Characterization of non-conventional opioid binding sites in rat and human lung

Peripheral opioid receptor antagonism alleviates fentanyl-induced cardiorespiratory depression and is devoid of aversive behavior

Millions of Americans suffering from Opioid Use Disorders face a high risk of fatal overdose due to opioid-induced respiratory depression (OIRD). Fentanyl, a powerful synthetic opioid, is a major contributor to the rising rates of overdose deaths. Reversing fentanyl overdoses has proved challenging due to its high potency and the rapid onset of OIRD. We assessed the contributions of central and peripheral mu opioid receptors (MORs) in mediating fentanyl-induced physiological responses. The peripherally restricted MOR antagonist naloxone methiodide (NLXM) both prevented and reversed OIRD to a degree comparable to that of naloxone (NLX), indicating substantial involvement of peripheral MORs to OIRD. Interestingly, NLXM-mediated OIRD reversal did not produce aversive behaviors observed after NLX. We show that neurons in the nucleus of the solitary tract (nTS), the first central synapse of peripheral afferents, exhibit a biphasic activity profile following fentanyl exposure. NLXM pretreatment attenuates this activity, suggesting that these responses are mediated by peripheral MORs. Together, these findings establish a critical role for peripheral MORs, including ascending inputs to the nTS, as sites of dysfunction during OIRD. Furthermore, selective peripheral MOR antagonism could be a promising therapeutic strategy for managing OIRD by sparing CNS-driven acute opioid-associated withdrawal and aversion observed after NLX.

Peripheral opioid receptor antagonism alleviates fentanyl-induced cardiorespiratory depression and is devoid of aversive behavior

Millions of Americans suffering from Opioid Use Disorders (OUD) face a high risk of fatal overdose due to opioid-induced respiratory depression (OIRD). Fentanyl, a powerful synthetic opioid, is a major contributor to the rising rates of overdose deaths. Reversing fentanyl overdoses has proved challenging due to its high potency and the rapid onset of OIRD. We assessed the contributions of central and peripheral mu opioid receptors (MORs) in mediating fentanyl-induced physiological responses. The peripherally restricted MOR antagonist naloxone methiodide (NLXM) both prevented and reversed OIRD to a degree comparable to that of naloxone (NLX), indicating substantial involvement of peripheral MORs to OIRD. Interestingly, NLXM-mediated OIRD reversal did not produce aversive behaviors observed after NLX. We show that neurons in the nucleus of the solitary tract (nTS), the first central synapse of peripheral afferents, exhibit a biphasic activity profile following fentanyl exposure. NLXM pretreatment attenuates this activity, suggesting that these responses are mediated by peripheral MORs. Together, these findings establish a critical role for peripheral MORs, including ascending inputs to the nTS, as sites of dysfunction during OIRD. Furthermore, selective peripheral MOR antagonism could be a promising therapeutic strategy for managing OIRD by sparing CNS-driven acute opioid-associated withdrawal and aversion observed after NLX.

Significance Statement

In this study, we compare the central versus peripheral components underlying fentanyl-induced cardiorespiratory depression to prevent overdose deaths. Our data indicate that these effects are, at least partially, due to the activation of mu opioid receptors present in peripheral sites. These findings provide insight into peripheral contributions to fentanyl-induced overdoses and could potentially lead to the development of treatments selectively targeting the peripheral system, sparing individuals from the CNS-driven acute opioid withdrawal generally observed with the use of naloxone.

Neuronal mechanisms underlying opioid-induced respiratory depression: our current understanding

Opioid-induced respiratory depression (OIRD) represents the primary cause of death associated with therapeutic and recreational opioid use. Within the United States, the rate of death from opioid abuse since the early 1990s has grown disproportionally, prompting the classification as a nationwide "epidemic." Since this time, we have begun to unravel many fundamental cellular and systems-level mechanisms associated with opioid-related death. However, factors such as individual vulnerability, neuromodulatory compensation, and redundancy of opioid effects across central and peripheral nervous systems have created a barrier to a concise, integrative view of OIRD. Within this review, we bring together multiple perspectives in the field of OIRD to create an overarching viewpoint of what we know, and where we view this essential topic of research going forward into the future.

Professor Tess Cramond (1926–2015): Contributions to Anaesthesia and Pain Medicine

Professor Tess Cramond joined the Queensland anaesthesia workforce in 1958, and contributed to high standards of clinical practice, pain management, training, scholarship and research. Evidence of her excellence, within the clinical, political and community spheres was recognised by multiple awards. Though deceased in 2015, she remains a role model for all physicians, using her expert knowledge, technical skills, clinical reasoning, emotions and values for the benefit of the individuals and community which she served.

Efficacy and safety of nebulized morphine given at 2 different doses compared to IV titrated morphine in trauma pain

BACKGROUND

Our aim was to compare the efficacy and safety of intravenous (IV) titrated morphine with nebulized morphine given at 2 different doses in severe traumatic pain.

METHODS

In a prospective, randomized, controlled double-blind study, we included 300 patients with severe traumatic pain. They were assigned to 3 groups: Neb10 group received 1 nebulization of 10-mg morphine; Neb20 group received 1 nebulization of 20-mg morphine, repeated every 10 minutes with a maximum of 3 nebulizations; and the IV morphine group received 2-mg IV morphine repeated every 5 minutes until pain relief. Visual analog scale was monitored at baseline, 5, 10, 15, 20, 25, 30, and 60 minutes after the start of drug administration. Treatment success was defined by the percentage of patients in whom visual analog scale decreased greater than or equal to 50% of its baseline value. When this end point was not reached, rescue morphine was administered. Pain resolution time was defined by the elapsed time between the start of the protocol and the reach of treatment success criteria.

