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Rather, the use of other highly potent opioids also seems to be attended by an increased risk of death from overdose In contrast, the authors of a study published in perceived no connection between increasing medical consumption of opioids and abuse Independently of the discussion of opioid-associated deaths, elderly patients in particular are at greater danger of fractures while taking opioids. The fracture risk seems to differ among the various opioids; it appears to be greatest at the beginning of the treatment period, at higher doses, and with immediate release opioids 30 — The sharp rise we observed in the prescription volume of extended release preparations—especially of fentanyl—has also been described in other countries 5 , 14 , e Various publications have drawn attention to the failure to follow guidelines for the prescription of fentanyl 17 , 33 , e According to the current recommendation of the Drug Commission of the German Medical Association, against the backdrop of a recently published study, prescription of transdermal fentanyl as the first opioid should be avoided if at all possible 33 , The developments in prescription of immediate release preparations have to be viewed critically.

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Pharmaceuticals characterized by rapid pharmacokinetics and swift delivery to the CNS have increased addictive potential Because of their suspected negative effects, opioids in general are subject to a risk minimization program initiated by the FDA It currently remains unclear whether the introduction of additional products into the market leads to an increase in prescription volume or whether new active substances or forms of application displace existing preparations.

The short period of observation following the market entry of new preparations of fentanyl has shown a steep rise in prescription of fentanyl since while prescription of immediate release morphine has remained stable. Looking at international trends, particularly with regard to the increasing use of so-called rapid-onset opioids principally various preparations of fentanyl , undesirable developments can be discerned.

Our own data—showing doubling of the treatment prevalence of immediate release WHO step 3 opioids in opioid recipients with CNP eTable —go some way towards demonstrating this trend in Germany. The use of immediate release fentanyl for indications other than cancer pain is especially controversial 38 , 39 , e20 — e Furthermore, there are already early signs that the use of these substances can lead to symptoms of addiction, not only in cancer patients—i. The patients whose data we analyzed were all from the same region of Germany and all had the same form of health insurance.

Differences in age structure and sex ratio between our sample and the German general population were taken into account. We believe our data are robust, however, because the AOK insures approximately one quarter of the population of Hesse and because global parameters such as the change in total prescribed daily doses are comparable with the data in the Drug Prescription Report, which covers all types of health insurance provider eSupplement. The database contains no information on hospital treatment, private prescriptions, or the reason for prescription.

We cannot exclude the possibility that opioid recipients with a diagnosis of cancer may have been prescribed opioids for relief of non-cancer-related pain. In dividing the patients between the two groups cancer disease and CNP we adopted a conservative approach to the assessment of prescription for non-cancer pain, so we may have overestimated the number of prescriptions for cancer pain. The strengths of the database are that it permits observation of long-term developments and that the data are complete.

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There is no selection, no drop-out, and no recall or interviewer bias. We were able to improve the interpretability of the findings by differentiating between prescriptions for cancer and non-cancer disease, thus satisfying an oft-stated demand Opioids form an important element of medicinal pain treatment. Underuse of opioids can result in inadequate pain relief. Uncritical prescription may be hazardous, however, possibly even leading to abuse and addiction.

Our analysis shows that opioids are being used principally for treatment of non-cancer pain. An increase in total prescribed daily doses of opioids thus by no means permits the conclusion that cancer patients are being adequately supplied with opioids 1. Furthermore, the findings we present intensification of opioid treatment in CNP patients, increasing long-term treatment, high proportion of immediate release opioids in CNP patients point to possible shortcomings in the care of patients with CNP. Particularly in light of the potential risks involved, a close eye needs to be kept on the developments in opioid treatment.

Sabatowski has acted as consultant for Cephalon and Janssen-Cilag. Manuscript received on 3 July , revised version accepted on 17 October Corresponding author Dr. Schubert uk-koeln. For eReferences please refer to: www.

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Enlarge All figures. In: Schwabe U, Paffrath D eds. Arzneiverordnungs-Report Berlin, Heidelberg: Springer Verlag ; — J Pain Symptom Manage ; — Internal Med J ; — Eur J Pain ; — Eur J Clin Pharmacol ; —8. Cochrane Database of Systematic Reviews , Issue 3. Cochrane Database of Systematic Reviews , Issue 1. Breivik H: Opioids in chronic non-cancer pain, indications and controversies.

Eur J Pain ; 9: — Eur J Pain ; 7: —6. Dtsch Arztebl ; 99 33 : A —5. Ein Beitrag zur Diskussion um ein weitverbreitetes Arzneimittel. Gesundheitswesen aktuell Higher increases as fentanyl replaces morphine. Eur J Clin Pharmacol, ; —5. J Pain Palliat Care Pharmacother ; — Ann Oncol ; — CMAJ ; —6.

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J Anal Toxicol ; — JAMA ; — BMJ ; JAMA ; —7. Fischer B, Argento E: Prescription opioid related misuse, harms, diversion and interventions in Canada: a review. Pain Physician ; ES— Gudin JA: Clinical strategies for the primary health care professional to minimize prescription opioid abuse. Postgrad Med ; —8. Inj Prev ; —9. Centers for Disease Control and Prevention. Drug overdose deaths — Florida, — Morb Mortal Wkly Rep ; — Ann Intern Med ; 85— Pain Medicine ; 87— J Am Geriatr Soc ; —8. Arch Intern Med ; — J Gen Intern Med , —5.

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Pharmacoepidemiol Drug Saf ; —8. Dtsch Arztebl ; 14 : A Pharmacoepidemiol Drug Saf ; —3. Trends Pharmacol Sci ; 82—7. J Fam Pract ; 60, Suppl 2: S55— Nalamachu SR, Narayana A, Janka L: Long-term dosing, safety, and tolerability of fentanyl buccal tablet in the management of noncancer-related breakthrough pain in opioid-tolerant patients. Curr Med Res Opin ; — Passik SD, Messina J, Golsorkhi A, Xie F: Abberant drug-related behavior observed during clinical studies involving patients taking chronic opioid therapy for persistent pain and fentanyl buccal tablet for breakthrough pain.

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Curr Pharm Des ; — Schmerz ; — Analysis of outpatient care of pain patients insured with the AOK. Schmerz —9. Lister BJ: Dilemmas in the treatment of chronic pain. Am J Med ; 2S—5S. J Pain Palliat Care Pharmacother ; —9.


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