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Chronische nichttumorbedingte Schmerzen

Langzeitbehandlung mit schnell freisetzenden und kurz wirksamen Opioiden im Kontext von Missbrauch und Abhängigkeit

Chronic non-cancer-related pain

Long-term treatment with rapid-release and short-acting opioids in the context of misuse and dependency

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Zusammenfassung

Die jährlich veröffentlichten Daten zur Arzneimittelverordnung in Deutschland zeigen eine kontinuierliche Steigerung des Verordnungsvolumens im Bereich der Opioidanalgetika. Dies lässt auf eine Intensivierung der Opioidtherapie schließen. Der Hauptanteil der Verordnungen entfällt dabei auf die Therapie chronischer nichttumorbedingter Schmerzen. Vor dem Hintergrund aktueller Leitlinienempfehlungen sowie fehlender Daten zur Langzeitanwendung und -wirksamkeit der Substanzen über einen Zeitraum von 3 Monaten hinaus ist diese Entwicklung kritisch zu betrachten. In der vorliegenden Arbeit wird anhand einer Diskussion von 4 Fallbeispielen insbesondere der unserer Ansicht nach problematische Einsatz kurz wirksamer und schnell freisetzender Darreichungsformen vor dem Hintergrund der Entwicklung eines Medikamentenfehlgebrauchs oder einer Abhängigkeit kritisch bewertet.

Abstract

Annually published data show a continual increase in the volume of opioid prescriptions in Germany, thus indicating an intensification of opioid therapy. The majority of opioids are prescribed to treat chronic non-cancer-related pain. On the basis of current guidelines, as well as in terms of the lack of data regarding long-term use of opioids and their effectiveness beyond a period of 3 months, this development must be viewed critically. With reference to four case reports, we discuss and evaluate opioid therapy in relation to medication misuse and the development of drug dependency. Particular emphasis is placed on the administration of rapid-release and short-acting opioid preparations, which we consider to be particularly problematic. A full-text English version of the article is available.

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Literatur

  1. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) (2012) Langzeitanwendung von Opioiden bei nicht-tumorbedingten Schmerzen (LONTS). http://www.awmf.org/uploads/tx_szleitlinien/041-003l.pdf. Zugegriffen: 6. Juli 2012

  2. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) (2010) Medikamentenabhängigkeit (Sedativa-Hypnotika, Analgetika, Psychostimulantien). http://www.awmf.org/uploads/tx_szleitlinien/076-009_S2_Medikamentenabhaengigkeit_05-2006_05-2011.pdf. Zugegriffen: 18. Oktober 2010

  3. Arzneimittelkommission der deutschen Ärzteschaft (2012) Abhängigkeitspotenzial von Pregabalin (Lyrica®) (Aus der UAW-Datenbank). http://www.akdae.de/Arzneimittelsicherheit/Bekanntgaben/Archiv/2011/20110128.html. Zugegriffen: 5. September 2012

  4. Ashburn MA, Slevin KA, Messina J, Xie F (2011) The efficacy and safety of fentanyl buccal tablet compared with immediate-release oxycodone for the management of breakthrough pain in opioid-tolerant patients with chronic pain. Anesth Analg 112:693–702

    Article  PubMed  CAS  Google Scholar 

  5. Ballantyne JC, LaForge KS (2007) Opioid dependence and addiction during opioid treatment of chronic pain. Pain 129:235–255

    Article  PubMed  CAS  Google Scholar 

  6. Bell J (2010) The global diversion of pharmaceutical drugs: opiate treatment and the diversion of pharmaceutical opiates: a clinician’s perspective. Addiction 105:1531–1537

    Article  PubMed  Google Scholar 

  7. Bohnert AS, Valenstein M, Bair MJ et al (2011) Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 305:1315–1321

    Article  PubMed  CAS  Google Scholar 

  8. Bradshaw DH, Empy C, Davis P, Lipschitz D et al (2008) Trends in funding for research on pain: a report on the National Institutes Of Health grant awards over the years 2003–2007. J Pain 9:1077–1087

    Google Scholar 

  9. Bundesinstitut für Arzneimittel und Medizinprodukte (2012) Sachverständigenausschuss für Betäubungsmittel. http://www.bfarm.de/DE/Bundesopiumstelle/BtM/sachverst/Protokolle/Ergebnisse_38.html. Zugegriffen: 22. August 2012

  10. Caraceni A, Hanks G, Kaasa S et al (2012) Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 13:e58–e68

    Article  PubMed  CAS  Google Scholar 

  11. Caraceni A, Pigni A, Brunelli C (2011) Is oral morphine still the first choice opioid for moderate to severe cancer pain? A systematic review within the European Palliative Care Research Collaborative guidelines project. Palliat Med 25:402–409

