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Lang-Illievich K, Lang J, Rumpold-Seitlinger G, Dorn C, Brenna CTA, Klivinyi C, Bornemann-Cimenti H. The Dose-Response Relationship between Opioid Agonist Therapy and Alterations in Pain Pathways in Patients with Opioid Use Disorders: A Cross-Sectional Study. CNS Drugs 2024; 38:281-290. [PMID: 38421579 PMCID: PMC10980620 DOI: 10.1007/s40263-024-01069-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION The administration of opioids can be followed by enduring neuroplastic changes in the peripheral and central nervous systems. This remodeling can lead to opioid-induced hyperalgesia, causing an increased sensitivity to painful stimuli. The description of opioid-induced changes in the somatosensory system has seldom been described in the setting of opioid agonist therapy in the treatment of opioid use disorders, and the few existing reports provide no guidance with respect to the effect of varied doses or substances. OBJECTIVE The aim of the present study was to assess alterations of pain pathways among patients receiving opioid agonist therapy and to elucidate the dose-response relationship. METHODS This study was planned as cross-sectional in an outpatient clinic in Graz, Austria. Patients receiving opioid agonist therapy for opioid use disorders (including methadone, levomethadone, buprenorphine, and extended-release morphine) were asked to fill out a questionnaire, including the central sensitization inventory. A battery of somatosensory system assessments was then performed. RESULTS A total of 120 patients participated (85 men/35 women). The mean oral morphine milligram equivalent (MME) was 694 ± 249 mg/day. Our study found significant alterations in pain perception, conditioned pain modulation, and wind-up. We demonstrated a moderate dose-response relationship between high-dose opioids and markers of central sensitization. CONCLUSION The present trial demonstrates the clear effects of opioid agonist therapy on the somatosensory system. Both central sensitization and descending pain modulation are negatively affected by high doses of opioids and our data elucidate a moderate dose-response relationship for these phenomena.
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Affiliation(s)
- Kordula Lang-Illievich
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5/5, 8036, Graz, Austria
- Department of Anesthesia and Intensive Care Medicine, Klinik Güssing, Güssing, Austria
| | - Johanna Lang
- Comenius University Bratislava, Bratislava, Slovakia
| | - Gudrun Rumpold-Seitlinger
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5/5, 8036, Graz, Austria
| | - Christian Dorn
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5/5, 8036, Graz, Austria
| | - Connor T A Brenna
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5/5, 8036, Graz, Austria
| | - Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5/5, 8036, Graz, Austria.
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Noufal Y, Kringel D, Toennes SW, Dudziak R, Lötsch J. Pharmacological data science perspective on fatal incidents of morphine treatment. Pharmacol Ther 2023; 241:108312. [PMID: 36423714 DOI: 10.1016/j.pharmthera.2022.108312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
Morphine prescribed for analgesia has caused drug-related deaths at an estimated incidence of 0.3% to 4%. Morphine has pharmacological properties that make it particularly difficult to assess the causality of morphine administration with a patient's death, such as its slow transfer between plasma and central nervous sites of action and the existence of the active metabolite morphine-6-glucuronide with opioid agonistic effects, Furthermore, there is no well-defined toxic dose or plasma/blood concentration for morphine. Dosing is often adjusted for adequate pain relief. Here, we summarize reported deaths associated with morphine therapy, including associated morphine exposure and modulating patient factors such as pharmacogenetics, concomitant medications, or comorbidities. In addition, we systematically analyzed published numerical information on the stability of concentrations of morphine and its relevant metabolites in biological samples collected postmortem. A medicolegal case is presented in which the causality of morphine administration with death was in dispute and pharmacokinetic modeling was applied to infer the administered dose. The results of this analytical review suggest that (i) inference from postmortem blood concentrations to the morphine dose administered has low validity and (ii) causality between a patient's death and the morphine dose administered remains a highly context-dependent and collaborative assessment among experts from different medical specialties.
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Affiliation(s)
- Yazan Noufal
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Dario Kringel
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Stefan W Toennes
- Goethe-University, University Hospital Frankfurt, Institute of Legal Medicine, Kennedyallee 104, 60596 Frankfurt am Main, Germany
| | - Rafael Dudziak
- Goethe-University, University Hospital Frankfurt, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörn Lötsch
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany.