RESULTS

Success rate was significantly better at 97% (95% confidence interval [CI], 93-100) for Neb20 group compared to Neb10 group (81% [95% CI, 73-89]) and IV morphine group (79% [95% CI, 67-84]). The lowest resolution time was observed in Neb20 group (20 minutes [95% CI, 18-21]). Side effects were minor and significantly lower in both nebulization groups compared to IV morphine group.

CONCLUSIONS

Nebulized morphine using boluses of 10 mg has similar efficacy and better safety than IV titrated morphine in patients with severe posttraumatic pain. Increasing nebulized boluses to 20 mg increases the effectiveness without increasing side effects.

Does nebulized fentanyl relieve dyspnea during exercise in healthy man?

Few therapies exist for the relief of dyspnea in restrictive lung disorders. Accumulating evidence suggests that nebulized opioids selective for the mu-receptor subtype may relieve dyspnea by modulating intrapulmonary opioid receptor activity. Our respective primary and secondary objectives were to test the hypothesis that nebulized fentanyl (a mu-opioid receptor agonist) relieves dyspnea during exercise in the presence of abnormal restrictive ventilatory constraints and to identify the physiological mechanisms of this improvement. In a randomized, double-blind, placebo-controlled crossover study, we examined the effect of 250 μg nebulized fentanyl, chest wall strapping (CWS), and their interaction on detailed physiological and perceptual responses to constant work rate cycle exercise (85% of maximum incremental work rate) in 14 healthy, fit young men. By design, CWS decreased vital capacity by ∼20% and mimicked the negative consequences of a mild restrictive lung disorder on exercise endurance time and on dyspnea, breathing pattern, dynamic operating lung volumes, and diaphragmatic electromyographic and respiratory muscle function during exercise. Compared with placebo under both unrestricted control and CWS conditions, nebulized fentanyl had no effect on exercise endurance time, integrated physiological response to exercise, sensory intensity, unpleasantness ratings of exertional dyspnea. Our results do not support a role for intrapulmonary opioids in the neuromodulation of exertional dyspnea in health nor do they provide a physiological rationale for the use of nebulized fentanyl in the management of dyspnea due to mild restrictive lung disorders, specifically those arising from abnormalities of the chest wall and not affiliated with airway inflammation.

Opioid effect on lungs

Opioids are widely used for their analgesic properties for the management of acute and chronic pain related to a variety of illnesses. Opioid usage is associated with adverse effects on respiration which are often attributed to depression of the central nervous system. Recent data indicate that opioid use has increased over the last two decades. There is also increasing evidence that opioids have a variety of effects on the lungs besides suppression of respiration. Opioids can affect immune cells function, increase histamine release causing bronchospasm, vaso-constriction and hypersensitivity reactions. Together, these actions have a variety of effects on lung function. Here, we provide a comprehensive review of the effects of opioids on the lungs including the respiratory centre, immune function, airways and pulmonary vasculature.

Opioid receptor expression in human brain and peripheral tissues using absolute quantitative real-time RT-PCR

BACKGROUND

The actions of endogenous opioid peptides are mediated by 3 main classes of opioid receptors; mu (MOR), kappa (KOR), and delta (DOR).

METHODS

We developed an absolute quantitative real-time reverse transcriptase PCR (AQ-rt-RT-PCR) assay to quantify MOR, DOR, and KOR mRNA in 22 human tissues.

RESULTS

MOR mRNA was greatly enriched (12-20×10(6)copies/μg) in the cerebellum, nucleus accumbens, and caudate nucleus; moderate (6×10(6)copies/μg) in the dorsal root ganglion, spinal cord, and adrenal gland; low (2×10(4)copies/μg) in the pancreas and small intestine; and absent in the lung, spleen, kidney, heart, skeletal muscle, liver, and thymus. High levels (>8.8×10(6)copies/μg) of DOR mRNA were expressed in the brain and dorsal root ganglion; moderate (1.5×10(6)copies/μg) in the adrenal gland and pancreas; low (2×10(4)-6.5×10(5)copies/μg in the cerebellum, spinal cord, small intestine, skeletal muscle, thymus, lung, and kidney); and very low (3.8×10(3)copies/μg) in the heart. DOR mRNA was not detected in the spleen or liver. KOR mRNA was moderate (1×10(6)copies/μg) in brain regions and dorsal root ganglion, but low (1.6-7×10(5)copies/μg) in the cerebellum, temporal lobe and all other peripheral tissues.

CONCLUSIONS

Our data demonstrate that the AQ-rt-RT-PCR is a highly reproducible and precise method to study the expression of opioid receptors in various tissues and under different disease conditions.

WITHDRAWN: Opioids for the palliation of breathlessness in advanced disease and terminal illness

BACKGROUND

Breathlessness is a common symptom in people with advanced disease. The most effective treatments are aimed at treating the underlying cause of the breathlessness but this may not be possible and symptomatic treatment is often necessary. Strategies for the symptomatic treatment of breathlessness have never been systematically evaluated. Opioids are commonly used to treat breathlessness: the mechanisms underlying their effectiveness are not completely clear and there have been few good-sized trials in this area.

OBJECTIVES

To determine the effectiveness of opioid drugs given by any route in relieving the symptom of breathlessness in patients who are being treated palliatively.

SEARCH METHODS

An electronic search was carried out of Medline, Embase, CINAHL, T he Cochrane L ibrary, Dissertation Abstracts, Cancercd and SIGLE. Review articles and reference lists of retrieved articles were hand searched. Date of most recent search: May 1999.

SELECTION CRITERIA

Randomised double-blind, controlled trials comparing the use of any opioid drug against placebo for the relief of breathlessness were included. Patients with any illness suffering from breathlessness were included and the intervention was any opioid, given by any route, in any dose.

