Selective postoperative inhibition of gastrointestinal opioid receptors

Opioid analgesia for infants in the neonatal intensive care unit

There is an ethical obligation to relieve the pain and suffering in newborn infants. Opioids have been demonstrated to blunt the physiologic effects of pain and may prevent some of the clinical consequences of unmanaged pain. There are sufficient data to recommend the clinical use of opioid analgesics for the treatment of pain in the neonate. Neonates exposed to opioid analgesics can experience adverse effects. Adverse effects can be minimized by the use of various drug administration techniques and close monitoring. Further research is needed to determine how to optimize their effects. Data on the long-term effects of neonatal opioid exposure are warranted.

Opioid antagonists: a review of their role in palliative care, focusing on use in opioid-related constipation

Opioid antagonists have well-established indications in the reversal of life-threatening opioid toxicity, but also hold considerable promise for other applications in palliative care practice, particularly management of opioid-related constipation. We briefly review current understanding of opioid receptors, focusing on their complex role in gastrointestinal physiology. We summarize the pharmacology, conventional indications, and clinical usage of three major groups of opioid antagonists, including a promising new peripherally acting agent, methylnaltrexone, which is not commercially available. We suggest an approach to administering opioid antagonists for reduction of life-threatening opioid toxicity in patients with pain. The literature on opioid-induced constipation and its treatment with opioid-antagonists is reviewed in detail. Finally, other potential uses of opioid antagonists in palliative care are described, especially strategies for reducing such opioid side effects as nausea and pruritus and for improving analgesia or reducing tolerance by concomitantly administrating both an opioid agonist and low dosages of an antagonist.

Ileus in critical illness: mechanisms and management

Nonobstructive ileus, signifying the impairment of coordinated propulsive intestinal motility, remains a frequently documented and almost inevitable consequence of open abdominal surgery and sepsis. Despite the frequency and major impact of ileus on morbidity and mortality, the exact underlying molecular and cellular mechanisms of this important clinical conundrum are still ill defined. Animal models suggest that both neuronal and local inflammatory responses within the intestinal muscularis mechanistically contribute to intestinal ileus. The neuronal mechanism appears to involve the enhanced release of nitric oxide from inhibitory motor neurons. Likewise, nitric oxide and prostaglandins are released from inflammatory cells (macrophages and monocytes) via the induction of nitric oxide synthase (iNOS) and cyclooxygenase-2. Recently, preliminary data have confirmed the existence of an intraoperative local muscularis inflammatory response during surgery in human patients.

Involvement of mu- and kappa-, but not delta-, opioid receptors in the peristaltic motor depression caused by endogenous and exogenous opioids in the guinea-pig intestine

Opiates inhibit gastrointestinal propulsion, but it is not clear which opioid receptor types are involved in this action. For this reason, the effect of opioid receptor - selective agonists and antagonists on intestinal peristalsis was studied. Peristalsis in isolated segments of the guinea-pig small intestine was triggered by a rise of the intraluminal pressure and recorded via the intraluminal pressure changes associated with the peristaltic waves. Mu-opioid receptor agonists (DAMGO, morphine), kappa-opioid receptor agonists (ICI-204,448 and BRL-52,537) and a delta-opioid receptor agonist (SNC-80) inhibited peristalsis in a concentration-related manner as deduced from a rise of the peristaltic pressure threshold (PPT) and a diminution of peristaltic effectiveness. Experiments with the delta-opioid receptor antagonists naltrindole (30 nM) and HS-378 (1 microM), the kappa-opioid receptor antagonist nor-binaltorphimine (30 nM) and the mu-opioid receptor antagonist cyprodime (10 microM) revealed that the antiperistaltic effect of ICI-204,448 and BRL-52,537 was mediated by kappa-opioid receptors and that of morphine and DAMGO by mu-opioid receptors. In contrast, the peristaltic motor inhibition caused by SNC-80 was unrelated to delta-opioid receptor activation. Cyprodime and nor-binaltorphimine, but not naltrindole and HS-378, were per se able to stimulate intestinal peristalsis as deduced from a decrease in PPT. The results show that the neural circuits controlling peristalsis in the guinea-pig small intestine are inhibited by endogenous and exogenous opioids acting via mu- and kappa-, but not delta-, opioid receptors.

Alvimopan* (ADL 8-2698) is a novel peripheral opioid antagonist

Alvimopan (ADL 8-2698; Adolor Corporation, Exton, PA, USA) is a novel, peripherally restricted opioid antagonist. After oral administration, it has activity specific to the gastrointestinal (GI) tract. ADL 8-2698 has low systemic absorption and a high affinity for mu-opioid receptors. In healthy subjects, ADL 8-2698 antagonized loperamide-induced changes in GI transit and prevented morphine-induced delays in oral-cecal transit time without antagonizing centrally mediated opioid effects, such as analgesia or pupillary constriction. In the treatment of opioid naive patients who underwent surgery and received opioids for acute pain, oral ADL 8-2698 (6.0 mg) improved the management of postoperative ileus (POI) by shortening the time to achieve normal bowel function and, ultimately, hospital stay. Postoperative nausea and vomiting and the overall incidence of all GI side effects were reduced in patients treated with ADL 8-2698 for POI. Analgesia was not compromised, because there were no changes in median opioid consumption or Visual Analog Scale (VAS) pain scores in patients treated with ADL 8-2698 versus patients treated with placebo. No drug-related side effects were observed in acute pain postsurgical patients in the initial POI study. In patients treated with opioids for chronic pain or opioid addiction, lower doses of oral ADL 8-2698 (0.5 to 3.0 mg) reversed opioid bowel dysfunction (OBD) and normalized GI activity. These effects were evident without compromising opioid analgesia or inducing central nervous system symptoms of withdrawal. Some chronic opioid patients receiving apparently supramaximal doses of ADL 8-2698 (> or = 3.0 mg) reported localized GI side effects, possibly indicative of a localized GI withdrawal response. The most common side effects of ADL 8-2698 in chronic pain patients with OBD were abdominal pain, flatulence, and diarrhea. These effects were not observed in most OBD patients receiving lower doses of ADL 8-2698. Overall, ADL 8-2698 was well tolerated in clinical trials. Further studies to evaluate the efficacy and safety of ADL 8-2698 in clinical practice are in progress.