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to predict which patients will require
laxatives. This trend may be explained
by lack of published information on this
new formulation, coupled with limited
experience in its use in practice.
It is postulated that a high proportion of
patients who were recruited onto both
cohorts were acute, post-interventional
patients. There were only a limited
number of true chronic pain patients
for whom the products are licensed.
This probably explains why most
patients required small amounts of
additional analgesia in the form of
immediate release oxycodone. Both
preparations are indicated for chronic-
severe disabling pain with a steady
blood level being required to maintain
effectiveness. Although the onset of
analgesia with controlled release (CR)
oxycodone is equivalent to that of
immediate-release (IR) preparations.15
At the time of data collection, steady
state may not have been established.
This would in turn necessitate the need
for additional analgesia to maintain
consistent pain relief. However, there
is no evidence for a suitable timeframe
required for bridging or supplemental
analgesia when using these products in
the acute setting. This study indicates
patients with acute pain using the
combination product are more likely
to require some additional analgesia to
effectively manage with pain relief.
Utilisation of products in situations for
which they are not licensed ('off-label')
warrants attention from hospital
decision makers. In this study, two
low-priced and prevalent medications
employed off-label were examined.
A possibility for this observed practice
is the interruption of around-the-clock
dosing schedules with immediate
release (IR) formulations, which
especially during the hours of sleep may
cause or exacerbate pain. Both products
in this study are controlled release (CR)
preparations which reduce the number
of daily doses, facilitating uninterrupted
night time sleep and decreasing nursing
time required for drug administration.
Some studies also suggest that CR
products are associated with a shorter
length of stay.15 It may be possible the
licensing of both medications does not
reflect clinical practice, or our results
reflect a common off-label prescription
culture within the hospital.
Generally, the greater expense of newer
combination products is based on
the premise that use will be offset by
decreased administration costs when
compared to dispensing two separate
agents. Although oxycodone/naloxone
patients required fewer laxatives, this
cost-saving effect was offset by the
increase in amount of supplemental
immediate release oxycodone
co-administered. Furthermore, this
additional analgesia would have led to
consequential increases in staff costs
and patient pain or discomfort. It was
evident in this study, when the new
combination product is potentially
used off-label; the initial greater cost is
further compounded by supplemental
expenses that need to be considered in
the decision-making process (Table 3).
At present, the hospital has no policy
or procedure for the introduction of
new combination products. This study
highlights the need for a clinical practice
guideline for the appropriate use of new
products, but also a directive on the
co-prescription of auxiliary medications.
A consistent finding was that the usage
of oxycodone/naloxone and oxycodone
alone differ in the hospital, with the
combination product being more
expensive. There were additional costs
incurred through the use of adjunct and
This was a descriptive study of
shifting clinical practices following
the introduction of a new
combination preparation compared
to the conventional counterpart.
Further studies are needed to explain
the sudden rapid growth of off-label
prescribing when new products are
introduced. In addition, clarity is needed
around the irregularities observed in the
prescription of supplemental analgesia
and laxative agents with these two
formulations. Differences in direct and
indirect costs involved with introducing
new combination products into practice
also need scrutiny.
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