Opioid Titration Research Articles

Oxycodone Immediate Release for Cancer Pain Management in Turkey: Maximizing Value in Opioid Analgesics

Cancer pain can be severe, yet is often undertreated. In many parts of the world, there is a reluctance to prescribe narcotics for analgesia. Since the World Health Organization first published its pain ladder treatment paradigm in 1988, cancer pain is usually treated initially with nonopioids, then weak opioids, and finally strong opioids along with adjuvant agents as the pain intensifies. When initiating opioid therapy for cancer patients, the clinician must consider whether the patient is opioid naƒ¯ve or opioid experienced. For naƒ¯ve patients, opioid therapy must be started slowly, at a low dose initially, with adverse events anticipated and treated proactively. In all cases, opioid titration involves a controlled, stepwise increase of opioid dose until adequate (but not necessarily 100%) analgesia is achieved. A variety of opioid products are available, including immediate-release and controlled-release formulations. Immediate-releaseformulations are designed for easy titration to adequate analgesia; their rapid onset of action also makes them appropriate for managing breakthrough pain. Although morphine has long been considered the gold standard of cancer analgesics, oral oxycodone is increasingly used and is similar to morphine in efficacy and safety for cancer patients. Indeed, about 75% of morphine-tolerant patients can be successfully rotated to oxycodone. Adverse events with oxycodone are similar or perhaps favorable compared to those of other strong opioids. Because cancer pain can be challenging to treat, the addition of oral oxycodone IR is an important new tool for clinicians to consider when trying to control cancer pain.

Opioid Therapy for Chronic Low Back Pain

Chronic low back pain is a common, disabling, and costly condition, and advanced practice registered nurses (APRNs) must carefully evaluate patients before considering long-term opioid therapy as a management strategy. APRNs should refer patients suspected of having a serious condition, or identifiable etiology, for specialist evaluation, as many patients improve with physical therapy, interventional pain management procedures, or surgical intervention. For patients unresponsive to nonopioid treatment, APRNs with an understanding of opioids, and the experience to assess and manage the risks of opioid misuse, abuse, and diversion, may consider long-term opioid therapy as part of a multimodal management plan. Such prescribing necessitates careful patient selection; informed consent; prudent opioid dosing and titration; and monitoring for response to treatment, adverse effects, and aberrant drug-taking behavior. Treatment and regulatory guidelines can assist APRNs in providing safe and effective care to patients with chronic low back pain.

Strategies for preventing side effects of systemic opioid in postoperative pediatric patients

Opioid is the gold standard for treating moderate-to-severe pain in pediatric patients. However, its undesirable side effects lead to unsatisfied postoperative pain management outcome (Pediatr Anesth, 17, 2007, 756). The most commonly reported opioid-related side effects are vomiting (40%), pruritus (20-60%) (Anesthesiology, 77, 1992, 162; Drugs, 67, 2007, 2323), and constipation (15-90%) (Int J Clin Pract, 61, 2007, 1181). The potential life-threatening adverse event, respiratory depression, is less common (0.0013%) (Pediatr Anesth, 20, 2010, 119). The aim of this review was to evaluate prevention strategies that have been shown to decrease opioid side effects in pediatric patients during the postoperative period. Literature searches were conducted from 1984 to February 2013. Meta-analysis, systematic review, and randomized, placebo-controlled studies were obtained from PubMed and the Cochrane Library. The medical subject heading (MeSH) terms were opioid analgesics, adverse effects, pediatrics, children, side effects, and postoperative pain. Data from 62 studies were reviewed. The strategies that could effectively prevent and reduce opioid side effects in pediatric patients during the postoperative period included minimizing the amount of opioid consumption by a multimodal approach, opioid titration, using local anesthetic techniques and providing the specific prophylaxis for each side effect.

