Opioid And Nonopioid Analgesics PdfBy Yasmin B. In and pdf 18.04.2021 at 05:43 10 min read
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- National consumption of opioid and nonopioid analgesics in Croatia: 2007–2013
- Efficacy of non-opioid analgesics to control postoperative pain: a network meta-analysis
- Medications: opioids vs non-opioids
- Central Effects of Non-Opioid Analgesics
Analgesics such as non-steroidal anti-inflammatory drugs NSAIDs , weak and strong opioids are commonly used among elderly persons.
National consumption of opioid and nonopioid analgesics in Croatia: 2007–2013
Analgesics such as non-steroidal anti-inflammatory drugs NSAIDs , weak and strong opioids are commonly used among elderly persons. The aim of this study was to describe the demographic and clinical characteristics of elderly analgesic users and to measure the frequency of analgesic use, including the frequency of potentially inappropriate analgesic use.
The Arianna database was used to carry out this study. This database contains prescription data with associated indication of use for 1,, inhabitants registered with their general practitioners GPs in the Caserta Local Health Unit Caserta district, Campania region in Italy.
The date of the first analgesic prescription in the study period was considered the index date ID. From a source population of 1,, persons, , elderly persons were identified. Of these, 94, elderly persons received at least one analgesic drug: In terms of inappropriate analgesic use, 9. Furthermore, at least half all elderly persons with chronic kidney disease or congestive heart failure were prescribed NSAIDs, while these drugs should be avoided.
Analgesics are commonly used inappropriately among elderly persons, suggesting that prescribing practice in the catchment area may yet be improved. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: Data cannot be shared publicly because of an agreement signed between the authors and the data providers which precludes sharing of patient-level data to third parties.
Mario de Biasio, at direzionegenerale pec. The authors confirm they had no special access or privileges that other researchers would not have. GT has attended advisory boards on topics not related to this paper in the last 10 years, organized by Sandoz, Hospira, Sanofi, Biogen, Ibsen, Shire, and is consultant for Otsuka. He is the principal investigator of observational studies funded by several pharmaceutical companies e.
Pain is common medical problem among older persons and can lead to impaired functionality, depression and a lower quality of life [ 1 ].
Mild to moderate acute pain is treated with acetaminophen and non-steroidal anti-inflammatory drugs NSAIDs as first-line agents [ 2 ]. Due to their strong anti-inflammatory action, NSAIDs are generally indicated in pain of inflammatory origin. On the other hand, opioid analgesics are indicated in pain of visceral origin, in palliative care and in general, in moderate to severe pain not responding to NSAIDs.
Drug use and safety among elderly persons is of importance because this population is more likely to use several drugs concomitantly [ 4 ]. Elderly persons are also likely to be frailer in terms of increased multi-morbidity, impaired cognition and reduced independence in activities of daily living [ 5 ].
Indeed, the high prevalence of pain in frail elderly persons [ 6 ] in addition to the widespread overuse of opioids in some countries [ 7 ] creates an urgent need to understand pharmacological pain management approach among the elderly. This is important given the drug risk-benefit profiles may change as a function of cognitive and functional impairment [ 8 ].
The Beers criteria for inappropriate analgesic prescribing suggest that the NSAIDs ketorolac and indomethacin should not be prescribed in elderly persons and that non-selective NSAIDs should not be used chronically in elderly persons [ 9 ]. Furthermore, several analgesics are contraindicated in conditions which are more frequently present in elderly persons compared to younger ones, such as congestive heart failure CHF and chronic kidney disease CKD.
Analgesic drug utilization in this population may therefore be variable. This in addition to the widespread opioid epidemic in some countries is a further incentive to study analgesic use among elderly persons. The appropriateness of analgesic use in Italy has been the topic of limited published research, including the appropriateness of opioid use in cancer patients [ 16 ], inappropriate use in chronic pain [ 17 ] or in relation to a change in drug prescribing directives [ 18 , 19 ].
However, to our knowledge, there is no recent Italian study investigating inappropriate analgesic use in the elderly. The aim of this study was therefore to describe the demographic and clinical characteristics of elderly analgesic users and to measure the frequency of analgesic use in this population, including the frequency of potentially inappropriate analgesic use.
This database contains prescription data with associated indication of use for 1,, persons living in the catchment area registered with their GPs in the Caserta Local Health Unit Caserta district, Campania region in Italy.
