Pain relief in the ASC setting: Sublingual formulation offer new alternative

Poorly controlled post-operative pain negatively affects patients' cardiovascular systems, blood clotting mechanisms and immune systems. It also has been shown to contribute to the development of chronic pain. Effective management of post-operative pain has the potential to improve health outcomes and reduce hospital readmissions.

In the past, post-operative pain treatment was overly reliant on traditional narcotic painkillers that could be prescribed for use outside the medical setting. This contributed to America's opioid crisis. Fortunately, new pain control alternatives especially well-suited for the ASC setting have emerged in recent years.

At Becker's ASC 26th Annual Meeting in Chicago, AcelRx sponsored a workshop to explore how ASCs can address acute moderate to severe pain. Jacob L. Hutchins, MD, assistant professor in the department of surgery and division head in the department of anesthesiology at the University of Minnesota Medical School in Minneapolis, led the discussion.

Multimodal pain control in the ambulatory surgery center

In the last five to seven years, the healthcare sector has seen a rise in multimodal pain control. Dr. Hutchins explained, "Every patient coming into our surgery center gets acetaminophen and multimodal treatments like a local anesthetic, liposomal bupivacaine and nerve blocks. We try to combat pain in as many ways as possible." Despite these measures, some patients still experience pain that is severe enough to require an opiate.

In the operating room, pain medications in intravenous form are the most common. Many ambulatory surgery centers, however, promptly remove IVs to get patients moving quickly. If patients have a severe pain flare at that point, oral pain relievers are typically used — yet these can take 30 to 60 minutes to take effect. Intramuscular administration of pain medications is usually avoided, since it is painful.

DSUVIA: A new option for pain relief

A new pain relief alternative is DSUVIA, the first sublingual formulation of sufentanil. This drug is designed to treat acute moderate to severe pain in a medically supervised setting. Clinicians have had access to many IV, intramuscular and oral medications for acute pain, but have had limited sublingual delivery options.

Although DSUVIA is an opioid, it is not intended for use in the patient's home. To minimize diversion, abuse or misuse, it can only be used in medically supervised settings such as hospitals, surgery centers or hospital outpatient facilities. Dr. Hutchins noted, "If you are going to use this medication, you must sign a [FDA Risk Evaluation and Mitigation Strategies contract]. This means you commit to not prescribe this drug on an outpatient basis."

DSUVIA is a 30-microgram tablet that is administered under the tongue in the sublingual space. The tablet has a bioadhesive surface and begins to dissolve quickly once placed under the tongue. Patients should avoid swallowing DSUVIA, because this inhibits absorption and prevents effective pain relief.

DSUVIA can be taken as needed, but no more than once an hour with a maximum of 12 doses in a 24-hour period. During clinical trials, teams saw a 15-minute onset and a duration of effect around three hours. "The plasma half-time for the sublingual formulation is approximately 2.5 hours, compared to 0.2 hours for the IV formulation. This translates into longer pain relief for patients with moderate to severe acute pain," Dr. Hutchins said.

The most common adverse effects associated with DSUVIA in the pivotal clinical trial were nausea, headache, vomiting, dizziness and hypotension. No patients required Naloxone use.

Conclusion

DSUVIA offers a new option for clinicians in a variety of scenarios, such as when patients are preparing for discharge and their IV has been removed, in the post-anesthesia care unit if the IV has become dislodged, or before short procedures to ensure that patients are comfortable when they wake up.

As Dr. Hutchins noted, "Unfortunately, we aren't at that point in the pain control world where we are able to minimize or completely eliminate opioids in every patient. DSUVIA is another tool in your toolbox when you need a sublingual formulation."

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