hydrocodone and Chronic-Disease

This forum presents a clinical vignette of orofacial pain and expounds on ethical issues related to opioid therapy in the context of multidisciplinary treatment. The purpose of this forum is to assist health care providers from different disciplines in identifying ethical issues and conflicts regarding opioid therapy encountered in multidisciplinary clinical pain practices.. We use the case vignette and opioid therapy as a backdrop for a discussion of 1) an overview of ethics terminology; 2) a presentation of key ethics principles; 3) our conceptualization of ethical obligations of patients regarding opioid therapy; and 4) the process of developing an appropriate treatment plan within the context of the discussed ethical principles.

Topics: Analgesics, Opioid; Chickenpox; Cholecystectomy; Chronic Disease; Diazepam; Facial Pain; Female; Herpes Zoster; Humans; Hydrocodone; Hypnotics and Sedatives; Hysterectomy; Opioid-Related Disorders; Pain; Pain Clinics; Uterine Neoplasms

Opioids are important, if not essential, agents in treating certain types of chronic pain. However, the prevalence of drug misuse, abuse, and addiction has fostered considerable consternation among physicians, who may hesitate to prescribe these medications both due to concern for patients (misuse, abuse, and addiction), and fears of prosecution and/or professional sanction. Such practice may reflect 1) inadequate knowledge about patients' susceptibility to, or current drug misuse or abuse; 2) lack of familiarity with extant assessments and/or regulations, and/or 3) an unanticipated reaction to existing guidelines, policies or laws. We posit that assessing patients' predisposition to, and patterns of, drug misuse/abuse is a vital first step toward establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain. Adherence monitoring is critical to identify patients' prior and current drug use, establish treatment basis, and evaluate compliance, so as to avoid misuse and abuse, and ensure sound and proper pain management. This paper provides a review of the numerous monitoring approaches that have been described in the literature and addresses the benefits and limitations of these techniques and tools. The complex nature of the problem of drug misuse and abuse is discussed, and while no single monitoring technique can fully address this complex issue, we describe how multiple approaches to adherence monitoring may be employed to sustain the prudent use of opioids for the treatment of chronic pain.

Topics: Analgesics, Opioid; Chronic Disease; Codeine; Drug Monitoring; Heroin; Humans; Hydrocodone; Pain; Patient Compliance

Celecoxib is a cyclooxygenase-2-specific inhibitor indicated to treat acute pain and pain secondary to osteoarthritis and rheumatoid arthritis. Surgical models of acute pain have demonstrated superior pain relief to placebo. The objective of this study was to test the safety and efficacy of celecoxib for pain relief after tonsillectomy compared to placebo.. Adult subjects were randomized to 200 mg celecoxib versus placebo with a loading dose the night before surgery then twice daily for 10 days. Subjects were instructed to supplement the study drug with hydrocodone/acetaminophen liquid or acetaminophen for pain as needed. Subjects completed a daily diary regarding their pain, nausea, vomiting, diet, and activity.. Seventeen subjects enrolled. Intraoperative blood loss was similar between groups, and no subject had postoperative bleeding. Three patients returned to the emergency department for treatment, and 2 patients could not complete the diaries, all in the placebo group. Subjects in the placebo group required statistically significant (P < .05) higher doses of narcotic and acetaminophen to control pain. Pain and diet rating scores were slightly better in the celecoxib group compared to placebo.. In this small cohort, celecoxib reduced postoperative narcotic and acetaminophen requirements compared to placebo without complications.

Topics: Acetaminophen; Adult; Analgesics, Non-Narcotic; Analgesics, Opioid; Celecoxib; Chronic Disease; Cyclooxygenase 2 Inhibitors; Double-Blind Method; Drug Combinations; Female; Humans; Hydrocodone; Male; Pain Management; Pain Measurement; Pain, Postoperative; Prospective Studies; Recurrence; Tonsillectomy; Tonsillitis; Young Adult