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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] [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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Arout CA, Edens E, Petrakis IL, Sofuoglu M. Targeting Opioid-Induced Hyperalgesia in Clinical Treatment: Neurobiological Considerations. CNS Drugs 2015; 29:465-86. [PMID: 26142224 DOI: 10.1007/s40263-015-0255-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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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Brasher C, Gafsous B, Dugue S, Thiollier A, Kinderf J, Nivoche Y, Grace R, Dahmani S. Postoperative pain management in children and infants: an update. Paediatr Drugs 2014; 16:129-40. [PMID: 24407716 DOI: 10.1007/s40272-013-0062-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.
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Affiliation(s)
- Christopher Brasher
- Department of Anesthesiology, Intensive Care, Robert Debré Hospital, 48 Bd Sérurier, 75019, Paris, France
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Grider JS, Ackerman WE. Opioid-induced hyperalgesia and tolerance: understanding opioid side effects. Expert Rev Clin Pharmacol 2014; 1:291-7. [PMID: 24422653 DOI: 10.1586/17512433.1.2.291] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Opioid-induced pain or opioid tolerance should be considered when opioid therapy fails to provide expected analgesic effects or when there is unexplainable pain exacerbation following opioid treatment. As a result, an increase in the opioid dosage may not be the solution to ineffective opioid therapy for chronic pain management. A decrease in the opioid mass may actually provide pain relief in many instances. At one time, it was anticipated that opioid-induced pain was related to upregulation of NMDA receptors with a downregulation of mu receptors. However, there is growing evidence to suggest the opioid receptor-based hyperalgesic mechanism may be directly modulated by the NMDA receptor. Furthermore, the mechanism that causes opioid tolerance may be the same mechanism that causes opioid-induced pain. Current evidence suggests that opioid-induced pain sensitivity could be prevented by interrupting the cellular and molecular changes associated with the development of opioid tolerance. Continued research may lead the way to a new period in which patients prone to opioid-induced pain could be identified, allowing one to tailor pharmacologic pain therapy to each patient.
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Affiliation(s)
- Jay S Grider
- Assistant Professor, University of Kentucky, College of Medicine, Department of Anesthesiology, 800 Rose Street Suite, N 201, Lexington, KY 40536, USA. ; www.mc.uky.edu/anesthesiology
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[Dependency syndrome and hyperalgesia due to an opioid therapy for curative treatable pain. Case report of an apparent palliative patient]. Schmerz 2013; 27:506-12. [PMID: 24005817 DOI: 10.1007/s00482-013-1353-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Opioids are an essential part of cancer pain management but particularly in this patient group physicians could misinterpret opioid-induced potentially life-threatening side effects within the central nervous system (CNS) or hyperalgesia as a consequence of tumor progression. In this case increasing the opioid dose or switching to rapidly acting opioids may trigger a vicious circle. We describe a case report of a male patient who was treated with high doses of transdermal and endonasal fentanyl 2 years after pancreatomy due to cancer. The patient was referred to the palliative care unit presenting with delirious behavior and 30-40 severe abdominal pain attacks/day. After withdrawal of the opioid medication all CNS symptoms disappeared. Further diagnostics revealed multiple incisional hernia as the reason of the pain syndrome. The patient recovered after herniotomy and has now been pain free without any pain medication for more than 16 months. This case report underlines again the necessity of pain diagnostics also in assumed palliative patients with the risks of high dose opioid treatment.
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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: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [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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Michelet D, Andreu-Gallien J, Bensalah T, Hilly J, Wood C, Nivoche Y, Mantz J, Dahmani S. A meta-analysis of the use of nonsteroidal antiinflammatory drugs for pediatric postoperative pain. Anesth Analg 2011; 114:393-406. [PMID: 22104069 DOI: 10.1213/ane.0b013e31823d0b45] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Opioid side effects are a great concern during the postoperative period in children. Nonsteroidal antiinflammatory drugs (NSAIDs) have been shown to effectively decrease postoperative pain, but their opioid-sparing effect is still controversial. In this present meta-analysis, we investigated the postoperative opioid-sparing effect of NSAIDs in children. METHODS A comprehensive literature search was conducted to identify clinical trials using NSAIDs and opioids as perioperative analgesic compounds in children and infants. Outcomes measured were opioid consumption, pain intensity, postoperative nausea and vomiting (PONV), and urinary retention. All outcomes were studied during postanesthesia care unit (PACU) stay and the first 24 postoperative hours. Data from each trial were combined to calculate the pooled odds ratios (ORs) or standardized mean difference (SMD) and their 95% confidence interval. RESULTS Twenty-seven randomized controlled studies were analyzed. Perioperative administration of NSAIDs decreased postoperative opioid requirement (both in the PACU and during the first 24 postoperative hours; SMD = -0.66 [-0.84, -0.48] and -0.83 [-1.11, -0.55], respectively), pain intensity in the PACU (SMD = -0.85 [-1.24, -0.47]), and PONV during the first 24 postoperative hours (OR = 0.75 [0.57-0.99]). NSAIDs did not decrease pain intensity during the first 24 postoperative hours (OR = 0.56 [0.26-1.2]) and PONV during PACU stay (OR = 1.02 [0.73-1.44]). Subgroup analysis according to the timing of NSAID administration (intraoperative versus postoperative), type of surgery, or coadministration of paracetamol did not show any influence of these factors on the studied outcomes except the reduction of pain intensity and the incidence of PONV during the first 24 postoperative hours, which were influenced by the coadministration of paracetamol and the type of surgery, respectively. CONCLUSION This meta-analysis shows that perioperative NSAID administration reduces opioid consumption and PONV during the postoperative period in children.