Opioid titration with sustained-release oxycodone and immediate-release morphine for moderate/severe cancer pain: A pilot assessment of the CoDem protocol

Opioid titration is the first challenging stage for rapid control of moderate/severe cancer pain. Evidence shows that sustained-release formulations may be used for opioid titration. We set a pilot assessment of the efficacy and tolerability of our in-house protocol (continuous and on demand opioids [CoDem]) of the association of sustained-release oxycodone and immediate-release morphine as rescue dose for opioid titration/rotation in opioid-naïve (NAOP, n = 13), tolerant to weak (WOP, n = 20), or strong opioids (STOP, n = 44) in-patients with moderate/severe cancer pain. Observational and retrospective analysis of cancer in-patients treated for ≥7 days with the CoDem protocol. Pain intensity (patients self-reported pain with numerical rating scale [NRS] under static [NRSs] and dynamic [NRSd] conditions), amount of drug consumption, opioid adverse effects, and patient satisfaction. In more than 50 percent of the patients and in <72 hours, steady NRSs and NRSd score reduction of at least two points, NRSs ≤ 3 and NRSd ≤4; and mean daily morphine consumption < mean of one rescue dose and t1:t6 ratio of mean oxycodone daily dose < 1:2. Endpoints were reached within 24 hours both within the sample and subgroups. Only NAOP patients reached NRSd ≤ 4 endpoint within 48 hours. Against moderate and transient adverse effects, most patients (84.4 percent) found pain treatment to be good or excellent. The CoDem protocol was shown to be effective and reasonably tolerated for titration for moderate/severe cancer pain relief in both opioid-naïve or opioid-tolerant cancer in-patients. This pilot assessment warrants prospective and comparative studies with larger samples for more generalized results.

Safety profile of intravenous patient-controlled analgesia for breakthrough pain in cancer patients: a case series study

The WHO analgesic ladder supports medication choice according to pain intensity. The use of the analgesic ladder in an inverse way, has the advantage of using the same principles of the original ladder to treat crisis of pain in cancer patients. The purpose of this study is to describe the use of intravenous patient-controlled analgesia (IV-PCA) technique in patients admitted to an oncological Hospital. This is a case series study. Patients assigned to receive IV-PCA between March 2011 and May 2012 were selected for the study. Medical records were reviewed, patients stratified according to the Karnofsky Performance Score (KPS). The primary outcome was to verify if different IV-PCA opioid solutions could be equally effective providing pain relief. Secondary outcomes were the incidence of clinical side effects that can be associated to IV-PCA infusions. A total of 95 medical records were reviewed. Most patients used IV-PCA with morphine (42.1 %), fentanyl (42.1 %) or methadone (15.7 %) to treat exacerbation periods of cancer pain. IV-PCA used as supplementary therapy successfully improved pain control in 78.9 % of the patients, without any difference related to opioid solution. KPS <40 was related to higher rate of pain relief, without any difference in side effects in this group of patients. The most common side effects were sedation (10.5 %) followed by constipation (9.4 %) and nausea (4.2 %). Morphine presented a higher risk than fentanyl for sedation. Analgesia-related delirium or respiratory depression were not reported in this case series study. IV-PCA provided timely, safe and useful analgesia for patients with severe breakthrough pain and may be useful to help titration of opioids, weaning to oral analgesia and to decide for interventional procedures.

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Editor, We appreciate Dr Huxtable's and Dr Macintyre's interest1 in our review article about the perioperative management of pain in patients who abuse opioids.2 We have attentively read the letter to the editor by Huxtable et al.3 describing an extremely interesting alternative way of managing acute pain in patients who are in buprenorphine opioid substitution therapy (BOST) programmes.4 Currently, about 15 000 Austrian addicts are in a substitution treatment. Methadone is used in about 20 to 25% of them and buprenorphine in about 10 to 21%. Other substances, such as codeine, are used by only about 1% of these patients.5 The result of the described retrospective cohort study is undoubtedly interesting4 and seems to be a comfortable alternative in the management of acute pain in patients who are in BOST programmes to achieve adequate perioperative analgesia. However, the management of acute perioperative pain in a patient, as reported in the BOST article, depends mainly on local medical treatment regimens. In Austria, buprenorphine is replaced with methadone or a pure μ-opioid agonist throughout the perioperative period for elective major surgery to ensure adequate intraoperative and postoperative pain relief,2,6,7 because of buprenorphine′s well known pharmacological, especially potential μ-antagonistic, characteristics. We remain of the view that addicted patients have to be recognised as a high-risk group in the perioperative period, especially in major surgery, because of their higher perioperative risk for organic and psychological complications. These patients have to be monitored carefully to avoid adverse effects. Therefore, we highly recommend a continuous and careful opioid dose titration to avoid unnecessary complications.2 Acknowledgements relating to this article Assistance with the study: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.