This multicenter, randomized, double-blind, placebo-controlled study with an enriched enrollment, randomized withdrawal design was conducted to evaluate the analgesic efficacy and safety of single-entity, once-daily hydrocodone 20 to 120 mg tablets (HYD) in opioid-naive and opioid-experienced patients with uncontrolled moderate to severe chronic low back pain (CLBP).. The primary endpoint was week 12 pain intensity scores (11-point scale, 0 = no pain) using a mixed effect model with repeated measures incorporating a pattern mixture model framework. Responder analysis was a secondary endpoint. Safety was assessed.. Out of 905 patients who were treated with HYD during the open-label titration period, 588 (65%) were randomized to continue to receive HYD (n = 296, 20 - 120 mg taken once daily, average daily dose 57 mg) or a matching placebo (n = 292). HYD demonstrated superior pain reduction (p = 0.0016); this result was supported by sensitivity analyses using different approaches to handling missing data. Proportions of patients achieving ≥ 30 and ≥ 50% improvement in pain from screening to week 12 also favored HYD (p = 0.0033 and 0.0225, respectively). HYD was generally well tolerated.. HYD was shown to be an efficacious treatment for CLBP in this study. There were no new or unexpected safety concerns detected.

Topics: Adult; Analgesics, Opioid; Chronic Disease; Double-Blind Method; Female; Humans; Hydrocodone; Low Back Pain; Male; Middle Aged; Tablets; Treatment Outcome

Abuse liability is thought to possibly be lower in long- than in short-acting opioids because lower peak serum levels may be less likely to induce psychoactive effects.. We compared patient responses to extended-release morphine, hydrocodone plus acetaminophen, and placebo in a randomized, double-blind crossover study using markers of abuse liability. Patients indicated their craving for drugs on 5 visual analog scales (VASs), completed the Addiction Research Center Inventory, and underwent cue reactivity testing. To perform the latter, subjects watched a video intended to produce a positive or a negative affect, after which a vial of medication was or was not presented (the cue) and then indicated their craving for drugs on 5 different VASs (the reactivity).. Differences in Addiction Research Inventory scores were statistically significant but clinically unimportant. Neuropsychological test results were mixed and unrelated to the medications studied. Cue reactivity did not differ among conditions but was uniformly high.. Using several markers of abuse liability, long-acting opioids do not have lower abuse potential than do short-acting opioids or placebo. Although cue reactivity did not differ among the conditions, uniformly high results in these patients suggest that it may have some value as a component of abuse liability testing.

Topics: Adult; Analgesics, Opioid; Behavior, Addictive; Chronic Disease; Conscious Sedation; Cross-Over Studies; Cues; Double-Blind Method; Female; Humans; Hydrocodone; Male; Middle Aged; Morphine; Opioid-Related Disorders; Pain; Self Administration; Stress, Physiological; Substance Abuse Detection; Surveys and Questionnaires; Time Factors

Nicotine is reported to have analgesic properties. Patients with chronic pain who smoke could therefore, be expected to require less analgesia than non-smokers because of the possible synergism of the two substances. One hundred healthy patients were studied who had non-radicular low back pain for greater than three months. Each patient failed conservative therapies, which consisted of muscle relaxants, physical therapy and/or NSAIDS. Our study population consisted of two groups of 50 patients. Each group included: I, cigarette smokers; and II, non-smokers. Each patient received 0-40 mg/24hrs of hydrocodone as needed for pain relief for the duration of this four week study. Numeric pain intensity scores (0-10), mean total hydrocodone dosing, and quantitative blood nicotine and hydrocodone levels were assessed at the beginning and end of this study. Patients kept daily diaries and recorded pain scores and self hydrocodone dosing upon awakening, in the afternoon, and at bed time. Parametric and nonparametric statistical analysis was performed using the appropriate test with p < or = 0.05 necessary to reject the null hypothesis There were no differences in demographics between the two groups. Smokers had higher end of study pain scores and required more hydrocodone than non-smokers but had significantly lower serum levels of hydrocodone than non-smokers. The results of this study suggest that cigarette smoking adversely affects serum hydrocodone levels. Prescribing physicians should be aware that in some cigarette smokers, serum hydrocodone levels might not be detectible.

