Advertisement

Importance of Side Effects in Opioid Treatment: A Trade-Off Analysis With Patients and Physicians

      Abstract

      This study examined the relative impact of pain relief and opioid side effects on patients' and physicians' preferences for medication. An Internet survey was completed by 618 patients (302 acute pain, 316 chronic pain) and 325 physicians (83 primary care, 80 pain specialists, 41 oncologists, 40 general surgeons, 40 orthopedic surgeons, 20 rheumatologists, 21 neurologists). Respondents completed an Adaptive Conjoint Analysis (ACA) exercise in which they indicated their relative preference for 20 pairs of hypothetical opioid pain medications described by varying levels of pain relief and side-effect incidence. Almost all patients (96% of chronic, 92% of acute) reported experiencing at least 1 side effect while on opioid medication, but physician-estimated incidence rates of most opioid side effects were much lower than those reported by patients. Opioid side effects, rather than pain relief, explained the majority of variance for medication preference for both patients (74% for chronic, 73% for acute) and treating physicians (73% for chronic, 74% for acute) in this exercise. Nausea and vomiting were major determinants of opioid medication preference, with each explaining as much of the variance in preference as did pain relief (21% to 25%). Nausea and vomiting were the most important side effects based on the amount of pain relief that respondents were willing to give up for reducing the incidence of side effects. The importance of side effects was confirmed in an open-ended question where 51% of patients and 58% of physicians identified side-effect reduction as an unmet need for pain medications.

      Perspective

      This study provided insights into patient and physician preferences of the risk and benefit balance of opioid therapy. This information could improve understanding of patient needs and facilitate the incorporation of patient preference into therapy choice.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Aparasu R.
        • McCoy K.
        Opioid-induced emesis among hospitalized nonsurgical patients: Effect on pain and quality of life.
        J Pain Symptom Manage. 1999; 18: 280-288
        • Bech M.
        • Gyrd-Hansen D.
        • Kjær T.
        • Lauridsen J.
        • Sørensen J.
        Graded pairs comparison - does strength of preference matter? Analysis of preferences for specialised nurse home visits for pain management.
        Health Econ. 2007; 16: 513-529
      1. Bell T, Annuziata K, Freedman D, Turk D, Leslie J, Muller-Schwefe G: Opioid-induced constipation increases healthcare resource use and impairs work productivity: Comparison with other patient groups with and without constipation. Abstract presented at: The 26th Annual Scientific Meeting of the American Pain Society, Washington, DC, May 5-7, 2007