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Affiliation(s)
- Daphne Michelet
- Department of Anesthesia, Intensive Care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris, France
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&NA;. Take multiple factors into account when choosing the best opioid for pain therapy in paediatric palliative care. DRUGS & THERAPY PERSPECTIVES 2009. [DOI: 10.2165/0042310-200925110-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Zernikow B, Michel E, Craig F, Anderson BJ. Pediatric palliative care: use of opioids for the management of pain. Paediatr Drugs 2009; 11:129-51. [PMID: 19301934 DOI: 10.2165/00148581-200911020-00004] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pediatric palliative care (PPC) is provided to children experiencing life-limiting diseases (LLD) or life-threatening diseases (LTD). Sixty to 90% of children with LLD/LTD undergoing PPC receive opioids at the end of life. Analgesia is often insufficient. Reasons include a lack of knowledge concerning opioid prescribing and adjustment of opioid dose to changing requirements. The choice of first-line opioid is based on scientific evidence, pain pathophysiology, and available administration modes. Doses are calculated on a bodyweight basis up to a maximum absolute starting dose. Morphine remains the gold standard starting opioid in PPC. Long-term opioid choice and dose administration is determined by the pathology, analgesic effectiveness, and adverse effect profile. Slow-release oral morphine remains the dominant formulation for long-term use in PPC with hydromorphone slow-release preparations being the first rotation opioid when morphine shows severe adverse effects. The recently introduced fentanyl transdermal therapeutic system with a drug-release rate of 12.5 microg/hour matches the lower dose requirements of pediatric cancer pain control. Its use may be associated with less constipation compared with morphine use. Though oral transmucosal fentanyl citrate has reduced bioavailability (25%), it inherits potential for breakthrough pain management. However, the gold standard breakthrough opioid remains immediate-release morphine. Buprenorphine is of special clinical interest as a result of its different administration routes, long duration of action, and metabolism largely independent of renal function. Antihyperalgesic effects, induced through antagonism at the kappa-receptor, may contribute to its effectiveness in neuropathic pain. Methadone also has a long elimination half-life (19 [SD 14] hours) and NMDA receptor activity although dose administration is complicated by highly variable morphine equianalgesic equivalence (1 : 2.5-20). Opioid rotation to methadone requires special protocols that take this into account. Strategies to minimize adverse effects of long-term opioid treatment include dose reduction, symptomatic therapy, opioid rotation, and administration route change. Patient- or nurse-controlled analgesia devices are useful when pain is rapidly changing, or in terminal care where analgesic requirements may escalate. In this article, we present detailed pediatric pharmacokinetic and pharmacodynamic data for opioids, their indications and contraindications, as well as dose-administration regimens that include practical strategies for opioid switching and dose reduction. Additionally, we discuss the problem of hyperalgesia and the use of adjuvant drugs to support opioid therapy.
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Affiliation(s)
- Boris Zernikow
- Children's Hospital, Witten/Herdecke University, Vodafone Foundation Institute for Children's Pain Therapy and Paediatric Palliative Care, Datteln, Germany.
