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Withey SL, Cao L, de Moura FB, Cayetano KR, Rohan ML, Bergman J, Kohut SJ. Fentanyl-induced changes in brain activity in awake nonhuman primates at 9.4 Tesla. Brain Imaging Behav 2022; 16:1684-1694. [PMID: 35226333 DOI: 10.1007/s11682-022-00639-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 12/17/2022]
Abstract
Functional magnetic resonance imaging (fMRI) has been used to study the influence of opioids on neural circuitry implicated in opioid use disorder, such as the cortico-striatal-thalamo-cortical (CSTC) circuit. Given the increase in fentanyl-related deaths, this study was conducted to characterize the effects of fentanyl on patterns of brain activation in awake nonhuman primates. Four squirrel monkeys were acclimated to awake scanning procedures conducted at 9.4 Tesla. Subsequently, test sessions were conducted in which a dose of fentanyl that reliably maintains intravenous (IV) self-administration behavior in monkeys, 1 μg/kg, was administered and the effects on patterns of brain activity were assessed using: (1) a pharmacological regressor to elucidate fentanyl-induced patterns of neural activity, and (2) seed-based approaches targeting bilateral anterior cingulate, thalamus, or nucleus accumbens (NAc) to determine alterations in CSTC functional connectivity. Results showed a functional inhibition of BOLD signal in brain regions that mediate behavioral effects of opioid agonists, such as cingulate cortex, striatum and midbrain. Functional connectivity between each of the seed regions and areas involved in motoric, sensory and cognition-related behavior generally decreased. In contrast, NAc functional connectivity with other striatal regions increased. These results indicate that fentanyl produces changes within CSTC circuitry that may reflect key features of opioid use disorder (e.g. persistent drug-taking/seeking) and thereby contribute to long-term disruptions in behavior and addiction. They also indicate that fMRI in alert nonhuman primates can detect drug-induced changes in neural circuits and, in turn, may be useful for investigating the effectiveness of medications to reverse drug-induced dysregulation.
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Affiliation(s)
- Sarah L Withey
- Behavioral Biology Program, McLean Hospital - Harvard Medical School, 115 Mill Street, Belmont, MA, 02478, USA.
| | - Lei Cao
- Behavioral Neuroimaging Laboratory, McLean Hospital - Harvard Medical School, Belmont, MA, USA.,McLean Imaging Center, McLean Hospital - Harvard Medical School, Belmont, MA, USA
| | - Fernando B de Moura
- Behavioral Biology Program, McLean Hospital - Harvard Medical School, 115 Mill Street, Belmont, MA, 02478, USA.,Behavioral Neuroimaging Laboratory, McLean Hospital - Harvard Medical School, Belmont, MA, USA.,McLean Imaging Center, McLean Hospital - Harvard Medical School, Belmont, MA, USA
| | - Kenroy R Cayetano
- McLean Imaging Center, McLean Hospital - Harvard Medical School, Belmont, MA, USA
| | - Michael L Rohan
- McLean Imaging Center, McLean Hospital - Harvard Medical School, Belmont, MA, USA
| | - Jack Bergman
- Behavioral Biology Program, McLean Hospital - Harvard Medical School, 115 Mill Street, Belmont, MA, 02478, USA
| | - Stephen J Kohut
- Behavioral Biology Program, McLean Hospital - Harvard Medical School, 115 Mill Street, Belmont, MA, 02478, USA.,Behavioral Neuroimaging Laboratory, McLean Hospital - Harvard Medical School, Belmont, MA, USA.,McLean Imaging Center, McLean Hospital - Harvard Medical School, Belmont, MA, USA