    Article  PubMed  Google Scholar 

  12. Chapman CR, Lipschitz DL, Angst MS et al (2010) Opioid pharmacotherapy for chronic non-cancer pain in the United States: a research guideline for developing an evidence-base. J Pain 11:807–829

    Google Scholar 

  13. Chou R (2010) What we still don’t know about treating chronic noncancer pain with opioids. CMAJ 182:881–882

    Article  PubMed  Google Scholar 

  14. Chou R, Ballantyne JC, Fanciullo GJ et al (2009) Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 10:147–159

    Google Scholar 

  15. Chou R, Clark E, Helfand M (2003) Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review. J Pain Symptom Manage 26:1026–1048

    Google Scholar 

  16. Chou R, Fanciullo GJ, Fine PG et al (2009) Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 10:113–130

    Google Scholar 

  17. Chou R, Fanciullo GJ, Fine PG et al (2009) Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 10:131–146

    Google Scholar 

  18. Cicero TJ, Lynskey M, Todorov A et al (2008) Co-morbid pain and psychopathology in males and females admitted to treatment for opioid analgesic abuse. Pain 139:127–135

    Article  PubMed  Google Scholar 

  19. Compton WM, Volkow ND (2006) Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend 81:103–107

    Article  PubMed  Google Scholar 

  20. Davies AN, Dickman A, Reid C et al (2009) The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain 13:331–338

    Article  PubMed  Google Scholar 

  21. Deutsche Hauptstelle für Suchtfragen e. V. (Hrsg) (2012) Jahrbuch Sucht 2012. Pabst Science, Lengerich

  22. Dhalla IA, Mamdani MM, Sivilotti ML et al (2009) Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ 181:891–896

    Article  PubMed  Google Scholar 

  23. Dhalla IA, Persaud N, Juurlink DN (2011) Facing up to the prescription opioid crisis. BMJ 343:d5142. DOI: 10.1136/bmj.d5142.:d5142

    Article  PubMed  Google Scholar 

  24. Dilling H, Freyberger HJ (Hrsg) (2008) Taschenführer zur ICD-10-Klassifikation psychischer Störungen. Huber, Bern

  25. DIMDI (Hrsg) (2012) ICD-10-GM 2012 Systematisches Verzeichnis. Deutscher Ärzte-Verlag, Köln

  26. Dunn KM, Saunders KW, Rutter CM et al (2010) Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 152:85–92

    PubMed  Google Scholar 

  27. Edlund MJ, Sullivan M, Steffick D et al (2007) Do users of regularly prescribed opioids have higher rates of substance use problems than nonusers? Pain Med 8:647–656

    Article  PubMed  Google Scholar 

  28. Farrar JT, Messina J, Xie F, Portenoy RK (2010) A novel 12-week study, with three randomized, double-blind placebo-controlled periods to evaluate fentanyl buccal tablets for the relief of breakthrough pain in opioid-tolerant patients with noncancer-related chronic pain. Pain Med 11:1313–1327

    Article  PubMed  Google Scholar 

  29. Fine PG, Mahajan G, McPherson ML (2009) Long-acting opioids and short-acting opioids: appropriate use in chronic pain management. Pain Med 10(Suppl 2):S79–88

    Article  PubMed  Google Scholar 

  30. Fine PG, Messina J, Xie F et al (2010) Long-term safety and tolerability of fentanyl buccal tablet for the treatment of breakthrough pain in opioid-tolerant patients with chronic pain: an 18-month study. J Pain Symptom Manage 40:747–760

    Google Scholar 

  31. Fine PG, Narayana A, Passik SD (2010) Treatment of breakthrough pain with fentanyl buccal tablet in opioid-tolerant patients with chronic pain: appropriate patient selection and management. Pain Med 11:1024–1036

    Article  PubMed  Google Scholar 

  32. Fishbain DA, Cole B, Lewis J et al (2008) What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med 9:444–459

    Article  PubMed  Google Scholar 

  33. Fleming MF, Balousek SL, Klessig CL et al (2007) Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain 8:573–582

    Google Scholar 

  34. Furlan AD, Reardon R, Weppler C (2010) Opioids for chronic noncancer pain: a new Canadian practice guideline. CMAJ 182:923–930

    Article  PubMed  Google Scholar 

  35. Gilson AM, Kreis PG (2009) The burden of the nonmedical use of prescription opioid analgesics. Pain Med 10(Suppl 2):S89–100

    Article  PubMed  Google Scholar 

  36. Gomes T, Juurlink DN, Dhalla IA et al (2011) Trends in opioid use and dosing among socio-economically disadvantaged patients. Open Med 5:e13–e22

    PubMed  Google Scholar 

  37. Hamunen K, Paakkari P, Kalso E (2009) Trends in opioid consumption in the Nordic countries 2002–2006. Eur J Pain 13:954–962