These data are linked with the following patient-level claims data from the same catchment area: demographic registry, pharmacy claims database for drugs acquired through the Italian National Healthcare System NHS and a database of hospital discharge diagnoses.
Pharmacy claims contain prescription data for drugs that are covered by the Italian NHS, including most analgesics. Acetaminophen is not covered by the Italian NHS unless it is found in combination with other drugs.
Although most analgesics are covered by the Italian NHS, patients may still opt to buy them out-of-pocket. In addition to the demographic and clinical patient characteristics mentioned above, the results of a comprehensive geriatric assessment CGA concerning cognitive status, mobility, nursing needs and social support were used to further describe the study population. The study was carried out using retrospectively collected and anonymized data.
A cohort of patients from the Caserta catchment area was identified, including patients who had one year of database history, were aged at least 65 years old and received at least one analgesic drug prescription between and Patients were censored if transferred out of the database i.
Persons with no analgesic drug dispensing within one year before the index date were considered incident drug users. Analgesic drugs, i. NSAIDs, weak opioids and strong opioids were the exposure of interest and were identified within the population of elderly persons using ATC codes. Acetaminophen was not included as a main study drug as, this drug is not covered by the Italian NHS unless in combination with codeine and is mainly purchased out-of-pocket as an over-the-counter OTC drug.
Codeine was considered only in combination with acetaminophen as only this preparation is indicated for pain in Italy. Analgesics were further categorized by formulation oral, injection, transdermal, rectal or nasal. Indications associated with the analgesic drug prescriptions were reported.
The mean prescribed defined daily dose PDD for each analgesic prescription was estimated by dividing the drug doses prescribed i. Inappropriate analgesic drug prescribing was identified using Beers criteria [ 8 ]. For incident analgesic users, demographic and clinical characteristics in terms of age, sex, co-morbidities, specifically heart failure, diabetes mellitus, ischemic heart disease e. The use of analgesics among incident users was described in terms of indication of use median number of daily doses with interquartile range , formulation used and median number of inappropriate prescriptions with interquartile range.
Incident analgesic users were also described in terms of selected CGA evaluations. Only CGA data regarding elderly incident analgesic users was extracted; results were restricted to the CGAs closest to the index date. The frequency of inappropriate analgesic use was measured without restricting to incident analgesic users since the inappropriate use of these drugs concerns a broader group of patients, i.
Frequencies were calculated both considering number of persons with the disease as a denominator as well as number of elderly persons using the analgesic drugs of interest.
A time to event Kaplan-Meier analysis i. Persistence to analgesics therapy was assessed based on the maximum allowed treatment gap of 60 days, defined as the time between the last day covered by analgesic drug treatment and the time to the next refill. The Kaplan Meier analysis was carried out and results were stratified by pharmacological categories non-steroidal anti-inflammatory drugs, weak opioids and strong opioids.
A sub-analysis was carried using a different data source out to find to what extent non-opioid analgesics were purchased over the counter OTC from community pharmacies in the catchment area. This analysis was carried out using a database provided by IMS Health on pharmacy sales data for all pharmacies in Caserta.
Prescription data from IMS is aggregate prescription-level data through which it is possible to distinguish between units of drugs dispensed through the NHS and those OTC. Data management and analyses were carried out using SAS version 9. A p-value of 0. From a source population of 1,, persons in the catchment area, , elderly persons were identified.
Of these, 94, were elderly persons who were dispensed at least one analgesic drug Fig 1. There was no clear unifying trend concerning the yearly prevalence of non-opioid drugs from to , although several marked changes in use can be seen for single drugs S2 Fig.
The most commonly used opioid drug was codeine in combination with acetaminophen, which increased in prevalence from 4 to 5. Overall, 94, In terms of overall medical condition, defined using number of concomitant medications as a proxy of disease burden, strong opioid users received more concomitant drugs 7.
Among all three analgesic groups, the most common indication for analgesic prescribing was bone and joint disorders. Numbers in brackets refer to the percentages unless otherwise specified. Overall, strong opioid users showed more factors indicating frailty status than weak opioid or non-opioid users. For example, a larger proportion of elderly strong opioid users had mild cognitive impairment compared to weak opioids and non-opioid drug users, while there was no difference in the proportion of persons with moderate and severe cognitive impairment among the three analgesic groups.
