54 PHARMACY TODAY฀•฀OCTOBER 2007 www.pharmacytoday.org Pharmacist perspective on extended release analgesics for persistent pain Jeffrey Fudin, Bill H. McCarberg, Gavril Pasternak, Leslie N. Schechter, Sidney H. Schnoll, and Stephen D. Lande Objective: To provide an overview of the key patient- and drug-related issues relevant to the use of extended release (ER) versus immediate release (IR) analgesics and the variables that must be taken into consideration when select- ing a specific type of ER analgesic to optimize treatment, such as efficacy, dos- ing, safety, drug–drug and drug–disease interactions, and abuse and diversion issues. Data sources: Published articles identified through bibliographies from gath- ered articles. Study selection: By the authors. Data extraction: By the authors. Data synthesis: Persistent pain is a prevalent condition experienced by about 25% of Americans that continues to spur the use of prescription analgesic med- ications. ER analgesic formulations have been introduced that may offer several advantages over IR formulations, such as reduced “pill” burden, improved con- venience and adherence, and around-the-clock pain relief. ER analgesics offer more consistent steady-state plasma levels without the more pronounced peaks and troughs associated with short-acting formulations, leading to reduced adverse events. In this article, the formulations of ER analgesics and the practi- cal considerations, therapy options, and potential issues associated with them are discussed. In addition, several brief case studies are presented to highlight some of the clinical scenarios in which specific types of ER analgesics may offer greater benefit with less risk than other analgesics. Conclusion: Pharmacists are uniquely positioned to assess patients’ response to therapy with and susceptibility to risk from ER analgesics and to counsel patients on the differences between specific analgesic classes and products. Keywords: Analgesic, nonsteroidal anti-inflammatory, opioid, pain, pain man- agement. Pharmacy Today. 2007(Oct):13(10):54–68. painmanagement Abstract Jeffrey Fudin, PharmD, is Clinical Pharmacy Specialist, Pain Management, Department of Veterans Affairs Medical Center, Albany, N.Y. Bill H. McCarberg, MD, is Staff Physician, Kaiser Permanente, Escondido, Calif. Gavril Pasternak, MD, PhD, is Attending Neurologist, Memorial Sloan Kettering Cancer Center, New York Leslie N. Schechter, PharmD, is Advanced Practice Pharmacist, Nutrition and Pain Management, Thomas Jefferson Univer- sity Hospital, Philadelphia Sidney H. Schnoll, MD, PhD, is Vice Presi- dent of Pharmaceutical Risk Management, Pinney Associates, Inc., Bethesda, Md. Stephen D. Lande, PhD, is Executive Vice President, Interactive Forums, Inc., Bala Cynwyd, Pa. Disclosure: Support for the prepara- tion and publication of this article was provided by PRICARA, a unit of Ortho- McNeil, Inc. C hronic pain—pain that persists beyond the normal healing period and disrupts sleep and normal daily activities—remains a prevalent con- dition that drives the use of OTC and prescription analgesic use. 1 Indeed, persistent noncancer pain, specifically musculoskeletal pain, is the chief symp- tom that triggers new visits to primary care physicians. 2 The American Pain Foundation estimates that about 25% of all Americans experience persistent pain, and about 10% take prescription medication to manage it. 3 In 2006, prescription analgesics accounted for 7.2% (almost 266 million) of all prescriptions dispensed (about 3.7 billion) in all pharmacy settings and for 7.7% of all prescriptions dispensed in the community pharmacy sector. Extended release (ER) prescription analgesics accounted for 7.0% (about 181 million) of all prescription analgesics dispensed in 2006 and 6.2% of all prescription analgesics dispensed in the community pharmacy sector. The annual percentage growth rate in volume of ER analgesics has increased during the period 2003 to 2006, from 9.3% in 2003 to 11.4% in 2006. During 2003 to 2006, the annual percentage growth rate in volume of all analgesics increased from 4.0% to 5.7%. As a result, for pharmacists, analgesics, and increasingly ER analgesics, are among the most commonly dispensed prescriptions. 4 Indeed, community pharmacists are at the forefront of balancing analgesic drug efficacy with risks across an array