Analgesia

The Essence of Analgesia and
Analgesics
The Essence of Analgesia and

Analgesics
Edited by
Raymond S. Sinatra
Jonathan S. Jahr
J. Michael Watkins-Pitchford
cambridge university press

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Cambridge University Press 2011
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Library of Congress Cataloging in Publication data
The essence of analgesia and analgesics / edited by Raymond
S. Sinatra, Jonathan S. Jahr, J. Michael Watkins-Pitchford.
p. cm.
ISBN 978-0-521-14450-6 (pbk.)
1. Analgesics. 2. Analgesia. I. Sinatra, Raymond S. II. Jahr,
Jonathan S. III. Watkins-Pitchford, J. Michael.
RM319.E87 2010
615.783dc22 2010034377
ISBN 978-0-521-14450-6 Paperback
Cambridge University Press has no responsibility for the
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guarantee that any content on such websites is, or will
remain, accurate or appropriate.
Every effort has been made in preparing this book to provide
accurate and up-to-date information which is in accord with
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Although case histories are drawn from actual cases, every
effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers
can make no warranties that the information contained herein
is totally free from error, not least because clinical standards
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authors, editors and publishers therefore disclaim all liability
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to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Contents
Contributors xi
1. Introduction 1
Ian W. Rodger
Section 2. Oral and Parenteral Opioid

Analgesics
Section 1. Pain Definitions
13. Opioids and opioid receptors 73

Raymond S. Sinatra
2. Pain definitions and assessment 3

Raymond S. Sinatra
3. Pain pathways and pain processing 7
Amit Mirchandani and Shamsuddin
Akhtar
4. Pain characteristics 13
Alireza Sadoughi
5. Primary and secondary hyperalgesia 17
Brenda C. McClain
6. Pain pathophysiology 23
Alireza Sadoughi
7. Neuropathic pain 30
Ho Dzung and Oscar A. de Leon-Casasola
8. Genetics and pain 37
Keith A. Candiotti and Claudia R. Fernandez
Robles
9. Persistent post-operative pain 41
Peter G. Lacouture
10. Analgesic gaps 51
Sunil J. Panchal
11. Multimodal analgesia (sites of analgesic
activity) 57
Bryan S. Williams and Asokumar
Buvanendran
12. A stepwise approach to pain
managment 66
Raymond S. Sinatra
14. Morphine oral and parenteral 82

Joseph Rosa and Swati Patel
15. Morphine sulfate controlled-release 86
Parisa Partownavid
16. Combination agonistantagonist opioid
analgesics 90
Jeff Gudin
17. Meperidine 94
Ellen Flanagan and Brian Ginsberg
18. Codeine and codeine compounds 98
Anjali Vira
19. Oxycodone and oxycodone
compounds 101
Mary Keyes
20. Opioid plus ibuprofen compounds 105
Kellie Park
21. Oxycodone controlled-release 108
Amanda Barker, Justin Hata and Eric Hsu
22. Hydrocodone bitartrate 112
Edward J. Park
23. Hydromorphone (oral and parenteral) 115
Carsten Nadjat-Haiem and Joseph Rosa
24. Oxymorphone injectable 119
Balazs Horvath
25. Oxymorphone extended-release 123
Steven Levin and Imanuel Lerman
Table of contents
26. Methadone 127

Keun Sam Chung
43. Epidural sufentanil 191

Jill Zafar, Anthony T. Yarussi and Laura Mechtler
27. Fentanyl oral and buccal delivery

systems 131
Philip Levin
44. Extended-release epidural morphine 194

Akta Patel, Eugene R. Viscusi and Leslie
Schechter
28. Fentanyl transdermal system 134

Hamid Nourmand
45. Intrathecal morphine 197

James M. Moore
29. Tramadol and tramadol plus

acetaminophen 137
Julie Sramcik and Raymond S. Sinatra
46. Evaluating epidural catheters 200

Anna Clebone and Raymond S. Sinatra
30. Tramadol extended-release 140

Haruo Arita
31. Tapentadol 143
Dan Froicu and Raymond S. Sinatra
32. Remifentanil 147
Marjorie Podraza Stiegler
Section 4. NSAIDs
33. Nalbuphine 150

Ana M. Lobo
48. Nonselective nonsteroidal anti-inflammatory

drugs, COX-2 inhibitors, and
acetaminophen 211
Jonathan S. Jahr and Vivian K. Lee
34. Butorphanol 154

J. Michael Watkins Pitchford
49. Ibuprofen 215

Eric C. Lin and Shu-ming Wang
35. Buprenorphine: intravenous neuraxial and

transdermal applications 157
Nalini Vadivelu
50. Injectable ibuprofen 218

James H. Shull
36. Opioid dosing in pediatric patients 161

Debra E. Morrison, Abraham Rosenbaum, Co T.
Truong and Zeev N. Kain
37. Opioid tolerance and dependence 165
Sukanya Mitra
vi
47. Anticoagulants and regional anesthesia 204

Gregory Cain, Michael Seneca and Ashley
Vaughn
51. Naproxen 221

Dorothea Hall, Tyson Bolinske and Elizabeth
Sinatra
52. Diclofenac gel and diclofenac patch 225
Neil Singla
38. Opioid-induced hyperalgesia 171

Sukanya Mitra
53. Diclofenac oral and diclofenac plus

PPI 229
Nehal Gatha
39. Opioid rotation 174

Raymond S. Sinatra
54. Diclofenac injectable 232

Daniel B. Carr and Ryan Lanier
Section 3. Neuraxial Opioid Analgesics
55. Ketorolac 235

Christopher Wray
40. Epidural morphine 181

Siamak Rahman
56. Celecoxib 238

Joseph Marino
41. Epidural fentanyl 184

Bita H. Zadeh
57. Etoricoxib 243

Bryan S. Williams and Asokumar Buvanendran
42. Epidural hydromorphone 187

Susan Dabu-Bondoc and Greg Albert
58. Parecoxib 245

Jeff Gudin and Despina Psillides
Table of contents
59. Meloxicam 249

Gabriel Jacobs
60. Buffered aspirin and oral salicylate 252
Jeanna Blitz
61. Acetaminophen oral and rectal 256
Komal D. Patel
62. Acetaminophen injectable 258
Vivian K. Lee and Jonathan S. Jahr
63. Fiorinal and Fioricet 262
Alexander Timchenko
Section 5. Local Anesthetics

64. Overview of local anesthetics 267
Lars E. Helgeson and Raymond S. Sinatra
Section 7. NMDA Antagonists

75. Overview of NMDA receptors and
antagonists 310
R. Todd Rinnier, Michael E. Goldberg and
Marc C. Torjman
76. Ketamine 316
Carsten Nadjat-Haiem
77. Memantine 319
78. Dextromethorphan 321
Muhammad Anwar
79. NMDA antagonists: magnesium and
amantadine 325
Clinton Kakazu, John Charney and Yaw Wu
65. Bupivacaine 274

Thomas Halaszynski
Section 8. Alpha-Adrenergic Analgesics
66. Ropivacaine 276

Neesa Patel
80. Overview of adrenergic and serotoninergic

pain suppression 328
Frederick Conlin and Shamsuddin Akhtar
67. Lidocaine for neural blockade 279

Mary Hanna Bekhit
68. Topical local anesthetics 283
Steven J. Weisman
69. Lidocaine transdermal 288
Maggy G. Riad
Section 6. Anticonvulsant-Type
Analgesics
81. Clonidine (transdermal and parenteral) 330

Anahat Kaur Dhillon
82. Neuraxial clonidine hydrochloride 332
Richard W. Hong
83. Dexmedetomidine 335
David Burbulys and Kianusch Kiai
Section 9. Antidepressants
70. Overview of anticonvulsant analgesics 292

J. Michael Watkins-Pitchford and Veena Salgar
84. Overview and use of antidepressant

analgesics in pain management 338
Paul M. Peloso
71. Gabapentin 294

Boris Gelman and Eric S. Hsu
85. Tricyclic antidepressants 347

Carly Miller and Alan Miller
72. Pregabalin 298

Neil Sinha
86. Trazodone 351

JinLei Li
73. Carbamazepine 301

Keren Ziv
87. Duloxetine 353

Eric S. Hsu
74. Lamotrigine 306

Laurie Yonemoto
88. Milnacipran 357

Kristin L. Richards
vii
Table of contents
Section 10. Muscle Relaxants

89. Overview of muscle relaxants in
pain 360
David A. Lindley
90. Diazepam and lorazepam 365
Mirjana Lovrincevic and Mark J. Lema
91. Methocarbamol 368
Martha Zegarra
92. Cyclobenzaprine 370
Martha Zegarra
106. Methylnaltrexone 418

Kathleen Ji Park, Anthony DePlato and Jill Zafar
107. Alvimopan 420
Victor A. Filadora II and Sidney Allison
Section 12. New and Emerging

Analgesics
93. Metaxalone 372

Eric S. Hsu
108. Overview: novel targets for new

analgesics 424
Ian W. Rodger and Peter G. Lacouture
94. Tizanidine 375

Tariq Malik
109. Intranasal morphine 437

Denis V. Snegovskikh
95. Baclofen 379

Marisa Lomanto
110. Intranasal ketamine 440

Section 11. Adjuvant Analgesics and

Antiemetics
96. Corticosteroids: intravenous, neuraxial, and
articular 383
Johan Raeder
97. Oral corticosteroids 388
Kianusch Kiai and David Burbulys
98. Antihistamines 391
Sharon Lin
99. Parenteral antiemetics 396
Zhuang T. Fang
100. Oral antiemetics aprepitant 401
Philip F. Morway
viii
105. Ziconotide 415

Sunil J. Panchal
111. Inhaled fentanyl 444

Dana Oprea
112. Hydromorphone extended-release 448
Ira Whitten
113. Hydrocodone extended-release 452
Thomas Wong
114. Iontophoretic transdermal fentanyl 455
Craig T. Hartrick
115. Tapentadol ER 458
Raymond S. Sinatra
116. Tamper-resistant opioids 463
Christopher Gharibo and Fleurise Montecillo
117. Novel sustained-release analgesics 467
Danielle Perret and Michael M. Kim
101. Transdermal scopolamine 405

Joe C. Hong
118. Extended-duration bupivacaine 471

Tiffany Denepitiya-Balicki and Mamatha
Punjala
102. Topical capsaicin 407

Jure Marijic
119. Morphine-6-glucuronide 475

Stephen M. Eskaros
103. Topical salicylates 410

Jeremy M. Wong
120. Neostigmine 479

Rongjie Jaing and Balazs Horvath
104. Pamidronate 413

Rex Cheng and Zoreh Steffens
121. Buprenorphine transdermal 481

Martin Hale
Table of contents
122. Nicotine (transdermal) 484

Dmitri Souzdalnitski, Imanuel Lerman and
Keun Sam Chung
123. Local anesthetic bone paste 488
Vadim Tokhner and Inderjeet Singh Julka
124. Peripheral kappa agonists 490
Derek Chalmers
127. Injectable capsaicin 500

Muhammad K. Ghori
128. TRPV-1 ion channel blockers 504
Jeanette Derdemezi
129. Neramexane 507
Dajie Wang
130. Nociceptin 508
Juan Jose Egas and Bijal Patel
125. Cannabinoid agonists 492

Yasser F. Shaheen and Aziz M. Razzuk
131. Anti-nerve growth factor 512

Allison Gandey and Roger Chou
126. Peripheral cannabinoid receptor

agonists 497
Ho Dzung and Mark J. Lema
Index 515
ix
Contributors
Shamsuddin Akhtar MD
Assistant Professor of Anesthesiology, Yale
University School of Medicine, New Haven, CT,
USA
Greg Albert MD
Resident in Anesthesiology, Yale University School of
Medicine, New Haven, CT, USA
Sidney Allison
University at Buffalo, School of Medicine and
Biomedical Sciences, Roswell Park Cancer Institute,
Buffalo, NY, USA
Muhammad Anwar MD
Clinical Assistant Professor, Department of
Anesthesiology, Yale University, School of Medicine,
New Haven, CT, USA
Haruo Arita MD
Assistant Clinical Professor of Anesthesiology,
Department of Anesthesiology, David Geffen School
of Medicine at UCLA, Ronald Reagan UCLA Medical
Center, Los Angeles, CA, USA
Amanda Barker
Pain Fellow, Department of Anesthesiology and
Perioperative Care, UC Irvine School of Medicine,
Irvine, CA, USA
Mary Hanna Bekhit MD
Jeanna Blitz
NYU School of Medicine, New York City, NY, USA
Tyson Bolinske MD
Medical Student, University of North Dakota, and
Research Associate in Anesthesiology, Department of
Anesthesiology, Yale University School of Medicine,

New Haven, CT, USA
David Burbulys MD
Assistant Clinical Professor of Anesthesiology, David
Geffen School of Medicine at UCLA, Department
of Anesthesiology, Harbor-UCLA Medical Center,
Torrance, CA, USA
Asokumar Buvanendran MD
Associate Professor of Anesthesiology, Rush
Presbyterian Medical Center, Chicago, IL, USA
Gregory Cain MSN, CRNA
Department of Anesthesiology, Yale University
School of Medicine, New Haven, CT, USA
Keith A. Candiotti MD
Professor of Pain Medicine, and Vice-Chair University
of Miami School of Medicine, Miami, FL, USA
Daniel B. Carr MD
Saltonstall Professor of Pain Research, Tufts
Medical Center, Boston, MA, and Chief Medical
Officer, Javelin Pharmaceuticals, Inc., Cambridge,
MA, USA
Derek Chalmers PhD, DSc
President & CEO, Cara Therapeutics, Inc., Shelton,
CT, USA
John Charney MD
David Geffen School of Medicine at UCLA,
Department of Anesthesiology Harbor-UCLA
Medical Center, Torrance, CA, USA
Rex Cheng MD
Torrance, CA, USA
xi
Contributors
Roger Chou MD
Associate Professor of Medicine, Department of
Medicine and Department of Medical Informatics
and Clinical Epidemiology, Oregon Health & Science
University, Portland, OR, USA
Keun Sam Chung MD
Assistant Professor of Anesthesiology, Yale University
Anna Clebone MD
Frederick Conlin MD
Susan Dabu-Bondoc MD
Tiffany Denepitiya-Balicki MD
Medicine, Cedar Street, New Haven, CT, USA
Jeanette Derdemezi MD
Torrance, CA, USA
Anahat Kaur Dhillon MD
Department of Anesthesiology, David
Geffen School of Medicine at UCLA, Ronald
Reagan UCLA Medical Center, Los Angeles, CA,
USA
Ho Dzung MD
Pain Fellow, Department of Anesthesiology,
University at Buffalo, Buffalo, NY, USA
Juan Jose Egas MD
xii
Stephen M. Eskaros MD
Zhuang T. Fang MD
Geffen School of Medicine at UCLA, Ronald
Reagan UCLA Medical Center, Los Angeles,
CA, USA
Claudia R. Fernandez Robles MD
Assistant Professor of Pain Medicine, University of
Miami School of Medicine, Miami, FL, USA
Victor A. Filadora II
Buffalo, NY, USA
Ellen Flanagan
Assistant Professor of Anesthesiology, Duke
University Medical Center, Durham, NC, USA
Dan Froicu MD
Allison Gandey BJ, MJ
Senior Journalist, Medscape Neurology, WebMD
Professional News, New York, NY, USA
Nehal Gatha MD
Boris Gelman MD
Assistant Professor of Anesthesiology, Department
of Anesthesiology, David Geffen School of Medicine
at UCLA, Ronald Reagan UCLA Medical Center, Los
Angeles, CA, USA
Christopher Gharibo MD
Pain Management Clinic, NYU Department of
Anesthesiology, New York, NY, USA
Muhammad K. Ghori MD
School of Medicine, and Attending Anesthesiologist,
West Haven VA Medical Center, New Haven, CT,
USA
Brian Ginsberg MB BCh, FFA
Associate Professor, Medical Director, Acute Pain
Service, Duke University Medical Center, Durham,
NC, USA
Contributors
Michael E. Goldberg MD
Professor and Chief, Department of Anesthesiology,
Cooper University Hospital, The Robert Wood
Johnson Medical School UMDNJ, Camden, NJ,
USA
Eric S. Hsu MD
Clinical Professor of Anesthesiology and Director Pain
Fellowship Program, Department of Anesthesiology,
David Geffen School of Medicine at UCLA, Ronald
Reagan UCLA Medical Center, Los Angeles, CA, USA
Jeff Gudin MD
Director, Pain Management, Englewood Hospital,
Englewood, NJ, USA
Gabriel Jacobs
Thomas Halaszynski DMD, MD, MBA

Associate Professor of Anesthesiology, Yale
University School of Medicine, New Haven, CT, USA
Jonathan S. Jahr MD
Professor of Clinical Anesthesiology, David Geffen
School of Medicine at UCLA, Ronald Reagan UCLA
Medical Center, Los Angeles, CA, USA
Martin Hale MD
Medical Director, Gold Coast Research LLC, Weston,
FL, USA
Dorothea Hall MD
Clinical Assistant Professor of Anesthesiology,
Craig T. Hartrick MD
Director, Academic Affairs, Beaumont Hospital,
Royal Oak, MI, USA
Justin Hata MD
Assistant Clinical Professor, Departments of Anesthesio
logy & Perioperative Care, PM&R Acting Director,
Division of Pain Medicine, and Co-director, UC Irvine
Comprehensive Spine Program, UCI Medical Center, USA
Rongjie Jaing MD
Inderjeet Singh Julka MD
Torrance, CA, USA
Zeev N. Kain MD, MBA
Professor of Anesthesiology and Pediatrics and
Psychiatry, Chair Department of Anesthesiology
and Perioperative Care, Associate Dean of Clinical
Research, School of Medicine, University of
California, Irvine, Orange, CA, USA
Lars E. Helgeson MD
Clinton Kakazu MD
Torrance, CA, USA
Joe C. Hong MD
Kianusch Kiai MD
Associate Clinical Professor of Anesthesiology,
Richard W. Hong MD
Mary Keyes MD
Clinical Professor of Anesthesiology, Department of
Anesthesiology, David Geffen School of Medicine at
UCLA, Ronald Reagan UCLA Medical Center, Los
Angeles, CA, USA
Balazs Horvath MD
Michael M. Kim MD
Director, Resident Education in Pain Medicine,
Department of Anesthesiology & Perioperative Care,
xiii
Contributors
University of California, Irvine Medical Center,

Orange, CA, USA
Peter G. Lacouture MS, PhD
Executive Director, Scientific & Medical Affairs,
Magidom Discovery, Lithia, FL, USA, and Adjust
Assistant Professor of Medicine, Brown University
School of Medicine, Providence, RI, USA
Ryan Lanier
Senior scientist, Rock Creek Pharmaceuticals,
Gloucester, MA, USA
Vivian K. Lee MD
Resident Physician, Department of Anesthesiology,
David Geffen School of Medicine at UCLA, Ronald
Reagan UCLA Medical Center, Los Angeles, CA,
USA
Mark J. Lema MD
Professor and Chair, Department of Anesthesiology,
University at Buffalo SUNY, Roswell Park Cancer
Institute, Buffalo, NY, USA
Oscar A. de Leon-Casasola MD
Director, Pain Management, Department of
Anesthesiology, Roswell-Park Cancer Center, Buffalo,
NY, USA
Imanuel Lerman MD
Internal Medicine Doctor, Department of neurology,
Yale University School of Medicine New Haven, CT,
USA
Philip Levin MD
of Medicine at UCLA, Santa Monica/UCLA and
Orthopaedics Hospital and Medical Center, Los
Angeles, CA, USA
Steven Levin MD
Advanced Diagnostic Pain Treatment Centers, Yale New
Haven Medical at Long Wharf, New Haven, CT, USA
JinLei Li MD
xiv
Eric C. Lin
Yale University School of Medicine, New Haven, CT,
USA
Sharon Lin MD
Assistant Clinical Professor, University of California,
Irvine, Department of Anesthesiology and
Perioperative Care, Orange, CA, USA
David A. Lindley DO
Anesthesiology and Pain Management, University of
Miami, Miami, FL, USA
Ana M. Lobo MD
School of Medicine, Department of Anesthesiology,
New Haven CT, USA
Marisa Lomanto MD
Pain Fellow, Yale-New Haven Hospital, Yale
University School of Medicine, Department of
Anesthesiology, New Haven, CT, USA
Mirjana Lovrincevic MD
Associate Professor of Anesthesiology and
Oncology, University at Buffalo-SUNY, School of
Medicine and Biomedical Sciences, Buffalo, NY,
USA
Brenda C. McClain MD
USA
Tariq Malik MD
Assistant Professor of Anesthesiology, University
of Chicago School of Medicine, Department of
Anesthesia and Critical Care, Chicago, IL, USA
Jure Marijic MD
Joseph Marino MD
Attending Anesthesiologist and Director, Acute
Pain Management Service, Huntington Hospital,
Huntington, NY, USA
Laura Mechtler
Medical Student, Hungary
Alan Miller MD
Section of Interventional Pain Management, Jefferson
Medical College, Philadelphia, PA, USA
Contributors
Carly Miller MD
Section of Interventional Pain Management, Jefferson
Sunil J. Panchal MD
Director, National Institute of Pain, Lutz,
FL, USA
Amit Mirchandani MD
Edward J. Park MD
Sukanya Mitra MD
Associate Professor, Department of Anaesthesia and
Intensive Care, Government Medical College and
Hospital, Chandigarh, India
Fleurise Montecillo
Resident in Anesthesiology, NYU Department of
Anesthesiology, New York, NY, USA
James M. Moore MD
Debra E. Morrison MD
Director, Pediatric & Neonatal Anesthesia Services,
School of Medicine, University of California, Irvine,
Orange, CA, USA
Philip F. Morway MD
of Medicine at UCLA, Santa Monica/UCLA and
Orthopaedics Hospital and Medical Center, Los
Angeles, CA, USA
Carsten Nadjat-Haiem MD
Hamid Nourmand MD
Department of Anesthesiology, David Geffen
School of Medicine at UCLA, Ronald Reagan
UCLA Medical Center, Los Angeles, CA,
USA
Dana Oprea MD
Fellow in Anesthesiology, Yale University School of
Kathleen Ji Park
Buffalo, NY, USA
Kellie Park MD
Parisa Partownavid MD
Akta Patel
Thomas Jefferson University, Philadelphia, PA, USA
Bijal Patel
Komal D. Patel MD
Neesa Patel MD
UCLA Medical Center, Los Angeles, CA, USA
Swati Patel MD
of Medicine at UCLA, Ronald Reagen UCLA Medical
Paul M. Peloso MD, MSc
Merck & Co., Inc., NJ, USA
xv
Contributors
Danielle Perret MD
Director, Fellowship Training Program in Pain
Medicine, Department of Anesthesiology &
Perioperative Care, and Department of Physical
Medicine and Rehabilitation, University of
California, Irvine Medical Center, Orange, CA,
USA
Anthony DePlato
Buffalo, NY, USA
Marjorie Podraza Stiegler MD
Despina Psillides MD
Mamatha Punjala MD
USA
Johan Raeder MD, PhD
Professor in Anaesthesiology and Chairman of
Clinical Ambulatory Anaesthesia, Oslo University
Hospital, Ullevaal, Oslo, Norway
Siamak Rahman MD
USA
Aziz M. Razzuk MD
Research Associate, Occupational Health Services,
Kaiser Permanente, Honolulu, Hawaii
Maggy G. Riad MD
xvi
Kristin L. Richards MD
R. Todd Rinnier DO
Chief Resident, Department of Anesthesiology,
Cooper University Hospital, The Robert Wood
Johnson Medical School UMDNJ, Camden, NJ,
USA
Ian W. Rodger BSc, PhD, MRPharmS, FRCP
Vice President, Research & Academic, St Josephs
Healthcare Hamilton, and Professor, Department of
Medicine, McMaster University, Hamilton, Ontario,
Canada
Joseph Rosa MD
Clinical Professor of Anesthesiology, Department of
Anesthesiology, David Geffen School of Medicine at
UCLA, Ronald Reagan UCLA Medical Center, Los
Angeles, CA, USA
Abraham Rosenbaum MD
Assistant Professor of Clinical Anesthesia, Section of
Pediatric Anesthesia, University of California Irvine
Medical Center, Orange, CA, USA
Alireza Sadoughi MD
Veena Salgar MD
Leslie Schechter
Department of Pharmacy, Thomas Jefferson
University Hospital, Philadelphia, PA, USA
Michael Seneca MSN, CRNA
Yasser F. Shaheen MD
Assistant Clinical Professor, Division Director,
NORA, Department of Anesthesia, Yale University
School of Medicine , New Haven, CT, USA
James H. Shull MD
Elizabeth Sinatra BS
Research Associate in Anesthesiology, Yale University
Contributors
Raymond S. Sinatra MD
Professor of Anesthesiology, Yale University School
of Medicine, New Haven, CT, USA
Neil Singla MD
Director of Clinical Research, Department of
Anesthesia, Lotus Clinical Research, Huntington
Hospital, Pasadena, CA, USA
Nalini Vadivelu MD
USA
Ashley Vaughn MSN, CRNA
Neil Sinha MD
Anjali Vira MD
Denis V. Snegovskikh MD
of Anesthesiology, Yale University School of
Eugene R. Viscusi MD
Associate Professor of Anesthesiology, Jefferson
Dmitri Souzdalnitski MD
Resident in Anesthesiology, Yale University School
Julie Sramcik MD
USA
Zoreh Steffens MD
of Medicine at UCLA, Harbor-UCLA Medical
Center, Torrance, CA, USA
Alexander Timchenko MD
Resident in Anesthesiology, Yale University
Vadim Tokhner MD
Geffen School of Medicine at UCLA,
Harbor-UCLA Medical Center, Torrance,
CA, USA
Dajie Wang MD
Jefferson Medical College, Philadelphia, PA, USA
Shu-ming Wang MD
USA
J. Michael Watkins-Pitchford MD
Steven J. Weisman MD
Jane B. Pettit Chair in Pain Management,
Childrens Hospital of Wisconsin, and Professor of
Anesthesiology and Pediatrics, Medical College of
Wisconsin, Milwaukee, WI, USA
Ira Whitten MD
Bryan S. Williams MD MPH
Assistant Professor of Anesthesiology, Division of
Pain Medicine, Rush Presbyterian Medical Center,
Chicago, IL, USA
Marc C. Torjman PhD

Professor and Director of Research, Department of
Anesthesiology, Cooper University Hospital, The
Robert Wood Johnson Medical School UMDNJ,
Camden, New Jersey, USA
Jeremy M. Wong MD
of Anesthesiology, David Geffen School of Medicine
at UCLA, Ronald Reagan UCLA Medical Center, Los
Angeles, CA, USA
Co T. Truong MD
University of California Irvine Medical Center, Los
Angeles, CA, USA
Thomas Wong MD
Instructor of Anesthesiology, Yale University School
xvii
Contributors
Christopher Wray MD
Bita H. Zadeh MD
Yaw Wu MD
of Medicine at UCLA, Harbor-UCLA Medical
Center, Torrance, CA, USA
Jill Zafar MD
Assistant Professor of Anesthesiology, University at
Buffalo, School of Medicine and Biomedical Sciences,
Roswell Park Cancer Institute, Buffalo, NY, USA
Anthony T. Yarussi MD
Assistant Professor of Anesthesiology, University
at Buffalo, School of Medicine and Biomedical
Sciences, Roswell Park Cancer Institute, Buffalo, NY,
USA
Laurie Yonemoto MD
xviii
Martha Zegarra MD
Keren Ziv MD
USA
Chapter
Introduction
Ian W. Rodger
Pain is a wholly tormenting, disagreeable, multifactorial sensory experience. It is defined by the International Association for the Study of Pain (IASP) as
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage. Pain intensity can
vary from mild to severe. Its duration can be transient,
acute, intermittent or persistent. Several distinct, but
frequently overlapping, types of pain are recognized:
nociceptive/physiological, inflammatory and neuropathic. All pain is initially detected by a highly specialized sensory apparatus, the nociceptor, located on
sensory nerve terminals. Once activated by a noxious
stimulus the nociceptor transduces the signal into an
electrical impulse (action potential) that travels up the
primary sensory neuron en route to the brain. Given
the extensive neural and neurochemical processes that
are involved in pain signaling it is apparent that there
are abundant points at which chemical/drug interference with these processes can occur. The vast array of
analgesics and analgesic adjuncts that we have available today all have one thing in common; they interfere
with the pain signaling cascade in delivering their
analgesic effect(s).
Today healthcare providers are faced with a bewildering number of analgesics and adjunct agents in
addressing different pain conditions in their patients.
Indeed, the variety of analgesic agents available is also
frequently mystifying to experts in the field. Furthermore, the intensity of pain research has accelerated
dramatically in recent years given the recognition that
there is an enormous unmet medical need for
improved pain therapies, especially for those difficult
to treat, intractable pain states. Thus, under the glare
of this spotlight the complex molecular, genetic and
pathophysiological mechanisms underlying different
types of pain are steadily being unraveled. With this
understanding has come the consequent realization
that improved pain control is entirely feasible not only
with the analgesics available today but also with those

that are on the horizon for tomorrow. That said, however, today we work with analgesics that have unique
sites of action. They work peripherally and/or centrally, frequently have several sites of action, come in a
variety of dose strengths and formulations and have a
wide variety of durations of action. It is no surprise,
therefore, that many analgesics also come burdened
with a far less than desirable side-effect profile and
significant potential for interactions and toxicity.
In this textbook the editors have chosen to divide
the subject literature available into twelve sections,
each with a particular focus. Section 1 concentrates on
setting the stage for an understanding of analgesic
action. Thus, it describes the definitions and characteristics of different types of pain, the various pain
pathways including mechanisms underlying both
peripheral and central sensitization (aspects of
wind-up) and other elements of analgesic theory. Sections 2 through 11 describe the essence of commonly
prescribed acute and chronic pain medications. As a
deliberate policy, and for both convenience and continuity, the editors have opted to list each analgesic
according to its drug class. The final section (12)
deals with new and emerging therapies. This section
provides details of how existing therapies are being reengineered and reformulated to provide superior
analgesic control. It also provides a glimpse of the
future by identifying new molecular targets that hold
promise for the discovery and development of novel
analgesics with completely new mechanisms of
action.
In the final analysis this textbook provides a host
of welcome information, tightly packaged, that provides a much needed reference source on analgesia
and analgesics. It will benefit all healthcare professionals tasked with the responsibility of optimizing
the control, and ideally the elimination, of pain and
suffering.
The Essence of Analgesia and Analgesics, ed. Raymond S. Sinatra, Jonathan S. Jahr and J. Michael Watkins-Pitchford. Published by Cambridge
University Press. Cambridge University Press 2011.
Section 1
Chapter
Pain Definitions
Pain definitions and assessment

Raymond S. Sinatra
Introduction
Pain is among the most common of patient complaints encountered by health professionals and it
remains the number one cause of absenteeism and
disability. Each year, more than 60 million traumarelated pain episodes occur in the USA, as well as
acute pain related to over 40 million surgical procedures [1]. Pain has been defined by the International
Association for the Study of Pain as an unpleasant
sensory and emotional experience associated with
actual or potential tissue damage [2]. In clinical settings, it has been suggested that presence of pain and
the intensity of discomfort are whatever the patient
says they are unless proven otherwise by poor adherence
to an agreed treatment plan [35]. We now recognize
that in addition to the ethical and humanitarian reasons for minimizing discomfort and suffering, painrelated anxiety, sleeplessness and release of stress
hormones or catecholamines may have deleterious
effects upon post-surgical outcome, and may lead to
the development of chronic pain [68].
Classification of pain
Pain is a complex physiological process that can be
classified in terms of its intensity (mild, moderate,
severe) its duration (acute, convalescent, chronic), its
mechanism (physiological, nociceptive, neuropathic),
and its clinical context, (post-surgical, malignancyrelated, neuropathic, degenerative, etc.) [2]. Pain
detection, or nociception, requires the activation of
specialized transducers called nociceptors, which are
the peripheral endings of A-delta (A) and (C) sensory fibers. Nociceptors are activated following thermal, mechanical or chemical tissue injuries, and
initiate afferent transmission of action potentials to
the dorsal horn of the spinal cord. Pain perception follows activation of second-order sensory neurons
which relay noxious signals to higher thalamic and
cortical centers (Figure 2.1).
The mechanistic classification of pain is as follows [2,4,5]. (1) Physiological pain is defined as brief,
rapidly perceived, non-traumatic discomfort that
identifies a potentially dangerous stimulus. This
adaptive alerting response involves cortical perception and localization and a reflex withdrawal that
prevent and/or minimize tissue injury. Physiological
pain is also associated with learned avoidance and
adaptation that can modify future behavior. (2) Nociceptive pain results from the activation of physiologically normal nerve fibers in response to tissue injury.
In addition to cellular damage and neural irritation,
humoral mediators and peripheral inflammatory
responses play a major role in its initiation and progression. Nociceptive pain can be further divided
into somatic and visceral pain subtypes. Somatic
nociceptive pain is well localized, sharp, crushing, or
tearing pain that follows traumatic injury to dermatomally inervated structures. It includes cutaneous, muscular and ligamentous pain, but also
includes headache and osteogenic pain. In contrast,
visceral nociceptive pain is poorly localized nondermatomal specific discomfort that is usually
described as dull, cramping, or colicky. Visceral pain
includes discomfort related to bowel obstruction,
first-stage labor, dilatation of hollow viscus, early
appendicitis and peritoneal irritation. Visceral pain
is mediated by free nerve endings in gastro intestinal organs and peritoneum that respond to irritation or distention. Referred pain is a special form of
visceral pain that radiates in a somatic dermatomal
pattern. Referred pain may be explained by convergence of spinal input theory, or reflex response
theory [2].(3) Neuropathic pain results from irritation, infection, degeneration, transaction or compression injury to nervous tissue. It is usually
characterized as burning, electrical and/or shooting
in nature. Pain following injury to sensory nerves is
termed causalgia or chronic regional pain syndrome
II. Pain associated with injury or abnormal activity
Pain Definitions Section 1
Figure 2.1. A mechanistic

representation of nociception and pain
perception.
PAIN PERCEPTION
Cerebral Cortex
TRANSMISSION &
MODULATION
Descending
Fibers
Ascending
Fibers
NOCICEPTION
Spinal Cord
Nociceptors
Table 2.1.
Category
Cause
Symptom
Examples
Physiological
Brief exposure to a noxious

stimulus
Rapid, yet brief pain

perception
Touching a pin or hot object
Nociceptive/inflammatory
Somatic or visceral tissue

injury with mediators
impacting on intact nervous
tissue
Moderate to severe pain,

described as crushing or
stabbing; usually worsens
after the first 24 hours
Surgical pain, traumatic pain,

sickle cell crisis
Neuropathic
Damage or dysfunction of
peripheral nerves or CNS
Severe lancinating, burning or

electrical shock-like pain
Neuropathy, chronic regional

pain syndrome, postherpetic
neuralgia
Mixed
Combined somatic and

nervous tissue injury
Combinations of symptoms;
soft tissue pain plus radicular
pain
Low back pain, back surgery

pain
of sympathetic fibers is termed reflex sympathetic

dystrophy or chronic regional pain syndrome I.
Neuropathic pain is often associated with peripheral
and central sensitization, secondary hyperalgesia
and alterations in sympathetic tone and regional
perfusion. A common characteristic of neuropathic
pain is the coexistence of sensory deficits or sensory
abnormalities in the setting of increased pain sensation. These abnormalities include hyperpathia, or
increased or exaggerated pain intensity with minor
stimulation; allodynia, in which non-noxious sensory stimulation is perceived as painful; dysesthesia/
paresthesia, which are unpleasant sensations at rest
or following touch and movement. Differences

between physiological, nociceptive and neuropathic
pain are described in Table 2.1.
Hyperalgesia
Hyperalgesia describes a state of increased pain sensitivity and enhanced perception following acute injury
which is related to peripheral release of intracellular
or humoral noxious mediators [7,911]. Primary hyperalgesia (peripheral sensitization) describes an altered
state of sensibility in which the intensity of painful
sensation induced by noxious and non-noxious
Chapter 2 Pain definitions and assessment
stimulation is greatly increased. Hyperalgesia results

in dynamic or effort-dependent pain, in which discomfort during ambulation, coughing and physical
therapy is significantly increased [10]. Continued activation of nociceptors secondary to neural compression, stretch, infection, hematoma, and edema can
result in prolonged disability and impaired rehabilitation. Secondary hyperalgesia (central sensitization) is
related to ongoing noxious transmission and sensitization of second-order neurons in the dorsal horn
[11]. Clinical alterations associated with secondary
hyperalgesia include allodynia, multi-segmental flexion reflexes (splinting, muscle spasm) and alterations
in sympathetic tone and regional perfusion. As a
result, discomfort may be perceived at dermatomes
above and below the site of trauma. The duration of
central sensitization generally outlasts the initial barrage of high-threshold input and may become independent of further depolarization [6,7].
Pain temporality and duration

Acute pain
Acute pain is an adaptive physiological response that
follows traumatic injuries and surgery. It has two primary components. (1) The sensory discriminative
component describes the location and quality of the
stimulus. It is characterized by rapid response, short
latency to peak response, and short duration of
action. Noxious information is conveyed by rapidly
conducting A-delta fibers, and monosynaptic transmission to the sensory cortex [10,12]. This component rapidly identifies the site of injury or potential
injury, and initiates reflexive/cognitive withdrawal
responses. (2) The affective-motivational component
underlies suffering and the emotional components of
pain and is responsible for learned avoidance and
other adaptative and non-adaptative behavioral
responses.
The affective motivational component is mediated
by slowly conducting c-fibers, and polysynaptic transmission to the limbic cortex [10,12]. It is responsible
for continued pain perception, suffering, pain-related
behaviors, hyperalgesia, reflex spasm (splinting behavior). It is also responsible for immobilization, and protection of the injury site.
In general, acute pain is limited in duration (114
days) and is associated with temporal reductions in
intensity. Optimally controlled acute pain may be
mildmoderate at rest but generally worsens during
movement (effort-dependent or incident pain). Poorly

controlled acute pain is associated with peripheral
sensitization, spinal facilitation, hypothalamic/
adrenal responses, and emotional/behavioral changes
[7,9,12].
Rehabilitative/convalescent pain
A subacute pain state associated with convalescence
and rehabilitation may persist for 12 months after
surgery or traumatic injury. Patients may experience
moderate to severe incident pain and require opioid
analgesics for sleep and mobilization. Severe rehabilitative pain has a negative impact on physical therapy, return to normal functionality and quality of
life.
Chronic pain
Chronic pain refers to persistent or progressively
increasing discomfort beyond the normal time frame
of healing [2,10]. An alternative definition is moderate to severe discomfort persisting 3 months or more
following tissue injury (post-operative pain syndromes) or initial symptoms of cellular degeneration
(osteoarthritic disease). The etiological classification
of chronic pain refers to the clinical context in which
pain perception takes place, and can be categorized as
benign, malignancy-related, post-surgical, neuropathic, degenerative, or mixed.
Chronic pain is often associated with sensitization and plasticity changes in the peripheral and
central nervous system that facilitate pain transmission and impair intrinsic noxious modulatory mechanisms [7,9,13]. Transition from acute pain to
chronic pain involves ongoing peripheral and central sensitization, persistent hyperalgesia, the development of neuropathic symptoms and maladaptive
emotional responses (pain behavior) [10]. Patients
with chronic pain may be troubled by a persistent
pain state that remains constant or gradually
increases in frequency and intensity (malignancyassociated pain, osteoarthritis), or an intermittent
pain state that has peaks (flare) and troughs in intensity (vasculopathic pain, gout, low back pain). Others may present with a combination of persistent
pain plus intermittent flare, and complain of pain
that is constant or gradually increasing, with episodes of increased intensity or flare (rheumatoid
arthritis, neuropathic pain).
Chronic pain may also be characterized by its
localization. Peripheral pain is is associated with
Table 2.2.
Acute pain
Chronic pain
1. Usually obvious tissue damage
1. Multiple causes (malignancy, benign)
2. Distinct onset
2. Gradual or distinct onset
3. Short, well-characterized duration
3. Persists after 36 months of healing
4. Resolves with healing
4. Can be a symptom or diagnosis
5. Serves a protective function
5. Serves no adaptive purpose
6. Effective therapy is available
6. May be refractory to treatment
Table 2.3.
Temporal
Onset, duration, periodicity
Variability
Constant, effort-dependent, waxing and waning, episodic flare
Intensity
Average pain, worst pain, least pain, pain with activity of living
Topography
Focal, dermatomal, diffuse, referred, superficial, deep
Character
Sharp, aching, cramping, stabbing, burning, shooting
Exacerbating/relieving
Worse at rest, with movement or no difference
Quality of life
Interferes with movement, ambulation, daily life tasks or work
ongoing
nociceptor sensitization, neuropathic injury
and stimulation of sympathetic efferents. Myelopathic
pain is associated with spinal injuries and includes
localized irritative and compression-related pain,
radicular pain and skeletal muscular irritability. Central pain describes pain syndromes that follow CNS
injury (post-stroke, CNS tumor) that are generally ill
defined or poorly localized and difficult to treat. While
some forms of chronic pain have an unclear etiology
and unpredictable course, most begin as acute inflammatory or neuropathic pain. An increasing body of
evidence suggests that severe acute pain, analgesic
undermedication, nerve injury and genetic variabilities are responsible for the development of chronic
pain [13,14].
Although acute and chronic pain have distinguishing characteristics, there is often overlap, making the
diagnosis and management of pain challenging. Differences between acute and chronic pain are outlined
in Table 2.2.
Qualitative aspects of pain perception

6
Appreciating the clinical features of the different types

of pain not only helps properly classify pain and its
etiology, but also helps guide the often complex multimodal medical management that accompanies pain
management [10,13,14]. The healthcare provider must
be detailed in attaining the qualitative factors and history associated with a patients pain. The McGill Pain
Questionnaire may be used to measure the quality,
character, and intensity of acute and chronic pain. The
qualitative aspects of pain perception are outlined in
Table 2.3.
Finally, it is well recognized that certain acute
traumatic and chronic pain conditions are associated with a mixture of noiciceptive inflammatory
and neuropathic pain. For example, tissue injury
and a marked inflammatory response following
laparotomy or thoracotomy initiates a somatic
nociceptive component responsible for incisional
and muscular pain, while peritoneal or pleuritic
irritation is responsible for a visceral nociceptive
component. Neural injury related to retraction or
transection initiates a neuropathic component.
Clinical pain complaint, intensity of symptoms,
pain characteristics and choice of analgesic are
related to the extent of inflammation, visceral
versus somatic nociception, and neural tissue
injuries.
Chapter 3 Pain pathways and pain processing
References
1. Warfield CA, Kahn CH. Anesthesiology 1995;83:

10901094.
2. Bonica JJ. Definitions and taxonomy of pain. In
Bonica JJ, ed. Management of Pain. Philadelphia: Lea
& Febiger, 1990.
3. Fishman SM, et al. J Pain Sympt Manag 2000;20.
4. Bonica JJ. The need of a taxonomy. IASP Subcommittee
on the Taxonomy of Pain 1979;6(3):247252.
5. Melzack R, Wall PD. Science 1965;150:971.
6. Woolf CJ. Pulm Pharmacol 1995;8:161167.
7. Woolf and Salter. Science 2000;288: 1765.
8. Urban and Gebhart. Med Clin North Am 1999;83: 585.
9. Samad et al. Nature 2001;410:471.
10. Bonica JJ. Anatomic and physiologic basis of
nociception and pain. In Bonica JJ, ed. Management
Section 1
Chapter
of Pain. Philadelphia: Lea & Febiger, 1990,

pp. 2894.
11. LaMotte RH, Thalhammer JG, Robinson CJ.
Peripheral neural correlates of magnitude of
cutaneous pain and hyperalgesia. J Neurophysiol
1983;50:126.
12. Sinatra RS, Bigham M. The anatomy and
pathophysiology of acute pain. In Grass JA, ed.
Problems in Anesthesiology. Philadelphia: LippincottRaven, 1997.
13. Fields HL, Martin JB. Pain: pathophysiology and
management. In Braunwald E, Fauci AS, Isselbacher
KJ, et al., eds. Harrisons Principles of Internal
Medicine, 15th ed. New York: McGraw-Hill,
2001.
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15. Kehlet H. Br J Anaesth 1989;63:189195.
Pain Definitions
Pain pathways and pain processing

Amit Mirchandani and Shamsuddin Akhtar
Introduction
Understanding the anatomical pathways and key neurochemical mediators involved in noxious transmission and pain perception is fundamental to optimizing
the management of patients with acute and chronic
pain. In this chapter we will outline the basic anatomy
of the pain pathway and identify key neurochemical
mediators involved in pain modulation.
Nociception
The conduction of pain does not simply involve conduction of impulses from the periphery to the cortical
centers in the brain. Transmission of pain or nociception is a complex phenomenon and involves multiple
stages that can be grouped broadly into three processes: (1) activation of specialized peripheral nerve
endings; (2) conduction of noxious impulses to the
spinal cord; and (3) transmission of impulses from the
spinal cord to the supra-spinal and cortical centers.
The culmination of these processes results in the
localization and perception of pain. At each of these
stages, nociceptive impulses can be suppressed by
local interneurons or by descending inhibitory fibers
and modulated by a variety of neurotransmitters and
neuromodulators. Any abnormality of peripheral and
central pain pathways including pathological activation, or the imbalance of activation and inhibitory
pathways, may increase the severity of acute pain and
contribute to the development of persistent pain [1].
Activation of sensory end organs and/or

nerve endings
The nociception begins with the activation of peripheral sensory afferent receptors, also known as nociceptors, which are widely distributed throughout the
body. Nociceptors are the peripheral endings of pseudo-unipolar neurons, whose cell bodies are located in
the dorsal root ganglia (DRG). The nociceptor central
ending terminates in the spinal cord and transmits
noxious impulses to the dorsal horn [1,2].
Nociceptors convey noxious sensation, either
externally (i.e. skin, mucosa) or internally (i.e. joints,
intestines). They can be activated by any noxious
insult, most of which can be categorized as either
mechanical, chemical, or thermal in nature. Nociceptor activation is associated with a depolarizing Ca2+
current or a generator potential. Once a certain
threshold is met, the distal axonal segment depolarizes via an inward Na+ current, and an action potential
is conducted centrally.
Noxious stimuli are conducted from peripheral
nociceptors to the dorsal horn via both unmyelinated
and myelinated fibers. Nociceptive nerve fibers are classified according to their degree of myelination, diam
eter, and conduction velocity. For instance, A-delta axons
are myelinated and allow action potentials to travel at a
very fast rate of approximately 630 meters/second
towards the central nervous system. They are responsible for first pain or fast pain, a rapid (1 second) welllocalized, discriminative sensation (sharp, stinging) of
short duration [1,2]. Perception of first pain alerts the
individual of actual or potential tissue injury and initiates the reflex withdrawal mechanism. The more slowly
conducting non-myelinated C fiber axons conduct at
speeds of about 2 meters/second. These unmyelinated
C-fibers (termed polymodal-nociceptive fibers)
respond to mechanical, thermal, and chemical injuries.
C-fibers mediate the sensation of second pain, which
has a delayed latency (seconds to minutes) and is
described as a diffuse burning or stabbing sensation
that persists for a prolonged period of time. Larger
A-beta axons, which respond to maximally light touch
and/or movement stimuli, typically do not produce
pain, except in pathological conditions [1,2].
Multiple receptors located on the primary afferent
nerves are involved in specific transduction of
particular noxious stimuli. Vanilloid receptors (VRI)
and vanilloid receptor like-1 are excited by heat. VRI
and acid-sensing ion channels are also stimulated by
mechanical stimuli. Inotropic purinergic (P2X) receptors are excited by stretch and modulated by low pH
[1,3]. Temperature is sensed by receptors called transient receptor potential (TRP) channels. An important
TRP channel termed the TRPV-1 receptor has been
widely studied. Capsacian and other TRPV-1 blockers
initially activate and then deactivate nociceptors for
prolonged periods of time. These compounds may
provide long-term blockade of nociceptor function
and prolonged suppression of acute pain.
A number of inflammatory and noxious mediators are involved in peripheral pain transduction [1]
(Figure 3.1).
1. Substance P is a neuropeptide released from the
unmyelinated primary afferent fibers, and its role
in nociception is well established. Its effects can be
blocked by treatment with the neurotoxin
capsaicin, which destroys afferent nerve terminals.
The pro-inflammatory effects of substance P
include: vasodilatation and plasma extravasation,
degranulation of mast cells, resulting in histamine
release, chemo-attraction and proliferation of
leukocytes, and cytokine release.
2. Bradykinin is a markedly algesic (painproducing) substance that has direct activating
effects on peripheral nociceptors.
3. Histamine is stored in mast-cell granules and is
released by substance P and other noxious
mediators. The effects of histamine are mediated
by its interaction with specific receptors, resulting
in vasodilatation and edema and swelling
resulting from the enhanced permeability of
postcapillary venules.
4. Serotonin or (5-hydroxytryptamine; 5-HT) is
stored in the dense-body granules of platelets.
5-HT enhances microvascular permeability.
5. Prostaglandins (PGs) play a substantial role in the
initial activation of nociceptors and exacerbate
inflammation and tissue swelling at the site of
injury. Up-regulation of cyclooxygenase-2 leads
to rapid conversion of arachidonic acid from
injured cell membranes into a variety of
prostanoids (PGs and thromboxane A2).
6. Cytokines and interleukins released as part of the
peripheral inflammatory response can circulate to
and increase production of PGs in the brain. The
accumulation of noxious mediators at the site of
injury results in ongoing nociceptor stimulation,
nociceptor recruitment and development of
primary hyperalgesia.
Nociceptive Ending (Primary Afferent Fiber)

Noxious Soup
Ca++
PeptidessP, CCK,
CGRP
Local &
Vascular
MediatorsBradykinin,
Cytokines
Histamine,
5HT
ATP
Na+
TRP
Traumatic
MediatorsK+, H+,
PGE
TRP
Neural MediatorsEpinephrine,
Norepinephrine
Ca++
Generator
Potential
Figure 3.1. Nociceptive ending (primary afferent fiber). From: Sinatra RS. Pain pathways. In Sinatra RS, Viscusi G, de Leon-Casasola O,
Ginsberg B, eds. Acute Pain Management. Cambridge University Press, 2009.
Conduction of pain to the spinal cord

(and medulla)
Nearly all sensory afferents, regardless of peripheral
origin, terminate in the dorsal horns of the spinal cord
and medulla. Unmyelinated C fiber nociceptors terminate principally in lamina II (substantia gelatinosa).
Small myelinated A-delta nociceptors terminate lamina I of the dorsal horn. The terminal endings of the
primary afferent neurons in the spinal cord transmit
pain signals to second-order neurons via several neurotransmitters, including glutamate and substance P.
The second-order neurons involved in the pain pathway are principally of two types; (1) nociceptor-specific
neurons that respond exclusively to inputs from A-delta
and C fibers, and (2) wide-dynamic-range (WDR)
neurons that respond to both noxious and non-noxious stimuli [1,4,5]. Higher-frequency stimulation
leads to NMDA receptor activation, gradual increases
in WDR neuronal discharge and a sustained burst of
activity termed wind-up. In this situation, WDR neurons become sensitized and hyperresponsive and
transmit normal tactile responses as painful stimuli
[1,5]. These central sensitizing changes are responsible
for secondary hyperalgesia which increases the intensity of acute pain (refer to Chapter 5: hyperalgesia).
Reflexive intraspinal pathways connect primary

nociceptor afferents to motor neurons and the autonomic efferents. Activation of these pathways leads to
reflex skeletal muscular responses (muscle splinting/
spasm) and autonomic responses (increased vascular
tone hypertension, tachycardia, adrenal activation) [3].
A number of neurotransmitters, neuromodulators
and their respective receptors are involved in the neurotransmission at the dorsal horn. They can be broadly
classified into two groups.
1. Excitatory transmitters that are released from the
primary afferent nociceptors or interneurons
within the spinal cord.
2. Inhibitory transmitters that are released by
interneurons within the spinal cord or supraspinal sources.
Most often more than one neurotransmitter is
released at the same time. Aspartate and glutamate are
excitatory amino-acids (EAAs) involved in pain transmission [4,5]. Glutamate is the main excitatory CNS
neurotransmitter and mediates rapid, short-duration
depolarization of second-order neurons. Peptides
such as substance P and neurokinin are responsible
for delayed long-lasting depolarization. EAAs act on
various receptors, which principally include alphaamino-3-hydroxy-5-methyl-4-isoxazolepropionic
acid (AMPA) receptors, N-demethyl-D-asprtate

(NMDA) receptors, kaniate receptors (KA) and
metabotropic glutamate receptors [3, 4]. EAAs activate AMPA receptors, which mediate sodium influx,
cell depolarization and rapid priming of NMDA
receptors. Substance P and other peptides bind to
neurokinin receptors, leading to the activation of
second messengers, culminating in changes in protein synthesis, genomic activation and slow activation of NMDA receptors (Figure 3.2). Activation of
the NMDA receptor is associated with Ca2+ mobilization, and causes large and prolonged depolarization in the already partially depolarized neurons.
Increase in intracellular calcium leads to the activation of multiple downstream pathways triggering
second messengers including PG, inositol triphosphate (IP3), cGMP, eicosanoids, nitric oxide and
protein kinase C [4,5] (Figure 3.3). Persistent pathological activation of these pathways leads to central
sensitization and potential chronic pain conditions.
Metabotropic glutamate receptors are a family of
receptors that are coupled to G-protein. Though
they do not appear to be involved in acute pain,
there is compelling evidence that they play a modulatory role in nociceptive processing, central sensitization and pain behavior.
Afferent impulses arriving in the dorsal horn are
tempered and modulated by inhibitory mechanisms.
Inhibition occurs through local inhibitory interneurons and descending pathways from the brain.
Pain Processing in Spinal Cord

Inhibitory
Interneuron
Nociceptor
Terminal Ending
NE
Mu
Glu
SP
SP
Glu
Post Synaptic Membrane

of the Spinal Sensory Neuron
Glu
Na+
Glu
Na+
SP
AMPA
Receptor
Na+
Fast Prime
NMDA Receptor: Requires voltage

dependent priming for activation
10
SP
NMDA
Receptor
Glu
Kainate
Receptor
Mg++
Slow Prime
Mu
NK-1
Receptor
Second Messenger
Formation, (cAMP, PK-A)
Ca++
mRNA synthesis, and
up-regulation of inducible
enzymes/proteins
Figure 3.2. Targets of excitatory noxious mediators on second-order cells. Glutamate is the primary excitatory agonist for noxious transmission.
Glutamate activates specific binding sites located on AMPA, kainate, and NMDA receptors. Ion channels on activated AMPA and kainate
receptors allow Na+ to enter and depolarize the cell. Changes in intracellular voltage rapidly prime the NMDA receptor and allow an Mg2+ plug to
be dislodged. Following dislodgement an inward flux of Ca2+ is initiated. Glutamate binding to NMDARs maintains the inward Ca2+ flux.
Substance P binds and activates NK-1 receptors. This receptor up-regulates second messengers including cAMP and PKA which slowly prime
and maintain excitability of NMDARs. Activation of second messengers in turn up-regulates inducible enzymes, initiates transcription of mRNA,
and mediates synthesis of acute reaction proteins. These changes increase neuronal excitability and underlie subsequent plasticity. From: Sinatra
RS. Pain pathways. In Sinatra RS, Viscusi G, de Leon-Casasola O, Ginsberg B, eds. Acute Pain Management. Cambridge University Press, 2009.
Allosteric site (Zinc)

Glutamate binding site
Mg++
Plug
Glycine Binding
Site
Ca++ Ion Channel
Ketamine binding site
NR2
NR
Ziconitide binding site
Increased Electrical
Excitability
Ca++
Figure 3.3. The NMDA receptor is a

four-subunit, voltage-gated ligandspecific ion channel. The four subunits
include two NR-2 units which contain
glutamate binding sites and two NR-1
units which contain glycine binding sites
and an allosteric site that is sensitive to
zinc ions. Glutamate is the primary
agonist of NMDR while glycine functions
as a modulator. The central ion channel
is normally blocked by a magnesium ion.
Once dislodged, Ca2+ ions can pass
through the channel and induce
neuronal excitability. From: Sinatra RS.
Pain pathways. In Sinatra RS, Viscusi G, de
Leon-Casasola O, Ginsberg B, eds. Acute
Pain Management. Cambridge University
Press, 2009.
Upregulation of PGE,
NO and SO synthesis
GABAergic and glycinergic interneurons are involved

in tonic inhibition of nociceptive input and loss of
these neurons is implicated in the development of
chronic and neuropathic pain [5]. Endogenous opioids and noradrenergic pathways are also involved in
inhibitory pain modulation.
Transmission of impulses from the spinal

cord to the supraspinal structures
Several ascending tracts are responsible for transmitting nociceptive impulses from the dorsal horn to
supraspinal targets. These include spinothalamic,
spinoreticular, spinomesencephalic and spinolimbic
tracts. The spinocervicothalamic and post-synaptic
dorsal column are also involved in nociception. Of
these, the spinothalamic tract is considered the
primary perception pathway [1]. Axons traveling in
the spinothalamic tract (STT) travel to several regions
of the thalamus where pain signals diverge to broad
areas of the cerebral cortex. The STT is divided into
two tracts: the lateral neo-spinothalamic tract (nSTT)
and the more medial paleo-spinothalamic tract
(pSTT). The nSTT projects directly to the neothalamus. The neothalamus is a highly somatotopically
organized region with cells conveying nociceptive
impulses directly to the somatosensory cortex for
rapid perception (localization) and prompt withdrawal from the noxious stimulus [1,5]. The lateral
tracts are also discriminative and account for sensory

qualities, such as throbbing or burning. The pSTT is a
slow multisynaptic pathway that projects to the reticular activating system (RAS), periaqueductal gray
(PAG), and medial thalamus. The medial thalamus is
not somatotopically organized, and its cells project to
the frontal and limbic cortex. The pSTT is associated
with prolonged acute pain and chronic pain, and is
responsible for diffuse, unpleasant feelings, and suffering long after an injury has occurred. Nociceptive
impulses transmitted by the pSTT lead to persistent
supraspinal responses affecting circulatory, respiratory, and endocrine function and underlie emotional
and behavioral responses such as fear, anxiety, helplessness, and learned avoidance [1,5].
Descending control of pain

Descending neural pathways inhibit pain perception
and efferent responses to pain. The cerebral cortex,
hypothalamus, thalamus and brainstem centers (periaqueductal gray [PAG], nucleus rhaphe magnus
[NRM] and locus coeruleus [LC]) send descending
axons to the brainstem and spinal cord that modulate
pain transmission in the dorsal horn. These axonal
terminals either inhibit release of noxious neurotransmitters from primary afferents, or diminish the
response of second-order neurons to the noxious
input. Several neurotransmitters play critical roles in
11
6. Cortical Perception
7. Supraspinal Responses
CNS
(Sympathetic, Neuroendocrine, Motor, Emotional)
4. Spinal
Modulation
5. Descending
Inhibition
1.Transduction
2. Conduction
Noxious
Stimulus
Primary
Nociceptor
3. Transmission
Second Order Dorsal
Horn Cell
Figure 3.4. (1) Peripheral noxious mediators activate nociceptor endings via a process termed transduction. (2) Noxious impulses are
delivered to the spinal cord dorsal horn via the process of conduction in afferent fibers. (3) The process of transmission describes synaptic
transfer of noxious impulses from primary afferents to second-order cells in dorsal horn. (4) Modulation describes inhibitory and facilitatory
effects of spinal interneurons on noxious transmission. (5) Descending inhibition refers to descending brainstem, midbrain, and cortical
inhibitor nerve endings which supress pain transmission. (6) Cortical perception includes neocortical sites of pain localization and limbic
centers responsible for emotional and suffering components of pain. (7) Supraspinal responses include sympathetic, neuromuscular, and
neuroendocrine responses to pain. From: Sinatra RS. Pain pathways. In Sinatra RS, Viscusi G, de Leon-Casasola O, Ginsberg B, eds. Acute Pain
Management. Cambridge University Press, 2009.
12
modulating pain transmission, including the endogenous opioids (enkephalin, dynorphin), gamma-aminobutyric acid (GABA), and norepinephrine. The PAG
is an enkephalinergic brainstem nucleus responsible
for both morphine- and stimulation-produced analgesia. Descending axons from the PAG project to nuclei
in the reticular formation of the medulla, including
NRM, and then descend to the dorsal horn where they
synapse with and inhibit WDR and other neurons
[1,5]. Axon terminals from the NRM project to the
dorsal horn, where they release serotonin and nor
epinephrine. Axons descending from the LC modulate
nociceptive transmission in the dorsal horn primarily
via release of norepinephrine and activation of postsynaptic alpha-2-adrenergic receptors. GABAergic and
enkephalinergic interneurons in the dorsal horn also
provide local suppression of pain transmission [5].
From the preceding discussion it is very clear that
generation of acute pain is a complex process involving many neural structures, neurotransmitters and
neuromodulators. Key aspects of afferent pain signaling, cortical perception and efferent responses are
outlined in Figure 3.4.
is a complex phenomenon and involves multiple stages,

neurotransmitters, neuromodulators, inflammatory
mediators, and excitatory and inhibitory pathways.
Transition from acute to chronic pain is an even more
complex and less understood process. However, it is
clear that peripheral and central sensitization processes
play an important role in the pathological development
of chronic pain.
Conclusion
5. Sinatra R. Pain pathways and pain processing. In

Sinatra RS, deLeon-Cassasola O, Ginsberg B, Viscusi
G. Acute Pain Management. Cambridge University
Press, 2009, pp. 321.
Transmission of pain impulses from specialized sensory end-organs or nerve endings to the cortical centers
References
1. Sinatra RS, Bigham M. The anatomy and

pathophysiology of acute pain. In Grass JA, ed.
Problems in Anesthesiology. Philadelphia:
Lippincott-Raven, 1997.
2. Hudspith MJ, Siddall PJ, Munglani R. Physiology of
pain. In Hemmings HC, Hopkins P, eds. Foundations
of Anesthesia, 2nd ed. Elsevier, 2000, pp. 267286.
3. Benzon H. Essentials of Pain Medicine and Regional
Anesthesia, 2nd ed. Churchill Livingstone, 2005,
pp. 312.
4. Barash PG, Cullen BF, Stoelting RK, eds. Clinical
Anesthesia, 5th ed. Lippincott, Williams & Wilkins,
2006, pp. 14421449.
Section 1
Chapter
Pain Definitions
Pain characteristics
Alireza Sadoughi
Introduction
A variety of approaches for classifying pain have
been developed; the two most frequently used are
based on pain duration (i.e. acute vs. chronic pain)
and underlying pathophysiology (i.e. nociceptive vs.
neuropathic pain). During the past several decades
medicine has focused on the mechanism of pain, its
management, and the possible prevention of complications, including neuropathic pain. There has
been extensive research on neuropathic pain and the
neurotransmitters that are involved. Pain has several
different pathophysiological mechanisms, most
commonly described as nociceptive, inflammatory,
and neuropathic. With an acute noxious stimulus
(an actual or potentially damaging event), the
peripheral nervous system transmits noxious information to the central nervous system. However, with
ongoing and intense stimulation, acute pain can
become persistent and lead to the development of
chronic pain.
This chapter will highlight the mechanisms that
are particularly important for a rational, rather than
an empirical, approach to pain management. It takes
into account the concept that pain is an experience,
and it cannot be separated from the patients mental
state, including their environmental and cultural
background. These factors hold great importance
because they can cause the brain to trigger or abolish
the experience of pain, independent of what is occurring elsewhere in the body. Therefore, when assessing
a complaint of pain, it is critical to also investigate the
appropriate mental and environmental factors. In the
clinical setting, a physician must infer the pathophysiological aspect of a pain syndrome from the patients
clinical evaluation.
Temporal classifications
Acute pain is temporally associated with a noxious
stimulus secondary to an identifiable tissue injury,
disease process, or abnormal function of a muscle or

viscera, and is the normal physiological survival
response to potential harm. The function of acute pain
is to protect tissues from actual or potential injury by
muscular reflex responses, alerting processes, and
autonomic responses in vascular, visceral, and endocrine tissues. The global response to pain is produced
by a complex interaction of cognitive interpretations
and emotional responses, which are influenced by the
individuals general physical state, past experiences,
psychological state, social environment, and expectations. The source of acute pain is usually identifiable
and localizable. The pain intensity is usually proportional to the severity of tissue injury, and it subsides as
it heals. Acute pain is associated with an autonomic
nervous system response, which causes tachycardia,
increased blood pressure, anxiety, and stereotypic
behaviors of withdrawal, splinting, rubbing, grimacing, or a combination of these responses.
In contrast, patients with sustained or chronic
pain do not have autonomic over-activity, but have
varying degrees of physical dysfunction, anxiety,
depression, social isolation, and personality changes
that cause a decrease in their quality of life. The term
chronic pain is imprecise, but refers to pain lasting
longer than 3 to 6 months. In some patients, the pain
is chronic because the underlying pathological condition is chronic. Chronic neurogenic pain may be central pain resulting from pathology in the spinal cord,
brainstem, thalamus, or cortex. Neuropathic pain
may also be pain arising from damage to primary
afferent neurons. Examples of chronic nociceptive
pain include rheumatoid arthritis, osteoarthritis,
degenerative disk and joint disease, osteoporosis fractures, chronic gout, and ankylosing spondylitis.
Chronic pain associated with musculoskeletal disease
is a combination of chronic persistent pain with intermittent acute exacerbations. The pain that is associated with movement, pressure, and light touch is
neuropathic pain. Hyperalgesia and allodynia are
13
expressions of sensitization of peripheral nociceptors

and plasticity-induced central mechanisms in the spinal cord or brain. Hyperalgesia is a higher pain intensity felt upon noxious heat stimulation (thermal
hyperalgesia) or noxious mechanical stimulation
(mechanical hyperalgesia). Allodynia is the occurrence of pain that is elicited by stimuli that are normally below the pain threshold. Some authors include
this lowering of the threshold in the term hyperalgesia
in non-neuropathic pain [1].
Nociception and pain

The International Association for the Study of Pain
(IASP) has defined pain as an unpleasant sensory and
emotional experience that is evoked by actual or
potential noxious (i.e. tissue-damaging) stimuli or by
tissue injury. Normally, pain is the subjective result of
nociception. Nociception is the encoding and processing of noxious stimuli in the nervous system. It can be
objectively measured with various techniques, i.e.
with electrophysiological recordings. By contrast, pain
as a subjective experience can be verbally or visually
described by humans, and it cannot be measured
objectively. However, animals (as well as humans)
show reflex responses to acute noxious stimuli, which
can be assessed for the relationship between nociception and pain.
Nociceptive (tissue) pain
14
Nociceptive receptors are in skin, muscles, bone,

joints, and viscera. Nociceptors refer to specialized
pain receptors that are equipped in the periphery
with receptors that are sensitive to noxious or potentially noxious mechanical and chemical stimuli [1,2].
In normal, non-damaged tissue, nociceptors or protective nociceptors (PN) are activated. High-threshold mechanoreceptor skin afferents come in two
forms; lightly myelinated fast-conducting A-delta fibers and smaller unmyelinated slow-conducting C fibers. C fibers comprise around 70% of all nociceptors.
C fibers contain a variety of neuropeptides, including
substance P (SP) and calcitonin gene-related peptide
(CGRP), as well as a high-affinity receptor for nerve
growth factor (NGF). The tissue innervated as well as
the rate of stimulation determine the quality of pain
sensation. Furthermore, as a potent vasodilator, SP
increases the nitric oxide (NO) release and causes
axon reflex-mediated wheal and flare reaction. Then
nociceptors project to the outermost region of the
spinal dorsal horn (lamina I and outer lamina II) and

terminate largely on spinal neurons, which project to
higher-order pain centers in the brain.
Nociceptive pain is further subdivided into somatic
and visceral pain. Somatic pain, usually from muscles,
fascia, joints, bones, and tissue trauma, can be well
localized and described as dull, aching, throbbing, or
gnawing pain. This type of pain is associated with
bone metastases, soft tissue inflammation, and postoperative pain. Visceral pain usually comes from
injury by infiltration, compression, distention, or dilatation to the sympathetic nervous system innervated
organs, and is described as deep, squeezing, dragging,
or pressure-like. Visceral pain is usually poorly localized and often referred to distant locations. Primary
or metastatic tumors tend to distend, infiltrate, compress, or stretch the thoracic and abdominal viscera
causing visceral pain. Visceral pain is typically referred
to somatic structures and is often associated with
greater autonomic, motor, and emotional responses
compared to somatic pain [1].
All viscera receive dual innervation. Thus, in contrast to somatic input to the central nervous system,
which has a single, usually spinal, destination, input
to the central nervous system from organs in the thoracic cavity arrives at two locations: (1) the brainstem
nucleus tractus solitarii (vagal afferent input) and (2)
the thoracic spinal cord. Furthermore, visceral afferent fibers are disproportionately fewer than somatic
afferent fibers. Consequently, the low number of visceral afferents and greater intraspinal distribution
lead to a loss of spatial discrimination, consistent
with the diffuse, difficult-to-localize nature of visceral
pain [1].
In the peripheral and central nervous system, there
are several inhibitory mechanisms such as A-beta
neurons and enkephalins. Repetitive stimulation of
nerve fibers called A-beta mechanoreceptives, for
example, initially excites and then inhibits dorsal horn
spinothalamic tract (STT) neurons via interposed
interneurons releasing -aminobutyric acid (GABA)
or enkephalin, which decreases the stimulation of C
fibers.
The purpose of PN is to act as an early warning
system, with a sharp initial pain from the A-delta fibers followed by a dull pain from the slower C fibers.
This mechanism prevents tissue damage by alerting
the body to the presence of an intense, potentially
damaging stimulus in the environment. The resulting
pain protects tissue from being further damaged
Chapter 4 Pain characteristics
because withdrawal reflexes are usually elicited. In

patients who lack the capacity to feel nociceptive pain,
there is enormous damage. For instance, patients who
have congenital analgesia have deformities of the tips
of their fingers, lips, and tongues, and their life expectancy is reduced. Generally, nociceptive pain is responsive to nonsteroidal anti-inflammatory drugs
(NSAIDs) and opioids. Conditions associated with
inflammation, bone pain, and joint disease are particularly responsive to NSAIDs, which will be addressed.
Inflammatory pain
Inflammatory pain is often caused by direct injury to
tissue such as by a surgical scalpel or trauma. There
are several processes that contribute to this type of
pain. For example, silent nociceptors (SN), which are
completely insensitive to mechanical or thermal stimuli in normal tissue, start to respond to stimuli and are
sensitized. These SN are important in mediating neurogenic inflammation. Cyclooxygenase-2 (COX-2) is
a protein that acts as an enzyme and catalyzes the production of prostaglandins. Hours after peripheral
inflammation, there is a massive increase in COX-2.
COX-2 leads to the production of prostaglandins that
bind to specific receptors and initiate a cascade of
kinases causing sensitization of the nociceptors [1,2].
The cascade leads to both hyperexcitability and hypersensitivity through the activation of two kinases, specifically protein kinase A and protein kinase C. These
kinases serve to transduce proteins that are responsive. For instance, they heat stimuli, reducing the
threshold of activation as well as the phosphorylate
sodium channels, which are expressed in the membrane causing a hyperexcitable state. These two mechanisms allow peripheral sensitization of the peripheral
nociceptors and are responsible for reduction of the
pain threshold at the site of tissue damage.
As mentioned earlier, SP is released by nociceptors, causing vasodilatation, plasma extravasation and
other effects, i.e. attraction of macrophages or degranulation of mast cells. These events cause signs of
inflammation such as heat, redness, and swelling. In
spite of the complexity of the cytokines and neurotransmitters involved in inflammation, researchers
have identified interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF-a) [2].These chemicals cause
release of other mediators, which can produce further
sensitization or activation of primary afferent fibers
and nearby primary afferent nociceptors [1,2]. This
process is the basis of the neurogenic inflammation

associated with these changes that can be observed
following an injury.
Neuropathic (nerve) pain

Neuropathic pain is a state of complex, chronic pain
that is usually accompanied by neural and non-neural
tissue injury. It can be caused by trigeminal neuralgia,
HIV infection, herpes zoster, and diabetes. Among
intact nerves and tissue, a stimulus that is noxious will
usually induce a subjective pain response; however,
under clinically relevant conditions, e.g. surgical incisions, this association is not predictable. With constant activity from nociceptive afferents, sensitization
of the nociceptors occurs. Central and peripheral
pain-processing neurons or nerve fibers may be dysfunctional or injured. Damaged nerve fibers send
incorrect signals to the central nervous system and
cause a change in nerve function both at the site of
injury and in the surrounding areas (primary and secondary hyperalgesia respectively). The pain may persist for months or years beyond the apparent healing
of damaged tissues [1,3]. Plasticity is a term used to
refer to these changes that occur in the established
nervous system. Changes in neuronal structure, connections between neurons, and alterations in the
quantities and properties of neurotransmitters, receptors, and ion channels ultimately result in increased
functional activity of neurons in the pain pathway.
Conversely, plasticity can decrease the bodys own
pain inhibitory systems, resulting ultimately in
increased pain. Plasticity can result in short-term
changes, which last from minutes to hours, or longterm changes, which may become permanent. Both
peripheral and central nervous systems have a role in
neuronal plasticity [13].
In injury, commonly, the inhibiting A-beta fibers
begin to express SP and CGRP; low-threshold stimuli
can lead to SP release in the dorsal horn. These transmitters cause hyperexcitability by decreasing the stimuli threshold of the nociceptors. Moreover, Schwann
cells in damaged nerves start to produce increased
mRNA for NGF, leading to regenerative events. Often,
damaged axons also express adrenoreceptors, causing
discharges in response to circulating epinephrine and
norepinephrine. These neurotrophins may cause aberrant regeneration, such as the ingrowths of sympathetic
postganglionic axons or large myelinated afferents,
forming abnormal connections in the nociceptive
15
processing circuits within the dorsal horn. These

sprouts develop active sodium channels that become
sites of tonic impulse generations (in the absence of
noxious stimuli), known as ectopic foci. Regenerative
sprouts rewire the afferent sensory system and cause
alllodynia (i.e. pain resulting from a nonpainful stimulus) [3]. Persistent allodynia is a common characteristic of neuropathic pain. A light stroke of the patients
face may feel like a shock or lightning bolt and result in
the sudden pain of trigeminal neuralgia. In contrast,
patients with diabetic neuropathy suffer from dysesthesia; an unpleasantly strange or tingly sensation,
rather than a painful feeling.
In the central nervous system (CNS), low- and
high-frequency synaptic activation and the release of
neuromodulators and glutamate cause an increase in
the number of discharged action potentials with each
stimulus. These reversible changes in the excitability of
neurons via post-translational means are called modulation. As a result of repeated exposure to sensitizing
stimuli, such as inflammatory mediators, modulation
of peripheral neurons leads to heterosensitization, an
increase in the excitability of the nociceptor terminal
membrane [2,3]. Centrally, there is a loss of inhibitory
interneurons and the stimulus-response system is
greatly distorted. The result is persistent, pathological
pain. At the level of transcriptional change, inflammation produces up-regulation of genes and increased
expression of TRPV1 and sensory nerve-specific
sodium channels in response to injury and inflammatory mediators [3]. Consequently, the nerve growth
factor decreases the threshold to noxious stimulation,
resulting in hyperalgesia. Clustering of sodium channels in the axon membrane produces foci of irritability
and ectopic discharges, which is a major contributor to
spontaneous neuropathic pain. These sodium channels can be blocked by lidocaine, mexiletine, and anticonvulsants. The number of opioid mu receptors
decreases, and the number of 2 calcium channel
subunits increases, producing diminished effectiveness of morphine and enhanced effectiveness of gaba
pentin for neuropathic pain [3].
Mixed-category pain
16
In some conditions, the pain appears to be caused by

a complex mixture of nociceptive and neuropathic
factors. An initial nervous system dysfunction or
injury may trigger the neural release of inflammatory
mediators and subsequent neurogenic inflammation.
For example, migraine headaches probably represent
a mixture of neuropathic and nociceptive pain. Myofascial pain is probably secondary to nociceptive input
from the muscles, but the abnormal muscle activity
may be the result of neuropathic conditions.
Pharmacological management
Generally, neuropathic problems are not completely
reversible, but improvement is often possible with
appropriate treatment. Examples of conditions
amenable to treatment include post-herpetic neuralgia, reflex sympathetic dystrophy/causalgia
(nerve trauma), components of cancer pain, phantom limb pain, entrapment neuropathy (e.g., carpal
tunnel syndrome), and peripheral neuropathy (widespread nerve damage). Diabetes is the most common
cause of peripheral neuropathy, but other causes
include chronic alcohol use, exposure to other toxins
(e.g. chemotherapies), vitamin deficiencies, and a
variety of other medical conditions. When considering pharmacological options to treat chronic pain,
options in order of use include non-opioids (e.g. acetaminophen, NSAIDs), opioids, and co-analgesics. Generally, the non-opioids are unlikely to provide any
significant degree of pain relief in patients with neuropathic pain. Given the complicated nature of neuropathic pain, it is not surprising to find that, at best, an
opioid or co-analgesic agent will decrease the pain to
half. In fact, careful analgesic selection and dosage
titration are required, since many patients with neuropathic pain are elderly, taking multiple medications,
and carrying numerous comorbid conditions.
NSAIDs mechanism of action relays inhibition of
production of prostanoids to prevent the inflammatory pain. Two cyclooxygenase enzymes contribute to
the conversion of arachidonic acid to prostaglandin
H2; cyclooxygenase-1 (COX-1) is a constitutive form
of cyclooxygenase but COX-2 tends to be induced primarily by inflammation in most tissues. Many recent
medications and investigations are directed at inhibiting COX-2 to relieve pain, such as celecoxib.
Clustering of sodium channels in the axon membrane produces foci of irritability and ectopic discharges, which are a major contributor to spontaneous
neuropathic pain. Treatments that reduce peripheral
sensitization are drugs that affect the sodium channels
(e.g. carbamazepine, oxcarbazepine, phenytoin, topiramate, lamotrigine, lidocaine, and mexiletine). Coanalgesics that address central sensitization
by affecting calcium channels include gabapentin,
pregabalin, levetiracetam, oxcarbazepine, lamotrigine,
Chapter 5 Primary and secondary hyperalgesia
topiramate, and ziconotide. Tricyclic antidepressants

(TCAs), serotonin-norepinephrine reuptake inhibitor
(SNRIs), tramadol, and opioids will enhance the
descending inhibitory pathway.
Currently, there are a few agents that are US Food
and Drug Administration (FDA)-approved for neuropathic pain. These are carbamazepine (Tegretol) for
trigeminal neuralgia, duloxetine (Cymbalta) for diabetic neuropathy, gabapentin (Neurontin) and transdermal lidocaine (LidoDerm) for post-herpetic neuralgia,
and pregabalin (Lyrica) for both diabetic neuropathy
and post-herpetic neuralgia. However, there are a significant number of studies demonstrating the effectiveness of these and other co-analgesics in treating a wide
variety of neuropathic pain states. Gabapentin and pregabalin are alpha2-delta ligands that were introduced to
the market as anti-epileptic drugs. However, they have
been effective in treating post-herpetic neuralgia, painful diabetic neuropathy, mixed neuropathic pain syndromes, phantom limb pain, Guillain-Barr syndrome,
and spinal cord injury pain.
Opioids have proven less effective in management
of neuropathic pain. Nevertheless, the synergic effect
of opioids and co-analgesics such as gabapentin has
Section 1
Chapter
been proven to be very successful. Tramadol (Ultram)

is a norepinephrine and serotonin reuptake inhibitor
that has a weak mu opioid agonist as one of its metabolites. Tramadol is effective in treating painful diabetic neuropathy and polyneuropathy of various
causes. Several studies have also demonstrated the
effectiveness of neutralizing antibodies to IL-1 and
TNF receptors to reduce pain-associated behaviors.
The recent decades have brought a greater focus on
pain management and the medical community has
had more success in understanding pain and its management. With time, it is certain that more pathways
and neurotransmitters will be discovered, which will
bring about better medications and methods of treating acute as well as chronic neuropathic pain.
References
1. Bonicas Management of Pain, 3rd ed. Philadelphia:

Lippincott Williams & Wilkins, 2001.
2. Firestein G. Kelleys Textbook of Rheumatology, 8th ed.
Philadelphia: W.B. Saunders, 2008.
3. Stucky C. Mechanisms of pain. PNAS
2001;98:1184511846.
Pain Definitions
Primary and secondary hyperalgesia

Brenda C. McClain
Introduction
Hyperalgesia is defined by the International Association for the Study of Pain (IASP) as an increased
response to a stimulus which is normally painful. Primary hyperalgesia or peripheral sensitization reflects
the activation and sensitization of nociceptive A delta
and polymodal C-fiber terminal endings within the
injured area. Secondary hyperalgesia, or central sensitization, involves spinal neuroplasticity and facilitation
of supraspinal noxious transmission. The stimulus

response associated with primary hyperalgesia is
shifted to the left, such that reduction in noxious stimulation intensity is associated with increased intensity
of pain perception (Figure 5.1).
Primary hyperalgesia
Primary hyperalgesia follows primary nociceptor activation (or transduction) in response to mechanical,
17
Increasing Discomfort
Hyperalgesia
Normal Response
Allodynia
Increasing Stimulus Intensity
Figure 5.1. Physiological alterations associated with

hyperalgesia.
18
thermal, and chemical noxious stimulation [1].

Peripheral mediators of mechanical and thermal
injury include K+ and H+ ions, prostaglandins (PGE-2),
cytokines (IL-6, IL-10, TNF), and autacoids (substance P, angiotensin II, bradykinin, histamine, and
serotonin). Following exposure to this noxious soup
of algesic, inflammatory, and pro-inflammatory mediators, nociceptors become sensitized (peripheral sensitization) and depolarize either spontaneously or at
lower stimulating thresholds. Several membrane
receptors and ion channels are specifically expressed
in terminal nociceptor endings. These include certain
vanilloid receptors (TRPV-1), purinergic receptors,
and tetrodotoxinresistant sodium channels. TRPV-1
receptors initiate generator potentials within terminal
endings and are primarily responsible for encoding
noxious stimuli into a barrage of action potentials [2]
(Figure 5.2).
Up-regulation of cyclooxygenase-2 (COX-2) converts arachidonic acid released from damaged cell
membranes into prostaglandin E2 (PGE2), a primary
noxious mediator and transduction initiator. Bradykinin and kallidin bind to constitutive G-protein coupled
receptors termed B2 receptors, which in turn activate
phospholipases A2 and C, as well as protein kinase C.
Bradykinin also activates voltage-gated ion channels by
altering K+ and Na+ ion flux, resulting in enhanced
excitability of mechano-heat-sensitive C nociceptors
[3]. The co-localization of bradykinin with the vanilloid
receptor TRPV1 has been recently shown to play a
major role in bradykinin-induced hyperalgesia. TRPV1
receptors are activated at lower temperatures when sensitized by bradykinin [3,4]. Although the earliest phases
of primary hyperalgesia are mediated by the inflammatory soup of noxious substances, later phases involve
pathophysiological alterations including neural injury,
effects of efferent sympathetic potentiation, and the
effects of neutrophils and lymphocytic infiltration. This
later phase is associated with ectopic discharges and

stimulus-independent activity (Figure 5.3).
The process of neural sensitization and the clinical
term hyperalgesia also relate to discomfort in
response to sensations that normally would not be
perceived as painful. The term hyperpathia describes
exaggerated perception resulting from minor amounts
of peripheral noxious stimulation. Allodynia defines a
state in which non-noxious stimulation is perceived as
being painful. Allodynia is commonly observed following severe or extensive injuries, and in patients
developing persistent and neuropathic pain. Clinical
characteristics associated with hyperalgesia are presented in Table 5.1.
Secondary hyperalgesia
Secondary hyperalgesia is a form of central sensitization that follows ongoing tissue injury and inflammation. Its clinical manifestations include an exaggerated
response to noxious and innocuous stimuli applied to
undamaged tissue surrounding the site of injury. An
important role of secondary hyperalgesia and central
sensitization is to increase effort-dependent pain,
thereby limiting movement and further tissue damage
following acute injuries; however, an increasing body
of evidence suggests that these physiological adaptations are also responsible for pain persistence, symptoms of neuropathic pain, and the development of
chronic pain states [5,6].
Neurophysiology
Secondary hyperalgesia refers to the activation and
progressive sensitization of second-order nociceptive
specific (NS) and wide-dynamic-range (WDR) neurons in the dorsal horn as well as activation of other
nociceptive neurons in brainstem and thalamus [6].
These cells are activated by barrages of noxious afferent input from the injury site. WDR sensitization is
primarily limited to afferent mechanoreceptor input
and exaggerated responses to temperature input are
less obvious. Two forms of secondary hyperalgesia
have been described: hyperalgesia to light touch,
which is also referred to as allodynia, and hyperalgesia
to punctate stimuli. Hyperalgesia in response to heat
and light-touch stimuli is more difficult to induce,
less pronounced, of shorter duration and encompasses
a smaller receptive field than secondary hyperalgesia
to punctate stimuli.
The mechanisms leading to stimulation and sensitization of dorsal horn neurons include enhanced
Tissue
Injury
Skin
Inflammatory Soup
ROS
H+
NGF
O
xid
at
io
n
BK
BR
TRPA1
TRKA
TRPV1
Lipid
Lipid
Hydroperoxide Oxidation HNE
PLC-g
PLC-b
Figure 5.2. Inflammatory agents

regulate TRPV1 through direct and
indirect mechanisms. Tissue injury,
ischemia, or cellular stress generates an
array of pro-algesic and proinflammatory agents, collectively referred
to as the inflammatory soup. This
includes extracellular protons (H+),
prostaglandin (PGE), bradykinin (BK), and
nerve growth factor (NGF). Some factors,
such as H+ and K+, activate TRPA1 or
TRPV1 directly, whereas others, such as
BK and NGF, modulate channel gating
indirectly. TRPA1 and TRPV1 function as
polymodal signal integrators capable of
detecting products of cell and tissue
injury. These channels promote pain
hypersensitivity by depolarizing the
primary afferent nerve fiber and/or
lowering thermal or mechanical
activation thresholds. (Adapted from
Trevisani et al. PNAS 2007;
104(33):1351913524.)
Ca2+
Intracellular Calcium Stores
Primary Hyperalgesia: Sensitization of Peripheral Nociceptors

Ca++
Acute Injury
PGE, sP,
Bradykinin,
Serotonin,
Histamine
Activated Nociceptor
TRPV-1
TRPV-1
Ca++
Persistent Injury
Macrophage
and Lymphocyte
responses,
Cytokines,
Norepinephrine,
NGF
Damaged or Sensitized Nociceptor
afferent signaling, wind-up and long-term potentiation. (Refer to Chapter 2: Pain pathways). A study by
Zeigler et al. [7] has shown that intradermal injection
of capsaicin into the dorsum of the hand elicits a stable state of secondary hyperalgesia for at least 2 h that
is characterized by a leftward shift of the stimulusresponse function for punctate mechanical stimuli. They
also demonstrated that conduction blockade in both
Figure 5.3. Following acute injury,

primary noxious mediators including
PGE, sP. and bradykinin activate TRPV-1
receptors, which initiates intracellular
Ca2+ flux and depolarization of peripheral
terminal endings. This Ca2+ generator
potential in turn initiates Na+-mediated
axon potentials. With ongoing
inflammation, terminal endings become
sensitized and depolarize independently.
With persistent injury, macrophages and
lymphocytes infiltrate the terminal
endings and release cytokines,
interleukins and nerve growth factor,
which further sensitizes the nociceptor.
Courtesy of Sinatra RS: Lecture presented
at NYS PGA 2009.
small-diameter A-fiber subtypes where C fibers were

unaffected showed that intradermal injection of capsaicin produced pain that was equal in magnitude to
the pain produced without a nerve block; however, no
hyperalgesia to punctate stimuli could be detected.
After the block had been released, punctate hyperalgesia was present. These findings indicate that C-fiber
discharges induce central sensitization and that
19
Table 5.1. Characteristics of hyperalgesia

Hyperalgesia
Defines a state of increased pain sensitivity and enhanced perception following acute injury which may persist chronically
The hyperalgesic region may extend dermatomes above and below the area of injury and is associated with ipsilateral (and
occasionally contralateral) muscular spasm/immobility
Hyperalgesia may be observed following incision, crush, amputation, and blunt trauma
Primary hyperalgesia
Describes increased pain sensitivity at the injury site
Related to peripheral release of intracellular or humoral noxious mediators
Secondary hyperalgesia
Describes increased pain sensitivity at adjacent, uninjured sites
Related to changes in excitability of spinal and supraspinal neurons
Abnormal sensations associated with hyperalgesia
Hyperpathia increased or exaggerated pain intensity with minor stimulation
Allodynia non-noxious sensory stimulation is perceived as painful
Dysesthesia unpleasant sensation at rest or movement
Paresthesia unpleasant often shock-like or electrical sensation precipitated by touch or pressure (e.g. CRPS-II causalgia)
20
A-fiber nociceptors mediate secondary hyperalgesia

to punctate stimuli through a second pathway.
The concerted actions of excitatory amino acids
(EAAs) and neurokinin (NK) on facilitatory nociceptive pathways is the pharmacological crux of the phenomenon of secondary hyperalgesia. Most models of
secondary hyperalgesia are single-neuron models in
which a critical neuron, namely the nociceptive projection neuron, is sensitized by the combined interaction of EAAs and neurokinins [57]. Excitatory amino
acids such as glutamate (Glu) and aspartate are responsible for fast synaptic transmission and rapid neuronal
depolarization. Glutamate is released by all primary
afferents while substance P is found only in nociceptors. Excitatory amino acids activate AMPA and kainite (KAR) receptors that regulate Na+ and K+ ion
influx and intraneuronal voltage. Increasesd Na+ ion
flux facilitates priming and activation of NMDA receptors. Spinal and supraspinal NMDA receptors increase
intraneuronal Ca2+ ion influx, the major requisite for
the development of long-term potentiation (LTP).
Sensitization of CNS neurons also underlies the
transition from acute to persistent pain (Figure 5.4).
Central sensitization can be divided into transcriptiondependent and transcription-independent processes.
Transcription-independent sensitization reflects neurochemical and electrical alterations that follow acute
traumatic and experimentally induced pain. It includes
stimulus-dependent neuronal depolarization, and
stimulus-independent long-term potentiation. Transcription-dependent sensitization describes delayedonset, long-lasting, noxious facilitation that follows
genomic activation, transcription of mRNA and subsequent translational modifications. Activation of
NMDA and NK-1 receptors and continued influx
of Ca2+ leads to enhanced production of cAMP, protein
kinases, and phosphokinases [8]. Phosphokinases
and other nuclear activators initiate transcriptional
processes over a period of several hours to several days.
Key translational events include up-regulation of
non-constitutive enzymes and proteins including
superoxide dismutase, nitric oxide synthetase, and
cyclooxygenase-2. These enzymes are responsible for
production of the irritative and lytic mediators, superoxide, nitric oxide, and prostaglandins, which sensitize
neuronal cell membranes, synaptic contacts, and associated glial cells.
The activation of spinal extracellular signalingregulated kinase-1 and -2 (ERK1, ERK2) is also
required for secondary hyperalgesia [8]. Noxious activation of ionotropic, metabotropic, and tyrosine
kinase receptors in dorsal horn neurons activates protein kinase A (PKA) and protein kinase C (PKC),
leading to the production of ERK. Hyperalgesia after
thermal stimulation is mediated by non-NMDA
receptors. The thermal stimulus model demonstrates
distinct protein kinase involvement downstream from
spinal non-NMDA receptor activation. Jones et al. [9]
Inhibitory Cell
Activated
nociceptor
Central Sensitization: Progressive

Facilitation of Noxious Transmission
Hyperexcitable WDR
neuron (EPSPs)
Sensitized
nociceptor
Glial
Activation
High intensity
stimulation
Severe Acute Pain
Removal of
Inhibitory Contacts
Sensitized WDR
Neuron (Windup)
Prolonged Convalescent Pain
Sensitized
nociceptor
Synaptic
Sprouting
Altered WDR Neuron

(Transcription dependent plasticity)
High threshold Afferent
Chronic Pain
Courtesy of Sinatra RS, Lecture Presented at NYS PGA 2009
Figure 5.4. Following tissue injuries and release of noxious mediators, peripheral nociceptors become sensitized and fire repeatedly,
stimulating second-order WDR cells in the dorsal horn (upper figure). The cells also become electrically sensitized and demonstrate
excitatory postsynaptic potentials (EPSPs). Inhibitory interneurons and descending inhibitory fibers modulate and central sensitization by
suppressing nociceptor release of noxious transmitters as well as the excitability of WDR cells. Continued barrage of noxious impulses further
sensitizes second-order transmission neurons in dorsal horn, via a process termed wind-up (middle figure). The resulting process of central
sensitization results in secondary hyperalgesia and spread of the hyperalgesic area to nearby uninjured tissues. In certain settings ongoing
intracellular calcium influx and transcription-dependent changes lead to neurochemical/neuroanatomical plasticity, prolonged neuronal
discharge and increased pain intensity and persistence (lower figure).
found that incision-induced sensitization also involves

activation of protein kinases. These investigators confirmed that spinal calcium/calmodulin-dependent
protein kinase II (CaMKII) mediates secondary
hyperalgesia and spontaneous pain behavior after
plantar incision.
Clinical implications
The recognition and control of nociceptor transduction and development of primary hyperalgesia are key
to reducing the intensity and duration of acute pain.
Nociceptor sensitization leads to reductions in noxious thresholds, increased pain disability, and delayed
rehabilitation. The physiological response to transduction and the initiation of nociception can be limited or eliminated by peri-operative administration of
non-opioid analgesics and anti-inflammatory agents
(e.g. NSAIDS, steroids). Although opioids can inhibit
the release of substance P from primary afferent

nerves, this class provides limited analgesic effects
when nociceptors are sensitized by prostaglandins,
bradykinin, and other inflammatory mediators. The
development of TRPV-1 inhibitors and extendedduration local anesthetics may provide a safe and
effective means to reduce acute pain for an extended
duration of time, and eliminate the untoward effects
of primary hyperalgesia. Central sensitization appears
to play an important role in the persistence of pain
even when the original injury has abated. The temporal sequence from the initial traumatic event to the
development of chronic pain involves plasticity changes
and can occur rapidly particularly in settings of analgesic undermedication (Figure 5.5). As ongoing pain
signals bombard the dorsal horn, connections to WDR
neurons begin to sprout and the number of NMDA
receptors at the postsynaptic membrane is increased.
21
Acute Tissue Injury

Primary mediators
(K+, H+, PGE)
( sP, Bradykinin, NGF)
(Glutamate and sP)
Milliseconds
Nociceptor Activation
Peripheral Sensitization
Central Sensitization
EPSPs, NMDA Activation, wind- up
Transcription Dependent Changes

Upregulation of NOS,
Cox-2, SOD
Altered
connectivity
Seconds
Minutes
to Hours
Hours to
Days
Cell death
Figure 5.5. Temporal sequence of hyperalgesic and

plasticity changes that follow acute tissue injury.
WDR endings grow into the areas where pain-receiving nerve cell bodies are located. The enlarged receptive field can now conduct non-noxious inputs, an
effect that may be potentiated by the sprouting of
A-beta fibers. The result of these changes is that nonnoxious afferents (mechanical and proprioceptive) are
now perceived as painful stimuli and can contribute
towards maintaining sensitization even after the resolution of the primary injury. The current use of adjuvants for neuropathic pain includes many agents
(calcitonin, ketamine, calcium channel blockers, etc.)
that work to block or reduce facilitative pathways [10].
It is also appreciated that all patients with similar injuries do not develop persistent pain. This suggests that
there is a certain level of genetic variability that may
account for differences in clinical outcomes.
References
1. Treede RD, Magerl W. Modern concepts of pain and

hyperalgesia: beyond the polymodal C-nociceptor.
News Physiol Sci 1995;10:216228.
22
2. Ferreira J, da Silva GL, Calixto JB. Contribution of

vanilloid receptors to the overt nociception induced
by B2 kinin receptor activation in mice. Br J
Pharmacol 2004;141(5):787794.
3. Wang H, Ehnert C, Brenner GJ, Woolf CJ. Bradykinin
and peripheral sensitization. Biol Chem
2006;387(1):1114.
4. Couture R, Harrisson M, Vianna RM, Cloutier F.
Kinin receptors in pain and inflammation. Eur J
Pharmacol 2001;429(13):161176.
5. Serra J, Campero M, Bostock H, Ochoa J. Two types of
C nociceptors in human skin and their behavior in
areas of capsaicin-induced secondary hyperalgesia.
J Neurophysiol 2004;91(6):27702781.
6. Simone DA, Ochoa J. Early and late effects of
prolonged topical capsacin on Vanilloid receptors.
Pharmacol Rev 1999;51:159212.
7. Ziegler EA, Magerl W, Meyer RA, Treede R-D.
Secondary hyperalgesia to punctate mechanical
stimuli. Central sensitization to A-fibre nociceptor
input. Brain 1999;122:22452257.
8. Walker SM, Meredith-Middleton J, Lickiss T, Moss A,
Fitzgerald M. Primary and secondary hyperalgesia can
be differentiated by postnatal age and ERK activation
in the spinal dorsal horn of the rat pup. Pain
2007;128(12):157168.
9. Jones TL, Lustig AC, Sorkin LS. Secondary
hyperalgesia in the post-operative pain model is
dependent on spinal calcium/calmodulin-dependent
protein kinase II activation. Anesth Analg
2007;105:16501656.
10. Warncke T, Stubhaug A, Jorum E. Top of form
ketamine, an NMDA receptor antagonist, suppresses
spatial and temporal properties
of burn-induced secondary hyperalgesia
in man: a double-blind, cross-over comparison
with morphine and placebo. Pain 1997;72(12):
99106.
Section 1
Chapter
Pain Definitions
Pain pathophysiology
Alireza Sadoughi
Introduction
Pain is produced by stimuli that usually cause damage
to tissues. It is in the best interest of an organism to
detect potential damage to the body so it can take
appropriate steps to avoid being harmed. The presence
of pain usually forces immobilization of the injured
area and prevents additional tissue damage from taking place and allows for the healing and repair processes to occur. Without the aid of the bodys response
to tissue damage, survival would be difficult.
Pathological pain is considered abnormal given
that there is no protective value to the organism. This
is a morphism in the nervous system that involves
plasticity in both the peripheral and central nervous
systems. It affects the way the nervous system detects
the type of stimuli from the environment a shift
from a normally protective physiological mechanism
to an abnormal and possibly pathological mechanism.
Consequently, this justifies the concept that pain
should be considered a disease process on its own.
This chapter will outline mechanisms of physiological nociceptive pain resulting from inflammation
and from injury and its impact on the nervous system.
The effects of stress hormone release on the cardiovascular system and other key target organs will also be
discussed.
Central nervous system

pathophysiology
Hyperalgesia
Pain is a complex process involving both the peripheral nervous system (PNS) and the central nervous
system (CNS). Peripheral nociceptors are able to distinguish between noxious and innocuous stimuli and
can translate the intensity of the stimulus from the frequency of impulse firing. The second-order neurons
in the spinal-thalamic tract transmit noxious impulses
from the spinal cord to the thalamus. From here axons
within the thalamocortical system contact cells in sensory and limbic cortex responsible for conscious pain
sensation. While nociceptive pain is elicited by noxious stimulation of sensory endings, pathological pain
results from injury to tissue and neurons in the nervous system, which ceases to serve a protective function and instead degrades health and functional
capability. Evidence exists that chronic pathological
pain results from a combination of mechanisms,
including neural memories of previous pain. Examples of neuropathic pain include carpal tunnel syndrome, post-herpetic neuralgia, diabetic neuropathy,
and central pain syndrome [13]. There is a direct
relationship between the intensity of the stimulus and
the degree of pain sensation after application of a
stimulus to the body. Enhanced noxious perception
following peripheral tissue injury is termed hyperalgesia. Primary hyperalgesia defines increases in noxious sensitivity observed in areas around the site of
tissue damage. The endings of the peripheral nociceptors become sensitized and more responsive to any
applied stimulus. sh95:STARTSecondary hyperalgesia
reflects the sensitization of second-order dorsal horn
cells that receive input from primary afferent fibers.
Allodynia is the phenomenon of pain sensation from
a non-painful, normally innocuous stimulus despite
tissue healing. Essentially, it is a disease of the nervous
system where an area that normally is not sensitive to
pain, upon touch, becomes vulnerable to substantial
pain sensations. This process involves both peripheral
and central sensitization [13].
Central sensitization
Central sensitization describes changes that occur in
the central nervous system in response to repeated
nerve stimulation. Following repeated stimulation,
levels of neurotransmitters and brain electrical signals
change as neurons develop a memory for responding
to those signals. Frequent stimulation results in a
stronger brain memory, so that the brain will respond
23
24
more rapidly and effectively when experiencing the

same stimulation in the future. The resulting changes
in brain wiring and the responses are referred to as
nerve plasticity. The sensitization can only occur with
repeated stimuli and activation. For example, even
after removal of a herniated disc, pain may continue.
There are many important factors in building this sensitization including temporal summation, inflammatory response, production of new nerve fibers, and
receptor up-regulation.
Temporal summation refers to a central spinal
mechanism where repetitive noxious stimulations
results in the sensation of increased pain in humans. It
is due to the second pain from the C fibers, which is
more dull and strongly related to chronic pain conditions. Ongoing C-fiber nociceptive impulses lead to
increased glutamate release and repeated NMDA
receptor activation of the STT neurons. This NMDA
activation, along with SP release, results in a build-up
of intracellular calcium ion (Ca2+). Calcium influx
induces two activities, activation of nitric oxide (NO)
synthase as well as a Ca2+-induced PKC. NO can affect
the nociceptor terminals and enhance the release of
sensory neuropeptides (in particular, SP) from presynaptic neurons, thereby contributing to the development of hyperalgesia and maintenance of central
sensitization; whereas PKC induces sensitization of
NMDA receptors by phosphorylation that leads to
increased stimulation as well as reducing sensitivity to
the opioid receptors, allowing an increased response
to pain.
As discussed earlier, the inflammatory response of
tissue damage also has a key role in central sensitization. The induction of COX-2 and the production of
PG promotes an increase in presynaptic transmitter
release but more importantly causes direct depolarization postsynaptically in the dorsal horn roots by
removing the glycine receptor block and causing excitability. Furthermore, the widespread induction of
COX-2 within the central nervous system can exacerbate pain and change appetite, mood, and sleep, and
produce the general symptoms of illness.
In addition, after nerve and tissue destruction,
regenerative sprouts rewire the afferent sensory system, where non-noxious stimuli can cause pain (allodynia). Schwann cells in damaged nerves produce
increased mRNA for NGF and their receptors for
regenerative events. Damaged axons often express
adrenoreceptors, which cause discharges in response
to circulating epinephrine and norepinephrine (NE).
These neurotrophins also may cause aberrant regeneration, such as the ingrowth of sympathetic postganglionic axons into dorsal root ganglia. It may also
cause the ingrowth of large myelinated afferents into
lamina II, forming abnormal connections in the nociceptive processing circuits within the dorsal horn
(which may further explain allodynia). These sprouts
develop active sodium channels that become sites of
tonic impulse generation, known as ectopic foci. These
impulses occur in primary nociceptive axons in the
absence of noxious stimuli.
Loss of spinal inhibitory mechanisms

Spinal endogenous inhibitory systems serve as opposing compensatory influences and are gaining recognition for their powerful capacity to restrain allodynia
and hyperalgesia. These include numerous G proteincoupled receptors (- and -opioid, 2- adrenergic,
purinergic A1, neuropeptide Y1 and Y2, cannabinoid
CB1 and CB2, muscarinic M2, -aminobutyric acid
type B, metabotropic glutamate type IIIII, somatostatin) and perhaps nuclear receptors (peroxisome
proliferator-activated receptor gamma). Excessive
down-regulation or defective compensatory up-regulation of these systems may contribute to the maintenance of neuropathic pain. An increasing number of
pharmacotherapeutic strategies for neuropathic pain
are emerging that mimic and enhance inhibitory neurotransmission in the dorsal horn. In addition, inhibitory interneurons often stop functioning during severe
conditions of neuropathic pain. This is hypothesized
to result from denervation of input from A-beta afferent (deafferentation) or glutamate excitotoxicity.
Peripheral nervous system

pathophysiology
Peripheral sensitization occurs due to activation of
silent receptors, increased nociceptor receptors and
neurotransmitters, abnormal functioning of non-pain
receptors, and down-regulation of inhibitory neurotransmitters. Nerve growth factor (NGF), which is a
survival factor in the nervous system, is produced
during inflammation of tissue and it increases the synthesis of SP and CGRP through activating TrKA receptors. In normal tissue, there are silent nociceptors that
are insensitive to mechanical or thermal stimuli; however, in the presence of inflammation, SP lowers the
threshold of synaptic excitability resulting in the
unmasking of normally silent interspinal synapses
Chapter 6 Pain pathophysiology
and the sensitization of second-order spinal neurons.

Activation of silent nociceptors produces ongoing
pain even though the stimulus has been removed.
Furthermore, SP can extend long distances in the spinal cord and sensitize dorsal horn neurons at a distance from the initial input locus. This results in an
expansion of receptive fields and the activation of
WDR neurons by non-nociceptive afferent impulses.
Neuropeptides, specifically SP, also act on G proteincoupled receptors such as the neurokinin-1 (NK-1)
receptor, which results in slow synaptic currents that
change the level of excitability of the postsynaptic cell.
These G protein-coupled receptors can cause an
increase in transmission from the primary afferent
fiber to the second-order cell and again to the transmission of the signal to higher centers.
Inflammation produces up-regulation of genes and
increased expression of TRPV1 and other sensory
nerve-specific sodium channels in response to injury
and inflammatory mediators. NGF decreases the
threshold to noxious stimulation resulting in hyperalgesia as well as an increase in neurotransmitters such
as SP and brain-derived neurotrophic factors that can
amplify the input to spinal cord. The input to sodium
channels may be blocked by lidocaine, mexiletine, and
anticonvulsants.
Another important factor in peripheral sensitization
is through A-beta afferent fibers. Normally, nonpainful
sensations are detected by specialized corpuscle structures and free nerve endings that transduce mechanical
stimuli via large myelinated A-beta afferent fibers. However, injured A-beta fibers in damaged tissue paradoxically begin to express SP and CGRP. These abnormal
receptors have a low threshold and they release SP in the
dorsal horn and cause hyperexcitability.
increases massively and it leads to the production of

prostaglandins. As a result of this induction of COX-2,
a surge of prostaglandins are produced and act on
very specific receptors called EP receptors. These EP
receptors are G protein-coupled receptors that begin a
cascade of intracellular signal transductions in the
peripheral terminals. In particular, they activate two
kinases, protein kinase A (PKA) and protein kinase C
(PKC). The first is a cyclic AMP-dependent kinase,
and the latter is a calcium-activated protein kinase.
These kinases phosphorylate some of the transducing
proteins, causing increased sensitivity to stimuli such
as heat, reducing their threshold of activation. They
also phosphorylate sodium channels that are expressed
in the membrane, causing a hyperexcitable state. This
state is reached by enhancing the tetrodotoxin (TTX)
resistant Na+ channels. There has been a study that
demonstrated knockout of these channels caused pronounced mechanical hypoalgesia in mice.
CGRP and SP also cause vasodilatation. Hence,
they induce vasodilatation, plasma extravasation and
other effects, e.g. attraction of macrophages and
degranulation of mast cells. This may result in the
release of other mediators, which can produce further sensitization of primary afferent fibers, activation of primary afferent fibers, or sensitization or
activation of nearby primary afferent nociceptors.
There would be vasodilatation in the presence of heat,
redness, and swelling from plasma extravasation.
NGF also has the ability to act on mast cells directly
to activate and sensitize sensory endings by mast cell
degranulation [8].
Neurogenic inflammation
A large number of pathophysiological responses have

been characterized in patients suffering pain following acute traumatic injuries. These responses developed teleologically and provide important survival
benefits in young healthy individuals following lifethreatening injuries. However, these same responses
may significantly increase post-surgical morbidity in
high-risk patients (Table 6.1).
Inflammatory cells surround the areas of tissue damage and produce cytokines and chemokines that usually act as mediators in the process of healing and
tissue regeneration. However, these agents are also
irritants and change the properties of the primary sensory neurons surrounding the area of trauma.
Cyclooxygenase (COX) plays an important role in
both peripheral and central sensitizations. In normal,
non-inflamed skin, there is no cyclooxygenase-2
(COX-2). COX-2 is a protein that acts as an enzyme
and it catalyzes the production of prostaglandins.
However, hours after peripheral inflammation, COX-2
Humoral and hormonal responses to

poorly controlled pain
Catecholamine responses
Poorly controlled pain is associated with clinically significant humoral/hormonal alterations. These include
enhanced sympathoadrenal and neuroendocrine
25
Table 6.1. The acute injury response: potential benefits versus disadvantages in post-surgical settings
Beneficial effects after severe injury
Adverse effects in high-risk patients
1. M
aintenance of intravascular volume and mean arterial
pressure
1. Hypertension, hypervolemia, increased risk of arterial pressure

hemorrhage, stroke
2. Maintenance of cardiac output and cerebral perfusion
2. Tachycardia, arrhythmias, myocardial ischemia, perfusion

congestive heart failure
3. Enhanced hemostasis
3. Hypercoagulable state, increased risk of arterial and deep

venous thrombosis
4. Substrate mobilization, enhanced energy production
4. Hyperglycemia, negative nitrogen balance
5. Immobilization. minimizing further tissue injury
5. Reduction in respiratory volume and flow rates hypoxia,

pneumonia
6. Learned avoidance
6. Anxiety, fear, demoralization, prolonged convalescence
7. Nerve plasticity and regeneration
7. Nerve plasticity with development of chronic pain
Modified from: Ghori M, Sinatra RS. The pathophysiology of pain. In: Sinatra RS, Viscusi G, de Leon-Casasola O, Ginsberg B., eds., Acute Pain
Management. Cambridge University Press, 2008.
26
responses that can have negative effects on key target

organs [812]. The stress response to surgical or accidental trauma has been described as a general adaptation syndrome focused upon tissue repair and
improved survival. The sympathetic-adrenal response
to traumatic injury evolves in three stages. The initial
alarm stage or fight-flight reaction allows rapid
withdrawal from the traumatic event and maintains
blood flow to critical organs, and later an exhaustion
stage limits mobility and favors tissue repair. Following extensive tissue injury, nociceptive impulses stimulate sympathetic cells in the hypothalamus and
preganglionic neurons in the anterior lateral horn.
Once stimulated, catecholamines released by these
cells initiate cardiac inotropic and chronotropic
responses, increase peripheral vascular resistance, and
redistribute blood flow away from peripheral tissues
and viscera to the heart and brain [911]. These initially advantageous effects can become deleterious in
time, particularly in at-risk or debilitated patients
where myocardial activity and the work of breathing
may exceed the oxygen and metabolic supplies. In
general, highest elevations in plasma catecholamines
are observed following extensive procedures and in
younger individuals [1012]. Pathophysiological
changes associated with increased sympathetic tone
and altered regional perfusion include the following:
(1) an increased incidence of post-surgical hypertension, which ranges from 5% following minor, uncomplicated procedures to approximately 50% in patients
recovering from more extensive vascular surgery; (2)
increased peripheral vascular resistance, which is associated with increases in contractility and myocardial
oxygen consumption, as the organism attempts to

maintain or augment cardiac output.
Neuroendocrine responses
In patients experiencing severe pain, nociceptive
impulses traveling up the spinal cord via the midbrain
reticular formation activate hypothalamic centers and
initiate the neuroendocrine stress response [2023].
These well-described changes, termed the stress
response to injury, are characterized by an increased
secretion of catabolic hormones including cortisol, glucagon, growth hormone, catecholamines, and inhibition
of anabolic mediators such as insulin and testosterone
[9,10]. These mediators increase substrate mobilization,
resulting in hyperglycemia and a negative nitrogen balance. Associated metabolic changes including gluconeogenesis, glycogenolysis, proteolysis and breakdown of
lipid stores provide the injured organism with shortterm benefits of enhanced energy production. The negative nitrogen balance observed in patients experiencing
severe trauma-related pain has been related to release of
adrenocorticotropic hormone (ACTh), increased secretion of glucocorticoids, and an altered insulin:glucagon
ratio [9,10]. Plasma levels of beta-endorphin and the
posterior pituitary-derived octapeptide, arginine vasopressin (AVP), rise dramatically and remain elevated
for up to 5 days following extensive surgical trauma
[1012]. Increased secretion of AVP is responsible for
post-surgical fluid retention, plasma hypoosmolarity, and
oliguria. Prolonged negative nitrogen balance is associated with impaired wound healing and immunocompetence. Increased protein breakdown and diminutions in
protein synthesis may inhibit cell division, production

of collagen, and acute-phase/leukocytic responses. Such
inhibition results in stress-induced lymphopenia, granulocytosis, decreased natural killer and T-cell activity,
and impaired synthesis/release immunoglobulins
[1114]. In animal models, and initial clinical trials,
invasive surgery and poorly controlled pain are associated with profound immune suppression and increased
risk of tumor metastasis [14,15]. Diminished cellular
and humoral immunity may predispose debilitated
individuals and those with preexisting immune disorders to post-operative infections.
The pathophysiological impact of

poorly controlled pain on key
target organs
Cardiac and vascular effects
In high-risk populations, peri-operative cardiac
ischemia is most likely to occur following surgery,
most commonly between post-operative days 1 and 3
[16]. While a variety of factors may contribute to the
development of post-operative myocardial ischemia,
the above-mentioned responses to poorly controlled
pain appear to play a prominent role [9,16]. Catecholamine-induced tachycardia, enhanced myocardial
contractility, increased afterload, and hypervolemia,
secondary to enhanced release of AVP and aldosterone, are well-characterized factors responsible for
increased oxygen demand. Increased oxygen demand,
together with hypervolemia, may precipitate ischemia
and acute cardiac failure, especially in patients with
poorly compensated coronary artery and/or valvular
heart disease [9,1618]. In a setting where myocardial
oxygen requirements are increasing, oxygen supply
may be diminished because of coronary artery thrombosis and alterations in pulmonary function. Coronary artery blockage may result from: (1) high
circulatory levels of catecholamines and increased
coronary sympathetic tone; (2) stress-induced
increases in plasma viscosity and platelet-induced
thrombosis; and (3) coronary vasospasm secondary to
platelet aggregation and release of serotonin [1719].
Catecholamines, angiotensin, and other factors associated with surgical pain may increase platelet activation and accelerate coagulation. Increased
platelet-fibrinogen activation may be especially deleterious in patients with atherosclerotic vascular
disease, since increased plasma viscosity, platelet
aggregation, and platelet release of vasoconstrictive

factors may significantly reduce blood flow in critically stenosed vessels [9,10]. Enhanced sympathetic
tone and intense vasospasm may also compromise
distal graft patency and skin flap viability [10,11].
Pulmonary effects
Pulmonary alterations associated with poorly controlled pain include atelectasis secondary to hypoventilation and pulmonary edema resulting from
stress-induced hypervolemia [2022]. The magnitude
of symptoms is influenced by the extent of the injury,
location (thoracic and upper abdominal injuries),
effectiveness of pain management, and the physical
status of the patient. In contrast to resting pain, the
intensity of effort-dependent pain markedly increases
with inspiration and cough. The pain stimulus is also
hyperalgesic in that severe discomfort and reflexive
muscle splinting may be noted at many dermatomes
above and below the site of injury. Chest wall and
upper abdominal hyperalgesia are responsible for several pathophysiological alterations including musculoskeletal and diaphragmatic dysfunction, and
impaired gas exchange. The classic pulmonary
response to upper abdominal surgical pain includes
an increased respiratory rate and decreased tidal volume (TV), vital capacity (VC), forced expiratory volume (FEV1), and functional residual capacity (FRC)
[2224]. Significant reductions in VC are evident
within the first 3 hours, and declines to 4060% of
pre-operative values have been reported. Following
upper abdominal surgery, reductions in FRC and
FEV1 are detrimental, and are most pronounced at 24
hours; thereafter, values gradually return to near normal levels by post-operative day 7. As FRC declines,
resting lung volume approaches closing volume,
resulting in atelectasis, ventilation/perfusion mismatch, and hypoxemia. Following thoracotomy, alterations in chest wall motion reduce lung compliance
and increase the work of breathing [2022,24].
Splinting secondary to poorly controlled pain exaggerates this process by further decreasing respiratory
effort. If pneumonia or ARDS occurs, the risk of prolonged hospitalization and mortality increases.
Venous thrombotic effects

In the setting of intense pain and increased sympathetic
tone, perfusion of injured tissues is reduced and may
result in impaired wound healing, increased muscle
27
Anxiety, fear,
helplessness,
Sleep deprivation
Central Processing
(Cognitive changes)
Primary
Hyperalgesia
Neural Plasticity
Demoralization
Increased Pain Perception
Facilitated
Noxious
Transmission
Muscle Splinting
Tissue
Injury
Immobilization
Sympathoadrenal
Activation
Increased O2
Consumption
Coronary
Ischemia
Decreased
Regional
Blood Flow
Atelectasis,
Hypoxia
Venous Stasis
DVT
Neuroendocrine
Alterations
Platelet
Aggregation
Poor Wound Healing
Hyperglycemia,
Tissue Catabolism
Immunosuppression,
Increased infection risk
Figure 6.1. Pathophysiological impact of poorly controlled pain. Adapted from: Ghori M, Sinatra RS. The pathophysiology of pain. In: Acute
Pain Management, Sinatra RS, Viscusi G, de Leon-Casasola O, Ginsberg B. (eds), 2008. Cambridge University Press.
28
spasm, and visceral-somatic ischemia and acidosis

[810]. Inadequately controlled pain can predispose
patients to post-surgical deep venous thromboses
(DVT) and pulmonary embolism. As previously discussed, catecholamines and angiotensin released in
response to surgical stress may result in platelet-fibrinogen activation and the development of a hypercoagulable state. Severe pain is commonly associated with an
impaired ability to ambulate and decreased venous
flow, and development of DVT. Thrombotic fragments
can embolize and travel to the pulmonary arteries,
resulting in varing degrees of ventilation perfusion
mismatch and hypoxia. Pulmonary emboli incite the
local release of vasoactive and inflammatory cytokines,
worsening hypoxia symptoms within a short period of
time. If not recognized and promptly treated this complication is associated with a 2030% mortality [810].
monly troubled by sleep disturbances that negatively

impact on mood and motivation to participate in
rehabilitation [26,27]. Sleep quality and duration
appear to be most impaired in patients reporting
pain scores greater than 5 on a 010 scale. Many
patients require anxiolytics and sedatives to experience limited intervals of sleep and generally awake
experiencing increased pain. The widespread pathophysiological impact of poorly controlled pain is
outlined in Figure 6.1.
Emotional and quality of life effects
3. Jensen T. Pathophysiology of pain: from theory to

clinical evidence. Eur J Pain Supp 2008;2:1317.
Finally, poorly controlled and ongoing noxious perception can exacerbate emotional distress, increase
patient anxiety and lead to persistent pain states [25].
Poorly controlled pain is associated with reduced
morale, and learned helplessness. Patients are com-
References
1. Bonicas Management of Pain, 3rd ed. Philadelphia:

Lippincott Williams & Wilkins, 2001.
2. Firestein G. Kelleys Textbook of Rheumatology, 8th ed.
Philadelphia: W.B. Saunders, 2008.
4. Gottschalk A, Smith DS. New concepts in acute pain

therapy: preemptive analgesia. Am Fam Physician
2001;63:19791984.
5. Schaible H. Pathophysiology of Pain. Heidelberg:
Langenbecks Archives of Surgery, 2004, pp. 237243.
6. Samad TA. Interleukin-1-mediated induction of

Cox-2 in the CNS contributes to inflammatory pain
hypersensitivity. Nature 2001;410:471475.
hypertension by attenuating sympathetic

nervous system hyperactivity. JAMA 1989;261:
35773581.
7. Woolf CJ, Shortland P, Coggeshall RE. Peripheral

nerve injury triggers central sprouting of myelinated
afferents. Nature 1992;355:7578.
18. Freeman LJ, Nixon PG, Sallabank P, et al.

Psychological stress and silent myocardial ischemia.
Am Heart J 1987;114:477482.
8. Cousins MJ. Acute pain and the injury response:

immediate and prolonged effects. Reg Anesth
1989;16:162176.
19. Willerson JT, Golino P, Eidt J, et al. Specific platelet

mediators and unstable coronary artery lesions,
Circulation 1989;80:198205.
9. Kehlet H. Surgical stress: the role of pain and

analgesia. Br J Anaesth 1989;63:189195.
20. Moulton AL, Greenburg AG. The pulmonary

system. In OLeary JP, ed. The Physiologic Basis of
Surgery. Philadelphia: Williams & Wilkins, 1993,
pp. 512514.
10. Breslow MJ. Neuroendocrine responses to surgery. In

Breslow MJ, Miller CF, Rogers MC, eds. Perioperative
Management. St Louis: Mosby-Year Book, 1990.
11. Lyons A, Kelly JL, Rodick ML, et al. Major injury
induces increased production of interleukin-10 by cell
of the immune system with a negative effect on
infection resistance. Ann Surgery 1997:226:450460.
12. Dubois M. Surgical stress in humans is accompanied
by an increase in plasma beta-endorphin
immunoreactivity. Life Sci 1981;29:12491254.
13. Redmond HP, Watson RW, Houghton K, et al.
Immune function in patients undergoing open versus
laproscopic surgery. Arch Surg 1994;129:12401246.
14. Allendorf JD, Bessler M, Kaylow ML, et al. Increased
tumor establishment after laparotomy vs laparoscopy
in a murine model. Arch Surg 1995;130:649653.
15. Georges C, Lo T, Alkofer B, et al. The effects of
surgical trauma on colorectal liver metastasis. Surg
Endoscopy 2007;21:18171819.
16. Badner NH, Knoll RL, Brown JE, et al. Myocardial
infarction after non cardiac surgery. Anesthesiology
1998;88:572578.
17. Breslow MJ, Jordan DA, Christopherson R, et al.
Epidural morphine decreases post-operative
21. Sinatra RS, Ennevor S. Pain management following

thoracic and upper abdominal trauma. In Rosenberg
AD, ed. International Trauma Anesthesia and Critical
Care Society. Baltimore, 1999.
22. Duggan J, Drummond GB. Activity of lower
intercostal muscle function after upper abdominal
surgery. Anesth Analg 1987;66:852855.
23. Beecher HK. The measured effect of laparotomy on
the respiration. J Clin Invest 1933;12:639650
24. Ali J, Weisel RD, Layug AB. Consequences of
post-operative alterations in respiratory mechanics.
Am J Surg 1974;128:376382.
25. Kehlet H, Woolf CJ. Persistent postsurgical pain: risk
factors and prevention. Lancet 2006;367(9522):1618
1625.
26. Pavlin J, Chen C, Penaloza DA, Buckley P. A survey of
pain and other symptoms that affect the recovery
process after discharge from an ambulatory surgery
unit. J Clin Anesth 2004;16:200206.
27. Wu C, Naqibuddin M, Rowlingson AJ, et al. The effect
of pain on health related quality of life. Anesth Analg
2003;97:10781085.
29
Section 1
Chapter
Pain Definitions
Neuropathic pain
Ho Dzung and Oscar A. de Leon-Casasola
Background
30
Neuropathic pain (NP) is defined by the International

Association for the Study of Pain as pain initiated or
caused by a primary lesion or dysfunction in the nervous system.
For both diagnostic and therapeutic purposes, NP
has been divided in two large groups: peripheral and
central. Table 7.1 details the common causes and types
of neuropathic pain.
Diagnosis is based on medical history; review of
systems; physical and particularly neurological examination; motor and sensory examination (see below);
and appropriate laboratory studies, including blood
and serological tests, magnetic resonance imaging,
and electrophysiological studies [1,2]. Sensory symptoms include paresthesia (abnormal sensation, either
evoked or spontaneous), dysesthesia (evoked or spontaneous unpleasant, abnormal sensation), hyperalgesia (increased response to a normally painful stimulus),
and allodynia (painful response to a non-noxious
stimulus), hypoesthesia and hypoalgesia (loss of sensitivity to stimulation in general, and painful stimuli in
particular). Sensory and perception abnormalities
associated with neuropathic pain are described in
Table 7.2. Different scales and questionnaires have
been developed in an attempt to demonstrate discriminative features between neuropathic pain and nonneuropathic pain and various tools are available to
screen for neuropathic pain [3]. A 30% reduction in
pain scores using such scales is deemed clinically
important [4].
Sensory examination should include touch, pinprick, pressure, cold, heat, and vibration assessment
[5]. Responses are graded as normal, decreased, or
increased to determine whether negative or positive
sensory phenomena are involved. The stimulus-evoked
(positive) pain types are classified as dysesthetic, hyperalgesic, or allodynic, and according to the dynamic
or static character of the stimulus [6,7]. A more sophisticated neurophysiological test is the quantitative
sensory testing (QST), which uses a battery of standardized mechanical and thermal stimuli [8]. When
present, allodynia or hyperalgesia can be quantified by
measuring intensity, threshold for elicitation, duration, and area. More detailed information on the
assessment of pain, quantitative sensory testing, and
measures of neuropathic pain is available [813].
Pharmacological management of
neuropathic pain
Medications that are Food and Drug Administration
(FDA)-approved for the treatment of NP include carbamazepine (trigeminal neuralgia); gabapentin
(PHN); pregabalin (diabetic peripheral neuropathy
[DPN]; PHN), duloxetine (PHN), and the 5% lidocaine patch (PHN). Thus, a significant portion of drug
therapy used for neuropathic pain is off-label. Guidelines and systematic reviews on the pharmacological
management of neuropathic pain are available [14
21] and are summarized in Figure 7.1.
In general, patients with peripheral NP are treated
with the following algorithm.
1. A 5% lidocaine patch is used initially. If there is
no response, or there is inadequate pain control,
then a tricyclic antidepressant (TCA) is added to
the therapeutic protocol, assuming there is no
contraindication for it use. Alternatively a dual
reuptake inhibitor (serotonin-norepinephrine)
may also be used.
2. Alternative choices for TCAs include
amitriptyline, nortriptyline, or desipramine. All
of these agents have been shown to be effective in
the treatment of neuropathic pain. Consequently,
the choice is based on the drugs side-effect
profile. In this regard, desipramine is not
associated with sedation, as it lacks antihistaminic
effects. Moreover, the incidence of anticholinergic
effects is lower when compared to amitriptyline.
Alternatively, nortriptyline may be used if lack of
Chapter 7 Neuropathic pain
Table 7.1. Types of neuropathic pain

Peripheral
Acute and chronic inflammatory demyelinating
polyradiculopathy
Alcoholic
Chemotherapy-induced peripheral neuropathy
Complex regional pain syndrome type I and II
Entrapment neuropathies (e.g. carpal tunnel syndrome)
HIV sensory neuropathy
Post-surgical (e.g. postmastectomy pain or post-thoracotomy
pain)
Idiopathic sensory
Nerve compression, including tumor infiltration
Nutrition deficiency-related
Diabetic
Phantom limb pain
Post-herpetic neuralgia
Post-radiation plexopathy
Radiculopathy (cervical, thoracic, lumbar)
Toxin-related
Trigeminal neuralgia
Post-traumatic
Central neuropathic pain
Compressive myelopathy
HIV myelopathy
Multiple sclerosis-related
Parkinsons disease-related
Post-ischemic myelopathy
Post-radiation myelopathy
Post-stroke pain
Post-traumatic spinal cord injury
Syringomyelia
sleep is a problem because it will produce

sedation comparable to amitriptyline, but very
little anticholinergic effects. Moreover,
nortriptyline will not block the baroreceptor
reflex, making it an excellent choice for patients
with diabetic peripheral neuropathy. Patients are
started on 25 mg at bedtime and titrated up to
100 mg PO at bedtime on a weekly basis if
needed.
3 . If there is no response, or there is inadequate pain
control, then an anticonvulsant such as
gabapentin or pregabalin is added to the
therapeutic protocol. For gabapentin, patients are

started at 300 mg PO TID, and the dose is titrated
on 300 mg increments weekly, until a dose of 1200
mg PO TID is reached. For pregabaline, patients
are started at 50 mg PO TID and the dose is
titrated on 50100 mg increments weekly, until a
maximum dose of 300 mg PO TID is reached.
Patients are likely to experience sedation and
dizziness with these drugs. However, titration
continues until the maximum dose is reached, or
severe side effects such as hallucinations, ataxia or
severe myoclonic jerks are seen.
4. If no adequate clinical response is achieved with a
combination of these three agents, then an opioid
is indicated as a fourth-line agent. The opioid and
the dose will vary with the patients general
condition and attention to drugdrug interactions
plays an important role in the election of the
drug.
5. If no efficacy is seen with this pharmacological
algorithm, or severe side effects impair ones
ability to titrate the medications to the target
level, then invasive techniques are indicated (see
below).
Patients with central neuropathic pain are managed with the same algorithm, except that 5% lidocaine patch is not used as the first-line agent.
Practice guidelines from the American College of
Occupational and Environmental Medicine also
address various diagnostic and treatment issues related
to neuropathic pain, including drug therapy and some
of the other interventions discussed below (i.e. psychological services, rehabilitation, electrical stimulation therapies and interdisciplinary pain management
programs) [22].
Nonpharmacological management of
neuropathic pain
Nonpharmacological approaches include physical
modalities (physical therapy, massage, exercise, ice,
heat and ultrasound therapy), psychological interventions, and electrical stimulation; in some cases, more
invasive neuromodulatory or neurosurgical interventions may be needed as well.
Rehabilitation
Rehabilitation involves the restoration of lost function. All chronic illness, including persistent pain,
results in loss of function or dysfunction. Rehabilitation
31
Table 7.2.
Term
Definition
Allodynia
Pain due to non-noxious stimuli (clothing, light touch) when applied to the affected area. May be mechanical
(e.g. caused by light pressure), dynamic (caused by nonpainful movement of a stimulus), or thermal (caused
by nonpainful warm, or cool stimulus)
Analgesia
Absence of pain in response to stimulation that would normally be painful
Anesthesia
Loss of normal sensation to the affected region
Dysesthesia
Spontaneous or evoked unpleasant abnormal sensations
Eudynia
Symptom-based pain provoked by an identifiable injury or noxious stimulus
Hyperalgesia
Exaggerated response to a mildly noxious stimulus applied to the affected region
Hyperpathia
Delayed and explosive response to a noxious stimulus applied to the affected region
Hypoesthesia
Reduction of normal sensation to the affected region
Maldynia
Maladaptive pain that persists in the absence of ongoing tissue damage or injury
Neuralgia
Pain in the distribution of a nerve or nerves
Neuropathic pain
Pain initiated or caused by a primary lesion or dysfunction in the nervous system
Neuropathy
A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several

nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy
Nociceptor
A receptor preferentially sensitive to a noxious stimulus or to a stimulus that would become noxious if
prolonged
Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage
Paresthesias
Nonpainful spontaneous abnormal sensations
Phantom pain
Pain from a specific site that no longer exists (e.g. amputated limb) or where there is no current injury
Referred pain
Occurs in a region remote from the source
is essential in order to restore function and wellness.

