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ByBohlooli S. PhD
School of Medicine, Ardabil University of Medical Sciences
IntroductionOpium poppy is the source of crude opium Sertürner in 1803 isolated morphineNaming it after Morpheus, the Greek god
of dreamsOpioid analgesics is a widely used term
for:Natural, semi-synthetic, syntheticEndogenous peptides
SourceOpium, the source of morphine, is obtained
from the poppy, Papaver somniferum and P album
Opium contains many alkaloids, the principle one being morphine, which is present in a concentration of about 10%
Classification & ChemistryOpioid drugs include:
Full agonists Morphine
Partial agonists Codeine
Antagonists Naloxone
Chemical structure
ChemistryPhenanthrenes
Morphine, hydromorphone, and oxymorphone Codeine,oxycodone, dihydrocodeine, and
hydrocodonePhenylheptylamines
MethadonePropoxyphene
PhenylpiperidinesFentanyl, sufentanil, alfentanil, and remifentanilDiphenoxylate and its metabolite, difenoxinLoperamide
Morphinans
Chemistry; Opioids with Mixed Receptor ActionsPhenanthrenes
Nalbuphine , Buprenorphine Morphinans
ButorphanolBenzomorphans
PentazocineMiscellaneous
Tramadol, Tapentadol
Opioid Receptor Subtypes, Their Functions, and Their Endogenous Peptide Affinities
Receptor Subtype
Functions Endogenous Opioid Peptide Affinity
(mu) Supraspinal and spinal analgesia; sedation; inhibition of respiration; slowed gastrointestinal transit; modulation of hormone and neurotransmitter release
Endorphins > enkephalins > dynorphins
(delta) Supraspinal and spinal analgesia; modulation of hormone and neurotransmitter release
Enkephalins > endorphins and dynorphins
(kappa) Supraspinal and spinal analgesia; psychotomimetic effects; slowed gastrointestinal transit
Dynorphins > > endorphins and enkephalins
Endogenous Opioid PeptidesEndorphins
Drived from: prepro-opiomelanocortin Enkephalins
met-enkephalin leu-enkephalinDrived from: preproenkephalin
Dynorphins Drived from: preprodynorphin
EndomorphinsNociceptin / Orphanin FQ
Orphanin opioid-receptor-like subtype 1 (ORL1)
PharmacokineticsGeneric Name Receptor
Effects1
Approximately Equivalent Dose (mg)
Oral:Parenteral Potency Ratio
Duration of Analgesia (hours)
Maximum Efficacy
Morphine2
+++ + 10 Low 4–5 High
Hydromorphone +++ 1.5 Low 4–5 High
Oxymorphone +++ 1.5 Low 3–4 High
Methadone +++ 10 High 4–6 High
Meperidine +++ 60–100 Medium 2–4 High
Fentanyl +++ 0.1 Low 1–1.5 High
Sufentanil +++ + + 0.02 Parenteral only 1–1.5 High
Alfentanil +++ Titrated Parenteral only 0.25–0.75 High
Remifentanil +++ Titrated3
Parenteral only 0.054
High
PharmacokineticsGeneric Name Receptor
Effects1
Approximately Equivalent Dose (mg)
Oral:Parenteral Potency Ratio
Duration of Analgesia (hours)
Maximum Efficacy
Levorphanol +++ 2–3 High 4–5 High
Codeine ± 30–60
High 3–4 Low
Hydrocodone5
± 5–10 Medium 4–6 Moderate
Oxycodone2,6
± 4.57
Medium 3–4 Moderate
Propoxyphene (+, very weak)
60–1207
Oral only 4–5 Very low
Pentazocine ± + 30–507
Medium 3–4 Moderate
Nalbuphine –– ++ 10 Parenteral only 3–6 High
Buprenorphine ± –– –– 0.3 Low 4–8 High
Butorphanol ± +++ 2 Parenteral only 3–4 High
PharmacokineticsAbsorptionDistributionMetabolismExcretion
AbsorptionWell absorbedVariable first-pass metabolismSubcutaneous, intramuscular, and oral
routes- other routes:Nasal insufflationOral mucosa via lozenges Transdermal patches
MetabolismConverted to polar metabolites Morphine
morphine-3-glucuronide ::neuroexcitatory morphine-6-glucuronide ::potency four to six times Accumulation can produce unexpected results
Hydromorphone like morphine H3G has CNS excitatory properties
Esters (eg, heroin, remifentanil) are rapidly hydrolyzed Hepatic oxidative metabolism for phenylpiperidine opioids
meperidine, fentanyl, alfentanil, sufentanil Normeperidine cause seizures in renal failure
Polymorphism of CYP2D6 Codeine :: no significant analgesic effect or an exaggerated response
Mechanism of Action
Receptor TypesBased on pharmacologic criteria
1, 2
1, 2
1, 2, 3
Genetically one subtype from each of the , and receptor families
Cellular ActionsClosing voltage-gated Ca2+ channels on
presynaptic nerve terminalsInhibit release of
Glutamate, acetylcholine, norepinephrine, serotonin, and substance P
Hyperpolarizing and thus inhibiting postsynaptic neurons by opening K+ channels
Relation of Physiologic Effects to Receptor TypeOpioid analgesics act primarily at the -
opioid receptorAnalgesia, euphoria, respiratory depression,