        • Breivik H.
        • Collett B.
        • Ventafridda V.
        • Cohen R.
        • Gallacher D.
        Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment.
        Eur J Pain. 2006; 10: 287-333
        • Carroll N.V.
        • Miederhoff P.
        • Cox F.M.
        • Hirsch J.D.
        Postoperative nausea and vomiting after discharge from outpatient surgery centers.
        Anesth Analg. 1995; 80: 903-909
        • Chou R.
        • Fanciullo G.J.
        • Fine P.G.
        • Adler J.A.
        • Ballantyne J.C.
        • Davies P.
        • Donovan M.I.
        • Fishbain D.A.
        • Foley K.M.
        • Fudin J.
        • Gilson A.M.
        • Kelter A.
        • Mauskop A.
        • O'Connor P.G.
        • Passik S.D.
        • Pasternak G.W.
        • Portenoy R.K.
        • Rich B.A.
        • Roberts R.G.
        • Todd K.H.
        • Miaskowski C.
        Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
        J Pain. 2009; 10: 113-130
        • Daniels S.E.
        • Upmalis D.
        • Okamoto A.
        • Lange C.
        • Haeussler J.
        A randomized, double-blind, phase III study comparing multiple doses of tapentadol IR, oxycodone IR, and placebo for postoperative (bunionectomy) pain.
        Curr Med Res Opin. 2009; 25: 765-776
        • Daniels S.
        • Casson E.
        • Stegmann J.
        • Oh C.
        • Okamoto A.
        • Rauschkolbban C.
        • Upmalis D.
        A randomized, double-blind, placebo-controlled phase 3 study of the relative efficacy and tolerability of tapentadol IR and oxycodone IR for acute pain.
        Curr Med Res Opin. 2009; 25: 1551-1561
        • Drakopoulos S.A.
        Hierarchical choice in economics.
        J Econ Surv. 1994; 8: 133-153
        • Eberhart L.H.
        • Morin A.M.
        • Wulf H.
        • Geldner G.
        Patient preferences for immediate postoperative recovery.
        Br J Anaesth. 2002; 89: 760-761
        • Eisenberg E.
        • McNicol E.D.
        • Carr D.B.
        Efficacy and safety of opioid agonists in the treatment of neuropathic pain of nonmalignant origin: Systematic review and meta-analysis of randomized controlled trials.
        JAMA. 2005; 293: 3042-3052
        • Farrar J.T.
        • Young J.P.
        • LaMoreaux L.
        • Werth J.L.
        • Poole R.M.
        Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale.
        Pain. 2001; 94: 149-158
        • Fraenkel L.
        • Bogardus S.T.
        • Concato J.
        • Felson D.T.
        • Wittink D.R.
        Patient preferences for treatment of rheumatoid arthritis.
        Ann Rheum Dis. 2004; 63: 1372-1378
        • Fraenkel L.
        • Wittink D.R.
        • Concato J.
        • Fried T.
        Informed choice and the widespread use of anti-inflammatory drugs.
        Arthritis Rheum. 2004; 51: 210-214
        • Gan T.J.
        • Lubarsky D.A.
        • Flood E.M.
        • Thanh T.
        • Mauskopf J.
        • Mayne T.
        • Chen C.
        Patient preferences for acute pain treatment.
        Br J Anaesth. 2004; 92: 681-688
        • Gregorian R.
        • Kwong J.
        • Gasik A.
        • Voeller S.
        • Kavanagh S.
        Importance of opioid side effects in pain management from patient perspective.
        J Pain. 2009; 10: S51
        • Guyatt G.H.
        • Bombardier C.
        • Tugwell P.X.
        Measuring disease-specific quality of life in clinical trials.
        Can Med Asso J. 1986; 134: 889-895
        • Hale M.
        • Upmalis D.
        • Okamoto A.
        • Lange C.
        • Rauschkolb C.
        Tolerability of tapentadol immediate release in patients with lower back pain or osteoarthritis of the hip or knee over 90 days: A randomized, double-blind study.
        Currt Med Res Opin. 2009; 25: 1095-1104
        • Hardt J.
        • Jacobsen C.
        • Goldberg J.
        • Nickel R.
        • Buchwald D.
        Prevalence of chronic pain in representative sample in the United States.
        Pain Med. 2008; 9: 803-812
        • Hartrick C.
        • Van Hove I.
        • Stegmann J.
        • Oh C.
        • Upmalis D.
        Efficacy and tolerability of tapentadol immediate release and oxycodone HCI immediate release in patients awaiting primary joint replacement surgery for end-stage joint disease: A 10-day, phase III, randomized, double-blind, active- and placebo-controlled study.
        Clin Ther. 2009; 31: 260-271
        • Hartrick C.
        • Van Hove I.
        • Stegmann J.
        • Oh C.
        • Upmalis D.
        Efficacy and tolerability of tapentadol immediate release and oxycodone HCI immediate release in patients awaiting primary joint replacement surgery for end-stage joint disease: A 10-day, phase III, randomized, double-blind, active- and placebo-controlled study. Corrections.
        Clin Ther. 2009; 31: 1885
      2. Hudcova J, McNicol E, Quah C, Lau J, Carr DB: Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003868. DOI: 10.1002/14651858.CD003868

      3. IMS Health National Prescription Audit, 2006

        • Jamison R.N.
        • Raymond S.A.
        • Slawsby E.A.
        • Nedeljkovic S.S.
        • Katz N.P.
        Opioid therapy for chronic noncancer back pain: A randomized prospective study.
        Spine. 1998; 23: 2591-2600
        • Kalso E.
        • Edwards J.E.
        • Moore R.A.
        • McQuay H.J.
        Opioids in chronic non-cancer pain: Systematic review of efficacy and safety.
        Pain. 2004; 8: 372-380
        • Kopec J.A.
        • Richardson C.G.
        • Llewellyn-Thomas H.
        • Klinkhoff A.
        • Carswell A.
        • Chalmers A.
        Probabilistic threshold technique showed that patients' preferences for specific tradeoffs between pain relief and each side effect of treatment in osteoarthritis varied.
        J Clin Epidemiol. 2007; 60: 929-938
        • Lancaster K.
        Consumer Demand.
        1st ed. Columbia University Press, New York, NY1971
        • Lancaster K.
        A new approach to consumer theory.
        J Political Econ. 1966; 74: 134-157
        • Lee A.
        • Gin T.
        • Lau A.S.
        • Ng F.F.
        A comparison of patients' and health care professionals' preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting.
        Anesth Analg. 2005; 100: 87-93
      4. Leslie J, Bell T, Annunziata K, Freedman D: Opioid-induced constipation compromises pain management and impacts patient quality of life. Poster presented at: American Society of Anesthesiologists, 2007

