Document Sample
         Chapter 9
     Shannan Crumpler
     Andrea Matteliano
     Beverly Sessanna
      Ericka Sullivan
     Galen Westmoore
          History of Opioids
• Opium is extracted from poppy seeds
  (Paper somniforum)
• Used for thousands of years to produce:
  – Euphoria
  – Analgesia
  – Sedation
  – Relief from diarrhea
  – Cough suppression
             History cont’d
• Used medicinally and recreationally from
  early Greek and Roman times
• Opium and laudanum (opium combined
  with alcohol) were used to treat almost all
  known diseases
• Morphine was isolated from opium in the
  early 1800’s and since then has been the
  most effective treatment for severe pain
     History and Background
• Invention of the hypodermic needle in
  1856 produced drug abusers who self
  administered opioids by injection
• Controlling the widespread use of opioids
  has been unsuccessful because of the
  euphoria, tolerance and physiological
  dependence that opioids produce
• ―opium‖ is a Greek word meaning ―juice,‖
  or the exudate from the poppy
• ―opiate‖ is a drug extracted from the
  exudate of the poppy
• ―opioid‖ is a natural or synthetic drug that
  binds to opioid receptors producing
  agonist effects
 Natural opioids occur in 2 places:
• 1) In the juice of the opium poppy
  (morphine and codeine)
• 2) As endogenous endorphins
• All other opioids are prepared from either
  morphine (semisynthetic opioids such as
  heroin) or they are synthesized from
  precursor compounds (synthetic opioids
  such as fentanyl)
         Pharmacological Effects
• Sedation and anxiolysis
   –   Drowsiness and lethargy
   –   Apathy
   –   Cognitive impairment
   –   Sense of tranquility
• Depression of respiration
   – Main cause of death from opioid overdose
   – Combination of opioids and alcohol is especially dangerous
• Cough suppression
   – Opioids suppress the ―cough center‖ in the brain
• Pupillary constriction
   – pupillary constriction in the presence of analgesics is
     characteristic of opioid use
 Pharmacological effects cont’d.
• Nausea and vomiting
   – Stimulation of receptors in an area of the medulla called the
     chemoreceptor trigger zone causes nausea and vomiting
   – Unpleasant side effect, but not life threatening
• Gastrointestinal symptoms
   – Opioids relieve diarrhea as a result of their direct actions on the
• Other effects
   – Opioids can release histamines causing itching or more severe
     allergic reactions including bronchoconstriction
   – Opioids can affect white blood cell function and immune function
         Mechanism of action
• Activation of peripheral nociceptive fibers causes
  release of substance P and other pain-signaling
  neurotransmitters from nerve terminals in the
  dorsal horn of the spinal cord

• Release of pain-signaling neurotransmitters is
  regulated by endogenous endorphins or by
  exogenous opioid agonists by acting
  presynaptically to inhibit substance P release,
  causing analgesia
    Primary Effect of Opioid Receptor Activation

• Reduction or inhibition of neurotransmission, due largely
  to opioid-induced presynaptic inhibition of
  neurotransmitter release
• Involves changes in transmembrane ion conductance
   – Increase potassium conductance (hyperpolarization)
   – Inactivation of calcium channels
Three Opioid Receptors

         • Mu

        • Kappa

        • Delta
          Delta Receptor
• It is unclear what delta’s responsible for.
• Delta agonists show poor analgesia and
  little addictive potential
• May regulate mu receptor activity
     Mu-Receptor: Two Types
• Mu-1                       • Mu-2
  – Located outside spinal     – Located throughout
    cord                         CNS
  – Responsible for            – Responsible for
    central interpretation       respiratory depression,
    of pain                      spinal analgesia,
                                 physical dependence,
                                 and euphoria
      Kappa Receptor

       • Only modest analgesia
• Little or no respiratory depression
      • Little or no dependence
          • Dysphoric effects
  Mu and Kappa Receptor Activation

Response      Mu-1   Mu-2     Kappa




Decrease GI
    Mu and Kappa Receptors
   DRUGS          MU         KAPPA

Pure Agonists    Agonist      Agonist

Agonist-        Antagonist    Agonist
Pure            Antagonist   Antagonist

• Pure Agonist: has affinity for binding plus efficacy

• Pure Antagonist: has affinity for binding but no efficacy;
  blocks action of endogenous and exogenous ligands

• Mixed Agonist-Antagonist: produces an agonist effect at
  one receptor and an antagonist effect at another

