Buprenorphine vs. Opioid Dose Escalation Among Patients With Chronic Pain (Bup)
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|ClinicalTrials.gov Identifier: NCT01875848|
Recruitment Status : Terminated (Data safety monitoring board recommended due to low recruitment yield.)
First Posted : June 12, 2013
Results First Posted : December 21, 2016
Last Update Posted : December 21, 2016
|Condition or disease||Intervention/treatment||Phase|
|Pain||Drug: buprenorphine/naloxone Drug: opioid dose escalation||Phase 4|
Increasingly, Veterans are prescribed potent opioid analgesics for the treatment of chronic pain despite limited evidence for efficacy and increasing evidence of serious harms including addiction and non-fatal and fatal overdose. While guidelines recommend consideration of dose increase for patients not benefitting from opioid therapy, the rates of major harms are directly related to dose. Higher doses may also be more likely to precipitate opioid-induced hyperalgesia, a paradoxical increased pain response, in susceptible individuals. In summary, opioid dose increase, a currently accepted clinical response to poorly controlled pain, may offer little benefit and certainly increases risk, especially in patients already on moderate-high doses (30-100 mg daily morphine equivalents). Alternative treatment strategies to opioid dose escalation that lessen risk and possibly increase benefit are much needed.
Switching to buprenorphine/naloxone (BUP/NX), a partial opioid agonist approved for use in the treatment of opioid abuse/dependence, may be a safe and effective alternative strategy to opioid dose escalation in the treatment of chronic pain. As a partial agonist, there is a ceiling to BUP/NX's respiratory depressant and other opioid-like effects, meaning it is less likely to cause addiction and overdose. Additionally, there are pre-clinical data to suggest BUP/NX is less likely to produce opioid-induced hyperalgesia and may even reverse it in patients switched from full agonist opioids. Case series have demonstrated improvements in pain, functional status and quality of life among patients switched from full agonist opioids to BUP/NX for chronic pain. Controlled trials are needed to establish BUP/NX's efficacy compared to opioid dose escalation in the treatment of poorly-controlled pain.
The investigators propose a pilot 12-week, open label randomized trial of BUP/NX compared to opioid dose escalation among patients with poorly-controlled pain on the primary outcome of pain intensity. As patient acceptance of either opioid dose escalation or BUP/NX is unknown, the investigators' first objective is to assess willingness to enroll in a randomized trial and reasons for and against enrollment among eligible patients. The study will compare treatments on the primary outcome of pain intensity, measured using the 11-point pain numerical rating scale, and secondary outcomes of pain interference, using the Brief Pain Inventory functional interference subscale, medication adherence and patient global assessment of change. Mixed models will be employed in the analysis to accommodate potential unbalanced repeated measures with missing data. Effect size estimates will be used to generate sample size projections for a definitive trial. This line of research is a direct extension of the PI's HSR&D-funded CDA-2 project developing a screening tool to identify low efficacy opioid use in primary care and also well-aligned with the Strategic Plan and Focused Area of Research of the Pain Research, Informatics, Medical comorbidities, and Education (PRIME) Center's proposal for a Center of Innovation (COIN) and its strategic objective to "Promote access, continuity, and sustainability of safe and effective interventions for pain and pain-related disability."
|Study Type :||Interventional (Clinical Trial)|
|Actual Enrollment :||7 participants|
|Intervention Model:||Parallel Assignment|
|Masking:||None (Open Label)|
|Official Title:||Buprenorphine vs. Opioid Dose Escalation Among Patients With Chronic Pain|
|Study Start Date :||December 2013|
|Actual Primary Completion Date :||June 2015|
|Actual Study Completion Date :||June 2015|
induction onto buprenorphine/naloxone from opioid treatment
partial opioid agonist
Other Name: Suboxone
Active Comparator: opioid dose escalation
increase of up to 25% of current opioid dose
Drug: opioid dose escalation
up to 25% increase in patient's current opioid dose
Other Name: No other names
- Change in Numeric Rating Scale of Pain Severity [ Time Frame: Baseline and 12 wks ]Validated 11 pt scale 0-10, to evaluate a patient's current severity of pain. A rating of 0 indicates no pain while 10 indicates the worst pain imaginable. A score of 4 or above is considered a clinically significant pain level according to VHA treatment guidelines.
- Patient Global Impression of Change (PGIC) [ Time Frame: 12 wks ]The "Patient Global Impression of Change Scale" (PGIC) is one question capturing the individual's overall perception of efficacy of treatment in a clinical trial. It uses verbal outcome categories on a 7-point scale with "very much worse" and "very much better" as anchors and "no change" in the middle. The verbal categories were coded on a scale with -3 "very much worse",+3 "very much better", and 0 "same". To calculate the mean and standard deviation of each group (Bup/Opioid Increase) we took the sum of each participants final PGIC score and divided by the total number of participants.
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01875848
|United States, Connecticut|
|VA Connecticut Healthcare System West Haven Campus, West Haven, CT|
|West Haven, Connecticut, United States, 06516|
|Principal Investigator:||William C Becker, MD||VA Connecticut Healthcare System West Haven Campus, West Haven, CT|