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Angeli A, Micheli L, Turnaturi R, Pasquinucci L, Parenti C, Alterio V, Di Fiore A, De Simone G, Monti SM, Carta F, Di Cesare Mannelli L, Ghelardini C, Supuran CT. Discovery of a novel series of potent carbonic anhydrase inhibitors with selective affinity for μ Opioid receptor for Safer and long-lasting analgesia. Eur J Med Chem 2023; 260:115783. [PMID: 37678143 DOI: 10.1016/j.ejmech.2023.115783] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023]
Abstract
In this study, we investigated the development of dual-targeted ligands that bind to both μ-opioid receptor (MOR) and carbonic anhydrase (CA) enzymes, using fentanyl structure as a template. We synthesized and evaluated 21 novel compounds with dual-targeted affinity identifying the lead candidate compound 8, showing selective affinity for MOR and potent inhibition of several cytosolic CA isoforms. By means of repeated treatment of 3 daily administrations for 17 days, fentanyl (0.1 mg/kg, subcutaneously) led to tolerance development, pain threshold alterations and withdrawal symptoms in CD-1 mice, as well as astrocyte and microglia activation in the dorsal horn of the lumbar spinal cord. In contrast, compound 8 (0.32 mg/kg s.c.) maintained stable during days its analgesic effect at the higher dose tested with fewer withdrawal symptoms, allodynia development and glial cells activation. Our results suggest that targeting both MOR and CA enzymes can lead to the development of new class of potent analgesic agents with fewer side effects and reduced tolerance development. Further studies are needed to explore the potential mechanisms underlying these effects and to further optimize the therapeutic potential of these compounds.
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Affiliation(s)
- Andrea Angeli
- NEUROFARBA Department, Sezione di Scienze Farmaceutiche, University of Florence, Via Ugo Schiff 6, 50019, Sesto Fiorentino, Florence, Italy.
| | - Laura Micheli
- Pharmacology and Toxicology Section, Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Viale G. Pieraccini, 50139, Florence, Italy
| | - Rita Turnaturi
- Department of Drug Sciences and Health, Medicinal Chemistry Section, Università degli Studi di Catania, Viale A. Doria, 6, 95125, Catania, Italy
| | - Lorella Pasquinucci
- Department of Drug Sciences and Health, Medicinal Chemistry Section, Università degli Studi di Catania, Viale A. Doria, 6, 95125, Catania, Italy
| | - Carmela Parenti
- Department of Drug Sciences and Health, Pharmacology and Toxicology Section, Università degli Studi di Catania, Viale A. Doria, 6, 95125, Catania, Italy
| | - Vincenzo Alterio
- Istituto di Biostrutture e Bioimmagini-CNR, via Pietro Castellino, 111, 80131, Naples, Italy
| | - Anna Di Fiore
- Istituto di Biostrutture e Bioimmagini-CNR, via Pietro Castellino, 111, 80131, Naples, Italy
| | - Giuseppina De Simone
- Istituto di Biostrutture e Bioimmagini-CNR, via Pietro Castellino, 111, 80131, Naples, Italy
| | - Simona Maria Monti
- Istituto di Biostrutture e Bioimmagini-CNR, via Pietro Castellino, 111, 80131, Naples, Italy
| | - Fabrizio Carta
- NEUROFARBA Department, Sezione di Scienze Farmaceutiche, University of Florence, Via Ugo Schiff 6, 50019, Sesto Fiorentino, Florence, Italy
| | - Lorenzo Di Cesare Mannelli
- Pharmacology and Toxicology Section, Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Viale G. Pieraccini, 50139, Florence, Italy
| | - Carla Ghelardini
- Pharmacology and Toxicology Section, Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Viale G. Pieraccini, 50139, Florence, Italy
| | - Claudiu T Supuran
- NEUROFARBA Department, Sezione di Scienze Farmaceutiche, University of Florence, Via Ugo Schiff 6, 50019, Sesto Fiorentino, Florence, Italy
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Zhang X, Li R, Xu H, Wu G, Wu S, Wang H, Wang Y, Wang X. Dissecting the innate immune recognition of morphine and its metabolites by TLR4/MD2: an in silico simulation study. Phys Chem Chem Phys 2023; 25:29656-29663. [PMID: 37882236 DOI: 10.1039/d3cp03715k] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
A toll-like receptor 4/myeloid differentiation factor 2 complex (TLR4/MD2) has been identified as a non-classical opioid receptor capable of recognizing morphine isomers and activating microglia in a non-enantioselective manner. Additionally, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), the major metabolites of morphine, possess similar chemical structures but exhibit distinct effects on TLR4 signaling. However, the specific mechanisms by which morphine isomers and morphine metabolites are recognized by the innate immune receptor TLR4/MD2 are not well understood. Herein, molecular dynamics simulations were performed to dissect the molecular recognition of TLR4/MD2 with morphine isomers, M3G and M6G. Morphine and its (+)-enantiomer, dextro-morphine ((+)-morphine), were found to have comparable binding free energies as well as similar interaction modes when interacting with (TLR4/MD2)2. Binding with morphine and (+)-morphine caused the motion of the F126 loop towards the inside of the MD2 cavity, which stabilizes (TLR4/MD2)2 with similar dimerization interfaces. The binding free energies of M3G and M6G with (TLR4/MD2)2, while lower than those of morphine isomers, were comparable to each other. However, the binding behaviors of M3G and M6G exhibited contrasting patterns when interacting with (TLR4/MD2)2. The glucuronide group of M3G bound to the gating loop of MD2 and formed strong interactions with TLR4*, which stabilizes the active heterotetrameric complex. In contrast, M6G was situated in cavity A of MD2, where the critical interactions between M6G and the residues of TLR4* were lost, resulting in fluctuation of (TLR4/MD2)2 away from the active conformation. These results indicate that the pivotal interactions at the dimerization interface between MD2 and TLR4* in M6G-bound (TLR4/MD2)2 were considerably weaker than those in M3G-bound (TLR4/MD2)2, which partially explains why M6G fails to activate TLR4 signaling. The discoveries from this study will offer valuable insights for the advancement of next-generation TLR4 small molecule modulators based on opioids.
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Affiliation(s)
- Xiaozheng Zhang
- Key Laboratory of Coal Environmental Pathogenicity and Prevention (Shanxi Medical University), Ministry of Education, China
- Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Ran Li
- Key Laboratory of Coal Environmental Pathogenicity and Prevention (Shanxi Medical University), Ministry of Education, China
- Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Haoran Xu
- Key Laboratory of Coal Environmental Pathogenicity and Prevention (Shanxi Medical University), Ministry of Education, China
- Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Guicai Wu
- Key Laboratory of Coal Environmental Pathogenicity and Prevention (Shanxi Medical University), Ministry of Education, China
- Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Siru Wu
- Laboratory of Chemical Biology, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, Jilin, 130022, China.
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, Anhui, 230026, China.
| | - Hongshuang Wang
- Laboratory of Chemical Biology, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, Jilin, 130022, China.
| | - Yibo Wang
- Laboratory of Chemical Biology, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, Jilin, 130022, China.
| | - Xiaohui Wang
- Laboratory of Chemical Biology, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, Jilin, 130022, China.
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, Anhui, 230026, China.
- Beijing National Laboratory for Molecular Sciences, Beijing, 100190, China
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Lazaridou A, Paschali M, Zgierska AE, Garland EL, Edwards RR. Exploring the Relationship Between Endogenous Pain Modulation, Pain Intensity, and Depression in Patients Using Opioids for Chronic Low Back Pain. Clin J Pain 2022; 38:595-600. [PMID: 36108108 DOI: 10.1097/AJP.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/12/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Endogenous pain modulatory processes appear to play an important role in shaping pain-related outcomes, but we know relatively little about the influence of psychosocial factors on those pain modulatory processes. The primary objective of this study was to explore associations between endogenous pain modulation (ie, conditioned pain modulation, CPM; temporal summation, TS), chronic pain, and negative affective factors (ie, depression, anxiety symptoms) in a sample of participants with chronic low back pain (CLBP) treated with long-term daily opioids. METHODS Adults with opioid-treated CLBP (N=107) completed questionnaires assessing pain, pain symptoms, and psychological measures. CPM and TS were evaluated as predictors of pain intensity ratings (Brief Pain Inventory), with depression scores (Hospital Anxiety and Depression Scale, depression subscale) examined as potential moderators of those associations. RESULTS Moderation analyses demonstrated associations between CPM and back pain intensity ratings, moderated by depression symptom scores (B=-0.002, SE=0.0008, P<0.01) when controlling for daily opioid dose, with participants with higher depression scores showing a relatively stronger link between lower CPM and increased pain intensity ratings. Significant associations were observed between depression, pain intensity, and CPM-derived outcomes. CONCLUSION Our findings suggest that reduced pain-inhibitory capacity is associated with elevated self-reported pain intensity in adults with opioid-treated CLBP, particularly among those with higher severity of depression symptoms.