DATA COLLECTION AND ANALYSIS

Studies identified by the search were imported into a reference manager database. The full texts of the relevant studies were retrieved and data were independently extracted by two review authors. Studies were quality scored according to the Oxford Quality scale. The primary outcome measure used was breathlessness and the secondary outcome measure was exercise tolerance. Studies were divided into non-nebulised and nebulised and were analysed both separately and together. A qualitative analysis was carried out of adverse effects of opioids. Where appropriate, meta-analysis was carried out.

MAIN RESULTS

Eighteen studies were identified of which nine involved the non-nebulised route of administration and nine the nebulised route. A small but statistically significant positive effect of opioids was seen on breathlessness in the analysis of studies using non-nebulised opioids. There was no statistically significant positive effect seen for exercise tolerance in either group of studies or for breathlessness in the studies using nebulised opioids.

AUTHORS' CONCLUSIONS

There is evidence to support the use of oral or parenteral opioids to palliate breathlessness although numbers of patients involved in the studies were small. No evidence was found to support the use of nebulised opioids. Further research with larger numbers of patients, using standardised protocols and with quality of life measures is needed.

Inhaled fentanyl citrate improves exercise endurance during high-intensity constant work rate cycle exercise in chronic obstructive pulmonary disease

CONTEXT

Activity limitation and dyspnea are the dominant symptoms of chronic obstructive pulmonary disease (COPD). Traditionally, efforts to alleviate these symptoms have focused on improving ventilatory mechanics, reducing ventilatory demand, or both of these in combination. Nevertheless, many patients with COPD remain incapacitated by dyspnea and exercise intolerance despite optimal therapy.

OBJECTIVES

To determine the effect of single-dose inhalation of nebulized fentanyl citrate (a μ-opioid agonist drug) on exercise tolerance and dyspnea in COPD.

METHODS

In a randomized, double-blind, placebo-controlled, crossover study, 12 stable patients with COPD (mean ± standard error of the mean post-β(2)-agonist forced expiratory volume in one second [FEV(1)] and FEV(1) to forced vital capacity ratio of 69% ± 4% predicted and 49% ± 3%, respectively) received either nebulized fentanyl citrate (50 mcg) or placebo on two separate days. After each treatment, patients performed pulmonary function tests and a symptom-limited constant work rate cycle exercise test at 75% of their maximum incremental work rate.

RESULTS

There were no significant postdose differences in spirometric parameters or plethysmographic lung volumes. Neither the intensity nor the unpleasantness of perceived dyspnea was, on average, significantly different at isotime (5.0 ± 0.6 minutes) or at peak exercise after treatment with fentanyl citrate vs. placebo. Compared with placebo, fentanyl citrate was associated with 1) increased exercise endurance time by 1.30 ± 0.43 minutes or 25% ± 8% (P=0.01); 2) small but consistent increases in dynamic inspiratory capacity by ∼0.10 L at isotime and at peak exercise (both P≤0.03); and 3) no concomitant change in ventilatory demand, breathing pattern, pulmonary gas exchange, and/or cardiometabolic function during exercise. The mean rate of increase in dyspnea intensity (1.2 ± 0.3 vs. 2.9 ± 0.8 Borg units/minute, P=0.03) and unpleasantness ratings (0.5 ± 0.2 vs. 2.9 ± 1.3 Borg units/minute, P=0.06) between isotime and peak exercise was less after treatment with fentanyl citrate vs. placebo.

CONCLUSION

Single-dose inhalation of fentanyl citrate was associated with significant and potentially clinically important improvements in exercise tolerance in COPD. These improvements were accompanied by a delay in the onset of intolerable dyspnea during exercise near the limits of tolerance.

Local pulmonary opioid network in patients with lung cancer: a putative modulator of respiratory function

Recently, there has been growing interest in the opioid regulation of physiological respiratory function. However, evidence for a local opioid network that includes endogenous opioid peptides and their receptors is scarce. Tissue samples from patients with lung cancer were examined by immunohistochemistry to identify the components of the opioid network: beta-endorphin (END); its precursor, proopiomelanocortin (POMC); the key processing enzymes prohormone convertase 1 and 2; carboxypeptidase E; and END's corresponding opioid receptor, the mu-opioid receptor (MOR). Additionally, we tested pulmonary function parameters in a patient with advanced lung cancer after inhalation of nebulized morphine. Confocal immunofluorescence microscopy revealed that the opioid precursor POMC colocalizes with its active peptide END, key processing enzymes and MOR in alveolar macrophages, submucosal glands, cancerous cells, and pulmonary neuroendocrine cells within the bronchial epithelium. In addition, MOR was identified on sensory nerve endings within the bronchial epithelium. Furthermore, nebulized morphine improved pulmonary function parameters in advanced lung cancer. These findings provide evidence of a local opioid network in functionally important anatomical structures of the respiratory system; this network consists of all the machinery required for POMC processing into active peptides, such as END, and contains the receptors for END. Our findings indicate a need for further clinical trials to elucidate the modulatory function of peripheral endogenous opioids in the human lung.