Rehabilitation is not limited to physical rehabilitation.
It includes occupational, vocational, pharmacological,
social, and other forms of rehabilitation. Modalities
range from passive (massage, stretching) to active
(exercise, dancing). Therapy must be properly supervised and should be progressive in order to restore
function with minimal distress. It is important to
avoid iatrogenic trauma and exacerbation of pain.
Psychological interventions
32
Specific psychological traits or experiences affect an

individuals response to pain and suffering. These
include fear, attention and vigilance to pain, catastrophizing and worry, avoidance of pain-inducing activity, mood disorders, anger and hostility, self-denigration,
differences in the ability to achieve control in the face
of distress and disability, and the ability to comprehend the factors exacerbating pain [23]. These psychological factors must be addressed in managing patients
afflicted with persistent pain [24].
Behavioral treatments are designed to identify

social and environmental factors that provoke pain
behaviors or the lack of wellness behaviors. Withdrawal of attention (i.e. from spouse or caregiver) to
pain behaviors is encouraged and avoidance behaviors
(on the part of the patient) are discouraged through
the use of reinforcers and punishments [25,26]. Behavioral approaches also employ self-regulatory treatments for chronic pain that teach patients to control
certain bodily responses through relaxation, hypnosis
and/or biofeedback. Time-contingent instead of paincontingent drug use may be a part of this strategy as
well, although this approach does not work especially
well in patients who experience spontaneous, paroxy
smal pain. Graduated activity exposure or pacing is
another behavioral strategy used in chronic pain conditions to help patients regulate and gradually increase
their activity level.
Cognitive therapy consists primarily of education
and is generally employed in conjunction with behavioral therapy (see below). It demands patient participation and transfers the responsibility from an external
TCAs and SSRIs

Amitriptyline, Nortriptyline
Duloxetine
Regional Nerve Blockade

Stellate ganglion block,
Lumbar sympathectomy,
Peripheral nerve block
Anticonvulsant Agents
Pregabalin, Gabapentin, Carbamazepine
Interventional Techniques
Peripheral neural stimulation,
Spinal cord stimulation,
Neuroablation
Topical Agents
Capsaicin, 5% Lidocaine Patch
Non Pharmacological Approaches

Behavioral modification
Cognitive Therapy
Physical Therapy
Nutritional Counseling
Opioids
Tramadol, Tapentadol,
Hydrocodone, Oxycodone,
Methadone
NMDA
Inhibitors
Ketamine,
Amantidine,
Memantiine
Figure 7.1. Treatment options for neuropathic pain.
to an internal locus of control, attempting to make the

patient aware of the implications of pain and to better
align expectations of treatment.
Cognitive-behavioral therapy (CBT) represents a
selected combination and integration of treatments
aimed at reducing or extinguishing the influence of
the factors that reinforce or maintain patients maladaptive behaviors, beliefs and patterns of thought
[27]. Often the first stage in CBT is to educate and
provide a credible rationale for treatment by addressing the causes and consequences of pain. This can
assist in understanding the perpetuation of pain, disability and distress, and in challenging erroneous
beliefs, fears, and maladaptive avoidance behavior.
Patients are taught to develop insights into the nature
of self-defeating patterns of thinking and develop
ways of challenging the premises from which these
thoughts develop. This can lead to reversal of symptom-contingent declines in activity; crafting achievable goals that can be reinforced; and fostering anger
management, stress reduction, and development of
self-relaxation responses. Published randomized
controlled trials provide good evidence for the effectiveness of CBT or behavioral therapy for certain
chronic pain conditions (e.g. back pain, fibromyalgia) in adults [28,29].
Multidisciplinary treatment
Behavioral medicine is generally embedded in a comprehensive, multimodal pain treatment program.
Patients who suffer from chronic pain may experience
higher rates of comorbid psychiatric disorders (e.g.
depression, anxiety), as well as sleep disturbances.
Effective treatment of these conditions must be part of
the management plan.
Comprehensive treatments aim to eliminate maladaptive pain-related behaviors, achieve pain control,
and improve coping through use of the above-noted
techniques in combination with an interdisciplinary
team approach to improve psychological functioning,
reduce disability, and achieve rehabilitation [30]. A
multimodal approach requires the combined efforts
of: (1) a physician(s) knowledgeable in pharmacological and/or interventional procedures; (2) a psychiatrist or other mental health professional to diagnose
and treat psychiatric conditions that may result from,
cause, or exacerbate pain and suffering; referral for
33
biofeedback, cognitive-behavioral techniques, group

therapy, and counseling are warranted early in the
course of treatment in patients with psychosocial
impairment; (3) a physical therapist or rehabilitation
specialist to assess physical conditioning requirements; physical therapy referral is useful for neuromuscular rehabilitation, gait and prosthetic device
assessment, therapeutic exercise instruction, desensitization (especially in patients with allodynia and
hyperalgesia), and electrical stimulation trials (if warranted); and (4) nurses knowledgeable about these
approaches who serve to improve team function, and
provide valuable assistance in sustaining patient optimism and participation.
Several studies have evaluated the clinical and
cost-effectiveness of multidisciplinary pain centers,
generally supporting their efficacy on multiple outcome criteria [3134]. A recent systematic review of
multidisciplinary treatments for chronic pain showed
they were effective in patients with chronic low back
pain and fibromyalgia, but exhibited less robust effects
in patients with chronic pain of mixed etiology [35].
Interventional management of
neuropathic pain
When systemic or topical pharmacotherapy and other
non-invasive approaches provide inadequate relief in
patients with NP, interventional approaches may be
used, including sympathetic blockade with local anesthetics, intraspinal drug delivery, spinal cord stimulation, peripheral subcutaneous nerve stimulation, or
stimulation of specific central nervous system structures, and various neuroablative procedures (e.g. dorsal rhizotomy, neurolytic nerve block, intracranial
lesioning). Neuroablative procedures are not reversible and should be reserved for carefully and properly
selected patients with intractable pain.
Nerve blocks
34
The interruption, interference, or blockade of painful

stimuli has been used in the management of pain for
several decades. Acute, chronic, and post-operative
pain can be diminished with various types of regional
anesthesia or specific nerve blocks. In the setting of
chronic pain management, various peripheral nerve
blocks can be diagnostic, prognostic, or therapeutic in
nature. Nerve blocks are generally most useful when a
specific nerve or limb is affected. Neural blockade may
help differentiate a peripheral source of pain from a
neuroma or entrapped nerve root, identify sources of

referred pain, or assist in distinguishing somatic from
visceral pain.
Sympathetic ganglion blocks are widely employed
for diagnostic and therapeutic purposes: e.g. diagnosis of sympathetically maintained pain; neuropathic
pain, including phantom limb pain; complex regional
pain syndrome; and ischemic pain. If analgesia is
afforded with local anesthetic blockade, chemical or
thermal neurolysis may be used in an attempt to provide long-term relief. Many case reports, case series,
and retrospective reviews have been published, but
few prospective placebo-controlled, blinded studies
exist [36]. Controlled evidence supports the use of
neurolytic blocks in patients with low back pain, head,
neck and shoulder pain, fibromyalgia, complex
regional pain syndrome, and cancer pain. The strongest evidence exists for celiac plexus/splanchnic neurolytic blockade for cancer pain and lumbar sympathetic
block or neurolysis for reflex sympathetic dystrophy
and lower extremity ischemic pain [36,37].
Neurostimulation
In the past 25 years, the field of pain management has
increasingly incorporated technologies of neurostimulation as part of the treatment algorithm for patients
with maldynia. Methodological problems are encountered in blinding, recruitment, and assessment in
nearly all published trials of these interventions. Nevertheless, patients entered in these trials have generally suffered for extended periods, and many have
reported substantial relief.
Transcutaneous electrical stimulation

(TENS) for chronic pain
TENS is used in a variety of clinical settings to treat a
range of acute and chronic pain conditions and has
become popular with patients and healthcare professionals of different disciplines. By applying peripheral
stimuli (rubbing, vibration, heat, cold) or, in the case
of TENS, electrical stimulation directly over the area
of pain, sensory information from larger-diameter
(non-pain-carrying) afferents is activated, and affects
the processing of pain impulses within the dorsal horn
of the spinal cord. TENS is generally believed to be a
safe and relatively non-invasive intervention that can
be used to alleviate many different types of pain,
including neuropathic pain (primarily diabetic peripheral neuropathy) [38]. However, systematic reviews
have concluded there is insufficient evidence to draw

any conclusions about the effectiveness of TENS for
the treatment of chronic pain in adults, or in the treatment of chronic lumbar back pain [39,40].
Spinal cord stimulation

Spinal cord stimulation (SCS) is a form of therapy
used to treat certain types of chronic pain. An array of
stimulating metal contacts is positioned in the dorsal
epidural space. An electrical field is generated through
connection of the contacts with an electrical generator. The leads can be implanted by laminectomy or
percutaneously, and the source of power is supplied by
an implanted battery or by an external radio-frequency
transmitter. The resulting field presumably stimulates
DRG axons and dorsal column fibers [41,42]. The goal
is to create a field of (tolerable) paresthesias that overlap and cover the anatomic distribution of pain
reported by the patient. A temporary trial of stimulation, most commonly performed with percutaneous
lead placement, is required to identify patients who
might benefit.
A comprehensive set of practice parameters on the
use of spinal cord stimulation in the treatment of
chronic neuropathic pain has been developed [42].
Indications include failed back surgery syndrome,
complex regional pain syndrome, peripheral neuropathic pain, phantom limb/post-amputation syndrome, recalcitrant PHN, root injury pain, and spinal
cord injury or lesions. It also is being used in the management of pain associated with multiple sclerosis,
pain due to ischemic peripheral vascular disease, and
interstitial nephritis.
Motor cortex stimulation is reserved for the treatment of complex central and neuropathic pain syndromes that have proven refractory to medical treatment,
including post-stroke pain, deafferentation pain, and
some neuropathic pain states of peripheral origin.
Summary and conclusion

Neuropathic pain is distinct from normal, nociceptive
pain triggered by noxious stimuli. It is believed to be
triggered by persistent nociceptive stimuli or frank
nerve injury. These conditions activate a series of
adaptive and, eventually, maladaptive changes in the
function and properties of pain-carrying fibers and
other sensory neurons, including phenotypic changes
and alterations in gene expression, as well as the fundamental properties of specific neurons and sensory
pathways. Likewise, NP involves not only neuronal

pathways, but also Schwann cells, satellite cells in the
DRG, components of the peripheral immune system,
spinal microglia, and astrocytes. As such, it is a multidimensional process that warrants consideration as a
chronic degenerative disease not only affecting sensory and emotional processing, but also producing an
altered brain state, based on both functional imaging
and macroscopic measurements.
Despite recent advances in understanding of the
pathology related to nervous system injury, the management of NP remains a challenge. Patients who have
substantial disability and psychosocial problems, and
who have not benefited from conventional pain treatments, are often referred to multidisciplinary pain clinics. These multimodal programs aim to eliminate
maladaptive pain-related behaviors, achieve pain control, and improve coping through biopsychosocial techniques in combination with an interdisciplinary team
approach to improve psychological functioning, reduce
disability, and achieve rehabilitation. These programs
have largely been validated in patients with chronic
noncancer pain or certain mixed pain states, but not in
patients with NP per se. A number of interventional
approaches, including nerve blocks, spinal cord stimulation, and cortical stimulation, may be required when
patients do not respond adequately to medical, psychological, and pharmacological management.
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Chapter 8 Genetics and pain
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Section 1
Chapter
Pain Definitions
Genetics and pain

Keith A. Candiotti and Claudia R. Fernandez Robles
Introduction
Human beings differ widely in their rating and experience of painful stimulation. There are large variations
in interindividual sensitivities to noxious pain, susceptibility to acute or chronic pain (even among
patients with the same medical condition), and individual responses to analgesics. These individual
responses arise from a multitude of factors, including
environmental elements and genetic variations or polymorphisms [15]. Understanding the factors that
contribute to patient-related variability in pain behavior and responses to analgesics is critical for the effective treatment of patients and management of their
pain. This chapter will review some important pain
polymorphisms and how they can influence the pain
behavior of patients.
Genetic factors (Table 8.1)

Mu opioid receptor (MOR)
The mu receptor OPRM1 is the primary target site for
opioid medications. The gene for this receptor is
located on chromosome 6 and is a significant factor in
the variability of how a patient responds to opioids.
The most common single nucleotide polymorphism
(SNP), or basepair change, of the MOR gene consists

of a change of adenine to guanine in the 118 position
that leads to a substitution of the amino acid asparagine for aspartate. This substitution affects the function
of the receptor by increasing its binding affinity for
-endorphins and subsequently affects the action of
opioids at the receptor site [13].
Carriers of the G118 MOR variant, when compared
with homozygous carriers of the A118 allele (wild
type), have a decreased clinical response to opioids.
Klepsad et al. [1] found that chronic pain patients,
homozygous for the variant G118 allele, required more
morphine (225143 mg/day) to achieve pain control
when compared with heterozygous patients (A/G,
6650 mg/day) and patients having the homozygous
wild-type A/A (9789 mg/day). While imparting
resistance to the analgesic properties of morphine it
was also noted that patients who were homozygous for
G/G, and who had renal failure, better tolerated the
accumulated levels of morphine-6-glucoronide and
vomited less than non-carriers. In yet another study,
patients who were G/G homozygotes and were undergoing a total knee arthroplasty consumed significantly
more morphine in the first 24 and 48 hours (22.3
10.0 mg and 40.4 22.1 mg respectively) compared to
A/A homozygous (16 8 mg and 25.3 15.5mg) [3].
37
Table 8.1. Genetic modulation and clinical response to analgesics
Good medication response or

pain resistance
Poor medication response or pain

sensitivity
OPRM1
Carriers of the variant A118 allele
Carriers of the variant G118 allele
COMT
Carriers of val/val genotype
Carriers met/met genotype
CYP2D6
Extensive metabolizers
Poor metabolizers
MCR1
Carriers of two MCR1 alleles
Non-carriers of MCR1 alleles
GCH1
Carriers of the CGH1 haplotype
Non-carriers of CGH1 haplotype
ABCB1
Homozygous T/T carriers
Homozygous C/C carriers
OPRM1, Mu opioid receptor; COMT, catechol-O-methly transferase; CYP2D6, cytochrome 2D6; MC1R, melanocortin-1-receptor; GCH1,
guanosine triphosphate cyclohydrolase-1; ABCB1, ATP-binding cassette, sub-family B, member 1.
ATP-binding cassette, sub-family B,

member 1 (ABCB1)
Another important determinant of opioid bioavailability is the efflux transporter P-glycoprotein ABCB1
encoded by ABCB1/MDR1 gene. ABCB1 can limit
the entry of morphine and its metabolites into the
brain and actively pump drugs out of the central
nervous system. Campa et al. [4] demonstrated an
example of the cumulative effect of polymorphisms
in the ABCB1/MDR1 and OPRM1 genes by studying
the SNP C3435T in the ABCB1/MDR1 gene and for
the A118G SNP in the OPRM1 gene in patients
undergoing morphine therapy. They reported that
ABCB1 homozygous T/T carriers had significantly
greater pain relief from morphine than subjects who
were homozygous wild-type C/C carriers. Additionally, OPRM1 homozygous A/A subjects had a significantly greater decrease in pain than homozygous
patients with the OPRM1 G/G genotype. Finally,
when the two SNP were studied together, homozygous
patients for OPRM1 A/A and ABCB1/MDR1 T/T
were found to be best responders when compared
with patients who were heterozygous for the OPRM1
and ABCB1/MDR1 SNPs.
Catechol-O-methyltransferase (COMT)
38
COMT is an enzyme that acts as a key modulator of

the dopaminergic and adrenergic system. Recent studies have demonstrated the importance of this enzyme
in the regulation of pain perception [6,7]. The gene
encoding for this enzyme, located on chromosome 22,
contains a common functional polymorphism in
codon 158 that causes a substitution of valine for
methionine (val158met). This substitution results
in decreased thermostability of the enzyme and a
34-fold reduced activity, leading to a decrease in the

degradation of dopamine, and, as a consequence, an
increase in norepinephrine and epinephrine levels
which appear to lead to exaggerated levels of pain.
Three different COMT haplotypes have been identified:
The val/val genotype has the highest activity of the
COMT enzyme and patients are referred to as low
pain sensitivity (LPS) patients.
The met/met genotype has the lowest activity of the
COMT enzyme and patients are referred to as high
pain sensivity (HPS) patients.
Patients having the heterozygous genotype have an
intermediate COMT activity and are considered to
have average pain sensivity (APS).
In a study of cancer patients [6] it was noted that
homozygous carriers of the LPS genotype required
less morphine (95 99 mg/day) for relief of cancer
pain than heterozygous patients (117 10 0mg/day)
and HPS patients (155160 mg/day). In addition to
their phenotypic pain behavior, it was also noted that
LPS patients exhibit greater cortisol responses to
naloxone administration and had higher brain concentrations of receptors.
Cytochrome CYP2D6
Cytochromes (CYP) are significant phase I metabolizing enzymes. Of the various CYP enzymatic pathways
CYP2D6 has gained much attention in relation to
codeine, oxycodone, tramadol, and hydrocodone
metabolism. The variable clinical response to these
particular opioids can to a great extent be explained
by polymorphisms of the gene encoding for the
CYP2D6 enzyme [8,9].
Chapter 8 Genetics and pain
There are approximately 100 CYP2D6 allelic variants identified; however, there are basically four
metabolizer states: poor metabolizers (PM), who have
two inactive genes and have no enzymatic activity;
intermediate metabolizers (IM), who have less than
normal activity, usually one inactive and one low-
activity gene; extensive metabolizers (EM), who have
one or two wild-type genes; and ultrarapid metabolizers (UM), who possess more than two wild-type genes
and increased enzymatic activity. These genetic variations may account for the differences in intrinsic clearance of 70-fold between EM and PM for codeine
O-demethylation, 10-fold for dihydrocodeine and
oxycodone and 200-fold for hydrocodone.
Using codeine as an example of the effects of a
metabolizer state, patients who lack enzymatic activity (PM) will not be able to convert codeine to its most
active metabolite, morphine, and thus patients will get
little if any analgesic benefit from the drug. In contrast, it has been reported that ultrarapid metabolizers
(UM) may convert codeine to morphine too quickly,
resulting in an excessive dose of morphine even when
giving only a standard dose of codeine. A true codeine
overdose is probably due to multiple factors since it is
not commonly reported and the CYP2D6 UM can be
as high as approximately 30% in some populations.
CYP2D6 has also recently been demonstrated to
be a rate-limiting enzyme in the production of cellular
morphine in humans. It has been suggested that
CYP2D6 UM might have increased pain tolerance due
to potentially increased cellular morphine production. In one association study performed on surgical
patients it was noted that those patients possessing a
CYP2D6 UM state required less morphine in the acute
post-operative period when compared with other
CYP2D6 metabolizer groups [8].
Interleukin-1
The cytokine interleukin-1 (IL-1) acts as a major initial
inducer of a proinflammatory state. Two structurally
different forms (IL-1 and IL-1) exist, both of which
bind to the same receptor protein (IL-1R). A third component of the IL-1 complex is the IL-1 receptor antagonist (IL-1RA), which binds to the IL-1R but does not
activate it. IL-1RA plays an important role in inflammation due to the fact that it down-regulates IL1- and
IL1- thereby decreasing the inflammatory response
and subsequently pain. Recent evidence suggests that
the degree and severity of surgery-induced inflam
mation may be significantly influenced by genetic
polymorphisms of IL-1RA [2,10,11]. In a study performed in women undergoing transabdominal hysterectomy, a polymorphism in the IL-1RA gene, which leads
to higher levels of IL1-RA, was associated with decreased
morphine consumption [2]. In another study, conducted
in patients with painful knee osteoarthritis, an injection
of 150 mg of IL-1RA intra-articularly resulted in a significant improvement in pain scores (20.4 23.3 mm
[p = 0.008]) on a visual analog scale [10].
Melanocortin-1-receptor (MC1R)
Melanocortin-1-receptor (MC1R) is one of the key
proteins involved in regulating skin and hair color.
Humans having a mutation in this gene typically will
have a reddish hair color and fair skin. The protein is
located on the plasma membrane of melanocytes. Several SNPs have been identified which result in a loss of
function of MC1R due to impaired G protein coupling.
Studies have shown that subjects carrying a non-functional MC1R have 1.3-fold higher tolerance to electrical pain stimuli, and they are more sensitive to thermal
pain stimuli and more resistant to the analgesic effect
of subcutaneous lidocaine when compared to control
subjects with a functional MC1R gene [12,13].
MC1R variants appear to modulate opioid efficacy
in a sex-specific manner. Women carrying two nonfunctional MC1R alleles demonstrated a greater benefit from the analgesic effects of the -opioid agonist
pentazocine than women carrying only one or none of
the MC1R variant or men with the same MC1R genotype. Mogil et al. [12] reported that inactivation of
MC1R increased the analgesic effects of morphine-6glucuronide. The effect in this case was noted to be
gender-independent. Finally, it has also been reported
that female patients carrying the MC1R variants associated with red hair also require more anesthetic
agents to achieve a comparable MAC level compared
to women with dark hair [13].
Guanosine triphosphate cyclohydrolase-1

(GCH1)
GCH1 is the rate-limiting enzyme in the production
of tetrahydrobiopterin (BH4). It has been reported
that excessive BH4 is associated with the development
of neuropathic pain following injury. Polymorphisms
in GCH1 that decrease function have been reported to
be associated with decreased pain levels. This is noted
to be especially true in subjects carrying a series of
15 polymorphisms in the GCH1 gene. For example,
39
Ltsch et al. [14] reported that the need for the initiation of opioid pain medication was delayed in
homozygous carriers of this haplotype compared to
heterozygotes or non-carriers, indicating that it
imparts some degree of pain resistance.
Uridine diphosphate-glucuronosyltransferase 2 family polypepetide B7 (UGT)

Opioids such as morphine, buprenorphine, and
codeine are mainly glucuronidated by UGT. In the
case of morphine UGT metabolizes it to form morphine-6-glucoronide (M6G) and morphine-3-glucoronide (M3G); M6G acting as an opioid agonist and
MG3 demonstrating anti-analgesics effects. Polymorphisms in the UGT2B7 gene have been linked to variability in the level of morphine and its metabolites. In
a study performed on Japanese patients with cancer,
patients with the UGT2B7*2 variant allele had a lower
frequency of nausea when compared to subjects without the allele [15]. While variants of UGT have been
noted to affect drug levels and metabolites it is unclear
whether they have direct analgesic consequences.
Conclusion
Genetic variations appear to play a much bigger role in
inter-individual pain responses than was once thought.
This section is not meant to be a comprehensive review
of genetics and pain but is intended to point out the
significance of these factors in the pain phenotype.
While many patients are often given labels relative to
their pain behavior it seems likely that much of this
phenotypic behavior is not truly within their control
and may in fact be due to their individual genetics. It is
important for the practitioner to keep in mind that
resistance to opioids may not be due to acquired tolerance but rather genetic resistance [16,17]. When managing patients it would seem reasonable that if a
treatment was not successful in the past or less than
acceptable it should not be repeated. Overall, by keeping in mind that the genetics of a patient may be affecting their pain phenotype caregivers may be able to
deliver more individualized and effective care.
References
40
1. Klepstad P, Rakvg T, Kaasa S. The 118A_G

polymorphism in the human opioid receptor gene
may increase morphine requirements in patients with
pain caused by malignant disease. Acta Anaesthesiol
Scand 2004;48:12321239.
2. Bessler H, Shavit Y. Post-operative pain, morphine

consumption, and genetic polymorphism of IL-1
and IL-1 receptor antagonist. Neurosci Lett
2006;404:154158.
3. Chou WY, Yang LC. Association of m-opioid receptor
gene polymorphism (A118G) with variations in
morphine consumption for analgesia after total knee
arthroplasty. Acta Anaesthesiol Scand 2006;50: 787792.
4. Campa D et al. Association of ABCB1/MDR1 and
OPRM1 gene polymorphisms with morphine pain
relief. Clin Pharmacol Ther 2008; 83;559566.
5. Candiotti K, Yang Z. The impact of CYP2D6 genetic
polymorphisms on post-operative morphine
consumption. Pain Med 2009;10, No5.
6. Rakvag TT, Klepstad P, Baar C, et al. The Val158Met
polymorphism of the human catechol-Omethyltransferase (COMT) gene may influence
morphine requirements in cancer pain patients. Pain
2005;116:7389.
7. Zubieta JK, Heitzeg MM, Smith YR. COMT
val158met genotype affects mu-opioid
neurotransmitter responses to a pain stressor. Science
2003;299:12401243.
8. Foster A, Mobley E, Wang Z. Complicated pain
management in a CYP450 2D6 poor metabolizer. Pain
Practice 2007;4:352356.
9. Reynolds K, Ramey-Hartung B, Jortani S. The value of
CYP2D6 and OPRM1 pharmacogenetic testing for
opioid therapy. Clin Lab Med 2008;28:581598.
10. Chevalier X. Safety study of intraarticular injection of
interleukin 1 receptor antagonist in patients with
painful knee osteoarthritis: a multicenter study.
J Rheumatol 2005;32:7.
11. Edwards R. Genetic predictors of acute and chronic
pain. Curr Rheumatol Rep 2006; 8:411417.
12. Mogil JS, Ritchie J, Smith SB, et al. Melancortin-1 receptor
gene variants affect pain and mu-opioid analgesia in mice
and humans. J Med Genet 2005;42:583587.
13. Stamer U. Genetic factors in pain and its treatment
Curr Opin Anaesthesiol 2007;20:478484.
14. Ltsch J, Geisslinger G, Tegeder I. Genetic modulation
of the pharmacological treatment of pain. Pharmacol
Ther 2009;124:168184.
15. Fujita K, Ando Y, Yamamoto W, et al. Association of
UGT2B7 and ABCB1 genotypes with morphine-induced
adverse drug reactions in Japanese patients with cancer.
Cancer Chemother Pharmacol 2010;65:251258.
16. Compton P, Geschwind D. Association between
human m-opioid receptor gene polymorphism, pain
tolerance, and opioid addiction. Am J Med Genet Part
B (Neuropsychiatric Genetics) 2003;121B:7682.
17. Somogyi A, Barratt D, Coller J. Pharmacogenetics of
Opioids. Clin Pharmacol Ther 2007;81:429444.
Section 1
Chapter
Pain Definitions
Persistent post-operative pain

Peter G. Lacouture
Introduction
Some have defined persistent pain as a disease entity
unto itself. Persistent post-operative pain has challenged pain management specialists for decades; it is
only in the past several years that it has received significant attention. The continuation of pain and pain
disability beyond the immediate post-operative period
often results in medical (interventional and pharmacological), economic (healthcare utilization, loss of
productivity) and psychological (depression, anxiety)
complications.
Definition
In order to better understand the information that follows, a clear definition of the entity that we call persistent post-operative (post-surgical) pain needs to be
defined. Precision does not currently exist; however,
we will follow one of the original attempts in 1999 to
describe this condition as:
pain that develops after a surgical procedure
pain that is present for at least 2 months
pain where other causes are excluded
pain that is excluded if it exists from a presurgical problem
Obviously, the task of defining a pure condition or
syndrome is not within the scope of this chapter.
However, the limitations of the data from the literature must be appreciated.
Historical background
Chronic post-surgical pain was probably first described
in 1944 by army surgeons who noted persistent intercostal pain in soldiers who had undergone thoracotomy procedures for trauma. Nearly half a century later
in 1991, this condition was once again described in
patients following thoracic surgery. However, it was
not until 1998 that researchers published papers recognizing this condition and expanding its presence
beyond thoracic surgery. At that time the term coined

was chronic post-surgical pain. While this complication of surgery was well-recognized, the methodology
to properly study this issue was not well-developed.
However, attention to this condition increased and
one researcher stated that chronic pain associated
with inguinal hernia repair was the most serious and
long-term problem with these surgeries. The condition was then defined as persistent post-operative
pain. While any injury may lead to chronic painful
conditions, it is the post-surgical patients that are the
focus of this chapter. Clinical and scientific articles on
this subject continue to grow to include many surgical
procedures including thoracotomy, hernia repair,
breast cancer surgery, joint replacement, abdominal
surgery (hysterectomy, cholecystectomy, C-section)
and amputation [1,2].
Epidemiology
The incidence of persistent post-operative pain varies
not only with the operations involved but also with
the methodologies utilized to collect and evaluate
data. Table 9.1 presents the results of one such epidemiological exploration focusing on the incidence of
this condition with selected surgical procedures.
While incidence rates are not precise because of
the methodological variability used to gather this
information, they do provide insight into the presence
of this condition. The numbers reported from the UK
and USA suggest the operations noted are surgical
procedures that place patients at risk. The estimated
incidence of persistent post-operative pain in these
patients, based on more than 7 million operations,
ranges from 6% for cesarean section to upward of 85%
in amputation. While this rate with amputation could
be anticipated (often because of existing pathologies),
the incidence in hernia (up to 35%), mastectomy (up
to 50%) and thoracotomy (up to 65%) can be of concern.
41
Table 9.1.
Type of operation
Incidence of chronic
pain
Total operations
No. of ops in UK in
20056
No. of ops in USA

in 1994
7 125 000
22 629 000
Mastectomy
2050%
18 000
131 000
Cesarean section
6%
139 000
858 000
Amputation
5085%
15 000
132 000
Cardiac surgery
3055%
29 000
501 000
Hernia repair
535%
75 000
689 000
Cholecystectomy
550%
51 000
667 000
Hip replacement
12%
61 000
Thoracotomy
565%
660 000
(With permission from Macrae 2008 [1].)
Significance
One of the most significant factors related to the
importance of addressing this post-operative condition is the observation that the number of surgical
procedures that are at risk has increased markedly
over the decade. Subsequently, if we do not address
the pathways and treatments of these chronic pains,
the prevalence will probably increase. In turn, the
physical, social and economic burden will also
increase. In one study with post-thoracotomy patients,
persistent post-operative pain limited normal daily
activities in more than 50% of these patients and sleep
disturbances were reported in 2530% of this population. These disruptions are often driven by inadequate
pain control.
In summary, persistent post-operative pain is a
term that has its origin in the middle of the twentieth
century, but it has been largely ignored as a significant
issue with impact on patient comfort, social interactions and financial complications. The approach of this
chapter is to help shed light on the operative procedures that have been linked to this chronic condition
and define pathological mechanisms where possible.
Identifying risk factors and predicting those who will
develop this post-operative complication will be considered. Finally, treatments, both preventative and
post-surgical, will be examined and future directions
in this field of pain research identified.
Mechanisms
42
As with our understanding of the epidemiology of

this condition, our understanding of the mechanism(s)
involved is incomplete. To add complexity to the

identification of these mechanisms is the belief that
the pathways involved vary with the operative procedure, the skill of the surgeon, the patients pain
threshold, etc. Many of the changes seen in these
patients are believed to be either neuropathic or
inflammatory or probably both. In addition, visceral
pain pathways have been proposed to play an important role in the development of this condition. As
always, outcomes are complicated by the fact that
there is no single mechanism that is operative in
these patients. In general, mechanisms can be
described by pain processes, structures and neuronal
plasticity.
Pain processes
The three classic pain processes are believed to be
involved in the evolution of persistent post-operative
pain: nociceptive, inflammatory, and neuropathic.
Nociceptive high-threshold receptors are first to
respond to the incision made for the operation. These
receptor activities can largely be reduced once the
local tissue disruption is limited or removed. The next
in the sequence of events involves a complicated cascade of events as the tissue responds with inflammatory mediators. These cytokines, chemokines and
other tissue factors act by reducing the thresholds of
nociceptors in the injured tissue (peripheral sensitization), ultimately resulting in CNS changes (central
sensitization). These changes can go on for days if left
unchecked. The neuropathic changes are the final act.
Acute pain from the initial injury results in changes in
the spinal cord and brain. The seminal event driving
Chapter 9 Persistent post-operative pain
these changes is nerve injury (see below). Spontaneous pain, dysasthesia, hypersensitivity, allodynia,
hyperalgesia, and hyperpathia develop.
Structures
Nerve
Peripheral changes
It is widely assumed that traumatic injury to the nerve
is the major cause of post-operative neuropathic pain,
but it is probably more complicated than this suggestion. It is also likely that the particular procedure and
sensory systems in the surgical field contribute. Additionally, in some patients, continuous inflammatory
responses, such as after inguinal hernia repair, drive
the chronic response. However, it is the role of peripheral nociceptor sensitization that seems to be at the
center of this issue.
In thoracotomy studies, damage to the intercostal
nerves sustained from direct pressure, stretching and
ischemia may contribute; however, some investigators
have shown little relationship between nerve injury
and chronic pain after 3 months.
In investigations following mastectomy, damage to
the intercostobrachial nerve was believed to contribute to this condition, but one study demonstrated
post-mastectomy syndrome with patients who had
the intercostobrachial nerve spared. In a prospective,
randomized, controlled trial with this nerve being
spared in one group and sacrificed in another, while
sensory deficit was less in the preserved group, there
was no difference in the two groups at 3 months but
interestingly the symptoms were worsened more in
the group with the nerve preserved. While it is clear
that nerve disruption obviously contributes to chronic
involvement, it is equally clear that there are other
processes involved.
In amputation patients, the peripheral changes
evolve around the completely disrupted afferent nerve
from the extremity. Following the injury/surgery, the
neurons show retrograde degeneration and eventually
terminal swelling and sprouting leading to neuroma
formation. Ectopic discharges from these terminals
lead to spontaneous pain due to the electrical properties of the cell membrane probably related to changes
in sodium and potassium channels. Mechanistically it
is interesting to note that local anesthetics reduce the
stump pain, but not the phantom limb pain, suggesting involvement of proximal pathways. This possible
pathway lies in the dorsal root ganglia, possibly regulated by sympathetic sprouting.
The spinal cord

Once again we can gain insights into persistent postoperative pain through the amputation model.
Changes have been suggested to occur in several areas
of the dorsal horn neurons whereby repeated firing of
ectopic discharges from the damaged nerve result in a
destruction of inhibitory GABA-containing neurons
and a subsequent hyperexcitable spinal cord. Furthermore, down-regulation of the opioid receptors in the
region and up-regulation of the cholecystokinin system contributes to hyperexcitability.
Central changes
Central sensitization often expressed as hyperalgesia
and allodynia has always been considered a factor in
the development of this chronic pain state. Experimental data from animals and humans support the
thought that the continuous afferent barrage from the
periphery generates and maintains sensitization of
central neurons. Furthermore, studies examining the
difference between neuraxial block over general
anesthesia confirms this observation.
With persistent post-operative pain following
amputation there is extensive change in the brainstem,
thalamus and cortex. Axonal sprouting in the cortex
has been shown in monkeys to lead to reorganizational changes, as have changes in the thalamus. In
general, there are meaningful changes in cortical reorganization resulting in responses from surrounding
areas not normally associated with the site of the
injury. In addition, alterations in sensory and motor
feedback result from incongruence between these two
systems.
Non-nerve
Within the surgical field, there are many structures
which may be damaged including muscle, vascular
components, tendons, ligaments, etc. More recently,
investigators feel that persistent post-operative pain
may contain a visceral component generated by the
non-neuronal tissues involved.
Neuronal plasticity
Whether affected pathways are peripheral or central,
neuronal plasticity is certainly a key neuropathic component involved in persistent post-operative pain. A
schematic representation is shown in Figure 9.1 in
anatomical terms (central and peripheral).
Plasticity of neuronal tissue is generally divided into
two types: reversible changes in the nerve programming
43
Cortex
7
Thalamus
Limbic
system
Hypothalamus
Brain stem
Spinal
Cord
Dorsal root ganglion

3
4
Figure 9.1. Sites and mechanisms

responsible for chronic postsurgical
neuropathic pain. (1) Denervated
Schwann cells and infiltrating
macrophages distal to nerve injury
produce local and systemic chemicals
that drive pain signaling. (2) Neuroma at
site of injury is source of ectopic
spontaneous excitability in sensory
fibres. (3) Changes in gene expression in
dorsal root ganglion alter excitability,
responsiveness, transmission, and
survival of sensory neurons. (4) Dorsal
hom is site of altered activity and gene
expression, producing central
sensitisation, loss of inhibitory
interneurons, and microglial activation,
which together amplify sensory flow. (5)
Brainstern descending controls modulate
transmission in spinal cord. (6) Limbic
system and hypothalamus contribute to
altered mood behavior, and autonomic
reflexes. (7) Sensation of pain generated
in cortex (past experiences, cultural
inputs, and expectations converge to
determine what patient feels). (8)
Genomic DNA predispose (or not)
patient to chronic pain and affect their
reaction to treatment. (With permission
from Kehlet et al., 2006 [2].)
Nerve
2
Surgical
nerve injury
1
44
during inflammation and less reversible changes in the

nerve structure related to nerve injury. The early reversible phase occurs during inflammation and is characterized by hypersensitivity. Inflammatory mediators such
as by-products of the arachidonic acid cascade are
released and lead to initial peripheral sensitization (primary hyperalgesia). This in turn leads to intracellular
signaling through various ion channels which increases
nerve excitability. Once healing is complete, this type of
heightened nerve response generally abates. However,
the changes that follow this initial phase are far more
troublesome. The barrage of nerve input from the site of
the injury results in a synaptic plasticity in the spinal
cord that amplifies the pain signals. These signals are
transmitted via the dorsal horn upward to the brainstem, thalamus and cortex. The sprouting of neurons
that result leads to simple sensory input being magnified
to severe levels. To augment this action in the dorsal

horn there is an altered gene transcription of the sensory
nerves that increases excitatory transmitters and reduces
inhibitory transmitters. Interestingly, these early changes
can be reversed. However, if the central sensitization is
significant and does not reverse, a normally innocuous
stimulus activates pain pathways. This central sensitization is described as a normal sensory input that results in
sensitivity spread beyond the site of injury (secondary
hyperalgesia).
Unlike the plasticity orchestrated by inflammation,
primary injured sensory neurons and their neighbors
begin to fire spontaneously, further increasing central
sensitization and peripheral tactile allodynia. In addition to changes in sodium channel function there is an
up-regulation of voltage-gated calcium channels contributing to the negative central sensitization secondary
to nerve injury. Neuroimmune effects then create

changes at the distal end of the injured nerve axon
releasing substances such as TNF-alpha that create
more disturbances in the spinal cord, enhancing hypersensitivity. In addition, activated microglia responding
in the synaptic junctions of the dorsal horn contribute
to pain hypersensitivity. These changes continue for
days, but while some are reversible, some are not,
including the loss of sensory neurons resulting in a permanent CNS lesion. This largely peripheral effect
increases to involve genetic changes in the dorsal horn.
The damage is predominantly within the inhibitory
pathways which usually buffer incoming sensory input.
These changes continue upward until significant
changes occur in the cortex.
Despite the complexities, it is of great value to
attempt to dissect the important pathways that are
probably involved in the generation of this chronic
state. Whatever the pathway involved determining the
major contributor (inflammatory, neuropathic and/or
visceral) will help define the most successful treatment approach.
Operative procedures
There is a risk of persistent post-operative pain with
any surgery and the list is growing. However, some of
these operative procedures have received more scrutiny and investigation than others.
Thoracic surgery
Several studies have examined the incidence of chronic
post-thoracotomy pain and suggest that this condition exists in 4467% of patients. Reasons for thoracic
surgery may be many, but two surgical approaches are
defined: open chest (sternal or intercostal) or laparotomy (video-assisted thoracoscopy). While studies
vary in their methods of evaluation, all seem to agree
that there is significant risk of developing persistent
post-operative pain following these procedures. One
study investigated the possibility that the less invasive
thoracoscopy would produce less persistent postoperative pain and found that the prevalence was
approximately equal in both (4047%). This study also
suggested that only half of the pain suggested a neuropathic element and that a visceral element may also
play a role. This finding, if borne out in future studies,
suggests that intercostal nerve damage is not the only
operative in this chronic painful condition and that a
visceral component with more extensive surgery and/
or pleurectomy may complicate the picture.
Inguinal hernia repair

Inguinal hernia repair forms the basis of a common surgical procedure (2800 per million people in the USA)
in relatively healthy individuals to further explore the
nature and incidence of persistent post-operative pain.
While in the 1980s persistent post-operative pain was
considered somewhat rare, by the 1990s it was estimated
that upward of 50% of patients experienced this pain. In
a review of 40 studies on this subject, the overall incidence ranged from 15 to 53%. Pain was reported in 63%
at 1 year and 54% after 2 years. Patients with moderate
to severe pain (12%) reported persistent pain at 2 years.
In another study a cumulative prevalence of 30% at 3
years was reported, with 33% of these patients reporting
moderate to unbearable pain. In 17 trials comparing
laparoscopic to open repair techniques, eight trials
reported less persistent pain with laparoscopic, four trials reported more with laparoscopic and five trials found
no difference. It is interesting that the less invasive techniques may not demonstrate a lower incidence of this
chronic condition. Three studies evaluated mesh and
non-mesh repairs, with two of these studies reporting
less persistent post-operative pain with mesh repair.
From these studies, patients at risk of developing this
condition were those with recurrent hernia, those with
pre-operative pain, those with a visible bulge before surgery, those with high pain scores post-operatively and
those with outpatient surgeries. A definitive interpretation of all these data is difficult because of the lack of
consistent methodology among the studies.
Breast surgery
The majority of the information in this area relates to
cancer-related breast surgery. While chronic postoperative pain following breast cancer surgery was also
considered rare, many studies have indicated that the
incidence of this condition was over 50%. However,
the impact of emotional states and follow-up treatment (chemotherapy and/or radiation) makes precise
attribution to the surgical procedure difficult. Can we
learn from the type of surgery in the breast cancer
patient; i.e. is it radical (mastectomy) or is it conserving (lumpectomy)? Unfortunately, the incidence of
this persistent post-operative pain has not varied
greatly with these two substantially different procedures, mastectomy (2356%) and breast conserving
(3561%). This again reflects a similar observation
seen with thoracic and inguinal hernia surgery that
less invasive approaches still carry significant risk of
45
developing this chronic condition. It is of interest to

note that a study comparing the incidence in high volume (43%) with low volume (56%) hospitals was similar. Risk factors for the development of persistent
post-operative pain include age (suggesting that
younger patients are at greater risk), but this may be
complicated by the fact that these patients in general
have a poorer prognosis. Additionally, chemotherapy
and radiation have been possibly linked to a greater
risk. The presence of pre-operative pain and the severity of post-operative pain have also been shown to
increase the risk of developing persistent post-operative pain. Finally, psychosocial factors such as distress
may increase the risk for this condition. Additionally,
there is a need for quality studies comparing cancer
and non-cancer populations. In one such study, the
incidence reported with mastectomy with reconstructive implant was 53%, but 31% with a simple mastectomy and only 22% for breast reduction.
Abdominal hysterectomy
Little is known about persistent post-operative pain in
relation to gynecological procedures; however, hysterectomy is one of the more common surgical procedures. In a 2008 review, only eleven studies were
found, defined and analyzed. Pain was commonly
reported as a pre-operative symptom and pain 12
years after surgery ranged from 4.7 to 31.9%. Epidemiological studies with this procedure suggested that
the rate was 14.7% in the USA and 24% in the UK.
Pre-operative pain was associated with a higher risk of
having pelvic pain on follow-up and it was suggested
that this preexisting pain may have sensitized nerve
pathways and contributed to the development of
chronic pain. Interestingly, the presence of chronic
pain was similar whether surgery was trans-abdominal or trans-vaginal. Furthermore, pre-operative
depression resulted in a higher incidence of this postoperative pain.
Amputation
46
While persistent post-operative pain was believed to

be low following amputation (2%), phantom limb
pain occurs in anywhere from 50 to 80% of amputees.
It is suggested to be independent of age, but it is more
prevalent if the amputation is conducted in adulthood vs. childhood. It is also independent of gender
or site of amputation. Most studies show no relationship with health status and this condition exists
whether the amputation is for trauma or medical
reasons.
Onset is early, with 76% of patients developing pain within the first few days after amputation;
however, it can be delayed for months or years. There
are a series of mechanisms involved in the generation
of phantom limb pain including changes in the
periphery, the spinal cord and the brain. The first
events are likely to involve the periphery (deafferentation) and spread to the DRG (ectopic discharges
and sprouting), to the dorsal horn (central sensitization) and then to various areas of the brain (brainstem
and cortical reorganization). Clearly, neuroplastic
changes develop at all sites.
Cesarean section
One of the operative procedures that continues to
grow in western countries from 9% in 1980 to 12% in
1990 to 2224% in 2002 is cesarean section. A study of
women post-cesarean section in 2004 found that
nearly 20% reported chronic pain 3 months after surgery and 12% at 6 months. Interestingly, it has been
suggested that the frequency of chronic pain is higher
in patients receiving general anesthesia vs. those
receiving spinal anesthesia. This finding has many
pointing to the need to block the continuous barrage
from afferent pathways which leads to central sensitization (hyperalgesia and allodynia). In these studies
the level of immediate post-operative pain was positively correlated with the incidence of persistent postoperative pain.
Overall, persistent post-operative pain exists with
many operative procedures and the incidence varies,
but its impact may be based on the number of these
operations performed. It is of particular interest to
note that the theoretically less invasive procedures still
result in this chronic condition. One would suggest
that there is much more for us to learn about this condition and how to standardize evaluations defining
cause and effect. In general, however, research methodologies need to improve in order to better understand the operative risks and how to minimize their
impact.
Risk factors
Patient factors
Many factors related to the individual patient carry
importance in affecting the risk of developing
persistent post-operative pain. These include age,
psychosocial variables, pre-operative and post-operative experiences with pain, and genotype.
Interestingly, with breast cancer surgery and

inguinal hernia repair increasing age has been reported
to decrease the risk of developing persistent post-operative pain. With mastectomy, younger patients may
have larger tumors, poorer response to therapy and
poorer prognosis, leading to an incidence of 65% in
those 3049 years old, 40% in those 5069 years old
and 26% in those over 70 years old. In fact, it has been
approximated that with inguinal hernia and breast
cancer surgery the risk decreases by 5% with each year
increase of age. A similar relationship was also
reported with thoracic surgery. Juxtaposed to these
observations, phantom limb pain seems more common when the amputation occurred in adulthood and
less frequent in children.
While there are many studies that examine psychosocial variables in acute post-operative pain, there
are fewer that examine these factors related to persistent post-operative pain. To make things worse, the
results are often contradictory! One study in thoracotomy patients, possibly compromised by small
numbers, showed no relationship between depression
and anxiety in patients with or without persistent
post-operative pain. However, in a trial with breast
cancer surgery, one year after surgery, while pre-operative anxiety levels had returned to normal in patients
with or without persistent post-operative pain, depression remained high in those with persistent postoperative pain. In another investigation, fear of surgery
was associated with a negative outcome for persistent
post-operative pain. However, in these studies, catastrophizing was not identified as a risk factor. Furthermore, is seems the psychosocial factors that are
predictive for acute pain are generally not predictive
for persistent post-operative pain.
Pre-operative screening has been employed in an
attempt to identify those at risk. In one study with
patients S/P thoracotomy, testing for diffuse noxious
inhibitory control (DNIC) demonstrated its value. A
logistic regression revealed that DNIC and acute postoperative pain intensity were independent predictors
of persistent post-operative pain.
Pre-operative and acute post-operative pain has
been considered to play an important role in this condition. Pre-operative pain has been demonstrated in several trials on inguinal hernia repair to be related to the
development of persistent post-operative pain. Similar
suggestions for this relationship were determined in
post-amputation and breast cancer studies. However, a
correlation for total hip arthroplasty was not observed.
One of the variables that has been discussed is the impact
of acute post-operative pain. Severe pain post-operatively has been identified as a consistent risk factor for
developing this chronic pain condition. One investigation with thoracotomy even suggested that early postoperative pain was the only factor that significantly
predicted long-term chronic pain. These post-operative
pain investigations have included inguinal hernia repair,
breast cancer surgery, total hip arthroplasty and cesarean section.
Surgical/medical factors
While it is clear that the type of surgical procedure has
significant impact on the development of persistent
post-operative pain, the duration of surgery (longer
than 3 hours) was observed to correlate with the development of chronic pain. The duration could be a risk
factor because longer operations may reflect more
serious disease, complications of the surgery and final
outcomes. Additionally, the surgical technique also
weighs heavily on the incidence of persistent postoperative pain. The surgical procedure has also been
examined with different types of breast cancer surgery
(see above). With inguinal hernia repair there was no
clear relationship with type of procedure and persistent post-operative pain; however, with cholecystectomy the open procedure had a higher incidence than
the laparoscopic procedure. With thoracic surgery,
the less invasive video-assisted thoracoscopy failed to
show a lower incidence of persistent post-operative
pain.
While the skill of the surgeon is likely to play a
role, it is difficult to measure. Nevertheless, one study
evaluating breast surgery for cancer found that the
incidence of persistent post-operative pain was less in
high-volume specialists than with lower-volume less
experienced practitioners. However, this is in contrast
to the report that there was no difference between
high-volume and low-volume hospitals. Findings with
different operations including amputation (traumatic
vs. disease), thoracic surgery (esophageal disease vs.
lung cancer), and hernia surgery (initial vs. revision)
are equivocal.
Anesthetic and analgesic use has also been evaluated as a possible contributor to persistent post-operative pain. One study has suggested that properly used
regional anesthetic techniques can reduce the incidence of chronic post-thoracotomy pain. In another
study evaluating patients undergoing thoracotomy
procedures, it was shown that nearly 50% of the patients
taking opioid analgesics prior to surgery developed
47
persistent post-operative pain, but only 5% of those

not receiving opioids prior to surgery.
One of the areas of recent interest with anesthetics
and analgesics focuses on the theory that ascribes pain
before and after the operative procedure to result from
sensitizing of the nervous system which contributes to
the development of persistent post-operative pain. Preclinical research suggests that post-operative control of
acute pain may significantly reduce the incidence of
this condition. However, a major difference to be
addressed is the fact that animals tested in these trials
are pain-free before the operation where patients may
have pain and therefore already sensitize key pain pathways. Several trials suggest a benefit to post-operative
pain control including abdominal hysterectomy, cesarean section, thoracotomy and iliac crest harvesting.
However, there are other trials which show no benefit.
Also, multimodal therapy has been attempted, but
results are inconsistent. Despite these failures, it would
seem that the correct combination, at the correct time,
for the correct duration of control would have a positive
impact on reducing persistent post-operative pain.
Finally, concomitant therapy with radiotherapy or
chemotherapy may have a measureable negative impact
on persistent post-operative pain. In a study of women
following surgery for breast cancer, there was an increased
risk of persistent post-operative pain with radiotherapy.
Genetic factors
Several investigators have suggested that certain patients
many be genetically predisposed to developing chronic
pain following nerve injury. This theory has been supported by laboratory studies with mice. These studies
have investigated several models of neuropathic pain.
Conditions that could predispose patients include
fibromyalgia, migraine, IBS, irritable bladder and Raynauds syndrome. In a hernia population, a history of
backache, IBS or headache was positively associated
with the development of this chronic condition. Also, in
a study in women following abdominal hysterectomy, a
possible genetic link to fibromyalgia was proposed. This
is a new and growing area of research that is likely to
offer significant insight into this condition in the future.
Predicting persistent post-operative

pain
48
Predicting the occurrence of persistent post-operative

pain begins with an understanding of the surgical
procedure (and specific techniques) described above,
as well as the risk factors described above. However,

can we develop an algorithm or scoring system to
identify those patients at increased risk of developing
this potentially debilitating condition? While the
answer to this question is not complete at this time, it
is promising. In 2003 a scoring system based on age,
sex, type of injury, extent of post-operative pain and
level of anxiety was developed. Additionally, investigations into pre-operative sensitivity to heat and cold
stimuli in knee surgery, cholecystectomy and cesarean section suggest positive correlations with severe
post-operative pain experiences. Since the intensity of
post-operative pain has been linked to persistent postoperative pain, understanding those likely to have
severe pain following surgery may help eliminate this
finding in those patients. In even more advanced
thinking, pain-protecting or pain-producing gene
haplotypes identified by SNPs could contribute to our
understanding of this condition and guide our intervention. These steps are not fully validated; however,
they are steps that must be taken and repeated.
Management
Prevention
Is an ounce of prevention worth a pound of treatment?
Certainly the first ounce of prevention would
begin with describing to the patient pre-operatively
that with all surgery there is tissue damage by its
nature and sometimes disruption of nerve function.
Probably one of the easiest and often most productive
approaches to avoiding the development of this condition is to stabilize the psychological component.
Patients who wish to blame the surgeon often have
behavioral problems with their pain and are poor
responders to other treatment modalities. One study
found that patients who believe they were injured in
surgery had lower pain thresholds, deconditioning
and reduced activity. It is important to manage these
behaviors pre-operatively in order to minimize the
confusing input from psychological dimensions.
Probably the most obvious way to reduce the development of persistent post-operative pain is to utilize
surgical techniques that avoid damage to major nerves.
In inguinal hernia repair, laparoscopic procedures as
opposed to open procedures where possible can possibly reduce the risk of nerve injury. In addition, lightweight mesh may reduce the inflammatory response
following surgery; although, as noted above, some
believe these measures are not effective. In mastectomy,

preservation of the intercostobrachial nerve has been
suggested to reduce chronic pain. Also sentinel node
biopsy can indicate that further axillary dissection is
not necessary, thereby further protecting the intercostal
nerve structure. Similarly, minimally invasive thoracoscopy may spare the intercostal innervations. Stretch
and retraction with open thoracotomy has also been
shown to increase the risk of damaging the intercostal
nerve. The utilization of intercostal suture techniques
may help avoid nerve compression. Other anatomical
approaches such as using a posterolateral approach for
thoracotomy may reduce the impact of nerve disruption, although not all agree with these suggestions.
Treatment
Preemptive/preventative
Preemptive approaches to control post-operative pain
have been studied in many trials with many approaches.
To date, the results have been mixed, but have generally
been disappointing. Part of this finding may be that we
need to understand more about the pain mechanism
and the type and duration of pre-treatment efforts. This
approach is complicated by research that demonstrates
an inflammatory and neuropathic component to postsurgical pain. While local anesthetics may be effective
in reducing the barrage from injured nerves and subsequent development of central plasticity, does their effect
last long enough? In addition, the inflammatory component may need more aggressive therapy lasting
longer through the healing period. Some research indicates that the changes leading to plasticity may not
occur until well after the surgical procedure, indicating
that not only the mechanism of treatment but also the
timing of treatment is important. Furthermore, new
treatments may be needed to specifically address the
biological cascades and events that result in this persistent post-operative condition. Currently, much of the
approach to treating these patients lends itself to the
focused development of multimodal approaches.
Post-operative
Other than the preventative approaches taken above,
the most effective treatment is the aggressive management of post-operative pain. Some of the most significant information suggests that severe post-operative
pain is associated with a higher incidence of persistent
post-operative pain. While a perfect cause and effect
link is not available, we have strong suggestions that
aggressive and well-structured peri-operative pain
management is pivotal. A recent study in post-cesarean patients found that patients with persistent postoperative pain exhibited a stronger recall of
uncontrolled post-operative pain. While the results
are somewhat equivocal, it would appear that the
effectiveness and duration of treatment is more important than the timing (preemptive) of treatment. Many
believe that our inadequate treatment and anticipation of acute pain contributes on a psychological level
to the development of persistent post-operative pain.
Most suggest that a balanced multi-modal approach
may best address the myriad of mechanisms contributing to this condition. These strategies are largely
driven by differentiating neuropathic from non-neuropathic origins.
Opioids
Clearly nociceptor activity plays a role in post-surgical
pain. The most effective treatment of classic nociceptor pathways is mu-agonist opioids. There are many to
select from and the decision is largely based on the
severity of post-operative pain and the anticipated
duration of nociceptive firing.
COX-1/COX-2 inhibitors
These are commonly used interventions that have
merit because of the significant role that inflammation plays in this condition. However, the NSAIDs
that inhibit the constitutive cyclooxygenase (COX-1)
are not as likely to be effective as are the agents that
inhibit the inducible cyclooxygenase (COX-2), which
is more responsible for inflammation. Furthermore,
they are effective in visceral pain, significantly potentiate opioids and inhibit central prostaglandins
responsible in part for central sensitization.
Alpha-2 receptor agonist
The discovery of the alpha receptor in the regulation
of many of the centrally mediated pain responses has
made these agents an interesting option. Development
of central sensitization, wind-up leading to allodynia
and hyperalgesia has been significantly attenuated by
these agonists. They have also been shown to significantly potentiate opioids and local anesthetics.
Ketamine (NMDA antagonists)
While the NMDA antagonists commercially available
have not been extremely effective, the antagonism of
glutamate is likely to play an important role in the
neuropathic elements of this condition. Newer agents
targeted at several receptors in the glutamate family
49
may be available in the future, which could have significant impact on this chronic condition.
Local anesthetics
The use of injectable and topical local anesthetics may
have a palliative role in treatment of the immediate
post-operative period, resulting in more effective
treatment of pain. Generally, these agents have short
durations of action; however, continuous infusions
and potentially longer-acting agents (35 days) have
merit. While somewhat less effective, patches and
creams may be beneficial in some patients.
Multimodal
Given the complexity of persistent post-operative pain, it
is likely that a multifaceted approach to different pathological mechanisms is needed. Since the origins of the
pain differ with differing surgical procedures, the first
approach would be to consider the needs following differing surgeries. Since inflammation has been suggested to
play a significant role in this condition, the utilization of a
COX-2 inhibitor is logical; however, we will need antiinflammatory agents in the future that have a more pronounced and targeted effect. Tricyclic antidepressants are
commonly used in some analgesic cocktails because they
act through serotonin and noradrenaline to modulate
neuropathic elements. Other membrane-stabilizing
drugs such as gabapentin, topiramate, tiagabine, etc. work
in concert to block ion channels and glutamate release.
Approaches using ketamine or other NMDA antagonists
could help blunt central plasticity. Combining this
approach with a longer-acting local anesthetic could
prove effective. Once again, it is paramount to address the
multiple pain pathways involved post-operatively.
New targets
There are a number of new developments in the treatment of inflammatory and neuropathic pain that are in
development (see Chapter 108: Novel targets for new
analgesics). This includes the advancement of neurotrophic factors (NGF, BDNF, etc.) and other cytokines.
Also the ion channel modulators (sodium, calcium, and
potassium) show promise. Several receptor-driven
products including the purinergic receptors (P2X4 and
P2X7) and the glutamate receptors (NMDA, AMPA,
and the mGluR family) may have utility.
Epilogue future directions

50
The approach for the future in managing this disruptive post-operative condition starts with prevention.
Improvement in surgical techniques to reduce nerve

and other tissue disruption will be important. The role
of inflammation discussed above should always be
aggressively addressed and newer anti-inflammatory
treatments developed. Next is the need to better
understand and manage post-operative pain. Longeracting local anesthetics can interrupt the sensory
afferents to reduce neuronal sensitization. Application
of growth factors such as neurotropic factors may help
prevent transcriptional changes in the sensory nerves.
Prevention of microglial activation has been suggested
to help protect DRG and dorsal horn structures. Ion
channel (sodium, potassium, calcium) agents that
modify nerve transmission and those that modulate
glutamate transporters and reduce caspases decrease
excitotoxicity. Maybe one of the more significant
advances is in the area of research. We must try and
design studies that consistently capture information
that properly characterizes the procedure, the pain
and the persistence. Procedure-specific parameters
should be developed, as should studies with pre-operative, intra- and post-operative and extended (> 3
months) assessments.
There is little debate that persistent post-operative pain is an important phenomenon for us to consider and better understand. As in many areas of
science and medicine, there is much to be learned
from identifying those at risk to provide treatment
to minimize the personal, healthcare, and psychological burdens. While disagreement exists as to
description, quantification, differentiation, and
management of these patients, it is this spirit that
propels us forward to produce more research in this
area from the bench (pathways, genetics) to the bedside (pre- and post-operative and less disruptive
surgical procedures).
References
1. Macrae WA. Chronic post-surgical pain: 10 years on.

Br J Anaesth 2008;101:7786.
2. Kehlet H, Jensen TS, Woolf C. Persistent post-surgical
pain: risk factors and prevention. Lancet
2006;367:16181625.
3. Brandsborg B, Nikolajsen L, Kehlet H, Jensen TS.
Chronic pain after hysterectomy. Acta Anaesthesiol
Scand 2008;52:327331.
4. Flor H, Nikolajsen L, Jensen TS. Phantom limb pain: a
case of maladaptive CNS plasticity. Nature Rev
Neurosci 2006;7:873881.
Section 1
Chapter
10
Pain Definitions
Analgesic gaps
Sunil J. Panchal
Introduction
Despite significant efforts to improve acute pain management through the development and implementation of pain management guidelines and acute pain
services in many hospitals, acute post-operative pain
management remains inadequate. A number of variables have been cited as causes of undermedication,
including educational deficits, over-reliance on opioid
analgesic monotherapy, inadequate patient assessment and technology-related failures. Goals of the
clinical practice guideline established by the Agency
for Healthcare Research and Quality (formerly the
Agency for Health Care Policy and Research) include
reducing the incidence and severity of post-operative
pain and improving patient satisfaction and comfort
to optimize pain management [1]. Other organizations have also tried to address the under-treatment of
pain in the acute pain setting through evidence-based
clinical practice guidelines and position statements,
such as the International Association for the Study of
Pain; the American Pain Society; American Society of
Anesthesiologists (ASA); and the American Academy
of Pain Medicine [2]. Yet, a review of the literature
found that a significant proportion of patients receiving post-operative analgesia still experienced moderate-to-severe pain following surgery. A survey of 250
adults who had undergone surgical procedures was
performed in which questions were asked about the
severity of post-surgical pain, treatment, satisfaction
with pain medication, patient education, and perceptions about post-operative pain and pain medications.
Approximately 80% of patients experienced acute pain
after surgery. Of these patients, 86% had moderate,
severe, or extreme pain, with more patients experiencing pain after discharge than before discharge. Experiencing post-operative pain was the most common
concern (59%) of patients [3]. These findings were
very similar to a survey performed a decade earlier
[4]. This continuing problem has a significant impact
on patient outcomes, as management of acute
post-operative pain is often suboptimal, leading to

delayed recovery, prolonged hospital stays, and
increased patient distress and anxiety [5]. At the same
time it is important to recognize that while opioid
analgesics effectively control acute pain, they also can
cause life-threatening side effects [6]. Analgesics are
the most common class of drugs associated with preventable adverse drug events (ADE) [7], which are
defined as injuries resulting from medical intervention related to a drug, and may involve either the
appropriate or inappropriate use of a drug.
One contributor to the inadequate management of
post-operative pain may be the occurrence of analgesic gaps, defined as periods during which the patient
does not have access to analgesia. Patients may experience analgesic gaps while being transported from one
location to another, such as from the OR to the PACU
or ICU, or the PACU to hospital bed, for common
examples. Patients may also experience analgesic gaps
when waiting for nursing staff to administer bolus
doses of opioid via the intravenous (IV) or intramuscular (IM) route, or during the transition from one
analgesic modality to another, such as transitioning
from patient-controlled epidural analgesia (PCEA) to
IV-PCA [8,9]. In a study by Ng and colleagues, the
analgesic gap was defined as the shortfall of pain management during patients transition from post-surgical
epidural analgesia or IV-PCA to oral analgesics. A
period of inadequate analgesia occurred in 40 (45%)
of 89 post-operative patients within the first 2 days
after surgery and in 17 (17%) of 22 patients with high
pain scores after IV-PCA was discontinued. In a survey of 115 patients 24 hours after IV-PCA was discontinued per standard guidelines, Chen and coworkers
found that 38 (33%) patients requested that IV-PCA
be restarted, mostly because they believed that it
would be more effective than the prescribed oral analgesic [10]. To avoid this analgesic gap, it is critical to
consider the timing of discontinuing IV or epidural
therapy in the patients recovery, use equianalgesic
51
IV-PCA systems are also prone to patient errors and

system malfunctions. In some cases these issues occur
at a frequency great enough to cause the US Food and
Drug Administration (FDA) to take action by issuing
a recall due to a design defect that caused some of the
infusion pumps to disrupt analgesic therapy [11]. Furthermore, the complexity of the IV-PCA system may
increase the risk of SREs, due to problems with the
infusion pump, IV line, or other components of the
system.
Panchal and coworkers evaluated the incidence of
analgesic gaps resulting from SREs for patients using
the fentanyl iontophoretic transdermal system (ITS),
a non-invasive PCA system, or morphine IV-PCA for
post-operative pain management [12]. For morphine
IV-PCA, infiltration of the IV line was the most frequently reported SRE that resulted in an analgesic gap.
Infiltration at the catheter site is a problem commonly
encountered with IV-related procedures, and may
result in IV line failure and/or a subcutaneous depot
of opioid, leading to inadequate and ineffective delivery
conversions, and allowing time for oral therapy to take

effect before stopping any technology-supported pain
therapies. Above all, patients should be frequently
assessed for interruptions in pain control.
The incidence of analgesic gaps may vary depending on the analgesic delivery system used to administer
analgesia. For instance, systems that are complex, invasive, or involve multiple steps for analgesic administration may have a higher frequency of technology failures
or system-related events (SREs, defined as problems
related to the analgesic system that must be addressed
by healthcare providers) that may result in interruptions in pain control. Patient-controlled analgesia
(PCA) modalities may help to minimize analgesic gaps,
since they allow patients to control their pain according
to their personal analgesic needs. IV-PCA is routinely
used to manage post-operative pain and is often considered the gold standard for acute pain management.
However, analgesic administration using IV-PCA
requires manual programming of the infusion pump,
which introduces the potential for programming errors.
Table 10.1. Frequency of SREs resulting in an analgesic gap
52
Fentanyl ITS
Morphine IV-PCA
Type of SRE
(n = 647)
(n = 658)
Infiltration
none
17
Device malfunction or failure
26
11
Line pulled out
none
Low or dead battery
none
Alarm going off
none
Incorrect programming /dosing
none
Line leaking
none
Incompatible medication in line
none
Edema
none
Patient/family tampering
none
Could not locate button
Patient had difficulty with use
Air in the line
none
Phlebitis
none
Pain at the site
none
Itching
none
Erythema
none
Other
16
Total
41
98
SRE, system-related event; ITS, iontophoretic transdermal system; IV-PCA, intravenous PCA.
Chapter 10 Analgesic gaps
of analgesic, as well as pain and discomfort (Table

10.1). Incorrect programming and dosing errors
occurred with morphine IV-PCA in the two studies
included in this analysis. Many of the SREs encountered with morphine IV-PCA are not possible with
fentanyl ITS, as the system does not require IV access
or dose adjustment. Device malfunctions or failures
accounted for most of the SREs that occurred with the
fentanyl ITS; however, manufacturer diagnostics
found no problem with the system in 35% of these
cases. Such a result may be attributed to nurses unfamiliarity with this novel analgesic delivery system.
In other words, nurses may have mistakenly diagnosed a malfunctioning or failing unit when there was
no problem. Improved nurse training after product
availability is likely to decrease the rate of system
failures.
Use of the fentanyl ITS may require fewer resources
to address SREs and resulting analgesic gaps, including decreased time spent by nurses and other healthcare providers. Technological advances that reduce the
staff time and resource consumption required for analgesic administration may be an important consideration in determining preferred analgesic modalities.
Another study by Hankin and colleagues evaluated 2009 IV-PCA-related reports filed with the FDA
(MAUDE database) during a 2-year index period
(20022003), the majority of which could be classified
as possibly preventable (those classified as possible
operator errors, patient-related events, or device safety
events) [13]. Given that published accounts of IV-PCA
problems have historically focused on operator error
and patient tampering [1416], the authors were surprised to find that device safety events (i.e. device malfunctions) were the suspected cause of nearly 80% of
reported events (75% of these reportedly attributable
to defective switches, display boards, or motors) (Table
10.2). It is noteworthy that nearly two-thirds (64.9%)
of these device malfunctions were duplicated and confirmed upon inspection by the manufacturer. Of those
device malfunctions that were not confirmed, about
half are under continued evaluation by the manufacturer and nearly one-quarter were never received by
the manufacturer. Only 159 suspected device malfunctions (representing 10% of the total events in this
category) were conclusively cleared of defects upon
manufacturer inspection.
Although operator errors were less frequent than
device malfunctions, these events were associated
with the most severe consequences, including six
deaths, two occurrences of respiratory arrest, and

50 cases in which naloxone was administered. Device
safety events were associated with no deaths or
instances of respiratory arrest or depression, and
only four occurrences of naloxone administration.
This seems to suggest that operator errors were
more likely than device malfunctions to result in the
over-delivery of medications, which is the most dangerous consequence of an IV-PCA-related event.
In contrast, device safety events usually resulted in
under-delivery of medications, thereby creating
analgesic gaps.
In consideration that there are approximately 50000
device-related reports that are submitted annually
to the FDA, IV-PCA-specific reports identified during
this 2-year review represent 2% of total device-related
reports. The total number of events identified in this
analysis probably underestimates the true number of
IV-PCA-related events as there are substantial barriers to event reporting, including fear of potential
liability, assumptions that information provided will
not be meaningful to others, and concern regarding
the complexity and time required to complete narrative reports. Indeed, researchers estimate that only
1.27.7% of actual adverse events are ever reported
[1720], suggesting that the true rate of IV-PCArelated events that occurred during this two-year
index period ranged from 13 948 (1074 divided by
7.7%) to 89 500 (1074 divided by 1.2%). This is the
first study to comprehensively examine FDA reports
of IV-PCA-related problems since event reporting
became required by both industry and healthcare
facilities. It is clear that IV-PCA pumps are inherently
complex devices that may be especially susceptible to
both operator error and device malfunction. Continued in-depth study of adverse events involving these
devices can help identify innovations in device design
and testing to reduce the occurrence of preventable
adverse events, as well as analgesic gaps.
Conclusion
Analgesic gaps are a significant component as to why
patients are under-treated in regard to acute pain, and
occur from a variety of causes. In order to mitigate
this problem and improve patient outcomes, it is
important for institutions to take a comprehensive
approach. It is necessary to address transition issues
such as patient location changes, as well as transitions
from one analgesic therapy to another. This will
53
Table 10.2. Frequency of reported events by possible causes, results of manufacturer testing, and adverse event patient
outcomes
Reported
event and
possible
cause (per
narrative
text)
Total
reported
Results of manufacturer testing
Adverse event
Sent and
tested by
mfg
Possible cause confirmed

by mfg
% of
tested
% of
total
Defective reed
switch
516
32.5
437
409
93.6
79.3
Defective
motor
488
30.7
428
384
89.7
78.7
0.2
N(1)
Battery,
display board,
software
214
13.5
129
84
65.1
39.3
0.9
U(1), B(1)
Defective
support
assembly
114
7.2
96
80
83.3
70.2
0.0
Faulty alarm
system
48
3.0
29
22
75.9
45.8
0.0
Failure to
deliver drug
on demand
38
2.4
0.0
0.0
2.6
NoA(1)
Defective
patient
pendant
29
1.8
20
19
95.0
65.5
6.9
N(2)
Defective
mechanism
board
23
1.4
12
33.3
17.4
0.0
Defective or
loose 5 mL
switch and/or
EOS alarm
19
1.2
19
14
73.7
73.7
0.0
Faulty syringe
injector
assembly
0.4
100.0
16.7
Other
95
6.0
19
15
78.9
15.8
Total
1590
100.0
1191
1032
86.6
64.9
PCA pump
programming
error
106
80.9
58
39
67.2
36.8
54
50.9
D(3), N(38), RA(1),

S(5), U(4), RD(3)
Failure to
clamp or
unclamp
tubing
4.6
0.0
0.0
16.7
N(1)
% of total
reported
AE type (n)
Device safety
0.0
16.7
N(1)
1.1
NoA(1)
0.5
Operator error
54
Chapter 10 Analgesic gaps
Table 10.2. (cont.)
Reported
event and
possible
cause (per
narrative
text)
Total
reported
Results of manufacturer testing
Adverse event
Sent and
tested by
mfg
Possible cause confirmed

by mfg
% of
tested
% of
total
% of total
reported
AE type (n)
Pharmacy
error
4.6
0.0
0.0
66.7
D(1), N(1), RA (2)
Improperly
connected to
patient
3.1
0.0
0.0
50.0
S(1), N(1)
Improperly
loading
syringe or
cartridge
3.1
0.0
0.0
0.0
Medication
prescription
error
2.3
0.0
0.0
66.7
Battery
improperly
inserted
1.5
50.0
50.0
0.0
Total
131
100.0
65
40
61.5
86.8
63
48.1
Intentional
tampering
with device
66.7
33.3
12.5
50.0
Family
members
operating
demand
button
33.3
0.0
0.0
0.0
Total
12
100.0
16.7
8.3
33.3
Inaccurate
amount of
drug delivered
13
5.5
0.0
0.0
23.1
BL(1), BR(1), N(1)
Over-delivery
of drug
165
70.2
57
1.8
0.6
48
29.1
C(1), D(7), DZ(1),

N(31), RA(1), D(2),
S(1), U(4)
Under-delivery
of drug
57
24.3
22
0.0
0.0
0.0
Total
235
100.0
81
1.2
0.4
51
21.7
D(2)
Patient-related
N(4)
Indeterminate
B, battery fell on patient; BL, blood backed up into catheter; BR, catheter broke off in patient; C, coma; D, death; DZ, dizziness; N, naloxone/
narcan; NoA, no analgesia delivered; RA, respiratory arrest; D, respiratory depression; S, sedation; U, unspecified.
55
require understanding of the pharmacokinetic differences of various therapeutic options, as well as maintaining the availability of the therapy that is to be
discontinued until the new treatment option is confirmed to be effective. Analysis of the technologies
utilized and understanding of the ways that failure of
analgesic delivery can occur would allow strategies to
be created to cope with these issues. It is also important to be open to new technologies that may simplify
and thereby eliminate some factors that contribute to
analgesic gaps.
References
1. Agency for Health Care Policy and Research

(AHCPR) Public Health Service. Acute Pain
Management: Operative Medical Procedures and
Trauma. Clinical Practice Guideline No.1. AHCPR
Pub. No. 920032. Rockville, MD: AHCPR, 1992.
2. American Society of Anesthesiologists Task Force on
Acute Pain Management, Ashburn MA, Caplan RA,
Carr D, Connis R, Ginsberg B, Green C, Lema M,
Nickinovich DG, Rice LJ. Practice guidelines for acute
pain management in the perioperative setting: an
updated report by the American Society of
Anesthesiologists Task Force on Acute Pain
Management. Anesthesiology 2004;100:15731581.
3. Apfelbaum JL, Chen C, Mehta SS, Gan TJ.
Postoperative pain experience: results from a national
survey suggest postoperative pain continues to be
undermanaged. Anesth Analg 2003;97:534540.
4. Warfield CA, Kahn CH. Acute pain management.
Programs in U.S. hospitals and experiences and
attitudes among U.S. adults. Anesthesiology
1995;83(5):10901094.
5. Joshi GP, Ogunnaike BO. Consequences of inadequate
postoperative pain relief and chronic persistent
postoperative pain. Anesthesiol Clin North Am
2005;23:2136.
6. American College of Physicians. Common side effects
of opioids. In ACP Observer: American College of
Physicians, 2004.
7. Bates DW, Cullen DJ, Laird N, et al. Incidence of
adverse drug events and potential adverse drug events.
Implications for prevention. ADE Prevention Study
Group. JAMA 1995;274:2934.
8. Ng A, Hall F, Atkinson A, Kong KL, Hahn A. Bridging
the analgesic gap. Acute Pain 2000;3:194199.
56
9. Smith G, Power I. Audit and bridging the analgesic

gap. Anaesthesia 1998;53:521522.
10. Chen PP, Chui PT, Ma M, Gin T. A prospective
survey of patients after cessation of patient-controlled
analgesia. Anesth Analg 2001; 92(1):224227.
11. Baxter Healthcare Corp. signs consent decree with
FDA; agrees to correct manufacturing deficiencies.
Available at: http://www.fda.gov/bbs/topics/NEWS/
2006/NEW01402.html. Accessed October 3,
2006.
12. Panchal SJ, Damaraju CV, Nelson WW, Hewitt DJ,
Schein JR. System-related events and analgesic gaps
during postoperative pain management with the
fentanyl iontophoretic transdermal system and
morphine intravenous patient-controlled analgesia.
Anesth Analg 2007;105(5):14371441.
13. Hankin CS, Schein J, Clark JA, Panchal S. Adverse
events involving intravenous patient-controlled
analgesia. Am J Health Syst Pharm 2007; 64(14):
14921499.
14. Ashburn MA, Love G, Pace NL. Respiratory-related
critical events with intravenous patient-controlled
analgesia. Clin J Pain 1994;10:5256.
15. Brown SL, Bogner MS, Parmentier CM, et al. Human
error and patient-controlled analgesia pumps. J
Intraven Nurs 1997;20:311316.
16. Callan CM. An analysis of complaints and
complications with patient-controlled analgesia.
In Ferrante FM, Ostheimer GW, Covino BG, eds.
Patient-controlled Analgesia. Oxford, UK:
Blackwell Scientific Publications, 1990, pp.
139150.
17. Cullen DJ, Bates DW, Small SD, et al. The incident
reporting system does not detect adverse drug events:
a problem for quality improvement. Jt Comm J Qual
Improv 1995;21:541548.
18. Jha AK, Kuperman GJ, Teich JM, et al. Identifying
adverse drug events: development of a computerbased monitor and comparison with chart review and
stimulated voluntary report. J Am Med Inform Assoc
1998;5:305314.
19. Classen DC, Pestotnik SL, Evans RS, et al.
Computerized surveillance of adverse drug
events in hospital patients. JAMA 1991;266:
28472851.
20. Gardner S, Flack M. Designing a medical device
surveillance network: FDA Report to Congress;
1999.
Section 1
Chapter
11
Pain Definitions
Multimodal analgesia (sites of analgesic

activity)
Introduction
Clinicians are confronted with an array of medications for the treatment of pain conditions, and with
the pharmacological armamentarium available most
pain states can be treated effectively. The prevalence of
chronic pain in the general population has been estimated to range from 10% to over 40% [13], with 25
million Americans suffering from acute pain from
injury or surgery and 75 million suffering with chronic
pain [4]. Despite the ever-expanding number of medications indicated for various pain conditions, there
still remains an unmet need for chronic pain management [5]. Harden and Cohen [5] identify four possible
reasons for unmet analgesia in chronic pain, which
include inadequate diagnosis and appreciation of the
mechanisms involved; inadequate management of
comorbid conditions; incorrect understanding or
selection of treatment options; or use of inappropriate
outcome measures. With respect to the mechanism
involved, equally important is the mechanism by
which the medications have their analgesic effect. The
diversity of pain mechanisms, patient responses and
diseases necessitates a mechanistic approach to pain
management; based on current understanding of the
peripheral and central mechanisms involved in nociceptive transmission providing newer options for clinicians, to manage pain effectively treatment must be
individualized [6].
Several strategies have been adopted in order to
avoid the shortcomings of the unmet need of chronic
pain management, including multimodal pain management and mechanistic approaches. The former,
multimodal pain management, was introduced more
than a decade ago as a technique to improve analgesia
and reduce the incidence of opioid-related adverse
events. This concept can be applied to chronic pain
management utilizing our understanding of the mechanism by which injury occurs and the mechanism of
action of the medications used to treat pain conditions
[7]. Multimodal techniques reduce the total dose of

any one medication by attending to analgesic requirements through various receptor modulations. Multimodal analgesia is achieved by combining different
analgesics that act by different mechanisms, resulting in additive or synergistic analgesia, reducing
adverse effects of the sole administration of individual analgesics [7].
Therapeutic strategies aimed at selecting treatments by targeting the putative mechanisms of pain
(mechanism-based strategies) have been proposed [8,
9]. The signs of neuropathic pain (heat hyperalgesia,
mechano-hyperalgesia, mechano- and cold allodynia)
may have different pathophysiological mechanisms.
Evidence from animal models indicates that distinct
signs of neuropathic pain respond differently to various drugs [10]. Targets are being identified by pharmaceutical investigation for the discovery of highly
specific small molecules as potential novel analgesics.
The discovery of targets specific to particular pain
mechanisms will soon enable therapy to be targeted
specifically at those mechanisms [11].
In this chapter, we will review the analgesic sites of
action as a mechanistic and multimodal approach to
pain medicine and chronic pain management. The
mainstay of pain management has been opioid therapy, but, with the increasing knowledge of pain mechanisms, adjuvant medications are gaining a more
prominent role in chronic pain management.
Opioids
Endorphins and enkephalins are endogenous opioids
that are released from the periaqueductal gray matter
and nucleus raphe magnus, respectively, and travel
within the central nervous system (CNS) descending
pain-control systems [12]. Exogenous opioid agonists
mimic the activity of enkephalins and endorphins at
the central descending pathways of the pain-processing loop [13]. Opioid receptors are found at pre- and
57
postsynaptic sites of the ascending pain transmission

system in the dorsal horn of the spinal cord, the brainstem, thalamus, and the cortex. Opioid receptors are
also found in the midbrain periaqueductal gray, the
nucleus raphe magnus, and the rostral ventral
medulla, which comprise the descending inhibitory
system modulating spinal pain transmission [14].
There are at least three opioid receptors, mu (),
kappa (), and delta (), which are located at the dorsal horn of the spinal cord, the dorsal root ganglion
and peripheral nerves [15]. These opioid receptors
are guanine (G) protein-coupled. Opioid activation
mediates the reduction in neurotransmitter (e.g.
glutamate, substance P and calcitonin gene-related
peptide) release from the presynaptic membrane secondary to the inhibition of voltage-gated calcium
channels (Figure 11.1.). This is accomplished by the
reduction in the second messenger cyclic adenosine
monophosphate (cAMP). Additionally, the mode of
action of opioids is via activation of opioid receptors
in second-order pain transmission cells preventing
the ascending transmission of the pain signal at the
central terminals of C fibers in the spinal cord, and
activating opioid receptors in the periphery to inhibit
the activation of the nociceptors as well as inhibit
cells that may release inflammatory mediators
[16,17]. Postsynaptically, opioids cause inhibition of
adenyl cyclase and activation of inwardly rectifying
- Opioid
- Neurotransmitters
- Ca++
- K+
G-protein coupled receptor
Presynaptic
Postsynaptic
58
Figure 11.1. Opioid receptor agonist.
potassium currents resulting in neuronal hyperpolarization [18,19]

Opioids have been the mainstay of analgesia and by
interacting at the aforementioned receptors these
medications produce reliable analgesia, but these medications should only be a part of an analgesic regimen.
Adjuvant medications should be employed in any multimodal analgesic regimen, enhancing analgesia.
NSAIDs, acetaminophen and COX-2

inhibitors
Nonsteroidal anti-inflammatory drugs (NSAIDs) are
among the most widely used analgesic medications in
the world because of their ability to reduce pain and
inflammation [7,20,21]. They are structurally diverse,
but all have antipyretic, anti-inflammatory and analgesic or anti-hyperalgesic properties. NSAIDs have a
peripheral and central role of action [7,22,23]. Cell
injury induces the production of phospholipids with
conversion to arachidonic acid and the cyclooxygenase (COX) enzyme converts arachidonic acid to prostaglandins. Peripherally, prostaglandins (PGE1 and
PGE2) are not important mediators of pain transmission, but they contribute to hyperalgesia by sensitizing
nociceptive sensory nerve endings to other mediators
(histamine and bradykinin) and by sensitizing nociceptors to respond to non-nociceptive stimuli, such as
touch [22,24,25]. In the periphery NSAIDs prevent
the sensitization of peripheral nociceptors, diminishing prostaglandin formation, and centrally hyperalgesia evoked by spinal action of substance P and
N-methyl-d-aspartate [25,26]. Centrally, prostagland
ins are capable of enhancing pain transmission by
increasing substance P and glutamate, increasing
nociceptive transmission at second-order neurons
and inhibiting the release of descending inhibitory
neurotransmitters [25,2729]. To this end, the mechanism of action of the NSAIDs is inhibition of prostaglandin production by either reversible or irreversible
acetylation of cyclooxygenase.
Acetaminophen (paracetamol) probably produces
its analgesic effect by inhibiting central prostaglandin
synthesis with minimal inhibition of peripheral prostaglandin synthesis [30,31]. Often labeled as an NSAID,
acetaminophen and NSAIDs have important differences such as acetaminophens weak anti-inflammatory
effects and its generally poor ability to inhibit COX in
the presence of high concentrations of peroxides, as are
found at sites of inflammation [30,31], nor does it have
Chapter 11 Multimodal analgesia (sites of analgesic activity)
an adverse effect on platelet function [32] or the gastric

mucosa [30].
Non-selective NSAIDs inhibit both cyclooxygenase 1 and 2 and with increased COX-1 selectivity the
tendency is towards gastrointestinal toxicity [33]. It is
the COX-2 isoform that is induced by pro-inflammatory stimuli and cytokines causing fever, inflammation
and pain and thus the target for anti-inflammation by
NSAIDs [34]. The COX-1 isoform is constitutive, causing hemostasis, platelet aggregation, and the production of prostacyclin, which is gastric mucosal
protective. The inhibition of COX-1 isoform may be
responsible for the adverse effects related to the non
selective NSAIDs [35]. COX-2 inhibitors (celecoxib,
rofecoxib and valdecoxib) were approved for use in the
USA and Europe, but both rofecoxib and valdecoxib
were withdrawn from the market due to their adverse
event profile. Recently parecoxib and etoricoxib have
been approved in Europe but still await approval in the
USA. The newest drug in the class, lumiracoxib, is
under consideration for approval in Europe and the
USA. Upon administration most of the coxibs are distributed widely throughout the body, with celecoxib
possessing an increased lipophilicity enabling transport into the CNS. Lumiracoxib is more acidic than
the others, which may favor its accumulation at sites of
inflammation. Despite these subtle differences, all of
the coxibs achieve sufficient brain concentrations to
have a central analgesic effect [36]. The estimated
half-lives of these medications vary (2 to 6 hours for
lumiracoxib, 6 to 12 hours for celecoxib and valdecoxib, and 20 to 26 hours for etoricoxib). Likewise
the relative degree of selectivity for COX-2 inhibition
is lumiracoxib = etoricoxib > valdecoxib = rofecoxib
>> celecoxib [31].
Local anesthetics
One of the first uses of local anesthetics (LA) for
anesthesia was in the late nineteenth century with
William Halsted reporting a mandibular block and
brachial plexus block using cocaine [37,38]. The
chemical structure of local anesthetics in clinical use
consists of an aromatic (lipophilic) benzene ring
linked to an amino group (hydrophilic) via either an
ester or an amide intermediate chain. The intermediate
link classifies the local anesthetic as either an ester
(procaine, chloroprocaine, tetracaine, and cocaine) or
an amide (lidocaine, prilocaine, mepivacaine, bupivacaine, etidocaine, and ropivacaine).
Local anesthetics exert their action by binding to

sodium channels in nerve cell membranes and inhibiting the influx of sodium ions [39]. The limited influx
of sodium ions reduces the rate of rise of the action
potentials, increases the threshold for electrical excitability and slows impulse conduction [40]. The action
potential fails to reach the threshold level and no
impulses are conducted if sufficient sodium channels
are blocked. Local anesthetics, therefore, do not affect
the resting membrane potential, but rather affect the
formation and propagation of the action potential.
At peripheral nerves the reduction in sodium
influx leads to a decrement in action potential formation and propagation. In animal studies a reduction in
action potential by 50% is necessary for observable
loss of neuronal function and exposure length of the
nerve fiber is important in conduction blockade [41].
At central neuraxial administration of LA similar
mechanisms to those previously discussed occur at
the level of the spinal nerve roots. Additionally, at the
dorsal horn, LA possibly exert action at sodium and
potassium channels in ventral and dorsal horn neurons [41]. Furthermore local anesthetics may exert
action at neurotransmitters or neuropeptides such as
substance P or -aminobutyric acid (GABA) by either
directly binding to receptors or by altering local pharmacokinetics of endogenous agonists [41].
Anticonvulsants
The anticonvulsants are a diverse class of medications
that modulate multiple sites such as calcium channels,
sodium channels, GABA, and glutamate. The class
includes medications such as gabapentin, pregabalin,
topiramate, carbamazepine, lamotrigine phenytoin,
valproic acid, and others. Several studies have shown
this class of medications to be effective in a number of
chronic pain states [4245]. Two of the more widely
used anti-epileptics drugs (AEDs) are the gabapentenoid membrane stabilizers gabapentin and pregabalin.
Gabapentin, 1-(aminomethyl)cyclohexane acetic acid,
is a structural analog of the neurotransmitter GABA,
initially synthesized to mimic the chemical structure of
the GABA, but is not believed to bind directly to GABA
receptors or have any effect on the uptake or breakdown of GABA. The analgesic mechanism of action for
gabapentin remains unknown, although possible
mechanisms include the modulation or binding to the
21 subunits of the 2 voltage-dependent calcium
channels [46,47]. Gabapentin binds to the 2 subunit
and modulates calcium influx at the presynaptic nerve
59
terminal, reducing the release of several neurotransmitters, including glutamate, norepinephrine, and substance P [4850] (Figure 11.2). Gabapentin blocks the
tonic phase of nociception, and it exerts a potent inhibitory effect in several animal modes of neuropathic
pain such as mechanical hyperalgesia, mechanical allodynia, thermal hyperalgesia, and thermo-allodynia
[51,52]. Pregabalin, when compared to gabapentin, has
greater lipid solubility and binds to the 2 subunit
with six times greater affinity than gabapentin [48,53],
thus improving diffusion across the bloodbrain barrier, better pharmacokinetic properties, and fewer drug
interactions, due in part to an absence of hepatic
metabolism [54].
NMDA-receptor antagonists
The N-methyl-d-aspartate (NMDA) receptors are one
of the main mediators of excitatory neurotransmission
and through inhibition of NMDA receptors, which are
thought to play a crucial role in the generation and
maintenance of chronic pain, NMDA receptor antagonists can be administered to produce analgesia. The
receptor is a ligand-gated ion channel, which permits
the influx of calcium and sodium and the efflux of potas-
sium across the postsynaptic membrane. The NMDA

receptor activation is dependent on the binding of
both glutamate and the co-agonist glycine. Glutamate
is a major excitatory neurotransmitter in the brain and
spinal cord, exerting its effects postsynaptically. The
receptor can be modulated by a number of antagonists,
including competitive antagonists at the glutamate and
glycine binding sites and noncompetitive NMDA
receptor channel blockers (e.g. ketamine, memantine,
magnesium) [55]. NMDA receptor activation triggers
a cascade of events including a significant increase in
intracellular calcium and activation of protein kinases
and phosphorylating enzymes. NMDA receptor stimulation will also increase the production of spinal
phospholipase and induce the production of nitric
oxide synthetase. Inhibition at the NMDA receptor
prevents the influx of calcium and activation of protein
kinases and phosphorylating enzymes (Figure 11.3).
Ketamine, currently the most potent clinically available
- NMDAr antagonist
- Neurotransmitters
- Ca++
- Na+
- K+
- Gabapentenoid
- Neurotransmitters
- Ca++
Presynaptic
2 subunit
Presynaptic
Postsynaptic
Postsynaptic
60
Figure 11.2. Gabapentenoid receptor agonist.
Figure 11.3. NMDA receptor antagonist.
antidepressant effect [69]. The pharmacological

actions of tricyclic antidepressants can be linked to
their effect as a calcium channel antagonist, sodium
channel antagonist, their NMDA receptor antagonist
effect, but particularly the presynaptic reuptake
inhibition of the monoamines such as serotonin and
norepinephrine (Figure 11.4) [70,71]. The tricyclic
antidepressants have no effect on dopamine reuptake
but may have some indirect dopaminergic action by
the adrenergic effect and desensitization of dopamine
D2 receptors [70]. Additionally, TCAs have been
reported to bind to opioid receptors, but their binding
affinity is probably too low to be relevant in humans at
therapeutic drug concentrations [72]. More specifically, the analgesic effect is believed to occur primarily
through reuptake inhibition of norepinephrine rather
than serotonin at spinal dorsal horn synapses, with
secondary activity at the sodium channels [73,74].
Within the class of tricyclic antidepressants, variation
exists between the inhibition of norepinephrine and
serotonin. The tertiary amine agents (e.g. amitriptyline and imipramine) demonstrate a balance in their
ability to inhibit norepinephrine and serotonin, while
the secondary amines (e.g. nortriptyline and
desipramine) favor the inhibition of norepinephrine.
The secondary amines appear to be as effective as the
tertiary agents in treating neuropathic pain and produce markedly fewer side effects [75,76].
NMDA antagonist [56], has been studied in the treatment of acute and chronic pain [57]. The NMDA
receptor has a crucial role in excitatory synaptic transmission, plasticity, and neurodegeneration in the central nervous system [58] and has become an avenue to
modulate the excitatory effects of glutamate.
Ketamine not only functions as an antagonist at
NMDA receptors, but also blocks non-NMDA glutamate receptors, binds weakly to opioid receptors,
antagonizes muscarinic cholinergic receptors, facilitates GABAA signaling, and possesses local anesthetic and possibly neuroregenerative properties
[5961]. Animal studies have identified NMDA
receptors on unmyelinated and myelinated axons in
peripheral somatic tissues [62,63] and local injections of glutamate or NMDA result in nociceptive
behaviors that can be attenuated by peripheral
administration of NMDA receptor antagonists
[58,6466]. The peripheral administration of ketamine enhanced the local anesthetic and analgesic
actions of bupivacaine used for infiltration anesthesia [58,67] and inhibited the development of primary and secondary hyperalgesia after experimental
burn injuries [58,68].
Antidepressants
Tricyclic antidepressants (TCA) have an analgesic
effect that is demonstrated to be independent of their
Pain
2 Agonist
NMDA receptor antagonists
NSAID/ASA/COX-2
Gabapentinoids
Perception
2 Agonist
Modulation
Ascending Pathway
Figure 11.4. Site of action of adjuvant

medications.
Descending Pathway
Dorsal Horn
Spinal Cord
Transmission
Dorsal Root Ganglion
Peripheral Nerve
Trauma
NSAID/ASA/COX-2
Transduction
61
Serotonin-norepinephrine reuptake inhibitors

(SNRIs) (e.g. duloxetine, venlafaxine and desvenlafaxine) inhibit the reuptake of both serotonin and nor
epinephrine and are referred to as dual inhibitors or
selective serotonin norepinephrine inhibitors. The
SNRIs lack of anticholinergic side effects results in a
distinct advantage over traditional TCAs [13,77,78].
For example, duloxetine is a potent, balanced inhibitor of serotonin and norepinephrine reuptake [79].
Venlafaxine inhibits serotonin reuptake at lower dosages and inhibits both serotonin and norepinephrine
reuptake at higher dosages [70,80].
Alpha-2-adrenergic agonists
The analgesic activity of 2-agonists may be mediated by both supraspinal and spinal mechanisms.
The central 2-adrenoceptors in the locus coeruleus
(supraspinal site) and in the substantia gelatinosa of
the dorsal horn of the spinal cord are a primary site
of action by which the antinociceptive effect occurs
[8183]. Clonidine induces analgesia primarily by
stimulating presynaptic and postsynaptic 2adrenergic receptors in the dorsal horn of the spinal
cord [84,85], which inhibit substance P release [86]
and decrease dorsal horn neuronal firing [87,88].
Dexmedetomidine is eight times more specific for
2-adrenoceptors than clonidine [89]. As an 2agonist the actions of dexmedetomidine are suggested to be mediated through postsynaptic
2-adrenoceptors which activate pertussis toxinsensitive G proteins [90], thereby increasing conductance through potassium ion channels [91].
Summary
The knowledge of medications mechanism of action
and receptor modulation may provide a conceptual
framework for rational medication choice. A mechanistic approach and multimodal medication administration utilizing the synergistic effects of the
aforementioned medications may provide the most
effective analgesic regimen. Figure 11.4 represents the
pain pathway and the site within the pathway where
the medications have their effect.
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65
Section 1
Chapter
12
Pain Definitions
A stepwise approach to pain management

Raymond S. Sinatra
The traditional three-step approach
66
Up to 70% of patients with cancer experience moderate to severe pain during their illness. In an effort to
better manage malignancy-related pain, the World
Health Organization (WHO) in 1986 developed a
stepwise approach to analgesic dosing [13]. The
WHO three-step ladder correlated analgesic selection and dosing in relation to the intensity of the pain
complaint (Figure 12.1) The ladder classified cancer
pain into three levels of severity: mild, moderate, and
severe [1,2]. Patients with mild pain were assigned to
the lowest step or rung of the ladder (step 1) and were
to be treated with non-opioid analgesics. If pain persisted and progressed to moderate intensity, the
patient was advanced to step 2 and treated with weak
opioid analgesics such as codeine, propoxyphene, tramadol, oxycodone, and hydrocodone. Advancement
to step 2 was often problematic since weak opioids are
associated with the same risks of adverse effects, tolerance, and diversion/abuse as more potent agents. For
this reason, many clinicians consider step 2 to be a
large step when compared to those that precede and
follow it (Figure 12.2).
Patients may be advanced to step 3 of the ladder in
situations where pain has progressed to severe or very
severe intensity, and is inadequately controlled with
weak opioids. At this step, potent opioids including
morphine, hydromorphone, oxymorphone, and
transdermal delivered (TDS) fentanyl are commonly
prescribed. In general, sustained-release opioids are
provided daily or twice daily for baseline pain control
with immediate-release opioids taken as needed for
breakthrough pain. Total daily opioid dose is increased
as required, thereby allowing patients to gain freedom
from pain.
While simplistic in nature, the WHO analgesic
ladder was considered to be a successful therapeutic
advance as it provided an organized approach to pain
assessment and management on a global scale [3]. The
major drawback associated with the WHO stepwise
approach was the fact that approximately 2025% of

patients did not respond to morphine or other potent
opioids, and continued to suffer severe pain [35].
A stepwise analgesic care plan would be expected
to be even less effective for long-term chronic pain
management, and controversy exists as to whether
opioids should be prescribed to patients with musculoskeletal pain or benign disease-related pain [4,5].
Some caregivers argue that prescription of step 2 and
3 opioids may be the only way to provide effective pain
relief, while others worry that such therapy may lead
to lifelong dependencies, which can be particularly
problematic in younger patients. Despite acceptance
of a stepwise approach to chronic pain, many primary
care physicians and surgeons remain uncomfortable
prescribing opioids, while at the same time they lack a
clear understanding of pain processing and the benefits of multimodal analgesia. Other educational deficits, including patient assessment, determination of
need, initiation of opioid therapy, and how to treat
adverse effects, often lead to undermedication, intolerability, and inadequate management of chronic pain.
Comorbid conditions, including obesity, sleep apnea,
and chronic obstructive pulmonary disease, and mental health issues such as anxiety, depression, and posttraumatic stress, further complicate pain management
and reduce caregiver comfort in prescribing opioids
[4,5].
Rationale for a four-step approach

With the advent of anesthesiology and multi-specialtybased pain clinics and caregiver specialization in
interventional pain management, a four-step analgesic approach was developed to more effectively treat
patients with benign and malignancy-related chronic
pain (Figure 12.3). The first three steps of this care
plan are similar to the WHO analgesic ladder; however, a new fourth step, termed the interventional
step, utilizes invasive techniques that are placed and
managed by pain specialists. Interventional therapy
Chapter 12 A stepwise approach to pain management
The WHO Analgesic Ladder
Severe Pain
Moderate Pain
Mild Pain
Step 3
Strong Opioids
Step 2
Weak Opioids
Step 1
Non Opioids
Figure 12.1.
A Realistic View of The WHO Analgesic Ladder

Step 3
Strong Opioids
Severe Pain
Step 2
Weak Opioids
Moderate Pain
Mild Pain
Step 1
Non Opioids
Figure 12.2.
includes implantable analgesic pumps, peripheral and

epidural stimulators, regional and neuraxial steroids,
and neurolysis. Such therapy may provide measurable
reductions in pain intensity and opioid sparing effects
that are particularly beneficial to highly tolerant
patients, the elderly, and those suffering intolerable
dose-related adverse events
The current four-step approach for chronic pain
management is initiated and maintained in a manner
that is the exact opposite to analgesic treatment
plans employed for post-operative pain (Figure 12.4).
In acute settings, the intensity of pain is most severe
during the first 2472 h following surgery or traumatic
injury. During this period pain is optimally controlled
using step-4 interventional techniques including neuraxial analgesia and continuous peripheral neural
blockade. Analgesic benefits are greatest in high-risk
patients and those recovering from the most painful
of procedures, and must be balanced by the fact that
these techniques are more invasive, require skill and
specialization for placement, are associated with risk
of bleeding/infection, and are more expensive than

treatment with oral/IV opioids. As the patient recovers, interventional therapy is discontinued and the
patient is advanced downward to step 3, and treated
with intravenous PCA or strong parenteral opioids.
As bowel function returns, the patient may be
advanced downward to step 2 and treated with oral
opioid plus acetaminophen compounds for several
days to weeks depending upon the surgical procedure.
Thereafter, residual discomfort may be treated with
step-1 non-opioid analgesics, until complaints of pain
resolve entirely.
In chronic pain settings, patients follow the opposite clinical course characterized by progressive
increases in pain intensity. Progression of disease and
associated discomfort is best controlled by upward
steps in analgesic dose, and potency, as well as increasing complexity and invasiveness of analgesic delivery.
The major difference between the WHO three-step
ladder and the four-step approach is that the latter
care plan recognizes that not all patients can gain adequate pain relief with opioids, despite proportionate
increases in dose. The WHO ladder was designed for
malignancy-related chronic pain and palliation in
patients not expected to survive beyond several
months to a year [1,2,5,6]. This care plan is often unacceptable and inappropriate for individuals suffering
intractable benign pain that may last for many years.
For these patients, interventional techniques offer an
analgesic alternative that can often minimize risks of
excessive sedation and cognitive deficits while improving functionality and quality of life.
The four-step approach to chronic pain

management: common sense guidelines
Optimal pain management is initiated following a
thorough screening of the patient. In addition to history and diagnostic imaging, a focused yet detailed
physical examination is necessary to evaluate the pain
complaint [7]. The caregiver must not only localize the
site(s) involved and the intensity of discomfort but
should also characterize associated symptoms as being
either somatic, visceral, inflammatory neuropathic,
myelopathic or mixed pain. Pain complaints are rarely
the same and these clinical findings are key to formulating analgesic prescriptions and developing a treatment plan.
Whenever possible chronic pain management
should begin on step 1 with non-opioid analgesics.
67
Figure 12.3.
Four-Step Approach to Chronic Pain Management
Adjuvant Therapy: To be
considered at every Step
Step 4
Interventional
Severe Pain
Severe Pain
Moderate Pain
Mild Pain
Step 3
Strong Opioids
Step 2
Weak Opioids
Step 1
Non Opioids
Acetaminophen,
NSAIDS, Coxibs,
TCAs, SNRIs,
Gabapentinoids,
Clonidine, Muscle
Relaxants, TENS,
Lidocaine patch,
Acupuncture, Heating
& Cooling, Antianxiety agents.
Figure 12.4.
Acute and Chronic Pain: Temporal

Differences in Intensity and Management
Persistent pain with

static or increasing
intensity
Chronic
Pain
Resolving pain with

decreasing intensity
Interventional Pain Management
Potent IV or Oral Opioids
Acute
Pain
Oral Opioid Compounds

Non Opioid Analgesics
No Analgesics
68
Caregivers should always use the lowest effective

analgesic dose administered by the simplest route
and consider a multimodal approach rather than
relying on high-dose monotherapy. The caregiver
should maintain patients on step 1 as long as is possible by adding pharmacological adjuvants, physical
therapy, emotional and psychological support, and
non-pharmacological and non-traditional analgesic
techniques.
When opioids are deemed necessary to establish
or maintain effective pain control, caregivers often
face a controversial dilemma regarding whether
weak or potent agonists should be employed.
Conventional stepwise care plans recommend that
caregivers prescribe weaker agents including tramadol, buprenorphine, hydrocodone, and oxycodone,
while maximizing their effectiveness with non-opioid
analgesics and adjuvants. New thinking suggests that

step-2 opioids should not be prescribed at all for
malignancy-related pain, as these agents are associated with less uniform pain control, adverse events
and rapid dose escalation [5,6,8]. Instead, caregivers
should consider prescribing more potent step-3 agents
in low dose, and preferably as extended-duration tabs
or transdermal patches. The correct solution is to
adjust opioid potency and dose according to the current severity of pain complaint. For example, patients
initially presenting with excruciating or rapidly progressing pain should be given the option to bypass
step 2 and take an analgesic elevator to step 3 [8]. In
contrast, patients requiring minimal analgesic supplementation may gain effective relief for an extended
period of time, with occasional as needed doses of
step-2 agonists. If, or when, pain intensity increases
and step-2 opioid dosing is either ineffectual or excessive, advance to step 3 is appropriate.
Whether short-acting or sustained-release/extended-duration preparations, or their combination, are
most useful for step-3 analgesia is generally based on
patient need. Patients who complain of occasional
episodes of severe breakthrough pain are best treated
with rapid-acting short-duration opioids, while those
with constant discomfort or frequent episodes of pain
appreciate the convenience and uniformity of relief
provided by extended-duration opioids. The fact that
extended-duration formulations produce steady-state
concentration with fewer peak-and-trough levels may
also reduce the incidence of annoying AEs such as
nausea or somnolence.
Patients treated with extended-duration opioids
may experience breakthrough pain which can be controlled with immediate-release, short-acting opioids;
however, if three or more PRN doses are used daily,
the dose of extended-duration opioid should be
increased by 1025%. With regard to ongoing dose
escalation and total opioid dose, the caregiver should
think long term, and consider a daily maximum dose
that should not be exceeded. This is a very controversial aspect of chronic pain management and there are
few guidelines. In general, the maximum allowable
dose is determined by caregiver experience and level
of comfort, as well as other variables including adverse
effects and intolerability, patient age, expected duration of need (weeks, months, years, decades), and risk
of abuse and diversion.
Patients treated with potent opioids often experience reductions in analgesic efficacy related to tolerance development. As dosing escalates, many patients
experience intolerable adverse events that limit the
overall analgesic effectiveness of the agent originally
prescribed. In these individuals, opioid rotation to a
different agonist may be useful. The success of rotation has been related to differences in opioid receptor
subtypes, greater mu receptor affinity and differences
in metabolism, that may allow a new opioid to reestablish analgesic efficacy with greater tolerability.
Patients exceeding the maximum opioid daily dose
and those exhibiting intolerability and increased
adverse events despite rotation are candidates for
step-4 interventional therapy [9,10]. Techniques that
may be offered include spinal and peripheral neural
stimulation, which provides effective non-pharmacological modulation of pain transmission. Intrathecal
infusions of morphine or hydromorphone either alone
or in combination with local anesthetics offer powerful pain control as well as significant reductions in
total opioid dose. Intrathecal dosing is particularly
useful for patients suffering benign and malignancyrelated thoracic, abdominal, and pelvic pain. Other
techniques, including neurolysis, intrajoint and epidural steroids, and blockade or destruction of sympathetic ganglia or celiac plexus, can dramatically reduce
opioid dose requirements while restoring functionality and quality of life [10]. Following successful intervention, pain scores may decline dramatically;
however, opioids employed at step 3 should in most
cases be continued to further improve overall analgesic effectiveness, although significant dose reductions
may be achievable.
To further optimize analgesic effectiveness and
reduce opioid burden, non-opioid analgesics employed
at step 1 should be continued whenever possible, as
patients are advanced to steps 2, 3 and 4. In addition,
analgesic adjuvants including central norepinephrine
reuptake inhibitors, gabapentanoids, and NMDA
receptor inhibitors should be prescribed particularly
for patients with high-grade opioid tolerance and neuropathic pain. Finally, pharmacological, nonpharmacological, and non-traditional therapeutic techniques
including use of anxiolytics and antidepressants, heat/
cold applications, topical analgesics, transcutaneous
electrical neural stimulation (TENS), acupuncture,
and massage could be included at every step of the
ladder.
Moving toward a flexible approach to

pain managment
The previously described three- and four-step ladders
are widely employed for managing malignancyrelated and other terminal pain states; however, the
time has come to rethink and possibly discard these
traditional stepwise approaches [6,8,9]. Application
of flexible and more individualized treatment plans
would be particularly beneficial for patients suffering
benign chronic pain. For these individuals, care plans
that include non-opioid-based multimodal analgesia
and early application of interventional pain management may be superior to progressive increases in opioid dosing [10,11]. For example, an elderly female
with pain related to spinal stenosis can often gain
superior pain relief with greater safety and analgesic
tolerability by avoiding steps 2 and 3 and moving
directly to an interventional step-4 technique such as
69
epidural steroid injections. For patients with chronic

low back pain and chronic pelvic pain, early use of
spinal stimulation, neurolysis, and intrathecal analgesic techniques may improve functionality and quality
of life while avoiding the sedative effects of step-3
opioids. Even in patients with malignancy-related
pain, evidence suggests that substituting interventional procedures for high doses of potent opioids
offers more effective analgesia and possibly a more
prolonged survival rate [11].
Patients entering a flexible pain management care
plan can be treated with a mixture of peripheral and
central-acting non-opioid analgesics as well as psychological support, physical therapy, and non-traditional analgesic techniques. Entry-level analgesics
would include NSAIDs and COX-2 inhibitors for
patients suffering inflammatory pain, as well as acetaminophen, lidocaine transdermal patch and clonidine
for patients complaining of somatic pain. Muscle
relaxants should always be prescribed for skeletal
muscle spasm and associated discomfort. Norepinephrine reuptake inhibitors including tricyclic antidepressants, SNRIs (duloxetine), alpha-2 delta subunit
ion channel blockers (gabapentin, pregabalin), and
transdermal local anesthetic patches may be prescribed for patients presenting with neuropathic pain
(Figure 12.5).
Instead of being considered as a last resort, interventional pain management can be employed at an
early stage of care. Patients are carefully assessed and,
if deemed to be clinically appropriate, offered interventional procedures including neurolysis, spinal
stimulation, and intrathecal infusions. Such therapy,
while invasive and expensive, would be encouraged in
settings where patients might benefit from improved
pain relief and significant opioid-sparing effects.
If, and when, additional opioid-mediated analgesia is required, supplementation with dual-acting
analgesics such as tramadol and tapentadol can be
provided. Although the clinical usefulness of weaker
opioids in the management of cancer pain has been
challenged, these agents offer dosing versatility for
either moderate or severe discomfort and should be
considered as entry-level supplements for patients
with benign chronic pain. Tramadol is a relatively
weak unscheduled analgesic that can provide useful
supplementation of multimodal analgesic regimens
and can help control moderate breakthrough pain. In
Figure 12.5.
A Flexible, Non stepwise Approach to Chronic Pain Management.
Opioid Supplementation
for Severe to Very
Severe Pain
Sustained Plus
Immediate Release
Potent Opioids
(Morphine,
oxycodone,
hydrocodone,
oxymorphone)
Dual Acting
Analgesics
(Tramadol,
Tapentadol)
Buprenorphine,
Opioid Supplementation
for Moderate to
Severe Pain
Interventional
Pain Management
Pharmacological
Pain Management
Inflammatory Pain
NSAIDs, Coxibs
Joint blocks
Epidural steroids
Facet blocks
Neurolysis
Sympathetic blockade
Ganglionic/plexus
blockade
Plexus destruction
Spinal stimulators
Peripheral stimulators
Intrathecal pumps
DREZ Lesions
Somatic Pain
Acetaminophen,
Clonidine, Topical
Analgesics,
Muscle relaxants
Neuropathic Pain
Gabapentinoids,
NE reuptake inhibitors,
Lidoderm patch
Psychosocial Adjuncts
Antidepressants, Antianxiety
Agents, Psychotherapy,
Physical therapy, TENS
Acupuncture, Chiropractic,
Massage
Patients Requiring
Chronic Pain Management
70
contrast, tapentadol is a more powerful schedule II

agent that binds mu opioid receptors and blocks nor
epinephrine reuptake. Tapentadol 50100 mg provides
analgesic efficacy comparable to oxycodone 1015 mg
with an unexpectedly lower incidence of adverse
events [12]. Currently tapentadol has approval for
acute pain or acute breakthrough pain in patients with
chronic pain. A sustained-release tapentadol preparation is being developed for around the clock treatment
of chronic pain. Tapentadols improved tolerability
profile may overcome an important barrier to optimal
chronic pain management; that being the fact that
patients are often unwilling to take effective medications because they dont like how they make them feel.
Nevertheless, the added cost of tapentadol may restrict
its use as a first-line opioid analgesic. In that case,
judicious use of hydrocodone and oxycodone plus
acetaminophen compounds may also be considered.
In opioid-naive patients, supplemental opioids
should be prescribed for control of breakthrough incident pain and pain during sleep, not for constant pain.
A potential advantage of flexible pain management
plans that employ combinations of multimodal and
interventional analgesia is that many patients may
require only minimal to moderate amounts of opioid
supplementation in order to maintain effective relief
[10,13].
For patients presenting with excruciating pain or
those experiencing progressive increases in discomfort despite receiving multimodal and interventional
therapy, supplementation with potent sustained- and
immediate-release opioids may be indicated. Dosing
should not be restricted, but instead titrated according
to the individual patients needs. There are many
options, including oral administration of sustainedrelease morphine, oxycodone, and oxymorphone as
well as fentanyl transdermal patch [14]. Extendedrelease oxymorphone has been well tested in patients
with chronic low back pain where it provides uniform
and durable pain relief. Methadone in low dose has
also been advocated as a method of reducing dose
escalation of the primary opioid being administered.
In palliative care settings and for individuals suffering
intractable pain, parenteral opioids and infusions of
ketamine may also be provided [15].
Flexible chronic pain management care plans
would best be initiated at earlier stages of complaint
rather than after progression of symptoms and development of disability. Individuals suffering longstanding poorly controlled pain develop central sensitization
and neural plasticity changes that may be difficult to

overcome. These alterations facilitate noxious transmission and are associated with development of pain
behaviors, sleep deprivation, de-conditioning, fatigue,
and weight gain, which negatively influence the
patients ability to return to work or resume a normal
quality of life. The early application of analgesic adjuvants and interventional pain management may
restore CNS homeostasis and hopefully break the
cycle of sensitzation, plasticity, and intractable noxious transmission and perception. Other clinical benefits that may be achieved include a significant
reduction and possibly elimination of opioids and
their associated adverse events, and improvements in
functionality and rehabilitation.
This is an exciting time for both primary caregivers and pain specialists as a number of new analgesics
are emerging that will complement existing non-opioid regimens and further ensure the success of opioid-avoidance care plans. While there is no analgesic
silver bullet on the horizon, peripherally acting
agents in development, including anti-nerve growth
factor, TRPV-1 inhibitors, and peripherally selective
mu and kappa agonists, promise not only high analgesic efficacy but also improved patient safety and
greater tolerability than opioids and other centralacting agents.
The ultimate goal of flexible chronic pain management is to achieve a balance of patient safety and
meaningful pain relief, not a stepwise plan to eliminate all pain at the cost of therapeutic intolerability.
The patient must not be led to believe that you take
this pill and you will feel much better. Instead, the
patient agrees to, and actively participates in, a multidisciplined flexible care plan that includes interventional therapy, vigorous physical therapy, and
psychological support. The therapeutic goals are to
limit chronic pain disability and restore physical and
psychological functionality, while avoiding excessive
opioid dependency.
In summary, a stepwise approach to pain management, while useful for many patients, may not be
appropriate for all. The application of a flexible multimodal care plan and appropriate opioid supplementation can, in most settings, offer patients freedom
from severe chronic pain and return to baseline quality of life. Therapy should always be individualized
and provided in a logical order based on potential
benefits, associated risks, adverse events, and overall
cost.
71
References
1. World Health Organization. Cancer Pain Relief.

Geneva: World Health Organization, 1986.
2. World Health Organization. Cancer Pain Relief, 2nd
ed. Geneva: World Health Organization, 1996.
3. Foley KM. 2006. Appraising the WHO Analgesic
Ladder on Its 20th Anniversary. www.whocancerpain.
4. Adams NJ, Plane MB, Fleming MF, Mundt MP,
Saunders LA, Stauffacher EA. Opioids and the
treatment of chronic pain in a primary care sample. J
Pain Symptom Manage 2001;22:791796.
5. Portenoy RK. Opioid therapy for chronic
nonmalignant pain: a review of the critical issues.
J Pain Symptom Manage 1996;11:203217.
6. Nicholson B. Responsible prescribing of opioids
for the management of chronic pain. Drugs
2003;63:1732.
7. Brunton S. Approach to assessment and diagnosis of
chronic pain. J Fam Pract 2004;53:S310.
8. Eisenberg E, et al. J Clin Oncol 1994;12:27562765.
9. Justins D, Seimaszko O. Rational use of neural blockade
for the management of chronic pain. Pain 2002- An
72
updated Review, Refresher Course Syllabus. Seattle: IASP

Press, 2002.
10. JA Turner, JD Loeser, KG Bell. Spinal cord stimulation
for chronic low back pain: a systematic literature
synthesis. Neurosurgery 1995;37:10881095.
11. Wong GY, Schroeder DR, Carns PE, et al. Effect of
neurolytic celiac plexus block on pain relief, quality of
life, and survival in pancreatic cancer. JAMA
2004;291:10921099.
12. Hartrick C, Van-Hove I, Stegmann J, et al. Efficacy
and tolerability of tapentadol immediate release
and oxycodone immediate release in patients
awaiting primary joint replacement. Clin Ther
2009;31:260271.
13. Mercadante S. The use of anti-inflammatory drugs in
cancer pain. Cancer Treat Rev 2001;27:5161.
14. Farrar JT, Cleary J, Rauck R, Busch M, Nordbrock E.
Oral transmucosal fentanyl citrate: randomized,
double-blinded, placebo-controlled trial for treatment
of breakthrough pain in cancer patients. J Natl Cancer
Inst 1998;90:611616.
15. Hocking G, Cousins MJ. Ketamine in chronic pain
management: an evidence-based review. Anesth Analg
2003;97:17301739.
Section 2
Chapter
13
Oral and Parenteral Opioid Analgesics
Opioids and opioid receptors

Raymond S. Sinatra
Introduction
Opioids are a class of central-acting analgesics that
provide powerful dose-dependent relief of moderate
to severe pain [13]. They include compounds with
variable pharmacokinetics and pharmacodynamics,
no cardiac or hepato-renal toxic effects, no ceiling
effect for achievable pain relief, and are approved for
oral, nasal, parenteral, transdermal, and neuraxial
administration. Opioid analgesics include natural
derivatives of opium such as morphine, substituted
semisynthetics such as oxycodone and hydrocodone,
complex synthetics including meperidine, fentanyl,
and methadone, and endogenous ligands such as
enkephalin (Figure 13.1) [13].
Morphine, named after Morpheus, the god of
dreams, was isolated in the 1850s, and termed Gods
own medicine by Sydenham [1,2]. The use of morphine and intravenous syringes during the US Civil
War (1860s) greatly improved pain management;
however, misuse and overuse led to excessive rates of
dependency and addiction. Fears of opioid addiction
were responsible for the establishment of the US Narcotic Control Acts of the early 1900s which limited
opioid distribution and use [1,4,5]. Over the last two
decades, regulatory easements and greater medical
acceptance have dramatically increased opioid dosing
for patients suffering moderate to severe pain [4].
Nevertheless, because of highly publicized cases of
diversion and abuse, the pendulum has started to
swing back toward increasing restriction, as evidenced
by high-profile court cases and FDA/DEA statements
discouraging high-dose opioid prescriptions [5]. The
benefits and liabilities of opioid analgesics are outlined
in Table 13.1.
Opioid receptors
Opioids interact with specific transmembrane G protein-coupled binding sites termed opiate or opioid
receptors. These receptors are located primarily in spinal
dorsal horn, central gray, medial thalamus, amygdala,

limbic cortex and other regions of the central nervous
system (CNS) that process affective and suffering
aspects of pain perception [13]. Conversely, opioid
receptors are not concentrated in the somatosensory
cortex or other regions responsible for pain localization [13,6]. Opioid receptors serve as binding sites
for endogenous ligands including endorphin and the
enkephalins, which naturally modulate pain transmission and perception [1,6]. Naturally occurring opiates
and synthetic opioids have structural/chemical similarities that enable them to bind and activate opioid
receptors resulting in powerful, dose-dependent, analgesia (Figure 13.2). Opioids provide highly selective
analgesia in that they reduce or eliminate the suffering
aspects of pain while preserving noxious localization
[6,7]. Analgesic selectivity is also related to the fact
that opioids block noxious sensation without affecting
other forms of sensory perception such as light touch,
pressure, and temperature [1,2,6].
Four principal opioid receptor subtypes, designated as mu, kappa, delta, and sigma, have been
characterized [1,2]. A newer receptor classification
system utilizes labels OPR1, OPR2 and OPR3, which
correspond to mu, kappa, and delta receptors respectively [1,3,8]. Mu receptors (OPR1) mediate supraspinal analgesia, as well as respiratory depression,
nausea and vomiting, miosis and bowel hypomotility. Mu receptors also mediate euphoria and physical
and psychological dependence, and are responsible
for the increased release of prolactin and growth
hormone [1,2].
Kappa receptors (OPR2) are believed to mediate
spinal analgesia, visceral analgesia, and sedation, but
have minimal effect on respiration [13]. Peripheral
kappa receptors have been identified in the GI tract,
skin, muscle, and connective tissues, and provide
analgesic, antineuropathic, and anti-inflammatory
effects [1]. Kappa receptors localized in the kidney are
associated with antidiuresis and oligouria [1,2]. Delta
73
Oral and Parenteral Opioid Analgesics Section 2
Narcotics: Agents that alter CNS activity, and lead to

habituation, physical and psychological dependence
Cannabinoids
Opioids
Cocaine
Barbiturates
Opioids: Drugs that bind opioid receptors and have morphine-like activity
Opiates
Derivatives of Opium
Morphine
Codeine
Thebaine
Semi-synthetics
Substituted derivatives of
morphine or codeine
Hydromorphone
Oxymorphone
Levorphanol
Oxycodone
Hydrocodone
Agonist/Antagonists
Nalbuphine
Butorphanol
Pentazocine
Partial Agonist
Buprenorphine
Antagonists
Naloxone
Naltrexone
Synthetics
Non-morphinians
Phenylpipiridines
Meperidine
Fentanyl
Sufentanil
Alfentanil
Remifentanil
Endogenous Opioids
Natural peptides
Enkephalin
Endorphin
Dynorphin
Complex Analgesics
Tramadol
Tapentadol
Diphenylpropylamines
Methadone
Propoxyphene
Dextromethorphan
Figure 13.1. An overview of commonly administered opioid analgesics including naturally occurring, semisynthetic, synthetic, and
endogenous compounds.
74
receptors (OPR3) are not as well characterized but

appear to facilitate mu receptor activity and enhance
spinal and supraspinal analgesia. The primary ligand
for delta receptors is enkephalin [1]. An additional,
poorly characterized, receptor subtype designated the
sigma-1 receptor is activated by pentazocine. Sigma-1
receptors are no longer considered true opioid receptors since ligand binding is not antagonized by
naloxone and other opioid antagonists. Sigma-1 receptors are believed to mediate opioid-related dysphoria,
hallucinations, and confusion.
Of all subtypes, the mu receptor has been most
studied [1,2,8]. Mu receptors are located at pre- and
postsynaptic contacts between nociceptive cells and
function to limit release of noxious transmitters and

reduce neuronal excitation. The mu receptor complex
is activated following precise stereospecific attachment of agonist chemical groups, including a negatively charged hydroxyl group, the phenolic ring, and
tertiary nitrogen to complementary regions on the
extra-membrane binding site [13]. Receptor activation is followed by secondary activation of intracellular G proteins and an associated effector protein
complex. Effector proteins inhibit adenylate cyclase
and influence the activity of phosphokinases and other
second messengers [9]. These alterations decrease
cAMP, limit potassium and calcium ion flux, and
hyperpolarize nociceptive cells (Figure 13.2) [1,9].
Chapter 13 Opioids and opioid receptors
Table 13.1. Opioid analgesics

Benefits
1. Rapid onset of analgesia for moderate, severe and very severe pain
2. Highly effective analgesia (no analgesic dose ceiling)
3. Selective analgesia: reduction in pain suffering, minimal effects on pain localization
4. No effects on key organs: cardiac, renal, hepatic, and hemostatic safety
5. Multiple agents and routes of administration are available
6. Relatively inexpensive (morphine, oxycodone)
Drawbacks
1. Annoying adverse effects: nausea, pruritus, sedation, constipation
2. Clinically significant adverse effects: illeus, bowel obstruction, severe vomiting, confusion, dysphoria
3. Life-threatening effects: airway obstruction, respiratory depression, respiratory arrest
4. Social effects: dose escalation, physical dependence, diversion and abuse, addiction
5. May be expensive (sustained-release opioids, oral buccal preparations)
The Opioid Receptor

NH3
Morphine
OH
O
Extra-membrane
portion of mu OPR1
OH
Tertiary Nitrogen
Binding Site
G-protein
Anionic
Binding
Site
Figure 13.2. A schematic of the

extramembranous portion of the mu
opioid receptor and its interaction with
morphine and associated effector
proteins. Morphine and other opioid
agonists attach to specific portions of the
receptor including an anionic site, a
flattened surface site which accepts the
phenolic group, and a tertiary nitrogen
attachment site. Attachment at the
tertiary nitrogen binding site appears to
be important for receptor activation and
subsequent activation of the G protein. G
proteins in turn activate other effector
proteins within the complex that
influence second messengers and
neuronal ion flux. Opioid antagonists
bind with high affinity to portions of the
receptor; however, a bulky methyl or allyl
group added to the tertiary nitrogen
prevents receptor activation.
Flat Phenolic
Binding Site
Effector
Proteins
Opioid pharmacokinetics
Physiochemical and structural differences between
opioid agonists can influence affinity and binding kinetics at mu receptors, as well as their ability to activate G
proteins and other transducer molecules [1,3]. Receptor binding affinity influences agonist association/disassociation kinetics as well as pharmacological onset
and duration of activity. The intrinsic efficacy of a given
opioid agonist is related to its ability to activate coupled

G proteins [1,3]. In general, potent opioids such as fentanyl and sufentanil have greater intrinsic efficacy at
mu receptors than naturally occurring opiates such as
morphine and codeine. In clinical settings, pharmacokinetic variables such as lipid solubility, degree of
ionization and volume of distribution play key roles
in determining agonist potency, onset of effect, and
75
analgesic duration [13]. Analgesic onset is determined

by the ability of an agonist to enter the CNS compartment and distribute into gray matter where receptors
are primarily localized. Drugs that are highly lipophilic
and un-ionized easily enter the CNS and have a very
rapid onset of effect. In contrast, ionized hydrophilic
opioids such as morphine have difficulty penetrating
the bloodbrain barrier (BBB) and have a delayed onset
[13]. Opioid analgesic potency, or the amount of drug
required to achieve an analgesic effect, is closely related
to the octanol-water coefficient (lipophilicity vs.
hydrophilicity) and intrinsic efficacy of the agonist. As a
rule, highly lipophilic opioids have significantly greater
potency than less lipophilic or hydrophilic agents [1,3].
Analgesic duration is related to several factors
including receptor dissociation kinetics, redistribution, and elimination kinetics and volume of distribution. Lipophilic opioids including fentanyl and
sufentanil have dose-related durations of activity.
With low doses, duration is limited by rapid T1/2
alpha redistribution kinetics. With higher doses, duration correlates with T1/2 beta metabolism/elimination kinetics, which is dependent upon enterohepatic
reuptake, hepatic blood flow and extraction, and protein binding. Since T1/2 beta kinetics are time- and
enzyme-dependent, administration of higher doses
can markedly extend analgesic duration [13]. Morphine and methadone have unique attributes that also
affect analgesic duration. Morphines hydrophilic
properties slow BBB egress and favor its sequestration
in the CSF. These factors prolong its duration despite
declines in plasma morphine concentration. The formation of active metabolites (morphine-6-glucuronide) also tends to increase its duration of effect [1,3].
Methadones large volume of distribution leads to
accumulation and a progressive prolongation in analgesic duration with repeated doses. After achievement
of steady state, drug sequestered in peripheral compartments is taken up by the vasculature and maintains minimal effective plasma concentrations [1].
Opioid tolerance and hyperalgesia
76
Continued patient exposure to opioid analgesics leads

to tolerance development and clinical manifestations
such as physical dependence. Tolerance is defined as
the progressive increases in dose required to maintain
a desired pharmacological effect, and is characterized
by a shift to the right in the classic dose-response curve
[13,9,10]. This physiological adaptation is observed
in patients prescribed opioids for pain management, as

well as those abusing this class of drug. Endocytosis of
mu opioid receptors counteracts receptor desensitization and opioid tolerance by inducing fast reactivation
and recycling. Opioid agonists have differing abilities
to initiate endocytosis and regulate surface receptor
concentrations [10]. Development of tolerance is
delayed with opioids having high endocytotic efficacy;
however, these compounds are associated with a more
rapid onset of physical dependence [1,2].
Physical dependence is a normal and commonly
observed phenomenon in opioid-tolerant patients.
Upon abrupt discontinuation of opioids, the cAMP
pathway is further up-regulated and parasympathetic tone is markedly increased [1,9]. Patients
experience unpleasant, but rarely life-threatening,
withdrawal symptoms termed the abstinence syndrome, which includes sweating, shaking, cramping, and diarrhea.
Psychological dependence includes drug-seeking
behavior and drug administration for purposes other
than pain control. Addiction is a term describing an
extreme form of psychological dependence where
patients demonstrate impaired control, craving, compulsive use, and continued use despite harm. Although
opioid addiction is driven primarily by psychological
maladaptations, such behavior is also reinforced by
physical dependence and fears of withdrawal [13,9].
Unlike physical dependence, opioid addiction is rarely
observed in patients suffering moderate to severe
acute pain.
A second clinical alteration observed in patients
treated with opioids is termed opioid induced hyperalgesia [11]. This phenomenon is characterized by
paradoxical increases in pain intensity (hyperesthesia), the development of new pain complaints, and
alterations in pain characteristics (allodynia) in
response to continued administration or increased
dosing of opioid analgesics.
Opioid-induced hyperalgesia (OIH) is most often
observed in tolerant patients, but has also been
observed in naive individuals exposed to rapid-acting
short-duration opioids including remifentanil and
alfentanil. Mechanisms responsible for opioid-induced
analgesia are not completely understood; however,
glutamate-induced activation of NMDA receptors
and upregulation of cholecystokinin (CCK) and
dynorphin, which have anti-analgesic excitatory
effects, have been proposed [1,11]. Excitatory effects
of opioid metabolites (morphine-3-glucuronide,
hydromorphone-3-glucuronide) may also play a role

in the development and progression of OIH.
Historically, it was believed that patient responses to
opioid agonists were similar; nevertheless, measurable
inter-individual variability in efficacy, tolerability, and
incomplete cross-tolerance are commonly observed.
In recent years, opioid receptor pharmaco-genomic
research has uncovered significant mu receptor polymorphisms with over 20 different genetic variants
detected [1,8,12]. Differences in mu opioid receptor
gene (ORM1) expression do not affect ligand binding
kinetics at the extracellular membranous portion of the
receptor, but appear to influence subsequent activation
of associated proteins and second messengers [1,8,12].
Genetic variability of the catechol-O-methyltransferase
(COMT) gene also influences morphine dose requirements. Finally, polymorphisms of the transporter
P-glycoprotein (ABCB1) system also influence opioid
clearance from cerebrospinal fluid [1].
Opioid classification
According to their binding affinities and intrinsic
activity at receptor subtypes, opioids are classified as
either agonists, partial agonists, mixed agonistantagonists or complete antagonists [13]. Opioid agonists
include compounds such as morphine, hydromorphone or fentanyl that bind receptors with moderate
to high affinity, activate G proteins and are capable of
producing a maximal response following receptor
activation. Partial agonists such as buprenorphine
bind mu receptors with higher affinity than morphine
but activate the receptor and associated G proteins
incompletely. The analgesic efficacy curve of partial
agonists is bell-shaped, such that low doses provide
Fentanyl
Hydromorphone
increasing levels of analgesia to a point after which

additional doses either do not increase pain relief or
slightly diminish it [1,2].
Agonistantagonist-type opioids include butorphanol and nalbuphine. These compounds bind mu and
kappa receptor subtypes but differ in activation efficacy.
Generally they behave as agonists at kappa receptors
and antagonists at mu. At low doses, the analgesic properties of mixed agonistantagonists are comparable to
those of weak agonists, such as propoxyphene and
codeine; however, at higher doses no additional analgesia is achieved [13]. This phenomenon, termed the
analgesic ceiling effect, restricts their use to patients
with mild to moderate pain.
Antagonists such as naloxone and naltrexone bind
to all receptor subtypes with high affinity but do not
activate the receptor and G proteins. Antagonists
competitively block the activity of agonists by preventing or displacing their binding to the receptor.
Although antagonists provide no direct analgesic
effects, when administered in low doses they may alter
receptor conformation and increase the intrinsic efficacy of opioid agonists [1,2]. Dose-response curves
for opioid agonists, mixed agonists and antagonists
are presented in Figure 13.3.
Parenteral opioid therapy

Since oral analgesics generally have low bioavailability, delayed onset, and are poorly tolerated during
the immediate post-operative period, parenterally
(IV) administered opioids are commonly prescribed
for pain management. There are several situations
where parenteral opioids are employed. (1) They
are useful for patients advancing from IV-PCA or
Morphine
Buprenorphine
Butorphanol
Increasing
Effect
Naloxone
Figure 13.3. Dose-response curves of

commonly employed agonists, partial
agonists, mixed agonistantagonists, and
antagonists. Pure agonists are able to
achieve maximum effect; however, dose
requirements are dependent upon
potency. Mixed agonistantagonists and
partial agonists may have higher potency
than agonists at low doses; however,
analgesic efficacy is limited and
maximum effect is not achieved.
Antagonists have high affinity and can
competitively displace agonists; however,
they have no efficacy.
Increasing Dose
77
78
epidural opioid-based analgesia, who have moderate to severe discomfort, but have yet to tolerate oral
diets. Parenteral dosing is of particular importance
in patients who are nauseous or vomiting, who
might not absorb oral agents. (2) Several subsets of
patients including the elderly, the cognitively
impaired and overly dependent individuals are poor
candidates for IV-PCA and may achieve better pain
control with intravenous/intramuscular opioids
administered by the clock or PRN. In these individuals, parenteral opioid requirements during early
post-operative intervals may be used to provide a
conversion guide for oral analgesic dosing that follows. Opioid-dependent patients with significant
tolerance development may require both IV-PCA or
parenteral opioid infusions for baseline pain management, in addition to epidural or regional blockade for surgical pain.
Morphine remains the standard parenteral opioid
analgesic for control of acute pain following surgical
and traumatic injuries [1,2]. Ten milligrams of
parenteral morphine is generally recommended as a
starting dose for acute pain management in patients
over 50 kg. Onset of analgesia with IV morphine is
noted within 515 minutes while its duration ranges
from 13 hours depending upon dose administered.
Hydromorphone, oxymorphone, and, to a lesser extent,
meperidine offer therapeutic alternatives for patients
experiencing inadequate pain control with morphine
or intolerant of its adverse effects. In post-operative
settings, hydromorphone offers a more rapid onset,
higher analgesic potency and greater tolerability than
morphine [13]. Oxymorphone has been available for
over 40 years and is currently marketed as a 1 mg vial
for acute pain management. Oxymorphones onset to
peak effect is more rapid than morphines and its overall analgesic efficacy is superior [14]. IV oxymorphone
may be effectively employed in the PACU for patients
experiencing very severe pain. Parenteral doses of
methadone are also advocated for patients with opioid
tolerance and others suffering severe acute pain that is
poorly responsive or unresponsive to morphine and
hydromorphone [15]. Methadone may be employed in
low doses as an adjuvant or as primary therapy [15,16].
Fentanyl is best administered in patients with
marked hemodynamic instability or well-documented
allergies to naturally occurring or semisynthetic morphinians [13,17]. The quality of analgesia provided by
IV fentanyl infusions is excellent and equivalent to
comparable doses administered epidurally, but with less
pruritus [17]. The analgesic effectiveness of parenteral

opioids may be potentiated with small doses of anticholinergic/antihistaminics such as phenergan and vistaril; however, increased levels of sedation should be
expected [1,2,3]. Other complications associated with
parenteral opioids include respiratory depression, nausea and vomiting, pruritus and bowel dysfunction.
Oral analgesic dosing

Once patients are able to tolerate a liquid diet they
may be advanced to oral opioids, which should be
continued during the convalescent and rehabilitative
periods following surgery. Oral administration offers
a safe, convenient, non-invasive and cost-effective
method of controlling acute pain that should always
be considered in patients who continue to experience
moderate to severe pain.
Oral opioids including morphine, meperidine,
hydrocodone, and oxycodone and compounded preparations containing acetaminophen, aspirin, and ibuprofen provide effective relief for patients complaining
of moderate to severe pain. Orally administered morphine and meperidine are poorly absorbed and
undergo significant entero-hepatic metabolism [1,2].
When compared to parenteral dosing, onset is delayed,
duration is less predictable and dose requirements are
increased. In this regard equianalgesic oral morphine
and meperidine doses are 23 times higher than
parenteral requirements. Oxycodone is more reliably
absorbed than morphine. Following oral administration, both oxycodone and hydrocodone have a rapid
and predicable onset at 35 min, a peak effect at 60 min,
and duration of 3.54 h [1,18,19].
Sustained-release opioid preparations including
morphine (MS-Contin) and oxycodone (Oxycontin)
and oxymorphone (Opana ER) offer several advantages including less frequent administration intervals,
avoidance of peak and trough plasma levels and
greater analgesic uniformity. These preparations provide 812 hours of pain relief and are best suited for
patients suffering chronic pain and prolonged postoperative pain [1,2,20].
An additional opioid preparation that may be considered for patients who cannot tolerate oral analgesics but continue to experience brief episodes of severe
pain is the fentanyl oralet (Actiq). Fentanyl oralet
releases between 100400g of fentanyl within 15
minutes with high bioavailability. While not approved
for acute pain management, this preparation is effec-
tive when given 2030 minutes prior to short painful

procedures such as closed reduction, dressing changes,
or chest tube placement [21].
Less potent opioid analgesics such as tramadol and
codeine may be prescribed to patients recovering from
dental and ENT surgeries and medical procedures
associated with mild to moderate pain [22]. A compounded form of tramadol (Ultracet) provides greater
effectiveness than tramadol alone. Ultracet is an oral
multimodal analgesic containing tramadol plus acetaminophen, approved for the short-term management
of acute pain. A newly released dual acting analgesic, tapentadol (Nucynta), activates mu opioid receptors and also inhibits norepinephrine reuptake. Its
analgesic efficacy is equivalent to oxycodone; however,
it has a better tolerability profile, causing less nausea,
vomiting, constipation and pruritus [23].
Short-acting oral opioids agents such as morphine

immediate release (IR), hydrocodone IR, hydro
morphone IR, oxycodone IR, and oxymorphone IR
may be favored initially because they are easy to
titrate [24]. These agents are best employed in opioid-naive patients, recovering from uncomplicated
procedures that require relatively limited durations
of treatment. Following extensive surgery with severe
discomfort and prolonged and painful convalescence,
sustained-release opioids may be considered. Shortacting opioids are characterized by a rapid rise and
fall in serum opioid levels, whereas serum levels
of sustained-release opioids increase slowly to therapeutic levels, remain there for an extended period,
and then decline slowly [25]. (Opioid analgesics
and dosing recommendations are summarized in
Table 13.2.)
Table 13.2. Dosing guidelines for oral and parenteral opioids
Opioid
Route
Dose (mg)
Onset
Duration
Comments
Morphine
(PO)
(1545)
45 min
45 h
Poor oral effect
Morphine
(IV)
(515)
10 min
3.54 h
Histamine release
Meperidine
(PO)
(1300)
45 min
3.5 h
Toxic metabolite
Meperidine
(IV)
(75125)
10 min
3h
Useful for visceral

pain
Hydrocodone
(PO)
(7.515)
35 min
46 h
Similar to
oxycodone
Oxycodone
(PO)
(515)
30 min
46 h
Good oral
analgesic
Codeine
(PO)
(3070)
45 min
3.5 h
High side-effect
profile
Methadone
(PO)
(7.515)
1020 min
68 h
Prolonged
elimination
Methadone
(IV)
(57.5)
510 min
68 h
Difficult to titrate
Hydromorphone
(PO)
(7.515)
35 min
46 h
Well tolerated
Hydromorphone
(IV)
(13)
1015 min 3.54 h
3.54 h
Useful for severe

pain
Oxymorphone
(PO)
(515)
30 min
46 h
Poor oral
bioavailability
Oxymorphone
(IV)
(0.52)
510 min
4h
Useful for severe

pain
Fentanyl
(PO)
(2400 g)
510 min
60 min
Rapid onset
Fentanyl
(IV)
(1150 g)
35 min
30 min
Very rapid onset
Tramadol
(PO)
(1200 mg)
40 min
46 h
For mildmoderate pain
Tapendadol
(PO)
(50100 mg)
32 min 46 h
46 h
Dual-acting
analgesic
79
Opioid-related adverse events

In settings of acute pain, most opioid-related adverse
events are transient and tend to resolve with ongoing
treatment [13,26]. Common adverse events associated
with parenteral and orally administered opioids and
their active metabolites include nausea, vomiting, sedation, pruritus and constipation [26]. In sensitive individuals the incidence and severity of these adverse
events may be so annoying and distressing that patients
self-limit or discontinue opioid dosing and suffer poor
pain control. Patients recovering from abdominal and
gynecological surgery are generally at risk of opioid-
induced bowel dysfunction and ileus, mandating that
such therapy be supplemented with stool softeners, bulk
laxatives, and occasional enemas. Most opioid-related
AEs are dose-dependent, which is why it is important to
initiate therapy with the lowest effective dose and to utilize a multimodal analgesic approach. Some opioidrelated AEs are often treated symptomatically, for
example prescribing an antiemetic for nausea or laxatives and/or a peripheral mu antagonist for constipation [27]. Other side effects, such as sedation and
pruritus, are typically addressed by decreasing the
opioid dose rather than by treating the symptom. In
addition to dose reductions, other strategies that can
be employed to minimize opioid-related AEs include
changing the route of administration, switching to a
different opioid or providing multimodal pharmacological therapy [28].
Future directions with oral and

parenteral opioids for acute pain
80
In the near future improved and more selective opioid

analgesics may be developed that better suit individual
patient needs [29]. Rapidly disintegrating and readily
absorbed lingual and buccal preparations avoid gastric absorption and first-pass hepatic and offer advantages of convenience and rapid analgesic onset. While
originally developed for breakthrough chronic pain
these routes of delivery may become available for
acute pain management. Nasal and pulmonary delivered opioid preparations offer similar advantages as
well as convenience, and may displace the need for IV
dosing and possibly IV-PCA in patients who remain
NPO [30]. The use of the active and better-tolerated
morphine metabolite, morphine-6-glucuronide, may
become available as an alternative to morphine [31].
Kappa agonists are being developed that can activate peripheral receptors yet do not penetrate the
bloodbrain barrier. These selective peripheral agonists provide analgesia without central effects such as
excessive sedation, euphoria, and respiratory depression. They offer the promise of effective relief of visceral pain (Ob-GYN, GU-renal colic), with low risk of
mu-mediated respiratory depression.
Opioids with lower risk of diversion

and abuse
Opioids formulated in crush-resistant, water-insoluble tablets may provide a lower risk for diversion,
adulteration, and abuse (snorting, injecting). Tablets
containing mixtures of an agonist plus an antagonist
that is released if the tablet is adulterated are also being
studied.
References
1. Gutstein HB, Akil H. Opioid analgesics. In Hardman

JG, Limbird LE, Gilman AG, eds. Goodman & Gilmans
The Pharmacological Basis of Therapeutics, 10th ed.
New York: McGraw-Hill, 2002, pp. 569619.
2. Way WL, Fields HL, Schumaker MA. Opioid
analgesics. In Katsung BG, ed. Basic & Clinical
Pharmacology, 9th ed. Lange Medical Books/
McGraw-Hill, 2004.
3. Pasero C, Portenoy RK, McCaffery M. Opioid
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Clinical Manual. St. Louis, MO: Mosby, 1999, pp.
161299.
4. Joint Commission on Accreditation of Healthcare
Organizations. JCAHO Standards for Pain
Management [referenced from the Comprehensive
Accreditation Manual for Hospitals, Update 3, 1999
(effective January 1, 2001)]. Available at: http://www.
texmed.org/has/prs/pop/jps.asp.
5. Gilson AM, Joranson DE. U.S. policies relevant to the
prescribing of opioid analgesics for the treatment of
pain in in patients with addictive disease. Clin J Pain
2002;18:S9198.
6. Bonica JJ. Biochemistry and modulation of
nociception and pain. In Bonica JJ, ed. The
Management of Pain, 2nd ed. Philadelphia: Lea and
Febiger, 1990, pp. 94121.
7. Beecher H. Pain in men wounded in battle. Ann Surg
1946;123:96105.
8. Pan YX, Xu J, Bolan E, Moskowitz HS Pasternak GW.
Identification of four novel exon 5 splice variants of
the mouse mu opioid receptor gene. Mol Pharmacol
Fast Forward 2005; 68:866875.
9. Nestler EJ, Aghajanian GK: Molecular and cellular
basis of addiction. Science 1997;278:5863.
10. Zastrow M, Svingos A, Haberstock H, et al.

