Opioid Tolerance and Hyperalgesia
Total Page:16
File Type:pdf, Size:1020Kb
Load more
Recommended publications
-
Opioid-Induced Hyperalgesia in Humans Molecular Mechanisms and Clinical Considerations
SPECIAL TOPIC SERIES Opioid-induced Hyperalgesia in Humans Molecular Mechanisms and Clinical Considerations Larry F. Chu, MD, MS (BCHM), MS (Epidemiology),* Martin S. Angst, MD,* and David Clark, MD, PhD*w treatment of acute and cancer-related pain. However, Abstract: Opioid-induced hyperalgesia (OIH) is most broadly recent evidence suggests that opioid medications may also defined as a state of nociceptive sensitization caused by exposure be useful for the treatment of chronic noncancer pain, at to opioids. The state is characterized by a paradoxical response least in the short term.3–14 whereby a patient receiving opioids for the treatment of pain Perhaps because of this new evidence, opioid may actually become more sensitive to certain painful stimuli. medications have been increasingly prescribed by primary The type of pain experienced may or may not be different from care physicians and other patient care providers for the original underlying painful condition. Although the precise chronic painful conditions.15,16 Indeed, opioids are molecular mechanism is not yet understood, it is generally among the most common medications prescribed by thought to result from neuroplastic changes in the peripheral physicians in the United States17 and accounted for 235 and central nervous systems that lead to sensitization of million prescriptions in the year 2004.18 pronociceptive pathways. OIH seems to be a distinct, definable, One of the principal factors that differentiate the use and characteristic phenomenon that may explain loss of opioid of opioids for the treatment of pain concerns the duration efficacy in some cases. Clinicians should suspect expression of of intended use. -
Ong Edmund W 201703 Phd.Pdf (5.844Mb)
INVESTIGATING THE EFFECTS OF PROLONGED MU OPIOID RECEPTOR ACTIVATION UPON OPIOID RECEPTOR HETEROMERIZATION by Edmund Wing Ong A thesis submitted to the Graduate Program in Pharmacology & Toxicology in the Department of Biomedical and Molecular Sciences In conformity with the requirements for the degree of Doctor of Philosophy Queen’s University Kingston, Ontario, Canada March, 2017 Copyright © Edmund Wing Ong, 2017 Abstract Opioid receptors are the sites of action for morphine and most other clinically-used opioid drugs. Abundant evidence now demonstrates that different opioid receptor types can physically associate to form heteromers. Owing to their constituent monomers’ involvement in analgesia, mu/delta opioid receptor (M/DOR) heteromers have been a particular focus of attention. Understandings of the physiological relevance of M/DOR formation remain limited in large part due to the reliance of existing M/DOR findings upon contrived heterologous systems. This thesis investigated the physiological relevance of M/DOR generation following prolonged MOR activation. To address M/DOR in endogenous tissues, suitable model systems and experimental tools were established. This included a viable dorsal root ganglion (DRG) neuron primary culture model, antisera specifically directed against M/DOR, a quantitative immunofluorescence colocalizational analysis method, and a floxed-Stop, FLAG-tagged DOR conditional knock-in mouse model. The development and implementation of such techniques make it possible to conduct experiments addressing the nature of M/DOR heteromers in systems with compelling physiological relevance. Seeking to both reinforce and extend existing findings from heterologous systems, it was first necessary to demonstrate the existence of M/DOR heteromers. Using antibodies directed against M/DOR itself as well as constituent monomers, M/DOR heteromers were identified in endogenous tissues and demonstrated to increase in abundance following prolonged mu opioid receptor (MOR) activation by morphine. -
Opioid-Induced Hyperalgesia a Qualitative Systematic Review Martin S
