analgesicsedps674 1

NARCOTIC ANALGESICS Wanda Chaulk, Caroline LaPierre, Gabe Mandel & Maria Soubbotina

TABLE OF CONTENTS

• Characteristics • Applications • Controversies • Negative Effects

CHARACTERISTICS Narcotics •

also known as Opioids or Opiates and are sometimes referred to as Analgesics

• some common names for Opioids are: Codeine, Fentanyl, Demerol, Morphine, Heroin, Codeine, Oxycontin, Percocet, Vicodin

CHARACTERISTICS

Functions • used to make people sleep or feel less pain • used for severe pain that is not helped by other pain relievers. • not recommended for long term use

CHARACTERISTICS

History

• have been used since the early days of Chinese, Roman and Egyptian History • used by upper class to feel good • used for pain management during child birth • originally the leaves of the opium poppy were chewed to achieve the effect

CHARACTERISTICS

The Hypodermic Needle •

Lead to faster and stronger pain relief

•

Wider abuse of Opioids

•

Use in medical settings

CHARACTERISTICS How They Work • Opioids attach to proteins called opioid receptors, which are located primarily in the brain, spinal cord, gastrointestinal tract • Physical effects • Psychological effects

CHARACTERISTICS

Neurotransmitter • The body produces it’s own opiate like substance sometimes called endogenous opioids • Endogenous opioids help modulate reactions to painful stimuli

CHARACTERISTICS

Receptor • Opiates are so powerful because they bind to the same receptors are our endogenous opioids • Three kinds of receptors: mu, delta, and kappa • The excitability of neurons

CHARACTERISTICS

Inhibition of Neural Activity • When opioids attached to the mu receptors, exogenous opioids reduced the amount of GABA that is released. Gaba normally reduces the amount of dopamine that is released. • Chronic consumption of opiates causes inhibition of neural activity, which the brain then must compensate for.

APPLICATION

Chronic Pain Treatment

•

Children & Adults  chronic diseases  palliative care  infection, toxicity (e.g. chemotherapy), immune or metabolic disorders  nerve injury during surgery or trauma  pediatric chronic pain syndromes (‘NOS’)

APPLICATIONS

Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses (World Health Organization, 2012) • Two-Step Strategy i) Mild ii) Moderate to Severe • Dosing at Regular Intervals

APPLICATIONS

Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses (World Health Organization, 2012) • Appropriate Route of Administration  Orally  Intravenous (IV) • Adapting Treatment to the Individual Child  considering pain tolerance and presenting side effects  no maximum dosage or ceiling effect

APPLICATIONS

Opioid Rotation  helps prevent potential side effects  limits dose escalation  optimizing balance

• • •

at least 14% of children with cancer receiving opioids will require rotation resolved 90% of side-effects morphine & fentanyl

APPLICATIONS

Neonatal Pain

•

Opioids are the most often used analgesics among newborns as well  Morphine for moderate-to-severe postoperative pain  may prolong mechanical ventilation but no effects on apnea or hypotension after removing intubation

APPLICATIONS

APPLICATIONS

Treatment for Opioid Dependence • Opiate Substitution Therapy (OST)  Improves mental & physical health and social functioning  Reduces mortality, illicit drug use, crime, and risk-taking behavior  Continuous uninterrupted treatment = best predictor for drug-free discharge

APPLICATIONS

•

Methadone maintenance treatment (MMT)  main form of OST  3-Class Model of opiate-dependent individuals and outcomes • Class Low = low QoL scores in all domains • Class Intermediate = high scores ‘safety’ and ‘living situation’ • Class High = high QoL scores in all domains

APPLICATIONS •

Other important protective factors:  counseling psychology (CP)  contingency management (CM)

•

MMT with CP or CM = significantly greater outcomes  reduced injection rates  decreased incidences of HIV & HCV  MMT w/CP better than MMT w/CM