P111 Terminal opioid and sedative titration in two hospices

IntroductionThere was anecdotal observation by professionals working across both sites that there was a difference to practice with opioid and sedative titration at the end of life. As an extension...

Potential P-glycoprotein Pharmacokinetic Interaction of Telaprevir With Morphine or Methadone

ABSTRACTTelaprevir (TVR) effects on P-glycloprotein and cytochrome P450 (CYP) may significantly elevate serum levels of morphine and methadone. Recent literature points to major interactions when combining TVR with warfarin or rifampin. Opioid interactions are especially dangerous in hepatitis C patients, as coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) occurs in 50–90% of HIV-infected drug users that are prescribed opioids for chronic pain and/or methadone for maintenance. TVR has been shown to significantly inhibit the active transport enzyme pGP and may therefore increase intestinal morphine absorption. TVR also inhibits hepatic CYP3A4 that are responsible for metabolizing methadone. Patients requiring opioid analgesics must be carefully monitored because of potential for elevated opioid levels and overdose risk. Current recommendations minimize potential drug interactions between telaprevir and opioids, especially methadone, based on a single 7-day trial. We outline the various pharmacokinetic mechanisms involved when combining TVR with methadone or morphine and recommend that current data are not sufficiently robust to minimize the potentially significant interaction with opioids, especially methadone. Clinicians must be mindful of these understated interactions, know that the opioid dose may need to be significantly increased or reduced, and use caution during upward titration of opioids affected by these enzyme systems.

Randomized Clinical Trial of an Intravenous Hydromorphone Titration Protocol versus Usual Care for Management of Acute Pain in Older Emergency Department Patients

Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with less opioid over 60 min.

008 TRAINING IN CARDIOLOGY: IS END OF LIFE CARE BEING ADDRESSED?

Background It is widely accepted that end of life care for non-cancer conditions has lagged behind palliative care for cancer. To equip cardiologists of the future with the necessary knowledge, skills and behaviour, end of life care has been incorporated into the 2010 Cardiology Curriculum in the UK. The purpose of this survey was to evaluate the confidence of trainees in managing end of life issues in advanced heart failure patients. Methods An online questionnaire was distributed to all registrar-grade British Junior Cardiac Association members in the UK. Results The main themes from 220 respondents were: Clinical Experience: ▸ 69% of trainees experience difficulties in palliating patients with advanced heart failure. ▸ Only 54% of trainees seek specialist palliative care input when experiencing problems. ▸ 73% of trainees feel that the care that they provide patients with advanced heart failure is poor or only adequate. ▸ 70% of trainees do not routinely explain the possible future need for ICD deactivation. ▸ 84% of trainees feel that patients are better off knowing their diagnosis even if it is poor, yet more than 50% of trainees do not feel equipped to discuss advanced care planning and end of life issues when seeing advanced heart failure patients in an out-patient clinic setting. Training: ▸ 45% report receiving no training in palliation of advanced heart failure symptoms. ▸ Only 29% have received any specific training in symptom palliation of advanced heart failure at ST3 level or above. ▸ Only 17% have completed an assessment to demonstrate competencies in end of life care. ▸ 57% are unhappy with current provision of training. ▸ Over 86% think that end-of-life training is important or very important within the curriculum. ▸ In particular, trainees identify 4 key areas for specialist input: symptom control, opioid titration, communication skills and the role of the palliative care team. ▸ Trainees9 suggestions include more workplace-based supervision with additional regional and national training days, closer links with local hospices and specific fellowships for heart failure trainees in palliative care. Conclusions This survey shows that despite being part of the national curriculum for training in cardiology since 2010, trainees9 level of confidence in delivering end of life care in advanced heart failure and discussing prognosis in patients with an ICD is poor. Specific training in end-of-life care remains a neglected part of the curriculum; this could be rectified by joint training with palliative care and more formal assessment of these skills.

