The role of transdermal compounding in opioid safety

2018 ◽  
Vol 14 (1) ◽  
pp. 17
Author(s):  
Caitlin V. Bucher, PharmD ◽  
A.J. Day, PharmD ◽  
Maria Carvalho, PhD
Keyword(s):  
Pain Management ◽  
Healthcare Providers ◽  
Opioid Analgesics ◽  
Opioid Therapy ◽  
Patient Specific ◽  
Therapeutic Effects ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Management Options ◽  
Combination Drug

Since the number of prescriptions for opioid medications have continued to rise, there have been questions about the safety of using opioids in pain management. Traditionally, opioid analgesics were reserved for a few select conditions, such as terminal illness and surgery, but currently opioids have been readily prescribed for multiple conditions. The objective of this manuscript is to clarify the current state of opioid use and to discuss alternative transdermal analgesic therapies in pain management. Transdermal compounded medications are patient-specific and customizable to include different types of drugs, in various dosage strengths, that are to be delivered simultaneously in one application. Due to the different origins and types of pain, treatments may be most beneficial with multiple classes of drugs with various mechanisms of action. In addition, combination drug therapy may include nontraditional pain management options, and has the ability to maximize therapeutic effects of medications through additive or synergistic properties, without increasing the dosage strengths of the drugs. Many of the challenges faced when using oral opioid therapy may be overcome by using transdermal drug delivery since this route of administration reduces adverse effects, increases patient compliance, and limits exposure to potentially abusive drugs. Although prescribing practices surrounding opioids remains to be a controversial topic, the use of compounded pain medications may help healthcare providers effectively treat their patients while avoiding the use of addictive drugs.

Inappropriate opioid prescribing practices: A narrative review

2019 ◽  
Vol 76 (16) ◽  
pp. 1231-1237 ◽  
Author(s):  
Brian Kim ◽  
Seonaid Nolan ◽  
Tara Beaulieu ◽  
Stephen Shalansky ◽  
Lianping Ti
Keyword(s):  
Literature Review ◽  
Data Extraction ◽  
Inappropriate Prescribing ◽  
Healthcare Providers ◽  
Opioid Analgesics ◽  
Drug Misuse ◽  
Patient Specific ◽  
Prescribing Practices ◽  
Prescription Drug Misuse ◽  
Opioid Prescribing

Abstract Purpose Results of a literature review to identify indicators of inappropriate opioid prescribing are presented. Summary While prescription opioids can be effective for the treatment of acute pain, inappropriate prescribing practices can increase the risk of opioid-related harms, including overdose and mortality. To date, little research has been conducted to determine how best to define inappropriate opioid prescribing. Five electronic databases were searched to identify studies (published from database inception to January 2017) that defined inappropriate opioid prescribing practices. Search terms varied slightly across databases but included opioid, analgesics, inappropriate prescribing, practice patterns, and prescription drug misuse. Gray literature and references of published literature reviews were manually searched to identify additional relevant articles. From among the 4,665 identified articles, 41 studies were selected for data extraction and analysis. Fourteen studies identified high-daily-dose opioid prescriptions, 14 studies identified coadministration of benzodiazepines and opioids, 10 studies identified inappropriate opioid prescribing in geriatric populations, 8 studies identified other patient-specific factors, 4 studies identified opioid prescribing for the wrong indication, and 4 studies identified factors such as initiation of long-acting opioids in opioid-naive patients as indicators of inappropriate opioid prescribing. Conclusion A literature review identified various indicators of inappropriate opioid prescribing, including the prescribing of high daily doses of opioids, concurrent benzodiazepine administration, and geriatric-related indicators. Given the significant contribution of inappropriate opioid prescribing to opioid-related harms, identification of these criteria is important to inform and improve opioid prescribing practices among healthcare providers.

Review of nonopioid multimodal analgesia for surgical and trauma patients

2020 ◽  
Vol 77 (24) ◽  
pp. 2052-2063
Author(s):  
Stephy George ◽  
Meagan Johns
Keyword(s):  
Pain Management ◽  
Adverse Effects ◽  
Multimodal Analgesia ◽  
Transitions Of Care ◽  
Dose Titration ◽  
Patient Specific ◽  
Therapeutic Effects ◽  
Trauma Patients ◽  
Opioid Use ◽  
Nonopioid Analgesics

Abstract Purpose Pain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion. Summary In response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care. Conclusion Multimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.