Enkephalin, its precursor, processing enzymes, and receptor as part of a local opioid network throughout the respiratory system of lung cancer patients

Evidence is accumulating regarding the local opioid regulation of physiologic respiratory functions. However, anatomical evidence for a local opioid network of the respiratory system is scarce. In this study, tissue samples from 12 lung cancer patients undergoing lobectomy or pneumonectomy were examined immunohistochemically for the expression of the opioid network components met-enkephalin, the respective precursor proenkephalin, the key processing enzymes prohormone convertases 1 and 2, carboxypeptidase E, and the delta opioid receptor in different areas of human lung. Colocalization of proenkephalin with met-enkephalin, prohormone convertase 1, prohormone convertase 2, and carboxypeptidase E was demonstrated by double-immunofluorescence confocal microscopy in alveolar macrophages, submucosal glands, cancerous cells, and pulmonary neuroendocrine cells of bronchial epithelium. Corresponding delta opioid receptor was identified on cells of all these functionally relevant anatomical structures and on substance P-immunoreactive sensory nerve fibers arborizing within bronchial epithelium. Our findings provide evidence of a local opioid network, that is, the exact anatomical localization of proenkephalin, its functionally active peptide met-enkephalin, and the key processing enzymes as well as corresponding delta opioid receptor, linked to functionally important structures of the respiratory system. These findings encourage future studies to examine the functional role of local opioid peptides within the respiratory system.

Morphine inhalation by cancer patients: a comparison of different nebulization techniques using pharmacokinetic, spirometric, and gasometric parameters

Despite numerous case reports suggesting the value of morphine (M) nebulization in the treatment of breathlessness, only a few clinical trials have been able to support this. The reason for this could lie in the lack of understanding of the localization of opioid receptors in the airways and the biopharmaceutics and pharmacokinetics of nebulized morphine. In the present study, we compared two different methods of pneumodosimetric nebulization: the Bronchial Control Treatment System-Sidestream (BCTS-S) and the Bronchial Control Treatment System-Micro Cirrus (BCTS-MC). The first method delivers relatively large aerosol particles (2-5microm) preferentially to the bronchial tree and trachea. In the BCTS-MC method, small aerosol particles (0.5-2microm) mostly reach the alveoli. Ten patients with cancer were randomly assigned to either the BCTS-S or BCTS-MC inhalation of 5 mg morphine HCl. Patients using the BCTS-S method inhaled a morphine dose in 6.6+/-2 minutes, whereas with the BCTS-MC method, the inhalation time was 28.8+/-8 minutes. The areas under the curve of morphine and glucuronides were several times higher after BCTS-S than after BCTS-MC. The proportion of morphine-3-glucuronide to morphine-6-glucuronide (M6) was, on average, close to one for both methods. From the same amount of morphine in the BCTS-S method, five times more M6 was produced. In both methods, the time to maximum concentration for morphine metabolites was 20-40 minutes, much shorter than expected from oral, intranasal, or intravenous administration. The study shows that the method of inhalation may have a profound effect on the pharmacokinetics of morphine. It is possible that the lungs metabolize morphine to glucuronides themselves and in different proportions from those seen after systemic administration. The BCTS-S method was found to be potentially superior to the BCTS-MC method in local action in the lungs.

Air humidity may influence the aerosol distribution of normal saline administered by closed or vented nebulizers operated continuously or dosimetrically

In clinical practice the majority of inhaled agents require deposition in the most distant regions of the bronchial tree. Contrary to this, it is likely that morphine delivery in breathlessness and chronic cough should be directed to the tracheobronchial area. The aim of the present study was to assess how an environmental condition such as air humidity might influence the particle distribution of normal saline administered by closed or vented nebulizers operated continuously or dosimetrically. Aerosol generated as a saline solution was assessed for BCTSS (Bronchial Control Treatment System-Sidestream) and BCTS-MC (Bronchial Control Treatment System-Micro Cirrus), together with two pneumatic delivery systems: Pneumatic Inhalation-Sidestream (PI-S) and Pneumatic Inhalation-Micro Cirrus (PI-MC). To clarify the influence of humidity on the aerosol we introduced a fifth method, BCTS-S/C, which included a vented nebulizer operated continuously. The impact of different air humidity on the size of particles was examined. Only in the case of the vented methods (BCTS-S and BCTSS/C) of nebulization did air humidifying lead to a significant enlargement of particle size. Moreover, the mean particle size at 90% was almost twice as large with the use of BCTS-S than with BCTS-S/C. Our experiment demonstrated that ambient humidity has a greater effect on particle size with vented rather than nonvented nebulizers and the effect might be potentiated by the pulsative method of nebulization.

Cough sensors. III. Opioid and cannabinoid receptors on vagal sensory nerves

Cough is a persistent symptom of many inflammatory airways' diseases. Cough is mediated by receptors sited on sensory nerves and then through vagal afferent pathways, which terminate in the brainstem respiratory centre. Cough is often described as an unmet clinical need. Opioids are the only prescription-based antitussives currently available in the UK. They possess limited efficacy and exhibit serious unwanted side effects, such as physical dependence, sedation, respiratory depression and gastrointestinal symptoms. There are three classical opioid receptors: the mu, kappa and delta receptors. Peripheral opioid receptors are sited on sensory nerves innervating the airways. A greater understanding of the role of the peripheral and centrally sited opioid receptors is necessary to allow the development of targeted treatments for cough. Because of the limited efficacy and the side-effect profile of the opioids, potential new treatments are sought to alleviate cough. One class of compounds that is currently under examination is the cannabinoids. Like the opioids, cannabinoids have peripheral and centrally sited receptors and also suffer from the blight of unwanted centrally mediated side effects such as sedation, cognitive dysfunction, tachycardia and psychotropic effects. Two cannabinoid receptors have been identified, the CB(1) and CB(2) receptors, and their distribution varies throughout the peripheral and central nervous system. Encouragingly, early studies with these compounds suggest that it may be possible to separate their antitussive activity from their centrally mediated side effects, with CB(2) agonists showing potential as putative new treatments for cough. In this chapter, we describe the opioid and cannabinoid receptors, their distribution and the effects they mediate. Moreover, we highlight their potential advantages and disadvantages in the treatment of cough.