Regulatory endocytosis of opioid receptors: cellular
mechanisms and proposed role in physiological
adaptation to opiate drugs. Curr Opin Neurobiol
2003;13:348353.
11. Angst MS, Clark JD. Opioid-induced hyperalgesia: a
qualitative systematic review. Anesthesiology
2006;104:570587.
12. Ross JR, et al. Pharmacogenetics J 2005;5:324336.
Goodman & Gilmans Pharmacology, 11th ed. New
York: McGraw-Hill, 2006.
13. Mahler DL, Forrest WH. Relative analgesic potencies
of morphine and hydromorphone in post-operative
pain. Anesthesiology 1975;42:602607.
14. Sinatra RS, Harrison DM, Hyde N. Oxymorphone
revisited. Semin Anesthesiol 1988;7:209215.
15. Peng PW, Sandler AN. Fentanyl for post-operative
analgesia: a review. Anesthesiology 1999;90:576599.
16. Marco CA, Plewa MC, Buderer N, Black C, Roberts A.
Comparison of oxycodone and hydrocodone for the
treatment of acute pain associated with fractures: a
double-blind, randomized, controlled trial. Acad
Emerg Med 2005;12:282288.
17. Stambaugh JE, Reder RF, Stambaugh MD,
Stambaugh H, Davis M. Double-blind, randomized
comparison of the analgesic and pharmacokinetic
profiles of controlled- and immediate-release oral
oxycodone in cancer pain patients. J Clin Pharmacol
2001;41:5006.
18. Opana ER(R) (Oxymorphone extended-release
capsules, Endo Pharmaceuticals Incorporated, Chadds
Ford, Pennsylvania). Full prescribing information,
2005.
19. Mitra S, Sinatra RS. Perioperative management of
acute pain in the opioid-dependent patient.
Anesthesiology 2004;101:212227.
20. Shir Y, Rosen G, Zeiden A, Davidson M. Methadone is
safe for treating hospitalized patients. Canad J
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21. Sinatra RS. Treatment guidelines and unpublished
observations. Yale University Pain Management
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22. Sinatra RS, Sramcik J. Tramadol: its use in pain

management. In Hines RL, ed. Anesthesiology Clinics
of North America, vol. 2. Philadelphia: W.B. Saunders,
1998, pp. 5369.
23. Hartrick C, Van-Hove I, Stegmann J, et al. Efficacy and
tolerability of tapentadol immediate release and
oxycodone immediate release in patients awaiting
primary joint replacement. Clin Ther 2009;31:
260271.
24. Ginsberg B, Sinatra RS, Adler LJ, Crews JC, Hord AH,
Laurito CE, Ashburn MA. Conversion to oral
controlled-release oxycodone from intravenous opioid
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25. McCarberg BH, Barkin RL. Long-acting opioids for
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26. Wheeler M, Oderda GM, Asburn MA, Lipman AG.
Adverse events associated with post-operative
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27. Thomas J, Karver S, Austin Cooney G, et al.
Methylnaltrexone for opioid-induced constipation in
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28. Marret E, Kurdi O, Zufferey P, Bonnet F. Effects of
nonsteroidal antiinflammatory drugs on patientcontrolled analgesia morphine side effects: metaanalysis of randomized controlled trials.
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31. Romberg R, van Dorp E, Hollander J, et al. A
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81
Section 2
Chapter
14
Morphine oral and parenteral

Joseph Rosa and Swati Patel
Generic Names: morphine, morphine sulfate

Trade/Proprietary Names: oral Morphine
Sulfate Immediate Release Tablets, Morphine
Sulfate Oral Solution, OMS Concentrate, Roxanol Concentrated Oral Solution, Oramorph;
parenteral Min-I-Jet-Morphine Sulfate Injection, Morphine Sulfate Add-Vantage, SelectA-Jet Morphine Sulfate Injection, Infumorph
Drug Class: opioid analgesic
Manufacturers: Purdue Pharma, One Stamford
Forum, Stamford, CT; Roxane Laboratories,
1809 Wilson Rd, Columbus, OH; Baxter Healthcare, One Baxter Parkway, Deerfield, IL; Richwood-Shire Pharmaceuticals, 5 Riverwalk,
Citywest Business Campus, Dublin 24, Ireland
Chemical Structure: see Figure 14.1
Chemical Name: 7,8-didehydro-4,5--epoxy-17methylmorphinan-3,6--diol sulfate
Introduction
Morphine is the principal alkaloid of opium, and
remains the standard of comparison, and the most
widely employed opioid agonist worldwide for acute
and chronic pain management. It is available in a variety of dosing formulations; however, its major sites of
administration are via oral and parenteral routes.
Major and minor sites of action
82
As the principal opiate analgesic, morphine exerts its

pharmacological effects on the central nervous system
and the gastrointestinal tract with its primary actions
of therapeutic value being analgesia and sedation.
Clinically it has moderate analgesic potency, a slow
onset to peak effect, and an intermediate duration of
activity. Morphine is a hydrophilic drug that has
difficulty penetrating the bloodbrain barrier and
reaching sites of activity in the brain and spinal cord.

Morphines analgesic effects involve at least three anatomical areas of the CNS: the periaquaductal gray
matter, the ventromedial medulla and spinal cord.
Morphine is a mixed agonist that binds to and activates mu, kappa and delta receptor subtypes [1]:
moderates supraspinal analgesia and
respiratory depression
modulates spinal analgesia and sedation
associated with dysphoria, hallucinations, and
respiratory and vasomotor stimulation
Receptor interactions
Morphine interacts primarily with the mu () receptor. The mu receptor binding sites of morphine are
very discretely distributed in the brain with high densities in the posterior amygdala, hypothalamus, thalamus, caudate nucleus, and putamen [1,2]. The mu
receptors are also found on the terminal axons of primary afferents within the laminae I and II (substantia
gelatinosa) of the spinal cord and in the spinal nucleus
of the trigeminal (fifth cranial) nerve. Morphine
appears to increase the patients tolerance of pain and
decreases the perception of suffering. It also causes
mood alterations including euphoria, dysphoria,
drowsiness, and mental clouding. Morphine depresses
various respiratory centers, depresses the cough reflex,
and causes miosis. It may cause nausea and vomiting
by stimulating the chemoreceptor trigger zone (CTZ).
Gastrointestinal effects include increased tone and
decreased propulsive power of smooth muscle of the
GI tract, resulting in constipation and an increase in
the tone of the biliary tract, potentially worsening biliary colic. It decreases pancreatic, biliary, and gastric
secretions. Morphine increases the tone of the urinary
tract smooth muscle, which may result in urinary
retention and may reduce urine formation by increasing the release of ADH (antidiuretic hormone).
Morphine may result in histamine release to varying
Chapter 14 Morphine oral and parenteral
HO
3
4
Morphine
Figure 14.1.
1
12
13
5
11
14
15
HO
10
9
17
N
CH3
16
degrees and may, in some patients, cause orthostatic

hypotension.
Metabolic pathways, drug clearance

and elimination
After parenteral administration the typical t1/2 for
morphine is 2.12.6 hours. Metabolism occurs in the
liver via conjunction with glucuronic acid and the
majority of this morphine 3-glucuronide compound
is excreted in the urine by glomerular filtration.
Approximately 90% of excretion occurs within 24
hours of the last dose, with 710% being excreted in
the feces, the largest portion of which is through the
biliary system, as conjugated morphine [13]. The
onset of analgesia after SQ or IM administration is
1030 min, with a peak effect after SQ of 5090 min,
after IM of 3060 min, and after IV of approximately
20 min. Duration of analgesia is 36 h. Morphine is
relatively ineffective in the injection form taken orally
as it undergoes extensive first-pass by the intestinal
mucosa and liver.
Indications
Surgical acute pain: oral and parenteral doses of morphine are used commonly for the relief of moderate to
severe post-operative surgical pain.
Medical pain: morphine is the drug of choice for
the relief of pain due to myocardial infarction. Relief of
ischemic pain decreases sympathetic nervous system
activity thus reducing myocardial oxygen demand.
Morphine is used in patients with acute pulmonary
edema for its cardiovascular effects and to decrease air
hunger. Morphine can be used to treat the pain of sickle
cell disease with crisis. Morphine can be used to treat
the pain of Guillain-Barr syndrome, osteoarthritis
and obstetric pain. Morphines sedative effects can be
utilized in the intubated and ventilated patient.
Chronic non-malignancy pain: morphine can be

used for moderate to severe chronic pain especially in
terminally ill patients.
Cancer pain: morphine can be used for the treatment of moderate to severe cancer pain.
Somatic visceral and neuropathic pain: morphine
can be useful in the treatment of pain that has a
somatic visceral or neuropathic component or origin.
Contraindications
Absolute: known hypersensitivity to morphine
Relative: asthma, hypercarbia, paralytic ileus, res
piratory depression, heart failure secondary to chronic
lung disease, cardiac arrhythmia, intracranial mass
associated with increased intracranial pressure, acute
alcoholism, delirium tremens, obstructive sleep apnea.
Common doses
Oral: the usual adult dosage of morphine is 1030 mg
as conventional tablets, capsules or solutions. Dosages should be adjusted with sustained- or extendedrelease proportions accordingly. It is suggested to
initiate oral morphine therapy with an immediaterelease proportion as titration is more easily achieved.
The patient can then be switched to an extendedor sustained-release proportion. The initial dosage
of the extended- or sustained-release proportion
should be based on the total immediate-release
dosage.
Parenteral: the usual adult subcutaneous (SQ) or
intramuscular (IM) dose of morphine sulfate is 10 mg
every 4 hours as necessary; dosage may range from 5
to 20 mg every 4 hours as needed depending on patient
response and requirement. The IV dosage is 2.515
mg injected IV slowly every 45 minutes in adults. SQ
or IM dose in children is 0.10.2 mg/kg every 4 hours
as needed. IV dosage of 0.050.1 mg/kg may be given
slowly in children. In patients with acute MI morphine
may be given to relieve anxiety and pain associated
with myocardial ischemia. Dosages of 215 mg can be
administered parentally and repeated as needed.
When morphine sulfate is administered via patientcontrolled analgesia (PCA) dosage should be adjusted
according to the severity of the pain and the patients
response. When morphine is administered by continuous infusion for relief of severe, chronic pain
associated with primary or metastatic cancer the dose
(individualized according to response and tolerance of
the patient) should be started at 0.810 mg/h. Dosing
guidelines for morphine are presented in Table 14.1.
83
Table 14.1.
Indication
Route
Adult dose
Orala
Standard/
post-operative
pain
1030 mg
immediate
release (IR)
Pediatric dose
Parenteralb
IM/SQ
IV
520 mg
q4h
215 mg q5min
Acute MI
Cancer pain
Oral
Safety and
efficacy of
extended release
oral formulation
not studied in
pts under 18 yrs
of age
Parenteral
IM/SQ
IV
0.10.2 mg/kg
q4h
0.050.1 mg/
kg q3h
0.10.2 mg/kg
q4h
0.050.1 mg/kg
210 mg slowly
1030 mg q4h
(IR)
220 q4h
210 mg
30 mg q24h
(extended
release Avinza)
Mechanically
ventilated,
sedation
0.070.5 mg/kg
per h
0.010.03
mg/kg per h
0.010.15 mg/kg
q12h
Conversion from oral to parenteral morphine sulfate: the estimated daily requirement is one-third of the total daily oral requirement; with
the starting dose at 1/2 the calculated dose.
b
Conversion from parenteral to oral morphine sulfate: three times the estimated total daily parenteral requirement may be sufficient in
chronic use settings.
Dose adjustments:
Renal impairment: moderate failure (GFR 1050 mL/min), 75% of normal dose; severe failure (GFR less than 10 mL/min) 50% of normal.
Liver impairment: alter dose in cirrhotic patients.
Neonates: increase dosing frequency to every 46 h.
a
Potential advantages
Ease of use: morphine and all the other injectable opioids are very easy to use. One major advantage of
morphine that leads to its ease of use is the multiple
routes of administration (IV, IM, SQ, IT epidural,
intraventricular, rectal, oral, and inhalational). Morphine can easily be titrated to sedation levels, pain
scores, and respiratory rate.
Tolerability: morphine and all the other injectable
opioids are well tolerated in most patients. There are
some exceptions to be discussed.
Cost: morphine as a generic drug is very inexpensive.
Monotherapy: morphine is commonly used as the
sole analgesic agent.
Potential disadvantages
84
Toxicity: morphine is not known to have mutagenic

or carcinogenic potential at non-narcotic doses in
animals. However, mutagenicity and carcinogenicity

have not been established in humans.
Pregnancy, fertility and lactation

Pregnancy: there are no adequate controlled studies to
date in humans regarding the effects of morphine in
pregnancy. Morphine should only be used when the
benefits to the mother and fetus outweigh the risks.
Fertility: morphine is not known to impair fertility
at non-narcotic doses in animals: however, the effects of
morphine on human fertility have not been established.
Lactation: morphine should be used with caution
in nursing women since the drug has been reported to
distribute into milk.
Drug interaction
Morphine should be administered cautiously and in
reduced dosages when other CNS depressants are
used, including other narcotic analgesics, barbiturates,
Chapter 14 Morphine oral and parenteral
benzodiazepines,
antihistamines, phenothiazines, TCAs,
tranquilizers, major or minor, or in the presence of
alcohol. Morphine sulfate may compete with other
drugs such as cimetadine, mephenesin, meprebamate,
and clanrolene for hepatic glucuronidation. The concomitant use of centrally acting muscle relaxants and
opioid analgesics can cause exacerbations in respiratory
depression, hypotension, and profound sedation. Concomitant use of morphine and esmolol has been
reported to result in increased esmolol serum levels.
Multimodal analgesia
Morphine can be used in combination with other opioids
to decrease the dose of morphine or with other non-
opioids for an opioid-sparing effect and, depending on the
agent, an additive or synergistic effect is seen. Opioidsparing drugs include NSAIDs, TCAs, sedative-hypnotics,
analytics and agents such as neurontin. Some believe that
cross-tolerance between morphine and hydromorphone
is incomplete, making alternating morphine and hydromorphone in rotation beneficial.
Drug-related adverse events and

common side effects
Cardiovascular: <5% incidence of each of the following:
bradyarrhythmia, cardiac arrest secondary to respiratory or cardiac depression hypertension, hypotension
(probably secondary to histamine release). Morphine is
noted to have the greatest potential for histamine release
compared with other opioids, possibly leading to a <5%
chance of orthostatic hypotension, circulatory depression, palpitations, shock, syncope, and tachycardia and a
510% chance of peripheral edema.
Dermatological: pruritus (up to 80% incidence is
primarily seen with neuraxial injection), 510% incidence of rash, sweating, and urticaria. Recurrent herpes simplex virus I or II reactivation may be seen with
neuraxial delivery.
Endocrine, Metabolic: alterations in thermoregulation and hypogonadism.
Gastrointestinal: abdominal pain <510%, biliary
colic <5%, constipation <10%, diarrhea 510%, feed-
ing problems primarily in preterm infants. Loss of

appetite 510%, nausea and vomiting 770%, xerostomia 510%.
Neurological effects: asthenia 510%, confusion
<5%, dizziness 6%, headache 10%, insomnia 510%,
lightheadedness, myoclonus, parasthesia 510%, somnolence >10%, CNS excitation, and Menieres disease.
Seizures may be associated with high doses. Use with
extreme caution in patients with increased ICP as a
further increase may occur.
Psychological effects: anxiety <6%, delirium,
depression, dysphoria, euphoria, hallucinations, auditory and visual, psychosis.
Renal effects: nephrotoxicity, urinary retention
510%.
Reproductive effects: sexual dysfunction; prolonged use can result in repression of male secondary
sexual characteristics, and disruption of ovulation,
amenorrhea and depression of lactation.
Respiratory effects: cough suppression; may suppress
productive cough leading to pneumonia, dyspnea 5%,
irregular breathing, and pulmonary edema. Respiratory
depression with timing dependent upon route of administration (neuroaxial, epidural 512 hours; intrathecal
411 hours; IV, SQ 90 min; IM, 30 min; IV, 10 min).
Treatment of adverse events

Naloxone is the drug of choice for reversal of respiratory depression.
Nausea and vomiting can be treated with ondansetron, metoclopramide, droperidol, steroids, etc.
Pruritus from histamine release may be treated
with benadryl or other antihistamines. Can also be
treated with low-dose nalaxone (0.2 mg) or low-dose
propofol (10 mg).
References
1. AHFS Drug Information, 2009.

2. Goodman and Gilmans The Pharmacological Basis of
Therapeutics, 11th ed. New York: McGraw Hill, 2006.
3. Drugedex Evaluations.
4. Baxter Package Insert Doc, 2003.
85
Section 2
Chapter
15
Morphine sulfate controlled-release

Parisa Partownavid
Generic Names: morphine sulfate controlledrelease tablet; morphine sulfate extended-release

capsule
Trade/Proprietary Names: MS Contin, Avinza,
Kadian
Drug Class: opioid analgesic, Schedule 2
Forum, Stamford, CT; King Pharmaceuticals,
Inc., Bristol, TN; Alpharma Pharmaceuticals
LLC, One New England Avenue, Piscataway, NJ
08854
Chemical Structure: MS Contin and Kadian,
see Figure 15.1; Avinza, see Figure 15.2
Introduction
86
Of the commonly used opioids, morphine remains the

gold standard for the treatment of severe pain.
Extended-release morphine is available in tablet and
capsule formulations. One of the first controlledrelease systems for the oral administration of morphine is MS Contin tablet, which is a combination
matrix consisting of a hydrophilic granular system
inserted in a hydrophobic matrix. Upon ingestion,
gastric fluid dissolves the tablet surface and hydrates
the hydrophilic polymer to produce a gel layer through
which morphine is released at a rate determined by
the type of hydrophilic polymer, hydrophobic matrix
or their ratio. Various dosage strengths require different ratios of polymers to ensure dose proportionally.
Capsule formulations contain pellets or beads consisting of an inert core, surrounded by a morphine layer
and a polymer coat. Following administration, fluid in
the gastrointestinal tract diffuses through the polymer
coat to release the morphine. The nature of the inert
core and the thickness of the polymer coat control the
rate of dissolution of morphine while transiting through
the gastrointestinal tract in a pH-dependent fashion.
One capsule formulation, Avinza, contains both

immediate-release and extended-release beads of morphine for once-daily oral administration. Upon ingestion, 10% of the beads release their morphine content
immediately while the residual beads gradually release
their morphine content over the next 24 hours. Another
capsule formulation is Kadian, which is indicated for
every 12 hours or 24 hours dosing. Unlike Avinza it
does not contain immediate-release morphine.
Mode of activity
Morphine is a naturally occurring alkaloid from the
opium poppy seed. Modern formulations employ synthetic morphine. Major and minor sites of morphine
activity include spinal and supraspinal opioid receptors. Morphine binds to and activates mu, kappa and
delta receptor subtypes.
Receptor interactions: morphine is a pure opioid
agonist at mu, and is a weak agonist for kappa.
Metabolic pathway
Absorption: morphine is released from MS Contin
and Kadian somewhat more slowly than from Avinza
and immediate-release oral preparations. Following
oral administration of a given dose of morphine, the
amount ultimately absorbed is essentially the same
whether the source is controlled-release or an immediate-release formulation. Because of pre-systemic
elimination (i.e. metabolism in the gut wall and liver)
only about 40% of the administered dose reaches the
central compartment. Following the administration of
immediate-release oral morphine products, approximately 50% of the absorbed morphine reaches the
systemic circulation within 30 minutes. However, following the administration of MS Contin or Avinza,
this extent of absorption occurs after 1.5 hours, and
with Kadian on average after 8 hours
Metabolism: most of the metabolism of the opioids occurs in the liver. Although a small fraction (less
Chapter 15 Morphine sulfate controlled-release
Figure 15.1.
CH3
H
CH2
H2SO4 5H2O
CH2
HO
OH
Figure 15.2.
N CH3
HO
H2SO4 5H2O
OH
than 5%) of morphine is demethylated, virtually all

morphine is converted to glucuronide metabolites
including morphine-3-glucuronide, M3G (about 50%)
and morphine-6-glucuronide, M6G (about 5 to 15%).
M3G has no significant analgesic activity. M6G has
been shown to have opioid agonist and analgesic activity in humans.
Excretion: approximately 10% of morphine dose is
excreted unchanged in the urine. Most of the dose is
excreted in the urine as M3G and M6G. A small
amount of the glucuronide metabolites is excreted in
the bile and there is some minor enterohepatic cycling.
Seven to 10% of administered morphine is excreted in
the feces.
As with any drug, caution should be taken to guard
against unanticipated accumulation if renal and/or
hepatic function is seriously impaired.
Indications (approved/non-approved)
Controlled-release oral formulation of morphine sulfate is indicated for the management of moderate to
severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time.
These formulations are not intended for use as a PRN
analgesic.
Surgical acute pain: the only indication for postoperative use of the controlled-release oral formulation of morphine sulfate is if the patient is already
receiving the drug prior to surgery or if the postoperative pain is expected to be moderate to severe
and persist for an extended period of time.
Controlled-release oral formulation of morphine

sulfate is not indicated for pain in the immediate postoperative period (the first 1224 hours following surgery) in patients not previously taking the drug, because
its safety in this setting has not been established.
Controlled-release oral formulation of morphine
sulfate is also not indicated for pain in the postoperative period if the pain is mild, or not expected to
persist for an extended period of time.
Medical pain: controlled-release oral formulation
of morphine sulfate is indicated for relief of moderate
to severe pain in patients who require potent opioid
analgesics over periods more than few days.
Chronic non-malignancy pain: controlled-release
oral formulation of morphine sulfate could be administered in a more convenient schedule than immediate-release oral morphine products, and significantly
improves pain control at a lower daily opioid dose,
with less rescue doses for breakthrough pain.
Cancer pain: controlled-release oral formulation
of morphine sulfate is a well-recognized oral agent for
the treatment of cancer pain.
Contraindications
Absolute: controlled-release oral formulation of morphine sulfate is contraindicated in patients with known
hypersensitivity to morphine.
Relative: in any situation where opioids are contraindicated. This includes patients with respiratory
depression, and in patients with acute or severe bronchial asthma or hypercarbia. Morphine is contraindicated in any patient who has or is suspected of having
a paralytic ileus, renal and hepatic impairment.
Common doses
The controlled-release nature of the formulation allows
it to be administered on a more convenient schedule
than conventional immediate-release oral morphine
products. However, MS Contin does not release morphine continuously over the course of a dosing interval. The administration of single doses of MS Contin
on an every 12 hours dosing schedule will result in
higher peak and lower trough plasma levels than those
that occur when an identical daily dose of morphine is
administered using conventional oral formulations on
a q4h regimen. The clinical significance of greater fluctuations in morphine plasma level has not been systematically evaluated.
For patients who have not received narcotics
before, the starting dose should be the lowest, and the
87
patient needs to be monitored for side effects such as

respiratory depression. The dose may gradually be
increased until pain relief is obtained.
Conversion from parenteral to oral morphine:
because of inter-subject variation and cross-tolerance,
it is better to underestimate the 24-hour oral morphine requirement than to overestimate. Estimates of
the oral to parenteral potency of morphine vary. Some
authors suggest that a dose of oral morphine only
three times the daily parenteral morphine requirement may be sufficient in chronic use settings. In
patients whose daily morphine requirements are
expected to be less than or equal to 120 mg per day,
the 30 mg tablet strength is recommended for the initial titration period. Once a stable dose regimen is
reached, the patient can be converted to the 60 mg or
100 mg tablet strength, or an appropriate combination
of tablet strengths, if desired.
MS Contin tablets are available in the following
strengths: 15 mg, 30 mg, 60 mg, 100 mg, 200 mg; 100
mg and 200 mg tablets are for use in opioid-tolerant
patients
Avinza capsules are available as 30 mg, 45 mg, 60
mg, 75 mg, 90 mg, and 120 mg doses. The fumaric acid
(a component of Avinza capsules that promotes
absorption of the drug within the gastrointestinal tract
by acting as an osmotic agent and a local pH modifier)
limits the daily dose of Avinza to a maximum of 1600
mg, because of the potential for renal toxicity from
high doses of fumaric acid.
Kadian capsules are available in 20 mg, 30 mg, 50

mg, 60 mg, and 100 mg doses. Dosing guidelines for
controlled release morphine preparations are presented in Table 15.1.
Ease of use, tolerability: controlled-release oral
formulations of morphine sulfate provide significant
pain relief, ensure uniform blood concentrations, offer
less frequent dosing, fewer adverse side effects, and
flexible titration with different dosing strengths.
As monotherapy: controlled-release oral morphine is generally not used as monotherapy.
As used for multimodal analgesia: controlledrelease oral morphine is prescribed to control the
basal pain, and needs to be supplemented by immediate-release oral morphine for breakthrough pain.
Kadian capsules have the advantage of being swallowed whole, or opened and contents sprinkled on a
small amount of apple sauce or administered through
a 16 French gastrostomy tube. Avinza may be opened
too and the entire bead content sprinkled on a small
amount of apple sauce, but the beads should not be
chewed, crushed, or dissolved due to the risk of acute
overdose.
Cost: MS Contin is relatively economical, is available as a generic too, and is widely available at most
hospitals.
Avinza and Kadian are costly and currently not
available in generic form. The first patent for Avinza
Table 15.1.
88
Drug
Dose
Interval
Breakthrough pain
General
considerations
MS Contin
If daily requirement dose

expected to be less than
60 mg: start 15 mg tablet
812 h
May need to be
supplemented with
immediate-release
medication
Not to be broken,
chewed, dissolved, or
crushed
Avinza
In opioid-naive patients:
start 30 mg, increments not
greater than 30 mg every
4 days
24 h
515% of total daily

dose given in form of
immediate-release
The capsule may be

opened and bead
contents sprinkled on a
small amount of apple
sauce. Capsule or
beads not to be
chewed, crushed, or
dissolved
Kadian
In opioid-naive patients:
start 20 mg, increments not
greater than 20 mg every
other day
1224 h
May need to be
supplemented with
immediate-release
medication
The capsule may be

opened and contents
sprinkled on a small
amount of apple sauce
or administered through
a 16 French gastrostomy
tube
Chapter 15 Morphine sulfate controlled-release
will expire in November 2017, and for Kadian it

expired in March 2010.
Toxicity: acute overdosage with morphine can be
manifested by respiratory depression, somnolence
progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, rhabdomyolysis progressing to renal failure, and sometimes
bradycardia, hypotension, and death.
Drug interactions: morphine has additive effects
when used in conjunction with alcohol, other opioids, or illicit drugs that cause central nervous system depression because respiratory depression,
hypotension, and profound sedation or coma may
result.
Agonist/antagonist analgesics (i.e. pentazocine, nalbuphine, and butorphanol) should be administered with
caution to a patient who has received or is receiving
morphine sulfate. In this situation, mixed agonist/antagonist analgesics may reduce the analgesic effect of morphine sulfate and/or may precipitate withdrawal
symptoms in these patients.
Morphine decreases the metabolism of tricyclic
antidepressants, leading to toxicity.
Drug-related adverse events

Common/serious adverse events: the severe adverse
reactions include respiratory depression, apnea, respiratory arrest, circulatory depression, hypotension,
cardiac arrest, and shock.
Most common adverse events: constipation, lightheadedness, dizziness, sedation, nausea, vomiting,
sweating, dysphoria, and euphoria.
Less common adverse events: weakness, headache,
agitation, tremor, uncoordinated muscle movements,
seizure, alterations of mood, muscle rigidity, transient
hallucinations, disorientation, visual disturbances,
insomnia, increased intracranial pressure, dry mouth,
biliary tract spasm, laryngospasm, anorexia, diarrhea,
cramps, taste alteration, constipation, ileus, intestinal
obstruction, dyspepsia, increases in hepatic enzymes,
flushing of the face, chills, tachycardia, bradycardia,
palpitation, faintness, syncope, urine retention or
hesitance, amenorrhea, reduced libido and/or
potency, pruritus, urticaria, edema, diaphoresis, antidiuretic effect, paresthesia, bronchospasm, muscle
tremor, blurred vision, nystagmus, diplopia, miosis,
anaphylaxis.

In the treatment of morphine overdosage, primary
attention should be given to the re-establishment of a
patent airway and institution of assisted or controlled
ventilation. Supportive measures (including oxygen,
vasopressors) should be employed in the management of circulatory shock and pulmonary edema
accompanying overdose as indicated. The pure opioid antagonists, such as naloxone, are specific antidotes against respiratory depression, which results
from opioid overdose. Naloxone should be administered intravenously, however; because its duration of
action is relatively short, and considering the long
duration of action of the controlled-release form of
morphine sulfate, the patient must be carefully monitored until spontaneous respiration is reliably reestablished. If the response to naloxone is suboptimal
or not sustained, additional naloxone may be administered, as needed, or given by continuous infusion to
maintain alertness and respiratory function; however, there is no information available about the
cumulative dose of naloxone that may be safely
administered.
For the treatment of nausea and vomiting
ondansetron or metoclopramide is often useful. For
management of constipation one should consider that
tolerance does not usually develop for the constipating effects of opioids. Laxatives and/or stool softeners
should be used prophylactically from the beginning of
opioid therapy. Agents that increase gastrointestinal
propulsion should not be used as it may increase the
risk of bowel perforation, if the patient has ileus and
impacted stool.
References
1. Trescot AM, Helm S, Hansen H, et al. Opioids in the

management of chronic non-cancer pain: an update of
American Society of the Interventional Pain
Physicians (ASIPP) guidelines. Pain Physician,
Opioids Special Issue 2008;11:S5S62.
2. Holgado MA, Iruine A, Alvarez-Fuentes J, FernandezArevalo M. Development and in vitro evaluation of
controlled release formulation to produce wide dose
interval morphine tablets. Eur J Pharm Biopharm
2008;70(2):544549.
3. Pergolizzi J, Bger RH, Budd K, et al. Opioids and
the management of chronic severe pain in the
elderly: consensus statement of an international
expert panel with focus on the six clinically most
often used World Health Organization step III
opioids (buprenorphine, fentanyl, hydromorphone,
89
methadone, morphine, oxycodone). Pain Practice

2008;8(4):287313.
4. Rosenblum A, Marsch LA, Joseph H, Portenoy RK.
Opioids and the treatment of chronic pain:
controversies, current status, and future directions.
Exp Clin Psychopharmacol 2008;16(5):405416.
Section 2
Chapter
16
90
5. Sasaki J, Weil A, Ross E, Nicholson B. Effectiveness of

polymer-coated extended-release morphine sulfate
capsules in older patients with persistent moderate
to severe pain: a subgroup analysis of a large,
open-label, community-based trial. Curr Ther Res
2007;68(3):137150.
Combination agonistantagonist
opioid analgesics
Jeff Gudin
Generic Names: morphine plus naltrexone, oxycodone plus naloxone, oxycodone plus naltrexone
Trade/Proprietary Names: Embeda, OXN
Oxytrex
Manufacturers: King Pharmaceuticals, 501 Fifth
Street, Bristol, TN; Purdue Pharma Inc, One
Stamford Forum, Stamford, CT; Pain Therapeutics Inc., 2211 Bridgepointe Parkway Suite 500,
San Mateo, CA
Chemical Structures: morphine, see Figure
16.1; naltrexone, see Figure 16.2; oxycodone, see
Figure 16.3; naloxone, see Figure 16.4
Chemical Names:
morphine: (5,6)-7,8-didehydro-4,5-epoxy-17methylmorphinan-3,6-diol
naltrexone: 17-(cyclopropylmethyl)-4,5-epoxy3,14-dihydroxymorphinan-6-one
oxycodone: 4,5-epoxy-14-hydroxy-3-methoxy17-methylmorphinan-6-one
naloxone: 10,17-dihydroxy-4,12-oxa-4-azapentacyclooctadeca-18-trien-14-one
Introduction
During the last decade a dramatic rise in abuse of prescription opioids has occurred in the USA and other
countries. In testimony presented to Congress in 2008
on trends in unintentional drug overdose, the CDC
identified opioid pain relievers as a driver for recent
large increases in deaths. They called on drug manufacturers to modify opioid analgesics; to make them
more difficult to tamper with, and/or combine them
with agents that block the effect of the opioid, if it is
dissolved and injected [1]. These are complex problems
requiring multi-faceted solutions including hardening
of the tablet, combining the opioid with an antagonist
drug, or adding an irritant chemical that would prevent nasal or parenteral misuse. This chapter will
describe combination agonist plus antagonists that
have recently become available or that are in
development.
Opioid analgesics are one of the few classes of
medications available to treat severe levels of pain.
Adding another drug to an opioid (compounding)
may enhance analgesia, minimize adverse effects,
reduce opioid tolerance and/or potentially deter overuse or abuse. Most astute clinicians recognize that
concerns about abuse and addiction should not prevent the proper management of pain. In response,
Chapter 16 Combination agonist-antagonist opioid analgesics
HO
Figure 16.1.
Me
Table 16.1. Facts regarding opioid adulteration and abuse

in 2005
1. 5.2 million Americans used prescription pain relievers for
nonmedical purposes each month
2. Each day approximately 2500 teens try abusing prescription
painkillers for the first time
3. 5.2% of high school seniors abused long-acting oxycodone
4. 9.6% of high school seniors abused hydrocodone products

5. More than three in five say prescription pain relievers are
easy to get from parents medicine cabinets
HO
6. Total cost of opioid abuse = $9.5 billion in 2005 dollars

HO
Figure 16.2.
N
OH
O
H3CO
Figure 16.3.
OH
CH3
HO
Figure 16.4.
CH2
N
O
OH
much focus has been placed on appropriate prescribing and risk stratification of these controlled substances. One area of study and industry support has
been the development of tamper-resistant combination opioids with the potential to deter abuse. Many of
these conceptual and developed products utilize the
opioid antagonists naloxone and naltrexone as a key
ingredient in their formulations.
Summarized from References 3, 4, and 5.
Abuse data collected by NIDA/SAMHSA [3,4]

indicate that abusers will crush, chew or dissolve an
extended-released opioid formulation to convert the
drug to an immediate-release, more desirable and
abusable form. Oral consumption and nasal administration (snorting) are reported to be the most common modes of illicit prescription abuse by teenagers.
Data taken from 109 prescription drug abusers entering a treatment facility in central Kentucky showed
that the most commonly abused opioids were
hydrocodone (78%) and oxycodone-containing
products (69%) [2]. Most respondents reported altering the delivery system of prescribed sustainedrelease opioid tablets by either chewing or crushing.
Following crushing the adulterated drug was administered by snorting, subcutaneous skin popping or
IV administration. This form of adulteration and
misuse is also true for short-acting drugs [4,5]. Some
facts regarding opioid adulteration and abuse are
presented in Table 16.1.
Opioid agonistantagonist
combinations
Opioid antagonists reverse the subjective and analgesic effects of opioid agonists by binding competitively at the mu opioid receptor. Naloxone is an
opioid antagonist administered intravenously in
cases of overdose or in low doses to reverse some
bothersome, adverse effects of opioid analgesics.
Naltrexone is available as an orally administered opioid antagonist and is used most commonly to oppose
the potential effects of opioids or block cravings from
alcohol and other substances. Combining opioids in
an attempt to deter misuse is not a new concept. Talwin Nx was created in an attempt to curb the injection of the drug pentazocine by adding naloxone.
91
The amount of naloxone present in Talwin Nx (0.5

mg per tablet) has no action when taken orally and
does not interfere with the pharmacological action
of pentazocine. However, this amount of naloxone
given by injection has profound antagonistic action
to the opioid analgesics.
When considering new novel combination
agents, we must ensure that their primary function,
efficacy and safety are met. There are no guidelines
set for the development of tamper-proof or abuse
deterrent agents. Obviously they must first undergo
rigorous phase I, II and III trials to confirm the
pharmacokinetics, efficacy and safety of the primary
(opioid) ingredient. Then the pharmacokinetic and
pharmacodynamic properties of the additional
added agents (i.e. antagonists) must be assessed,
when the preparation is either taken whole or tampered with.
Morphine plus naltrexone

combination
92
Currently, the only FDA-approved controlled-release

opioid/naltrexone combination is Embeda. This
preparation of sustained-release (SR) morphine contains a sequestered antagonist that is released only
upon tampering. Embeda contains pellets of an
extended-release oral formulation of morphine sulfate
surrounding an inner core of naltrexone hydrochloride and is indicated for the management of moderate
to severe pain when a continuous, around-the-clock
opioid analgesic is needed for an extended period of
time. The morphine/naltrexone ratio is 25:1 (4%),
with the largest available dosage form being 100/4 mg.
Crushing, chewing, or dissolving combined morphine/naltrexone (Embeda) will result in the uncontrolled delivery of the opioid and pose a significant
risk to the abuser that could result in overdose and
death; it will also result in the release of naltrexone,
which may precipitate withdrawal in opioid-tolerant
individuals.
Combined morphine/naltrexone capsules have
shown comparable analgesia, adverse effects and
bioequivalence to a similar morphine sulfate extended-release capsule product (Kadian) with regard to
rate and extent of plasma morphine absorption [8]. In
the clinical efficacy trial in patients with pain due to
osteoarthritis, change in the weekly BPI average pain
score was statistically significantly superior for those
treated with Embeda as compared to placebo. A review
of the Subjective Opiate Withdrawal Scales (SOWS)
and Clinical Opiate Withdrawal Scale (COWS) and

adverse event profile did not detect an increased risk
of opioid withdrawal for combined morphine/naltrexone compared to placebo [8].
Combined morphine/naltrexone capsules are to be
swallowed whole or the contents of the capsules sprinkled on apple sauce and the pellets in the capsules are
not to be crushed, dissolved, or chewed. A pK study of
combined morphine/naltrexone crushed vs. whole
was done to compare the plasma concentrations and
relative bioavailability of morphine, naltrexone, and
the major naltrexone metabolite (6--naltrexol).
Plasma morphine levels from crushed morphine/naltrexone capsules showed no extended-release properties. While concurrent administration of high-fat food
decreased the rate and extent of morphine absorption
from combined morphine/naltrexone, the total bio
availability or sequestration of naltrexone was not
affected. An alcohol effects study examined the bio
availability of combined morphine/naltrexone when
dosed under fasting conditions with 4%, 20% and 40%
alcohol compared to water. The rate and extent of bioavailability and total exposure to morphine (AUC,
Cmax) were not affected when the drug was administered concomitantly with either 4% or 20% alcohol,
when compared to administration with water. When
combined morphine/naltrexone was administered
with 40% alcohol (240 mL over 15 minutes), the rate
and extent of bioavailability (Cmax) doubled and the
tmax was 5 hours earlier, when compared to administration with water. The total systemic exposure to morphine (AUC) was not affected [9].
Abuse liability
Abuse liability is the potential for a drug to produce
positive effects that will reinforce a pattern of misuse,
abuse, or diversion. To date, there is no evidence that
the naltrexone component of combined morphine/
naltrexone will prevent or deter abuse. Novel abuse
liability trials have been developed to assess the effects
of combined morphine/naltrexone when tampered
with. The pharmacodynamic effect of naltrexone in
the setting of crushed morphine/naltrexone capsules
was examined in two clinical trials: an oral and an
intravenous abuse liability trial [8]. These were conducted in nondependent recreational opioid abusers,
as dependent, daily or habitual users would probably
experience a withdrawal syndrome when exposed to
the naltrexone component with crushed morphine/
naltrexone capsules.
Chapter 16 Combination agonist-antagonist opioid analgesics
The oral abuse liability study was a randomized

double-blind four-way crossover trial comparing
120 mg oral morphine delivered in the following
routes: placebo, MSIR (immediate release), Embeda
whole, and Embeda crushed [8]. The greatest drug
liking scores were for MSIR. Overall, 87.5% of subjects had some degree of reduced drug liking after
receiving crushed morphine/naltrexone, while 12.5%
had no reduction in drug liking. There was considerable individual variability in the degree of reduction
in drug liking, ranging between 10 and 50%. Similarly, 69% of subjects showed some decrease in
euphoria with crushed morphine/naltrexone compared to IR morphine and 31% of subjects did not
report a reduction in euphoria. There was similar
individual variability in the degree of reduction in
euphoria.
In addition to the oral abuse study above, an intravenous abuse liability study was performed. This was
a randomized double-blind, placebo-controlled,
three-way crossover trial in nondependent recreational opioid-users administered placebo, 30 mg of
IV morphine alone or 30 mg of IV morphine in combination with 1.2 mg of IV naltrexone to simulate
parenteral use of crushed capsules containing morphine/naltrexone [8]. The primary objective was to
determine the relative drug liking and euphoric
effects of IV morphine alone compared to IV morphine plus naltrexone following single bolus doses.
Pharmacodynamic measures were assessed by subjective responses to the Drug Effects Questionnaire
(DEQ) Question #5 How high are you now? The
combination of morphine with naltrexone resulted in
71% of subjects reporting a reduction in euphoria
compared to morphine alone. Note that the intravenous injection of crushed morphine/naltrexone may
result in serious injury and death due to a morphine
overdose or an embolic event. Intravenous injection
of crushed morphine/naltrexone may precipitate a
severe withdrawal syndrome in opioid-dependent
patients.
The clinical significance of the degree of reduction
in drug liking and euphoria reported in these studies
has not yet been established. To reiterate, there is no
evidence that the naltrexone in combined morphine/
naltrexone reduces its abuse liability.
Future combinations
Although only available currently as an SR morphine
combination, other naltrexone-containing analgesic
products are in development. Multiple companies

are researching combination oxycodone/naltrexone
products, including Purdue Pharmas combined
oxycodone/naloxone (OXN) and Pain Therapeutics
Inc.s combined oxycodone/naltrexone preparation
(Oxytrex). Animal and phase 3 human data indicate
that these combinations of oxycodone and either
naloxone or naltrexone minimize the development of
physical dependence and analgesic tolerance while
prolonging analgesia. They may also reduce opioidinduced bowel dysfunction, since released antagonist
might inhibit mu receptors in the gut. Oxytrex is in
late-stage clinical development for the treatment of
moderate-to-severe chronic pain. To evaluate the
safety and efficacy of the oxycodone/naltrexone combination, three clinical studies have been conducted,
one in healthy volunteers and the other two in patients
with chronic pain. The putative mechanism of ultralow-dose naltrexone is to prevent an alteration in
G-protein coupling by opioid receptors that is associated with opioid tolerance and dependence. Opioid
agonists are initially inhibitory but become excitatory
through constant opioid receptor activity. The agonist/
antagonist combination of Oxytrex may reduce the
conversion from an inhibitory to an excitatory receptor, thereby decreasing the development of tolerance
and physical dependence.
References
1. CDC Report to Congress on opioid analgesic

overdose. March 12, 2008.
2. Passik SD, Hays L, Eisner N, Kirsh KL. Psychiatric and
pain characteristics of prescription drug abusers
entering drug rehabilitation. J Pain Palliat Care
Pharmacother 2006;20(2):513.
3. Substance Abuse and Mental Health Services
Administration Office of Applied Studies. Rockville,
MD: 2008. Results from the 2007 National Survey on
Drug Use and Health: National Findings DHHS
Publication No. SMA 074293. http://www.oas.samhs
a.gov/NSDUHlatest.htm. Published September 2008.
Accessed October 30, 2008.
4. Office of National Drug Control Policy. National
Youth Anti-Drug Media Campaign: Campaign
Overview Fact Sheet. http://www.mediacampaign.org/
newsroom/press08/fs_012408.pdf. Published January
24, 2008. Accessed February 26, 2008.
5. Johnston LD, OMalley PM, Bachman JG,
Schulenberg JE. Secondary School Students.
Bethesda, MD: National Institute on Drug Abuse;
2007. Monitoring the Future: National Survey Results
on Drug Use, 19752006; vol I. NIH Publication
93
076205. http://www.monitoringthefuture.org/pubs/
monographs/vol1_2006.pdf. Published September
2007. Accessed February 26, 2008.
6. The Partnership for Drug Free America. The
Partnership Attitude Tracking Study Teens 2005
(PATS). http://www.drugfree.org/Files/Ful
l_Teen_Report. Published May 15, 2006. Accessed
February 26, 2008.
Section 2
Chapter
17
Meperidine
Ellen Flanagan and Brian Ginsberg
Generic Name: meperidine, pithidine, pethanol

Trade Name: Demerol
Class of Drug: opioid analgesic (Schedule II)
Manufacturers: Abbott Laboratories, Hospital
Products Division, Abbott Park, IL 60064;
Sanofi-Aventis U.S. LLC, 55 Corporate Drive,
Bridgewater, NJ 08807
Chemical Name: ethyl 1-methyl-4-phenylpiperidine-4-carboxylate; C15H21NO2
Description
94
7. Birnbaum HG, White AG, Reynolds JL, et al.

Estimated costs of prescription opioid analgesic
abuse in the United States in 2001. Clin J Pain
2006;22(8).
8. Embeda package insert, King Pharmaceuticals.
9. Embeda: Alcohol effect study (Study 103) Data on File,
King Pharmaceuticals.
Meperidine is a synthetic phenylpiperidine-based

opioid analgesic, with structural similarities to fentanyl and sufentanil. It was first synthesized in 1939
as an anticholinergic agent and subsequently on
routine screening its analgesic effect was demonstrated [1,2]. Meperidines analgesic activity is primarily mediated by binding and activating mu opioid
receptors and secondarily via activation of alpha 2
adrenergic and delta opioid receptors. In clinically

relevant concentrations, meperidine is a potent agonist at the 2B adrenoceptor.

Sodium channel blocker
Meperidine reversibly blocks voltage-gated Na+ currents with a half-maximum inhibiting concentration
(IC50) of 112 M. Clinically, meperidine shows a dosedependent blockade of both the sensory and motor fibers of the ulnar nerve after infiltration. Two percent
meperidine blocks both sensory and motor activity at
the hypothenar muscle. Intrathecal doses of meperidine
50 mg can provide short-duration spinal anesthesia.
Anticholinergic
Meperidine has no spasmolytic effects but an anticholinergic effect, displacing the dose-response curve
for carbacholine to the right, indicating competitive
antagonism. Only chemically induced spasm of guinea
pig large intestine is relaxed by direct application of
meperidine solution, possibly due to meperidines
local activity.
Chapter 17 Meperidine
Figure 17.1.
COOC2H5
N
CH3
Opioid receptor
Meperidine binds to the mu opioid receptor to promote analgesia. Animal studies demonstrate counterclockwise hysteresis between the blood level of
meperidine and analgesia, reflecting a delay while
meperidine crosses the bloodbrain barrier. At meperidines EC50, it induces less stimulation of the mu
opioid receptor and had less efficacy than morphine,
fentanyl or sufentanil. In contrast to other opioids,
meperdine is not a substrate for P glycoprotein
(P-gp), which mediates the efflux of opioids across
the bloodbrain barrier, impacting the onset, magnitude, and duration of analgesic response. Genetic
variability and pharmacological agents do not influence the flux of meperidine across the bloodbrain
barrier.
Alpha-2-adrenergic receptors
Recent data have provided convincing evidence
in mice that meperidine reduces the thermoregulatory temperature threshold primarily by activation
at the alpha-2-adrenoreceptor and that this mechanism is probably independent of the mu opioid
receptor, as evidenced by the lack of effect of
naloxone.
In an elegant series of experiments, knockout
mice have been used to determine the specific alpha
adrenergic receptor subtype responsible for the
thermoregulatory effects of meperidine [3]. Wildtype and knockout mice with deletions of either the
alpha 2a, alpha 2b or alpha 2c adrenoreceptor
were studied after meperidine treatment in the presence or absence of atipamezole, an alpha 2 receptor
antagonist. Wild-type and alpha 2b or 2c knockout
mice treated with meperidine exhibited decreased
thermoregulatory threshold temperatures antagonized, that is prevented, by atipamezole. In contrast,
thermoregulatory thresholds in alpha 2a knockout
mice were unaffected by meperidine. It was demonstrated that the alpha 2a receptor is probably the
primary mechanism responsible for the meperidineinduced decrease in thermoregulatory threshold [3].
While these data are derived from mice rather than
humans, and the primary mechanism of thermo
regulation differs between species, these data are
intriguing.

and elimination
Meperidine is metabolized by two different pathways, primarily by hepatic carboxylesterase to meperidinic acid, an inactive metabolite which is
glucuronated and then excreted. In addition, meperidine undergoes N-demethylation via the cytochrome
P450 system to normeperidine. Normeperidine formation in human liver microsomes is mainly catalyzed by CYP2B6 and CYP3A4, with a minor
contribution from CYP2C19. Normeperidine is further metabolized to either normeperidinic acid by
carboxylesterase or by microsomal hydroxylation to
N-hydroxynormeperidine followed by renal elimination. Normeperidine has half the analgesic potency
of meperidine but two to three times the potency as
a CNS excitatory agent. Signs and symptoms of
normeperidine-related CNS excitation include irritability, tremors, myoclonus, muscle twitches, shaky
feelings and generalized seizures [1,3]. Elevated levels of normeperidine occur with prolonged administration of high doses of meperidine and decrease
excretion.
After oral administration, the levels of normeperidine are increased compared to systemic administration. In hepatic disease, the reduced hepatic
clearance of meperidine results in increased absorption necessitating a reduction in dose. Following
intramuscular administration of meperidine, the
elimination half-life (t) is 3.6 hours (3.14.1 hours).
Intramuscular absorption is highly variable with a
two-fold variation in blood levels in the same patient
and a wider five-fold intra-patient variability. The t
is 111.4 hours in cirrhotic patients (range 8.318.7),
but the levels of normeperidine are reduced. The
elimination half-life of meperidine and normeperidine are prolonged in patients with renal failure. The
t elimination half-life of normeperidine is anywhere from 1421 h to 2448 h and as long as 34 h in
renal failure [3].
95
Indications
Surgical acute pain
Fifty milligrams of meperidine shows no superiority
over placebo but a 100 mg dose is comparable to
1015 mg morphine. Following IM administration,
onset of analgesia occurs within 1015 minutes
and peak effects occur within 1 hour. In a comparison of three doses of meperidine compared to three
equipotent doses of morphine delivered via PCA,
meperidine demonstrated equivalent analgesia at
rest but morphine was superior with activity. These
data have been replicated by others. In children,
PCA morphine produced significantly better pain
scores than meperidine with no difference in the
side-effect profiles [1]. Low doses of meperidine,
12.5 mg, are used effectively to treat post-operative
shivering and the shivering induced by an infusion
of amphotericin.
Medical pain
Renal colic
Meperidine has been used extensively to treat renal
colic [13]. There is some evidence which suggests
that meperidine may produce less smooth muscle
spasm than equianalgesic doses of morphine. A comparison of meperidine with ketorolac, in the management of renal colic, demonstrated that the NSAID had
a more rapid onset of action and fewer side effects
than meperidine. Similarly, a comparison of 1 mg
hydromophone to 50 mg of meperidine, also used to
treat renal colic, demonstrated the need for fewer
breakthrough medications (hydromophone 31% vs.
meperidine 68%), fewer IV pyelograms (28% vs. 54%),
fewer hospital admissions (25% vs. 49%) and improved
analgesia.
Migraine
Meperidine is commonly used in the management
of migraine but ketorolac is as effective as an anal
gesic with fewer side effects reported with the
NSAID.
Rigors
96
Rigors, or involuntary shivering, are a poorly understood but common post-operative complication.
Shivering is also associated with fever seen in
malignancy and amphotericin or granulocyte infusions. Numerous investigations have proven the
efficacy
of meperidine for the prophylaxis and
abortive treatment of shivering with treatment of
established shivering slightly more effective than
prophylaxis. Clearly, the evidence supports the use
of meperidine for the treatment of post-operative
shivering.
Meperidine appears to have the greatest effect on
shivering when compared to the analgesic equivalents
of fentanyl and sufentanil. Using a non-shivering thermogenesis mouse model, it was demonstrated that
intraperitoneal injection of meperidine led to a
decrease in threshold of non-shivering thermogenesis
as measured by expiratory carbon dioxide and body
temperature [3]. Meperidines effect was abolished if
mice were subsequently treated with atipamezole, an
alpha-2 antagonist. Control mice injected with saline
maintained a normal threshold of non-shivering thermogenesis that was unaffected by further treatment
with atipamezole.
Chronic nonmalignant pain

Sickle cell disease
Since oral meperidine results in higher levels of
normeperidine than equipotent doses of intravenous
or intramuscular meperidine, its use has been limited
to the management of acute pain of sickle cell disease
and precludes the use of oral meperidine in the management of chronic pain that is associated with sickle
cell disease. A literature review found an incidence of
seizures in the sickle cell population of 1 to 12% and
questions have been raised regarding the role of
meperidine and its metabolite normeperidine in precipitating seizures [3]. A pain protocol using morphine or hydromorphone coupled with increased
access to outpatient clinics decreased ED visits, hospitalizations, and increased utilization of a more stable primary care clinic setting by patients with sickle
cell disease. Appropriate pharmacological treatment
of sickle pain entails the use of non-opioid analgesics,
opioid analgesics (excluding meperidine) and adjuvants singly or in combination depending on the
severity of pain.
Bilary spasm
All opioids increase the phasic wave frequency of
the sphincter of Oddi, which may impair filling of
the sphincter and increase pressure. All studies
to date have shown no statistical difference in the
mean basal pressure between morphine and meperidine [1].
Chapter 17 Meperidine
Contraindications
Absolute
The absolute contraindication to the use of meperidine is a history of a serotonergic crisis in the past and
renal failure.
Relative
Relative contraindications to the use of meperidine
include other anti-serotonin drugs, renal dysfunction
and seizures.
Common doses/uses
Oral
Approximately 50% of oral meperidine is absorbed
into the systemic circulation (range 41 to 61%). After
oral administration the onset of analgesia is within
15 minutes and peak effects occur in 6090 minutes
[1,3]. In hepatic disease, with reduced hepatic clearance, the absorption of meperidine is increased from
the gastrointestinal tract, necessitating a reduced
dose.
Parenteral
Following subcutaneous or IM administration, onset
of analgesia occurs within 1015 minutes and peak
effects occur within 1 hour [1,3]. Meperidine binds to
both albumen and alpha-1-acid glycoprotein (AAG).
The AAG level is dependent on the stress response and
levels increase with trauma and infection. Further
variability may be induced by eryrthocyte binding.
Following intramuscular administration of meperidine the elimination half-life (t) is 3.6 hours (3.14.1
hours). The average parenteral dose of meperidine is
11.5 mg/kg.
Neuraxial
The epidural dose of meperidine has ranged from
20 to 150 mg with an infusion rate of 520 mg/h.
The onset of action occurs in 5 minutes after a
bolus and the analgesia lasts 4 to 8 hours. Meperidine, 10 to 30 mg, has been used for subarachnoid
bolus with an anticipated analgesia of 10 to 24
hours [1,3].
Meperidine may offer advantages for relief of visceral
pain [13].
Potential disadvantages associated with meperidine

are primarily related to the neurotoxic effects of its
metabolite, normeperidine.
Studies in rats have determined that subcutaneous
doses of both meperidine and normeperidine lower
the seizure threshold. In contrast, after intracerebro
ventricular (ICV) administration, meperidine raised
the threshold while normeperidine lowered it.
Naloxone antagonized this anticonvulsant effect of
ICV-administered meperidine and enhanced the proconvulsant effect of normeperidine. Neurotoxic symptoms can range from muscle twitching and jerking to
full tonic-clonic seizures. Symptoms are worsened
with parenteral doses approaching 1 g/day, in patients
with underlying seizure disorders, pre-eclampsia, and
acute renal failure.
Adverse events
Respiratory effects
The respiratory depressant effect of meperidine
exceeds that of morphine. Naloxone reverses the respiratory depression seen with relative overdoses of
meperidine.
Euphoria
In human volunteers meperidine causes dose-related
subjective effects such as sedated, coasting or spaced
out, or feel drug effect that persisted for 4 or 5
hours. These subjective effects were associated with
drug liking.

Serotonin crisis
Meperidine is thought to inhibit both the 5-HT2A
receptors and norepinephrine (NE) reuptake mechanism which may precipitate a serotonin syndrome,
a toxic state secondary to excessive serotonin agonism of the CNS [3,4]. This adverse drug reaction
occurs most commonly in patients who are using
single or multiple medications that increase postsynaptic serotonin levels. Inherited deficiencies in
the metabolism of serotonin may contribute to the
development of the syndrome. Hypertension, atherosclerosis, and hyperlipidemia are all associated with
a reduction in endothelial MAO activity and thus
a reduced capacity to metabolize serotonin may
increase the risk of a serotonin crisis. The diagnosis
97
of serotonergic crisis is made by the presence of

tremor, hyperreflexia, spontaneous clonus or inducible clonus with agitation and diaphoresis, a temperature > 38C and muscle rigidity.
Conclusions
Meperidine is an older opioid analgesic with typical
annoying and occasionally serious adverse events
such as respiratory depression. It is also associated
with significant risks of cortical irritability and potential neurotoxicity. Meperidine may provide useful
relief of visceral pain, post-operative shivering, and
sickle cell crisis-related pain; however, because of its
adverse event profile, its role in modern pain medicine is becoming increasingly limited [4].
Section 2
Chapter
18
98
References
1. Clark R, Wei E, Anderson P. Meperidine:

therapeutic use and toxicity. J Emerg Med
1995;13:797802.
2. Kranke P, Eberhart L, Roewer N, Tramer M.
Pharmacological treatment of post-operative
shivering: a quantitative systematic review of
randomized controlled trials. Anesth Analg
2002;94:453460.
3. Latta K, Ginsberg B, Barkin R. Meperidine: a critical
review. Am J Ther 2002;9(1);5368.
4. Raymo L, Camejo M, Fudin J. Eradicating analgesic
use of meperidine in a hospital. Am J Health Syst
Pharm 2007;64(11);11481152.
Codeine and codeine compounds

Anjali Vira
Generic Name: codeine

Trade/Proprietary Names: Robafen AC, Robitussin A-C Syrup, Tylenol with Codeine (No. 2,
No. 3, No. 4), Nurofen Plus
Manufacturer: Roxane Laboratories Inc., 1809
Wilson Rd, Columbus, OH; Reckitt Benckiser
plc, Slough, UK
Drug Class: opioid analgesic, opiate antitussive
Chemical Name: methylmorphine, 3-methoxy17-methylmorphinan-6-ol; C18H21NO3
Description
Codeine is an opiate alkoloid that can be extracted

from the opium poppy, Papaver sominiforum. It was
first isolated in 1832 and remains a widely used oral
opiate analgesic that has roughly one-tenth the
potency of oral morphine [1]. Codeine is a useful
antitussive and is a component of numerous coughsuppressant compounds. It is commonly prescribed
for management of acute pain following dental surgery, minor general surgery and for relief of acute
trauma. Codeine tablets are manufactured alone
(Schedule II) or in combination with aspirin or acetaminophen (Schedule III). The combination of codeine
Chapter 18 Codeine and codeine compounds
MeO
Figure 18.1.
Me
H
HO
plus ibuprofen (Nurofen Plus) is available as a pain

reliever in Europe and the UK. Codeine is medically
prescribed for the relief of mild to moderate pain but
is less effective for severe and very severe pain. Compared to morphine, codeine produces less analgesia,
sedation, and respiratory depression. Codeine is the
parent drug used for the production of dihydrocodeine and hydrocodone.
Mode of activity
Site of activity
Like other opioid agonists, codeines major sites of
action are localized to and mediated by supraspinal
and spinal opioid receptors. Codeine has a low affinity
for mu and kappa opioid receptors and its major
effects are due to its conversion to morphine. Morphine binds mu opioid receptors with higher affinity,
producing dose-dependent analgesia, as well as negative effects typical of mu receptor agonists such as respiratory depression, constipation, and nausea.
Codeine also provides clinically useful central antitussive effects through a central mechanism that is not
completely understood [1].
Metabolic pathways
Codeine is a prodrug that exerts most of its effects
through two active metabolites, namely morphine
and codeine-6-glucuronide. N-Demethylation of
codeine into norcodeine by CYP3A4 and the glucuronidation of codeine are the main pathways for converting the molecule into inactive compounds,
accounting for more than 80% of its clearance.
O-Demethylation of codeine into morphine by the
cytochrome P450 enzyme CYP2D6 represents a
minor pathway of codeine metabolism accounting for
less than 10% of clearance. Nevertheless, this pathway
is essential in order to gain analgesic activity as it
allows codeine to be converted to morphine. Because
codeine itself is not an effective analgesic, individuals
who are not able to convert codeine to morphine do

not gain adequate analgesia [2]. Genetic polymorphisms of CYP2D6 are found in 10% of the Caucasian
population and 2% of Asians. Lack of efficacy in these
poor metabolizers should be recognized quickly
and they should be switched to equianalgesic doses
of an alternative opioid [2]. Conversely patients with
induction of this enzyme system or others with phenotypic ultrarapid metabolism may experience opioid intoxication following exposure to small doses
of codeine [3]. This situation may be worsened in
patients with renal failure who have difficulty eliminating the G-6 metabolites of codeine and morphine.
The concentration of O-demethylated metabolites can
be as much as 45 times as high in persons with ultrarapid CYP2D6 metabolism as it is in those with poor
metabolism. Codeine has a half-life of roughly 2.53
hours and has an oral bioavailability that is poor when
compared to other oral narcotics such as oxycodone
and methadone.
Indications
Codeine is approved to treat mild to severe acute and
chronic pain, post-operative pain, irritable bowel syndrome, diarrhea, and cough. It is also commonly used
as a post-procedure analgesic for patients recovering
from dental procedures.
Contraindications
Absolute: hypersensitivity to codeine.
Relative: codeine and other narcotics should be
used with caution in patients who have severe respiratory compromise as they can cause respiratory depression. Because 90% of oral codeine is renally cleared,
patients with severe renal disease require prolonged
monitoring for delayed respiratory depression and
sedative effects of codeine. Care should be exercised in
patients co-treated with drugs that either inhibit or
up-regulate CYP2D6.
Common doses
Dosage should be adjusted according to the severity of
the pain and the response of the patient. It may occasionally be necessary to exceed the usual dosage
recommended below or employ a more potent opioid
in cases of very severe pain or in patients who have
developed opioid tolerance.
Oral: the recommended analgesic starting dose
for adults is 3060 mg every 34 hours (or 1 mg/kg
99
every 34 hours as needed for children or adults

weighing less than 50 kg). The recommended antitussive dose for adults and children over 12 years of age
is 1020 mg every 46 hours. Codeine is readily absorbed
from the GI tract with the peak analgesic effects noted
4560 minutes post administration
Nurofen Plus contains 12.8 mg of codeine and 200
mg of ibuprofen per tablet, and is prescribed as 12 tablets every 46 h as required. When prescribing codeine
compounds, caregivers should calculate total daily exposure to acetaminophen, aspirin and ibuprofen to reduce
risks of hepatotoxicity and gastrointestinal bleeding
Parenteral: the recommended starting dose of
codeine is 60 mg every 2 h given as intramuscular or
subcutaneous injection.
Codeine is one of the few opioids that possess central
antitussive effects. Furthermore codeine suppresses
cough at doses that are significantly lower than the
dose required to effect analgesia. The combination of
antitussive effect and analgesia may be useful in
patients suffering pain related to lung cancer and other
terminal forms of lung and tracheal disease. The typical antitussive dose of codeine starts at 10 or 20 mg,
which can be titrated to effect. At these lower antitussive but sub-analgesic doses, the unwanted side effects
such as respiratory depression are low. Compared with
other drugs codeine is relatively inexpensive.
As discussed above, the analgesic effect of codeine
depends greatly on its ability to be metabolized to
morphine. In patients in whom large amounts of
codeine have been administered without relief, the
possibility of a polymorphism of the CYP2D6 enzyme
must be considered. Medications that inhibit CYP2D6
may reduce or even completely block the conversion
of codeine to morphine. These include selective serotonin reuptake inhibitors (SSRIs), cimetidine, and
antidepressants such as buproprion. On the other
hand agents that induce CYP450 isozymes, such as
rifampin and dexamethasone, increase the conversion
rate and increase the risk of adverse events.
100
As an oral drug, codeine is much less effective as

an analgesic due to its large first-pass hepatic metabolism compared to morphine, hydrocodone and oxycodone. The plasma half-life of codeine is also shorter
than many other orally available opiates such as morphine, hydromorphone, and oxymorphone. Like all
opioids, continued use of codeine may result in tolerance development and physical dependence. However,
when compared to potent mu agonists, codeine is less
addictive and is associated with mild withdrawal
symptoms.

Codeine is associated with the same adverse events
that may occur with an opiate. Respiratory depression,
sedation, nausea, constipation, and pruritus are all
common side effects of codeine. These effects are especially pronounced in the elderly and may be more prolonged in any patient who is slow to clear the drug,
such as patients with renal failure.
Conclusion
Codeine is an older opioid agonist that offers few analgesic advantages over newer derivatives such as
hydrocodone and oxycodone, and appears to be associated with a higher incidence of annoying side effects,
such as sedation, nausea, and vomiting. Since the drug
must be metabolized to an active compound, codeine
has a delayed analgesic onset, and may be associated
with inadequate pain relief in patients who have
CYP2D6 deficiencies.
References
1. Brunton LL. Goodman and Gilmores The

Pharmacological Basis of Therapeutics, 11th ed. New
York: McGraw Hill, 2006, pp. 563580.
2. Sindrup SH, Brosen K. The pharmacogenetics of
codeine hypoalgesia. Pharmacogenetics 1995;5:
335346.
3. Yue QY, Hasselstrom J, Svensson JO, Sawe J.
Pharmacokinetics of codeine and its metabolites in
Caucasian healthy volunteers: comparisons between
extensive and poor hydroxylators of debrisoquine.
Br J Clin Pharmacol 1991;31:635642.
Section 2
Chapter
19
Oxycodone and oxycodone compounds

Mary Keyes
Section 1
Generic Names: oxycodone, oxycodone plus

acetaminophen compound, oxycodone plus
aspirin compound
Proprietary Names: Roxicodone, Roxicodone
oral solution, Intensol: Oxy IR, Oxyfast,
Oxydose. Compounds: Percocet, Percodan,
Endodan, Tylox, Roxiprin, Roxicet, Percolone, Combunox.
Drug Class: opioid analgesic (Schedule II)
Forum, Stamford, CT; Xanodyne Pharmaceutical,
Newport, KY; Endo Pharmaceuticals, 100 Endo
Boulevard, Chadds Ford, PA; Ortho McNeil
Pharmaceutical, Raritan, NJ; Roxane Laboratories,
Columbus, OH
Chemical Name: 6-deoxy-7,8-dihydro-14-
hydroxy-3-O-methyl-6-oxomorphine
Chemical Formula: C18H2NO4; molecular wt 315
Introduction
Oxycodone is a semi-synthetic opioid analgesic
related to codeine and derived from thebaine, an
alkaloid found in opium. Although it has been in
clinical use since 1917 (first manufactured in Germany), the use of oxycodone for the treatment of
acute and chronic pain has grown remarkably in the
past decade.
Mode of activity
Oxycodone is a mu-receptor-specific ligand, although
with binding affinity less than that of morphine and
methadone. Some animal studies have established
that some portion of the antinociceptive properties
of oxycodone are mediated through kappa receptors

as well.
Oxycodone is structurally similar to codeine
while pharmacodynamically comparable to morphine in onset and duration of action. It is approximately 1.5 times more potent than morphine with
equivalent effectiveness in equianalgesic dosages.
Oxycodone has high oral bioavailability (60%) compared with morphine (2030%), which is the most
notable difference between these drugs. It also
explains why oxycodone has a rapid analgesic onset
and onset-to-peak effect. In clinical practice oxycodone does not release significant amounts of histamine and may cause less sedation than equivalent
doses of morphine.
As for all opioids, hepatic biotransformation is
the primary route of metabolism for oxycodone.
Methylation at position 3 in both oxycodone and
codeine protects both drugs from rapid first-pass
elimination. Approximately half of an oxycodone
dose undergoes N-demethylation, producing noroxy
codone, which has weak analgesic properties. The
second pathway, which accounts for 10%, involves
the isoenzyme CYP2D6 of the P450 cytochrome.
The O-methylation that occurs results in the production of oxymorphone, a potent analgesic. The
small quantities of oxymorphone produced have little clinical relevance. Inhibition of this pathway by
other drugs likewise has little clinical relevance. The
use of concomitant medications interacting with
these pathways may affect the plasma levels of oxycodone, resulting in reduced analgesia or adverse
events.
Oxycodone and its metabolites are eliminated
by the kidneys. Dosage adjustments are required
in patients with moderate to severe liver and kidney dysfunction, although to a lesser extent than
with morphine. No dosing decrements are required
in the elderly except for those who are debilitated.
101
CH3
H N
Figure 19.1.
CH2
HO
HCI
CH2
CH3O
Indications
102
Oxycodone is indicated for the treatment of moderate

to severe pain that is either acute or chronic. It is
effective for the treatment of pain caused by a variety
of etiologies including malignancies, surgery, somatic,
visceral, and neuropathic disease.
Patients having outpatient surgical procedures
who experience moderate to moderately severe pain
are frequently prescribed an oxycodone product as
soon as oral intake is possible. The drug has high oral
bioavailability and is well absorbed as either a tablet or
elixir. Oxycodone oral solution is particularly useful
to treat post-operative pain in children in the outpatient setting. Like many drugs used for children, oxycodone has not been approved for pediatric use by the
FDA.
Oxycodone compounds that are combined with
aspirin, acetaminophen, or ibuprofen are limited in
dose by the amount of the non-opioid component.
These combination products provide enhanced analgesic effect with fewer opioid side effects, and possibly
better compliance because the patient does not need
two separate medications. Use of oxycodone alone
may be advantageous in those patients who are at risk
for toxicity from NSAIDs or acetaminophen. The
maximum daily dose of acetaminophen is 4000 mg in
a person with no liver impairment.
Oxycodone IR (immediate release) is appropriate
for use in acute pain as in the post-operative setting,
acute injuries, or breakthrough pain. The onset of
action is within 15 minutes, reaching peak blood levels at 1 hour with a 4 hour duration of action. The
pharmacokinetics of morphine IR is similar.
Oxycodone CR (controlled release) is indicated
for patients whose pain requires control around the
clock on a longer term or chronic basis as in cancer,
osteoarthritis, or during rehabilitation following
major orthopedic surgery (refer to Chapter 21).
Oxycodone CR and IR have equal analgesic efficacy
(10 mg of CR oxycodone b.i.d. is equivalent to 5 mg IR

oxycodone q.i.d.).
Contraindications
True allergy to opioids is rare. Hypersensitivity to oxycodone or its non-opioid component in a combination product is an absolute contraindication.
Hepatic impairment
Oxycodone is extensively metabolized in the liver,
impairing clearance in patients with significant
hepatic dysfunction or failure. Usual doses should be
reduced by 3050% and adjusted accordingly. Compounds that include acetaminophen should be
avoided.
Renal impairment
Elimination is prolonged in uremic patients due to
increased volume of distribution and reduced clearance. Usual doses should be reduced by 50% and
avoided for patients on hemodialysis.
Respiratory depression
Respiratory depression is the chief hazard from all
opioid agonist drugs. Respiratory depression occurs
most frequently in elderly or debilitated patients, usually following large initial doses in non-tolerant
patients, or when opioids are given in conjunction
with other agents that depress respiration.
Oxycodone should be used with caution in patients
with significant chronic obstructive pulmonary disease or cor pulmonale, and in patients having
decreased respiratory reserve, hypoxia, hypercapnia,
or preexisting respiratory depression. In such patients,
even usual therapeutic doses may decrease respiratory
drive to the point of apnea.
Common doses/uses
Although parenteral preparations of oxycodone
exist, in the USA oral formulations only are available. Controlled-release forms must be swallowed
whole so as not to interfere with the controlledrelease mechanism; chewing or cutting may lead to
an overdose. Available oxycodone preparations are
listed in Table 19.1.
Initial doses of oxycodone IR (all oxycodone is IR
unless in the controlled-release formulation) are 5 to
Chapter 19 Oxycodone and oxycodone compounds
Table 19.1.
Formulations
Oxycodone
Oxycodone/acetaminophen (mg)
Strengths
Common brand names
5 mg, 15 mg, 30 mg tablets
Roxicodone
5mg capsules
OxyIR
5/325, 7.5/325, 10/325
Percocet
5/500, 7.5/500, 10/500
Tylox
Roxicet
Oxycodone/aspirin (mg)
2.5/325, 5/325
Percodan
Endodan
Oxycodone/ibuprophen (mg)
5/400
Combunox
Roxiprin
Oxycodone oral solution
1 mg/mL
Roxicodone
Percolone
Oxycodone oral concentrate solution
5 mg/mL
Roxicodone Intensol
Oxyfast
Oxydose
Oxycodone CR
10 mg, 15 mg, 20 mg,

30 mg, 40 mg, 60 mga, 80 mga,
160 mga
OxyContin
60, 80, 160 mg strengths to be used in opioid-tolerant patients only. The 160 mg tablets are no longer available in the USA.
15 mg every 4 hours. It is recommended to start with

an immediate-release product and titrate to adequate
pain relief. When pain control is achieved, the conversion to a controlled-release oxycodone is suggested to improve compliance and avoid fluctuating
blood levels in patients with long-term pain management needs. The total daily dose is closely equivalent
whether IR or CR. For example, oxycodone 20 mg
q.i.d is equivalent to 40 mg oxycodone CR b.i.d.
Some patients may require an additional dose of an
IR product in between the b.i.d. dosing for breakthrough pain.
The pediatric dose published in the Harriet Lane
Handbook is 0.050.15 mg/kg q 46 hours. It is useful in young children who cannot swallow capsules
or tablets and in older pediatric patients having painful procedures, particularly tonsillectomies. (As
stated above, oxycodone is not FDA approved for
children.)
Oxycodone provides rapid onset of analgesic effect
following oral administration.
A number of studies have shown fewer hallucinations and less nausea and pruritus when oxycodone
is compared to morphine. There is less inter-

individual variability in plasma levels with oxycodone because of its higher and more predictable oral
bioavailability.
According to a US Veterans Administration study,
oxycodone CR is a higher-priced option when compared to both morphine CR and methadone.
The use of oxycodone (as well as some other opioids) has been associated with causing the serotonin
syndrome in susceptible patients taking antidepressants of the SSRI class.
Oxycodone may also decrease the bioavailability
of cyclosporine in renal transplant patients.
Oxycodone compounds containing acetaminophen
can be overprescribed and overused, increasing the
risk of hepatotoxicity. The FDA has recommended
removal of acetaminophen or a marked reduction in
compounded dose.
Oxycodone compounds containing aspirin
increase risks of gastric irritation and bleeding.
Oxycodone CR contains a relatively large dose of
drug per tablet, which when chewed or crushed provides rapid release of the total dose.
103

Respiratory: the most serious adverse effect is respiratory
depression, which may lead to apnea and respiratory
arrest. Respiratory depression is treated with naloxone,
preferably given intravenously, but it may be given intramuscularly, subcutaneously, or sublingually.
Gastrointestinal: constipation and nausea are
common. Nausea may be treated with antiemetics,
and frequently improves with ongoing therapy. Virtually all patients taking opioids become constipated
and do not become tolerant to this side effect. Activation of mu receptors in the gastrointestinal tract slows
peristalsis, which promotes further absorption of
water and electrolytes in the colon. Patients should
be treated prophylactically with stool softeners and/
or laxatives. There is an oral oxycodone/naloxone
prolonged-release tablet in clinical trials to counteract opioid-induced constipation, which is often
debilitating.
Compounds containing acetaminophen or aspirin
are associated with respective increases in risk of
hepatotoxicity or gastrointestinal bleeding.
Nervous system: somnolence, dizziness, headache,
and dry mouth are not uncommon. These adverse
effects usually subside over time and can be minimized by slow titration of the dose.
Dermatological: pruritus occurs with all opioids,
although less so with oxycodone due to its semisynthetic chemistry leading to less histamine release (as
104
compared with morphine and codeine, which are natural opioids).

Psychiatric: paranoia, psychosis, and hallucinations have all been reported.
Conclusions
Oxycodone and compounds containing oxycodone
are widely prescribed and more effective alternatives
to codeine. The high oral bioavailability ensures a
rapid and reliable analgesic effect, while the adverse
event profile, particularly incidences of nausea and
pruritus, is superior to codeine and provides improved
tolerability.
References
1. Coluzi F, Mattia C. Oxycodone: pharmacological

profile and clinical data in chronic pain management.
Minerva Anesthesiol 2005;71:451460.
2. Kalso E. Oxycodone. J Pain Symptom
Manage2005;29(5S).
3. Gallego OA, Baron GM, Arranz EE. Oxycodone: a
pharmacologic and clinical review. Clin Transl Oncol
2007;9:298307.
4. Mandema JW, Kaiko RF, Oshlack B, et al.
Characterization and validation of a pharmacokinetic
model for controlled-release oxycodone. Br J Clin
Pharmacol 1996:42:747756.
Section 2
Chapter
20
Opioid plus ibuprofen compounds

Kellie Park
Generic Name: hydrocodone + ibuprofen, oxycodone + ibuprofen

Proprietary Names: Vicoprofen, Ibudone,
Reprexain, Combunox
Manufacturers:
Vicoprofen: Abbot Labs, 100 Abbott Park Road,
Abbott Park, IL 600643500
Combunox: Forest Pharmaceuticals, 909 Third
Avenue, New York, NY 10022
Ibudone: ProEthic Pharmaceuticals, 530 Industrial Park Boulevard, Montgomery, AL
Reprexain: Centrix Pharmaceuticals, 31
Inverness Center Parkway, Suite 270, Birmingham, AL 35242
Drug Class: opioid analgesic compound
Chemical Names: 4,5-epoxy-3-methoxy-17ethylmorphinan-6-one + 2-(4-isobutylphenyl)
propionic acid; 4,5-epoxy-14-hydroxy-3-me
thoxy-17-methylmorphinan-6-one + 2-(4-isobut
ylphenyl) propionic acid
Chemical Structures: hydrocodone, see Figure
20.1; oxycodone, see Figure 20.2; ibuprofen,
see Figure 20.3
Introduction
Combination medications, including opioid plus
NSAID preparations, are more effective than either
drug alone for relief of acute pain, including post-surgical pain [1]. Vicoprofen, hydrocodone plus ibuprofen, was developed in 1997. Combunox, oxycodone
plus ibuprofen, was developed in 2001 and approved
for use in 2004 [2]. Reprexain also was marketed in
2004, while Ibudone was released in 2006. These
combination medications were approved for use for
approximately 710 days for relief of acute moderate
to severe pain. They are not approved for chronic pain

management.
Major and minor site of action/

receptor interactions [3]
Hydrocodone and oxycodone are widely prescribed
opioid analgesics that are agonists at the mu, kappa,
and delta receptors in the central nervous system. The
cellular changes that occur with agonism at the opioid
receptors are still under investigation. However, it is
known that mu opioid receptors are G proteincoupled receptors that decrease intracellular levels of
cAMP. This decrease in intracellular cAMP inhibits
the release of critical neurotransmitters and hormones
including substance P, acetylcholine, GABA, somatostatin, and other substances that activate or sensitize
nociceptors. Inhibition of neurotransmitter release
causes a subsequent decrease in the perceived level of
pain by the patient. Also, activation of opioid receptors modifies specific calcium channels at the surface
of cells, which hyperpolarizes and decreases excitability of neurons.
Ibuprofen is an analgesic and antipyretic. Its mechanism of action is not fully determined. However, part
of its effect is its inhibition of cyclooxygenase (COX)
and the subsequent production of prostaglandin.
Prostaglandins are lipid compounds that regulate a
variety of tissue functions and also cause tissue inflammation. By inhibiting COX, ibuprofen limits prosta
glandin production, which in turn limits tissue
inflammation and associated pain.
Metabolic pathways/drug clearance

and elimination [3]
Hydrocodone and oxycodone are metabolized similarly.
Both are subject to a high degree of first-pass metabolism once absorbed from the GI tract. Both drugs are
metabolized to more potent compounds in the liver;
105
MeO
Figure 20.1.
Me
H
O
MeO
Figure 20.2.
Me
OH
O
Figure 20.3.
O
OH
they are demethylated by cytochrome P450 2D6 to

hydromorphone and oxymorphone, respectively. Both
parent drugs and their metabolites are conjugated in the
liver, and both unconjugated and conjugated forms of
the drug are excreted by the kidneys and are found in
the urine. The approximate half-life of hydrocodone is
3.8 hours, while that of oxycodone is 3.5 hours. Ibuprofen is metabolized through hydroxylation, carboxylation, and glucuronidation. Metabolites are excreted by
the kidneys. The primary metabolites are (+)-2[p-(2hydroxymethyl-propyl)phenyl] propionic acid and
(+)-2-[p-(2carboxypropyl)phenyl] propionic acid. Both
conjugated and unconjugated metabolites are present in
the urine. The approximate half-life of ibuprofen is 1.8
hours.
Acute surgical pain
106
Both types of combination medications, hydrocodone/ibuprofen and oxycodone/ibuprofen, are used

for pain associated with surgery and trauma in selected
populations of patients [1]. They are approved for use

for 7 to 10 days for moderate to severe pain. Treatment
beyond 7 days is not approved nor is it recommended.
Studies have clearly demonstrated that the combination of hydrocodone plus ibuprofen provides a more
rapid onset than ibuprofen alone, and a more prolonged and powerful effect than hydrocodone/oxycodone alone.
Cancer
Data from studies on cancer pain treated with combination opioid plus NSAIDs are equivocal. NSAIDs
with opioids have shown no improvement or limited
improvement in pain control. However, the medications have not been approved for long-term therapy,
which probably would be required for treatment of
cancer pain. Further studies are needed to determine
safety and efficacy of combination drugs in this patient
population.
Chronic non-malignancy pain

Studies on treatment of chronic non-malignancy pain,
such ash chronic low back pain, showed a measurable
improvement in symptoms when patients took opioid
plus NSAID combination drugs versus the drugs
alone. As with cancer pain, the duration of treatment
in the studies was short (8 days). It is reasonable to
suspect that longer duration of therapy would be necessary in these patients. Therefore, further studies are
needed to determine the safety and efficacy of longer
duration therapies in this patient population.
Contraindications
Absolute contraindications for both opioids and
NSAIDS include hypersensitivity reactions, such as
development of shortness of breath, severe rash, etc.
Oxycodone and hydrocodone are contraindicated in
patients with risk for significant respiratory depression. Because of the inhibition of GI motility by narcotic medications, oxycodone and hydrocodone are
contraindicated in the setting of paralytic ileus.
NSAIDs, including ibuprofen, are contraindicated
in patients with active bleeding, ulceration, or perforated viscous. NSAIDs are contraindicated in the setting of acute or chronic renal dysfunction. NSAIDs
have been shown to increase the risk of cardiovascular
thrombotic events, myocardial infarction, and stroke,
especially in patients with known cardiovascular
disease or with known risk factors for cardiovascular
Chapter 20 Opioid plus ibuprofen compounds
disease. Patients should not take NSAIDS to treat pain

in the peri-operative period prior to coronary artery
bypass graft (CABG) surgery.
There are numerous relative contraindications to
combination opioids and NSAIDs. They include but
are not limited to a past medical history of GI bleeding, history of chronic renal disease, a history of abuse
of drugs or other substances, a history of seizures
related to head trauma, brain tumor, or increased
intracranial pressure, or documented urinary retention with use of narcotics.
Common doses (oral)

Combination opioids and NSAIDs are provided in
oral preparations. Vicoprofen is supplied as 7.5 mg
hydrocodone plus 200 mg ibuprofen tablets. For acute
moderate to severe pain 1 tablet should be taken every
46 hours. Ibudone is supplied as a 10 mg/200 mg tablet, while Reprexain is manufactured as 2.5 mg, 5 mg
or 10 mg/200 mg combination tablets. Each is commonly prescribed as 1 tablet every 46 hours for acute
moderate to severe pain. Combunox is 5 mg oxycodone and 400 mg ibuprofen, every 6 hours, with a
maximum of four tablets daily. Combunox may offer
advantages over other preparations since it contains a
higher dose of ibuprofen (400 mg) equivalent to doses
commonly prescribed for acute pain. It is recommended that therapy be limited to 710 days or less.
Potential advantages/disadvantages
(opioid sparing/cost and side effects)
As indicated above, combination opioids and ibuprofen are a more effective treatment for pain in selected
patients with moderate to severe pain. Marret et al. [7]
recently described the results of a meta-analysis of the
effect of nonsteroidal anti-inflammatory drugs
(NSAIDs) on opioid dose and opioid-related adverse
events. Their meta-analysis showed a significant 30%
decrease in the incidence of post-operative nausea
and vomiting (PONV) with morphine with the addition of NSAIDs. The authors attribute this reduction
to the morphine-sparing effect of the NSAID addition
on the basis of a documented linear relation between
the incidence of PONV and morphine consumption
in the post-operative period. Of interest, data collected from 2437 patients enrolled in randomized,
double-blind, single-dose studies of the combination
of oxycodone 5 mg/ibuprofen 400 (Combunox) in
the ambulatory surgery setting reveal similar results
(Table 20.1). The combination of the NSAID ibuprofen (400 mg) with oxycodone 5 mg significantly
enhanced analgesia while reducing the incidence of
post-operative nausea and vomiting by nearly 50%
compared with oxycodone 5 mg alone.
Reductions in the incidences of nausea and vomiting in these studies [5,6] with the combination of ibuprofen and oxycodone compared with oxycodone
alone and oxycodone plus acetaminophen may be
related to significant opioid-sparing effects. In addition, reductions in the incidence of nausea and vomiting may be related to NSAID-related inhibition of
PGE synthesis. Several studies in animal models have
shown that the emetic reflux in the medullary vomiting center is potentiated by the presence of prosta
glandins. Opioids also exert their emetic effects by
stimulating prostaglandin synthesis in the central
nervous system. It is possible that co-administered
doses of ibuprofen may suppress opioid-induced
up-regulation of PGE sysnthesis and attenuate symptoms of nausea and vomiting.
Despite these advantages therapy with opioid plus
ibuprofen combinations is limited at this time to short
duration (710 days) because of risks associated with
long-term NSAID use, including GI bleeding and
renal injury. In fact, a recent paper in the Journal of
American Geriatrics Society [6] describes updated
warnings and recommendations for geriatric patients
taking NSAIDs. They recommend a proton pump
inhibitor or misoprostol (Cytotec) for GI prophylaxis
and regular evaluation of renal, GI, and cardiac
Table 20.1. Incidence of nausea and vomiting in single-dose studies of oxycodone 5 mg/ibuprofen 400 mg [5]
Incidence of event, n (%)
Oxycodone 5 mg/
ibuprofen 400 mg
(n = 923)
Oxycodone HCl
5 mg (n = 286)
Ibuprofen 400
mg (n = 913)
Placebo (n = 315)
Nausea
81 (8.8%)
46 (16.1%)
44 (4.8%)
21 (6.7%)
Vomiting
49 (5.3%)
30 (10.5%)
16 (1.8%)
10 (3.2%)
107
function. Also, it should be noted the recommendations state that patients taking aspirin for cardiac
prophylaxis should not use ibuprofen. Overall, further
studies are needed to determine whether long-term
use is safe or efficacious.
References
1. Raffa RB. Pharmacology of oral combination

analgesics: rational therapy for pain. J Clin Pharm Ther
2001;26:25764.
5. Palangio M, Morris E, Doyle RT Jr, Dornseif BE,

Valente TJ. Combination hydrocodone and ibuprofen
versus combination oxycodone and acetaminophen in
the treatment of moderate or severe acute low back
pain. Clin Ther 2002;24(1):8799.
2. Hydrocodone and Oxycodone. Opioids: past, present

and future. http://www.opioids.com. Accessed
November 26, 2009.
6. Ferrell B, Argoff CE, Epplin J, Fine P, Gloth FM, Herr

K, Katz JD, Mehr DR, Reid C, Reisner L.
Pharmacological management of persistent pain
in older persons. J Am Geriatr Soc 2009;57(8):
13311346.
3. Hardman JG, Limbird LE, Gilman AG, eds. Goodman

and Gilmans The Pharmacological Basis of
Therapeutics, 10th ed. New York: McGraw-Hill, 2001,
pp. 587591, 711712.
7. Marret E, Kurdi O, Zufferey P, Bonnet F. The

effect of NSAIDS on PCA morphine side effects:
a meta-analysis. Anesthesiology 2005;102(6):
12491260.
Section 2
Chapter
21
Oxycodone controlled-release
Amanda Barker, Justin Hata and Eric Hsu
Generic Name: oxycodone hydrochloride controlled-release tablets

Proprietary Name: OxyContin
Drug Class: opioid analgesic, Schedule II
Manufacturer: Purdue Pharma L.P., One Stamford Forum, Stamford, CT
Chemical Name: 4,5-epoxy-14-hydroxy-3methoxy-17-methylmorphinan-6-one hydrochloride
108
4. McNicol ED, Strassels S, Goudas L, Lau J, Carr DB.

NSAIDS or paracetamol, alone or combined with
opioids, for cancer pain. Cochrane Database Syst Rev
2005; 2:CD005180.
Chemical Formula: C18H21NO4HCl; molecular

wt 351.83
Introduction
OxyContin (oxycodone hydrochloride controlledrelease, Oxycodone CR) is an extended-duration oral
opioid analgesic. It is formulated as a tablet with an
outer more rapidly acting component and slower-
release inner matrix that provides up to 12 hours of
pain relief. Oxycodone CR offer prolonged and uniform analgesia avoiding trough effects observed with
immediate-release oxycodone. Controlled-release
oxycodone has abuse and diversion liability since the
tablet can be easily crushed, and the entire 12 h dose
administered nasally, leading to excessive acute effects
and potential overdose [1].
Chapter 21 Oxycodone controlled-release
NCH3
Figure 21.1.
OH
CH3O
Mode of activity
The pharmacological effect of OxyContin tablets is
primarily related to the parent drug oxycodone.
Oxycodone, like other opioid agonists, binds to and
activates spinal and superspinal opioid receptors.
Following activation, these receptors suppress pain
transmission at pre- and postsynaptic sites along
the noxious transmission pathway. For further discussion regarding oxycodones mode of action see
Chapter 19.
Metabolic pathways/drug clearance and

elimination
OxyContin tablets are designed to provide controlled delivery of oxycodone over 12 hours. Oxycodone
release from OxyContin tablets is pH-independent.
Oxycodone is well absorbed from OxyContin tablets with an oral bioavailability of 60% to 87%. The
relative oral bioavailability of OxyContin to immediate-release oral dosage forms is 100%. Steady-state
levels are achieved within 2436 hours in normal
volunteers after repeated dosing in pharmacokinetic
studies.
Oxycodone is extensively metabolized and eliminated primarily in the urine as both conjugated and
unconjugated metabolites. The apparent elimination
half-life of oxycodone following the administration of
OxyContin was 4.5 hours compared to 3.2 hours for
immediate-release oxycodone. About 60% to 87% of
an oral dose of oxycodone reaches the central compartment in comparison to a parenteral dose. This
high oral bioavailability is due to low pre-systemic
and/or first-pass metabolism.
In normal volunteers, OxyContin tablets exhibit a
biphasic absorption pattern with two apparent absorption half-lives of 0.6 and 6.9 hours, which describes
the initial release of oxycodone from the tablet followed by a prolonged release [1,2].
Indications
Chronic non-surgical pain: OxyContin tablets are a
controlled-release oral formulation of oxycodone hydrochloride indicated for the management of moderate to
severe pain when a continuous, round-the-clock analgesic is needed for an extended period of time.
Acute surgical pain: OxyContin is only indicated for
post-operative use if the patient is already receiving the
drug prior to surgery. OxyContin may be considered if
the post-operative pain is expected to be moderate to
severe and persist for an extended period of time.
Neuropathic pain: patients with neuropathic pain,
including post-herpetic neuralgia and diabetic neuropathy, have successfully been treated with oxycodone. Higher opioid doses may be needed for
neuropathic pain. Data suggest that incorporation of
opioids earlier on might be beneficial.
Somatic pain: treatment with OxyContin for
patients with osteoarthritis, back pain and pre- and
post-operative pain is well documented. Round-theclock controlled-release oxycodone therapy seems to
provide effective analgesia for patients with chronic,
moderate to severe, osteoarthritis-related pain.
Visceral pain: myocardial ischemia, urinary
colic, irritable bowel syndrome, and pancreatitis
patients have received adequate pain relief with
OxyContin.
Cancer pain: OxyContin has been shown to successfully manage cancer pain. OxyContin has been
shown to provide equivalent analgesic efficacy compared to CR morphine.
Contraindications
Absolute: OxyContin is contraindicated in patients
with known hypersensitivity to oxycodone, or in any
situation where opioids are contraindicated. OxyContin is contraindicated in any patient who has or is suspected of having paralytic ileus.
Relative: a single dose greater than 40 mg, or total
daily doses greater than 80 mg, are only indicated in
opioid-tolerant patients.
Oxycodone CR should be used with caution in
patients with certain co-morbidities:
General: morbid obesity
Psychiatric: patients with a history of drug abuse or
acute alcoholism
Neurological: head trauma or elevated intracranial
pressure, CNS depression/coma, patients with a
history of seizures
109
Pulmonary: COPD, skeletal disorders which may

restrict respiratory function
Endocrine: Addisons disease, thyroid dysfunction
Gastrointestinal: hepatic impairment, biliary tract
impairment
Genitourinary: prostatic hyperplasia or urinary
stricture, renal impairment
Obstetrics/gynecology: pregnancy (caution with
prolonged use or high doses at term)
Dosage
110
Once therapy is initiated, pain relief and other opioid

effects should be frequently assessed. Because steadystate plasma concentrations are approximated within
24 to 36 hours, OxyContin dosage adjustment may be
carried out accordingly. The usual starting dose for
opioid-naive patients or patients presenting with
severe pain uncontrolled by weaker opioids is 10 mg
twice daily. Dosing must be carefully monitored and
titrated. For the majority of patients, the maximum
dose is 200 mg twice daily. It is most appropriate to
increase the q12h dose instead of decreasing dosing
interval. There is no clinical information on dosing
intervals shorter than q12h [2,3,4].
As a guideline, the total daily OxyContin dose usually can be increased by 25% to 50% of the current dose
at each increase. If signs of excessive opioid-related
adverse experiences are observed, the next dose may be
reduced. If this adjustment leads to inadequate analgesia, a supplemental dose of immediate-release oxycodone may be given. Alternatively, non-opioid analgesic
adjuvants may be employed. Dose adjustments should
be made to obtain an appropriate balance between pain
relief and opioid-related adverse experiences. During
periods of changing analgesic requirements, including
initial titration, frequent contact is recommended
between the physician, other members of the healthcare team, the patient, the caregiver and family.
Most patients given round-the-clock therapy with
controlled-release opioids may need to have immediate-release medication available for exacerbations of
pain or to prevent pain that occurs predictably during
certain patient activities (incident pain). During
chronic therapy, especially for non-cancer pain syndromes, the continued need for round-the-clock opioid therapy should be reassessed periodically (e.g.
every 6 to 12 months) as appropriate.
When the patient no longer requires therapy with
oxycodone CR tablets, doses should be tapered gradu-
ally to prevent signs and symptoms of opioid withdrawal in physically dependent patients [3,4].
A single-dose, double-blind, placebo- and dose-controlled study was conducted using OxyContin (10,
20, and 30 mg) in an analgesic pain model involving
182 patients with moderate to severe pain. Twenty
and 30 mg of OxyContin were superior in reducing
pain compared with placebo, and this difference was
statistically significant. The onset of analgesia with
oral OxyContin occurred within 1 hour in most
patients.
Although early studies showed oxycodone CR and
morphine CR to be essentially equivalent milligram
for milligram, oxycodone CR has been shown to have
a higher bioavailability than morphine, resulting in an
equianalgesic ratio of approximately 2 mg oral oxycodone to 3 mg oral morphine. Because of its greater
oral bioavailability, patients may require lower doses
compared to morphine.
Comparison studies show that oxycodone CR has
an improved side-effect profile compared to morphine
with less occurrence of reactions, including nausea,
vomiting, pruritus, and fewer hallucinations.
Drug interactions: oxycodone hydrochloride is extensively metabolized to noroxycodone, oxymorphone,
noroxymorphone, and their glucuronides. The major
circulating metabolite is noroxycodone. Noroxycodone is reported to be a considerably weaker analgesic
than oxycodone. Oxymorphone, although possessing
analgesic activity, is present in the plasma only in low
concentrations. The correlation between oxymorphone concentrations and opioid effects was much
less than that seen with oxycodone plasma concentrations. The analgesic activity profile of other metabolites is not known. The formation of oxymorphone
and noroxycodone is mediated by cytochrome P450
2D6 and cytochrome P450 3A4, respectively. In addition, noroxymorphone formation is mediated by both
cytochrome P450 2D6 and cytochrome P450 3A4.
Therefore, the formation of these metabolites can, in
theory, be affected by other drugs. Oxycodone is
metabolized in part by cytochrome P450 2D6 to oxymorphone, which represents less than 15% of the total
administered dose. This route of elimination may be
blocked by a variety of drugs (e.g. certain cardiovascular drugs including amiodarone and quinidine as well
Chapter 21 Oxycodone controlled-release
as polycyclic antidepressants). However, in a study

involving 10 subjects using quinidine, a known inhibitor of cytochrome P450 2D6, the pharmacodynamic
effects of oxycodone were unchanged.
Drug abuse and addiction

Oxycodone, like morphine and other opioids used in
analgesia, can be abused and is subject to criminal
diversion. Breaking, chewing or crushing oxycodone
CR tablets eliminates the controlled delivery mechanism and results in the rapid release and absorption of
a potentially fatal dose of oxycodone.
Review of case reports has indicated that the risk
of fatal overdose is further increased when oxycodone
CR is abused concurrently with alcohol or other CNS
depressants, including other opioids.
This should be considered when prescribing or
dispensing oxycodone CR in situations where the
physician or pharmacist is concerned about an
increased risk of misuse, abuse, or diversion.
Toxicity: oxycodone CR consists of a dual-polymer
matrix, intended for oral use only. Abuse of the
crushed tablet poses a hazard of overdose and death.
This risk is increased with concurrent abuse of alcohol
and other substances. With parenteral abuse, the tablet excipients, especially talc, can be expected to result
in local tissue necrosis, infection, pulmonary granulomas, and increased risk of endocarditis and valvular
heart injury.
How supplied
Oxycodone CR is supplied in 10 mg, 15 mg, 20 mg, 30
mg, 40 mg, 60 mg, 80 mg, and 160 mg tablet strengths
for oral administration. A 40 mg tablet of OxyContin by
prescription costs approximately $4 $400 for a 100-tablet bottle in a retail pharmacy. Street prices vary depending on geographic location, but generally OxyContin
sells for between 50 cents and $1 per milligram.

Use of OxyContin is associated with increased potential risks and it should be used only with caution in the
following conditions: acute alcoholism; adrenocortical insufficiency (e.g. Addisons disease); CNS depression or coma; delirium tremens; debilitated patients;
kyphoscoliosis associated with respiratory depression;
myxedema or hypothyroidism; prostatic hypertrophy
or urethral stricture; severe impairment of hepatic,
pulmonary or renal function; and toxic psychosis.
Oxycodone CR should be used with caution and

started in a reduced dosage (1/3 to 1/2 of the usual
dosage) in patients who are concurrently receiving
other central nervous system depressants including
sedatives or hypnotics, general anesthetics, phenothiazines, other tranquilizers, and alcohol. Interactive
effects resulting in respiratory depression, hypotension, profound sedation, or coma may result if these
drugs are taken in combination with the usual doses
of oxycodone CR.
Discussion
Previous registry data demonstrated that a subgroup
of non-cancer patients reported extensive pain relief
and tolerable side effects with oxycodone CR. There
was only modest need for dose escalation throughout
the long-term follow-up. However, with alarming
rates of abuse in prescription drugs, oxycodone CR
will continue to result in challenges to many healthcare providers. Physicians should be aware of potential patients who are seeking oxycodone CR for
recreational use. Those individuals who become
dependent on oxycodone CR may exhibit a trend from
oral use to either snorting or intravenous administration [4]. A better sociocultural understanding is
needed to manage these cases of oxycodone CR diversion. It is imperative to maintain a collaborative communication between the pain management society
and the addiction treatment community [5].
References
1. Portenoy RK, Farrar JT, Backonja MM, Cleeland CS,

Yang K, Friedman M, Colucci SV, Richards P.
Long-term use of controlled-release oxycodone for
noncancer pain: results of a 3-year registry study. Clin
J Pain 2007;23(4):287299.
2. Watson CPN, Babul N. Efficacy of oxycodone in
neuropathic pain. A randomized trial in postherpetic
neuralgia. Neurology 1998;50:18371841.
3. Mucci-LoRusso P, Berman BS, Silberstein PT, et al.
Controlled-release oxycodone compared with
controlled-release morphine in the treatment of
cancer pain: a randomized, double-blind, parallelgroup study. Eur J Pain 1998;2:239249.
4. Aquina CT, Marques-Baptista A, Bridgeman P, Merlin
MA. OxyContin use and misuse in three populations:
substance abuse patients, pain patients, and criminal
justice participants. Postgrad Med 2009;121(2):163167.
5. Wunsch MJ, Cropsey KL, Campbell ED, Knisely JS.
OxyContin abuse and overdose. J Opioid Manage
2008;4(2):7379.
111
Section 2
Chapter
22
Hydrocodone bitartrate
Edward J. Park
Generic Names: hydrocodone (also dihydrocodeinone)

Proprietary Names: (1) combined with acetaminophen: (multiple different preparations in
tablet, capsule, and elixir form) Vicodin,
Lortab, Norco, and numerous generic formulations; (2) combined with aspirin or ibuprofen:
Damason-P, Vicoprofen
Drug Class: opioid analgesic compound
(Class III)
Manufacturers: Abbott Laboratories, Abbott
Park, IL; Watson Pharmaceuticals, Inc., 311 Bonnie Circle, Corona, CA; Mason Pharmaceuticals,
4425 Jamboree St, Suite 450, Newport Beach,
CA; Natures Bounty, 2100 Smithtown Avenue,
Ronknokoma, NY; UCB Pharmaceuticals, Brussels, Belgium
Chemical Name: 4,5-epoxy-3-methoxy-17methylmorphinan-6-one
Chemical Formula: C18H21NO3; molecular wt
299.3
Introduction
112
First produced in 1920, hydrocodone is a semisynthetic hydrogenated ketone related to the phen
anthrene derivative codeine. It is only available as
an enteral agent in oral preparations. Hydrocodone
bitartrate is currently approved in the USA only for
use in fixed combinations with non-opioid medications as an analgesic or antitussive agent. Another
preparation, hydrocodone polistirex, is used as an
antitussive agent, again only in combination with nonopioid medications. Hydrocodone bitartrate forms
a water-soluble crystalline powder; it is sensitive to
light and typically stored at room temperature in a
light-resistant fashion. Hydrocodone bitartrate in

combination with acetaminophen is a less restricted
opioid preparation (Schedule III) and is more easily
prescribed in many States in the USA. Because of their
relative ease in prescription and perceived safety and
efficacy, compounds containing hydrocodone plus
acetaminophen have become the most widely prescribed opioid analgesics in the USA.
Mode of activity
Like all other opioid agonists, hydrocodone interacts
with endogenous opioid receptors found principally in
the central nervous system and gastrointestinal tract.
Analgesic properties are attributed to agonism at the
receptors located primarily in the CNS at both the spinal and supraspinal levels, though peripheral opioid
receptors may also mediate analgesia to an undefined
extent. Through unclear mechanisms, perceptions of
pain at the spinal cord and higher centers of the brain,
as well as their attendant emotional responses, are
altered. Neuronal transmission thresholds and
response to noxious stimuli do not seem to be affected
in involved afferent nerves.
With respect to opioid receptor subtypes, hydrocodone is thought to interact primarily with receptors,
and the full significance of its distribution and agonism at other G protein-coupled opioid receptors (,
, and subtypes) is not yet fully understood. Binding
at the 1 receptor subtype is thought to mainly promote supraspinal analgesia, while agonism at the 2
receptor subtype mediates many of the untoward side
effects of opioids, such as respiratory depression and
decreased gastrointestinal motility. Spinal analgesia
may be the result of interaction with receptors, while
sedation and segmental spinal analgesia are thought to
occur through modulation of receptors.
Chapter 22 Hydrocodone bitartrate
NCH3
CH3O
Figure 22.1.
Metabolic pathways
Hydrocodone bitartrate is administered orally, with
excellent absorption from the gastrointestinal tract
and a bioavailability of approximately 5060%. Peak
serum concentrations of hydrocodone occur after
approximately 1.3 hours, with an elimination half-life
of approximately 3.8 hours, in normal adults. It is
probably metabolized mostly in the liver and primarily cleared via renal pathways. Similar to codeine and
oxycodone, hydrocodone is known to undergo
metabolism by the cytochrome P450 isoenzyme
CYP2D6, genetic polymorphisms of which may
explain some of the observed interindividual variation noted with its use. This enzyme converts hydro
codone to hydromorphone, which displays significantly
more avid binding for receptors and may account
for much of hydrocodones clinical effect. Concurrent
use of hydrocodone with medications known to
induce or inhibit this isoenzyme may thus alter its
efficacy and toxicity.
Indications (approved and

non-approved)
As an analgesic agent, hydrocodone bitartrate is used
for the symptomatic relief of temporary pain that is
moderate to moderately severe, such as acute postoperative pain. It may also be appropriate for the
symptomatic treatment of pain associated with acute
medical disorders, particularly in the treatment of
migraine headaches. For the treatment of chronic nonmalignant pain, hydrocodone bitartrate preparations
should only be used when non-opioid pharmacological and non-pharmacological modalities have been
exhausted and fail to provide measurable symptomatic
relief. In the management of severe chronic pain associated with cancer or other terminal illness, hydrocodone
may not be potent enough to offer effective pain relief

compatible with adequate quality of life. As with all
other opioid agonists, patients who are unable to tolerate the side effects of hydrocodone may benefit by
switching to a different agent of the same class.
Currently, hydrocodone bitartrate is available in
the USA only in combination with other agents, and
its use is only indicated as an analgesic or antitussive
agent. On October 1, 2007, only hydrocodone salts or
esters prepared with other medications in fixed combinations approved by the Food and Drug Administration were allowed to be marketed by drug
manufacturers. All other preparations, without valid
new drug applications, would subject violating companies to enforcement actions and penalties. Manufacturing and distribution deadlines for unapproved
combinations ranged from October 31, 2007, to
March 31, 2008, though preparations manufactured
and distributed before these dates were still available
for sale for a short period of time that has since
passed.
Contraindications
Absolute contraindications
Hydrocodone bitartrate is absolutely contraindicated in patients with known hypersensitivity reactions to hydrocodone. Commercial preparations
may also contain sulfite compounds that can produce allergic reactions, including bronchospasm
and anaphylaxis, in certain susceptible individuals,
particularly asthmatic patients. In addition, the dye
tartrazine is present in one preparation of hydrocodone bitartrate, combined with chlorpheniramine
maleate and phenylephrine hydrochloride, that is
used as an antitussive and expectorant agent (Vanex).
Also known as FD&C yellow No. 5, tartrazine can
cause asthmatic and other allergic reactions in some
susceptible patients, especially those with aspirin
sensitivities.
Relative contraindications
General precautions associated with the use of all opioid agonists should be observed with the use of
hydrocodone bitartrate; respiratory depression and
adverse CNS effects are primary concerns, and the use
of hydrocodone should be individually tailored in
those patients at risk for these complications, if undertaken at all. Particular attention is warranted in
113
patients who have undergone general anesthesia or

are being concomitantly treated with other opioid
agonists, anxiolytics, sedative-hypnotic agents, or
other medications with CNS depressant properties. As
with other opioid agonists, hydrocodone use may
obscure the diagnosis and management of patients
with acute abdominal processes and may possibly
contribute to the development of ileus or bowel
obstruction, especially in patients with impaired gastrointestinal motility or those taking anticholinergic
medications. It should also be used in caution in
patients with liver and kidney disease, as well as those
at the extremes of age, as inadequate and/or impaired
hepatic and renal function may contribute to toxic
effects in smaller doses. Safety in pregnancy has not
been clearly demonstrated, and whether hydrocodone
redistributes into breast milk has not been elucidated.
Therefore, its use should be limited in parturients and
nursing mothers to clinical situations where its benefits outweigh the potential associated risks.
Common doses
For the symptomatic relief of moderate to moderately
severe pain, hydrocodone should be administered in
the smallest dose as infrequently as possible to
achieve the desired treatment effect and minimize
the development of tolerance and dependence. The
usual adult dosage is 5 to 10 mg PO every 4 to 6 hours
as necessary, with manufacturer recommendations
on maximum daily total doses of 60 mg when combined with acetominophen and 37.5 mg when combined with ibuprofen. Unlike when used as an
antitussive, where the recommended dose for children 6 to 12 years of age is 2.5 mg PO every 4 to 6
hours as necessary with a daily maximum of 15 mg,
there is no consensus pediatric recommendation for
the use of hydrocodone bitartrate as an analgesic
agent. Additionally, in both cases, there are no data
on the efficacy and safety of its use in children under
6 years of age. However, some authors and clinicians
recommend an analgesic pediatric starting dose,
based on the hydrocodone component of various
preparations, of 0.1 mg/kg every 4 to 6 hours as
needed, similar to the pediatric dose of oxycodone.
114
Given that all opioid agonists tend to produce relatively equivalent effects at equipotent doses, combining hydrocodone with other medications that achieve
analgesia via different mechanisms of action, as with

the commercially available preparations noted above,
results in an additive but not synergistic cumulative
effect that may result in lower overall total doses of
each. This has been observed in studies evaluating
post-operative analgesia following abdominal, gynecological, and obstetric surgeries, as well as in one
study evaluating the treatment of postpartum pain.
Additionally, since the physiological side effects of
opioid agonists, as well as the other medications
combined therewith, are also dose-dependent, the
use of hydrocodone combined with other medications may also result in decreased incidences of these
unwanted effects.
Similar to other opioid agonists, the main disadvantage of hydrocodone is the possibility of clinically
significant respiratory depression with its use,
though this should never discourage clinicians from
the appropriate treatment of either symptomatic
acute or chronic pain. There should never be a ceiling to the maximum dose of an opioid agonist in the
treatment of pain if its use is effective. However,
given that hydrocodone is only available in fixed
combinations with other medications that may demonstrate significant hepatic (acetominophen), renal
(ibuprofen and other NSAIDs), or other dose-related
organ system toxicities at higher doses, its use is necessarily curtailed to the maximum acceptable and
allowable doses of its co-administered agents.

The most common side effects of hydrocodone include
CNS reactions (dizziness, lightheadedness, sedation)
and GI disturbances (nausea and vomiting), both of
which can be exacerbated in ambulatory versus
recumbent patients and possibly ameliorated by
adopting the supine position. Other adverse reactions
include constipation, urinary retention, dysphoria
and/or euphoria, rash, and pruritus. Patients should
also be advised that the use of hydrocodone may
impair the performance of certain daily activities that
require increased physical coordination or mental
acuity, such as driving or operating machinery.
Because hydrocodone is only available in commercial
preparations combining it with other medications,
such as aspirin, ibuprofen, or acetominophen, observation of the precautions associated with those adjunct
agents is obviously also warranted.
Chapter 23 Hydromorphone (oral and parenteral)
References
1.
Barkin RL. Acetominophen, aspirin, or ibuprofen in

combination analgesic products. Am J Ther 2001;
8(6):433442.
2.
Golianu B, Krane EJ, Galloway KS, Yaster M. Pediatric

acute pain management. Pediatr Clin North Am 2000;
47(3):559587.
3.
Lurcott G. The effects of the genetic absence and

inhibition of CYP2D6 on the metabolism of codeine
Section 2
Chapter
23
4.
5.
and its derivatives, hydrocodone and oxycodone.

Anesth Prog 1999;45(4):154156.
McEvoy GK, ed. AFHS Drug Information. STAT!Ref
Online Electronic Medical Library 2009; Bethesda, MD:
American Society of Health-System Pharmacists,
28:08.08, 48:08.
Tobias JD. Weak analgesics and nonsteroidal antiinflammatory agents in the management of children
with acute pain. Pediatr Clin North Am
2000;47(3):527543.
Hydromorphone (oral and parenteral)

Carsten Nadjat-Haiem and Joseph Rosa
Generic Names: hydromorphone, dihydromorphinone, dimorphone

Trade/proprietary Names: Dilaudid, Dilocol,
HydroStat, Liberaxim, Opidol, PMS Hydromorphone, Sophidone
Drug Class: opioid analgesic (Class II)
Forum, Stamford, CT; Roxane Laboratories,
1809 Wilson Rd, Columbus, OH; Baxter Healthcare, One Baxter Parkway, Deerfield, IL; Abbott
Laboratories, 100 Abbott Park Rd, Abbott Park,
IL; Barr Laboratories, 223 Quaker Road,
Pomona, NY; Richwood-Shire Pharmaceuticals,
5 Riverwalk, Citywest Business Campus, Dublin
24, Ireland
Chemical Name: 4,5--epoxy-3-hydroxy-17methyl morphinan-6-one
Chemical Formula: C17H19NO3; molecular wt:
321
Introduction and description

Hydromorphone is a potent semi-synthetic phenanthrene-derived centrally acting opiate agonist. Hydromorphone is very lipid-soluble, which allows for rapid
central nervous system penetration. Hydromorphone
is second only to morphine in its use as an analgesic in
the acute post-operative setting. It was first researched
and synthesized in 1924 in Germany, and marketed by
Knoll Pharmaceuticals in 1926 under the brand name
Dilaudid. Hydromorphone hydrochloride is a fine,
white or essentially white, crystalline powder and is
freely soluble in water and sparingly soluble in alcohol.
Mode of activity
Hydromorphone is a hydrogenated ketone derivative
of morphine which is about seven to eight times as
potent as the parent compound morphine. The duration of action is shorter or similar to morphine at
about 45 hours. When administered orally or intramuscularly, it retains only about one-fifth the potency
of an intravenous dose, and the onset of action is
slower, but the duration of action is longer [13].
115
CH3
Figure 23.1.
CH2
H
HCI
CH2
OH
Hydromorphone binds to mu and delta opiod

receptors in the central nervous system. It has no effect
at the kappa, sigma, or epsilon opioid receptors. Activity at the mu receptors causes analgesia, but also miosis, urinary retention, constipation, hyperthermia, and
euphoria. Other side effects such as respiratory depression, pruritus, nausea, vomiting, and development of
tolerance are due to binding at both mu and delta
receptors. Hydromorphone, unlike other opioids, also
has a direct depressant effect on the respiratory brainstem center and the cough center in the medulla.
Parenteral dosing results in initial pain relief in
about 15 minutes and a duration of action of about 4
to 5 hours. Oral dosing causes initial pain relief after
30 minutes, a peak of relief after 60 to 90 minutes, and
a duration of action of about 3 to 4 hours (up to over
13 hours with sustained-release formulation). Peak
plasma levels after epidural administration were
achieved after 8 minutes, while peaks after oral administration were reached after about an hour.
Oral hydromorphone has a bioavailability of 62%
regardless of whether it is given as regular hydromorphone or extended-release capsules. Food has no effect
on peak levels. The drug is 20% protein-bound. The
two distribution half-lives are 1.3 and 14.7 minutes.
The volume of distribution is 4 L/kg [1,2].
Hydromorphone is primarily conjugated in the
liver. Its metabolites are dihydroisomorphine and
dihydromorphine. Excretion via the kidneys occurs
up to 13% as unchanged parent compound, and
2251% as conjugated hydromorphone. Total body
clearance is 1.66 L/min. The elimination half-life is
about 2.5 hours for the immediate-release compound
and the intravenously administered drug, and about
19 hours for the extended-release drug [1,4].
Indications
116
Hydromorphone is FDA-approved for the treatment

of moderate to severe acute and chronic pain. A high-
potency formulation is available for opioid-tolerant

patients. Hydromorphone is used to treat pain secondary to cancer, myocardial infarction, burns, renal
colic, biliary colic, surgery, and soft tissue and bone
trauma. It is an excellent analgesic if given epidurally
after cesarean section.
Off-label use has been reported for treatment of
refractory erythromelalgia, and good pain relief is
achieved with a combination of epidural hydromorphone and clonidine.
Contraindications
The only absolute contraindication is use in patients
who have a hypersensitivity or allergy to hydromorphone.
Relative contraindications:
1. Acute or severe bronchial asthma, status
asthmaticus
2. Depressed ventilatory function such as
encountered in COPD, cor pulmonale,
emphysema, and kyphoscoliosis
3. Intracranial lesions associated with increased
intracranial pressure
4. Obstetrical analgesia
5. Known or suspected paralytic ileus
6. Respiratory depression in the absence of
resuscitative equipment
Common doses
Reported epidural therapeutic doses for treatment of
acute pain in adults are 0.51.5 mg diluted in normal
saline to a total volume of 515 mL. This can be supplemented with a continuous infusion of 0.2 mg/h.
The epidural hydromorphone needs to be preservative
free, and the standard 2 and 4 mg/mL single dose vials
fulfill this requirement. The spread of analgesia can be
increased by increasing the diluent to 15 mL, and if
epinephrine is added to the solution at 1:200 000 concentration, the onset of action is hastened and the
duration of action is prolonged [5,6].
The intramuscular route for chronic cancer pain
based on a timed regimen is given at a dose of 34 mg
every 34 hours. Terminal cancer patients may have
much higher requirements, and, as with all opioids, there
is no ceiling effect. The dose for the acute treatment of
pain is 12 mg IM every 46 hours. Tolerance to this
regimen is typically evidenced by a reduction in duration of pain relief. A reduction in the duration of action
indicates a developing tolerance to hydromorphone.
Chapter 23 Hydromorphone (oral and parenteral)
Hydromorphone can be administered intrathecally by an implanted infusion pump for the treatment
of intractable cancer pain. Clonidine is an important
adjunct when pain becomes refractory to increasing
doses of hydromorphone.
Hydromorphone 0.2 mg/mL intravenously is used
extensively for patient-controlled analgesia (PCA) in
the treatment of acute pain. A typical bolus dose is 0.2
mg with a lock-out period of 6 minutes. When used on
an as-needed basis hydromorphone is given at a dose
of 12 mg every 46 hours. A lower initial dose should
be used in opiate-naive patients. Doses can be escalated in refractory pain. Again, a decrease in the duration of pain-free periods suggests the development of
tolerance to the analgesic effects of hydromorphone.
Intravenous administration of hydromorphone should
be slow over 23 minutes.
Oral hydromorphone is about one-fifth as effective
as intravenous hydromorphone. Oral hydromorphone
used for chronic pain is usually given at a dose of 24
mg every 34 hours, and as needed. Extended-release
hydromorphone is usually reserved for opioid-tolerant patients. Care must be taken not to overestimate
the initial dose when converting from another opioid.
Capsules have to be swallowed whole, and alcohol use
must be avoided due to the risk of rapid release of the
drug. Dosing must be individualized, taking into
account prior opioid treatment, medical conditions,
risk of abuse, type of pain, concomitant medications,
variability in opioid conversion, and balance between
adequate pain management and adverse reactions.
Standard conversion tables can be used when switching opioids, taking into account the duration of action
of the prior opioid used. Of note, it is prudent to be
conservative with the initial dose, and therefore one
has to make allowance for medication for breakthrough pain. Oral hydromorphone therapy for acute
pain in non-tolerant patients is usually initiated at a
dose of 24 mg every 4 hours. Doses may need to be
adjusted to achieve at least 34 hours pain relief with
a single dose.
Rectal hydromorphone is generally given for
chronic pain at a dose of 36 mg every 34 hours,
while the dosing schedule for acute pain is 3 mg every
68 hours.
Continuous subcutaneous infusion is an alternative for patients who are unable to take hydromorphone orally. Patients with inadequate subcutaneous
tissue, severe heart disease, renal, metabolic, electrolyte, fluid, or coagulation abnormalities should not be
considered. The starting dose over 24 hours should be

the same as the oral one; however, the mean maintenance dose may be several times higher than the oral
dose. The dose is increased by 25% to 50% every 24 to
48 hours until adequate pain control is achieved or
side effects become intolerable. Programming of the
pump should include available doses for breakthrough
pain that are 2550% of the hourly dose. Adverse reactions of this route of administration are subcutaneous
edema, infection, and local inflammatory reactions.
The site of injection should be changed frequently.
Subcutaneous injections for acute pain are typically
stated at 12 mg every 46 hours.
Pediatric dosing on a weight basis is similar to
adult dosing. A typical intravenous dose for moderate
to severe acute pain is 0.015 mg/kg, while the equivalent oral dose is 0.050.1 mg/kg.
Doses should be decreased for patients with moderate to severe renal and hepatic disease. Also, because
of decreased hepatic, renal, and cardiac function and
concomitant disease or drug therapy geriatric patients
have to be dosed with caution. Other patients who
may need lower doses are those who are debilitated,
following gastrointestinal surgery, and patients with
the following conditions: myxedema or hypothyroidism, adrenocortical insufficiency, CNS depression
or coma, toxic psychoses, prostatic hypertrophy or
urethral stricture, gall bladder disease, acute alcoholism, delirium tremens, or kyphoscoliosis.
Hydromorphone is easily available and titrateable,
inexpensive (except extended release), and well tolerated. It causes less pruritus than morphine. It is
equivocal whether it causes less nausea in cases where
substantial doses are administered. Hydromorphone
can be used in a multimodal approach to treat both
acute and chronic pain. It carries less risk of toxic
metabolites when compared to morphine and meperidine in patients with renal disease. Overdoses are
readily treated with the antagonist naloxone.
Like all opioid drugs hydromorphone carries a risk
of abuse and both psychological and physical
dependence. It must be stressed that development of
dependence is rare if the drug is used for indicated
medical reasons. In acute pain situations the onset
of action may be too slow to gain control of pain and
117
may have to be bridged with faster-acting opioids

such as fentanyl.