Pharmacogenomics in Pain Management: A Review of Relevant Gene-Drug Associations and Clinical Considerations

2021 ◽  
pp. 106002802110038
Author(s):  
Emily Brandl ◽  
Zachery Halford ◽  
Matthew D. Clark ◽  
Chris Herndon
Keyword(s):  
Clinical Practice ◽  
Pain Management ◽  
Health Care Professionals ◽  
Data Extraction ◽  
Clinical Care ◽  
Genomic Medicine ◽  
Opioid Use Disorder ◽  
Patient Specific ◽  
Therapeutic Effects ◽  
Opioid Use

Objective: To provide an overview of clinical recommendations regarding genomic medicine relating to pain management and opioid use disorder. Data Sources: A literature review was conducted using the search terms pain management, pharmacogenomics, pharmacogenetics, pharmacokinetics, pharmacodynamics, and opioids on PubMed (inception to February 1, 2021), CINAHL (2016 through February 1, 2021), and EMBASE (inception through February 1, 2021). Study Selection and Data Extraction: All relevant clinical trials, review articles, package inserts, and guidelines evaluating applicable pharmacogenotypes were considered for inclusion. Data Synthesis: More than 300 Food and Drug Administration–approved medications contain pharmacogenomic information in their labeling. Genetic variability may alter the therapeutic effects of commonly prescribed pain medications. Pharmacogenomic-guided therapy continues to gain traction in clinical practice, but a multitude of barriers to widespread pharmacogenomic implementation exist. Relevance to Patient Care and Clinical Practice: Pain is notoriously difficult to treat given the need to balance safety and efficacy when selecting pharmacotherapy. Pharmacogenomic data can help optimize outcomes for patients with pain. With improved technological advances, more affordable testing, and a better understanding of genomic variants resulting in treatment disparities, pharmacogenomics continues to gain popularity. Unfortunately, despite these and other advancements, pharmacogenomic testing and implementation remain underutilized and misunderstood in clinical care, in part because of a lack of health care professionals trained in assessing and implementing test results. Conclusions: A one-size-fits-all approach to pain management is inadequate and outdated. With increasing genomic data and pharmacogenomic understanding, patient-specific genomic testing offers a comprehensive and personalized treatment alternative worthy of additional research and consideration.

scholarly journals Updates on chronic non-cancer pain management in face of the opioid crisis

2018 ◽  
Vol 87 (1) ◽  
pp. 46-48
Author(s):  
Gayathri Sivakumar ◽  
Alexandra Budure ◽  
Elise Quint
Keyword(s):  
Pain Management ◽  
Cancer Pain ◽  
Significant Proportion ◽  
Opioid Analgesics ◽  
Opioid Therapy ◽  
Prescribing Patterns ◽  
Steady Increase ◽  
Prescribing Practices ◽  
Health Crisis ◽  
Canadian Guideline

Chronic pain not associated with malignancy is experienced by a significant proportion of the Canadian population. As the quality of life and physical functioning are markedly impaired in patients with chronic non-cancer pain, clinicians have commonly turned to opioid therapy for pain management. Since the 1990s, the steady increase in dispensing of prescription opioids has paralleled trends in opioid-related hospitalizations, overdoses, and fatalities. In fact, over-prescription and longterm opioid therapy are among the many root causes fueling Canada’s rise in opioid addiction and opioid-related deaths. Physicians and medical regulators have responded to this public health crisis by developing the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. The new evidence-based guideline aims to encourage safe prescribing practices, reduce and eliminate the use of opioid analgesics and promote non-opioid pharmacotherapy. While clear clinical guidelines will optimize physician prescribing patterns, it is imperative to recognize the need for non-pharmacological modalities for pain management, treatment, and care to holistically address the complex roots of opioid abuse.

