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BJA Advance Access originally published online on September 6, 2009
British Journal of Anaesthesia 2009 103(4):576-585; doi:10.1093/bja/aep253
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 BJA: October 2009
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© The Author [2009]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients with chronic non-malignant pain

J. Devulder1,*, A. Jacobs2, U. Richarz3 and H. Wiggett2,4

1 Department of Anaesthesia and Pain Clinic, Ghent University Hospital, De Pintelaan 185, Ghent 9000, Belgium.
2 Dianthus Medical Limited, 4 Lyon Road, London SW19 2RL, UK.
3 Janssen-Cilag AG, Sihlbruggstrasse 111, 6341 Baar, Switzerland

* Corresponding author: Department of Pain Therapy 3B2, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium. E-mail: jacques.devulder{at}ugent.be

Background: There is little evidence that short-acting opioids as rescue medication for breakthrough pain is an optimal long-term treatment strategy in chronic non-malignant pain. We compared clinical studies of long-acting opioids that allowed short-acting opioid rescue medication with those that did not, to determine the impact of opioid rescue medication use on the analgesic efficacy and tolerability of chronic opioid therapy in patients with chronic non-malignant pain.

Methods: We searched MEDLINE (1950 to July 2006) and EMBASE (1974 to July 2006) using terms for chronic non-malignant pain and long-acting opioids. Independent review of the search results identified 48 studies that met the study selection criteria. The effect of opioid rescue medication on analgesic efficacy and the incidence of common opioid-related side-effects were analysed using meta-regression.

Results: After adjusting for potentially confounding variables (study design and type of opioid), the difference in analgesic efficacy between the ‘rescue’ and the ‘no rescue’ studies was not significant, with regression coefficients close to 0 and 95% confidence intervals that excluded an effect of more than 18 points on a 0–100 scale in each case. There was also no significant difference between the ‘rescue’ and the ‘no rescue’ studies for the incidence of nausea, constipation, or somnolence in both the unadjusted and the adjusted analyses.

Conclusions: We found no evidence that rescue medication with short-acting opioids for breakthrough pain affects analgesic efficacy of long-acting opioids or the incidence of common opioid-related side-effects among chronic non-malignant pain patients.

Keywords: analgesics opioid; pain, chronic; pharmacology, analgesics opioid

4 Present address: Parexel International, Navigation House, 1 South Quay Drive, Victoria Quays Sheffield S2 5SY, UK


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