APPLICATIONS •

Buprenorphine as opiate substitute  partial agonist vs full agonist (methadone)  extended release less withdrawal symptoms if cease treatment  reduces heroin use, but less effective than methadone  completion of treatment associated with counseling attendance and having had a past injury

CONTROVERSERIES Addictions Prescription Drug Abuse  Physician Guidelines • 50,000 people with opioid addictions in Northern Ontario • Ontario 2007, Accidental overdoses 3rd leading cause of unintentional deaths • fatal overdose number one cause of accidental death in the United States

CONTROVERSERIES Spin off Issues Children - 34 deaths, > 6 years of age in United States (2003,TESS data base) - predictable tolerance and dependence if opioids are administered longer than four weeks Adolescents - feel prescription drugs are legal and safe - high risk of drug abuse, especially if administered prescription drugs prior to age 16

CONTROVERSERIES

Health Tragedy Purdue Pharma • profiting billions on OxyContin sales • marketing of OxyContin • addicts – breakdown of safety mechanisms

NEGATIVE EFFECTS Adverse Side Affects

• • • • • • • •

nausea/vomiting constipation dizziness sedation euphoria/dysphoria skin irritation respiratory depression individual differences in response to opioids

NEGATIVE EFFECTS Complications Related to Prolonged Use

• • • • •

tolerance physical dependence hyperalgesia hormonal changes immunosuppression

NEGATIVE EFFECTS Withdrawal Symptoms ACUTE

• • • • •

muscle ache runny nose fever sweating diarrhea

PROLONGED

• • • •

anxiety insomnia anhedonia depression

• withdrawal occurs in kids in medical settings • moderated by dose/duration (Ista et al, 2008)

DSM-V

Diagnostic Categories • • • • •

Opioids Use Disorder Opioids Intoxication Opioids Withdrawal Other Opioids-Induced Disorders Unspecified Opioids - Induced Disorders

REFERENCES Barrett, A., Cook, C., Terner, J., Craft, R., & Picker, M. (2001). Importance of sex and relative efficacy at the mu opioid receptor in the development of tolerance and cross-tolerance to the antinociceptive effects of opioids. Psychopharmacology, 158(2), 154–164. Buenaventura, R., Adlaka, R., % Sehgal, N. (2008). Opioid complications and side effects. Pain Physician, 11, S105S120 De Maeyer, J., van Nieuwenhuizen, C., Bongers, I. L., Broekaert, E., & Vanderplasschen, W. (2013). Profiles of quality of life in opiate-dependent individuals after starting methadone treatment: A latent class analysis. International Journal of Drug Policy, 24(4), 342-350. doi: 10.1016/j.drugpo.2012.09.005

Drake, R., Longworth, J., & Collins, J. J. (2004). Opioid rotation in children with cancer. Journal of Palliative Medicine, 7(3), 419-422. El Sayed, M.F., Taddio, A., Fallah, S., De Silva, N., & Moore, A.M. (2007). Safety profile of morphine following surgery in neonates. Journal of Perinatology, 27(7), 444-447 Fleary, S.A., Heffer, R.W.,& McKyer, E.L.J. (2011) Dispositional, ecological and biological influences on adolescent tranquilizer, ritalin and narcotics misuse. Journal of Adolescence 34, 653-663. doi:10.1016/ j.adolescence.2010.09.07 Furniss, C. (2006). A global addiction. Geographical, 78(8), 37-47. Gregoire, M. –C. & Finley, G. A. (2013). Drugs for chronic pain in children: A commentary on clinical practice and the absence of evidence. Pain Res Manag, 18(1), 47-50.