Hydromorphone can cause significant hypotension,
especially if given IV or IM. The incidence and severity are significantly higher than with an equipotent
dose of morphine sulfate. The incidence of hypotension when given IV can be decreased by slow administration over 23 minutes. Hydromorphone-induced
histamine release may be responsible for pruritus,
flushing of the face, and sweating. Allergic reactions
are rare; pruritus, urticaria, and skin rashes are most
common. Gastrointestinal tract issues include nausea,
vomiting, and constipation. The risk of constipation is
as high as 40%. Nausea and vomiting occur more frequently in ambulatory than recumbent patients.
Hydromorphone may produce biliary tract spasm
thereby increasing the intraluminal pressure of the
common bile duct. This may disrupt surgical anastamoses. Patients with ulcerative colitis may experience
increased colonic motility, which in the acute phase
may lead to toxic dilatation. The most common central nervous system side effects are drowsiness and
sedation, which occur in up to 60% of patients. There
are reports of seizures and myoclonus in severely compromised cancer patients. Other central nervous system issues include confusion, agitation, dizziness,
restlessness, paresthesia, sensory changes, vertigo,
headache, mental clouding, tremor, weakness, myoclonus, anxiety, fear, euphoria, psychological dependence, and mood changes. Genitourinary side effects
include oliguria, urinary retention, and ureteral and
vesicular sphincter spasm. Respiratory side effects
relate primarily to respiratory depression due to a
direct effect on the brainstem. One milligram of
hydromorphone has similar depressant effects to 10
mg morphine. This depression can be antagonized by
titration of the opioid antagonist naloxone. It must be
kept in mind that the duration of action of naloxone is
shorter than that of hydromorphone, and therefore
118
repeated doses of naloxone may be needed to avoid

recurrence of respiratory depression, as well as vigilant monitoring of the patient. Respiratory control
can also be affected by hydromorphone, leading to
irregular and periodic breathing.
Hydromorphone should be used with caution if
other central nervous system depressants are given
concomitantly. These drugs are other opioids, general
anesthetics, phenothiazine, tricyclic antidepressants,
sedative-hypnotics, and other central nervous system
depressants (including ethanol).
The FDA labels hydromorphone as a Category C.
Hydromorphone readily crosses the placenta. The
Thompson Lactation Rating states that infant risk is
minimal.
References
1. Micromedex Healthcare Series, DrugDex

Evaluations, Thompson Healthcare. Hydromorphone,
2009. http://www.thomsonhc.com/hcs/librarian/ND_
T/HCS/ND_PR/Main/CS/4A9061/DUPLICATIONS
HIELDSYNC/236166/ND_PG/PRIH/ND_B/HCS/SB
K/2/ND_P/Main/PFPUI/JbY1nE2XnPyXj/PFActionId/
hcs.common.RetrieveDocumentCommon/DocId/053
1/ContentSetId/31#all.
2. Inturrisi C, Portenoy R, Stillman M, et al.
Hydromorphone bioavailability and pharmacokineticpharmacodynamic relationships. Clin Pharm Ther
1988;43:162169.
3. Ritschel WA. Absolute bioavailability of
hydromorphone after oral and rectal administration
in humans. J Clin Pharmacol 1987;27:647653.
4. Babul N, Darke AC, Hagen N. Hydromorphone
metabolite accumulation in renal failure. J Pain Sympt
Management 1995;10(3):184186.
5. Brodsky JB, Chaplan SR, Brose WG, Mark JBD.
Continuous epidural hydromorphone for
postthoracotomy pain relief. Ann Thorac Surg
1990;50:888893.
6. Sinatra RS, Levin S, Ocampo CA. Neuroaxial
hydromorphone for control of postsurgical, obstetric,
and chronic pain. Semin Anesth Periop Med Pain
2000;19:108131.
Section 2
Chapter
24
Oxymorphone injectable
Balazs Horvath
Generic Name: oxymorphone hydrochloride

Proprietary Names: Opana injection; Numorphan Injection
Manufacturers: Endo Pharmaceuticals, Endo
Corporate Headquarters, 100 Endo Boulevard,
Chadds Ford, PA 19317; Bristol-Myers Squibb
Canada, Pharmaceutical Group, 2344 AlfredNobel Boulevard, Montreal, Quebec, H4S0A4
Class: Semi-synthetic opioid analgesic
Chemical Name: 14-hydroxydihydromorphinone (4,5-epoxy-3,14-dihydroxy-17-methy
lmorphinan-6-one hydrochloride)
Chemical Formula: C17H19NO4; molecular
weight: 337.80
Introduction
Oxymorphone hydrochloride is a potent, semi-synthetic opioid analgesic approved for control of moderate to severe pain. It is a white or slightly off-white,
odorless powder, which is sparingly soluble in alcohol
and ether, but freely soluble in water. The octanol/
aqueous partition coefficient at 37C and pH 7.4 is
0.98. Oxymorphone is a synthetic derivative of thebane, and its structural configuration is similar to
morphine and other morphinians. Like other opioid
analgesics, oxymorphone exerts its principal pharmacological effects by activating opioid receptors in the
CNS and the gastrointestinal tract. Oxymorphones
principal therapeutic effect is analgesia, but it is also
associated with dose-dependent sedation, euphoria,
cognitive deficits, nausea and vomiting and respiratory depression. Following intravenous administration, 1 mg of injectable oxymorphone is approximately
equivalent in analgesic activity to 10 mg of injectable
morphine sulfate. Attesting to the high therapeutic
efficacy of intravenous administration, 1 mg of injectable oxymorphone is equivalent to 10 mg of oral oxymorphone [14].
Historical overview
First approved by the US Food and Drug Administration (FDA) in 1959, oxymorphone was initially used
in postanesthesia care units, intensive care units and
in the emergency department for rapid relief of severe
surgical pain, and on medical wards for chronic pain
flare [46]. Sinatra and colleagues have previously
reviewed the positive characteristics of the molecule
that make it useful in these settings, including its
rapid onset, clean profile, powerful analgesic effects,
high specificity for the receptor, and increased penetrance to the central nervous system relative to morphine [5,6]. Given these advantages the preparation
has been advocated for intra-operative anesthetic
supplementation and for post-operative pain management for use with intravenous patient-controlled
analgesia.
Eddy and coworkers [7] were first to compare the
effectiveness of injectable oxymorphone with morphine in the same patients for relief of chronic cancer
pain. Under these conditions 1.02 mg of oxymorphone hydrochloride is equivalent to 10 mg of morphine sulfate. These doses were not materially
different with regard to peak effect or duration of
analgesic effect. If the dose of oxymorphone was
increased to 2.0 mg, the peak effect was increased and
analgesia was somewhat better sustained, but the
overall duration of effect was not greater than with
12.0 mg of morphine. The side effects of equipotent
analgesic doses were slightly less for oxymorphone; at
least there appeared to be less nausea and vomiting.
As might be expected, increases in oxymorphone
dose, compared in the same patients, increases the
side effects and may be accompanied by severe respiratory depression in debilitated individuals, possibly
to a greater extent than with morphine.
119
HO
Figure 24.1.
Abs
OH
120
Robinson et al. [8] noted that oxymorphone

injectable was less likely to release histamine in dogs
than equivalent doses of morphine. Since cardiovascular effects associated with histamine release
(vasodilatation, hypotension) are minimal with oxymorphone this opioid may offer safety advantages for
patients presenting with cardio- and cerebrovascular
disease.
The safety and efficacy of fentanyl and oxymorphone, used as adjuncts in general anesthesia, were
studied in 39 patients undergoing elective gynecological surgery of at least 2 hours duration [6]. It was
found that less narcotic and recovery room analgesics
were required in the oxymorphone-treated group. On
the other hand, decreased naloxone requirements and
a more rapid emergence suggested that fentanyl was a
safer agent when administered in relatively unrestricted fashion.
Oxymorphone has also been evaluated for use as a
post-operative analgesic [9,10]. Seventy-five patients
(n = 75) recovering from elective cesarean delivery
were randomly assigned to receive one of three opioid
analgesics, oxymorphone, morphine or meperidine,
via patient-controlled analgesia (PCA). After adjusting
for potency, no differences in 24-h dose requirements
were noted between treatment groups (NS). However,
onset of analgesia was most rapid with oxymorphone.
Oxymorphone was associated with a higher incidence
of nausea and vomiting, whereas increased sedation
and pruritus were noted with morphine. Whereas
morphine is a more commonly utilized PCA analgesic,
the excellent analgesia, low incidence of sedation, and
high patient satisfaction provided by oxymorphone
suggested a useful alternative [9].
In a follow-up clinical trial, the analgesic efficacy
and adverse effects of morphine and oxymorphone
in patients who received traditional PCA following
cesarean delivery were compared with those in
patients receiving the same agents via PCA plus basal
opioid infusion (PCA + BI) [10]. Patients utilizing

PCA + BI noted significant reductions in resting
pain scores with oxymorphone and decreased pain
during movement with both opioids when compared
with individuals using PCA alone. There were no significant differences between treatment groups in
24-h dose requirements or patient satisfaction with
therapy [10].
Oxymorphone has also been evaluated for subcutaneous administration. White [11] evaluated 120
patients undergoing major orthopedic, urological or
gynecological procedures who were randomly
assigned to receive either morphine or oxymorphone
post-operatively using a patient-controlled analgesic
(PCA) delivery system. The opioid analgesic was
administered either intravenously (IV-PCA) or subcutaneously (SQ-PCA) during the 72-h study period.
The average morphine and oxymorphone dose
requirements were significantly higher with SQ-PCA
when compared to IV-PCA. Post-operative analgesia
scores and patient satisfaction were similar in all four
PCA treatment groups. Thus SQ-PCA with either oxymorphone or morphine represents a clinically acceptable alternative to IV-PCA in the treatment of
post-operative pain, particularly in patients with poor
intravenous access.
Clinical pharmacology
Like other potent opioid agonists, oxymorphone provides dose-dependent analgesia, sedation, euphoria,
and respiratory depression by binding and activating
mu opioid receptors located in brain, brainstem and
spinal cord. Activation of mu receptors in the medulla
oblongata results in depression of the cough reflex and
provocation of nausea and vomiting. Minor sites of
action include the gastrointestinal tract where oxymorphone increases smooth muscle tone, decreases
motility, and causes constipation.
Oxymorphone has minimal effects on peripheral
vascular resistance and is associated with less histamine release than morphine. Oxymorphones clearance and elimination kinetics are similar to
hydromorphone. Average time to onset following IM
and SQ administration is 515 minutes with a duration of action of 3.5 h. The drug is primarily metabolized in the liver, and is primarily conjugated with
glucuronic acid. Oxymorphone is excreted primarily
via the kidneys, renal, and with bile. Thirty-three
to 38% of the drug is excreted as oxymorphone-3glucuronide, with less than 1% excreted unchanged.
Chapter 24 Oxymorphone injectable
Oxymorphone is also produced as a metabolite of

oxycodone the liver metabolises oxycodone by
means of O-demethylation and it is catalysed by cytochrome P4502D6.
Indications
Relief of moderate to severe acute pain, surgical pain,
medical pain, chronic non-malignancy pain, cancer
pain and labor pain.
Contraindications
Known hypersensitivity to oxymorphone hydrochloride, morphine analogs such as codeine, or any of the
other ingredients of OPANA, moderate or severe
hepatic impairment and any situation where opioids
are contraindicated such as: patients with respiratory
depression (in the absence of resuscitative equipment
or in unmonitored settings), acute or severe bronchial
asthma, hypercarbia, and in any patient who has or is
suspected of having paralytic ileus.
Common doses/uses
Acute pain management
Injectable oxymorphone may be employed as a substitute for morphine or hydromorphone intra-operatively
and for post-surgical pain management. Subcutaneous or intramuscular oxymorphone should initially be
administered as 1 mg to 1.5 mg doses repeated every 4
to 6 hours as needed. Intravenous oxymorphone can
be administered in doses of 0.5 mg. In non-debilitated
patients the dosages can be titrated to 1.52.5mg until
satisfactory pain relief is obtained. Oxymorphones
rapid onset-to-peak effect offers clinical advantages
for patients experiencing very severe pain. Onset is
noted within 5 minutes, and, unlike fentanyl, the duration of effect may be prolonged for several hours [5].
Rather than spending time titrating morphine to
patients recovering from extremely painful procedures

or those with high-grade opioid tolerance, 12 mg of
IV oxymorphone can be administered to rapidly establish a powerful level of analgesia.
IV-PCA
PCA syringe concentration is generally 0.20.3 mg
per mL. This requires that up to 10 ampoules be
opened and diluted with saline to make up a standard
30 mL PCA syringe. Earlier clinical trials employed
oxymorphone PCA doses of 0.3 mg with a 68 minute
lockout interval [9,10]. This dose was associated with
a high incidence of nausea and vomiting, particularly
when a 0.3 mg/hour basal infusion was employed [11].
To reduce adverse events, we recommend lower doses
of 0.10.2 mg every 6 min. PCA dosing guidelines for
oxymorphone are presented in Table 24.1.
Labor analgesia
Injectable oxymorphone in doses of 0.51 mg may be
administered for analgesia during labor. OPANA
injection should be used with caution during labor.
Sinusoidal fetal heart rate patterns may occur with the
use of opioid analgesics. Opioids cross the placenta
and may produce respiratory depression and psychophysiological effects in neonates. Neonates whose
mothers received opioid analgesics during labor
should be observed closely for signs of respiratory
depression. A specific opioid antagonist, such as
naloxone or nalmefene, should be available for reversal
of opioid-induced respiratory depression.
It is not known whether oxymorphone is excreted
in human milk. Because many drugs, including some
opioids, are excreted in human milk, caution should
be exercised when OPANA injection is administered
to a nursing woman. Ordinarily, nursing should not
be undertaken while a patient is receiving oxymor-
Table 24.1. Oxymorphone doses for IV-PCA
Route
Dose
Dose/Frequency
Note
IV-PCA (opioid-naive patients)
0.51.5 mg loading dose
0.10.2 mg every 68 min
May provide basal

infusion
of 0.10.2 mg/ha
IV PCA (opioid-tolerant patients)
1.53 mg loading dose
0.30.5 mg every 68 minb
Provide basal infusion of

0.30.5 mg/h b
May increase the incidence of nausea and vomiting.

Higher doses may be required.
a
b
121
Table 24.2. Injectable oxymorphone dosing
Route
Dose
Frequency
Note
IV (opioid-naive patients)
0.51.5 mg
Every 4 hours
In opioid-naive patients,
titrate the dose based on
the patients response to the
initial dose, pain intensity and
adverse reactions
IM/SC
11.5 mg
Every 46 hours
IV (opioid-tolerant patients)
1.53 mg initial dose
Every 34 h
Cautious increase until

satisfactory pain relief
General consideration: oxymorphone should be started at 1/3 to 1/2 of the usual dose in patients who are concurrently receiving other
CNS depressants including sedatives or hypnotics, general anesthetics, phenothiazines, tranquilizers, and alcohol, because respiratory
depression, hypotension, and profound sedation or coma may result. No specific interaction between oxymorphone and monoamine
oxidase inhibitors has been observed, but caution in the use of any opioid in patients taking this class of drugs is appropriate.
phone because of the possibility of sedation and/or

respiratory depression in the infant.
Conversion from oral OPANA to OPANA

Injection
Oxymorphones absolute oral bioavailability is very
low, and is equivalent to 10% of that observed with
intravenous dosing. Patients receiving oral doses of
OPANA IR may be converted to OPANA Injection
by administering one-tenth the patients total daily
oral oxymorphone dose as OPANA Injection in four
or six equally divided doses. Patients receiving 10 mg
oral oxymorphone (OPANA IR) every 46 hours (40
mg total daily dose) may be converted to injectable
oxymorphone 1 mg every 46 hours or 45 mg total
daily. Due to patient variability with regard to opioid
analgesic response, upon conversion patients should
be closely monitored to ensure adequate analgesia
and to minimize side effects. Safety and effectiveness
of OPANA Injection in pediatric patients below the
age of 18 years have not been established. Intravenous dosing guidelines are presented in Table 24.2.
Preparations
Oxymorphone is available for oral, rectal, and
parenteral administration. Oxymorphone injectable
(OPANA Injection) is available in 1 mL ampoules
containing 1 mg/mL oxymorphone hydrochloride. In
addition, each 1 mg/mL ampule contains 8.0 mg/mL
sodium chloride. pH is adjusted with hydrochloric
acid.
122
Opana Injection: supplied as 1 mL ampoules (1

mg/mL)
Numorphan Injection; supplied in 1 mL or 5mL

vials (1 mg/mL or 1.5mg/mL); also supplied as 5
mg suppositories
Price: approximately $2.00/1 mg
Drug interactions
Injectable oxymorphone is not associated with
CYP450 PK drugdrug interactions at clinically relevant doses. No dose adjustments required for concomitant medications metabolized via the CYP450
pathway.

Serious adverse events: respiratory depression, similar
to other potent injectable opioids particularly in elderly or debilitated patients. Predisposing conditions
include hypoxia, hypercapnia, or decreased respiratory reserve such as asthma, chronic obstructive pulmonary disease or cor pulmonale, severe obesity, sleep
apnea syndrome, myxedema, kyphoscoliosis, central
nervous system (CNS) depression, or coma.
Major CNS depression may be observed in elderly,
debilitated patients, with co-administration of opioid
analgesics, general anesthetics, phenothiazines or other
tranquilizers, sedatives, hypnotics, or other CNS depressants (including alcohol) and mild hepatic dysfunction.
References
1. OPANA Full Prescribing Information. Chadds Ford,

Pa: Endo Pharmaceuticals; 2006
2. Opana Injection: www.endo.com/pdf/products/
opana_injection_PI.pdf.
3. Gimbel JS. Oxymorphone: a mature molecule with new
life. Drugs Today (Barc) 2008; 44(10):76782. Review.
Chapter 25 Oxymorphone extended-release
4. Prommer E. Oxymorphone: a review. Support

Care Cancer 2006;14(2):109115. Epub 2005
Nov 30.
5. Sinatra RS, Hyde NH, Harrison DM. Oxymorphone
revisited. Semin Anesth 1988;7:209215.
6. Sinatra RS, Harrison DM. A comparison of
oxymorphone and fentanyl as narcotic supplements in
general anesthesia. J Clin Anesth 1989;1:253258.
7. Eddy NB, Lee LE. The analgesic equivalence to
morphine and relative sideeffect liability of
oxymorphone. J Pharmacol Exp Ther
1959;125(2):116121.
8. Robinson EP, Faggella AM, Henry DP, Russell WL.
Comparison of histamine release induced by
Section 2
Chapter
25
morphine and oxymorphone administration in dogs.

Am J Vet Res 1988;49(10):16991701
9. Sinatra RS, Lodge K, Sibert K, et al. A comparison of
morphine, meperidine, and oxymorphone as utilized
in patient-controlled analgesia following cesarean
delivery. Anesthesiology 1989;70:585590.
10. Sinatra R, Chung KS, Silverman DG, Brull SJ, Chung
J, Harrison DM, Donielson D, Weinstock A. An
evaluation of morphine and oxymorphone
administered via patient-controlled analgesia (PCA)
or PCA plus basal infusion in postcesarean-delivery
patients. Anesthesiology 1989;71(4):502507.
11. White PF. Subcutaneous-PCA: an alternative to
IV-PCA for postoperative pain management.
Clin J Pain 1990;6:297300.
Oxymorphone extended-release
Steven Levin and Imanuel Lerman
Generic Name: oxymorphone hydrochloride

extended release
Proprietary Name: OPANA ER
Manufacturers: Endo Pharmaceuticals Inc., 100
Endo Boulevard, Chadds Ford, PA 19317; Novartis
Consumer Health Inc., Lincoln, NE 68517
Chemical Name: 4,5-epoxy-3,14-dihydroxy17-methylmorphinan-6-one hydrochloride
Chemical Formula: C17H19NO4HCl
Introduction
Oxymorphone is a semi-synthetic opioid analgesic,
which is freely soluble in water. Oxymorphone and
morphine share the same benzylisoquinoline alkaloid

structure with two ring closures. Oxymorphone has a
molecular weight of 337.8, and differs from morphine
by a ketone substitution at C6 and a saturation of the
double bond at C7C8. These structural differences
make oxymorphone more lipid-soluble than morphine and may account for faster diffusion across the
bloodbrain barrier. Oxymorphone was first synthesized in Germany in 1914. In 1955, Dr. Ulrich Weiss
synthesized and patented oxymorphone while working at ENDO Products. By January 1959, oxymorphone was introduced to the USA market as the
parenteral form now available under the trade name
OPANA Injection. Oxymorphone was also made
available in an immediate-release tablet and a rectal
suppository; however, the oral immediate-release
form of oxymorphone was withdrawn from the
market in 1972. Oxymorphone ER under the trade
name of Opana ER is a long-acting oral form of
123
HO
Figure 25.1.
O
N
OH
O
oxymorphone that was FDA approved in June of 2006.

The Opana ER formula uses TIMERx, a controlled
release delivery system, which was developed by Penwest Pharmaceuticals Co. in Danbury, Connecticut.
The controlled-release technology uses an agglomerated hydrophilic matrix which releases the drug, as
water penetrates the matrix, to sustain plasma levels
during the 12-hour dosing interval [1].
Mode of activity
Oxymorphone is a synthetic derivative of thebane. It is
an opioid agonist which has a higher specificity for the
the opioid and opioid receptor when compared to
the opioid receptor [2]. Compared to morphine,
oxymorphone has a binding affinity that is logarithmically greater and has more specificity for the and
opioid receptor [3]. Oxymorphone has a more rapid
onset of action and several times the analgesic potency
of morphine. The selective activation of the opioid
receptor causes analgesia by activating descending
inhibitory signals that modulate spinal cord pain
transmission. This selective activation of the receptor also contributes to adverse effects such as constipation, urinary retention, hyperthermia, and respiratory
depression [1]. Oxymorphones selective activation of
the opioid receptor potentiates the -mediated analgesic effects [3]. In addition, the opioid receptor
plays a key role in the activation of reward circuitry
and subsequent euphoria [4].

and elimination
124
Oxymorphone ER has an absolute bioavailability of

approximately 10%. This bioavailability is thought to be
primarily due to pre-systemic (first pass) metabolism in
the liver [1]. Oxymorphone ER has a mean steady-state
plasma concentration which linearly increases with
dose [1]. The time to maximum concentration is estimated to be 2590 minutes for all doses. Oxymorphone
ER has a mean t of 9.3511.30 hours for doses of 540
mg, and if given at steady state the t increases to 13.05

hours. Oxymorphone ER has a low fluctuation in
plasma concentration when dosed at 12-hour intervals
during steady state [2]. Oxymorphone ER has a maximum peak concentration that is prolonged close to 1
hour by co-administration with food. Because of the
effect of food on absorption, oxymorphone ER should
be taken 1 hour before or 2 hours after a meal. If ethanol
is co-administered with oxymorphone ER there is a
potential for increased bioavailability and a faster tmax
[1]. In addition, there is risk from the additive effects of
opiates and ethanol on CNS depression, which may
lead to respiratory depression, hypotension, profound
sedation, and death. Therefore co-administration of
oxymorphone and ethanol should be avoided.
Absorption
Oxymorphone ER is absorbed by the gastrointestinal
tract. Oxymorphone ER is a sustained-release tablet
which has been developed to provide 12 hours of sustained analgesia. The mechanism of prolonged analgesia is due to the extended-release matrix, TIMERx,
which delays drug dissolution and absorption of the
drug from the gastrointestinal tract. The extended-release technology uses an agglomerated hydrophilic
matrix which releases the drug, as water penetrates the
matrix, to sustain plasma levels during the 12-hour dosing interval.
Metabolism
Oxymorphone undergoes extensive metabolism in the
liver via conjugation with glucuronic acid. This
produces oxymorphones primary metabolites, oxymorphone-3-glucuronide and 6-OH-oxymorphone.
6-OH-oxymorphone and oxymorphone-3-glucuronide
are both excreted in the urine and feces. In normal
patients, 3338% of the total dose of oxymorphone
administered is excreted in the urine as oxymorphone3-glucuronide and 0.250.62% of total dose is excreted
as 6-OH-oxymorphone. The remaining 6267% of
oxymorphone ER is excreted in the feces as its metabolites oxymorphone-3-glucuronide and 6-OH-oxymorphone. Less than 1% of the oxymorphone ER is excreted
as the parent compound in both feces and urine [1,5]. In
patients with moderate to severe hepatic failure there is
significant risk of increased bioavailability, up to 12.2fold greater than controls, and therefore it is contraindicated in patients with moderate to severe liver impairment
[1]. In patients with a creatinine clearance less than
3050 mL/min the bioavailability of oxymorphone
Chapter 25 Oxymorphone extended-release
increased up to 65% [1]. Oxycodone, another opioid

analgesic, undergoes extensive hepatic metabolism by
the CYP450 system, producing the metabolite oxymorphone. Oxymorphone does not undergo significant
CYP450 metabolism. The intrinsic activity of the
CYP450 system is probably genetically determined and
therefore a source of variation in opioid analgesic
response, and can alter side-effect profiles. Up to 67% of
chronic pain patients are treated with non-opiate medications which undergo CYP450 metabolism [7]. These
non-opiate medications can cause either induction or
inhibition of the CYP450 enzyme metabolism which
can make efficacious opiate dosing more difficult when
using opiates that do undergo CYP450 metabolism.
Besides methadone, opiates do not induce or inhibit
CYP450 metabolism directly, therefore most opioids
do not directly affect the CYP450 metabolism of nonopiate medications. Oxymorphone ER does not
undergo significant CYP450 metabolism, which eliminates the potential for intrinsic CYP450 enzyme activity variability and drugdrug interactions that could
affect its efficacy [5].
Indications
Oxymorphone ER is indicated for the relief of moderate to severe pain in patients requiring continuous,
round-the-clock opioid treatment for an extended
period of time [1].
Oxymorphone ER is not intended for use as an asneeded analgesic [1].
Oxymorphone ER is not indicated for pain in the
immediate post-operative period (1224 hours following surgery) for patients not previously taking
opioids because of the risk of oversedation and respiratory depression requiring reversal with opioid
antagonists [1].
Oxymorphone ER is not indicated for pain in the
post-operative period if the pain is mild or not expected
to persist for an extended period of time [1].
Contraindications
Absolute contraindication: oxymorphone ER is contraindicated in patients with a known allergy or hypersensitivity to oxymorphone hydrochloride, morphine
analogs, or other ingredients which are used in the
manufacturing of oxymorphone ER [1].
Relative contraindication: oxymorphone ER is
contraindicated in patients with acute or severe
bronchial asthma or hypercarbia and patients with
respiratory depression that is difficult to control,
monitor, or manage [1]. Oxymorphone ER is contraindicated in patients with or suspected of having

a paralytic ileus [1]. Oxymorphone ER is contraindicated in patients with moderate or severe hepatic
impairment [1].
Common doses and routes of

administration
Adult dosing
In opioid-naive patients oxymorphone ER can be initiated in 5 mg tabs given every 12 hours. The usual
titration for opioid-naive patients is to increase by
510 mg every 37 days. Oxymorphone ER should
not be broken, chewed, dissolved, or crushed, because
a rapid release and absorption of a potentially fatal
dose of oxymorphone can occur. Oxymorphone ER
should never be co-administered with alcohol because
there is a risk of increased plasma levels which can
lead to potentially fatal overdose [5]. Patients currently treated with opioids yet having poor analgesic
response or intolerability can be converted to oxymorphone ER. A conversion table has been developed to
aid dose conversion from morphine, oxycodone, and
hydrocodone to oxymorphone ER [1] (Table 25.1) To
convert from oxymorphone IR to oxymorphone ER,
one can add the total amount of oxymorphone IR and
divide that dose into two separate doses of oxymorphone ER.
Table 25.1. Conversion ratios to oxymorphone ER
Opioid
analgesic
Approximate
equivalent
dose
Oral
conversion
ratio
Oxymorphone
10 mg
Hydrocodone
20 mg
0.5
Oxycodone
20 mg
0.5
Methadone
20 mg
0.5
Morphine
30 mg
0.333
Select opioid and multiply the dose by the conversion ratio to

calculate the approximate oral oxymorphone equivalent. Sum
the total daily dose for the opioid and multiply by the conversion
ratio to calculate the oxymorphone total daily dose.
For patients on a regimen of mixed opioids, calculate the
approximate oral oxymorphone dose for each opioid and sum
the totals to estimate the total daily oxymorphone dose.
The dose of OPANA ER can be gradually adjusted, preferably
at increments of 10 mg every 12 hours every 37 days, until
adequate pain relief and acceptable side effects have been
achieved.
125
LSM (SEM) VAS Pain Intensity (mm)
80
60
40
20
0
ing
en
re
Sc
14
21
Study Day
28
42
A recent clinical trial of patients currently on chronic

opioid therapy provided guidelines for dose conversion
as well as information regarding oxymorphone ERs
sustained and uniform analgesia effect. Oxymorphone
ER was dosed every 12 hours to approximate an equianalgesic dose of their pre-study opioid medication.
Patients responding to oxymorphone ER entered a
12-week double-blind treatment phase with placebo.
Patients were allowed an unlimited number of oxymorphone IR 5 mg tablets, every 46 hours as supplemental
analgesia for the first 4 days; thereafter the number
was limited to two tablets per day. Seventy percent of
patients treated with oxymorphone ER completed the
12-week trial. Oxymorphone ER provided superior
analgesia compared to placebo (Figure 25.2). The analgesic effect of OPANA ER was maintained in 80% of
patients who completed the study. A significantly higher
proportion of OPANA ER patients (79.7%) had at least
a 30% reduction in pain score from screening to study
endpoint compared to placebo patients (34.8%).
Dosage forms
Oxymorphone ER is available as an oral medication in
5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, 30 mg and 40 mg
tablets.
126
Figure 25.2. Pain Intensity as assessed

with visual analog scale scores for
patients with chronic low back pain
during administration of oxymorphone
extended-release (ER) or placebo.
Screening = visit before enrollment, day
0 = baseline before randomization; *P,
0.001 versus placebo. With permission
from: Peniston JH and Gould E.
Oxymorphone extended-release tablets
for control of chronic low back pain. Clin
Therapeutics 2009;31:347359.
Screening (n - 575)
Oxymorphone ER (n - 175)
Placebo (n - 172)
The use of oxymorphone ER has a series of potential

advantages stemming from issues relating to clinical
practicality, ease of use, as well as favorable pharmacodynamic and pharmacokinetic attributes. Oxymorphone ER has high analgesic uniformity, with minimal
fluctuations in plasma concentration when dosed
every 12 hours during steady state [2]. Such limited
variation in the oxymorphone plasma concentration
56
70
84
levels is likely to provide consistent pain relief and

avoid the need for shortening the dosing interval as
reported clinically with other long-acting agents. Less
frequent dosing requirements often translate into
improved compliance and oxymorphone ER is very
lipid-soluble, permitting a rapid diffusion across the
bloodbrain barrier, and it has a greater affinity for
both opioid and opioid receptors than morphine,
both of which contribute to its rapid and potent analgesic effects. Oxymorphone ER provides linear pharmacokinetics which allow the physician to be confident
that an increase in the dose of oxymorphone ER will
have an equal and predictable increase in the plasma
drug concentration. Oxymorphone ER does not
undergo significant CYP450 metabolism. Oxymorphone ER is less likely to have drugdrug interactions
and eliminates a potential intrinsic CYP450 enzyme
activity variability that could affect its efficacy and its
side-effect profile.
Oxymorphone ER is an opioid and there is a potential
for risk of abuse and both psychological and physical
dependence. The development of opioid abuse is relatively rare when the drug is used for indicated medical
reasons and there is no presence or history of substance abuse. Oxymorphone ER, like many other
brand-name sustained-release opioids, continues to
have a high cost which is a potential disadvantage to
patients.

Patients treated with oxymorphone ER listed the
following adverse events as most common (>10%):
nausea, constipation, dizziness, vomiting, pruritus,
Chapter 26 Methadone
somnolence, headache, sweating, and increased sedation [1]. Patients treated with oxymorphone ER listed
the following adverse events as common (>1% to less
than 10%): tachycardia, vomiting, constipation, dry
mouth, abdominal distention, flatulence, sweating
increased, dizziness, somnol-ence, headache, anxiety,
confusion, disorientation, restlessness, nervousness,
depression, sedation, confusion, hypoxia, pruritus,
flushing, and hypertension [1].
References
1. Endo Pharmaceuticals, 2009. Opana and Opana ER

monograph. Endo Chadds Ford.
2. Adams MP, Ahdieh H. Pharmacokinetics and
dose-proportionality of oxymorphone extended
Section 2
Chapter
26
release and its metabolites: results of a randomized

crossover study. Pharmacotherapy 2004;24(4):
468476.
3. Prommer E. Oxymorphone: a review. Support Care
Cancer 2006;14:109115.
4. Inturrisi CE. Clinical pharmacology of opioids for
pain. Clin J Pain 2002;18(4):S3S13.
5. Micromedex Healthcare Series, DrugDex Evaluations.
Thompson Healthcare. Accessed August 17, 2009.
6. Adams M, Pieniazek HJ, Gammaitoni AR, Ahdieh H.
Oxymorphone extended release does not affect
CYP2C9 or CYP3A4 metabolic pathways. J Clin
Pharmacol 2005;45:337345.
7. National Disease Therapeutic Index (NDTI). Accessed
October 25, 2007.
Methadone
Keun Sam Chung
Generic Name: methadone, methadone hydrochloride injection

Trade/proprietary Name: Dolophine
Drug class: opioid analgesic, Schedule II
Manufacturers: Roxane Labarotories Inc., 1809
Wilson Rd, Columbus, OH 43228;
Xanodyne Pharmaceutical Inc., Newport, KY
41071
Chemical Name: 6-dimethyl amino-4,4-di
phenyl-3-heptanone hydrochloride
Chemical Formula: C21H27NOHCl
Introduction
Methadone is a potent synthetic opioid analgesic,
structurally unrelated to any of the opium-derived
alkaloids. It is a highly lipophilic, basic drug (pKa 9.2)
available as a hydrochloride powder formulation that
can be reconstituted for oral, rectal, or parenteral
administration. Methadone was developed in Germany in 1942 as a synthetic substitute for morphine,
and has been approved and widely employed for opioid detoxification maintenance as well as acute and
chronic pain management.
Mode of activity
Methadone is traditionally classified as a synthetic
opioid agonist, which binds to , , and opioid
127
Figure 26.1.
O
CCH2CH3
C
CH3
HCI
CH2CHN
CH3
CH3
128
receptors. In addition, it is also an inhibitor of serotonin and norepinephrine reuptake and a moderate
antagonist at the N-methyl-d-aspartate (NMDA)
receptor. It is, therefore, called a broad-spectrum
opioid. Methadone that is used clinically is a racemic
mixture of equal amounts of the l-isomer and the
d-isomer. The opioid-like activity of methadone is
almost entirely due to l-methadone, while d-methadone has an NMDA receptor antagonist, including
anti-hyperalgesic activity and the ability to prevent
the development of opioid tolerance.
Unlike morphine and meperidine, methadone is
well absorbed from the gastric mucosa, and has high
oral bioavailability of around 75% (36100%). It can
be detected in blood 1545 minutes after oral administration, and peak plasma concentration is achieved
at 2.54 hours. Methadone is highly bound to plasma
proteins, in particular to 1-acid glycoprotein.
Methadone is characterized by highly variable
pharmacokinetics and pharmacodynamics among
individuals and in an individual as well, which makes
methadone one of most difficult and potentially dangerous opioids for most primary physicians to use. Its
mean free fraction is around 13%, with a four-fold
inter-individual variation. Methadones volume distribution is about 4 L/kg (213 L/kg). Total body clearance is about 0.095 L/min with wide inter-individual
variation (0.022 L/min). Methadone undergoes a
biphasic pattern of elimination, with an alpha-elimination phase persisting 812 hours and a beta-elimination phase ranging from 30 to 60 hours. The
alpha-elimination phase equates to the period of analgesia, which typically does not exceed 68 hours. This
probably underscores why methadone is prescribed
every 24 hours for opioid maintenance therapy and
every 68 hours for initial analgesic titration.
Methadone undergoes hepatic metabolism and
renal excretion. Because of its ionized and lipophilic
properties, changes in the pH of the urinary tract can
be an important determinant in the elimination of
methadone. For example, at a urinary pH above 6,
renal clearance constitutes only 4% of total drug elimination. However, when urinary pH is below 6, the
unchanged methadone excreted by the renal route can
increase to 30% of the total administered dose.
Unlike morphine, which undergoes hepatic glucuronidation, methadone is metabolized mainly by
cytochrome P450(CYP)-catalyzed hepatic N-demethylation to the pharmacologically inactive primary
metabolite 2-ethyl-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) with some urinary excretion of
unchanged drug. CYP 2B6 and CYP3A4 are the main
isoforms mediating N-demethylation of methadone.
Interindividual variations in the genetic expression of
CYP 2B6 and CYP3A4 is the main factor responsible
for interindividual variability in clearance. Methadone
metabolism and clearance have been attributed for
over a decade to CYP3A4 on the basis of extrapolation
of in vitro drug metabolism studies. Nevertheless, a
recent study provided robust and unequivocal evidence against a major role for CYP3A in methadone
clearance. Practitioner guidelines identifying methadone as a CYP3A substrate and warning of CYP3Amediated drug interactions require thorough and
thoughtful reevaluation.
Maintenance for heroin addiction
Initially, methadone was limited to detoxification
treatment or maintenance treatment within US
Food and Drug Administration-approved narcotic
addiction programs. This restriction was removed in
1976; all physicians with appropriate Drug Enforcement Agency registration now are allowed to prescribe
methadone for analgesia.
Medical pain
In addition to maintenance treatment for opioiddependent individuals, methadone is very useful as a
long-acting analgesic, particularly for neuropathic pain
syndromes that accompany malignancy, and chronic
non-malignancy pain, or where the efficacy and side
effects of commonly employed opioids are unacceptable.
Pain which is poorly responsive to morphine or other
opioid agonists should be identified quickly so that futile
dose escalation and intolerability can be avoided.
Acute pain crisis in the emergency room

When the patient reports severe pain, uncontrolled
with other potent opioids, and the pain is causing the
Chapter 26 Methadone
patient and family severe distress, rotation to methadone can provide effective analgesia. When switching
to methadone, the equianalgesic ratio and dose are
dependent on the patients degree of tolerance and
central sensitization to the previous opioids, and they
can vary over 20-fold (see Table 26.2).
Post-operative acute surgical pain

Uncontrolled post-operative acute pain, particularly
in patients with a history of chronic pain and opioid
dependency, can be quickly and effectively relieved
by careful and slow titration of intravenous methadone. Similar results may be achieved in some opioidnaive patients who are refractory to high doses of
potent opioids administered in the post-anesthesia
care unit (PACU). This author uses 2.5 mg of methadone every 510 minutes to extinguish the fire associated with poorly controlled pain, and, once adequate
analgesia is obtained, initiates hydromorphone intravenous PCA bolus with or without continuous infusion. It is likely that the intrinsic NMDA antagonistic
property of the d-isomer of methadone blunts NMDA
receptor activation and spinal sensitization induced
by opioids (opioid hyperalgesia) as well as poorly
controlled pain.
Intra-operative use for prolonged

post-operative analgesia
Prolonged and effective post-operative analgesia
(median value 25 hours) can be obtained in 40% of
patients after a single intravenous dose of methadone
20 mg when it is given as an anesthetic adjunct for
Table 26.1.
Injection solution: 10 mg/mL
Oral solution: 5 mg/5 mL, 10 mg/5 mL, 10 mg/mL
Oral tablet: 5 mg, 10 mg, 40 mg
Oral tablet for suspension: 40 mg
painful surgical procedures lasting longer than 2

hours. Supplementary PACU doses of methadone
(total 2.510 mg in incremental doses) elevates the
plasma concentration and prolongs the duration of
post-operative analgesia for an additional 7 h or
longer. The prolonged analgesic duration with this
method appears to be related to a minimum effective
analgesic concentration (MEAC) of methadone
achieved and maintained by a larger loading dose followed by small incremental doses of methadone when
the pain returns.
Contraindications
Absolute: patients with documented severe allergic
reaction to methadone.
Relative: patients with known or suspected QT
prolongation; patients taking other drugs that could
prolong the QT interval; patients with known risk factors for arrhythmia, such as hypokalemia.
Common doses/uses
There is no agreement in the literature and textbooks
about dosing guidelines. A safe starting dose in most
opioid-naive patients is 2.5 mg every 8 hours, with
dose increases occurring no more frequently than
weekly. Repetitive analgesic doses of methadone lead
to drug accumulation because of the discrepancy
between its plasma half-life and the duration of analgesia. Sedation, confusion, and even death can occur
when patients are not carefully monitored during the
early accumulation period, which can last from 5 to 10
days. In older patients or those with renal or hepatic
comorbidities, less frequent dosing and more cautious
dose titration are recommended. Dose guidelines for
methadone are provided in Table 26.1.
In opioid-tolerant patients, no single ratio is suitable for converting a specific dose of morphine
into an equivalent dose of methadone and the conversion to methadone should be performed cautiously.
Table 26.2.
Route of
administration
Pain control (q68h)
Maintenance for
addiction (daily)
Opioid-naive patient
Opioid-tolerant patient
Oral
510 mg
0.1% to 10% morphine equivalents

(lower at higher doses)
Parenteral
2.55 mg
3090 mg
50100% oral dose
129
Table 26.3. Conversion ratios from morphine to

methadone*
Daily chronic oral

morphine dose
Conversion ratio oral

morphine to oral methadone
<100 mg
3:1 (90 mg to 30 mg)
100300 mg
5:1 (300 mg to 60 mg)
300600 mg
10:1 (600 mg to 60 mg)
600800 mg
12:1 (800 mg to 60 mg)
8001000 mg
15:1 (900 mg to 60 mg)
>1000 mg
>20:1 (1200 mg to 60 mg)
Note: because of incomplete cross-tolerance and the nonopioid analgesic properties of methadone, it often has greater
analgesic potency than what might be expected. In general,
the higher the dosage of the opioid being converted to
methadone, the lower the conversion methadone dose that
should be used.
Methadone guidelines for opioid-tolerant patients are

provided in Table 26.2. Equianalgesic dose ratios for
methadone relative to other opioids are variable and
can range from 0.1% to 10% morphine equivalents
(lower at higher doses). Starting methadone doses
should generally not exceed 30 to 40 mg a day even in
patients on high doses of other opioids. Methadone
should not be used to treat breakthrough pain or as an
as-needed medication. Dose conversion guidelines for
methadone are provided in Table 26.3.
Intrathecal and epidural neuraxial analgesia

Intrathecal methadone, a lipophilic opioid, is rapidly
cleared from the cerebrospinal fluid by absorption
into the spinal cord. Consequently little, if any, is available to migrate to and activate brainstem opioid receptors. Therefore, intrathecal methadone produces
analgesia by a spinal mechanism and is associated
with fewer supraspinal adverse effects than highly
hydrophilic morphine. Duration of analgesia is shorter
than morphine but longer than highly lipophilic fentanyl because of its intermediate lipophilic and
hydrophilic property.
Epidural methadone raises a dose-dependent significant plasma level and supraspinal side effects without prolongation of analgesia.
Opioid conversion
130
Many opioid conversion charts misrepresent the

equipotency ratios of morphine to methadone, as
they extrapolate a single-dose effect and are not appli-
cable to repeated therapy and its associated tissue

accumulation. Adherence to new dosing guidelines
could significantly diminish the risk of cumulative
toxicity.
Methadone has a number of clinically useful advantages:
Once a day dosing therapy for addiction
maintenance
Highly effective analgesic for neuropathic pain,
severe cancer pain, acute and chronic pain
refractory to other potent opioids
Can be administered via the oral, rectal,
subcutaneous, intramuscular, intravenous and
neuraxial routes
High oral bioavailability (36100%) and rapid
mucosal absorption
Interaction with NMDA receptors potentiates its
opioid receptor-mediated analgesic effects
No known active metabolites
Low cost
Availability: easily available at most hospitals
Methadone should be adjusted frequently and
increases should be based on symptoms and need for
breakthrough pain.
Drug interactions
Methadone undergoes N-demethylation via the cytochrome P450 group of enzymes to such a variable
extent that there can be inter-individual variability in
steady-state serum levels. Thus, there are multiple
potential drug interactions with medications commonly employed in pain management. While inducers
of the CYP3A4 enzyme, phenytoin and carbamazepine,
can potentially lead to opioid withdrawal symptoms,
inhibition at CYP3A4 with serotonin reuptake
inhibitors(SSRIs) can increase circulating methadone
levels, amplify its effects, and possibly induce toxicity.
There is also potential instability in methadones effects
related to variability in protein binding, excretion,
and equianalgesic potency.
Adverse events
Methadone prolongs the QT interval. Its most severe
side effect is the development of life-threatening
Chapter 27 Fentanyl oral and buccal delivery systems
Torsades de pointes ventricular tachycardia and sudden cardiac-related death in the setting of a prolonged QT interval. QT prolongation is more likely
to occur in patients taking high dose of methadone
in the presence of contributing factors, such as
cocaine abuse, other CYP450 enzyme inhibitors, and
hypokalemia.
Other common/serious adverse events are similar
to those described for morphine and include: respiratory depression, nausea, vomiting, dizziness, mental
clouding, dysphoria, pruritus, constipation, and urinary retention.
Treatment of adverse events: naloxone is the drug
of choice for reversal of respiratory depression, and
sedation. Nausea and vomiting are treated with
ondansetron, metaclopramide and other antiemetics.
Increased QT interval and re-entry type arrhythmia
should be carefully evaluated and treated with magnesium and other anti-arrhythmics.
Section 2
Chapter
27
References
1. Toombs JD, Kral LA. Methadone treatment for pain

states. Am Fam Physician 2005;1(7):13531358.
2. Fishman SM, Wilsey B, Mahajian G, Molina P.
Methadone reincarnated: novel clinical applications
with related concerns. Pain Med 2002;3:339348.
3. Eap CB, Buclin T, Baumann P. Interindividual variability
of the clinical pharmacokinetics of methadone;
implications for the treatment of opioid dependence.
Clin Pharmacokinet 2002;41(14):11531193.
4. Gourlay GK, Willis RJ, Wilson PR. Post-operative
pain control with methadone: influence of
supplementary doses and blood concentration
response relationships. Anesthesiology 1984;61:1926.
5. Kharasch ED, Hoffer C, Whittington D, Walker A,
Bedynek PS. Methadone pharmacokinetics are
independent of Cytochrome P4503A (CYP3A) activity
and gastrointestinal transport. Insights from
methadone interactions with ritonavir/indinavir.
Fentanyl oral and buccal delivery systems

Philip Levin
Generic Names: fentanyl oralet, fentanyl buccal

tablet
Trade/Proprietary Names: ACTIQ, FENTORA
Manufacturer: Cephalon Inc., Salt Lake City, UT
Description
Fentanyl buccal tablet (Fentora) and fentanyl lozenge
(Actiq) both contain fentanyl, an opioid agonist and a
Schedule II controlled substance, with a potential
abuse similar to other opioid analgesics. Fentora is
formulated as a tablet meant to be placed in the oral

cavity for a period sufficient to allow disintegration of
the tablet and absorption of fentanyl across the oral
mucosa.
Fentanyl oralet (ACTIQ) is formulated as a solid
formulation of fentanyl, and is designed to be dissolved slowly in the mouth to facilitate transmucosal
absorption (Figure 27.2). Fentanyl buccal tablets have
a higher bioavailability of fentanyl than fentanyl oralet
so they are not equivalent on a g per g basis.
Mode of activity
Major and minor sites of action: spinal and supraspinal opioid receptors. Fentanyl, the active ingredient
in both fentora (fentanyl buccal tablets) and Actiq
131
CO2H
HO
CO2H
CO2H
Figure 27.1.
dose of fentanyl oralet, if chewed and swallowed,

might result in lower peak concentrations and lower
bioavailability than when consumed as directed.
Fentanyl buccal tablet has peak plasma concentrations generally attained within an hour after oral
administration.
Fentanyl buccal tablets and fentanyl oralet are both
indicated for the management of breakthrough pain
in patients with cancer and who are already receiving
and who are tolerant to opioid therapy for their underlying continual cancer pain.
Contraindications
Figure 27.2. Fentanyl oralet (Actiq).
132
(fentanyl oralet), is a pure opioid agonist and it acts

mostly with the opioid receptors which are located
throughout the brain, central nervous system, and
other bodily tissues. Effects include analgesia, sedation, respiratory depression, nausea and reduction in
GI motility. These effects are dose-dependent and
antagonized by naloxone.
Metabolic pathways: fentanyl buccal tablets have
an absolute bioavailability of 65% following oral
administration, compared to an absolute bioavailability of 50% following oral administration of fentanyl oralet. The difference is mainly due to the fact
that 50% of the total dose administered of fentanyl
buccal tablet is absorbed transmucosally vs. 25% of
fentanyl oralet. The remaining half of the total dose
of fentanyl buccal tablets and 75% of the total dose of
fentanyl oralet is swallowed and undergoes more
prolonged absorption from the gastrointestinal tract.
About 1/3 of this amount (25% of the total dose)
escapes hepatic and intestinal first-pass elimination
and becomes systemically available. Therefore, a unit
Absolute: fentanyl buccal tablets and fentanyl oralets

are contraindicated in patients with known severe
allergic reaction to fentanyl.
Relative: they are contraindicated in the management of acute or post-operative pain. They are not indicated for use in opioid non-tolerant patients. The safety
and efficacy of fentanyl buccal tablets and fentanyl oralet
have not been established in pediatric patients below
the age of 16 years. They should be used cautiously in
patients with a history of bradyarrhthymias, or with evidence of increased intracranial pressure or impaired
consciousness, or with history of chronic obstructive
pulmonary disease, or preexisting medical conditions
predisposing them to respiratory depression.
Common doses
The initial dose of fentanyl buccal tablets should be
100 g. Dosing can be repeated once, 30 minutes after
the initial administration of fentanyl buccal tablets, if
pain is not adequately relieved by one dose. Thus
patients should only use a maximum of two dosages
for any one breakthrough pain event. They should
wait 4 hours to treat another breakthrough pain event.
Patients should be closely followed and the dosage
strength changed until the patient reaches a dose that
provides adequate analgesia with tolerable side effects
using a single fentanyl buccal tablet.
If the initial dose of 100 g was inadequate, then
the patient should be instructed to place two 100 g
tablets (one on each side of the mouth in the oral cavity) during the next breakthrough pain event, while
watching for signs of over-sedation. If this dose is not
acceptable, then four 100-g tablets should be given to
the patient to place two on each side of their mouth
Chapter 27 Fentanyl oral and buccal delivery systems
Table 27.1. Fentora Actiq
Indications
Management of breakthrough
cancer pain with Fentora (fentanyl buccal tablets)
Management of breakthrough
cancer pain with Actiq (fentanyl oralet)
Initial doses
100 g
200 g
Dose timing
q 4 hours PRN
4 or fewer doses a per day
Adverse events
Respiratory depression, circulatory depression, nausea,

vomiting, fatigue, dizziness, drowsiness, oral ulcers
Respiratory depression, circulatory

depression, nausea, vomiting, fatigue,
dizziness, drowsiness, dental caries
during the next breakthrough pain event. Titrate

above 400 g by 200-g increments, never having
more than four tablets in the mouth simultaneously. It
is important to minimize having the patient take two
different-strength tablets since there is great risk of
confusion and overdose.
Once a successful dose has been established,
patients should generally use only one fentanyl buccal
tablet of the correct strength per breakthrough pain
event. Also if the patient experiences more than four
breakthrough pain episodes per day, the dose of the
maintenance (round-the-clock) opioid used for persistent pain should be re-evaluated.
The fentanyl buccal tablet should not be sucked,
chewed or swallowed, as this will result in lower plasma
concentrations than when taken as directed. The buccal tablet should be left between the cheek and gum
until it has disintegrated, which usually takes approximately 1425 minutes. After 30 minutes, if remnants
remain, then they can be swallowed with a glass of
water. Fentanyl buccal comes in five different-size
tablets: 100 g, 200 g, 400 g, 600 g, and 800 g.
The initial dose of fentanyl oralet is 200 g. During
titration for unrelieved pain, patients should take only
one additional dose of the same dosage strength separated by 30 minutes per breakthrough cancer pain episode. If several consecutive breakthrough pain events
require more then one oralet per episode, you should
increase the dosage to the next higher available
strength. A single fentanyl oralet dosage unit per
breakthrough pain event should be attempted. Consumption should be limited to four or fewer units per
day once a successful dose is found. Fentanyl oralet
comes as a solid drug matrix on handles in six different strengths: 200 g, 400 g, 600 g, 800 g, 1200 g,
and 1600 g [3].
For patients switching from oralets to buccal
tablets:
if the patient took 200400 g of oralet, they
should start with a 100 g buccal tablet;
if they took 600800 g of oralet, they should start

with a 200g buccal tablet;
if they took 12001600 g of oralet, they should
start with a 600 g buccal tablet.
Ease of use, tolerability: since both fentanyl buccal
and oralet are oral medications they are easier to use,
more portable, and require less technical expertise
than medications delivered intravenously.
When comparing the two, the buccal tablets have
some potential advantages over fentanyl oralets. The
buccal tablet formulation is more discreet than the oralet
lollipop. Also the enhanced oral mucosal absorption
allows for faster onset of pain relief (510 minutes)
versus the oralet (1020 minutes). Differences between
the two preparations are outlined in Table 27.1.
Toxicity
Drug interactions: since fentanyl is metabolized
mainly via the human cytochrome P450 3A4 isoenzyme system (CYP3A4) possible interactions may
occur when fentanyl buccal tablet or fentanyl oralet is
given along with medications that affect CYP3A4
activity.
Also both fentanyl buccal tablets and fentanyl
oralet should not be given to patients who have also
taken an MAO inhibitor within 14 days, because MAO
inhibitors have been reported to unpredictably potentiate fentanyl.
Adverse events: there is a greater risk of abuse of
both fentanyl buccal tablets and fentanyl lozenges since
they are both taken orally. Fentanyl oralet has been
shown to have variability in fentanyl availability
because of variation in patient mouth surface area, and
the percentage of medication that is absorbed through
oral mucosa versus the percentage swallowed.
133

The most common adverse events seen with fentanyl
buccal tablets and fentanyl lozenges are typical of opioid side effects. The most serious adverse reactions
with all opiods include respiratory depression, circulatory depression, hypotension, and shock. Other
common opioid side effects include nausea, vomiting,
fatigue, dizziness, drowsiness, constipation, and headache. Dental caries has been reported with the use of
fentanyl oralet. A minor adverse event with fentanyl
buccal tablets is mouth ulcer.

To treat the most serious adverse event, respiratory
depression, ventilatory support should be implemented, intravenous access obtained, and nalaxone or
other opioid antagonists should be given.
Section 2
Chapter
28
References
1. Actiq Package Insert, Cephalon, Inc.; Salt Lake City,

UT, 2007.
2. Fentora Package Insert, Cephalon, Inc.; Salt Lake
City, UT, Oct 2007.
3. Simpson DM, Messina J, Xie F, Hale M. Fentanyl
buccal tablet for the relief of breakthrough pain in
opioid-tolerant adult patients with chronic
neuropathic pain: a multicenter, randomized,
double-blind, placebo-controlled study. Clin Ther
2007;29(4):588601.
4. Lecybyl R, Hanna M. Fentanyl buccal tablet: faster
rescue analgesia for breakthrough pain? Future Oncol
2007;3(4):375379.
Fentanyl transdermal system

Hamid Nourmand
Generic Name: fentanyl transdermal system

Trade/Proprietary Name: Duragesic
Drug Class: opioid analgesic (Schedule II)
Manufacturer: Ortho-McNeil Division of Johnson & Johnson Inc., Raritan, NJ 08869
Chemical Name: N-phenyl-N-(1-(2-phenyl
ethyl)-4-piperidinyl) propanamide
Introduction
134
Nausea and vomiting are treated with ondansetron

or metaclopramide. Constipation is treated with laxatives or stool softeners.
Fentanyl transdermal system (Duragesic) is a rectangular transdermal patch containing a high concentra-
tion of fentanyl, a potent, short-acting Schedule II

opioid agonist. Fentanyl transdermal system (FTS)
provides a continuous systemic delivery of fentanyl
for 72 hours, and offers additional benefits including
prolonged and uniform analgesic effect as well as
reduced adulteration and abuse potential. The FTS
includes a drug reservoir that contains fentanyl in a
gel matrix, a release membrane that allows time- and
surface-limited absorption of the drug, and an adhesive backing that ensures that the preparation attaches
firmly to skin (Figure 28.2).
Mode of activity
Fentanyl interacts predominantly with the mu receptors in the brain and spinal cord to produce analgesia,
euphoria, and dysphoria [1,2]. Because of its low
Chapter 28 Fentanyl transdermal system
N CH2 CH2
CH3 CH2 CON
Figure 28.1.
Fentanyl Transdermal System

Drug Reservoir
Adhesive
Release
Membrane
Protective Liner
Figure 28.2. Schematic representation of the fentanyl

transdermal system.
molecular weight, high potency and lipid solubility,

fentanyl is an ideal agent for transdermal application.
Soon after application of the patch to the intact skin, a
fentanyl depot concentrates in the subcutaneous fat,
and it is then gradually released to the systemic circulation. Peak plasma concentration is reached between
24 and 72 hours of the treatment.
Fentanyl transdermal system should only be used in
patients who have developed tolerance to opioids. It is
indicated for the treatment of chronic and long-term
pain that:
is moderate to severe in intensity, and
is persistent, and requires continuous, round-theclock opioid administration for an extended period
of time, and
cannot be managed by other means such as
nonsteroidal analgesics, opioid combination, or
immediate-release opioids.
Non-approved uses of FTS include treatment of
migraine headaches, post-operative pain, or pain from
an injury, and severe but short-term pain.
Contraindications
Fentanyl transdermal system is contraindicated in:
patients with known hypersensitivity to fentanyl
patients who are not opioid-tolerant, or in patients
who are opioid-naive,
the management of pain that is acute (such as

post-operative pain), short-term, mild in intensity,
or intermittent in duration
patients who have acute or severe bronchial asthma
patients with paralytic ileus
patients with significant risk of respiratory
depression, especially when adequate resuscitative
equipment is not available.
Common doses
Fentanyl transdermal system is intended for transdermal use only. Doses should be individualized and calculated based on the PO, IM, or IV opioid requirements
(see below, as published by the manufacturer). Available
patch dosages are 12.5, 25, 50, 75, and 100 g per hour.
The 25 g/h FTS patches were recalled in February 2008
due to a concern that small cuts in the gel reservoir could
result in accidental exposure to fentanyl [1].
When switching to FTS, the first step is to calculate the previous 24-hour analgesic requirement and
then convert it according to the dose conversion table
(Table 28.1). It is important to start low and advance
slowly, especially in the elderly, debilitated, cachectic, and those with impaired renal or hepatic function. The mean elimination half-life of FTS is 17
hours, and the shortest titration period is 3 days, but
it takes up to 6 days to reach equilibrium on the new
dose. In addition, when changing the dose, it may
take 13 to 24 hours for the fentanyl to reach the new
therapeutic level [1,2]. While titrating the dose,
patients may require short-acting opioids for breakthrough pain.
Fentanyl transdermal system provides a safe, effective, continuous, and round-the-clock delivery of
fentanyl. It is ideal for the management of chronic,
moderate to severe pain and in patients who are opioid-tolerant [2]. It is best reserved for patients whose
opioid requirements are stable. Upon successful dose
titration, and once the target analgesia is reached, the
drug administration is convenient and subsequent
dose titration may be safely managed in an outpatient setting. In comparison with oral opioids, FTS
causes fewer gastrointestinal side effects, and, it has
an obvious advantage in dysphagic patients or those
that do not tolerate oral medication. FTS may result
in increased quality-adjusted life-days at a nominal
increased cost.
135
Table 28.1. Dose conversion guidelines
Current analgesic
Daily dose (mg/d)
Oral morphine
60134
135224
225314
315404
IM/IV morphine
1022
2337
3852
5367
Oral oxycodone
3067
67.5112
112.5157
157.5202
IM/IV oxycodone
1533
33.156
56.178
78.1101
Oral codeine
150447
448747
7481047
10481347
Oral hydromorphone
817
17.128
28.139
39.151
IV hydromorphone
1.53.4
3.55.6
5.77.9
810
IM meperidine
75165
166278
279390
391503
Oral methadone
2044
4574
75104
105134
IM methadone
1022
2337
3852
5367
Recommended Duragesic dose

(g/h)
25
50
75
100
It is important to note that the dose conversion guidelines should not be used to convert a Duragesic dose to other opioids, since it can
significantly overestimate the dose of the new agent.
Due to the delayed onset of action of FTS, and the
potential for serious respiratory depression, it may
take a long time to achieve adequate analgesia safely.
Therefore, one main disadvantage of FTS is the slow
titration process. During this period, other short-acting opioids may be administered to manage the pain.
For this same reason, FTS is not suitable for the treatment of acute pain [3]. There are also reports that the
effectiveness of analgesia decreases during the third
day. Fentanyl transdermal system is also not ideal for
end-of-life care, especially in patients with uncontrolled pain.
136
The most serious potential risk of FTS is respiratory

depression due to overdose [4]. In order to minimize
the risk of overdose, the recommended starting dose
when converting from other opioids to FTS is probably too low for 50% of patients. Additionally, in
patients receiving FTS concurrently with cytochrome
P450 3A4 inhibitors (including ritonavir, fosamprenavir, amprenavir, nelfinavir, ketoconazole, fluconazole, itraconazole, troleandomycin, clarithromycin,
erythromycin, nefazodone, amiodarone, aprepitant,
diltiazem, verapamil, and grapefruit juice) plasma
fentanyl concentration may increase and result in
worsening and prolongation of the adverse events,
especially fatal respiratory depression. Caution should
be taken in patients who have received MAO inhibitors
within 14 days of FTS use, since severe and unpredictable potentiation by MAOI has been reported. Increase
in body temperature, due to fever or exercise, may
hasten the absorption of fentanyl and increase the
plasma concentration.
Other less serious side effects of FTS include nausea, vomiting, constipation, drowsiness, dry mouth,
sweating, and pruritus.

Naloxone is the drug of choice for the treatment of
respiratory depression. Due to the long half-life
of Duragesic compared to naloxone, repeat dosing of
naloxone may be necessary, and patients should be
monitored for at least 24 hours following overdose.
References
1. http://www.duragesic.com/duragesic/shared/pi/durag
esic.pd.
2. Payne R, Mathias SD, Pasta DJ, et al. Quality of life
and cancer pain: satisfaction and side effects with
transdermal fentanyl versus oral morphine. J Clin
Oncol 1998;16:15881593.
3. Bernstein K. Inappropriate use of transdermal
fentanyl for acute postoperative pain. J Oral Maxillofac
Surg 1994;52: 896.
4. Horton R, Barber C. Opioid-induced respiratory
depression resulting from transdermal fentanylclarithromycin drug interaction in a patient with
advanced COPD. J Pain Symptom Manage 2009;37:
25.
Section 2
Chapter
29
Tramadol and tramadol plus acetaminophen

Julie Sramcik and Raymond S. Sinatra
Generic Names: tramadol, tramadol plus acetaminophen

Trade/Proprietary Names: Ultram, Ultracet,
Adolonta, Contramal, Tramal, Trodon,
Zydol
Drug Class: central acting analgesic, opioid
analgesic
Manufacturers: Upjohn-McNeil Division of
Johnson & Johnson, Raritan, NJ; Grnenthal
GmbH, Aachen, D-52099, Germany
Structural Formula: see Figure 29.1
Chemical Name: 2-[(dimethylamino)methyl]1-(3-methoxyphenyl)-cyclohexanol]
Introduction
Tramadol is a synthetic analgesic that has an aminocyclohexanol structure similar to codeine [1,25]. It is
approved to treat moderate to severe acute post-operative pain as well as chronic oncological and neuropathic
pain. Tramadol was developed by Grunenthal Pharma
and entered the market in West Germany in 1977 and in
the USA in 1999 [13]. In comparison with typical opioid agonists such as morphine, tramadol rarely causes
respiratory depression or physical dependence. Its analgesic efficacy is similar to codeine and propoxyphene.
Tramadol is available in formulations suitable for oral,
rectal, and parenteral administration. In Europe, patientcontrolled analgesia (PCA) with tramadol is used and is
well accepted by patients. In the US, tramadol is available only as an oral tablet (Ultram) or combined with
acetaminophen (Ultracet). Ultracet was developed as
a low-dose preparation (37.5 mg) which when combined
with acetaminophen produced analgesia equivalent to
higher doses of tramadol, but with a reduced adverse
event profile [4,5].
Mode of action
Tramadol is a dual-mechanism, central-acting analgesic. It interacts weakly with opioid receptors and to a
lesser extent at kappa and delta receptors. Interactions
at these receptors provide weak opioid agonist properties. It also has effects on noradrenergic and serotonergic reuptake proteins and accentuates spinal and
supraspinal monamine-based analgesia [5,6,7]. Tramadols opioid and non-opioid sites of action appear
to act additively to provide more effective pain relief.
Of the two tramadol enantiomers, the (+) enantiomer
acts as a receptor agonist and as a 5-HT reuptake
inhibitor, while the () enantiomer is a norepinephrine reuptake inhibitor [2,5].
Tramadol behaves as a prodrug and hepatic metabolism influences its effectiveness at opioid receptors.
Tramadol is metabolized by CYP2D6 into an active
metabolite that is five times as powerful as the parent
compound. This O-demethylated metabolite has 200
times greater receptor-affinity and 24 times greater
potency, and a longer half-life. As with codeine, approximately 20% of individuals have CYP2D6 enzyme polymorphisms that result in poor metabolism. These
patients cannot form the active metabolite and are at
increased risk of analgesic failure [2,3].
Metabolism
Tramadol is metabolized in the liver by cytochrome
P450 2D6 sparteine oxygenase to produce O-desmethyl
tramadol (M1). As mentioned above, the desmethyl
metabolite demonstrates receptor activity that is
significantly higher than tramadol. Patients with low
levels of CYP2D6 either as a result of genetics or competition by co-adminstered drugs will be unable to
metabolize tramadol via this pathway. Drugs that are
inducers for this enzyme may increase O-desmethyl
tramadol, leading to exaggerated opioid effects. The
O-desmethyl metabolite is excreted primarily through
the kidneys [1,4]. Therefore, in patients with significant
137
OCH3
Figure 29.1.
HCI
HO
H
CH3
CH2
N
CH3
hepatic or renal impairment, the tramadol dose should

be reduced. Tramadol plasma concentrations peak 90
minutes following oral administration, and its elimination half-life is approximately 6 hours.
Indications
Chronic degenerative joint disease
Tramadol and tramadol with acetaminophen are
increasingly prescribed for the treatment of osteoarthritis (OA) because unlike NSAIDs they do not produce gastrointestinal bleeding or renal problems [8].
Cepeda and coworkers [9] performed a meta-analysis
of 11 RCTs with a total of 1019 participants who
received tramadol or tramadol/acetaminphen and 920
participants who received placebo or active control.
Patients treated with tramadol reported less pain (8.5
units on a 0100 scale; 95% CI 12.0 to 5.0), a 12%
relative decrease in pain intensity [2], and greater global improvement in stiffness in Western Ontario Osteo
arthritis Index score than patients who received
placebo. In terms of adverse events, one of every five
participants who received tramadol or tramadol/paracetamol experienced minor adverse events and one of
every eight stopped taking the medication.
Post-operative pain
138
Tramadol has been shown to provide effective analgesia after both oral and intravenous administration for
the treatment of post-operative pain [10]. Comparative studies have generally shown that tramadol is
more effective than NSAIDs for controlling postoperative pain; however, wide individual variations
exist, possibly related to low P450-2D6 metabolism in
certain patients. A single 100 mg oral dose of tramadol is equivalent to 1000 mg of acetaminophen. At
doses of 100 mg, the incidence of adverse effects

(headache, nausea, vomiting, dizziness, somnolence)
was similar to comparator drugs. In dental trials there
was increased incidence of vomiting, nausea, dizziness and somnolence compared to NSAIDs [10]. In a
comparative study tramadol 50 mg was found to be a
better analgesic compared to ketorolac (30 mg) for
patients recovering from same-day gynecological
laparoscopic procedures. Patients treated with tramadol reported lower pain scores in the post-anesthesia
care unit; however, the incidence of post-operative
nausea and vomiting was higher and recovery time
was prolonged.
Co-administration of tramadol and NSAIDs
allows the tramadol dose to be reduced and results in
a lower incidence of adverse effects. Also the combination of tramadol plus acetaminophen provides
superior analgesia than tramadol alone. In a randomized, double-blind, active- and placebo-controlled
trial the safety and effectiveness of tramadol plus
acetaminophen (APAP) were evaluated in 300 patients
recovering from orthopedic or abdominal surgery
[11]. Patients were randomized to receive two tablets
of 37.5 mg tramadol plus 325 mg APAP (n = 98),
codeine 30 mg plus APAP 300 mg (n = 109), or placebo (n = 98); thereafter, they received 1 or 2 tablets
every 4 to 6 hours as needed for pain for 6 days. Tramadol plus APAP was superior to placebo for total
pain relief, and not inferior to codeine plus APAP. For
average daily pain relief, average daily pain intensity,
and overall medication assessment, tramadol plus
APAP was superior to placebo and codeine plus
APAP. Tramadol plus APAP showed better tolerability, as the incidence of nausea, vomiting, and constipation, as well as discontinuation because of adverse
events, was higher in the codeine plus APAP group.
Neuropathic pain
Because of its dual analgesic effects, tramadol may be
more effective than standard opioids for neuropathic
pain. The efficacy of tramadol was evaluated in patients
suffering painful polyneuropathy. Forty-five patients
were treated with either tramadol 200 mg/day to 400
mg/day or placebo over a period of 4 weeks. Upon
study completion, ratings for pain (median 4 vs. 6),
paresthesia (4 vs. 6), allodynia (0 vs. 4). and touchevoked pain (3 vs. 5) were significantly lower with
tramadol treatment than with placebo [12]. In an evaluation of safety and efficacy in painful diabetic neuropathy, patients were treated with tramadol (n = 65)
Chapter 29 Tramadol and tramadol plus acetaminophen
or placebo (n = 66) four times daily [13]. Tramadol, at

an average dosage of 210 mg/day, was significantly
(p < 0.001) more effective than placebo for relieving
diabetic neuropathic pain. No statistically significant
treatment effects on sleep were identified.
Oncology pain
Tramadol has been advocated as a safe and effective
opioid analgesic for step II according to the World
Health Organization guidelines for cancer pain management. Moderate cancer pain can be controlled with
tramadol alone or in combination with NSAIDs and
other adjuvant analgesics. Grond and colleagues [14]
evaluated the efficacy and safety of high doses of oral
tramadol (300 mg/d) with low doses of oral morphine
(60 mg/d). Eight hundred patients received oral tramadol for a total of 23497 days, and 848 patients
received oral morphine for a total of 24 695 days. The
average dose of tramadol was 428 101 mg/d while the
average dose of morphine was 42 13 mg/d (range
1060 mg/d). The mean pain intensity on a 0100 scale
was 27 21 in the tramadol versus 26 20 in the morphine group (NS). The analgesic efficacy was good in
74% and 78%, satisfactory in 10% and 7%, and inadequate in 16% and 15% of patients receiving tramadol
and morphine, respectively (NS). Constipation and
pruritus and the need for antiemetics were more frequent in the morphine group. The authors concluded
that tramadol can be used for the treatment of moderate cancer pain, when non-opioids alone are not effective. Tramadol may be less effective in patients with
severe and progressive cancer pain, and analgesic therapy may need to be advanced to a more potent opioid.
Adverse events
Tramadol is usually well tolerated; like most opioids,
the main adverse reactions are gastrointestinal, and
include nausea and vomiting. Other common adverse
effects may include, dizziness, sedation, dry mouth,
sweating, hypertension, and seizures. Although the
risk of seizures is low, tramadol should be avoided in
epileptics, and with concomitant use of drugs that
lower seizure threshold. Like other opioids it should be
avoided in patients with elevated ICP (intracranial
pressure). Tramadol is contraindicated in patients taking MAO (monoamine oxidase) inhibitors as it may
induce psychotic behavior. In acute pain settings, doses
of tramadol should not exceed 300 mg/day. Co-administration of tramadol may increase plasma concentrations of digoxin and warfarin to toxic levels [15].
Advantages
(1) Because of its dual site of action pharmacology, tramadol is less likely to be associated with mu receptormediated respiratory depression, constipation, and
abuse when compared to pure mu agonists. These qualities may make this drug choice more advantageous for
elderly and high-risk patients with moderate pain.
(2) Although respiratory depression is unlikely
following oral administration it has been observed in
patients treated with intravenous tramadol. In the EU,
tramadol is available for intravenous use and is used
as an analgesic for childbirth and post-operative analgesia. When administered during labor, tramadol does
not cause respiratory depression in neonates [3,15].
(3) Tramadol has negligible abuse potential, and is
a less restricted, easily prescribed analgesic.
Disadvantages
(1) Unlike potent opioids that provide dose-dependent increases in analgesic effect, tramadol is a comparatively weak analgesic not suitable for patients with
very severe pain.
(2) One of the main issues related to tramadol is
the fact that it blocks serotonin reuptake and may
cause serotonin syndrome in susceptible patients.
Serotonin syndrome is characterized by neurological
and cardiovascular stimulation, and can lead to seizures and death. Risks of developing serotonin syndrome are increased in patients treated with selective
serotonin reuptake inhibitors and serotonin and nor
epinephrine reuptake inhibitors.
Contraindications
Absolute: tramadol should not be administered to
patients with documented intolerance to the drug. It
should not be administered to patients currently taking MAO inhibitors, or patients with documented histories of serotonin syndrome.
Relative: renal failure, hepatic failure, patients with
seizure disorders, patients treated with SSRIs and
NSRIs, patients taking coumadin or warfarin (dose
reduction are required).
Preparations
Tramadol is supplied in 50 mg tablets. Tramadol
extended release is supplied in 100 mg, 200 mg, and 300
mg tablets. Tramadol plus acetaminophen is available
in a dose of 37.5 mg plus 325 mg of APAP. The recommended dosage is 50100 mg orally every 46 hours as
needed for pain. The maximum dose should not exceed
139
400 mg in 24 hours. In the USA, tramadol is available

only in oral form and is prescribed for patients 16 years
of age and older. In Europe, tramadol is used orally and
parenterally in children under age 16 and adults [3,15].
References
1. Bamigbade TA, Langford RM. The clinical use of

tramadol hydrochloride. Pain Rev 1998;5(3):155182.
2. Dayer P, Desmeules J, Collart L. Pharmacology of
tramadol. Drugs 1997;53(Suppl. 2):1824.
3. Desmeules JA. The tramadol option. Eur J Pain 2000;4
(Suppl. A):1521.
4. Sinatra RS, Sramcik J. Tramadol: its use in pain
management. In Hines RL, ed. Anesthesiology Clinics
of North America, vol. 2. Philadelphia: W.B. Saunders,
1998, pp. 5369.
5. Klotz U. Tramadolthe impact of its pharmokinetic and
pharmacodynamic properties on the management of
pain. Arzneim. Forsch./Drug Res 2003;53(10):681687.
6. Marcou TA, Marque S, Mazoit JX. The median
effective dose of tramadol and morphine for postoperative patients: a study of interactions. Anesth
Analg 2005;100:469474.
7. Raffa, RB, Friderichs E, Reinann W. Opioid and
nonopioid components independently contribute to the
Section 2
Chapter
30
140
mechanism of action of tramadol, an atypical opioid

analgesic. J Pharmacol Exp Ther 1992;260:275285.
8. Reig E. Tramadol in musculoskeletal pain- a survey.
Clin Rheumatol 2002;Suppl.
9. Cepeda SM, Carmargo F, Zea C, Valencia L. Tramadol
for osteoarthritis: a systematic review and
metaanalysis. J Rheumatol 2007;34(3):543555.
10. Scott LJ, Perry CM Tramadol. A review of its use in
perioperative pain. Drugs 2000;60.
11. Smith AB, Ravikumuar T, Kamin M, et al.
Combination tramadol plus acetaminophen for
postsurgical pain. Am J Surg 2004;187;521527.
12. Harati Y, Gooch D, Swenson M. Double blind
randomized trial of tramadol for the treatment of
diabetic neuropathy. Neurology 1998;50(6):18421846.
13. Sindrupab H, Andersen G, Madsen C. Tramadol relieves
pain and allodynia in polyneuropathy: a randomised,
double-blind, controlled trial. Pain 1999;83:8590.
14. Grond S, Radbruch L, Meuser T, et al. High-dose
tramadol in comparison to low-dose morphine for
cancer pain relief. J Pain Symptom Manage
1999;18:174179.
15. Dayer P, Desmules J, Collart L. Pharmacology of
tramadol. Drugs 1997;53(Suppl 2):18243.
Tramadol extended-release
Haruo Arita
Generic Name: tramadol ER

Trade/Proprietary Name: Ultram ER
Drug Class: central-acting analgesic
Manufacturer: PriCara, Division of OrthoMcNeil, Inc., Raritan, NJ; release technology:
Biovail Corporation, Mississauga, Canada
ChemicalName: cis-2-[(dimethylamino)methyl]1-(3-methoxyphenyl)-cyclohexanol

263.
Introduction
Tramadol ER (tramadol hydrochloride) is a centrally
acting synthetic analgesic in an extended-release formulation. It offers extended duration of pain relief
with potential improvements in tolerability. Tramadol
Chapter 30 Tramadol extended-release
OCH3
Figure 30.1.
HCI
HO
H
CH3
CH2
N
CH3
binds to opioid receptors and weakly inhibits

reuptake of norepinephrine and serotonin. Immediate-release tramadol has been available commercially
for 15 years. An extended-release formulation of tramadol, named tramadol extended-release (ER) tablets, was formulated to be taken once daily, potentially
facilitating compliance and long-term therapy [1].
Mode of activity
Tramadol is a synthetic, centrally acting analgesic
with multiple mechanisms of action. The drug is a
opioid receptor agonist, with the active metabolite
(+)-O-desmethyltramadol [(+)-M1] being the major
contributor to its action at opioid receptors. The
enantiomers of tramadol also act synergistically by
different mechanisms to inhibit pain transmission:
the (+)-enantiomer inhibits neuronal reuptake of
serotonin and the ()-enantiomer inhibits neuronal
reuptake of noradrenaline [1,2].
Tramadol ER formulation uses Biovails Smartcoat diffusion-controlled tablet technology to achieve
a gradual release of tramadol from the tablets, allowing for a 24-hour dosing interval. Tablets made with
this technology consist of a solid tablet core, which
contains tramadol and inert excipients, surrounded
by a semipermeable coating that is composed of watersoluble and water-insoluble polymers and a plasticizer.
Thus, the coating forms a membrane that controls the
release of tramadol hydrochloride from the tablet core
in vivo and is independent of pH changes as it passes
through the gastrointestinal tract [1].
Indications
Tramadol ER is indicated for the management of
moderate to moderately severe chronic pain in adults
who require round-the-clock treatment of their pain
for an extended period of time. The efficacy of trama-
dol ER has been investigated in two studies of patients

with chronic pain caused by osteoarthritis and results
from both studies confirmed the superior analgesic
efficacy of tramadol ER relative to placebo [2].
Contraindications
Tramadol ER should not be administered to patients
who have previously demonstrated hypersensitivity to
tramadol, any other component of this product or
opioids. Tramadol ER is contraindicated in any situation where opioids are contraindicated, including
acute intoxication with any of the following: alcohol,
hypnotics, narcotics, centrally acting analgesics, opioids, or psychotropic drugs. Tramadol ER should not
be used in patients with creatinine clearance less than
30 mL/min, or severe hepatic impairment (ChildPugh Class C).
Common doses
According to the manufacturers prescribing information, the initial recommended dosage of tramadol
ER is 100 mg once daily, with titration in 100 mg
increments every 5 days (if required) up to a maximum dosage of 300 mg once daily. The drug is to be
used in adults only, and may be administered without
regard to food.
For patients on immediate-release (IR) tramadol,
calculate the total daily IR dose and round down to the
next lowest 100-mg increment. Tramadol ER tablets
are supplied in 100 mg, 200 mg, and 300 mg form
[1,2].
Long-acting pain control; Ultram ER provides steadystate plasma concentrations sustained over 24 hours
with fewer peaks and troughs. Short-acting agents
dosed PRN may increase the likelihood of breakthrough pain. Night-time troughs may lead to breakthrough pain and interrupt sleep, for which patients
are forced to re-dose during the night [3]. Poor sleep
results in an increased pain intensity.
Ease of use, tolerability: tramadol ER was well tolerated in controlled clinical trials, with a safety profile
similar to short-acting tramadol, which has been used
for over 10 years in the USA and 30 years worldwide.
Tramadol ER appears to be better tolerated than narcotic preparations with fewer adverse events for the level
of analgesia achieved. Tramadol ER does not contain
acetaminophen or NSAIDs. Tramadol has low potential
141
for induction of respiratory depression and dependence. Unlike NSAIDs and COX-2 inhibitors, tramadol
does not have black-box warnings regarding cardiovascular or gastrointestinal risk or lower-level warnings for
renal toxicity with long-term use. Ultram ER had a low
incidence of cognitive side effects. For example, cognitive disorders, impaired balance, disturbance in attention, and sedation also occured at low rates.
NSAID dose-sparing potential: combination of
tramadol with NSAIDs for the management of chronic
pain has the potential to reduce NSAID requirements,
while providing more effective pain relief.
Availability: tramadol ER is widely available at most
pharmacies and is not a federally scheduled drug.
Less abuse potential: the use of opioid analgesics is
accompanied by concerns regarding the potential for
abuse, dependence, diversion, misuse, addiction, tolerance, and withdrawal. In contrast, short-acting tramadol has been shown to have a low potential for
abuse, probably even less with tramadol ER.
Tramadol ER must be swallowed whole and must not be
chewed, crushed, or split. Chewing, crushing, or splitting the tablet will result in the uncontrolled delivery
of the opioid and could result in overdose and death.
This risk is increased with concurrent abuse of alcohol
and other substances. Tramadol, like other opioids
used in analgesia, can be abused [1,2].
Seizures have been reported in patients receiving

tramadol. The risk of seizure is increased with doses of
tramadol above the recommended range. Concomitant use of tramadol increases the seizure risk in
patients taking tricyclic antidepressants, selective
serotonin reuptake inhibitors, or other opioids. Tramadol may enhance the seizure risk in patients taking
MAO inhibitors, neuroleptics, or other drugs that
reduce the seizure threshold. Risk of convulsions may
also increase in patients with epilepsy, those with a
history of seizures, or in patients with a recognized
risk for seizure (such as head trauma, metabolic disorders, alcohol and drug withdrawal, CNS infections).
Tramadol ER should be used with caution and in
reduced dosages when administered to patients receiving CNS depressants such as alcohol, opioids, anesthetic agents, narcotics, phenothiazines, tranquilizers,
antidepressants, or sedative hypnotics. Tramadol ER
increases the risk of CNS and respiratory depression
in these patients.
The development of a potentially life-threatening
serotonin syndrome may occur with tramadol, particularly when combined with serotonergic drugs such
as SSRIs, SNRIs, TCAs, MAOIs, triptans, drugs that
alter metabolism of serotonin, and drugs that alter
metabolism of tramadol (CYP2D6 and CYP3A4
inhibitors) [1,2]. When combined treatment with
these drugs is clinically warranted, patients should be
closely observed for signs and symptoms of serotonin
Table 30.1. Incidence (%) of patients with adverse event rates 5% from two 12-week placebo-controlled studies in patients
with moderate to moderately severe chronic pain by dose
142
MedDRA
preferred term
Ultram ER
Placebo
100 mg
(n = 403) n (%)
200 mg
(n = 400) n (%)
300 mg
(n = 400) n (%)
400 mg
(n = 202) n (%)
(n = 406) n (%)
Dizziness (not
vertigo)
64 (15.9)
81 (20.3)
90 (22.5)
57 (28.2)
28 (6.9)
Nausea
61 (15.1)
90 (22.5)
102 (25.5)
53 (26.2)
32 (7.9)
Constipation
49 (12.2)
68 (17.0)
85 (21.3)
60 (29.7)
17 (4.2)
Somnolence
33 (8.2)
45 (11.3)
29 (7.3)
41 (20.3)
7 (1.7)
Flushing
31 (7.7)
40 (10.0)
35 (8.8)
32 (15.8)
18 (4.4)
Pruritus
25 (6.2)
34 (8.5)
30 (7.5)
24 (11.9)
4 (1.0)
Vomiting
20 (5.0)
29 (7.3)
34 (8.5)
19 (9.4)
11 (2.7)
Insomnia
26 (6.5)
32 (8.0)
36 (9.0)
22 (10.9)
13 (3.2)
Asthenia
14 (3.5)
24 (6.0)
26 (6.5)
13 (6.4)
7 (1.7)
Postural
hypotension
7 (1.7)
17 (4.3)
8 (2.0)
11 (5.4)
9 (2.2)
Chapter 31 Tapentadol
syndrome such as mental status changes, autonomic

instability, neuromuscular aberrations, and/or gastrointestinal symptoms, especially during treatment
initiation and dosage escalation. Patients with serotonin syndrome require immediate medical attention.

Tramadol ER was administered to a total of 3108
patients during studies conducted in the USA. These
included four double-blind studies in patients with
osteoarthritis and/or chronic low back pain and one
open-label study in patients with chronic non-malignant pain. A total of 901 patients were 65 years or
older. Adverse events increased with dose from 100
mg to 400 mg in the two pooled, 12-week, randomized, double-blind, placebo-controlled studies in
patients with chronic non-malignant pain [4) (see
Table 30.1)
Section 2
Chapter
31
There are no specific drugs for reversal of adverse

effects; however, naloxone may be used to treat respiratory depression.
References
1. Hair PI, Curran MP, Keam SJ. Tramadol extendedrelease tablets. Drugs 2006;66(15):20172027.
2. Ultram ER. Prescribing information. www.ultramer.com.
3. Barking RL. Extended-release tramadol (ULTRAM
ER): a pharmacotherapeutic, pharmacokinetic, and
pharmacodynamic focus on effectiveness and safety in
patients with chronic/persistent pain. Am J Ther
2008;15:157166.
4. Ganal T, Pascual MG. Extended-release tramadol in
the treatment of osteoarthritis: a multicenter,
randomized, double-blind, placebo-controlled
clinical trial. Curr Med Res Opin 2006;22:
13911401.
Tapentadol
Dan Froicu and Raymond S. Sinatra
Generic Name: tapentadol hydrochloride

Trade Name: Nucynta
Drug Class: opioid analgesic, Class II, centralacting analgesic
Manufacturer: PriCara, Division of Johnson &
Johnson Inc., Raritan, NJ 08869
Chemical Name: 3-[(1R,2R)-3-(dimethylamino)-1ethyl-2-methylpropyl]phenolmonohydrochloride
Chemical Formula: C14H23NOHCl; molecular
wt:257.8
Introduction
Tapentadol is the first new analgesic for moderate
to severe acute pain in more than 25 years [1]. Grunenthal GbmH and Johnson & Johnson Research
signed a licensing agreement for tapentadol in 2003,
and have shared development responsibilities. Grunenthal licensed marketing rights to tapentadol to
Ortho-McNeil-Janssen Pharmaceuticals, Inc. for the
USA, Canada, and Japan. Grunenthal maintains marketing rights in Europe and other parts of the world.
In November 2008, the FDA approved tapentadol for marketing in the USA as a drug for moderate-to-severe acute pain. Tapentadol was licensed
and approved for distribution as a schedule II (strong
143
Figure 31.1.
HO
N
opioid) in June 2009. Tapentadol is marketed as

Nucynta (possibly derived from new central acting
analgesic) and is available as 50, 75 and 100 mg
immediate-release tablets. Immediate-release tablets
are film-coated to facilitate oral administration
and should not be broken or crushed. Sustainedrelease tablets are in development for chronic pain
management (refer to Chapter 115).
Mode of activity
Tapentadol is a centrally acting analgesic. While its
action mechanism is unknown it is presumed that
tapentadol has dual effects in suppressing pain transmission, combining opioid receptor (MOR) agonism with monoamine reuptake inhibition (Figure
31.2) [13]. Tapentadol has an 18-fold lower affinity

for the human opioid receptor compared with
morphine but is only 23-fold less potent than morphine, which is probably due to its norepinephrine
reuptake inhibition activity [2,3]. In animal trials
tapentadol had only minor effects on serotonin
reuptake. Tapentadol exists as a single active enantiomer [3] and is metabolized mainly by O-glucuronidation; its principal metabolite is inactive, having no
affinity for MOR or the NE transporter. As the analgesic activity of tapentadol is limited to the primary
molecule, no enzymes are needed to convert it to an
active metabolite (such as tramadol, or codeine).
This implies fewer if any individual variations in its
action compared to drugs that require polymorphic
enzymes.
Tapentadol provides high analgesic efficacy that is
comparable to classic opioids, but is associated with
unexpectedly improved gastrointestinal tolerability
[4,5,6,7]. Its two mechanisms of action appear to be
additive and provide an opioid-sparing effect while
maintaining effective analgesia. The efficacy and
safety of various doses of tapentadol IR compared
Descending Inhibitory
Pathway from the
Midbrain and Brainstem
Ascending Pathway to
Thalamus and Cortex
NE
Tapentadol*
_
-OR
2-AR
+
SP
++
Secondary Spinal
Sensory Cell
144
+
Glu
Noxious
signal
Primary Afferent Fiber
Figure 31.2. Diagram demonstrating sites of tapentadol activity in the pain transmission pathway. Tapentadol binds to and activates mu
opioid receptors and also blocks norepinephrine reuptake by inhibiting the NE transporter protein. NE = norepinephrine; 2-AR = alpha2adrenoceptor; -OR = opioid receptor; SP = substance P; Glu = glutamate. Cylinder represents the NE reuptake transporter protein. After (1)
Tzschentke TM et al. J Pharmacol Exp Ther 2007;323(1):265276; (2) American Pain Society.
Chapter 31 Tapentadol
with oxycodone HCl IR have been evaluated in

several placebo-controlled acute post-operative pain
trials [4,5]. A large phase III study (n = 901) demonstrated that tapentadol IR 50 and 75 mg provided
efficacy that was non-inferior to oxycodone HCl IR
10 mg for the management of moderate to severe
pain after bunionectomy [5]. Prespecified tolerability
comparisons showed that a significantly lower
percentage
of patients in the tapentadol IR 50 mg
group reported composite nausea and/or vomiting
than patients treated with oxycodone HCl IR 10 mg
(35% vs. 59%; P < 0.001). The percentage of patients
who experienced nausea and/or vomiting in the
tapentadol IR |75 mg group was also lower (51%)
than the oxycodone HCl IR 10 mg group (59%), but
the difference marginally failed to reach statistical
Table 31.1. Percentages of patients experiencing nausea and vomiting in randomized, double-blind, placebo-controlled, studies
of tapentadol IR
Phase 3 study
Adverse
event
Placebo
Tapentadol
IR 50 mg
Tapentadol
IR 75 mg
Tapentadol
IR 100 mg
Oxycodone
HCl IR (10
or 15 mg)
Bunionectomy 1 trial
Nausea
13
35
38
49
67
Vomiting
18
21
32
42
Nausea and/
or vomiting
41a
53b
70
Nausea
17
34
46
57
Vomiting
12
28
26
Nausea and/
or vomiting
35
51
59
Nausea
18
21
41
Vomiting
14
34
Nausea and/
or vomiting
22
30
57
Bunionectomy 2 trial
End-stage joint disease
Data taken from references 4, 5, and 6.

IR, immediate release.
P = 0.007 vs oxycodone HCl IR 15 mg.
c
P <0.001 vs oxycodone HCl IR 10 mg.
d
P = 0.057 vs oxycodone HCl IR 10 mg.
a
b
Table 31.2. Percentage of patients reporting adverse events in a 90-day safety trial
System/organ class
Tapentadol IR 50 mg or 100 mg
(n = 679), % of subjects
Oxycodone IR 10 mg or 15 mg
(n = 170), % of subjects
Gastrointestinal disorders
44.2
63.5
Nausea
18.4
29.4
Vomiting
16.9
30.0
Constipation
12.8
27.1
Diarrhea
6.6
5.9
Dry mouth
5.3
2.9
Dizziness
18.1
17.1
Headache
11.5
10.0
Somnolence
10.2
9.4
Pruritus
4.3
11.8
145
significance (P = 0.057). A similar reduction in the

incidence of nausea and vomiting with tapentadol
IR compared with oxycodone IR was demonstrated
in a separate phase III study of tapentadol IR in
patients with moderate to severe osteoarthritis pain
from end-stage joint disease [6] (Table 31.1). Analgesic onset with tapentadol 5100 mg is fairly rapid
and comparable to other immediate-release opioid
agonists. Data taken from 602 patients enrolled in
the post-operative bunionectomy pain trials indicated that tapentadol provided perceptible pain relief
as early as 32 to 46 minutes following administration
[4,5].
The FDA required a safety study of 90 days duration in at least 300 patients where tapentadol was
compared to another immediate-release opioid [7].
For the 849 adult subjects enrolled in this study, the
average baseline pain intensity score was 7.1. About
half the patients were opioid-experienced. Supplemental analgesics (acetaminophen 2 g per day or
ibuprofen 400 mg per day) were allowed in this study.
The treatment groups were tapentadol IR 50 mg
or 100 mg every 4 to 6 hours PRN versus oxycodone
IR 10 mg or 15 mg every 4 to 6 hours PRN. Adverse
events were monitored as part of the tolerability
evaluation. Tapentadol was well tolerated, and had
a lower incidence of GI adverse events than in
patients treated with the comparator (refer to Table
31.2). Other tolerability evaluations included findings from the Clinical Opioid Withdrawal Scale
(COWS) which indicated that 83% of patients
abruptly discontinued from therapy did not experience withdrawal symptoms within 2 to 4 days of
treatment cessation.
Indications
Tapentadol is FDA approved for moderate to severe
acute pain management in patients age 18 or older.
Contraindications
146
Significant respiratory depression in unmonitored

settings or the absence of resuscitative equipment.
Nucynta is also contraindicated in patients with
acute or severe bronchial asthma or hypercapnia in
unmonitored settings or the absence of resuscitative
equipment.
Paralytic ileus (proven or suspected).
Patients who are receiving monoamine oxidase
(MAO) inhibitors or who have taken them within
the last 14 days due to potential additive effects on

norepinephrine levels which may result in adverse
cardiovascular events.
Patients at risk of developing serotonin syndrome: the
development of a potentially life-threatening serotonin syndrome may occur with use of SNRI products,
including tapentadol, particularly with concomitant
use of serotonergic drugs such as SSRIs, SNRIs, TCAs,
MAOIs, and triptans, and with drugs which impair
metabolism of serotonin (including MAOIs). Serotonin syndrome may include mental-status changes
(e.g. agitation, hallucinations, coma), autonomic
instability (e.g. tachycardia, labile blood pressure,
hyperthermia), and neuromuscular aberrations (e.g.
hyperreflexia, incoordination).
Common doses
Tapentadol can be given in doses of one tablet of
50 mg, 75 mg, or 100 mg every 4 to 6 hours depending
on the pain intensity. The maximum daily dose of
tapentadol is 700 mg (for the first day of treatment)
and 600 mg (day 2 and after). Doses higher than 700
mg per day have not been studied. No dosage adjustment is needed in mild or moderate renal impairment.
Little information exists regarding tapentadol dosing
in opioid-dependent patients. Data taken from the
90-day safety trial in which some patients had been
taking opioids prior to enrollment suggest that tapentadol doses of 100 mg every 4 hours may be appropriate. Although tapentadol IR has only been approved
for acute pain management there is no limitation with
regards to duration of therapy listed in the package
insert.
Unlike tramadol, tapentadol is an active molecule, it is
not a prodrug and does not have to be converted into
an active form.
Metabolized by glucoronidation: less individual
variability due to the fact that there is no interaction
with CYP-450 or CYP-2AD-6.
Better gastrointestinal tolerability than hydrocodone, less nausea, vomiting, and constipation in an
end-term osteoarthritis efficacy trial and 90-day safety
trial.
Nephrotoxicity or hepatotoxicity have not been
reported.
Chapter 32 Remifentanil
Risk of opioid-induced respiratory depression, nausea, vomiting and constipation. Tapentadol should
not be used during breast feeding.

Tapentadol has an abuse potential similar to other
opioids and is subject to criminal diversion. After 90
days of continuous administration, abrupt discontinuation of tapentadol was associated with mild to moderate withdrawal symptoms in 17% of patients
References

Evaluations, Thompson Healthcare. 2009.
2. Vanderah TW. Pathophysiology of pain. Med Clin
North Am 2007;91(1):112.
3. Tzschentke TM et al. J Pharmacol Exp Ther
2007;323(1):265276.
4. Daniels SE, Upmalis D, Okamoto A, Lange C,
Heussler J. A randomized, double-blind, phase III
Section 2
Chapter
32
study comparing multiple doses of tapentadol IR,

oxycodone IR, and placebo for postoperative
(bunionectomy) pain. Curr Med Res Opin
2009;25(3):765776.
5. Daniels S, Casson E, Stegmann J-U, et al. A
randomized, double-blind, placebo-controlled phase 3
study of the relative efficacy and tolerability of
tapentadol IR and oxycodone IR for acute pain. Curr
Med Res Opin 2009;25(6):15511561.
6. Hartrick C, Van Hove I, Stegmann J-U, Oh C, Upmalis
D. Efficacy and tolerability of tapentadol immediate
release and oxycodone HCl immediate release in
patients awaiting primary joint replacement surgery
for end-stage joint disease: a 10-day, phase III,
randomized, double-blind, active- and placebocontrolled study. Clin Ther 2009;31(2):112.
7. Hale M, Upmalis D, Okamoto A, Lange C,
Rauschkolb C. Tolerability of tapentadol immediate
release in patients with lower back pain or
osteoarthritis of the hip or knee over 90 days: a
randomized, double-blind study. Curr Med Res Opin
2009;25(5):10951104.
8. Nucynta(Tapentadol) Package insert 2008, PriCara,
Division of Ortho-McNeil-Janssen Pharmaceuticals,
Inc. Raritan, NJ 08869.
Remifentanil
Marjorie Podraza Stiegler
Generic Name: remifentanil hydrochloride

Trade Name: Ultiva
Manufacturer: GlaxoSmithKline, GSK House,
Brentford, London, UK; Abbott Laboratories,
Abbott Park, IL
Chemical Name: 1-(2-methoxycarbonyl-ethyl)-4(phenylpropionyl-amino)-piperidine-4-carboxylic acid methyl ester hydrochloride

Chemical Formula: C20H28N2O5HCl
Introduction
Remifentanil is a unique opioid agonist that has a
rapid bloodbrain equilibration half-time of 1 1
147
Figure 32.1.
CO2CH3
N
CH3
O
N
HCI
CO2CH3
minutes, and very rapid onset and offset of analgesic

effects. It is a 4-anilidopiperidine fentanyl analog with
dose-dependent adverse effects similar to other opioids [1,2].
Mode of activity
148
Remifentanil binds to and activates receptors in the

brain and spinal cord. It is generally administered as
an intravenous bolus or continuous infusion. The
average clearance of remifentanil in young healthy
adults generally correlates with total body weight; in
severely obese patients it correlates with ideal body
weight. Blood concentration decreases 50% in 3 to 6
minutes after cessation of infusion and clinical recovery from the effects occurs rapidly, within 5 to 10 minutes. The terminal half-life is 10 to 20 minutes. Distinct
from other opioids in its class, the duration of action
does not increase with prolonged administration
[1,2].
Remifentanil is rapidly and extensively metabolized by nonspecific blood and tissue esterases (but
not plasma cholinesterase) to a carboxylic acid
derivative that is 4600 times less active than the parent compound [2]. Approximately 95% of remifentanil is excreted in the urine as this metabolite. It
follows that the pharmacokinetics of remifentanil
are not significantly changed in patients with renal
impairment. The clearance of the carboxylic acid
metabolite is reduced with renal dysfunction; however, there is no demonstrated clinical relevance of
the accumulated metabolite. The pharmacokinetics
are also unchanged in patients with severe hepatic
impairment (even those awaiting liver transplant,
or during the anhepatic phase of liver transplant

surgery).
Remifentanil crosses the placenta, resulting in fetal
blood concentrations approximately half that of
maternal blood. Additionally, remifentanyl may be
transferred to breastmilk. Neonates can metabolize
remifentanil. The half-life of remifentanil is not significantly different in neonates or pediatric patients as
compared to adults.
Among patients >65 years of age, the EC50 for
delta-wave formation on EEG is 50% lower; thus, the
initial dose should be reduced accordingly, with careful titration to effect.
Indications
Adjunct with induction of anesthesia
Remifentanil can be used as an adjunct, and only
when intubation and mechanical ventilation are
intended. Remifentanil is inadequate as a sole induction agent, as loss of consciousness cannot be ensured
[2,3].
Intra-operative analgesia during anesthesia

maintenance
Because remifentanil can be rapidly titrated, it is useful for analgesia intra-operatively without prolonging
recovery. It is particulatly useful in procedures that are
generally associated with little post-operative pain
but significant intra-operative stimulation. If postoperative pain is anticipated, long-acting narcotics
should be administered prior to discontinuing
remifentanil. Even after prolonged infusion, recovery
from respiratory depression adequate for extubation
can be expected within 5 to 10 minutes of discontinuation. Remifentanil is inadequate as a sole agent for
maintenance of anesthesia.
Post-operative analgesia
Due to its potential for respiratory depression,
remifentanil is not recommended for post-operative
analgesia, except in mechanically ventilated patients
in a properly supervised environment.
ICU sedation
Infusion rates of 0.10.15 g/kg per min are effective for establishing and maintaining analgesia and
sedation in a wide range of ICU patients, including
those with severe renal or hepatic impairment.
Chapter 32 Remifentanil
Hemodynamic effects are similar to those of morphine or fentanyl.
by as much as 75%, as remifentanil is synergistic with

thiopental and propofol.
Procedural sedation
With proper monitoring and personnel skilled in airway rescue procedures, remifentanil may be used
safely for analgesia and sedation during procedures.
Off-label indications
Rapid-sequence intubation: remifentanil has been
reported for use in lieu of neuromuscular blockade
during rapid sequence intubations and is reported to
provide good to excellent intubating conditions with
doses of 34 g/kg given as a slow IV push. Notably,
studies do not indicate chest wall rigidity or hypotension as problematic with this technique.
Labor analgesia: remifentanil has also been
reported for PCA use in obstetric analgesia during the
first stage of labor.
Contraindications
Absolute: contraindicated for epidural and intrathecal
use, due to glycine in the formulation; unsuitable as
the sole agent for induction or maintenance of general
anesthesia.
Relative: not recommended for use in spontaneous
ventilation anesthesia; not recommended as an analgesic in the immediate post-operative period except in
ventilated patients.
Common doses
Remifentanil is only available for parenteral administration, either as a bolus or infusion.
Manufacturer-recommended doses range from 0.1
g/kg per min to 0.5 g/kg per min, and as high as 1.0
g/kg per min in children. These doses are much
higher than those used in actual clinical practice,
which generally range from 0.0250.1 g/kg per min
for sedation and up to 0.11 g/kg per min for anesthesia, titrated to effect. Remifentanil may also be used in
a process called target controlled infusion, in which
computer-controlled infusion pumps maintain desired
plasma concentrations.
For induction of anesthesia, the dose of 1 g/kg
should be administered over 60 seconds. As a replacement for neuromuscular blocker, a higher dose of 34
g/kg is suggested, again over 60 seconds. A hypnotic
agent is still required, though the dose may be reduced
The primary advantage to remifentanil remains its rapid

onset, offset, and ease of titration, even when using
a prolonged infusion. This may result in faster time
to extubation both in the OR and in the ICU [2,3].
Fast-track cardiac anesthesia.
High-dose infusion (starting doses 13 mg/kg per
min) effectively attenuates response to major surgical
stress, such as sternal spread, and is still associated
with a rapid recovery profile. However, remifentanil
may be associated with a higher incidence of intraoperative hypotension.
Neuroanesthesia
Remifentanil may be particularly advantageous for
procedures in which a crisp post-operative neurological exam is desired.
Side effects: remifentanil may cause adverse effects
characteristic of opioids, such as respiratory depression, bradycardia, hypotension, pruritus, and skeletal
muscle rigidity.
Incompatibilities: nonspecific esterases in blood
products may lead to the hydrolysis of remifentanil to
its carboxylic acid metabolite. Therefore, administration of ULTIVA into the same IV tubing with blood is
not recommended.
Hyperalgesia: infusions of remifentanil have been
associated with acute tolerance development and opioid-induced hyperalgesia. Both factors can increase
post-operative opioid dose requirements and increase
pain intensity scores [4].
Schedule II with potential for abuse.
Pregnancy Category C, although no animal studies
have demonstrated tetratogenic effects, even at doses
400 times the maximum recommended human dose.
Cost: remifentanil costs about ten times as much
as fentanyl. If operating-room time or ICU stay is
reduced, this cost may be offset. This has not been
demonstrated conclusively.

Adverse events including respiratory depression,
bradycardia, hypotension, pruritus, and skeletal muscle
rigidity will dissipate within minutes of discontinuing
149
or decreasing the infusion rate; they can also be reversed

promptly with naloxone.
Remifentanil is known to cause nausea and vomiting.
Hypotension and bradycardia are vagally mediated and unrelated to histamine release.
Diaphoresis, post-operative shivering, dizziness,
and agitation have also been reported.
References
1. Servin FS, Billard V. Remifentanil and other opioids.

Handb Exp Pharmacol 2008;(182):283311.
Section 2
Chapter
33
3. Beers R, Camporesi E. Remifentanil update: clinical

science and utility. CNS Drugs 2004;18(15):1085
1104.
4. Joly V, Richebe P, Guignard B, et al. Remifentanilinduced postoperative hyperalgesia and its prevention
with small-dose ketamine. Anesthesiology
2005;103(1):147155.
Nalbuphine
Ana M. Lobo
Generic Name: nalbuphine

Brand Names: Nubain, Nubain Injectable
(USA), Nalbufina (Argentina)
Class: opioid agonistantagonist analgesic
Manufacturer: Hospira Inc., 275 North Field
Drive, Lake Forest, IL 60045. Also: Astra-Zeneca
Pharmaceuticals, Moore, H.L. Drug Exchange
Inc., Southwood Pharmaceuticals Inc.
Chemical Name: ()-17-(cyclobutylmethyl)-4,5epoxymorphinan-3,6,14-triol hydrochloride
Chemical Formula: C21H27NO4; molecular wt:
393.91
Introduction
150
2. Komatsu R, Turan AM, Orhan-Sungur M, McGuire J,

Radke OC, Apfel CC. Remifentanil for general
anaesthesia: a systematic review. Anaesthesia
2007;62(12):12661280.
Nalbuphine is a semi-synthetic agonistantagonist

opioid of the phenanthrene series. It is structurally
similar to, and chemically related to, both the potent
opioid agonist oxymorphone, and the narcotic antagonist naloxone [1]. Nalbuphine is a moderately potent
analgesic that simultaneously exhibits opioid antagonist activity. It is primarily a kappa receptor agonist
and partial mu receptor antagonist. Analgesic potency
is equivalent to that of morphine, milligram to milligram for doses up to 10 mg. At higher doses morphine
provides progressively improved analgesic efficacy.
Typically, at normal dosages, pulmonary artery pressure, myocardial work load, and systemic vascular
resistance do not increase. The same degree of respiratory depression may occur with nalbuphine as with
equianalgesic doses of morphine. However,in the
absence of other central nervous system depressants
which are compromising respiration, nalbuphine shows
a ceiling effect on further respiratory compromise, in
doses in excess of 30 mg. Similarly, at this juncture,
there is a ceiling effect on analgesia. Naloxone is 25
times more potent than nalbuphine with respect to its
antagonistic effects [1,2]. Nalbuphines antagonist effect
occurs at doses equal to, or lower than, those which
produce analgesia. Indeed, respiratory depression
Chapter 33 Nalbuphine
HO
Figure 33.1.
OH
HO
caused by other concomitantly administered mu agonists may be blocked or partially reversed by nalbuphine. If given orally, this drug may be 80% less potent
than when it is administered intramuscularly [2].
Pharmacokinetics
Nalbuphine loses much of its potency, when given
orally, due to first-pass metabolism in the liver. In
terms of distribution, it is not bound to plasma proteins, and crosses the placenta. Metabolism, to pharmacologically inactive conjugates, occurs in the liver.
Conjugates and unchanged drug are secreted into bile
[13]. Elimination is predominantly fecal. Seven percent is excreted in the urine unchanged. The plasma
elimination half-life is 23 hours in healthy adults and
children over the age of eight, only 1 hour in children
between the ages of 1.5 and 8 years, and 4 hours in
neonates. Clinical effect is maintained for approximately 36 hours [13].
Indications
Nalbuphine is indicated for the treatment of moderate
to severe somatic and visceral pain. Additional indications include its use as a component of balanced
anesthesia, treatment of pain associated with labor
and delivery, and for the treatment of pre-operative

and post-operative pain. Unlabeled uses include treatment pf pruritus secondary to intrathecal morphine
in patients recovering from cesarean section. Intrathecal and epidural dosing have also been studied [1,3].
Dosage
The recommended adult dose is 10 mg SQ/IM/IV per
70 kg every 36 hours [13]. Dosing should be adjusted
based on severity of pain, the patients medical and
overall condition, and the presence or absence of concommitent narcotic use and/or dependency. In nondependent patients, no more than 20 mg/dose should
be administered, or 160 mg/day. Activation of kappa
opioid receptors can attenuate visceral pain in animals, and like other mixed agonistantagonist opioids
nalbuphine is effective for controlling abdominal and
pelvic visceral pain [3]. Doses of 0.10.2 mg/kg may
be administered to control pain associated with gall
stones, renal stones, and discomfort following laparoscopic pelvic surgery. There is evidence to suggest that
nalbuphine is more effective in female patients [4].
When used as part of a balanced anesthetic, induction doses range from 0.3 mg/kg to 3 mg/kg IV over
1015 minutes [1,3]. Maintenance doses of 0.25 to 0.5
mg/kg may be utilized, as required, in single intravenous boluses. The advantage in general anesthesia is
that patients will exibit less respiratory depression
upon emergence, and in PACU, than patients treated
with morphine or fentanyl. In our experience, these
patients may be moderately to very sedated in PACU,
resulting in delays in discharge. Over-sedation may be
treated with low doses of naloxone (4080 g as
required).
Nalbuphine has been evaluated for use with intravenous patient-controlled analgesia. In a double-blind
trial of 48 patients, nalbuphine, morphine, and pethidine (meperidine) administered with IV-PCA were
compared in the first 24 hours after cholecystectomy.
Table 33.1. Self-administered nalbuphine following cholecystectomy
PCA drug
Mean VAS pain score

(24 h)
Mean pain score with

movement
24 h self-administered
dose
Nalbuphine
50 mm
70 mm (2)
70 mg
Morphine
44 mm
52 mm (5)a
46 mg
Meperidine
53 mm
67 mm (7)
614 mg
mm = millimetres; 0 = no pain, 100 = worst pain.

a
Significant reduction vs. nalbuphine (P > 0.05).
From: Bahar M, Rosen M, Vickers MD. Self administered nalbuphine, morphine, and pethidine. Anaesthesia 2007;40:529532.
151
152
Using this mode of administration nalbuphine 15 mg

was approximately equivalent to morphine 10 mg or
meperidine 120 mg; however, nalbuphines ability to
reduce pain with movement was inferior to that provided by morphine [5] (Table 33.1).
The safety and efficacy of nalbuphine, with respect
to the treatment of pediatric pain, have not been fully
established. For patients older than 1 year of age, doses
of 0.10.2 mg/kg SQ/IM/IV every 34 hours are utilized, and individualized, as above [6]. The maximum
dose is 20 mg/administration and the daily total dose
should not exceed 160 mg. Nalbuphine, in doses of
0.050.1 mg/kg SQ/IM/IV, has been used to facilitate
weaning from mechanical ventilation in the pediatric
intensive care unit setting. Nalbuphine is also used to
relieve pruritus, caused by narcotic administration, in
this population as well as in adults.
The efficacy and adverse effects of intrathecal nalbuphine were evaluated in patients recovering from
cesarean delivery. Doses of 0.8 mg added to bupivacaine provided the longest duration of effective pain
relief. Increasing the nalbuphine dose to 1.6 mg did not
further improve analgesia. Intrathecal nalbuphine provided a significantly faster onset of pain relief than the
comparator, intrathecal morphine (0.2 mg), probably
because of its lipophilic properties. Analgesic duration
was significantly less than morphine (240 min vs. 600
min). Unlike the comparator pruritus and PONV were
not observed with nalbuphine 0.2 and 0.8 mg [7].
Nalbuphine 510 mg IV has been used to reduce
the incidence and severity of pruritus in patients treated
with intrathecal morphine and other neuraxially
administered opioids. The efficacy of nalbuphine and
propofol for treating intrathecal morphine-induced
pruritus was evaluated in a randomized, double-blinded
study [8]. One-hundred and eighty-one patients recovering from cesarean section who developed moderate
to severe pruritus after the administration of intrathecal morphine were treated with either 3 mg IV nalbuphine (n = 91) or 20 mg IV propofol (n = 90). The
treatment success rate was higher in the nalbuphine
group than in the propofol group (83% vs. 61%; P <
0.001). Recurrence rates of moderate to severe pruritus
within 4 h were not significantly different (nalbuphine
9% versus propofol 7%; P = 0.76). Sedation with both
drugs and pain on injection with propofol were the two
most common side effects, and had no clinical consequences.
Administration of naloxone (0.20.4 mg) is indicated to treat an overdosage of, or adverse reaction to,
nalbuphine. Additional supportive measures such as

oxygen administration, respiratory support, intravenous fluids, and vasopressors may also be indicated
[1,2].
Drug interactions
Nalbuphine may cause psychological or physical
dependence. Abrupt discontinuation after prolonged
use can cause signs and symptoms of opioid withdrawal. Increased CNS and respiratory depression
may be observed when nalbuphine is used with other
CNS depressants and barbiturates. If such medications are currently being administered, decreasing the
dose of nalbuphine, or lengthening the time interval
between dosing, should be considered. In opioid-naive
patients, doses of nalbuphine should be decreased.
Nalbuphine does not consistently antagonize other
narcotics in opioid-naive patients, and may potentiate
analgesic effects when given in close proximity. Nalbuphine is ten times more potent than pentazocine as
an antagonist and will precipitate withdrawal in opiate-tolerant individuals. Nalbuphine-induced withdrawal has been observed in patients chronically
treated with opioid agonists as well as those abusing
narcotics. It should not be used to control post-operative pain or labor and delivery pain in patients treated
with methadone or those abusing heroin. Concomitant use of drugs which potentially depress liver function should be taken in consideration when nalbuphine
will be administered for more than 24 h [1,9].
Adverse reactions
The most common adverse reaction noted with nalbuphine is sedation, occurring in 30% of patients receiving this drug. Other side effects which occur with a
frequency of < 10% include the following: nausea/
vomiting, sweaty/clammy feeling, vertigo/dizziness,
headache, and dry mouth. Other side effects, occurring with a frequency of < 1%, include the following
[1,2,9]:
CNS: confusion, faintness, dysphoria,
hallucinations, unusual dreams, restlessness
cardiovascular: hypotension, bradycardia,
hypertension, tachycardia
gastrointestinal: dyspepsia, cramps, nausea,
vomiting, biliary tract sphincter spasm
respiratory: depression
Chapter 33 Nalbuphine
dermatological: flushing, itching, burning

obstetric: fetal bradycardia, pseudo-sinusoidal
heart rhythm, decrease in fetal heart rate variability
Contraindications: nalbuphine should not be used
in patients with known major or minor hypersensitivity reactions to any of the ingredients in the injectable
preparation.
Use during labor and delivery: nalbuphine readily
and rapidly crosses the placenta. Documented fetal
adverse effects include bradycardia, apnea and/or
respiratory depression at birth, hypotonia, and cyanosis. These adverse effects have resulted in permanent neurological damage to the fetus. If nalbuphine
has been administered to a pregnant or laboring
female, it is prudent to monitor the fetus, after birth,
for any of the above. In addition, nalbuphine is frequently administered in combination with vistaril or
benadryl, to potentiate its perceived effect. Both may
add to maternal sedation with concomitant fetal
compromise. Nalbuphine is a Pregnancy Category B
drug [1,9].
Nursing mothers: nalbuphine is excreted in
maternal milk, but in small amounts (<1% of administered dose). The effect on the fetus is clinically
insignificant. Administer to a lactating female with
caution.
Abuse liability: caregivers must recognize that as
an injectable formulation, nalbuphine may be liable to
abuse; however, it is less attractive to heroin addicts or
highly tolerant opioid abusers due to its potent antagonist effects. A limited number of anecdotal reports
suggest that nalbuphine is abused by healthcare professionals and by body-builders (anabolic steroid
users). Nalbuphine is rarely encountered by law
enforcement personnel or submitted to forensic laboratories for analysis. This may, in part, be due to its
non-controlled status.
Routes of administration: intravenous, intramuscular and subcutaneous; intrathecal and epidural (offlabel use).
Formulation: sterile, non-pyrogenic injectable

solution in water containing sodium citrate hydrous,
citric acid anhydrous, sodium metabisulfite, methylparaben and propylparaben. pH is adjusted with
hydrochloric acid or sodium hydroxide. Supplied
as ampoules or bottles, concentration10 mg/mL, 20
mg/mL.
References
1. Gutstein HB, Akil H. Opioid analgesics. In Hardman

JG, Limbird LE, Gilman AG, eds. Goodman & Gilmans
The Pharmacological Basis of Therapeutics, 10th ed.
New York: McGraw-Hill, 2002, pp. 569619.
2. The Merck Manual.
www.merck.com/mmpe/index.htm
3. www.drugs.com/pro/Nalbuphine.html: Use of the
mixed agonistantagonist nalbuphine in opioid based
analgesia.
4. Gear RW, Miaskowski C, Gordon NC, Paul SM, Heller
PH, Levine JD. The kappa opioid nalbuphine produces
gender- and dose-dependent analgesia and
antianalgesia in patients with post-operative pain.
Pain 1999;83;339345.
5. Bahar M, Rosen M, Vickers MD. Self administered
Nalbuphine, morphine, and pethidine. Anaesthesia
2007;40:529532.
6. Yaster M, Deshpande JK. Management of pediatric
pain with opioid analgesics. J Pediatrics
1988;113(3):421429.
7. Culebras X, Gaggero G, Zatloukal J, et al. Advantages
of intrathecal nalbuphine compared to intrathecal
morphine after cesarean section. Anesth Analg
2000;91:601605.
8. Charuluxananan S, Kyokong O, Somboonviboon W, et
al. Nalbuphine versus propofol for treatment of
intrathecal morphine-induced pruritus after cesarean
delivery. Anesth Analg 2001;93:162165.
9. Gunion MW, Marchionne AM, Andersons CTM,
Seifert S. Opioid medications. In Dart RC, ed. Medical
Toxicology, 3rd ed. Philadelphia: Lippincott Williams
and Wilkins, 2003, pp. 756782.
153
Section 2
Chapter
34
Butorphanol
J. Michael Watkins-Pitchford
Generic Name: butorphanol, butorphanol tartrate, butorphanol tartrate injection, USP, butorphanol tartrate nasal spray
Trade/Proprietary Names: Nasal Stadol; Moradol and Beforal (the brand name Injectable
Stadol is no longer available in the USA)
Manufacturers: Roxane Laboratories, 1809 Wilson Rd, Columbus, OH; Barr Laboratories, 223
Quaker Road, Pomona, NY
Structure: see Figure 34.1
Chemical Name: ()-17-(cyclobutylmethyl)morphinan-3,14-diol d-()-tartrate(1:1)(salt)
Chemical Formula: C21H29NO2C4H6O6; molecular wt 477.6
Introduction
Butorphanol tartrate is a synthetically derived opioid
agonistantagonist analgesic of the phenanthrene
series, structurally similar to levorphanol. In the USA,
butorphanol is used as a substitute for meperidine for
patients complaining of moderate pain. Butorphanol
and other mixed agonistantagonists appear to be more
effective in female patients and are primarily prescribed
for visceral pain and headache [1,2]. It is used to control
pain associated with ureteral and gall stones and is also
employed for labor and delivery analgesia.
General pharmacology and mechanism

of action
154
Butorphanol has antagonistic activity at opioid

receptors. It is an agonist at opioid receptors, effecting visceral and spinal analgesia. With this set of differential effects, it can provide pain relief, while
blocking -mediated respiratory depression.
Butorphanol increases cardiac work and can cause

pulmonary hypertension. At super-therapeutic doses,
it can incite dysphoria. Other CNS effects include
depression of spontaneous respiratory activity and
cough, stimulation of the emetic center, miosis, and
sedation. Effects possibly mediated by non-CNS
mechanisms include alteration in cardiovascular
resistance and capacitance, bronchomotor tone, gastrointestinal secretory and motor activity, and bladder
sphincter activity. Butorphanol metabolites have
minor analgesic activity [2,3].
Uptake and elimination

Butorphanol is extensively metabolized in the liver.
Metabolism is qualitatively and quantitatively similar following intravenous or intramuscular administration. Oral bioavailability is only 5 to 17% because
of extensive first-pass metabolism of butorphanol
[2,3].
The major metabolite of butorphanol is hydroxybutorphanol, while norbutorphanol is produced in
small amounts. Both have been detected in plasma
following administration of butorphanol, with norbutorphanol present at trace levels at most time points.
The elimination half-life of hydroxybutorphanol is
about 18 hours and, as a consequence, considerable
accumulation (~5-fold) occurs when butorphanol is
dosed to steady state [24].
Elimination occurs by urine and fecal excretion.
When 3H-labeled butorphanol is administered to normal subjects, most (70 to 80%) of the dose is recovered
in the urine, while approximately 15% is recovered in
the feces.
About 5% of the dose is recovered in the urine as
butorphanol. Forty-nine percent is eliminated in the
urine as hydroxybutorphanol. Less than 5% is excreted
in the urine as norbutorphanol [3,4].
Butorphanol pharmacokinetics in the elderly differ from younger patients.
Chapter 34 Butorphanol
CH2
Use in balanced anesthesia
COOH
CH2
HO
HO
OH
CH2
COOH
The usual dose is 2 mg IV shortly before induction and/

or 0.5 mg to 1 mg IV in increments during anesthesia.
Larger increments may be used, up to 0.06 mg/kg (4
mg/70 kg), depending on other drugs administered.
The total dose ranges between 4 mg and more than 12.5
mg (approximately 0.06 to 0.18 mg/kg) [24].
Labor
HO
Figure 34.1.
In renally impaired patients with creatinine

clearances <30 mL/min, the elimination half-life
was approximately doubled and the total body clearance was approximately one-half of that in healthy
subjects.
After intravenous administration to patients with
hepatic impairment, the elimination half-life of butorphanol was approximately triple and total body clearance was approximately one-half compared to healthy
subjects.
Indications
Parenteral: management of moderate-to-severe
pain; pre-operative medication, a supplement to
balanced anesthesia, management of pain during
labor, anesthesia.
Nasal spray: management of moderate-to-severe
pain, including migraine headache pain [4].
Dose guide
IV for pain: 1 mg repeated every 3 to 4 hours, as necessary. However, depending on the severity of pain, dosing can range from 0.5 mg to 2 mg repeated every 3 to
4 hours [3,4].
IM: 2 mg repeated every 3 to 4 hours as necessary.
A dose range is 1 mg to 4 mg repeated every 3 to 4
hours. There are insufficient clinical data to recommend single doses above 4 mg. Higher doses are associated with increased drowsiness and somnolence, so
bed rest is advised.
Use as pre-operative/preanesthetic
medication
The usual adult dose is 2 mg IM, 60 to 90 minutes
before surgery, roughly similar to the sedative effect of
10 mg morphine or 80 mg meperidine.
For parturients in early labor, a 1 to 2 mg IV or IM

may be repeated 4 hourly, but other analgesia should
be employed if delivery is expected within 4 hours.
Contraindications
Hypersensitivity to butorphanol or any component of
the formulation. Opiate-dependent patients may
experience acute opiate withdrawal.
Butorphanol tartrate injection is contraindicated in
patients hypersensitive to butorphanol tartrate or the
preservative benzethonium chloride in the multipledose vial.
Precautions and relative

contraindications
Head injury and increased intracranial
pressure
Butorphanol use in patients with head injury may be
associated with carbon dioxide retention and secondary
elevation of cerebrospinal fluid pressure, drug-induced
miosis, and alterations in mental state. As with other
opioids, such use may obscure important clinical signs
in patients with head injuries.
Disorders of respiratory function or control

Butorphanol may produce respiratory depression,
with other medications with significant CNS action
and in patients with CNS or respiratory diseases.
Hepatic and renal disease

Hepatic or renal impairment may indicate a half-dose
initially (0.5 mg IV and 1 mg IM). Repeat doses in these
patients should be determined by the patients response.
As a guide, the interval should not be less than 6 hours.
Cardiovascular effects
Butorphanol may increase the work of the heart,
and is associated with pulmonary hypertension, so
155
butorphanol use with acute myocardial infarction,

ventricular dysfunction, or coronary insufficiency
should only be used if the benefits clearly outweigh
the risk. Severe hypertension has been reported rarely.
Naloxone and anti-hypertensive drugs have been
found effective.
Use in ambulatory patients

Car driving or operating machinery can be impaired
by drowsiness or dizziness as with other opioids. These
effects may persist for varying periods of time but are
common in the first hour. Patients should not drive or
operate dangerous machinery until the effects of the
drug are no longer present [4].
Alcohol is associated with increased drowsiness
and impairment of mental functions; it should be
avoided.
Butorphanol has abuse potential, particularly the
nasal spray. Patients and prescribers need to be aware
of the danger.
Drug interactions
Concurrent use of butorphanol with central nervous
system depressants (e.g. alcohol, barbiturates, tranquilizers, and antihistamines) may result in increased
central nervous system depressant effects. When
used concurrently with such drugs, the dose of butorphanol should be the smallest effective dose and the
frequency of dosing reduced as much as possible
when administered concomitantly with drugs that
potentiate the action of opioids.
It is not known whether the effects of butorphanol
are altered by concomitant medications that affect
hepatic metabolism of drugs (erythromycin, theophylline, etc.), but physicians should be alert to the
possibility that a smaller initial dose and longer intervals between doses may be needed.
Caution should be used if butorphanol treatment
is considered with MAO inhibitors.
Mixed opioid agonistantagonist analgesics such
as buprenorphine, butorphanol, nalbuphine, and pentazocine may theoretically decrease the analgesic
156
effects of tramadol or cause withdrawal symptoms in

patients who have been taking tramadol and other
opioids [1,2,4].
Cost
US$100200/month, depending on source and product.
Adverse events
Many adverse events have been reported, though it is
unclear in many instances whether butorphanol was
to blame. The following is a list of common events
reported in trials at a frequency of 1% or more, and
probably related to the use of butorphanol:
Body as a whole: asthenia/lethargy, headache, sensation of heat.
Cardiovascular: vasodilatation, palpitations.
Digestive: anorexia, constipation, dry mouth, nausea and/or vomiting, stomach pain.
Nervous: anxiety, confusion, dizziness, euphoria,
floating feeling, insomnia, nervousness, paresthesia,
somnolence, tremor.
Respiratory: bronchitis, cough, dyspnea, epistaxis,
nasal congestion, nasal irritation, pharyngitis, rhinitis, sinus congestion, sinusitis, upper respiratory infection.
Skin and appendages: sweating/clammy, pruritus.
Special senses: blurred vision, ear pain, tinnitus,
unpleasant taste.
References
1. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?i
d=4752 #nlm340893 Butorphanol, description by
NIH-NLM-H&HS, DailyMed.
2. https://online.epocrates.com/noFrame/showPage.do?
method=drugs&MonographId=1685 Butorphanol on
Epocrates.
3. Brunton LL, ed. Opioid analgesics (Chapter 21).
In Goodman & Gilmans The Pharmacological
Basis of Therapeutics,11th ed. New York: McGraw
Hill, 2006.
4. http://www.drugs.com/pro/butorphanol.html
Butorphanaol on Drugs.com.
Section 2
Chapter
35
Buprenorphine: intravenous neuraxial

and transdermal applications
Nalini Vadivelu
Generic Name: buprenorphine, buprenorphine

hydrochoride
Trade/Proprietary Names: Anorfin; Buprenex;
Buprex; Buprine
Chemical Class: opioid analgesic
Manufacturers: Spectrum Chemical Mfg Corp.,
202 E Laurel Street, Bellingham, WA 98225,
USA; Archimedes Pharma Ltd (United Kingdom), 250 South Oak Way, Green Park,
Reading,RG2 6UG; Reckitt Benckiser Pharmaceuticals Inc., 10710 Midlothian Turnpike,
Richmond, VA 23235; Otsuka Pharmaceuticals
Co. Limited (Japan), 227, Otedori, 3-Chome,
Chuoku, Osaka 5400021
Chemical Name: 17-(cyclopropylmethyl)-(1,1-dimethylethyl)-4,5-epoxy-18,19-dihydro3 - hy d r o x y - 6 - m e t h o x y - - m e t hy l - 6 , 1 4 ethenomorphinan-7-methanol, [5,7(S)]
Chemical Formula: C29H41NO4; molecular wt: 467
Introduction
Buprenorphine was first synthesized in 1966 as a
semisynthetic opioid alkaloid derivative of thebain.
Its unique mixed agonistantagonist properties combined with its long-acting lipid solubility make it a
useful analgesic with a lower abuse liability in
humans. Its high affinity to mu opioid receptors
along with a slow dissociation rate has led to its use
as an analgesic for patients with opioid dependence
as well. Buprenorphine has been widely used as an
analgesic in the peri-operative setting and as an analgesic for moderate to severe acute pain as well as for
chronic pain.
Pharmacodynamics and
pharmacokinetics of buprenorphine
Buprenorphine binds to mu, kappa, and delta opioid
receptor subtypes. It has a partial agonist activity at
mu receptors and an antagonist activity at kappa
receptors. Less is known about the activity of buprenorphine at delta receptors. Buprenorphine is more
lipophilic than morphine and penetrates the blood
brain barrier more easily and has a rapid onset of
effect.
The onset of action of buprenorphine is 515
minutes for intravenous of intramuscular injection
and 1545 minutes for sublingual buprenorphine.
Buprenorphine has been seen to have a antinociceptive potency about 2070 times greater than that of
morphine [1].
Buprenorphine is metabolized to an active
N-dealkylated metabolite, norbuprenorphine. Norbuprenorphine has one-fourth the potency of buprenorphine. It is metabolized in the liver and the gut. It is
seen that the excretion of buprenorphine is not affected
by the presence of end-stage renal failure.
Side effects
Its high affinity to the mu receptors and slow dissociation could lead to a lower incidence of side effects of
sedation, nausea, pruritus, respiratory depression, and
urinary retention. Being an agonist and antagonist it
has side effects seen with this group of drugs such as
dry mouth, lightheadedness, confusion, and blurred
vision [2].
Buprenorphine for acute pain relief

Initial studies performed in animals demonstrated the
analgesic efficacy of buprenorphine. These were followed by human analgesic trials evaluating different
routes of administration. Buprenorphine does not have
157
Figure 35.1.
HO
3
4
11
15
12
13
5
17
14
8
CH3O
10
16
9
21
24
22
23
7
19
HO
CH3
20
CH3
CH3
CH3
Table 35.1. Commonly used routes and doses of

buprenorphine for analgesia
158
Route
Dose
Intravenous
414 g/kg
Subcutaneous
30 g/h
Sublingual
0.52 mg single dose
Intramuscular
0.30.4 mg single dose
Epidural
15 g/h
Caudal in pediatrics
34 g/kg
Transdermal buprenorphine
35, 52.5, and 70 g/h
Intrathecal
0.2 mg single dose
tive as morphine in doses of 80 g per hour. Buprenorphine can also be used as a continuous epidural
infusion. A dose of 15 g per hour can produce satisfactory post-operative pain relief after lower abdominal surgery [6]. Buprenorphine has also been used
caudally in children to safely and reliably produce
post-operative pain relief. Kamal and Khan. [7] compared caudal buprenorphine with caudal bupivacaine
in children aged 111 years undergoing genitourinary
surgery looking at quality and duration of analgesia.
They found that patients with caudal buprenorphine
had better immediate post-operative relief as well as
delayed post-operative relief after 2024 hours with
fewer side effects as compared with caudal bupivacaine.
Epidural buprenorphine has been shown to produce
good post-operative pain control for patients recovering from gynecological surgery [5]. Epidural doses of 4
or 8 g/kg provided good post-operative analgesia.
Buprenorphine has also been used epidurally in the
management of pain associated with multiple rib fractures [8]. It is interesting to note that there was no urinary retention or hypotension in these patients. Nausea,
vomiting, and pruritus were the only complications [4].
Intrathecal buprenorphine
significant therapeutic value when given orally because

of its poor absorption and oral bioavailability; however, multiple clinical trials have demonstrated its analgesic efficacy following administration via epidural,
intrathecal, sublingual, intramuscular, intra-articular,
and transdermal routes (Table 35.1).
Intrathecal administration of buprenorphine provides

potent and effective analgesia with fewer adverse effects
than the epidural route since the dose of buprenorphine
is significantly less [1012]. Intrathecal buprenorphine
has been used effectively to control pain after cesarean
section. The doses of intrathecal buprenorphine in this
study were between 0.03 mg and 0.045 mg buprenorphine with the higher dose of intrathecal buprenorphine producing a longer duration of analgesia [11].
Epidural buprenorphine
Intravenous buprenorphine
Epidural buprenorphine has been used to provide

analgesia after a wide range of surgeries. Mehta et al.
[3] found that post-operative analgesia produced by
buprenorphine administered at lumbar epidural sites
was comparable to that provided at thoracic sites in
patients recovering from CABG surgery. Epidural
buprenorphine can produce spinal segmental analgesia, which develops 2 to 6 hours after administration.
This property is useful for control of pain after rib
fractures [4]. A study by Miwa et al. [5] showed that
epidurally administered buprenorphine in a dose of 4
or 8 g/kg provided post-operative analgesia as effec-
Intravenous buprenorphine has been used in doses in

the range of 515 g/kg body weight with good pain
relief. The high (15 g/kg) dose produced analgesia
lasting up to 13 hours [13].
In a study of patients recovering from gynecological surgery, buprenorphine was noted to have an intravenous analgesic potency 24 times greater than
morphine [14]. Intravenous buprenorphine was compared with thoracic epidural buprenorphine/bupivacaine mixture for treatment of post-thoracotomy
pain. Surprisingly, it was shown that patients in the
intravenous buprenorphine group required significantly
Chapter 35 Buprenorphine: intravenous neuraxial and transdermal applications
less rescue analgesics as compared to the epidural

buprenorphine/bupivacaine group [15]. Subcutaneous administration of buprenorphine offers advantages in palliative care settings where intravenous
access may be a problem. Matsumoto et al. [16] found
that an effective dose of subcutaneous buprenorphine
is 30 g an hour for early post-operative pain relief.
as an effective analgesic for the treatment of acute

pain as well as for the treatment of chronic pain. Its
advantages over the commonly used mu agonists
include effectiveness via many different routes of
administration, greater potency, smaller molecular
weight, longer duration of action and less respiratory
depression.
Sublingual buprenorphine
References
The great lipophilicity of buprenorphine allows it to

be a suitable sublingual agent [17]. Sublingual
buprenorphine in doses of 0.2 mg has been used as a
premedication for extracorporeal kidney lithotripsy
[18] and prostatectomy [19], providing effective analgesia with few side effects. Witjes et al. [20] evaluated
sublingual buprenorphine in patients recovering
from cholecystectomy. They reported that there was a
need for supplemental analgesics for some of the
patients. The authors recommended intravenous
PCA for such cases.
Buprenorphine via other routes

Buprenorphine can also be used intramuscularly
where it provides an analgesic onset at 15 minutes,
peak effect at 1 hour and a duration of 6 hours. The
development and use of transdermal buprenorphine for the treatment of chronic pain is ongoing
and is discussed in Chapter 121. Buprenorphine in
conjunction with local anesthetic has been used
intra-articularly for control of pain after knee
arthroscopy [21] and for perivascular axillary brachial plexus block [22]. It was seen that buprenorphine in conjunction with local anesthetic produced
analgesia that was three times longer than the analgesia produced by the use of bupivacaine alone.
Buprenorphine added to the local anesthetic for
axillary brachial plexus block prolongs post-operative analgesia [23].
Finally, buprenorphine has been found to be effective and safe for the treatment of chronic pain that is
refractory to treatment with long-term opioids [24].
In another study treating chronic pain it was shown
that sublingual and intravenous buprenorphine produced longer antihyperalgesic effects than pure mu
agonists [25].
Conclusion
Recent studies have revealed that buprenorphine has
a great potential as an analgesic and it has been used
1. Capogna G, Celleno D, Tagariello V, LoffredaMancinelli C. Intrathecal buprenorphine for postoperative analgesia in the elderly patient. Anaesthesia
1988;43(2):128130.
2. Harcus A, Ward A, Smith D. Buprenorphine in
post-operative pain: results in 7500 patients.
Anaesthesia 1980;35(4):382386.
3. Mehta Y, Juneja R, Madhok H, Trehan N. Lumbar
versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass
graft surgery. Acta Anaesthesiol Scand
1999;43(4):388393.
4. Govindarajan R, Bakalova T, Michael R, Abadir A.
Epidural buprenorphine in management of pain in
multiple rib fractures. Acta Anaesthesiol Scand
2002;46(6):660665.
5. Miwa Y, Yonemura E, Fukushima K. Epidural
administered buprenorphine in the perioperative
period. Can J Anaesth 1996;43(9):907913.
6. Hirabayashi Y, Mitsuhata H, Shimizu R, Saitoh J,
Saitoh K, Fukuda H. [Continuous epidural
buprenorphine for post-operative pain relief in
patients after lower abdominal surgery]. Masui
1993;42(11):16181622.
7. Kamal R, Khan F. Caudal analgesia with
buprenorphine for post-operative pain relief in
children. Paediatr Anaesth 1995;5(2):101106.
8. Govindarajan R, Bakalova T, Michael R, Abadir AR.
Epidural buprenorphine in management of pain in
multiple rib fractures. Acta Anaesthesiol Scand
2002;46(6):660665.
9. Girotra S, Kumar S, Rajendran K. Comparison of
caudal morphine and buprenorphine for postoperative analgesia in children. Eur J Anaesthesiol
1993;10(4):309312.
10. Tejwani G, Rattan A. The role of spinal opioid
receptors in antinociceptive effects produced by
intrathecal administration of hydromorphone and
buprenorphine in the rat. Anesth Analg
2002;94(6):15421546.
11. Celleno D, Capogna G. Spinal buprenorphine for
post-operative analgesia after caesarean section. Acta
Anaesthesiol Scand 1989;33(3):236238.
159
12. Dahm P, Lundborg C, Janson M, Olegrd C, Nitescu P.