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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 MEDICINE 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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Chen L, Malarick C, Seefeld L, Wang S, Houghton M, Mao J. Altered quantitative sensory testing outcome in subjects with opioid therapy. Pain 2009; 143:65-70. [PMID: 19237249 DOI: 10.1016/j.pain.2009.01.022] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Revised: 01/08/2009] [Accepted: 01/22/2009] [Indexed: 11/26/2022]
Abstract
Preclinical studies have suggested that opioid exposure may induce a paradoxical decrease in the nociceptive threshold, commonly referred as opioid-induced hyperalgesia (OIH). While OIH may have implications in acute and chronic pain management, its clinical features remain unclear. Using an office-based quantitative sensory testing (QST) method, we compared pain threshold, pain tolerance, and the degree of temporal summation of the second pain in response to thermal stimulation among three groups of subjects: those with neither pain nor opioid therapy (group 1), with chronic pain but without opioid therapy (group 2), and with both chronic pain and opioid therapy (group 3). We also examined the possible correlation between QST responses to thermal stimulation and opioid dose, opioid treatment duration, opioid analgesic type, pain duration, or gender in group 3 subjects. As compared with both group 1 (n=41) and group 2 (n=41) subjects, group 3 subjects (n=58) displayed a decreased heat pain threshold and exacerbated temporal summation of the second pain to thermal stimulation. In contrast, there were no differences in cold or warm sensation among three groups. Among clinical factors, daily opioid dose consistently correlated with the decreased heat pain threshold and exacerbated temporal summation of the second pain in group 3 subjects. These results indicate that decreased heat pain threshold and exacerbated temporal summation of the second pain may be characteristic QST changes in subjects with opioid therapy. The data suggest that QST may be a useful tool in the clinical assessment of OIH.
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Affiliation(s)
- Lucy Chen
- MGH Center for Translational Pain Research, Department of Anesthesia and Critical Care, WACC 324, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Hewitt M, Goldman A, Collins GS, Childs M, Hain R. Opioid use in palliative care of children and young people with cancer. J Pediatr 2008; 152:39-44. [PMID: 18154896 DOI: 10.1016/j.jpeds.2007.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Revised: 04/03/2007] [Accepted: 07/03/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Identify opioids prescribed, preferred routes, and doses among children with incurable cancer. STUDY DESIGN Prospective survey with monthly questionnaires regarding patients 0 to 19 years old from oncology centers. Data were collected by professionals on each patient for 6 months or until death, and analyzed from patients who died. Impact of tumor was analyzed with Kruskal-Wallis and Mann-Whitney tests. Major opioid dosages are expressed as oral morphine equivalents. RESULTS Of 185 children recruited, 164 (88 boys, 76 girls) died. Mean palliative care duration was 67 days. One hundred forty-seven (89.6%) received major opioids. Morphine, diamorphine, and fentanyl were prescribed in 75%, 57.9%, and 11.6%, respectively. Seventy-three (44.5%) received >1 major opioid. Median monthly maximum doses prescribed rose from 2.1 mg/kg/24 h (study entry) to 4.4 mg/kg/24 h (death) (P < .001); overall variable (0.09-1500 mg/kg/24 h, median 3.7 mg/kg/24 h). Opioids were given by the oral (117/164, 71.3%), intravenous (68/164, 41.5%), subcutaneous (40, 28%), rectal (20, 12.2%), and transdermal (18, 11%) routes. There was a shift to intravenous use as death approached. Numbers within each tumor group were too small to show significance. Children with solid tumors outside the central nervous system were likely to receive more opioids, be given multiple different opioids, and receive opioids in the last month. CONCLUSIONS The study shows the United Kingdom practice of opioid use and provides comparator data for practice in children's palliative medicine.
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Affiliation(s)
- Martin Hewitt
- Queen's Medical Centre, University Hospital, Nottingham, United Kingdom
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Abstract
Opioids have been successfully used for the management of acute and cancer-related pain. Concerns regarding side effects, tolerance, dependence, addiction, and hyperalgesia have limited the use of opioids for the management of chronic nonmalignant pain. This article will review updated information from both clinical and preclinical studies regarding opioid-induced hyperalgesia, tolerance, and dependence. The implications of these issues in clinical opioid therapy also will be discussed.
