Patients with chronic pain and dysphagia (CPD): unmet medical needs and pharmacologic treatment options

Abstract

Background:

For properly selected patients experiencing chronic pain, extended-release opioid formulations may represent an appropriate pain management choice. For the many adults, elderly, and children who have medical conditions that make swallowing solid, oral-dose formulations difficult (dysphagia) or painful (odynophagia), this option may be limited. The combination of chronic pain with dysphagia (CPD) presents a challenge to physicians and patients alike when oral opioid analgesia is needed to control pain, but patients are unable to swallow solid, oral dosage forms.

Methods:

A Medline search was performed (1990 to 2013) using the search terms swallowing difficulties, dysphagia, odynophagia, adults, pediatrics, elderly, chronic pain, pain, and opioids. The following websites were searched: American Dysphagia Network, Dysphagia Research Society, World Health Organization, American Pain Society, International Association for the Study of Pain, American Academy of Pain Medicine, and American Society of Interventional Pain Physicians. Chronic pain guidelines from the following professional organizations were searched: American Pain Society, National Comprehensive Cancer Network, American Society of Interventional Pain Physicians, British Geriatric Society, European Society of Medical Oncology, World Health Organization, and the European Association for Palliative Care.

Findings:

There is an unmet medical need for greater recognition of dysphagia, awareness of potential problems with medication administration in these patients, recognition of alternative drug formulations that are available for use in CPD, and an appreciation that there are new, solid, oral-dose, opioid formulations in development that can mitigate these issues associated with swallowing difficulty while still providing practical, effective analgesia. Current pharmacologic treatments have limitations; new, prospective opioid formulations in clinical development may offer physicians and patients with CPD effective treatment options while mitigating accidental exposure and abuse liability.

Conclusions:

The number of patients with CPD may be larger than is currently anticipated by healthcare providers. Physicians should proactively include a discussion of dysphagia as part of the patient examination. CPD is an unmet medical need. There are novel opioid formulations in clinical development that address the limitations of current opioid treatments. This manuscript reviews the problems associated with dysphagia on medication administration and adherence, currently available treatment options, and opioid analgesic formulations currently in clinical development.

Keywords::

• Abuse-deterrent
• Analgesics
• Chronic pain
• Chronic pain with dysphagia
• Dysphagia
• Odynophagia
• Opioid
• Opioid formulations
• Swallowing difficulty

Transparency

Declaration of funding

Editorial assistance was funded by Collegium Pharmaceutical Inc., Canton, MA, USA.

Declaration of financial/other relationships

C.E.A. has disclosed that he is a consultant/scientific advisor for Collegium Pharmaceutical Inc. and was asked to fulfill the role of lead author based on his clinical and medical expertise as a practicing pain specialist. E.A.K. has disclosed that he is a salaried employee and stock holder at Collegium Pharmaceutical Inc.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors would like to acknowledge the editorial assistance of Richard S. Perry PharmD in the preparation of this manuscript, which was supported by Collegium Pharmaceutical Inc., Canton, MA, USA.

Notes

*Morphine sulphate ER is a generic formulation produced by Mallinckrodt Inc., Hazelwood, MO, USA.

**Kapanol is a registered trade name of Mayne Pharma International Pty Ltd, Salisbury, South Australia

†Avinza is a registered trade name of Pfizer Inc., New York, NY, USA

‡Kadian is a registered trade name of Actavis Elizabeth LLC, Dublin, Ireland

§MS Contin is a registered trade name of Purdue Pharma LP, Stamford, CT, USA

¶Oramorph SR is a registered trade name of Xanodyne Pharmaceuticals Inc., Newport, KY, USA

*Embeda is a registered trade name of Pfizer Inc., New York, NY, USA

†OxyNEO is a registered trade name of Purdue Pharma, Pickering, ON, Canada

‡Targin is a registered trade name of Mundipharma International Ltd, Cambridge, UK

§Targin is a registered trade name of Purdue Pharma, Pickering, ON, Canada

¶Targinact is a registered trade name of Napp Pharmaceuticals Ltd, Cambridge, UK

⊥OxyContin is a registered trade name of Purdue Pharma LP, Stamford, CT, USA

∥Targiniq ER is a registered trade name of Purdue Pharma LP, Stamford, CT, USA

**Opana ER is a registered trade name of Endo Pharmaceuticals Inc., Malvern, PA, USA

††Exalgo is a registered trade name of Mallinckrodt Pharmaceuticals, St. Louis, MO, USA

*Durogesic is a registered trade name of Janssen-Cilag Ltd, High Wycombe, Buckinghamshire, UK

†Duragesic is a registered trade name of Janssen Pharmaceuticals Inc., Titusville, NJ, USA

‡Addnok is a registered trade name of Activase Pharmaceuticals Ltd, Nicosia, Cyprus

§Norspan is a registered trade name of Mundipharma Laboratories GmbH, Basel, Switzerland

¶Butrans is a registered trade name of Purdue Pharma LP, Stamford, CT, USA

⊥Zohydro is a registered trade name of Zogenix Inc., San Diego, CA, USA

∥Palexia SR is a registered trade name of Grunenthal Ltd, Stokenchurch, UK

**Tapal is a registered trade name of MSN Laboratories Ltd, Sanathnagar Hyderabad, India

††Nucynta is a registered trade name of Janssen Pharmaceuticals Inc., Titusville, NJ, USA

‡‡Conzip is a registered trade name of Vertical Pharmaceuticals LLC, Sayreville, NJ, USA

§§Durela is a registered trade name of Cipher Pharmaceuticals Inc., Mississauga, ON, Canada

¶¶Tramal is a registered trade name of Grunenthal, Aachen, Germany

⊥⊥Ultram ER is a registered trade name of Janssen Pharmaceuticals Inc., Titusville, NJ, USA

*Remoxy is a registered trade name of Pfizer Inc., New York, NY, USA

†OraGuard is a registered trade name of Teva Pharmaceutical Industries Ltd, North Wales, PA, USA

‡DETERx is a registered trade name of Collegium Pharmaceutical, Inc., Canton, MA, USA

§BEMA is a registered trade name of Endo Pharmaceuticals Inc., Malvern, PA, USA