Comparison of 0.5% intrathecal bupivacaine with
0.5% intrathecal ropivacaine in the treatment of
refractory cancer and noncancer pain conditions:
results from a prospective, crossover, double-blind,
randomized study. Reg Anesth Pain Med
2000;25(5):480487.
13. Abrahamsson J, Niemand D, Olsson A, Trnebrandt K.
[Buprenorphine (Temgesic) as a peroperative analgesic.
A multicenter study]. Anaesthesist 1983;32(2):7579.
14. Ho S, Wang J, Liu H, Tzeng J, Liaw W. The analgesic
effect of PCA buprenorphine in Taiwans gynecologic
patients. Acta Anaesthesiol Sin1997;35(4):195199.
15. Satoh M, Hirabayashi Y, Seo N. [Intravenous patient
controlled analgesia combined with continuous
thoracic epidural analgesia for post-thoracotomy
pain]. Masui 2000;49(11):12221225.
16. Matsumoto S, Mitsuhata H, Akiyama H, Terada H,
Matsumoto H. [The effect of subcutaneous
administration of buprenorphine with patient
controlled analgesia system for post-operative pain
relief]. Masui 1994;43(11):17091713.
17. Bullingham R, McQuay H, Dwyer D, Allen M, Moore
R. Sublingual buprenorphine used post-operatively:
clinical observations and preliminary pharmacokinetic
analysis. Br J Clin Pharmacol 1981;12(2):117122.
18. Tauzin-Fin P, Saumtally S, Houdek M, Muscagorry J.
[Analgesia by sublingual buprenorphine in
extracorporeal kidney lithotripsy]. Ann Fr Anesth
Reanim 1993;12(3):260264.
19. Gaitini L, Moskovitz B, Katz E, Vaisberg A, Vaida S,
Nativ O. Sublingual buprenorphine compared to
160
morphine delivered by a patient-controlled analgesia

system as post-operative analgesia after prostatectomy.
Urol Int 1996;57(4):227229.
20. Witjes W, Crul B, Vollaard E, Joosten H, von Egmond
J. Application of sublingual buprenorphine in
combination with naproxen or paracetamol for
post-operative pain relief in cholecystectomy patients
in a double-blind study. Acta Anaesthesiol Scand
1992;36(4):323327.
21. Rodriguez N, Cooper D, Risdahl J. Antinociceptive
activity of and clinical experience with buprenorphine
in swine. Contemp Top Lab Anim Sci 2001;40(3):17
20.
22. Varrassi G, Marinangeli F, Ciccozzi A, Iovinelli G,
Facchetti G, Ciccone A. Intra-articular buprenorphine
after knee arthroscopy. A randomised, prospective,
double-blind study. Acta Anaesthesiol Scand
1999;43(1):5155.
23. Candido K, Winnie A, Ghaleb A, Fattouh M, Franco
C. Buprenorphine added to the local anesthetic
for axillary brachial plexus block prolongs
postoperative analgesia. Reg Anesth Pain Med
2002;27(2):162167.
24. Malinoff H, Barkin R, Wilson G. Sublingual
buprenorphine is effective in the treatment of chronic
pain syndrome. Am J Ther 2005SepOct;12(5):379384.
25. Koppert W, Ihmsen H, Krber N, Wehrfritz A, Sittl R,
Schmelz M, Schttler J. Different profiles of
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Section 2
Chapter
36
Opioid dosing in pediatric patients

Debra E. Morrison, Abraham Rosenbaum, Co T. Truong and Zeev N. Kain
General principles of opioid dosing and

pain management in pediatric
patients
Opioids are usually used for acute and chronic pain
management in pediatric practice, as described below.
However, an opioid may be used as an anesthetic in a
critical premature or newborn infant who either cannot tolerate a conventional ventilator or cannot tolerate a volatile anesthetic: this will be addressed at the
end of the chapter.
There are size and developmental considerations
to consider when prescribing opiates to pediatric
patients in addition to the setting in which opiates are
prescribed.
Pediatric patients from birth through adolescence
can be classified into six groups:
( 1) Premature infants (less than 38 weeks gestation)
(2) Newborn/neonate (term birth to 1 month or
4044 weeks gestational age)
(3) Infant (1 month or 44 weeks to 24 months)
(a) term infant less than 6 months of age
(b) term infant more than 6 months of age
(4) Young child (2 to 4 years)
(5) Older child (6 to12 years)
(6) Adolescent (13 to 18 years)
All pediatric drug orders and prescriptions should
include weight.
A comparative oral and parenteral dosage table
and initial approximate oral and parental dosage tables
are included below.
Dosing for pediatric patients who weigh less than
50 kg is in mg or g per kg.
Dosing for pediatric patients who weigh 50 kg or
greater is similar to adult dosing.
Dosing for pediatric patients in the 5070 kg range
can be more closely titrated by using a ratio to determine dose/kg: 1/70 adult dose = dose/1 kg.
Weight may not be proportional to developmental

age.
Ideal body weight should be considered when
patients weight is out of proportion to height and age,
especially in dosing water-soluble opiates. Older children and adolescents who are developmentally appropriate can tolerate patient-controlled analgesia (PCA).
PCA by proxy for younger children is not recommended, except with certain parents who have experience with and understanding of their childs pain
management.
Opiates are indicated when adjunct medications
(local anesthetics, acetaminophen, NSAIDS) are inadequate, but these medications should not be abandoned when opiates are added to the regimen: drugs
should be layered as pain management escalates.
Parents as well as all members of the healthcare
team caring for pediatric patients should be educated
about pediatric pain and pain management with a
goal of achieving optimal pain management.
It is easier to use non-combination opiates in order
to avoid confusion leading to acetaminophen toxicity,
and to prescribe acetaminophen separately, despite
the ease and familiarity (for the prescriber) of prescribing combination drugs.
Dosing should start low and titrate upward, but
pain management should be aggressive.
Codeine, a weak opiate with many side effects,
including nausea, is generally not a good drug for
pediatric patients. In addition, many people, especially many African-Americans and Asians, do not
metabolize codeine.
Pain management should not be limited in end of
life care.
Doses for breakthrough pain should always be
available.
Doses for treatment of side effects should be calculated in advance.
Even young children and their parents who have
past experience with opiates will be able to give credible
161
histories of dysphoria but inadequate pain relief with

one opiate but not another: please listen.
Issues of tolerance and withdrawal are relevant to
pediatric pain management.
Initial opiate dosage guide for

patients over 6 months of age
For children too young to swallow pills, an oral
elixir is the best option (awake children often find
suppositories undignified, but suppositories may
be necessary in patients who find swallowing even
liquid painful). Opiates available in liquid form
include:
Morphine
Oral regular release 10 mg/5mL, 20 mg/mL,
20 mg/5mL
(Roxanol) 20 mg/mL
Hydromorphone (Dilaudid) 1 mg/mL
Codeine 15 mg/5 mL
Codeine phosphate/acetaminophen elixir
(Tylenol #4) 60 mg codeine/300 mg

acetaminophen
Hydrocodone elixir (Lortab) 2.5 mg
hydrocodone/167 mg acetaminophen/5 mL
Methadone oral solution 5 mg/mL (5, 500 mL),
10 mg/5mL (500 mL)
Oxycodone
(Roxicodone) solution 5 mg/5 mL
(Roxicet) 5 mg oxycodone/325 mg
acetaminophen/5 mL
Remember that not all neighborhood pharmacies
have liquid opiates available.
For patients whose pain will be short-term in
nature, oxycodone (in appropriate formulation) can
be given around the clock. For patients whose pain is
anticipated to be longer-term in nature, oxycodone
HCl CR (Oxycontin) or MS Contin can be given.
Oral opioid dose recommendations are presented
in Table 36.1.
IV equivalent doses

acetaminophen
acetaminophen
Morphine, with a half-life of 3 hours, is the basic

unit of comparison: other drugs are compared to
morphine. Morphine 1 mg : hydromorphone 0.2 mg :

fentanyl 50 g : meperidine 10 mg.
Table 36.1. Initial approximate oral doses and intervals

Codeine
0.51 mg/kg every 34 h
3060 mg every 34 h
Morphine
Immed. release
Immed. release
0.3 mg/kg
1530 mg
every 34 h
every 34 h
Sustained release
3045 mg
every 34 h
Oxycodone
Methadone
Hydromorphone
Meperidine
162
0.10.2 mg/kg
510 mg
every 34 h
every 34 h
0.1 mg/kg
10 mg
every 48 h
every 48 h
0.040.08
24 mg
every 34 h
every 34 h
23 mg/kg
100150 mg
every 34 h
every 34 h
Avoid if other drugs available, avoid chronic use since metabolite causes seizures.
Chapter 36 Opioid dosing in pediatric patients
The average morphine loading dose is 100 g/kg.

The average morphine infusion is 20 g/kg per h.
Drugs appropriate for PCA include morphine and
hydromorphone.
PCA morphine dose should start at a bolus dose of
0.03 mg/kg, with or without a continuous infusion of
0.03 mg/kg per h, with a 610 min lockout. If pain is
not controlled, increase bolus by 1020%, increase
infusion by 2040%, decrease interval, and check to

see that patient is not reaching the 4 h maximum dose.
Refer to Table 36.2 for IV-PCA dosing.
If the patient is experiencing side effects, such as
itching, nausea and vomiting, hallucinations, dysphoria, constipation, urinary retention: consider switching
opioids and/or treating treatable side effects (itching,
nausea and vomiting, constipation) individually.
Table 36.2. Approximate PCA doses and dose intervals
Drug
Child <50 kg
Child > 50 kg
Morphine
Bolus:
Bolus:
0.10.3 mg/kg
58 mg
every 24 h
every 24 h
Infusion:
Infusion:
0.2.0.3
1.5 mg/h
mg/kg per h
Methadone
0.1 mg/kg
58 mg every 48 h
(see sliding scale)

Fentanyl
Hydromorphone
Bolus:
Bolus:
0.51.0 g/kg
2550 g
every 12 h
every 12 h
Infusion:
Infusion:
0.52.0 g/kg per h
25100 g/h
Bolus:
Bolus:
0.010.02 mg/kg
1 mg
every 24 h
every 24 h
Infusion:
Infusion:
0.006 mg/kg per h
0.3 mg/h
(6 g/kg/ per h)
Meperidinea
Bolus:
Bolus:
0.81.0 mg/kg
5075 mg
every 23 h
every 23 h
(No infusion)
(No infusion)
Avoid if other drugs available, avoid chronic use since metabolite causes seizures
Methadone sliding scale: The methadone sliding scale or reverse PRN method is useful for patients for whom PCA is not appropriate.
The patient is assessed every 4 hours for the first 24 hours, then every 6 hours subsequently. Methadone is titrated to pain intensity at the
time of assessment. The drug is given around the clock and held only for significant side effects.
Pain score
Dose
Zeromild pain
25 g/kg
Mildmoderate pain
50 g/kg
Moderatesevere pain
75 g/kg
163
Diphenhydramine (Benadryl) 5 mg/kg per 24 h,

given every 68 h (not recommended for <1 yr old
because of its sedative side effect)
Naloxone (Narcan)
Respiratory depression 10 g/kg IV push every 3
minutes
Apnea or impending apnea 100 g/kg, maximum 2
mg/dose
Antiemetics (see appropriate chapter)
Stool softeners and laxatives
Neuraxial opiates will not be addressed, since in
pediatric patients, opiates may be given enterally
or parentally as adjuncts to regional or neuraxial
analgesia.
Transdermal fentanyl (Duragesic) can be used in
older and larger children (>50 kg).
Fentanyl Oralet (Actiq) can be a useful adjunct in
children with cancer pain or other chronic pain. Dont
call it a lollipop.
Other sedating agents are held for 1 hour before
and after the methadone dose to avoid respiratory
depression.
Accumulation of methadone occurs after several
days, so a decrease in dosing frequency and/or dose is
necessary with prolonged administration.
For tolerance, in patients with chronic or escalating pain, the sliding-scale dose can be increased by
25 g/kg.
Breakthrough pain can be treated first with adjunct
agents, and second with immediate release oral morphine or IV morphine every 12 h PRN.
Dosing conversion from oral to iV opioids are presented in Table 36.3.
Initial opioid dosage guide for patients

under 6 months of age
For term infants under 6 months of age, if non-opiate
pain medications are inadequate, use dosing tables
above, but limit drugs to morphine and fentanyl.
If the patient is naive to opioids, start with a smaller
than recommended dose per kg, and titrate up.
If the patient has received prior opioids, use past
history as a guideline to determine starting doses.
Consider leaving patients intubated post-operatively after major/painful surgery in order to allow
safe and effective pain relief.
Consider regional and continuous neuraxial analgesia (without opiates) with low-dose opiates for
breakthrough pain.
Opioids as anesthetics
An opiate may be used as an anesthetic in a critical
premature or newborn infant who either cannot tolerate a conventional ventilator or cannot tolerate a volatile anesthetic.
Premature infants who require ligation of a patent
ductus arteriosus (PDA) or who present with necrotizing enterocolitis (NEC) often weigh less than 1 kg and
are not on conventional ventilators, thus often cannot be
moved from the neonatal intensive care unit and cannot
tolerate an anesthesia machine or a volatile anesthetic.
Other larger but very critical infants who are able
to be transported to the operating room may be too
unstable to tolerate a volatile anesthetic.
Fentanyl, in high doses, can be used as the sole
anesthetic, with a nondepolarizing muscle relaxant.
Doses used in our practice are 50150 g/kg (or higher,
Table 36.3. Comparing oral and parenteral doses
164
Drug
Equianalgesic doses
parenteral
Oral
Parenteral/oral
dose ratio
Codeine
120 mg
200 mg
1:2
Morphine
10 mg
30 mg (long-term)
1:3
Oxycodone
N/A
1520 mg
N/A
Methadone
10 mg
1020 mg
1:2
Fentanyl
100 g (0.1 mg)
N/A
N/A
Hydromorphone
1.52 mg
68 mg
1:4
Meperidinea
75100 mg
300 mg
1:4
Avoid if other drugs available, avoid chronic use since metabolite causes seizures.
Chapter 37 Opioid tolerance and dependence
depending on the length of operation, the degree of

surgical stimulation, and whether or not local anesthetics can be used as adjuncts). The goal is to block
pain such that any rise in heart rate is attributable only
to hypovolemia. These patients are not extubatable for
other reasons, thus respiratory depression is not an
issue here. Although remifentanil might seem like a
candidate as an anesthetic in this setting, it is not FDAapproved for this population, and it is much more
likely to cause hypotension than is fentanyl, which
allows these patients to remain surprisingly stable.
References
Clinical pearls
For routine post-operative analgesia, we rely on acetaminophen, local anesthetics, NSAIDS if not contraindicated, and, finally, opiates. Even if pain control is
adequate without opiates, small doses of fentanyl may
be used at the time of emergence to ease a patient
through emergence delirium and the first moments in
PACU when even parental presence is not a comfort.
Section 2
Chapter
37
1.
Anand KJS, Stevens BJ, McGrath PJ. Pain in Neonates

and Infants, 3rd ed. Philadelphia: Elsevier, 2007.
2.
Bartolome SM, Cid JL-H, Freddi N. Analgesia and

sedation in children: practical approach for the most
frequent situations. J Pediatr (Rio J) 2007;83(2
Suppl):S7182.
3.
Fortier MA, MacLaren JE, Martin SR, Perret-Karimi

D, Kain ZN. Pediatric pain after ambulatory surgery:
wheres the medication? Pediatrics
2009;124;e588-e595; originally published online Sep 7
2009; DOI: 10.1542/peds.20083529.
4.
Kraemer FW, Rose JB. Pharmacologic management of

acute pediatric pain. Anesthesiology Clin 2009;27:
241268.
5.
Tobias JD, Desphande JK. Pediatric Pain Management

for Primary Care, 2nd ed. American Academy of
Pediatrics, 2005.
6.
Tollison CD, Satterthwaite JR, Tollison JW, eds.

Practical Pain Management, 3rd ed. Philadelphia:
Lippincott, Williams & Wilkins, 2002.
Opioid tolerance and dependence

Sukanya Mitra
Introduction
Anesthesiologists, surgeons, pharmacists and nursing
staff are increasingly asked to care for a variety of opioid-tolerant patients in peri-operative and pain management settings. The majority are those suffering
from chronic pain conditions, who have been taking
opioid analgesics for a prolonged period (months to
years). A less common but important second group
exhibiting tolerance includes the opioid abuser or
addicted patient. Former addicts enrolled in longterm methadone or buprenorphine maintenance programs constitute an increasing third group. A final
subset of opioid-dependent patients comprises those
who suffer well-documented chronic pain who, superficially, resemble opioid abusers by virtue of their often
obsessive drug-seeking behavior. These patients are
usually found to have visited numerous physicians
and have filled multiple prescriptions for opioids. In
actuality these individuals are not addicted but undermedicated and are only seeking adequate pain relief.
This phenomenon was not recognized until recently
and has been termed pseudo-addiction.
Opioid tolerance
Opioid tolerance is a normal and predictable pharmacological adaptation of the body to continued opioid
165
administration. Continued opioid exposure results in

a rightward shift in the dose-response curve and
patients require increasing amounts of drug to maintain the baseline pharmacological effects. The phenomenon of tolerance develops to analgesic, euphoric,
sedative, respiratory depressant, and nauseating effects
of opioids, but very little to their effects on miosis and
constipation. Further, tolerance develops to some
drug effects much more rapidly than to other effects of
the same drug. For example, tolerance develops rapidly to the euphoria produced by opioids such as heroin. In contrast, tolerance to the gastrointestinal effects
of opiates develops more slowly. The discrepancy
between the rapid development of tolerance to euphorigenic effects and slow development of tolerance to
effects on respiration and blood pressure can lead to
potentially fatal accidents in opioid addicts.
The degree or gradation of opioid tolerance is generally related to duration of exposure, daily dose
requirement, and receptor association/disassociation
kinetics. While there are no clear gradation guidelines,
individuals requiring the equivalent of 1 mg or more
intravenous or 3 mg or more of oral morphine per
hour for a period greater than 1 month may be considered clinically to have high-grade opioid tolerance.
Tolerance is observed in patients legitimately prescribed opioids for pain management as well as in
those abusing this class of drug. In general, the higher
the daily dose requirement the greater the degree of
tolerance development. This is of importance for
many patients and caregivers who perceive an
increasing opioid dose requirement as reflecting
harmful addiction rather than normal pharmacological adaptation.
Types of opioid tolerance
166
Several types of opioid tolerance including innate

(genetic) tolerance, pharmacokinetic tolerance,
learned tolerance and pharmacodynamic tolerance
may be observed. Innate tolerance refers to genetically
determined lack of sensitivity to a drug that is observed
the first time that the drug is administered (and hence
it is not true tolerance according to the definition of
tolerance, which requires repeated or continuous opioid administration). Recent research has identified
certain genetic variations of the mu opioid receptor
gene (particularly the A118G single nucleotide polymorphism), beta-2-adrenergic receptor gene and the
abcb1b gene of the P glycoprotein drug transporter to
be associated with innate opioid tolerance.
The other three types of tolerance (pharmacokinetic, pharmacodynamic, and learned) are clubbed as
acquired tolerance. In contrast to innate tolerance,
this type of tolerance develops with continued opioid
administration, and thus represents true tolerance
rather than genetically mediated lack of sensitivity to
opioids.
Learned tolerance refers to a moderation of the
effects of a drug (usually behavioral) because of learning mechanisms that are acquired by past experiences.
An example of learned behavioral tolerance is continuing the complex psychomotor act of driving despite
high blood alcohol levels and the motor impairment
produced by alcohol intoxication. This probably
involves both acquisition of motor skills and the
learned awareness of ones deficit. At higher levels of
intoxication, of course, behavioral tolerance is overcome and the deficits are unmasked.
Pharmacokinetic tolerance refers to changes in
distribution or metabolism of the drug, usually by
enzyme induction and subsequent acceleration in
metabolism. Opioids are biotransformed in the liver
by two types of metabolic processes. Phase I reactions
include oxidative and reductive reactions, such as
those catalyzed by the cytochrome P450 (CYP)
enzyme system, and hydrolytic reactions. Phase II
reactions involve conjugation of a drug or its metabolite to an endogenous substrate, such as d-glucuronic
acid, generating highly hydrophilic chemicals that are
then excreted primarily by the kidneys. With the
exceptions of the N-dealkylated metabolite of meperidine and the 6- and possibly 3-glucuronides of morphine, opioid metabolites are generally inactive. Since
the P450 enzyme system is inducible by a host of
compounds including opioids, barbiturates and antiepileptics, patients chronically exposed to these drugs
can metabolize some opioids faster, thus producing
pharmacokinetic tolerance. The CYP2D6 oxidation
system has been particularly implicated in the
hypoalgesic effect of opioids.
Perhaps the most important form of tolerance
relevant to opioids is pharmacodynamic tolerance.
Pharmacodynamic tolerance has been related to
neuroadaptive changes that take place following
chronic exposure to the drug. These include changes
at various levels: receptor properties, receptor coupling to G proteins, signal transduction pathways,
genetic expression profiles of several enzymes,
receptors and other molecules, neural and glial networks, etc.
Mechanisms of pharmacodynamic
tolerance
Basic animal research has provided a better though
yet incomplete understanding of the cellular and
molecular mechanisms mediating pharmacodynamic
opioid tolerance. These mechanisms occur at three
levels and have been termed receptor-level tolerance,
cellular-level tolerance and system-level tolerance.
Receptor tolerance occurs at the level of the opioid
receptor and involves receptor desensitization upon
chronic or repeated exposure to opioids. The concept
of receptor desensitization underlies acute-onset opioid tolerance. Receptor desensitization means loss in
the coupling of mu opioid receptor to its cellular effectors, particularly its major cellular effector the
G-protein-regulated inwardly rectifying potassium
channel. Several potential mechanisms could account
for tolerance at this level of organization, but changes
in coupling to G protein and perhaps expression of
the receptors on the cell surface appear to be most
important.
Earlier, removal of opioid receptors from the cell
surface by beta-arrestin mediated endocytosis (a process termed internalization) was also thought to be
important in producing receptor tolerance. However,
the observation that morphine, while causing very
poor receptor internalization, nonetheless produces
severe tolerance has led to a recent re-thinking on this
mechanism. Internalized opioid receptors are not
degraded but predominantly dephosphorylated and
recycled to the cell surface in a reactivated state. In
fact, it has been demonstrated that agonist induced
receptor internalization plays an important role in
actually reducing the development of opioid tolerance
after chronic agonist treatment. The tentative explanation for this apparently paradoxical phenomenon is
that internalized receptors quickly resurface in an
activated state, whereas morphine-bound receptors
remaining at cell surface remain desensitized (i.e.,
uncoupled to K+ channel and other intracellular effectors) and thus produce tolerance.
Receptor-level tolerance represents the early
(minutes to hours) and often short-lived adaptations
to opioid administration. The slower-onset (hours to
days) and longer-lasting adaptation to chronic opioid
administration is better explained by cellular-level
and system-level tolerance. Cellular tolerance refers
to the second-messenger and further downstream
changes induced by opioids that eventually counter-
act opioids own action. There are many different

pathways, involving several enzymes (e.g., adenylyl
cyclase, protein kinase A, protein kinase C, calcium/
calmodulin-dependent kinase type 2, G protein-coupled receptor kinase, mitogen-activated protein
kinase, other protein kinases, monoxide signaling
systems heme oxygenase and nitric oxide synthase,
phospholipase C) and their signaling cascades. Perhaps the best-established pathway involves up-regulation of the cyclic adenosine monophosphate
(cAMP). Acutely, opiates inhibit the functional activity of the cAMP pathway by blocking adenylyl cyclase
(AC), the enzyme that catalyzes the synthesis of
cAMP. However, with chronic opiate exposure, the
cAMP pathway gradually recovers, and tolerance
develops. Up-regulation of cAMP may be responsible
for physical dependence and physiological changes
associated with withdrawal. In this regard, the activity of the cAMP pathway increases far above baseline
levels following abrupt discontinuance of opioid
binding. Although up-regulation of cAMP has been
most clearly demonstrated in the locus coeruleus of
the brain, up-regulation within the spinal cord dorsal
horn appears to be responsible for tolerance to
opioid-induced analgesia. Up-regulation of calcium
ion channels is another mechanism of cellular-level
tolerance.
Prolonged or long-term tolerance may represent a
persistent neural adaptation, and is best explained by
evoking the concept of system-level tolerance that
involves altered sensitivity, functionality or even
microstructure of not only opioid but related nonopioid neural and neural-glial networks. This phenomenon may be observed in patients who
discontinued prescribed or illicit opioid use many
months or years ago yet continue to exhibit diminished responsiveness or opioid insensitivity. Longterm adaptations at the molecular and cellular level
involve, amongst others: (1) induction of transcription factors, such as delta Fos B, which regulate the
function of several genes in a stable fashion, thus initiating neuronal plasticity; (2) activation of the central
glutamate system and NMDA receptor activation as
the pronociceptive system. Prolonged exposure to
morphine indirectly activates NMDA receptors via
second-messenger mechanisms, and also down-regulates spinal glutamate transporters. The resultant high
synaptic concentration of glutamate and NMDA activation contribute to opioid tolerance and abnormal
pain sensitivity.
167
Opioid dependence
Physical dependence is a state that develops as a result
of the adaptation of the body to repeated opioid use
because of resetting of various homeostatic processes
to a different set point (a process known as allostasis).
Opioids affect numerous systems that previously were
in equilibrium; these systems find a new balance in
the presence of chronic inhibition by opioids. A person in this adapted or physically dependent state
requires continued administration of the drug to
maintain normal function. However, if and when
administration of the drug is stopped abruptly, there
is another imbalance (because the allostatic set points

are different from the original ones), and the affected
systems again must go through a process of readjusting to a new equilibrium without the drug. This readjustment process is often clinically manifest as a set of
characteristic symptoms and signs known as the withdrawal syndrome. The appearance of a withdrawal syndrome when administration of the drug is terminated
is the only actual evidence of physical dependence.
Withdrawal signs and symptoms occur when drug
administration in a physically dependent person is
terminated abruptly. Thus, abrupt termination of a
Table 37.1. Substance use disorder: related definitions

Addiction
Commonly used term meaning the aberrant use of a specific psychoactive substance in a manner
characterized by loss of control, compulsive use, preoccupation, and continued use despite harm;
pejorative term, replaced in the DSM-IV-TR in a non-pejorative way by the term substance use disorder
(SUD) with psychological and physical dependence
Dependence
1. Psychological dependence: need for a specific psychoactive substance either for its positive effects or to
avoid negative psychological or physical effects associated with its withdrawal
2. Physical dependence: a physiological state of adaptation to a specific psychoactive substance
characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in
total or in part by readministration of the substance
3. One category of psychoactive substance use disorder
Chemical dependence
A generic term relating to psychological and/or physical dependence when one or more psychoactive
substances or classes of psychoactive substances are abused (alcohol; sedatives, hypnotics and anxiolytics;
cannabis; opioids; cocaine; amphetamine and other sympathomimetics; hallucinogens; caffeine; nicotine;
phencyclidine)
Substance use disorders
Term of DSM-IV-TR19 comprising two main groups:

1. Substance dependence disorder and substance abuse disorder
2. Substance-induced disorders (e.g., intoxication, withdrawal, delirium, psychotic disorders)
168
Tolerance
Normal neurobiological event; a state in which an increased dosage of a psychoactive substance is needed
to produce the original effect. Cross-tolerance: induced by repeated administration of one psychoactive
substance that is manifested toward another substance to which the individual has not been recently exposed
Withdrawal syndrome
The onset of a predictable constellation of signs and symptoms following the abrupt discontinuation of or
a rapid decrease in dosage of a psychoactive substance
Polydrug dependence
Concomitant use of two or more psychoactive substances in quantities and frequencies that cause individually
significant physiological, psychological, and/or sociological distress or impairment (polysubstance abuser)
Recovery
A process of overcoming both physical and psychological dependence on a psychoactive substance with
a commitment to sobriety
Abstinence
In recovery, non-use of any psychoactive substance
Maintenance
Prevention of craving behavior and withdrawal symptoms of opioids by permanently acting opioid (e.g.,
methadone, buprenorphine)
Substance abuse
Use of a psychoactive substance in a manner outside sociocultural conventions; according to this, any use of
illicit and licit drugs in a manner not dictated by convention (e.g., according to physicians order) is abuse
Pseudo-addiction
Behavioral changes in patients that seem similar to those in patients with opioid dependence or addiction
but are secondary to inadequate pain control
Drug-seeking behaviors
Directed or concerted efforts on the part of the patient to obtain opioid medication or to ensure an
adequate medication supply: may be an appropriate response to inadequately treated pain
Opioid-induced
hyperalgesia
A neuroplastic change in pain perception resulting in an increase in pain sensitivity to painful stimuli,
thereby decreasing the analgesic effects of opioids.
drug (such as an opioid agonist) that produces miotic

(constricted) pupils and slow heart rate will produce a
withdrawal syndrome including dilated pupils and
tachycardia. Tolerance, physical dependence, and
withdrawal are all biological phenomena. They are the
natural consequences of drug use and can be produced
in experimental animals and in any human being who
takes certain medications repeatedly. These symptoms
in themselves do not imply that the individual is
involved in abuse or addiction. Patients who take
medicine for appropriate medical indications and in
correct dosages still may show tolerance, physical
dependence, and withdrawal symptoms if the drug is
stopped abruptly rather than gradually.
In contrast, some persons repeatedly taking opioids
develop a psycho-behavioral syndrome characterized
by a compulsive, irresistible quality in their drug-taking
behavior, which persists despite drug-induced harm
and which continues at the cost of neglecting other

interests and responsibilities of life. These persons
crave the drug (even in the absence of pain or other
obvious physical reasons), cannot control the initiation,
quantity, or termination of the drug intake, and spend a
lot of time arranging for the drug, using it, or recovering
from its effects. The diagnostic system of the American
Psychiatric Association uses the term substance dependence instead of addiction for this behavioral syndrome.
It also applies the same general criteria to all types of
drugs regardless of their pharmacological class.
Thus, the word opioid dependence can mean two
different things: one, a biological state produced in all
receiving chronic opioid administration, primarily
characterized by appearance of withdrawal phenomena when the opioid is abruptly stopped; and two, a
clinical syndrome seen in some opioid consumers,
characteristics of which may include tolerance and
Table 37.2. Guidelines for peri-operative pain management in opioid-tolerant patients

Pre-operative
1.
Evaluation: should include early recognition and high index of suspicion
2.
Identification: identify factors such as total opioid dose requirement, previous surgery/trauma resulting in
undermedication, inadequate analgesia or relapse episodes
3.
Consultation: meet with addiction specialists and pain specialists with regard to peri-operative planning
4.
Reassurance: discuss patient concerns related to pain control, anxiety, and risk of relapse
5.
Medication: calculate opioid dose requirement and mode(s) of administration, provide anxiolytics or other
medications: as clinically indicated
Intra-operative
1.
Maintain baseline opioids (oral, transdermal, intravenous)
2.
Increase intra-operative and post-operative opioid dose to compensate for tolerance
3.
Provide peripheral neural or plexus blockade, consider neuraxial analgesic techniques when clinically
indicated
4.
Utilize non-opioids as analgesic adjuncts
Post-operative
1.
Plan pre-operatively for post-operative analgesia; formulate primary strategy as well as suitable alternatives
2.
Maintain baseline opioids
3.
Employ multimodal analgesic techniques.
4.
Patient-controlled analgesia: as primary therapy or as supplementation for epidural or regional techniques
5.
Continue neuraxial opioids: intrathecal or epidural analgesia
6.
Continue continuous neural blockade
Post-discharge
1.
If surgery provides complete pain relief, opioids should be slowly tapered, rather than abruptly discontinued
2.
Develop a pain management plan prior to hospital discharge; provide adequate doses of opioid and nonopioid analgesics
3.
Arrange for a timely outpatient pain clinic follow-up or a visit with the patients addictionologist
169
withdrawal, but which is essentially characterized by

an overpowering sense of compulsion to take the drug
and the range of behaviors associated with it. Failure
to appreciate this difference can lead to inappropriate
undermedication of biologically opioid-dependent
people who need opioids for the control of their pain
conditions. Table 37.1 provides the definitions of some
of these and related terms.
Patient management
Detailed pain management of patients displaying opioid tolerance or dependence is beyond the scope of
this brief chapter (see the references below for detailed
reviews). However, the broad goals of pain management in the opioid-dependent patients are:
1. Identification of the populations at risk: patients
on long-term opioid therapy for various chronic
pain situations (musculoskeletal, neuropathic,
sickle cell disease, HIV-related disease, and
palliative care), drug abusers, recovering addicts
in opioid maintenance programs.
2. Prevention of withdrawal symptoms and
complications.
3. Symptomatic treatment of psychological affective
disorders such as anxiety.
4. Effective analgesic treatment in acute phase.
5. Rehabilitation to an acceptable and suitable
maintenance opioid therapy.
Peri-operative management of these patients can
present unique challenges. Table 37.2 provides an
overview of the peri-operative management of opioidtolerant and dependent patients. There are several
general principles that help guide the anesthesiologist
and pain specialist with peri-operative pain management. First and foremost is to uncover the fact that
170
their patient is an opioid user or an abuser and to recognize that issues related to physical and psychological dependence and opioid tolerance could profoundly
influence the post-operative course. The importance
of patient assessment and early recognition cannot be
overemphasized, because failing this essential first
step, principles that follow becomes less relevant.
References
1. Mitra S, Sinatra RS. Perioperative management of

acute pain in the opioid-dependent patient.
2. Gutstein HB, Akil H. Opioid analgesics. In Brunton
LL, Lazo JS, Parker KL, eds. Goodman and
Gilmans The Pharmacological Basis of Therapeutics,
11th ed. New York: McGraw-Hill, 2006, pp. 569619.
3. OBrien CP. Drug addiction and drug abuse. In
Brunton LL, Lazo JS, Parker KL, eds. Goodman and
Gilmans The Pharmacological Basis of Therapeutics,
11th ed. New York: McGraw-Hill, 2006,
pp. 621642.
4. Mehta V, Langford RM. Acute pain management for
opioid dependent patients. Anaesthesia 2006;61 :
269276.
5. Christie MJ. Cellular neuroadaptations to chronic
opioids: tolerance, withdrawal, and addiction. Br J
Pharmacol 2008;154:384396.
6. Ueda H, Ueda M. Mechanisms underlying morphine
analgesic tolerance and dependence. Front Biosci
2009;14:52605272.
7. Chu LF, Clark D, Angst MS. Molecular basis and
clinical implications of opioid tolerance and opioidinduced hyperalgesia. In Sinatra RS, de Leon-Casasola
OA, Ginsberg B, Viscusi ER, eds. Acute Pain
Management. New York: Cambridge University Press,
2009, pp. 114146.
Section 2
Chapter
38
Opioid-induced hyperalgesia
Sukanya Mitra
Introduction
In recent years it has become increasingly clear
that opioids can produce paradoxical pain and hyperalgesia under many circumstances, and that such
an effect might contribute to the drawbacks of acute
and chronic administration of opioids. This phenomenon (opioid-induced lowering of pain threshold)
has been described as opioid-induced hyperalgesia
(also termed opioid-induced abnormal pain sensitivity, opioid hyperalgesia, opioid-induced paradoxical
pain, or opioid-induced abnormal pain). The recognition of opioid-induced hyperalgesia (OIH) has important clinical implications. A major issue confronting
the clinician dealing with patients on opioids is to disentangle apparent opioid tolerance from true tolerance vis--vis OIH. The differential diagnosis of a
patient not responding to, or even complaining of
increased pain in response to, high doses of opioids
necessitates a rational and scientific clinical approach
to the problem. Further management will necessarily
depend on such clarification.
Characteristics of OIH
The common underlying clinical theme of OIH is the
worsening of pain in patients receiving high, escalating doses of opioids, and, more importantly, appearance of pain with characteristics different from those
of the original pain syndrome for which the opioid
treatment was instituted, e.g., pain arising in a different location, becoming more diffuse in nature, often
spreading beyond the original disease location, even
giving rise to whole-body hyperesthesia, and allodynia (pain elicited by normally innocuous stimulation
such as touch). This may be accompanied or followed
by generalized neuro-excitatory features such as agitation, multifocal myoclonic jerks, seizures, and even
delirium. Thus, although there is an apparent tolerance to the analgesic action of opioids in these patients,
opioid-induced hyperalgesic syndrome is more than
simply an opioid tolerance phenomenon. Table 38.1

gives a comparison between true opioid tolerance and
opioid-induced hyperalgesia.
Pathophysiology
The pathophysiology of OIH is poorly understood.
Various non-opioid chemicals, neurotransmitters,
and receptors have been implicated, e.g., cholecystokinin (CCK), N-methyl D-aspartate (NMDA) receptor,
neurokinin, etc. One mechanism for opioid-induced
enhanced pain sensitivity may be the neuroplastic
changes that result in part from the activation of
descending pain facilitation mechanisms arising from
the rostral ventromedial medulla (RVM) by increasing the activity of CCK in the RVM. These activated
descending neural tracts facilitate nociceptive processing in the spinal cord.
A conceptual model of OIH implicates a state of
disturbed balance between the anti-nociceptive and
pro-nociceptive systems. Under normal states, there is
an assumed balance between [1] the activity produced
by endogenous opioids (the anti-nociceptive system)
and [2] the anti-opioid system involving the NMDA
receptor and CCK (the pro-nociceptive system).
Immediately after morphine administration, increased
release of excitatory peptides such as substance P by
morphine produces transient hyperalgesia. With time,
the inhibitory effect of morphine grows, resulting in
analgesia. However, along with its usual expected
analgesic effects due to its action on the opioid receptors, morphine itself also paradoxically somehow activates the pro-nociceptive system. This is manifested as
a transient period of delayed hyperalgesia when the
opioid-induced inhibition is diminished and the activity of anti-opioid mechanisms is increased. Then the
system oscillates back to equilibrium as before.
In the opioid-tolerant state, however, due to
chronic opioid exposure the anti-opioid system is upregulated, resulting in an increased pro-nociceptive
171
Table 38.1. Opioid tolerance versus opioid-induced hyperalgesia (OIH)
Background
factors
Clinical
characteristics
Opioid tolerance
OIH
Duration of opioid
exposure
Long (chronic exposure)
May be long (chronic exposure) or

short (acute exposure)
Opioid dose escalation
Slow (over weeks to months)
May be slow, but typically rapid

escalation (days to weeks)
Nature of pain
Unaltered from the original pain

condition
Altered from the original pain

condition (usually more diffuse in
nature)
Location of pain

condition
Altered from the original pain condition

(usually extends to other locations,
even whole body hyperalgesia)
Quality of pain

condition
Altered from the original pain

condition (e.g., allodynia)
Pain sensitivity
Unchanged
Increased
Pain threshold
Unchanged
Decreased
Additional clinical features
Usually absent
May be present as generalized neuroexcitatory features (agitation, mutifocal

myoclonus, seizures, even delirium)
Attenuation of anti-nociceptive
system (primarily involving opioid
receptors and cells)
Enhancement of pro-nociceptive
system (involving non-opioids e.g.,
NMDA, CCK, and other system e.g.,
RVM)
Effect of additional opioids
At least temporarily relieves pain
Pain is typically increased further,

especially with rapid escalation of
opioid doses
Effect of adjunct nonopioid agents (especially

NMDA-blockers, e.g.,
ketamine)
May be useful
Often useful
Essential focus during

clinical management
Ensure adequate (often very high)

doses of opioids to overcome
tolerance temporarily. Additional
methadone or opioid rotation often
useful. Non-opioid adjuncts may be
useful
Avoid escalation of opioid doses. May

substitute with methadone (because
of its additional NMDA-blocking
properties). Use of ketamine seems
promising
Basic postulated
mechanism
Management
implications
Source: reprinted with permission from: Mitra S. Opioid-induced hyperalgesia: pathophysiology and clinical implications. J Opioid
Manage 2008;4:123130.
activity under basal conditions. Further repeated opioid administration actually helps even more up-regulation of the anti-opioid system, possibly through
CCK-mediated descending pain facilitation at the
RVM as described above. The net result is the clinical
phenomenon of opioid hyperalgesia. Although attractive as a conceptual model, this awaits experimental
verification.
Clinical and management

implications of OIH
172
Recognition of the phenomenon of opioid-induced

hyperalgesia in the clinical setting is the foremost
challenge for the clinician. When a patient receiving

opioids starts complaining of worsening pain, often
demanding more opioids, the clinician is immediately
confronted with a dilemma. The increasing pain complaints, despite the opioids that the patient is already
on, could be because of several distinct reasons, each
meriting a different response: (a) the original underlying pain-producing pathology; (b) true opioid tolerance; (c) opioid addiction, or severe psychological
problems such as anxiety or depression; and (d)
opioid-induced hyperalgesia. In contrast to all the
three clinical scenarios mentioned above, even a
short-term further escalation of opioid doses in OIH
would lead to further worsening of pain, allodynia,
Chapter 38 Opioid-induced hyperalgesia
Worsening pain despite continuing opioid (apparent opioid tolerance)
Progression of original pain-producing or related cause?

(Disease, pathology, intervention, surgery)
Yes
Address these
issues
Figure 38.1. Clinical algorithm for

differentiating worsening pain states
despite continuation of opioid therapy.
(Reprinted with permission from: Mitra S.
Opioid-induced hyperalgesia:
pathophysiology and clinical
implications. J Opioid Manage
2008;4:123130.)
No
Are psycho-behavioral factors relevant?

(Severe anxiety, depression, addiction)
Does it help?
Yes
Yes
No
No
True opioid tolerance or OIH?
Clinical pointers indicate OIH?

(Worsening pain following opioid dose escalation;
Allodynia; Altered pain quality; Extension of pain
localization; Myoclonus, seizures, delirium)
Yes
No
Empirical trial of one further dose

escalation with same opioid: does it help?
No
Likely to be true
OIH
Yes
Likely to be true
opioid tolerance
Table 38.2. Some therapeutic options available for empirical trial in OIH, after reduction in doses of the primary opioid
Methods/Agents
Specific drugs
Comments/Cautions
Opioid rotation
Buprenorphine; methadone; other mu receptor

agonists
Some of these drugs, including methadone,

might themselves cause or add to OIH
Ketamine (low dose); dextromethorphan
Many case reports available. S-ketamine, if

available, may be used at even lower doses,
though risk of adverse effects remains
NSAIDs and COX-2 inhibitors
Indirect evidence for NSAID
Direct evidence for IV parecoxib
Timing of parecoxib administration important for

preventing OIH
Others
Clonidine; magnesium sulfate; ultra-lowdose opioid antagonists; ultra-rapid opioid

detoxification
Anecdotal or single case-report-based

evidence: not recommended for use
currently
Change of route of opioid
From IV to spinal
Single case report of two cases
173
extension of pain from the original pain site, etc.

Hence, however counterintuitive it may sound, further opioid dose escalation is clearly contraindicated
in this situation.
It may be difficult to differentiate the two phenomena of true tolerance and OIH purely on clinical
grounds. At this point, it has been suggested the best
practical step would be to go for a trial of another opioid dose escalation, using the same opioid as before. If
the patients pain improves, the cause of the pain is
more likely to be tolerance. However, if the patients
pain worsens or changes character, it is likely to be due
to opioid-induced hyperalgesia. This approach has
been schematically shown as a clinical algorithm for
differentiating worsening pain states despite continuation of opioid therapy (Figure 38.1).
After this crucial distinction is clinched by this
empirical dose escalation trial and OIH is suspected,
the immediate next step should be reduction of the
opioid dose. Along with this vital step, several other
options are potentially available (Table 38.2), though
these are based on case reports and empirical trials
Section 2
Chapter
39
References
1. Chu LF, Clark D, Angst MS. Molecular basis and

clinical implications of opioid tolerance and opioidinduced hyperalgesia. In Sinatra RS, de Leon-Casasola
OA, Ginsberg B, Viscusi ER, eds. Acute Pain
Management. New York: Cambridge University Press,
2009, pp. 114146.
2. Mitra S. Opioid-induced hyperalgesia:
pathophysiology and clinical implications. J Opioid
Manage 2008;4:123130.
3. Chang G, Chen L, Mao J. Opioid tolerance
and hyperalgesia. Med Clin N Am 2007;91:
199211.
4. Koppert W, Schmelz M. The impact of opioid-induced
hyperalgesia for postoperative pain. Best Pract Res Clin
Anaesthesiol 2007;21:6583.
5. Angst MS, Clark JD. Opioid-induced hyperalgesia.
A qualitative systematic review. Anesthesiology
2006;104:570587.
Opioid rotation
Raymond S. Sinatra
Introduction
174
rather than controlled trials preceded by formal diagnosis of OIH.
The overall effectiveness of analgesic therapy is determined by the efficacy and tolerability of the drug(s)
administered. Opioid analgesics remain the foundation of acute and chronic pain management; however,
their associated adverse effects often result in intolerability, poor dosing compliance, and inadequate analgesia [13]. In a systematic review that analyzed
post-operative opioid-associated adverse events, 31%
of patients experienced troubling gastrointestinal
events, including nausea, vomiting, ileus, or constipa-
tion. Other common adverse events included excessive sedation, (30.4%), pruritus (18.3%), and urinary
retention (17.5%) [1]. In a different post-operative
study the severity of opioid-related side effects was
considered more important than the quality of pain
relief, suggesting that many patients were willing to
trade analgesic efficacy for a reduction in side-effect
severity [2].
Patients with chronic pain also experience opioidinduced nausea, sedation, cognitive dysfunction, and
constipation that can be so troublesome that many
choose to cope with pain rather than continue taking
Chapter 39 Opioid rotation
their medication. Such adversity not only prevents

opioids from being dosed to maximal efficacy, but is
also responsible for premature discontinuation of
therapy. Studies of patients with chronic pain have
shown that patients often switch opioid medications
at least once, and sometimes as many as three or four
times, before achieving effective analgesia with tolerable AEs [3,4].
Most patients requiring long-term opioid therapy
experience moderate to high-grade tolerance development. Tolerance, or diminishing response to a given
dose, develops rapidly to the analgesic and euphoric
effects of opioids, more slowly to their sedative and
nauseating effects, and rarely to their inhibition of
bowel function and constipatory effects [5,6]. Tolerance occurs most rapidly with immediate-release
short-duration opioids which achieve rapid and high
peak plasma levels (Cmax) followed by rapid decline
(Cmin). Tolerance development has been related to upregulation of metabolic enzymes, enhanced drug
elimination, down-regulation of receptors, and receptor endocytotic activity [6]. The major clinical issue
associated with tolerance development is that moderate to very large escalations in opioid dose may be
required in order to maintain baseline analgesic
effects. Opioid dose escalation often results in a progressive increase in sedation, loss of appetite, and
constipation that may become intolerable and limit
further dose augmentation.
Another troubling clinical alteration that can lead
to treatment failures in patients receiving long-term
opioid therapy is termed opioid-induced hyperalgesia. This phenomenon is characterized by paradoxical
increases in pain intensity (hyperesthesia), the development of new pain complaints, and alterations in
pain characteristics (allodynia) in response to continued administration or increased dosing of opioid
analgesics [7]. Treatment of OIH includes discontinuation or dose reduction of the offending opioid/
metabolite, switching (or rotation) to a different opioid including methadone, and use of analgesic adjuvants including ketamine.
Variabilities in opioid response

A therapeutic failure with one opioid agonist does not
necessarily mean that the patient will fail to respond
to others. Pharmacokinetic and pharmacodynamic
variabilities as well as genetic polymorphisms in mu
opioid receptors are known to influence opioid dose
response. These inter-individual variations are respon-
sible for clinically measurable differences in analgesic

efficacy, adverse effect profile and tolerance development between opioid agonists [8,9]. The concept of
incomplete cross-tolerance describes the unexpectedly improved effectiveness or tolerability of newly
prescribed agonists when compared to equivalent
doses of others the patient has found unacceptable.
This concept must be appreciated in order to understand the rationale underlying opioid rotation. Incomplete cross-tolerance may be related to a variety of
factors including differences in CNS penetration, CSF
transport, and receptor affinity of one agonist such as
fentanyl over another such as morphine. In addition,
variability in the phenotypic expression of mu opioid
receptors may allow one agonist to achieve greater
binding affinity and intrisic efficacy than another.
Alterations in metabolic enzymes may result in greater
or lesser amounts of free drug in plasma and CNS.
Finally, some agonists such as methadone and tapentadol may provide additional non-opioid receptor
mediated analgesic effects.
Historically, leaders in pharmacology believed that
there were more similarities than differences between
opioid agonists used in clinical practice [10]. However, observed inter-individual variations in opioid
dose response and side-effect profile as well as incomplete cross-tolerance underscored the inaccuracy of
this statement. We now recognize that one size does
not fit all and that patients responding poorly to one
agonist may do well with another. In recent years,
pharmacogenomic research has uncovered significant
mu receptor polymorphisms with over 10 different
genetic variants detected [1113]. Differences in mu
opioid receptor gene (OPRM1) expression appear to
influence subsequent activation of associated proteins
and second messengers [12,13] and may affect pain
intensity and morphine requirements. In the first
bench-to-bedside evaluation of mu opioid receptor
polymorphism, OPRM1 genotypes of patients undergoing total knee arthroplasty were analyzed pre-
operatively [14]. The authors found that patients
homozygous for allele G118 self-administered significantly more morphine during the first 48 hours following surgery (homozygous AA, 25 mg; heterozygous
AG, 26 mg; homozygous GG, 40 mg). Similar variability was observed in cancer pain management, with
homozygous GG patients requiring an average morphine dose that was 93% higher than that needed by
homozygous AA patients [15].
175
Box 39.1. Patient variability in opioid response

A variety of genetic, pharmacological, and pathophysiological factors influence patient response to opioid
analgesics
( 1) Genetic polymorphisms
(a) OPRM1 encoding mu-opioid receptor
(b) Enzymes responsible for opioid metabolism (CYP2D6 and others)
(c) Genes modifying receptor activation (transporter P-glycoprotein COMT)
(2) Receptor endocytotic efficacy
(3) Incomplete cross-tolerance
(4) Extremes in patient age
(5) Exposure to drugs that compete for metabolic enzymes
(6) Exposure to drugs that increase CNS depression
(7) Patient comorbidity (hepatic failure, CNS lesions, renal failure)
176
Genetic variability of the catechol-O-methyltransferase (COMT) gene also influences morphine

dose requirements. Patients homozygous for the
Val:Val genetic variant required 63% more drug than
Met:Met variants [16]. Heterozygous Val:Met variants required 23% more. When the two genes are
taken into account the Met/Met genotype required
the least amount of morphine to maintain equivalent
analgesia. The transporter P-glycoprotein (ABCB1)
system influences opioid clearance from cerebrospinal fluid. In a recent article, Park and coworkers
reported that genetic polymorphism in this enzyme
system significantly influenced respiratory rate in
patients exposed to 2.5 g/kg of fentanyl [17].
Genetic variations of this enzyme system affect the
clearance of morphine, methadone, and fentanyl but
not meperidine.
Genetic variations in hepatic enzyme cytochrome
P450 2D6 are also associated with important metabolic consequences [18]. Cytochrome 2D6 metabolizes a number of opioid agonists and its activity ranges
from complete deficiency to ultrafast metabolism,
depending on at least 16 different known allele polymorphisms. Codeine, substituted derivatives of
codeine (oxycodone, hydrocodone), and tramadol are
O-demethylated into active compounds by CYP-2D6.
Loss of CYP2D6 function alleles with poor to absent
drug metabolism is noted in 10% of Caucasians. These
patients gain superior analgesic effects with equianalgesic doses of morphine, hydromorphone, and oxymorphone, which are primarily metabolized by
glucoronyl transferase [19].
The above-mentioned receptor polymorphisms
and genetic variations in enzymes involved in metab-
olism and clearance contribute to the wide range of

patient responses to opioid analgesics. If the clinician
has been unable to achieve adequate pain control with
acceptable adverse effects, an alternative opioid should
be considered. At the present time, opioid rotation is
the only method available to determine which patient
will respond best to a particular drug [1921]. Patient
variabilities that influence opioid response are summarized in Box 39.1.
Opioid rotation
Pain specialists often discontinue an offending opioid
analgesic and switch patients to an alternative agonist
(rotation) in order to identify a derivative that produces the most favorable ratio of analgesia to adverse
effects [1921]. Opioid rotation has been shown to be
an effective strategy for managing increasing adverse
events associated with dose escalation. The availability
of multiple opioid analgesics is crucial to achieving
clinically satisfactory outcomes, and the development
of new opioids or new formulations such as oxymorphone ER and IR, and tapentadol IR, as well as existing preparations such as oxycodone ER, fentanyl
transdermal patch, and morphine ER provide useful
options. Opioid rotation guidelines can facilitate discontinuation and introduction of a new prescription,
and are intended to reduce the risk of relative overdosing or underdosing.
The first and perhaps most important rotation
guideline is the assumption that caregivers will utilize
standardized opioid equianalgesic dosing tables and
become thoroughly familiar with their use and limitations. Tables provide evidence-based values for the
relative potencies of different opioid agonists and var-
Table 39.1. Opioid dosing guidelines
Opioid
Route
Dose
Potency
Metabolism
Comments
Morphine
IV
10 mg
1.0
Glucoronidation
The standard of
comparison for
opioid analgesia
Morphine
PO
30 mg
0.3
Glucoronidation
Poor oral effect,

active metabolite
Meperidine
PO
200 mg
0.02
Demethylation
Toxic metabolite,
not for chronic
pain
Hydrocodone
PO
15 mg
0.5
CYP450
Good oral
analgesic,
Schedule III
Oxycodone
PO
15 mg
0.5
CYP2D6
Good oral
bioavailability
Codeine
PO
200 mg
0.01
Demethylation
Prolonged
elimination
Hydromorphone
PO
10 mg
1.0
Glucoronidation
Well tolerated
Oxymorphone
PO
10 mg
1.0
Demethylation
Low oral
bioavailability,
stable release
kinetics
Methadone
PO
10 mg
1.0
Demethylation
Difficult to titrate,
may accumulate
in tissues
Tramadol
PO
200 mg
0.02
CYP2D6
O-demethylated
to an active
compound
Tapentadol
PO
100 mg
0.5
Glucoronidation
No active
metabolites, Dual
acting analgesic
Fentanyl (TDS)
TDS
25 g
40.0
Demethylation
12 h latency to
peak effect
Equianalgesic dosing table. Values listed represent approximations based on single dose calculations. According to this conversion scheme,
IV morphine 10 mg is assigned a potency of 1 while oral morphine is considered 0.3 due to its poor bioavailability and higher dose
requirement. Methadone values represent single-dose effects; accumulation of drug and duration of action will increase with continued
dosing. To calculate oral to oral dose conversions, determine the prior 24 h opioid dose (both scheduled and rescue doses) then utilize
opioids according to the PO equianalgesic dose and potency listed above. Utilize the following proportion: potency of current opioid /24
h dose of current opioid = potency of new opioid / X. X equals the 24 h dose of the new opioid. Solve for X by cross multiplying. Divide
the 24 h dose and administer into increments according to the duration of action of the new drug. For patient safety the recommended
conservative dose should be 25 to 50% less than the amount calculated. Subsequent dosing may be increased or decreased as necessary.
Dose conversions to and from fentanyl TDS are complicated. Please refer to the prescriber guidelines, product information. Adapted from
references 22,23,24.
ying routes of administration [2224] (Table 39.1).

Equianalgesic dosing tables simplify opioid rotation
by listing agonist potencies relative to a standard of
comparison, which is parenteral morphine 10 mg. It is
important to note that doses recommended in many
equianalgesic dose tables represent comparisons following single-dose administration and that opioid
dose response is associated with wide inter-patient
variability. These values may not be accurate in patients
who have developed tolerance or have been taking
opioids for long periods of time. Based on clinical

experience, the starting conservative dose for opioid
rotation should always be less than the calculated
equianalgesic dose. There are several reasons to err on
the side of caution with the first and several follow-up
doses of the new agonist. First, there is a potential for
incomplete cross-tolerance whereby the analgesic
potency and adverse effects may be greater than
expected. Also, because of clinically significant interindividual pharmacokinetic and pharmacodynamic
177
Box 39.2 Opioid rotation: a clinical example

Over the past 24 hours a patient has received 60 mg sustained release (SR) morphine (30 mg, PO, q12h), as well as
six 10 mg PO doses of immediate-release (IR) morphine for breakthrough pain and is complaining of excessive
nausea and sedation. You wish to rotate the patient to oxymorphone.
First step: calculate total opioid dose over 24 hours
Baseline (SR morphine) doses: 30 mg 2 doses = morphine 60 mg (PO)
Breakthrough doses: 10 mg 6 doses = morphine 60 mg (PO)
Total: morphine 120 mg (PO) per 24 hours
Second step: conversion to an equivalent dose of oral oxymorphone
Oral morphine potency (= 0.03) to oral oxymorphone potency (= 1.0); ratio ~ 3:1
Thus, 120 mg morphine (PO)/24 h is equivalent to 40 mg oxymorphone (PO)/24 h.
Third step: divide equianalgesic dose by 2
Split calculated oxymorphone dose into two divided doses; (i.e. 20 mg SR oxymorphone BID)
Fourth step: convert the equianalgesic dose to a conservative dose
To compensate for incomplete cross tolerance round down 24 h oxymorphone dose by 25 to 50% (i.e. 1015
mg SR oxymorphone BID)
Fifth step: breakthrough analgesia
This may or may not be required. If the patient complains of moderate to severe breakthrough pain, provide
immediate release oxymorphone 2.55 mg every 6 h as required. If frequent breakthrough doses are required,
increase the SR oxymorphone dose to 20 mg BID, and assess the quality of analgesia and incidence of adverse
events. If, on the other hand, the patient notices improved pain relief, does not require breakthrough doses, but
still complains of sedation, nausea or vomiting, consider reducing the SR oxymorphone dose to 7.5 mg BID.
178
variabilities, opioid potency ratios listed in the equianalgesic table may over- or underestimate the effectiveness of the new agonist. Finally, the caregiver
should always exercise caution when rotating agonists
in patients with comorbidities that increase opioid
risk, including COPD, sleep apnea, obesity, polydrug
dependency, hepatic or renal disease, and advanced
age [2224]. A clinical example of opioid rotation is
presented in Box 39.2.
The following dosing guidelines provide a reasonable starting point. For patients reporting good
pain control but unacceptable adverse events the
starting dose of the agonist being rotated to can usually be reduced to 4060% of the calculated equianalgesic dose of poorly tolerated opioid [20,21]. For
patients with poor pain control and unacceptable
AEs, the starting dose of the new agonist should
probably be lowered to 2550% of the calculated
equianalgesic dose. On the other hand, patients
reporting severe pain after receiving several conservative doses of the new agonist should have the dosage
increased to the calculated equianalgesic dosage
without delay [1922].
Exceptions to these guidelines exist for conversions to and from transdermal fentanyl and oral
methadone. Opioid rotation to a TDS fentanyl patch

offers dosing convenience and uniform plasma concentrations, and appears to cause significantly less
constipation than oral doses of morphine [25]. Fentanyl has high affinity at mu opioid receptors, can accumulate in fatty tissue, and has no active metabolites.
Dosing equivalency between transdermal and orally
administered opioids is complicated and referral to
the TDS fentanyl package insert is recommended [26].
In general, 25 g/h of TDS fentanyl is equipotent to
13 mg oral morphine/h. Since there is a latency to
peak effect of 1012 h with this preparation, the
patient may notice a period of less effective pain control followed by progressive increases in efficacy as
well as diminished safety. For this reason, initial doses
should be reduced significantly (4050% of the equipotent calculation) and analgesia supplemented as
needed with rapid-acting short-duration opioids.
Caution should be provided when rotating patients
to methadone. Based on clinical findings of greater
than expected potency gain when switching to methadone from morphine, a significant 75% to 90% reduction in the calculated equianalgesic dose may be
warranted [20,27]. The increase in analgesic effect is
greater when converting patients on very high daily
doses of morphine than for patients on low to moderate doses [21,27]. The greater analgesic effectiveness of
methadone may be related to its d-isomer, which
blocks the N-methyl-d-aspartate receptor, providing
independent analgesic effects and partial reversal of
opioid tolerance.
Patients participating in opioid rotation and dose
conversion should be monitored closely to assess the
adequacy of pain relief as well as the incidence and
severity of therapy-related AEs. As with any opioid
regimen, subsequent dose adjustments, gradual
upwards or downwards dose titration, will probably
be necessary. In some individuals rotation will be
unsuccessful and a second rotation and possibly conversion to methadone may be required. If tolerability
and efficacy improve following rotation, the new treatment plan may be maintained; however, if moderate
symptoms remain, other options may be considered.
Many patients may accept the new opioid if residual
adverse effects such as excessive sedation are treated
with CNS stimulants and constipation is controlled
with peripheral opioid antagonists [28]. Others may
experience reductions in pain intensity and greater
tolerability by reducing the daily dose of the new opioid and providing multimodal non-opioid analgesic
supplementation [29,30].
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the mouse mu opioid receptor gene. Mol Pharmacol
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candidate gene for pain: polymorphisms, variations in
expression, nociception, and opiate responses. Proc
Natl Acad Sci U S A 1999;96:77527755.
14. Chou WY et al. Acta Anaesthesiol Scand
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of genes and the clinical efficacy of morphine for
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20. Indelicato RA, Portenoy RK. Opioid rotation in the
management of refractory cancer pain. J Clin Oncol
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cancer pain. part 1: clinical considerations. J Pain
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22. Anderson A, Saiers JH, Abram S, Schlicht C. Accuracy
in equianalgesic dosing conversion dilemmas. J Pain
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nonopioid analgesics in chronic pain states. J
Pharmacol Exp Ther 2001;299:811817.
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to manage the adverse effects of oral morphine:
an evidence-based report. J Clin Oncol 2001;19:
25422554.
Section 3
Chapter
40
Neuraxial Opioid Analgesics
Epidural morphine
Siamak Rahman
Name of Analgesic Agent: Duramorph, Infumorph

Generic Name: morphine sulfate, preservative-free
Chemical Name: (C17H19NO3)2H2SO45H2O
Manufacturer: Baxter Healthcare, Round Lake,
IL 60073
Class of Drug: opioids
Mode of activity
Epidural morphine must redistribute to the spinal
cord to produce analgesia, although it is not clear how
exactly epidural morphine reaches the spinal cord.
Injection of morphine, the prototypic hydrophilic
opioid with octanol:water partition coefficients of
1.42, results in slow onset and a wide band of analgesia surrounding the site of injection in epidural space.
Transfer to the systemic circulation is slow and concentrations within the CSF decline more slowly than
similar doses of lipophilic opioids, accounting for the
greater degree of rostral spread, and delayed respiratory depression. Analgesic contribution from systemic
redistribution is minimal after the first 3060 minutes
of epidural administration.
Historical development
The discovery of opioid receptors within the brain and
spinal cord followed direct application of morphine at
the spinal cord level for patients with severe pain associated with advanced cancer.

Opiate receptors in the substantia gelatinosa of the
spinal cord appear to be the main site of drug action
after epidural drug administration. However, an
additional systemic effect for this selective spinal analgesia cannot be excluded.
Receptor interactions: binds to various opioid receptors, producing analgesia and sedation (opioid agonist).
Metabolic pathways/drug clearance and elimination: morphine is metabolized primarily in the
liver and approximately 87% of a dose of morphine
is excreted in the urine within 72 hours of administration. Morphine is primarily metabolized into
morphine-3-glucuronide (M3G) and morphine-6glucuronide (M6G) via glucuronidation by the
phase II metabolism enzyme UDP-glucuronosyl
transferase-2B7. About 60% of morphine is converted to M3G, and 610% is converted to M6G.
The cytochrome P450 (CYP) 2D6 family of enzymes
involved in phase I metabolism plays a lesser role.
Not only does the metabolism occur in the liver but
it may also take place in the brain and the kidneys.
M3G does not undergo opioid receptor binding and
has no analgesic effect. M6G binds to mu receptors
and is a more potent analgesic than morphine.
Preservative-free morphine is the same medication as
for systemic opioid analgesia, but used for epidural
administration. It is used for the management of pain
not responsive to non-narcotic analgesics. Preservative-free morphine administered epidurally provides
selective dermatomal pain relief for extended periods
without attendant loss of motor, sensory or sympathetic function.
Labor analgesia: in isolation, the efficacy of epidural (up to 7.5 mg) morphine for labor analgesia is
limited by a long latency (1560 min), incomplete
analgesia, and maternal side effects. It needs to be used
in combination with local anesthetic and/or lipophilic
opioids, to prolong or improve labor analgesia.
Cesarean delivery: morphine is currently the goldstandard neuraxial opioid for post-cesarean analgesia. It
provides effective post-operative analgesia for 1224 h.
181
Neuraxial Opioid Analgesics Section 3
CH3
N
Figure 40.1.
CH2
H2SO4 5H2O
H
CH2
HO
OH
Surgical acute pain: in patients undergoing abdominal surgery, pelvic and lower extremity surgery, epidural
morphine with or without added local anesthetic provides better analgesia than parenteral opioids.
Medical pain: has been successfully used for
advanced peripheral vascular disease.
Chronic nonmalignancy pain: has been used
widely with help of an externalized, tunnelled epidural
catheter. Since an externalized catheter may only be
maintained for a few months, an intrathecal catheter
plus an internal delivery system is prefered.
Cancer pain: it has been used widely with help of
an externalized, tunnelled epidural catheter.
Somatic, visceral, or neuropathic pain: epidural
morphine is capable of relieving visceral as well as
somatic and neuropathic pain.
Contraindications
182
Preservative-free morphine is contraindicated in those

medical conditions which would preclude the administration of opioids by the intravenous route allergy
to morphine or other opiates, acute bronchial asthma,
upper airway obstruction.
Preservative-free morphine, like all opioid analgesics, may cause severe hypotension in an individual
whose ability to maintain blood pressure has already
been compromised by a depleted blood volume or a
concurrent administration of drugs, such as phenothiazines or general anesthetics.
Absolute: allergy to morphine.
Relative: use in patients with increased intracranial pressure or head injury. Preservative-free morphine should be used with extreme caution in patients
with head injury or increased intracranial pressure.
Pupillary changes (miosis) from morphine may
obscure the existence, extent, and course of intracranial pathology
Use in chronic pulmonary disease: care is urged
in using this drug in patients who have a decreased
respiratory reserve (e.g. emphysema, severe obesity,
kyphoscoliosis, or paralysis of the phrenic nerve).
Preservative-free morphine should not be given in

cases of chronic asthma, upper airway obstruction or
in any other chronic pulmonary disorder without due
consideration of the known risk of acute respiratory
failure following morphine administration in such
patients.
Use in hepatic or renal disease: the elimination
half-life of morphine may be prolonged in patients
with reduced metabolic rates and with hepatic and/or
renal dysfunction. Hence, care should be exercised in
administering preservative-free morphine epidurally
to patients with these conditions, since high blood
morphine levels, due to reduced clearance, may take
several days to develop.
Use in biliary surgery or disorders of the biliary
tract: as significant morphine is released into the systemic circulation from neuraxial administration, the
ensuing smooth muscle hypertonicity may result in
biliary colic.
Use with disorders of the urinary system: initiation of neuraxial opiate analgesia is frequently associated with disturbances of micturition, especially in
males with prostatic enlargement. Early recognition
of difficulty in urination and prompt intervention in
cases of urinary retention is indicated.
Use in ambulatory patients: patients with reduced
circulating blood volume, impaired myocardial function or on sympatholytic drugs should be monitored
for the possible occurrence of orthostatic hypotension, a frequent complication in single-dose neuraxial
morphine analgesia. Epidural morphine should not be
given to outpatient surgical patients.
Use with other central nervous system depressants: the depressant effects of morphine are potentiated by the presence of other CNS depressants such as
alcohol, sedatives, antihistaminics or psychotropic
drugs. Use of neuroleptics in conjunction with neuraxial morphine may increase the risk of respiratory
depression.
Common doses
Usual single epidural dose for post-operative pain is
initial injection of 25 mg in the lumbar region. If
adequate pain relief is not achieved within 1 hour,
careful administration of incremental doses of 1 to 2
mg at intervals sufficient to assess effectiveness may
be given. No more than 10 mg/24 h should be administered. For continuous infusion, an initial dose of 2
to 4 mg/24 h is recommended. Doses need to be
selected according to history of sleep apnea, coexist-
Chapter 40 Epidural morphine
ing diseases or conditions (e.g. diabetes, obesity),

current medications (including pre-operative opioids), and adverse effects after opioid administration.
The lowest efficacious dose of neuraxial opioids
should be administered to minimize the risk of respiratory depression. No information is available
regarding the use of preservative-free morphine in
patients under the age of 18.
Preservative-free Duramorph (morphine sulfate injection, USP) is a sterile, nonpyrogenic, isobaric solution
of morphine sulfate, free of antioxidants, preservatives
or other potentially neurotoxic additives. Selective
blockade of pain sensation is possible by neuraxial
application of morphine and duration of analgesia
may be much longer by this route compared to systemic administration.
Ease of use: preservative-free morphine should be
administered by or under the direction of a physician
experienced in the techniques and familiar with the
patient management problems associated with epidural or intrathecal drug administration.
Preservative-free morphine contains no preservative
or antioxidant, so it has to be protected from light and
kept in controlled room temperature 2025C
(6877F). Most of the potential side effects associated
with systemic administration of opioids such as CNS
effects, respiratory depression, sedation, nausea and
vomiting, pruritus, and urinary retention are still seen
with epidural administration.
Drug interactions
Epidural chlorprocaine: the efficacy and duration of
epidural morphine analgesia is diminished when
administered after 2-chloroprocaine compared with
lidocaine. The mechanism of the interaction between
2-chloroprocaine and morphine is unknown. The
observed interaction between epidural morphine and
2-chloroprocaine may be a result of differences in
onset and duration of action of the two drugs.
Adverse events
Observational studies report a range in the occurrence of respiratory depression from 0.01% to 3.0%
of patients who are given single-injection neuraxial
opioids. When single-injection neuraxial opioids are
compared with parenteral (i.e. intravenous, intramuscular, or intravenous patient-controlled) opioids, meta-analysis indicates no difference in the
frequency of respiratory depression and less somnolence or sedation. Although respiratory depression
risk is dose-related and larger doses are more likely
to cause respiratory depression, small doses can also
cause respiratory depression. Neuraxial opioids
depress the respiratory centers in the brainstem via
direct and/or indirect mechanisms. Respiratory
depression after neuraxial morphine is biphasic; it
can occur early (3090 min) after epidural administration of hydrophilic morphine due to systemic vascular absorption, or it can occur late (618 h) after
epidural or intrathecal morphine due to rostral
spread in cerebrospinal fluid and slow penetration
into the brainstem.
Delays gastric emptying: gastric emptying is
delayed and orocecal transit time prolonged after epidural morphine.
Post-operative delirium and cognitive decline: the
available studies suggest that IV or epidural techniques
do not influence cognitive function differently.
Pruritus: mild to severe genralized pruritus is
the only side effect that is seen more frequently following neuraxial dosing than with systemic administration.
Prevention of respiratory depression: opioid
effects on respiration include decreased minute ventilation (decreased respiratory rate, tidal volume, or
both), decreased response to hypoxia, and a rightward shift and depression of the CO2 response. So,
all these patients receiving epidural morphine need
appropriate methods of respiratory monitoring (e.g.
respiratory rate, depth of respiration [assessed without disturbing a sleeping patient]), oxygenation (e.g.
pulse oximetry when appropriate), and level of consciousness. Monitoring should be performed for a
minimum of 24 h after administration, at least once
per hour for the first 12 h after administration, followed at least once every 2 h for the next 12 h. In the
case of continuous infusion or PCEA with morphine, monitoring should be performed the same as
above for the first 24 h. After 24 h monitoring should
be performed at least once every 4 h.
Less common adverse events: recurrence of oral
herpes simplex virus (HSV) infections involving the
third division of the trigeminal nerve with epidural
morphine.
Treatment of adverse events: supplemental oxygen
should be administered to patients with altered level
183
of consciousness, respiratory depression, or hypoxemia and continued until the patient is alert and no
respiratory depression or hypoxemia is present. In the
presence of severe respiratory depression, reversal
agent (naloxone), single-dose or continous infusion,
should be given and appropriate resuscitation should
be initiated. Consider non-invasive positive-pressure
ventilation if frequent or severe airway obstruction or
hypoxemia occurs during post-operative monitoring.
References
Available in the USA as a schedule II drug.
1. Practice guidelines for the prevention, detection, and

management of respiratory depression associated with
neuraxial opioid administration. An updated report by
the American Society of Anesthesiologists Task Force
on Neuraxial Opioids. Anesthesiology 2009;110:218230.
Pearls
2. Carvalho B. Respiratory depression after neuraxial opioids

in the obstetric setting. Anesth Analg 2008;107:956961.
Availability
Intravenous access should be maintained for 24 h after

administration of epidural morphine. Whether the
addition of parenteral opioids or hypnotics to neuraxial opioids is associated with increased occurrence of
respiratory depression or hypoxemia is unclear.
Section 3
Chapter
41
3. Epocrates.
Evaluations.
5. Goodman and Gilmans Pharmacological basis of
therapeutics. New York: McGraw-Hill.
Epidural fentanyl
Bita H. Zadeh
Generic Name: fentanyl

Chemical Name: fentanyl citrate
Trade Name: Sublimaze
Manufacturer: multiple, including Hospira, Inc., Lake Forest, IL 60045; Baxter
Healthcare Corporation, Deerfield, IL
60015
Class: analgesic, opioid, schedule II drug
184
Parenteral opioids or hypnotics should be cautiously

administered in the presence of neuraxial opioids. The
concomitant administration of neuraxial opioids and
parenteral opioids, sedatives, hypnotics, or magnesium requires increased level of monitoring.
Description
Fentanyl was first created in 1959 by a chemist named
Dr. Paul Jannsen. It was released for human use in
1963. Fentanyl citrate is a sterile, nonpyrogenic solution of fentanyl citrate in water.
Fentanyl citrate has a molecular weight of 528.6.
Each milliliter contains fentanyl (as the citrate) 50 g
(0.05 mg). May contain sodium hydroxide and/or
hydrochloric acid for pH adjustments. pH is 47.5 and
pKa 7.38.4.
It is freely soluble in organic solvents and sparingly
soluble in water. It has a relative lipid solubility of 580.
Chapter 41 Epidural fentanyl
CH2COOH
CH3CH2CON
N-CH2CH2
HO
COOH
CH2COOH
Figure 41.1.
Mode of activity
Epidural fentanyl has been used in practice since 1975.
When fentanyl is placed in the epidural space, it must
first cross the dura mater before it can reach the spinal
cord. Epidural fentanyl binds to opioid receptors
located throughout the spinal cord and nerve roots,
and provides analgesia. The epidural space is highly
vascularized, and some redistribution of drug to the
systemic circulation occurs. The epidural space also
contains fat, connective tissues, a lymphatic network,
and the dorsal and ventral roots of the spinal nerves,
all of which can serve as repositories for lipophilic
agents.
Epidural fentanyl, given as a bolus, will redistribute to the lipophilic sites found in the epidural space
and limit rostral spread. However, given as a
continuous infusion, those sites will become saturated and serum levels 24 hours after a continuousrate infusion are similar to those obtained from a
similar IV infusion.
Depending on whether epidural administration of
fentanyl is as a bolus or a continuous infusion, analgesic effects are predominantly mediated by spinal or
supraspinal mechanisms, respectively.
Fentanyl is metabolized primarily in the liver via
the cytochrome P450 3A4 isoenzyme system. It is
metabolized primarily by N-dealkylation to norfentanyl and other inactive metabolites that do not contribute materially to the observed activity of the
drug.
Fentanyl is excreted primarily by the kidneys, 90%
as metabolites, 10% as unchanged drug.
Indications
The benefits of giving fentanyl in the epidural space
for improving intra-operative and post-operative analgesia are very clear. The analysis of current literature
shows that the addition of fentanyl to local anesthetics
for intra-operative and post-operative epidural analgesia is safe and advantageous. The reduction in the
incidence
of pain is quantitatively high, and adverse
effects are mild.
Epidural fentanyl has been approved for a variety
of circumstances including surgical acute pain. Fentanyl given in thoracic epidurals (thoracotomy, bowel
cases, etc.) works extremely well; due to its lipopholic
quality, it will give more segmental analgesia and have
less rostral spread. It is also used in lumbar epidurals
for labor and any surgery in the pelvic region or lower
extremity. Fentanyl can be used as the sole analgesic in
epidurals. This can be very useful in laboring patients
who require minimal or no motor blockade, walking
epidural.
It can be used in thoracic or lumbar epidurals, to
treat other pains such as medical pain, chronic nonmalignancy pain, and cancer pain within those
dermatomes.
Contraindications
The only absolute contraindication to epidural fentanyl is in patients with known intolerance to the
drug.
The use of cervical epidural administration of
fentanyl is questionable. In a study of patient-controlled cervical epidural fentanyl infusion, compared with
patient-controlled IV fentanyl infusion for pain relief
after pharyngolarynx surgery, results show that cervical epidural fentanyl analgesia provides marginally
better pain relief at rest with no decrease in fentanyl
consumption. Also, administration of fentanyl in the
cervical epidural space is questionable because of the
possible complications of the technique.
Common doses/uses
The dose of epidural fentanyl should be appropriately
reduced in elderly, debilitated, pregnant, or pediatric
patients as well as in patients with obstructive sleep
apnea.
Epidural fentanyl can be given as a single bolus, a
continuous infusion, or a combination of both.
Fentanyl can be given as a one-time bolus during
initiation of epidural analgesia. The dose range is
50200 g, with an average onset time of 1015
minutes, and duration of 23 hours. Based on review
of current literature, 100 g fentanyl, administered as
a single bolus into the epidural space appears to be the
optimal safe dose for most patients. Dose must be
appropriately reduced for patients at an increased risk
of respiratory depression.
185
For continuous infusion techniques, fentanyl

0.51.0 g/kg per h, after initial bolus administration,
provides effective analgesia both alone and in combination with low concentrations of local anesthetic.
Lumbar epidural analgesia for labor requires effective analgesia with significantly less motor block. In
these patients, a continuous infusion of fentanyl (12
g/mL) in combination with low concentrations of a
local anesthetic at a rate of 68 ml/h is effective.
Epidural fentanyl 520 g/h at an infusion rate of
310 mL/h used as solo anesthetic can provide near
total analgesia with minimal side effects, while allowing
the patient to ambulate safely and more comfortably.
Epidural fentanyl markedly improves the analgesic
effect of epidural infused local anesthetic. It works
synergistically with and helps prevent tachyphylaxis
to local anesthetics. In addition to better analgesia,
one can reduce the local anesthetic concentration to
avoid motor block. Because of its greater lipophilicity,
fentanyl offers a number of advantages over morphine
for epidural analgesia, including a lower incidence of
side effects and reduced risk of delayed-onset respiratory depression. The greater lipid solubility of epidural
fentanyl results in rapid-onset analgesia and rapid
clearance from cerebrospinal fluid, resulting in a relatively short duration of action. Fentanyls relatively
short duration of action makes it more ideally suited
for continuous infusion or PCEA (patient-controlled
epidural analgesia). Epidural fentanyl lacks spread
through the cerebrospinal fluid, and therefore achieves
a segmental nature to the analgesia. Hence the location of epidural catheter placement is most important
when fentanyl is used. Rapid clearance from cerebro
spinal fluid allows for less cephalad spread, causing
fentanyl to be associated with fewer and less severe
adverse effects.
186
Prolonged infusion of epidural fentanyl may result in

systemic concentrations not dissimilar to IV infusion,
and therefore it is more efficacious to combine it with
a low concentration of local anesthetic to get a synergistic effect. Although the addition of fentanyl to local
anesthetic in the epidural space has been shown to
reduce the incidence of pain in adults, this may not
be true for pediatric patients. In fact, the addition of
0.2 g/kg per h fentanyl to 1.5 mg/mL ropivacaine
increased the incidence of side effects without

improvement of analgesia in infants and children
undergoing urological surgery.
Another disadvantage of epidural fentanyl is that
it reduces the shivering threshold when combined
with epidural local anesthetic. Epidural local anesthetics and IV opioids both decrease the core temperature, which triggers shivering. Fentanyl is often
added to local anesthetic to improve the quality of
epidural blockade and to reduce side effects. However, it has been shown that patients are at increased
risk of hypothermia when fentanyl is added to local
anesthetics.
Epidural fentanyl analgesia is commonly used as a
therapeutic modality in the management of pain during labor. Healthcare providers have a general perception that drugs administered in the maternal
epidural space remain there and do not compromise
the respiratory status of newborns. There have been
case reports of newborns developing respiratory
depression following epidural fentanyl analgesia. Respiratory depression in the newborn related to fentanyl
is more related to the amount of drug received within
2 to 4 hours preceding delivery than used during the
entire course of labor.
There are variations in fentanyl maternal-placental-fetal kinetics, and hence it is not easy to pinpoint with complete certainty which baby will have
respiratory depression following birth. However,
the case reports suggest that babies delivered after
mothers have received >300 g fentanyl (approx 5
g/kg) during the last 4 hours of labor may be at
greater risk.

One great advantage of epidural fentanyl administration compared to morphine is its lower incidence and
severity of adverse effects.
Adverse reactions include pruritus (most common
in 1035%); nausea and/or vomiting (530%), and urinary retention (05%). Mild to moderate sedation can
occur early on and is brief. Early respiratory depression is rare and there is no delayed respiratory depression. Shivering has been reported. There are a few case
reports of respiratory depression of newborn and
decreased apgar scores (if >5 g/kg are given within
the last 4 hours of labor). Reactivation of oral herpes
simplex virus, which has been reported with epidural
morphine, has not been reported with fentanyl.
Chapter 42 Epidural hydromorphone
References
1. Micromedex Healthcare Series.

2. Ginosar Y, Riley E, Angst M. The site of action of
epidural fentanyl in humans: the difference between
infusion and bolus administration. Anesth Analg
2003;97:14281438.
3. Curatolo M, Petersen-Felix S, Scaramozzino Z,
Binden A. Epidural fentanyl, adrenaline and
Section 3
Chapter
42
clonidine as adjuvants to local anesthetics for surgical

analgesia: meta-analyses of analgesia and side-effects.
Acta Anaesthesiol Scand 1998;42:
910920.
4. Grass JA. Fentanyl: clinical use as postoperative
analgesic-epidural/intrathecal route. J Pain Symptom
Manage 1992;7:419430.
Epidural hydromorphone
Susan Dabu-Bondoc and Greg Albert
Generic Name: hydromorphone (dihydromorphinone-HCl)

Proprietary Name: Dilaudid (preservative-free)
Manufacturer: Abbott Laboratories, 8401 TransCanada Highway, Saint-Laurent, Qubec, Canada
H4S 1Z1
Chemical Name: 4,5a-epoxy-3-hydroxy-17-methylmorphinan-6-one hydrochloride
Description
Hydromorphone is a semisynthetic opioid agonist
prescribed for control of moderate to severe pain. It
was first synthesized in 1924 and introduced by Knoll
pharmaceuticals under the brand name Dilaudid.
Intravenous hydromorphone is about 56 times more
potent than morphine; however, when administered
epidurally, morphine provides greater spinal selectivity and 23 times greater analgesic potency than
hydromorphone. Hydromophone is available as a
preservative-free
solution which has been advocated
for neuraxial administration. While not formally
FDA-approved, hydromorphone was one of the first
opioids administered via the epidural route, and its
safety and analgesic efficacy have been evaluated in a
number of clinical trials [13].

Epidural hydromorphones primary site of action is at
endogenous opioid receptors located on neurons in
lamina III (substantia gelatinosa) and lamina V of the
spinal dorsal horn. Following epidural administration,
hydromorphone enters the spinal cord and activates
pre- and postsynaptic mu receptors and suppresses pain
transmission. Systemic absorption and activation of
central opioid receptors may provide additional analgesia. Hydromorphone is not particularly hydrophilic,
and rostral migration in CSF is of lower magnitude than
that observed with morphine. Rostral spread of hydromorphone may result in undesirable side effects such as
pruritus, nausea and vomiting, and sedation. Epidural
hydromorphone is associated with dose-dependent
reductions in respiratory rate and minute ventilation;
however, unlike morphine, delayed-onset respiratory
depression is less likely to occur [3,4].
187
CH3
H
N
Figure 42.1.
CH2
H
HCI
CH2
OH

and elimination
Epidural hydromorphone has a short metabolic
and elimination half-life: typically 24 hours (23
hours with IV hydromorphone), with peak plasma
levels achieved in 214 minutes (510 min with IV
hydromorphone, 3060 min with oral dosing), and
peak CSF levels achieved in 60 min after epidural
administration. In those with renal impairment,
the half-life of hydromorphone can increase to as
much as 40 hours, hence caution must be exercised
when dosing hydromorphone in patients with kidney problems which can result in drug accumulation. Fortunately the glucoronated metabolite has
minimal clinical activity. Single-dose epidural
hydromorphone (1 mg) has an average clinical
analgesic duration of 67 h, only one-third as long
as morphine.
Indications
Surgical acute pain: epidural hydromorphone alone or
in combination with dilute local anesthetics can effectively relieve moderate to severe surgical pain.
Chronic pain: infusions of intrathecal and epidural
hydromorphone may be employed for control of chronic
benign and malignancy-related pain.
Contraindications
188
Contraindications to epidural hydromorphone infusions include documented severe allergic reaction or

hypersensitivity, patient refusal, infection or tumor at
the insertion site, septicemia, vertebral fractures/
instability, neural deficit, coagulopathy, and treatment
with low molecular weight heparinoids. As with other
epidural opioids, the American Society of Regional
Anesthesia (ASRA) issued guidelines with respect to
the safe use of anticoagulants when considering neuraxial anesthesia/analgesia.
Epidural doses
Intermittent bolus dosing
Chestnut and colleagues [5] were first to evaluate single doses of epidural hydromorphone (1 mg in 10 mL
saline) or placebo for pain control following cesarean
delivery. Patients assigned to the epidural hydromorphone group benefited from superior pain control,
with 92% reporting good or excellent pain relief versus 56% in the control group. Time to first request for
supplemental analgesia (IV hydromorphone) was
extended (13 vs. 3.1 h), and 24 hour requirement was
reduced (4.7 vs. 10.2 mg). Patients undergoing lower
extremity orthopedic and vascular procedures with
epidural anesthesia plus conscious sedation may be
given an intra-operative epidural dose of 0.51.5 mg
hydromorphone with appropriate doses of 0.50.75%
bupivacaine or ropivacaine to achieve surgical anesthesia. Supplemental boluses of local anesthetic may be
administered as required during the procedure. Epidural hydromorphone may be administered for relief
of post-operative pain following arthroscopic and less
invasive pelvic/perineal surgery.
Continuous epidural infusion

Patients undergoing orthopedic, abdominal, and thoracic surgeries with general anesthesia plus epidural
anesthesia/analgesia may be given an intra-operative
loading dose of 0.51.5 mg hydromorphone alone or in
combination with 0.1250.25% bupivacaine or 0.20.5%
ropivacaine depending on patient age and comorbidities. Supplemental boluses of local anesthetic are administered as required during the case. In extremely
prolonged procedures, an additional bolus of hydromorphone (2550% of loading dose) is given 6 hours into the
procedure. Alternatively, for elderly debilitated patients,
a light general anesthesia may be combined with epidural infusion using a reduced hydromorphone loading
dose of 0.250.75 mg with 810 mL 0.125% bupivacaine
or 0.2% ropivacaine followed by an intra-operative infusion of dilute hydromorphone (1020 g/mL) plus 0.1
0.031% bupivacaine at a rate of 816 mL/h. Infusions are
maintained during the course of a light sevoflurane, desflurane, or propofol-based general anesthetic. On near
completion of the surgical procedure or following arrival
in the PACU, the intra-operative basal infusion may be
maintained for 2472 h. Infusion rates are reduced by
one-third to one-half in patients greater than 70 yrs or
when administered via thoracic catheters.
Chapter 42 Epidural hydromorphone
Epidural patient-controlled analgesia

Guidelines for loading doses and continuous infusion
rates are similar or slightly less than those described
for the continuous infusion technique. When patients
become alert and oriented in the post-anesthesia care
unit, the patient is given a PCA button. PCA bolus
doses (14 mL of solution) with a 68-minute lockout
interval are added to supplement the epidural infusion. To further improve the overall quality of analgesia, non-opioid analgesics such as IV ketorolac (7.515
mg every 6 hours), and oral Celecoxib (200 mg twice
a day) may be prescribed to augment hydromorphonebased epidural analgesia. A standardized order set
for epidural PCA (EPCA) with hydromorphone is
presented in Table 42.1.
Epidural PCA is maintained for 24 days, depending upon the procedure and potential benefit to
the patient. Most patients make a smooth transition
to oral opioids such as oxycodone or oxycodone-
acetaminophen compounds, or to low-dose IV-PCA
therapy for some who remain nil per os (NPO) for
extended periods. For opioid-dependent or chronic
pain patients the loading dose of epidural hydromorphone is increased by 50100% and the infusion concentration increased by 100% or more to compensate
for opioid tolerance and down-regulation of spinal
opioid receptors. Judicious use of adjuvants such as
epidural clonidine, or IV ketamine infusions, or methadone may be administered to further augment pain
relief in opioid-dependent patients. These patients
should always receive their baseline opioids either
orally or parenterally (IV-PCA) in addition to the epidural infusion, to prevent opioid withdrawal and provide supraspinal analgesic potentiation [2]. Dosing
guidelines for epidural hydromophine are summarized in Table 42.2.
At Yale New Haven Hospital, epidural solutions are
prepared by hospital pharmacy services by adding 5
mg (0.5 mL) preservative-free hydromorphone (taken
from a mutidose vial of Dilaudid-HP 10 g/mL) to a
500 mL normal saline solution. Calculated volumes of
0.75% bupivacaine (without epinephrine) are added to
achieve infusate concentrations of 0.06250.031%,
kept sterile and refrigerated at 40F [2,4].
Table 42.1. Hydromorphone EPCA order set

1.
Patient has an epidural catheter for post-operative pain control and will be managed by the anesthesiology pain management
service, beeper ____
2.
Catheter is placed at ____ interspace. and is ____cm at the skin
3.
Please check the insertion site per shift. Notify the pain service if any of the following is observed: leaking of infusate, redness,
bleeding
4.
Epidural analgesic: hydromorphone 10 g/mL plus bupivacaine 0.031%

Hydromorphone 10 g/mL plus bupivacaine 0.0625%
Hydromorphone 20 g/mL plus bupivacaine 0.625%
Hydromorphone_____g/mL
Hydromorphone _____g/mL plus ropivacaine 0.1%
5.
Epidural continuous infusion rate_______mL/h
6.
Epidural bolus dose______mL, per______min
7.
Four hour dose limit__________mL
8.
Adjunctive analgesia: ketorolac____mg, _____h

Celecoxib____mg, _____h
9.
Treatment of adverse events:

______ (Pruritus) naloxone infusion (400 g/L, infuse at _____mL/h)
_______ (Nausea) ondansetron ____mg, ____h
_______ (Nausea) droperidol ____mg, ____h
_______ (Respiratory depression) naloxone____ g
10.
Notify the anesthesiology pain service if the patient has a respiratory rate of 10 or less, oxygen saturation 90% or less, is troubled
by pain intensity greater than 5, or is troubled by nausea, vomiting and pruritus unresponsive to standard therapy
189
Table 42.2. Dosing guidelines for epidural hydromorphone

1.
Single bolus technique: administer 0.51.5mga in 10 mL preservative free saline, or dilute local anesthetic every 68 h
2.
Continuous infusion technique: administer 0.51 mg bolusa followed by infusion (hydromorphone 1020 g/mL) alone or with
local anesthetic (bupivacaine 0.10.031% or ropivacaine 0.10.2%) at a rate of 816 mL/h
3.
Patient-controlled technique: administer 0.51 mg bolusa followed by infusion (hydromorphone 1020 g/mL) alone or with
local anesthetic (bupivacaine 0.10.031% or ropivacaine 0.10.2%) at rate of 812 mL/h, Provide PCA boluses of 24 mL of
solution with lockout of 68 min
4.
Adjunctive therapyb: ketorolac IV (7.515 mg every 6 h), celecoxib PO (200 mg every 12 h)
Dependent on age, physical status, height, extent of surgical dissection, degree of opioid tolerance and so on, reduce dose by 2533%
with thoracic epidural placement.
b
Unless contraindicated.
a
Being moderately lipid-soluble, vascular uptake of epidural hydromorphone is lower than that of fentanyl,
although its ability to remain in CSF and spread rostrally is greater. This property provides important clinical advantages: (1) like morphine, doses administered
via high lumbar and low thoracic catheters can control
pain at higher dermatomal segments, and (2) epidural
administration is associated with three times greater
potency than similar amounts given IV. Unlike morphine, which is more hydrophilic, rostral spread to
brainstem respiratory centers and delayed respiratory
depression is less likely to occur. The short latency and
long duration of analgesia in spinal cord regions far
distant from the site of hydromorphone injection are
desirable characteristics. Epidural hydromorphone has
a more rapid onset, and a less troublesome side-effect
profile compared to morphine. Its safety and side-effect
profile is superior to morphine as equianalgesic doses
are associated with less risk of excess sedation and
delayed respiratory depression. In our experience, epidural hydromorphone is associated with less nausea
and vomiting, less sedation, and fewer histamine-related side effects such as itching and skin erythema,
than that observed with morphine. Preservative-free
hydromorphone is relatively inexpensive and is widely
available. Cost: 4 mg/mL (20 cartridges, 1 mL): $35.00.
190
Like other epidural opioids, invasiveness and placement/follow-up expenses are greater compared to
parenteral administration.
Like most other neuraxial opioids, it may increase
risk of respiratory compromise in patients who are
morbidly obese or have chronic obstructive pulmonary disease and those with chronic sleep apnea.
Hydromorphone may compete with other drugs
for hepatic glucoronidation.

and treatments
Common adverse events: sedation, respiratory depression, pruritus, nausea/vomiting, constipation, and
urinary retention, which are treated with a naloxone
4080 g IV bolus followed by an infusion of 50100
g/h. However, these adverse events are relatively less
commonly observed with epidural hydromorphone
than with neuraxial morphine regimens. Pruritus is
treated with a naloxone infusion of 50100 g/h,
diphenhydramine 12.550 mg or propofol infusion of
10 mg/h. Nausea and vomiting is best treated with
either ondansetron (48 mg IV), low-dose droperidol
(0.6251.25 mg IV), metoclopramide (10 mg IV every
46 h), or transdermal scopolamine patch during the
first 10 hours following administration.
References
1. Brose WG, Tanelian DL, et al. CSF & blood

pharmacokinetics of hydromorphone and morphine
following lumbar epidural administration. Pain
1991;45:1115.
2. Dabu-Bondoc S, Franco S, Sinatra R. Neuraxial
analgesia with hydromorphone, morphine, and
fentanyl: dosing and safety guidelines. In Sinatra RS,
de Leon-Casasola OA, Ginsberg B, Viscusi ER, eds.
Acute Pain Management. New York: Cambridge
University Press, 2009, pp. 230244.
3. Wong C, et al. Spinal and Epidural Anesthesia. New
York: McGraw-Hill, 2007, pp. 75110.
4. Ayoub C, Sinatra RS. Postoperative analgesia: epidural
and spinal techniques. In Chestnut DH, ed. Obstetric
Anesthesia: Principles and Practice, vol. III. St Louis:
Mosby, 2004.
5. Chestnut DH, Choi WW, Isbell TJ. Epidural
hydromorphone for postcesarean analgesia. Obstet
Gynecol 1986;68(1):6569.
Section 3
Chapter
43
Epidural sufentanil
Jill Zafar, Anthony T. Yarussi and Laura Mechtler
Generic Name: sufentanil

Trade Name: Sufenta
Chemical Name: N-{4-(methoxymethyl)-1-(2thiophen-2-ylethyl)piperidin-4-yl}-N-phenylpropanamide
Manufacturer: Claris Lifesciences Inc., 542
Industrial Way West, Eastontown, NJ 07724
Class: opioid analgesic
Description
fast onset of action when it selectively binds to the

spinal mu receptors. Mu opioid receptors are coupled to G proteins and are thus able to activate the
intracellular secondary messenger system when the
opioid agonist binds to its receptor in the CSF. Subsequently, activated G protein subunits alter the ion
channel conductance of the neuron by inhibiting
Ca influx and enhancing the outward movement of
K from the cell. Presynaptically this inhibits the
release of neurotransmitters such as substance P
and glutamate.
Duration of action of epidural sufentanil is between
that of fentanyl and morphine, usually between 2 and
4 hours. Once systemically absorbed it is metabolized
by the liver and excreted by the kidney.
Sufentanil is a potent opioid analgesic that is primarily

administered intravenously as an adjunct in anesthesia during surgery or as an epidural analgesic during
labor and vaginal delivery. Sufentanil is a synthetic
anilinopiperidine that binds to and activates the mu
opioid receptors on neuronal cell membranes which
are present in large quantities in the periaqueductal
gray matter (human brain) and the substantia gelatinosa (spinal cord). Activation of mu receptors predominantly causes analgesia and sedation along with
other side effects. Sufentanil is the thienyl analog of
fentanyl and is approximately 510 times more potent
than fentanyl.
Indications
Mode of activity
The addition of epidural sufentanil to local anesthetics

significantly potentiates their analgesic effects. They
also provide for safe and effective analgesia at a lower
concentration and dose of local anesthetics. As a result
this decreases the incidence of side effects such as
motor blockade and hypotension.
Sufentanil (as other opioids) given epidurally can

produce analgesia one of three ways. It can spread
cephalad in the CSF to supraspinal centers, be
absorbed systemically and transfer to supraspinal
centers, or act directly in the dorsal horn of the spinal cord on the spinal opioid receptors. It is felt that
the main site of action of epidural sufentanil is presynaptic modulation of the nociceptive signal in the
lamina of Rexed in the spinal cord. Sufentanil has a
In the 1970s sufentanil was first introduced as a new

potent opioid for use in anesthesia. The use of this
drug was originally recommended for intravenous
peri-operative analgesia. In the following years other
uses for this opioid were explored, such as intrathecal
and epidural use for peri-operative analgesia, labor and
delivery, and chronic pain. Although epidural sufentanil is only FDA-approved for use in labor and delivery, studies have found it to be an acceptable option in
other clinical situations.
Labor and delivery
Post-operative pain management

Sufentanil is an effective analgesic when used in
continuous epidural infusions. It has been used for
191
O
H3C
C22H30N2O2S
N
OCH3
Figure 43.1.
post-operative pain control in general surgery, orthopedic, thoracic, and cesarean section procedures.
When sufentanil is combined with bupivacaine epidurally, the dose requirement for post-operative analgesia has been shown to be 50% less than intravenous
requirements.
Chronic pain
Epidural sufentanil is beneficial in chronic pain
patients tolerant to morphine. Recent evidence has
shown that tolerance occurs from a progressive loss of
receptor site action due to prolonged agonist exposure. With prolonged opioid use there is an eventual
loss of receptors on the cell surface and fewer binding
sites, resulting in higher dose requirements. When
this occurs, sufentanil can be used as it is a more
effective opioid. It has a higher intrinsic efficacy than
morphine, and an analgesic effect will occur with less
receptor binding.
Epidural sufentanil is not typically used for neuropathic pain.
Contraindications
Absolute: patients with known hypersensitivity to
sufentanil or known intolerance to other opioid
agonists.
Relative: patients with chonic obstructive pulmonary disease and head injuries. In addition, patients
with hepatic or renal impairment are at risk due to the
importance of these organs in the metabolism and
excretion of sufentanil.
Common doses/uses
192
Epidural opioids are frequently used for the management of pain. Sufentanil, which is five times more
potent than fentanyl, has been studied for its analgesic
effects epidurally. It can be administered by either
bolus dose or continuous infusion technique. Bolus
dosing can range from 10 to 50 g with a duration of

action of approximately 24 hours. Continuous infusion techniques can also be used. Rates of 0.3 g/kg
per h have been shown to provide rapid onset and sustained analgesia in abdominal surgery. In addition
rates of 48 mL h of a 12 g/mL solution have been
used with good success. These techniques may be safer
as they take advantage of the drugs shorter duration
of action and can reduce the respiratory risks that are
present with bolus use. Patient-controlled epidural
anesthesia can be used as well at a dose of 2.5 g every
10 min as needed. During labor and vaginal delivery
10 to 15 g doses can be given epidurally mixed with
10 mL of 0.125% bupivacaine. This dose can be
repeated two times at intervals of not less than 1 hour
until delivery.
Sufentanil is a sterile, preservative-free, aqueous solution that is readily available in the majority of hospitals and pain clinics in the USA. Due to its
lipophilicity and high affinity for the mu opioid receptors, sufentanil has a more rapid onset of action (5 to
15 minutes) and shorter duration of action as an
analgesic than morphine. Sufentanil is effective in
epidural PCA and provides a good quality of analgesia. It is primarily used as a multimodal agent combined with local anesthetics epidurally for
post-operative pain control. A combination of analgesic drugs provides more effective pain control at
lower doses than relying on one drug alone. In addition, the drug combination reduces the risk of adverse
effects from any one drug.
It produces less respiratory depression due to its
lipophilic properties so less drug accumulates in
the CSF.
There is no known toxicity even at epidural doses as
high as 600800 g/day. Patients on high doses should
be monitored with neurological exams for myoclonic
movements or changes in behavior.
Epidural spread of lipophilic drugs is limited in
the epidural space as a result of their high lipid solubility. As a result, these opioids are more dermatom
ally restricted than hydrophilic ones so that epidural
catheters need to be placed at the center of the dermatomes involved in the surgical procedure to achieve
a good quality of analgesia.
Chapter 43 Epidural sufentanil
Table 43.1. Drug-related adverse events
Body system
Common/serious adverse side

effects
Less common adverse effects
Central nervous system
Sedation
Spinal cord damage from toxic

preservatives rare, tonic skeletal
muscle rigidity
Respiratory
Regulatory depression within 2 hours from

systemic absorption
Gastrointestinal
Nausea, vomiting
Genitourinary
Urinary rentention
Dermatological
Pruritus most common side effect from

neuraxial opioids, most cases are mild; due
to cephalad migration of opioid in CSF
Drug interactions: barbiturates, tranquilizers, other

narcotics, antihistamines, antidepressants, MAO inhibitors, and alcohol can all increase CNS depression. The
risk of bradycardia and hypotension increases for
patients on beta blockers and calcium channel blockers. Cimetidine, used to treat peptic ulcers, interacts
with sufentanil and increases the risk of respiratory
depression.
Cost: sufentanil provides a faster onset and a more
rapid recovery than morphine or fentanyl. However,
morphine and fentanyl are chosen as the cost effective
alternatives.

See Table 43.1 for the main adverse effects.
Other infrequent side effects include ocular dysfunction with miosis and nystagmus. Inhibition of
shivering from loss of thermoregulatory function and
oliguria with water retention from ADH stimulation
can occur.
Naloxone, an opioid antagonist, is used clinically
to reverse respiratory depression, sedation, or opioid
overdose caused by sufentanil. Naloxone has a high
Delayed gastric emptying

Cold sores from viral reactivation
mu receptor affinity and therefore competes with the

opioid from the same receptor sites. Intravenous doses
of naloxone (0.10.4 mg) repeated every 2 to 3 minutes are administered until the patient is breathing or
responds.
References
1. Ballantyne J, Fishman S, Salahadin A, eds. The

Massachusetts General Hospital Handbook of Pain
Management, 2nd ed. Philadelphia: Lippincott
Williams & Wilkins, 2002.
2. Joris JL, Jacob EA, Sessler DI. Spinal mechanisms
contribute to analgesia proceduced by epidural
sufentanil combined with bupivacaine for postoperative
analgesia. Anesth Analg 2003;97(5):14461451.
3. Sufenta. Janssen-Ortho Inc., 26 July 1985.
http://www.janssenortho.com/JOI/pdf_files/sufenta_E.pdf. Accessed
August 4, 2009.
4. de Leon-Casasola OA, Lema MJ. Epidural
bupivacaine/sufentanil therapy for postoperative pain
control in patients tolerant to opioid and unresponsive
to epidural bupivacaine/morphine. Anesthesiology
1994;80:303309.
193
Section 3
Chapter
44
Extended-release epidural morphine

Akta Patel, Eugene R. Viscusi and Leslie Schechter
Generic Name: morphine extended-release

liposome injection
Trade/Proprietary Name: DepoDur
Manufacturer: Pacira Pharmaceuticals Inc., San
Diego, CA 92121; distributed by EKR Therapeutics Inc., Cedar Knolls, NJ 07927
Chemical Name: 7,8-didehydro-4,5-epoxy-17methylmorphinan-3,6-diol sulfate (2:1) (salt)
pentahydratemax
Introduction
DepoDur is a sterile, non-pyrogenic, white to offwhite, preservative-free suspension of multi-vesicular
lipid-based particles containing morphine sulfate,
USP. The lipid carrier is a proprietary drug delivery
system known as DepoFoam. After the administration of DepoDur into the epidural space, morphine
sulfate is released from the multivesicular liposomes
over a period of time [13] (Figures 44.2 and 44.3).
Mode of activity
194
It is absorbed both neuraxially and systemically. DepoDur has a principal effect on opioid receptors in the
dorsal horn of the spinal cord as well as in other regions
of the central nervous system (CNS). Additionally, it
works in the gastrointestinal (GI) tract and other smooth
muscles. However, it does not have a major effect on the
cardiovascular system at therapeutic doses.
Effects on the CNS: principal therapeutic action of
morphine is analgesia; other effects include euphoria,
anxiolysis, and feelings of relaxation.
Effects on the GI tract and other smooth muscles:

decreases gastric, biliary, and pancreatic secretions;
causes a reduction in motility.
Effects on the cardiovascular system: no major
effects; may result in orthostatic hypotension and
fainting.
Receptor interactions: morphine is a pure opioid
agonist relatively selective for the receptor, although
it can interact with other opiate receptors at higher
doses.
Metabolic pathways/drug clearance and elimination: the major metabolic pathway is conjugation,
either with d-glucuronic acid in the liver to produce
glucuronides or with sulfuric acid to give morphine-3etheral sulfate. Approximately 10% of morphine dose
is excreted unchanged in the urine. Most of the dose is
excreted as glucuronide metabolites, including morphine-3-glucuronide (M3G; about 50%) and morphine-6-glucuronide (M6G; about 5 to 15%). M3G
has no significant analgesic activity. M6G has been
shown to have opiate agonist and analgesic activity in
humans. Seven to ten percent is excreted in the feces.
The mean adult plasma clearance is about 2030 mL/
min per kg. The terminal half-life of morphine is
approximately 2 hours.
Indications
DepoDur is approved for the treatment of pain following major surgery or after clamping the umbilical
cord during cesarean section by a single-dose administration into the lumbar epidural space.
It is not intended for intrathecal, intravenous, or
intramuscular administration. Administration of Depo
Dur into the thoracic epidural space or higher has not
been evaluated and therefore is not recommended.
Contraindications
Absolute: patients with known hypersensitivity to morphine, morphine salts, or any components of the product.
Chapter 44 Extended-release epidural morphine
Figure 44.1.
H3C
H
CH2
H2SO4 5H2O
H
C
H2
HO
OH
Relative: patients with respiratory depression,

acute or severe bronchial asthma, and upper airway
obstruction; any patient who has or is suspected of
having paralytic ileus; patients with suspected or
known head injury or increased intracranial pressure.
It is contraindicated in circulatory shock as it causes
vasodilatation, which may exacerbate hypotension
and hypoperfusion.
Approved doses (based on FDA pivotal

trials)
Major orthopedic surgery of the lower extremity
15 mg
Lower abdominal or pelvic surgery 10 to 15 mg
Some patients may benefit from a 20-mg dose of
DepoDur
Cesarean section 10 mg
Clinically useful dosing (based on the

authors clinical experience)
In most circumstances and particularly with multimodal analgesia, patients may benefit from doses of
EREM lower than those in the label. Lower dosing
may reduce opioid-related side effects.
Figure 44.2. DepoFoam Particle.
Total hip arthroplasty 7.5 10 mg

Total knee arthroplasty 10 12.5 mg
Lower abdominal surgery 7.5 10 mg
Cesarean section 7.5 10 mg
How supplied
Preservative-free DepoDur 10 mg/mL singleuse, amber vials for epidural administration
10 mg/1 mL vial packaged in cartons of 5
15 mg/1.5 mL vial packaged in cartons of 5
Figure 44.3. Internal structure of DepoFoam (freeze fracture

electron microscope image).
Ease of use: the potential of providing extended analgesia without an epidural catheter and epidural pump
or IV-PCA pump is very desirable. External pump
technology is cumbersome for the patient, time-consuming for the nursing staff, and is associated with
medication errors and pump programming errors. In
many surgical settings, anticoagulation to prevent
195
venous thromboembolism is now standard care. Consequently, indwelling epidural catheters may increase
the risk of epidural hematoma formation. DepoDur
may provide extended analgesia without the need for
indwelling epidural catheters and without the difficulties associated with current epidural and IV-PCA
pumps.
Tolerability: DepoDur is intended for single-dose
administration; therefore accumulation of morphine
or its metabolites is not expected even in patients with
impaired hepatic or renal function [3].
In a pilot study including 37 patients, the opioidsparing effect of DepoDur on subsequent fentanyl
PCA requirements was assessed. DepoDur use
resulted in reduced total fentanyl requirements,
increased time-to-rescue, and lower pain ratings over
48 hours [4].
In a double-blind, double-dummy, sham-controlled study including 168 total knee arthroplasty patients,
subjects were assigned to receive DepoDur 30 mg,
DepoDur 20 mg, or sham epidural injection, to compare DepoDur with morphine PCA. DepoDur
patients experienced less pain and required less opioid
rescue as compared to morphine PCA patients [5].
Hartrick and Hartrick [1] conducted a study
assessing the safety of DepoDur by combining and
analyzing the adverse effects from previous trials.
This study showed that patients in the high-dose
DepoDur group experienced a higher incidence of
pruritus as compared to standard epidural morphine.
There were no differences between low-dose DepoDur and standard epidural morphine. In general,
opioid-related adverse effects were seen in all groups,
which is not surprising, as multimodal analgesia was
not used to reduce DepoDur dose in many of these
studies.
Availability: widely available at most hospitals.
Cost : although the cost of DepoDur ($327$491/
dose) is significantly greater than morphine sulfate
injection (~$1/syringe), there are many cost advantages for DepoDur, which include the following:
196
(1) decreased post-operative IV-PCA use and

therefore costs and potential for pump
programming errors;
(2) decreased use of sciatic nerve blocks, which can last
up to 24 hours and delay time to ambulation and
physical therapy and may impact length of stay;
(3) ability to initiate anticoagulation (heparin,
LMWH) after surgery without the risk of spinal
hematomas associated with epidural catheters.
Toxicity: prolonged and serious respiratory depression or apnea has occurred when administration of
epidural DepoDur was associated with subarachnoid
puncture.
Drug interactions: administration of DepoDur
after an analgesic dose of bupivacaine (0.25% 20 mL)
increases peak serum concentrations of morphine.
Increasing the interval between the analgesic dose and
DepoDur administration to greater than 30 minutes
minimizes this pharmacokinetic interaction.
Warnings: epidural local anesthetics should not be
used before or after DepoDur except: (1) in the form
of a 3 mL test dose with lidocaine 1.5% and epinephrine 1:200,000, or (2) a therapeutic dose of bupivacaine 0.25% 20 mL.
Do not mix or co-administer DepoDur with any
other medications, including local anesthetics. Once
DepoDur has been administered, no other medication should be administered into the epidural space
for at least 48 hours [2,3].

Common adverse events (>10%): decreased oxygen
saturation, hypotension, urinary retention, vomiting,
constipation, nausea, pruritus, pyrexia, anemia, headache, and dizziness.
Adverse events (510%): hypoxia, tachycardia,
insomnia, and flatulence.
Other adverse events (25%): respiratory depression, hypercapnia, paralytic ileus, somnolence, bladder spasm, abdominal distension, dyspepsia, rigors,
dyspnea, hypokalemia, paresthesia, and decreased
hematocrit.
The concurrent use of other CNS depressants,
including sedatives, hypnotics, general anesthetics,
droperidol, phenothiazines or other tranquilizers, or
alcohol, increases the risk of respiratory depression,
hypotension, profound sedation, or coma.
MAOIs markedly potentiate the action of morphine. DepoDur should not be used in patients taking
MAOIs or within 14 days of stopping such treatment.

Respiratory depression: naloxone slow titration to
achieve adequate ventilation without reversing all
analgesia is recommended. An initial dose of 0.1 mg
IV may be administered; an infusion may be necessary
to treat ongoing respiratory depression. In situations
Chapter 45 Intrathecal morphine
of severe respiratory depression, assisted or controlled

ventilation may be necessary.
Nausea: ondansetron 4 mg IV every 6 h; metoclopramide 10 mg PO/IVP every 6 h; promethazine 6.25 mg
IV every 8 h. Preventive treatment is recommended.
Pruritus: diphenhydramine 2550 mg PO/IVP
every 6 hours. Non-sedating antihistamines are also
effective. Low-dose opioid antagonists may be effective when antihistamines are ineffective.
References
1. Hartrick CT, Hartrick KA. Extended-release epidural

morphine (DepoDur): review and safety analysis.
Expert Rev Neurother 2008;8(11):16411648.
2. DepoDur (package insert). Cedar Knolls, NJ: EKR
Therapeutics, Inc., 2007
3. DepoDur (updated package insert). Bedminster, NJ:
EKR Therapeutics, Inc., 2008
4. Gambling D, Hughes T, Martin G, et al. A comparison
of DepoDur, a novel, single-dose extended-release
Section 3
Chapter
45
epidural morphine, with standard epidural morphine

for pain relief after lower abdominal surgery. Anesth
Analg 2005;100(4):10651074.
5. Viscusi ER, Martin G, Hartrick CT, et al. Forty-eight
hours of postoperative pain relief after total hip
arthroplasty with a novel, extended-release epidural
morphine formulation. Anesthesiology
2005;102(5):10141022.
6. Viscusi ER. Liposomal drug delivery for postoperative
pain management (translational vignette). Reg Anesth
Pain Med 2005;30(5):491496.
7. Viscusi E, Gambling D, Hughes T, Manvelian G. The
serum pharmacokinetics of extended-release epidural
morphine sulfate (DepoDur): a pooled analysis of 6
clinical studies. Am J Health-Syst Pharm
2009;66:10201030.
8. Viscusi ER, Manvelian G. A randomized controlled
study of the serum pharmacokinetics, effectiveness, and
safety of thoracic extended-release epidural morphine
(Depodur) after lidocaine-epinephrine test dose
administration in patients undergoing upper abdominal
surgery. Int J Pharmacol Ther 2009;47:659670.
Intrathecal morphine
James M. Moore
Class: analgesic agent

Generic Name: morphine, intrathecal
Structural Formula: 5,6-7,8-didehydro-4,5epoxy-17-methylmorphinan-3,6-diol; molecular wt 285.34; for intrathecal use, morphine is
available as the sulfate salt with the following
formula: (C17H19NO3)2H2SO45H2O; molecular
wt 758.83
Description
Morphine is the principal active alkaloid of opium
and a phenanthrene derivative. Morphine sulfate
for intrathecal administration is available in the
USA under the brand names Astramorph/PF and
Duramorph for use in acute pain and Infumorph
for chronic intrathecal use. These preparations are all
isobaric and preservative-free aqueous solutions.
Mode of activity
Intrathecal morphine binds opioid receptors within
the neurons of the gray matter of the dorsal horn of the
197
CH3
H
Figure 45.1.
CH2
H2SO4 5H2O
CH2
HO
OH
spinal cord, including but not limited to the substantia

gelatinosa. Opioid receptor activation blocks release of
substance P and other excitatory neurotransmitters,
causing inhibition of ascending nociceptive pathways
and altering the perception of and response to pain.
Due to morphines hydrophilic nature, the spinal
cords exposure over time to intrathecal morphine
greatly exceeds that of other spinal opioids, leading to
a prolonged analgesic effect but also greater rostral
spread and the potential for delayed respiratory
depression and sedation. Compared to less hydrophilic
opioids, morphine has a lower spinal cord distribution
volume, slower clearance from the spinal cord into the
plasma, and higher bioavailability in the extracellular
fluid space of the spinal cord [1].
Drugs injected into the cerebrospinal fluid may
redistribute into the epidural space and fat, and morphine does so to a significant extent. However, doses of
intrathecal morphine used clinically are so small that
substantial plasma levels are not seen. The propensity
for intrathecal morphine to penetrate the spinal cord to
enter the gray matter of the dorsal horn is greater than
for other less hydrophilic opioids. Although pulsation
of the cerebrospinal vasculature produces motion of
cerebrospinal fluid, such motion is complex and less
pronounced in the lumbar region than in the cervical
region. Other factors that may influence the spread of
intrathecal morphine include the baricity and volume
of injectate as well as the force of injection.
198
Intrathecal morphine is indicated for the management

of pain not responsive to non-narcotic analgesics, but
it should be administered in a fully equipped and
staffed environment. Naloxone injection should be
immediately available. Patients receiving intrathecal
morphine should remain in this environment for at
least 24 hours following the initial dose. Repeated
intrathecal injections of morphine for acute pain are
not recommended.
Single-dose intrathecal morphine may be effective for

patients at risk for severe post-operative pain from a variety of major surgical procedures, including lower extremity orthopedic surgery, abdominal surgery, and operations
of the lumbar and thoracic spine. It is commonly given for
analgesia for patients undergoing cesarean section.
In some cases usually amenable to continuous epidural analgesia, the use of an indwelling epidural catheter
at an optimal spinal level is not feasible, such as when epidural catheter placement is unsuccessful or is precluded
by planned post-operative anticoagulation. In such circumstances, intrathecal morphine may be given instead.
Non-approved uses include administration of
intrathecal morphine to pediatric patients, and use
in pediatric patients undergoing scoliosis repair is
common.
Contraindications
Intrathecal morphine is contraindicated in the presence of a true allergy to morphine and in patients with
preexisting severe respiratory depression or sedation.
It should be avoided in patients with elevated intracranial pressure and used with caution in patients with or
at risk for upper airway obstruction. Systemic morphine administration can exacerbate bronchospasm
in patients with acute asthma, and systemic absorption of intrathecally administered morphine might
have a similar effect, although the amount of morphine entering the systemic circulation is small.
Like all opioid analgesics, intrathecal morphine
may cause severe hypotension in a patient whose ability to maintain blood pressure is already compromised
by hypovolemia or concurrent drug administration.
Common doses
Intrathecal morphine may be given alone for analgesia or
as part of a surgical spinal anesthetic. Limited information is available on which to base rational dosing choices.
It is unclear whether any anthropometric patient characteristics such as height and weight relate to intrathecal
morphine dose requirement for analgesia. Elderly patients
are more at risk for respiratory depression and sedation
and should receive lower doses than other patients. The
more cephalad the site of spinal innervation of the surgical site, the greater the dose requirement may be. On the
other hand, dosing is constrained by potential side effects,
especially respiratory depression and sedation, and in
some models escalating intrathecal morphine dose does
not confer further analgesia over low doses.
Chapter 45 Intrathecal morphine
In many patients, intrathecal morphine at a dose

of 0.10.2 mg produces effective analgesia for at least
12 hours and acceptable side effects. Higher doses may
be used, but increasing dose can increase the risk of
pruritus and especially respiratory depression.
For hip arthroplasty in elderly patients, a dose of
0.2 mg confers analgesia with a favorable side-effect
profile [2]. For major abdominal surgery a dose of
0.20.4 mg has been reported. Much higher doses are
sometimes used in cardiac surgery in patients who
will initially have post-operative ventilation. Effectiveness limits the use of intrathecal morphine in patients
undergoing thoracotomy. Adult patients undergoing
major spine surgery receive effective analgesia and a
low risk of respiratory depression with an intrathecal
morphine dose of 0.3 mg [3].
For cesarean section, intrathecal morphine is often
given as part of the surgical spinal anesthetic. Most
commonly doses of 0.10.2 mg morphine are given,
and a dose of 0.1 mg may be as effective as higher
doses with less risk of pruritus [4].
For pediatric patients undergoing posterior spinal
fusion and segmental spinal administration for idiopathic scoliosis, a dose of pre-operative intrathecal
morphine ranging from 9 to 19 g/kg with a mean of
14 g/kg provided effective analgesia with a low frequency of respiratory depression and intensive care
unit admission [5]. Another report of pediatric spinal
fusion patients showed no advantage of 15 g/kg
intrathecal morphine over a dose of 5 g/kg [6].
Compared to epidural and intravenous use, intrathecal morphine administration produces profound analgesia at a low dose and leads to minimal systemic
absorption and low plasma levels. Intrathecal needle
placement is often technically easier and less traumatic than epidural needle placement.
A single dose of intrathecal morphine may produce analgesia for 12 to 33 hours.
For post-operative analgesia, intrathecal morphine is
usually given as a one-time injection, thus limiting the
duration of effect and obviating the ability to titrate
the dose to effect as can be done with opioids administered by other routes.
Information on appropriate dosing is limited.
Generally, effective dosing must be tempered to avoid
side effects, especially respiratory depression.

