REVIEWA Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Noncancer Pain: Tailoring Therapy to Meet Patient Needs
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PHARMACOKINETICS AND PHARMACODYNAMICS OF LAOs AND SAOs
Few studies directly compare the pharmacokinetic and pharmacodynamic properties of SAOs and LAOs.37, 38, 39, 40, 41 Compared with SAOs, LAOs are associated with fewer peak-trough fluctuations and thus provide more stable drug plasma concentrations, which may lead to fewer periods of inadequate pain control.42 However, the analgesic effects of short- and long-acting formulations of the same opioid were similar when dosed consistently in several trials.37, 43
Comparisons of similar opioid
ANALGESIC EFFICACY OF LAOs AND SAOs IN COMMON CNCP CONDITIONS
The use of opioids for the treatment of CNCP is supported by a number of professional organizations, including the American Academy of Pain Medicine and the American Pain Society.16 However, few studies have compared SAOs with LAOs head to head; most data concerning the efficacy of opioids are based on comparisons of the active study drug with a placebo control. Therefore, little evidence shows that either SAOs or LAOs are superior for the treatment of CNCP.48, 49, 50, 51
OSTEOARTHRITIS
Osteoarthritis, the most common rheumatologic disorder and a primary cause of disability, is associated with structural malfunction of the synovial joints.52 Osteoarthritis affects approximately half the population 65 years and older and currently affects 1 in 5 Americans overall.53 The number of Americans 65 years and older is expected to double by 2030; therefore, the social burden of osteoarthritis will likely increase.53 The American College of Rheumatology recommends opioid analgesics if
LOW BACK PAIN
Chronic LBP occurs in 28.3% of adults 18 years or older61 and is the fifth most common reason that Americans consult with a physician.62 Opioid therapy, as part of a multimodal approach to pain management, may prove beneficial for some people with chronic LBP. The American College of Physicians and the American Pain Society consensus guidelines for the treatment of chronic LBP state that opioids are a treatment option for severe, disabling pain not controlled by acetaminophen or NSAIDs.15
The
NEUROPATHIC PAIN
Neuropathic pain, resulting from a lesion or dysfunction in the peripheral and/or central nervous system, is associated with such conditions as diabetic neuropathy (DN), postherpetic neuralgia (PHN), and phantom limb pain.2 The most recently published evidence-based guidelines call for the initial treatment of neuropathic pain with TCAs, the α2δ ligands gabapentin and pregabalin, or selective SNRIs, alone or in combination.19, 20 These guidelines recommend that opioid analgesics be used when
QUALITY OF LIFE
Pain is a complex experience for patients, encompassing psychological and emotional aspects that can be difficult to fully articulate. Pain affects the physical, mental, and social functions that allow patients to take part in ADLs. Conventional numeric pain scales ranging from 0 to 10 do not distinguish between the physical and emotional pain components. Learning how pain affects QOL may help to improve function, a critical goal of pain therapy. To aid the physician in identifying baseline and
SLEEP
Comorbid pain-related sleep disturbances are reported by 88.9% of patients with chronic pain.79 The pain-sleep relationship is such that pain may exacerbate sleep disturbances, which, in turn, may further intensify physical and mental symptoms, such as pain, disability, impaired daily functioning, and depression.4, 79 Therefore, providing effective analgesia may relieve pain-related sleep disorders (Figure).80
The LAO formulations may effectively improve sleep in some patients with chronic pain.
ADVERSE EFFECTS
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.85 With opioid therapy, common AEs include constipation, nausea, vomiting, dry mouth, and sedation.86 In several studies comparing SAOs and LAOs, no definitive evidence linked the pharmacokinetic profile of the formulation and
APPROACHES TO RISK ASSESSMENT AND MANAGEMENT WITH SAOs AND LAOs
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; 5.2 million people abused pain relievers in 2006, an increase from 4.7 million in 2005.93 Historically, conventional wisdom suggested that SAOs are more likely to lead to abuse and that aberrant behavior is less likely with LAOs because of their pharmacokinetic and pharmacodynamic features.94, 95 Several studies,
IMPLICATIONS FOR MANAGEMENT OF CHRONIC PAIN
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
CONCLUSION
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.
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Dr Argoff acknowledges that he has served as a consultant/speaker for Endo Pharmaceuticals, King Pharmaceuticals, Pricara, Alpharma, and Cephalon and has served as a consultant for Abbott Laboratories. Dr Silvershein has acted as a consultant to the McMahon Group relating to their work with King Pharmaceuticals.
This article is freely available on publication.