Bain KT, Knowlton CH. Role of Opioid-Involved Drug Interactions in Chronic Pain Management. J Am Osteopath Assoc 2019;119(12):839–847. doi: https://doi.org/10.7556/jaoa.2019.136.
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The use of opioids for chronic pain management is extraordinarily common despite substantial evidence of only modest benefits, when compared with nonopioid analgesics. Opioid use is also associated with serious risks, including overdose and death. A growing body of evidence suggests that opioids are involved in significant drug interactions that often go unrecognized in clinical practice. Understanding opioid-involved drug interactions is of great practical importance for all health care professionals caring for patients with chronic pain. In this article, we describe the mechanisms of opioid-involved drug interactions and their potential consequences, which have major public health implications. Additionally, this article provides practical strategies to aid health care professionals in avoiding and mitigating opioid-involved drug interactions in order to obtain a favorable balance in the risk-benefit ratio associated with opioid use. These strategies include using osteopathic principles for chronic pain management, separating the times of administration of the opioid(s) from the nonopioid(s) involved in the interaction, changing the opioid(s) adversely affected by the interaction, changing the nonopioid(s) causing the interaction, and partnering with pharmacists in clinical practice.
a This list includes substrates with moderate to strong affinity for the CYP2D6 isoenzyme and inhibitors of this isoenzyme that can interfere with the metabolism of opioids, especially the activation of prodrug opioids that have weak affinity for the CYP2D6 isoenzyme. However, this list is not all-inclusive.
Abbreviation: CYP, cytochrome P450 system.
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