Bronchial mucus transport velocity in patients receiving anaesthesia with propofol and morphine or propofol and remifentanil

In vitro morphine does not reduce cilia beat frequency, a key factor determining bronchial mucus transport velocity. There are no reports about the effect of remifentanil on bronchial mucus transport. We compared the bronchial mucus transport velocity in patients having total intravenous anaesthesia with either propofol and morphine, or propofol and remifentanil. Twenty patients scheduled for elective surgery were randomly allocated to the two groups. Fifteen minutes after insertion of the laryngeal mask airway, bronchial mucus transport velocity was assessed by fibreoptic observation of the movement of methylene blue dye applied to the right main bronchus. Compared with morphine, bronchial mucus transport velocity was significantly reduced in patients receiving remifentanil (morphine mean (SD) 9.2 (5.8) vs remifentanil 4.2 (3.0) mm.min(-1), p = 0.028). Anaesthesia with remifentanil may lead to significantly impaired bronchociliary clearance in comparison to morphine. This could have clinical implications, in particular in patients at risk.

Endomorphin1 and endomorphin2, endogenous potent inhibitors of electrical field stimulation (EFS)-induced cholinergic contractions of rat isolated bronchus

In the present study, we determined whether endomorphin1 (EM1) and endomorphin2 (EM2), selective endogenous mu-opioid receptor (MOR) agonists, inhibited the response to EFS in rat isolated bronchus in a concentration- and frequency-dependent manner. EM1 (1 microM) produced significant inhibition at relatively low frequencies (< 5 Hz) (74.02 +/- 5.53%, 56.16 +/- 10.24% and 37.64 +/- 5.92% inhibition at 1, 2 and 4 Hz, respectively, p < 0.05 versus control), but no significant inhibition at 8, 16, 32 and 64 Hz (17.15 +/- 9.4%, 14.51 +/- 4.23%, 9.11 +/- 2.38% and 5.93 +/- 3.5%, respectively, p > 0.05 versus control). Similar modulations were observed in response to EM2 (1 microM). It is therefore considered that the inhibition effects of EM1 and EM2 may take place at frequencies under physiological conditions. Furthermore, EM1 and EM2 (0.01-10 microM) induced inhibition of cholinergic constriction in a dose-dependent manner at 1, 2 and 4 Hz. The inhibitory effect on EFS was blocked by the opioid receptor antagonist naloxone (10 microM), indicating that opioid receptors were involved. Neither EM1 nor EM2 (1 microM) had an effect on the contractile response to exogenous acetylcholine, indicating a prejunctional effect. All the results indicate that EM1 and EM2 are potent inhibitors of EFS-induced cholinergic bronchoconstriction. These also imply that EM1 and EM2 may modulate cholinergic bronchoconstriction under physiological conditions and that these tetrapeptides could have therapeutic potential in the treatment of airway diseases.

A Prospective Randomized Trial of Nebulized Morphine Compared with Patient-Controlled Analgesia Morphine in the Management of Acute Thoracic Pain

BACKGROUND

Successfully managing pain for the trauma patient decreases morbidity, improves patient satisfaction, and is an essential component of critical care. Using patient-controlled analgesia (PCA) morphine to control pain may be complicated by concerns of respiratory depression, hemodynamic instability, addiction, urinary retention, and drug-induced ileus. Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract, achieving systemic concentrations equal to 20% of equivalent intravenous doses. The purpose of this study was to evaluate the safety, efficacy, and utility of nebulized morphine in patients with posttraumatic thoracic pain.

METHODS

This double-blinded, prospective study randomized patients with severe posttraumatic thoracic pain into two groups. The experimental group (NMS) received nebulized morphine every 4 hours and normal saline by PCA. The control group (PCA) received nebulized saline every 4 hours and morphine by PCA. Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale (VAS) for pain. Pulmonary function, pain relief (VAS), level of sedation (0-3), total drug administration, and systematic side effects were recorded.

RESULTS

Forty-four patients were randomized (22 per group). Seven hundred seventy observations were made. The mean 4-hour dose of morphine was 11.96 +/- 3.4 mg for NMS and 6.22 +/- 4.7 mg for PCA (p < 0.001). Patients with NMS had lower heart rates compared with PCA (79 +/- 11 bpm versus 92 +/- 12 bpm; p < 0.001) and were less sedated (0.33 +/- 0.7 versus 0.56 +/- 0.9; p = 0.03). The mean pain level (VAS) was 3.38 +/- 1.8 for NMS and 3.84 +/- 2.7 for PCA (p = 0.2). There was no difference between pain levels before and after dosing. There were no differences between groups with respect to arterial blood pressure, respiratory rate, vital capacity, mean forced expiratory volume in 1 second, spirometric volumes, or Sao2.

CONCLUSION

Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain. Pain can be successfully managed while vital capacity, mean forced expiratory volume in one second, and spirometric volumes are maintained. Compared with PCA morphine, nebulized morphine provides equivalent pain relief with less sedative effects.

Morphine modulates inducible nitric oxide synthase expression and reduces pulmonary oedema induced by α-naphthylthiourea

This study was designed to investigate the possible participation of morphine in pulmonary oedema induced by alpha-naphthylthiourea (ANTU), which is a well-known noxious chemical agent in the lung. Injection of ANTU (15 mg/kg i.p.) produced pulmonary oedema as indicated by an increase in lung weight/body weight ratio and pleural effusion reaching a maximum within 4 h in rat. Administration of morphine prior to ANTU significantly inhibited to pulmonary oedema with a dose-dependent manner. The protective effect of morphine is prevented by peripheral opioid receptor antagonist, naloxone methiodide. ANTU-treated rats were shown positive by inducible nitric oxide synthase immunohistochemical staining. There was no staining in the control group. On the other hand, the degree of staining was markedly reduced in tissue sections by morphine. These results suggest that previous administration of subcutaneous morphine has preventive effect on ANTU-induced pulmonary inflammatory reaction and its effect mediated via peripheral opioid receptors. Application of naloxone with ANTU has no effect on the lung parameters indicating that endogenous opioids do not modulate ANTU-induced damage.

