Immediate release opioids for pain control are a poorer choice than extended release

“I want to share my understanding of better ways to control pain with opioids. My comment here is not putting the post below in perspective, but a chance to share what I learned controlling acute and chronic pain by prescribing opioid medications. My comments are not research, just experience.

Immediate release (IR) opioids for pain control are the poorer choice when extended release (ER) forms of the same medication exist. The extended release drugs have a lower and slower rise in maximum blood level, do not have a trough of inadequate dose level and do not have frequency and severity of personality impairments seen with immediate-release medications. The lack of personality changes is with ER medications prescribed at drug levels controlling the pain adequately. The same degree of pain control with an IR drug can have personality changes. The personality side effects are especially concerning in co-morbidities such as depression. Ten percent of Americans studied have depression, often don’t get treatment, and are at risk for depressive exacerbations on pain control medication.

 Examples of ER medications that have been approved and used extensively are tramadol, both IR and ER, hydrocodone, both IR and ER, oxycodone IR and ER. The costs of the ER form is higher than IR of the same drug. Buprenorphine, Butrans, is available in an extended release patch that lasts a week.

 There are two factors that have delayed the more common use of ER opioids. First is the first formulations of ER drugs could be altered and injected by drug abusers. The new ER formulations are much harder to inject. They cannot be crushed by common methods using. They don’t dissolve to inject the drug intravenously and similar. The second factor is that the prescriber must create and submit a “prior authorization” form before you can get the ER medication. There are free software that makes obtaining the “prior auth” a matter of only a few keyboard clicks, if your provider uses them. I find using the software for prior authorizations and the software to look up your insurance drug formulary is efficient. It’s more work and time to get the ER form of an opioid than prescribing the IR form of the same drug.“ Bill Chesnut, MD.

To go back to New Health News:

 Leading the News  AMA Morning Rounds 3.23.2016.    FDA to update warning for immediate-release opioids

The Washington Post (3/22, Bernstein) reports in “To Your Health” that the Food and Drug Administration announced that “it will require new warnings about the risk of addiction, abuse, overdose and death for short-acting opioid pain medications.” The boxed warning for immediate-release opioids “also will warn of the danger that chronic use of the drugs by pregnant women can result in…Neonatal Opioid Withdrawal Syndrome” in newborns. The new warnings “will emphasize that immediate-release opioids should be a last resort for severe pain.”

The New York Times (3/22, A13, Tavernise, Subscription Publication) reports that “the new labels also include ‘clearer instructions’ for directions like initial drug dose and dose changes during therapy.”