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Affiliation(s)
- Grace Chang
- Massachusetts General Hospital Pain Center, Division of Pain Medicine, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Gabra BH, Berthiaume N, Sirois P, Nantel F, Battistini B. The kinin system mediates hyperalgesia through the inducible bradykinin B1 receptor subtype: evidence in various experimental animal models of type 1 and type 2 diabetic neuropathy. Biol Chem 2006; 387:127-43. [PMID: 16497144 DOI: 10.1515/bc.2006.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Both insulin-dependent (type 1) and insulin-independent (type 2) diabetes are complex disorders characterized by symptomatic glucose intolerance due to either defective insulin secretion, insulin action or both. Unchecked hyperglycemia leads to a series of complications among which is painful diabetic neuropathy, for which the kinin system has been implicated. Here, we review and compare the profile of several experimental models of type 1 and 2 diabetes (chemically induced versus gene-prone) and the incidence of diabetic neuropathy upon aging. We discuss the efficacy of selective antagonists of the inducible bradykinin B1 receptor (BKB1-R) subtype against hyperalgesia assessed by various nociceptive tests. In either gene-prone models of type 1 and 2 diabetes, the incidence of hyperalgesia mostly precedes the development of hyperglycemia. The administration of insulin, achieving euglycemia, does not reverse hyperalgesia. Treatment with a selective BKB1-R antagonist does not affect basal nociception in most normal control rats, whereas it induces a significant time- and dose-dependent attenuation of hyperalgesia, or even restores nociceptive responses, in experimental diabetic neuropathy models. Diabetic hyperalgesia is absent in streptozotocin-induced type 1 diabetic BKB1-R knockout mice. Thus, selective antagonism of the inducible BKB1-R subtype may constitute a novel and potential therapeutic approach for the treatment of painful diabetic neuropathy.
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Skarke C, Geisslinger G, Lötsch J. Is morphine-3-glucuronide of therapeutic relevance? Pain 2005; 116:177-180. [PMID: 15982815 DOI: 10.1016/j.pain.2005.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2005] [Indexed: 11/20/2022]
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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Abstract
The metabolism of opioids closely relates to their chemical structure. Opioids are subject to O-dealkylation, N-dealkylation, ketoreduction, or deacetylation leading to phase-I metabolites. By glucuronidation or sulfatation, phase-II metabolites are formed. Some metabolites of opioids have an activity themselves and contribute to the effects of the parent compound. This can go as far that the main clinical activity is exerted through active metabolites while the parent compounds are only weak agonist at mu-opioid receptors, as in the case of codeine and tilidine. The clinical effects of tramadol also involve an important contribution of its active metabolite. With morphine, the active metabolite morphine-6-glucuronide exerts important clinical opioid effects when it accumulates in the plasma of patients with renal failure. However, after short-term administration of morphine, its contribution to the central nervous effects of morphine is probably poor. Morphine-6-glucuronide has recently been identified to exert important peripheral opioid effects. By this, it may play an important role in the clinical effects of morphine. Several other opioids, such as meperidine and perhaps also morphine and hydromorphone, produce metabolites with neuroexcitatory effects. In sum, the evidence suggests that the metabolites of several opioids account for an important part of the clinical effects that must be considered in clinical practice.
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Affiliation(s)
- Jörn Lötsch
- Pharmazentrum Frankfurt, Institute of Clinical Pharmacology, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
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Abstract
Unrelieved pain may have a major impact on the care of children with cancer. The type and severity of pain experienced by children with cancer varies from acute, procedure-related pain to progressive chronic pain associated with the progression of the disease or sequelae of treatment. Drugs are the mainstay of treatment. Regular pain assessments combined with appropriate analgesic administration at regular dosing intervals, adjunctive drug therapy for control of adverse effects and associated symptoms, and nonpharmacological interventions are recommended. Although standard dosing of opioids adequately treats most cancer pain in children, more complex treatment is required by a significant group. Strategies to improve analgesia include the use of epidural or intrathecal infusions of a combination of opioids and other adjuvants, or other regional anaesthesia techniques. Procedure- and treatment-related pain is an even greater problem than cancer pain. Recommendations have been published with regard to the monitoring and personnel required when children are sedated which aim to set the standard of care and minimize both physical discomfort or pain and negative psychological responses, by providing analgesia; and to maximize the potential for amnesia; and to control behaviour.
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Parisod E, Siddall PJ, Viney M, McClelland JM, Cousins MJ. Allodynia after acute intrathecal morphine administration in a patient with neuropathic pain after spinal cord injury. Anesth Analg 2003; 97:183-6, table of contents. [PMID: 12818963 DOI: 10.1213/01.ane.0000068482.67289.1a] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPLICATIONS Acute intrathecal administration of relatively small doses of opioids may precipitate neuropathic pain and allodynia in those with spinal cord injury.