Anesthesiology 2006; 104:570–87 © 2006 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Opioid-induced Hyperalgesia A Qualitative Systematic Review Martin S. Angst, M.D.,* J. David Clark, M.D., Ph.D.† Opioids are the cornerstone therapy for the treatment of an all-inclusive and current overview of a topic that may moderate to severe pain. Although common concerns regard- be difficult to grasp as a whole because new evidence ing the use of opioids include the potential for detrimental side accumulates quickly and in quite distinct research fields. effects, physical dependence, and addiction, accumulating evi- dence suggests that opioids may yet cause another problem, As such, a comprehensive review may serve as a source often referred to as opioid-induced hyperalgesia. Somewhat document. However, a systematic review also uses a paradoxically, opioid therapy aiming at alleviating pain may framework for presenting information, and such a frame- Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/104/3/570/360792/0000542-200603000-00025.pdf by guest on 01 October 2021 render patients more sensitive to pain and potentially may work may facilitate and clarify future communication by aggravate their preexisting pain. This review provides a com- clearly delineating various entities or aspects of OIH. prehensive summary of basic and clinical research concerning opioid-induced hyperalgesia, suggests a framework for organiz- Finally, a systematic review aims at defining the status ing pertinent information, delineates the status quo of our quo of our knowledge concerning OIH, a necessary task knowledge, identifies potential clinical implications, and dis- to guide future research efforts and to identify potential cusses future research directions. -
Case Discussions in Palliative Medicine Levorphanol For
JOURNAL OF PALLIATIVE MEDICINE Volume 21, Number 3, 2018 Case Discussions in Palliative Medicine ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2017.0475 Feature Editor: Craig D. Blinderman Levorphanol for Treatment of Intractable Neuropathic Pain in Cancer Patients Akhila Reddy, MD,1,* Amy Ng, MD,1,* Tarun Mallipeddi,2 and Eduardo Bruera, MD1 Abstract Neuropathic pain in cancer patients is often difficult to treat, requiring a combination of several different pharmacological therapies. We describe two patients with complex neuropathic pain syndromes in the form of phantom limb pain and Brown-Sequard syndrome who did not respond to conventional treatments but re- sponded dramatically to the addition of levorphanol. Levorphanol is a synthetic strong opioid that is a potent N- methyl-d-aspartate receptor antagonist, mu, kappa, and delta opioid receptor agonist, and reuptake inhibitor of serotonin and norepinephrine. It bypasses hepatic first-pass metabolism and thereby not subjected to numerous drug interactions. Levorphanol’s unique profile makes it a potentially attractive opioid in cancer pain man- agement. Keywords: Brown-Sequard syndrome; cancer; cancer pain; levorphanol; neuropathic pain; phantom limb pain Introduction changes, structural reorganization of spinal cord and primary somatosensory cortex, and increased sensitization of spinal ne-third of cancer patients who experience pain cord may be the neurological basis for PLP.8,9 Because the Oalso experience neuropathic pain1 and about half the pathophysiology of PLP is not clearly understood, the treat- patients with cancer who suffer from neuropathic pain also ment options are mainly based on clinical experience.9 There have nociceptive pain.2 Most neuropathic pain exists as are case series showing that tramadol and methadone may be mixed pain in combination with nociceptive pain. -
Contents (WELCOME)
Contents (WELCOME) ................................................................................................................................................ 2 (TERMINOLOGY) ....................................................................................................................................... 4 (SAFETY) ..................................................................................................................................................... 7 (GOLDEN RULES NOT TO BREAK) ...................................................................................................... 11 (PATIENT ASSESSMENT) ....................................................................................................................... 13 (PAIN RELIEF VS FUNCTION/ADL) ..................................................................................................... 15 (ADJUVANT THERAPIES) ...................................................................................................................... 16 (MEDICATION SIDE EFFECTS) ............................................................................................................. 18 (ONGOING THERAPY AND MONITORING) ....................................................................................... 24 (MEDICATION SAFE STORAGE AND DISPOSAL) ............................................................................. 26 (DISCONTINUING OPIOID THERAPY) ................................................................................................ 28 (CO-USE WITH -
Page 1 of 17 10/11/2017 File:///C:/Users/Henadzi.Sobal/Documents
