Acute cardiotoxicity following 'poppy seed tea' consumption

Insect damage to, and sub-optimal harvesting practices of the Papaver somniferum poppy are associated with contamination of its seeds with opium alkaloids. Consumption of poppy seeds has been linked to opium-like overdose symptoms, such as reduced consciousness and respiratory depression. However, acute cardiotoxicity secondary to ingestion of contaminated poppy seeds has not been reported previously. We report a case of a 21-year-old man who presented with severe biventricular dysfunction and cardiogenic shock following consumption of homemade poppy seed tea. We highlight the importance of prompt recognition of the myocardial effects of opiates along with the more common respiratory and neurological effects. In this case, the acute cardiotoxicity was fully reversed with high-dose naloxone, milrinone and noradrenaline. In addition, we recommend offering high-level care due to the possibility that specialist cardiac services may be required. Ergo, early transfer to an appropriate centre is recommended.

The Role of Opioids and Their Receptors in Urological Malignancy: A Review

PURPOSE

We reviewed the literature surrounding the role of opioids and their receptors in urological malignancy. Recent studies have suggested clinically significant effects of agonism or antagonism of opioid receptors on cancer related outcomes and tumorigenesis. The focus of these efforts has centered on nonurological malignancies. However, a compelling body of evidence is growing in the fields of prostate, bladder and kidney cancer.

MATERIALS AND METHODS

A systematic review of English language articles published through 2020 was conducted with key phrases related to kidney, bladder or prostate cancer, and opioids or narcotics. A total of 837 unique records were identified, of which 49 were selected for full text review and 33 were included in the qualitative analysis. Eight records were identified via citation review and 1 study was recently presented at a national meeting.

RESULTS

Retrospective reviews suggest poorer disease specific and recurrence-free survival with increased perioperative opioid administration in patients undergoing prostate or bladder cancer surgery. However, the data are controversial. Kappa opioid receptors are implicated in both proliferation and inhibition of prostate cancer cell growth across in vitro studies, with a proposed interaction with the androgen cascade. Similarly opioid growth factor receptor is highly expressed in prostate cancer cells and repressed by androgens. Prostate cancer tissue stains more intensely for the mu opioid receptor, and patients with higher expression have poorer oncologic outcomes. Opioid agonism in vitro induces urothelial cell carcinoma proliferation, migration and invasion, with possible additional influence from interactions with the bradykinin b2 receptor. Agonism of the mu, kappa and delta opioid receptors induces renal cell carcinoma tumorigenesis, possibly via upregulation of survivin. Meanwhile, opioid growth factor receptor agonism has the opposite effect in renal cell carcinoma.

CONCLUSIONS

Evidence surrounding the role of opioids and their receptors in urological malignancy is provocative and should serve as an impetus for further investigation.

Opiate Prescribing Practices in the Postpartum Unit

BACKGROUND

Louisiana is significantly impacted by the opioid epidemic. In preparation for a quality improvement project aimed at decreasing postpartum narcotics prescriptions, we evaluated routine prescribing practices on a postpartum unit and the number of patient-initiated encounters for postpartum pain.

METHODS

We conducted a retrospective medical record review of all vaginal deliveries occurring at Ochsner Baptist Medical Center in New Orleans, LA in December 2016 and January 2017. We collected patient demographics, inpatient and outpatient pain medications, and the number of postpartum pain-related encounters prior to the scheduled postpartum visit. We evaluated the cohort for inpatient medication usage and for postpartum encounters for pain.