        • Martin B.I.
        • Deyo R.A.
        • Mirza S.K.
        • Turner J.A.
        • Comstock B.A.
        • Hollingworth W.
        • Sullivan S.D.
        Expenditures and health status among adults with back and neck problems.
        JAMA. 2008; 299: 656-664
      5. Opana (oxymorphone hydrochloride) prescribing information. Available at: http://www.endo.com/pdf/Opana_IR_PI.pdf

      6. Opana ER (oxymorphone hydrochloride) extended release tablets prescribing information. Available at: http://www.endo.com/pdf/Opana_ER_PI.pdf

        • Orme B.
        Getting Started with Conjoint Analysis: Strategies for Product Design and Pricing Research.
        1st ed. Research Publishers LLC, Madison, WI2006 (pp 57-78)
      7. Oxycontin (oxycodone hydrochloride) prescribing information. Available at: http://www.pharma.com/PI/prescription/OxyIR.pdf

        • Portenoy R.
        • Ugarte C.
        • Fuller I.
        • Haas G.
        Population-based survey of pain in the United States: Differences among white, African American, and Hispanic subjects.
        J Pain. 2004; 5: 317-328
        • Ratcliffe J.
        • Buxton M.
        • McGarry T.
        • Sheldon R.
        • Chancellor J.
        Patients' preferences for characteristics associated with treatments for osteoarthritis.
        Rheumatology (Oxford). 2004; 43: 337-345
        • Ratcliffe J.
        • Haselen R.V.
        • Buxton M.
        • Hardy K.
        • Colehan J.
        • Partridge M.
        Assessing patients' preferences for characteristics associated with homeopathic and conventional treatment of asthma: A conjoint analysis study.
        Thorax. 2002; 57: 503-508
        • Ryan M.
        • Farrar S.
        Using conjoint analysis to elicit preferences for health care.
        BMJ. 2000; (3;320(7248)): 1530-1533
        • Sawtooth Software
        The ACA/Hierarchical Bayes v3.0 Technical Paper.
        Sawtooth Software, Sequim, WAJuly 2006
        • Sawtooth Software
        How Many Questions Should You Ask in Choice-Based Conjoint Studies?.
        Sawtooth Software, Sequim, WA1996
        • Schmier J.K.
        • Palmer C.S.
        • Flood E.M.
        • Gourlay G.
        Utility assessments of opioid treatment for chronic pain.
        Pain Med. 2002; 3: 218-230
        • Stewart W.F.
        • Ricci J.A.
        • Chee E.
        • Morganstein D.
        • Lipton R.
        Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce.
        JAMA. 2003; 290: 2443-2454
        • Strassels S.A.
        • Chen C.
        • Carr D.B.
        Postoperative analgesia: Economics, resource use and patient satisfaction in an urban teaching hospital.
        Anesth Analg. 2002; 94: 130-137
      8. Survey Sampling International. Global Panel Book, 2009

      9. U.S. Census Bureau, Survey of Income and Program Participation, 2004 Panel, Wave 5. Available at: http://www.census.gov/population/www/socdemo/computer/2007.html

        • Walder B.
        • Shafer M.
        • Henzi I.
        • Tramer M.R.
        Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain: A quantitative systematic review.
        Acta Anesthesiol Scand. 2001; 45: 795-804
        • Watkins E.A.
        • Phil D.
        • Wollan P.
        • Melton L.J.
        • Yawn B.
        A population in pain: Report from the Olmsted County Health Study.
        Pain Medicine. 2008; 9: 166-174
      10. Wiffen PJ, Edwards JE, Barden J, McQuay HJM: Oral morphine for cancer pain. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003348. DOI: 10.1002/14651858.CD003348.pub2