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Affiliation(s)
- Eric Parisod
- Pain Management & Research Centre, University of Sydney, Royal North Shore Hospital, Australia.
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24
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Moran TD, Smith PA. Morphine-3beta-D-glucuronide suppresses inhibitory synaptic transmission in rat substantia gelatinosa. J Pharmacol Exp Ther 2002; 302:568-76. [PMID: 12130717 DOI: 10.1124/jpet.102.035626] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
High doses of intrathecally applied morphine or morphine-3beta-D-glucuronide (M3G) produce allodynia and hyperalgesia. Whole-cell patch-clamp recordings were made from substantia gelatinosa neurons in transverse slices of adult rat lumbar spinal cord to compare the actions of M3G with those of the mu-opioid agonist, DAMGO ([D-Ala(2),N-Met-Phe(4),Gly-ol(5)]-enkephalin), and the ORL(1) agonist, nociceptin/orphanin FQ (N/OFQ). M3G (1-100 microM) had little or no effect on evoked excitatory postsynaptic currents (EPSC) and no effect on postsynaptic membrane conductance. In contrast, 1 microM DAMGO and 1 microM N/OFQ reduced the amplitude of evoked EPSCs and activated an inwardly rectifying K(+) conductance. M3G did not attenuate the effect of DAMGO or N/OFQ on evoked EPSC amplitude. However, 1 to 100 microM M3G reduced the amplitude of evoked GABAergic and glycinergic inhibitory postsynaptic current (IPSC) by up to 48%. This effect was naloxone-insensitive. The evoked IPSC was also attenuated by DAMGO, but not by N/OFQ. Because M3G reduced the frequency of tetrodotoxin-insensitive miniature IPSCs and increased paired-pulse facilitation, it appeared to act presynaptically to disinhibit substantia gelatinosa neurons. This effect, which does not appear to involve mu-opioid or ORL(1) receptors, may contribute to the allodynia and hyperalgesia observed after intrathecal application of high doses of morphine.
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Affiliation(s)
- Timothy D Moran
- Department of Pharmacology, University Centre for Neuroscience, University of Alberta, Edmonton, Alberta, Canada T6G 2H7
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Bruins Slot LA, Pauwels PJ, Colpaert FC. Sign-reversal during persistent activation in mu-opioid signal transduction. J Theor Biol 2002; 215:169-82. [PMID: 12051972 DOI: 10.1006/jtbi.2001.2509] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A concept of signal transduction in biological systems specifies that any instantaneous input is appreciated by its departure from the moving average of past activity. The concept provides an adequate account of the occurrence of both the one-directional (e.g. analgesic) effects induced by opioid receptor activation, and of the contra-directional (e.g. hyperalgesic) effects that can be observed when activation is discontinued. Following this transduction concept, the numerical simulations reported here revealed, remarkably, that under some parametric conditions, the input's effect may reverse even as input is maintained at a constant magnitude. In in vitro conditions that are proximal to the signal transduction that occurs when an opioid agonist binds to the G-protein coupled opioid receptor, the effects of opioid receptor activation were monitored by measuring time-dependent Ca(2+) responses in CHO-K1 cells transfected with a mu-opioid receptor and G(alpha 15) protein. The results indicate morphine to produce an initial increase in intracellular Ca(2+) concentration followed by a decrease below basal level. The occurrence of a sign-reversal was confirmed in native conditions of receptor-to-G protein coupling; the continuous in vivo infusion over a 2-week period of 0.31 mg rat(-1)day(-1) of fentanyl initially caused an increase of the mechanical threshold to induce a pain response (i.e. analgesia) that was followed by a decrease (i.e. hyperalgesia). The findings indicate that with opioid signaling systems, transduction mechanisms operate that may cause the sign of the effect to reverse not only when activation is discontinued but also whilst it is maintained at a constant magnitude.
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Affiliation(s)
- L A Bruins Slot
- Centre de Recherche Pierre Fabre-17, Avenue Jean Moulin, Castres Cedex, F81106, France.
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26
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Affiliation(s)
- M K Makin
- Pain Relief Foundation's Pain Research Institute, Marie Curie Centre Liverpool, Speke Road, Woolton L25 8QA, UK
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Marples IL, Murray P. Morphine induced allodynia in child with brain tumour. Signs are more likely to have been due to underlying medical condition. BMJ (CLINICAL RESEARCH ED.) 2000; 320:381. [PMID: 10657347 PMCID: PMC1127157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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