• Partial Agonist: has affinity for binding but low efficacy

     General Pharmacokinetics
•   *oral (15-30 minutes)
•   *intranasal (2-3 minutes)
•   *intravenous (15 – 30 seconds)
•   *pulmonary-inhalation (6-12 seconds)
• DURATION OF ACTION – anywhere between 4 and 72
  hours depending on the substance in question.
• Metabolism – hepatic via phase 1 and phase 2
  biotransformations to form a diverse array of metabolites
  ( eg., morphine to morphine-6-glucuronide).
• Routes of administration (preferred)
     latency to onset –(15 – 60 minutes )
•   * it is also sniffed, swallowed and injected.
•   * duration of action – ( 3 – 6 hours)
•   * First-pass metabolism results in poor
•         availability from oral dosing.
•   * 30% is plasma protein bound
•   *symptomatic relief of moderate to severe pain
•   *relief of certain types of labored breathing
•   *suppression of severe cough (rarely)
•   *suppression of severe diarrhea
•   *AGONIST for mu, kappa, and delta receptors.
•   *Routes of administration (Preferred)
•   *Oral
•       *latency to onset (15 – 30 minutes)
•   *Intravenous
•   *Duration of Action (3-4 hours)
•   *Peak effect (30-60 minutes)
•   * potent analgesic like morphine but is 7-10
•     times as potent in this capacity.
•   *used fequently in surgical settings for moderate to
•     severe pain. (cancer, bone trauma, burns, renal colic.)
•  Pharmacokinetics
•   Routes of Administration
   * Oral, and transdermal (possibly intravenous)
   *Highly lipophilic
   *latency to onset (7-15 minutes oral; 12-17 hours
   *duration of action ( 1-2 hours oral; 72 transdermal)
   *80 – 85% plasma protein bound
   *90 % metabolized in the liver to inactive metabolites
Other properties
   * 80 times the analgesic potency of morphine
      and 10 times the analgesic potency of
   *high efficacy for mu 1 receptors.
   *most effective opiate analgesic
•     Naloxone
•     Naltrexone
•  *latency to onset (oral tablet 15-30 min.)
•  *duration of action 24-72 hours
•  *peak effect (6-12 hours)
•  *Differs from naloxone insofar as the
•   allyl group on the nitrogen atom is supplanted
•   by a cyclopromethyl group.
•   *Reverses the psychotomimetic effects of opiate
•    agonists.
•   * Reverses hypotension and cardiovascular instability
•    secondary to endogeneous endorphins (potent vasodilators)
•    *inhibits Mu, Delta, and Kappa receptors.
Tolerance and Dependence
• Tolerance is a diminished responsiveness to the drug’s
  action that is seen with many compounds
• Tolerance can be demonstrated by a decreased effect
  from a constant dose of drug or by an increase in the
  minimum drug dose required to produce a given level of
• Physiological tolerance involves changes in the binding
  of a drug to receptors or changes in receptor
  transductional processes related to the drug of action
• This type of tolerance occurs in opioids
           Tolerance continued
• Molecular basis of tolerance involves glutaminergic
  mechanisms (glutamate-excitatory amino acid
• 1997, Gies and colleagues stated that activation of
  glutamate NMDA receptors correlates with resistance to
  opioids and the development of tolerance
• Mu-receptor mRNA levels are regulated by activation of
  these receptors
• NMDA receptor blocker ketamine prevented the
  development of this late-onset and long-lasting
  enhancement in pain sensitivity after the initial analgesia
  effect dissipated
          Tolerance continued
• Thus, glutaminergic NMDA receptors MAY regulate mu-
  receptor mRNA, accounting for the development of
  tolerance to the continuous presence of opioid
• Cross-tolerance is the condition where tolerance for one
  drug produces tolerance for another drug – person who
  is tolerant to morphine will also be tolerant to the
  analgesic effect of fentanyl, heroin, and other opioids
• * note that a subject may be physically dependent on
  heroin can also be administered another opioid such as
  methadone to prevent withdrawl reactions
• Methadone has advantages of being more orally
  effective and of lasting longer than morphine or heroin
           Tolerance continued
• Methadone maintenance programs allow heroin users
  the opportunity to maintain a certain level of functioning
  without the withdrawl reactions
• Although most opioid effects show tolerance, locomotor
  stimulation shows sensitization with repeated opioid
• Toxic effects of opioids are primarily from their
  respiratory depressant action and this effect shows
  tolerance with repeated opioid use
• Opioids might be considered ―safer‖ in that a heroin
  addicts drug dose would be fatal in a first-time heroin
• Physiological dependence occurs when the drug is
  necessary for normal physiological functioning – this is
  demonstrated by the withdrawl reactions
• Withdrawl reactions are usually the opposite of the
  physiological effects produced by the drug
             Withdrawl Reactions
        Acute Action                  Withdrawl Sign
•   Analgesia                  •   Pain and irritability
•   Respiratory Depression     •   Hyperventilation
•   Euphoria                   •   Dysphoria and depression
•   Relaxation and sleep       •   Restlessness and insomnia
•   Tranquilization            •   Fearfulness and hostility
•   Decreased blood pressure   •   Increased blood pressure
•   Constipation               •   Diarrhea
•   Pupillary constriction     •   Pupillary dilation
•   Hypothermia                •   Hyperthermia
•   Drying of secretions       •   Lacrimation, runny nose
•   Reduced sex drive          •   Spontaneous ejaculation
•   Flushed and warm skin      •   Chilliness and ―gooseflesh‖
        Dependence continued
• Acute withdrawl can be easily precipitated in drug
  dependent individuals by injecting an opioid antagonist
  such as naloxone or naltrexone – rapid opioid
  detoxification or rapid anesthesia aided detoxification
• The objective is to enable the patient to tolerate high
  doses of an opioid antagonist and undergo complete
  detox in a matter of hours while unconscious
• After awakening, the person is maintained on orally
  administered naltrexone to reduce opioid craving
      Chapter 10:
    Nonnarcotic, Anti-
Inflammatory Analgesics
Treatment for: mild to moderate pain, fever,
              inflammation, stroke/heart attack
              prevention, arthritis, *? prevention of
              Alzheimer’s Dementia
   Aspirin and related NSAIDs