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Murphy GS, Avram MJ, Greenberg SB, Shear TD, Deshur MA, Dickerson D, Bilimoria S, Benson J, Maher CE, Trenk GJ, Teister KJ, Szokol JW. Postoperative Pain and Analgesic Requirements in the First Year after Intraoperative Methadone for Complex Spine and Cardiac Surgery. Anesthesiology 2020; 132:330-342. [PMID: 31939849 DOI: 10.1097/aln.0000000000003025] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Methadone is a long-acting opioid that has been reported to reduce postoperative pain scores and analgesic requirements and may attenuate development of chronic postsurgical pain. The aim of this secondary analysis of two previous trials was to follow up with patients who had received a single intraoperative dose of either methadone or traditional opioids for complex spine or cardiac surgical procedures. METHODS Preplanned analyses of long-term outcomes were conducted for spinal surgery patients randomized to receive 0.2 mg/kg methadone at the start of surgery or 2 mg hydromorphone at surgical closure, and for cardiac surgery patients randomized to receive 0.3 mg/kg methadone or 12 μg/kg fentanyl intraoperatively. A pain questionnaire assessing the weekly frequency (the primary outcome) and intensity of pain was mailed to subjects 1, 3, 6, and 12 months after surgery. Ordinal data were compared with the Mann-Whitney U test, and nominal data were compared using the chi-square test or Fisher exact probability test. The criterion for rejection of the null hypothesis was P < 0.01. RESULTS Three months after surgery, patients randomized to receive methadone for spine procedures reported the weekly frequency of chronic pain was less (median score 0 on a 0 to 4 scale [less than once a week] vs. 3 [daily] in the hydromorphone group, P = 0.004). Patients randomized to receive methadone for cardiac surgery reported the frequency of postsurgical pain was less at 1 month (median score 0) than it was in patients randomized to receive fentanyl (median score 2 [twice per week], P = 0.004). CONCLUSIONS Analgesic benefits of a single dose of intraoperative methadone were observed during the first 3 months after spinal surgery (but not at 6 and 12 months), and during the first month after cardiac surgery, when the intensity and frequency of pain were the greatest.
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Affiliation(s)
- Glenn S Murphy
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois (G.S.M., S.B.G., T.D.S., M.A.D., D.D., S.B., J.B., C.E.M., G.J.T., K.J.T., J.W.S.) the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (M.J.A.)
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Machado FC, Palmeira CCDA, Torres JNL, Vieira JE, Ashmawi HA. Intraoperative use of methadone improves control of postoperative pain in morbidly obese patients: a randomized controlled study. J Pain Res 2018; 11:2123-2129. [PMID: 30323647 PMCID: PMC6174683 DOI: 10.2147/jpr.s172235] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives Surgical patients still commonly experience postoperative pain. With the increasing prevalence of obesity, there is a growing demand for surgical procedures by this population. Intraoperative use of methadone has not been well assessed in this population. Materials and methods Patients with a body mass index of 35 kg/m2 or more undergoing bariatric surgery were randomly assigned to receive either fentanyl (group F) or methadone (group M) in anesthesia induction and maintenance. The primary outcome was morphine consumption during the first 24 hours after surgery through a patient-controlled analgesia device. Secondary outcomes were pain scores at rest and while coughing, opioid related side effects, and patient satisfaction. The patients were also evaluated 3 months after surgery for the presence of pain, dysesthesia, or paresthesia at surgical site. Results Postoperative morphine consumption was significantly higher for patients receiving fentanyl than methadone during the postoperative period at 2 hours (mean difference [MD] 6.4 mg; 95% CI 3.1-9.6; P<0.001), 2-6 hours (MD 11.4 mg; 95% CI 6.5-16.2; P<0.001), 6-24 hours (MD 10.4 mg; 95% CI 5.0-15.7; P<0.001), and 24-48 hours (MD 14.5 mg; 95% CI 3.9-25.1; P=0.01). Patients from group F had higher pain scores until 24 hours postoperatively, higher incidence of nausea and vomiting, lower satisfaction, and more evoked pain at surgical scar at the 3-month postoperative evaluation than group M. Conclusion Intraoperative methadone can safely lower postoperative opioid consumption and improve postoperative pain scores compared with fentanyl in morbidly obese patients.