Topics: Adult; Analgesics, Opioid; Chronic Disease; Dipyrone; Female; Humans; Hydrocodone; Low Back Pain; Male; Middle Aged; Nicotine; Pain Measurement; Smoking

Concern about abuse/dependence in chronic pain patients taking opioid analgesics may lead to undertreatment of pain, yet little is known about the prevalence of abuse/dependence in these patients and how it differs among analgesic agents. The objective of this study was to assess the prevalence of tramadol abuse compared to nonsteroidal anti-inflammatory drugs (NSAIDs) and hydrocodone-containing analgesics in patients with chronic noncancer pain (CNP). The study had three arms. The first arm consisted of subjects prescribed tramadol alone; the second of subjects randomized to either NSAIDs or tramadol; and the third of subjects randomized to hydrocodone or tramadol. Each investigator received two boxes of prescriptions randomized so that one in every four prescriptions was for tramadol. Upon deciding on the therapeutically appropriate arm, the physician selected the appropriate box, opened the next envelope and completed the enclosed prescription. After the initial randomization, physicians could prescribe whatever medication was therapeutically appropriate. A total of 11,352 subjects were enrolled. Up to nine interviews using a structured questionnaire were conducted over a 12-month period. An algorithm called the "Abuse Index" was developed to identify subjects who were abusing the drug. The primary components of the index were increasing dose without physician approval, use for purposes other than intended, inability to stop its use, and withdrawal. The percent of subjects who scored positive for abuse at least once during the 12-month follow-up were 2.5% for NSAIDs, 2.7% for tramadol, and 4.9% for hydrocodone. When more than one hit on the algorithm was used as a measure of persistence, abuse rates were 0.5% for NSAIDs, 0.7% for tramadol, and 1.2% for hydrocodone. Thus, the results of this study suggest that the prevalence of abuse/dependence over a 12-month period in a CNP population that was primarily female was equivalent for tramadol and NSAIDs, with both significantly less than the rate for hydrocodone.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Anti-Inflammatory Agents, Non-Steroidal; Chronic Disease; Female; Humans; Hydrocodone; Male; Middle Aged; Pain; Prevalence; Substance-Related Disorders; Tramadol

The objective of this study was to compare the effectiveness of combination hydrocodone 7.5 mg and ibuprofen 200 mg with that of combination codeine 30 mg and acetaminophen 300 mg for the treatment of chronic pain.. Hydrocodone 7.5 mg with ibuprofen 200 mg is the only approved fixed-dose combination analgesic containing an opioid and ibuprofen.. In this randomized, parallel-group, double-blind, repeated-dose, active-comparator, 4-week, multicenter study, 469 patients were randomly assigned to receive a 1-tablet (n = 156) or 2-tablet (n = 153) dose of combination hydrocodone 7.5 mg and ibuprofen 200 mg (HI1 and HI2, respectively) or a 2-tablet dose of combination codeine 30 mg and acetaminophen 300 mg (CA, n = 160), the active comparator, every 6 to 8 hours as needed for pain. Efficacy was measured through pain relief scores, number of daily doses of study medication, number of daily doses of supplemental analgesics, number of patients who discontinued therapy due to an unsatisfactory analgesic response, and global assessment scores.. Of the 469 patients, 255 (54.4%) were female and 214 (45.6%) were male. The mean age was 51.1 years. Types of chronic pain included back (214; 45.6%), arthritic (145; 30.9%), other musculoskeletal (65; 13.9%), cancer (6; 1.3%), diabetic neuropathic (3; 0.6%), postherpetic neuralgic (5; 1.1%), other neurologic (21; 4.5%), and other unclassified chronic pain (10; 2.1%). During the 48 hours prior to the study, 351 (74.8%) patients had been treated with opioid or opioid-nonopioid combination analgesics. The overall mean daily pain relief score was significantly greater in the HI2 group (2.25+/-0.89) than in the HI1 group (1.98+/-0.87) (P = 0.003) or the CA group (1.85+/-0.96) (P < 0.001). The overall mean number of daily doses of study medication was significantly less in the HI2 group (2.94+/-0.99) than in the HI1 group (3.23+/-0.76) (P = 0.036) or the CA group (3.26+/-0.75) (P = 0.014). The overall mean number of daily doses of supplemental analgesics was significantly less in the HI2 group (0.24+/-0.49) than in the HI1 group (0.34+/-0.58) (P = 0.021) or CA group (0.49+/-0.85) (P = 0.010). The number of patients who discontinued treatment due to an unsatisfactory analgesic response was significantly less in the HI2 group (2; 1.3%) than in the CA group (12; 7.5%) (P = 0.008). HI2 was more effective than HI1 and CA as measured by pain relief scores for week 1 (P < 0.001 vs HI1 and CA), week 2 (P < 0.001 vs HI1 and CA), and week 3 (P = 0.008 vs HI1 and P < 0.001 vs CA); daily doses of study medication for week 1 (P = 0.019 vs HI1 and P = 0.011 vs CA); daily doses of supplemental analgesics for week 1 (P = 0.010 vs HI1 and CA); and global assessment scores for week 1 (P = 0.018 vs HI1 and P < 0.001 vs CA), week 2 (P = 0.005 vs HI1 and P < 0.001 vs CA), and week 4 (P = 0.013 vs HI1 and P = 0.023 vs CA). There were no significant differences between HI1 and CA in any efficacy variable. There were no significant differences in the number of patients experiencing adverse events in the HI2 (127; 83%), HI1 (124; 79.5%), and CA (129; 80.6%) groups. However, the mean number of patients who discontinued treatment due to adverse events was significantly greater in the HI2 group (40; 26.1%) than in the HI1 group (23; 14.7%) (P = 0.013).. The results of this study suggest that 2-tablet doses of combination hydrocodone 7.5 mg and ibuprofen 200 mg may be more effective than either 1-tablet doses of this combination or 2-tablet doses of combination codeine 30 mg and acetaminophen 300 mg. Moreover, 1-tablet doses of combination hydrocodone 7.5 mg and ibuprofen 200 mg may be as effective as 2-tablet doses of combination codeine 30 mg and acetaminophen 300 mg.