Peripheral opioidergic regulation of the tracheobronchial mucociliary transport system

We hypothesized that, in the airway mucosa, opioids are inhibitory neural modulators that cause an increase in net water absorption in the airway mucosa (as in the gut). Changes in bidirectional water fluxes across ovine tracheal mucosa in response to basolateral application of the opioid peptides beta-endorphin, dynorphin A-(1-8), and [d-Ala(2), d-Leu(5)]-enkephalin (DADLE) were measured. beta-Endorphin and dynorphin A-(1-8) decreased luminal-to-basolateral water fluxes, and dynorphin A-(1-8) and DADLE increased basolateral-to-luminal water flux. These responses were electroneutral. In seven beagle dogs, administration of aerosolized beta-endorphin (1 mg) to the tracheobronchial airways decreased the clearance of radiotagged particles from the bronchi in 1 h from 34.7 to 22.0% (P < 0.001). Naloxone abrogated the beta-endorphin-induced changes in vitro and in vivo. Contrary to our hypothesis, the opioid-induced changes in water fluxes would all lead to a predictable increase in airway surface fluid. The beta-endorphin-induced increases in airway fluid together with reduced bronchial mucociliary clearance may produce procongestive responses when opioids are administered as antitussives.

Opioids, respiratory function, and dyspnea

Dyspnea, the sensation of difficult breathing, is a common debilitating symptom in advanced cancer and chronic progressive cardiopulmonary disease. Primary treatment is correction of the underlying etiology. In incurable illness wherein the cause is irreversible and the goal is palliation, opioids are the drugs of choice for symptomatic relief. This article reviews current knowledge in the pathophysiology of dyspnea, proposed opioid mechanism of action, and evidence of efficacy.

Endogenous opioids as mediators of asthma

Changes in airway innervation are believed to play a key role in the pathophysiology of asthma. A group of regulatory peptides which act as neuroregulators is resembled by the opioids. Their localization to neurons projecting into airways suggested a possible role as regulators of neurogenic inflammation, bronchoconstriction and mucus secretion. They mainly act through modification of tachykinergic and cholinergic impulses and their ability to inhibit bronchoconstriction prompted discussion of their potential value in asthma therapy. Apart from the presence of the classical opioids and their receptors in the lung and their functional role, a new group of peptides such as nociceptin and endomorphins have been characterized in the airways. Whereas at least endomorphin-1 acts via the classical OP(3) (mu) receptor, nociceptin binds to a new receptor termed opioid receptor-like-receptor (ORL(1)) and inhibits tachykinergic constriction. Contrary to these promising modulatory effects on airway smooth muscle tone, effective therapeutic strategies have not been developed yet. In conclusion, opioids resemble a group of regulatory peptides which are present within airway-innervating nerve fibres and influence a multitude of airway functions via modification of neural transmission.

Opioids for the palliation of breathlessness in terminal illness

BACKGROUND

Breathlessness is a common symptom in people with advanced disease. The most effective treatments are aimed at treating the underlying cause of the breathlessness but this may not be possible and symptomatic treatment is often necessary. Strategies for the symptomatic treatment of breathlessness have never been systematically evaluated. Opioids are commonly used to treat breathlessness: the mechanisms underlying their effectiveness are not completely clear and there have been few good-sized trials in this area.

OBJECTIVES

To determine the effectiveness of opioid drugs given by any route in relieving the symptom of breathlessness in patients who are being treated palliatively.

SEARCH STRATEGY

An electronic search was carried out of Medline, Embase, Cinahl, the Cochrane library, Dissertation Abstracts, Cancercd and SIGLE. Review articles and reference lists of retrieved articles were hand searched. Date of most recent search: May 1999

SELECTION CRITERIA

Randomised double-blind, controlled trials comparing the use of any opioid drug against placebo for the relief of breathlessness were included. Patients with any illness suffering from breathlessness were included and the intervention was any opioid, given by any route, in any dose.

DATA COLLECTION AND ANALYSIS

Studies identified by the search were imported into a reference manager database. The full texts of the relevant studies were retrieved and data were independently extracted by two reviewers. Studies were quality scored according to the Jadad scale. The primary outcome measure used was breathlessness and the secondary outcome measure was exercise tolerance. Studies were divided into non-nebulised and nebulised and were analysed both separately and together. A qualitative analysis was carried out of adverse effects of opioids. Where appropriate, meta-analysis was carried out.

MAIN RESULTS

Eighteen studies were identified of which nine involved the non-nebulised route of administration and nine the nebulised route. A small but statistically significant positive effect of opioids was seen on breathlessness in the analysis of studies using non-nebulised opioids. There was no statistically significant positive effect seen for exercise tolerance in either group of studies or for breathlessness in the studies using nebulised opioids.

REVIEWER'S CONCLUSIONS

There is evidence to support the use of oral or parenteral opioids to palliate breathlessness although numbers of patients involved in the studies were small. No evidence was found to support the use of nebulised opioids. Further research with larger numbers of patients, using standardised protocols and with quality of life measures is needed.

Inhaled morphine to relieve dyspnea in advanced cystic fibrosis lung disease

Inhaled morphine has been used to treat dyspnea in a variety of clinical settings. There are, however, no reports of its use in treating patients with end-stage lung disease due to cystic fibrosis (CF). We report on the use of inhaled morphine sulfate in a 13-year-old boy with CF, advanced lung disease, and acute respiratory failure. Therapy was effective in reducing his subjective feeling of air hunger and improving his BORG score. His sole significant adverse effect was headache after 2 days of treatment at 4-hourly intervals.