REFERENCES Hawley, P., Liebscher, R., & Wilford, J. (2013) Continuing methadone for pain in palliative care. Pain Res Manag. 18 (92) 83-86 Henry, K.,& Harris, C.R. (2006) Deadly ingestions. Pediatric Clinics of North America, 53, 293-315 doi:10.1016/j.plc. 2005.09.007 Hewitt, M., Goldman, A., Collings, G. S., Childs, M., & Hain, R. (2008). Opioid use in palliative care and young people with cancer. The Journal of Pediatrics, 152(1), 39-44. doi: 10.1016/j.jpeds.2007.07.005 Ista, E., van Dijk, M., Gamel, C., Tibboel, D., & de Hoog, M. (2008). Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: A first evaluation. Critical Care Medicine, 36,(8), 2427-2432 Lee, M., Silverman, S., Hansen, K., & Patel, V. (2011) A comprehensive review of opioid-induced hyperalgesia. Pain Physician, 14, 145-161 Lee, C. & Ho, I.K. (2013). Sex differences in opioid analgesia and addiction: Interactions among opioid receptors and estrogen receptors. Molecular Pain, 9(45), 1-10. Lomas, L., Barrett, A., Terner, J., Lysle, D., & Picker, M. (2007). Sex differences in the potency of kappa opioids and mixed-action opioids administered systemically and at the site of inflammation against capsaicininduced hyperalgesia in rats. Psychopharmacology, 191(2), 273-285. Manubay, J.M., Muchow, C. (2011) Prescription drug abuse: epidemiology, regulatory issues, chronis pain management and narcotic analgesics. Primary Care Clinical Office Practice, 38, 71-90. doi: 10.1016/ j.pop.2010.11.006

REFERENCES Mattick, R. P., Breen, C., Kimber, J., Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, Issue 2. Retrieved from http://ovidsp.ovid.com.ezproxy.lib.ucalgary.ca /ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=&AN=00075320-10000000001723&PDF=y National Institute on Drug Abuse (2013). History of Narcotics. Retrieved from http://www.narcotics.com/history/ Neumann, A.M., Blondell, R.D., Azadfard, M., Nathan, G., & Homish, G.G. (2013). Primary care patients characteristics associated with completion of 6-month buprenorphine treatment. Addictive Behaviors, 38(11), 2724-2728. doi: 10.1016/j.addbeh.2013.07.007 Paramenter, J., Mitchell, C., Keen, J., Oliver, P., Rowse, G., Neligan, I., Mathers, N. (2013) Predicting biospsychosocial outcomes for heroin users in primary care treatment: a prospective longitudinal cohort study. British Journal of General Practice, 63(612), e499-505. doi: 10.3399/bjgp13X669220 Pasternak, G. (2014). Opioids and their receptors: Are we there yet? Neuropharmacology, 76, 198-203. Rozisky, J. R., Dantas, G., Adachi, L. S., Alves, V. S., Ferreira, M. B. C., Sarkis, J. J. F., & Da Silva Torres, I. L. (2013). Long-term effect of morphine administration in young rats on the analgesic opioid response in adult life. International Journal of Developmental Science, 26, 561-565. doi: 10.1016/j.ijdevneu.2008.05.005 Van Zee, A. (2009). The Promotion and marketing of oxycotin: commercial triumph, public health tragedy. American Journal of Public Health, 99(2), 221-227. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/

REFERENCES

Wang, L., Wei, X., Wang, X., Li, J., Li, H., & Jia, W. (2014). Long-term effects of methadone maintenance treatment with different psychosocial intervention. PLoS ONE, 9(2), e87931 Whistler, J.L. (2012). Examining the role of mu opioid receptor endocytosis in the beneficial and side-effects of prolonged opioid use: From a symposium on new concepts in mu-opioid pharmacology. Drug Alcohol Depend, 121, 189–204. World Health Organisation. (2012). WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Retrieved from http://www.who.int/medicines/areas/quality_safety/children_persisting_pain/en/ Zernikow, B., Michel, E., & Anderson, B. (2007). Transdermal fentanyl in childhood and adolescence: A comprehensive literature review. The Journal of Pain, 8(3), 187-207. doi: 10.1016/j.jpain.2006.11.008 http://www.rxreform.org