Prescription opioid formulations designed to resist or deter abuse are an important step in reducing opioid abuse. In creating these new formulations, the paradigm of drug development target should be introduced. Biological targets relating to the nature of addiction may pose insurmountable hurdles based on our current knowledge and technology, but products that use behavioral targets seem logical and feasible. The population of opioid abusers is large and diverse so behavioral targets are more challenging than they appear at first glance. Furthermore, we need to find ways to correlate behavioral observations of drug liking to actual use and abuse patterns. This may involve revisiting some pharmacodynamic concepts in light of drug effect rather than peak concentration. In this paper we present several new opioid analgesic agents designed to resist or deter abuse using physical barriers, the inclusion of an opioid agonist or antagonist, an aversive agent, and a prodrug formulation. Further, this paper also provides insight into the challenges facing drug discovery in this field. Designing and screening for opioids intended to resist or deter abuse is an important step to meet the public health challenge of burgeoning prescription opioid abuse.
Patient‐controlled analgesia (PCA) is a mainstay for postoperative and acute in‐hospital pain management. Its role in the chronic pain setting, for example for palliative care as well as the care of ambulatory patients with chronic pain syndromes, is not well defined. Acute PCA typically involves intravenous PCA using morphine, although other opioid analgesics may be used. Chronic PCA may take advantage of emerging PCA technologies including transmucosal and transdermal delivery systems, novel dispensing units for oral tablets, and device‐based therapies including implantable systems and external transcranial stimulation devices. Of particular concern in defining and developing chronic PCA systems are safety issues and concerns relating to long‐term opioid therapy, whether administered via PCA or in oral form by prescription. Since chronic pain populations are diverse, chronic PCA solutions—if appropriate at all—may vary. Chronic PCA has been studied in palliative care cancer patients, but other groups who might benefit from chronic PCA are less thoroughly investigated.
Aim: This paper reviews the concept of the use of PCA as an option for the management of chronic pain in an appropriate patient population. It does so from the point of view of medical need, i.e., the optimal management of pain. We fully recognize, however, that there are also potential negatives and consequences that could arise from the point of view of misuse, abuse, and diversion. It is our hope that this paper stimulates not only a discussion of the use of PCA for chronic pain patients, but also a discussion about how best to balance medical need vs. inappropriate use.
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