Rapid opioid titration protocol for acute on chronic cancer pain in the emergency department setting: a pilot study

Rapid opioid titration protocol for acute on chronic cancer pain in the emergency department setting: a pilot study

PC-FACS

PC-FACS

Morphine and Hydromorphone-Induced Hyperalgesia in a Hospice Patient

Opioids including morphine and hydromorphone are widely used for control of moderate to severe pain and dyspnea in hospice and palliative care patients. Accumulation of the active morphine-3-glucuronide (M3G) and hydromorphone-3-glucuronide (H3G) metabolites is one proposed mechanism for the development of neuroexcitatory effects including allodynia and opioid-induced hyperalgesia (OIH). We report the case of a 43-year-old female hospice patient with metastatic non-small cell lung cancer who initially developed allodynia following morphine administration and again following administration of hydromorphone. The allodynia resolved both times following the discontinuation of the opioid and rotation to a different opioid regimen. Potential opioid-induced neuroexcitatory treatment options include opioid rotation to an agent with inactive metabolites, use of adjuvant pain medications for opioid-sparing effects, management of undesired symptoms (e.g., myoclonus), or increasing opioid clearance with intravenous (IV) fluids. Although the incidence is not well defined in the literature, hospice and palliative care clinicians should suspect OIH in patients with allodynia and/or hyperalgesia, especially when repeated dose escalations do not improve analgesia or pain escalates following opioid dose titration.

Treatment of cancer pain: Spanish Society of Medical Oncology (SEOM) recommendations for clinical practice

Cancer pain should be controlled in most patients, however this is not always achieved. These guidelines describe the classification, evaluation and treatment of chronic cancer pain in accordance with the WHO treatment strategy of pain stages: mild, moderate and severe. For treatment during the third stage, we cover titration and rotation of opioids, as well as their side effects and prevention. Also described is neuropathic pain and refractory pain, coadjuvant treatments and non pharmacological analgesic treatments. Finally, treatment of breakthrough pain is defined.

Successful Treatment of Intractable Low Back and Pelvic Pain Caused by Advanced Prostate Cancer with Intrathecal Clonidine and Baclofen Infusion

Background: Intrathecal opioid infusion therapy has been increasingly utilized in patients with severe malignant and nonmalignant pain syndromes in the past few decades. By infusing small amount of analgesics directly into the cerebrospinal fluid (CSF) in close proximity to the receptor site in the spinal cord, spinally mediated analgesia may be achieved while sparing some of the side effects due to systemic opioids. Traditionally, the most commonly infused analgesic for intrathecal infusion is an opioid. Morphine represents the only FDA-approved opioid for intrathecal administration, although other opioids may also be used off-label. However, in patients who have demonstrated intolerance to oral opioid(s), alternative analgesics may be tried to achieve satisfactory analgesia. Objective: To present a case report of a 73-year old male with intractable low back and pelvic pain due to invasive prostate cancer, unable to tolerate any opioid, being successfully treated by intrathecal infusion of clonidine and baclofen. Case Report: A 73-year-old male with intractable low back pain and pelvic pain due to invasive prostate cancer was referred to our clinic for pain management. The patient had undergone hormonal therapy, radiation therapy, radical prostectomy, and rectal resection. Trial of non-opioid analgesics was unsuccessful in controlling his pain. Multiple opioids trials were complicated by persistent nausea and vomiting. Other interventional techniques were attempted, but only offered short-term efficacy. Intraspinal drug delivery (IDD) therapy was considered and attempted. Considering his intolerance to various oral opioids despite meticulous opioid dose titration, an outpatient continuous epidural infusion of clonidine was conducted, which provided satisfactory analgesia. The patient subsequently underwent permanent IDD pump placement. Results: The intrathecal infusion of clonidine was initiated at 50 mcg/day. Over the following 4 months, the dosage was gradually titrated up to 350 mcg/day, with satisfactory pain relief. However, he did report frequent drowsiness during daytime, which was felt to be due to intrathecal clonidine. The decision to add low dose baclofen to the intrathecal infusion and simultaneously lower the clonidine dose was made. The intrathecal regimen was changed to clonidine 150 mcg/day and baclofen 50 mcg/day. His daytime sleepiness improved significantly and his pain control remained satisfactory. Over the following 3 months, his intrathecal regimen was further titrated to clonidine 200 mcg/day and baclofen 100mcg/day. He remained on this regimen for over 12 months with satisfactory pain relief and without experiencing excessive sedation. Addition of baclofen to intrathecal clonidine infusion led to improved analgesia without affecting his alertness, probably via a synergistic mechanism. Conclusion: Under certain circumstance when intrathecal opioid infusion cannot be tolerated, intrathecal clonidine and baclofen may be used as alternatives to provide spinally mediated antinociception.

