Addressing sleep problems- The role of long-acting opioids 10 : 40 – 11 : 10 Addressing sleep problems- The role of long-acting opioids 邵 幼 雲 Yu-Yun Shao Moderator 趙 大 中 Ta-Chung Chao

Addressing Sleep Problems The Role of Long-Acting Opioids 台大醫院 腫瘤醫學部 邵幼雲 助理教授 2017 May 6

Prevalence of Cancer Pain A metaanalysis of 52 articles 33% 59% patients after curative treatment patients under anticancer treatment Ann Oncol (2007); 18: 1437-1449

Prevalence of Cancer Pain A metaanalysis of 52 articles 64% 53% Advanced or terminal disease  all disease stages Ann Oncol (2007); 18: 1437-1449

Prevalence of Cancer Pain A metaanalysis of 52 articles 64% 53% Advanced or terminal disease  all disease stages Ann Oncol 2007; 18: 1437-1449

Taiwan National Data 2003 to 2011 1,424,048 cancer patients Acta Anaesthesiologica Taiwanica 2016; 54: 51-56

Pain Decreases Life Quality 1190 patients in 10 Asian countries Cancer Med 2015; 4:1196-1204

Pain and Sleep Disturbance – A Vicious Cycle Pain Pract. 2011; 11:282-9

How to Manage Pain for Better Sleep Long-acting Stable concentration Increase pain threshold continuously Good compliance Short-acting Rapid onset but short duration Unstable blood concentration Frequent trough levels Suitable for background analgesia to prevent pain occurrence Suitable for breakthrough pain only

The Importance of Stable Opioid Concentration Drug A Immediate Release (q4h) Drug B Monophasic Extended Release (q24h) Pain Time Increased Pain Intensity Gupta et al. J Pain Sympt Manage 2007; 34: 40-47

Long-Acting Opioids for Cancer Pain Control USA & Canada Long-Acting Opioids for Cancer Pain Control Phase I Prior Opioid stabilization Phase II (Titration) 3 to 21 days Phase III (Maintenance) 14 days OROS® hydromorphone qd OROS® hydromorphone qd Previous opioid Therapy N=148 N=127 N=85 conversion Opioid stabilization: ≥ 3 consecutive days dose remained unchanged; < 4 doses of rescue medication For patients receiving transdermal fentanyl, the initial OROS® hydromorphone dose was 8 mg for each 25 μg/h of fentanyl Patients with chronic cancer pain receiving at least 45 mg morphine equivalent daily (85% under strong opioids) Titration with increments of 25 –100% of the current OROS® hydromorphone dose if > 2 doses of rescue medications in 24 hours J Int Med Res. 2008;36:343–352

Average Pain Improved after Conversion J Int Med Res. 2008;36:343–352

Sleep and Life Quality Improved after Conversion J Int Med Res. 2008;36:343–352

Long-Acting Opioids for Pain Control & Sleep Disturbance Korea Long-Acting Opioids for Pain Control & Sleep Disturbance Screening Efficacy evaluation 14 days Extension phase 84 days OROS® hydromorphone qd OROS® hydromorphone qd Previous opioid Therapy N=190 N=120 titration N=74 conversion Opioid stabilization: ≥ 3 consecutive days dose remained unchanged; < 4 doses of rescue medication For patients receiving transdermal fentanyl, the initial OROS® hydromorphone dose was 8 mg for each 25 μg/h of fentanyl Patients with chronic moderate to severe cancer pain and sleep disturbance and under strong opioids Cancer Res Treat. 2014;46:331-338

Pain and Sleep Improved after Conversion All p < 0.01 Cancer Res Treat. 2014;46:331-338

Sleep Better with Hydromorphone OROS Cancer Res Treat. 2014;46:331-338

Long-Acting Opioids for Noncancer Pain Control USA & Canada Long-Acting Opioids for Noncancer Pain Control Phase I Prior Opioid stabilization Phase II (Titration) 3 to 14 days Phase III (Maintenance) 28 days OROS® hydromorphone qd OROS® hydromorphone qd Previous opioid Therapy N=208 N=207 N=131 conversion Opioid stabilization: ≥ 3 consecutive days dose remained unchanged; < 4 doses of rescue medication For patients receiving transdermal fentanyl, the initial OROS® hydromorphone dose was 8 mg for each 25 μg/h of fentanyl Patients with moderate to severe chronic low back pain Titration with increments of 25 –100% of the current OROS® hydromorphone dose if > 3 doses of rescue medications in 24 hours Current Medical Research and Opinion 2007; 23: 981-989

Pain Improved after Conversion Worst pain in 24 hrs Average pain Pain right now Least pain in 24 hrs Current Medical Research and Opinion 2007; 23: 981-989

Sleep and Life Quality Improved after Conversion Current Medical Research and Opinion 2007; 23: 981-989

Hydromorphone OROS vs. Oxycodone USA Hydromorphone OROS once daily R Titration phase Maintenance phase Oxycodone twice daily 14 d 28 d N = 124 Patients with chronic osteoarthritis and moderate to severe pain under NSAID Patient 2008; 1: 223-238

Hydromorphone OROS Offers Better Sleep Patient 2008; 1: 223-238

Stop the Vicious Cycle! Long-acting opioids that provide stable blood concentration Pain Pract. 2011; 11:282-9

Take Home Message Pain leads to sleep disturbance and decreased life quality Long-acting opioids provide better pain control and better sleep Hydromorphone OROS was proven to relieve sleep disturbance caused by pain