Opioid side effects may occur with intrathecal morphine just as with any opioid administration.
The most concerning and least common opioid
side effect with intrathecal morphine is the combination of respiratory depression and sedation, often
occurring approximately 8 hours after intrathecal
morphine administration with a steady, gradual onset.
Monitoring patients on an hourly basis for changes in
respiratory rate and sedation level for at least 12 hours
after intrathecal morphine dosing should detect clinically significant episodes of respiratory depression
and sedation. The need for and duration of such monitoring may depend on the dose of morphine. A traditional dose of intrathecal morphine is at least 0.1 mg,
but much lower doses have not been well studied and
may be associated with very low risk of respiratory
depression. Intrathecal morphine dose of <0.3 mg
may be less likely to produce respiratory depression
than higher doses [7].
Pruritus is the most common opioid side effect of
intrathecal morphine. It may occur even with small
doses and can be effectively treated with either intermittent intravenous nalbuphine or an infusion of
low-dose intravenous naloxone. Pruritus due to
intrathecal morphine does not respond well to
diphenhydramine.
Urinary retention may occur and may be due to
reduced parasympathetic output causing detrusor
muscle relaxation and inhibition of sphincter relaxation. Some patients have urinary catheters prophylactically inserted out of concern for this side effect.
Nausea and vomiting may occur, possibly due
to direct stimulation of the medullary vomiting
center [8].
References
1. Umenhofer WC, et al. Comparative spinal distribution

and clearance kinetics of intrathecally administered
morphine, fentanyl, alfentanil, and sufentanil.
2. Rathmell JP, et al. Intrathecal morphine for postoperative analgesia: a randomized, controlled,
dose-ranging study after hip and knee arthroplasty.
Anesth Analg 2003;97:14521457.
3. Boezaart AP, et al. Intrathecal morphine: double-blind
evaluation of optimal dosage for analgesia after
major lumbar spinal surgery. Spine 1999;24:
11311137.
199
4. Gurgin NK, et al. Intrathecal morphine in anesthesia

for cesarean delivery: dose-response relationship
for combinations of low-dose intrathecal morphine
and spinal bupivacaine. J Clin Anesth 2008;20:
180185.
5. Tripi PA, et al. Intrathecal morphine for postoperative
analgesia in patients with idiopathic scoliosis
undergoing posterior spinal fusion. Spine
2008;33:22482251.
Section 3
Chapter
46
Evaluating epidural catheters

Anna Clebone and Raymond S. Sinatra
General considerations
200
6. Eschertzhuber S, et al. Comparison of high- and

low-dose intrathecal morphine for spinal fusion in
children. Br J Anaesth 2008;100:538543.
7. Gehling M, Tryba M. Risks and side-effects of
intrathecal morphine combined with spinal
anaesthesia: a meta-analysis. Anaesthesia
2009;64:643651.
8. Gwirtz KH. Intrathecal analgesia. Problems Anesth
1998;10:7179.
First! Gather all relevant information from the anesthesia team and record to determine where the catheter is
and its functionality.
Always remember: continuous monitoring of BP,
HR, and SaO2 is required before, during, and after epidural test or bolus dosing in all patients.
Before dosing any medication:
a. Who placed the epidural? A senior experienced
attending (probably placed correctly) or a very
junior resident (catheter could be anywhere!).
b. How sure is the team of the catheters placement? If
the team states we think its in or it was difficult
but we think its in, it is probably not placed
correctly!
c. How many attempts were required? If multiple
attempts were required, or the team may have
caused a dural puncture, be very cautious giving a
test dose and use only dilute 1/8% bupivacaine
(see Dosing box below).
d. How deep is the catheter placed? How many cm is
the catheter from the skin and into the epidural
space? The OR team will have recorded this in the
anesthesia record. Ideally it should be 3 cm into
the epidural space. If too deep and not working
well, consider pulling the catheter out to 3 cm. If

the catheter is only 1.5 cm or less in the epidural
space, it may not be usable, but consider retesting
before discontinuing completely (see Dosing
box below).
e . How much supplemental anesthesia was needed? If
the team states the blood pressure dropped
following boluses of local anesthesia, or the
patient required minimal general anesthesia, it
may be positioned correctly in the epidural space!
How to determine initial dosing

a. Was the catheter bolused intra-operatively with
fentanyl or hydromorphone? If not, consider
bolusing with 50 g fentanyl, 0.51 mg
hydromorphone.
b. When was the catheter dosed? If more than 6
hours ago, the patient may a need a rebolus of
hydromorphone 0.51 mg.
c. Is the patient opioid-dependent/tolerant? Consider
rebolus with 1.52 times the standard
hydromorphone dose (up to 2 additional mg).
Then consider a double strength epidural infusion
(hydromorphone 2030 g/mL and bupivacaine
1/16%).
Chapter 46 Evaluating epidural catheters
d. Where was the catheter placed? If the patient has a

low lumbar catheter for an upper abdominal/
thoracic incision, you may need to bolus large
volumes (1520 mL) of dilute local anesthetic
(bupivacaine 1/161/8%) to cover the affected
dermatomes. If the patient has a thoracic (T6
78) epidural for an upper abdominal/thoracic
incision, consider reducing the bolus dose and
infusion rate by one third.
Before dosing medications: ensure that

the epidural infusion or test dose will not
destabilize the patient
First, evaluate for adequate respiration and oxygenation, hemodynamic stability, and absence of oversedation. Special care should be exercised in elderly, frail,
or post-pneumonectomy patients who are at increased
risk of epidural complications.
How to manage
Continuous monitoring of BP, HR, and SaO2 is required
before, during, and after dosing in all patients.
If the patient is hypovolemic, anemic, or hypotensive, avoid testing the catheter with local anesthetic
until the patient is volume-repleted. Infusions containing only an opioid will decrease blood pressure
less than those containing both an opioid and a local
anesthetic.
Ensure that the epidural catheter is not

placed intravascularly or intrathecally
Always aspirate the epinephrine catheter in the PACU
before starting an infusion or giving a test dose.
How to manage
If a small quantity of free-flowing blood or any CSF is
aspirated, the catheter will need to be repositioned or
removed. Pulling out the catheter by 1/2 cm at a time
and re-aspirating can occasionally reposition the catheter into the epidural space.
Give a test dose: if no blood or CSF is detected on
aspiration, test the catheter with a small quantity of
local anesthetic containing epinephrine (see Dosing
box):
Evaluate for hemodynamic changes: increases in
heart rate or blood pressure immediately after dosing
signify that the catheter is in the intravascular space.
Reposition, re-aspirate, and re-dose, or remove.
Evaluate for toxicity due to intravascular placement: symptoms such as lightheadedness, dizziness,
a metallic taste, ringing in the ears, or perioral
numbness signify potential intravascular injection
and risk for toxicity. Local anesthetic toxicity can
also cause late symptoms such as hypotension,
blurry vision, seizures, and cardiac arrhythmias.
Stay with the patient for the first 10 minutes after a
test dose or bolus.
Before dosing any epidural, aspirate the catheter
and rule out the presence of blood or cerebrospinal
fluid.
Never bolus more than 3 mL of local anesthetic at
any time; additional boluses may be given incrementally every 23 min after watching the hemodynamic
response. The minimum dose of epidural to achieve a
reliable hemodynamic reponse is 15 g.
Evaluate for intrathecal placement: results that are
too good from the test dose (such as dense sensory
or motor block) can indicate intrathecal placement of
the catheter.
Evaluate for equivocal results: if you are unsure of
the catheters placement after a test dose, you may
rebolus another 3 mL. With attending supervision/
approval, you may bolus up to 10 mL 1/8% bupivicaine with epinephrine or 20 mL 1/16% bupivacaine
with epinephrine (3 mL at a time).
Dosing
Typical test dose:
3 mL of 0.5% lidocaine with 1:200 000 epinephrine (5 g/mL) or 3 mL of 0.50.25% bupivacaine with 1:200 000
epinephrine (5 g/mL) or a combination of the two.
Typical infusion solution:
10 g/mL Dilaudid with 0.031% bupivicaine at 814 mL/h, with patient-controlled bolus of 3 mL every 6
minutes.
201
Troubleshooting: how to manage

a patient with an epidural who
complains of pain in the
post-operative care unit (PACU)
Patients with mild to moderate incisional
pain
(Most likely a well-placed functional catheter, in a
non-opioid-dependent patient.)
Ensure continuous HR, BP and O2 Sat monitoring.
Aspirate catheter, attach to the infusion pump, and
bolus 1020 mL of infusion solution. Infusion solutions: 0.031% bupivacaine with hydromorphone
(10g/mL) or fentanyl (24g/mL)
If pain is unchanged or worsening after 10
minutes, and blood pressure has not declined,
consider the catheter to be suboptimal, and test
with local anesthetic (refer to dosing box below).
If pain intensity and blood pressure have
declined, consider the catheter to be functional,
and either start a standard infusion rate (1012
mL per hour) or slightly increase the infusion rate
(1416 mL per hour).
Patients with moderate to severe

incisional pain
(Possibly a well placed functional catheter, in a nonopioid-dependent patient.)
Aspirate catheter, test with local anesthetic (see dosing box).
Evaluate for significant increases in HR or
symptoms of local anesthetic toxicity (which could
signify intravascular catheter placement, signifying
the need to reposition and re-test, or remove).
If pain is unchanged or worsening after 10
minutes, and the blood pressure has not declined,
the catheter is probably non-functional. However,
before discontinuing, consider retesting with a

more concentrated local anesthetic (68 mL
lidocaine 2% with epi, or 68 mL of lidocaine 1%
with epi combined with bupivacaine 0.25% with
epi, given 3 mL at a time). If no improvement,
discontinue catheter, consider placing another
epidural immediately. If the patient notices some
relief and blood pressure drops slightly, consider
the catheter to be functional, and start infusion.
If the pain remains at a point higher than the level of
the catheter, with good pain relief lower than the
level of the catheter, consider infusing larger volumes
of solution (1416 mL/h). To further optimize pain
relief, consider giving an additional loading dose of
0.5 mg hydromorphone. Alternatively consider an
additional loading dose of 1020 mL of infusion
solution via the epidural pump.
Patients with severe incisional pain

(crying-screaming!)
(Most likely a non functional catheter! but also assess
placement, intra-operative dosing, and opioid dependency variables.)
Aspirate catheter, test with concentrated local anesthetic
(610 mL lidocaine 2% with epi or 610 mL lidocaine 1%
with epi combined with bupivacaine 0.25% with epi).
If pain relief or a drop in BP is not observed
within 10 minutes, pull epidural catheter,
administer IV opioids and consider immediate
replacement of the epidural.
If partial pain relief is noted but analgesia is better
on one side than the other, the catheter could be
in too far or off midline. If the catheter is in
greater than 3 cm, pull it out one or two cm then
rebolus with 1020 mL of infusate solution.
If the pain remains at a point higher than the level
of the catheter, consider infusing larger volumes of
solution (1416 mL/h). As above, consider giving an
additional loading dose of 0.5 mg hydromorphone
Dosing
202
Typical test dose:

minutes.
Chapter 46 Evaluating epidural catheters
epidurally, or up to 2 mg hydromorphone if the

patient is opioid-dependent. Also consider a more
concentrated epidural infusion. Finally, patients
with very high incisions often benefit from small
parenteral (IV) doses of morphine (24 mg) or
hydromorphone (0.51 mg). After consulting with
the surgical team, a judicious dose of ketorolac
(1530 mg) may also be administered to control
upper abdominal and thoracic pain.
Before dosing any epidural, aspirate the catheter and
rule out the presence of blood or cerebrospinal fluid.
Troubleshooting: how to manage a

patient with an epidural who
complains of pain or in the intensive
care unit
Patients with moderate incisional pain
(Patients may have finished ambulating or physical
therapy, or were more comfortable earlier.)
Check epidural site for leakage, catheter
withdrawal, or catheter obstruction. Aspirate
catheter to rule out intravascular migration.
Consider surgical complications.
Assess epidural PCA use. If minimal, educate the
patient to press the bolus button every 6 minutes
as needed. If approaching the maximum, consider
increasing the bolus dose by 2533%. Also
consider an epidural loading dose of 10 mL of
infusion solution, which may be repeated 15
minutes later.
Consider supplementing with parenteral opioids,
taking into consideration the patients
hemodynamic, respiratory, and sedation status.
Patients with moderate to severe

incisional pain
(Patients may have finished ambulating or physical
therapy, or were more comfortable earlier.)
Consider surgical complications such as
compartment syndrome.
Treat similarly as above instructions for In the
PACU; however, dose with a maximum of 3 mL
of local anesthetic on the floor as an inpatient.
Patients with severe pain (cryingscreaming!)

(Most likely a non-functional catheter! But also assess
placement, intraop dosing, and opioid-dependency
variables.)
Ensure continuous HR, BP and O2 Sat
monitoring. Also ensure that a senior-level
resident or attending is immediately available.
Prescribe small doses of parenteral
hydromorphone (12 mg), less if opioid-naive.
Consider surgical complications such as
compartment syndrome.
Aspirate the catheter, and test with local
anesthetic (46 mL lidocaine 1% with epi, or
lidocaine 1% with epi combined with bupivacaine
0.25% with epi). The patient must be closely
observed for the next 20 minutes. If pain relief or
a drop in BP is not observed within 10 minutes,
pull out the epidural catheter, administer IV
opioids and consider immediate replacement of
the epidural. If the catheter cannot be replaced,
Dosing
Typical test dose:
minutes.
203
initiate IV-PCA hydromorphone and follow the

patient overnight.
If you have relief over only part of the incisional
site, consider infusing larger volumes of solution
(1416 mL/h). As above, consider giving an
additional loading dose of 0.5 mg
hydromorphone epidurally, or up to 2 mg
hydromorphone if the patient is opioiddependent. Also consider a more concentrated
epidural infusion.
If the patient is highly opioid-dependent,
consider administering a more concentrated
epidural infusion (hydromorphone 2030 g/mL
plus bupivacaine 1/16th%). In addition, opioiddependent patients will almost always require
oral or IV opioid supplementation. They may
benefit from combined IV-PCA hydromorphone
(0.41 mg q 6 min) plus a continuous epidural
infusion of more concentrated solution.
Alternatively, parenteral doses of morphine
Section 3
Chapter
47
Symptom management
An epidural catheter that is working very well but
causing hypotension, excessive pruritus, and muscle
weakness could be in the intrathecal space. Alternatively, the catheter could be in the epidural space but
the infusate could be leaking into the intrathecal space
through a dural puncture made inadvertently during
placement of the epidural. Decrease the infusate solution rate to 12 mL/h, and use a dilute naloxone solution of 400800 g/L of the IVF already prescribed by
the primary team (at a rate of 75150 mL/h dependent
on patients fluid requirements).
Anticoagulants and regional anesthesia

Gregory Cain, Michael Seneca and Ashley Vaughn
Introduction
204
(410 mg) or hydromorphone (13 mg) or

baseline doses of oral oxycontin may be
provided. Opioid-dependent patients also exhibit
polydrug dependence and may require
benzodiazepines for anxiolysis, sleep, and muscle
spasm.
Neuraxial and peripheral anesthetic techniques provide several unique advantages when used in lieu of
or in combination with systemic analgesics and anesthetic agents. Regional techniques have been demonstrated to offer reductions in post-operative
morbidity and mortality, although the extent of this
reduction and applicability to all patient populations
remain controversial. Specific benefits offered by
regional techniques include decreased intra-operative blood loss, earlier ambulation, improved postoperative pain control, and a decreased incidence of
post-operative nausea and vomiting. However, these
techniques also have a unique set of risks that warrant consideration when planning the anesthetic
management of patients.
One factor that has been particularly controversial
is how to adjust neuraxial and peripheral techniques
and timing for the anticoagulated patient. The relationship between anticoagulants and the development
of bleeding complications remains complex and multifactorial. Many patients receiving systemic anticoagulants have safely undergone neuraxial techniques
without sequelae. Conversely, there are documented
cases of patients spontaneously developing severe
bleeding complications such as epidural hematoma
Chapter 47 Anticoagulants and regional anesthesia
without having previously received exogenous anticoagulants. Nevertheless, assessment of coagulation status remains a central component when considering
regional anesthetic techniques. Establishment of
standards for venous thromboembolic prophylaxis as
well as development of more efficacious anticoagulant
agents have made the management of regional anesthetic techniques increasingly challenging and complex. Additionally, a paucity of data regarding certain
facets of patient management, such as timing, in the
face of newer or even multiple anticoagulants has been
a continual source of controversy. The American Society of Regional Anesthesia and Pain Medicine (ASRA)
released a set of guidelines based upon available data
that aimed to simplify management for patients
undergoing neuraxial anesthetic techniques. However,
minimal data exist and significant controversy remains
with regard to peripheral techniques. This chapter will
summarize and highlight the most current ASRA
guidelines as well as some additional research data
that may provide some direction to practitioners managing these patients.
Potential complications
Recent advancements in regional anesthesia are often
paralleled by the introduction of new thromboprophy
laxis guidelines and therapeutic agents. Complications including bleeding, infection, hematoma, and
transient or permanent neurological injury from
peripheral and neuraxial anesthesia can be particularly devastating to the patient. Although sources vary,
the incidence of hematoma is estimated to be 1:150000
for epidural techniques and 1:220 000 for spinal techniques. The introduction of low molecular weight
heparin (LMWH) in 1993 was implicated in over 40
spinal hematomas over a 5-year period. The widespread use of antithrombotic agents continues to pose
a significant challenge to practitioners considering
regional techniques. Guidelines were introduced in
1998 and subsequently revised in 2002 and 2010 [1] by
ASRA to help simplify management of these patients
based upon available data. However, it is important to
note that adverse clinical events have been reported
even when procedures were performed within the
guidelines. Tam et al. [2] presented a case study in
which the patient developed an epidural hematoma
after a combined spinal-epidural anesthetic while
concomitantly taking clopidogrel and dalteparin for
thromboprophylaxis. An epidural hematoma developed despite following standard guidelines concern-
ing administration of LMWH peri-operatively and

discontinuing the clopidogrel 7 days prior to the
scheduled anesthetic.
Even low-risk patients treated with antiplatelet
agents that currently have no specific recommendations undergoing epidural anesthesia are at risk for
developing complications such as epidural hematoma.
Gilbert et al. [3] published a case report in which an
epidural hematoma developed post-operatively in a
35-year-old healthy patient who underwent an outpatient knee arthroscopy under epidural anesthesia. An
atraumatic L3L4 epidural catheter was placed. Thirty
milligrams of ketorolac was administered intravenously 45 minutes after epidural placement. The operation was uneventful, the catheter was removed in the
recovery room, and the patient was discharged home.
The patient developed severe back pain and was
advised to return to the surgery center immediately,
where she was administered multiple intravenous
doses of fentanyl in addition to a repeat dose of ketorolac. The patient developed lower extremity weakness
and was subsequently diagnosed with an L1L3 epidural hematoma via magnetic resonance imaging
(MRI). An emergency decompressive laminectomy
with hematoma evacuation was performed. The
patient had full return of motor function in the following weeks with some persistent sensory deficit over the
right soleus area. This case raised the issue of the use of
nonsteroidal anti-inflammatory (NSAIDS) drugs during the immediate and post-operative course.
Anticoagulated patients are considered at an
increased risk for epidural hematoma. The removal of
an intrathecal or epidural catheter is as important as
its placement when considering the risk involved. The
coagulation status must be evaluated prior to discontinuing these catheters as noted in the case report presented by Rosen et al. [4]. An 18-year-old patient
presented for aortic valve replacement secondary to
aortic stenosis. A thoracic T9T10 epidural was placed
after an inhalation induction of general anesthesia.
Three hours later, the patient received 21 000 units of
heparin in preparation for cardiopulmonary bypass
(CPB). After CPB the heparin was reversed with protamine. Forty-nine hours post-operatively, intravenous heparin was started for thrombophylaxis of the
prosthetic aortic valve. Fifty-three hours post-operatively, the PICC line became clotted and 2 mg of
alteplase was administered. Intense back pain and
blood in the epidural catheter and around the epidural
puncture site were noted. The pediatric team removed
205
the epidural catheter with the onset of the intense back

pain. The patients activated partial thromboplastin
time (aPTT) at that time was found to be 87.4 seconds.
With removal of the catheter, sudden onset of numbness and weakness distal to T9 was observed. An MRI
revealed a T9T10 epidural hematoma with cord displacement and compression. An urgent decompressive laminectomy was performed. Six weeks following
the laminectomy, the patients neurological status had
returned to baseline. The authors postulated that the
blood loss through the epidural catheter helped to
decrease the pressure effects of the developing
hematoma. Removal of the epidural catheter in the
presence of impaired coagulation may have increased
the bleeding and compounded the problem.
Epidural anesthesia has been demonstrated to be
an effective and acceptable alternative to opioid
patient-controlled analgesia in many patients. However, the increased risks of hematoma in patients
receiving anticoagulants have limited its use beyond
the recovery period in these patients.
The following guidelines are adapted from The
2010 Third ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation, with additional
information provided when available from current
literature.
Heparin
206
Heparin is frequently used in the intra-operative

period and may be associated with increased risk
when combined with spinal or epidural anesthesia.
Three main risk factors have been identified: traumatic needle placement, less than 1 hour between
needle placement and heparin administration, and
concomitant use of other anticoagulants.
Subcutaneous (SC) heparin use for prophylaxis of
venous thromboembolism, typically 5000 units every
12 hours, has been used extensively and is not a contraindication for neuraxial techniques. Withholding
heparin until the block is placed and assessing platelet
count in patients who have received heparin for more
than 4 days may reduce the risk of complications.
Intra-operative systemic anticoagulation with
heparin is generally compatible with neuraxial anesthesia and has been used safely in vascular and cardiopulmonary bypass surgery. Most of the published case
studies regarding CPB and systemic heparinization
have observed the following recommendations: avoid
neuraxial blocks in patients with existing coagulopathies of any origin, a minimum of 24 hour delay in the
event of traumatic needle placement, time from instrumentation to systemic heparinization should be greater
than 1 hour, heparin effect and its reversal should
be tightly controlled, epidural catheters should be
removed only when normal coagulation is restored,
and patients should be monitored closely for a minimum of 24 hours for signs and symptoms of hematoma
formation.
The following recommendations are advised for
combining spinal or epidural anesthesia with heparin
during vascular anesthesia: delay heparin adminis
tration for a minimum of 1 hour following block or
catheter placement, avoid in patients with existing
coagulopathies, indwelling catheters should be removed
24 hours after the last dose of heparin and assessment
of the patients coagulation status, and reheparinization
should occur a minimum of 1 hour after catheter
removal.
Low molecular weight heparin (LMWH)

Underestimating the pharmacological differences
between LMWH and standard heparin led to over 40
reported cases of spinal hematoma within 5 years of
its introduction into the US market. New indications
and labeling for LMWH warrant additional discussion and research regarding the anesthetic management of patients on these medications.
Patients presenting for surgery on LMWH thromboprophylaxis should have needle placement delayed
until at least 1012 hours after the LMWH dose. These
patients can be assumed to have altered coagulation
states. Patients on higher treatment doses of LMWH
will require delays of at least 24 hours to return to normal coagulation states prior to needle placement.
Management of post-operative thromboprophylaxis and neuraxial anesthesia may be done safely
and is based on total daily dosing, timing of dosing,
and dosing schedule. Twice-daily dosing of LMWH
may be associated with an increased risk of spinal
hematoma and the first dose should be administered
no earlier than 24 hours post-operatively. If a catheter
is left in place for a continuous technique, it should be
removed at least 2 hours prior to the first dose of
LMWH.
Single daily dosing, which more closely approximates the European dosing regime and its associated
lower incidence of neuraxial complications, should be
administered 68 hours post-operatively, with the
second dose no sooner than 24 hours after the initial
dose. Indwelling catheters may be maintained safely,
although the catheter should not be removed until

1012 hours after the last dose. Subsequent LMWH
doses should be held until at least 2 hours following
catheter removal.
Fondaparinux (Arixtra)
Fondaparinux is a newer, unique anticoagulant utilized for thromboembolic prophylaxis. It is a synthetic
Factor Xa inhibitor. Data with this drug in patients
receiving regional anesthesia are limited. Current recommendations suggest avoiding indwelling catheters
and utilizing neuraxial techniques with extreme caution. However, a study by Singelyn et al. in 2007 [5]
suggested that both neuraxial techniques and indwelling catheters may be safe. The Singelyn study had a
sample of 5704 patients who received 2.5 mg SC injections of fondaparinux once daily. Of this sample, 1553
patients had indwelling neuraxial or peripheral nerve
catheters. The incidence of venous thromboembolism
in this study was the same (about 1%) for patients with
and without indwelling catheters. There were no
reports in this study of neuraxial or peripheral
hematoma. Singelyn recommended discontinuing
fondaparinux for 48 hours before discontinuing an
indwelling catheter.
Oral anticoagulants (warfarin)

Warfarin exerts its anticoagulant effects indirectly by
inhibiting the synthesis of vitamin K-dependent clotting factors. The effects of warfarin are not clinically
apparent until a significant amount of inactive factors
are synthesized and the remaining active factors are
consumed. Individual patient variability, a narrow
therapeutic range, a lack of data regarding complications, risks in the patient who recently discontinued
warfarin, and a long list of drugs that potentiate warfarin are just some of the challenges presented to practitioners managing this patient population. Peri-operative
management of these patients remains controversial.
Caution should be used when considering neuraxial techniques in patients who have recently discontinued warfarin therapy, and prothrombin time (PT/INR)
should be assessed prior to needle placement. Therapy
should be withheld 45 days prior to the operation. It
is important to note that concomitant use of other
medications that affect the clotting mechanism, such
as aspirin or heparin, may interact synergistically with
warfarin without any demonstrated prolongation of
the PT/INR. Other medications that may potentiate
warfarin include NSAIDs, clopidogrel, LMWH, and

ticlopidine.
If a patient has received an initial oral dose of warfarin greater than 24 hours prior to surgery the PT/
INR should be checked. The PT/INR should also be
checked if the patient has received more than one oral
dose, even if less than 24 hours has gone by.
Patients receiving continuous epidural anesthesia
and low-dose warfarin therapy should have their PT/
INR monitored daily and assessed prior to catheter
removal. Most studies evaluating low-dose warfarin
therapy have observed 5 mg dosing of warfarin. Higher
doses may require more frequent assessment. When
initiating thromboprophylaxis with warfarin, the
catheter should be removed when the INR is less than
1.5, as this is associated with clotting factor activity
levels of more than 40%. Neurological, sensory and
motor function assessment should be performed on
all patients receiving warfarin therapy and epidural
anesthesia. It is preferable to choose an anesthetic
technique that minimizes the degree of sensory and
motor blockade. These assessments should be continued for a minimum of 24 hours following catheter
removal and longer if the INR was greater than 1.5 at
the time it was removed.
An INR greater than 3 may require the next dose
of warfarin to be held or reduced in patients with an
indwelling catheter. There are no recommendations or
consensus views regarding the removal of neuraxial
catheters in patients with therapeutic levels of anticoagulation. Reduced doses of warfarin should be considered in patients who may have an enhanced or
exaggerated response to the drug.
Antiplatelet agents
The safety of neuraxial blockade in combination with
NSAIDs has been demonstrated in several large studies and is also supported by both the rarity of case
reports and the widespread usage in the general population. There are no restrictions at this time with regard
to NSAID administration and timing of neuraxial
anesthesia. There are few data, however, regarding
neuraxial anesthesia in the presence of thienopyridine
derivatives or GP IIb/IIIa platelet receptor antagonists.
Surgical and radiology recommendations include
delay of elective surgery for 24 to 48 hours following
abciximab and 4 to 8 hours after eptifibatide and
tirofiban. Concomitant therapy with other anticoagulants and antiplatelet medications has been shown to
increase the risk of hemorrhagic complications.
207
Direct thrombin inhibitors (DTIs)

Numerous DTIs have been studied clinically, although
only a few are in routine clinical use. In particular,
argatroban is often used for anticoagulation in patients
with or at risk for heparin-induced thrombocytopenia. The effects of these drugs can be monitored using
the aPTT, similar to heparin. Few data exist establishing the safety of these agents alongside neuraxial
anesthesia, so caution is recommended.
Herbal therapies
Herbal medications, including garlic, ginko, and ginseng, alone do not appear to represent any additional
risk in patients having epidural or spinal anesthesia.
However, combination therapy with herbal medications and other forms of anticoagulation may increase
the risk of bleeding complications and there is not yet
an accepted test to measure hemostasis in this patient
population. Some sources recommend discontinuing
herbal agents 57 days to surgery. However, the 2010
recommendations by ASRA are to allow patients to
continue any herbal remedies without interruption.
Additionally, the current ASRA recommendations
provide no restrictions to neuraxial or peripheral
techniques on patients taking herbal medications
(Table 47.1).
Complications in peripheral
nerve blocks
208
A lack of data available to the first two ASRA conferences limited the ability to offer specific guidelines on
continuous peripheral nerve blocks (CPNB) in anticoagulated patients. Case reports suggest that significant
blood loss, not neurological deficits, may be the most
common and serious complication of peripheral
anesthesia in the anticoagulated patient. Prior conferences also noted that applying the same neuraxial
guidelines to CPNB could be overly restrictive. However, the 2010 ASRA guidelines recommend using the
same guidelines for neuraxial techniques in deep
plexus and peripheral blocks. The development of
guidelines regarding peripheral nerve blocks in anticoagulated patients by ASRA has not been done within
the same environment of urgency in which the neuraxial guidelines were developed. As stated, the most common serious complications related to CPNB are from
bleeding rather than neurological damage. Anecdotal
evidence suggests that CPNB is safe in anticoagulated
patients. However, the decision to proceed with CPNB

should be made considering the risks and benefits for
individual patients. Additionally, the availability of
qualified personnel for performance and follow-up as
well as resources at the institution where blocks are
performed should be considered.
Recent data, presented by Buckenmaier et al. [6],
described the use of CPNB in polytrauma combat
casualty patients at Walter Reed Army Medical Center.
The high risk of thromboembolism in this patient
population necessitated the use of twice-daily dosing
of LMWH and, according to the ASRA guidelines, would
have precluded the use of CPNBs as well as requiring
waiting 24 hours before the first dose of LMWH. The
study, noting ASRAs lack of available data, the roundthe-clock availability of an acute pain service, and
twice-daily visits by an anesthesia provider, elected for
a more liberal approach. Ten to 12 hours after the last
dose of prophylactic enoxaparin, patients could receive
an indwelling catheter or single injection block, as
well as have a catheter discontinued. Patients on therapeutic enoxaparin differed slightly, allowing for a single injection block at staff discretion and requiring a
24-hour wait between the last dose and CPNB placement, which was not to be placed if therapeutic anticoagulation was to be continued. If a CPNB catheter
was in place and the dose of enoxaparin increased to
therapeutic dosage, with the exception of lumbar
plexus blocks, CPNB was recommended to be continued. Lumbar plexus catheters were to be removed 24
hours after the last dose due to the relatively higher
risk of bleeding complications. No bleeding complications were reported in any of the 187 patients included
in the study. The patient population was primarily
composed of young, otherwise healthy, male military
personnel and may not be applicable to other patient
populations.
A retrospective case study was conducted by Chelly
et al. [7] that examined patients receiving warfarin
therapy and continuous lumbar plexus block following total hip replacemnt. At the time of lumbar plexus
catheter removal, 36.2% of patients had an INR >1.4,
24% had an INR between 1.5 and 1.9, while 12% had
an INR above 2.0. Six hundred and seventy patients
were included in this study. There was one reported
case of bleeding at the catheter site after removal in
which the INR was 3.0 at the time of removal. The
bleeding was managed with direct pressure and vitamin K. The preliminary findings of this study suggested that the removal of a deep perineural catheter
Table 47.1. Guidelines for neuraxial techniques in patients receiving anticoagulants
Heparin
Guidelines
Additional Notes
Subcutaneous heparin: delay dosing until after

neuraxial technique, if possible
Evaluate platelet count in patients

receiving heparin for >4 days
Intravenous heparin: discontinue 1 hour before and

after needle placement
Discontinue infusion 24 hours prior to catheter
removal
Avoid resuming infusion for minimum of 1 hour after
catheter removal
Monitor for 24 hours after removal
LMWH
Avoid administration for minimum of 1012 hours

before or after needle placement: patients on higher
dosing regimens may require 24 hours for normal
coagulation
Fondaparinux (Arixtra)
Avoid indwelling catheters
Utilize neuraxial techniques with

extreme caution
Avoid traumatic needle placement

Warfarin (Coumadin)
Discontinue 45 days prior to needle placement
Monitor PT/INR, ensure INR <1.5 prior

to needle placement or catheter
removal
Monitor for 24 hours after epidural or spinal techniques

Antiplatelet agents
Aspirin/NSAIDs (no restrictions)

Clopidogrel (Plavix) discontinue 57 days prior to
needle placement;
Ticlopidine (Ticlid), discontinue 14 days prior to needle
placement
Eptifibatide (Integrilin) and Tirofiban (Aggrastat), avoid
neuraxial anesthesia
Direct thrombin inhibitors (DTIs)
Hirudin-based, bivalent DTIs including bivalirudin

(Angiomax), lepirudin (Refludan), and desirudin
(Iprivask), risk of bleeding complications unknown
Monitor aPTT
Univalent DTIs including argatroban and dabigatran

(Pradaxa), risk of bleeding complications unknown
Herbal medications
No restrictions
Agents of concern: ginger, ginkgo,

ginseng, garlic, feverfew, and vitamin
E. Prior recommendations were to
discontinue 57 days prior
Where available, based upon 2010 ASRA Guidelines. When inconsistencies were observed in literature, more conservative guidelines are
utilized
The 2010 ASRA guidelines are the first to provide recommendations regarding deep plexus and peripheral blocks in patients receiving
anticoagulants. Current ASRA recommendations are to apply the same guidelines for neuraxial blockade to deep plexus and peripheral
blocks.
may be safely performed with an INR >1.4 in patients

receiving warfarin for thromboprophylaxis.
Conclusion
For a variety of reasons, recommendations in the
current literature can be inconsistent regarding the
management of anticoagulated patients receiving

regional anesthesia. Pharmacological therapies for
thromboembolic prophylaxis are continually evolving
and dosing regimens for anticoagulants can vary by
patient population, indications, and even by region.
Numerous case studies demonstrate inconsistent
209
results with current recommendations, which focus

on neuraxial anesthesia and may be overly restrictive
when applied to peripheral nerve blocks. However,
current ASRA guidelines are conservative in this
regard and recommend using the same guidelines
whether performing neuraxial, deep plexus, or
peripheral techniques.
References
1. Horlocker TT, Wedel DJ, Denise J, et al. Regional

anesthesia in the patient receiving antithrombotic or
thrombolytic therapy: American Society of Regional
Anesthesia and Pain Medicine Evidence-Based
Guidelines (Third Edition). Reg Anesth Pain Med
2010;35(1):64101.
2. Tam NLK, Pac-Soo C, Pretorius PM. Epidural
haematoma after a combined spinal-epidural
anaesthetic in a patient treated with clopidogrel and
dalteparin. Br J Anaesth 2006;96(2):262265.
210
3. Gilbert AG, Owens BD, Mulroy MF. Epidural

hematoma after outpatient epidural anesthesia. Anesth
Analg 2002:94(1):7778.
4. Rosen DA, Hawkinberry DW, Rosen KR, et al. Anesth
Analg 2004;98(4):966969.
5. Singelyn FJ, Verheyen C, Piovella F, Van Aken HK,
Rosencher N. The safety and efficacy of extended
thromboprophylaxis with fondaparinux after
major orthopedic surgery of the lower limb with
or without a neuraxial or deep peripheral nerve
catheter: The EXPERT Study. Anesth Analg
2007;105(6):15401547.
6. Buckenmaier CC, Shields CH, Auton AA, et al.
Continuous peripheral nerve block in combat
casualties receiving low molecular weight heparin.
Br J Anaesth 2006;97(6):874877.
7. Chelly JE, Szczodry DM, Neumann KJ. International
normalized ratio and prothrombin time values
before the removal of a lumbar plexus catheter in
patients receiving warfarin after total hip replacement.
Br J Anaesth 2008;101(2):250254.
Section 4
Chapter
48
NSAIDs
Nonselective nonsteroidal
anti-inflammatory drugs, COX-2
inhibitors, and acetaminophen
Jonathan S. Jahr and Vivian K. Lee
Analgesics, such as nonselective nonsteroidal antiinflammatory drugs (NSAIDs), COX-2 inhibitors, and
acetaminophen, are amongst the most commonly used
medications in the USA and worldwide. An estimated
70 million NSAID prescriptions are written every year
in the USA alone. Moreover, non-presciption strength
NSAIDs and oral acetaminophen are readily accessible over-the-counter. In the peri-operative setting,
these analgesics are gaining recognition as an important alternative and/or adjunct to the historically
mostly opioid-based analgesia.
The appeal of NSAIDs, COX-2 inhibitors, and
acetaminophen is that the unfavorable opioid-related
side effects may be mitigated. Although opioids are
potent and effective drugs for pain control, they are
well known for adverse side effects such as excessive
sedation, dose-dependent respiratory depression,
pruritus, nausea, vomiting, biliary spasm, hypotension, constipation, and urinary retention. Minimizing
these effects has the advantage of earlier ambulation
post-operatively and consequently a shorter hospitalization, as well as higher patient satisfaction and quality of recovery.
The multimodal analgesic approach aims to reduce
opioid-related adverse effects peri-operatively. Multimodal analgesia combines different classes of analgesics and methods of pain management to provide
superior pain relief than any one class or method
alone. The basic principle is that using various classes
of medications will simultaneously and synergistically
inhibit the different pain receptor pathways. The combination reduces the dose of each analgesic and
thereby decreases the incidence of side effects of any
particular medication used. The American Society of
Anesthesiologists Task Force on Acute Pain Management currently advocates this approach. In fact, guidelines suggest all patients receive NSAIDs, COX-2
inhibitors, or acetaminophen for acute pain management peri-operatively, unless contraindicated. This is
consistent with the World Health Organization
(WHO) pain ladder method of controlling pain (see

Figure 48.1). The WHO pain ladder was initially
created for treating cancer pain but is now commonly
used as a paradigm for treating all types of pain. The
bottom rung of the ladder consists of non-opioids
such as NSAIDs, COX-2 inhibitors, and acetaminophen. If pain persists, medications of escalating
strength are recommended.
No medication is without adverse effects, and
NSAIDs, COX-2 inhibitors, and acetaminophen are
no exception. These adverse effects may or may not
be less significant compared to the adverse effects of
opioids. Nonselective NSAIDs, for example, invariably affect platelet aggregation and it remains controversial whether administration peri-operatively
increases the risk of bleeding. Clinicians must weigh
the risk of bleeding with the reduction in opioid
consumption if the NSAID is administered preemptively prior to emergence. On the other hand, the
anti-platelet effects of the nonselective NSAID aspirin are beneficial when used for venous thromboembolism prophylaxis. Without prophylaxis, the
reported incidence of deep venous thrombosis and
pulmonary embolism following total hip arthroplasty and total knee arthroplasty has been reported
to be as high as 5060% and 711%, respectively.
Studies have demonstrated that aspirin can be used
for venous thromboembolism prophylaxis in lowrisk patients being discharged home following orthopedic surgery.
Aside from their important role in multimodal
analgesic therapy, they have also been extensively
studied in preemptive analgesia. Preemptive analgesia is an anticipatory anesthetic approach that intends
to prevent the pain and inflammatory response
initiated by surgical incision and manipulation, and
prevent the wind-up phenomenon. NSAIDs,
COX-2 inhibitors, and acetaminophen have all demonstrated efficacy in the management of mild to
moderate post-operative pain. Additionally, they are
211
NSAIDs Section 4
Figure 48.1. WHO pain ladder (adapted

from http://www.abpi.org.uk).
Pain Relief Ladder

Freedom from Pain
Pain Persisting
or Increasing
2
Opioid for moderate to severe pain +/- non-opioid

and +/- adjuvant
e.g. morphine, hydromorphone, fentanyl
Opioid for moderate to severe pain +/- non-opioid
and +/- adjuvant
e.g codeine
+/- non-opioid and +/- and adjuvant
e.g aspirin, NSAID, acetaminophen
Pain Persisting
or Increasing
1
Pain
Adapted from the World Health Organization Pain Ladder

Lee, 2010
important analgesic adjuncts in moderate to severe

post-operative pain.
Nonselective nonsteroidal
anti-inflammatory drugs
212
The nonselective nonsteroidal anti-inflammatory drugs

(NSAIDs) are mostly derived from carboxylic and
enolic acids. They possess analgesic, anti-inflammatory,
as well as antipyretic properties, and have proven efficacy in the treatment of headache, rheumatoid arthritis, dysmenorrhea, gout, osteoarthritis, among many
other clinical disorders. Because of these properties,
they have also proven to be useful in the pre-operative
and post-operative period. There are more than 20 different NSAIDs currently available. There are oral, rectal, and parenteral forms, although the only intravenous
NSAIDs that are approved for clinical use in the USA
are ketorolac and ibuprofen. Many studies have demonstrated no major difference in analgesic efficacy
among the various NSAIDs. However, the doses leading to toxicity can be highly variable. When selecting
which NSAID to use, it is therefore important to consider toxicity, bioavailability, duration of analgesia, cost,
and route of administration. For example, the bioavailability of orally administered NSAIDs has been shown
to be higher than after rectal administration. In postoperative patients who are unable to tolerate oral medications, it may be a more prudent choice to administer
the drug parentally rather than rectally even though the
intravenous form may be more expensive.
The mechanism of action of NSAIDs involves the

inhibition of prostaglandin synthesis in response to
tissue injury. Lipases release arachidonic acids from
membrane phospholipids when cells are faced with
insult. The arachidonic acids are normally oxidized to
eicosanoids, fatty-acid-derived signaling molecules
that have been implicated in pathways affecting the
cardiovascular system, nervous system, reproductive
system, coagulation, gastrointestinal system, among
others. Prostaglandins are among the four known
families of eicosanoids and are synthesized by the
cyclooxygenase (COX) enzymes. The COX enzymes
are required for both prostaglandin and thromboxane
synthesis. The NSAIDs are reversible inhibitors of the
COX enzymes with the exception of aspirin, which
irreversibly inactivates cyclooxygenase.
At least two cyclooxygenase isoenzymes exist
COX-1 and COX-2 which are differentially expressed
in the tissues of the human body (see Figure 48.2).
COX-1 is expressed constitutively and functions in
platelet aggregation, renal blood flow, and gastric protection. In contrast, COX-2 expression is induced by
factors mediating the inflammatory cascade. The
COX-2 enzyme is therefore responsible for inflammation and pain. Aspirin and nonselective NSAIDs
inhibit both COX-1 and COX-2. Common adverse
effects of this class of drugs are related to the nonspecific inhibition of prostaglandin and thromboxane
synthesis, and include an increased risk of significant
gastrointestinal bleeding, compromised platelet function, and renal dysfunction.
Chapter 48 Nonselective nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, and acetaminophen
Figure 48.2. NSAIDs mechanism of

action (adapted from
http://www.arcoxia.ae).
CO2
Arachidonic Acid
COX-1 (constitutive)
NSAID
Prostaglandins
Kidney
Protection of Gastric Mucosa
Hemostasis
COX-2 (inducible)
Prostaglandins
Pain and Fever
Inflammation
Adapted from Arcoxia Website, E.I. du Pont de Nemours and Company

Lee, 2010
COX-2 inhibitors
COX-2 inhibitors are a subclass of NSAIDs that are
relatively more specific inhibitors of the cyclooxygenase-2 enzyme. Research and development of this subclass was initially driven by the potential to improve
the gastrointestinal safety profile of traditional
NSAIDs while providing similar analgesic relief. The
mechanisms by which NSAIDs cause gastrointestinal
damage include disruption of the gastric mucosal
layer, vasoconstriction, and decreased bicarbonate
secretion. Selective inhibition of the COX-2 enzyme
provides the anti-inflammatory and analgesic effects
without compromising COX-1 expression and causing gastrointestinal insult. The adverse effects on the
gastrointestinal tract affect an estimated 60% of
patients taking NSAIDs.
COX-2 inhibitors are not absolutely selective for
the COX-2 enzyme. Rather, all NSAIDs have some
COX-1 and COX-2 inhibition, but along this continuum, the COX-2 inhibitors are much more selective
for the COX-2 enzyme. Increasing COX-2 selectivity
does not necessarily correlate with increased therapeutic efficacy.
The first COX-2 inhibitor approved by the US
Food and Drug Administration (FDA) in 1998 was
celecoxib (Celebrex). This was soon followed by the
approval of rofecoxib (Vioxx) and valdecoxib (Bextra). Since then, valdecoxib and rofecoxib have both
been voluntarily withdrawn from the US market
because of an increased stroke and cardiovascular
risk, especially that of thrombosis. Currently,
celecoxib is the only COX-2 inhibitor available in the
US market and and has a FDA-mandated black-box

warning regarding cardiovascular risk. Its FDA-
approved indications include treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis,
primary dysmenorrhea, familial adenomatous polyposis, as well as acute pain management. Other
COX-2 inhibitors used in Europe but not yet approved
for use in the USA include parecoxib, etoricoxib, and
lumiracoxib.
Additional use of the COX-2 inhibitors in the perioperative setting helps avoid the adverse effects of
opioids. Given the increased cardiovascular risk and
FDA-mandated black-box warning, however, the
COX-2 inhibitors seem to have fallen out of favor in
the management of post-operative pain. Regardless, it
is important to be aware of the general guidelines for
using COX-2 inhibitors.
Studies have suggested a dose-dependent increase
in cardiovascular risk, and the lowest effective dose
for the shortest duration possible should be used
when COX-2 inhibitors are indicated. According to
current American Heart Association recommendations, naproxen is the safest alternative to COX-2
inhibitors in patients at increased risk of major thrombotic events. There is, however, no clear data that traditional NSAIDS are without the cardiovascular risk
of COX-2 inhibitors. In patients who have a history of
gastrointestinal bleeding, current guidelines suggest
pairing a COX-2 inhibitor with a proton pump inhibitor. Additionally, eradication of Helicobacter pylori in
the GI tract seems to reduce the risk of gastrointestinal complications caused by NSAIDS. COX-2 inhibitors alone have been shown to more effectively protect
213
NSAIDs Section 4
the gastrointestinal tract than a traditional NSAID

along with a gastroprotective agent such as a proton
pump inhibitor, an H2 receptor antagonist, or prostaglandin analogs.
Acetaminophen
In patients who may be highly susceptible to the
adverse effects of traditional NSAIDs and COXinhibitors, acetaminophen is a favorable alternative.
Acetaminophen is a commonly used analgesic and
antipyretic that is readily available in its oral form as
an over-the-counter drug. It is also known as paracetamol or N-acetyl-para-aminophenol (APAP), and
is supplied in oral, rectal, and parenteral forms.
Although the intravenous form has been available in
various countries worldwide since 2002, it is currently still undergoing approval by the US Food and
Drug Administration at the time of writing of this
chapter.
Acetaminophen exerts weaker inhibition of
peripheral prostaglandin synthesis than NSAIDs. Its
mechanism of action is not clearly understood but
involves central inhibition of cyclooxygenases. Some
studies have suggested that NSAIDs seem to be a
more effective analgesic than acetaminophen, but it
may also depend on the type of surgery being performed. Regardless, acetaminophen is a useful drug
for the monotherapy management of mild to moderate peri-operative pain, and as an adjunct to other
analgesics for the management of moderate to severe
peri-operative pain.
Although acetaminophen has a narrow therapeutic index, when used within the recommended dosage
ranges it has been shown to have an extremely low
incidence of adverse effects. It can be used as an
adjunct to the NSAIDs to decrease the incidence of
NSAID-related adverse effects, and similarly as an
adjunct to opioids to decrease the incidence of opioidrelated adverse effects.
In day-to-day practice, clinicians must weigh the
risk/benefit ratio for each medication they prescribe to
patients. Given their widespread usage peri-operatively
as well as non-peri-operatively, a basic understanding
of NSAIDs, COX-2 inhibitors, and acetaminophen is
certainly imperative. The following chapters provide
an overview of key points regarding specific agents
within these classes, such as their recommended doses,
214
indications, advantages, disadvantages, and both

common and serious adverse reactions. With this
information, clinicians can choose the optimal agent
from their armamentarium to treat patients in the
acute peri-operative setting.
References
1. Jahr JS, Donkor KN, Sinatra RS. Non-selective

non-steroidal anti-inflammatory drugs (NSAIDs),
cyclooxygenase-2 inhibitors (COX-2Is), and
acetaminophen in acute perioperative pain:
analgesic efficacy, opiate-sparing effects, and adverse
effects. In Sinatra R, de Leon-Casasola O, Ginsberg B,
Viscusi ER, eds. Acute Pain Management, 2nd ed.
New York: Cambridge University Press 2009,
pp. 332365.
2. Ong CKS, et al. An evidence-based update on
nonsteroidal anti-inflammatory drugs. Clin Med Res
2007;5(1):1934.
3. Hyllested M, et al. Comparative effect of
paracetamol, NSAIDs or their combination in post-operative pain Management: a
qualitative review. Br J Anaesth 2002;88
(2):199214.
4. Scheiman JM. Balancing risks and benefits of
cyclooxygenase-2 selective nonsteroidal antiinflammatory drugs. Gastroenterol Clin N Am
2009;38:305314.
5. Jones R, et al. Gastrointestinal and cardiovascular
risks of nonsteroidal anti-inflammatory drugs. Am J
Med 2008;121(6):464474.
6. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER,
Groudine SB, Payen-Champenois C. The analgesic
efficacy and safety of single and repeated
administration of intravenous paracetamol
(acetaminophen) 1 g for the treatment of
postoperative pain following orthopedic surgery.
7. Sinatra RS, Boice JA, Loeys TL, Ko AT, Kashuba MM,
Jahr JS, Rhondeau S, Singla N, Cavanaugh PF.
Evaluation of the effect of perioperative rofecoxib
treatment on pain control and clinical outcomes in
patients recovering from gynecologic abdominal
surgery: a randomized, double-blind, placebocontrolled clinical study. Reg Anesth Pain Med 2006;
31(2):134142.
8. Buvanendran A, Kroin JS. Multimodal analgesia for
controlling acute postoperative pain. Curr Opin
Anaesthesiol 2009; [Epub ahead of print].
9. Snyder BK. Venous thromboembolic prophylaxis: the
use of aspirin. Orthop Nurs 2008;27(4):225230.
Section 4
Chapter
49
NSAIDs
Ibuprofen
Eric C. Lin and Shu-ming Wang
Generic Name: ibuprofen

Trade/Proprietary Names: Advil, Motrin
Chemical Name: D2-(4-isobutylphenyl)propanoic acid
Description
Ibuprofen (2-arylpropionate derivatives) contains a
stereocenter in the -position of the propinate moiety.
Ibuprofen is also known as Advil, Genpril, Ibu, Midol,
Motrin, and Nuprin. Ibuprofen was developed during
the 1960s by the research arm of Boots Group in the
UK. Stewart Adams, John Nicholson, and Collin Burrows discovered this compound and patented it in
1961. In 1969, this drug was launched as a treatment
for rheumatoid arthritis in the UK and later on was
launched in the USA in 1974. The clinical outcomes of
ibuprofen as a treatment for pain, inflammation, and
fever won Boots Group the Queens Award for Technical Achievement in 1987.
Mode of activity
Major sites of action: ibuprofen produces reversible
cyclooxygenase inhibition by competing with the substrate, arachidonic acid, for the active site of enzyme.
This leads to the inhibition of prostaglandin synthesis.
The inhibition of prostaglandin synthesis by ibuprofen has been demonstrated in a wide variety of cell
types and tissues.
Receptor interactions: ibuprofen interacts nonselectively with cyclooxygenase 1 (COX-1) and 2 (COX2). Effects of ibuprofen include analgesia and antipyretic
and anti-inflammatory properties through the COX-2
inhibition. Unwanted effects, such as preventing platelet aggregation and ulcerating gastrointestinal mucosa,
are mediated through COX-1 inhibition. In contrast to

other NSAIDs, ibuprofen shows non-time-dependent
inhibition, but retains its initial ratio of activity against
COX-1/COX-2.
Metabolic pathways: ibuprofen is absorbed from
the gastrointestinal tract and peak plasma concentrations are reached within about 1 to 2 hours after
ingestion. Bioavailability is greater than or equal to
80%, 99% of ibuprofen is bound to plasma proteins,
and 90% is transformed to two inactive metabolites.
Following a single dose ingestion, the plasma half-life
is about 2 0.5 hours. However, as the dosage
increases, the half-life ranges between 4 and 8 hours.
Ibuprofen is rapidly excreted in the urine, mainly as
metabolites and their conjugates. The majority of the
dose is recovered in the urine within 24 hours as the
hydroxy (25%) and carboxypropyl (37%) phenylpropionic acid metabolites. The percentages of free and
conjugated ibuprofen found in urine are about 1%
and 14% respectively. The remainder of the drug is
found in the stool as both metabolites and an unabsorbed drug.
Oral suspension
Fever: ibuprofen is indicated for the reduction of fever
in patients aged 6 months and older.
Medical pain: ibuprofen is commonly used to relieve
mild to moderate pain and primary dysmenorrhea.
Cancer pain: a small randomized clinical trial
indicated that ibuprofen combined with methadone
has significantly increased analgesia in patients suffering from moderate to severe cancer-related pain.
Chronic non-malignancy pain: ibuprofen frequently is used to assist in the management of various
chronic pain syndromes such as osteoarthritis, rheumatoid arthritis, low back pain, fibromyalgia, and
peripheral neuropathy.
215
NSAIDs Section 4
Figure 49.1.
OH
Suspension 100 mg/2.5 mL and 100 mg/5 mL

Oral drops 40 mg/mL
Topical 5% cream
Suppository 60 mg
Topical cream and gel
Medical pain: 5% ibuprofen cream is found to be useful in treating acute ankle sprains and knee osteoarthritis.
Acne treatment: 5% ibuprofen cream is found to
be effective in treating patients with mild acne.
Contraindications
Absolute: patients with documented hypersensitivity
to ibuprofen, individuals with a history of allergic
manifestations to aspirin or other NSAIDs, and severe
anaphylactic-like reaction to ibuprofen.
Relative: (1) patients with serious gastrointestinal events and other risk factors known to be associated with peptic ulcer disease such as alcoholism,
smoking, etc. (2) Elderly and debilitated patients
who cannot tolerate ulceration or bleeding well.
(3) Patients with bronchospastic reactivity (e.g.
asthma), nasal polyps, or those with a history of
angioedema can have an anaphylactoid reaction after
ibuprofen. (4) Patients with advanced renal disease
should be monitored closely during the treatment of
ibuprofen.
Common doses
Oral: the recommended dosage is based upon body
mass and indications. Generally, the oral dosage is
200400 mg for adults or 510 mg/kg for children
every 46 hours. The usual dose in adults is 400800
mg daily for analgesia and up to 1600 to 2400 mg for
its anti-inflammatory action. The maximum daily ibuprofen dose for over-the-counter use is 1200 mg.
Under the medical direction of physicians, the daily
allowable dose can be up to 3200 mg.
Drug preparation
216
Tablets 200 mg, 400 mg, 600 mg and 800 mg

Chewable tablets 50100 mg
Capsule 200 mg
Ease of use, tolerability: for most patients, ibuprofen is

well tolerated and has less toxicity as compared to
other analgesic treatments.
Cost: relatively inexpensive when generic versions
are available.
Availability: widely available in every hospital and
pharmacy.
As monotherapy: ibuprofen has been used to treat
fever and relieve mild to moderate pain.
As used for multimodal analgesia: study has shown
that ibuprofen can be used as an adjunct for narcotics
in managing cancer pain.
Toxicity: ibuprofen has become very common ever
since it was licensed as an over-the-counter medication. Although there are many ibuprofen overdose
experiences in the medical literature, the frequency of
life-threatening complications from the overdose is
low. The toxic effect is unlikely at doses below 100 mg/
kg, but the toxic effect can be severe when ibuprofen is
above 400 mg/kg. The lethal dose may vary with age,
weight, and concomitant diseases of the individual
patient. Therapy for the overdose of ibuprofen is
largely symptomatically. In cases presented early, gastric decontamination is recommended (by using active
charcoal to absorb the ibuprofen before it enters the
systemic circulation).
Drug interactions: ibuprofen affects the antihypertensive effect of ACE inhibitors, reduces the natriuretic effects of furosemide and thiazides, elevates the
plasma lithium level by reducing renal lithium clearance, enhances the toxicity of methotrexate, and affects
prothrombin time.

Common adverse events
(1) Serious gastrointestinal toxicity such as ulceration,
bleeding, and perforation can occur at any time,
with or without warning symptoms in patients
receiving chronic ibuprofen treatment. In patients
Chapter 49 Ibuprofen
treated with ibuprofen for 36 months, 1% of

patients can present with symptomatic upper GI
ulcers, gross bleeding or perforation. When the
duration of ibuprofen treatment increases to 1 year,
24% of patients will have gastrointestinal toxicity.
(2) Ibuprofen can increase the risk of life-threatening
cardiovascular events, including heart attack or
stroke.
(3) Fluid retention can occur in association with
ibuprofen usage. Therefore, the drug should be
used with caution in patients with a history of
cardiac decompensation or hypertension.
(4) Ibuprofen can inhibit platelet aggregation. But
unlike aspirin, its effect on platelet function is
reversible, quantitatively less, and of shorter
duration. Thus, in patients with underlying
hemostatic defects, ibuprofen should be used with
caution.
(5) Elevation of one or more liver function tests (LFTs)
may occur in up to 15% of patients who receive
ibuprofen treatment. The changes of LFTs can be
transient or may progress with continued treatment.
(6) Blurred and diminished visions, scotomata, and
changes in color vision have been reported with
ibuprofen treatment.
(7) Dizziness, headache, and nervousness can occur.
(8) Rashes and pruritus can be present.
(2) Aseptic meningitis with fever and coma has been

observed on rare occasions in patients on
ibuprofen therapy. It is probably more likely to
occur in patients with systemic lupus
erythematosus and related connective tissue
diseases.
Rare adverse events
3. Vale JA, Meredith TJ. Acute poisoning due

to non-steroidal anti-inflammatory drugs.
Clinical features and management. Med Toxicol
1996;1:1231.
(1) Anaphylactoid reactions may occur in patients

with bronchospastic reactivities and angioedema.

The treatment will have to be based on the adverse
events. Physicians should discuss with their patients
the potential adverse events associated with ibuprofen treatment. They should also advise patients to
report to their physicians about signs and symptoms
of chest pain, weakness, shortness of breath, slurred
speech, gastrointestinal ulceration, bleeding, blurred
vision or other eye symptoms, skin rash, weight gain,
or edema.
References

anti-inflammatory drugs. Scand J Rheumatol 1996;25
(suppl 102):912.
2. Frlich JC, Fricker RM. Pain therapy and
analgesics-antipyretics (nonsteroidal antirheumatic
drugs-NSAR). In Frlich JC, Kirch W, eds. Praktiche
Arzneitherpie, 4th ed. Heidelberg: Springer, 2006,
pp. 675706.
217
Section 4
Chapter
50
NSAIDs
Injectable ibuprofen
James H. Shull
Generic Name: injectable ibuprofen

Trade Name: Caldolor
Chemical Class: nonsteroidal anti-inflammatory drug
Manufacturer: Cumberland Pharmaceuticals,
Nashville, TN
Chemical Name: D2-(4-isobutylphenyl)propanoic acid
Description
Ibuprofen is a nonsteroidal anti-inflammatory drug
with a long history that has found a broad range of uses
in a wide variety of clinical settings. Initially released in
oral form in the UK in 1969 (and later in the USA in
1974) as a treatment for rheumatoid arthritis, ibuprofen is now used to treat acute and chronic pain, fever,
inflammation and as an anti-platelet agent. Although
originally released as an oral agent, later an injectable
form became available in Europe, Australia, and New
Zealand and has been used as an alternative to
indomethacin in the treatment of patent ductus arteriosus. Injectable ibuprofen was recently studied, FDAapproved and introduced to the US market by
Cumberland Pharmaceuticals under the trade name
Caldolor. Injectable ibuprofen in the USA is marketed
both as an analgesic for use in mild to moderate pain
and as an adjunct to opiods in the treatment of moderate to severe pain. In addition to its use as an analgesic,
injectable ibuprofen may also be useful as an antipyretic
in patients, for whom oral ibuprofen is not an option,
although it is not FDA-approved for this indication.
Mode of activity
218
Injectable ibuprofen is thought to act through the

inhibition of cyclooxygenase-mediated prostanoid
(prostaglandin, prostacyclin, and thromboxane) formation through nonselective inhibition of both

COX-1 and COX-2 isoenzymes. COX-2 is an inducible enzyme found at sites of inflammation. Inhibition of COX-2 activity at sites of inflammation is
chiefly responsible for the analgesic, anti-inflammatory, and antipyretic actions of injectable ibuprofen
(and NSAIDs in general). In contrast, the COX-1
isoenzyme is a constitutive enzyme found in a wide
variety of sites throughout the body and is responsible for many of the untoward effects of ibuprofen
administration, including the formation of gastric
ulcers and anti-platelet activity.
Indications
Injectable ibuprofen is FDA-approved for the treatment of mild to moderate pain and the treatment
of moderate to severe pain as an adjunct to opiod
analgesics.
Contraindications and precautions

(1) Patients with known hypersensitivity to ibuprofen
or previous hypersensitivity reactions to other
NSAIDS.
(2) Injectable ibuprofen is contraindicated in the
peri-operative period in patients undergoing
coronary artery bypass graft (CABG) surgery
secondary to an increased risk of thrombotic
events and myocardial infarction.
(3) Patients who have previously had asthma, urticaria,
or allergic-type reactions after taking NSAIDS.
(4) Injectable ibuprofen should not be used in
pregnant women after 30 weeks of gestation
because of the potential for premature closure of
the fetal ductus arteriosis. Prior to 30 weeks
gestation ibuprofen is Pregnancy Class C.
(5) The safety and effectiveness of injectable
ibuprofen in the pediatric population has not
been established.
Chapter 50 Injectable ibuprofen
Figure 50.1.
HO
(6) Like any NSAID, injectable ibuprofen should be

avoided in patients with renal dysfunction.
(7) Injectable ibuprofen may cause toxic epidermal
necrolysis, exfoliative dermatitis, or Stevens
Johnson syndrome. The drug should be
discontinued if a local skin reaction occurs.
(8) Patients taking ACE inhibitors should closely
monitor their blood pressure as NSAIDs may
reduce ACE inhibitors antihypertensive effect.
Common doses
Injectable ibuprofen is administered for analgesia in
doses of 400 mg to 800 mg every 6 hours as needed,
with the total 24 hour dose not to exceed 3200 mg.
Injectable ibuprofen is available in single-dose vials of
400 mg/4 mL and 800 mg/8 mL. The 400 mg dose
should be diluted in no less than 100 mL of diluent
(normal saline, lactated Ringers, or D5W), while the
800 mg dose should be diluted in no less than 200 mL
of diluent. Both the 400 mg and 800 mg doses should
be infused in no less than 30 minutes. Rapid IV boluses
may cause pain and adverse events (phlebitis, venous
injury) and are not recommended [1].
The chief advantage of injectable ibuprofen is as a
means to provide non-opioid analgesia in patients
with mild to moderate pain in whom the oral route is
not possible or not preferred. Injectable ibuprofen is
also useful in the setting of moderate to severe pain
when an intravenous route is preferred for an adjunct
to opioid analgesia to reduce opioid requirement and
thus unwanted opioid side effects such as respiratory
depression, pruritus, and nausea. Injectable ibuprofen
has not been compared directly with injectable ketorolac; however, efficacy and overall safety of equivalent
doses would be expected to be comparable. Like IV
ketorolac, injectable ibuprofen may play a role in postoperative multimodal analgesia. In several clinical trials in gynecological and orthopedic surgery, the
combination of IV ibuprofen and PCA morphine was
superior to IV-PCA morphine alone (Table 50.1).
The analgesic effect of IV ibuprofen was evaluated
in two large double-blind, placebo-controlled studies
in post-surgical patients, all with access to IV or IVPCA morphine (Table 50.1) [35]. The first was a doseranging study in patients recovering from abdominal
and orthopedic surgery. Patients randomized to receive
800 mg IV ibuprofen had a 22% reduction in median
morphine use while patients receiving 400 mg had a
3% reduction, compared with those receiving placebo.
Patients receiving 800 mg IV ibuprofen reported
reductions in rest and movement associated VAS pain
intensity scores over the 24 hours following surgery (P
= 0.001) Patients receiving 400 mg reported a 7%
reduction in pain intensity over the 24 hours following
surgery (P = 0.057) (Table 50.2) [4]. These data formed
the basis for the dosing in the second study, the
Abdominal Hysterectomy Pain Study. In this second
study, patients undergoing abdominal surgery had a
19.5% reduction in median morphine usage with IV
Table 50.1. Reduction in pain intensity: effect of Caldolor, 24 hours post-surgery
400 mg
800 mg
Medium decreases at hour 24 at rest
0%
33%
P valueb
P = 0.419
P = 0.009
Medium decreasesa at hour 24 with movement
2%
18%
P value
P = 0.894
P = 0.005
In those receiving ibuprofen multimodal therapy compared with those receiving standard, morphine-only therapy.
b
The analysis is based on a linear 4-way ANOVA model with fixed effects for age group, weight group, randomization center, and treatment
group. The P values are based on the difference in LS means from the final ANOVA model.
Source: Key IV Ibuprofen (Caldolor) Clinical Trials. From: http://www.caldolor.com/.
a
219
NSAIDs Section 4
ibuprofen 800 mg as compared with placebo (P <

0.001) (Table 50.2). In addition to using less morphine,
patients receiving 800 mg IV ibuprofen reported a 21%
median reduction in pain intensity following surgery
from post-op through study hour 24 (P = 0.011) (Table
50.3) [35]. Based on these findings and subsequent
approval of IV ibuprofen, physicians comfortable with
the use of oral ibuprofen have been given an alternative therapy for pain and fever in the hospital setting
where an injectable medicine is often needed [35].
Another advantage of injectable ibuprofen is the lack
of black-box warning for pre-operative dosing. Unlike
ketorolac, injectable ibuprofen is approved for administration prior to tissue injury where it can inhibit traumatic synthesis of prostaglandin and more effectively
attenuate the intra-operative inflammatory response.
A final advantage is that ibuprofen and the proprietary preparation Motrin are well-recognized and
respected analgesics that are widely accepted by
patients and caregivers alike. Patients may be treated
with injectable doses to initiate analgesia and antiinflammatory effects, and then converted to and
maintained on oral ibuprofen, which is inexpensive
and widely available as an over-the-counter analgesic.
Table 50.2. Injectable ibuprofen dose ranging study: pain at rest and with movement and incidence of gastrointestinal
adverse events
IV ibuprofen 400 mg +
PCA morphine
IV ibuprofen 800 mg +
PCA morphine
IV placebo +
PCA morphine
(n =111)
(n = 116)
(n = 115)
Pain at rest (VAS - AUC mm-h) 124 h,

Mean (SD)
81.9 (44.6)
76.9 (41.0)
90.2 (45.5)
Pain with movement (VASa- AUC

mm-h) 124 h, mean (SD)
111.8 (44.1)
108.5 (45.0)
122.1 (47.3)
PCA morphine requirement (mg)

mean (SD)
44.7 (27.0)
42.1 (32.0)
48.8 (28.3)
Incidence of nausea, number (%)
77 (57)b
82 (59)
94 (70)
Incidence of vomiting, number (%)
30 (22)
31 (22)
38 (28)
Incidence of constipation, number (%)
23 (17)
25 (18)
28 (21)
As measured using a visual analog scale (VAS scale, 0 = no pain, 100 = intense pain), area under the curve.
b
Significant difference P = 0.042 vs. placebo.
Source: Southworth S, Peters J, Ludbrook G, et al: A multicenter, randomized, double- blind, placebo-controlled trial of intravenous
ibuprofen for the management of post-operative pain in adults. Clin Ther 2009;31:113.
a
Table 50.3. Injectable ibuprofen: analgesic effects observed during the immediate 24 hours following abdominal hysterectomy
Variable
IV-PCA morphine + IV
placebo
IV-PCA morphine + IV
ibuprofen (800 mg)
Number of patients
153
166
Mean morphine dose (mg) (SD)
56.0 (20.6)
47.3 (25.6)*
Median morphine dose (mg)
54.0
43.5*
Percentage reduction in median morphine dose
19.5%*
Pain intensity (rest)
Significant Reduction
Pain intensity (movement)
Significant Reduction
Incidence of nausea
56%
48%
Incidence of vomiting
8%
9%
220
Significant reduction P < 0.05.
Source: Kroll, P., et al. Randomized double blind, placebo-controlled trial of ibuprofen injection for treatment of pain in post-operative
adult patients. Poster #50, 20th Annual AAPM Meeting, Oct 10, 2009.
Chapter 51 Naproxen
Drug-related adverse reactions
Injectable ibuprofen shares disadvantages in common

with oral ibuprofen and other NSAID analgesics
including gastrointestinal irritation and ulceration,
increased bleeding secondary to antiplatelet effects,
renal toxicity, and cardiovascular complications
including stroke and myocardial infarction. IV ibuprofen is contraindicated for patients recovering
from coronary artery bypass surgery. As a new entry
to the market in the USA, injectable ibuprofen suffers a price disadvantage when compared to the other
widely available injectable NSAID, ketorolac, which
is available in generic form. Nevertheless it is a drug
that is well-recognized and proven safe and efficacious in over 40 years of use. It also offers the caregiver ease of dosing transition from an IV
preparation to an inexpensive oral preparation which
can be easily purchased and continued upon hospital
discharge. Further comparative studies of both effectiveness and the relative side-effect profiles of the
respective drugs are needed to determine whether
the higher cost for brand-name injectable ibuprofen
is justified.
The most common adverse reactions reported with

injectable ibuprofen are nausea, flatulence, vomiting,
headache, dizziness, and hemorrhage. The most common reaction that leads to discontinuation of the drug
is pruritus, which occurs in less than 1% of patients.
Section 4
Chapter
51
References
1. Caldolor product monograph: available from

Cumberland Pharmaceuticals, Nashville, TN.
anti-inflammatory drugs. Scand J Rheumatol
1996;25(suppl 102): 912.
3. Data on file and Cumberland Pharmaceuticals Inc.
4. Kroll P, Meadows L, Rock A, et al. Randomized double
blind, placebo-controlled trial of ibuprofen injection for
treatment of pain in postoperative adult patients. Poster
#50, 20th Annual AAPM Meeting, October 10, 2009
5. Southworth S, Peters J, Ludbrook G, et al. A multicenter,
randomized, double- blind, placebo-controlled trial of
intravenous ibuprofen for the management of
postoperative pain in adults. Clin Ther 2009;31:113.
NSAIDs
Naproxen
Dorothea Hall, Tyson Bolinske and Elizabeth Sinatra
Generic Name: naproxen, naproxen sodium

Trade/Proprietay Names: Naprosyn, Anaprox,
EC-Naprosyn, Alleve, Naprelan, numerous
generics
Drug Class: nonsteroidal anti-inflammatory
drug
Manufacturer: Roche Laboratories USA, Nutley, NJ 07110; Bayer Health Care, 100 Bayer
Road, Pittsburgh, PA 152059741; Pfizer-Wyeth

Pharmaceuticals, 235 East 42nd Street, New
York, NY 10017
Chemical Name: sodium 2-(6-methoxynaphthalen-2-yl)propanoate
Chemical Structure (salt form): see Figure
51.1
Chemical Formula: C14H14O3
221
NSAIDs Section 4
CH3
Figure 51.1.
H 3C
C
H
O
O- Na+
Description
Naproxen is one of many drugs in the group classified

as nonsteroidal anti-inflammatory drugs (NSAIDs).
Naproxen is in the chemical class of propionic acid
derivatives and possesses analgesic, antipyretic, and
anti-inflammatory properties. It was first introduced
in 1976 under the trade name Naprosyn by Roche
Pharmaceuticals. Both the acid and salt formulations
are currently used, with the salt form having a slightly
more rapid absorption rate. Reduced-dose naproxen
sodium was approved as an over-the-counter (OTC)
pain reliever in the USA in 1994 and entered the market under the trade name of Alleve [1,2].
Mechanism of action
In a manner similar to other NSAIDs, naproxen
decreases pain by inhibiting inflammation and nociception at the cellular level. Naproxen reversibly inhibits
cyclooxygenase (COX). Cyclooxygenase converts arachidonic acid to endoperoxides, and blocks the COX1-mediated production of thromboxane A2 as well as
the COX-2-mediated production of prostaglandin E2.
Whereas COX-1 is constitutive and synthesizes prostaglandins for normal renal and gastrointestinal function, COX-2 is inducible and primarily responsible for
synthesis of prostaglandins involved in inflammatory
reactions. Prostaglandins have direct effects on peripheral terminals of nociceptor sensory neurons, sensitizing pain receptors to histamine and bradykinin and
thus reducing their threshold to peripheral noxious
stimuli [1].
Pharmacodynamics and
pharmacokinetics
222
Although the exact mechanism of action is not fully

understood, it is known that by blocking synthesis
of prostaglandins and suppressing the peripheral
inflammatory response, activation and amplification
of nociceptive inputs and sensitization of nociceptive

receptors are diminished.
Both naproxen and its sodium salt are rapidly
absorbed in the gastrointestinal tract and are generally fully absorbed when taken orally. Peak plasma
levels are obtained in 24 hours after ingestion of
naproxen, and 12 hours after ingestion of the sodium
salt form (Anaprox). The latter has significantly
increased aqueous solubility. The enteric coated form
of naproxen dissolves in the small intestine as opposed
to the stomach; therefore its absorption is delayed.
Distribution: naproxen has a volume of distribution
of 0.16 L/kg. The elimination half-life of naproxen is
approximately 15 hours following normal therapeutic
doses. Naproxen is almost completely (99%) bound to
albumin and other plasma proteins. It crosses the placenta and appears in the milk of lactating women at
approximately 1% of the plasma level concentration.
Substantial amounts are found in the spinal fluid [13].
Metabolism: naproxen undergoes various forms of
hepatic metabolism (95%) with about 30% of
the drug being subjected to 6-demethylation. Most of
this metabolite, along with naproxen itself, is excreted
as the glucuronide or other conjugate. After liver conjugation, 95% of the drug is excreted by the kidneys,
primarily in the metabolite form. Decreased kidney
function as seen in the elderly or patients with endstage liver disease may increase drug elimination halflife two-fold or greater. The combination of decreased
protein binding and delayed excretion put the elderly
at increased risk of drug toxicity [2,3].
Indications
Acute surgical pain: depending upon the extent of surgery and intensity of post-operative pain, naproxen
may be administered as monotherapy or combined
with opioid analgesics such as morphine, oxycodone,
hydrocodone, or hydromorphone. Oral doses of
naproxen 500 mg and naproxen sodium 400 mg provide effective analgesia in adults with moderate to
severe acute post-operative pain following dental sugery and bunionectomy. Concomitant use of naproxen
in a multimodal analgesic regimen has been shown to
reduce pain intensity and the amount of narcotic medications patients require for effective post-operative
analgesia. In a recent review of 1509 patients, 400 to 500
mg of oral naproxen provided effective analgesia in
adults with moderate to severe acute post-operative
pain [4]. In randomized double-blinded trial, pre-operative doses of oral naproxen (550 mg) were compared
Chapter 51 Naproxen
to placebo in 44 patients recovering from laparoscopic

tubal ligation [5]. Patients treated with naproxen benefited from lower VAS pain intensity scores (0.9 vs. 2.3
cm, P > 0.05), reduced need for opioids in the PACU
(0% vs. 34%), and reduced day surgery stay (168 vs. 188
min, P > 0.05) (Table 51.1). Except for one patient in the
naproxen group who developed gastric discomfort,
there were no other adverse events [5].
Although opioid dose requirements are reduced
with short-term use of NSAIDs including naproxen,
it remains unclear whether reductions in dose are
associated with a decrease in opioid-related adverse
events such as nausea, vomiting, and constipation.
Like other nonselective NSAIDs, naproxen is often
withheld in the peri-operative period for fear of surgical site and GI bleeding. It should be appreciated that
unlike aspirin, inhibition of platelet aggregation with
naproxen is reversible, and temporally related to
serum drug concentration.
Medical pain and non-malignancy chronic pain:
naproxen can be used to treat mild to moderate pain.
Enteric coated naproxen, however, is not indicated for
the treatment of acute pain. Common indications for
enteric coated preparations include general somatic
pain, acute gout, osteoarthritis, rheumatoid diseases,
juvenile arthritis, tendonitis, bursitis, ankylosing,
spondylitis, and dysmenorrhea. Recommended dosing for these conditions is 250500 mg PO q12h with
daily dosage caps set between 1250 and 1500 mg/day.
These levels should be maintained no longer than 6
months to limit adverse reactions and potential CV
and GI morbidity. Naproxen is also used to treat acute
gout. It is generally recommended to have a dosing
scheme of 250 mg PO q8h with divided doses reaching no higher than 750 mg per day.
Cancer pain: naproxen and other NSAIDs are used
for the treatment of cancer pain, often in combination
with an opioid. NSAIDs alone have been shown to be
efficacious in treating cancer pain in the short term.
Naproxen dosage schemes have not been formulated
specifically for cancer pain; however, patients experiencing mild to moderate pain may be treated with
250500 mg PO q12h for acute use with a 1250 mg/
day maximum. Maximum dose should be reduced to
1000 mg/day if used for long-term maintenance analgesia. When using naproxen as an adjunct to opioid
analgesics for management of moderate to severe cancer pain, dosage must be tailored to the patients coagulation status to limit hemostatic side effects.
Contraindications
Absolute: hypersensitivity to naproxen, aspirin, other
NSAIDs, or a component of their formulations. Postcoronary artery bypass graft (CABG) surgery.
Relative: history of renal insufficiency, peptic ulcer
disease, gastrointestinal (GI) bleeds.
Concomitant use of corticosteroids: increased risk
of gastroduodenal ulcers. Patients undergoing anticoagulation therapy with products such as warfarin or
heparin.
Patients with a bleeding disorder including hemophilia, von Willebrand disease, various factor deficiencies, disseminated intravascular coagulation (DIC),
idiopathic thrombocytopenia purpura (ITP), antithrombin III deficiency, or protein C or S deficiency.
Third trimester of pregnancy, Pregnancy Category
D, meaning the drug has been found to be unsafe but
its use in certain circumstances may be justified. The
use of acetaminophen is recommended instead.
The drug is extensively bound to albumin, therefore use with caution in patients with liver disease.
May increase levels of methotrexate, lithium,
phenytoin, digoxin, and cyclosporine.
Fluid retention from an inhibition of renal prostaglandins may exacerbate heart failure.
Caution if patient is under sodium restriction or if
using a diuretic.
Naproxen increases intravascular fluid volume and
blunts the effects of antihypertensive medications.
Table 51.1. Visual analog pain scores following tubal ligation
Pain Intensity (1 h)
Naproxen group
Control group
(n = 23)
(n = 21)
0.9 + 0.2
3.5 + 0.6
<0.05
Pain Intensity (2 h)
1.1 + 0.2
2.4 + 0.5
<0.05
Pain Score (Next Day)
0.2 + 0.1
0.6 + 0.2
NS
With permission from Comfort KV, Code WE, Rooney ME et al. Can J Anesthesia 1992;39:349392.
223
NSAIDs Section 4
Naproxen should not be used in patients with creatinine clearance of less than 30 mL/min, in patients at
risk for surgical bleeding and gastrointestinal bleeding
and those treated with anticoagulants.
Cigarette smoking and alcohol consumption may
increase the risk of ulcers.
Common doses/uses
Dosing is generally based on naproxen content; 200,
500 mg naproxen = 220, 550 mg naproxen sodium.
Naproxen tablets or suspension at 250, 375 or 500
mg q12 hours
EC-naproxen delayed-release enteric coated tablets
at 375 or 500 mg q12 hours
Naproxen sodium at 220 mg, 275 mg, 550 mg, and
825 mg q12 hours
The maximum daily dose of naproxen is 1500 mg/
day and is the point where increased doses are no longer
efficacious and produce significant side-effect risks.
Naproxen is administered orally (PO). To start treatment, the lowest dose likely to be effective for a given
patient is prescribed twice daily. The dose is then adjusted
by observing benefit and possible adverse effects.
For post-operative pain, 500 mg of oral naproxen
or 550 mg of oral naproxen sodium have been shown
to provide effective analgesia [3].
Adverse events
224
Common side effects: these occur in approximately

310% of patients treated and are seen at higher
frequencies in patients on higher doses and who
undergo treatment for longer periods of time. Naproxen
is observed to primarily affect the gastrointestinal tract;
heartburn, abdominal pain, nausea, constipation,
diarrhea, dyspepsia, and stomatitis. More severe gastrointestinal side effects include stomach ulcers and GI
bleeds. Elderly patients are at greater risk for suffering
from gastrointestinal side effects, edema, visual disturbances, hearing disturbances, headache, dizziness,
drowsiness, lightheadedness, and pruritus. Gastrointestinal side effects and the potential for developing
ulcers and GI bleeding remain the limiting factor in
the widespread use of naproxen for analgesia.
Less common adverse events include cardiovascular palpitation, lightheadedness, vertigo, purpura, rash,
diarrhea, dyspepsia, stomatitis, gross bleeding/perforation, indigestion, ulcers, vomiting, abnormal renal
function, anemia, increased bleeding time, diaphoresis,
thirst, and increased hepatic enzymes (LFTs) [13].
Treatment of non-acute adverse events is directed

toward utilizing the lowest effective dose for the shortest
duration of time. Patients at a high risk for adverse effects
should be evaluated for the use of alternative therapies.
Cardiovascular risk: increasing evidence is surfacing that NSAID use, but particularly the use of COX-2
selective NSAIDS, elevates the risk of cardiovascular
morbidity and mortality. This is especially true in
patients with preexisting cardiovascular disease. Thrombotic cardiovascular events are related to a relative
increase in thromboxane and a relative diminution in
prostacycline. Since most selective as well as nonselective NSAIDS affect this relative imbalance of throm
boxane over prostacycline they are all implicated in
increasing the risk for thrombotic cardiovascular events
[6]. However, naproxen appears to be risk-neutral with
regard to cardiovascular events and may in fact be
somewhat cardioprotective due to its nonselectivity [7].
Easy to use and administer
Over-the-counter formulations available
Little risk of side effects with a low-dose nonchronic dosing schedule
Opioid-sparing when employed as multimodal
analgesia
Unlike opioids, naproxen does not cause physical
or psychological dependency, severe cognitive
dysfunction, excessive nausea, vomiting, or
constipation
Regular administration of naproxen 500 mg BID
can produce an antiplatelet COX-1 effect similar to
that of low-dose aspirin
Naproxen toxicity can occur at very high doses (150
500 mg/kg). Naproxen toxicity is relatively uncommon
compared to other NSAIDs such as aspirin and
ibuprofen. See below for description of signs and
symptoms of naproxen toxicity.
Drug interactions occur with many commonly
prescribed medications and are mostly due to naproxens effects on renal prostaglandins and the associated
changes in kidney filtration rate, although many other
mechanisms exist. Many drug interactions exist, with
examples being ACE inhibitors, beta blockers, metho
trexate, lithium, probenecid, antiplatelet agents, diuretics, and vancomycin.
Chapter 52 Diclofenac gel and diclofenac patch
The ceiling effect of naproxen limits the amount

of pain relief that can be expected. It may increase risk
of gastrointestinal irritation, inflammation, ulceration, bleeding, and perforation. Enteric coated formulations are available to help reduce the risk of such
complications.
Toxicity
2.
3.
4.
Toxicity most commonly begins within 4 hours of

ingestion with symptoms such as headache, tinnitus,
drowsiness, abdominal pain, nausea, and vomiting.
Severe toxicity is reported mainly in children. Severe
toxicity occurs with ingestions of 400 mg/kg or more
of naproxen with symptoms including seizures, apnea,
hypertension, and renal and hepatic dysfunction.
5.
6.
References
1. Capone M, Tacconelli S, Sciulli M, et al. Clinical

pharmacology of platelet, monocyte and vascular
cyclooxygenase inhibition by naproxen and low-dose
Section 4
Chapter
52
7.
aspirin in healthy subjects. Circulation 2004;109:

14681471.
Hamilton RJ, ed. Tarascon Pocket Pharmacopoeia 2009
Deluxe Edition. Sudbury, MA: Jones and Bartlett,
pp. 79.
MICROMEDEX Healthcare Series: DRUGDEX
Drug Point.
Derry C, Derry S, Moore RA, McQuay HJ. Single dose
oral naproxen and naproxen sodium for acute
post-operative pain in adults. Cochrane Database Syst
Rev 2009;1:CD004234.
Comfort KV, Code WE, Rooney ME, et al. Naproxen
premedication reduces postoperative tubal ligation
pain. Can J Anesthesia 1992;39:349392.
Hennekens CH, Borzak S. Cyclooxygenase-2
inhibitors and most traditional nonsteroidal antiinflammatory drugs cause similar moderately
increased risk of cardiovascular disease. J Cardiovasc
Pharmacol Ther 2008;13(1):4145.
Bing RJ, Lomnicka M. Why do cyclo-oxygenase-2
inhibitors cause cardiovascular events? J Am Coll
Cardiol 2002;39:521522.
NSAIDs
Diclofenac gel and diclofenac patch

Neil Singla
Generic Names: diclofenac sodium topical gel;

diclofenac epolamine topical patch
Trade/Proprietary Names: Voltaren Gel; Flector Patch
drug (NSAID)
Manufacturer: Novartis Pharma Produktions
GmbH, Oflinger Strasse 44, D-79644 Wehr/
Baden, Germany; King Pharmaceuticals, Inc.,
501 Fifth Street, Bristol, TN 37620
Chemical Names: 2-[(2,6-dichlorophynyl)

amino]benzeneacetic acid, monosodium salt;
2-[(2,6-dichlorophenyl)amino]benzeneacetic
acid, 2-(pyrrolidin-1yl)ethanol salt
Chemical Structures: diclofenac sodium topical
gel (Figure 52.1); molecular formula: C14H10Cl2NNaO2; diclofenac epolamine patch (Figure 52.2);
molecular formula; C20H24Cl2N2O3
225
NSAIDs Section 4
O- Na+
Figure 52.1.
O
NH
Cl
Cl
CH2COO-
DICLOFENAC Cl
NH
Cl
EPOLAMINE
H
2-(pyrrolidin-1-y1)ethanol
N+
CH2-CH2-OH
Figure 52.2.
Introduction
226
Diclofenac is a nonsteroidal anti-inflammatory drug

(NSAID) and is the active ingredient in both the gel
and patch formulations described in this chapter.
Diclofenac inhibits the enzyme cyclooxygenase
(COX), an early component of the arachidonic acid
cascade, resulting in reduced formation of prostaglandins, thromboxane, and prostacyclin. It is not completely understood how reduced synthesis of these
compounds results in therapeutic efficacy. The chief
therapeutic effects of diclofenac are anti-inflammatory
activity, anti-nociception and antipyresis. When
applied topically (via gel or patch), diclofenac is
absorbed into the epidermis. However, the amount of
topical diclofenac absorbed and the ultimate systemic
exposure is substantially less than that seen after oral
administration of the compound.
After application of 4 grams of the 1% gel to the
knee four times daily (total daily dose of 160 mg of
diclofenac sodium) for 7 days, the mean Cmax was 15
7.3 ng/mL, the time to the maximum concentration
was 14 hours (range 024 hours), and the AUC over
24 hours was 233 128 ng/h per mL. The Cmax was
0.6%, and the AUC was 5.8% of the values obtained
after administration of oral diclofenac sodium 50 mg
three times daily.
Ten to 20 hours after a single application of the
diclofenac patch to the upper inner arm, peak plasma
diclofenac concentrations of 0.76 ng/mL were
recorded. Diclofenac plasma concentrations of 1.38.8
ng/mL were noted after 5 days of twice-daily patch
application.
Diclofenac appears to be widely distributed, with

significant amounts in synovial fluid. Protein binding
is roughly 99%, primarily to albumin. It is unknown
whether diclofenac crosses the placenta. Significant
distribution into breast milk does not occur. Metabolism of diclofenac via hepatic cytochrome P450 2C9
and 3A4 involves conjugation at the carboxyl group of
the side chain or single or multiple hydroxylations
resulting in several phenolic metabolites, most of
which are converted to glucuronide conjugates. The
elimination half-life of diclofenac is about 1.22 hours
after oral administration. After application of the
diclofenac patch, the elimination half-life is approximately 12 hours. Metabolites are subsequently excreted
through urinary and biliary pathways. About 65% of
a dose is excreted in the urine and about 3.5% in the
bile [1].
Indications
Diclofenac gel is indicated for the relief of the pain of
osteoarthritis of the joints amenable to topical treatments such as the knees and those of the hands.
Diclofenac patch is indicated for the topical treatment of acute pain due to minor strains, sprains and
contusions [2,3]. In controlled trials during the premarketing development approximately 600 patients
with minor sprains, strains, and contusions were
treated safely with diclofenac patch for up to 2 weeks
[4]. A randomized, double-blind, placebo-controlled,
trial evaluated the efficacy and tolerability of
diclofenac patch, self-administered every 12 h to
injury site, in 384 patients aged 1865 years with
minor soft tissue injury and moderate to severe pain
intensity 5 (010 scale). The most common injuries
were contusion (42.6%), strain (31.1%), and sprain
(24.4%); most common sites were ankle, shoulder,
knee, and foot (67.3%). Patients treated with
diclofenac patch experienced improved mean pain
scores (40.4% of baseline score) vs. patients using
placebo (47.4%, P < 0.05); with an overall pain reduction of 14.8% (Figure 52.3). Patients treated with the
patch reached pain resolution 3 days sooner than
those in the placebo group (median 10.0 vs. 13.5 days,
P = 0.01). Patient response to treatment was rated
good to excellent 57.8% for the diclofenac patch vs.
48.4% placebo (P < 0.01).
Diclofenac patch and gel preparations have not
been evaluated for use in labor and delivery, in pregnant and nursing women or in pediatrics. The Flector
diclofenac patch is supplied in resealable envelopes,
Percent of Patients Improved
Chapter 52 Diclofenac gel and diclofenac patch
100
90
80
70
60
50
40
30
20
10
Diclofenac Patch
Placebo
0
10
20
30
40
50
60
70
80
Percent Improvement from Baseline
90
100
Figure 52.3. Patients achieving various levels of pain relief at end

of study; 14-day study percent improvement from baseline. With
permission from Carr W, Beks P, Jones C, et al: (Poster Presentation
American Pain Society Annual meeting 2008) The Journal of Pain
Volume 9, Issue 4, Supplement 2, 45; April 2008.
each containing 5 patches (10 cm 14 cm), with six

envelopes per box. Each patch contains 180 mg of
diclofenac epolamine in an aqueous base (13 mg of
active drug per gram of adhesive or 1.3%). The patch
is intended for topical use only. The envelopes should
be sealed at all times when not in use.
Contraindications
The absolute and relative contraindications for
diclofenac, both the topical and gel formulations, are
described below:
Absolute
Known hypersensitivity to diclofenac, aspirin, or
other NSAIDs.
History of asthma, urticaria, or other allergictype reactions after taking aspirin or other
NSAIDs.
Use during the peri-operative period in the
setting of coronary artery bypass graft (CABG)
surgery.
Relative
Serious and potentially fatal cardiovascular (CV)
thrombotic events, myocardial infarction, and
stroke can occur with NSAID treatment.
Diclofenac should be used with caution in
patients with known CV disease or risk factors for
CV disease.
Diclofenac can cause serious GI adverse events
including inflammation, bleeding, ulceration and
perforation. Patients with a prior history of ulcer

disease or GI bleeding should be treated with
caution.
Long-term administration of NSAIDs can result
in renal papillary necrosis and other renal injury.
Diclofenac should be used with caution in
patients at greatest risk, including the elderly,
those with impaired renal function, heart failure,
liver dysfunction, and those taking diuretics and
ACE inhibitors.
Fluid retention and edema have been observed in
some patients taking NSAIDs and therefore
diclofenac should be used with caution in
patients with a history of fluid retention or heart
failure.
Common doses/uses
Diclofenac gel is available in tubes, each containing
100 g of gel. One gram of the gel base contains 10 mg
of the active ingredient, diclofenac sodium. Dosing
information is considered in terms of grams of gel, not
in terms of milligrams of diclofenac. Total daily dose
should not exceed 32 g of gel per day over all affected
joints. When prescribed, a dosing card is dispensed to
the patient so they can appropriately measure 2 and 4
g aliquots of the gel. Specific dosing information is as
follows:
Lower extremities; the gel (4 g) is applied to the
affected area four times daily. More than 16 g
daily should not be applied to any one of the
affected joints of the lower extremity.
Upper extremities; 2 g of gel should be applied
to the affected area up to four times daily.
More than 8 g daily should not be applied to
any one of the affected joints of the upper
extremity.
The diclofenac patch measures 10 cm 14 cm and is
composed of an adhesive material containing 1.3%
diclofenac epolamine. There is a total of 180 mg of
diclofenac epolamine distributed throughout each
patch (13 mg of diclofenac per gram of adhesive). The
recommended dose of the diclofenac patch is one
patch to the most painful area of the body applied up
to twice daily.
Both diclofenac gel and the diclofenac patch have been
designed with the idea of providing local analgesia
227
NSAIDs Section 4
while reducing systemic NSAID exposure. The local

analgesic effects of both the gel and patch formulations have been fairly well established in the literature.
PK data (as described above) seem to indicate that systemic exposure after application of either formulation
is relatively limited when compared to routine oral
dosing. In this regard, systemic exposure (AUC) and
maximum plasma concentrations of diclofenac, after
repeated dosing for 4 days with diclofenac patch, were
lower (<1%) than after a single oral 50 mg diclofenac
sodium tablet [5].
A literature review suggests that the clinical adverse
event data may demonstrate a lower potential for systemic toxicities than oral diclofenac [6].
The active ingredient, diclofenac, has a side-effect
profile similar to most NSAIDs. The main clinical
concerns with this class of agents are GI bleeding and
renal insufficiency. A more complete description of
the side-effect profile can be gleaned from the contraindications mentioned above. When using NSAIDs
over long periods of time to treat chronic conditions
such as osteoarthritis, the risk of serious side effects
becomes more significant. In the controlled trials, 3%
of patients in both the diclofenac patch and placebo
patch groups discontinued treatment due to an
adverse event. The most common adverse events
leading to discontinuation were application site reactions, occurring in 2% of both the diclofenac patch
and placebo patch groups. Application site reactions
leading to dropout included pruritus, dermatitis, and
burning. Rare toxicities associated with diclofenac
are: StevensJohnson syndrome, toxic epidermal
228
necrolysis, anaphalactoid reactions, and hepatic

insufficiency.

For both the gel and patch preparations of diclofenac, by
far the most common drug-related adverse events were
site-specific reactions such as itching and irritation.
References
1. Rainsford KD. Review of the pharmaceutical

properties and clinical effects of the topical NSAID
formulation, diclofenac epolamine. J Curr Med Res
Opin 2008;24(10): 29672992.
2. Petersen B. Diclofenac epolamine (Flector) patch:
evidence for topical activity. J Clin Drug Investig
2009;29:19.
3. Flector Patch (diclofenac epolamine topical patch
1.3%). Prescribing information; September 2007,
Alpharma, Inc., Bridgewater, NJ.
4. Carr W, Beks P, Jones C, et al. Efficacy and
tolerability of FLECTOR Patch (diclofenac
epolamine topical patch) in the treatment of minor
soft tissue injury pain (Poster Presentation American
Pain Society Annual meeting 2008). J Pain 2008;9(4,
Suppl. 2):45.
5. Voltaren Gel (diclofenac sodium topical gel)
Prescribing information. October 2007, Novartis
Consumer Health, Inc. Parsippany, NJ.
6. Gold Standard Inc. 2009: Diclofenac. Drug
Monograph. MD Consult Web site, Core Collection.
Available at http://www.mdconsult.com/das/pharm/b
ody/1620786053/892674727/full/183. Accessed
September 22, 2009.
Section 4
Chapter
53
NSAIDs
Diclofenac oral and diclofenac plus PPI

Nehal Gatha
Generic Name: diclofenac sodium, diclofenac

potassium, diclofenac with misoprostol
Proprietary Names: Voltaren, Cataflam,
Voltaren-XR, Solaraze, Arthrotec
Manufacturers: Novartis Pharmaceuticals,
Basel, Switzerland; Pfizer, New York City, NY;
Kowa Pharmaceuticals Inc, Montgomery, AL
drug
Chemistry: diclofenac is a phenylacetic acid
derivative; its chemical name is 2-(2-(2,6-dichlorophenylamino)phenyl)acetic acid
Molecular Formula: C14H11Cl2NO2
Introduction
Diclofenac sodium was introduced with the aim of
developing a nonsteroidal anti-inflammatory drug
(NSAID) with high activity and improved tolerability. Three older and highly effective NSAIDS,
indomethacin, phenylbutazone, and mefanamic
acid, all have favorable acidity constants, pKa,
between 4 and 5, a similar degree of lipophilicity,
and two aromatic rings that are twisted in relation
to each other. The diclofenac molecule includes
these favorable characteristics. It has a pKa of 4.0, a
partition coefficient of 13.4, and includes a phenyl
acetic acid group, an amino group, and a phenyl ring
containing chlorine, which results in maximal twisting of the ring. Arthrotec is a combination of
diclofenac and misoprostol. It was developed to create a combination drug with protective effects
against the major gastrointestinal side effects of
NSAIDS.
Major and minor sites of action,

receptor interactions
Diclofenac acts primarily by inhibiting prostaglandin
synthesis via inhibition of cyclooxygenase (COX-1
and 2). This provides its anti-inflammatory, antipyretic, and analgesic actions. Inhibition of COX receptors also decreases prostaglandins in the epithelium
of the stomach. Diclofenac has a moderate preference
to block the COX-2 receptor, but is not as selective
as celecoxib. The exact mechanism of diclofenac, as
with other NSAIDS, is not completely known. There
is also some evidence that diclofenac inhibits the
lipoxygenase pathways, reducing inflammation by
decreasing production of leukotrienes. There has been
suggestion that diclofenac also inhibits phospolipase
A2. Diclofenac also may work by inhibiting reactivation of volatage-dependent sodium channels, blocking acid-sending ion channels, as well as modulation
of KCNQ- and BK-potassium channels.
Misoprostol is a synthetic prostaglandin E1 analog
with gastric mucosal protective properties. There are
specific prostaglandin receptors in the gastric mucosa
which have a high affinity for misoprostol and its
metabolites. Receptor affinity for misoprostol has been
shown to correlate with antisecretory activity of gastric acid. Misoprostol also produces a decrease in pepsin concentrations. Deficiency of prostaglandins such
as misoprostol in the gastric and duodenal mucosa
may lead to diminishing mucus and bicarbonate secretion, which are protective in these mucosa.

and elimination
Diclofenac oral is absorbed directly from the GI tract.
The pharmaceutical preparations of diclofenac commonly available are not as soluble in gastric fluid (lower
pH), but allow a more rapid release of drug in the duodenum, which has a slightly higher pH. Approximately
229
NSAIDs Section 4
Figure 53.1.
OH
NH
Cl
Cl
50% of the absorbed dose is available due to first-pass

metabolism. Peak plasma levels of the drug are achieved
within 14 hours, with plasma levels declining in a bioexponential fashion, with the terminal phase having a
half-life of approximately 2 hours. Clearance is 350 mL/
min with a volume of distribution of approximately 550
mL/kg. Diclofenac sodium is more than 99% reversibly
bound to plasma albumin. Diclofenac is metabolized
and broken down into its glucuronide and sulfate conjugates, with elimination occurring through metabolism
and also subsequent urinary and biliary excretion of
these conjugates. Sixty-five percent is excreted through
the urine, with the remaining 35% in bile. Conjugates of
unchanged diclofenac account for 7% of the dose excreted
in the urine, and for less than 5% in the bile. Less than 1%
of the drug is excreted unchanged or unconjugated. Conjugates of the major metabolite account for 2030% of
the drug excreted in the urine and 1020% of the dose in
the bile. The accumulation and activity of diclofenac
metabolites are unknown. The action of a dose of
diclofenac sodium is 68 hours, much longer than the
aforementioned short half-life. This could be due to high
concentration levels in the synovial fluids.
The misoprostol in diclofenac + misoprostol is
extensively absorbed, and is metabolized rapidly to its
active metabolite, misoprostol acid. Misoprostol acid
reaches peak plasma concentration within 20 minutes
and has an elimination half-life of 30 minutes. No accumulation of misoprostol acid has been found. The serum
protein binding of this metabolite is less than 90%.
Approximately 70% of misoprostol is excreted in the
urine. Activity of misoprostol is evident within 30 minutes of administration and lasts for 3 hours. Administration of diclofenac and misoprostol together as diclofenac
+ misoprostol leads to similar absorption and elimination as when the two are administered alone.
Indications
230
Diclofenac oral, as in many NSAIDS, has a wide application of use in acute, subacute, and chronic pain. It is
approved to use, and most commonly used, for conditions relating to chronic musculoskeletal type pain.
These include osteoarthritis, rheumatoid arthritis,
ankylosing spondylitis, spondylarthritis, and gout. It
is also indicated in the treatment of acute visceral and
somatic pain related to nephrolithiasis, cholelithiasis,
and abdominal pain. An additional use is for the treatment of acute migraines. Diclofenac is commonly
used to treat mild to moderate surgical pain post-operatively or post-traumatically, once the patient is taking oral medications; however, it is less useful as a sole
agent in a patient with moderate to severe pain acutely
post-operatively. Diclofenac has also been shown to
be effective against menstrualtype pain.
Arthrotec is indicated for these patients who will
be on NSAIDS long-term, or those at high risk for GI
bleed or gastric irritation, as long-term use can predispose to peptic ulcer.
Diclofenac is also used off-label or for investigational trials in chronic pain patients with cancer, especially when inflammation is present. Examples include
patients with breast or prostate cancer with bony
metastases.
It has also showed limited effectiveness in reduc
ing fever in patients with malignant lymphogranulo-
matosis.
Contraindications
Black-box warning: cardiovascular risk may increase
risk of cardiovascular thrombotic events, MI, stroke.
GI risk may increase risk of serious GI adverse events
such as bleeding, ulceration, or perforation. Arthrotec
also carries these black-box warnings, but with additional black-box warnings for pregnant patients as
well as in women of child-bearing age as misoprostol
increases the chance of miscarriage and can induce
labor.
Absolute: hypersensitivity to drug class, third-trimester pregnancy, patients with active stomach or
duodenal ulceration or gastrointestinal bleeding;
patients with angioedema or bronchospastic reactions
to NSAIDs.
Relative: use caution in patients with cardiovascular disease or status post cardiac surgery, patients with
history of allergic reactions following the use of aspirin or other NSAIDS, HTN, CHF, peptic ulcer disease,
inflammatory intestinal disorders such as Crohns or
ulcerative colitis, patients using corticosteroids,
patients using anticoagulants or with history of coagulopathy, history of alcohol use or smoking, elderly
Chapter 53 Diclofenac oral and diclofenac plus PPI
patients, patients with hepatic or renal insufficiency,

patients taking ACEI or ARBs, patients with preexisting hepatic porphyria. Use extreme caution in patients
with severe, active bleeding such as cerebral hemorrhage.
Common doses/uses
Diclofenac sodium: 25, 50, 75 mg tablets, 100 mg
extended-release tablets. Common doses include
2575 mg PO BID-TID with a maximum dose of
150 mg/day. Alternative dose includes 100 mg ER
daily.
Arthrotec: 50/0.2, 75/0.2 diclofenac/misoprostol.
Common doses include 1 tab PO TID-QID, with a
maximum dose of 225 mg/day diclofenac.
As an NSAID, diclofenac is easy to use, and has been
shown to be efficacious in arthritic syndromes, as well
as for acute treatment of migraines, and small procedures. A major advantage of diclofenac, as with other
NSAIDs, is its use in multimodal analgesia. In patients
who are post-operative or with certain chronic pain
syndromes, diclofenac can be used to provide additive
analgesia and an opioid-sparing effect. Diclofenac has
decreased side effects when compared to opioids in
terms of nausea, respiratory depression, sedation, and
constipation.
A major advantage of diclofenac as compared to
other NSAIDs is that it has an approximately 10-fold
preference to block the COX-2 isoenzyme, which
leads to reduced incidence of GI upset, peptic ulcers,
and GI bleeding compared with other NSAIDs. In
patients at increased risk of GI complications,
diclofenac with misoprostol is available to protect
from diclofenacs effects.
Cost is also a potential advantage as there are now
generic forms available relatively inexpensively, and
can reduce cost as part of a multimodal approach to
pain.
NSAIDs can lead to gastric complications, including
GI upset, peptic ulcers, and GI hemorrhage. This risk
is increased with long-term use, use in the elderly, and
use with anticoagulants or steroids. These complications are exceedingly rare when diclofenac is used in
the short term, and even less when used in the combination form of diclofenac with misoprostol. Diclofenac,
as with other NSAIDS, can also lead to renal impairment, and should be used with caution in those with
renal insufficiency. The risk of bleeding is also
increased with diclofenac, and should be assessed preoperatively. Diclofenac, and especially misoprostol,
can lead to miscarriage or early labor.
Drug interactions
Diclofenac can lead to displacement of other highly
protein-bound drugs, as it is largely protein-bound
like most NSAIDS. Drugs such as diuretics may be
less effective when being used with diclofenac.

Common adverse events: nausea, dyspepsia, abdominal pain, headache, constipation, dizziness, rash, urticaria, drowsiness, tinnitus.
Diclofenac, in addition to causing gastric and renal
side effects, can have other adverse events. Rare hepatic
failure, which is usually reversible, can occur. Occasionally, bone marrow depression will also be seen.
Disruption of the normal menstrual cycle can also
occur. In 2004, it was shown that selective COX-2
inhibitors may lead to increased cardiac events; however, subsequent studies in 2006 showed no increased
adverse events with diclofenac. Susceptible patients
with asthma, nasal polyps and mastocytosis may experience severe bronchospasm following exposure to
diclofenac.
References
1. Arthrotec Package Insert, Pfizer Inc., 2009

2. Epocrates Essentials. Epocrates, Inc. Drug search:
naproxen.
3. Hennekens CH, Borzak S. Cyclooxygenase-2
inhibitors and most traditional nonsteroidal antiinflammatory drugs cause similar moderately
increased risk of cardiovascular disease. J Cardiovasc
Pharmacol Ther 2008;13(1):4150.
4. Lewis JA, Furst DE. Nonsteroidal Anti-inflammatory
Drugs: Mechanisms and Clinical Uses 2nd ed., Informa
Health Care, 1994, pp. 247266.
5. Sallmann AR. The history of diclofenac. Am J Med
1986;80(4B):2933.
6. Stoelting R, Hillier S. Chapter 19. Drugs used for
psychopharmacologic therapy. In Pharmacology and
Physiology in Anesthetic Practice, 4th ed.
pp. 398406.
231
Section 4
Chapter
54
NSAIDs
Diclofenac injectable
Generic Name: diclofenac sodium for injection

Brand/Proprietary name: Dyloject
Drug Class: nonsteroidal anti-inflammatory drug
Manufacturer: Javelin Pharmaceuticals, Inc.,
Cambridge, MA; Javelin was recently acquired
by Hospira, Lake Forest, IL
Chemical Name: 2-[(2,6-dichlorophenyl)amino]
benzeneacetic acid, monosodium (diclofenac
sodium)
Molecular Formula: C14H10Cl2NNaO2
Description
232
Injectable diclofenac sodium (Dyloject) was developed to provide a ready to use injectable dose in
a small volume with prolonged stability at room
temperature. Solubilization of diclofenac in this
novel formulation is accomplished by the use of
hydoxypropyl--cyclodextrin (HPCD). HPCD is
a cyclic carbohydrate derivative that is pharmacologically inert and is considered ideal for intravenous (IV)
applications due to its high water solubility, excellent
solubilizing potential, and favorable safety profile. The
new formulation of injectable diclofenac is available as
a 37.5 mg/mL solution that can be administered as a
rapid IV bolus to provide rapid pain relief. Unlike the
earlier formulation of diclofenac for injection (marketed as Voltarol in the UK), the new formulation
does not employ organic solvents to solubilize
diclofenac, does not contain sulfites, and has proven
less irritating to veins when given IV. The new formulation of injectable diclofenac is provided in the form
of a solution that is ready to use without buffering,
mixing, or dilution. In contrast, the older formulation
requires such preparation prior to IV administration
and, even then, its potential for venous irritation
requires it to be infused slowly over at least 30 minutes.

The new formulation may also be administered IM, in
which case its uptake into the circulation is more rapid
than after IM injection of the old formulation.
Because the older formulation of diclofenac for
parenteral injection was approved in the UK decades ago
and marketed there continuously since, with ample experience as to its safety and efficacy, the regulatory pathway
for approval of the new formulation in that country as
an essentially similar product was relatively straightforward. The new formulation was approved and has
been marketed in the UK since late 2007 for parenteral
use, 75 mg every 12 hours as needed for the treatment of
acute moderate to severe pain. This dose, dosing interval,
and indication are the same as for the earlier formulation. Other European submissions are planned and our
new formulation of injectable diclofenac is currently
under clinical development in the USA. Because no
injectable diclofenac has previously been approved in the
USA, the US clinical development program has been
more comprehensive than that in the UK, including clinical trials that have assessed various doses and dose intervals in several pain models and in subjects ranging from
healthy normal subjects to post-surgical patients, and
patients with renal or hepatic insufficiency.
Mode of activity
Diclofenac is an NSAID with anti-inflammatory, analgesic, and antipyretic activity. It is an amino-phenyl
acetic acid derivative that inhibits prostaglandin
biosynthesis to produce analgesic, antipyretic, and
anti-inflammatory activity secondary to its nonselective inhibition of the cyclooxygenase (COX) isoenzymes, COX-1 and COX-2. It lies approximately in the
middle of the COX-1/COX-2 inhibitory spectrum.
Uniquely among NSAIDs, diclofenac opens KCNQ2/3
potassium channels and may inhibit sensory neuronal
depolarization. Please refer to the oral diclofenac
chapter for additional information.
Chapter 54 Diclofenac injectable
Figure 54.1.
ROCCH2
Cl
NH
Cl
R = Na
Because the newer formulation of injectable

diclofenac can be administered as a rapid bolus IV
injection, in comparison to the older formulation
which must be infused slowly over 30 minutes, measurable plasma levels of diclofenac are observed almost
immediately following IV injection of the newer formulation and peak plasma levels are achieved in
approximately 3 minutes. The active substance is
99.7% protein-bound, mainly to albumin (99.4%).
Parenteral administration of diclofenac avoids the
first-pass metabolism observed with orally administered diclofenac, whereby only about 60% of the orally
administered drug reaches the systemic circulation in
unchanged form [1].
Indications
Pending US regulatory approval of the newer formulation of injectable diclofenac, any discussion of its
indications at present refers to the UK, where the
approved indications for the newer formulation are
broad. For decades, prior injectable formulations of
diclofenac sodium have been found effective and safe
for the relief of acute pain following a large variety of
procedures and conditions, including laparoscopy,
laparotomy, thoracotomy, thoracoscopic lung biopsy,
joint replacement surgery, cancer, biliary colic, renal
colic, migraine, acute sciatic pain, third molar extraction, cesarean section, laparoscopic cholecystectomy,
tonsillectomy, upper abdominal surgery, knee-joint
arthroscopy, and maxillofacial surgery. Accordingly,
IM injection of the newer formulation of injectable
diclofenac is indicated for post-operative pain and
other types of acute pain including renal colic, exacerbations of osteo- and rheumatoid arthritis, acute back
pain, acute gout, acute trauma, and fractures. IV
administration of the newer formulation of injectable
diclofenac is indicated for the treatment or prevention
of acute post-operative pain. Injectable formulations
of diclofenac sodium have long been used pre- and
intra-operatively as prophylaxis for pain following
major orthopedic surgery, major abdominal surgery,

gynecological surgery, dental surgery, day-case laparoscopy, and for children undergoing herniotomy or
orchidopexy.
The approved indication of injectable diclofenac
for preemptive use contrasts with the more restrictive
indication for injectable ketorolac, a relatively COX-1selective inhibitor that is not approved for the prevention of post-operative pain but only for its treatment.
Given the propensity of COX-1-selective NSAIDs
such as ketorolac or aspirin to interfere with platelet
function, the more restricted indication for ketorolac
is understandable. Further, in the USA an unacceptably high incidence of gastrointestinal bleeding during
ongoing use of ketorolac has led to a black-box warning that restricts the total duration of treatment with
this agent to 5 days regardless of the formulation. No
such restriction on the duration of use of diclofenac
exists or (to our knowledge) has been proposed in the
USA, where diclofenac is marketed in immediate- and
controlled-release oral forms as well topical and
intraocular formulations.
Contraindications
The contraindications and precautions for injectable
diclofenac are the same as described elsewhere in this
volume for NSAIDs in general, and such NSAID class
labeling appears on the UK package insert. More specifically, in the UK all injectable forms of diclofenac
are contraindicated in patients with known hypersensitivity to that agent as well as to diclofenac-containing
products. Injectable diclofenac should not be given to
patients who have experienced asthma, angioedema,
urticaria, rhinitis, or other allergic-type reactions after
taking aspirin or other NSAIDs. Severe, rarely fatal,
anaphylactic-like reactions to diclofenac have been
reported in such patients. Parenteral diclofenac should
not be used concomitantly with other diclofenac-containing products since they also circulate in plasma as
the diclofenac anion.
The advantages of the newer formulation of injectable diclofenac over the prior formulation available in
the UK (as well as in many other countries throughout the world) include both safety and efficacy. In the
pivotal UK registration trial (a three-arm, doubleblinded RCT in 155 patients with pain after third
molar extraction) the incidence of thrombophlebitis
233
NSAIDs Section 4
was half that in patients who received the newer

diclofenac formulation as a rapid IV bolus compared
with those who received the older formulation as a
30-minute IV infusion (5.7% vs. 12%, respectively)
[2]. Similar results were seen on formal thrombophlebitis assessment at 8 hours post-dosing. Aggregating
the total experience with thrombophlebitis in the
531 subjects who received either of the two diclofenac
formulations in a total of seven pharmacokinetic
and analgesic studies conducted up through that
pivotal study, this difference was highly significant
(P < 0.01) [3].
In that same pivotal registration trial the onset of
analgesia following administration of the newer formulation of injectable diclofenac was significantly
more rapid compared to the older formulation (see
Table 54.1). This finding was consistent across several measures of analgesia including pain intensity,
pain relief, and the proportion of patients reporting a
30% or greater reduction of pain intensity. The 30%
threshold is generally felt to indicate meaningful
pain relief.
The surprisingly rapid onset of analgesia after
administration of the newer formulation of injectable
diclofenac led us to begin assessing pain and pain
relief in our subsequent US dose-ranging studies as
early as 5 minutes post-injection, compared with 15
minutes for the first assessment time in the pivotal UK
trial. For the US program ketorolac 30 mg IV was
included as an active comparator in our first doseranging post-molar extraction trial. The doses of the
newer formulation of injectable diclofenac tested
ranged from 3.75 through 75 mg. The proportion of
patients who reported >30% reduction in pain intensity at 5 minutes post-dose was lower (11.8%) in the
ketorolac group than in any of the injectable diclofenac

dose groups (15.731.2%), a significant difference (P <
0.05).
Two subsequent large US Phase 3 trials involving
multiple doses of injectable diclofenac administered
over multiple days in patients following abdominal,
pelvic, orthopedic, or other general surgery, have
confirmed the safety and efficacy of this product
candidate. Detailed results of these studies are being
prepared for publication. Notably, these two trials
and a large safety observational trial enrolled patients
who received routine anticoagulation post-operatively,
as well as those with known pre-operative renal
or hepatic insufficiency without untoward safety
consequences.
To understand better the potential for improved
safety of injectable diclofenac compared with ketorolac in terms of their effects upon platelet aggregation,
we conducted a preclinical trial in healthy subjects
administered IV diclofenac, oral immediate-release
diclofenac, IV ketorolac, or oral aspirin [4]. Subjects
were exposed to these agents in random sequences of
single doses separated by a 2-day washout interval,
except that due to its long-lasting effects aspirin was
always the final agent tested. Consistent with the
prior published literature, injectable or oral
diclofenac had minimal (albeit detectable) effects
upon platelet aggregation as measured in a standard
instrument (PFA-100) that estimates aggregation
time in platelets exposed to epinephrine and collagen. In contrast, highly significant interference with
platelet function occurred after single doses of
ketorolac or aspirin.
Most recently, an investigator-initiated UK case
series described the use of the newer formulation of
Table 54.1. Clinical efficacy of a newer formulation of injectable diclofenac (Dyloject) versus an older formulation (Voltarol) in a
randomized double-blinded, placebo-controlled pivotal UK registration trial [2]
Primary variable
234
Secondary variables
Treatment
Total pain relief

over 4-h period
post-dose
(TOTPAR4)
Pain relief 15 min

post-dose (VAS, mm)
>30% reduction in
pain intensity in
first hour, n (%)
Pain relief over

12-h period
post-dose
(VAS, mm)
Dyloject (n = 53)
300.6 73.61a
40.4a, c
49 (92.5)a
44.7b
Voltarol (n = 50)
266.2 91.63a
19.5a
46 (92.0)a
46.5b
Placebo (n = 52)
52.5 88.77
5.7
11 (21.2)
12.8
TOTPAR4 values presented as mean SD; P < 0.001 vs. placebo; P < 0.0001 vs. placebo; P < 0.0001 vs. Voltarol.
a
Chapter 55 Ketorolac
injectable diclofenac in 200 children from 8 months to

16 years undergoing a wide range of surgical procedures including tonsillectomy and appendectomy [5].
A single dose of 0.5 mg/kg IV was given either prior to
induction of anesthesia or during surgery, again with
an unremarkable safety profile. The authors of that
case series cited speed of onset and ability to titrate
dose with the newer formulation of injectable
diclofenac (compared with fixed, limited dose selections available in diclofenac suppositories) as a factor
influencing them to apply it in this setting.
In conclusion, the use of non-opioids as the foundation of a multimodal strategy for acute pain management is now the worldwide standard. NSAIDs such
as diclofenac that are of sufficiently high intrinsic efficacy produce an opioid-sparing effect whose magnitude is sufficient to decrease opioid-related side effects,
and also enhance the quality of analgesia. The wellunderstood safety profile (including minimal effects
upon platelet aggregation) of a new formulation of
injectable diclofenac, together with its speed of onset
and paucity of injection site irritation make it an
attractive candidate for ongoing development and
future availability in the USA.
Section 4
Chapter
55
References
1. McCormack PL, Scott LJ. Diclofenac sodium

(Dyloject) in post-operative pain. Drugs 2008;68:
123130.
2. Leeson RM, Harrison S, Ernst CC, Hamilton DA,
Mermelstein FH, Gawarecki DG, Moshman M, Carr
DB. Dyloject, a novel injectable diclofenac
formulation, offers greater safety and efficacy than
Voltarol for post-operative dental pain. Reg Anesth
Pain Med 2007;32:303310.
3. Colucci RD, Wright C, Mermelstein F, Gawarecki DG,
Carr DB. Dyloject, a novel injectable diclofenac
solubilised with cyclodextrin: reduced incidence of
thrombophlebitis compared to injectable diclofenac
solubilised with polyethylene glycol and benzyl
alcohol. Acute Pain 2009;11:1521.
4. Bauer KA, Gerson W, Ruais K, Wang J, McNicol E,
Lanier RK, Kramer W, Carr DB. Platelet function
following administration of a novel formulation of
intravenous diclofenac sodium versus active
comparators: a randomized, single dose, crossover study
in healthy male volunteers. J Clin Anesthesia (in press).
5. Gandhi M, Prosser D. Our experience of Dyloject
(intravenous diclofenac) in children. Pediatric
Anesthesia 2009;19:908928.
NSAIDs
Ketorolac
Christopher Wray
Analgesic Agent: ketorolac (injectable)

Trade Name: ketorolac tromethamine (Toradol, Roche Pharmaceuticals, Nutley NJ)
Description
Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) with potent analgesic activity
and weaker anti-inflammatory and antipyretic effects.

Structurally, ketorolac is a weakly acidic, highly watersoluble pyrrolo-pyrrole, chemically similar to tolmentin and indomethacin. Ketorolac was developed in
humans due to its potent analgesic effects demonstrated in animal testing. Ketorolacs analgesic potency
was found to be 350 times that of aspirin in animal
studies, and was also noted to have a long duration of
action, up to 6 hours. The dosages of ketorolac that
produced analgesia in animals were well below those
235
NSAIDs Section 4
CH2OH
O
COH
C
H2N
CH2OH
CH2OH
Figure 55.1.
that caused gastrointestinal toxicity. Due to its high

potency, high water-solubility, and its potential for
causing minimal muscle damage with IM administration compared with other NSAIDs, ketorolac was
developed for human analgesia. In 1989, ketorolac
became the first NSAID approved for parenteral
administration in the U.S.
Mode of activity
Ketorolac is classified as a peripherally acting analgesic. It produces its analgesic effects by its nonspecific
inhibition of the enzyme cyclooxygenase-1 (COX-1).
It is generally believed that NSAIDs reduce pain by
decreasing the enzymes conversion of arachidonic
acid into prostaglandin E2, the inflammatory prostaglandin that directly activates and up-regulates peripheral nociceptors. No other analgesic mechanisms of
action have been discovered for ketorolac. Its antiinflammatory and antipyretic effects are less potent
than its analgesic effect. Comparative studies with
other NSAIDs suggest that the analgesic activity of
ketorolac may be separate from its anti-inflammatory
and antipyretic activity. The analgesic potency of
ketorolac 30 mg IM is equivalent to approximately
912 mg of morphine or 100 mg of meperidine.
Metabolic activity
236
Oral and parenteral ketorolac demonstrate similar

pharmacokinetics. Parenteral ketorolac has a rapid
onset (<1 min IV, <10 min IM) due to its rapid absorption and negligible plasma metabolism. Onset of clinical effects occurs within 15 to 20 minutes. Plasma
halflife is approximately 6 hours, intermediate in duration compared with other NSAIDs. Ketorolac undergoes mainly renal metabolism. Over half of an entire
ketorolac dose is excreted unchanged in the urine with
smaller proportions of minimally active polar metabolites. Elimination is minimally affected by age or
hepatic function. Renal insufficiency may decrease the
clearance of ketorolac. IM ketorolac demonstrates linear pharmacokinetics. Clearance does not change with
chronic dosing. Ketorolac does not cross the blood
brain barrier, and there appears to be little central

nervous system activity of the drug.
Indications
Ketorolac is indicated for the short-term management
of moderately severe acute pain. The primary setting
for ketorolac is in post-operative patients that require
opioid level analgesia. Duration of therapy should not
exceed 5 days of use because of the potential for
adverse reactions associated with prolonged therapy
(>5 days). Single doses of ketorolac have been shown
to be safe and effective in pediatric patients between
the ages of 2 and 16 years: however, there are limited
data to support the use of multiple doses in pediatric
patients.
Contraindications
Absolute: patients with documented allergic reaction
to ketorolac or other NSAIDs; patients with complete
or partial syndromes of nasal polyps, angioedema,
and bronchospastic reactions to NSAIDs.
Relative: patients with advanced renal impairment. Patients with active peptic ulcer disease, recent
gastrointestinal bleeding, or gastric perforation.
Patients with platelet disorders, coagulation abnormalities, or patients receiving anti-platelet or anticoagulant medications. Surgical patients at high risk
for post-operative bleeding. Labor and delivery
patients, due to potential adverse effects of prostaglandin-inhibiting drugs on fetal circulation and inhibition of uterine contractions. Nursing mothers, due
to potential adverse effects of prostaglandin-inhibiting drugs on neonates. Patients with or at risk for
cerebrovascular bleeding, hemorrhagic diathesis, or
incomplete hemostasis. Pre-operative or intra-operative patients having major surgery with a risk of major
bleeding
Common doses
Single-dose treatment: IM dosing:
Patients < 65 years of age: 60 mg (0.51.0 mg/kg).
Patients 65 years of age, with renal impairment,
and/or less than 50 kg: 30 mg.
Single-dose treatment: IV dosing:
Patients < 65 years of age: 30 mg. Patients 65
years of age, with renal impairment, and/or less
than 50 kg: 15 mg.
Multiple-dose treatment (IV or IM):
Chapter 55 Ketorolac
Patients < 65 years of age: 30 mg every 6 hours.

Maximum daily dose should not exceed 120 mg
(1.52.5 mg/kg per day). Patients 65 years of
age, with renal impairment, and patients less than
50 kg: 15 mg every 6 hours. Maximum daily dose
should not exceed 60 mg
Ketorolac (both IM and IV routes) has been studied
in a variety of post-operative patients. Studies assessing single and multiple doses have demonstrated its
efficacy in orthopedic, gynecological, abdominal,
and dental surgery. One of the major advantages of
injectable ketorolac is its use in multimodal analgesia, providing for an opioid-sparing effect. Studies
using ketorolac for post-operative pain have noted
decreased incidences of side effects when compared
with opioids (nausea, vomiting, sedation, respiratory
depression, urinary retention, ileus). Low doses of
an opioid analgesic at levels below those associated
with typical opioid side effects in combination with
ketorolac have been shown to provide maximal postoperative pain control in procedures with more
severe abdominal pain (abdominal hysterectomy,
cholecystectomy).
Cost: inexpensive generic versions are available.
Availability: widely available in most hospitals.
Toxicity: NSAID-induced gastric complications
include the potential for hemorrhage and ulcerations.
Gastropathy risk is increased in the elderly, patients
with a history of peptic ulcer, and concomitant use
of anticoagulants or corticosteroids. Ketorolac may
cause gastric complications even with short-term
therapy, but these are rare when compared to longterm use. Current recommendations limiting ketorolac therapy to 5 days duration are designed to decrease
gastric toxicity. Other disadvantages of ketorolac
administration include renal impairment and platelet

inhibition. The risk of renal impairment is increased
with significant reductions in blood volume and in
patients with underlying renal dysfunction. NSAID
inhibition of platelet aggregation can prolong bleeding time. The risk of peri-operative bleeding may be
increased in patients with underlying coagulation
abnormalities, in patients receiving anticoagulants,
and in surgical settings requiring strict hemostasis.
Platelet dysfunction caused by ketorolac is reversible
as the drug is eliminated from the body. Platelet function usually returns to baseline levels within 24 hours
of administration.
Drug interactions: like other NSAIDs, plasma
protein binding of ketorolac is extensive, leading to
potential drug interactions due to displacement of
other highly protein-bound drugs. Concurrent use of
probenicid with ketorolac will decrease its elimination.
Concurrent use of furosemide with ketorolac will
decrease the diuretics effect. Concurrent administration of other NSAIDs may increase plasma levels of
ketorolac.

