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Paul AK, Smith CM, Rahmatullah M, Nissapatorn V, Wilairatana P, Spetea M, Gueven N, Dietis N. Opioid Analgesia and Opioid-Induced Adverse Effects: A Review. Pharmaceuticals (Basel) 2021; 14:1091. [PMID: 34832873 PMCID: PMC8620360 DOI: 10.3390/ph14111091] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 01/08/2023] Open
Abstract
Opioids are widely used as therapeutic agents against moderate to severe acute and chronic pain. Still, these classes of analgesic drugs have many potential limitations as they induce analgesic tolerance, addiction and numerous behavioural adverse effects that often result in patient non-compliance. As opium and opioids have been traditionally used as painkillers, the exact mechanisms of their adverse reactions over repeated use are multifactorial and not fully understood. Older adults suffer from cancer and non-cancer chronic pain more than younger adults, due to the physiological changes related to ageing and their reduced metabolic capabilities and thus show an increased number of adverse reactions to opioid drugs. All clinically used opioids are μ-opioid receptor agonists, and the major adverse effects are directly or potentially connected to this receptor. Multifunctional opioid ligands or peripherally restricted opioids may elicit fewer adverse effects, as shown in preclinical studies, but these results need reproducibility from further extensive clinical trials. The current review aims to overview various mechanisms involved in the adverse effects induced by opioids, to provide a better understanding of the underlying pathophysiology and, ultimately, to help develop an effective therapeutic strategy to better manage pain.
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Affiliation(s)
- Alok K. Paul
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia;
| | - Craig M. Smith
- School of Medicine, Institute for Mental and Physical Health and Clinical Translation, Deakin University, Geelong, VIC 3216, Australia;
| | - Mohammed Rahmatullah
- Department of Biotechnology & Genetic Engineering, University of Development Alternative, Dhanmondi, Dhaka 1207, Bangladesh;
| | - Veeranoot Nissapatorn
- School of Allied Health Sciences, World Union for Herbal Drug Discovery (WUHeDD) and Research Excellence Center for Innovation and Health Products (RECIHP), Walailak University, Nakhon Si Thammarat 80160, Thailand;
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Mariana Spetea
- Department of Pharmaceutical Chemistry, Institute of Pharmacy and Center for Molecular Biosciences (CMBI), University of Innsbruck, Innrain 80–82, 6020 Innsbruck, Austria;
| | - Nuri Gueven
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia;
| | - Nikolas Dietis
- Medical School, University of Cyprus, Nicosia 1678, Cyprus;
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Babić Leko M, Hof PR, Šimić G. Alterations and interactions of subcortical modulatory systems in Alzheimer's disease. PROGRESS IN BRAIN RESEARCH 2021; 261:379-421. [PMID: 33785136 DOI: 10.1016/bs.pbr.2020.07.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The pathogenesis of Alzheimer's disease (AD) is not fully understood. Here we summarize current knowledge on the involvement of the serotonergic, noradrenergic, dopaminergic, cholinergic, and opioid systems in AD, emphasizing the importance of interactions between the serotonergic and the other subcortical modulatory systems during the progression of AD. In physiological conditions, all neurotransmitter systems function in concert and are interdependent at both the neuroanatomical and molecular levels. Through their early involvement in AD, cognitive and behavioral abilities that rely on their interactions also become disrupted. Considering that serotonin (5HT) regulates the release of noradrenaline (NA), dopamine (DA) and acetylcholine (ACh), any alteration in 5HT levels leads to disturbance of NA, DA, and ACh homeostasis in the brain. One of the earliest pathological changes during the prodromal phase of AD is a decrease of serotonergic transmission throughout the brain, with serotonergic receptors being also affected. Additionally, serotonergic and noradrenergic as well as serotonergic and dopaminergic nuclei are reciprocally interconnected. As the serotonergic dorsal raphe nucleus (DRN) is affected by pathological changes early in AD, and the noradrenergic locus coeruleus (LC) and dopaminergic ventral tegmental area (VTA) exhibit AD-related pathological changes, their connectivity also becomes altered in AD. Such disrupted interactions among neurotransmitter systems in AD can be used in the development of multi-target drugs. Some of the potential AD therapeutics (such as ASS234, RS67333, tropisetron) target multiple neurotransmitter systems to achieve the best possible improvement of cognitive and behavioral deficits observed in AD. Here, we review how serotonergic system interacts with other subcortical modulatory systems (noradrenergic, dopaminergic, cholinergic, and opioid systems) during AD.
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Affiliation(s)
- Mirjana Babić Leko
- Department for Neuroscience, Croatian Institute for Brain Research, University of Zagreb Medical School, Zagreb, Croatia
| | - Patrick R Hof
- Nash Family Department of Neuroscience, Friedman Brain Institute, and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Goran Šimić
- Department for Neuroscience, Croatian Institute for Brain Research, University of Zagreb Medical School, Zagreb, Croatia.