• display a ceiling effect for analgesia (not
  as effective as opioids)
• can be used in combination with opiate
  analgesics (summation effect)

Bark of willow tree: Pain relief from chemical in bark,
  salicin (chemically related to aspirin)
NSAID prototype:
       Acetylsalicylic acid (ASA) = aspirin
Action of NSAIDs:
       through either selective or non-selective blocking of
       enzymes involved in the synthesis of prostaglandins

NSAID= non-steroidal anti-inflammatory drug
• Members of group of lipid-derived paracrines

     • chemicals secreted by a cell to act on cells in the
       immediate vicinity via process of diffusion

• Can be released by all cells in the body
• An enzyme involved in prostaglandin
  – cyclooxygenase-1 (COX-1): beneficial
  – cyclooxygenase-2 (COX-2): harmful
COX Enzyme:Prostaglandin Effects
                    COX-1: beneficial COX-2: harmful

Peripheral injury                    Inflammation
Brain                                Modulate pain
                                     Promote fever
Stomach             protect mucosa
Platelets           aggregation

Kidney              vasodilation
       Effects of COX Inhibition
           by Most NSAIDS

                      COX-1               COX-2

Gastric ulcers                                  Reduce inflammation

    Bleeding                                        Reduce pain

Acute renal failure                                 Reduce fever

     NSAIDs : anti-platelet—decreases ability of blood to clot
        Pharmacokinetics: ASA
Absorption: from stomach and intestine
Distribution: readily, into most fluids/tissues
Metabolism : primarily hepatic
• ASA contraindicated for use in children with viral
  fever –can lead to Reye’s Syndrome
• Fatal overdose is possible

Similar pharmacokinetics for ibuprofen and related NSAIDs
   Pharmacokinetic Variability of
   Non-Selective COX-Inhibitors
Name                 Time to peak ½ life parent
                     (hours)      ½ life*active
Aspirin              1-2          0.25-0.33
                                  (*3-10 L-H)
Naproxen              2-4          12-15
Oxaprozin             3-5          42-50
*Sulindac (pro-drug) 2-4           7.8
Ketorolac (inj)      .5-1          3.8-8.6
Ibuprofen            1-2           1.8-2.5
   Selective Cox-2 Inhibitors
• Greater affinity for cyclooxygenase-2
• Decreased incidence of negative effects
  associated with non-selective COX-inhibitors

Name              Time to peak      ½ life
                  (hours)           (hours)
Celecoxib           3                11

Rofecoxib            2-3             17
     N-Acetyl-P-Aminophenol (APAP)

Classification: analgesic, antipyretic, misc.
                not an NSAID

Mechanism: inhibits prostaglandin synthesis
           via CNS inhibition of COX (not
           peripheral)---doesn’t promote
           ulcers, bleeding or renal failure;
           peripherally blocks generation
           of pain impulses, inhibits
           hypothalamic heat-regulation center
       APAP Liver Metabolism

1. Major pathway —Majority of drug is
      metabolized to produce a non-toxic
2. Minor pathway —Produces a highly reactive
      intermediate (acetylimidoquinone) that
  conjugates with glutathione and is inactivated.

• At toxic APAP levels, minor pathway metabolism
  cannot keep up (liver’s supply of glutathione is
  limited), causing an increase in the reactive
  intermediate which leads to hepatic toxicity and
    Pharmacokinetics: APAP

Metabolism: major and minor pathways
Half-life: 1-3 hours
Time to peak concentration: 10-60 min

Treatment for overdose: Acetylcysteine
  See ―New Approach…Pain‖