View
1.326
Download
4
Category
Preview:
Citation preview
Narcotic analgesics – opium plant – poppy plant - capsule
These neurons release excitatory neurotransmitters which relay signals from one neuron to another.
“The signals are sent to the thalamus, in which pain perception occurs. From the thalamus, the signal travels to the somatosensory cortex in the cerebrum, at which point the individual becomes fully aware of the pain (2).”
Pain Signaling
Types of Pain
Types of Pain – contd.
Opioids
Narcotic analgesics
Prototype: MORPHINE
Major action - CNS/spinal cord
Potent analgesia–Mu receptor agonist
Mu, Kappa, Sigma, Delta
Opioid receptor decreased calcium decreased glutamate decreased excitation
Opioid Analgesics – important terms Analgesics: Drugs -selectively relieves pain-
acting in the CNS or on peripheral pain mechanisms(without significantly altering the consciousness) – Opioids and NSAIDS
Opioids: drug binds -opioid receptors-antagonized by Naloxone .
– Natural, Synthetic and semi-synthetic Narcotics: Drugs-opium or opium like
compounds-potent analgesic effects-a/w significant alteration of mood and behavior-with the potential for dependence and tolerance-repeated administration.
Agonist Antagonist
Mu Strong: Morphine, Pethidine, Methadone, Levorphanol, fentanyl, alfentanil, sufentanil, remifentanil
Moderate: Oxycodone, codeine
Weak: Propoxyphene
PA: Buprenorphine- (long)
Naloxone
Naltrexone
Nalmefene
Nalbuphine
PentazocineNalorphine – weak antagonistButorphanol – weak antagonist
kappa Nalbuphine,PentazocineButorphanol, Nalorphine
Naloxone, Naltrexone
Nalmefene
Delta Naloxone, Naltrexone , Nalmefene
Nalorphine (weak antagonist)
Butorphanol – weak antagonist
Sigma Naloxone, Naltrexone,
Nalmefene
OPIOID/OPIATE RECEPTORSMu = µ Delta = δsupraspinal analgesia, euphoria, respiratorydepression, physical dependence
µ1 = mainly analgesia
µ2 = mainly respiratory depression
Kappa = κ = spinal analgesia, miosis, sedation
Sigma = σ = Dysphoria, halluci, respiratory depr and vasomotor stimulation
Where are the receptors ? Limbic system including amygdaloid nucleus,
hypothalamus Medial and lateral thalamus, area postrema
(CTZ) Nucleus of tractus solitarious (cough center) Substantia nigra, and spinal cord
Terminology Opioid agonist = activates some or all opioid
receptors and do not block any. Partial agonist = a drug that can activate
opioid receptor, but the response is submaximal
Mixed agonist-antagonist = a drug that activates some receptor subtypes and blocks some other subtypes
Pure antagonist = a drug that blocks all receptor subtypes
OPIOID RECEPTOR TRANSDUCER MECHANISMS
Mechanism of action
Opioid drug bind to opioid receptor widely distributed in CNS & other tissues
A part of family of G-protein complex receptor
Open K+ channels Prevent opening of Ca 2+ channels Inhibit the release of other neurotransmitters
Endogenous Opioid Peptides
3 distinct families of peptides
Enkephalins Endorphins Dynorphins Each family -derived - distinct precursor of
polypeptide
Acute effects
-Analgesia
-Dose dependent CNS depression
-Respiratory depression– medulla
-Histamine release – hypotension, peripheral vasodilation (decreased preload,afterload) bronchospasm
-Cough suppressant
-Decrease GI motility – constipation
Stimulant actions Euphoria, CTZ – N, V Increased ICT PINPOINT PUPILS - III N nucleus NOTE : Meperidine (Pethidine)
(ATROPINE- LIKE – MYDRIASIS) Biliary sphincter contraction Increased detrusor, sphincter tone
urgency but retention Uterine stimulation
Uses
Severe acute shooting visceral pain MI Terminal stages in malignancy Severe crush injuries Postoperative pain
Contraindications/A/E
Respiratory depression -Old, young,COPD, kyphoscoliosis Hypovolemia, hypotension Increase ICT HEAD INJURY Increased intrabiliary pressure UNDIAGNOSED ACUTE ABDOMEN Liver disease, renal disease Labor: respiratory depression in newborn
Acute morphine poisoning Respiratory depression, hypoxia Profound CNS depression, coma Hypotension, PINPOINT PUPILS
Use antagonist NALOXONE 0.4 mg IV q 2-3 min – pure
anta- competitive – all receptors VENTILATORY SUPPORT NARROW MARGIN OF SAFETY
Chronic effects Dependence – physical, psychic Tolerance – Effect goes on decreasing on
chronic use. Tissue tolerance – means - some tissues do
not get tolerant. CNS develops tolerance, but GIT (constipation)
and EYE (pinpoint pupils) do not develop tolerance !!
So, Opiate addict has constipation and pinpoint pupils
How to treat – Morphine dependence Substitute an agonist ! Which will be less potent than original drug – and - which will have long duration of action This will give similar pleasure and withdrawing this
drug will be easier due to long duration of action
(withdrawal symptoms will be less severe) So – 1. Methadone (long duration of action)
or 2. Buprenorphine (mild withdrawal)
Opiate withdrawal symptoms Hyperalgesia muscle cramps, stomach pain Mydriasis Diarrhea, Insomnia, Anxiety, Craving,
Sweating, Rhinorrhea, Tachycardia, increased blood pressure
Treat with – Methadone or buprenorphine (as replacement) Clonidine Beta blockers Benzodiazepines
What is heroin?
