Are extended release opioids always more dangerous than immediate release opioids?
No. In fact, if used properly, extended release opioids may be a safer option of treatment over immediate release opioids but only if taken as intended. Use of certain extended release (ER) opioid preparations may actually result in less total daily opioid dose than use of short acting opioids. Therefore, the prescriber must be knowledgeable about the specific preparation being prescribed to prescribe safely and effectively. Potential benefits of extended release opioids include less sedation, decreased fall risk, and less end-of-dose failure. Despite these known benefits, use of extended release opioids is also a known risk factor for opioid-induced respiratory depression (OIRD) if misused or abused, but also even if used appropriately. Furthermore, despite relatively low prescribing rates, methadone is responsible for up to 30 percent of overdose deaths, likely due to prescribing by inexperienced providers unfamiliar with its complex pharmacokinetics, and extensive risk for both drug interactions and variable half-life due to interpatient variability by genetic phenotype. Although methadone is classified as a “long-acting” drug by the US Food and Drug Administration (FDA), it in fact has only 6 to 8 hours of analgesic activity, but does have a long and variable half-life with a large volume of distribution.