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Opioid system and Alzheimer's disease. Neuromolecular Med 2012; 14:91-111. [PMID: 22527793 DOI: 10.1007/s12017-012-8180-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 04/04/2012] [Indexed: 12/15/2022]
Abstract
The opioid system may be involved in the pathogenesis of AD, including cognitive impairment, hyperphosphorylated tau, Aβ production, and neuroinflammation. Opioid receptors influence the regulation of neurotransmitters such as acetylcholine, norepinephrine, GABA, glutamate, and serotonin which have been implicated in the pathogenesis of AD. Opioid system has a close relation with Aβ generation since dysfunction of opioid receptors retards the endocytosis and degradation of BACE1 and γ-secretase and upregulates BACE1 and γ-secretase, and subsequently, the production of Aβ. Conversely, activation of opioid receptors increases the endocytosis of BACE1 and γ-secretase and downregulates BACE1 and γ-secretase, limiting the production of Aβ. The dysfunction of opioid system (opioid receptors and opioid peptides) may contribute to hyperphosphorylation of tau and neuroinflammation, and accounts for the degeneration of cholinergic neurons and cognitive impairment. Thus, the opioid system is potentially related to AD pathology and may be a very attractive drug target for novel pharmacotherapies of AD.
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Abstract
After a brief overview of the history of narcotic use in anesthesia, the various opiates are reviewed mainly from a stress-reducing, antiinflammatory and hemodynamic perspective. The emphasis is placed on cardiac anesthesia.
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Affiliation(s)
- B H Scott
- Department of Anesthesiology, University Hospital and Medical Center, State University of New York at Stony Brook, 11794-8480, USA
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Abstract
BACKGROUND Although rare, paralysis secondary to spinal cord ischaemia after aortic aneurysm surgery is a devastating complication. Many papers have been published on this topic but without a clear consensus on the best way of minimizing the problem. Recent articles have included advanced pharmacological approaches and the literature has been reviewed in light of these. METHODS Relevant papers were identified by an extensive text word search of the Medline database and a review of quoted articles. RESULTS Spinal cord complications are commoner after the repair of Crawford type II aneurysms than less extensive aneurysms. The presence of dissection, rupture and prolonged clamp times are associated with an increased incidence. About a quarter of all cord problems develop over 24 h after surgery and this may be due to a reperfusion type injury, although the exact mechanisms are by no means clear. CONCLUSION A combination of rapid surgery, left heart bypass for the repair of more extensive aneurysms, free spinal drainage and the avoidance of postoperative hypoxia and hypotension help to minimize spinal cord ischaemia. No pharmacological agent has yet been shown conclusively to improve outcome in the clinical setting.
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Affiliation(s)
- P Lintott
- Academic Surgical Unit, Imperial College School of Medicine at St Mary's, St Mary's Hospital, London, UK
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Bovill JG. Mechanisms of actions of opioids and non-steroidal anti-inflammatory drugs. EUROPEAN JOURNAL OF ANAESTHESIOLOGY. SUPPLEMENT 1997; 15:9-15. [PMID: 9202932 DOI: 10.1097/00003643-199705001-00003] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are the commonest drugs used to treat pain. Opioids mimic the actions of endogenous opioid peptides by interacting with mu, delta or kappa opioid receptors. The opioid receptors are coupled to G1 proteins and the actions of the opioids are mainly inhibitory. They close N-type voltage-operated calcium channels and open calcium-dependent inwardly-rectifying potassium channels. This results in hyperpolarization and a reduction in neuronal excitability. They also decrease intracellular cAMP which modulates the release of nociceptive neurotransmitters (e.g. substance P). Inhibition of prostaglandin synthesis by cyclooxygenase is the principal mode of the analgesic and anti-inflammatory actions of NSAIDs. Cyclo-oxygenase is inhibited irreversibly by aspirin and reversibly by other NSAIDs. The widespread inhibition of cyclo-oxygenase is responsible for many of the adverse effects of these drugs. NSAIDs also reduce prostaglandin production within the CNS. This is the main action of paracetamol.
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Affiliation(s)
- J G Bovill
- Department of Anaesthesiology, University Hospital Leiden, The Netherlands
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Acher CW, Wynn MM, Hoch JR, Popic P, Archibald J, Turnipseed WD. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg 1994; 19:236-46; discussion 247-8. [PMID: 8114185 DOI: 10.1016/s0741-5214(94)70099-0] [Citation(s) in RCA: 161] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE This report summarizes our experience with the use of cerebral spinal fluid drainage (CSFD) and naloxone for prevention of postoperative neurologic deficit (paraplegia or paraparesis). METHODS We reviewed 110 consecutive patients with 86 thoracoabdominal aneurysms and 24 thoracic aneurysms. The status of 47 patients (43%) was acute (rupture or dissection), and the status of 52 (47%) was Crawford type I or II. None of the patients had intercostal artery reimplantation. There were two patient groups for analysis of neurologic deficit risk. Group A (61 patients) received naloxone and CSFD, and group B (49 patients) did not. RESULTS One deficit occurred in group A and 11 deficits occurred in group B (p = 0.001). By multiple logistic regression analysis, the variables acute status, Crawford type II, or group B classification were significant factors for deficit risk. Use of the same logistic regression analysis on the subgroup of 47 patients with acute aneurysms and 33 patients with Crawford type 2 aneurysms confirmed the protective effect of combined CSFD and naloxone (group A) and that clinical presentation and extent of aorta replaced are the primary risk factors for development of deficit. To test this conclusion we developed a highly predictive model (correlation coefficient 0.997 with 16 series of thoracoabdominal aneurysms) for neurologic deficit. We applied our data to this model. Group B had the predicted number of deficits, and group A had substantially fewer deficits than predicted. CONCLUSIONS We conclude that the combined use of CSFD and naloxone offers significant protection from neurologic deficits in patients undergoing thoracoabdominal and thoracic aortic replacement.