Page 1 of 17 GOT18-0018. Impact of Clinical Pharmacist Analysis to Clinical Decision-Making for Drug Therapy Management in the Hospital Care Setting Background A deeper understanding of pharmacist clinical decision-making should provide the influence that pharmacists have on patient health care, should guide pharmacy policy and education, should contribute to educating less experienced pharmacists on decision-making processes, should promote more interprofessional work, and should encourage pharmacist decision-making toward the wisest selections of patients’ medication therapy. Purpose The overarching objective of this research study was to document drug therapy decision-making processes of clinical pharmacists in the hostital care setting. The specific aims of this study were to examine the current clinical decision-making of clinical pharmacists in the context of the hospital care clinic setting, to compare and contrast pharmacist clinical decision-making with current decision-making models. Material and methods We used a quasi-randomized design to evaluate a quality improvement project in three hospitals in Kazakhstan. Three audio-taped data collection methods of participant observation and semi-structured interview were utilized and exactly transcribed to provide textual data for analysis. Thematic analysis provided emerging themes of clinical pharmacist-led medication and clinical decision-making which were further subdivided into subsuming themes after much reflection and interpretation of the entire study data. Results Other health professions have identified experienced clinical decision-aking to encompass the Decision Analysis, intuition and pattern recognition. Clinical pharmacists’ clinical decision-making processes are considered in light of other health professionals’ decision-making techniques; however the results show that clinical pharmacists use a different model of clinical decision-making using constant dialogue between two different types of knowledge (objective and context-related). -
PEOLC Provincial Guideline for Treatment Opioid Neurotoxicity
Guideline for the Treatment of Opioid Neurotoxicity Definition Patients on chronic opioids can develop neuroexcitatory side effects: hyperalgesia (increased sensitivity to pain), cognitive changes (disordered attention and impaired short-term memory), delirium with hallucinations, myoclonus. Etiology This can be due to an opioid dose which is too high for the patient, dehydration and/or renal failure. General Approach Review the medical record (pattern of opioid use and dose escalation, other medications, the presence of electrolyte abnormalities and major organ dysfunction). Whenever medically appropriate, easily treatable causes or exacerbating factors should be corrected (e.g., correct hypomagnesemia). Treatment Strategies 1. Opioid dose reduction. Make sure you are not reducing the opioid dose solely to control side effects at the expense of good pain control. Consider changing the frequency if renal function is impaired (i.e., from q4h to q6h) 2. Rotate to a dissimilar opioid. Rotating to a lower dosage of a structurally dissimilar opioid will often reduce neuroexcitatory effects within 24 – 48 hours, while achieving comparable pain control. Rotation is especially important in patients with opioid-induced hyperalgesia. Decrease the morphine equianalgesic dose by 25 – 50% when switching to a new opioid (to account for incomplete cross tolerance). Use immediate release formulations until a new stable dose is achieved. To rotate a patient to a new opioid, use the following equianalgesic ratios (see chart on page 3): Oral Routes: Morphine 10 mg = Oxycodone 5 mg = Codeine 100 mg = Hydromorphone 2 mg Oral to Subcutaneous Routes: Ratio (PO) 2:1 (IV/SC) i.e., Morphine 10mg PO = Morphine 5mg IV/subcut or Hydromorphone 10mg PO = Hydromorphone 5mg IV/subcut April 22, 2020 Seniors Health, Palliative and End of Life Care A Caregiver’s Resource for Caring for your Loved One at Home during COVID-19 • 2 Transdermal Fentanyl/ Fentanyl infusion: There are various accepted methods. -
Opioid-Induced Hyperalgesia (OIH)
