Comparing Combination Analgesics With Longacting Opioids

Only five RCTs have directly compared opioid-para-cetamol combinations with long-acting opioids and a systematic review of three of these trials was incon-clusive.20[I] In one trial, short-acting oxycodone/para-cetamol was just as effective as long-acting oxycodone; however, side effects were greater with the combination therapy.72[II] Two RCTs found that oxycodone 5mg/ paracetamol 325 mg or hydrocodone 7.5 mg/paracetamol 325 mg combinations were as effective as transdermal buprenorphine (5-20 mg/hour) in chronic low back

pain.

Although specific data are lacking, it seems logical to use multimodal analgesia with paracetamol, NSAIDs, or COX-2-specific inhibitors in patients on long-term opioids for chronic pain, if the risks associated with use of adjuvant agents (e.g. NSAIDs and gastrointestinal, renal, or cardiovascular effects) are acceptable. At the very least, multimodal analgesia may provide a degree of opioid-sparing, perhaps reducing dose escalation (due to tolerance or hyperalgesia), or side effects. The use of paracetamol or NSAIDs/COX-2 inhibitors may also be useful in the treatment of breakthrough pain or during opioid rotation.

Based on limited data, fixed-dose combinations of short-acting opioids (including tramadol) and paracetamol may be as effective as long-acting opioids in the treatment of mild-to-moderate CNCP.

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