A Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Noncancer Pain: Tailoring Therapy to Meet Patient Needs

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. For many patients with CNCP, the analgesic regimen will include opioids. Physicians should consider the available evidence of efficacy, the routes of administration, and the pharmacokinetics and pharmacodynamics of the various formulations as they relate to the temporal characteristics of the patient's pain. When making initial decisions, physicians should decide whether to prescribe a shortacting opioid (SAO) with a relatively quick onset of action and short duration of analgesic activity, a long-acting opioid (LAO) with a longer duration of analgesic action but a potentially longer onset of action, or both. Studies suggest that SAOs and LAOs are both effective for most types of CNCP. A review of published studies found no data to suggest that either SAOs or LAOs are generally more efficacious for treating any particular CNCP condition. The LAOs may provide more stable analgesia with less frequent dosing; however, opioid therapy should be tailored to the pain state and the individual patient, and SAOs may be appropriate for some patients with CNCP. MEDLINE and PubMed searches were conducted to locate relevant studies published from January 1975 to April 2008 using the following search terms: opioids, short-acting opioids, long-acting opioids, chronic pain, chronic pain AND opioids, and narcotics. English-only randomized controlled trials and nonrandomized studies were considered.Mayo Clin Proc. 2009;84(7):602-612 ADL = activities of daily living; AE = adverse effect; ATC = around-theclock; BPI = Brief Pain Inventory; CNCP = chronic noncancer pain; CR = controlled-release; DN = diabetic neuropathy; ER = extended-release; IR = immediate-release; LAO = long-acting opioid; LBP = low back pain; NSAID = nonsteroidal anti-inflammatory drug; PHN = postherpetic neuralgia; QOL = quality of life; SAO = short-acting opioid; SNRI = serotonin norepinephrine reuptake inhibitor; SR = sustained-release; TCA = tricyclic antidepressant

Acute Pain Management in the Emergency Department: Emphasis on NSAIDs

“…Immediate-Release (IR) opioids are characterized by a relatively rapid increase in serum blood levels and subsequent relatively rapid decrease, resulting in a relatively rapid onset of analgesia and relatively short duration of action [74]. These formulations are considered appropriate for the management of acute pain, postsurgical pain, and other transient pain syndromes [75].…”

Contemporary Clinical Opioid Use: Opportunities and Challenges

“…These and related issues are addressed in 4 articles and 1 additional editorial in the current issue of Mayo Clinic Proceedings. Specifically, Passik 3 discusses long-term prescription opioid therapy; Argoff and Silvershein 4 address the use of long-vs short-acting opioids for treating chronic noncancer pain; Smith 5 reviews opioid metabolism; and Berge et al 6 discuss chemical dependency in physicians, with a focus on opioids. In their editorial, Oreskovich and Caldeiro 7 discuss whether select groups of health care professionals, such as anesthesiologists, have unacceptably poor outcomes after initial opioid addiction and whether this should dictate policies of rehabilitation and possible return to clinical practice.…”

“…Concurrent with the introduction of fentanyl and other novel opioids, laboratory-based investigators began exploring the receptors responsible for opioid effects and discovered a veritable treasure trove (eg, delta, kappa, mu) of receptor subtypes. As reviewed in part by the aforementioned authors in this issue of the Proceedings, the new opioid agonists vary greatly in duration (ranging from long-acting drugs such as methadone, which lasts hours to days, 3,4 to remifentanil, with a duration of only a few minutes), potency, receptor selectivity, and clinical application.…”

“…In the hands of anesthesiologists or other highly trained clinicians, such adverse effects are anticipated, mitigated, and prevented. However, in the hands of those with inadequate pharmacological knowledge, unfortunate opioid events can occur to individual patients [3][4][5] or practitioners 6,7 and en masse. 16 In 2002 when Russian troops attempted to immobilize 50 Chechnyan rebels and their 800 hostages inside a Moscow theater, the troops allegedly used an aerosolized potent opioid (presumably carfentanil or a related drug) as a mass "calmative"; 127 (16%) of the hostages died, and others became critically ill.…”

“…Because of its long half-life and duration of effect, methadone also is a highly effective, and an increasingly used, first-line drug in treating acute, chronic, neuropathic, and cancer pain and as an alternative to morphine and other firstline opioids. 3,4 It is cost-effective at less than $0.25 per dose (pharmacy cost) compared to more than $8 per dose for some sustained-release opioids. Unfortunately, coincident with the intensified focus on adequate pain treatment (specifically that involving methadone) and increased administration of pain therapies by primary care professionals, methadone-related deaths have increased considerably.…”