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Thomas KR, Watt J, Wu CMJ, Akinrinoye A, Amjad S, Colvin L, Cowe R, Duncan SH, Russell WR, Forget P. Pain and Opioid-Induced Gut Microbial Dysbiosis. Biomedicines 2022; 10:1815. [PMID: 36009361 PMCID: PMC9404803 DOI: 10.3390/biomedicines10081815] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/10/2022] [Accepted: 07/22/2022] [Indexed: 12/12/2022] Open
Abstract
Opioid-induced dysbiosis (OID) is a specific condition describing the consequences of opioid use on the bacterial composition of the gut. Opioids have been shown to affect the epithelial barrier in the gut and modulate inflammatory pathways, possibly mediating opioid tolerance or opioid-induced hyperalgesia; in combination, these allow the invasion and proliferation of non-native bacterial colonies. There is also evidence that the gut-brain axis is linked to the emotional and cognitive aspects of the brain with intestinal function, which can be a factor that affects mental health. For example, Mycobacterium, Escherichia coli and Clostridium difficile are linked to Irritable Bowel Disease; Lactobacillaceae and Enterococcacae have associations with Parkinson’s disease, and Alistipes has increased prevalence in depression. However, changes to the gut microbiome can be therapeutically influenced with treatments such as faecal microbiota transplantation, targeted antibiotic therapy and probiotics. There is also evidence of emerging therapies to combat OID. This review has collated evidence that shows that there are correlations between OID and depression, Parkinson’s Disease, infection, and more. Specifically, in pain management, targeting OID deserves specific investigations.
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Gabel F, Hovhannisyan V, Berkati AK, Goumon Y. Morphine-3-Glucuronide, Physiology and Behavior. Front Mol Neurosci 2022; 15:882443. [PMID: 35645730 PMCID: PMC9134088 DOI: 10.3389/fnmol.2022.882443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Morphine remains the gold standard painkiller available to date to relieve severe pain. Morphine metabolism leads to the production of two predominant metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). This metabolism involves uridine 5′-diphospho-glucuronosyltransferases (UGTs), which catalyze the addition of a glucuronide moiety onto the C3 or C6 position of morphine. Interestingly, M3G and M6G have been shown to be biologically active. On the one hand, M6G produces potent analgesia in rodents and humans. On the other hand, M3G provokes a state of strong excitation in rodents, characterized by thermal hyperalgesia and tactile allodynia. Its coadministration with morphine or M6G also reduces the resulting analgesia. Although these behavioral effects show quite consistency in rodents, M3G effects are much more debated in humans and the identity of the receptor(s) on which M3G acts remains unclear. Indeed, M3G has little affinity for mu opioid receptor (MOR) (on which morphine binds) and its effects are retained in the presence of naloxone or naltrexone, two non-selective MOR antagonists. Paradoxically, MOR seems to be essential to M3G effects. In contrast, several studies proposed that TLR4 could mediate M3G effects since this receptor also appears to be essential to M3G-induced hyperalgesia. This review summarizes M3G’s behavioral effects and potential targets in the central nervous system, as well as the mechanisms by which it might oppose analgesia.
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Affiliation(s)
- Florian Gabel
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Volodya Hovhannisyan
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Abdel-Karim Berkati
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Yannick Goumon
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
- SMPMS, Mass Spectrometry Facilities of the CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
- *Correspondence: Yannick Goumon,
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Chalil A, Staudt MD, Harland TA, Leimer EM, Bhullar R, Argoff CE. A safety review of approved intrathecal analgesics for chronic pain management. Expert Opin Drug Saf 2021; 20:439-451. [PMID: 33583318 DOI: 10.1080/14740338.2021.1889513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Intrathecal (IT) drug therapy is an effective treatment option for patients with chronic pain of malignant or nonmalignant origin, with an established safety profile and fewer adverse effects compared to oral or parenteral pain medications. Morphine (a μ-opioid receptor agonist) and ziconotide (a non-opioid calcium channel antagonist) are the only IT agents approved by the U.S. Food and Drug Administration for the treatment of chronic pain. Although both are considered first-line IT therapies, each drug has unique properties and considerations.Areas Covered: This review will evaluate the pivotal trials that established the use of morphine and ziconotide as first-line IT therapy for patients with chronic pain, as well as safety and efficacy data generated from various retrospective and prospective studies.Expert Opinion: Morphine and ziconotide are effective IT therapies for patients with chronic malignant or nonmalignant pain that is refractory to other interventions. IT ziconotide is recommended as a first-line therapy due to its efficacy and avoidance of many adverse effects commonly associated with opioids. The use of IT morphine is also considered first-line; however, the risks of respiratory depression, withdrawal with drug discontinuation or pump malfunction, and the development of tolerance require careful patient selection and management.
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Affiliation(s)
- Alan Chalil
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael D Staudt
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA.,Michigan Head and Spine Institute, Southfield, Michigan, USA
| | - Tessa A Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Elizabeth M Leimer
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Ravneet Bhullar
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
| | - Charles E Argoff
- Department of Neurology, Albany Medical College, Albany, New York
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Kreye G, Heidecker B, Masel EK. The top ten things that must be known about end of life therapy in patients with advanced cancer. memo 2020; 13:88-92. [DOI: 10.1007/s12254-020-00572-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dhar D, Poree LR, Yaksh TL. Evolution of the Spinal Delivery of Opiate Analgesics. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Janssen S, Bloem BR, van de Warrenburg BP. The clinical heterogeneity of drug-induced myoclonus: an illustrated review. J Neurol 2017; 264:1559-66. [PMID: 27981352 DOI: 10.1007/s00415-016-8357-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 11/28/2022]
Abstract
A wide variety of drugs can cause myoclonus. To illustrate this, we first discuss two personally observed cases, one presenting with generalized, but facial-predominant, myoclonus that was induced by amantadine; and the other presenting with propriospinal myoclonus triggered by an antibiotic. We then review the literature on drugs that may cause myoclonus, extracting the corresponding clinical phenotype and suggested underlying pathophysiology. The most frequently reported classes of drugs causing myoclonus include opiates, antidepressants, antipsychotics, and antibiotics. The distribution of myoclonus ranges from focal to generalized, even amongst patients using the same drug, which suggests various neuro-anatomical generators. Possible underlying pathophysiological alterations involve serotonin, dopamine, GABA, and glutamate-related processes at various levels of the neuraxis. The high number of cases of drug-induced myoclonus, together with their reported heterogeneous clinical characteristics, underscores the importance of considering drugs as a possible cause of myoclonus, regardless of its clinical characteristics.
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Abstract
A 76-year-old man was admitted to hospital with a right-sided fractured neck of femur requiring repair via a cemented hemiarthroplasty. Intraoperatively he received 10 mg of intravenous morphine. Post-operatively he received a short course of low-dose oral opioids and subsequently developed myoclonic jerks and hyperalgesia. The opioids were discontinued and both adverse effects resolved. This case report discusses the concurrent development of myoclonus and hyperalgesia following a low dose of opioids and explores possible management options.
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Lee KA, Ganta N, Horton JR, Chai E. Evidence for Neurotoxicity Due to Morphine or Hydromorphone Use in Renal Impairment: A Systematic Review. J Palliat Med 2016; 19:1179-1187. [PMID: 27399959 DOI: 10.1089/jpm.2016.0101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Opioids are the mainstay of pain control for patients with chronic pain. Often, opioids with reported active metabolites, such as morphine and hydromorphone, are thought to increase the risk of neurotoxicity in renal impairment. OBJECTIVES To identify and assess the quality of evidence for neurotoxic effects in patients with renal impairment receiving morphine or hydromorphone. METHODS Systematic searches were conducted of the following databases from inception to December 2015: MEDLINE, CINAHL, EMBASE, in addition to hand-searching relevant review articles' citations. Studies were included if they reported neurotoxic effects of either morphine or hydromorphone for chronic or malignant pain in patients with renal impairment. Review articles and case reports were excluded. Narrative review was undertaken. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess study quality. RESULTS Six original articles, three prospective and three retrospective studies were identified and assessed. No relevant randomized clinical trials were identified. CONCLUSIONS Although morphine and hydromorphone use may be associated with neurotoxic effects in patients with renal impairment, current evidence consists of very low-quality studies with conflicting findings. Clinicians may consider using either morphine or hydromorphone in mild-to-moderate renal impairment, while closely monitoring for neurotoxic effects, particularly when used in high doses and for extended duration.
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Affiliation(s)
- Kathleen A Lee
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Niharika Ganta
- 2 Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Jay R Horton
- 3 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Emily Chai
- 3 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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Wang W, Wang Y, Zhang W, Jin X, Liu Y, Xu S, Lei L, Shen X, Guo X, Xia X, Wang F. Opioid-induced redistribution of 6TM and 7TM μ opioid receptors: A hypothesized mechanistic facilitator model of opioid-induced hyperalgesia. Pharmacol Rep 2016; 68:686-91. [PMID: 27116700 DOI: 10.1016/j.pharep.2016.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/30/2016] [Accepted: 03/02/2016] [Indexed: 01/21/2023]
Abstract
Opioids are still the most popular form of pain treatment, but many unavoidable side effects make opioids a big challenge in effective pain management. Opioid-induced hyperalgesia (OIH), a paradoxical phenomenon, portrays an increased sensitivity to harmful stimuli caused by opioid exposure. Changes in the neural modulation are considered a major contributor to the development of OIH. Activation of opioid receptors (ORs) and corresponding downstream molecules are the vital composition of functional performance of opioids. Increasing interests were proposed of the interaction between ORs and other neural transmitter systems such as glutamatergic, GABAergic and adrenergic ones to the genesis of OIH. G protein coupled μ-opioid receptor (MOR) was studied comprehensively on its role in the development of OIH. In addition to the relationship between MOR and other neurotransmitter receptors, a new intracellular MOR that has six transmembrane (6TM) domains was identified, and found to perform a pro-nociceptive task in contrast to the counterpart 7TM isoform. A mechanistic model of OIH in which both 6TM and 7TM MORs undergoing membrane redistribution upon opioid exposure is proposed which eventually facilitates the neurons more sensitive to nociceptive stimulation than that of the preceding opioid exposure.