Heroin, not heroine !!
What is heroin?
Synthetic derivative of morphine (diacetyl morphine) Similar properties Treatment of overdose or withdrawal –
same as morphine
Heroin’s effects on the body
Important opioids
Analgesia (MI, terminal cancer pain, post-op) -Meperidine(pethidine)- atropine-like -fentanyl (also as patches) -methadone, buprenorphine
Others: -oxycodone, hydrocodone, propoxyphene Diarrhea – diphenoxylate, loperamide Cough-codeine, dextromethorphan
Pethidine (agonist) Opioid agonist, but is an atropine substitute So, atropine-like effects: Less spasmogenic, less
sphincter contraction No urinary retention, produces MYDRIASIS Less histamine release, safe in asthma PO, IV, IM 50-100 mg. Short duration – 2-3 hours Slow tolerance and dependence Uses: Preanesthetic medication Post-operative pain, other severe pains For analgesia during labor
Fentanyl (agonist) Congener of pethidine, Rapidly enters brain Short duration of action: 30-40 min
During anesthesia as analgesic - IV Post-operative pain - IV Along with droperidol (neuroleptanalgesia)-IV Cancer pains – as patch Chronic pains – as patch
IV: 1-2 mcg/kg Transdermal patch – 25-50 mcg per hour –
this acts for 2-3 days
Methadone (agonist) (long duration)
T1/2 – 24-36 hours, Slow persistent action Less abuse potential Withdrawal gradual, prolonged, less
severe 1 mg methadone = 4 mg morphine = 2 mg
heroin = 20 mg Pethidine Is also Analgesic 2.5 – 10 mg oral or im Used as substitute to treat morphine
addiction
Mixed agonist-antagonists Commonly used: Pentazocine Mu antagonist, K agonist: So, Good analgesic Oral (50-100 mg),IV IM (30-60 mg) Short duration of action Post-operative pain Pain due to burn, trauma, fracture, cancer Analgesia during anesthesia and other
procedures
Increases heart rate, BP, Remember: Do not use in MI
Remember: such a drug can precipitate withdrawal in a morphine addict due to Mu antagonistic effect
Diphenoxylate (Lomotil) therapeutic use is as antidiarrheal
drug (treats diarrhea) meperidine type drug has very little analgesic properties at
therapeutic dose no antitussive effect at high doses- analgesic problems causes respiratory depression and
euphoria at high doses
Codeine change in the methyl group on 3 position one tenth the potency of morphine the absorption is more regular than morphine and
more predictable metabolized like morphine through glucuronic
acid tolerance and physical dependence is protracted
from morphine since potency of codeine is low withdrawal from codeine is mild in relation to
morphine antitussive drug for cough
Structural Activity Relationship
O
HOH
NH
CH3
HO1
23
4
5
6
7
8
9
10
11
12
1314
15 16
Morphine (Astramorph)
HO- Group is needed for activity
HO- Group not important to activity
O
HOH
NH
CH3
CH3O
Codeine (5X LESS potent than morphine)
Inefficiently converted to HO group in the liver
PURE ANTAGONIST
Pure antagonists Naloxone – for acute morphine
poisoning – 0.4 mg IV q 2-3 min
Naltrexone – tablet 50 mg qd - is of more benefit to decrease the sensation of craving during treatment of addiction – opiates, alcohol, and other drugs of abuse
Nalmefene
Naloxone no analgesic activity at all competitive antagonist at mu, kappa, and
sigma receptor displaces morphine and other OPIOID from
receptor site reverses all actions of the OPIOID and does
it rather quickly it will precipitate withdrawal increases blood pressure metabolized same as morphine through
glucuronic acid conjugation and excreted through kidney
Naltrexone same effect of naloxone except -used orally so
can't be used for person with acute toxicity long duration of activity single dose block action of heroin-24 hours used for emergency treatment once stabilized, give patient naltrexone After giving naltrexone patient- no euphoric
effect from heroin so person gets off heroin (negative reinforcement)
approved for use by the FDA also used for treatment of alcoholism
Pharmacokinetics of opoids
Absorption from GI tract, nasal mucosa, lung. Also through subcutaneous, intramuscular, and
intravenous route
Distribution Bound/free morphine accumulates- kidney,
lung, liver, and spleen CNS is primary site of action
(analgesia/sedation)
Metabolism/Excretion metabolic transformation -liver conjugates with glucuronic acid excreted by kidney - glomerular filteration half life -2.5 to 3 hours morphine 3 glucuronide - main excretion
product 90% is excreted in first day. duration of 10 mg dose- 3 to 5 hours
Drug interactions with Opioids in general, the
coadministration of CNS depressants with OPIOID often produces at least an additive depression (potentiation)
OPIOID and phenothiazines produces an additive CNS depression as
well as enhancement of the actions of OPIOID (respiratory depression)
this combination - orthostatic hypotension OPIOID and tricyclic
antidepressants produce increased hypotension meperidine and MAO inhibitors - severe
and immediate reactions that include excitation, rigidity, hypertension, and severe respiratory depression
OPIOID and barbiturates increased clearance
morphine and amphetamine enhanced analgesic effect
Recommended