The end of the line for modified-release opioids in acute pain management: how did we get here?

Abstract

Following announcements from professional and governmental bodies across a number of countries, modified-release (MR) opioids are no longer recommended in the routine management of acute pain, and so should not be initiated for this reason. The recommendations are not new, but a recent cluster of publications by key professional and governmental bodies has more clearly challenged their use and highlighted the need for change in guideline-driven and individual practice. The inclusion of MR opioids in many postoperative pain regimens relatively soon after they were first marketed for use in patients with chronic non-cancer pain, was not based on sound evidence, and there remains no evidence of benefit. In contrast, however, good evidence has accumulated that shows they not only provide less effective pain relief compared with immediate-release opioids, but that they lead to a higher risk of adverse effects including opioid-induced ventilatory impairment and persistent opioid use.