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Affiliation(s)
- Wei Wang
- Department of Anesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Yan Wang
- Department of Anesthesiology, Affiliated Chaohu Hospital, Anhui Medical University, Chaohu, Anhui, China
| | - Wei Zhang
- Department of Anesthesiology, Nanjing T.C.M. Hospital, Nanjing, China
| | - Xiaoju Jin
- The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Yusheng Liu
- Department of Anesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Shiqin Xu
- Department of Anesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Liming Lei
- Department of Anesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaofeng Shen
- Department of Anesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xirong Guo
- Pediatric Institute, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaoqiong Xia
- Department of Anesthesiology, Affiliated Chaohu Hospital, Anhui Medical University, Chaohu, Anhui, China.
| | - Fuzhou Wang
- Department of Anesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China; Division of Neuroscience, The Bonoi Academy of Science and Education, Chapel Hill, NC, USA.
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Lee YJ, Suh SY, Song J, Lee SS, Seo AR, Ahn HY, Lee MA, Kim CM, Klepstad P. Serum and urine concentrations of morphine and morphine metabolites in patients with advanced cancer receiving continuous intravenous morphine: an observational study. BMC Palliat Care 2015; 14:53. [PMID: 26507979 PMCID: PMC4624671 DOI: 10.1186/s12904-015-0052-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 10/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The feasibility and clinical implication of drug monitoring of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) need further investigation. This study aimed to determine what predicts serum concentrations of morphine in cancer patients receiving continuously intravenous morphine, the relationships between serum concentration of morphine/its metabolites and urinary concentrations, and the relation between morphine concentrations and with clinical outcomes. METHODS We collected serum and urine samples from 24 patients with advanced cancer undergoing continuously intravenous morphine therapy. Serum samples were obtained at day one. Spot urine samples were collected once daily on three consecutive days. Pain and adverse drug events were assessed using the Korean version of MD Anderson Symptom Inventory. RESULTS A total of 96 samples (72 urine and 24 serum samples) were collected. Median dose of morphine was 82.0 mg/24 h. In a multivariate analysis, total daily morphine dose was the most significant predictors of both serum and urine concentration of morphine. Morphine, M6G, and M3G in serum and urine were statistical significantly correlated (correlation coefficient = 0.81, 0.44, 0.56; p values < 0.01, 0.03, 0.01, respectively). CONCLUSION Spot urine concentrations of morphine and its metabolites were highly correlated to those of serum. Total dose of daily morphine was related to both serum and urine concentration of morphine and its metabolites.
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Affiliation(s)
- Yong Joo Lee
- Department of Palliative Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Sang-Yeon Suh
- Department of Medicine, Dongguk University School of Medicine, 30 Pildong-ro 1-gil, Jung-gu, Seoul, 100-715, South Korea.
| | - Junghan Song
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea.
| | | | - Ah-Ram Seo
- Department of Statistics, Dongguk University, Seoul, South Korea.
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University, Seoul, South Korea.
| | - Myung Ah Lee
- Division of Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Chul-Min Kim
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Pål Klepstad
- Departments of Anaesthesiology and Intensive Care Medicine, St. Olvas University Hospital, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Medical Faculty, Norwegian University of Technology and Science, Trondheim, Norway.
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Kurita GP, Lundström S, Sjøgren P, Ekholm O, Christrup L, Davies A, Kaasa S, Klepstad P, Dale O. Renal function and symptoms/adverse effects in opioid-treated patients with cancer. Acta Anaesthesiol Scand 2015; 59:1049-59. [PMID: 25943005 DOI: 10.1111/aas.12521] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 06/19/2014] [Accepted: 03/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Renal impairment and the risk of toxicity caused by accumulation of opioids and/or active metabolites is an under-investigated issue. This study aimed at analysing if symptoms/adverse effects in opioid-treated patients with cancer were associated with renal function. METHODS Cross-sectional multicentre study (European Pharmacogenetic Opioid Study, 2005-2008), in which 1147 adult patients treated exclusively with only one of the most frequently reported opioids (morphine/oxycodone/fentanyl) for at least 3 days were analysed. Fatigue, nausea/vomiting, pain, loss of appetite, constipation and cognitive dysfunction were assessed (EORTC QLQ-C30). Glomerular filtration rate (GFR) was estimated using Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI Creatinine) equations. RESULTS Mild to severe low GFR was observed among 40-54% of patients. CG equation showed that patients with mild and moderate/severe low GFR on morphine treatment had higher odds of having severe constipation (P < 0.01) than patients with normal GFR. In addition, patients with moderate/severe low GFR on morphine treatment were more likely to have loss of appetite (P = 0.04). No other significant associations were found. CONCLUSION Only severe constipation and loss of appetite were associated with low GFR in patients treated with morphine. Oxycodone and fentanyl, in relation to the symptoms studied, seem to be safe as used and titrated in routine cancer pain care.
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Affiliation(s)
- G. P. Kurita
- Department of Oncology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
- Multidisciplinary Pain Centre; Department of Neuroanaesthesiology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
| | - S. Lundström
- Stockholms Sjukhem Foundation and Department of Oncology Pathology; Karolinska Institute; Stockholm Sweden
| | - P. Sjøgren
- Department of Oncology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
- Department of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - O. Ekholm
- National Institute of Public Health; University of Southern Denmark; Copenhagen Denmark
| | - L. Christrup
- Department of Drug Design and Pharmacology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - A. Davies
- Royal Surrey County Hospital; Guildford UK
| | - S. Kaasa
- Department of Oncology; Trondheim University Hospital; St. Olav Hospital; Trondheim Norway
- European Palliative Care Research Centre; DMF; Norwegian University of Science and Technology; Trondheim Norway
| | - P. Klepstad
- Department of Intensive Care Medicine; St Olavs University Hospital; Trondheim Norway
- Department of Circulation and Medical Imaging; Norwegian University of Science and Technology; Trondheim Norway
| | - O. Dale
- Department of Circulation and Medical Imaging; Norwegian University of Science and Technology; Trondheim Norway
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15
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Abstract
Ethanol (alcohol) is one of the most widely used legal drugs in the world. Ethanol is metabolized by alcohol dehydrogenase (ADH) and the cytochrome P450 (CYP) 2E1 drug-metabolizing enzyme that is also responsible for the biotransformation of xenobiotics and fatty acids. Drugs that inhibit ADH or CYP2E1 are the most likely theoretical compounds that would lead to a clinically significant pharmacokinetic interaction with ethanol, which include only a limited number of drugs. Acute ethanol primarily alters the pharmacokinetics of other drugs by changing the rate and extent of absorption, with more limited effects on clearance. Both acute and chronic ethanol use can cause transient changes to many physiologic responses in different organ systems such as hypotension and impairment of motor and cognitive functions, resulting in both pharmacokinetic and pharmacodynamic interactions. Evaluating drug interactions with long-term use of ethanol is uniquely challenging. Specifically, it is difficult to distinguish between the effects of long-term ethanol use on liver pathology and chronic malnutrition. Ethanol-induced liver disease results in decreased activity of hepatic metabolic enzymes and changes in protein binding. Clinical studies that include patients with chronic alcohol use may be evaluating the effects of mild cirrhosis on liver metabolism, and not just ethanol itself. The definition of chronic alcohol use is very inconsistent, which greatly affects the quality of the data and clinical application of the results. Our study of the literature has shown that a significantly higher volume of clinical studies have focused on the pharmacokinetic interactions of ethanol and other drugs. The data on pharmacodynamic interactions are more limited and future research addressing pharmacodynamic interactions with ethanol, especially regarding the non-central nervous system effects, is much needed.
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Affiliation(s)
- Lingtak-Neander Chan
- Department of Pharmacy, University of Washington, Box 357630, Seattle, WA, 98195, USA
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16
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Abstract
Opioid analgesics have become a cornerstone in the treatment of moderate to severe pain, resulting in a steady rise of opioid prescriptions. Subsequently, there has been a striking increase in the number of opioid-dependent individuals, opioid-related overdoses, and fatalities. Clinical use of opioids is further complicated by an increasingly deleterious profile of side effects beyond addiction, including tolerance and opioid-induced hyperalgesia (OIH), where OIH is defined as an increased sensitivity to already painful stimuli. This paradoxical state of increased nociception results from acute and long-term exposure to opioids, and appears to develop in a substantial subset of patients using opioids. Recently, there has been considerable interest in developing an efficacious treatment regimen for acute and chronic pain. However, there are currently no well-established treatments for OIH. Several substrates have emerged as potential modulators of OIH, including the N-methyl-D-aspartate and γ-aminobutyric acid receptors, and most notably, the innate neuroimmune system. This review summarizes the neurobiology of OIH in the context of clinical treatment; specifically, we review evidence for several pathways that show promise for the treatment of pain going forward, as prospective adjuvants to opioid analgesics. Overall, we suggest that this paradoxical state be considered an additional target of clinical treatment for chronic pain.