RESULTS

After exclusions, 187 of 369 patients were included in the analysis: 78 patients had no perineal laceration, 40 had a first-degree laceration, and 69 had a second-degree laceration. The no-laceration (P=0.007) and second-degree laceration (P=0.011) groups had a significantly higher mean morphine milligram equivalent (MME) per patient during hospitalization than the first-degree group. Sixty-four patients were primiparous, and 123 were multiparous. Parity decreased as the severity of the laceration increased. Multiparous patients had a higher mean MME than primiparous patients (34.5 vs 30.0, respectively) during hospitalization, but the difference was not significant. In the no-laceration group, multiparous patients used significantly more narcotics during hospitalization (mean 41.4 MME) than primiparous patients (mean 22.5 MME) (P=0.029). A total of 3,635 narcotic pills were prescribed for our cohort at discharge, an average of 19.4 pills per patient. Overall, the mean number of postpartum encounters for pain was 0.19 per patient, with no difference between groups.

CONCLUSION

Despite a high number of outpatient narcotics prescriptions, approximately 1 in 5 patients initiated an encounter to address pain after vaginal delivery. Parity may play a role in postpartum inpatient narcotic usage, possibly because multiparous patients have had prior exposure to narcotics use in postpartum care.

Slow-release oral morphine for opioid maintenance treatment: a systematic review

This review article summarizes the results of all available clinical trials considering the use of slow-release oral morphine (SROM) for opioid maintenance treatment (OMT). All studies published up to October 2010 and assessing SROM for OMT in adult patients are included. Three independent reviewers assessed the selected articles using a standardized checklist. Study design, study length and number of subjects included were recorded. Data about retention rate (proportion of participants remaining under maintenance treatment at the end of the study), quality of life, withdrawal symptoms, craving, additional drug consumption, driving capacity and adverse events were collected. We identified 13 articles corresponding to nine clinical trials considering the use of SROM for OMT. Among them, only one was a randomized trial and one was a controlled not randomized trial. All other studies were uncontrolled. Retention rates were good (from 80.6 to 95%) with SROM maintenance, but similar retention rates were obtained with methadone. Most of the studies showed that quality of life, withdrawal symptoms, craving and additional drug consumption improved with SROM. However, there was no comparison with other maintenance drugs. As most of the studies assessing SROM efficacy were uncontrolled, there is no definite evidence that SROM is an effective alternative to methadone for OMT.

Activation and internalization of the mu-opioid receptor by the newly discovered endogenous agonists, endomorphin-1 and endomorphin-2

The multiple effects of opiate alkaloids, important therapeutic drugs used for pain control, are mediated by the neuronal miro-opioid receptor. Among the side effects of these drugs is a profound impairment of gastrointestinal transit. Endomorphins are opioid peptides recently isolated from the nervous system, which have high affinity and selectivity for micro-opioid receptors. Since the miro-opioid receptor undergoes ligand-induced receptor endocytosis in an agonist-dependent manner, we compared the ability of endomorphin-1, endomorphin-2 and the micro-opioid receptor peptide agonist, [D-Ala2,MePhe4,Gly-ol5]-enkephalin (DAMGO), to induce receptor endocytosis in cells transfected with epitope-tagged micro-opioid receptor complementary DNA, and in myenteric neurons of the guinea-pig ileum, which naturally express this receptor. Immunohistochemistry with antibodies to the FLAG epitope or to the native receptor showed that the micro-opioid receptor was mainly located at the plasma membrane of unstimulated cells. Endomorphins and DAMGO induced micro-opioid receptor endocytosis into early endosomes, a process that was inhibited by naloxone. Quantification of surface receptors by flow cytometry indicated that endomorphins' and DAMGO stimulated endocytosis with similar time-course and potency. They inhibited with similar potency electrically induced cholinergic contractions in the longitudinal muscle-myenteric plexus preparation through an action antagonized by naloxone. The apparent affinity estimate of naloxone (pA2 approximately 8.4) is consistent with antagonism at the micro-opioid receptor in myenteric neurons. These results indicate that endomorphins directly activate the micro-opioid receptor in neurons, thus supporting the hypothesis that they are ligands mediating opioid actions in the nervous system. Endomorphin-induced micro-opioid receptor activation can be visualized by receptor endocytosis.