Opioid safety among high-risk cancer survivors.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e19169-e19169
Author(s):  
Talya Salz ◽  
Akriti A. Mishra ◽  
Renee L. Gennarelli ◽  
Allison Lipitz-Snyderman ◽  
Denise Boudreau ◽  
...  
Keyword(s):  
Pain Management ◽  
Cancer Survivors ◽  
Management Strategies ◽  
Opioid Therapy ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Management Procedure ◽  
After Cancer ◽  
High Risk Cancer ◽  
First 90 Days

e19169 Background: To mitigate risks of opioid-related harms, ASCO’s pain management guidelines for cancer survivors recommend that opioids be used in conjunction with other pharmacologic and non-pharmacologic approaches. The guidelines also recommend caution when prescribing opioids and benzodiazepines concurrently. We evaluated these 2 metrics of safe prescribing as applied to chronic opioid therapy (COT) among older survivors of head and neck cancer (HNC) and lung cancer (LC), two growing populations with high pain burden and prevalent risk factors for opioid-related harms (e.g., opioid use during treatment, history of substance use, distress). Methods: Using SEER-Medicare, we identified opioid-naïve adults diagnosed 2008-2015 with HNC or LC. We restricted analyses to survivors with ≥1 COT episode (≥90 days) occurring ≥1 year after cancer diagnosis and ≤120 days prior to hospice entry or cancer-related death (survivorship period). We report 2 opioid safety metrics during the survivorship period: 1) the proportion of survivors with non-opioid pain management (≥1 dispensing for a non-opioid, non-benzodiazepine pain medication or ≥1 claim for pain management procedure) concurrent with the first 90 days of the first COT episode and 2) the proportion of survivors with 0 dispensings for benzodiazepines within the first 90 days of the first COT episode. Results: Among opioid-naïve HNC (N = 5,500) and LC (N = 21,090) patients, 306 HNC (5.6%) and 927 LC survivors (4.4%) received COT during follow-up. Median duration of first survivorship COT episode was 5.2 and 4.9 months for HNC and LC, respectively. 64% of HNC survivors received non-opioid pain management concurrent with their first COT episode; 55% received an analgesic and 24% underwent a procedure. 75% of LC survivors received non-opioid pain management concurrent with their first COT episode; 67% received an analgesic and 35% underwent a procedure. 79% of HNC and 81% of LC survivors did not receive benzodiazepines during the first COT episode. Conclusions: Among older survivors of LC and HNC, less than 6% receive COT. However, of those, one-half of HNC survivors and more than a third of LC survivors receive guideline-discordant care by using COT without other pain management strategies or while using benzodiazepines. To minimize opioid-related harms, efforts should focus on improving safe COT prescribing practices for survivors. [Table: see text]

Pain Management in Context of Emotionally Unstable Personality Disorder

2016 ◽  
Vol 33 (S1) ◽  
pp. S500-S500
Author(s):  
E. Dobrzynska ◽  
N. Clementi
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Personality Disorder ◽  
English Language ◽  
Opioid Analgesics ◽  
Management Options ◽  
Cognitive Behavioural ◽  
Keywords Chronic Pain ◽  
Competing Interest ◽  
Emotionally Unstable Personality Disorder

IntroductionEmotionally unstable personality disorder (EUPD) is characterised by Pain Paradox. The response for acute, self-induced pain seems to be attenuated while chronic, endogenous pain is usually intolerable. Pain management of this group of patients poses many difficulties, including discrepancies between subjective and objective pain assessment, patients’ demands for strong analgesics and impact on relationship with other professionals.Objectives and aimsThe purpose of the study was to review pain management options for persons diagnosed with EUPD and complaining of chronic pain.MethodsMEDLINE and PsycINFO databases were searched for all English-language articles containing the keywords “chronic pain”, “pain management”, “borderline personality disorder”, and “emotionally unstable personality disorder”.ResultsSeventeen relevant papers were identified. Suggested first step in pain management was ongoing clarification with EUPD patients that analgesics are unlikely to fully treat their pain and support of non-pharmacological approaches to pain, including cognitive-behavioural strategies. Regarding pharmacology, liberal use of non-addicting analgesics was recommended with highly conservative use of opioid analgesics. Importance of evaluation and treatment of any underlying mood and/or anxiety syndromes was stressed as well as liaison with other professionals (e.g. psychologists, neurologists, orthopaedics, and physiotherapists).ConclusionsPatients with EUPD often report chronic pain, which can only be managed by close collaboration of professionals from different disciplines.Disclosure of interestThe authors have not supplied their declaration of competing interest.

scholarly journals Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use

Children ◽  
2018 ◽  
Vol 5 (12) ◽  
pp. 163
Author(s):  
Genevieve D’Souza ◽  
Anava A Wren ◽  
Christina Almgren ◽  
Alexandra C. Ross ◽  
Amanda Marshall ◽  
...  
Keyword(s):  
Pain Management ◽  
Side Effects ◽  
Stress Responses ◽  
Physiological Stress ◽  
Opioid Therapy ◽  
Outpatient Basis ◽  
Opioid Use ◽  
Pediatric Populations ◽  
Special Expertise ◽  
Pain Symptoms

As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: 1) Review the current practice of opioid-reduction during pharmacological therapies; and 2) highlight concrete opioid weaning strategies and management of opioid withdrawal.