    Article  PubMed  Google Scholar 

  38. Hyman SE, Malenka RC, Nestler EJ (2006) Neural mechanisms of addiction: the role of reward-related learning and memory. Annu Rev Neurosci 29:565–598

    Article  PubMed  CAS  Google Scholar 

  39. Ives TJ, Chelminski PR, Hammett-Stabler CA et al (2006) Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res 6:46

    Article  PubMed  Google Scholar 

  40. Jage J (2005) Opioid tolerance and dependence—do they matter? Eur J Pain 9:157–162

    Article  PubMed  CAS  Google Scholar 

  41. Koob GF, Ahmed SH, Boutrel B et al (2004) Neurobiological mechanisms in the transition from drug use to drug dependence. Neurosci Biobehav Rev 27:739–749

    Article  PubMed  CAS  Google Scholar 

  42. Landesapothekenkammer Baden-Würtemberg (2012) http://www.lak-bw.de/infocenter/apothekenpraxis/vorsicht-gefaelschte-rezepte.html. Zugegriffen: 17. Oktober 2012

  43. Maier C (2008) Auch Sucht ist eine Krankheit. Schmerz 22:639–643

    Article  PubMed  CAS  Google Scholar 

  44. Manchikanti L, Fellows B, Ailinani H et al (2010) Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician 13:401–435

    PubMed  Google Scholar 

  45. Manchikanti L, Manchukonda R, Damron KS et al (2006) Does adherence monitoring reduce controlled substance abuse in chronic pain patients? Pain Physician 9:57–60

    PubMed  Google Scholar 

  46. Markman JD (2008) Not so fast: the reformulation of fentanyl and breakthrough chronic non-cancer pain. Pain 136:227–229

    Article  PubMed  CAS  Google Scholar 

  47. Martell BA, O’Connor PG, Kerns RD et al (2007) Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 146:116–127

    PubMed  Google Scholar 

  48. McLellan AT, Turner BJ (2010) Chronic noncancer pain management and opioid overdose: time to change prescribing practices. Ann Intern Med 152:123–124

    PubMed  Google Scholar 

  49. Bundesärztekammer in Zusammenarbeit mit der Arzneimittelkommission der deutschen Ärzteschaft (Hrsg) (o J) Medikamente – schädlicher Gebrauch und Abhängigkeit. Leitfaden für die ärztliche Praxis. http://www.bundesaerztekammer.de/downloads/LeitfadenMedAbhaengigkeit.pdf. Zugegriffen: 6. Juli 2012

  50. Mercadante S, Radbruch L, Caraceni A et al (2002) Episodic (breakthrough) pain: consensus conference of an expert working group of the European Association for Palliative Care. Cancer 94:832–839

    Article  PubMed  Google Scholar 

  51. Michna E, Ross EL, Hynes WL et al (2004) Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage 28:250–258

    Google Scholar 

  52. Noble M, Treadwell JR, Tregear SJ et al (2010) Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev:CD006605

    Google Scholar 

  53. Okie S (2010) A flood of opioids, a rising tide of deaths. N Engl J Med 363:1981–1985

    Google Scholar 

  54. Pabst A, Piontek D, Kraus L, Müller S (2010) Substanzkonsum und substanzbezogene Störungen. Ergebnisse des Epidemiologischen Suchtsurveys 2009. Sucht 56:327–336

    Article  Google Scholar 

  55. Passik SD (2009) Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc 84:593–601

    PubMed  Google Scholar 

  56. Passik SD, Hays L, Eisner N et al (2006) Psychiatric and pain characteristics of prescription drug abusers entering drug rehabilitation. J Pain Palliat Care Pharmacother 20:5–13

    Google Scholar 

  57. Passik SD, Messina J, Golsorkhi A et al (2011) Aberrant drug-related behavior observed during clinical studies involving patients taking chronic opioid therapy for persistent pain and fentanyl buccal tablet for breakthrough pain. J Pain Symptom Manage 41:116–125

    Google Scholar 

  58. Porada S (2011) REMS; red tape, or a remedy for opioid abuse? J Fam Pract 60:S55–S62

    Google Scholar 

  59. Portenoy RK, Bennett DS, Rauck R et al (2006) Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain. J Pain 7:583–591

    Google Scholar 

  60. Portenoy RK, Messina J, Xie F et al (2007) Fentanyl buccal tablet (FBT) for relief of breakthrough pain in opioid-treated patients with chronic low back pain: a randomized, placebo-controlled study. Curr Med Res Opin 23:223–233

    Article  PubMed  CAS  Google Scholar 

  61. Reinecke H, Sorgatz H (2009) S3-Leitlinie LONTS. Langzeitanwendung von Opioiden bei nicht tumorbedingten Schmerzen. Schmerz 23:440–447