and physical dependenceButorphanol and nalbuphine
Preference for opioid receptorsGreater analgesia in women
Receptor Distribution and Neural Mechanisms of Analgesia: Transmission
Receptor Distribution and Neural Mechanisms of Analgesia: Modulation
Ion Channels & Novel Analgesic Targets: chronic Pain Capsaicin receptor, TRPV1 and TRPA1 P2X : purines receptor Tetrodotoxin-resistant voltage-gated sodium channel (Nav1.8)-
PN3/SNS channel Lidocaine and mexiletine
Ziconotide, a blocker of voltage-gated N-type calcium channels Related to marine snail toxin -conotoxin
Gabapentin/Pregabalin : analogs of GABA Ketamine: NMDA antagonists Nicotine 9-tetrahydrocannabinol
Tolerance and Physical DependenceTolerancePhysical dependenceWithdrawal or abstinence syndromeMechanism
receptor recyclingreceptor uncoupling
Organ System Effects of Morphine
Central Nervous System Effects
Cardiovascular SystemGastrointestinal TractBiliary TractRenal
UterusNeuroendocrinePruritus
Central Nervous System EffectsDegrees of Tolerance that May Develop to Some of the Effects of the Opioids.
High Moderate Minimal or None
Analgesia Bradycardia Miosis
Euphoria, dysphoria Constipation
Mental clouding Convulsions
Sedation
Respiratory depression
Antidiuresis
Nausea and vomiting
Cough suppression
Central Nervous System EffectsAnalgesia
Sensory Affective (emotional) Nonsteroidal anti-inflammatory analgesic drugs
Has no effect on emotional partEuphoria
Pleasant floating sensation Lessened anxiety and distress Dysphoria may occure
Sedation are common effects no amnesia Sleep is in the elderly Occurs more frequently phenanthrene derivatives
Central Nervous System Effects Respiratory Depression
Significant respiratory depression Sepressed response to a carbon dioxide challenge Influenced significantly by the degree of sensory input Most difficult clinical challenges
Cough Suppression Codeine May allow accumulation of secretions
Miosis Mediated by parasympathetic pathways
Truncal Rigidity Intensification of tone in the large trunk muscles
Nausea and Vomiting Activate the brainstem chemoreceptor trigger zone
Temperature -opioid receptor agonists hyperthermia -opioid receptor agonists hypothermia
Cardiovascular SystemBradycardiaMeperidine antimuscarinic action
tachycardiaHypotension may occur
Peripheral arterial and venous dilation Release of histamine Central depression of vasomotor-stabilizing
mechanisms
Caution in patients with decreased blood volume
Gastrointestinal TractConstipationthe stomach
Motility decrease Tone increaseGastric secretion of hydrochloric acid is
decreasedBiliary Tract
Contract biliary smooth muscle biliary colic
Sphincter of Oddi may constrict
Other Peripheral EffectsRenal
Antidiuretic effectEnhanced renal tubular sodium reabsorptionIncreased ureteral and bladder tone
UterusMay prolong labor
Neuroendocrinestimulate the release of ADH, prolactin, and
somatotropininhibit the release of luteinizing hormone
• Clinical Use of Opioid Analgesics• Toxicity & Undesired Effects
Alternative Routes of AdministrationRectal suppositories
morphine and hydromorphone
Transdermal patchFentanyl
IntranasalButorphanol
Buccal transmucosalFentanyl citrate lozenge
Patient-controlled analgesia (PCA) infusion device
Toxicity & Undesired EffectsBehavioral restlessness, tremulousness,
hyperactivity (in dysphoric reactions)Respiratory depressionNausea and vomitingIncreased intracranial pressurePostural hypotension accentuated by
hypovolemiaConstipationUrinary retentionItching around nose, urticaria (more frequent
with parenteral and spinal administration)
Tolerance and DependenceDoes not become clinically manifest until
after 2–3 weeksTolerance to methadone develops more
slowlyCross-tolerance is an extremely important
But often be partial or incompleteOpioid rotationRecoupling opioid receptor ketamine
Physical DependenceSigns and symptoms
RhinorrheaLacrimationYawningChillsGooseflesh (piloerection)HyperventilationHyperthermiaMydriasisMuscular achesVomitingDiarrheaAnxiety, and hostility
Physical Dependencetime of onset, intensity, and duration of
abstinence syndrome depend onbiologic half-lifemorphine or heroin, usually start within 6–10
hoursmethadone required several days
Psychologic DependenceEuphoria, indifference to stimuli, and sedationAbdominal effects that have been likened to an
intense sexual orgasmReinforced by the development of physical
dependence
The Opioid AntagonistsNaloxone,naltrexone, and nalmefeneMethylnaltrexone bromide Alvimopan