With regard to nursing needs, non-opioid users were more commonly those with no additional nursing needs, compared to the other two analgesic groups; conversely, strong opioid users more commonly required nursing assistance than the other two analgesic groups.
Strong opioid users were also more likely to be required assistance regarding mobility Table 2. Overall, a total of 10, 9. In contrast, the chronic use of non-selective non-steroidal anti-inflammatory drugs, defined as that exceeding 90 days, was less common 1, patients, 1. There were only 4 elderly persons with a prescription for pentazocine. Overall, Using any definition, persistence was always slightly higher for strong opioid use.
None of the analgesic users were persistent at 1 year from the start of analgesic use Fig 2. The analysis on analgesic dispensing using IMS pharmacy sales data confirmed that by and large, about half of non-opioid analgesic drugs acquired in community pharmacies was indeed bought over-the-counter and could not have been captured by the NHS administrative drug dispensing databases S4 Fig.
To our knowledge, the present study is the first to describe analgesic use and appropriateness among elderly persons in Italy. Among the incident elderly analgesic users identified, more persons were prescribed non-opioid analgesics than opioid analgesics, and among opioid analgesics, weak opioids were more commonly used than strong opioids.
This is in line with the recommended stepped use of analgesic drugs, where non-opioids are first-line agents, followed by weak and strong opioids. In Italy there has been a four-fold increase in the number opioid prescriptions from to , as reported by the Italian Society of Pharmacology, however this increase is modest compared to other European countries [ 22 ].
Indeed, the cautious use of opioids is confirmed by the very short median duration of these drugs: 5 days IQR: 5—11 for weak opioids and 8 days IQR: 5—22 for strong opioids; there is no study to which these results can be compared at the time of writing.
While a recently published study using data from pharmacy sales on a national level confirmed a relative increase in opioid use in Italy from to , this study reported that opioid use is overall low; the most commonly used drug was codeine, which was used at 5 DDD per day per 1, persons in [ 23 ]. Evaluating the appropriateness of opioid prescribing is a challenge, as this depends on an accurate classification of the severity of pain.
For example, the present study found that weak and strong opioids were commonly used for bone and joint disorders, although less commonly than non-opioid analgesics. Although opioids can be used appropriately in joint and bone-related pain, they should only be used for moderate to severe pain [ 24 ].
On the other hand, opioids were commonly used in persons with cancer as an indication, in line with the indication of these drugs in palliative care [ 25 ]. In the context of frailty, it is surprising that strong opioids were used more commonly in frailer persons compared to persons with a better cognition and functional status because elderly persons who are frail are likely to have poorer mobility [ 26 ]. This is likely to predispose such elderly persons to ADRs such as falling with risk of facture, increasing the risk of hospitalization and disability [ 27 ].
The decreasing prevalence of nimesulide among elderly persons is perhaps the most notable trend among non-opioid analgesics. This may be related to concerns as early as , when EMA reviewed nimesulide after the government of Ireland suspending the marketing authorization for this drug due to concerns about drug-induced liver disease [ 28 ]. Uncertainty about this drug remained unresolved, because in , EMA requested the Committee for Medicinal Products for Human Use to evaluate the nimesulide risk-benefit profile and recommend a regulatory course of action such as changing, suspending or withdrawing the marketing authorization of the drug throughout the European Union.
The Italian Drug Agency published a notice on the risk of hepatotoxicity with use of NSAIDs, with specific mention of nimesulide in , however the reduction in the use of nimesulide after was minimal compared to the reduction from to [ 29 ]. On the other hand, the mild increase in the prevalence of etoricoxib use from to may make sense in the context of sequence of safety concerns about this drug, and indeed the whole class of COX-2 inhibitors.
Efficacy of non-opioid analgesics to control postoperative pain: a network meta-analysis
Acute periradicular abscess is a condition characterized by the formation and propagation of pus in the periapical tissues and generally associated with debilitating pain. The aim of this study was to compare the overall analgesic effectiveness of two combinations of opioid and non-opioid analgesics for acute periradicular abscess. This study included 26 patients who sought emergency care in a Brazilian dental school. Two factors were evaluated: 1 pain scores recorded by the patients in a pain diary 6, 12, 24, 48, and 72 h after treatment, using the Visual Analogue Scale; and 2 the occurrence of adverse effects. In both groups, there was a reduction in pain scores over time. This study suggests that, considering both analgesic efficacy and safety, the combination of codeine and acetaminophen is more effective to control moderate to severe pain from acute periradicular abscesses.