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Affiliation(s)
- Caroline A Arout
- Department of Psychiatry, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA,
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17
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Kango Gopal G, Hewton C, Pazhvoor SK. Myoclonus associated with concomitant ciprofloxacin and oxycodone in an older patient. Br J Clin Pharmacol 2015; 77:906-7. [PMID: 23879446 DOI: 10.1111/bcp.12213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022] Open
Affiliation(s)
- Gopinath Kango Gopal
- Aged and Extended Care Services, The Queen Elizabeth Hospital, Woodville, SA, Australia
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18
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De Gregori S, Minella CE, De Gregori M, Tinelli C, Ranzani GN, Govoni S, Allegri M, Regazzi M. Clinical Pharmacokinetics of Morphine and Its Metabolites During Morphine Dose Titration for Chronic Cancer Pain. Ther Drug Monit 2014; 36:335-44. [DOI: 10.1097/ftd.0000000000000009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Affiliation(s)
- Justin Kullgren
- South College School of Pharmacy, Knoxville, Tennessee
- Nathan Adelson Hospice, Las Vegas, Nevada
| | - Vy Le
- Nathan Adelson Hospice, Las Vegas, Nevada
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20
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Abstract
Opioids including morphine and hydromorphone are widely used for control of moderate to severe pain and dyspnea in hospice and palliative care patients. Accumulation of the active morphine-3-glucuronide (M3G) and hydromorphone-3-glucuronide (H3G) metabolites is one proposed mechanism for the development of neuroexcitatory effects including allodynia and opioid-induced hyperalgesia (OIH). We report the case of a 43-year-old female hospice patient with metastatic non-small cell lung cancer who initially developed allodynia following morphine administration and again following administration of hydromorphone. The allodynia resolved both times following the discontinuation of the opioid and rotation to a different opioid regimen. Potential opioid-induced neuroexcitatory treatment options include opioid rotation to an agent with inactive metabolites, use of adjuvant pain medications for opioid-sparing effects, management of undesired symptoms (e.g., myoclonus), or increasing opioid clearance with intravenous (IV) fluids. Although the incidence is not well defined in the literature, hospice and palliative care clinicians should suspect OIH in patients with allodynia and/or hyperalgesia, especially when repeated dose escalations do not improve analgesia or pain escalates following opioid dose titration.
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Affiliation(s)
- Katherine M Juba
- Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York 14618, USA.
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21
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Chu LF, D'Arcy N, Brady C, Zamora AK, Young CA, Kim JE, Clemenson AM, Angst MS, Clark DJ. Analgesic tolerance without demonstrable opioid-induced hyperalgesia: a double-blinded, randomized, placebo-controlled trial of sustained-release morphine for treatment of chronic nonradicular low-back pain. Pain 2012; 153:1583-1592. [PMID: 22704854 DOI: 10.1016/j.pain.2012.02.028] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/24/2012] [Accepted: 02/24/2012] [Indexed: 10/28/2022]
Abstract
Although often successful in acute settings, long-term use of opioid pain medications may be accompanied by waning levels of analgesic response not readily attributable to advancing underlying disease, necessitating dose escalation to attain pain relief. Analgesic tolerance, and more recently opioid-induced hyperalgesia, have been invoked to explain such declines in opioid effectiveness over time. Because both phenomena result in inadequate analgesia, they are difficult to distinguish in a clinical setting. Patients with otherwise uncomplicated low-back pain were titrated to comfort or dose-limiting side effects in a prospective, randomized, double-blind, placebo-controlled clinical trial using sustained-release morphine or weight-matched placebo capsules for 1 month. A total of 103 patients completed the study, with an average end titration dose of 78 mg morphine/d. After 1 month, the morphine-treated patients developed tolerance to the analgesic effects of remifentanil, but did not develop opioid-induced hyperalgesia. On average, these patients experienced a 42% reduction in analgesic potency. The morphine-treated patients experienced clinically relevant improvements in pain relief, as shown by a 44% reduction in average visual analogue scale pain levels and a 31% improvement in functional ability. The differences in visual analogue scale pain levels (P = .003) and self-reported disability (P = .03) between both treatment groups were statistically significant. After 1 month of oral morphine therapy, patients with chronic low-back pain developed tolerance but not opioid-induced hyperalgesia. Improvements in pain and functional ability were observed.
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Affiliation(s)
- Larry F Chu
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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22
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Spevak C, Hamsher C, Brown CQ, Wedam EF, Haigney MC. The clinical significance of QT interval prolongation in anesthesia and pain management: what you should and should not worry about. Pain Med 2012; 13:1072-80. [PMID: 22680349 DOI: 10.1111/j.1526-4637.2012.01406.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The most feared drug-induced complication is fatal cardiac arrest. Torsades de pointes (TdP) is a polymorphic ventricular tachycardia occurring in the setting of a QT interval prolongation and is the most frequent type of drug-induced pro-arrhythmia. The most common mechanism of QT prolongation and TdP is blockade of the rapid component of the delayed rectifier repolarizing potassium conductance IKr. Anesthesiologists have extensive experience with QT prolonging drugs, but there are relatively few reports of TdP occurring in the perioperative setting. Nevertheless, regulatory concern regarding the drug droperidol resulted in a significant reduction in its use. Concern regarding two other agents that potently block IKr, i.e., sevoflurane and methadone, has grown, and practitioners are worried that these valuable agents may meet the same fate. In this review, the data regarding the TdP risk of droperidol, sevoflurane, and methadone are compared with particular emphasis on the different settings in which they are employed. While the three drugs are potent IKr inhibitors, little evidence exists to suggest that droperidol or sevoflurane are associated with significant proarrhythmia in the perioperative setting. Due to factors such as inhibition of the parasympathetic nervous system, prevention of hypoxia and hypercarbia, and attention to serum electrolytes, TdP is a very rare occurrence in the perioperative environment. Methadone, however, is typically given to outpatients, over long periods, and in combination with agents that inhibit its metabolism or are QT prolonging in their own right. Thus, pre- and post-drug electrocardiograms may be appropriate when prescribing methadone for outpatients, while the much lower risk for TdP (and the difficulties inherent in QT measurement in the perioperative period) render this approach unfruitful and worthy of reevaluation.
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Affiliation(s)
- Christopher Spevak
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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23
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Andersen G, Sjøgren P, Hansen SH, Jensen NH, Christrup L. Pharmacological consequences of long-term morphine treatment in patients with cancer and chronic non-malignant pain. Eur J Pain 2012; 8:263-71. [PMID: 15109977 DOI: 10.1016/j.ejpain.2003.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2003] [Accepted: 09/22/2003] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with pain of malignant origin morphine may be administered in high and often increasing doses during extended periods of time. In patients with chronic pain of non-malignant origin morphine may be an important remedy, and in these cases the goal is to keep the morphine dose stable. The pharmacokinetic as well as the pharmacodynamic consequences of long-term morphine treatment with special reference to the two most important metabolites of morphine morphine-6-glucuronide (M-6-G) and morphine-3-glucuronide (M-3-G) remain to be settled. METHODS Assessments for pain, sedation and other morphine induced side effects were made several times for 19 cancer patients treated with changing doses of oral sustained release (SR) morphine and twice for 17 non-cancer patients treated with stable doses of SR morphine. Blood samples were obtained simultaneously and analysed for contents of morphine, M-3-G and M-6-G by high-performance liquid chromatography (HPLC). RESULTS Significant correlations were found between the daily dose of SR morphine and plasma morphine (r = 0.469, p < 0.01), plasma M-6-G (r = 0.677, p < 0.01), and plasma M-3-G ((r = 0.827, p < 0.01), in the cancer patient group, but only between the daily dose of SR morphine and plasma M-3-G (0.662, p < 0.01) and plasma M-6-G (0.571, p < 0.01) in the non-cancer patient group. Normalised M-3-G/M and M-6-G/M ratios for the cancer patient group were independent of duration of treatment and daily dose of SR morphine. Likewise in the non-cancer patient group duration of treatment did not influence the metabolite ratios. Correlations between pain score and plasma morphine, M-6-G and M-6-G/M were weak in the cancer patient as well as in the non-cancer patient group making it impossible to draw any conclusion regarding the potential contributory analgesic effect of M-6-G. Dryness of the mouth was the most frequent adverse effect reported in the non-cancer as well as the cancer patient group. In the latter group patients complaining of dryness of the mouth had significantly higher plasma morphine and M-6-G concentrations than patients who did not suffer from this side effect. This difference persisted (or was close to significance) when excluding patients receiving antidepressants. CONCLUSION In the cancer patient group neither dose nor treatment period seems to influence morphine glucuronidation. Likewise in the non-cancer patient group receiving stable doses of morphine duration of treatment does not seem to influence morphine glucuronidation. Dryness of the mouth was positively correlated to high plasma concentrations of morphine and M-6-G.
