Exploring the use of extended release opioids at shortened dosing intervals in people with chronic pain and high risk medication or substance use

BackgroundCritical attention to rational opioid prescribing has emerged from the opioid epidemic in North America. Individuals with chronic pain are prescribed extended release opioids in an effort to maintain stable drug levels and for more convenient dosing, though evidence to support improvements in pain or function is lacking. It has been observed that extended release opioid products are used at intervals shorter than recommended by product monographs. The need for shortened intervals has been linked with potential inter-patient variability in pharmacokinetics, among other rationale. Implications of shortened dosing intervals for extended release opioids have not been systematically studied.ObjectiveThe aim of this study was to characterize the use of extended release opioid formulations at shortened dosing intervals in a population of patients with chronic pain and high risk for opioid-related harms.SettingThis study took place in the Interprofessional Pain and Addiction Recovery Clinic, a specialty ambulatory clinic at the Centre for Addiction and Mental Health in Toronto, Canada for adults with chronic pain and a diagnosis or suspicion of substance use disorder.MethodThis was a retrospective cross-sectional study. Data were collected from records of patients with assessments completed in the years 2012-2017 (n = 210).Main outcome measureProportion of patients using extended release opioids at shortened intervals.ResultsSixty-one percent of individuals using extended release opioids (n = 78) were using them at shortened intervals. This use was associated with a higher daily morphine equivalent dose (533 mg vs 236 mg,p < 0.01), use of oxycodone extended release products (50% vs. 27%,p < 0.01), a longer duration of opioid therapy (8.9 vs. 6.8 years,p = 0.03) and a diagnosis of chronic neuropathic pain (63% vs. 39%,p < 0.01), with no differences in reported pain intensities, compared with use at standard intervals.ConclusionThe use of extended release opioids at shortened intervals was associated with increased daily morphine equivalent doses, thus an increased risk of opioid-related mortality. It is unlikely that of those using extended release opioids, the high proportion of use at shortened intervals is the result of inter-patient differences in metabolism alone. Further study is warranted to explore the underlying drivers and implications for people with chronic pain.