Response to Dr Howard Smith

Abstract

I would like to thank Dr Howard Smith for his insightful comments in regard to the use of opioids in the long-term management of temporomandibular joint dysfunction. The purpose of our review was to provide a rationale and understanding of the value of opioids in the management of chronic noncancer pain such as temporomandibular joint pain. The omission of tapentadol, transdermal buprenorphine, and oxymorphone resulted from a paucity of independent studies addressing these drugs in this patient group. This is particularly the case for tapentadol and transdermal buprenorphine. Tapentadol is a relatively new drug, and both a μ receptor agonist and a norepinephrine reuptake inhibitor, resulting in 2 potentially different mechanisms for treating acute and chronic pain, respectively. 1 Pergolizzi J. Alegre C. Blake D. et al. Current considerations for the treatment of severe chronic pain: The potential for tapentadol. Pain Pract. 2011 July 29; (Epub) Google Scholar Buprenorphine has been available as an oral drug for 30 years and has not been used for the management of chronic pain. A transdermal system has recently been introduced to enable the use of buprenorphine for chronic pain. 2 Steiner D. Munera C. Hale et al. Efficacy and safety of buprenorphine transdermal system (BTDS) for chronic moderate to severe low back pain: A randomized, double blind study. J Pain. 2011 July 30; (Epub) PubMed Google Scholar It is interesting that several Cochrane databases, which provide a robust method of evaluating clinical studies, have also not included these drugs in their meta-analyses. Oxymorphone is also a relatively newer drug. The use of oxymorphone extended release appears to be increasing, although there are only limited clinical studies addressing this drug for chronic noncancer pain. Of the 5 articles cited by Dr Smith in support of oxymorphone, 1 is a review of the literature, 3 Sloan P. Barkin R. Oxymorphone and oxymorphone extended release: A pharmacotherapeutic review. J Opioid Manag. 2008; 4: 131 PubMed Google Scholar and 4 others are industry funded clinical trials. 4 Hale M.E. Ahdieh H. Ma T. et al. Efficacy and safety of OPANA ER (oxymorphone extended release) for relief of moderate to severe chronic lower back pain in opioid experienced patients: A 12-week, randomized, double blind, placebo-controlled study. J Pain. 2007; 8: 175 Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar , 5 Kivitz A. Ma C. Ahdieh H. et al. A 2-week, multicenter, randomized, double blind, placebo controlled, dose ranging, phase III trial comparing the efficacy of oxymorphone extended release and placebo in adults with pain associated with osteoarthritis of the hip or knee. Clin Ther. 2006; 28: 352 Abstract Full Text PDF PubMed Scopus (69) Google Scholar , 6 Matsumoto A.K. Babul N. Ahdieh H. Oxymorphone extended release tablets relieve moderate to severe pain and improve physical function in osteoarthritis: Results of a randomized, double blind, placebo- and active-controlled phase III trial. Pain Med. 2005; 6: 357 Crossref PubMed Scopus (104) Google Scholar , 7 Katz N. Rauck R. Ahdieh H. et al. A 12-week randomized placebo controlled trial assessing the safety and efficacy of oxymorphone extended release for opioid naïve patients with chronic lower back pain. Curr Med Res Opin. 2007; 23: 117 Crossref PubMed Scopus (127) Google Scholar The outcomes reported in these studies suggest a favorable response with varying daily doses of oxymorphone extended release (10 to 80 mg) compared with placebo. However, the superiority over oxycodone controlled release was not clearly established in these studies. Additional independent clinical studies with oxymorphone are required, although this drug appears to be promising. Response to Bouloux: Use of Opioids in Long-Term Management of Temporomandibular Joint DysfunctionJournal of Oral and Maxillofacial SurgeryVol. 69Issue 11PreviewRecently, Dr Gary Bouloux reviewed opioid management of chronic temporomandibular joint dysfunction-related pain.1 Appropriately, the review discussed the biopsychosocial model of chronic pain, issues of risk and benefit (consistent with the guidelines),2,3 adjunct pain medications, and monitoring of use and misuse. Some available products were compared based on how well their characteristics match “the ideal opioid.” However, the regrettable reality is that no opioid remains “ideal” for a given patient indefinitely. Full-Text PDF