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Affiliation(s)
- Gertrud Andersen
- Multidisciplinary Pain Centre, Herlev University Hospital, Herlev 2730, Denmark.
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24
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King S, Forbes K, Hanks GW, Ferro CJ, Chambers EJ. A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. Palliat Med 2011; 25:525-52. [PMID: 21708859 DOI: 10.1177/0269216311406313] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative's opioid guidelines project. OBJECTIVE The objective of this study was to identify and assess the quality of evidence for the safe and effective use of opioids for the relief of cancer pain in patients with renal impairment and to produce guidelines. SEARCH STRATEGY The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals. SELECTION CRITERIA Studies were included if they reported a clinical outcome relevant to the use of selected opioids in cancer-related pain and renal impairment. The selected opioids were morphine, diamorphine, codeine, dextropropoxyphene, dihydrocodeine, oxycodone, hydromorphone, buprenorphine, tramadol, alfentanil, fentanyl, sufentanil, remifentanil, pethidine and methadone. No direct comparator was required for inclusion. Studies assessing the long-term efficacy of opioids during dialysis were excluded. DATA COLLECTION AND ANALYSIS This is a narrative systematic review and no meta-analysis was performed. The Grading of RECOMMENDATIONS Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the studies and to formulate guidelines. MAIN RESULTS Fifteen original articles were identified. Eight prospective and seven retrospective clinical studies were identified but no randomized controlled trials. No results were found for diamorphine, codeine, dihydrocodeine, buprenorphine, tramadol, dextropropoxyphene, methadone or remifentanil. CONCLUSIONS All of the studies identified have a significant risk of bias inherent in the study methodology and there is additional significant risk of publication bias. Overall evidence is of very low quality. The direct clinical evidence in cancer-related pain and renal impairment is insufficient to allow formulation of guidelines but is suggestive of significant differences in risk between opioids. RECOMMENDATIONS RECOMMENDATIONS regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.
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Affiliation(s)
- S King
- Department of Palliative Medicine, University of Bristol, Bristol Oncology and Haematology Centre, Bristol BS2 8ED, UK.
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25
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Abstract
INTRODUCTION The use of chronic opioid therapy for chronic non-cancer pain is growing and is now accepted as an effective treatment modality. AREAS COVERED Although there are guidelines and reviews for chronic opioid therapy for chronic non-cancer pain patients, physicians may still have concerns and be reluctant to prescribe strong opioids for chronic non-cancer pain. Common issues and concerns when prescribing opioid for chronic pain management are reviewed and discussed. The literature search was done using Medline with key words 'chronic non-cancer pain', 'chronic opioid therapy', 'effectiveness', 'opioid tolerance', 'opioid-induced hyperalgesia', 'adverse effect', 'opioid dependency', 'addiction', 'monitoring', 'opioid contract' and various combinations with these key words. Studies from 1990 - 2010 have been included. This article helps readers to update, clarify and understand the common concerns when using opioid for chronic non-cancer pain. Clinical effectiveness and adverse effects with chronic opioid therapy, opioid tolerance and opioid-induced hyperalgesia, opioid dependency and addiction, monitoring during chronic opioid use, and opioid contact are discussed in detailed. EXPERT OPINION Not much strongly positive data supports the long-term use of opioids for pain relief, and the evidence for an improvement in functional activity is inconclusive. With careful selection of patients, meticulous prescription and monitoring protocol, chronic non-cancer pain patients who are likely to benefit from potent opioids should not be prevented from obtaining this treatment.
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Affiliation(s)
- Bob Kwok Bun Chan
- The University of Hong Kong, Queen Mary Hospital, Department of Anaesthesiology, Room 424, Block K, 102 Pokfulam Road, Hong Kong, China
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Waxman AR, Juni A, Kowalczyk W, Arout C, Sternberg WF, Kest B. Progesterone rapidly recruits female-typical opioid-induced hyperalgesic mechanisms. Physiol Behav 2010; 101:759-63. [PMID: 20816879 DOI: 10.1016/j.physbeh.2010.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 08/12/2010] [Accepted: 08/26/2010] [Indexed: 12/25/2022]
Abstract
Continuous morphine treatment can paradoxically increase nociception (i.e. hyperalgesia) in male and female mice, but sex differences have been reported. Here, we studied progesterone modulation of these differences by assessing nociception on the tail-withdrawal test in male and female mice rendered hyperalgesic during continuous infusion of two different morphine doses (1.6 and 40.0mg/kg/24h). Although the lower morphine infusion dose increased nociception in both sexes by infusion Day 4, this hyperalgesia dissipated by Day 6 in males and ovariectomized females, but not gonadally intact females. A single subcutaneous progesterone (0.0016mg/kg) injection to males and ovariectomized females on Day 6 caused hyperalgesia to recur within 30min and to persist for a minimum of 120min. The larger morphine infusion dose also increased nociception in both sexes on Days 4 and 6. However, the NMDA receptor antagonist MK-801 (0.05mg/kg) reversed hyperalgesia in males and ovariectomized females but not gonadally intact females on infusion Day 6. Subcutaneous progesterone (0.0016mg/kg) injection inhibited this reversal in male and ovariectomized female mice but had no effect on nociception in saline-infused mice of either sex. These data confirm our previous findings that male and female mice utilize distinct hyperalgesic mechanisms, and show for the first time that a single progesterone bolus dose can recruit female-typical hyperalgesia in ovariectomized females and males.
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Affiliation(s)
- Amanda R Waxman
- Neuropsychology Program, Queens College, City University of New York, Flushing, NY 11367, United States
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Lewis SS, Hutchinson MR, Rezvani N, Loram LC, Zhang Y, Maier SF, Rice KC, Watkins LR. Evidence that intrathecal morphine-3-glucuronide may cause pain enhancement via toll-like receptor 4/MD-2 and interleukin-1beta. Neuroscience 2010; 165:569-83. [PMID: 19833175 DOI: 10.1016/j.neuroscience.2009.10.011] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 10/04/2009] [Accepted: 10/05/2009] [Indexed: 12/22/2022]
Abstract
Morphine-3-glucoronide (M3G) is a major morphine metabolite detected in cerebrospinal fluid of humans receiving systemic morphine. M3G has little-to-no affinity for opioid receptors and induces pain by unknown mechanisms. The pain-enhancing effects of M3G have been proposed to significantly and progressively oppose morphine analgesia as metabolism ensues. We have recently documented that morphine activates toll-like receptor 4 (TLR4), beyond its classical actions on mu-opioid receptors. This suggests that M3G may similarly activate TLR4. This activation could provide a novel mechanism for M3G-mediated pain enhancement, as (a) TLR4 is predominantly expressed by microglia in spinal cord and (b) TLR4 activation releases pain-enhancing substances, including interleukin-1 (IL-1). We present in vitro evidence that M3G activates TLR4, an effect blocked by TLR4 inhibitors, and that M3G activates microglia to produce IL-1. In vivo, intrathecal M3G (0.75 microg) induced potent allodynia and hyperalgesia, blocked or reversed by interleukin-1 receptor antagonist, minocycline (microglial inhibitor), and (+)-and (-)-naloxone. This latter study extends our prior demonstrations that TLR4 signaling is inhibited by naloxone nonstereoselectively. These results with (+)-and (-)-naloxone also demonstrate that the effects cannot be accounted for by actions at classical, stereoselective opioid receptors. Hyperalgesia (allodynia was not tested) and in vitro M3G-induced TLR4 signaling were both blocked by 17-DMAG, an inhibitor of heat shock protein 90 (HSP90) that can contribute to TLR4 signaling. Providing further evidence of proinflammatory activation, M3G upregulated TLR4 and CD11b (microglial/macrophage activation marker) mRNAs in dorsal spinal cord as well as IL-1 protein in the lumbosacral cerebrospinal fluid. Finally, in silico and in vivo data support that the glucuronic acid moiety is capable of inducing TLR4/MD-2 activation and enhanced pain. These data provide the first evidence for a TLR4 and IL-1 mediated component to M3G-induced effects, likely of at least microglial origin.
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Affiliation(s)
- S S Lewis
- Department of Psychology and Neuroscience, University of Colorado at Boulder, Boulder, CO, USA.