In addition to the gastric, renal, and antiplatelet
side effects of ketorolac, other adverse effects of
ketorolac have been reported. Ketorolac, like other
COX-1 inhibitors, can produce bronchoconstriction
in asthmatic patients and in patients with complete or
partial syndromes of nasal polyps, angioedema, and
allergic reactions to NSAIDs.
References
1. Lewis JA, Furst DE. Nonsteroidal Anti-inflammatory

Drugs: Mechanisms and Clinical Uses, 2nd ed. Informa
Health Care, 1994, pp. 247266.
2. Della Rocca G, Chiarandini P, Pietropaoli P. Analgesia
in PACU: nonsteroidal anti-inflammatory drugs.
Current Drug Targets 2005;6:781787.
237
Section 4
Chapter
56
NSAIDs
Celecoxib
Joseph Marino
Generic Name: celecoxib

Trade Name: Celebrex
Manufacturer: Pfizer Pharmaceuticals, 235 East
42nd Street, New York, NY 10017
Description
Celebrex (celecoxib) is a selective cyclooxygenase
(COX)-2 inhibitor nonsteroidal anti-inflammatory
drug chemically designated as 4-[5-(4-methylphenyl)3-(trifluoromethyl)-1-H-pyrazol-1-yl)benzenesulfonamide. It is a diaryl-substituted pyrazole with an
empirical formula of C17H14F3N3O2S and a molecular
weight of 381.38. The potent anti-inflammatory effects
of an original diarylheterocyclic compound, phenyl
butazone, directed scientists to pharmacologically
manipulate this chemical scaffold. As a result, celecoxib
was the first of the coxibs to be introduced in 1999 by
Searle/Pharmacia (now part of Pfizer Inc., USA) [1].
Mechanism of action
238
Cyclooxygenase (COX) is an enzyme that catalyzes the

rate-limiting step in the arachidonic acid cascade
involving the conversion of arachidonic acid to prostaglandin H2 (PGH2), the common biosynthetic precursor to prostaglandins and thromboxane. Cyclooxygenase
exists in two isoforms: COX-1 and COX-2. COX -1 and
COX-2 are monotropic enzymes bound to cellular
membranes of the endoplasmic reticulum and nuclear
envelope [2].
Non-selective NSAIDs inhibit both COX isoforms.
Celecoxib is an NSAID that exhibits antipyretic, analgesic, and anti-inflammatory activities. The mechanism of action of celecoxib is due to inhibition of
prostaglandin synthesis via inhibition of COX-2. At
therapeutic concentrations in humans, celecoxib does
not inhibit the COX-1 isoenzyme. In general terms,

COX-1 is the enzyme responsible for basal, constituitive prostaglandin synthesis, whereas COX-2 is important in various inflammatory settings. Celecoxib
produces its analgesic effects by blocking the production of prostaglandins, critical to the processing of
pain in the periphery and by augmenting the processing of pain information at the spinal cord level.
There is a structural basis for COX-2 selectivity.
Although the active sites within both cyclooxygenase
isoforms are similar, a single amino acid difference in
position 523 accounts for the COX-2 selectivity of
celecoxib. The substitution of the smaller valine molecule in COX-2 as opposed to the larger isoleucine
molecule in COX-1 provides access to a side-pocket
that is the binding site for the phenylsulfonamide
moiety of celecoxib (Figure 56.2) [3].
Pharmacokinetics
Absorption
Celecoxib is insoluble in oils and is absorbed throughout the gastrointestinal tract, with most occurring in
the jejunum and duodenum. It is well absorbed with
peak plasma concentrations being reached within 3
hours after oral administration. With chronic dosing,
celecoxib displays linear pharmacokinetics and
reaches steady-state conditions on or before day 5 [1].
Distribution
Celecoxib is extensively distributed in tissues and is
97% protein-bound. It is bound primarily to albumin
and to a lesser extent alpha-1-acid glycoprotein. The
approximate volume of distribution at steady state is
400 liters, suggesting extensive distribution into the
tissues. This extensive volume of distribution may be
related to the lipophilic nature of celecoxib as well
as to its high PKa (11.1). The effective plasma t1/2 is
approximately 11 hours under fasting conditions [1].
Chapter 56 Celecoxib
NH2
O
S
Figure 56.1.
O
N
N
CF3
CH3
Metabolism
The metabolism of celecoxib involves three steps: (1)
oxidative hydroxylation of the methyl group to form a
primary alcohol; (2) oxidation to a carboxylic acid
(the major metabolite); and (3) conjugation to glucoronic acid, forming the 1-o-glucoronide.
Celecoxib undergoes extensive hepatic metabolism and in vitro studies indicate that it is predominantly mediated via cytochrome P450 (CYP) 2C9.
Concomitant administration of celecoxib with drugs
known to inhibit CYP2C9 (e.g. fluconazole, lovastatin,
fluvastatin) resulted in a two-fold increase in celecoxib
plasma concentrations; this is due to the inhibition of
celecoxib metabolism via CYP2C9. CYP2C9 genotypes which are known or suspected poor metabolizers should be administered celecoxib with caution as
they may have abnormally high levels due to reduced
clearance [1].
Excretion
Celecoxib is eliminated predominantly by hepatic
metabolism with little unchanged drug recovered in
the urine and feces. Fifty-seven percent of the dose
was excreted in the feces and 27% was excreted in
the urine. As a result, the daily recommended dose
of celecoxib should be reduced by 50% in patients
with moderate hepatic impairment (Child-Pugh
Class B) [1].
Circadian effects
Differences in celecoxib oral bioavailability between
morning and evening administration exist. Twelvehour post-dosing levels were higher in the evening
than the morning. These results indicate that in
order to maximize control of early morning symptoms, patients on a once-daily dosing schedule
should take celecoxib in the evening rather than
morning [1].
Indications
Acute surgical pain
Simultaneously utilizing several analgesic approaches
rather than one has the potential to provide superior
pain control while minimizing side effects. The evidence strongly supports this concept of multimodal
analgesia. The American Society of Anesthesiology
task force on post-operative pain management, which
included members from a spectrum of practice environments, concluded in its practice guidelines that:
all patients should receive an around-the-clock regimen of NSAIDs, coxibs or acetaminophen. Using a
comprehensive, preemptive, multimodal, analgesic
protocol including celecoxib demonstrated improved
peri-operative outcomes including a shortened length
of hospital stay, accelerated physiotherapy and a significant reduction in opioid-related side effects [4].
Post-orthopedic surgery, post-general surgery, and
post-oral surgery pain studies demonstrated that
celecoxib provided significantly greater analgesic efficacy than placebo in terms of onset, magnitude, and/
or duration of analgesia. There were lower incidences
of dizziness, nausea, vomiting, and somnolence in
patients treated with celecoxib than in patients treated
with opioid comparator drugs [1].
The recommended dose of celebrex for the management of acute pain in adults is 400 mg initially, followed by an additional 200 mg dose if needed on the
first day. On subsequent days, the recommended dose
is 200 mg twice a day as needed. At one major medical
institution, the following multimodal analgesic regimen is used consisting of:
continuous perineural/neuraxial blockade where
appropriate
low-dose opioids
acetaminophen (1 g every 6 hours for 48 hours)
celecoxib (400 mg) pre-operatively followed
post-operatively by 200 mg daily, unless
contraindicated by cardiovascular,
gastrointestinal, hepatic, or renal comorbidities or
allergies to sulfa-containing medications.
If patients manifest inflammatory as well as neuropathic symptoms consider the following multimodal
regimen:
celecoxib 200mg twice daily
pregabalin (Lyrica) (150 mg twice daily)
transdermal clonidine (0.1 mg TTS [Transdermal
Therapeutic System] skin patch applied weekly).
239
NSAIDs Section 4
Figure 56.2. Celecoxib bound to

COX-2; the phenylsulfamoyl group
occupies the side pocket blocking
arachidonic acid binding and hence
PG synthesis. Adapted from Ref. 3.
Medical pain and common doses
Osteoarthritis: 200 mg once daily or 100 mg twice daily

Rheumatoid arthritis: 100200 mg twice daily
Juvenile rheumatoid arthritis: 50 mg twice daily in
patients 1025 kg, 100 mg twice daily in patients more
than 25 kg
Ankylosing spondylitis: 200 mg once daily single
dose or 100 mg twice daily. If no effect is observed
after 6 weeks, a trial of 400 mg (single or divided
doses) may be of benefit
Primary dysmenorrhea: 400 mg initially, followed
by 200 mg dose if needed on first day. On subsequent
days, 200 mg twice daily as needed.
Familial adenomatous polyposis (FAP): 400 mg
twice daily with food, as an adjunct to usual care. (FAP
is a hereditary polyposis syndrome with a progression
to colorectal cancer. Increased COX-2 protein was
found in the polyp specimens from patients with FAP;
in a dose-dependent manner, early treatment with
celecoxib significantly reduces the number of colorectal polyps in patients with FAP) [1].
Acute/chronic low back pain

Celecoxib is not approved by the FDA for the treatment of acute/chronic low back pain. Evidence-based
data demonstrated greater analgesic efficacy with
celecoxib compared to non-opioid comparators for
acute and chronic low back pain:
chronic low back pain: 200 mg daily
acute low back pain: 200 mg twice daily [1].
Cancer pain
240
Non-opioid analgesics (NSAIDs, COX-2 inhibitors,

APAP), including celecoxib, are part of the World
Health Organizations (WHO) analgesic ladder for the
treatment of mild to moderate cancer pain. There are
no celecoxib dosing guidelines for the treatment of
somatic pain associated with cancer.
Contraindications
Absolute: known hypersensitivity to celecoxib or
sulfonamides; history of asthma, urticaria, or other
allergic-type reactions after taking aspirin or other
NSAIDs; for the treatment of peri-operative pain in
the setting of coronary artery bypass grafting (CABG)
surgery [1].
Routes of administration
Celebrex capsules contain either 50 mg, 100 mg, 200
mg, or 400 mg of celecoxib for oral administration
together with inactive ingredients including: croscarmellose sodium, edible inks, gelatin, lactose monohydrate, magnesium stearate, povidone, and sodium
lauryl sulfate [1].
One of the benefits of celecoxib is its convenience and
ease of use based on once to twice daily dosing [1].
Peri-operative use of celecoxib in a structured
multimodal anesthetic regimen provides both analgesic and opioid-sparing effects for the post-surgical
patient resulting in improved patient outcomes [1].
It has been demonstrated clinically that COX-2selective inhibitors resulted in a lower incidence of
gastrointestinal (GI) complications as compared to
standard NSAIDs. COX-1 predominates in the gastric
mucosa and yields salutary prostaglandins. By sparing
COX-1 inhibition GI mucosal integrity is maintained.
In a pooled analysis of celecoxib-treated patients with
osteoarthritis, rheumatoid arthritis, and ankylosing
spondylitis, celecoxib offered the prospect of improved
GI tolerability and, in patients not taking aspirin for
cardioprophylaxis, a GI safety advantage [1].
Results indicate that even at supratherapeutic
doses, celecoxib will not interfere with normal mechanisms of platelet aggregation and hemostasis. Patients
treated with celecoxib experienced fewer decreases in
Chapter 56 Celecoxib
hemoglobin/hematocrit than patients treated with

comparator NSAIDs [1].
Celecoxib does not demonstrate any adverse effects
on bone healing in clinical trials [1].
Celecoxib is not approved by the FDA for the
treatment of cancers. However, celecoxib as monotherapy or as part of combination therapy has been
demonstrated to suppress tumor growth in a variety of
neoplasms and has benefited patients with prostate
cancer. Potential mechanisms of anticancer activity of
celecoxib include inhibition of endogenous carcinogen formation, modulation of inflammation, increased
cellular sensitivity to apoptosis, and inhibition of
angiogenesis[1].
There is no known potential for addiction associated with the use of celecoxib.
Prothrombotic potential may be more of a drugspecific effect rather than a COX-2 class effect. Celecoxib
is currently the only remaining selective COX-2 inhibitor on the market. Analysis of data from a variety
of clinical trials demonstrated an unacceptably high
incidence of cardiovascular events with rofecoxib
and valdecoxib. As a result, rofecoxib and valdecoxib
were voluntarily withdrawn from clinical practice by
2005.While all the coxibs are lipophillic and have a
similar volume of distribution, rofecoxib exhibits
higher specificity for COX-2 compared to celecoxib
(up to 300 times more affinity in contrast to celecoxib,
which had up to 30 times more affinity for COX-2
over COX-1). Rofecoxib has a slower almost irreversible dissociation from the active site, and a longer
half-life compared to celecoxib. A coxib with a more
rapid dissociation from the COX active site might
permit recovery of endothelial PGI2 formation
and reduce unopposed platelet COX-1-dependent
thromboxane formation. There is a greater body
of evidence supporting the relative cardiovascular
safety of celecoxib when used at the doses prescribed
than for any other selective or nonselective cox-2
inhibitor [1,2].
Celecoxib has several drug interactions.
Co-administration with drugs known to inhibit
cytochrome P450 (CYP) 2C9 (fluconazole, statin
drugs) should be done with caution [1].
Co-administration of celecoxib with lithium
results in elevated lithium concentrations (mean
steady-state levels increased by approximately 17%).
Close monitoring of lithium levels is advised when
celecoxib is either introduced or withdrawn from

patients concomitantly using lithium [1].
Celecoxib co-administration may result in
increases in international normalized ratio (INR) in
patients who were on warfarin and had stable INRs
before the addition of celecoxib [1].
Celecoxib can be used with low-dose aspirin.
However, concomitant administration with aspirin
may increase the rate of GI ulceration or other complications, compared to the use of celecoxib alone [1].

Common adverse events: most common adverse reactions in arthritis trials include abdominal pain,
diarrhea, dyspepsia, flatulence, peripheral edema, accidental injury, dizziness, pharyngitis, rhinitis, sinusitis,
upper respiratory tract infection, and rash [1].
Serious adverse events

The development of COX-2 inhibition as an anti-
inflammatory agent without gastric toxicity is based on
the premise that COX-1 predominates in the gastric
mucosa, producing cytoprotective prostaglandins,
while COX-2 is induced in inflammation, leading to
hyperalgesia. Selective COX-2 inhibitors decrease vascular prostacyclin (PGI2) production and may alter
the balance in vascular homeostasis between prothrombotic (TBXA2) and antithrombotic (PGI2) prostanoids. Celecoxib therapy may be associated with an
increased risk of cardiovascular events, but only when
used at doses substantially higher than that recommended [1]. The package insert on Celebrex states that
Celebrex may cause an increase of serious thrombotic
events, myocardial infarction, and stroke, which can be
fatal. Patients with known cardiovascular disease/risk
factors may be at a greater risk. All NSAIDs may have
a similar risk. This risk may increase with duration of
use. An analysis of data from two combined colorectal
prevention trials (APC: adenoma prevention with
celecoxib; and Pre-SAP: prevention of colorectal sporadic adenomatous polyps) showed a nearly two-fold
higher risk for the composite of nonfatal heart attack,
nonfatal stroke, and death from cardiovascular causes
combined, with celecoxib compared to placebo [1].
Serious gastrointestinal (GI) adverse events, which
can be fatal. The risk is greater in patients with a prior
history of ulcer disease or GI bleeding and in patients
at high risk for GI events, especially the elderly [1].
Elevated liver enzymes and, rarely, severe hepatic
reactions [1].
241
NSAIDs Section 4
New onset or worsening of hypertension [1].

Fluid retention and edema [1].
Renal papillary necrosis and other renal injury
with long-term use. Most of the unwanted renal side
effects of the class of NSAIDs are related to the inhibiton of prostanoid synthesis. The COX-2 enzyme has
been implicated as a mediator of renal blood flow,
renin release and sodium excretion. As a result, COX-2
inhibitors may lead to an alteration of renal homeostasis resulting in decreases in glomerular filtration
rate, renal blood flow, sodium and water retention,
and hyperkalemia [1].
Anaphylactoid reactions: not to be used in patients
with the aspirin triad (asthma, aspirin sensitivity, and
nasal polyps) [1].
Serious skin adverse events such as exfoliative dermatitis, StevensJohnson syndrome, and toxic epidermal necrolysis, which can be fatal and can occur
without warning even without known prior sulfa
allergy [1,2].
Overdosage
No overdosage of celecoxib was reported during clinical trials. Doses up to 2400 mg/day for up to 10 days in
12 patients did not result in serious toxicity. Symptoms following acute NSAID overdoses are usually
limited to lethargy, drowsiness, nausea, vomiting, and
epigastric pain which are generally reversible with
supportive care. Gastrointestinal bleeding can occur.
242
Hypertension, acute renal failure, respiratory depression, and coma may occur, but are rare.
Patients should be managed by symptomatic and
supportive care following NSAID overdose. There
are no specific antidotes. Based on its high degree
of plasma protein binding, forced diuresis, alkal
inization of urine, dialysis, or hemoperfusion is
unlikely to be useful in overdose. Emesis and/or activated charcoal and/or osmotic cathartis may be indicated in patients seen within 4 hours following
overdose [5].
References
1. Celebrex and (celecoxib) package insert.

2. Pairet M, van Ryn J. Cox-2 inhibitors. In Milestones in
Drug Therapy. Basel: Birkhauser, 2004.
3. Jahr JS, Donkor KN, Sinatra RS, Nonsteroidal
anti-inflammatory drugs, Cox-2 inhibitors and
acetaminophen for postoperative pain management.
In Sinatra R, de Leon-Casasola O, Ginsberg B, Viscusi
E, eds. Acute Pain Management. New York: Cambridge
University Press, 2009, p. 347.
4. Practice guidelines for acute pain management in the
perioperative setting. An updated report by the
American Society of Anesthesiology Task Force on
Acute Pain Management. Anesthesiology
2004;100:15731581.
5. Physicians desk reference, 63rd ed. Montvale, NJ:
Thomson Reuters, 2009.
Section 4
Chapter
57
NSAIDs
Etoricoxib
Generic Name: etoricoxib; etoricoxibum;

etorikoksib; etorikoksibi; etorikoxib
Chemical Name: 5-chloro-6-methyl-3-[p(methy-lsulfonyl)phenyl]-2,3-bipyridine
Proprietary Names: Algix (Gentili, Ital.), Arcoxia
(MSD, Arg., Austria, Brazil, Iudon., Irl., Israel,
Mex., Philip., Singapore, Swed., UK, Venez.).
Manufacturer: Merck, Whitehouse Station, NJ
Drug Class: selective (cyclooxygenase-2 inhibition) nonsteroidal anti-inflammatory
Description
Etoricoxib is a second-generation, highly selective
cyclooxygenase 2 (COX-2) inhibitor with anti-inflammatory and analgesic properties [1]. It shows dosedependent inhibition of COX-2 across the therapeutic
dose range, without inhibition of COX-1, does not
inhibit gastric prostaglandin synthesis and has no
effect on platelet function [2]. Etoricoxib shows 106fold selectivity for COX-2 over COX-1 [3], compared
with 7.6-fold selectivity observed with celecoxib [2,3].
Etoricoxib was first introduced clinically as a medication in 2002 by Merck & Co and is now available in at
least 62 countries throughout the world, but still await
approval in the USA.
Mode of activity
Traditional nonselective NSAIDs inhibit both COX-1 and
COX-2 enzymes. The COX-2 inhibition is associated with
anti-inflammatory and analgesic effects, but the COX-1
inhibition is associated with unwanted effects such as gastrointestinal (GI) bleeding. The selective COX-2 inhibitors were developed with the aim of reducing the GI
adverse effects associated with COX-1 inhibition.
Major sites of action: inhibition of prostaglandin

production.
Minor sites of action: inhibits activation of the
transcription factors cyclic adenosine monophosphate
response element-binding protein and nuclear factor
kappa-B.
Metabolic pathways/drug clearance and elimination: etoricoxib is well absorbed from the gastrointestinal tract after oral doses. Peak plasma concentrations
are reached in about 1 hour in fasted adults; food
delays absorption by about 2 hours, although it has no
effect on the extent of absorption. Plasma protein
binding is about 92%. At steady state the half-life of
etoricoxib is about 22 hours. Etoricoxib is extensively
metabolized with less than 2% of a dose recovered in
the urine as the parent drug. The major route of
metabolism is via cytochrome P450 isoenzymes
including CYP3A4. Excretion is mainly via the urine
(70%) with only 20% of a dose appearing in the feces.
Indications (non-approved in the USA)

Etoricoxib is a selective cyclooxygenase (COX-2)
inhibitor, approved in Europe for the symptomatic
treatment of osteoarthritis, rheumatoid arthritis,
ankylosing spondylitis and acute gouty arthritis. Etoricoxib does not have Food and Drug Administration
approval.
Medical pain: in osteoarthritis, etoricoxib is given
orally in a usual dose of 30 mg once daily, increased to
60 mg once daily if necessary. The recommended dose
in rheumatoid arthritis and in ankylosing spondylitis
is 90 mg once daily; higher doses of 120 mg once daily
are used in gouty arthritis although such doses should
only be used for the acute symptomatic period and for
a maximum of 8 days [4].
Surgical acute pain: single dose oral etoricoxib
(120 mg) has shown usefulness in analgesia after surgery [5].
243
NSAIDs Section 4
Figure 57.1.
O
S
Cl
Contraindications
Key contraindications include congestive heart failure
(New York Heart Association class IIIV), inadequately controlled hypertension with persistent BP
elevation >140/90 mmHg, established ischemic heart
disease, peripheral arterial disease and/or cerebrovascular disease, active peptic ulceration or GI bleeding,
creatinine clearance <30 mL/min, or severe hepatic
dysfunction [4].
Common doses
Etoricoxib is approved in Europe for the treatment of
patients with osteoarthritis (recommended dosage
3060 mg once daily), rheumatoid arthritis (90 mg
once daily), acute gouty arthritis (120 mg once daily
for a maximum of 8 days) and ankylosing spondylitis
(90 mg once daily); although an inhibition of COX-2
by 80% may be reached after the administration of 40
mg, suggesting that the dosage of the drug could be
reduced without affecting efficacy [6].
Nonselective NSAIDs are commonly associated with
GI adverse effects and, while NSAIDs that are selective for COX-2 generally have improved GI tolerability, they can be associated with an increased risk of
cardiovascular events. COX-2 inhibitors are associated with a reduced risk of GI events compared with
nonselective NSAIDs, although the most frequent
adverse events with etoricoxib were generally GI in
nature. However, etoricoxib was associated with a
reduced risk of upper GI events compared with nonselective NSAIDs [1].
244
The increased risk of cardiovascular events associated
with COX-2 inhibitors led to the voluntary withdrawal
of rofecoxib and valdecoxib, in 2004 and 2005, respectively. While COX-2 inhibitors as a class are associated
with an increased risk of CV adverse events compared
with placebo, different agents may be associated with
different degrees of risk, especially in those with
preexisting risk factors. To date, there have been few
large, long-term controlled trials specifically evaluating the relative CV risk with different drugs within the
overall NSAID class [2]. The MEDAL (Multinational
Etoricoxib and Diclofenac Arthritis Long-term) program was one such evaluation. In this multinational
study, composed of three randomized, controlled,
double-blind studies involving 34 701 patients, investigators found that etoricoxib was not inferior to
diclofenac in terms of the overall rate of thrombotic
CV events. After an average duration of 18 months,
320 patients in the etoricoxib group and 323 patients
in the diclofenac group experienced thrombotic
cardiovascular events, yielding event rates of 1.24 and
1.30 per 100 patient years and a hazard ratio of 0.95
(95% CI 0.81, 1.11) [1]. Additionally NSAIDs should
be utilized with caution in patients with renal impairment. Etoricoxib is contraindicated in patients with an
estimated renal creatinine clearance <30 mL/min [2].

Etoricoxib was generally well tolerated in clinical trials in patients with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and acute gouty arthritis.
The most commonly reported drug-related adverse
events were generally GI (e.g. dyspepsia, upper
abdominal pain, diarrhea, nausea) or CV (e.g. hypertension and peripheral edema).
References
1. Takemoto JK, Reynolds JK, Remsberg CM, et al.

Clinical pharmacokinetic and pharmacodynamic
profile of etoricoxib. Clin Pharmacokinet
2008;47(11):703720.
2. Croom KF, Siddiqui MA. Etoricoxib: a review of its
use in the symptomatic treatment of osteoarthritis,
rheumatoid arthritis, ankylosing spondylitis and acute
gouty arthritis. Drugs 2009;69(11):15131532.
Chapter 58 Parecoxib
3. Riendeau D, Percival MD, Brideau C, et al. Etoricoxib

(MK-0663): preclinical profile and comparison with
other agents that selectively inhibit cyclooxygenase-2.
J Pharmacol Exp Ther 2001;296(2):558566.
Evaluations, Thompson Healthcare. Etoricoxib;
2009.
Section 4
Chapter
58
5. Clarke R, Derry S, Moore RA, et al. Single dose oral

etoricoxib for acute postoperative pain in adults.
Cochrane Database Syst Rev 2009;2:CD004309.
6. Patrignani P, Tacconelli S, Capone ML. Risk
management profile of etoricoxib: an example of
personalized medicine. Ther Clin Risk Manag
2008;4(5):983997.
NSAIDs
Parecoxib
Jeff Gudin and Despina Psillides
Generic Name: parecoxib

Trade/Proprietary Name: Dynastat (available
in EU)
Manufacturer: Pfizer Inc.
Drug class: COX-2 selective inhibitor
Chemical Formula: C19H18N2O4S; molecular wt
370
Introduction
Parecoxib is unique in that it is the first COX-2-specific inhibitor that can be parenterally administered.
This feature of parecoxib allows for its role in pre-
operative and post-operative analgesia when patients
are often unable to take oral pain medications.
Parecoxib has a long history in the literature, which
will be reviewed below. However, it must be stated that
parecoxib is not FDA-approved in the USA, but is
available in other countries for short-term peri-operative analgesia.
Parecoxib, N-{[4-(5-methyl-3-phenylisoxazol-4-yl)
phenyl]sulfonyl}propanamide, is an inactive prodrug
of valdecoxib. After injection, either intramuscular or
intravenous, parecoxib rapidly undergoes hepatic
metabolism, predominantly via cytochromes P450

3A4 and P450 2C9, to valdecoxib. The peak plasma
concentration of valdecoxib occurs 30 minutes after IV
and 60 minutes after IM injection of parecoxib [1].
Parecoxib is 100% bioavailable, and is renally excreted
in the urine, with 70% as inactive metabolites. The
half-life of parecoxib is approximately 22 minutes as
opposed to 8 hours for valdecoxib.
Parecoxib and the other COX-2 inhibitors may provide anti-inflammatory effects while still maintaining
gastrointestinal integrity and normal platelet functioning. The cyclooxygenases, both COX-1 and COX-2,
lead to the production of prostaglandins. The difference
between the two forms is that they are expressed at different times and in different cellular locations. Cyclooxy
genase-1 (COX-1) is expressed at times of normal
physiological functioning and has its main role in the
production of prostaglandins in gastric mucosa, kidneys, and platelets [2]. Cyclooxygenase-2 (COX-2), on
the other hand, has restricted expression during normal functioning but is induced in response to physiological stress and mediates inflammation and pain.
COX-1 plays a major role in the production of
thromboxane A2 (TxA2), which is a prostaglandin that
stimulates platelet aggregation. Generally it is believed
that inhibition of COX-1 can block the production of
TxA2, thus preventing platelet aggregation and prolonging bleeding time. This becomes important when
245
NSAIDs Section 4
O O
S
Figure 58.1.
O
N
H
CH3
N
O
246
CH3
considering the use of nonselective COX inhibitors in

the peri-operative setting because they may increase
the risk of bleeding. Parecoxib has been studied for its
platelet-sparing effects. Noveck et al. [3] studied the
effects of parecoxib versus ketorolac or placebo on
platelet function and bleeding time in two double-blind
active and placebo-controlled trials. In one study
involving elderly patients qualified as ages 6595, there
were three groups that received either intravenous
parecoxib 40 mg twice daily, intravenous ketorolac 15
mg four times daily intravenously, or placebo for 5
days. Another study evaluated the non-elderly (ages
1855); the study groups received either 40 mg of
parecoxib intravenously twice daily, intravenous
ketorolac 30 mg four times daily, or placebo. The two
studies evaluated a total of 105 patients, 60 elderly and
45 non-elderly. Both studies showed that parecoxib had
no effect on platelet function, while ketorolac significantly reduced platelet aggregation. Also, as compared
to parecoxib, ketorolac caused a significant prolongation in bleeding time at 2 and 4 hours after infusion.
Another implication of altered platelet function is
the increased risk of gastrointestinal bleeding. As
mentioned above, COX-1 plays a protective role in the
gastric mucosa and thus inhibition of this enzyme may
lead to increased incidence of gastrointestinal ulceration. Parecoxib was evaluated for its role in the gastrointestinal system because of the implication of a
peri-operative analgesic that could be administered
intravenously, while not increasing the risk of bleeding
or gastrointestinal ulceration. There are two studies by
Harris et al. [4] that evaluated parecoxib in the settting
of upper gastrointestinal complications. In the first
study, a randomized, double-blind, double-dummy,
placebo-controlled, parallel group study, parecoxib
was studied in comparison to ketorolac, naproxen, and
placebo. The participants underwent a baseline endoscopy and then qualified subjects were randomized to
either intravenous parecoxib 10 mg twice daily, oral
naproxen 500 mg twice daily, placebo for 7 days, or
placebo for 2 days with intravenous ketorolac 15 mg

four times daily given afterwards for 5 days. The participants had follow-up endoscopies after 7 days. The
data collected showed that there were no ulcerations
observed in the parecoxib group on follow-up endoscopy, but there were ulcerations observed in all the
other active groups. The data were so concerning that
the study was terminated early and thus there were no
significant data on the safety profile of parecoxib. In
2004, Harris et al. [5] repeated a similar study. The
study was again double-blinded and placebo-controlled. The study participants had endoscopic documentation of normal upper intestinal mucosa and were
randomized to intravenous parecoxib 40 mg twice
daily, placebo for 2 days followed by intravenous
ketorolac 30 mg four times daily for 5 days, or placebo
for 7 days. In this study, ketorolac showed a statistically significant rate of gastrointestinal complications
as compared to placebo and parecoxib (P < 0.001). The
effects of longer administration of parecoxib were also
evaluated in a double-blind placebo-controlled trial.
Stoltz et al. [6] evaluated the use of intravenous
parecoxib 40 mg administered for 7 days versus intravenous ketorolac 15 mg four times daily for 5 days, or
placebo for 7 days. This study demonstrated a statistically significant difference in the incidence of stomach
and duodenal ulcers with parecoxib and placebo versus ketorolac. Based on the above studies, the gastrointestinal safety profile of parecoxib appears to be better
than that of ketorolac.
The efficacy of parecoxib for analgesia has also
been evaluated in clinical trials. The goal was usually
to compare parecoxib to other analgesics, such as
NSAIDs or opioids. Oral surgery was the model in
multiple studies. The outcomes measured included
pain relief, pain intensity difference (PID) score, time
to onset of analgesia, and time to rescue medication.
The overall results were that parecoxib is comparable
to ketorolac in providing effective analgesia in the
post-operative setting [7]. In one study, the participants were randomized to intramuscular parecoxib
20 mg or 40 mg, intravenous parecoxib 20 mg or 40
mg, intramuscular ketorolac 60 mg, or placebo. There
were no statistically significant differences in pain
relief or PID scores of patients randomized to
parecoxib versus ketorolac. One significant difference
was that parecoxib 40 mg had a longer duration of
action. Another study [8] compared intravenous
parecoxib 20 mg, 40 mg, 80 mg, and placebo given as
a one-time dose prior to oral surgery. The time to res-
Chapter 58 Parecoxib
cue medication was used as the primary outcome. The

40 mg and 80 mg dosages or parecoxib had a longer
duration of action than the 20 mg dose, but there was
no significant difference in resue analgesic use between
the 40 mg and 80 mg groups.
From early work on the drug, it appears the benefits of parecoxib were promising and had great
potential to be used as adjunctive pain management
in many situations [911]. Studies were conducted
with oral surgery, orthopedics, and gynecological
models that suggested the COX-2 inhibitor parecoxib
offered opioid-sparing attributes. Minimizing opioids in the post-operative period offered obvious benefits, including reduced adverse effects such as nausea
and vomiting. However, amidst these promising
studies there also emerged data that demonstrated
that parecoxib in certain clinical arenas increased the
risk of cardiovascular events. The first study by Ott
et al. [12] at first demonstrated that parecoxib could
be used as an effective analgesic after CABG. An
unanticipated side effect of the use of parecoxib in
this setting was an increased risk of sternal wound
infections, incidence of post-operative myocardial
infarction, and severe cerebrovascular events. As the
study was not designed primarily to look at adverse
events associated with the use of parecoxib, Nussmeier et al. performed another study the results of
which were published in the New England Journal of
Medicine NEJM [13]. The study was a randomized,
double-blind study that compared three different
10-day regimens of either intravenous parecoxib use
followed by oral valdecoxib, intravenous placebo
followed by oral valdecoxib, or all oral placebo. The
participants were then examined for a number of
predefined adverse events such as cardiovascular
events, renal, gastrointestinal, and wound-healing
complications. Of all the participants, the two groups
that included either parecoxib or valdecoxib treatment did have a higher incidence of adverse events as
compared to placebo (P = 0.02). The incidence of
combined events such as myocardial infarction,
stroke, pulmonary embolism, and cardiac arrest was
also higher in the treatment groups versus placebo (P
= 0.03). In 2005, the FDA released a letter of nonapproval for parecoxib. Although no official reason
was ever documented as to the non-approval, it is
likely that the data from the above-mentioned studies were taken into consideration.
The theory behind the increased incidence of cardiovascular thromboembolic events with the use of
parecoxib or other COX-2 inhibitors is very interesting.

It is thought that the use of these agents causes an
imbalance of pro and anti-platelet aggregation influences though the selective inhibition of COX-2 production of prostacyclin while sparing COX-1 production of
thromboxanes [14]. This theory is fascinating and
seems to offer a plausible explanation for the increased
risk observed, and also would prove a class effect of
COX-2 inhibitors and not just of parecoxib or valdecoxib. However, other authors [14,15] have postulated that this theory is inadequate because in the
post-CAGB studies all the patients had already been
started on low-dose aspirin, which would effectively
negate the postulated COX-1 effect. These authors
believe that the bypass procedure itself is what causes
increased sheer stress [16], which in turn results in the
alteration of the tertiary structure of von Willebrand
factor, exposing the site of glycoprotein Ib receptors in
platelets and causing aggregation. Much research is still
needed in this area to fully understand the mechanism
behind adverse cardiovascular events associated with
parecoxib and any possible way to decrease this risk.
New studies are now emerging which are evaluating the use of parecoxib in non-cardiac surgery and
whether there is increased risk in this patient population [17]. Interestingly, the authors of the original
NEJM article which evaluated post-CABG patients
performed this study. This study was similar in design
to the NEJM study. The trial was a randomized double-blind study which evaluated the use of parenteral
parecoxib for 3 days and oral valdecoxib for 7 days
versus 10 days of placebo. The goal was to measure the
frequency of predefined adverse events such as cardiovascular thromboembolism, renal, gastrointestinal,
and wound-healing complications. No significant
difference in adverse events was noted in either group
(P = 0.58). One of the criticisms of the study is that it
was not powered to show significant differences in
cardiovascular thromboembolic events because of the
low incidence of these events in noncardiac surgery
patients.
More study and research is needed to evaluate
parecoxib fully and the possible risks and benefits of its
use. The benefits of opioid-sparing effects and decreased
bleeding risk must be weighed against the cardiovascular risk in certain patient populations. The data available are still not definitive in the absolute risk profile
of parecoxib. The possibilities for use in non-cardiac
patients, as well as the use of other agents in cardiac
patients to temper the physiological mechanisms of
247
NSAIDs Section 4
COX-inhibitors and shear stress, still need to be evaluated. Currently, parecoxib is not approved for use in the
USA and is not approved for use after cardiac surgery in
Europe.
References
1. Cheer SM, Goa KL. Parecoxib (parecoxib sodium).

Drugs 2001; 61(8):11331141.
2. Kasper DL, Braunwald E, et al., eds. Harrisons
Principles of Internal Medicine, 16th ed. New York:
McGraw-Hill, 2005.
3. Noveck RJ, Laurent A, Kuss M, Talwalker S, Hubbard,
RC. Parecoxib sodium does not impair platelet
function in healthy elderly and non-elderly
individuals: two randomized, controlled tirals. Clin
Drug Investig 2001;21:465476.
4. Harris SI, Kuss M, Hubbard, RC, Goldstein, JL. Upper
gastrointestinal safety evaluation of parecoxib sodium,
a new parenteral cyclooxygenase-2-specific inhibitor,
compared with ketorolac, naproxen, and placebo. Clin
Ther 2001;23:14221428.
5. Harris SI, Stoltz RR, LeComte D, Hubbard RC.
Parecoxib sodium demonstrates gastrointestinal safety
comparable to placebo in healthy subjects. J Clin
Gastroenterol 2004;38(7):575580.
6. Stoltz RR, Harris SI, Kuss ME, LeComte D, Talwalker
S, Dhadda, S, Hubbard RC. Upper gastrointestinal
mucosal effects of parecoxib sodium in healthy elderly
subjects. Am J Gastroenterol 2002;97:6571.
7. Daniels SE, Grossman EH, Kuss ME, Talwalker S,
Hubbard RC. A double-blind, randomized
comparison of intramuscularly and intravenously
administered parecoxib sodium versus ketorolac and
placebo in a post-oral surgery pain model. Clin Ther
2001;23(7):10181031.
8. DesJardins PJ, Grossman EH, Kuss ME, Talwalker S,
Dhadda S, Baum D, Hubbard RC. The injectable
cyclooxygenase-2-specific inhibitor parecoxib sodium
248
has analgesic efficacy when administered

preoperatively. Anesth Analg 2001;93(3):721727.
9. Ng A, Smith G, Davidson AC. Analgesic effects of
parecoxib following total abdominal hysterectomy. Br
J Anaesth 2003;90:746749.
10. Malan TP Jr, Marsh G, Hakki SI, Grossman E, Traylor
L, Hubbard RC. Parecoxib sodium, a parenteral
cyclooxygenase 2 selective inhibitor, improves
morphine analgesia and is opioid-sparing following
total hip arthroplasty. Anesthesiology 2003;98:
950956.
11. Joshi GP, Viscusi ER, Gan TJ, et al. Effective treatment
of laparoscopic cholecystectomy pain with
intravenous followed by oral COX-2 specific inhibitor.
Anesth Analg 2004;98:336342.
12. Ott E, Nussmeier NA, Duke PC, et al. Efficacy and
safety of the cyclooxygenase 2 inhibitors parecoxib
and valdecoxib in patients undergoing coronary artery
bypass surgery. J Thorac Cardiovasc Surg
2003;125:14811492.
13. Nussmeier NA, Whelton AA, Brown MT, et al.
Complications of the COX-2 inhibitors parecoxib and
valdecoxib after cardiac surgery. NEJM
2005;352:10811091.
14. Krotz F, Schiele TM, Klauss V, John H. Selective
COX-2 inhibitors and risk of myocardial infarction. J
Vasc Res 2005;42:312324.
15. Schug S, Joshi G, Camu F, Pan S, Cheung R.
Cardiovascular safety of the cyclooxygenase-2
selective inhibitors parecoxib and valdecoxib in the
postoperative setting: an analysis of integrated data.
Anesth Analg 2009;108:299307.
16. Borgdorff P, Tangelder GJ, Paulus WJ. COX-2
inhibitors enhance shear stress-induded platelet
aggregation. J AM Coll Cardiol 2006;48:817823.
17. Nussmeier NA, Whelton AA, Brown MT, Joshi GP,
Langford RM, Singla NK, Boye ME, Verburg KM.
Safety and efficacy of the cyclooxygenase-2 inhibitors
parecoxib and valdecoxib after noncardiac surgery.
Section 4
Chapter
59
NSAIDs
Meloxicam
Gabriel Jacobs
Generic Name: meloxicam

Trade/Proprietary name: Mobic
Drug Class: NSAID
Manufacturer: Boehringer Ingelheim Parmaceuticals, Inc., P.O. Box 368, 900 Ridgebury
Road, Ridgefield, CT 068770368
Chemical Name: 4-hydroxy-2-methyl-N-(5methyl-2-thiazolyl)-2H-1,2-benzothiazine-3carboxamide-1,1-dioxide
Empirical Formula: C14H13N3O4S2 [1]; molecular
wt 351
Introduction
Meloxicam is classified as a partially selective COX-2
inhibitor, a subclass of nonsteroidal anti-inflammatory drugs (NSAIDs). It is believed to provide similar anti-inflammatory and analgesic effects similar to
nonselective NSAIDs but with a lower gastrointestinal bleeding risk and less effect on platelet aggregation. Meloxicam is an oxicam-type anti-inflammatory
drug, chemically related to an earlier released compound, piroxicam. The primary advantage of oxicams is their prolonged elimination half-life (1820
h) which allows once per day dosing [1]. Meloxicam
is approved and primarily prescribed to control pain
and inflammation associated with rheumatoid and
degenerative joint diseases. Non-approved uses may
include control of acute pain related to traumatic
injury or following surgery, and chronic low back
pain.
Mode of action
The anti-inflammatory nature of NSAIDs is widely
attributed to their action of inhibiting the synthesis of
prostaglandins. Prostaglandin endoperoxide synthase
(PGHS) is a key enzyme involved in inflammation.

PGHS has been shown to exist in two isoforms,
cyclooxygenase 1 and 2 (COX-1 and COX-2). Most
conventional NSAIDs inhibit the cyclooxygenase
activity of both COX-1 and COX-2. Meloxicam
inhibits the enzyme COX-2, in turn lowering levels of
prostaglandins, which are key inflammatory and
algesic mediators. The precise degree of meloxicams
ability to inhibit COX-2 selectively over COX-1 is
still under investigation but it appears to be less selective than true COX-2 inhibitors such as celecoxib and
parecoxib [2].
The Meloxicam Large-scale International Study
Safety Assessment (MELISSA) trial evaluated the tolerability of meloxicam, and potential COX-2 selectivity of meloxicam compared to diclofenac [3]. This
large-scale (9323 patients), double-blind, prospective
trial was conducted over 28 days in patients with
symptomatic osteoarthritis. Patients received standard doses of either meloxicam 7.5 mg or diclofenac
100 mg slow release. Significantly fewer adverse
events were reported by patients receiving meloxicam. This was attributable to fewer GI adverse events
(13%) compared to diclofenac (19%, P < 0.001).
Of the most common GI adverse events, there was
significantly less dyspepsia (P < 0.001), nausea and
vomiting (P < 0.05), abdominal pain (P < 0.01), and
diarrhea (P < 0.001) with meloxicam compared to
diclofenac. No endoscopically verified ulcer complication was detected in the meloxicam group compared to four with diclofenac. Patients treated with
meloxicam required a total of 5 days hospitalization
for drug-related complications versus 121 with
diclofenac. On the other hand, patients in the
diclofenac group consistently reported lower pain
intensity scores. Although differences in analgesic
efficacy were small (4.59.0% difference), significantly more patients discontinued meloxicam because
of lack of efficacy (80 out of 4635 vs. 49 out of 4688;
P < 0.01).
249
NSAIDs Section 4
OH
Figure 59.1.
H3C
S
N
H
H3C
S
O
Metabolism
Meloxicam is metabolized in the liver via P450
enzymes and converted into four inactive metabolites
[1,3]. The mean t1/2 of meloxicam is 15 to 20 hours.
Most of meloxicam is excreted in the form of metabolites; very little of the drug is excreted in its unchanged
form. Near equal parts of meloxicams metabolites are
excreted in both the urine and feces. Significant billary and enteral secretion has been demonstrated [1].
Indications
Adult indications: osteoarthritis, rheumatoid arthritis, acute musculoskeletal pain, post-operative pain.
Pediatric indications: juvenile idiopathic arthritis.
Potential indication under

investigation
Meloxicam is currently under investigation for being
used in the treatment of diabetic polyneuropathy.
Translational studies from Hokuriku University in
Japan demonstrate some positive results. Meloxicam
was studied in the treatment of induced diabetic neuropathy in mice. In the study, diabetic mice treated
with meloxicam showed improvement in established
allodynia when compared with ibuprofen and placebo
[4]. These results may lead to further investigation in
more animal and human trials. However, with renal
impairment and cardiovascular derangements a major
concern with many diabetic patients the use of meloxicam in the treatment of diabetic neuropathy could
make future human investigation challenging.
250
concomitant anticoagulation, tobacco or alcohol use,

elderly patients, patients with kidney or liver impairment, and asthmatics. Prolonged use of meloxicam
should also be avoided if possible [1,3,5].
Common doses
Meloxicam is available only in oral formularies which
include both pill and liquid suspension. Tablet: 7.5 mg
and 15 mg. Liquid suspension: 7.5 mg/5mL.
Adult dosing: for osteoarthritis and rheumatoid
arthritis dosage is 7.515 mg PO qd. Practitioners
should prescribe the lower dose of 7.5 mg PO qd and
advance to 15 mg PO qd if lower dose proves ineffective in treating symptoms [1,5].
Pediatric dosing (ages 217) for juvenile idiopathic
arthritis dosing is weight-based at 0.125 mg/kg PO qd
with a maximum pediatric dose of 7.5 mg per day
[1,5] (Table 59.1).
Meloxicam has advantages in the treatment inflammatory processes compared to conventional NSAIDs
in that it is classified as a selective COX-2 inhibitor.
The anti-inflammatory effect of most NSAIDs is
attributed to the inhibition of COX-2 enzyme, while
many of the deleterious effects such as gastrointestinal bleeding and ulceration have been attributed to
the inhibition of COX-1. Though the precise selectivity of meloxicam for COX-2 is still not clear,
in vitro studies have shown a 3 to 300 times preferential inhibition of COX-2 over COX-1 [2,6,7].
Long-term data are still lacking with regard to meloxicams improved side-effect profile, thus the same
considerations should be made by a practitioner as
with prescribing other NSAIDs. Once-a-day dosing
could also help improve patient compliance with
meloxicam.
Table 59.1. Juvenile rheumatoid arthritis dosing using the
oral suspension should be individualized based on the
weight of the child
Contraindications
Dose weight
(1.5 mg/mL)
Delivered dose
Meloxicam should be avoided in patients with known

NSAID allergies, pregnancy, and peri-operative period
for patients undergoing CABG surgery. Also, meloxicam should be used cautiously in patients with the following: cardiovascular disease, HTN, CHF, history of
PUD or GI bleeding, concomitant corticosteroid use,
12 kg (26 lb)
1.0 mL
1.5 mg
24 kg (54 lb)
2.0 mL
3.0 mg
36 kg (80 lb)
3.0 mL
4.5 mg
48 kg (106 lb)
4.0 mL
6.0 mg
60 kg (132 lb)
5.0 mL
7.5 mg
Chapter 59 Meloxicam
Meloxicam is only available in oral formulations. An
IV formulation is not available for human use but has
been employed for pain management in veterinary
medicine. Despite studies demonstrating improved
tolerability, meloxicam, like other NSAIDs, is associated with the potential for serious gastrointestinal and
wound site bleeding. Treatment with meloxicam may
worsen renal function or precipitate acute renal failure.
Drug interactions
Meloxicam has been shown to have interactions with
the following common medications: ACE inhibitors,
aspirin, cholestyramine, cimetidine, digoxin, furosemide, lithium, methotrexate, warfarin [1].

Serious events meloxicam has been implicated in
the following serious adverse events: GI bleeding, MI,
stroke, GI ulceration and perforation, anaphylactoid
reactions, HTN, CHF, bronchospasm, nephrotoxicity,
renal papillary necrosis, hepatotoxicity, exfoliative
dermatitis, blood dyscrasias, anemia, toxic epidermal
necrosis, Stevens-Johnson syndrome, thromboembolism [1,5].
Common events meloxicam has been implicated
in the following common adverse events: rash, urticaria, dyspepsia, nausea, abdominal pain, elevated
liver transaminases, dizziness, somnolence, fluid
retention, edema, tinnitus [1,5].
Conclusions
Meloxicam appears to have the advantage of reduced
gastrointestinal morbidity; however, it is unclear
whether it offers advantages over more selective
COX-2 inhibitors such as celecoxib and etoricoxib.

Although it offers the convenience of once-a-day
dosing, its efficacy in reducing pain intensity appears
to be inferior to diclofenac for management of degenerative joint disease. Despite lack of FDA approval,
meloxicam has been advocated for acute pain management. Large-scale well-controlled trials will be
required to asses its safety and effectiveness in this setting.
References
1. Mobic (meloxicam) Prescribing Information June

2008. U.S. Department of Health and Human Services.
http://www.accessdata.fda.gov/drugsatfda_docs/
label/2008/020938s018, 02153s006lbl.pdf. June 2008.
2. Van Hecken A, Schwartz JI, Depre M, et al.
Comparative inhibitory activity of rofecoxib,
meloxicam, diclofenac, ibuprofen, and naproxen on
COX-2 versus COX-1 in healthy volunteers. J Clin
Pharmacol 2000;40:11091120.
3. Hawkey C, Kahan A, Steinbru, et al. Gastrointestinal
tolerability of meloxicam compared to diclofenac in
osteoarthritis patients. Rheumatology 1998;37:937945.
4. Kimura Satoko, Kontani Hioshi. Demonstration of
antiallodynic effects of the cyclooxygenase-2 inhibitor
meloxicam on established diabetic neuropathic pain
in mice. Journal of Pharmacological Sciences. The
Japanese Pharmacological Society 2009.
5. Epocrates Online. https://epocrates.com/u/10a2227/
Mobic.
6. Panara M, Giulia R, Sciulli M. Dose-dependent
inhibition of platelet cyclooxygenase-1 and monocyte
cyclooxygenase-2 by meloxicam in healthy subjects.
J Pharmacol Exp Ther 1999;290(1).
7. Lipscomb GR, Wallis N. Gastrointestinal tolerability
of meloxicam and iroxicam: a double-blind placebocontrolled study. Br J Clin Pharmacol 1998;46:
133137.
251
Section 4
Chapter
60
NSAIDs
Buffered aspirin and oral salicylate

Jeanna Blitz
Generic Name: aspirin

Trade/Proprietary Name: Bayer Aspirin, Bufferin, Ecotrin, Empirin, Anacin
Drug Class: anti-inflammatory drug
Manufacturers: Bayer Health Care, 100 Bayer
Road, Pittsburgh, PA 15205; Bristol MyersSquibb, 5 Research Pkwy, Wallingford, CT
064921996
Chemical Name: acetylsalicylic acid
Description
Aspirin is a nonsteroidal anti-inflammatory drug
(NSAID) that has analgesic and antipyretic properties. It can be used alone to treat minor to moderate
acute and chronic pain as well as pain associated with
cancer. It is also available as preparations combined
with caffeine or with an opioid analgesic to treat moderate to severe acute and chronic pain. Aspirin can be
buffered (with calcium carbonate, magnesium oxide,
and magnesium carbonate), or enteric coated to
decrease the risk of gastric side effects such as dyspepsia, gastritis, bleeding, and ulceration.
Mechanism of action
252
Aspirin works to decrease pain by inhibiting inflammation at the cellular level. Prostaglandins sensitize
pain receptors in afferent nerve endings to histamine
and bradykinin, which begin the sensation of pain.
Like other NSAIDs, aspirin inhibits cyclooxygenase
(COX): the enzyme responsible for converting arachidonic acid to prostaglandin. Aspirin nonspeci
fically inhibits both COX 1 and 2 by acetylating
them. Aspirin is a more potent inhibitor of both
prostaglandin synthesis and platelet aggregation
than other salicylic acid derivatives. The differences
in activity between aspirin and salicylic acid are

thought to be due to the acetyl group on the aspirin
molecule.
Pharmacokinetics
Absorption
In general, immediate-release aspirin is well and
completely absorbed from the gastrointestinal (GI)
tract. Following absorption, aspirin is hydrolyzed to
salicylic acid with peak plasma levels of salicylic acid
occurring within 12 hours of dosing. The rate of
absorption from the GI tract is dependent upon the
dosage form, the presence or absence of food, gastric
pH (the presence or absence of GI antacids or buffering agents), and other physiological factors.
Enteric coated aspirin is absorbed in the small intestine, and its absorption is erratic. In clinical studies,
enteric coated aspirin was associated with less
gastritis and GI bleeding than buffered aspirin or
standard aspirin.
Distribution
Salicylic acid is widely distributed to all tissues and
fluids in the body including the central nervous system (CNS), breast milk, and fetal tissues. The highest
concentrations are found in the plasma, liver, renal
cortex, heart, and lungs.
Metabolism
Aspirin is rapidly hydrolyzed in the plasma to salicylic
acid such that plasma levels of aspirin are essentially
undetectable 12 hours after dosing. Salicylic acid is
primarily conjugated in the liver to form salicyluric
acid. Salicylic acid has a plasma half-life of approximately 6 hours. The clearance of aspirin is limited by
the ability of the liver to conjugate salicyclic acid. After
conjugation by the liver, the metabolites undergo renal
excretion.
Chapter 60 Buffered aspirin and oral salicylate
O
C
OH
Figure 60.1. Molecular structure image

obtained from The Chemical Heritage
Foundation website.
Cancer pain
O
O
with 65 mg caffeine (trade name Anacin), but with

little increase in efficacy over aspirin alone.
Aspirin and other NSAIDs are part of the World

Health Organization (WHO) analgesic ladder. Doses
of 325650 mg PO or PR q4 hours are recommended
for the treatment of mild to moderate somatic pain
associated with cancer (Table 60.1).
CH3
Indications
Acute surgical pain
Aspirin is not often used for acute surgical pain due to
its inhibition of platelet aggregation; however, it may
be prescribed after minor surgery either alone, or in
combination with an opioid analgesic such as oxycodone (trade name Percodan). A common dose would
be 12 tabs PO Q4h as needed. The combination of
butalbital (a mild barbiturate), caffeine, and aspirin
(trade name Fiorinol) is approved for use in nonvascular headache and has been used to treat postdural
puncture headache.
Medical pain and chronic

non-malignancy pain
Aspirin may be used alone to treat mild to moderate
somatic pain, or in combination with an opioid analgesic such as oxycodone or hydrocodone to treat more
severe pain. The common dose of 650 mg of aspirin
PO or PR has been demonstrated to be as efficacious
as 10 mg of morphine administered IM. The maximum dose is 6 g/day in divided doses. It is often prescribed for the treatment of arthritis and other
rheumatological pain. The dose of aspirin for the
treatment of rheumatological pain is 34 g/day in
divided doses. With regard to the treatment of
migraines, 650 mg of aspirin can also be combined
Contraindications
Absolute
Aspirin is contraindicated in patients with a known
allergy to nonsteroidal anti-inflammatory drugs
(NSAIDs).
Aspirin also places patients at risk for gastrointestinal bleeding, ulceration and perforation. Patients
with a history of significant GI bleeding or peptic ulcer
disease should not be prescribed aspirin. Patients who
are already taking another type of NSAID should not
take aspirin, as this increases the risk for upper GI
bleeding even more.
Patients with severe renal or hepatic failure should
not be prescribed aspirin.
In addition, it should not be used in children or
teenagers with viral infections (with or without fever)
because of the risk of Reyes syndrome.
Aspirin is a Pregnancy Category D medication and
should not be used in pregnant women.
Relative
Aspirin should be used with caution in patients with
asthma or nasal polyps as it may cause urticaria,
angioedema, and bronchospasm.
Table 60.1. Aspirin dosing table: acute and chronic pain, cancer pain, and headache
Drug
Dose
Route
Frequency
Maximum
daily dose
Aspirin
325650 mg
PO or PR
q4h
46 g
Aspirin + oxycodone (Percodan)
325 mg/4.5 mg
PO
12 tabs q4h
46 g
Aspirin + hydrocodone
500 mg/5 mg
PO
12 tabs q4h
46 g
Aspirin + caffeine (Anacin)
650 mg/65 mg
PO
12 tabs q4h
46 g
Aspirin + caffeine + butalbital

(Fiorinol)
330 mg/40 mg/50 mg
PO
12 tabs q46h
4g
Aspirin + caffeine + butalbital +

codeine (Fiorinol-C)
330 mg/40 mg/50 mg /15 mg
PO
12 tabs q46s
4g
253
NSAIDs Section 4
Patients with preexisting coagulation abnormalities such as liver disease, vitamin K deficiency or
hemophilia should avoid aspirin because of its ability
to inhibit platelet aggregation.
Patients who are on a sodium-restricted diet
should avoid taking buffered aspirin preparations that
contain a high concentration of sodium.
Aspirin may increase levels of lithium and enhance
toxicity of valproic acid.
The efficacy of oral hypoglycemic medications is
also enhanced by moderate to high doses of aspirin.
Renal clearance of methotrexate is inhibited by
aspirin; the increased serum levels of methotrexate
can lead to bone marrow toxicity.
Fluid retention from an inhibition of renal prostaglandins may exacerbate heart failure. See Table 60.2
for a summary of contraindications.
Drug abuse and dependence

There is no known potential for addiction associated
with the use of aspirin.
Common doses and routes

of administration
Aspirin may be administered via either the oral (PO)
or rectal (PR) route. The common dose is 325650 mg
q4 hours. The maximum dose is approximately 6 g/day.
This is due to the fact that aspirin exhibits a ceiling
Table 60.2. Contraindications to aspirin
Absolute
Known allergy to NSAIDS
Significant GI bleed or peptic ulcer disease
Renal failure
Hepatic failure
Children or teenagers with viral illness (risk of Reyes
syndrome)
Pregnant women
Relative
Asthma or nasal polyps (risk of angioedema, bronchospasm)
Preexisiting hypercoaguable state
Sodium-restricted diet
Patients taking lithium or valproic acid
Patients taking oral hypoglycemics
Patients taking methotrexate
254
Heart failure
effect, where higher doses do not provide any greater

pain relief and are associated with a higher risk of toxicity and side effects.
Inexpensive (cost as monotherapy): enteric coated
$13.99 for 325-mg tabs 1000/ bottle, buffered
aspirin $10.99 for 500-mg tabs 130/ bottle
Easy to use and administer
Opioid-sparing as multimodal analgesia
There is no known potential for addiction
associated with the use of aspirin.
Salicylate toxicity can occur at very high doses
(150500 mg/kg). See below for description of
signs, symptoms and treatment of salicylate
toxicity.
Drug interactions occur with many commonly
prescribed medications such as oral hypoglycemic
agents, valproic acid, methotrexate, lithium, and
ACE inhibitors.
The ceiling effect of aspirin limits the amount of
pain relief that can be expected from this agent
alone.
Although enteric coated aspirin is associated with
a reduction in gastric side effects, its absorption is
less reliable, making consistent dosing difficult.

Many adverse reactions due to aspirin ingestion are
dose-related. Table 60.3 is a list of adverse reactions
that have been reported in the literature.
Salicylate toxicity may result from acute ingestion
(overdose) or chronic intoxication. Symptoms start to
occur at plasma concentrations of 200 g/mL and
increase in severity as plasma levels reach 300400
g/mL. Severity of aspirin intoxication is determined
by measuring the blood salicylate level. The earliest
sign of overdose is usually tinnitus. Respiratory
alkalosis is another early sign: the patients respiratory center is directly stimulated, causing hyperventilation. However, in more severe cases of toxicity,
metabolic acidosis ensues, resulting in a raised gap
metabolic acidosis: the salicylate overdose inhibits
the citric acid cycle and uncouples oxidative phosphorylation, leading to hypercarbia, and an increase
in ketones and lactic acid production. The kidneys
Chapter 60 Buffered aspirin and oral salicylate
Table 60.3. Potential adverse events

Significant adverse events
Salicylate toxicity
Reyes syndrome
GI bleeding, perforation, ulceration and gastritis
Less common adverse events
General: fever, hypothermia, thirst
Cardiovascular: dysrhythmias, hypotension, tachycardia
Fluid and electrolyte: dehydration, hyperkalemia, metabolic
acidosis, respiratory alkalosis
Gastrointestinal: transient elevation of LFTs, hepatitis,
pancreatitis
Hematological: prolongation of prothrombin time,
coagulopathy, thrombocytopenia
Musculoskeletal: rhabdomyolysis
Metabolism: hyperglycemia, hypoglycemia (in children)
Reproductive: prolonged labor, low birth weight infants,
antepartum and postpartum bleeding
Urogenital: interstitial nephritis, papillary necrosis,
proteinuria, renal insufficiency/failure
secrete potassium, sodium, and bicarbonate, resulting in an alkaline urine. The severe acidbase and
electrolyte disturbances may be complicated by
hyperthermia and dehydration. The treatment of salicylate toxicity consists of supporting vital functions,
increasing salicylate elimination, and correcting the
acidbase disturbance: acidbase status should be
closely followed with serial blood gas and serum pH
measurements. Gastric emptying and/or lavage is
recommended as soon as possible after ingestion,
even if the patient has vomited spontaneously. After
lavage and/or emesis, administration of activated
charcoal is beneficial, if less than 3 hours have passed
since ingestion. Fluid and electrolyte balance should
also be maintained: urinary alkalinization can be
performed by administering an IV bolus of sodium
barcarbonate 12 mEq/kg and then maintaining a
constant infusion of D5W with 100150 mEq/L of

sodium bicarbonate and potassium chloride 2040
mEq/L at 1.52.5 mL/kg per h. Serum electrolytes
need to be closely monitored along with urine
pH. The goal is to maintain alkalinization of the urine
at a pH 7.58. Serum glucose levels must also be
closely monitored: although the patient may at first
be hyperglycemic, this may soon lead to hypoglycemia, which will worsen any CNS symptoms of agitation and delirium.
In severe cases, hyperthermia and hypovolemia
are the major immediate threats to life.
Dialysis can be performed to reduce the total body
drug content. In patients with renal insufficiency or
in cases of life-threatening intoxication, it is usually
required.
Reyes syndrome is a rare but potentially fatal disease of encephalopathy and hepatitis after ingestion of
aspirin. This syndrome most commonly occurs in
children (age 412) who have recently suffered from
influenza, chicken pox, or an upper respiratory infection associated with a fever that was treated with aspirin. The disease usually starts with vomiting that gives
way to agitation, lethargy, and coma or seizures.
Abnormal LFTs may also occur. Because there is no
specific treatment for Reyes syndrome, supportive
treatment is recommended.
References:
1. Rainsford KD, ed., Ch 4: Pharmacokinetics and

metabolism of the salicylates; Ch 10: Salicylates in
the treatment of acute pain. In Aspirin and Related
Drugs. Boca Raton: CRC Press, 2004, pp. 97137,
587607.
2. Barkin RL. Acetaminophen, aspirin, or ibuprofen in
combination products, 2001analgesic products. Am J
Ther 2001;8:433442.
3. Hamilton RJ, ed. Tarascon Pocket Pharmacopoeia 2009
Deluxe Edition. Sudbury, MA: Jones and Bartlett,
pp. 57.
255
Section 4
Chapter
61
NSAIDs
Acetaminophen oral and rectal

Komal D. Patel
Generic Name: acetaminophen

Proprietary Names: TylenolR, Acephen
Manufacturers: McNeil-ppc, Inc., Fort Washington, PA (Tylenol); Grand W Labs, South
Plainfield, NJ (Acephen)
Drug Class: analgesic and antipyretic, miscellaneous
Chemical Name: N-acetyl-para-aminophenol
Formula: C8H9NO2
Mode of activity
Acetaminophen produces analgesia by inhibiting
prostaglandin synthesis in the central nervous system
and peripherally. It produces antipyresis by inhibition
of the hypothalamic heat-regulating center, resulting
in peripheral vasodilatation and increased dissipation
of heat.
Metabolic pathways
Acetaminophen is metabolized primarily in the liver
by glucuronidation and sulfation to non-toxic metabolites. Less than 15% is metabolized by the cytochrome
P450 enzyme system to a highly reactive intermediate
N-acetyl-p-benzoquinoneimine (NAPQI), which is
conjugated with glutathione and inactivated. At toxic
doses glutathione conjugation becomes insufficient to
meet the metabolic demand, causing an increase in
NAPQI concentration, which may cause hepatic cell
necrosis.
Clearance and elimination

256
Peak plasma levels occur between 10 and 60 minutes

after oral dose. Elimination half-life is 13 hours in
adults and 25 hours in neonates. Excreted primarily in

urine (25% unchanged, 55% as glucuronide metabolites, 30% as sulfate metabolites) [1]. The bioavailability
of rectal acetaminophen is variable. It is approximately
80% of that of an oral dose and the rate of absorption is
slower, with maximum plasma concentrations achieved
about 23 hours after administration.
Surgical pain
Oral and rectal acetaminophen is used as a non-opioid
analgesic to treat mild to moderate post-operative pain
of nonvisceral origin, particularly after ambulatory
surgery. Higher doses of rectal acetaminophen (4060
mg/kg) have been shown to have a morphine-sparing
effect in day-case surgery in children [2]. In combination with nonsteroidal anti-inflammatory drugs
(NSAIDs) or opioids, acetaminophen is also used in
management of moderate to severe post-operative pain
and cancer pain [3]. Commonly used analgesic combinations with opioids are Tylenol 1, 2, 3, and 4 (with
codeine 10 mg, 15 mg, 30 mg, and 60 mg respectively),
Percocet (with oxycodone), Vicodin (with hydrocodone), and Darvocet (with propoxyphene napsylate).
These combinations are available only by prescription.
Medical pain
Acetaminophen is commonly used for relief of fever
and headaches and is a major ingredient in numerous
cold and flu remedies. It is also used in multi-ingredient preparations for migraine headache, tension headache, and vascular headaches.
Chronic non-malignancy pain

Acetaminophen in doses <4 g/day is recommended as
a first-line medication for many chronic pains such as
back pain and arthritis by the American Pain Society.
It is less effective in arthritis pain than NSAIDs.
Chapter 61 Acetaminophen oral and rectal
H
N
HO
Figure 61.1.
Cancer pain
The World Health Organizations (WHO) three-step
analgesic ladder for cancer pain control recommends
using acetaminophen alone for mild pain (step 1) and in
combination with opioids for moderate pain (step 2).
Contraindications
Absolute: hypersensitivity to acetaminophen or any
component of the formulation.
Relative: in patients who consume more than three
alcoholic drinks per day, acetaminophen may increase
the risk of liver damage. In patients with G6PD deficiency, acetaminophen may induce hemolysis.
Common doses
Adult (oral or rectal): 325650 mg every 46 hours or
1000 mg 34 times per day. Maximum dose 4 g/day.
Children < 12 years old (oral or rectal): 1015 mg/
kg/dose every 46 hours as needed. Maximum 5 doses
in a day.
Renal impairment: Clcr 1015 mL/minute
administer every 6 hours. Clcr < 10 mL/minute
administer every 8 hours.
Ease of use, availability: acetaminophen is a readily
available over-the-counter medicine. It is available in
many different formats (tablet, caplet, liquid suspension, suppository) for self-medication.
Tolerability, reduction of adverse events: in recommended doses, acetaminophen does not irritate the
lining of the stomach, affect blood coagulation as
much as NSAIDs or affect the function of the kidneys.
It is safe in pregnancy and does not affect the closure
of the fetal ductus arteriosus as NSAIDs can. Unlike
aspirin, acetaminophen is safe in children as it is not
associated with a risk of Reyes syndrome in children
with viral illnesses. Unlike opioids, acetaminophen
does not cause euphoria, alter mood, or pose a risk of
addiction, dependence, tolerance, and withdrawal.
Cost: relatively inexpensive generic versions are
available over-the-counter as well as in hospitals.
Toxicity: accidental or intentional acetaminophen
overdose (7.510 g in adults; >150 mg/kg in children) can cause hepatotoxicity, which is the most
common cause of acute liver failure in the USA. Toxicity from acetaminophen is not from the drug itself
but from one of its metabolites, NAPQI. Normally
this metabolite undergoes conjugation with glutathione, but at toxic doses conjugation depletes glutathione. This in combination with direct cellular injury
by NAPQI leads to hepatic cell necrosis. It is usually
asymptomatic initially. Symptoms related to hepatotoxicity may develop over 15 days: anorexia, nausea, vomiting, right upper quadrant pain, diaphoresis,
jaundice, hypoglycemia, coagulation defects, encephalopathy, and renal failure. Treatment of acetaminophen overdose includes administration of oral
activated charcoal to decrease absorption of acetaminophen and N-acetylcysteine as an antidote
which acts as a precursor for glutathione. If damage
to the liver becomes severe, a liver transplant is often
required.
Drug interactions: anticonvulsants (phenytoin,
barbiturates, carbamazepine) increase the risk of
hepatotoxicity by increasing conversion of acetaminophen to toxic metabolites. Isoniazide also increases
risk of acetaminophen hepatotoxicity. Acetaminophen
may enhance the anticoagulant effect of warfarin with
daily doses > 1.3 g for > 1 week. Phenothiazines may
increase risk of severe hypothermia with acetaminophen. Cholestyramine resin may decrease the
absorption of acetaminophen.

Serious adverse events: hypersensitivity rare. Hepatotoxicity as described above. In patients with G6PD
deficiency, acetaminophen can cause hemolysis.
Less common adverse events: other rare adverse
reactions with acetaminophen include rash, anemia,
neutropenia, pancytopenia; increase in bilirubin,
alkaline phosphatase, ammonia, chloride, uric acid,
glucose; decrease in sodium, bicarbonate and calcium. Frequency of these adverse reactions not
defined.
References
1. McEvoy GK, ed. Acetaminophen. In AHFS Drug

Information 2003. Bethesda, MD: American Society of
Health-System Pharmacists, 2003, pp. 20772085.
257
NSAIDs Section 4
2. Korpela R, Korenoja P, Meretoja OA. Morphinesparing effect of acetaminophen in pediatric day-case

surgery. Anesthesiology 1999;91(2).
Section 4
Chapter
62
NSAIDs
Acetaminophen injectable
Vivian K. Lee and Jonathan S. Jahr
Generic Name: intravenous acetaminophen or

paracetamol
Chemical Name: N-acetyl-para-aminophenol
Proprietary Name: Perfalgan, Ofirmev
Manufacturer: Bristol-Myers Squibb Pharmaceuticals (Europe), Cadence Pharmaceuticals,
San Diego, CA (USA and Canada)
Distributor: currently submitted for FDA
approval, not yet distributed in the USA
Class: antipyretic, analgesic, anesthetic adjunct
Description
258
3. Romsing J, Moiniche S, Dahl JB. Rectal and parenteral

paracetamol, and paracetamol in combination with
NSAIDs, for postoperative analgesia. Br J Anaesth
2002;88:215226.
Intravenous acetaminophen is a synthetic, non-opiate,

centrally acting analgesic and antipyretic derived from
p-aminophenol. It is recommended as a first-line analgesic in mild to moderate acute pain states and is
effective in combination with other analgesics for
more severe pain. Another available parenteral form is
the prodrug propacetamol, which is rapidly hydrolyzed by esterases in the blood to acetaminophen. A
dose of 2 g propacetamol is hydrolyzed to 1 g of acetaminophen. Studies have shown these doses to be
bioequivalent. However, propacetamol is less favorable because it is associated with pain at the injection
site or along the vein where it is infused. Additionally,
propacetamol is supplied in powder form and requires

reconstitution, whereas IV acetaminophen is supplied
in a ready-to-use form.
Mode of activity
Major site of action: the mechanism of action of acetaminophen is not clearly understood. It is a centrally
acting inhibitor of cyclooxygenases with weak peripheral effects.
Receptor interactions: the antipyretic and analgesic effects of acetaminophen have been attributed to
inhibition of prostaglandin synthesis by blocking the
cyclooxygenase-2 pathway in vascular endothelial
cells and neurons. Acetaminophen acts as a reducing
co-substrate for the peroxidase-active site of the
prostaglandin H2 synthase. It has a variable capacity
to inhibit prostaglandin production in different tissues and cells, which explains its weak antiplatelet
and anti-inflammatory effects at recommended
doses. It may also act as an NMDA receptor antagonist and inhibit production of nitric oxide, a molecule important in nociception. Acetaminophen
activity has also been associated with the 5-HT3
receptor.
Onset of analgesia: occurs within 510 minutes.
Peak analgesic effect is obtained in 1 hour and its
duration is approximately 46 hours.
Onset of antipyretic effects: occurs within 30 minutes. Duration is at least 6 hours.
Chapter 62 Acetaminophen injectable
Figure 62.1.
H
HO
Distribution: readily crosses the bloodbrain barrier as well as the placenta (but does not adversely
affect the fetus at therapeutic doses). Does not extensively bind to plasma proteins.
Metabolism: acetaminophen is 9095% metabolized in the liver by conjugation with sulfate and glucuronide to inactive compounds. At higher doses, the
drug is metabolized in the liver by the cytochrome
P450 enzyme CYP2E1.
Elimination: metabolites are predominantly
eliminated in the urine as glucuronide and sulfide
conjugates. Less than 5% of the drug is excreted
unchanged in the urine, and less than 1% is eliminated in bile.
Half-life: 2.7 hours.
Indications
Intravenous acetaminophen is currently undergoing
FDA approval for the short-term treatment of mild to
moderate pain and fever in adult and pediatric
patients. It has already been in use in numerous countries worldwide since 2002.
In the peri-operative setting, the parenteral form
of acetaminophen is preferred because most patients
are unable to tolerate oral medications and/or may
have unpredictable gastrointestinal function following surgery. Intravenous administration can achieve
effective levels in a shorter time with predictable drug
levels compared to oral and rectal forms. Additionally,
it has demonstrated superior analgesia at least in the
first hour after it is administered and a longer duration
of action. In clinical trials, it has demonstrated an
adverse reaction profile similar to that of placebo, and
is therefore an appropriate analgesic option for
patients undergoing ambulatory surgery. IV acetaminophen can also be used as an adjunct to other analgesics. In theory, it can reduce the amount of opiates
required for post-operative pain, potentially leading
to reduced narcotic-related adverse effects, earlier
ambulation, and shorter hospital stays.
Contraindications
Absolute: intravenous acetaminophen is absolutely
contraindicated in patients in fulminant hepatic
failure.
Relative: severe chronic alcohol abusers may be at
increased risk of liver toxicity from acetaminophen
exceeding the recommended doses. Any disorder
leading to glutathione depletion, such as malnourishment or viral illness with dehydration, may decrease
the tolerance for acetaminophen. Acetaminophen
should be used with caution in patients with severe
hepatic impairment, although hepatoxicity has not
been shown to occur at the recommended doses. In
patients with severe renal impairment, the minimum
interval re-dosing of the drug should be increased to 6
hours.
Common doses
General: IV acetaminophen is available as a 1 g
infusion that does not require reconstitution. It
should be administered over 15 minutes and can be
given through a peripheral IV. It is comparable to
other IV analgesics for the treatment of moderate
post-operative pain (see Table 62.1).
Adults: for adults weighing > 50 kg, the recommended dose is 1 g every 46 hours, with a maximum
of 4 g per day. For adults weighing < 50 kg, the dose
is 15 mg/kg every 46 hours, with a maximum of 3 g
per day.
Elderly: the pharmacokinetics of IV acetaminophen are unchanged in the elderly. No adjustment
in dosage is necessary for older patients.
Pediatric: for children weighing >33 kg, the dose is
15 mg/kg every 46 hours, with a maximum of 3 g per
day. For children weighing 1033 kg, the dose is 15
mg/kg every 46 hours, with a maximum of 2 g per
day. For full-term newborn infants, infants, toddlers
and children weighing < 10 kg, the dose is 7.5 mg/kg,
with a maximum of 30 mg per kg per day.
Table 62.1. Efficacy of IV acetaminophen 1 g versus other
IV analgesics in post-operative pain
Dose
Comparable efficacy
IV acetaminophen 1 g
Ketorolac 30 mg
Diclofenac 100 mg
Metamizol 2.5 g
Morphine 10 mg
Efficacy may depend on type of surgery performed.
259
NSAIDs Section 4
Intravenous acetaminophen has advantages over its
prodrug form proparacetamol. Unlike proparacetamol, IV acetaminophen is rarely associated with pain
at the infusion site because it has a pH and osmolarity
more similar to that of plasma. The lower rate of local
intolerance improves patient compliance. Moreover,
proparacetamol is supplied as a powder and must be
dissolved in saline or glucose immediately before infusion, and is therefore costly, time-consuming, and
more prone to dosing or administration error by the
healthcare provider. There have also been reports of
contact dermatitis in healthcare providers handling
the powder, which can be avoided with ready-to-use
IV acetaminophen.
Effective blood concentrations of IV acetaminophen can be achieved intra-operatively prior to
emergence from anesthesia. This has been the potential
for faster discharge for ambulatory surgery. Additionally, intravenous administration is more efficient, faster,
and longer-acting than oral administration of acetaminophen. The pharmacodynamic effect appears to correlate well with CSF levels. Achieving an earlier and
higher concentration appears to be responsible for the
superior early efficacy of IV acetaminophen compared
to other routes of administration. Pharmacokinetic

modeling suggests that avoidance of first-pass hepatic
metabolism by the intravenous route reduces the
potential for hepatoxicity.
When used as monotherapy, IV acetaminophen
does not cause excessive sedation, biliary spasm, respiratory depression, nausea, vomiting, ileus, or pruritus associated with opioids, nor the harmful
cardiovascular, renal, gastrointestinal, and hematological effects associated with NSAIDs and COX-2
inhibitors.
Studies also indicated that differences in the variables studied did not have significant impact on IV
APAPs efficacy. A reduction in narcotic requirements has been shown in adult patients undergoing
dental, orthopedic, or gynecological surgery (see
Table 62.2). For example, in a combined study of
three randomized, placebo-controlled trials, acetaminophen 1000 mg given intravenously following
major orthopedic surgery significantly reduced both
narcotic requirements (by 33 to 63%) and the need
for opioid rescue. It is likely that the efficacy as an
anesthetic adjunct is also dependent on the type of
surgery.
When used in conjunction with opiate analgesics,
the narcotic-sparing effect of IV acetaminophen is
Table 62.2. Randomized, controlled trials with IV acetaminophen for post-operative pain
260
Surgery
Patients
Treatment
Anesthesia
Treatment
timing and
duration
Scale
Outcome
Ref
Orthopedic
Hospitalized
adults 2287
years
2 g prop vs.
1 g para vs.
placebo
General
Given post-op
every 6 hours
for 24 hours
VAS, VRS
Prop and para both

significantly reduced
morphine consumption
over 24-h period
Tonsillectomy
Ambulatory
adults 1640
years
1 g para vs.
placebo
General
Given post-op
every 6 hours
for 24 hours
VAS
Para significantly
reduced meperidine
consumption over 24-h
period
Cardiac
surgery
Adults
4579 years
1 g para vs.
placebo
General
15 min before
end of surgery
and every 6
hours for 72
hours
VAS
Para significantly
reduced pain at rest
and at 12 hours,
nonsignficant
reduction in morphine
consumption
Total
abdominal
hysterectomy
Hospitalized
women
1 g para vs.
placebo
General
Given once
either 30 min
before surgery
or prior to skin
closure
VAS
Preemptive para
significantly reduced
post-op morphine
consumption, no
hemodynamic effects
prop, proparacetamol; para, paracetamol; VAS, visual analog scale; VRS, visual rating scale.
Chapter 62 Acetaminophen injectable
controversial. Studies seem to indicate that although

IV acetaminophen as an adjunct significantly improved
patient satisfaction regarding post-operative anal
gesia, it did not necessarily reduce opioid-related side
effects.
Beyond post-operative analgesia, randomized
controlled trials have demonstrated that IV acetaminophen 1000 mg administration resulted in a statistically significant reduction in fevers in the post-operative
setting compared to placebo. A reduction in fevers
represents an indirect measure of IV APAPs efficacy.
Additionally, it may also suggest that in the proper
clinical setting, IV APAPs use as post-operative pain
treatment may lead to a reduction of unnecessary
fever workups in the immediate post-operative
period.
In aggregate these trials indicate IV acetaminophen (known outside the USA as paracetamol) is
an effective analgesic in a variety of surgical procedures. IV acetaminophen was well tolerated and has
multiple direct and indirect benefits when used for
post-operative pain management.
Adverse events
Adverse reactions related to the use of the intravenous
formulation of acetaminophen are extremely rare
less than 1 in 10 000. It has demonstrated a safety profile similar to that of placebo. Adverse events include
hypotension, malaise, hypersensitivity reaction, elevated hepatic transaminases, thrombocytopenia, and
pain at the infusion site.

Hepatotoxicity does not occur at recommended doses
of acetaminophen. Administration of 2 g, or twice
the recommended dose, of intravenous paracetamol
in healthy subjects has been shown to stay far below
the threshold of hepatotoxicity. When ingested at
high doses, acetaminophen is metabolized to
N-acetyl-p-benzoquinone-imine (NAPQI). NAPQI
is rapidly conjugated with glutathione to a nontoxic
compound. The depletion of glutathione results in
the accumulation of NAPQI that is responsible for
liver injury. Acetaminophen has a narrow therapeutic
window and even minor overdoses may cause severe
hepatic injury. Liver necrosis occurs at 7.510 g of
acetaminophen.

Drug interactions
The cytochrome P450 enzyme CYP2E1 is responsible
for metabolizing acetaminophen to NAPQI. Drugs
that induce CYP2E1 may enhance toxicity. Potential
drug interactions include alcohol, long-term anticonvulsant use, probenecid, and salicylamide. Caution
should be taken and a reduced dose of acetaminophen
should be considered when patients are on any of
these drugs. Administration of acetaminophen to
patients on coumadin may also be associated with
elevated international normalized ratio (INR) values.
Additional monitoring of INR values for these
patients is recommended for up to 1 day after stopping
acetaminophen.

Acetaminophen exceeding the recommended daily
doses can be treated with the administration of N-acetylcysteine, and should be given regardless of time of
ingestion. N-acetylcysteine is a precursor of glutathione and increases the availability of glutathione for
NAPQI metabolism. It is most effective if given within
810 hours of acetaminophen ingestion. Progression
to fulminant liver failure requires continuously monitoring in an intensive care unit and evaluation for liver
transplantation.
References
1. Duggan ST, et al. Intravenous paracetamol

(acetaminophen). Drugs 2009;69(1):101113.
2. Remy C, et al. State of the art of paracetamol in acute
pain therapy. Curr Opin Anaesthesiol 2006;19:562565.
3. Jahr JS, et al. Chapter 21: Nonselective nonsteroidal
anti-inflammatory drugs, COX-2 inhibitors, and
acetaminophen in acute perioperative pain. In Sinatra
RS, de Leon-Casasola OA, Ginsberg B, Viscusi ER,
eds. Acute Pain Management. New York: Cambridge
4. Sinatra RS, Jahr JS, Reynolds LW, et al. The analgesic
efficacy and safety of single and repeated
administration of intravenous paracetamol
(acetaminophen) 1 g for the treatment of postoperative pain following orthopedic surgery.
5. Atef A, Aly Fawaz A. Intravenous paracetamol is highly
effective in pain treatment after tonsillectomy in adults.
Eur Arch Otorhinolaryngol 2007;265(3):351355.
261
NSAIDs Section 4
6. Cattabriga I, et al. Intravenous paracetamol as

adjunctive treatment for post-operative pain after
cardiac surgery: a double blind randomized controlled
trial. Eur J Cardio-thorac Surg 2007;32(3):527531.
7. Arici S, et al. Preemptive analgesic effects of
intravenous paracetamol in total abdominal
hysterectomy. Agri 2009;21(2):5461.
11. Royal MA, Fong L, Pan C, Breitmeyer JB. IV

acetaminophen administered to treat postoperative
pain significantly decreases the incidence of patient
reporting of postoperative fever. Reg Anesth Pain Med
2009;PS1:16.
8. Grcs TS, et al. Efficacy and tolerability of ready-touse intravenous paracetamol solution as monotherapy
or as an adjunct analgesic therapy for postoperative
pain in patients undergoing elective ambulatory
surgery: open, prospective study. Int J Clin Pract
2009;1:112120.
12. Smith HD, Pan C, Breitmeyer JB, Royal MA.

Acetaminophen produces clinically meaningful pain
response and opioid sparing effect after major
orthopedic surgery: Pooled data from three
randomized, placebo controlled trials. Reg Anesth Pain
Med 2009;PS1:21.
9. Jahr JS, Reynolds LW, Royal MA, Pan CP, Breitmeyer

JB. A posthoc analysis of a randomized, double-blind,
placebo-controlled study of IV acetaminophen for the
treatment of postoperative pain after major
orthopedic surgery. Reg Anesth Pain Med 2009;
PS1:10.
13. Breitmeyer JB, Smith HD, Sweeney K, Royal MA. CSF

penetration of acetaminophen is an important
determinant of efficacy. Reg Anesth Pain Med
2009;PS1:4.
10. Royal MA, Gosselin NH, Pan C, Moukassi S,

Breitmeyer JB. Route of administration may
Section 4
Chapter
63
262
significantly impact hepatic acetaminophen exposure.

Reg Anesth Pain Med 2009;PS1:17.
14. Macario A, Royal MA. A systematic literature review

of randomized clinical trials of intravenous
acetaminophen (paracetamol) for acute postoperative
pain. Reg Anesth Pain Med 2009;PS2:6.
NSAIDs
Fiorinal and Fioricet

Alexander Timchenko
Trade Names: Fiorinal, Fioricet

Generic Names: acetaminophen, butalbital, plus
caffeine compound; aspirin, butalbital, plus caffeine compound
Manufacturer: Watson Pharmaceuticals, Inc.,
311 Bonnie Circle, Corona, CA 92880
Drug Class: anti-headache medication, Rx
Drug Structures: aspirin (Figure 63.1), 2-acetyloxy-benzoic acid, C9H8O4; molecular wt 180.16;
acetaminophen (Figure 63.2), 4-hydroxyacetan
ilide, C8H9NO2; molecular wt 151.17; caffeine
(Figure 63.3), 1,3,7-trimethylxanthine, C8H10N4O2;
molecular wt 194.19; butalbital (Figure 63.4),
5-allyl-5-isobutylbarbituric acid, C11H16N2O3,
molecular wt 224.26
Chapter 63 Fiorinal and Fioricet
Figure 63.1.
HO
H3C
O
Figure 63.2.
NHCOCH3
OH
Figure 63.3.
CH3
CH3
N
N
O
N
CH3
Figure 63.4.
H
O
CH2 = CHCH2
NH
(CH3)2CHCH2
Introduction
Chronic headache represents one of the major medical and socio-economic issues patients face. Approximately 4% of the US population suffers from frequent
headaches. Of these, 37% or 1.5% of the population
experience daily headaches [1,2].
The pathophysiology of tension-type headache is
incompletely understood. Experimental studies suggest that it may be caused by increased excitability of
the CNS generated by repetitive and sustained
pericranial myofacial input [3]. Peripheral nociceptive factors may play a role in the episodic form of
tension headache, whereas central sensitization predominates in the chronic form. Epidemiological studies report an increased familial risk in tension-type
headaches [4].
Currently, there is no specific abortive treatment for
a tension-type headache (TTH). Self-medication constitutes the most common treatment. Among headache
sufferers, 91% of TTH and 90% of migraine patients
use non-opioid, over-the-counter analgesics, which are
often taken without any other form of treatment and
without consulting a physician. A community-based
telephone survey demonstrated that 98% of TTH sufferers depend on OTC medications [57].
Fiorinal and Fioricet are known as combination
analgesics that were introduced to the market as
medications for abortive treatment of headache.
Fiorinal was formulated in 1950s and contained
phenacetin as well as aspirin, caffeine, and butalbital.
Later, the phenacetin was withdrawn from the market
in the 1960s and compound Fiorinal thereafter consisted of aspirin 325 mg, caffeine 40 mg and butalbital
50 mg. At the time of reformulation, Fioricet was
introduced to the market, substituting acetaminophen 325 mg for aspirin [8].
Fioricet is a combination analgesic medication,
prescribed as one to two tablets every 4 hours as
needed. Each tablet contains:
acetaminophen USP 325 mg; non-opiate,
non-salicylate analgesic and antipyretic
butalbital USP 50 mg; (5-allyl-5-isobutylbarbituric
acid) short-to-immediate acting barbiturate,
provides anxiolysis and muscle relaxation
caffeine USP 40 mg; (1, 3, 7 trimethylxan
thine) central nervous system stimulant
Fiorinal is a combination analgesic medication,
prescribed as one to two capsules every 4 hours as
needed, total daily dose should not exceed 6 capsules.
Each tablet contains:
aspirin USP 325 mg; analgesic, antipyretic and
anti-inflammatory
butalbital USP 50 mg; (5-allyl-5isobutylbarbituric acid) short- to immediateacting barbiturate, provides anxiolysis and muscle
relaxation
caffeine USP 40 mg; (1,3,7-trimethylxanthine)
central nervous system stimulant
Indications
Fioricet and Fiorinal are indicated for the relief of
the complex of symptoms known as tension headache. Fioricet is also widely employed for relief of
postdural puncture headache (PDPHA), although it
is not approved by the FDA for this indication. The
mechanism of the drug effect is not completely
understood.
Contraindications
Fioricet or Fiorinal are contraindicated in case of
known hypersensitivity to any of their components.
263
NSAIDs Section 4
Fioricet should be prescribed with caution in patients

with known liver or kidney insufficiency. Liver and
renal function laboratory tests should be performed
to ensure safety when using the medication.
Pharmacokinetics and
pharmacodynamics
264
Since Fiorinal and Fioricet are combined medications

the brief overview of each component should be given.
Acetaminophen (Fioricet) is rapidly absorbed
from the gastrointestinal tract and is distributed
throughout most body tissues. The plasma half-life is
from 1.25 to 3 hours, but may be increased in liver
insufficiency or in the case of medication overdose.
Elimination occurs by conjugation in the liver and
excretion of conjugates in urine. Acetaminophen 1000
mg provided improvement similar to that of acetylsalicylic acid 650 mg in 269 TTH patients in a controlled study [9]. In well-controlled trials both aspirin
(500 and 1000 mg) and acetaminophen (1000 mg but
not 500 mg) were superior to placebo in the treatment
of TTH [10].
Aspirin (Fiorinal) systemic availability after oral
intake is highly dependent on the dosage form, the
presence of food, the gastric pH, antacids, the gastric
emptying time, and particle size. During the absorption process and following the absorption, aspirin is
mainly hydrolyzed to salicylic acid and distributed to
all body tissues and fluids, including fetal tissues,
breast milk, and the central nervous system. In plasma,
about 5080% of the salicylic acid and its metabolites
are bound to proteins. The elimination of therapeutic
doses is through the kidneys in the form of salicylic
acid or biotransformation products. Aspirin causes
irreversible inhibition of cyclooxygenase. In addition
to inhibition of pro-inflammatory mediators, acetylsalicylic acid induces endogenous anti-inflammatory
factors. Compared to placebo, aspirin was more effective in reducing headache from severe to mild or in
achieving pain relief 1 h after administration. A range
of aspirin dosages between 650 mg and 1000 mg
proved to be considerably more successful for pain
reduction than placebo [9,11].
Caffeine is rapidly absorbed and distributed in all
body tissues and fluids, including CNS, fetal tissues,
and breast milk. Elimination is by biotransformation
in liver and renal excretion of metabolites. Some
authors believe that caffeine alone might have analgesic properties for specific types of pain in humans and
in human experimental pain models. Caffeine when

used in combination with simple analgesics was
reported to shift the dose-response curve to the left
and enhance analgesic properties of simple analgesics
by about 40% [12]. Six randomized, double-blind,
two-period crossover studies showed the caffeinecontaining analgesics were significantly superior both
to placebo and to 1000 mg acetaminophen [13]. Other
studies showed that caffeine provided no adjuvant
analgesic effect when added to aspirin in patients with
post-operative pain [14].
Butalbital is readily absorbed and distributed in
most tissues in the body. This component can appear
in breast milk and readily cross the placental barrier.
Butalbital is excreted in urine as unchanged drug and
as metabolites. The effect of butalbital alone has not
been studied since butalbital is not available except in
combination products. Barbiturates have anti-anxiety
and muscle-relaxant properties. Barbiturates do not
have analgesic action per se. Another potentially bene
ficial effect of butalbital is to antagonize the unwanted
central stimulant effect of caffeine [8].
Clinical studies of Fiorinal and Fioricet

Information obtained from the Food and Drug
Administrations web resource indicates that Fioricet
lacks evidence supporting the efficacy and safety of its
use. Fiorinals effectiveness in treatment of tension
headache was demonstrated in double-blind, placebocontrolled multicenter studies. Fiorinal was shown to
be more effective clinically as compared to its components prescribed separately.
The literature describing randomized double-blind
studies of effectiveness of Fiorinal and Fioricet is very
limited. In one study Fiorinal PA, aspirin 200 mg and
acetaminophen 200 mg (replacing the phenacetin in
the old formulation) with caffeine 40 mg and butalbital 50 mg were compared to placebo. Among patients,
84% responded to treatment, compared to placebo
response of 27% (P < 0.05) [15,16]. In another study,
Fioricet (acetaminophen 325 mg, caffeine 40 mg, and
butalbital 50mg) was statistically more effective when
compared to placebo [17].
Side effects and precautions

The most frequently reported adverse reactions with
use of Fiorinal and Fioricet were drowsiness, lightheadedness, dizziness, sedation, shortness of breath,
nausea, abdominal pain, and intoxicated feeling.
Chapter 63 Fiorinal and Fioricet
When these drugs were the only ones implicated,

there were nine reports presented to the Food and
Drug Administration on Fiorinal and 16 attributed
to Fioricet. Serious adverse events associated with
Fiorinal were one case of acute overdose and two
cases of hepatic and renal failure related to prolonged
(more than 10 years) use. Serious adverse effects
associated with Fioricet use were one case each of
pancreatitis and multisystem illness, three deaths
due to overdose, three cases of coma (presumably
secondary to overdose), and two cases of other
encephalopathy due to overdose. Drug dependence
was reported twice. In short, serious adverse events
were almost always associated with acute overdose
(e.g. ingestion of 30 pills) or prolonged (e.g. 10 years)
overuse [8].
Caution should be taken when using Fiorinal
(aspirin-containing) in patients with hemorrhagic
diathesis (e.g. hemophilia, hypoprothrombinemia,
von Willebrands disease, thrombocytopenia, thrombasthenia, and other platelet disorders; severe vitamin
K deficiency and severe liver disease) or on anticoagulation therapy. Fiorinal is contraindicated in patients
with peptic ulcer or other gastrointestinal lesions. In
Fioricet (acetaminophen-containing) use the most
serious adverse effect from overdosing is hepatic
necrosis; other effects include renal tubular necrosis
and hypoglycemic coma.
Caffeine is a CNS stimulant, which may account for
such adverse effects as cardiac stimulation, palpitations, irritability, insomnia, delirium, tremor, and
hyperglycemia. Toxic dose for adults is 1 g (25 tablets).
Fioricet and Fiorinal can be habit-forming and
addicting due to the presence of butalbital as a component [7]. Therefore, extended use is not recommended. As tolerance develops, the amount of
medication needed to maintain the same level of
response increases. Withdrawal seizures were
reported in a 2-day-old infant whose mother had
taken butalbital-containing medication during the
last 2 months or pregnancy. Butalbital was found in
the infants plasma. Butalbital may impair mental or
physical abilities required for the performance of
potentially hazardous tasks such as driving a car or
operating machinery. Butalbital as a short-acting
barbiturate may enhance the CNS depressant effect
of narcotic analgesics, alcohol, tranquilizers, and
sedative-hypnotics. Toxicity from barbiturate poisoning may include drowsiness, confusion, and
coma. The toxic dose of butalbital for adults is 1 g (20
tablets). At present, the main argument for removing

butalbital-containing compounds from the market is
not the obvious abuse and overuse that may occur
with any drug. Rather, it is the insidious overuse that
does not cause systemic symptoms, but may cause
the evolution of episodic primary headaches to
chronic headache [18].
Other serious side effects associated with use of
combination analgesics is medication-overuse headache. Medication-overuse headache is an inherent risk
of abortive treatment of headache in general and TTH
is no exception. Medication-overuse headache implies
a consumption of simple analgesics for 15 days/month
or more, and opioid or combination analgesics for 10
days/month or more, and therefore represents a challenge in chronic TTH patients suffering from daily
headache. Therefore, frequent intake of simple analgesics or NSAIDs should be avoided and patients should
be thoroughly informed about this [19, 20].
Summary
Fioricet and Fiorinal are old polypharmaceutical preparations used for abortive treatment of chronic headache
and PDPHA unresponsive to over the counter analgesics containing aspirin, acetaminophen, or NSAIDs.
What was the reason for use of combination analgesics
instead of making a separate prescription for each of
three components? The advantages of combination
analgesics are cost, convenience, and compliance.
Clearly, a single pill containing the three components is
less expensive than purchasing each component separately [8]. These factors may outweigh the benefits of the
cumbersome tailoring of the doses of three drugs to the
patients needs. Although Fioricet may provide greater
gastrointestinal safety than Fiorinol, the lack of an antiinflammatory component may limit its effectiveness in
controlling the dural irritative aspects of PDPHA. When
clinically indicated, it may be prudent to combine Fioricet and an NSAID (ibuprofen, celecoxib, naproxen) for
additive relief of inflammatory pain.
Combination analgesics represent important alternatives for those patients who cannot or should not
take vasoconstricting medications or opioids. The
acetaminophen compound of Fioricet is also a major
alternative to those patients who cannot use NSAIDs.
Nevertheless, Fioricet and Fiorinal contain the shortacting barbiturate butalbital and may be habit-forming and addictive. Serious adverse effects may be
associated with acute overdose or prolonged overuse.
265
NSAIDs Section 4
References
1. Ostergaard S, Russel MB. Comparison of first degree

relatives and spouses of people with chronic tension
headache. Br Med J 1997:314:10921093.
2. Sher AI, et al. Prevalence of frequent headache in a
population sample. Headache 1998:38:497506.
3. Lenaerts M. Pharmacotherapy of tension-type
headache (TTH). Expert Opin Pharmacother
2009:10(8):12611271.
4. Russel MB, et al. Inheritance of chronic tension-type
headache investigated by complex segregation
analysis. Hum Genet 1998:102:138140.
5. Edmeads J, et al. Impact of migraine and tension-type
headache on life-style, consulting behavior, and
medication use: a Canadian population survey. Can J
Neurol Sci 1993;20:131137.
6. Pfaffenrath V, Scherzer S. Analgesics and NSAID in
the treatment of the acute migraine attack. Cephalgia
1995;15(Suppl 5):1420.
7. Ashina M. Pathophysiology of tension-type headache:
potential drug targets. CNS and Neurol Disord Drug
Targets 2007:6:238239.
8. Solomon S. Butalbital-containing agents: should they be
banned? No. Curr Pain Headache Rep 2002;6:147150.
9. Farinelli I, Martelletti P. Aspirin and tension-type
headache. J Headache Pain 2007:8:4955.
10. Lipton RB, et al. Aspirin is efficacious for the treatment
of acute migraine. Headache 2005;45:283292.
11. Steiner TJ, et al. Aspirin in episodic tension-type
headache: placebo-controlled dose-ranging comparison
with paracetamol. Cephalgia 2003;23:5966.
266
12. Migliardi JR, et al. Caffeine as an analgesic adjuvant in

tension headache. Clin Pharmacol Ther
1994;56(5):576586.
13. Laska EM, et al. Caffeine as an analgesic adjuvant.
JAMA 1984;251:17111718.
14. Bigal ME, et al. Advances in the pharmacologic
treatment of tension-type headache. Curr Pain
Headache Rep 2008;12:442446.
15. Friedman AP, DiSerio FJ. Symptomatic treatment
of chronically recurring tension headache: a
placebo-controlled multicenter investigation of
Fioricet and acetaminophen with codeine. Clin Ther
1987:10:6981.
16. Thorpe P. Controlled and uncontrolled studies on
Fiorinal PA for symptomatic relief in tension
headache. Med J Aust 1970:2:180181.
17. Diener HC, et al. The fixed combination of
acetylsalicylic acid, paracetamol and caffeine is
more effective than single substances and dual
combination for the treatment of headache: a
multicentre, randomized, double-blind, single-dose,
placebo-controlled parallel group study. Cephalgia
2005;25:776787.
18. Bigal ME, et al. Acute migraine medication and
evolution from episodic to chronic migraine: a
longitudinal population-based study. Headache
2008;48:11571168.
19. Lenaerts ME, Couch JR. Medication overuse
headache. Minerva Medica 2007:98:221231.
20. Mathew NT, et al. Transformation of episodic
migraine into daily headache: analysis of factors.
Headache 1982;22: 6668.
Section 5
Chapter
64
Local Anesthetics
Overview of local anesthetics

Lars E. Helgeson and Raymond S. Sinatra
Introduction
Local anesthetics (LA) represent a class of analgesic
compounds that block trans-membrane sodium channels and reduce conduction safely in peripheral, spinal,
and cortical axons [13]. Local anesthetics were first
employed in South American cultures, where coco leaf
poultices were found to provide effective topical analgesia when applied to wounds [1]. The active ingredient in coco leaf was later isolated by Albert Niemann in
1860 and named cocaine. Niemann noted that when
tasted, small amounts of purified cocaine produced
localized numbing of his tongue. In 1884 Carl Koller
began using cocaine topically for ophthalmological
surgery [1,2]. Since that time, a number of local anesthetics have been developed, utilized and abandoned.
Ester-based LAs, including procaine, were first to be
commercially developed and utilized in clinical practice. Amide LAs were developed later in the 1950s, the
first being lidocaine.
Chemical structure
Local anesthetics all contain a lipophilic aromatic
ring, a hydrophilic tertiary amine and an ester or amide
linkage.The general chemical structures of amide and
ester anesthetics are illustrated in Figure 64.1.
Local anesthetics are broadly classified either as
amide or ester based on the nature of the linkage
between the lipophilic aromatic ring and the
hydrophilic amine. A simple way to distinguish an
amide from an ester is the presence of an i in the
name of the generic drug (excluding the -caine). For
example, lidocaine is an amide, whereas tetracaine is
an ester.
There are multiple agents which, when administered appropriately, have safe and effective anesthetic
and analgesic effects. Local anesthetics are pharmacologically distinguished by differences in the aromatic
ring and/or tertiary amine. Chemical groups attached
to the aromatic ring influence speed of onset, while
groups attached to the tertiary amine influence lipid/

aqueous solubility and anesthetic potency.
Mode of action
In contrast to most drugs used in anesthesia and pain
medicine, local anesthetics are only effective when
deposited on or in the vicinity of the nerve fibers to be
blocked. Local anesthetics act by reversibly interfering
with both the initiation and propagation of neuronal
action potentials (nerve impulses). They do this by
decreasing or eliminating Na+ influx in the voltagegated sodium channels at the nodes of Ranvier [24].
The result is an inability to raise axonal membrane
potential to threshold and conduction blockade. Some
local anesthetics (benzocaine, and biotoxins such as
tetrodotoxin) physically block the Na+ channel. Most
others diffuse through the axonal plasma membrane
and bind to an internal receptor site located on the
internal portion of the ion channel [25] (Figure 64.2)
Local anesthetic binding results in configurational
alterations in the ion channel that limit or prevent
futher Na+ conductance. Some local anesthetics (bupivacaine, ropivacaine) can also block the sodium channel directly by a process termed frequency-dependent
blockade. These spindle-shaped amides can fit directly
through the ion channel during axonal depolarization. Once they pass the channel they can directly
bind to the receptor site and prevent further Na+ conductance. This process of selective neural blockade is
highly efficient and effectively turns off those fibers
that are firing most frequently. The ability to selectively block nerve fibers in proportion to their firing
frequency underscores the clinical phenomenon
termed differential blockade, whereby specific noxious fibers may be blocked to a greater extent than
other sensory or motor fibers [25]. For example, low
concentrations of bupivicaine and levo-bupivicaine
block conduction in C fibers with greater selectivity
than procaine and tetracaine, which are less effective
267
Local Anesthetics Section 5
O
O
(2) upper extremity block, where surgical pain is

differentially blocked and perfusion is improved,
while motor function is maintained;
(3) treatment of complex regional pain syndrome
(CRPS), where autonomic fibers are preferentially
blocked over motor fibers.
R1
N
R2
Ester
Other neuroanatomical factors responsible for differential block are discussed in the sections that follow.
R1
O
NH
Amide
Aromatic Ring
Linkage
Physiochemical correlates of local

anesthetic activity
R2
Tertiary Amine
Figure 64.1. Chemical components of ester- and amide-based

local anesthetics.
at low concentrations and block all fiber types equally

at high concentration. Differential block offers advantages in multiple settings, including the following:
(1) labor analgesia, where selective blockade of
noxious fibers and sparing of sensory motor
fibers may offer advantages;
A number of LA physiochemical properties have been

classically advocated to explain the pharmacokinetics
of this drug class. In recent years a number of investigators have challenged these ideas [2,4,5] as being
overly simplistic or incomplete explanations. Nevertheless, some degree of correlation between pKa, lipid
solubility, and protein binding and onset/duration of
LA effect have been described [3,4]. The pKa of a particular local anesthetic dictates its functionality and
onset of activity. If the pKa is approximately physiological pH [7,4] the portion of drug in its uncharged
CH
3
NH-CHOCH2
Axonal Membrane
Lipid Bilayer
CH3
Na+ Channel
Frequency
Dependent
Blockade
268
Local Anesthesics Reversibly

Block Na+ Flux and Decrease
Axonal Conduction
Figure 64.2. Local anesthetics can block sodium conductance and reduce conduction safety by two mechanisms. Most local anesthetics
bind to a receptor located on the inner portion of the sodium channel and initiate a conformational change that closes the ion channel.
Local anesthetics reach this site by diffusing across the axonal membrane. Highly charged local anesthetics have difficulty crossing this
barrier although the charged moiety is able to bind the receptor more efficiently. Local anesthetics having a pKa close to physiological pH
have 50% of drug ionized and 50% un-ionized. This optimal ratio allows enough uncharged molecules to pass through the membrane yet
provides enough charged molecules to bind at the sodium channel receptor site. Some local anesthetics such as bupivacaine and
ropivacaine are spindle-shaped and can penetrate the ion channel directly, but only when it opens during an action potential. These agents
can rapidly reach and more efficiently bind to the receptor as they do not have to diffuse through the axonal membrane. This mechanism
which allows actively firing nerve fibers to become selectively blocked in the presence of relatively low concentrations of LA is termed
frequency-dependent neural blockade.
Chapter 64 Overview of local anesthetics
form is nearly equivalent to the charged form. The

drug is therefore less ionized and can more rapidly
pass through the internodes or axonal membranes to
reach its internal site of action [3,4]. This explains why
the onset time of lidocaine (pKa = 7.6) is more rapid
than bupivacaine (pKa = 8.5). Lidocaines time to
onset can be further reduced by the addition of bicarbonate. The low pKa of chloroprocaine also implies a
slow onset; however, the higher concentration (3%) of
drug solution can overcome this drawback, resulting
in rapid onset of effect [2,4]. Localized infection
decreases the tissue pH, which increases the number
of charged molecules and often results in decreased
neural penetration. This may explain why LAs are less
effective in infected and ischemic tissue.
Local anesthetic potency correlates with increasing
lipid solubility, which is influenced by the polar groups
attached to the tertiary amine. Like other anesthetics
and analgesics, the more lipid-soluble the LA, the more
potent it is. In other words, less drug is needed to
achieve the desired anesthetic blockade. Highly lipid
soluble LAs include tetracaine and bupivacaine [24].
Duration of activity has been related to the degree
of protein binding of the local anesthetic, the concentration of the local anesthetic, and the addition of
epinephrine to LAs that are intrinsic vasodilators (lidocaine, tetracaine). Drugs with high protein binding
attach to intra-membrane proteins in axons, Schwann
cells, and endoneurium and epineurium, to the extent
that a reservoir of LA molecules remains sequestered at
the site of deposition and is less likely to be removed by
blood circulation in the vasa nervorum. This reservoir
is able to maintain prolonged neural blockade by replacing LA that dissociates from the receptor site [3].
Neuro-anatomical correlates of
noxious blockade
Certain aspects of neural anatomy and ultrastructure
favor LA blockade of noxious impulses [25]. To
reduce conduction safely in sensory and motor fibers,
at least three myelin inter-nodes must be blocked. This
rule of three favors blockade of thin unmyelinated
fibers and also A-delta fibers which have small internodal distances. Larger A-alpha and A-beta fibers are
more resistant to blockade because of their size and
large distance between nodes of Ranvier (Figure 64.3).
Unmyelinated C fibers are easiest to block since LAs
can impede Na+ conductance and action potential
propagation at any single site along the course of the
nerve fiber.
Spread of Local
Anesthetic Solution
C-Fiber
A-Delta Fiber
A-Alpha Fiber
Figure 64.3. The rule of three suggests that a minimum of three

internodes must be blocked by local anesthetic to reduce
salutatory conduction safety to the point that an action potential
will no longer be propagated along the nerve fibers. Because of the
large internodal distance of thick myelinated A-alpha and A-beta
fibers, a relatively large amount of surface must be bathed in local
anesthetic solution in order to ensure conduction blockade.
Smaller A-delta fibers have relatively small internodal distances, and
three or more nodes can be more easily blocked (X). Unmyelinated
C fibers do not employ salutatory conduction and are particularly
vulnerable to local anesthetic blockade. Propagation of action
potentials can be prevented by local anesthetic blockade at any
point along the course of the nerve fiber.
Additional factors which have significant impact on

LA activity include the thickness of the peripheral or
spinal nerve and its epineural and perineural coverings,
as well as its microscopic anatomy. Increasing the concentration of a drug will speed its onset and intensity of
blockade but may also increase its systemic toxicity. An
exception is chloroprocaine, which has a very rapid
onset due to its delivery concentration of up to 3%, and
its ability to penetrate thick fibrous connective tissues
making up the perineurium and epineurium. Epidural
administration of 2,4-chloroprocaine is effective in
eliminating a commonly observed L5S1 root anesthetic window, as it can rapidly penetrate into this very
thick mixed nerve and establish anesthetic conditions.
The microscopic anatomy of peripheral mixed
nerves also has an influence on the fiber types that are
blocked. It takes time for LA to diffuse through the
nerve and a concentration gradient develops, whereby
higher levels of drug occur at the peripheral site of deposition, and progressively lower levels accumulate in
the central core. In general, unmyelinated fibers and
A-delta fibers are segregated to the outermost regions
of the nerve (mantle) and are first to be blocked and last
to recover. Motor and larger sensory fibers are located
primarily in the core and tend to be more slowly and
less effectively blocked, and are first to recover [24]
(Figure 64.4). This finding as well as the above-described
269
Mixed Sensory Motor Nerve

Mantle
Core
C-Fibers (unmyelinated)
A-Delta Noxious Fibers
A-Beta Sensory Fibers
A-Alpha Motor Fibers
Figure 64.4. Anatomical correlates of local anesthetic blockade.
In mixed sensory nerves, noxious C fibers and A-delta fibers are
generally localized to the outer regions of the nerve (Mantle), while
greater numbers of larger motor and sensory fibers are localized in
the center of the nerve (Core). Because of a concentration gradient
from the site of local anesthetic deposition to the center of the
nerve, the mantle fibers are first to be blocked and last to recover.
As local anesthetic diffuses further into the nerve, core fibers are
blocked; however, they are first to recover. This orientation of fibers
favors selective conduction blockade in noxious fibers and analgesic
effects that outlast the duration of sensory/motor anesthesia.
rule of three help to explain the rapidity and increased

intensity of blockade, and prolonged duration of LA
effect on smaller-caliber noxious fibers, compared to
sensory and motor fibers [2,4,5]. The usual sequence
for differential blockade of various fiber types with low
to increasing concentrations of local anesthetic is autonomic > noxious > cold > warm > light touch > deep
touch > proprioception > motor fibers. In summary,
LA blockade of proprioceptive and motor function
occurs more slowly and often incompletely due to the
greater degree of myelination, large intranodal distances, and core location of these fiber types.
Metabolism
270
Inactivation of LA clinical effect occurs by diffusion

away from the neuronal Na+ channels and by uptake
into the vas nervorum and into the systemic circulation. It is here that metabolic inactivation of the
linkage between the aromatic ring and tertiary amine
can occur. The mechanism and site are very different
for the amide and ester local anesthetics.
Ester linkages are metabolized primarily by
pseudocholinesterase, plasma cholinesterase and red
blood cell esterase (minor). Hydrolysis occurs at the

ester linkage, resulting in an alcohol and para-aminobenzoic acid (PABA) (or its derivatives). The formation of PABA is a major drawback of ester-linked LAs
as it is responsible for mild to severe allergic reactions.
Amide linkages are metabolized in the liver by
one of three pathways: aromatic hydroxylation,
N-dealkylation, and amide hydrolysis.
Conditions which delay diffusion from the nerve
fiber into the vasculature will prolong the duration of
action of these drugs. The most common method to
prolong LA duration is by the addition of a vasoconstrictor (epinephrine, clonidine) [68]. The micro
vasculature constricts resulting in a decreased blood
flow and slowed drug uptake by the blood. Decreased
uptake can also occur with hypothermia, hypotension
and hypovolemia [35].
Site of injection is an important determinant in
uptake and is dependent on tissue vascularity. The
more vascular tissues have a faster drug uptake than
less vascular tissue. Sites of injection with faster to
slower uptake are noted as follows: intercostal > caudal > epidural > brachial plexus > femoral/sciatic >
intrathecal.
Indications
Local anesthetics are used to locally anesthetize a wide
range of specific body parts or areas to allow painless
surgery. Local anesthetics are most commonly used
for dental procedures and repair of lacerations. They
can also be used to provide neural blockade for larger,
more painful procedures. Sites of LA application
include localized injection, peripheral nerve blocks as
well as central nerve blockade. The only safe agents
which can be utilized for intravenous regional anesthesia (Bier block) are lidocaine and prilocaine. Other
typical indications are outlined in Table 64.1.
Contraindications
An allergic reaction to specific agents is an obvious
contraindication. Allergy to para-aminobenzoic acid
(PABA) is a contraindication to use of ester local anesthetics due to the fact that PABA is a metabolic product of ester metabolism. Methylparaben is a common
preservative chemically similar to PABA and likewise
can cause an allergic reaction. Metabisulfite is a commonly used preservative that may also cause allergic
reactions but more notably is neurotoxic when used
intrathecally. Local anesthetics containing any preservative should not be used intrathecally. Ester local
Table 64.1. Local anesthetic applications
Topical
Infiltration
Table 64.2. Temporal sequence of lidocaine toxicity
Drugs
Numb tongue
Ophthalmic
Tetracaine
Lightheadedness
Nasal
Cetacaine
Visual/auditory (ringing sound)
Skin intact and

abrasions
EMLA
Muscle twitching
Oral
Cetacaine
Seizures
Laryngeal
Cetacaine
Coma
Uretheral
Lidocaine
Respiratory arrest
Field block
Lidocaine
Cardiovascular depression
Unconsciousness
Ropivacaine
Bupivacaine
Levobupivacaine
Specific nerve block
(brachial plexus, ankle,
intrabulbar, dental, etc.)
Lidocaine
Bupivacaine
Ropivacaine
Levobupivacaine
Neuraxial
Intravenous regional
Lidocaine
Intrathecal
Bupivacaine
Tetracaine
Epidural
Lidocaine
Bupivacaine
Ropivacaine
Levobupivacaine
Other
Trigger point
Bupivacaine
Chronic regional pain

syndrome
Lidocaine
anesthetics should be avoided in patients with atypical

plasma cholinesterase due to slowed metabolism that
can lead to enhanced local anesthetic toxicity. Total
dosage must be monitored, with attention to avoiding
the toxic dose and continous monitoring of symptoms. The clinical symptomatology of lidocaine toxicity is presented in Table 64.2.
Local anesthetic + opioid additive

analgesic
There is an additive anesthetic effect when combining
local anesthetics with opioid analgesics. There are
well-documented spinal opioid receptors in the dorsal
horn, and up-regulation of opioid receptors has been
described in chronically inflamed peripheral nerves.
The addition of morphine and fentanyl to intrathecal

and epidurally administered local anesthetics
decreases local anesthetic dose requirements while
reducing surgical and post-operative pain intensity.
One exception is chloroprocaine, which may antagonize epidural opioid analgesic effects.
Dosages
Correct dosing of LAs is primarily dependent on the
particular agent, total amount of drug administered
(mg/kg), and nerve or area to be injected. Descriptions
of specific nerve blocks and appropriate LA dosages
are described elsewhere. The onset duration and toxic
doses of specific LAs are presented in Table 64.3.
Advantages
These agents reliably un-bind from their sites of action
leaving no lasting effects. They are well tolerated
and considered to be very safe when administered
properly.
They are generally predictable regarding their
individual onset times and durations of action.
Varying the concentration and volume coupled with
the addition of vasoconstrictors allows the duration
and degree of blockade to be customized to whatever specific surgical or patient requirements
present.
In the immediate post-operative period, patients
can experience little to no pain, allowing for significant
narcotic sparing, thereby minimizing narcotic-associated adverse effects.
Conduction blockade prior to incision can lessen
the imprinting in the spinal cord of the nociceptive
pathways thereby lessening the level of pain experienced over the next several days. The exact nature of
this wind-up is being investigated.
271
Table 64.3. Onset of action (infiltration)
Ester
Amide
Onset
(minutes)
Duration
(hours)
Prolongation
with epinephrine
Toxic dose with single

administration
Procaine
35
++
1012 mg/kg
Chloroprocaine
10
++
1012 mg/kg
Tetracaine
<15
23+
++
2 mg total
Benzocaine (topical)
<2
++
200 mg total
Lidocaine
<2
++
45 mg/kg (7 with epinephrine)
Bupivacaine
24
+/
1.7 mg/kg (2 with epinephrine)
Mepivacaine
<5
++
Prilocaine
<2
Ropivacaine
13
Pre-incision conduction blockade may also decrease

the incidence of developing a surgical site chronic
pain syndrome.
These agents are available at low cost and can
present significant cost savings, especially when considering the pharmacological costs of general
anesthesia, shorter PACU times and less management time needed to address pain post-operatively.
Additionally, some patients are able to be discharged
sooner with fewer (immobility) complications such
as deep venous thrombosis, ileus, and pulmonary
atalectisis.
LAs may be combined neuraxially with opioids to
gain additive analgesic benefits.
Esters are less cardiotoxic and neurotoxic than
amides due to their rapid metabolism by plasma
cholinesterase.
Amides offer several clinical advantages over
esters, particularly fewer allergic reactions and easier
titratability.
Disadvantages
272
These agents must be delivered directly to the desired

nerve bundle. The delivery is often a problem due to
technical issues accessing these anatomical sites, particularly cervical, brachial plexus, lumbar plexus,
sciatic, and popliteal blocks. This is commonly the
reason for inadequate neural blockade. There may be
other issues precluding needle or catheter placement,
such as patient cooperation, infection, or coagulation concerns.
All of these agents have some degree of neurotoxicity, which is dose and exposure duration dependent;
particularly the amide agents.
45 mg/kg (7 with epinephrine)

810 mg/kg
+/-
3 mg/kg
Systemic dosage toxicity is related to several factors

(Table 64.4). In addition to dosage and rapid vascular
uptake, toxicity may also be metabolism-dependent.
Rapidly metabolized agents such as chloroprocaine are
less toxic. Agents (especially in a large dose) placed in
highly vascular tissues are more rapidly absorbed by
the blood which can quickly reach toxic levels, compared to less vascular tissues [8].
Adverse events
Situations which affect the level or efficacy of pseudocholinesterase can significantly alter the duration of
action and toxicity of ester local anesthetics. This is
more likely in premature infants, individuals with
atypical pseudocholinesterase production or advanced
liver disease.
Allergic reactions are very rare, but occur more
commonly with the ester local anesthetics. Ester
local anesthetics should be avoided in known
PABA-allergic patients. Other allergic reactions
may be due to the preservative methylparaben,
which is chemically similar to PABA.
Table 64.4. Factors affecting systemic toxicity of local
anesthetics
Site of injection
High perfusion tissues results in faster

blood uptake
Dosage
Larger dosage results in faster uptake
Vasoconstrictors
Decreases blood flow with decreased

uptake
Metabolism
Minimal, except in liver failure

(amides)
Toxicity is a concern with either unintentional IV

administration or rapid vascular uptake from tissue
[8]. Central nervous system symptoms are the most
common type of toxic reaction to local anesthetics.
Initial symptoms are excitatory (dizziness, visual,
and auditory) followed by CNS depression such as
unconsciousness, seizures, and coma. Some agents
are reasonably benign such as lidocaine, prilocaine
or chloroproacaine, but others such as bupivicaine or
tetracaine can result in seizures or fatal ventricular
arrhythmias. Depending on the agent, dosage and
injection location, treatment of toxicity may not
be necessary. For example, symptoms may rapidly
resolve without required treatment, such as lidocaine-associated dizziness or numb lips. Other agents
may only require supportive care such as oxygen.
Required supportive care may be airway and ventilatory support, seizure treatment, blood pressure support, and arrhythmia control. In cases of systemic
toxicity due to bupivicaine, IV administration of a fat
emulsion is effective [9]. Refer to Table 64.5.
Prilocaine can result in methemoglobinemia,
when the total dose exceeds 600 mg.
Lidocaine and mepivicaine when given intrathecally have been associated with transient neurological
syndrome, causing intrathecal nerve injury resulting
in prolonged pain radiating to one or both legs.
Although usually of short duration, it can last up to
several months.
Chloroprocaine when administered intrathecally
may result in prolonged sensory or motor deficits.
This is most probably due to the bisulfate preservative
and/or its very low pH.
Cauda equine syndrome is associated with intrathecal micro-catheters delivering a high concentration
of lidocaine (and perhaps the preservatives). It consists of prolonged neural injury with motor weakness,
significant pain and other sensory changes. These
catheters are no longer in use.
Clinical presentation of systemic toxicity is variable, depending on the specific agent. Several agents
are so rapidly metabolized that toxicity symptoms are
very rarely seen, as with procaine and chloroprocaine.
Different drugs present toxic symptoms in different
sequence. For example, lidocaine first presents with
dizziness or a numb tongue whereas bupivicaine is
generally associated with dose-dependent depression
of myocardial contractility and conduction and may
result in fatal ventricular dysrhythmias.
.
Table 64.5. Treatment of bupivacaine cardiac toxicity

Fat emulsion 20% (Intralipid)
Bolus 1.5 mL/kg over 1 minute may repeat 1
Infusion 0.25 mL/kg per min until stable
Maximum total 8 mL/kg
References
1. Calatayud J, Gonzalez A. History of the development

and evolution of local anesthesia since the coca leaf.
2. Butterworth J. Local anesthetics in regional anesthesia
and acute pain management. In Sinatra RS, de
Leon-Casasola OA, Ginsberg B, Viscusi ER, eds. Acute
Pain Management. London: Cambridge University
Press, 2008.
3. Arthur GR. Pharmacokinetics. In Strichartz GR, ed.,
Local Anesthetics. Handbook of Experimental
Pharmacology, vol. 81. Berlin: Springer, 1987, pp.
165186.
4. Strichartz GR, Sanchez V, Arthur GR, et al.
Fundamental properties of local anesthetics. II.
Measured octanol:buffer partition coefficients and
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1990;71:158170.
5. Butterworth J, Ririe DG, Thompson RB, et al.
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6. Chambers WA, Littlewood DG. Anesthesia with
hyperbaric bupivacaine: effect of added
vasoconstrictors. Anesth Analg 1982;61:49.
7. Ilfeld BM, Morey TE, Thannikary LJ, et al.
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ropivacaine perineural infusion to improve
postoperative analgesia: a randomized, double-blind,
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9. Rosenblatt MA, Abel M, Fischer GW, et al. Successful
use of a 20% lipid emulsion to resuscitate a patient
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273
Section 5
Chapter
65
Local Anesthetics
Bupivacaine
Thomas Halaszynski
Major and minor sites of action: nerve cells, sodium

channels, pain nerve fibers.
Receptor interactions: bupivacaine binds to the
intracellular portions of sodium channels and blocks
sodium influx into nerve cells which therefore prevents nerve cell depolarization. Since pain-transmitting nerve fibers tend to be thinner (small diameter)
and either unmyelinated or only lightly myelinated
(myelin is non-polar and lipophilic), the local anesthetic agent can diffuse more readily into them than
into thicker and more heavily myelinated nerve fibers
such as touch and proprioception.
Metabolic pathways/drug clearance and elimination: bupivacaine is bound to plasma proteins in varying degree. It undergoes hepatic metabolism (via
conjugation with glucuronic acid) and renal excretion
(410% unchanged).
For example: bupivacaine often is administered by

epidural injection before total hip arthroplasty. It also
is commonly injected into surgical wound sites to
reduce pain for up to 20 hours after the surgery. Bupivacaine is often co-administered with adrenaline to
prolong the duration of its action. It may be combined
with opioids for epidural and subarachnoid analgesia.
Bupivacaine may also be combined with glucose (dextrose), resulting in a hyperbaric (increases density of
the local anesthetic solution above that of cerebrospinal fluid) solution; sterile water resulting in a hypobaric (decreases density of the local anesthetic solution
above that of cerebrospinal fluid, floats) solution;
and mixed with cerebrospinal fluid prior to injection
to create an isobaric (commercially available solutions
are commonly formulated with sodium chloride)
solution for spinal anesthesia. An understanding of
the baricity of the combined local anesthetic solution
will permit an ability to direct the solution in the subarachnoid space toward the appropriate spinal nerves
innervating the surgical site. For obstetrical procedures, only the 0.25% and 0.5% concentrations are
indicated for obstetrical anesthesia.
Medical pain: oral surgery procedures as well as
diagnostic and therapeutic procedures where a local
anesthetic is necessary.
Chronic non-malignancy pain: as an anesthetic
and analgesic option when patients present with medical pain or for acute surgical pain needs.
Cancer pain: useful for somatic, visceral, or neuropathic pain.
Contraindication
Generic Name: bupivacaine

Trade/Proprietary Names: Marcain, Marcaine,
Sensorcaine and Vivacaine
Manufacturer: AstraZeneca, London, UK, and
Sdertlje, Sweden
Drug Class: local anesthetic (amino amide)
Chemical Name: 1-butyl-N-(2,6-dimethylphenyl)piperidine-2-carboxam: C18H28N2O
Mode of activity
274
Surgical acute pain: bupivacaine is indicated as a local

anesthetic and used for infiltration, peripheral nerve
block, nerve plexus blockade, epidural, and intrathecal (spinal) anesthesia and analgesia. It can be used as
a single-shot injection or administered through a
catheter for prolonged anesthesia and/or analgesia.
Absolute: bupivacaine is contraindicated for IV

regional anesthesia (IVRA, Bier block) because of the
potential risk of tourniquet failure and systemic
absorption of a toxic volume of the drug. Bupivacaine
is contraindicated in obstetrical paracervical block
anesthesia as its use in this technique has resulted in
Chapter 65 Bupivacaine
CH2(CH2)2CH3
Figure 65.1.
CH3
N
HCI H2O
CONH
CH3
fetal bradycardia and death. Bupivacaine is contraindicated in patients with a known hypersensitivity to it
or to any agent of the amide type or to other components of bupivacaine solutions.
Relative: the dose of bupivacaine varies with the
anesthetic procedure, the area to be anesthetized, the
vascularity of the tissues, the number of neuronal segments to be blocked, the depth of anesthesia and
degree of muscle relaxation required, the duration of
anesthesia desired, individual tolerance, and the physical condition of the patient. Dosages of bupivacaine
should be reduced for young, elderly and/or debilitated patients and patients with cardiac and/or liver
disease. The rapid injection of a large volume of local
anesthetic solution should be avoided.
Common doses
Parenteral and topical routes of administration: maximum single dose for an average 70 kg adult is 175 mg.
Local infiltration 0.250.75%, peripheral nerve block
0.25% and 0.5%, retrobulbar block 0.75% (1530 mg),
and sympathetic block 0.25% (50125 mg).
Neuraxial: dose is determined by vertebral level of
initial block placement and desired dermatome level of
anesthesia/analgesia. Sympathetic block 0.25%, spinal
0.250.75% (615 mg), lumbar and thoracic epidural
(25150 mg) 0.25%, 0.5%, and 0.75% (non-obstetrical),
caudal 0.25% and 0.5% (35150 mg), epidural test dose
(3 mL 0.25%). Use only the single-dose ampoule and
single-dose vials for spinal, caudal, or epidural anesthesia as the multiple-dose vials contain a preservative and,
therefore, should not be used for these procedures.
Ease of use, tolerability, opioid sparing. Bupivacaine
provides clinically useful differential block particularly when dilute infusions are employed. It is associated with frequency-dependent blockade whereby
noxious nerve fibers that conduct action potentials
most frequently are first to be blocked, while largercaliber less active sensory motor fibers are relatively
spared. The rapid injection of a large volume of bupi-
vacaine should be avoided and fractional (incremental) doses should be used.

Reduction in adverse events: the smallest dose and
concentration required to produce the desired result
should be administered.
Drug interactions: intravenous administration of a
benzodiazepine will provide sedation and hypnosis
for patient comfort during anesthetic procedures and
also serve to raise the seizure threshold, thus minimizing the adverse CNS affect of bupivacaine.
As monotherapy: bupivacaine blocks the generation and the conduction of nerve impulses by increasing the threshold for electrical excitation in the nerve,
slowing the propagation of the nerve impulse, and
reducing the rate of elevation of the action potential.
As used for multimodal analgesia: bupivacaine
regional anesthesia/analgesia plays a vital role as the
center of a multimodal pain management protocol.
Toxicity: compared to other local anesthetics, bupivacaine is markedly cardiotoxic.
Drug interactions: bupivacaine solutions containing epinephrine or norepinephrine administered to
patients receiving monoamine oxidase inhibitors or tricyclic antidepressants may produce severe, prolonged
hypertension. Concurrent administration of vasopressor drugs added to bupivacaine/vasoconstrictor solutions and of ergot-type oxytocic drugs may cause severe,
persistent hypertension or cerebrovascular accidents.
Phenothiazines and butyrophenones may reduce
or reverse the pressor effect of epinephrine added to
bupivacaine.
Adverse events: bupivacaine can be neurotoxic
and/or cardiotoxic, although adverse drug reactions
are rare when it is administered correctly. Most adverse
drug events relate to the administration technique used
or direct pharmacological effects of bupivacaine, which
may result in a toxic systemic exposure. Although rare,
allergic reactions can occur with bupivacaine. Systemic
exposure to excessive quantities of bupivacaine mainly
results in central nervous system (CNS) and/or cardiovascular effects. The CNS effects usually occur at lower
blood plasma concentrations and the additional cardiovascular effects present at higher concentrations (it
has been reported that cardiovascular collapse may
also occur with low concentrations). CNS effects may
include CNS excitation (nervousness, tingling around
the mouth, tinnitus, tremor, dizziness, blurred vision,
seizures) followed by depression (drowsiness, loss of
275
consciousness, respiratory depression and apnea). Cardiovascular effects include hypotension, bradycardia,
arrhythmias, and/or cardiac arrest (some of which
may be due to hypoxemia secondary to respiratory
depression). It has been reported that bupivacaine was
determined to be the cause of death when the intended
epidural anesthetic drug (bupivacaine) dose was accidentally administered intravenously.

Common/serious adverse events: CNS effects such as
nervousness, tingling around the mouth, tinnitus,
tremor, dizziness, blurred vision, seizures, drowsiness,
loss of consciousness, respiratory depression, and
apnea. Cardiovascular effects such as hypotension,
bradycardia, and cardiac arrhythmias are also possible.
Less common adverse events: injection site reaction,
allergic reactions, cardiovascular collapse and asystole.
Treatment of adverse events: benzodiazepines
(IV), addition of vasoconstrictors that cause blood
vessel contraction that may reduce vascular absorption, and IV fluid hydration prior to neuraxial blockade should all be considered.
Section 5
Chapter
66
276
Lipid rescue as a treatment of bupivacaine overdose: there is evidence with animal studies [1] that
Intralipid, a commonly available intravenous lipid
emulsion, is effective in treating the severe cardiotoxicity that may result secondary to local anesthetic
overdose. In addition, there are human case reports of
successful use of Intralipid for rescue from cardiotoxic
and cardiovascular collapse from systemic bupivacaine
overdose [2] as well as a widespread campaign to publicize Intralipid as an available drug for emergencies in
all anesthetizing locations where bupivacaine is used.
References
1. Weinberg G, Ripper R, Feinstein DL, Hoffman W.

