid Risk Tool, Revised Screener and Opioid Assessment for Patients with Pain are available to help stratify patients into low-, moderate-, and high-risk categories. When appropriately used, urine drug tests and opioid treatment agreements can be useful tools for physicians. Opioid treatment agreements codify the responsibilities of both the patient and physician.
Urine drug testing allows the physician to monitor patient adherence and identify the use of illicit drugs. Standardizing risk assessment procedures and individualizing the level of monitoring can help improve patient outcomes and protect the health care professional from legal risk.
Although SAOs and LAOs are efficacious in a variety of chronic pain conditions, their appropriate roles in the management of chronic pain are specific to the individual patient. Chronic noncancer pain should be managed like other chronic conditions. For example, in the treatment of hypertension, the goal is to maintain consistent control over the condition as soon as possible, using medications that provide consistent blood pressure control.
In appropriately selected patients with chronic pain who are prescribed SAOs, a change to LAOs shortly after titration to effective analgesia may be appropriate to provide consistent pain reduction.
The pharmacokinetic profiles of LAOs, which result in more sustained and stable plasma opioid concentrations compared with SAOs, may allow more consistent and prolonged analgesia. Such analgesia could be vitally important for patients with CNCP and unremitting levels of daytime pain or those seeking improved nighttime sleep.
By definition, LAOs are associated with less frequent dosing than SAOs, which may improve adherence to the therapeutic schedule in older adults and any patient dealing with polypharmacy. However, some patients with CNCP are comforted by the rapid onset of analgesia associated with SAOs, particularly to address intermittent or breakthrough pain. Management of CNCP should be tailored to the individual patient.
Because patients will have different pain profiles and therapeutic goals, optimal treatment must be individualized, accounting for not only the characteristics of the pain state but also its effects on QOL and the therapeutic goals. Editorial assistance in the preparation of the submitted manuscript was provided by the McMahon Group and funded by King Pharmaceuticals.
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Individual reprints of this article are not available. Address correspondence to Charles E. This article has been cited by other articles in PMC.
Abstract Management of chronic noncancer pain CNCP requires a comprehensive assessment of the patient, the institution of a structured treatment regimen, an ongoing reassessment of the painful condition and its response to therapy, and a continual appraisal of the patient's adherence to treatment.
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Opioids for Management of Breakthrough Pain in Cancer Patients
The following pages explain what opioids are and what we think you may want to replace conversations with your doctor, nurse or pharmacist. Examples of long acting and fast acting forms of opioids are given in the boxes below. 2 -. Opioids in Palliative Care version ; October ; Due to be reviewed Aug Long-acting opioid pain relievers are medicines used to relieve moderate to severe If you take multiple daily doses of short-acting medicine, your doctor may give you He or she may be able to lower your dose or change your medicine. Calculate the total short-acting (IR) opioid dose used in 24 hours → Convert this total to a long-acting opioid. 2. Add a short-acting “rescue dose” for breakthrough pain controlled, but that it tends to reoccur around 1 hour before her next scheduled dose. She is status or delivery methods necessitate a change in therapy.