Lung opioid receptors: pharmacology and possible target for nebulized morphine in dyspnea

Opioid receptors are located throughout the respiratory tract. Yet, these have received relatively scant attention compared to other opioid receptors. The most abundant sites within the respiratory tract appear localized within the alveolar walls, other sites appear to line the smooth muscle within the trachea and main bronchi near the lumen. There is about 100-times greater [3H]morphine binding density within the bronchioles and lobes than in the main bronchi or trachea. In addition to the usual mu, delta and kappa types of opioid receptors, 'non-conventional' opioid binding sites have been suggested, although the function of these or of the other opioid receptors in the pulmonary tract is not known. However, they might explain the otherwise counterintuitive apparent utility of morphine treatment of dyspnea. Dyspnea is a common and distressing symptom in terminally-ill cancer patients and patients with chronic lung disease. It results from multiple causes, is difficult to treat and is a significant precipitating factor for late-stage hospital or hospice admissions. Nebulized morphine or other opioids have been reported to have beneficial effect, but the mechanism by which opioids might produce this seemingly contradictory effect is not clear. We review here lung opioid receptor distribution, pharmacology and possible clinical relevance in the treatment of dyspnea.

Morphine reduces pulmonary inflammation in response to influenza infection

The present study shows that morphine reduces the pulmonary inflammatory response to intranasal influenza virus infection in rats. Rats were infected with rat-adapted influenza virus (RAIV), which is a unique infectious agent because normal rats develop an acute pulmonary inflammatory response to RAIV and rapidly clear the virus within a few days with no mortality. Male Lewis rats were implanted with 75 mg morphine pellets or placebo pellets 72 hours prior to intranasal RAIV infection. Rats were euthanized at 2, 24, 48, 72, and 96 hours after infection. Assessment of inflammation included accumulation of inflammatory cells in the lungs, lung weight, and protein and LDH content of bronchial alveolar lavage fluid (BALF). Placebo-treated rats showed a marked inflammatory response to RAIV infection, and morphine-treated rats mounted less vigorous inflammatory responses to the infection. Taken together, these data suggest that morphine treatment impairs the inflammatory response to RAIV infection in the lungs, which is consistent with prior work demonstrating that morphine is a potent anti-inflammatory agent in other areas of the body.

Intraarticular and periarticular opioid binding in inflamed tissue in experimental canine arthritis

Small-dose (1 mg) intraarticular morphine has been used successfully in many studies to provide long-lasting analgesia after arthroscopic knee surgery. We used radioligand binding to determine whether these effects could be mediated by opioid binding sites in the joint, particularly after the induction of inflammation. Inflammation was induced by the injection of oleyl alcohol (20 microL) in sterile peanut oil (0.25 mL) into the left radiocarpal joint of 27 dogs, and the dogs were euthanized at 12 h. The articular and periarticular tissues from both treated and control joints were collected, and membranes were prepared for equilibrium binding assays. The density of specific opioid binding was markedly enhanced (P < 0.05) in homogenates prepared from the treated relative to those from the control joint. The binding affinities (KD values) for morphine and naloxone (mean +/- SEM) were approximately one one-hundredth (79 +/- 17 nM and 124 +/- 5.5 nM, respectively) that of the corresponding published affinities in brain tissue. However, the binding site densities were approximately one hundred times larger (Bmax = 1032 +/- 265 and 543 +/- 51 fmol/mg of protein) than the respective published values in brain tissue. These findings imply that the opioid binding sites, found in the inflamed articular and periarticular tissues in this study, are similar to those of putative mu 3-opioid binding sites that appear to be present on cultured thymocytes and in the airways of rats and humans.

IMPLICATIONS

The high density of opioid binding sites found in inflamed canine joint tissue supports the clinical use of intraarticular opioids in the treatment of postoperative and chronic inflammatory joint pain.

The palliation of dyspnea in terminal disease

Dyspnea is a complex subjective experience that is common in terminal illness. Patients may present at any time during the course of their illness, although prevalence increases with disease progression. Dyspnea has physical, psychological, social and spiritual components; without recognizing how each of these contributes to the total suffering of dyspnea, management is unlikely to be successful. The management of dyspnea involves both pharmacological and non-pharmacological treatment. The main pharmacological palliative treatments are oxygen, opioids, and benzodiazepines, but the evidence to support these treatments is limited. More research is urgently needed to establish the efficacy of current treatments and to identify new ones.

Morphine alters the immune response to influenza virus infection in Lewis rats

Although the in vitro immunomodulatory effects of morphine are well-documented, few studies have explored the impact of morphine on viral infection in intact rats. We report that morphine can alter in vivo immune responsiveness to pulmonary influenza virus infection in Lewis rats. We studied rat-adapted influenza virus (RAIV) infection, which is a unique infectious disease system because normal rats develop an acute inflammatory response to RAIV in the lung, and rapidly clear the virus within a few days, with no mortality (13,20,21). Male Lewis rats were implanted with 75 mg morphine pellets or placebo pellets 72 hours prior to intranasal RAIV infection. Rats were euthanized at 2, 24, 48, 72 and 96 hours after infection and inflammation and viral load were measured in the lungs. Placebo-treated rats showed marked inflammatory responses to RAIV infection, and quickly cleared the virus from their lungs. Morphine-treated rats mounted less vigorous inflammatory responses to the infection and cleared the virus more slowly than placebo-treated rats. Although these initial data indicate that morphine can alter the response to RAIV, additional studies are necessary to fully characterize these effects.

