Opioid Balancing Act: Measuring Benefits of Medication Therapy against Potential Abuse

Medication therapy for all conditions is a balancing act. Pharmacological treatments that don’t involve any concern whatsoever about adverse effects are like unicorns: able to be imagined, never to be found. But the balancing act is particularly acute for pain management professionals. First, pain is a global epidemic, impacting global productivity and quality of life for millions of people. Second, beyond adverse events, opioid analgesics in particular come with the ever-present possibility of abuse, dependence, addiction, and diversion.

Opioid prescribing and consumption has exploded in recent years in the United States, but public health concerns are among the many factors that have contributed to the lack of opioid use in many other countries. A new study in ActaAnaesthesiologica Taiwanica points out that in Taiwan, a survey of community-dwelling senior citizens in Taiwan revealed a pain prevalence of 50%, and a Taipei study found that 42% of seniors suffered chronic pain. Yet most simply don’t have access to opioid therapy.

The ActaAnaesthesiologica Taiwanica study looked at the potential for the opioid analgesic buprenorphine to counteract some of these concerns. Buprenorphine, of course, is far from a novel medication, it has been in use for pain patients for three decades. But as the study authors note, buprenorphine has a unique pharmacology with immediately obvious therapeutic applications as an analgesic of low abuse potential, and a long history of clinical support.*

The review includes a table with the collected clinical evidence showing demonstrated safety and effectiveness of buprenorphine. But it also discusses the mechanism of action for buprenorphine: because it is primarily excreted through the feces and does not accumulate in the body, it is suitable for patients with compromised renal function.

The American Geriatric Society recommends that opioids should be the first-line treatment for chronic pain, because of the gastrointestinal and cardiovascular side effects that are prevalent with NSAIDS. Buprenorphine, the study authors point out, “does not accumulate in the system and dosing adjustments need not be made for those with slower metabolisms or renal failure…In contrast to morphine and other opioid agents, the pharmacokinetics of buprenorphine remain unchanged in hemodialysis patients. Thus, buprenorphine may be considered one of the safest opioid analgesics for use in patients in renal failure or on dialysis.” The review also looks at the relatively benign adverse event profile associated with buprenorphine.

Much of the review is spent discussing the potential—or lack thereof—for potential for buprenorphine abuse. “In general,” the study authors note, “people who use opioids prefer substances with a rapid onset of action that reach peak plasma concentration quickly. Substance likeability is often used to measure its potential for nonmedical use and reward-reinforcing effects.”

Transdermal buprenorphine can discourage tampering used to extract as much opioid as possible, because it cannot be from the patch matrix directly with a needle and syringe. Thus, successfully extracting the active agent from the patch matrix in sufficient quantities is complex and time-consuming. “In summary, other full agonist opioids are more desirable for nonmedical misuse, and other formulations of opioids are more attractive and less challenging to misuse than the transdermal formulation of buprenorphine,” the study authors conclude.

* NOTE:(Buprenorphine is manufactured in the United States by Purdue Pharma, under the brand name Butrans; several of the study authors are employed by or have received funding from divisions of Purdue Pharma.)