Is There A Ceiling Effect For Patient Controlled Analgesia Using Tramadol? A Case Report And Review Of The Literature.

Patient controlled analgesia (PCA) devices are a commonly used method of self-administered intravenous opioid titration postsurgery. Tramadol PCA has been shown to be a safe and effective modality of post-operative analgesia when compared with morphine. Reports of Tramadol toxicity are well documented in the literature; however there are no clear guidelines on maximal doses that should be administered by PCA. We report a case of seizure related to Tramadol and review the literature to determine a safe dosing range for Tramadol PCA.

Managing Pain with Algorithms: An Opportunity for Improvement? Or: The Development and Utilization of Algorithms to Manage Acute Pain

Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committee's efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management.

Severe Pulmonary Hypertension and Right Ventricular Failure Complicate a Total Abdominal Hysterectomy

The 2007 American College of Cardiology/American Heart Association guidelines report that no significant studies have been conducted assessing the perioperative risk of pulmonary hypertension in noncardiac surgery. However, the presence of right ventricular failure has been well documented to have poor prognostic implications. The presence of pulmonary hypertension and right ventricular failure present unique perioperative challenges. These include maintenance of adequate cardiac function, acid-base management, intraoperative monitoring, and postoperative pain management. The authors report the case of a patient with severe pulmonary hypertension who underwent an open total abdominal hysterectomy. The case was complicated by known right ventricular failure, severe portal hypertension, obstructive sleep apnea, extensive smoking history, and systemic anticoagulation therapy. The patient was not a candidate for postoperative neuraxial analgesia because of the timing and dose of systemic anticoagulation. Two-dimensional transesophageal echocardiography was used for real-time visualization and intraoperative cardiac monitoring. The patient was transferred to the intensive care unit for careful titration of opioids and slow ventilator wean to extubation. The postoperative course proceeded without significant morbidity or mortality. (a) Preoperative assessment of pulmonary hypertension, (b) postoperative pain control, (c) cardiovascular stability, and (d) intraoperative monitoring. This case illustrates the unique challenges associated with pulmonary hypertension and right ventricular failure in the setting of noncardiac surgery. This case also demonstrates that continuous, real-time data provided by transesophageal echocardiography can be used to successfully manage a complicated patient with pulmonary hypertension.

