Abuse of immediate-release opioids and current approaches to reduce misuse, abuse and diversion

Abstract

Deaths from opioid overdoses have increased dramatically over the past few years. Given that immediate-release (IR) opioids account for most of the U.S. market share, and that abusers generally prefer IR opioids over extended-release (ER) opioids, it is not surprising that rates of abuse are higher for IR than ER opioids. IR opioids are widely prescribed, often without consideration for risks of abuse, misuse, and diversion. Prescription opioid abuse and misuse often begins through oral administration and progresses into non-oral routes (e.g. snorting, injecting) as abusers gain more experience; non-oral routes carry heightened safety concerns. Current approaches used for reducing opioid abuse include U.S. Food and Drug Administration regulations, state legislation, insurance company policies, the use of multimodal analgesic therapy, patient risk assessment and monitoring, limiting access to opioids by reducing IR opioid prescription quantity and length, prescription drug monitoring programs, patient education on proper disposal of unused medication and risks of diversion, as well as abuse-deterrent formulations. Albeit, most abuse-deterrent formulations have focused on ways to prevent the circumvention of ER characteristics rather than placing obstacles to abuse of IR opioid formulations. Reducing opioid abuse requires the combined efforts of multiple stakeholders, including prescribing clinicians, patients, pharmacists, nurses, insurance companies, government agencies, and pharmaceutical companies.

Updated Clinical Pharmacokinetics and Pharmacodynamics of Oxycodone

“…Unfortunately, the CR oxycodone formulation is appealing to drug abusers since it contains a higher amount of opioid [137,141]. The original CR tablets were manipulated to achieve IR properties and thus higher drug-liking.…”

<p>Safe Opioid Storage and Disposal: A Survey of Patient Beliefs and Practices</p>

“…7,9,10 Regulatory actions at the federal and state levels have sought to limit access to unused medications while still ensuring effective pain management. 11 The US Food and Drug Administration (FDA) Opioid Analgesic Risk Evaluation and Management Strategy (REMS) program, approved in September 2018, requires that training be provided to all healthcare providers involved in patient pain management. 12 This training includes fundamental concepts of pain management, strategies to identify risk factors for addiction and abuse, and best practices for counseling patients on the safe use of opioids.…”

“…12,13 Several states have implemented legislation limiting the supply and/or dose of initial opioid prescriptions and have initiated drug take-back programs. 11 In addition, the importance of interventions targeting opioid prescription diversion at the patient/provider level has been highlighted in the literature. 7,11,[14][15][16] This includes the need for patient/caregiver education on opioid misuse and diversion risk and proper opioid storage and disposal, as well as strategies for healthcare providers to reduce the quantity of prescribed pills and identify the signs and symptoms of addiction and abuse among their patients.…”

Abuse-Deterrent Opioid Analgesics: A Guide for Clinicians

“…Prescription opioids are abused via multiple routes, including oral consumption of intact medications, oral ingestion after product manipulation (such as crushing or chewing), nasal inhalation ('snorting') and injection [7,8]. Manipulation for nonoral use, which occurs with both immediate-release and extended-release (ER) opioids, is intended to convert the active ingredient to a form that is more easily abused (e.g., powder for nasal inhalation, solution for intravenous (IV) injection ) and to release the opioid more rapidly (known as dose dumping) [9][10][11][12]. More severe medical outcomes are observed with nonoral routes of opioid administration [13].…”