Pharmacological Effects
Opioid agonists interact with
receptors in the brain and in the spinal cord. The initial binding of opioids
in the brain causes the release of the inhibitory neurotrans-mitter serotonin,
which in turn induces inhibition of the dorsal horn neurons. Both the brain and
the spinal cord are required for the production of a maximal analgesic effect
following systemic administration of opioids, although analgesia can be
elicited by spinal administra-tion only. In the spinal cord, morphine inhibits
the release of most nociceptive peptides. Morphine also affects descending
noradrenergic pathways. Norepi-nephrine release in response to opioid
administration results in an analgesic effect at the spinal level.
Opioids have profound effects
upon the cerebrocor-tical regions that control the somatosensory and
dis-criminative aspects of pain. Thus, the opioids
suppress the perception of pain by
eliminating or altering the emo-tional aspects of pain and inducing euphoria
and sleep with higher doses. Patients become inattentive to the painful stimuli, less anxious, and more
relaxed. Disruption of normal REM sleep occurs with opioid ad-ministration. In
addition, opioids depress polysynaptic responses but can increase monosynaptic
responses and lead to convulsant effects in high doses. In patients with
chronic pain, the euphoric effect of opioids, mediated by the μ-receptor, is usually
blunted. Some patients feel a dysphoric effect upon the administration of
opioids, which is most likely mediated by the σ-receptor.
Opioids depress respiration
via the μ2-receptor at the level of the medulla and thereby increase PCO2. Opioids reduce respiration,
an effect that is fatal in the case of overdose, by a dual action. The opioids decrease both the sensitivity of the medulla to carbon dioxide
concentra-tions and the respiratory rate. Cardiovascular function and the response to hypoxia are not
compromised. By contrast, tolerance to
the respiratory depressant effects of the
opioids does not appear to occur, while tolerance to the emetic effects of the opioids occurs upon repeated
administration. The area postrema chemoreceptor trig-ger zone of the medulla
mediates opioid-induced vom-iting.
Miosis, or the pinpoint
pupillary response to the opi-oids, is diagnostic of the use and abuse of the
opioids. No tolerance to such an effect is observed. Miosis is due to
disinhibition of the Edinger-Westphal nucleus in the cortex resulting in
increased pupillary constrictor tone.
The opioids have pronounced
effects on the release of hormones from both the pituitary and the
hypothala-mus. Stimulation of some of the opioid receptors in hy-pothalamic
nuclei decrease the release of dopamine, thus increasing release of prolactin.
Opioids bind in the supraoptic nuclei of the hypothalamus and increase the
release of antidiuretic hormone (vasopressin).
Morphine and most other
opioids produce some degree of constipation by increasing sphincter tone and
de-creasing gastric motility. Such an effect is uncomfort-able for patients
required to take opioids chronically. Tolerance to the constipative effects of
the opioids does not generally occur. In addition, the decrease in gastric
motility increases gastric emptying time and reduces absorption of other drugs.
The constriction of sphinc-ters, especially the bile duct, may result in
increased pain in certain patients with biliary colic or other GI distress.
Constriction of the urinary sphincter can lead to painful urine retention in
some patients. The effects of opioids on the GI tract are largely mediated by
the parasympathetic release of acetylcholine. All of the opi-oid receptors have
been shown to mediate such GI ef-fects.
Opioids induce the release of
histamine, which leads to the itching sensation associated with use and abuse
of opioids. Bronchiolar constriction is possible. Opioids are also
immunosuppressive, having effects on the T-helper and T-suppressor cells.
The opioids block cough by a
mechanism that is not yet understood. No stereoselectivity of the opioids for
blockade of the cough reflex has been shown. Thus, the isomers of opioids, such
as dextrorphan, are as effica-cious as the L-isomers as antitussives. This lack of stere-oselectivity prompted the development of the D-isomers of opioids as antitussives since they are devoid of the
de-pendence liability of L-isomers
All of the opioid agonists
produce some degree of tol-erance and physical dependence. The biochemical
mechanisms underlying tolerance and physical depend-ence are unclear. It is
known, however, that intracellular mechanisms of tolerance to opioids include
increases in calcium levels in the cells, increased production of cAMP,
decreased potassium efflux, alterations in the phosphorylation of intracellular
and intranuclear pro-teins, and the resultant return to normal levels of
re-lease of most neurotransmitters and neuromodulators. Tolerance to the
analgesic effects of opioids occurs rap-idly, especially when large doses of
the drugs are used at short intervals. However, tolerance to the respiratory
depressant and emetic effects of the opioids occurs more slowly. The miotic and
constipative effects of the opioids rarely show tolerance.
Tolerance to one opioid usually renders a patient cross-tolerant to
other opioids but not to drugs of other classes. Within the opioid class of
drugs, certain drugs with high
intrinsic activity (e.g., fentanyl) appear to lack cross-tolerance to opioids
of lower intrinsic activity (e.g., morphine), an effect thought to be related
to the change in receptor number induced by the chronic opi-oid administration.
Theoretically, a drug with high in-trinsic activity would need to occupy fewer
receptors to exert an effect and would be less affected by changes in receptor
number, which occurs upon chronic adminis-tration of drugs with lower intrinsic
activity.
The cessation of opioid drug
administration leads to an observable abstinence syndrome. In the case of the
opioids, signs of withdrawal include chills, fever, sweat-ing, yawning,
vomiting, diarrhea, nausea, dizziness, and hypertension. The onset of symptoms
occurs 6 to 12 hours after the last drug dose (depending on the kinet-ics of
the drug) and continues for several days, with most of the signs of withdrawal
ending by 72 hours af-ter the last dose of the drug. However, signs of
with-drawal, including restlessness, anxiety, and drug craving, may be
detectable for 6 months to 1 year after cessation of drug use.
In general, the effects
observed upon withdrawal from a drug are opposite to those observed when the
person is taking the drug, and such is the case with the opioids. The degree of
dependence is generally reflected by the severity of withdrawal signs. In
addition, drugs with long half-lives, such as methadone, produce a grad-ual and
prolonged withdrawal. The use of methadone replacement for heroin is based upon
the pharmacoki-netics of methadone. The longer onset and duration of action and
the oral bioavailability render the drug use-ful for the treatment of opioid
addiction by decreasing the rapid highs and lows associated with fast-onset,
short-duration drugs such as heroin. Drugs with a short duration of action
produce a more rapid onset of with-drawal signs.
A derivative of methadone, L- -acetyl-methadol (LAAM) has
been approved for the treatment of opi-oid addiction. In some addicts whose
degree of toler-ance is not known, the patient is first given methadone to
stabilize the withdrawal signs and is then switched to LAAM. LAAM has an
advantage over methadone in that it has a longer duration of action. Dosing is
re-quired only three times per week in most addicts to pre-vent withdrawal.
Babies born to
opioid-addicted women also exhibit withdrawal signs, but because of the slower
metabolism of opioids in the newborn, the withdrawal signs are more protracted.
The babies are often treated with the opium preparation paregoric to reduce
withdrawal signs.
Related Topics
Privacy Policy, Terms and Conditions, DMCA Policy and Compliant
Copyright © 2018-2024 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.