    Article  PubMed  CAS  Google Scholar 

  62. Roset PN, Farre M, de la Torre R et al (2001) Modulation of rate of onset and intensity of drug effects reduces abuse potential in healthy males. Drug Alcohol Depend 64:285–298

    Article  PubMed  CAS  Google Scholar 

  63. Sabatowski R (2012) Critical issues in cancer pain management. Pain Manage 2:201–204

    Article  Google Scholar 

  64. Samaha AN, Robinson TE (2005) Why does the rapid delivery of drugs to the brain promote addiction? Trends Pharmacol Sci 26:82–87

    Article  PubMed  CAS  Google Scholar 

  65. Savage SR, Joranson DE, Covington EC et al (2003) Definitions related to the medical use of opioids: evolution towards universal agreement. J Pain Symptom Manage 26:655–667

    Google Scholar 

  66. Schubert I, Ihle P, Sabatowski R (2012) Zunahme der Opioidverordnungen in Deutschland zwischen 2000 und 2010. Eine Studie auf Basis von Krankenkassendaten. Dtsch Arztebl Int (im Druck)

  67. Schwabe U, Paffrath D (Hrsg) (2011) Arzneiverordnungsreport 2011. Springer, Berlin

  68. Simpson DM, Messina J, Xie F et al (2007) Fentanyl buccal tablet for the relief of breakthrough pain in opioid-tolerant adult patients with chronic neuropathic pain: a multicenter, randomized, double-blind, placebo-controlled study. Clin Ther 29:588–601

    Article  PubMed  CAS  Google Scholar 

  69. Soyka M, Queri S, Kufner H et al (2005) Wo verstecken sich 1,9 Millionen Medikamentenabhängige? Nervenarzt 76:72–77

    Article  PubMed  CAS  Google Scholar 

  70. Sullivan MD, Ballantyne JC (2012) What are we treating with long-term opioid therapy? Arch Intern Med 172:433–434

    Article  PubMed  Google Scholar 

  71. Sullivan MD, Edlund MJ, Zhang L et al (2006) Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med 166:2087–2093

    Article  PubMed  Google Scholar 

  72. Taylor DR, Webster LR, Chun SY et al (2007) Impact of breakthrough pain on quality of life in patients with chronic, noncancer pain: patient perceptions and effect of treatment with oral transmucosal fentanyl citrate (OTFC, ACTIQ). Pain Med 8:281–288

    Article  PubMed  Google Scholar 

  73. Treede RD, Jensen TS, Campbell JN et al (2008) Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology 70:1630–1635

    Article  PubMed  CAS  Google Scholar 

  74. Volkow ND, McLellan TA (2011) Curtailing diversion and abuse of opioid analgesics without jeopardizing pain treatment. JAMA 305:1346–1347

    Article  PubMed  CAS  Google Scholar 

  75. Volkow ND, McLellan TA, Cotto JH et al (2011) Characteristics of opioid prescriptions in 2009. JAMA 305:1299–1301

    Article  PubMed  CAS  Google Scholar 

  76. Webster LR, Messina J, Xie F et al (2011) Effect of fentanyl buccal tablet on pain-related anxiety: a 4-week open-label study among opioid-tolerant patients with chronic and breakthrough pain. J Opioid Manag 7:297–308

    Google Scholar 

  77. Weisner CM, Campbell CI, Ray GT et al (2009) Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders. Pain 145:287–293

    Article  PubMed  CAS  Google Scholar 

  78. Wissenschaftliches Institut der AOK (2012) http://www.wido.de/fileadmin/wido/downloads/pdf_arzneimittel/wido_arz_avr2012pk_0912.pdf. Zugegriffen: 17. Oktober 2012

  79. Zeppetella G (2011) Opioids for the management of breakthrough cancer pain in adults: a systematic review undertaken as part of an EPCRC opioid guidelines project. Palliat Med 25:516–524

    Article  PubMed  Google Scholar 

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  1. UniversitätsSchmerzCentrum, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland

    R. Scharnagel, U. Kaiser, A. Schütze, R. Heineck, G. Gossrau & R. Sabatowski

  2. Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland

    R. Scharnagel, R. Heineck & R. Sabatowski

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  1. R. Scharnagel
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  2. U. Kaiser
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  3. A. Schütze
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  4. R. Heineck
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  5. G. Gossrau
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  6. R. Sabatowski
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Correspondence to R. Scharnagel.

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Scharnagel, R., Kaiser, U., Schütze, A. et al. Chronische nichttumorbedingte Schmerzen. Schmerz 27, 7–19 (2013). https://doi.org/10.1007/s00482-012-1278-6

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