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Freye E, Levy JV. No hyperalgesia following opioid withdrawal after the oripavine derivative etorphine compared to remifentanil and sufentanil: . Eur J Anaesthesiol 2010; 27:174-80. [DOI: 10.1097/eja.0b013e32832ff528] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Juni A, Cai M, Stankova M, Waxman AR, Arout C, Klein G, Dahan A, Hruby VJ, Mogil JS, Kest B. Sex-specific mediation of opioid-induced hyperalgesia by the melanocortin-1 receptor. Anesthesiology 2010; 112:181-8. [PMID: 19996949 DOI: 10.1097/ALN.0b013e3181c53849] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND N-Methyl-D-aspartate receptor antagonists reverse hyperalgesia during morphine infusion in male mice only. Because the melanocortin-1 receptor can act as a female-specific counterpart to N-methyl-D-aspartate receptors in kappa-opioid analgesic mechanisms, the authors assessed the contribution of melanocortin-1 receptors to the sex-specific mechanisms underlying morphine hyperalgesia. METHODS The tail-withdrawal test was used to compare the nociceptive responses of male and female C57BL/6J (B6) mice with those of C57BL/6J-Mc(1r(e/e)) mice, spontaneous mutants of the B6 background lacking functional melanocortin-1 receptors, during continuous morphine infusion (1.6 and 40.0 mgkg(-1) . 24 h(-1)). Separate groups of hyperalgesic B6 and outbred CD-1 mice were injected with MK-801 or MSG606, selective N-methyl-D-aspartate and melanocortin-1 receptor antagonists, respectively. RESULTS Morphine infusion (40.0 mg . kg(-1) . 24 h(-1)) reduced baseline withdrawal latencies by 45-55% in B6 mice of both sexes, indicating hyperalgesia; this increased nociception was manifest in male e/e mice only. Although MK-801 reversed hyperalgesia in male mice only, increasing latencies by 72%, MSG606 increased latencies by approximately 60% exclusively in females. A lower morphine infusion dose (1.6 mg . kg(-1) . 24 h(-1)) reduced baseline withdrawal latencies by 45-52% in B6 and e/e mice of both sexes, which was reversed by MK-801, but not MSG606, in both male and female B6 mice. CONCLUSIONS The data indicate the sex-specific mediation of high-dose morphine-induced hyperalgesia by N-methyl-d-aspartate and melanocortin-1 receptors in male and female mice, respectively, suggesting a broader relevance of this known sexual dimorphism. The data further indicate that the neural substrates contributing to hyperalgesia are morphine dose-dependent.
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Abstract
The case of a 78-year-old patient with cancer-related pain and additionally mixed-pain syndrome is presented. Pain therapy with buprenorphine TTS 210 microg/h every 3 days was sufficient in the beginning, later the therapy was changed because of increasing problems of tape fixing during fever periods under chemotherapy to a continuous infusion of buprenorphine intravenously via an external medication pump. During the course of therapy it became necessary to increase the dose to 99.9 mg/day buprenorphine. Under this medication a sufficient pain reduction (median NRS 2-3) over a period of 135 days could be achieved. At the same time the patient was vigilant and cooperative without signs of intoxication until the end of life at home in the presence of his family.If no signs of intoxication occur under extreme opioid therapy and a sufficient pain therapy can be achieved, a rotation to another opioid is not necessary. However, outpatient palliative care requires a frequent adaptation to the individually varying opioid demand of the patient and time-consuming nursing care.
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Affiliation(s)
- K Gastmeier
- Schwerpunkt Krebsschmerztherapie, Zentrum für ambulantes Operieren und ambulante Schmerztherapie, Karl-Marx-Str. 42, 14482, Potsdam, Deutschland.
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Sulaiman M, Zakaria Z, Abdul Rahman A, Mohamad A, Desa M, Stanslas J, Moin S, Israf D. Antinociceptive and Antiedematogenic Activities of Andrographolide Isolated From Andrographis paniculata in Animal Models. Biol Res Nurs 2010; 11:293-301. [DOI: 10.1177/1099800409343311] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The current study was performed to evaluate the antinociceptive and antiedematogenic properties of andrographolide isolated from the leaves of Andrographis paniculata using two animal models. Antinociceptive activity was evaluated using the acetic acid— induced writhing and the hot-plate tests, while antiedematogenic activity was measured using the carrageenan-induced paw edema test. Subcutaneous (s.c.) administration of andrographolide (10, 25, and 50 mg/kg) did not affect the motor coordination of the experimental animals but produced significant (p < .05) antinociceptive activity when assessed using both tests. However, 2 mg/kg naloxone failed to affect the 25 mg/kg andrographolide activity in both tests, indicating that the activity was modulated via nonopioid mechanisms. Furthermore, andrographolide showed significant (p < .05) antiedematogenic activity. In conclusion, the results obtained suggest that andrographolide has antinociceptive and antiedematogenic activities; it may be useful for treating pain and inflammation once human studies are conducted.
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Fishbain DA, Cole B, Lewis JE, Gao J, Rosomoff RS. Do Opioids Induce Hyperalgesia in Humans? An Evidence-Based Structured Review. Pain Med 2009; 10:829-39. [DOI: 10.1111/j.1526-4637.2009.00653.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Graziani M, Antonilli L, Togna AR, Brusadin V, Viola S, Togna G, Badiani A, Nencini P. Non-opioid induction of morphine-6-glucuronide synthesis is elicited by prolonged exposure of rat hepatocytes to heroin. Drug Alcohol Depend 2008; 98:179-84. [PMID: 18597954 DOI: 10.1016/j.drugalcdep.2008.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Revised: 05/13/2008] [Accepted: 05/18/2008] [Indexed: 11/16/2022]
Abstract
BACKGROUND Liver metabolism of morphine leads to the formation of morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), the latter possessing strong opioid activity that however differs from that of the parent compound. In previous studies conducted in rats we have shown that repeated in vivo exposure to phenanthrene class of mu opioid receptor (MOR) agonists or antagonists (heroin, morphine, and naltrexone), but not to non-phenanthrene class of MOR agonist methadone, affects morphine glucuronidation by liver microsomes. METHODS In the present study, we measured the in vitro formation of M3G and M6G by rat hepatocytes incubated for 120 min with morphine (0.1-1.0 mM) after 72h pre-incubation with one of the following MOR agonists: heroin (3.3 or 6.6 microM), morphine (7.8 microM), or methadone (12 microM). The MOR antagonist naltrexone (10 or 25 microM) was also tested, alone or in combination with heroin. The amount of M3G and M6G synthesized was then measured by HPLC method. RESULTS Heroin inhibited M3G synthesis and induced the formation of M6G, which under basal conditions is not synthesized in rats. Heroin effects were not blocked by naltrexone. Morphine, but not methadone, produced effects similar to those of heroin but more modest in intensity. Pre-incubation with naltrexone alone slightly increased M3G synthesis, but had no effect on M6G formation. CONCLUSIONS These results are in agreement with those of previous ex vivo studies and indicate that exposure to heroin or, to a lesser extent, morphine, can affect morphine glucuronidation via direct non-opioid actions on the hepatocytes.
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Affiliation(s)
- Manuela Graziani
- Department of Human Physiology and Pharmacology Vittorio Erspamer, University of Rome Sapienza, Piazzale Aldo Moro 5, Rome, Italy
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Abstract
A patient with pain associated with metastatic leiomyosarcoma received escalating doses of opioids. Upon discontinuation of intravenous morphine, transdermal fentanyl was initiated, and after several days, the dose was increased to 200microg/hour for persistent, severe pain. The patient became somnolent, and further dose adjustments and route change were carried out. She then exhibited severe allodynia, myoclonus, and delirium thereafter fentanyl was stopped. All symptoms resolved with discontinuation of fentanyl and subsequent introduction of a weak opioid. Pain was well controlled. Gradually increasing standard doses of fentanyl may lead to severe neurotoxicity, which may respond to opioid discontinuation and/or rotation. Vigilant scrutiny of all possible causes of apparent analgesic failure followed by consideration of opioid reduction and rotation is warranted in cases of neurotoxicity accompanying opioid treatment.
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Affiliation(s)
- Tomasz R Okon
- Department of Palliative Medicine, Marshfield Clinic, Marshfield, WI 54449, USA.
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Abstract
Remifentanil is a synthetic opioid derivate with an agonist activity at mu-opioid receptors. The pharmacokinetic profile differs from other synthetic opioids. Remifentanil is rapidly metabolised by unspecific blood and tissue esterases and the metabolites have almost no intrinsic activity. According to its unique pharmacokinetic profile, remifentanil-based anaesthesia might be associated with a high level of postoperative pain, therefore, an appropriate postoperative pain management is an import aspect. In addition, remifentanil withdrawal induces a compensatory up-regulation of secondary messenger pathways, inducing hyperalgesia. This review provides a comprehensive summary of basic and clinical research concerning the intraoperative use of remifentanil and postoperative pain therapy. The relative contribution of rapid degradation and withdrawal-induced hyperalgesia to postoperative pain will be discussed. In addition, this review attempts to identify potential clinical implications and treatment strategies.
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Affiliation(s)
- C Zöllner
- Klinik für Anaesthesiologie und operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin.
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Saboory E, Derchansky M, Ismaili M, Jahromi SS, Brull R, Carlen PL, El Beheiry H. Mechanisms of Morphine Enhancement of Spontaneous Seizure Activity. Anesth Analg 2007; 105:1729-35, table of contents. [PMID: 18042875 DOI: 10.1213/01.ane.0000287675.15225.0b] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Opioid tolerance and opioid-induced hyperalgesia are conditions that negatively affect pain management. Tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in a decrease of the drug's effects over time. Opioid-induced hyperalgesia occurs when prolonged administration of opioids results in a paradoxic increase in atypical pain that appears to be unrelated to the original nociceptive stimulus. Complex intracellular neural mechanisms, including opioid receptor desensitization and down-regulation, are believed to be major mechanisms underlying opioid tolerance. Pain facilitatory mechanisms in the central nervous system are known to contribute to opioid-induced hyperalgesia. Recent research indicates that there may be overlap in the two conditions. This article reviews known and hypothesized pathophysiologic mechanisms surrounding these phenomena and the clinical implications for pain management nurses.