Opioid use in the acute setting: A survey of providers at an academic medical center

2018 ◽  
Vol 14 (3) ◽  
pp. 203-210 ◽  
Author(s):  
Douglas R. Oyler, PharmD ◽  
Kristy S. Deep, MD ◽  
Phillip K. Chang, MD
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Healthcare Providers ◽  
High Risk Patient ◽  
Opioid Analgesics ◽  
Opioid Use ◽  
Cross Sectional ◽  
Academic Medical ◽  
Clinical Scenarios ◽  
Nonopioid Analgesics

Objective: To examine attitudes, beliefs, and influencing factors of inpatient healthcare providers regarding prescription of opioid analgesics.Design: Electronic cross-sectional survey.Setting: Academic medical center.Participants: Physicians, advanced practice providers, and pharmacists from a single academic medical center in the southeast United States.Main Outcome Measures: Respondents completed survey items addressing: (1) their practice demographics, (2) their opinions regarding overall use, safety, and efficacy of opioids compared to other analgesics, (3) specific clinical scenarios, (4) main pressures to prescribe opioids, and (5) confidence/comfort prescribing opioids or nonopioids in select situations.Results: The majority of the sample (n = 363) were physicians (60.4 percent), with 69.4 percent of physicians being attendings. Most respondents believed that opioids were overused at our institution (61.7 percent); nearly half thought opioids had similar efficacy to other analgesics (44.1 percent), and almost all believed opioids were more dangerous than other analgesics (88.1 percent). Many respondents indicated that they would modify a chronic regimen for a high-risk patient, and use of nonopioids in specific scenarios was high. However, this use was often in combination with opioids. Respondents identified patients (64 percent) and staff (43.1 percent) as the most significant sources of pressure to prescribe opioids during an admission; the most common sources of pressure to prescribe opioidson discharge were to facilitate discharge (44.8 percent) and to reduce follow-up requests, calls, or visits (36.3 percent). Resident physicians appear to experience more pressure to prescribe opioids than other providers. Managing pain in patients with substance use disorders and effectively using nonopioid analgesics were the most common educational needs identified by respondents.Conclusion: Most individuals believe opioid analgesics are overused in our specific setting, commonly to satisfy patient requests. In general, providers feel uncomfortable prescribing nonopioid analgesics to patients.

How I treat pain in hematologic malignancies safely with opioid therapy

Blood ◽  
2020 ◽  
Vol 135 (26) ◽  
pp. 2354-2364
Author(s):  
Holly L. Geyer ◽  
Halena Gazelka ◽  
Ruben Mesa
Keyword(s):  
Survival Rates ◽  
Hematologic Malignancies ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Screening Tools ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Prescription Drug Monitoring Programs ◽  
Urine Drug ◽  
Life Threatening

Abstract The field of malignant hematology has experienced extraordinary advancements with survival rates doubling for many disorders. As a result, many life-threatening conditions have since evolved into chronic medical ailments. Paralleling these advancements have been increasing rates of complex hematologic pain syndromes, present in up to 60% of patients with malignancy who are receiving active treatment and up to 33% of patients during survivorship. Opioids remain the practice cornerstone to managing malignancy-associated pain. Prevention and management of opioid-related complications have received significant national attention over the past decade, and emerging data suggest that patients with cancer are at equal if not higher risk of opioid-related complications when compared with patients without malignancy. Numerous tools and procedural practice guides are available to help facilitate safe prescribing. The recent development of cancer-specific resources directing algorithmic use of validated pain screening tools, prescription drug monitoring programs, urine drug screens, opioid use disorder risk screening instruments, and controlled substance agreements have further strengthened the framework for safe prescribing. This article, which integrates federal and organizational guidelines with known risk factors for cancer patients, offers a case-based discussion for reviewing safe opioid prescribing practices in the hematology setting.

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