Profiling non-medical use of tapentadol products among recreational drug abusers

Taryn Dailey-Govoni, Jared Beaumont, Theresa Cassidy
Inflexxion, Inc., Waltham, MA, USA
Presented at PAINWeek 2017
“Profiling non-medical use of tapentadol products among recreational drug abusers”

Purpose
Prescription opioid misuse and abuse is a public health epidemic in the United States (ONDCP 2015) and a growing source of morbidity, mortality, and substance abuse treatment admissions (SAMHSA 2015, SAMHSA 2014, Okie 2010, and Dart 2015). It is crucial to evaluate and characterize the abuse profiles associated with specific opioid compounds and formulations so that prescribers, payers, and patients can make informed decisions regarding pain treatment with opioid medications. Tapentadol is a centrally acting analgesic with two mechanisms of action: opioid receptor agonism and noradrenaline reuptake inhibition (Tzschentke 2013, Kress 2010). Tapentadol has a lower affinity to the opioid receptor compared to morphine and its noradrenaline reuptake inhibition may not be significantly rewarding compared to other opioids, suggesting an opioid-sparing effect and lower abuse potential for tapentadol products (Terlinden 2007, Raffa 2012). Previous literature suggests that the prevalence of non-medical use (NMU) of tapentadol is relatively low compared to other prescription opioid compounds (Butler 2015, Cepeda 2013). However, little has been published on the profile of those who use tapentadol products non-medically, including their motivation for use, methods of administration, tampering efforts, opinions, and experiences with tapentadol products. The Tapentadol Use Internet survey and follow-up semi-structured online interviews were developed to describe and characterize

NMU of tapentadol products (i.e., Nucynta ® and Nucynta ER ®) among a community of recreational drug abusers frequenting the online discussion forum website Bluelight.org.

Methods
A mixed-methods qualitative study was conducted via a survey and in-depth active online interviews to better understand NMU of tapentadol. NMU was defined as use of prescription opioids “in a way not prescribed,” including: 1) taking a medication not prescribed to you, 2) taking a medication for reasons other than what it was prescribed for, and/or 3) using a medication in a way not intended (e.g., taking more than prescribed, using an unintended route of administration, or tampering with the product).

Participants for the survey and interviews were recruited from January through May 2017. To  participate, individuals must have met the following conditions: ability to read/understand English; visited Bluelight.org; consented to participate; at least 18 years of age; resided in the United States; and reported NMU of Nucynta and/or Nucynta ER. Survey participants were asked if they were interested in a follow-up active online interview and, if so, were prompted to provide contact information (Bluelight.org username or email address). Eligibility requirements included the ability to use an online chat program and consent to participate. The survey was administered using the online data collection software Qualtrics. Survey data was analyzed using SAS ® statistical software, with descriptive statistics reported using frequencies and percentages for binary/categorical variables and calculated means, medians, and ranges for continuous variables. Interviews were conducted using Cryptocat, a free, open-source, encrypted online chat program (Cryptocat, 2017). Interview transcripts were qualitatively evaluated by multiple reviewers using a modified Grounded Theory approach.

Results
Seventy-eight adults completed the survey, eight of whom completed a follow-up interview. Most survey participants were under 35 years old, male, White, and completed at least some college. Over half  indicated opioids were their preferred recreational substance. A similar demographic profile was noted among the subset (n=8) who completed the follow-up interview.

Among survey participants, NMU of Nucynta IR (n=67) was indicated more frequently than Nucynta ER (n=30) (19 used both formulations). Oral routes were the most common route for both products. Compared to Nucynta IR, a greater proportion of Nucynta ER users indicated tampering with the  product. Motivations for NMU of tapentadol included enhanced pain relief, self-medication of  anxiety/depression, alleviation of withdrawal, experimentation, and/or to get high. Most who indicated NMU of Nucynta ER and IR no longer used these products at the time of survey completion (73.3% and 82.1%), citing lack of access, better options, ineffective or unpleasant high, and/or negative side effects.

The highest median NMU desirability ratings were given to oxymorphone (ER and IR), oxycodone (ER and IR), and morphine IR. Median desirability ratings were comparatively low for tapentadol products and desirability of tapentadol IR was greater than that of tapentadol ER. Among interview participants (n=8), all reported NMU of Nucynta IR and half indicated NMU of Nucynta ER. Most used tapentadol orally, and those who had used both formulations of Nucynta typically preferred the IR version.  Interview participants shared that tapentadol was a rare, unique opioid that was not well known among recreational drug abusers. While some interviewees experienced no high when using tapentadol, others experienced recreational effects along with hallucinations and/or other atypical effects at higher dosages. Opinions of tapentadol were influenced by opioid tolerance and individual preferences.

Conclusions
This mixed methods study contributes valuable qualitative information on NMU of tapentadol products. Tapentadol was characterized as a unique opioid with atypical effects, including hallucinations at a high milligram dosage. Nucynta products were typically used via oral routes, and tampering was more  common with the ER formulation. Desirability ratings were low for tapentadol relative to other opioid compounds. These data suggest that, among this community of recreational drug abusers, tapentadol may be less attractive for NMU compared to other prescription opioid compounds, and the ER  formulation of Nucynta is less attractive for NMU compared to the IR version.