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Affiliation(s)
| | | | | | - Joaquim Edson Vieira
- Anesthesiology Department, hcFMUsP, Universidade de São Paulo, São Paulo, Brazil,
| | - Hazem Adel Ashmawi
- Anesthesiology Department, hcFMUsP, Universidade de São Paulo, São Paulo, Brazil,
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Ma K, Ma P, Lu H, Liu S, Cao Q. Fentanyl Suppresses the Survival of CD4+T Cells Isolated from Human Umbilical Cord Blood through Inhibition of IKKs-mediated NF-κB Activation. Scand J Immunol 2017; 85:343-349. [PMID: 28199730 DOI: 10.1111/sji.12538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/09/2017] [Indexed: 11/29/2022]
Affiliation(s)
- K. Ma
- Department of Anesthesiology; The Fourth Hospital of Shijiazhuang; Shijiazhuang China
| | - P. Ma
- Department of Anesthesiology; The First Hospital of Shijiazhuang; Shijiazhuang China
| | - H. Lu
- ICU; The Second Hospital of Hebei Medical University; Shijiazhuang China
| | - S. Liu
- Department of Anesthesiology; The Fourth Hospital of Shijiazhuang; Shijiazhuang China
| | - Q. Cao
- The Fourth Hospital of Shijiazhuang; Shijiazhuang China
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Mercadante S, Bruera E. Opioid switching in cancer pain: From the beginning to nowadays. Crit Rev Oncol Hematol 2016; 99:241-8. [DOI: 10.1016/j.critrevonc.2015.12.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/02/2015] [Accepted: 12/22/2015] [Indexed: 11/15/2022] Open
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Abstract
Abstract
Background:
The intensity of pain after cardiac surgery is often underestimated, and inadequate pain control may be associated with poorer quality of recovery. The aim of this investigation was to examine the effect of intraoperative methadone on postoperative analgesic requirements, pain scores, patient satisfaction, and clinical recovery.
Methods:
Patients undergoing cardiac surgery with cardiopulmonary bypass (n = 156) were randomized to receive methadone (0.3 mg/kg) or fentanyl (12 μg/kg) intraoperatively. Postoperative analgesic requirements were recorded. Patients were assessed for pain at rest and with coughing 15 min and 2, 4, 8, 12, 24, 48, and 72 h after tracheal extubation. Patients were also evaluated for level of sedation, nausea, vomiting, itching, hypoventilation, and hypoxia at these times.
Results:
Postoperative morphine requirements during the first 24 h were reduced from a median of 10 mg in the fentanyl group to 6 mg in the methadone group (median difference [99% CI], −4 [−8 to −2] mg; P < 0.001). Reductions in pain scores with coughing were observed during the first 24 h after extubation; the level of pain with coughing at 12 h was reduced from a median of 6 in the fentanyl group to 4 in the methadone group (−2 [−3 to −1]; P < 0.001). Improvements in patient-perceived quality of pain management were described in the methadone group. The incidence of opioid-related adverse events was not increased in patients administered methadone.
Conclusions:
Intraoperative methadone administration resulted in reduced postoperative morphine requirements, improved pain scores, and enhanced patient-perceived quality of pain management.
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Poulain P, Michenot N, Delorme T, Filbet M, Hubault P, Jovenin N, Rostaing S, Colin E, Chvetsoff G, Ammar D, Delorme C, Diquet B, Krakowski I, Magnet M, Minello C, Morere JF, Serrie A. Mise au point sur l’utilisation pratique de la méthadone dans le cadre des douleurs en oncologie. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.douler.2014.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Turabi A, Plunkett AR. The application of genomic and molecular data in the treatment of chronic cancer pain. J Surg Oncol 2012; 105:494-501. [DOI: 10.1002/jso.21707] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Mercadante S, Bruera E. The effect of age on opioid switching to methadone: a systematic review. J Palliat Med 2012; 15:347-51. [PMID: 22352334 DOI: 10.1089/jpm.2011.0198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this review was to assess from the existing literature the effect of age on the outcome of opioid switching to methadone, and the possible influence on conversions ratios. DISCUSSION Older patients represent a challenge for physicians, as a further factor may play a role in dosing methadone and possibly on successful switching. Although existing data are not conclusive because this aspect did not receive particular attention in most studies, at the present time age has not been found to be independently associated with the dose ratio. Further prospective studies in a large sample of patients, subgrouped for classes of age, opioid doses, and reasons to switch, should be designed to provide more information.
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Affiliation(s)
- Sebastiano Mercadante
- Pain Relief and Palliative Care Unit, La Maddalena Cancer Center & Palliative Medicine, University of Palermo, Palermo, Italy.