Sign up to an individual subscription to the Oxford Textbook of Palliative Medicine. View additional online only references. Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. Non-opioid analgesics encompass the non-steroidal anti-inflammatory drugs NSAIDs and paracetamol acetaminophen.
Non-opioid medications may be beneficial in helping to control chronic pain. Some examples of non-opioid pain medications include over the counter medications such as Tylenol acetaminophen , Motrin ibuprofen , and Aleve naproxen. Some prescription medications may also be used to manage pain. Neurontin gabapentin is often prescribed to manage nerve pain. Corticosteroids may be used to decrease pain caused by inflammation, and some types of antidepressants may also be effective in treating chronic pain. Sometimes, your doctor may recommend a topical pain medication such as lidocaine or capsaicin. It is important to discuss the use of these medications with your doctor as they may have dangerous interactions with other prescription medications or cause dangerous side effects for some people.
Medications: opioids vs non-opioids
An analgesic or painkiller is any member of the group of drugs used to achieve analgesia, relief from pain. Analgesic drugs act in various ways on the peripheral and central nervous systems. They are distinct from anesthetics , which temporarily affect, and in some instances completely eliminate, sensation. Analgesics include paracetamol known in North America as acetaminophen or simply APAP , the nonsteroidal anti-inflammatory drugs NSAIDs such as the salicylates , and opioid drugs such as morphine and oxycodone. When choosing analgesics, the severity and response to other medication determine the choice of agent; the World Health Organization WHO pain ladder  specifies mild analgesics as its first step.
Central Effects of Non-Opioid Analgesics
An analgesic or painkiller is any member of the group of drugs used to achieve analgesia, relief from pain. Analgesic drugs act in various ways on the peripheral and central nervous systems. They are distinct from anesthetics , which temporarily affect, and in some instances completely eliminate, sensation. Analgesics include paracetamol known in North America as acetaminophen or simply APAP , the nonsteroidal anti-inflammatory drugs NSAIDs such as the salicylates , and opioid drugs such as morphine and oxycodone.
Comparison of two combinations of opioid and non-opioid analgesics for acute periradicular abscess: a randomized clinical trial. Acute periradicular abscess is a condition characterized by the formation and propagation of pus in the periapical tissues and generally associated with debilitating pain. The aim of this study was to compare the overall analgesic effectiveness of two combinations of opioid and non-opioid analgesics for acute periradicular abscess. This study included 26 patients who sought emergency care in a Brazilian dental school. Two factors were evaluated: 1 pain scores recorded by the patients in a pain diary 6, 12, 24, 48, and 72 h after treatment, using the Visual Analogue Scale; and 2 the occurrence of adverse effects. In both groups, there was a reduction in pain scores over time. This study suggests that, considering both analgesic efficacy and safety, the combination of codeine and acetaminophen is more effective to control moderate to severe pain from acute periradicular abscesses.
To evaluate effectiveness and harms of opioids compared to nonopioid analgesics as treatment of moderate to severe acute pain in the prehospital setting.
Many data indicate that some non-opioid analgesics exert their analgesic activity both at the peripheral and central level. The central effect has been observed in behavioural, electrophysiological and biochemical studies in animals. In humans, evidence has been reported both in healthy individuals and in postoperative pain states. In the CNS, some of these drugs interfere with prostaglandin synthesis or with serotonergic, opioidergic and nitric oxide systems. Thus, drugs acting both at peripheral and central levels may produce a more complete control of some types of pain, such as pain generated by surgery or arthritic pain. This is a preview of subscription content, access via your institution. Rent this article via DeepDyve.
Желтый сигнал тревоги вспыхнул над шифровалкой, и свет, пульсируя, прерывистыми пятнами упал налицо коммандера. - Может, отключить его самим? - предложила Сьюзан.
Ему сказали, что бортовой телефон вышел из строя, поэтому позвонить Сьюзан не удастся. - Что я здесь делаю? - пробормотал. Ответ был очень простым: есть люди, которым не принято отвечать. - Мистер Беккер, - возвестил громкоговоритель.