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Affiliation(s)
- Anna DuPen
- Pain and Palliative Care Research Department, Swedish Medical Center, Seattle, Washington 98122-5711, USA.
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Abstract
CASE DESCRIPTION A healthy 6-year-old 28.5-kg (62.7-lb) spayed female Boxer undergoing surgical repair of a ruptured cranial cruciate ligament was inadvertently administered an overdose of morphine (1.3 mg/kg [0.59 mg/lb]) via subarachnoid injection. CLINICAL FINDINGS 50 minutes after administration of the overdose, mild multifocal myoclonic contractions became apparent at the level of the tail; the contractions migrated cranially and progressively increased in intensity and frequency during completion of the surgery. TREATMENT AND OUTCOME The myoclonic contractions were refractory to treatment with midazolam, naloxone, phenobarbital, and pentobarbital; only atracurium (0.1 mg/kg [0.045 mg/lb], IV) was effective in controlling the movements. The dog developed hypertension, dysphoria, hyperthermia, and hypercapnia. The dog remained anesthetized and ventilated mechanically; treatments included continuous rate IV infusions of propofol (1 mg/kg/h [0.45 mg/lb/h]), diazepam (0.25 mg/kg/h [0.11 mg/lb/h]), atracurium (0.1 to 0.3 mg/kg/h [0.045 to 0.14 mg/lb/h]), and naloxone (0.02 mg/kg/h [0.009 mg/lb/h]). Twenty-two hours after the overdose, the myoclonus was no longer present, and the dog was able to ventilate without mechanical assistance. The dog remained sedated until 60 hours after the overdose, at which time its mentation improved, including recognition of caregivers and response to voice commands. No neurologic abnormalities were detectable at discharge (approx 68 hours after the overdose) or at a recheck evaluation 1 week later. CLINICAL RELEVANCE Although intrathecal administration of an overdose of morphine can be associated with major and potentially fatal complications, it is possible that affected dogs can completely recover with immediate treatment and extensive supportive care.
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Affiliation(s)
- Anderson F da Cunha
- Department of Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
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Juni A, Klein G, Pintar JE, Kest B. Nociception increases during opioid infusion in opioid receptor triple knock-out mice. Neuroscience 2007; 147:439-44. [PMID: 17544222 DOI: 10.1016/j.neuroscience.2007.04.030] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Revised: 03/06/2007] [Accepted: 04/20/2007] [Indexed: 11/15/2022]
Abstract
Opioids are extensively used analgesics yet can paradoxically increase pain sensitivity in humans and rodents. This hyperalgesia is extensively conceptualized to be a consequence of opioid receptor activity, perhaps providing an adaptive response to analgesia, and to utilize N-methyl-D-aspartate (NMDA) receptors. These assumptions were tested here in opioid receptor triple knock-out (KO) mice lacking all three genes encoding opioid receptors (mu, delta, and kappa) by comparing their thermal nociceptive responses to the opioids morphine and oxymorphone with those of B6129F(1) controls. Injecting acute opioid bolus doses in controls caused maximal analgesia that was completely abolished in KO mice, confirming the functional consequence of the KO mouse opioid receptor deficiency. Continuous opioid infusion by osmotic pump in control mice also initially caused several consecutive days of analgesia that was shortly thereafter followed by several consecutive days of hyperalgesia. In contrast, continuously infusing KO mice with opioids caused no detectable analgesic response, but only immediate and steady declines in nociceptive thresholds culminating in several days of unremitting hyperalgesia. Finally, injecting the non-competitive NMDA receptor antagonist MK-801 during opioid infusion markedly reversed hyperalgesia in control but not KO mice. These data demonstrate that sustained morphine and oxymorphone delivery causes hyperalgesia independently of prior or concurrent opioid or NMDA receptor activity or opioid analgesia, indicating the contribution of mechanisms outside of current conceptions, and are inconsistent with proposals of hyperalgesia as a causative factor of opioid analgesic tolerance.
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Affiliation(s)
- A Juni
- Neuropsychology Doctoral Program, Queens College, City University of New York, Flushing, NY 11367, USA
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Weschules DJ, Bain KT, Reifsnyder J, McMath JA, Kupperman DE, Gallagher RM, Hauck WW, Knowlton CH. Toward evidence-based prescribing at end of life: a comparative analysis of sustained-release morphine, oxycodone, and transdermal fentanyl, with pain, constipation, and caregiver interaction outcomes in hospice patients. Pain Med 2006; 7:320-9. [PMID: 16898943 DOI: 10.1111/j.1526-4637.2006.00184.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The primary goal of this investigation was to examine selected outcomes in hospice patients who are prescribed one of three sustained-release opioid preparations. The outcomes examined include: pain score, constipation severity, and ability of the patient to communicate with caregivers. PATIENTS AND SETTINGS This study included 12,000 terminally ill patients consecutively admitted to hospices and receiving pharmaceutical care services between the period of July 1 and December 31, 2002. DESIGN We retrospectively examined prescribing patterns of sustained-release morphine, oxycodone, and transdermal fentanyl. We compared individual opioids on the aforementioned outcome markers, as well as patient gender, terminal diagnosis, and median length of stay. RESULTS Patients prescribed a sustained-release opioid had similar average ratings of pain and constipation severity, regardless of the agent chosen. Patients prescribed transdermal fentanyl were reported to have more difficulty communicating with friends and family when compared with patients prescribed either morphine or oxycodone. On average, patients prescribed transdermal fentanyl had a shorter length of stay on hospice as compared with those receiving morphine or oxycodone. CONCLUSION There was no difference in observed pain or constipation severity among patients prescribed sustained-release opioid preparations. Patients receiving fentanyl were likely to have been prescribed the medication due to advanced illness and associated dysphagia. Diminished ability to communicate with caregivers and a shorter hospice course would be consistent with this profile. Further investigation is warranted to examine the correlation between a patient's ability to interact with caregivers and pain control achieved.
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Morrish GA, Foster DJR, Somogyi AA. Differential in vitro inhibition of M3G and M6G formation from morphine by (R)- and (S)-methadone and structurally related opioids. Br J Clin Pharmacol 2006; 61:326-35. [PMID: 16487227 PMCID: PMC1885024 DOI: 10.1111/j.1365-2125.2005.02573.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AIMS To determine the in vitro kinetics of morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) formation and the inhibition potential by methadone enantiomers and structurally related opioids. METHODS M3G and M6G formation kinetics from morphine were determined using microsomes from five human livers. Inhibition of glucuronide formation was investigated with eight inhibitors (100 microm) and the mechanism of inhibition determined for (R)- and (S)-methadone (70-500 microm) using three microsomal samples. RESULTS Glucuronide formation displayed single enzyme kinetics. The M3G Vmax (mean+/-SD) was 4.8-fold greater than M6G Vmax (555+/-110 vs. 115+/-19 nmol mg-1 protein h-1; P=0.006, mean of difference 439; 95% confidence interval 313, 565 nmol mg-1 protein h-1). Km values for M3G and M6G formation were not significantly different (1.12+/-0.37 vs. 1.11+/-0.31 mm; P=0.89, 0.02; -0.29, 0.32 mm). M3G and M6G formation was inhibited (P<0.01) with a significant increase in the M3G/M6G ratio (P<0.01) for all compounds tested. Detailed analysis with (R)- and (S)-methadone revealed noncompetitive inhibition with (R)-methadone Ki of 320+/-42 microm and 192+/-12 microm for M3G and M6G, respectively, and (S)-methadone Ki of 226+/-30 microm and 152+/-20 microm for M3G and M6G, respectively. Ki values for M3G inhibition were significantly greater than for M6G for (R)-methadone (P=0.017, 128; 55, 202 microm) and (S)-methadone (P=0.026, 75; 22, 128 microm). CONCLUSIONS Both methadone enantiomers noncompetitively inhibited the formation of morphine's primary metabolites, with greater inhibition of M6G formation compared with M3G. These findings indicate a mechanism for reduced morphine clearance in methadone-maintained patients and reduced relative formation of the opioid active M6G compared with M3G.
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Affiliation(s)
- Glynn A Morrish
- Department of Clinical and Experimental Pharmacology, The University of Adelaide, and Department of Clinical Pharmacology, Royal Adelaide Hospital, Australia.