Topics: Acetaminophen; Adult; Aged; Analgesics; Chronic Disease; Codeine; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Hydrocodone; Ibuprofen; Male; Middle Aged; Pain; Pain Measurement; Placebos

Topics: Acetaminophen; Administration, Cutaneous; Adult; Analgesics; Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthesia, Spinal; Back Pain; Chronic Disease; Clonazepam; Clonidine; Female; Fentanyl; GABA Modulators; Granuloma; Humans; Hydrocodone; Infusion Pumps, Implantable; Magnetic Resonance Imaging; Morphine; Opioid-Related Disorders; Vertebroplasty

Topics: Adult; Analgesics, Opioid; Chronic Disease; Female; Humans; Hydrocodone; Male; Middle Aged; Oxycodone; Pain

Topics: Acetaminophen; Adult; Amines; Analgesics, Non-Narcotic; Analgesics, Opioid; Anti-Anxiety Agents; Chronic Disease; Continuity of Patient Care; Cyclohexanecarboxylic Acids; Diagnosis, Differential; Drug Therapy, Combination; Endometriosis; Female; Gabapentin; gamma-Aminobutyric Acid; Humans; Hydrocodone; Hypoglycemic Agents; Interdisciplinary Communication; Pelvic Pain; Risk Factors; Rosiglitazone; Substance-Related Disorders; Thiazolidinediones; Trazodone; Uterine Cervical Dysplasia; Uterine Cervical Neoplasms

A visual analogue scale (VAS) and a 4-point scale (FPS) have been compared in patients suffering from prolonged constant pain due to chronic inflammatory or degenerative arthropathy. Each patient was treated with a constant low or high dose of paracetamol or dihydrocodeine throughout a four week period. The VAS was accurate, as reliable and more sensitive than the FPS in registering the intensity of chronic pain. Separate records of each estimate, sealed immediately on completion by the patient, resulted in omission of significantly more pain recordings on the FPS, whereas retention by the patients of their previous records did not systematically influence subsequent judgments. In this study, the VAS appeared to be more satisfactory than the FPS for patient self-rating of pain intensity.

Topics: Acetaminophen; Chronic Disease; Dose-Response Relationship, Drug; Female; Humans; Hydrocodone; Male; Pain

Topics: Chronic Disease; Codeine; Hydrocodone; Lung Diseases