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Affiliation(s)
- C W Acher
- University of Wisconsin Hospital, Madison
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Abstract
The analgesic effects of morphine administration were determined in post-partum, lactating female rats, as well as in intact, cycling females during the diestrous stage of the estrous cycle. All doses of morphine (2.5, 5 and 10 mg/kg, iv) produced a significant analgesic response in both post-partum and diestrous females using the hot water tail immersion latency test. However, the analgesic response in the post-partum females was significantly less than during diestrus at all doses tested. In addition, pretreatment with the mu 1 specific antagonist, Naloxonazine, significantly blunted the analgesic response in diestrous females, but did not significantly affect analgesia in post-partum females. These results indicate that morphine is less effective in producing analgesia in post-partum females. The mu 1 opiate receptor site does not appear to be involved in the analgesia produced during the post-partum period.
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Affiliation(s)
- J Janik
- Department of Zoology, Miami University, Oxford, OH 45056
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Janik J, Callahan P, Rabii J. The role of the mu(1) opioid receptor subtype in the regulation of prolactin and growth hormone secretion by Beta-endorphin in female rats: studies with naloxonazine. J Neuroendocrinol 1992; 4:701-8. [PMID: 21554657 DOI: 10.1111/j.1365-2826.1992.tb00221.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The μ opioid receptor subtype has been reported to mediate the prolactin secretory response to opioids. This receptor subtype has been implicated in the morphine-induced prolactin increase, as well as the prolactin response to μ-specific opioid peptides. Subtypes of the μ receptor have been proposed and the μ(1) , site has been postulated as the receptor subtype involved in the morphine-induced prolactin secretory response. However, the role of this receptor subtype in mediating the endocrine effects of the endogenous opioid peptides has not been characterized. In order to determine the physiological significance of this receptor subtype, animals were pretreated with saline, WIN 44,441-3 (a μ, δ and κ antagonist) or naloxonazine (a μ(1) antagonist) followed by a stimulatory dose of morphine or β-endorphin. A dose response study for β-endorphin was conducted to determine the minimal stimulatory dose of β-endorphin on the prolactin and growth hormone (GH) secretory response. The dose response study indicated that β-endorphin is a more potent stimulus for prolactin release than for GH. A dose as low as 25 ng increased prolactin levels as much as 100-fold in both lactating and diestrous female rats. In contrast, 2.5 μg β-endorphin was required in order to consistently and significantly increase circulating levels of GH by 2- to 3-fold. WIN 44,441-3 antagonized the stimulatory effects of β-endorphin on both prolactin and GH secretion. Naloxonazine pretreatment abolished the morphine-induced prolactin secretory response, without affecting the GH increase in diestrous females. Naloxonazine also antagonized the prolactin response to β-endorphin in both lactating and diestrous females. In addition, it attenuated the GH secretory response but did not totally abolish it. These data indicate that β-endorphin elicits an increase in prolactin release through an opioid specific receptor which appears to be the μ(1) opioid receptor subtype. They further suggest that β-endorphin may increase GH levels, at least partially, via its action at this μ(1) site.
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Affiliation(s)
- J Janik
- Department of Biological Sciences, Rutgers University, Piscataway, New Jersey 08854, USA
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Abstract
Pain is a common problem in the early postoperative period. Techniques that provide perioperative analgesia to alleviate pain may have a significant effect on postoperative events, such as earlier ambulation and earlier dismissal from the hospital with use of epidural analgesia than with systemic analgesia. Spinal opioids, which can be administered epidurally or intrathecally, provide analgesia that is superior to that achieved with systemically administered narcotics. For procedures on the upper extremities, selective analgesia can be achieved with use of various types of neural blockade--for example, brachial plexus blockade, interscalene blockade, and axillary plexus blockade. Intercostal nerve block, a valuable but underutilized procedure appropriate for unilateral upper abdominal or flank operations or for thoracotomy, has been shown to reduce postoperative narcotic requirements and pulmonary complications. A patient-controlled analgesia device, consisting of an electronically controlled infusion pump with a timing device that can be triggered by the patient for intravenous administration of a narcotic when pain is experienced, avoids the vast fluctuations in analgesia that accompany parenteral administration of drugs. In most patients, postoperative pain can be prevented or diminished, and clinicians should be aware of the available techniques for achieving this goal.
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Affiliation(s)
- L J Lutz
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905
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Stanley TH. Opiates, receptors, and the new anesthetics and anesthetic delivery systems. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1987; 1:503-9. [PMID: 17165347 DOI: 10.1016/0888-6296(87)90035-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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