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Gardell LR, King T, Ossipov MH, Rice KC, Lai J, Vanderah TW, Porreca F. Opioid receptor-mediated hyperalgesia and antinociceptive tolerance induced by sustained opiate delivery. Neurosci Lett 2006; 396:44-9. [PMID: 16343768 DOI: 10.1016/j.neulet.2005.11.009] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2005] [Revised: 11/04/2005] [Accepted: 11/04/2005] [Indexed: 10/25/2022]
Abstract
Opiates are commonly used to treat moderate to severe pain and can be used over prolonged periods in states of chronic pain such as those associated with cancer. In addition, to analgesic actions, studies show that opiate administration can paradoxically induce hyperalgesia. At the pre-clinical level, such hyperalgesia is associated with numerous pronociceptive neuroplastic changes within the primary afferent fibers and the spinal cord. In rodents, sustained opiate administration also induces antinociceptive tolerance. The mechanisms by which prolonged opiate exposure induces hyperalgesia and the relationship of this state to antinociceptive tolerance remain unclear. The present study was aimed at determining whether sustained opiate-induced hyperalgesia, associated neuroplasticity and antinociceptive tolerance are the result of specific opiate interaction at opiate receptors. Enantiomers of oxymorphone, a mu opioid receptor agonist, were administered to rats by spinal infusion across 7 days. Sustained spinal administration of (-)-oxymorphone, but not its inactive enantiomer (+)-oxymorphone or vehicle, upregulated spinal dynorphin content, produced thermal and tactile hypersensitivity, and produced antinociceptive tolerance. These results indicate that these pronociceptive actions of sustained opiate administration require specific interaction with opiate receptors and are unlikely to be the result of accumulation of potentially excitatory metabolic products. While the precise mechanisms, which may account for these pronociceptive changes remain to be unraveled, the present data point to plasticity initiated by opiate receptor interaction.
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Affiliation(s)
- Luis R Gardell
- Department of Pharmacology, College of Medicine, University of Arizona Health Sciences Center, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA
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Athanasos P, Smith CS, White JM, Somogyi AA, Bochner F, Ling W. Methadone maintenance patients are cross-tolerant to the antinociceptive effects of very high plasma morphine concentrations. Pain 2006; 120:267-275. [PMID: 16427197 DOI: 10.1016/j.pain.2005.11.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2004] [Revised: 08/31/2005] [Accepted: 11/14/2005] [Indexed: 11/26/2022]
Abstract
Opioid dependent patients require higher than normal doses of opioid analgesics. However, this regimen has not been formally tested. This study utilised a double-blind placebo-controlled design to examine antinociceptive responses to saline and pseudo-steady-state plasma morphine concentrations (173+/-11 (mean+/-SEM), range 106-305 ng/ml) in 18 methadone participants in three stable, once daily methadone dose ranges 11-45 mg (n=6), 46-80 mg (n=6), 81-115 mg (n=6) and 10 controls. Testing commenced approximately 20 h after the maintenance dose with the next dose given 1h after morphine cessation. Nociceptive stimuli (cold pressor (seconds) and electrical stimulation (volts)) were used to measure pain detection threshold and pain tolerance. Blood samples were analysed by HPLC for plasma morphine and R-(-)-methadone concentrations. Methadone participants were hyperalgesic to cold pressor pain. High plasma morphine concentrations failed to significantly change cold pressor and electrical stimulation pain tolerance for methadone patients, but in controls, morphine significantly (P<0.05) increased mean pain tolerance to cold pressor by 59+/-29% (range -17% to 311%) and electrical stimulation by 19+/-6% (range 0% to 58%). Morphine significantly (P<0.05) decreased respiration rates by 12+/-3% (range -29% to 8%) in methadone subjects. On saline days, rising methadone concentrations significantly (P<0.01) increased cold pressor pain detection threshold by 32+/-6% (range 1-81%) and cold pressor pain tolerance by 23+/-6% (range -32% to 56%). Methadone maintained patients are hyperalgesic and cross-tolerant to the antinociceptive effects of very high plasma morphine concentrations. While even higher morphine doses may achieve some pain relief, this may be at the cost of unacceptable respiratory depression.
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Affiliation(s)
- Peter Athanasos
- Department of Clinical and Experimental Pharmacology, University of Adelaide, Adelaide, SA 5005, Australia Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA 5005, Australia Integrated Substance Abuse Programs, University of California, Los Angeles, CA 90025, USA
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Juni A, Klein G, Kest B. Morphine hyperalgesia in mice is unrelated to opioid activity, analgesia, or tolerance: Evidence for multiple diverse hyperalgesic systems. Brain Res 2006; 1070:35-44. [PMID: 16409995 DOI: 10.1016/j.brainres.2005.11.054] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 11/15/2005] [Accepted: 11/16/2005] [Indexed: 11/29/2022]
Abstract
Hyperalgesia following chronic morphine treatment is thought to be a response to opioid receptor activation and analgesia and contribute to the development of analgesic tolerance. Here, the relationship between these variables was studied in mice tested for nociceptive sensitivity on the tail-withdrawal test during chronic infusion of various morphine doses. Hyperalgesic onset was preceded by dose-dependent analgesia except for the lowest morphine dose, which caused hyperalgesia 6 h after the start of infusion. Morphine ED50 values obtained at various infusion intervals demonstrated both analgesic tolerance in the absence of hyperalgesia and hyperalgesia in the absence of tolerance. Continuous opioid receptor antagonism using naltrexone pellets abolished analgesia during continuous morphine administration, transiently potentiated hyperalgesia, and revealed differences in hyperalgesic onset between morphine infusion doses. Acute injection of the N-methyl-D-aspartate (NMDA) receptor antagonist MK-801 attenuated hyperalgesia in naltrexone-treated mice, demonstrating a role for this receptor in morphine hyperalgesia unrelated to its effects upon morphine analgesia. In mice where hyperalgesia subsided after continuous infusion of the highest morphine dose (i.e., hyperalgesic adaptation), hyperalgesia was restored after infusing the lower but not higher morphine dose. In addition, acute injection of morphine-3beta-glucoronide (M3G) caused hyperalgesia that was cross-adaptive with the lower morphine dose only. The data demonstrate that morphine hyperalgesia is independent of prior or concurrent opioid receptor activity or analgesia and is unrelated to analgesic tolerance. Furthermore, the lack of hyperalgesic cross-adaptation between high and low morphine doses, and their differential cross-adaptation with M3G hyperalgesia, also suggests distinct morphine dose-dependent hyperalgesic systems.
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Affiliation(s)
- Aaron Juni
- Doctoral Program in Neuropsychology, Queens College, City University of New York, Flushing, NY 11367, USA
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Abstract
PURPOSE The pharmacotherapy and assessment of postoperative pain in general pharmacy practice settings are reviewed. SUMMARY Numerous factors related to all levels of society and the health care system contribute to suboptimal treatment of postoperative pain, despite awareness of this challenge for at least the past 30 years and the availability of potent analgesics and tools to help clinicians care for persons with postoperative pain. The consequences of acute pain include clinical, economic, and patient-reported outcomes; thus, improving the treatment of postoperative pain has the potential to improve health care from a broad perspective. Opioids remain the cornerstone of treatment of postoperative pain. Multimodal analgesia also has the potential to improve the pharmacotherapy of postoperative pain. In addition to the appropriate use of drugs, it is important that clinicians be comfortable with equianalgesic dosage conversion, helping ensure that analgesic-related adverse effects are minimal, assessing pain and function, and incorporating this information into patient care. CONCLUSION Providing optimal management of postoperative pain is a vital goal for all health care providers. There is substantial potential for pharmacists to help meet this goal.
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Affiliation(s)
- Scott A Strassels
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA 98195, USA.
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Abstract
BACKGROUND Glucuronidation is a major drug-metabolizing reaction in humans. A pharmacological effect of glucuronide metabolites is frequently neglected and the value of therapeutic drug monitoring has been questioned. However, this may not always be true. METHODS In this review the impact of glucuronidation on therapeutic drug monitoring has been evaluated on the basis of a literature search and experience from the own laboratory. RESULTS The potential role of monitoring glucuronide metabolite concentrations to optimize therapeutic outcome is addressed on the basis of selected examples of drugs which are metabolized to biologically active/reactive glucuronides. Furthermore indirect effects of glucuronide metabolites on parent drug pharmacokinetics are presented. In addition, factors that may modulate the disposition of these metabolites (e.g. genetic polymorphisms, disease processes, age, and drug-drug interactions) are briefly mentioned and their relevance for the clinical situation is critically discussed. CONCLUSION Glucuronide metabolites can have indirect as well as direct pharmacological or toxicological effects. Although convincing evidence to support the introduction of glucuronide monitoring into clinical practice is currently missing, measurement of glucuronide concentrations may be advantageous in specific situations. If the glucuronide metabolite has an indirect effect on the pharmacokinetics of the parent compound, monitoring of the parent drug may be considered. Furthermore pharmacogenetic approaches considering uridine diphosphate (UDP) glucuronosyltransferases polymorphisms may become useful in the future to optimize therapy with drugs subject to glucuronidation.
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Affiliation(s)
- Maria Shipkova
- Department of Clinical Chemistry and Laboratory Medicine, Klinikum Stuttgart, Stuttgart, Germany.
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Affiliation(s)
- Carsten Skarke
- Institute of Clinical Pharmacology, Johann Wolfgang Goethe-University, pharmazentrum frankfurt/ZAFES, Theodor Stern-Kai 7, 60590 Frankfurt am Main, Germany
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