Combination of Intrathecal Opioids with Bupivacaine Attenuates Opioid Dose Escalation in Chronic Noncancer Pain Patients

The purpose of this study was to examine the effect of intrathecal (IT) coadministration of bupivacaine with opioids during the initial phase of opioid titration and up to 1 year after implantation of an IT drug delivery system (IDDS). The study was designed as a retrospective study. OUTCOMES ANALYZED: The outcomes analyzed for this study were pain relief, oral opioid consumption, IT opioid, and bupivacaine dosage. METHODS AND PATIENT POPULATION: The patient population for this study were consecutively implanted patients over a period of 6 years in a tertiary single center with multiple practitioners. In this retrospective study, 126 consecutive noncancer intractable pain patients were implanted with IDDS and initiated with an IT opioid (O) as a single medication or an IT opioid and bupivacaine (O + B). Pain intensity, amount of oral opioids, dose, rate, and concentration of IT opioids and bupivacaine, and number and type of IT medication used were recorded at preimplant, implant, and at 3, 6, and 12 months postimplant. The intervention used for the study was the IT delivery device implant. Significant reduction in pain intensity was observed in both groups at 12 months postimplant (O group: baseline 7.42 ± 2.1 to 5.85 ± 2.8 [n = 72, P < 0.001]; O + B group 7.35 ± 2 to 5.03 ± 2.4 (n = 54; P < 0.001]). The combination of opioids with bupivacaine from the start of IT infusion treatment resulted in a reduced progression of opioid dose escalation in comparison to patients started with opioids (O group). The rate of increase of IT opioids in the O group at 12 months was 535 ± 180%, whereas in the O + B, the dose increase was significantly lower at 185 ± 85% (P < 0.004). In both groups, there was a statistically significant decrease in oral opioid consumption compared with preimplant doses. Concomitant initial coadministration of IT bupivacaine with opioids blunts the rate of IT opioid dose escalation during the first year after implant of an IDDS. More studies are necessary to thoroughly examine IT opioid dose escalation and the effects of addition of bupivacaine to IT opioids. Blunting IT opioid dose escalation may be a beneficial long-term effect of IT bupivacaine.

Opioid Titration and Conversion in Patients Receiving Morphine Sulfate and Naltrexone Hydrochloride Extended Release Capsules

Objective: To determine the number of steps and identify characteristics associated with attaining a stable dose of morphine sulfate and sequestered naltrexone extended release capsules (MS-sNT). Patients and Methods: Data from an open-label, long-term multicenter study designed to assess the safety of MS-sNT for managing chronic (≥ 3 m), moderate-to-severe pain were analyzed post hoc. Initial MS-sNT dose was 20 mg twice daily (BID) for opioid-naïve patients and 50% to 75% of current daily opioid dose for opioid-experienced patients. Dose adjustments upward/downward were allowed throughout the study with ≥ 3 days between increases; opioid-experienced patients could increase ≥ 24 hours after initial drug dispensing. Nonopioid analgesics were permitted as rescue medication. Stable dose was defined post hoc as one maintained for 2 consecutive study visits. Results: Overall, 69% of patients (n = 319/465) achieved a stable dose; 85% (n = 272) achieved a stable dose in ≤ 2 titration dose adjustments or “steps,” and 96% (n = 305) achieved a stable dose in ≤ 4 steps. The mean time to stable dose was 28.9 days (standard deviation [SD], 34.1 days); the median was 12 days. A stable dose was achieved in 70% (118/168) of opioid-naïve patients (mean, 24.2 days [SD, 33.4 days]; median, 8 days) and 68% (201/297) of opioid-experienced patients (mean, 31.7 days [SD, 34.3 days]; median, 25 days). A stable dose was achieved by 79% (19/24) of patients who previously used morphine, 64% (27/42) who used oxycodone, 59% (47/79) who used hydrocodone, and 71% (83/117) who used multiple opioids. Baseline pain scores were similar between patients who did and did not achieve a stable dose. At the time of stable dose achievement, average, least, worst, and current pain were all decreased from baseline. Conclusions: The study provides information about anticipated rates of achieving stable opioid dose in patients who received MS-sNT for up to 1 year to manage chronic, moderate-to-severe pain. Both opioid-naïve and opioid-experienced patients achieved a stable dose of MS-sNT, generally in ≤ 2 steps. Opioid experience and previous opioid use may influence ability to achieve a stable dose and number of steps required. More studies are needed on the anticipated experience of opioid titration/conversion to help physicians and patients set expectations for initiation of and conversion between opioid therapies.