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Exploring the use of extended release opioids at shortened dosing intervals in people with chronic pain and high risk medication or substance use

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Abstract

Background Critical attention to rational opioid prescribing has emerged from the opioid epidemic in North America. Individuals with chronic pain are prescribed extended release opioids in an effort to maintain stable drug levels and for more convenient dosing, though evidence to support improvements in pain or function is lacking. It has been observed that extended release opioid products are used at intervals shorter than recommended by product monographs. The need for shortened intervals has been linked with potential inter-patient variability in pharmacokinetics, among other rationale. Implications of shortened dosing intervals for extended release opioids have not been systematically studied. Objective The aim of this study was to characterize the use of extended release opioid formulations at shortened dosing intervals in a population of patients with chronic pain and high risk for opioid-related harms. Setting This study took place in the Interprofessional Pain and Addiction Recovery Clinic, a specialty ambulatory clinic at the Centre for Addiction and Mental Health in Toronto, Canada for adults with chronic pain and a diagnosis or suspicion of substance use disorder. Method This was a retrospective cross-sectional study. Data were collected from records of patients with assessments completed in the years 2012–2017 (n = 210). Main outcome measure Proportion of patients using extended release opioids at shortened intervals. Results Sixty-one percent of individuals using extended release opioids (n = 78) were using them at shortened intervals. This use was associated with a higher daily morphine equivalent dose (533 mg vs 236 mg, p < 0.01), use of oxycodone extended release products (50% vs. 27%, p < 0.01), a longer duration of opioid therapy (8.9 vs. 6.8 years, p = 0.03) and a diagnosis of chronic neuropathic pain (63% vs. 39%, p < 0.01), with no differences in reported pain intensities, compared with use at standard intervals. Conclusion The use of extended release opioids at shortened intervals was associated with increased daily morphine equivalent doses, thus an increased risk of opioid-related mortality. It is unlikely that of those using extended release opioids, the high proportion of use at shortened intervals is the result of inter-patient differences in metabolism alone. Further study is warranted to explore the underlying drivers and implications for people with chronic pain.

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Acknowledgement

We would like to acknowledge Anam Quraishi, Pharmacy Student at the Leslie Dan Faculty of Pharmacy, University of Toronto, for her contribution to data collection.

Funding

This work has not received any pharmaceutical or industry support.

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Authors and Affiliations

  1. Leslie Dan Faculty of Pharmacy, University of Toronto, University Health Network, 550 University Ave., Toronto, ON, M5G 2A2, Canada

    Laura Murphy

  2. Health Canada, Department of Pharmacology and Toxicology, University of Toronto, Centre for Addiction and Mental Health, Toronto, ON, Canada

    Bruna Brands

  3. Kingston Health Sciences Centre, Kingston, ON, Canada

    Daniel Grant

  4. Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada

    Andrew Smith

  5. Centre for Addiction and Mental Health, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada

    Maria Zhang

  6. Centre for Addiction and Mental Health, Leslie Dan Faculty of Pharmacy and Department of Psychiatry, University of Toronto, Toronto, ON, Canada

    Beth Ann Sproule

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  1. Laura Murphy
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Correspondence to Laura Murphy.

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Murphy, L., Brands, B., Grant, D. et al. Exploring the use of extended release opioids at shortened dosing intervals in people with chronic pain and high risk medication or substance use. Int J Clin Pharm 43, 404–410 (2021). https://doi.org/10.1007/s11096-020-01027-y

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