Uso y abuso de opioides en el área norte de la provincia de Cádiz

Abstract

Introduction: The treatment of chronic noncancer pain (CNCP) with opioids is controversial because its effectiveness on the long-term outcomes has not been proven. The few trials focusing on dependence and addiction demonstrated increased mortality among CNCP patients receiving high doses of opioids. We therefore decided to analyze patients living in the northern area of the province of Cadiz who had exceeded the defined daily dose (DDD). The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. Materials and methods: The northern area of Cadiz has a population of 360,000 inhabitants. Patients who exceeded the DDD of opioid in December 2014 were identified. The clinical history of each of these patients was studied retrospectively. Results: Twenty-three patients were identified who at least needed to double the DDD of their opioids. Consequently, the incidence of patients exceeding the DDD in the area under consideration was 1 per 15,000 inhabitants. Four of these were cancer patients (17 %) while the others suffered from CNCP (83 %). CNCP in these patients predominantly was of the osteo-articular type of pain (65 %), with the failed back syndrome, occurring in 8 cases (35 %), representing the most frequent diagnosis. Patient ages ranged from 34 to 84 Y with a median of 58 Y. The youngest of these (34 Y) requiring the largest amounts of drugs. The daily consumption of this youngest patient corresponded to 34 times the DDD, two other patients took 8 times the DDD, 1 four times, 4 three times and, finally, 11 patients needed to double the DDD. Todos los pacientes tomaban un opiáceo para el dolor irruptivo, la gran mayoría (17 pacientes) tomaban comprimidos de fentanilo oral transmucoso, effentora o actiq. Most of the patients were taking opioids for breaktrough pain, the vast majority of these (17 patients) using transmucosal fentanyl citrate formulations, i.e. Effentora® or Actiq®. Most of the patients took oxycodone (7) or transdermal fentanyl (8), as delayed action opioid. Two patients were not taking opioids with delayed action. It was noted that 11 patients (47 %) had a psychiatric history, 2 of them had a suicide attempt. Conclusions: The inappropriate use of opioids occurs mainly in non-cancer patients. There was a clear relationship with psychiatric disorders. There are relations of misuse and abuse of fast-acting drugs, especially fentanyls. Although the abuse of opioids is rare, so we must be cautious about starting treatment CNCP. It shoulf be bourne in mind that in these patients the effectiveness of opioids needs to be reassessed periodically, considering referral to the pain unit when opioid requirements exceeding 180 mg of morphine or its equivalent.