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Dale O, Moksnes K, Kaasa S. European Palliative Care Research Collaborative pain guidelines: opioid switching to improve analgesia or reduce side effects. A systematic review. Palliat Med 2011; 25:494-503. [PMID: 21708856 DOI: 10.1177/0269216310384902] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
According to a Cochrane review on opioid switching, sound evidence on the practice of substituting one strong opioid with another to improve pain control and reduce adverse effects was lacking in 2004. A systematic search strategy was developed to include studies after 2004, with adult cancer patients switching between strong opioids and reporting estimates of effect on pain and adverse effects. The search retrieved 288 publications (71 duplicates); 187 abstracts and 19 full papers were excluded. Eleven papers met the inclusion criteria; none were randomized controlled trials/meta-analyses. Studies comprised 280 patients (group size 10-32). A variety of opioids and switching strategies were studied. Pain intensity was significantly reduced in the majority of studies. Serious adverse effects were improved. Due to serious design limitations, the level of evidence was low (D). Randomized trials, with standardization of cohort classification, use of outcomes and analysis are warranted to establish the practice of opioid switching.
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Affiliation(s)
- Ola Dale
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Norway.
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Mercadante S, Caraceni A. Conversion ratios for opioid switching in the treatment of cancer pain: a systematic review. Palliat Med 2011; 25:504-15. [PMID: 21708857 DOI: 10.1177/0269216311406577] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this paper we describe the results of a systematic search of the literature on conversion ratios during opioid switching. This is part of a project of the European Palliative Care Research Collaboration to update the European Association for Palliative Care recommendations for the use of opioid analgesics in the treatment of cancer pain. Studies were eligible for inclusion if they involved adult patients with chronic cancer pain, contained data on opioid conversion ratios, were prospective and were written in English. Thirty-one studies were identified and included. The majority of the studies had methodological flaws and were not designed to explore or demonstrate equianalgesic dose data. However, the data allow some recommendations to be made that could be helpful to clinicians for whom there are few reliable experimental data on which to base dosing guidelines. Switching to transdermal fentanyl (TDfe) or buprenorphine (TDbu) is an option for patients with stable, controlled pain. Reliable and consistent studies show a ratio of 100 : 1 between oral morphine (ORmo) and TDfe. A ratio of 75 : 1 between ORmo and TDbu may be appropriate, but the supporting evidence here is much less robust. Data are relatively consistent to support a conversion ratio between ORmo and oral hydromorphone (ORhy) of 5 : 1. Despite some limitations, there is evidence to support the use of an approximate conversion ratio of ORmo:oral oxycodone (ORox) of 1.5 : 1. The conversion between ORox and ORhy is estimated to be 1 : 4. When switching from different opioids to methadone the conversion ratio is highly variable, ranging from 5 : 1 to 10 : 1 and much higher in some studies. The derived ratios are influenced by several factors, including the reasons for switching and previous opioid doses. An individual treatment decision and strict monitoring is recommended for patients considered at risk.
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Abstract
BACKGROUND Methadone is an opioid analgesic of step 3 of the World Health Organization (WHO) analgesic ladder. AIM AND METHODS To outline pharmacodynamics, pharmacokinetics, drug interactions, equianalgesic dose ratio with other opioids, dosing rules, adverse effects and methadone clinical studies in patients with cancer pain. A review of relevant literature on methadone use in cancer pain was conducted. RESULTS Methadone is used in opioid rotation and administered to patients with cancer pain not responsive to morphine or other strong opioids when intractable opioid adverse effects appear. Methadone is considered as the first strong opioid analgesic and in patients with renal impairment. Methadone possesses different pharmacodynamics and pharmacokinetics in comparison to other opioids. The advantages of methadone include multimode analgesic activity, high oral and rectal bioavailability, long lasting analgesia, lack of active metabolites, excretion mainly with faeces, low cost and a weak immunosuppressive effect. The disadvantages include long and changeable plasma half-life, high bound to serum proteins, metabolism through P450 system, numerous drug interactions, lack of clear equianalgesic dose ratio to other opioids, QT interval prolongation, local reactions when administered subcutaneously. CONCLUSIONS Methadone is an important opioid analgesic at step 3 of the WHO analgesic ladder. Future controlled studies may focus on establishment of methadone equianalgesic dose ratio with other opioids and its role as the first strong opioid in comparative studies with analgesia, adverse effects and quality of life taken into consideration.
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Affiliation(s)
- W Leppert
- Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland.
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