Nebulized Morphine for the Treatment of Dyspnea in Cancer Patients

Objective:

To review the literature concerning the use of nebulized opioids to treat dyspnea in terminally ill cancer patients.

Data Sources:

English-language journal articles were obtained by a MEDLINE search (1966-August 1997).

Study Selection:

All clinical trials and case reports involving nebulized opioids. Representative studies discussing neurogenic inflammation and pulmonary opioid receptors were also reviewed.

Data Extraction:

Studies were selected for review on the basis of study design and use of nebulized opioids. Case reports were selected from the palliative care literature.

Data Synthesis:

High-density, low-affinity opioid receptors have been identified in lung tissue and may play a role in the alleviation of dyspnea in some patients. The activation of these receptors in the lung may attenuate the release of inflammatory mediators and neuropeptides such as substance P. However, because nebulized opioids are absorbed buccally or through the airway mucosa, the relief observed may be due to a central rather than peripheral effect.

Conclusions:

Several case reports in the palliative care literature have described favorable results when nebulized opioids are used to treat dyspnea. However, data from controlled trials in populations other than patients with cancer do not substantiate the use of nebulized opioids. Unfortunately, controlled clinical trials have not been conducted in cancer patients; thus, extrapolation is difficult. Well-designed clinical trials in patients with cancer are necessary to determine the efficacy of nebulized morphine in treating dyspnea.

Specific gene blockade shows that peptide nucleic acids readily enter neuronal cells in vivo

Peptide nucleic acids (PNAs) are DNA analogs that can hybridize to complementary sequences with high affinity and stability. Here, we report the first evidence of intracellular delivery of PNAs in vivo. Two CNS receptors, an opioid (mu) and a neurotensin (NTR-1), were targeted independently by repeated microinjection of PNAs into the periaqueductal gray. Behavioral responses to neurotensin (antinociception and hypothermia) and morphine (antinociception) were lost in a specific manner. Binding studies confirmed a large reduction in receptor sites. The loss of behavioral responses was long lasting but did fully recover. The implications of specifically and readily turning off gene expression in vivo are profound.

Acute respiratory depression as a complication of nebulised morphine

PURPOSE

To present a case of respiratory depression following the administration of nebulised morphine.

CLINICAL FEATURES

A 74-yr-old, 51-kg woman with a history of hypertension controlled with 5 mg.day-1 enalapril and 50 mg.day-1 atenolol was admitted for evaluation of low back pain, loss of appetite, and weight loss. Investigation revealed advanced metastatic disease with a probable primary in the right lung. The patient's pain was well controlled with 10 mg continuous release morphine p.o. three times daily, and 10 mg immediate release morphine p.o. for breakthrough pain as required. During the two weeks following the commencement of this treatment she occasionally complained of shortness of breath. Examination revealed a fully conscious patient with slight dyspnoea and mild wheezing which responded to oxygen 30% and nebulised bronchodilators. An oncological consultation recommended 4 mg nebulised morphine and 4 mg dexamethasone in saline as treatment for the bouts of breathlessness. Approximately 15 min after the first administration of nebulised morphine the patient became markedly bradypneic (respiratory rate: 4-5 bpm), hypotensive (BP 70/40 mmHg), and responded only partially to command. The pupils were pinpoint. The trachea was immediately intubated and the lungs ventilated with oxygen 40% for four hours. Following this occurrence of respiratory depression nebulised morphine was discontinued and no further events occurred.

CONCLUSION

Patients receiving inhaled morphine should be closely monitored and resuscitation equipment should be readily available.

Quantitative autoradiography of peripheral opioid binding sites in rat lung

Previous studies in our laboratory have characterized non-conventional opioid binding sites in membrane preparations from both rat and human lung. The studies described in this paper utilized autoradiography to investigate the regional distribution of these [3H]morphine binding sites within rat lungs. Specific binding of [3H]morphine was saturable and Rosenthal analysis of tissue section wipes revealed the presence of both high-affinity and low-affinity opioid binding sites. The mean +/- S.E.M. binding affinity and the mean +/- S.E.M. density values for the low-affinity binding site (Kd = 217 +/- 160 nM, Bmax = 12 +/- 8 pmol/mg protein) were similar to the values obtained in our previous whole-rat lung membrane binding assays (Kd = 187 +/- 36 nM, Bmax = 13.5 +/- 2 pmol/mg protein) (Cabot, P.J., P.R. Dodd, T. Cramond and M.T. Smith, 1994, Eur. J. Pharmacol. 268, 247). Quantitative autoradiography showed that the highest density of opioid binding sites appeared to be present within the alveolar wall (13.2 +/- 0.8 pmol/mg protein). A significantly lower (P < 0.05) density of binding was also observed in the smooth muscle of the trachea and main bronchi (5.5 +/- 2.1 pmol/mg protein). However, no morphine binding sites were evident in the smooth muscle surrounding the smaller airways and pulmonary vasculature within the lobes of the rat lung. It remains to be investigated whether the opioid binding sites located within the trachea and main bronchi of the rat airways are the prejunctional opioid receptors on C-afferent nerve fibres which modulate the release of potent inflammatory neuropeptides.

Abnormal modulation of cholinergic neurotransmission by opioid in hyperresponsive bronchus of rats

1. The electrical field stimulation (EFS)-induced bronchoconstriction in vitro in rats challenged by DNP-Ascaris antigen was significantly greater than that in normal rats. 2. Morphine inhibited the EFS-induced bronchoconstriction in normal rats. Whereas the inhibition of EFS-induced bronchoconstriction by the opioid was little, if any, in the DNP-Ascaris-challenged rats. 3. These findings suggest that dysfunction of presynaptic inhibitory modulation through the opioid receptor may take place in the airways of DNP-Ascaris-challenged rats.