Opioid-Induced Hyperalgesia (OIH) Brian Johnson M.D. Assoc Prof Psychiatry and Anesthesia SUNY Upstate Medical University Disclosures • Research on shifts in the hypothalamic- pituitary-adrenal system and depression during and after alcohol withdrawal sponsored by the Distilled Spirits Council of the United States (Johnson 1986) Learning Objectives 1. Get the “big picture” about why opioid prescribing has accelerated recently, setting the environment for OIH to be commonplace 2. Know the definition of OIH 3. Know the neural mechanisms of OIH 4. Know the effect of methadone or buprenorphine maintenance on OIH Learning Objectives 2 5. Know how long it takes to induce OIH 6. Know what to do about OIH; with addicted patients and non-addicted patients 7. Understand the surgical pain management of a patient with OIH 1. The Big Picture • Practitioners often remark that use of opioids has become ubiquitous. The following slides show how common opioid prescribing has become, what the impetus was behind the shift in medical practice, and what are some of the unimagined consequences of a social movement that was not evidence-based. The existence of OIH has been recognized only after the impact of the right to pain treatment movement had its effect. Opioid Use Has Exploded! • 2009 USA, 5% of world’s population • 56% of global morphine • 81% of global oxycodone • 99% of global hydrocodone (Huxtable 2011) Opioid-Associated Deaths - USA • Year 1998 2005 • Oxycodone 14 1007 • Morphine 82 329 • Fentanyl 92 1245 • Methadone 8 329 (Huxtable 2011) “Pain Management: A Fundamental Human Right” “Reasons for deficiencies in pain management included cultural, societal, religious and political attitudes, including acceptance of torture. -
Revisiting Old Friends: Update on Opioid Pharmacology
VOLUME 37 : NUMBER 2 : APRIL 2014 ARTICLE Revisiting old friends: update on opioid pharmacology Ben Snyder Advanced trainee SUMMARY General medicine and clinical pharmacology Opioids are commonly prescribed for pain due to malignant and non-malignant diseases. They are effective, but have potentially fatal toxicities. Key words Opioid analgesics act as agonists at the mu opioid receptor. Some products combine a mu analgesia, codeine, agonist and antagonist, but there are limitations to their use. morphine, naloxone, pharmacogenetics Genetic variations may explain why people respond differently to opioids. Some patients have an inadequate response to codeine because they poorly metabolise it to morphine. Aust Prescr 2014;37:56–60 Switching from one opioid to another is sometimes necessary, but must be done carefully. Use conversion tables as a reference, but be aware of their limitations. Introduction These cellular events can inhibit neuronal firing and Opioid drugs are prescribed for acute and chronic neurotransmitter release. pain of moderate or severe intensity arising from both All of the opioid analgesics act as agonists at the mu malignant and non-malignant diseases (see Table).1,2 receptor. Mu activation inhibits the ascending pain They benefit many patients, but there are increasing pathway, which includes neurons passing through the numbers of unintentional fatal overdoses.3 A clinician dorsal horn of the spinal cord, brainstem, thalamus weighing up the potential benefits and harms of and cortex. Mu agonists also activate the inhibitory opioids is also confronted with an array of newly descending pain pathway, which involves sites in the available drugs and formulations. Understanding the brainstem. -
Ultra Low Dose Naltrexone - for Lower Opiate Tolerance - Res
Ultra Low Dose Naltrexone - For Lower Opiate Tolerance - Res... https://www.khemcorp.com/ultra-low-dose-naltrexone-for-lowe... SHOPPING CART You have 0 items Home Online Shop ∠ Learn & How To ∠ Contact Us – You – ∠ About Us & FAQ ∠ Search Ultra Low Dose Naltrexone – For Lower Opiate Tolerance – Research Products Summary Oxytocin Nasal Spray Posted by Anonymous on November 04, 2015 / Posted in Khemcorp Originals, Reverse Tolerance 60ml 6500 IU V2.0 (For Autism, Social Anxiety and Empathy) $49.99 Synaptic Focus 6000mg (For ADHD, Procrastination, Brain Fog) $49.99 What is Naltrexone? OASIS Pro (CES Contents [hide] Device) (Electric Stimulation Therapy) Naltrexone is described as a 1 What is Naltrexone? $450.00 substituted oxymorphone, it’s 2 What is Ultra Low Dose Naltrexone? active metabolites are antagonists 3 How Does Ultra Low Dose Naltrexone Potentiate Opioids? at the u-opioid receptor (MOR), 4 How Does ULDN Work to Reverse Opiate tolerance or tolerances of Other Drugs? Q-wiz Suite k-opioid receptor (KOR), and the 5 Why Ultra Low Dose Naltrexone, rather than Low Dose or even just Naltrexone? $2,795.00 $2,515.50 o-opioid receptor (DOR). 6 What’s the Dosage and How Should It Be Taken? 7 What’s the Upper Ceiling? Naltrexone’s primary use (in 8 Potential Interactions and Risks to Watch Out normal doses) is in the 9 Bonus Information management of opioid and 10 Research References Q-wiz Elemental alcohol dependency. It is also 11 Related Posts often used to reduce $995.00 $895.50 Benzodiazepine withdrawal symptoms as both Benzodiazepines and alcohol rely on agonizing GABA receptors, which is also why addiction to alcohol or benzodiazepines are also notoriously difficult to treat. -