Lipid emulsion infusion rescues dogs from
bupivacaine-induced cardiac toxicity. Reg Anesth Pain
Med 2003;28:198202.
2. Rosenblatt MA, Abel M, Fischer GW, et al. Successful
use of a 20% lipid emulsion to resuscitate a patient
after a presumed bupivacaine-related cardiac arrest.
Local Anesthetics
Ropivacaine
Neesa Patel
Generic Name: ropivacaine HCl

Brand Names: Naropin, Naropin Polyamp, Naropin SDV
Ropivacaine Strength Descriptions: 0.2%; 0.5%;
0.75%; 1%
Chemical Name: (S)-1-propyl-2,6-dimethylanilino-formoxy1piperidine, monohydrochloride, monohydrate
Description
Ropivacaine is part of the amino amide class of longacting local anesthetics. It is a pure S-()-enantiomer,
and is an optically pure solution. Ropivacaine is very
similar to bupivacaine in its pKa and molecular weight,
but is much less lipophilic. Ropivacaine is primarily
used both as a local anesthetic for surgical anesthesia
and for acute pain management. The onset, duration,
and depth of sensory blockade is similar to that of
bupivacaine; however, the motor blockade is much
less for ropivacaine.
Chapter 66 Ropivacaine
Metabolism
H
N
N
O
Figure 66.1. Molecular structure image obtained from

en/wikipedia.org.
Mechanism of action
Like all local anesthetics, ropivacaine binds directly to
the intracellular voltage-dependent sodium channels.
It blocks primarily open and inactive sodium channels. Thus, this blocks the generation and conduction
of nerve impulses. Lipid solubility appears to be the
primary determinant of intrinsic anesthetic potency
and toxicity. The more lipid-soluble, the greater is the
potency of the local anesthetic. Hence, ropivacaine is
less potent and less toxic than bupivacaine. In addition, the progression of blockade is affected by the
diameter, myelination, and conduction velocity of the
nerve fibers.
Pharmacokinetics
Absorption
Ropivacaine follows linear pharmacokinetics and the
maximum plasma concentration is proportional to
the dose. In general, the systemic concentration is
dependent on multiple factors, including the route of
administration, vascularity of the administered site,
total dose and concentration given, and the patients
medical condition. Ropivacaine is primarily used for
epidural and peripheral nerve blockade. From the epidural space, ropivacaine shows complete and biphasic
absorption, half-life of the two phases being 14 7
minutes and 4.2 .9 h.
Distribution
Ropivacaine is 94% bound to alpha-1 glycoprotein
and is mainly protein-bound. After intravascular
infusion, steady-state volume of distribution is 41 liters. In addition, ropivacaine readily crosses the placenta and unbound concentration equilibrium is
quickly reached. The degree of plasma protein binding in the fetus is less than in the mother. This results
in lower total plasma concentrations in the fetus than
in the mother. The ratios of umbilical vein to maternal
vein total and free concentrations are 0.31 and 0.74,
respectively.
Like all amide local anesthetics, ropivacaine is metabolized extensively in the liver via aromatic hydroxylation mediated by cytochrome P4501A. The metabolite
is 3-hydroxy ropivacaine.
Elimination
Ropivacaine metabolites are excreted by the kidney. If
given intravenously, only 1% is excreted unchanged in
the urine.
Indications
Ropivacaine is indicated for both surgical anesthesia,
and acute pain management.
Epidural administration for surgical anesthesia: 25
clinical studies with 900 patients were done to evaluate the use of epidurally administrated ropivacaine for
surgical anesthesia. Median onset time to T10 sensory
level was 10 minutes and the median duration at the
T10 level was 4 hours. Higher doses produced more
profound blockade and duration of effect.
Epidural for labor and delivery: many studies have
shown that in comparison to bupivacaine, ropivacaine
produced equally adequate pain relief. In addition,
detailed evaluation of the delivered newborns demonstrated no difference in clinical outcome.
Epidural for cesarean section: in general, ropivacaine provides adequate muscle relaxation for surgical anesthesia. Many studies have evaluated
ropivacaine at a concentration of 0.5% in doses up to
150 mg, with median onset time to T6 level of 11 to 26
minutes.
Epidural for post-operative pain control: most
studies have tested ropivacaine 0.2% for post-operative epidural infusion. Infusion rates of 614 mL per
hour of 0.2% ropivacaine provide adequate analgesia
with only slight and non-progressive motor block in
cases of moderate to severe pain. Most studies have
dosed ropivacaine for up to 72 hours.
Peripheral nerve blockade: for surgical anesthesia,
0.5% to 0.75% concentrations are routinely used, with
an onset time depending on technique. The median
duration of anesthesia ranged from 11.4 and 14.4
hours.
Two clinical trials were done to verify the safety of
ropivacaine in the intrathecal space, both with doses of
3 mL. Both studies showed that 3 mL doses did produce an adequate spinal anesthesia blockade with no
277
Table 66.1. Dosing recommendations
Conc.
(mg/mL)
(%)
Volume
(mL)
Dose
(mg)
Onset
(min)
Duration
(hours)
Surgical anesthesia
Lumbar epidural
5.0
(0.5%)
1530
75150
1530
24
Administration
7.5
(0.75%)
1525
113188
1020
35
Surgery
10.0
(1%)
1520
150200
1020
46
Lumbar epidural
5.0
(0.5%)
2030
100150
1525
24
Administration
7.5
(0.75%)
1520
113150
1020
35
Thoracic epidural
5.0
(0.5%)
515
2575
1020
n/a
Administration
7.5
(0.75%)
515
38113
1020
n/a
5.0
(0.5%)
3550
175250
1530
56
Cesarean section
Surgery
Major nerve block
(eg. Brachial plexus block)
7.5
(0.75%)
1040
75300
1025
610
Field block
5.0
(0.5%)
140
5200
115
26
Labor pain management

Lumbar epidural administration
Initial dose
2.0
(0.2%)
1020
2040
1015
.51.5
Continuous infusion
2.0
(0.2%)
614
1228
n/a
n/a
Incremental
2.0
(0.2%)
n/a
n/a
n/a
n/a
n/a
n/a
Injections (top-up)
1015
2030
mL/h
mg/h
1228
Post-operative pain management

Lumbar epidural administration
Continuous
2.0
(0.2%)
614
Ml/h
Mg/h
2.0
(0.2%)
614
1228
mL/h
mg/h
Infusion
Thoracic epidural
Administration
Continuous infusion
Infiltration
2.0
(0.2%)
1100
2200
15
26
eg. Minor nerve block
5.0
(0.5%)
140
5200
15
26
serious adverse event. The drug has not been studied

for use in paracervical block and retrobulbar blockade.
Contraindications and warnings
278
Systemic toxicity may occur due to inadvertent intravascular administration or excessively high doses.
Signs of toxicity are either central nervous system
(CNS) or cardiovascular in origin.
Use of ropivacaine with other local anesthetics
should be monitored closely as the toxic effects are
additive.
CNS toxicity: initial signs are usually excitatory

in nature, as there is a preferential block of inhibitory central pathways. These include shivering,
muscle twitching, and tremors. Patients may report
dizziness, ear disorder and deafness, tinnitus,
speech disorders, circumoral paresthesia, and taste
perversion.
After a certain plasma concentration is reached,
toxicity manifests as CNS depression, with respiratory
depression, hypoventilation, and convulsions.
Cardiovascular toxicity: CV toxicity can also be
excitatory in nature at first due to activation of the
Chapter 67 Lidocaine for neural blockade
sympathetic nervous system, followed by arrhythmias

and profound myocardial depression. Ropivacaine
shows a dose-dependent prolongation of cardiac conduction, with an increase in the PR interval and QRS
duration. These effects are explained by the persisting
block of sodium channels into diastole, predisposing
to re-entrant arrhythmias. In addition, the conductivity of potassium channels is affected, increasing the
QTc interval and enhancing the block of the inactivated state of the sodium channel.
Given bupivacaines high lipid solubility, it
is more toxic and has greater CV affects than ropivacaine.
Clinical recommendations
Dosing and timing
References
Ropivacaine, like all other local anesthetics, should

never be rapidly infused, but given in incremental dosing with adequate monitoring of hemodynamic and
mental status, and functional intravenous access. Dosage varies depending on: anesthetic procedure and area
to be anesthetized, vacularity of surrounding tissues,
number of neuronal segments to be blocked, degree of
muscle relaxation required, individual tolerance, and
physical condition of the patient (Table 66.1).
Section 5
Chapter
67
As compared with bupivacaine, ropivacaine has the

clinical advantage of a stronger differentiation between
sensory and motor blocks. This is particularly useful
when doing peripheral nerve blockade for post-operative pain control when early mobilization is important for recovery. Ropivacaine is 4050% less potent
than bupivacaine because of its lower lipid solubility.
However, the duration of blockade is very similar to
bupivicaine, making it ideal as a long-acting local
anesthetic with a better toxicity profile. This is especially meaningful for long-term infusions.
1. Leone, Stefania et al. Pharmacology, toxicology, and

clinical use of new long acting local anesthetics,
ropivacaine and levobupivacaine. Acta Biomed
2008;79:92105.
2. Avery P, Redon D, Schaenzer G, Rusy B. The influence
of serum potassium on cerebral and cardiac toxicity of
bupivacaine and lidocaine. Anesthesiology
1984;61:134138.
3. Naropin (ropivacaine HCL) injection package insert
and ; APP Pharmaceuticals, Llc.
Local Anesthetics
Lidocaine for neural blockade

Mary Hanna Bekhit
Lidocaines chemical name is 2-(diethylamino)-N-(2,6dimethylphenyl)ethanamide (IUPAC). Its other chem

ical names include: N-diethylaminoacetyl-2,6,xylidine
hydrochloride, 2-(diethylamino)-N-(2,6-dimethylphe
nyl)acetamide, 2-diethylamino-2,6-acetoxylidide, and
omega-diethylamino-2,6-dimethylacetanilide.Lido-
caine is also known as lignocaine (former British

Approved Name).
Its proprietary names include Akten, Xylocaine,
Xylotox, Leostesin, EMLA, Rucaina, Isicaine, Lidoderm, Cuivasal, Duncaine, Sylestesin, Anestacon,
Gravocain, Lidothesin, Xylocitin, and Xylestesin.
279
Figure 67.1.
CH3
C2H5
NH CO CH2 N
C2H5
CH3
Lidocaine in its generic form is manufactured by many

different pharmaceutical companies worldwide.
Chemical structure/properties (Figure 67.1): lidocaines aromatic group, a benzene ring, confers its
lipophilic properties, and its tertiary amine group
possesses hydrophilic properties. The two groups are
linked by an amide bond. Lidocaine has a molecular
weight of 234 g/mol, melting point of 68C, and a pKa
of 7.9. It is usually prepared as lidocaine hydrochloride, a white, odorless, crystalline powder.
Historical development
Lidocaine is the most widely used and first synthesized
amide local anesthetic. Nils Lofgren, a Swedish chemist
who later became a professor of organic chemistry at
the University of Stockholm, synthesized the chemical
in 1943 and named it xylocaine. His coworker Bengt
Lundqvist first tested the chemical on himself via injection prior to marketing the drug in 1948 [13].
Mode of activity/pharmacodynamics
Lidocaine, like other local anesthetics, binds axonal
membrane voltage-gated fast Na+ channels and thus
prevents Na+ transport across the channels, thus inhibiting cell membrane depolarization. It is by this same
mechanism that lidocaine exerts its effect as a class Ib
antiarrhythmic to inhibit cardiac smooth muscle excitability and as an anti-epileptic drug to inhibit cortical
excitability. Its lipophilic aromatic group allows the
molecule to penetrate the nerve membrane, while its
hydrophilic charged amine group is the portion of the
molecule that actually binds the Na+ channel [13].
Pharmacokinetics
280
Lidocaine undergoes primarily (>90%) hepatic metabolism via CYP3A4 and CYP1A2 enzymes to the pharmacologically active metabolite monoethylglycinexylidide,
the majority of which is hepatically converted to the
inactive metabolite glycinexylidide. Both metabolites
are renally excreted, so adverse side effects from
metabolite accumulation may present in patients with
renal failure, despite normal serum lidocaine levels.
Its elimination half-life ranges from 1 to 1.5 hours in
healthy patients, but can exceed 2 hours in patients

with congestive heart failure or 5 hours in patients
with hepatic dysfunction [1,4].
Lidocaine is 6570% protein-bound in serum.
Albumin accounts for about 30% of the protein binding, while alpha-1-acid glycoprotein (AGP) accounts
for the other 70%. Since AGP synthesis may increase as
an acute-phase reactant during physiological stresses
such as trauma, myocardial infarction, or infection,
the protein-bound fraction of lidocaine can significantly increase in these situations to 8590%. Thus, the
drugs clearance can be dramatically reduced, with
potentially higher serum concentrations in patients
receiving infusions for longer than 24 hours [1,4].
Metabolism
In the same way that a number of disease processes
can impair lidocaines hepatic metabolism by the cytochrome P450 enzymes, surprisingly so can hormone
replacement therapy. Gawronska-Sklarz and colleagues in 2006 studied in a randomized controlled
trial 18 women who received hormone replacement
therapy for 6 months [5]. They followed their pharmacokinetic response 360 minutes after an intravenous
injection of lidocaine 1 mg/kg before initiation of
hormone therapy, at 3 months and at 6 months. They
found that the patients showed accelerated drug
elimination after 3 months of oral (not transdermal)
hormone replacement therapy, which resolved at the
6-month mark. Further studies with larger patient
populations are needed to further elucidate this interaction between hormone replacement therapy and
lidocaines hepatic metabolism.
Onset of action
Lidocaine has a rapid onset of action of 57 minutes,
but can even approach 3 minutes depending on added
adjuvants such as sodium bicarbonate, the volume
and concentration of drug injected, and the site of
peripheral nerve blockade. Alkalinization of the drug
to a pH closer to its pKa to increase the nonionized
fraction, higher concentration such as 2%, larger volume, and the nerve sheath lying within a confined
space (such as the supraclavicular brachial plexus
which passes between the clavicle and first rib) all help
to speed the local anesthetic saturation of Na+ channels and thus onset of action [2,3].
Mixtures of lidocaine with long-acting local anesthetics such as bupivacaine or ropivacaine for periph-
Chapter 67 Lidocaine for neural blockade
eral nerve blockade have long been common in clinical

practice. Lidocaines rapid onset of action has been
noted clinically to decrease the time to attainment of
surgical anesthesia, thus improving efficiency when a
peripheral nerve block functions as the sole anesthetic.
Cuvillon and colleagues in 2009 sought to demonstrate a clear benefit to adding lidocaine to peripheral
nerve blocks, in terms of improving onset of block
without significant adverse effects [6].
In a randomized controlled trial involving 82 patients
undergoing lower extremity surgery, they demonstrated faster onset of sensorimotor blockade as well
as shorter duration of action in patients receiving a
mixture of lidocaine with a long-acting local anesthetic for femoral and sciatic nerve blocks, compared
with patients receiving a long-acting local anesthetic
alone. The patients who received a mixture of local
anesthetics did demonstrate higher lidocaine plasma
concentrations. These patients also had higher morphine PCA cumulative doses during the 48 hours
post-operatively, compared to the patients who
received long-acting local anesthetics only. The mixed
results in Cuvillon et al.s study suggest addition of
lidocaine to local anesthetic mixtures for peripheral
nerve blockade clearly improves time to onset of the
block, but with significant serum lidocaine concentrations, decreased duration of sensory blockade, and
increased post-operative requirement for other analgesics [6].
Duration of action
Its duration of action is 60120 minutes, depending
on the vascularity of the site blocked as well as added
adjuvants such as epinephrine. The drug is 70% protein-bound, with 30% in the free unbound form. It is
this 30% that is rapidly cleared by the systemic circulation for hepatic metabolism. The vasoconstrictive
properties of epinephrine help to decrease this systemic uptake of the drug and thus to prolong its duration of action. Other adjuvants such as the alpha-2
receptor agonists clonidine and dexmedetomidine
have been studied recently and found to prolong the
duration of action of lidocaine. Their mechanism of
action (specific receptor vs. pharmacokinetic/pharmacodynamic interaction with local anesthetics) and
site (central vs. peripheral) of action have not been
fully elucidated [68].
Bernard and Macaire in 1997 demonstrated
improved onset, quality, and duration of sensory
blockade from addition of clonidine to lidocaine for
axillary brachial plexus blockade [7]. In a randomized

controlled trial, they assigned 56 patients undergoing
carpal tunnel surgery to receive an axillary block with
either lidocaine 400 mg or lidocaine 400 mg with varying doses of clonidine (30, 90, or 300 g). They found
that the addition of clonidine dose-dependently
reduced the time to onset of sensory block, prolonged
the duration of post-operative analgesia, and extended
the field of anesthesia. They found that the patients
receiving lidocaine with clonidine 300 g had more
hypotension (MAP < 55 mmHg) and arterial oxyhemoglobin desaturation < 90% than the other three
groups, in some cases preventing discharge from the
recovery room.
Pratap and colleagues in 2007 studied the effects of
clonidine when added to lidocaine during subcutaneous infiltration of the forearm in a randomized controlled trial on 20 healthy volunteers [8]. They used
lidocaine 0.5% on one forearm and lidocaine 0.5%
with clonidine 10 g on each patients contralateral
forearm. They found that clonidine significantly prolonged the duration of sensory blockade to pinprick
(median time at least 6 hours) when compared to the
lidocaine alone (median time 3.5 hours).
Dexamethasone has also been postulated to prolong the duration of action of lidocaine, with mechanism unknown. Movafegh and colleagues in 2006
enrolled 60 patients undergoing hand and forearm
surgery under axillary brachial plexus blockade in a
randomized controlled trial assessing the efficacy of
dexamethasone in prolonging lidocaines duration of
action [9]. Patients received either lidocaine 1.5% (34
mL lidocaine with 2 mL saline) or lidocaine 1.5% with
dexamethasone 8mg (34 mL lidocaine with 2 mL dexamethasone). They found that patients receiving dexamethasone as an adjuvant had significantly longer
duration of sensory (242 minutes) and motor (310
minutes) blockade compared to the patients receiving
lidocaine only (98 and 130 minutes, respectively).
They also demonstrated no difference in onset of
action between the two groups.
Differential blockade
Lidocaines differential blockade has been examined
with peripheral and neuraxial administration [1011].
Peripheral nerve fibers seem to respond differently to
lidocaine than dorsal nerve roots. Epidural lidocaine
seems to block small unmyelinated C fibers (supplying temperature sensation) more effectively than
larger myelinated A fibers (A-beta supplying touch,
281
and A-delta supplying pinprick sensation). Wildsmith

and colleagues [10] postulated that perhaps the myelinated axons of A fibers in the epidural space may not
have a large number of consecutive nodes of Ranvier
exposed and bound by lidocaine (at least three nodes
needed [11]) to effectively block electrical transmission, while the small unmyelinated C fibers have more
exposed axon for effective blockade.
However, these results contradict long-accepted in
vitro studies on mammalian peripheral nerve fiber
axon diameter. These studies suggest that larger myelinated A fibers which conduct with higher velocity
may be more susceptible to peripheral nerve blockade
with local anesthetics than smaller unmyelinated C
fibers which conduct more slowly [12,13]. Jaffe and
Rowe in 1996 [14] actually found no difference in sensitivity to lidocaine based on axon diameter. Many
mechanisms in addition to axon diameter have been
proposed for lidocaines differential neural blockade,
such as differences in Na+ channel block (state-dependent vs. frequency-dependent) between different
nerve fiber types. Further research is needed to elucidate the underlying mechanism as well as the discrepancy between the differential blockade witnessed in
epidural and peripheral nerve blocks.
Indications
Lidocaine is commonly administered for peripheral
neural blockade when rapid onset of surgical anesthesia is desired. It is also routinely administered intrathecally for outpatient gynecological and urological
procedures. It is frequently administered in labor epidurals to provide rapid surgical conditions in emergency cesarean section deliveries, and is the most
commonly used local anesthetic for topicalization of
the airway prior to awake fiberoptic intubation. The
transdermal lidocaine patch has also been approved
by the FDA for treatment of post-herpetic neuralgia,
and has gained popularity with several other off-label
conditions such as chronic low back pain and osteoarthritic knee pain [15]. Lidocaine is classified under
Pregnancy Category B.
Contraindications
282
Patients with hypersensitivity reactions to amide local

anesthetics should not receive lidocaine. Lidocaine
should be used with caution in patients with severe
hepatic dysfunction or congestive heart failure, both
of which may impair hepatic metabolism and lead to
toxic serum levels of the drug.
Common doses/uses
For intravenous regional anesthesia, lidocaine is
administered in 0.5% solution. For peripheral neural
blockade, the 2% solution with or without epinephrine
is most commonly administered to provide fastest
onset of action as well as maximal surgical motor
blockade. More dilute concentrations such as 11.5%
may also be administered, but provide less motor
blockade than the 2% solution.
Lidocaines rapid onset of action makes it an ideal
choice for peripheral neural blockade that will function as the sole surgical anesthetic. Its relatively safe
cardiotoxicity profile also increases its attractiveness
when compared to other local anesthetics such as
bupivacaine or ropivacaine. It is also widely available
commercially in generic form for low cost. A 20-mL
vial of lidocaine 2% with epinephrine 1:200k costs
between $4 and $6 [1,2].
Lidocaines short duration of action makes it a poor
candidate as the local anesthetic for peripheral nerve
blockade for surgical anesthesia when the surgery will
last longer than 2 hours, or for post-operative analgesia when maximal duration of effect is desired after
highly painful surgery. Its potential for neurotoxicity
presenting with seizures also limits the total dose that
may be used in combined nerve blocks. Lidocaine
should be used with caution in patients with significant hepatic impairment or renal disease, due to
potential toxic metabolite accumulation.
Adverse events
Most of the adverse events related to lidocaine are
associated with serum toxicity, with various symptoms
presenting at different serum levels. Symptoms such as
lightheadedness, perioral numbness, tinnitus, nausea,
or metallic taste in the mouth may occur when plasma
lidocaine concentrations are 15 g/mL. Dysarthria,
local muscle twitches, hallucinations, or nystagmus
may present at plasma concentrations from 5 to 8 g/
mL. Seizures may occur at 812 g/mL, followed by
respiratory depression or coma at levels higher than 20
g/mL. Hypotension, bradycardia, cardiac arrest, and
arrhythmias may also occur at serum levels greater
than 20 g/mL. Intralipid remains the only available
treatment for adverse events related to serum toxicity.
Chapter 68 Topical local anesthetics
References
1. Bauer LA. Applied Clinical Pharmacokinetics, 2nd ed.

New York: McGraw Hill Professional Publishing,
2008, pp. 356397.
2. www.Xylocaine@3dchem.com./.
3. Wang JS, Backman JT, Taavitsainen P, Neuvonen PJ,
Kivist KT. Involvement of CYP1A2 and CYP3A4 in
lidocaine N-deethylation and 3-hydroxylation in
humans. Drug Metab Dispos 2000;28(8):959695.
4. Hersh EV. In Fonseca RJ, ed. Oral and Maxillofacial
Surgery: Local Anesthetics. Elsevier Health Sciences,
2000, pp. 5878.
5. Gawronska-Szklarz B, Zarzycki M, Musial HD, Pudlo
A, Loniewski I, Drozdzik M. Lidocaine
pharmacokinetics in postmenopausal women on
hormone therapy. Menopause 2006;13(5):793798.
6. Cuvillon P, Nouvellon E, Ripart J, Boyer JC, Dehour L,
Mahamat A, Lhermite J, Boisson C, Vialles N, Lefrant
JY, de La Coussaye JE. A comparison of the
pharmacodynamics and pharmacokinetics of
bupivacaine, ropivacaine (with epinephrine) and their
equal volume mixtures with lidocaine used for
femoral and sciatic nerve blocks: a double-blind
randomized study. Anesth Analg 2009;108(2):641649.
7. Bernard JM, Macaire P. Dose-range effects of
clonidine added to lidocaine for brachial plexus block.
Section 5
Chapter
68
8. Pratap JN, Shankar RK, Goroszeniuk T. Co-injection

of clonidine prolongs the anesthetic effect of lidocaine
skin infiltration by a peripheral action. Anesth Analg
2007;104:982983.
9. Movafegh A, Razazian M, Hajimaohamadi F,
Meysamie A. Dexamethasone added to lidocaine
prolongs axillary brachial plexus blockade. Anesth
Analg 2006;102(1):263267.
10. Wildsmith JAW, Brown DT, Paul D, Johnson S.
Structure-activity relationships in differential nerve
block at high and low frequency stimulation. Br J
Anaesth 1989;63:444452.
11. Tasaki, I. Nervous Transmission. Springfield: CC
Thomas, 1953.
12. Gissen AJ, Covino BG, Gregus J. Differential
sensitivities of mammalian nerve fibers to local
anesthetic agents. Anesthesiology 1980; 53:467474.
13. Mama KR, Steffey EP. In Adams HR, ed. Veterinary
Pharmacology and Therapeutics: Local Anesthetics, 8th
ed, Blackwell, 2001, pp. 343359.
14. Jaffe RA, Rowe MA. Differential nerve block: direct
measurements on individual myelinated and
unmyelinated dorsal root axons. Anesthesiology
1996;84:14551464.
15. Sakai T, Tomiyasu S, Yamada H, Ono T, Sumikawa K.
Quantitative and selective evaluation of differential
sensory nerve block after transdermal lidocaine.
Anesth Analg 2004;98:248251.
Local Anesthetics
Topical local anesthetics

Steven J. Weisman
Generic Names: topical lidocaine/prilocaine,

topical lidocaine/tetracaine, tetracaine gel, 4%
liposomal lidocaine, 1,1,1,3,3-pentafluoropropane and 1,1,1,2-tetrafluoroethane
Trade/Proprietary Names: EMLA (Eutectic
Mixture of Local Anesthetics), Synera, Ametop
Gel, LMX-4, PainEase (vapocoolant spray)
Manufacturers: (EMLA) Ferndale Laboratories,

Ferndale, MI; (Synera) ZARS Pharma, Salt Lake City,
UT; (LMX-4) APP Pharmaceuticals, LLC, Schaumburg, IL; (Ametop) Smith and Nephew, St-Laurent,
Quebec; (Vapocoolant) Gebauer, Cleveland, OH
Chemical Structure: lidocaine (lignocaine), see
Figure 68.1; prilocaine, see Figure 68.2
283
Figure 68.1.
CH3
C2H5
NH CO CH2 N
C2H5
CH3
C14H22N2O
M.W. 234.3
Figure 68.2.
CH3
NH CO CH NH CH2 CH2 CH3
CH3
C13H20N2O M.W. 220.3
EMLA
Description
EMLA is a eutectic mixture of 2.5% lidocaine and 2.5%
prilocaine, which, when mixed, form a liquid that is formulated into a water-oil emulsion. EMLA is available as
a cream, a gel and an anesthetic disc. Only the cream
and gel are available in the USA. The cream is approved
for use on intact skin for local anesthesia or genital
mucosa for superficial minor surgery and as pretreatment for infiltration anesthesia. The gel is approved for
adults who require localized anesthesia in periodontal
pockets during scaling and/or root planning [1].
Mode of action/pharmacology
The cream is applied to the skin and is usually contained under a transparent dressing for 4560 minutes. Local anesthesia persists for 60 to 120 minutes
after removal of the occlusive dressing [1,2]. The
amount of EMLA that should be applied to the skin is
age- and weight-based as follows: age 03 months or <

5 kg should receive 1 g over 10 cm2 skin for up to 1
hour; age 312 months and > 5 kg should receive 2 g
over 20 cm2 skin for up to 4 hours; age 16 years and >
10 kg should receive 10 g over 100 cm2 skin for up to 4
hours; and age 712 years and > 20 kg should receive
20 g over 200 cm2 skin for up 4 hours (see Table 68.1).
How to use
EMLA has been used in practice for many years. It has
been studied and used for venipuncture, intravenous
cannulation, needle immunizations, subcutaneous
port access, subcutaneous reservoir access, circumcision, chest tube removal, lumbar puncture, bone marrow aspiration, and laser treatment of port-wine
stains. Significant treatment effect has been demonstrated in individual as well as meta-analysis study of
EMLA. Initially, a 30 min application time was recommended. However, 60 minutes will ensure significantly
more anesthesia and even longer duration (90 min)
and produce improved pain relief [1,3].
Inherent in these observations lies the major drawback of EMLA cream. In busy clinical practice, anticipatory application of the cream is challenging. Most
often, when decisions to perform minor needle-based
procedures are made, they are in an acute clinical setting. Therefore, time will often preclude application.
In addition, the cream is available in 5 g (24 applications) and 30 g tubes with a significant cost associated
with use. As noted below, there are some additional
constraints associated with use.
Nonetheless, application before anticipated procedures, such as bone marrow aspiration, lumbar puncture or planned venipuncture/IVcannulation can be
Table 68.1. EMLA cream maximum recommended dose, application area, and application time by age and weight for infants
and children based on application to intact skin
284
Age and body weight

requirements
Maximum total
dose of EMLA cream
Maximum
application area
Maximum
application time
0 up to 3 months or < 5 kg
1g
10 cm2
1 hour
3 up to 12 months and > 5 kg
2g
20 cm2
1 to 6 years and > 10 kg

7 to 12 years and > 20 kg
4 hours
10 g
100 cm
4 hours
20 g
200 cm2
4 hours
Please note: if a patient greater than 3 months old does not meet the minimum weight requirement, the maximum total dose of EMLA
cream should be restricted to that which corresponds to the patients weight.
For more individualized calculation of how much lidocaine and prilocaine may be absorbed, physicians can use the following estimates of
lidocaine and prilocaine absorption for children and adults: the estimated mean (SD) absorption of lidocaine is 0.045 (0.016) mg/cm2 per
h; the estimated mean (SD) absorption of prilocaine is 0.077 (0.036) mg/cm2 per h.
Figure 68.3.
CH3
C2H5
NH CO CH2 N
C2H5
CH3
C14H22N2O
M.W. 234.3
pholipids and cholesterol that enclose an aqueous

compartment. This technology leads to protection of
the active agent (lidocaine) from degradation and to
enhanced absorption with better penetration through
the statum corneum.
This product has been safely employed across the age

continuum, from birth to the elder years, with excellent
efficacy. It is totally non-invasive and easy to apply.
This product is also applied to the skin with an occlusive clear dressing. It is effective without the covering,
but as the cream warms, it will drip off the desired
location. After a 30 min application, analgesia is comparable to that achieved with a 60 min application of
EMLA. The local anesthetic effect lasts for 60 min after
a typical 30 min application. LMX-4 application
should be limited to 100 cm2 in children weighing
10 kg or between 10 kg and 20 kg for each use. There
are limited data in children under 2 years of age, but
adverse reaction in small infants has generally not
been reported.
How to use
Application to open wounds will result in significantly

higher plasma levels of the local anesthetics. Since this
is a product that is most commonly employed in children, extreme care must be taken to avoid accidental
oral ingestion. Prilocaine has been associated, in susceptible individuals, with methemoglobinemia. This
may be more common in the very young and the
product should probably be avoided in infants less
than 37 weeks gestation. Concomitant use of phenytoin or acetaminophen may predispose to methemoglobinemia in those susceptible.
Another well-known limitation of EMLA is that it
causes vasoconstriction with observable skin blanching. This can lead to more difficult visualization of
superficial veins.
Use of LMX4 is identical to that for EMLA. LMX is

recommended for treating pain, itching, soreness, and
discomfort of the skin or mucous membranes due to
certain conditions such as eczema, scratches, minor
burns, insect bites, and hemorrhoids. Thus the guidelines allow for application even to open skin.
Contraindications
readily incorporated into the healthcare workflow. In

the peri-operative environment, the cream can be
applied while the patient is undergoing check-in and
pre-operative preparation. Patients can also apply the
cream at home, if it is dispensed before a planned
intervention.
Known history of methemoglobinemia or in patients

with a known history of sensitivity to amide local anesthetics.
LMX4 (Liposomal Lidocaine 4%)

Chemical structure: see Figure 68.3
Description
This is an over-the-counter product of 4% lidocaine
formulated in biocompatible, non-immunogenic vesicles. The liposomes are multilamellar vesicles of phos-
This, surprisingly, is an over-the-counter pharmaceutical. There is more rapid onset with LMX4 than EMLA.
Clinically efficacy appears to be comparable to EMLA,
as well as buffered lidocaine injections for IV cannulation. Methemoglobinemia is not a problem with lidocaine alone. Blanching, vasoconstriction, and loss of
visibility of veins is not commonly seen with LMX4.
Care to avoid oral ingestion by small children is

needed.
Contraindications
Allergy or sensitivity to lidocaine.
Synera (lidocaine/tetracaine topical

patch)
Chemical structure: lidocaine, see Figure 68.4; tetracaine, see Figure 68.5
285
Figure 68.4.
CH3
C2H5
NH CO CH2 N
C2H5
CH3
C14H22N2O
CH3(CH2)3NH
M.W. 234.3
COOCH2CH2N(CH3)2
Figure 68.5.
Description
Since absorption of local anesthetics through the skin
is enhanced by heat, a topical patch with an intrinsic
heating system was developed [4]. This incorporates a
controlled heat-assisted delivery system that is physically separated from a eutectic mixture of 70 mg of
lidocaine and 70 mg of tetracaine. The surface area of
the entire Synera patch is approximately 50 cm2, 10
cm2 of which is active.
The patch adheres to the skin and when it is exposed
to air, the contained heating element is activated and
through oxidation releases heat. Local skin temperature remains between 39 and 41C during the heating phase of application. Systemic absorption is
minimal and even with sequential or simultaneous
applications of up to four patches, lidocaine plasma
levels were low (912 ng/mL in adults) and tetracaine levels were essentially non-detectable. The
product insert indicates that application of one Synera patch for up to 30 minutes in children 4 months
to 12 years of age produced maximum peak plasma
concentrations of lidocaine and tetracaine of 63 ng/
mL and 65 ng/mL, respectively. Application of two
Synera patches for up to 30 minutes to children 4
months to 12 years of age produced peak lidocaine
levels of up to 331 ng/mL and tetracaine levels of less
than 5 ng/mL.
How to use
286
same procedures as EMLA. Application to open skin

is not recommended. The product is approved for use
by the FDA in children over 3 years of age. In fact,
application to a small child can be challenging due to
the size of the patch.
Application is recommended for 2030 min to the

area that will be punctured. It too can be used for the
Like LMX4, onset of clinically important anesthesia is

much more rapid than EMLA. The local anesthetics
used are not as likely to induce methemoglobinemia.
The use of heat enhances vasodilatation and may facilitate venous identification.
The patch must stick to the skin and bring the local
anesthetics into contact with the skin. In a small limb
in a child, the patch can often not fit very well. Once
the application time has elapsed, the patch must then
be peeled off. Although it might seem minor, some
children become quite upset with removal of the
patch, much like when a Band-aid is removed. In my
opinion, the major deterrent to use of this otherwise
efficacious system remains the cost ($1220/application).
Contraindications
Synera is contraindicated in patients with a known
history of sensitivity to lidocaine, tetracaine, or local
anesthetics of the amide or ester type. Synera is also
contraindicated in patients with para-aminobenzoic
acid (PABA) hypersensitivity.
Amethocaine (tetracaine) gel

(Ametop)
Chemical structure: tetracaine, see Figure 68.6
Description
This is a 4% (w/w) gel formulation of tetracaine
approved for use in Canada, Europe, New Zealand,
Australia and many other parts of the world to be used
for dermal analgesia.
CH3(CH2)3NH
Figure 68.6.
COOCH2CH2N(CH3)2
Description
Approximately 1 gram of the gel will cover 30 cm

when used under an occlusive dressing. The gel actually contains solid tetracaine particles which melt
when applied to the skin and then form an oil emulsion that penetrates the stratum corneum. A 30 (venipuncture) to 45 (IV cannulation) minute application
is recommended. Anesthesia will last 46 hours, as
tetracaine has a considerably longer elimination halflife. It appears to have clinical comparability in providing anesthesia/analgesia when compared to
EMLA.
2
How to use
Approximately 1 gram (packaged in 1.5 g tubes) is
applied to the skin and covered with a clear occlusive
dressing. As with EMLA and LMX4, a variety of cutaneous invasive procedures can be accomplished after
the requisite waiting time. It should only be applied to
intact skin. It also should not be applied to mucous
membranes or the conjunctivae.
Tetracaine gel appears to have an excellent safety profile. Its extended duration of action could lend some
advantage when the time of the procedure is not easily
determined. Tetracaine is also vasodilating and even
associated with some transient erythema at the application site. This then avoids the vasoconstricting
effects of EMLA. The product may be used in infants
as young as 1 month of age.
As with all the other aforementioned topical products,
care to prevent ingestion by children is required. Erythema and skin rash may occur at application site
Contraindications
Use in premature babies or full-term infants less than
1 month of age, in whom the metabolic pathway for
tetracaine may not be fully developed, is not recommended. In addition, it should be avoided if patients
have known hypersensitivity to any of the local anesthetics of the ester type.
Vapocoolant spray (PainEase)
Chemical structure: CF3CH2CHF2 (1,1,1,3,3-pentafluoropropane);

CH2FCF3
(1,1,1,2-tetrafluoroethane)
PainEase is a mixture of two fluorocarbons dispensed

in spray cans. PainEase is a vapocoolant (skin refrigerant) spray for topical application to skin, intact mucous
membranes (oral cavity, nasal passageways and the
lips) and minor open wounds [5]. PainEase controls
pain associated with injections (venipuncture, IV
starts, cosmetic procedures), minor surgical procedures (such as lancing boils, incisions, drainage of
small abscesses and sutures) and the temporary relief
of minor sports injuries (sprains, bruising, cuts and
abrasions). PainEase can also be used for myofascial
release procedures employed in physical therapy or
physiatry to manage myofascial pain.
The product is non-flammable. The spray is directed
to the area that will be manipulated and the vapocoolant properties offer cutaneous analgesia. The analgesic
effect is quite transitory, so the operator must be prepared to proceed with the procedure expeditiously.
How to use
Vapocoolant sprays have been shown to be beneficial
for immunization pain, venipuncture, as well as intravenous cannulation.
There is immediate onset of action. The cost per application and personnel time is minimal.
The main disadvantage is the brief duration of action.
This requires precise orchestration of the brief procedure. The cold spray can be startling and even upsetting to younger children.
Contraindications
PainEase is contraindicated in individuals with a history of hypersensitivity to 1,1,1,3,3-pentafluoropropane and 1,1,1,2-tetrafluoroethane
References
1. Koh JL, Harrison D, Myers R, Dembinski R, Turner H,

McGraw T. A randomized, double-blind comparison
study of EMLA and ELA-Max for topical anesthesia in
children undergoing intravenous insertion. Paediatr
Anaesth 2004;14:977982.
287
2. Taddio A, Stevens B Craig K, Rastogi, P, Ben-David S,

Shennan A, Mulligan P, Koren G. Efficacy and safety
of lidocaine-prilocaine cream for pain during
circumcision. N Engl J Med 1997;336:11971201.
3. Zempsky WT. Pharmacologic approaches for reducing
venous access pain in children. Pediatrics
2008;122:S140153.
4. Sethna NF, Verghese ST, Hannallah RS, Solodiuk JC,
Zurakowski D, Berde CB. A randomized controlled
Section 5
Chapter
69
5. Cohen Reis E, Holubkov R. Vapocoolant spray is

equally effective as EMLA cream in reducing
immunization pain in school-aged children. Pediatrics
1997;100: e5 at www.pediatrics.org/cgi/content/full/100
/6/e5.
Local Anesthetics
Lidocaine transdermal
Maggy G. Riad
Generic Name: lidocaine transdermal patch

Trade Name: Lidoderm Patch 5%
Manufacturer: Endo Pharmaceuticals, Chadds
Ford, PA
Description
Lidoderm is a 10 cm 14 cm patch containing 50 mg
of lidocaine per gram of adhesive material. Each patch
contains a total of 700 mg of lidocaine, the only active
ingredient.
Mode of activity and pharmacology
288
trial to evaluate S-Caine patch for reducing pain

associated with vascular access. Anesthesiology
2005;102:403408.
Lidocaine or lignocaine is an amide-type local anesthetic and anti-arrhythmic agent that was first synthesized and marketed in the 1940s. Lidocaine acts by
blocking the fast voltage-gated Na channels in neurons by decreasing the frequency of their opening. As
a consequence, depolarization and transmission of
action potential in neurons is blocked, thereby
decreasing both the peripheral nociceptor sensitization as well as the central nervous system hyperexcitability. In small doses lidocaine inhibits nerve
discharges at aberrant or ectopic foci generated as a
result of nerve injury, without interfering with normal
neuronal conduction.
Bioavailability after topical administration of lidocaine via the Lidoderm patch is only 3%, which is
about only 10% of its bioavailability after oral ingestion. With 70% of lidocaine being bound to plasma
proteins, the blood lidocaine concentration after
application of Lidoderm patch remains very low (average concentration 128 ng/mL). These low blood lidocaine levels are sufficient to produce topical analgesia
without causing a complete sensory block, thus preserving skin sensation to light touch and pinprick.
This effect represents a key difference between the
Lidoderm patch and other topical lidocaine formulations (Table 69.1).
Lidocaine is primarily metabolized by the cytochrome P450 hepatic enzyme system into active but
less potent metabolites, mainly monoethyl-glycinexylidide (MEGX). Lidocaine has a half-life of 1.52.5
hours and is excreted mainly via the renal system.
Chapter 69 Lidocaine transdermal
Figure 69.1.
CH3
C2H5
NH CO CH2 N
C2H5
CH3
How to use this drug in pain

management
Lidoderm patch was approved by the FDA in 1999 for
the treatment of post-herpetic neuralgia (PHN) based
on its efficacy, tolerability, and safety. PHN is the most
frequent complication of shingles (herpes zoster), the
most common neurological ailment in the USA,
affecting as many as 850 000 people annually. PHN is
the result of sensory nerve damage by the varicella
zoster virus causing development of abnormal sodium
channels and the generation of ectopic or aberrant
nerve discharges. Clinically it manifests as sharp,
shooting or dull aching pain, usually associated with
allodynia along the dermatomal distribution of
affected nerve fibers.
Evidence-based treatment guidelines recommend
Lidoderm patch and Pregabalin as first lines of treatment for neuropathic pain associated with PHN.
Other unapproved uses: other conditions associated with neuropathic pain. Randomized controlled
multi-center European studies evaluated Lidoderm
for the treatment of neuropathic pain associated with
diabetic polyneuropathy. Results show Lidoderm to
be as efficacious as systemic analgesics, with substantially fewer systemic side effects.
A recent randomized double-blind controlled
study examined Lidoderm patch efficacy for relief of
post-surgical pain after unilateral knee arthroplasty
and found it to be beneficial in relieving post-operative pain and consequently improving early joint
mobility. This application of Lidoderm patch is of
particular benefit to elderly patients who cannot
tolerate side effects of systemically administered
analgesics.
There is evidence of the usefulness of low doses
of lidocaine, such as obtained by using the Lidoderm patch, in the termination and early relief of
migraine headache that is preceded by an aura. This
application is based on lidocaines effectiveness in
the suppression of clinical and electrographic manifestations of seizures at low blood concentrations
(below 5 g/mL).
Lidoderm is also reported to work well for relief of
mild to moderate pain resulting from localized conditions such as carpal tunnel syndrome, chronic bursitis, muscle sprains and arthritic joint pain.
Drug is delivered directly to the site of pain, minimal
systemic absorption and risk of toxicity, decreased
incidence of drugdrug interactions, no need to titrate
dosage, ease of use.
It is seldom effective in conditions associated with
moderate to severe pain when used alone. Studies
show no significant difference between Lidoderm and
placebo when used as a sole analgesic in cases of PHN
or other causes of neuropathic pain.
Contraindications
Known sensitivity to amide-type local anesthetics.
Table 69.1. Other lidocaine preparations: indications and dosage
Lidocaine form
Dosage
Common clinical application (including off-label

uses)
Local infiltration
5 mg/kg (7 mg/kg if used with epi)
Preemptive analgesia, post-op pain management
Peripheral nerve block
200450 mg
Surgical anesthesia, post-op pain management
Neuroaxial block
200500 mg
Surgical anesthesia, post-op pain management
Intravenous infusion
14 mg/kg per h
Diagnostic tool, treatment of fibromyalgia, post-op pain,

chronic pain syndromes, neuropathic pain
Subcutaneous infusion
80150 mg/h
Neuropathic pain, localized post-op pain, palliative care
Topical patch
7002100 mg for 12 h
PHN, neuropathic pain, localized pain
Topical gel/ointment
2%, 4%, 5%
Localized minor pains, topicalization prior to procedures
Oral
200300 mg TID
Treatment of fibromyalgia, neuropathic pain
289
Table 69.2. Pharmacokinetics of Lidoderm patch
Lidoderm dose
Site
Duration
Dose absorbed
Blood concentration
2100 mg
Back
12 hours
3296 mg
0.070.19 g/mL
Caution: use only if necessary during pregnancy

(Pregnancy Category B) and lactation. The clinical
effects on humans during pregnancy and nursing
have not been studied. Lidocaine crosses the placenta
and is known to be secreted in milk at a milk/plasma
ratio of 0.4/1. Lidoderm use in the pediatric population has not been studied and is not recommended.
Dosing
Each Lidoderm patch may be used only once for up to
12 hours/day. Lidoderm patches should be applied to
the most painful area, only if the skin is intact. No
more than three patches are to be applied at a time.
Average blood concentration achieved with this dosing is between 0.13 and 0.25 g/mL of lidocaine,
depending on the site of application (Table 69.2).
Lidocaine toxicity coincides with a lidocaine blood
level at or above 5 g/mL.

Lidoderm may cause transient skin irritation, blistering or burning at the application site. Wearing
transdermal drug patches with backings that contain
even a small amount of aluminum or other metals in
the MRI suite may result in severe skin burns at
the application site. Even though the Lidoderm
patch backing consists of a non-woven polyester
felt, devoid of visible metals, it is currently the FDAs
recommendation to temporarily remove all transdermal patches while undergoing MRI examinations or
procedures. The FDA is currently conducting a formal investigation to examine the safety and compatibility of all transdermal patches with the MRI
environment.
Patients with known allergic reactions to methyl
paraben or propylparaben may develop allergic
reactions to the lidoderm patch. Severe hypersensitivity-types of reactions to lidoderm are rare.
Complications related to increased blood

lidocaine concentrations
290
Lidocaine overdose from transdermal absorption only

is rare but possible. Conditions that result in increased
lidocaine absorption and hence increase its blood

concentrations include:
Application of a lidoderm patch for longer than
12 hours/day
Application of more than three patches at a time
Patients with low body mass index
Application to areas where the skin barrier is
violated
Concomitant administration of other medications
containing lidocaine
Concomitant administration of other local
anesthetics
Concomitant administration of drugs that
decrease hepatic blood flow
Decreased metabolism due to severe liver
impairment
Concomitant administration with cytochrome
P450 hepatic enzyme inhibitors, e.g. macrolide
antibiotics, antifungal agents, verapamil,
cimetidine, ciprofloxacin, enoxacin, fluvoxamine,
amiodarone
Patients with decompensated congestive heart
failure
Decreased elimination due to renal failure
Accidental ingestion of discarded patches by
children or pets
Systemic effects of lidocaine overdose include:
CNS: tremors, dizziness, restlessness, agitation,
dysarthria, confusion, hallucinations, tinnitus,
nystagmus, blurred vision, seizures
Respiratory: increased airway tone, airway
narrowing, bronchospasm, respiratory arrest
Cardiovascular: hypotension, sinus bradycardia,
asystole, cardiovascular collapse
Gastrointestinal: nausea, vomiting
Treatment of overdose: life support and symptomatic treatment for acute lidocaine toxicity. Most of
the cases present with mild symptoms that respond to
temporary discontinuation of treatment and decreasing the dosage. Dialysis was found to play no role in
the treatment of lidocaine overdose.
Chapter 69 Lidocaine transdermal
Caution should be exercised with the disposal of

used lidoderm patches, since about 95% of its lidocaine content could still be found in each used patch.
It is therefore imperative to discard used patches after
folding them so that the medication side of the patch
is covered in order to avoid accidental ingestion by
small children or pets.
References
1. Transdermal drug patches with metallic backings

www.fda.gov/safety/medwatch/safetyinformation/
safety.
2. Lidoderm: Endo Pharmaceuticals Inc. 2008.
3. Efficacy and safety of 5% lidocaine medicated plaster
in comparison with pregabalin in patients with
postherpetic neuralgia and diabetic polyneuropathy.
Clin Drug Investig 2009;29:231241.
291
Section 6
Chapter
70
Anticonvulsant-Type Analgesics
Overview of anticonvulsant analgesics

J. Michael Watkins-Pitchford and Veena Salgar
Neuropathic pain caused by injury and sensitization of

the peripheral or central nervous system does not generally respond to traditional pain therapies such as opioids
and nonsteroidal-anti-inflammatory drugs. Neuronal
sensitization and ectopic noxious transmission resemble
to some degree the abnormal, easily triggered neural circuits associated with seizure disorders. Drugs acting to
reduce such ectopic activity, anticonvulsants, or anti-
epileptic drugs (AED), date from 19101970, and include
first-generation agents such as benzodiazepines, barbiturates, phenytoin (Dilantin), ethosuximide (Zarontin), carbamazepine (Tegretol, Carbatrol), and valproic
acid (Depakon, Depakene). Second-generation agents
are represented by felbamate (Felbatol), gabapentin
(Neurontin), lamotrigine (Lamictal), levateracetam
(Keppra), oxcarbazepine (Trileptal), pregabalin (Lyrica),
tiagabine (Gabitril), topiramate (Topamax), vigabatrin
(Sabril), and zonisamide (Zonegran). The adoption of
anti-convulsant drugs into mainstream neuropathic pain
therapy has been a long process, as many were developed
for very different applications. In general, first-generation
agents had great patient intolerability, higher toxicity,
and variable effectiveness. Second-generation drugs,
often termed gabapentinoids, offer greater tolerability
and selectivity [1,2]. The mechanism of action of firstand second-generation drugs is often multiple, with the
major sites of action summarized in Table 70.1.
Some anticonvulsants appear to exhibit anti-
inflammatory effects. The wound-healing effects of
phenytoin and its associated gingival hypertorophy
may reflect its action on fibroblast activity. It appears
in animal studies that gabapentin and lamotrigine
have peripheral analgesic effects, suggesting an effect
on peripheral neurotransmission.
Applications of first-generation AEDs

292
Carbamazepine: trigeminal neuralgia, migraine

prophylaxis, post-herpetic neuralgia, diabetic
neuropathy
Valproic acid: migraine prophylaxis, chronic pain

Phenytoin: diabetic neuropathy, cancer pain
Clonazepam: trigeminal neuralgia, myofascial
pain, migraine prophylaxis
Currently the most commonly prescribed anticonvulsants for pain control are gabapentin and pregabalin [1,2]. Gabapentin is an aminobutyric acid analog
that received Food and Drug Administration approval
in 1993 for adjunctive treatment of partial seizures in
adults. Soon after its release a number of case reports
and uncontrolled trials were published attesting to
its safety and effectiveness in controlling intractable
neuropathic pain in patients presenting with reflex
sympathetic dystrophy, post-herpetic neuralgia,
migraine, and trigeminal neuralgia. In a letter to the
editor Mellick was one of the first to report remarkable
effectiveness of gabapentin in relieving pain associated with reflex sympathetic dystrophy [3]. These
authors reported that the drug was very well tolerated
but that dose adjustments (3002400 mg/day) and
upwards titration were required to compensate for
significant variabilites in patient response. Subsequently, a number of well-controlled gabapentin trials
were performed which validated earlier anecdotal
observations, and secured FDA approval for its use in
the management of neuropathic pain.
Despite extensive studies, gabapentins mechanism
of action is unknown. While it was initially believed to
function as a GABA analog, it does not appear to act on
GABA receptors. However, muscular relaxation associated with gabapentin has been related to indirect
presynaptic activation of GABA pathways. It is now
recognized that gabapentin and pregabalin have high
binding affinity for the 2 subunit of presynaptic voltagegated calcium channels [4]. Their analgesic effects may
be related to inhibition of calcium influx and release of
excitatory neurotransmitters in spinal and supraspinal
pain pathways. They also appear to reduce the excitability of irritated and injured peripheral noxious fibers.
Chapter 70 Overview of anticonvulsant analgesics
Table 70.1. AED modes of action

Sodium channel blockade
Carbamazepine, felbamate, lamotrigine, oxcarbazepine, phenytoin,

topiramate, zonisamide
Calcium channel blockade
Carbamazepine, ethosuximide, felbamate, gabapentin, lamotrigine,

levitiracetam, oxcarbazine, pregabilin, topiramate, valproic acid,
zonisamide
Glutamate release reduction and action on NMDA / AMPA

receptors
Carbamazepine, felbamate, gabapentin, lamotrigine, oxcarazine,

phenytoin, pregbalin, topiramate, valproic acid
Peripheral anti-inflammatory and fibroblast activity
Phenytoin, gabapentin, lamotrigine
Both gabapentin and pregabalin are commonly

employed in neuropathic pain and are approved for
post-herpetic neuralgia and diabetic neuropathy. The
commonest side effects with therapeutic doses are dizziness and sedation, which are often tolerable if doses
are started low. Renal elimination requires that dosage
be reduced significantly in patients with renal impairment. Gabapentin has complex pharmacokinetics,
requiring dosage three times daily, gradually increasing up to 3600 mg/day until pain relief is achieved or
intolerability limits further increase of dosage. Finding
optimal dosage can take 3 months or more.
In contrast to gabapentin, the more recently
approved gabapentinoid, pregabalin, was conceived,
developed, and marketed as an analgesic as well as an
anticonvulsant [5]. Pregabalin has neurochemical and
therapeutic similarities to gabapentin, but is more
selective, has greater tolerability, and is simpler to
dose. Commonly, 75150 mg/day is given in two
divided doses, increasing to 300 mg/day after a week
or two as tolerated. Higher does have been used, up to
600 mg/day, generally without much benefit but
increased side effects [5].
Gabapentin and pregabalin and, to a lesser extent,
lamotrigine have displaced almost all first-generation
anticonvulsants for the management of neuropathic
pain, perhaps the only exception being carbamazepine,
which is still prescribed for poorly controlled trigeminal neuralgia-related pain. They are approved for diabetic neuropathy and post-herpetic neuralgia, and
while there are no controlled trials to attest safety
and efficacy, they are frequently prescribed to control
neuropathic symptoms associated with reflex sympathetic dystrophy, sciatica, polyneuropathy, and phantom limb. Other off-label uses include management of
migraine, nystagmus, and restless leg syndrome. Pregabalin effectively reduces spinal cord sensitization and
centrally mediated neuropathic pain, and has recently
been approved for management of fibromyalgia [6].
In addition to their use in chronic pain both gabapentin and pregabalin have been advocated for use
as post-operative analgesic adjuvants [7,8]. Pre- and
post-operative dose of gabapentin (900 mg) and pregabalin (150 mg) significantly reduced opioid consumption in several post-surgical models. While they
do not improve pain intensity scores, they do appear
to reduce wound site hyperalgesia. There is also evidence to suggest that peri-operative dosing may
reduce central sensitization and the development of
persistent pain.
Adverse effects
Early side effects such as drowsiness are often tolerated as time passes. Later side effects are often more
serious and an indication for cessation of the AED.
The frequency of side effects of AEDs is classified and
listed in the product inserts according to Food and
Drug Administration (FDA) guidelines. Adverse reactions are classified as frequent (>1/100), infrequent
(<1/100), or rare (<1/1000). Most of the frequent
adverse events are dose-related, CNS-mediated side
effects. Non-neurological side effects are hirsutism
and gingival hyperplasia with phenytoin, leukopenia
and hyponatremia with carbamazepine, and weight
gain and hair loss with valproate. Some of the most
severe and life-threatening adverse events do not affect
the CNS (e.g. StevensJohnson syndrome [SJS], aplastic anemia, and hepatic failure). These are rare and
early recognition is essential.
While there are ample studies to confirm the efficacy of gabapentin and pregabalin, there is a dearth of
comparisons with established antidepressant drugs
such as amitriptyline and other tricyclics. Other concerns include the possible ability of gabapentin to
cause neuropathy, so reassurance would be welcome
that the benefits outweigh the risks in differing clinical
circumstances, particularly in the long term.
293
Anticonvulsant-Type Analgesics Section 6
Conclusion
The mechanisms by which these different agents work
in the pain setting, often far from their original purpose, remain unclear though progress is rapid. The
efficacy is undoubted, while the frequency of side
effects and adverse reactions continue to diminish.
Their marketing has legally tested the limits of offlabel prescription, and still their acceptance increases.
Gabapentin and now pregabalin offer new and exciting therapeutic options for mostly adjuvant treatment
of neuropathic pain and may have a future role in
acute pain management.
References
1. http://en.wikipedia.org/wiki/Gabapentin. Accessed
January 16, 2010.
2. Goa KL, Sorkin EM. Gabapentin: a review of its
pharmacological properties and clinical potential in
epilepsy. Drugs 1993;46(3):409427.
3. Mellick GA, Mellick LB. Gabapentin in the
management of reflex sympathetic dystrophy. (Letter)
J Pain Symptom Manage 1995;10:265266 .
4. Lou ZD, Calcutt NA, Higuera ES, et al. Injury
type-specific calcium channel alpha2delta-1 subunit
Section 6
Chapter
71
294
up-regulation in rat neuropathic pain models

correlates with antiallodynic effects of gabapentin.
J Pharmcol Exp Ther 2002;303:11991205.
5. http://en.wikipedia.org/wiki/Pregabalin. Accessed
January 16, 2010.
6. Crofford LJ, Rowbotham MC, Mease PJ, et al.
Pregabalin for the treatment of fibromyalgia
syndrome: results of a randomized, double-blind,
placebo-controlled trial. Arthritis Rheum
2005;52(4):12641273.
7. Gilron I, Orr E, Tu DS, ONeill JP, Zamora JE, Bell AC.
A placebo-controlled randomized clinical trial of
perioperative administration of gabapentin, rofecoxib
and their combination for spontaneous and
movement-evoked pain after abdominal hysterectomy.
Pain 2005;113:191200.
8. Dahl JB, Mathiesen O, Moiniche S. A review of
gabapentin and pregabalin in the treatment of
post-operative pain. Acta anaesthesiologica
Scandinavica 2004;48:11301139.
9. Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of
chronic pain: a synthesis of recommendations from
systematic reviews. Gen Hosp Psychiatry 2009;
31:206219.
10. OConnor AB, Dworkin RH. Treatment of
neuropathic pain: an overview of recent guidelines.
Am J Med 2009;122(10A) S2232.
Gabapentin
Boris Gelman and Eric S. Hsu
Generic Name: gabapentin

Trade Name: Neurontin
Manufacturer: Pfizer Inc.
Class: anticonvulsant analgesic
Description
Gabapentin is an analgesic commonly used in the
treatment of neuropathic pain. It is described as
1-(aminomethyl)cyclohexaneacetic acid with a mole
cular formula C9H17NO2. It has a molecular weight of
171.24 and a pKa1 of 3.7 and pKa2 of 10.7. It is freely
soluble in water and both basic and acidic aqueous
Chapter 71 Gabapentin
CH2NH2
Figure 71.1.
CH2CO2H
solutions. Gabapentin is currently only available in

the oral form as capsules (100 mg, 300 mg, and 400
mg), tablets (600 mg and 800 mg), or oral solution
(250 mg/5 mL).
Mode of activity
Pharmacodynamics
The mechanism by which gabapentin exerts its analgesic action is unknown. It has been shown in animal
models to prevent allodynia (pain-related behavior in
response to a normally innocuous stimulus) and
hyperalgesia (exaggerated response to painful stimuli). Particularly, gabapentin has been shown to
attenuate pain-related responses in several animal
models of neuropathic pain (diabetes, spinal nerve
ligation, spinal cord injury, acute herpes zoster infection) and also decreases pain-related responses after
peripheral inflammation. However, gabapentin did
not alter immediate pain-related behaviors in animal
models.
Gabapentin is structurally related to the neurotransmitter GABA (gamma-aminobutyric acid) but it
does not modify GABAA or GABAB radioligand
binding. Gabapentin is not converted metabolically
into GABA or a GABA agonist, and it is not an inhibitor of GABA uptake or degradation. Gabapentin was
shown to activate the descending noradrenergic system after pre-operative oral administration at the time
of surgery. Therefore, a central mechanism of oral
gabapentin in modulation of post-operative pain was
proposed and this could be magnified by treatments
that boost the effect of norepinephrine release.
It was proposed that gabapentin may modulate
the central voltage-gated calcium channels similarly
to pregabalin as a potential mechanism of clinical
efficacy in neuropathic pain. Pregabalin binds with
high affinity to the alpha2-delta site (an auxiliary subunit of voltage-gated calcium channels) in CNS tissues of animal models. Although the exact mechanism
of action of pregabalin is unknown, results with
genetically modified mice and with compounds
structurally related to pregabalin (such as gabapentin) suggest that binding to the alpha2-delta subunit
may be involved in antinociceptive and antiseizure

effects of pregabalin in animal models. Pregabalin
reduces the calcium-dependent release neurotransmitters (glutamate, substance P) via possible modulation of calcium channel function.
Pharmacokinetics
The bioavailability of gabapentin is approximately
60%, 47%, 34%, 33%, and 27% following 900, 1200,
2400, 3600, and 4800 mg/day given in three divided
doses, respectively. The bioavailability is not dose-
proportional (as the dose is increased, bioavailability
decreases). In contrast, pregabalin offers a more linear
pharmacokinetic profile over gabapentin and a consistent >90% bioavailability. Pregabalin may result in a
shorter course of titration and quicker response in
clinical application.
Less than 3% of gabapentin is protein-bound,
therefore it has insignificant drug interactions. The
elimination half-life of gabapentin is 57 hours and
follows linear kinetics even with multiple doses.
Because of its short half-life, gabapentin may be
administered either twice or three times daily.
Gabapentin is not appreciably metabolized in the
body and is excreted in urine unchanged. The elimination rate constant, plasma and renal clearance of
gabapentin are all directly proportional to the creatinine clearance.
Drug interactions
There was a slight degree of inhibition (1430%) of
P450 CYP2A6 observed only at the highest concentration (approximately 15 times the Cmax at 3600 mg/day).
No inhibition of any of the other isoforms (CYP1A2,
CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A4)
tested was observed. Gabapentin is not appreciably
metabolized in liver nor does it inhibit any cytochrome
P450 enzymes in standard clinical dosing. Gabapentin
does not interfere with the metabolism of commonly
co-administered anti-epileptic drugs.
Indications
There are only two US FDA-approved indications for
gabapentin:
1. Post-herpetic neuralgia (PHN)
2. Partial seizures
However, gabapentin has been commonly prescribed for off-label uses such as neuropathic pain and
chronic pain syndromes. Here are some examples.
295
Post-operative pain
Cancer pain
The administration of gabapentin to patients undergoing craniotomy for supratentorial tumor resection
was effective for acute post-operative pain. It also
decreased other analgesic consumption after surgery.
Gabapentin appears safe and well tolerated when
used for persistent post-operative and post-traumatic
pain in thoracic surgery patients despite minor side
effects. Gabapentin may relieve refractory chest wall
pain especially in those patients with more severe pain.
Neuropathic cancer pain can be relieved by gabapentin

as part of the multimodal treatment following WHOs
three-step analgesia guidelines since the majority of cancer pain involves various etiologies of pathophysiology.
Reduce chronic post-operative

neuropathic pain
Although pre-operative gabapentin did not modify
immediate pain relief in thyroidectomy patients
receiving superficial cervical plexus block, it did
prevent the delayed neuropathic pain at 6 month
follow-up.
Phantom pain
Gabapentin monotherapy was better than placebo in
post-amputation phantom limb pain after 6 weeks.
There were no significant differences in mood, sleep
interference, or activities of daily living.
Complex regional pain syndrome (CRPS)

Gabapentin was shown to significantly reduce the sensory deficit in the affected limb in CRPS despite only
modest relief of pain. Therefore, a subpopulation of
CRPS patients may benefit from gabapentin as part of
timely and comprehensive intervention.
Contraindications
Absolute contraindication: hypersensitivity to gabapentin.
Relative contraindication:
1. Renal insufficiency: gabapentin is excreted via the
kidneys thus dose should be adjusted based on
creatinine clearance.
2. Suicidal behavior and ideation: all anti-epileptic
drugs (AEDs) including gabapentin may increase
the risk of suicidal thoughts or behavior in
patients taking these drugs for any indication.
Patients should be monitored for the emergence
or worsening of depression, suicidal thoughts or
behavior, and/or any unusual changes in their
mood or behavior.
Common doses
Post-herpetic neuralgia (PHN): gabapentin therapy
may be initiated as a single 300-mg dose on day 1, 600
mg/day on day 2 (divided BID), and 900 mg/day on
day 3 (divided TID). The dose can subsequently be
titrated up as needed for pain relief up to a target daily
dose of 1800 mg (divided TID). In clinical studies,
efficacy was also demonstrated over a range of doses
Table 71.1. Gabapentin dosage based on renal function
Renal function
(mL/min)
Total daily
dose range
(mg/day)
Dose regimen (mg)
60
9003600
300 TID
400 TID
600 TID
800 TID
1200 TID
>3059
4001400
200 BID
300 BID
400 BID
500 BID
700 BID
>1529
200700
200 QD
300 QD
400 QD
500 QD
700 QD
15a
100300
100 QD
125 QD
150 QD
200 QD
300 QD
125b
150b
200b
250b
300b
Post-hemodialysis supplemental dose (mg)

Hemodialysis
For patients with creatinine clearance < 15 mL/min, reduce daily dose in proportion to creatinine clearance (e.g. patients with a creatinine
clearance of 7.5 mL/min should receive one-half the daily dose that patients with a creatinine clearance of 15 mL/min receive).
Patients on hemodialysis should receive maintenance doses based on estimates of creatinine clearance as indicated in the upper
portion of the table and a supplemental post-hemodialysis dose administered after each 4 hours of hemodialysis as indicated in the
lower portion of the table.
296
Chapter 71 Gabapentin
from 1800 mg/day to 3600 mg/day with comparable

effects across the dose range. Additional benefit related
to doses higher than 1800 mg/day of gabapentin was
not demonstrated. Gabapentin needs to be tapered
over 7 days when discontinuing.
Dosage in renal impairment: creatinine clearance is
difficult to measure in outpatients. In patients with stable renal function, creatinine clearance (CCr) can be
reasonably well estimated using the equation of Cockcroft and Gault: for females CCr = (0.85) (140age)
(weight)/[(72) (SCr)] for males CCr = (140age)
(weight)/[(72) (SCr)] where age is in years, weight is
in kilograms and SCr is serum creatinine in mg/dL.
Dosage adjustment in patients 12 years of age
with compromised renal function or undergoing
hemodialysis is recommended as shown in Table 71.1.
1. Gabapentin presents with minimal drug
interaction so it appears versatile in combination
with other neuropathic pain medications in
clinical use.
2. Gabapentin is affordable with generic form and
available in outpatient and hospital settings.
Abrupt discontinuation and withdrawal of gabapentin
may precipitate seizure (status epilepticus). The most frequently reported events following abrupt discontinuation were anxiety, insomnia, nausea, pain, and sweating.
Precaution and instruction for patients: patients
should be instructed to take gabapentin only as
prescribed since gabapentin may cause dizziness, somnolence, and other CNS depression. Patients should be
advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience on gabapentin to gauge whether or not it affects
their mental and/or motor performance adversely.

The most commonly observed adverse events associated with the use of gabapentin versus placebo in
adults with PHN were dizziness, somnolence, and

peripheral edema. In the two controlled studies in
PHN, 16% of the 336 patients who received gaba
pentin and 9% of the 227 patients who received placebo discontinued treatment because of an adverse
event.
Postmarketing and other experience: these data
are insufficient to support an estimate of their incidence or to establish causation. The listing is alphabetized: angioedema, blood glucose fluctuation, breast
hypertrophy, erythema multiforme, elevated liver
function tests, fever, hyponatremia, jaundice, movement disorder, and StevensJohnson syndrome.
Overdose and treatment: acute oral overdoses of
gabapentin up to 49 grams have been reported. In
these cases, double vision, slurred speech, drowsiness,
lethargy, and diarrhea were observed. All patients
recovered with supportive care. Gabapentin can be
removed by hemodialysis. Although hemodialysis was
not performed in the few overdose cases reported, it
may be indicated by the patients clinical state or in
patients with significant renal impairment.
References
1. Gabapentin. Micromedex Healthcare Series.

Thompson Healthcare, 2009.
2.
Gabapentin prescribing information. New York:

Pfizer. Revised April 2009.
3. Hayashida K, et al Gabapentin activates spinal

noradrenergic activity in rats and humans
and reduces hypersensitivity after surgery.
4. Sills GJ. The mechanisms of action of gabapentin
and pregabalin. Curr Opin Pharmacol
2006;6(1):108113.
5. Rice AS, Maton S. Postherpetic Neuralgia Study
Group. Gabapentin in postherpetic neuralgia: a
randomized, double blind, placebo controlled study.
Pain 2001;94(2):215224.
6. Rowbotham M, Harden N, Stacey B, et al. Gabapentin
for the treatment of postherpetic neuralgia: a
randomized controlled trial. JAMA 1998;280(21):
18371842.
297
Section 6
Chapter
72
Pregabalin
Neil Sinha
Generic Name: pregabalin

Trade Name: Lyrica
Drug Class: anticonvulsant analgesic
Manufacturer: Pfizer Pharmaceuticals, 235 East
42nd Street, New York, NY
Chemical Name: (S)-3-(aminomethyl)-5-methyl
hexanoic acid
159.2
Introduction
Pregabalin (Lyrica) is an anti-epileptic drug used for
the treatment of neuropathic pain, fibromyalgia, postherpetic neuralgia, and as an adjunct therapy for partial seizures. The systemic (IUPAC) description of
pregabalin is (S)-3-(aminomethyl)-5-methylhexanoic
acid and its molecular formula is C8H17NO2. It has a
molecular weight of 159.23. Pfizer, Inc. introduced
this drug (under the trade name Lyrica) and it was
approved in the European Union in 2004 and by the
FDA (initially for the treatment of epilepsy, diabetic
neuropathic pain, and post-herpetic neuralgia) in
December 2004 [1,2].
Mechanism of action
298
Voltage-gated calcium channels (VGCC) are cell

membrane glycoproteins that regulate action potential of neurons. VGCC consist of four subunits (designated 1, 2-, 2-, and 2-) present in equal ratios
with six transmembrane helices each. Calcium entry
into neurons through the VGCC results in the release
of neurotransmitters into the synaptic cleft. Certain
physiological states such as epilepsy or neuropathy
may have hyper-excited VGCCs resulting in the
continuous infux of calcium ions and the sustained
release of excitatory neurotransmitters as glutamate,

norepinephrine, and substance P [2,3].
Pregabalin, like gabapentin, binds to the 2- subunit of the presynaptic voltage-gated calcium channels
in the dorsal horn of the spinal cord and the brain,
causing conformational changes that prevent the
influx of calcium and the subsequent release of excitatory neurotransmitters. In particular, pregabalin has
higher affinity to hyper-excited neurons, selectively
targeting the pathological neurons. Although pregabalin is structurally a GABA analog, it has no affinity to
the GABAA or GABAB receptors. In addition, it has no
affinity to the cardiac or vascular calcium receptors.
Pharmacokinetics
After oral intake, pregabalin is transported across the
gastrointestinal tract by the l-amino acid transport
system and displays linear pharmacokinetics across
and even above clinical dosing regimens. Maximal
absorption (>90% bioavailability) after oral administration in fasting subjects occurs in 1 to 1.5 hours.
With chronic dosing, pregabalin reaches a steady state
in 2448 hours [2,3]. Pregabalin is not appreciably
bound to plasma proteins and has a volume of distribution of 0.56 L/kg after oral administration. In animal models, pregabalin has been shown to cross the
bloodbrain barrier by the l-amino acid transport
system. The half-life of pregabalin under fasting conditions and in patients with normal renal function is 6
hours.
Pregabalin undergoes negligible metabolism in
humans. Approximately 90% of radiolabeled pregabalin is detected in urine after single-dose administration. The major metabolite, N-methylated pregabalin,
was found in urine at 0.9% of original administered
does.
In humans, pregabalin is primarily excreted from
systemic circulation by the renal system as an unchanged
drug. Renal clearance of pregabalin, in young healthy
Chapter 72 Pregabalin
H3C
Figure 72.1.
CH3
H
OH
O
H2N
volunteers with normal functions, is estimated to be 67.0

to 80.9 mL/min. Because pregabalin is only negligibly
metabolized and does not bind to plasma proteins, its
elimination is nearly proportional to creatinine clearance [3].
Routes of administration
Pregabalin is currently available as an oral administered drug. It is supplied in 25 mg, 50 mg, 75 mg, 100
mg, 150 mg, 200 mg, 225 mg, and 300 mg tablets. The
capsule shell is composed of gelatin and titanium
dioxide [2,3].
Contraindications
The only contraindication to pregabalin is known
hypersensitivity to pregabalin or any of its components.
Indications
The FDA has approved the use of pregabalin for the
following classes of pain.
1. Neuropathic pain associated with

diabetic peripheral neuropathy
Diabetes mellitus is a worldwide disease that, according to estimates by the World Health Organization,
affects at least 171 million people; by 2030, this number
is expected to double. Diabetic peripheral neuropathy
(DPN) is a frequent complication, occurring in approximately 2024% of patients with diabetes and in 50% of
those with diabetes for greater than 25 years. The
symptoms of DPN range from mild tingling to deep,
severe lacinating and burning pain. DPN may have a
profoundly devastating effect on the quality of life and
the psychological well being of those affected. Multiple
multi-center, double-blind, randomized controlled trials
have demonstrated that pregabalin use in patients with
diabetes results in an early and sustained decrease in
pain scores and a beneficial effect on sleep [3,4].
Pregabalin dosing for DPN should begin at 50 mg
three times a day and may be increased to a maximum
of 100 mg three times a day over the period of a week

in patients with normal renal function. Higher doses
(greater than 300 mg/day) have not shown any additional benefits [5].
2. Post-herpetic neuralgia
Post-herpetic neuralgia (PHN) is persistent pain
that continues 3 months after the resolution of the
herpes zoster eruption. In the USA, approximately 1
million individuals develop herpes zoster; of those,
20% develop PHN. The symptoms are variable in
nature ranging from mild discomfort to a very
severe burning or stabbing sensation that is typically
confined to a single dermatome of skin. Multiple
multi-center, double-blind, randomized controlled
trials have demonstrated that pregabalin use in PHN
results in an early and sustained decrease in pain
scores.
Pregabalin dosing for PHN should begin at 50 mg
three times a day (or 75 mg times twice a day) in
patients with normal renal function [3]. Dosing may
be increased to 300 mg per day within 1 week. If sufficient pain relief is not achieved by 24 weeks, the
pregabalin dose may be increased to 600 mg per day
(administered in twice a day or thrice a day schedule).
However, doses above 300 mg a day should only be
reserved for those with ongoing pain despite pregabalin therapy of 300 mg per day [3].
3. Fibromyalgia
Fibromyalgia is a rheumatological condition that is
characterized by widespread pain in all four quadrants
of the body lasting for more than 3 months; in addition, in fibromyalgia, patients experience tenderness
in at least 11 of 18 designated trigger points. Approximately 2% of Americans suffer from fibromyalgia,
with a strong female preponderance (9:1 by ACR criteria). Pregabalin, in a randomized controlled trial,
has shown a 50% reduction in pain (NNT is 6). The
Cochrane Database analysis concludes that A minority
of patients will have substantial benefit with pregabalin,
and more will have moderate benefit. Many will have
no or trivial benefit, or will discontinue because of
adverse events.
Pregabalin dosing for fibromyalgia should begin at
75 mg twice a day and may be increased to 150 mg
twice a day within a week in patients with normal
renal function. In those patients who do not exhibit
sufficient benefits, the pregabalin dose may be
increased to 225 mg twice a day [3]. Doses higher than
299
450 mg a day have not been shown to confer any additional benefits.
Although these are the only FDA-approved uses,
pregabalin is often used for off-label adjunctive analgesia for moderate to severe acute pain (including surgery and dental procedures), and also for non-DPN/
PHN neuropathic pain.
1. Pregabalin displays linear pharmacokinetics
across its therapeutic range and has high
bioavailability resulting in predictable dosedependent responses.
2. It has a short titration period as the dose may be
increased after 1 week.
3. It is well tolerated; less than 10% of patients will
discontinue the use of pregabalin as a
consequence of adverse side effects.
4. Pregabalin is largely excreted unchanged in the
urine and does not bind to plasma proteins,
resulting in minimal drugdrug interactions.
5. Pregabalin may be taken with or without food.
6. It is a schedule V controlled substance.
Disadvantages
1. Pergabalin requires dose modification in patients
with renal dysfunction
2. Pregabalin is a relatively expensive medication;
(but in some areas of the country, pregabalin
remains cheaper than Neurontin and generic
gabapentin).
3. Pregabalin has not demonstrated superiority to
alternative treatments.
4. There are limited studies demonstrating the
long-term safety of pregabalin.
5. Pregabalin should be gradually tapered for a
period of at least 1 week; abrupt discontinuation
may result in insomnia, headache, nausea, and
diarrhea
6. Pregabalin crosses the placenta and is present in
breast milk. It has been designated a Pregnancy
Category C drug by the FDA.
Drug-related adverse effects

300
The most frequent adverse effects of pregabalin are

dizziness and drowsiness; other common effects
include visual disturbances, ataxia, dysarthria, tremor,
lethargy, memory impairment, euphoria, constipa-
tion, dry mouth, peripheral edema, a decrease or loss

in libido, and weight gain.
Special precautions should be taken for:
Angioedema, which may occur with initial or
chronic treatment with pregabalin and may occur
at higher rates with patients on ACE inhibitors
and those with a history of angioedema.
Pregabalin should be immediately stopped and
supportive care instituted.
Hypersenstivity, which typically presents as rash,
hives, dyspnea, and wheezing. Pregabalin should
be immediately stopped and supportive care
instituted.
Suicidal ideation, which may occur within a week
of initiation or at any stage of treatment.
Pregabalin, like all AEDs, may increase the risk of
depression and suicidal thoughts and behaviors
and special care should be given to patients with
preexisting depression and/or suicidal ideation
before starting pregabalin.
Peripheral edema, which occurred in 6% of
patients administered pregabalin in controlled
trials (compared to 2% in the placebo arm). The
peripheral edema is not a consequence of
congestive heart failure, or renal or hepatic
insufficiency. The thiazolidinedione class of oral
hypoglycemics may increase the risk of fluid
retention. In addition, because of limited data,
pregabalin should be administered cautiously in
patients with NYHA class III or IV cardiac status.
Dizziness, which may occur in up to 31% of
pregabalin treated patients. Hence, caution with
driving should be taken.
Weight gain of over 7% of baseline weight
occurred in 9% of patients in controlled trials.
Overdose
The highest reported accidental overdose of pregabalin has been 8 grams of pregabalin, which resulted in
no long-term consequences. In the case of overdose,
emesis or gastric lavage can be used to eliminate
unabsorbed drug (if down within 11.5 hours). In
addition, the patient should be carefully monitored
and supportive care is indicated. Hemodialysis may
be attempt in patients with severe renal compromise,
which significantly eliminates pregabalin from systemic circulation (50% in 4 hours with standard hemo
dialysis).
Chapter 73 Carbamazepine
References
1. Bellioti T, Capiris T, Wustruw D, et al.

Structureactivity relationships of pregabalin and
analogues that target the 2- protein. J Med Chem
2005;48(7):22942307.
2. Kavoussi R. Pregabalin: from molecule to medicine.
Eur Neuropsychopharmacol 2006;16(S2):S128S133.
3. Lyrica (pregabalin). Prescribing information. New
York: Pfizer, 2006. http://www.pfizer.com/products/
Section 6
Chapter
73
rx/rx_product_lyrica.jsp. Accessed August 25,

2009.
4. Lesser H, Sharma U, LaMoreaux L, Poole RM.
Pregabalin relieves symptoms of painful diabetic
neuropathy: a randomized controlled trial. Neurology
2004;63:21042110.
5. Thomas J, Walker R. Pregabalin (Lyrica) for the
management of pain associated with diabetic
neuropathy. Steps New Drug Rev 2006;74(12):
20932094.
Carbamazepine
Keren Ziv
Trade Names: Atretol (Athena, USA Neurosciences), Carbatrol (Shire Richwood, USA),
Equetro (Shire Richwood, USA), Tegretol
Chewable Tablets, Tegretol Suspension,
Tegretol-XR (Novartis, USA)
Clinical Class: anticonvulsant
Chemical Class: iminostilbene
Chemical Name: 5H-Dibenz[b,f]azepine-5-carbo
xamide
Description
Carbamazepine is an anticonvulsant that is structurally related to tricyclic antidepressants such as
amitriptyline and imipramine. Carbamazepine is
effective in the treatment of psychomotor and grand
mal seizures and pain from trigeminal neuralgia and,
in combination with other drugs, for psychiatric disorders such as mania and extreme aggression. Carbamazepine is also occasionally used to control pain
in persons with cancer. Carbamazepine was first mar-
keted as an anti-seizure medication and as a first-line

treatment for trigeminal neuralgia. Because it was
later noted to be effective in patients with certain psychiatric disorders, psychiatrists began combining it
with other drugs such as lithium and major tranquilizers in severe cases of bipolar disease and aggressive
behavior that could not be managed with single-drug
therapy.
Mode of activity
Although not fully understood, animal studies have
shown that carbamazepine blocks voltage-sensitive
sodium channels resulting in stabilization of hyperexcited neural membranes, inhibition of repetitive neuronal firing and inhibition of the spread of discharges.
Pain relief is believed to be due to reduction in ectopic
nerve discharges and stabilization of neural membranes.
Seizure control is due to reduction of post-tetanic potentiation of synaptic transmission in the spinal cord.
Absorption: oral, extended-release tablets: time to
peak concentration, 3 h to 12 h; oral, regular-release tablets: time to peak concentration, 4 h to 5 h; oral, suspension, time to peak concentration, 1.5 h. Bioavailability:
301
Figure 73.1.
N
CONH2
oral, 7080% and is increased by the presence of food in

the stomach.
Distribution: Vd: 0.8 to 2 L/kg. Protein binding:
76%.
Metabolism: hepatic (98%); via cytochrome P450
isoenzyme CYP3A4. During prolonged treatment,
carbamazepine induces its own metabolism. Active
metabolites: carbamazepine-10,11-epoxide (CBZ-E).
Excretion: 72% renal and 28% fecal. Half-life of a
single dose is 2565 hours initially, then 12 to 17 hours
after repeated doses (3 to 5 weeks) due to autoinduction. Dialyzable: yes via hemodialysis.
Indications
FDA-labeled indications: epilepsy: partial, generalized
and mixed episodes; trigeminal neuralgia; glossopharyngeal neuralgia; bipolar 1 disorder, acute manic and
mixed episodes.
Epilepsy
Carbamazepine is indicated for use as an anticonvulsant drug. Evidence supports the use of carbamazepine
in the control of partial seizures with complex symptomatology (psychomotor, temporal lobe), generalized tonic-clonic seizures (grand mal), and mixed
seizure patterns which include the above. Absence seizures (petit mal) do not appear to be controlled by
carbamazepine.
302
Carbamazepine is indicated in the treatment of the

pain associated with trigeminal neuralgia. Most of the
studies that have examined its use in this disorder
were conducted in the 1960s and 1970s. On review, in
a 5-day placebo-controlled trial, using dose titration
to a maximum of 1 g/day, 19/27 participants had a
complete or very good response on 5 days treatment
of trigeminal neuralgia. A higher dosage of up to 2.4
g/day was used in a 2 week trial in which 15/20 patients
achieved a good or excellent response. Although most
of these studies were conducted with a small number
of patients in short-term trials, the quality of the studies is rated as level 1 (good quality, patient-oriented
evidence). Beneficial results have also been reported

in glossopharyngeal neuralgia.
Glossopharyngeal neuralgia
Carbamazepine has also been shown to be effective in
the treatment of glossopharyngeal neuralgia. Like
trigeminal neuralgia, original studies were performed
in the 1960s and recent studies have confirmed the use
of carbamazepine as initial treatment for glossopharyngeal neuralgia.
Diabetic neuropathy
Small placebo-controlled studies have demonstrated
improvement in parasthesias and pain in patients with
diabetic neuropathy treated with carbamazepine. In a
30-day comparison of carbamazepine and nortriptyline for the treatment of painful diabetic neuropathy,
no difference in pain reduction was observed.
Other forms of neuropathic pain

Small studies have shown moderate benefit in the
treatment of post-herpetic neuralgia and post-stroke
pain. Treatment of other neurogenic pain syndromes
with carbamazepine is considered a non-FDA-labeled
indication.
Black-box warning
Serious dermatological reactions
and HLA-B*1502 allele
Serious, sometimes fatal dermatological reactions have
been reported, including StevensJohnson syndrome
and toxic epidermal necrolysis. The risk is 10 times
greater in some Asian countries due to a strong association with the HLA-B*1502 allele, which is found
almost exclusively in Asian patients. Genetically
at-risk patients should be screened prior to receiving
carbamazepine, and carbamazepine should not be
given to patients who test positive for the allele.
Aplastic anemia/agranulocytosis
Aplastic anemia and agranulocytosis have been
reported. Complete hematological testing should be
obtained pretreatment. If a patient during the course
of treatment exhibits low or decreased white blood
cell or platelet counts, the patient should be monitored
closely. Discontinuation of carbamazepine should be
considered if any evidence of significant bone marrow
depression develops.
Contraindications
Carbamazepine should not be used in patients with a
history of previous bone marrow depression, or known
hypersensitivity to carbamazepine or tricyclic compounds. It is contraindicated with concomitant use of
an MAOI or within 14 days of discontinuing an MAOI.
Co-administration of carbamazepine and nefazodone
may result in insufficient plasma concentrations of
nefazodone and decreased drug effectiveness. Coadministration of carbamazepine with nefazodone is
contraindicated.
Cautions
As listed above in Warning and Contraindications as
well as:
Caution if hepatic porphyria history; acute
attacks reported
Caution if hypersensitivity to other
anticonvulsants; risk of cross-sensitivity
Caution if absence, atonic, or myoclonic seizures;
may increase generalized convulsion frequency
Caution if increased intraocular pressure; may
cause exacerbation due to cholinergic antagonism
Caution if hepatic or renal impairment
Caution if cardiac disease, or cardiac conduction
disturbances; increased risk of atrioventricular
heart block
Caution in SLE
Caution in elderly; may cause confusion or
agitation
Caution in mental illness history; risk of latent
psychosis activation or increased risk of suicidality
Caution in pregnancy (FDA Pregnancy Category D)
Common doses
Monitoring of blood levels has increased the efficacy
and safety of anticonvulsants. Complete pretreatment
blood counts, including platelets and possibly reticulocytes and serum iron, should be obtained as a baseline. If a patient during treatment exhibits low or
decreased white blood cell or platelet counts, the
patient should be monitored closely. Discontinuation
of the drug should be considered if any evidence of
significant bone marrow depression develops (see
Warning). Baseline and periodic evaluations of liver
function, especially in patients with a history of
hepatic disease, must be performed during treatment
with this drug since liver damage may occur. Car-
bamazepine should be discontinued if indicated by

newly occurring or worsening clinical or laboratory
evidence of hepatic dysfunction.
Dosage should be adjusted to the needs of the
individual patient. A low initial daily dosage with a
gradual increase is advised. As soon as adequate control is achieved, the dosage may be reduced very
gradually to the minimum effective level. Tablets
should be taken with meals. Sudden discontinuation
of this drug is not advised. Patients should not take
carbamazepine suspension with other liquid medications or diluents, as precipitation may occur. Patients
should not eat grapefruit or grapefruit juice while
taking this medication.
Conversion of patients from oral carbamazepine
tablets to carbamazepine suspension: patients should
be converted by administering the same number of
mg per day in smaller, more frequent doses (i.e., BID
tablets to TID suspension). No adjustment for renal
dosing.
Adult dosing
Seizure disorder
Immediate-release form: 8001200 mg/day PO
divided BID-QID; start: 200 mg PO BID, increase
200mg/day per week; max: 1600 mg/day; rare patients
may require up to 2400 mg/day.
Extended-release form: 400600 mg ER PO bid;
start: 200 mg ER PO BID, increase 200 mg/day per week;
max: 1600 mg/day ER; do not cut/crush/chew ER form.
Immediate-release form: 200400 mg PO BID; start:
100 mg PO BID, increase 200 mg/day divided BID;
max: 1200 mg/day.
Extended-release form: 200400 mg ER PO BID;
start: 100 mg ER PO BID, increase 200 mg/day; max:
1200 mg/day ER; do not cut/crush/chew ER form.
Glossopharyngeal neuralgia
Regular-release tablets: initial, 100 mg PO every
12 hours, may increase by 200 mg/day (divided into
two doses) as needed for pain control (max dose
1200mg/day).
Extended-release tablets: initial 100 mg PO every
12 hours, may increase by 200 mg/day (divided into
two doses) as needed for pain control (max dose
1200mg/day).
303
Maintenance: 400800 mg/day PO (range 200

1200 mg/day); at least once every 3 months throughout the treatment period, attempts should be made to
reduce the dose.
Cost guide
Generic: $615, branded, $1435. Extended release
$36196, per month treatment.
In addition to the treatment of partial and secondarily
generalized tonic-clonic seizures, carbamazepine has
a long history of use in the treatment of trigeminal
neuralgia. It has been studied in the treatment of
patients with trigeminal neuralgia since the 1960s and
is considered the drug of choice for this condition. A
100 mg tablet may produce significant and complete
relief within 2 hours, and for this reason it is a suitable
agent for initial trial of treatment. So predictable and
powerful is the relief that if the patient does not
respond at least partially to carbamazepine, the diagnosis of trigeminal neuralgia may need to be reconsidered. Satisfactory pain relief may be achieved in 70%
or more of patients. Carbamazepine is one of the oldest medications in its class and therefore inexpensive.
Although rare life-threatening adverse reactions are
possible (see warnings), most side effects are mild and
carbamazepine is usually well tolerated. Baclofen may
be added to carbamazepine as adjunct therapy. In
addition there is no evidence of abuse potential associated with carbamazepine, nor is there evidence of
psychological or physical dependence in humans.
304
In addition to the warning/contraindications as discussed above, consider the following disadvantages of

carbamazepine: increased risk of contraceptive failure
in women with concomitant use; risk of congenital
malformations especially spina bifida; increasing dosage may be necessary with prolonged treatment.
Acute toxicity: lowest known lethal dose: adults, 3.2 g.
Signs and symptoms: the first signs and symptoms
appear after 13 hours. Neuromuscular disturbances
are the most prominent. Cardiovascular disorders are
generally milder, and severe cardiac complications
occur only when very high doses (>60 g) have been
ingested. Other signs and symptoms include: respiratory depression, tachycardia, hypotension or
hypertension, shock, conduction disorders, coma,
convulsions, ataxia, nausea, vomiting, anuria, or

oliguria,
Treatment: the prognosis in cases of overdose is
dependent upon prompt elimination of the drug, by
inducing vomiting, gastric lavage, activated charcoal.
There is no specific antidote. Dialysis is indicated only
in severe poisoning associated with renal failure.
Drug interactions
Carbamazepine levels are increased by CYP3A4
inhibitors (cimetidine, macrolides, diltiazem, fluoxetine, ketoconazole, verapamil, valproate); levels are
decreased by CYP3A4 inducers (cisplatin, doxorubicin, felbamate, phenobarbital, phenytoin, primidone, rifampin, theophylline). Carbamazepine may
increase levels of clomipramine, phenytoin, and primidone and lithium toxicity; may decrease levels of
phenytoin, warfarin, oral contraceptives, doxycycline,
theophylline, haloperidol, alprazolam, clozapine,
ethosuximide, and valproate; may interfere with other
anticonvulsants.
Adverse reactions
If adverse reactions are of such severity that the drug
must be discontinued, the physician must be aware
that abrupt discontinuation of any anticonvulsant
drug in a responsive epileptic patient may lead to seizures or even status epilepticus.
The most severe adverse reactions have been
observed in the hematopoietic system, the skin, (see
Warning), liver, and the cardiovascular system.
The most frequently observed adverse reactions,
especially during initial therapy, are dizziness, drowsiness, unsteadiness, nausea, and vomiting. Therapy
should be initiated at the low dosage recommended to
minimize such reactions.
The following additional adverse reactions have
been reported:
Hemopoietic system: aplastic anemia, agranulocytosis, pancytopenia, bone marrow depression, thrombocytopenia, leukopenia, leukocytosis, acute
intermittent porphyria.
Skin: pruritic and erythematous rashes, urticaria,
toxic epidermal necrolysis, Stevens-Johnson syndrome (see Warnings), photosensitivity reactions,
erythema multiforme, aggravation of disseminated
lupus erythematosus.
Cardiovascular system: congestive heart failure,
edema, aggravation of hypertension, hypotension,
syncope, aggravation of coronary artery disease,

arrhythmias and AV block.
Liver: abnormalities in liver function tests, cholestatic and hepatocellular jaundice, hepatitis, very rare
cases of hepatic failure.
Respiratory system: pulmonary hypersensitivity
characterized by fever, dyspnea, pneumonitis, or
pneumonia.
Genitourinary system: urinary frequency, acute
urinary retention, oliguria with elevated blood pressure, azotemia, renal failure.
Nervous system: dizziness, drowsiness, ataxia,
confusion, headache, fatigue, blurred vision, visual
hallucinations, transient diplopia, oculomotor disturbances, nystagmus, abnormal involuntary movements,
peripheral neuritis and paresthesias, depression with
agitation, and tinnitus.
Gastrointestinal system: nausea, vomiting, gastric distress and abdominal pain, diarrhea, constipation, anorexia, and dryness of the mouth,
pancreatitis.
Eyes: scattered punctate cortical lens opacities,
conjunctivitis.
Musculoskeletal system: aching joints and muscles, and leg cramps.
Metabolism: fever and chills, syndrome of inappropriate antidiuretic hormone (ADH) secretion,
water intoxication with decreased serum sodium

(hyponatremia) and confusion.
Other: multi-organ hypersensitivity reactions
occurring days to weeks or months after initiating treatment have been reported in rare cases. Signs or
symptoms may include fever, skin rashes, vasculitis,
lymphadenopathy, disorders mimicking lymphoma,
arthralgia, leukopenia, hepatosplenomegaly, and abnormal liver function tests. These signs and symptoms may
occur in various combinations and not necessarily concurrently. Signs and symptoms may initially be mild.
References
1. Micromedex Healthcare Series: http://www.thomsonh

c.com/hcs/librarian/ND_T/HCS/ND_PR/Main/CS/A
9C255/DUPLICATIONSHIELDSYNC/08B79F/ND_
PG/PRIH/ND_B/HCS/SBK/1/ND_P/Main/PFActionId/
hcs.common.RetrieveDocumentCommon/DocId/
106598/ContentSetId/100/SearchTerm/carbamazepine/
SearchOption/BeginWith.
2. Wiffen PJ, McQuay HJ, Moore RA. Carbamazepine for
acute and chronic pain in adults. Cochrane Database
Syst Rev 2005;3:CD005451. DOI: 10.1002/14651858.
CD005451.
3. Eisenberg E, River Y, Shifrin A, et al. Antiepileptic
drugs in the treatment of neuropathic pain. Drugs
2007;67(9):12651289.
305
Section 6
Chapter
74
Lamotrigine
Laurie Yonemoto
Generic Name: lamotrigine

Brand/Proprietary Names: Lamictal, Lamictin,
Lamogine
Drug Class: anticonvulsant analgesic
Manufacturer: GlaxoSmithKline, 980 Great West
Road, Brentford, Middlesex, TW8 9GS, UK
Chemical Name: 3,5-diamino-6-(2,3-dichloro
phenyl)-as-triazine
Chemical Formula: C9H7Cl2N
Inroduction
Lamotrigine is an anticonvulsant drug developed by
GlaxoSmithKline in 1994 as an adjunctive treatment of
seizures, both generalized and partial seizures as well
as seizures associated with LennoxGastaut syndrome.
Lamotrigine was later approved in 2003 as an alternative to lithium maintenance therapy to prevent and
treat depressive symptoms in bipolar I disorder without triggering mania, hypomania, or rapid cycling.
Lamotrigine may also possess antinociceptive and
antineuropathic properties. Several recent clinical
evaluations have found that lamotrigine is effective in
controlling neuropathic pain associated with diabetic
neuropathy, phantom limb pain, trigeminal neuralgia,
HIV polyneuropathy and complex regional pain syndrome [13].
Mode of activity
306
Although the exact mechanism of action is not known,

in vitro pharmacological studies suggest that lamotrigine, like other anticonvulsant-class analgesics, acts
by inhibiting voltage-sensitive sodium channels thus
blocking the release of excitatory and noxious neurotransmitters such as glutamate and aspartate. In ani-
mal studies lamotrigine was found to inhibit selective

NMDA subunits (NR2B) without important sensory
or motor impairment [2,3].
Eisinberg and colleagues [4] evaluated clinical
investigations of lamotrigine for the treatment of various forms of neuropathic pain. They identified five
open trials and six out of seven controlled trials that
identified measurable analgesic efficacy. Many of these
trials were hypothesis-driven clinical evaluations performed in patients with either intractable pain or in
those not responding to standard anti-neuropathic
therapy. Some were small randomized studies that
were not well controlled, or individual case reports.
Duvulder and De Laat [5] evaluated 20 patients
with chronic, neuropathic pain not responding to
interventional therapy who were treated with lamotrigine, as monotherapy or in combination with oral
morphine. The latter occurred in patients who lost
pain relief from morphine after time. Ten patients did
not respond to the drug; four were temporary responders and six patients obtained sustained pain relief.
These authors noted that five patients regained opioid
responsiveness and that lamotrigine plus morphine
combination produced excellent pain relief for more
than 5 months. The most compelling case was a patient
with spinal cord tumor, who was using 3600 mg oral
morphine, yet complained of inadequate relief. After
receiving lamotrogine (200 mg/day) morphine consumption was reduced significantly and and pain relief
was improved. Based on these observations, the
authors recommended follow-up control trials to
evaluate the possible synergy between lamotrigine
and opioids.
Radicular pain syndromes caused by disk herniation are often difficult to treat.
In a patient with severe radicular pain and central
cord syndrome, the addition of lamotrigine 100200
mg/day over a period of 6 weeks reduced pain intensity scores from 100mm down to 20mm and greatly
improved quality of life [6].
Chapter 74 Lamotrigine
Figure 74.1.
efficacy as an adjunctive treatment of neuropathic

pain.
N
Cl
Metabolic clearance/elimination
N
Cl
H2N
NH2
The safety and efficacy of lamotrigine was evaluated in 68 patients with chronic neuropathic pain who
had failed at least two or more other anti-neuropathic
medications [7]. Patients were started on lamotrigine
at a dose of 50 mg/day for 2 weeks, increased to 100
mg/day for 2 weeks and titrated upward by 50 mg/day
at weekly intervals. The target dose was 200 mg/day.
Thirty-eight percent of patients responded to lamotrigine and reported reductions in pain intensity. It was
most effective in patients with diabetic neuropathy,
followed by post-herpetic neuralgia, trigeminal neuralgia, peripheral neuropathy and central pain. Most
patients with radiculopathy were non-responders as
were patients with atypical head pain and failed back
syndrome. The average dose of lamotrigine in responders was 300 mg/day while the average dose in nonresponders was 160 mg/day. Four patients discontinued
due to side effects.
One negative trial was published by Silver and
co-workers [8]. They performed a double-blind, placebo-controlled study which was undertaken to
evaluate the efficacy and tolerability of lamotrigine
added to gabapentin, a tricyclic antidepressant, or a
non-opioid analgesic in patients with inadequately
controlled neuropathic pain. Patients were randomized to receive doses of lamotrigine 200, 300, or
400 mg daily (n = 111) or placebo (n = 109) for up to
14 weeks, in addition to their prestudy analgesic
regimen. No statistically significant difference in the
mean change in pain-intensity score from baseline
to week 14 (primary endpoint) was detected between
lamotrigine and placebo (P = 0.67). Lamotrigine
was generally well tolerated but did not demonstrate
Lamictal is well absorbed when given orally with negligible first-pass metabolism. Lamictal has a bioavailbility of 98% which is not affected by food with peak
plasma concentrations occurring 1.44.8 hours following drug administration. In vitro studies show that
lamotrigine is approximately 55% bound to plasma
proteins, suggesting that clinically significant interactions with other drugs through competition for protein binding sites is very unlikely [2,3,9].
Lamotrigine is metabolized by glucuronic acid
conjugation resulting in the production of an inactive
metabolite 2-N-glucoronide. The majority of lamotrigines clearance is via renal excretion as glucuronide
conjugates with a minor amount excreted in feces.
Lamotrigine has an elimination half-life of 2533
hours. This elimination half-life is increased in patients
with renal failure and hepatic impairment [9].
Contraindications
Absolute contraindications to lamotrigine include
any hypersensitivity reaction to Lamictal or any component for the formulation. Relative contraindications or concerns to administration of lamotrigine
include hypersensitivity to antiepileptic drugs, in
patients with renal or hepatic impairment, and in
patients on valproic acid, as this has been shown to
increase the incidence of rash. Lamotrigine inhibits
dihydrofolate reductase. In studies on pregnant rats,
administration of Lamictal resulted in decreased concentrations of fetal and maternal folate levels, which
are frequently associated with teratogenesis and fetal
abnormalities such as cleft lip or palate. Due to the
potential increased risk of teratogenesis, lamotrigine
is not advised for use during the first trimester of
pregnancy [2,9].
Table 74.1. Lamictal doses
Disorder
Recommended dosage
Partial and generalized seizures
Initial dose: 25 mg/day for first 12 weeks, increasing dose by 50 mg/day for weeks 34. Titrate
dose to effect. Maintenance dose: 225375 mg/day divided into two doses
Bipolar disorder
Initial dose: 25 mg/day for first 12 weeks, increasing dose by 50 mg/day for weeks 34. Increase
dose to 100 mg/day for week 5. Maintenance dose: 200 mg/day
Neuropathic pain
Initial dose: 50 mg/day for first week with weekly increases of 50 mg/day titrate to effect. In many
patients analgesia is observed with doses up to 300400 mg/day.
307
Table 74.2. Adverse effects
System
Adverse reaction
Cardiovascular
Chest pain (5%), peripheral edema (25%), atrial fibrillation (<1%), tachycardia (<1%)
CNS
Somnolence (9%), fatigue (8%), anxiety (5%), ataxia (25%), suicidal ideation (25%),
agitation (15%), emotional lability (15%)
Dermatological
Rash (non-serious 7%), dermatitis (25%), dry skin (25%), acne (<1%), alopecia (<1%),
StevensJohnson syndrome (<1%)
Endocrine
Dysmenorrhea (5%), increased libido (25%), menorrhagia (<1%)
Gastrointestinal
Nausea (714%), vomiting (59%), dyspepsia (7%), xerostomia (26%), constipation (5%),
weight loss (5%), weight gain (15%), anorexia (25%), flatulence (15%)
Genitourinary
Urinary frequency (15%), urinary incontinence (<1%), hematuria (<1%)
Neuromuscular and skeletal
Back pain (8%), weakness (25%), myalgia (15%), paresthesia (1%), rhabdomyolisis (<1%)
Ocular
Nystagmus (25%), photophobia (<1%), conjunctivitis (<1%), dry eyes (<1%)
Hematological
Disseminated intravascular coagulation, hemolytic anemia, leukopenia, neutropenia,

pancytopenia, red cell aplasia, thrombocytopenia (<1%)
Table 74.3. Cost
Brand
Generic
25 mg
$4.67/tab
$3.86
100 mg
$5.33
$4.00
150 mg
$5.83
$4.95
200 mg
$6.50
$5.39
Common doses/uses
Lamotrigine (Lamictal) is available as an oral regimen in 25 mg, 100 mg, 150 mg and 200 mg tablets.
Only whole tablets are recommended for use and
doses should be rounded down to the nearest whole
tablet. It is recommended that Lamictal therapy be
initiated at low doses and slowly escalated over the
first 4 weeks of therapy to minimize adverse side
effects such as skin rash (see Table 74.1).
308
Lamotrigine is relatively easy to use, is well tolerated

and has a safe pharmacological profile. The high bioavailability with oral administration adds to lamotrigines easy administration and, unlike other
anti-epileptic drugs, it has no significant metabolic
or neurological effects and does not require laboratory testing of plasma concentrations. Lamotrigine
can be used as a monotherapy in the treatment of
chronic neuropathic pain syndromes such as dia-
betic neuropathy and trigeminal neuralgia by inhibiting neuronal transmission of pain signal and
sparing the use of opioids in these types of pain syndromes.
Adverse events
See Table 74.2.
Cost
See Table 74.3.
References
1. Barash PG, Cullen BF, Stoelting RK, Cahalan MK,

Stock MC. Clinical Anesthesia, 6th ed. Philadelphia:
Lipincott Williams & Wilkins, 2009.
2. Maizels M, McCarberg B. Antidepressants and
antiepileptic drugs for chronic non-cancer pain. Am
Fam Physician 2005;71:483490.
3. Sadok B, Sadok V. Concise Textbook of Clinical
Psychiatry, 3rd ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, pp. 51514.
4. Eisenberg E, Shifrin A, Krivoy N. Lamotrigine for
neuropathic pain. Expert Rev Neurother 2005;5(6):729735.
5. Devulder J, Martine De Laat M. Lamotrigine in the
treatment of chronic refractory neuropathic pain. J
Pain Symptom Manage 2000;19:398406.
6. Titlik M, Junuk I, Tonkic A, et al. Lamotrigine therapy
for resistant pain in radicular lesions. Acta Clinica
Croat 2009;48:157160.
Chapter 74 Lamotrigine
7. Gabriela-Gregory M, Semenchuck RM.

Lamotrigine is effective in refractory neuropathic
pain 2002; Poster presentation, 10th World
Congress on Pain.
8. Silver M, Blum D, Grainger J, et al. Double-blind,
placebo-controlled trial of lamotrigine in
combination with other medications for

neuropathic pain. J Pain Symptom Manage
2007;34:446454.
9. Stoelting R, Hiller S. Pharmacology & Physiology in
Anesthetic Practice, 4th ed. Philadelphia: Lippincott
Williams & Wilkins, 2006, pp. 569579.
309
Section 7
Chapter
75
NMDA Antagonists
Overview of NMDA receptors

and antagonists
R. Todd Rinnier, Michael E. Goldberg and Marc C. Torjman
NMDA receptors and receptor agonists

General description of the receptor
310
The N-methyl-d-aspartate (NMDA) receptor is classified as part of the larger family of glutamate receptors
often referred to as a superfamily. The primary role of
the glutamate receptor is to process rapid synaptic
transmission of an excitatory nature throughout the
nervous system. It performs this function utilizing a
group of receptors located on the cell membrane.
These can be divided into ionotropic and metabotropic receptors. The primary ionotropic receptors in
the glutamate superfamily are the alpha-amino-3-
hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)
receptors, kainate receptors, and N-methyl-d-aspartate (NMDA) receptors. The nomenclature for these
receptors is derived from the synthetic agonists that
result in activation of said receptors [19].
The NMDA receptor, along with the AMPA receptor, have been implicated in the processing and mediation of acute and chronic pain [20]. The NMDA
receptor is associated with persistent changes within
neurons of patients with pain. The activation of these
receptors leads to removal of a magnesium ion plug
followed by calcium entry into the postsynaptic neuron along with other biochemical events such as c-Fos
transcription and G-protein activation. These events
allow development of CNS plasticity at a cellular level
which is expressed as long-term potentiation. The
NMDA receptor is a ligand-gated ion channel recognized for some of its unique characteristics. It exerts
its effects on a cation channel that is very permeable to
calcium and monovalent ions. In order to activate the
receptor, simultaneous binding of glutamate and glycine are required. In its resting state the NMDA receptor is blocked by magnesium [7]. Activation of this
receptor may also occur via polyamine stimulation.
NMDA receptor modulation can occur through arachidonic acid, while it is inhibited by zinc ions [19].
The receptor will only open when both binding of agonist and simultaneous depolarization occur.
Receptor structure
Structurally, the NMDA receptor has been described
to contain four transmembrane (helical domains)
channels that utilize both glycine and glutamate for
activation. The primary result of this activation is
transmembrane influx of calcium ion. Additionally
when the NMDA receptor membrane channel is iso
electric, the receptor is blocked by magnesium. The
magnesium block will only be released by simultaneous depolarization and receptor agonist binding [20].
By exploiting the receptor activation and inactivation
through the use of various compounds, the NMDA
receptor can be manipulated to facilitate pain relief.
NMDA receptors are further divided into three
subunits: NR1, NR2 (subunits: A, B, C, D) and NR3
(subunits: A, B). A combination of the essential
channel-forming subunit NR1 and one or more of
the NR2 subunits is vital for the expression of a functional NMDA receptor. Studies have demonstrated
that the NR2B subunit has specifically been most
involved in the process of nociception, and thus a
target for drug therapy aimed at reducing pain [20]
(Figure 75.1).
Receptor function
These receptors function in the excitatory neurotransmission pathway in the CNS, together with various
excitatory amino-acid receptors. The activity of glutamate excitatory neurotransmission is a complex process
that involves co-transmission and summation. The
effectiveness of the active transporter mechanisms
responsible for clearing glutamate from the synaptic
cleft heavily influences the activity of these receptors. At
a cellular level, the permeability of calcium in the CNS
is controlled by excitatory neurotransmission. This
explains why excitatory neurotransmission exerts its
Chapter 75 Overview of NMDA receptors and antagonists
A: Activated
NMDAR
Glutamate
Glutamate
binding
site
Allosteric binding site

Glycine
Glycine binding site
Cell membrane
2+
Ca
B: Competitive
antagonist
Glutamate
channel
Figure 75.1. Activated NMDA receptor

and assorted NMDA receptor blockers.
(With permission from Kim AH, Kerchner
GA, Choi DW. (2002). Blocking
excitotoxicity. In CNS Neuroproteciton.
Marcoux FW Choi DW, eds. Springer,
New York. Pages 336.)
Intracellular
space
C: Glycine
antagonist
Competitive
antagonist
Glycine
Glycine site
antagonist
Glutamate
binding
site
D: Noncompetitive
antagonist
Noncompetitive
antagonist
Allosteric
site
E: Uncompetitive
antagonist
Channel
blocker
effects immediately, but over the long term induces synaptic plasticity. Synaptic plasticity is the process by
which neural circuits modify their strength or efficacy
of synaptic transmission at preexisting synapses [8].
Several mechanisms exist that make this possible,
including changes in the quantity of neurotransmitters
in the synapse, and the effectiveness of the cells ability
to respond to these neurotransmitters. Synaptic plasticity is a fundamental neurobiological process involved in
learning and memory development. The basic mechanism behind these processes bears a striking resemblance to those involved in the processing of pain
transmission [7]. NMDA receptors also play an integral
role in the CNS, such that antagonists to these receptors
can have serious neurological consequences, including
psychotomimetic effects, memory impairment, motor
impairment, and ataxia to name a few [20].
NMDA receptors also appear in the spinal dorsal
horn where, with NMDA receptor activation, ion channels
are opened, intracellular calcium levels rise leading to

increased levels of protein kinase C. There is a concomitant decrease in the sensitivity of the mu opioid receptor [13]. Protein kinase C activation, in vitro, occurs
following the activation of mu opioid receptors, resulting in NMDA activation and increased glutamate
response. It is these excitatory neurotransmitters,
glutamate and aspartate, that work on the NMDA
receptors to create and maintain continued chronic
pain states [18]. Multiple and intense stimulation
causes the NMDA receptor to become activated. This
can create a long-term rise in cell excitability due to
calcium influx, thereby initiating the second-messenger effect. In the spinal cord dorsal horn, NMDA receptors are heavily expressed at nociceptive synapses. Both
chronic pain and opioid tolerance can sensitize the central pain pathways and result in an NMDA receptormediated increase in dorsal horn synaptic efficacy [14].
NMDA receptor antagonists reduce central sensitization,
311
NMDA Antagonists Section 7
Clinical studies have shown that activation of the

NMDA receptor results in increased pain and the
development of neuropathic pain, including opioidresistant pain [6]. NMDA receptors have a substantial
role in synaptic plasticity including CNS facilitation of
the pain processing pathway [7]. N-Methyl-d-aspartate
receptor antagonists are known to modulate central
sensory processing, are potent antihyperalgesics,
potentiate opioid-induced analgesia, and prevent the
development of opioid tolerance [1]. Many compounds
including ketamine, amantidine, memantine, dextromethorphan, and magnesium ions have been utilized in both clinical practice and research protocols
for pain modulation. Several of these clinical effects
will be described in greater detail by other authors.
It is through varied receptor activation and inactivation mechanisms that these compounds are able to
exert their effect to modulate the pain response.
limb amputation [1,3]. A recent systematic review concluded that out of the 24 studies that examined ketamine, 58% demonstrated a positive effect in blocking
pain. IV ketamine showed positive results in nine
studies, and negative results in seven studies when
administered to provide analgesia. Epidural or intrathecal administration was effective in four studies, negative in three studies, while subcutaneous administration
showed positive results in one study [17]. With respect
to pediatric use, a recent study suggested a ketaminerelated opioid-sparing effect. Eight out of eleven children or adolescents with advanced cancer who were
taking high-dose opioids had positive results with
the addition of a low-dose ketamine infusion (0.11
mg/kg per h) for 175 days. There was a concomitant
reduction in opioid consumption, improved pain control, and improved alertness and interactiveness [18].
Moreover, these patients did not experience psychotropic effects, attributable to 0.025 mg/kg lorazepam
given every 12 hours to protect against these untoward
effects. Ketamine has therefore demonstrated some
promise in the area of chronic pain and future studies
are needed with focus on route of administration, timing of dose, and more interestingly, the effect of ketamine metabolites.
Ketamine
S-(+)-Ketamine
Ketamine, a phenyl-piperidine derivative, is a noncompetitive NMDA receptor antagonist which exerts its
effect through a conformational change resulting in
release of the magnesium block and transmembrane
influx of calcium [20]. The compound is rapidly distributed in the brain and other highly perfused tissues, with
about 10% of the drug bound to plasma. The bioavailability of ketamine is dependent on the route of administration, being as high as 93% for an intramuscular
dose, 2050% for an intranasal dose, and approximately
20% for an oral dose. Recent treatment with anesthetic
doses of ketamine for severely ill, generalized chronic
regional pain syndrome (CRPS) patients has shown
some efficacy and prompted its use in less severely ill
patients by low-dose infusion [22]. Goldberg et al. also
showed that a 4 hour infusion of sub-anesthetic doses
of ketamine over a 10 day period in the outpatient setting resulted in a significant reduction of pain with
increased mobility, and a tendency to decreased autonomic dysregulation. Numerous studies involving animals and humans have demonstrated its opioid-sparing
effect and potentiation of opioid-induced analgesia, as
well as ability to decrease phantom limb pain after lower
Ketamine exists as a chiral compound with two optical enantiomers: S-(+) and R-() ketamine. The analgesic potency of the dextro- S- (+) form is two- to
four-times that of the levo- R-() form.[27]. In addition, animal model receptor studies have shown that
S-(+)-ketamine displays a four-fold greater affinity on
the NMDA receptor phencyclidine binding sites compared to R-()-ketamine [28]. The S-(+) enantiomer
inhibits serotonin transport half as much as the enantiomer. Compared to racimic ketamine, the S-(+) form
has a significantly higher elimination rate. S-(+)-Ketamine has a therapeutic index (LD50/ED50) 2.5 greater
than that of racimic or R-()-ketamine. Even though
the potency is greater allowing for a decreased effective dose, evidence for a lowered side-effect profile is
lacking between S-(+) and that of racemic ketamine.
However, due to the decreased effective dose and
higher elimination rate for S-(+)-ketamine, the recovery time seems to be faster [28]. Recently, S-(+)-ketamine was shown to decrease acute pain in CRPS
patients, with long-term effects lasting beyond the
infusion period when drug levels were well below the
analgesic threshold [27].
which has been shown to prevent the development of

persistent pain in animal studies [1]. NMDA receptors
are found not only centrally but also in the periphery,
encompassing both visceral and somatic structures
[20].
Clinical pharmacology
312
Amantidine
Amantidine was first approved in 1966 as an antiviral
agent that works by disrupting the function of the
transmembrane domain of the viral M2 protein effectively blocking the release of infectious viral nucleic
acid into the host cell. It has also been shown in some
cases to interrupt virus replication by stopping virus
assembly. Amantidine was later found to possess antiparkinsonian properties through its direct and indirect effects on dopamine neurons, as well as its effects
on NMDA receptors. Recent interest for its use in pain
management is attributed to its weak noncompetitive
NMDA antagonism (Ki = 10 M) [25] which may be
useful in decreasing pain and analgesic requirements
by preventing post-operative central sensitization,
opioid-induced hyperalgesia, and acute opioid tolerance. Interestingly, it displays anticholinergic-like side
effects (dry mouth, urinary retention, and constipation) [25]; however, animal studies have yet to show
direct anticholinergic activity [26]. One study showed
that given pre- and post-operatively, amantidine was
able to decrease opioid consumption in post-operative
radical prostatectomy patients [15]. Another study
showed that when compared to lidocaine, it failed to
decrease sciatic-related pain effectively. There are conflicting data regarding amantidines use in pain management and it appears that this agent may be better
suited as an antiviral and antiparkinsonian therapy.
Dextromethorphan and derivatives

Dextromethorphan, administered intravenously, intramuscularly, or orally has been used for over 40 years
[1]. It is a central antitussive agent that exerts its effect
by increasing the cough threshold in the medulla
oblongata [23]. It is the d-isomer of the codeine analog
levorphanol [7]. Dextromethorphans active metabolite, dextrorphan, is a low-affinity noncompetitive
NMDA receptor antagonist. It has a weak affinity for
the mu opioid receptor and, according to several investigations, has either very weak or no analgesic properties [6,7]. The drug has extensive first-pass metabolism
and the oral bioavailability of the drug is low [7]. In
experimental animal studies, dextromethorphans use
exhibited inhibited expression of central sensitization
including a facilitated response to sensory inputs,
hyperalegsia, and wind-up pain. There are conflicting
data concerning dextromethorphans use in the acute
pain (peri-operative) setting as post-operative pain
relief studies have not shown much benefit [7]. More
importantly, in a recent review of 12 studies that examined dextromethorphan, 67% demonstrated clinically
significant analgesia. The positive studies (pain relief)
used both oral and IV/IM routes, while the negative
studies used only the oral form. The dosage given did
not appear to be associated with success of treatment,
varying from 0.5 mg/kg to 150 mg [17]. Dextromethorphans use in chronic pain has demonstrated mixed
results. Therefore its role in chronic pain is still uncertain. The dose necessary for effective pain management
increases its side-effect profile, raising concerns of its
potential for abuse [23]. Aside from antitussive use,
and mixed results in chronic pain, dextromethorphan
has shown some additional usefulness in the treatment
of cancer-related pain, as well as methotrexate-induced
neurotoxicity [23].
Magnesium
Magnesium is a naturally occurring mineral and is
the fourth most abundant mineral in the body. Magnesium is a vital component of homeostasis and is
responsible for maintaining normal nerve and muscle function, supporting immune system functions,
regulating blood sugar, supporting healthy bones,
promoting normal blood pressure, maintaining a
normal heart rhythm, and is a key component in
energy metabolism and protein synthesis [21]. Magnesium ions function as noncompetitive NMDA
receptor antagonists that modulate NMDA receptor
activation by preventing extracellular calcium from
gaining entry into the cell. Experimental animal
models of tissue injury and central sensitization have
shown that magnesium, in combination with morphine, created an increased analgesic effect greater
than either drug alone [9]. There is also evidence that
when administered intrathecally, in combination
with morphine, magnesium sulfate potentiated morphine antinociception, suggesting that it also works
on spinal NMDA receptors [10]. Clinical studies have
shown conflicting evidence on intravenous magnesium administration to reduce analgesic requirements
or post-operative pain. Recently, it was shown that
intravenous magnesium given as a bolus, followed by
continuous infusion after extubation in cardiac surgery patients, moderately decreased remifentanil
dose required for post-operative pain management
[24]. A current review of IV magnesiums clinical efficacy concluded that none of the four studies examined demonstrated a preventative analgesic effect
greater than standard therapies [17]. One possible
313
explanation of magnesiums lack of efficacy is that it

may be removed from the extracellular space too rapidly, or that the ion is specific to the NMDA channel,
but not to the receptor site where other NMDA receptor antagonists bind and exert their effect [17].
Another explanation is that the dose may be insufficient, as studies using bolus dosing have not shown
magnesium to be as efficacious as those using bolus
and continuous infusions. Based on available data,
magnesiums potential seems to be as an adjuvant as
opposed to monotherapy.
Memantine
314
Memantine is an oral long-acting voltage-dependent

uncompetitive NMDA receptor antagonist with a
high therapeutic index approved for the treatment of
Alzheimers disease [14]. In addition, it acts as an
uncompetitive antagonist at the 5HT3 receptor and as
a noncompetitive antagonist at different neuronal
nicotinic acetylcholine receptors which may also be
responsible for the processing of pain. There is also a
weak to negligible affinity for adrenergic, benzodiazepine, dopamine, GABA, glycine, and histamine
receptors, in addition to voltage-dependent Ca2+, Na+
or K+ channels [25].
Its greatest potency is achieved as compared to
other NMDA antagonists when given intrathecally as
demonstrated in animal studies [1]. Memantine may
have several advantages compared to ketamine, displaying a higher potency, longer elimination half-life
(6080 hours vs. 2.5 hours), and a decreased sideeffect profile [1]. Memantines adverse effects are much
milder than ketamines, including dizziness and restlessness which disappear with discontinuation [14].
Memantines tolerability may be explained by its low
affinity to the receptor-associated ion channel with
resultant decreased dwell-time in the channel, in addition to preferential blockade of pathologically overactivated channels [14]. One study has shown
memantine (30 mg/day for 4 weeks) to decrease phantom limb pain, citing a four-fold decrease 6 months
after amputation [4]. One unique application has been
described in a recent case report of a patient with metastatic liposarcoma and opioid-refractory pain that
responded to low-dose IV ketamine, and then was
successfully transitioned to oral memantine for longterm outpatient pain management [14]. Memantine,
although useful for Alzheimers disease, has demonstrated some clinical usefulness in acute and chronic
pain management and warrants further study.
Neramexane
Neramexane is an oral moderate-affinity, strong voltage-dependent, open-channel, uncompetitive NMDA
receptor antagonist [29]. This drug prevents pathological activation of the NMDA receptor, but maintains the physiological activity relating to its minimal
side-effect profile. Like memantine, neramexane displays rapid blocking/unblocking kinetics leading to
its minimal side-effect profile at therapeutic doses.
Currently, neramexane is under development for
various central CNS disorders as a potential neuroprotectant. Neramexane was recently shown to have a
marked analgesic effect in response to intradermal
capsaicin injection which represented a surrogate
model of neurogenic hyperalgesia [30]. It is currently
in various phases of drug trials for Alzheimers disease, drug and alcohol abuse, depression, tinnitus,
and chronic pain.
Methadone
Methadone is a synthetic opioid agonist that may have
some potential as it also functions as a weak NMDA
antagonist [6]. Several authors will discuss these drugs
as well as other drugs in greater detail in following
chapters.
References
1. Suzuki Manzo. Role of N-methyl-D-asparate receptor

antagonists in post-operative pain management. Curr
Opin Anaesthesiol 2009;22.
2. Michelet P, Guervilly C, Helaine A, et al. Adding
ketamine to morphine for patient-controlled analgesia
after thoracic surgery: influence on morphine
consumption, respiratory function, and nocturnal
desaturation. Br J Anaesth 2007;99:396403.
3. Wilson JA, Nimmmo AF, Fleetwood-Walker SM,
Colvin LA. A randomized double blind trial of the
effect of preemptive epidural ketamine on persistent
pain after lower limb amputation. Pain 2008;135:
108118.
4. Schley M, Topfer S, Weich K, et al. Continuous
brachial plexus blockade in combination with NMDA
receptor antagonist memantine prevents phantom
limb pain in acute traumatic upper limb amputees.
Eur J Pain 2007;11:299308.
5. Jantus D, Lason, W. Different mechanisms of
NMDA-mediated protection against neurinal
apoptosis: a stimulus-dependant effect. Neurochem Res
2009; 10.1007/s110640099991-y.
6. Lucas L, Lipman A. Recent advances in

pharmacotherapy for cancer pain management.
Cancer Practice 2002;10:suppl. 1.
7. Kock M, Lavandhomme P. The clinical role of NMDA
receptor antagonists for the treatment of postoperative
pain. Best Pract Res Clin Anesth 2007;21:8598.
8. Malenka R. Synaptic plasticity. In
Neuropsychopharmacology: 5th Generation of Progress.
Nashville, TN: American College of
Neuropsychopharmacology, 2002.
9. Begon S, Pickering G, Eschalier A, Dubray C.
Magnesium increases morphine analgesic effect in
different experimental models of pain. Anesthesiology
2002;96:627632.
10. Kroin JS, McCarthy R, Von Roenn N, et al.
Magnesium sulfate potentiates morphine at the spinal
level. Anesth Analg 2000;90:913917.
11. Liu HT, Hollmann M, Lui WH, et al. Modulation of
the NMDA receptor function by ketamine and
magnesium: Part 1. Anesth Analg 2001;92:11731181.
12. Ilkjaer S, Bach LFL, Nielsen PA, et al. Effect of
perioperative oral dextromethorphan on immediate
and late postoperative pain and hyperalgesia after total
abdominal hysterectomy. Pain 2000;86:1924.
13. Suzuki M, Kinoshita T, Kikutani T, et al. Determining
the plasma concentration of ketamine that enhances
epidural bupivacaine-and-morphine-induce analgesia.
Anesth Analg 2005;101:77784.
14. Grande LA, ODonnell BR, Fitzgibbon DR, Terman
GW. Ultra-low dose ketamine and memantine
treatment for pain in an opioid-tolerant oncology
patient. Int Anesth Res Socy 2008;107(4).
15. Snijdelaar DG, Koren G, Katz J. Effects of
perioperative oral amantadine on postoperative pain
and morphine consumption in patients after radical
prostatectomy: results of a preliminary study.
16. Galer BS, Lee D, Ma T, et al. MorphiDex (morphine
sulfate/ dextromethorphan hydrobromide
combination) in the treatment of chronic pain: three
multicenter, randomized, double-blind, controlled
clinical trials fail to demonstrate enhanced opioid
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17. McCartney C, Sinha A, Katz J. A qualitative systematic

review of the role of N-methyl-D-aspartate receptor
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18. Finkel JC, Pestieau SR, Quezado ZM. Ketamine as an
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315
Section 7
Chapter
76
NMDA Antagonists
Ketamine
Carsten Nadjat-Haiem
Generic name: ketamine hydrochloride

Trade names: Anesject, Brevinaze, Keiran,
Keta, Ketaject, Ketalar, Ketalin, Ketamax
Drug class: NMDA receptor antagonist, centralacting analgesic
Manufacturers: Pfizer Pharmaceuticals, 235
East 42nd Street, New York, NY
Chemical name: (RS)-2-(2-chlorophenyl)- 2-methylaminocyclohexan-1-one
Chemical Formula: C13H16ClNO; molecular
wt 238
Introduction
Ketamine is a central-acting anesthetic and analgesic. It was developed by Calvin Stevens at Parke-Davis
in 1962 in an effort to synthesize a drug with fewer
side effects than phencyclidine and cyclohexamine.
Ketamine was originally named C1581, and was patented in 1965 and sold under the trade name Ketalar.
Ketamine was officially released for human use in
1970 and was used extensively during the Vietnam
War [1].
Ketamine has a molecular weight of 238 and is
partially soluble at pH 7.4 (pKa 7.5). All commercial
ketamine is composed of a racemic mixture of the
R- and S- enantiomers, and is prepared in an acidic
solution with a pH between 3.5 and 5.5.
Mode of activity
316
Ketamine(2-(O-chlorophenyl)-2-methylamino
cyclohexanone) is a nonbarbituate anesthetic/analgesic agent structurally related to phencyclidine and
cyclohexamine. The drug is water-soluble, and has
a lipid solubility about 10 times that of thiopental.
Ketamine is the only single-agent anesthetic capable
of producing dissociative anesthesia [1,2]. The agent

provides potent analgesia even at sub-anesthetic
doses. It is believed that analgesic and anesthetic
actions are due to different mechanisms. There are
many hypotheses proposed to explain the clinical
effect of ketamine. These include binding and antagonism at the N-methyl-d-aspartame (NMDA) receptors in the central nervous system, interactions with
opiate receptors at both the spinal and central levels,
and interactions with muscarinic cholinergic, serotoninergic, and norepinephrine receptors. This is evidenced by the fact that some of the effects of ketamine
are reversed by antagonists at the opioid level
(naloxone), and the muscarinic cholinergic level
(4-aminopyrdine and physostigmine).
Ketamine is a rapidly acting anesthetic and analgesic. It can be given intravenously, intramuscularly,
nasally, orally, rectally, epidurally, spinally, and topically. The initial anesthetic response if given intravenously is seen after 3040 seconds, while a response
after intramuscular administration is seen after 34
minutes. Nasal administration results in a response
after 812 minutes. Analgesic effects after intramuscular, oral, and epidural injection are 1015, within
30, and within 1530 minutes, respectively.
Bioavailability of ketamine is 9093% after intramuscular injection, 16% after oral administration, and
77% after epidural injection. Protein binding of ketamine is 47%, and it is initially distributed to highly
perfused tissues such as brain, heart, and the lungs.
There the concentration can reach up to five times the
plasma concentration. Redistribution is similar to
thiopental. The distribution half-life after intravenous
administration is 7 to17 minutes, and the volume of
distribution is 2 to 3 L/kg.
Ketamine is extensively metabolized in the liver
via N-demethylation via the cytochrome P450 system
to yield norketamine. This metabolite has one-third
the activity of the parent compound, and is subsequently hydroxylated and conjugated to become a
Chapter 76 Ketamine
Figure 76.1.
Cl
O
NH
water-soluble compound. Subsequently, the metabolites (hydroxylated and conjugated compounds, 3%

unchanged as norketamine) are cleared by the kidney.
The clearance rate is 1217 mL/min per kg, yielding a
mean residence time of about 3 hours in adults, which
also reflects the approximate elimination half-life.
Indications
Ketamine has many indications and uses, but is only
FDA-approved as an adjunct for general anesthesia
and procedural sedation. Ketamine is useful for short
procedures due to its relatively rapid induction and
emergence, and is particularly helpful in the management of patients in whom cardiovascular depression
is to be avoided (pericardial tamponade, cardiogenic
or hypovolemic shock, non-ischemic cardiomyopathy,
and constrictive pericarditis). It can be used for induction of general anesthesia for cesarean sections. The
potential ketamine-induced emergence reactions can
be minimized with concomitant administration of a
benzodiazepine, and cardiovascular effects of potential tachycardia and hypertension can be well managed with the use of beta-blockers and clonidine. The
use of glycopyrrolate as an antisialagogue is also advisable. Ketamine is approved for short-term procedural
sedation not requiring skeletal muscle relaxation, and
has been used extensively in children undergoing cardiac interventional procedures, either as the sole
agent, or with the use of propofol, midazolam, opioids,
and others.
The non-FDA-approved indications are discussed
below. One of the most encountered clinical scenarios
is the use of ketamine as an analgesic for sedation
(gastroenterological procedures, biopsies, painful
emergency room procedures, burn dressing changes,
lumbar punctures, etc.), especially in patients with a
history of bronchospasm. It is frequently used as an
adjunct to local anesthesia alone, or with the use of
propofol and midazolam.
Ketamine potentiates opioid-induced analgesia and
hence has an opioid-sparing effect [2]. Co-administered
with an opioid it can reduce the incidence of opioid

side effects such as respiratory depression and psychotropic side effects. One successful combination if used
in patient-controlled analgesia (PCA) is ketamine and
morphine sulfate in a 1:1 ratio on a milligram basis
with a dosing interval of 8 minutes. If patients continue
to experience pain despite this regimen it is inadvisable
to increase the dose further because excessive sedation
and psychotropic side effects due to ketamine may
arise. One has to realize that this dosing regimen may
need to be altered taking into account patient factors,
use of adjunct analgesics, and anesthetic regimen used
during surgery. Another way to potentiate opioid analgesia is to provide for a ketamine infusion. The target
serum concentration of ketamine is probably anywhere
between 50 and 100 ng/mL. This corresponds to a continuous infusion to reach 2 mg/kg per day. One must
realize that the contribution of ketamine to analgesia in
both the PCA and continuous infusion regimen to
analgesia is probably small, but coupled with a multimodal approach (epidural use, peripheral nerve blocks,
NSAIDs, tramadol) pain relief can be excellent. This
multimodal approach may also reduce the risk of opioid-induced hyperalgesia due to overall reduced opioid
requirements.
Ketamine may be ideal to treat post-operative
pain after adenotonsillectomy. It avoids the feared
risks of bleeding with NSAIDs and respiratory
depression with opioids. Ketamine at a dose of 0.5
mg/kg IV reduces post-operative pain and need for
other analgesics. Peritonsillar infiltration at the
same dose has a similar effect to the intravenous
dose. The time of administration either before the
start or the conclusion of surgery has no bearing on
the analgesic effect. If prolonged pain is anticipated
a ketamine infusion of 0.3 6 mg/kg per h can be
started after the administration of a loading dose of
0.5 mg/kg.
Ketamine may play a role in the prevention of
post-amputation pain and development of phantom
limb pain if given epidurally over a period of 48 hours
at a dose of 0.03 mg/kg per h. Ketamine can be used as
second-line treatment in refractory status asthmaticus
in both adults and children should conventional treatment have failed.
Ketamine may be a good alternative to conventional treatment of bronchospasm on mechanical
ventilation.
There are some limited data showing the use of
ketamine in the treatment of chronic pain. Ketamine
317
in a topical gel is used in the treatment of neuropathic

pain. It has some limited use if administered IV in
terminal cancer patients, but increases duration of
action of epidural morphine in the same group of
patients.
Ketamine may be used to decrease the duration of
a migraine with aura in patients with familial hemiplegic migraine, and can be used to decrease opioid
withdrawal symptoms. It can decrease phantom limb
pain if given IV.
Ketamine has been used extensively in the realm
of electroconvulsive therapy due to its seizure-prolonging effect.
Other off-label indications are second-line
treatment for refractory priapism, pruritus of the
skin secondary to erythroderma, and restless leg
syndrome.
Contraindications
The only absolute contraindication is use in patients
who have a hypersensitivity or allergy to ketamine
products.
Relative contraindications:
1. Mild to severe hypertension, a history of
congestive heart failure, tachyarrythmias, and
myocardial ischemia
2. Acute alcohol intoxication or history of alcohol
abuse
3. Sole use of ketamine in airway surgery
4. Use in the presence of intracranial mass lesions,
head and globe injuries, hydrocephalus, and
increased intracranial pressure
5. Preexisting respiratory depression.
Common doses
318
Ketamine as an adjunct for induction of general

anesthesia in adults is given at a dose of 14.5 mg/kg
IV as a single dose, or as an infusion of 12 mg/kg at a
rate of 0.5 mg/kg per min in addition to small doses of
diazepam or midazolam [2]. Alternatively, it can be
given IM at a dose of 6.513 mg/kg. Maintenance can
be accomplished either with an infusion of 0.010.03
mg/kg per min, or by repeated half or full initial
induction doses.
Procedural sedation doses are 12 mg/kg IV over
12 minutes, followed by 0.250.5 mg/kg IV every
510 minutes.
The rapid-sequence induction dose is 2 mg/kg.
Ketamine is used extensively in the pediatric population, but does not have FDA approval for children
under 16 years of age. Doses for the indications above
are similar for older children, but may be much higher
in younger children.
Oral and rectal administration is less predictable
than the IV and IM routes. A dose for anxiolysis would
be 0.510 mg/kg depending on age.
Topical ketamine gel for neuropathic pain would
be administered at a dose of 0.240.37 mg/kg, and a
typical dose for epidurally administered drug for cancer pain would be 0.20 mg/kg.
Ketamine is an excellent anesthetic, analgesic, and
sedative in specialized settings. It can be used in
patients who cannot tolerate barbiturates, in settings
where cardiovascular depression must be avoided, and
in patients with refractory bronchospasm. It is useful
in one-lung ventilation, asthmatic patients, or when
there is need for an intramuscular route of administration. It is very helpful in specific situations such as
the need for anesthesia in uncontrollable, mentally
retarded patients. It can be simply mixed with syrup if
oral premedication is desired.
Ketamine, in contrast to opioid medications, does
not cause significant respiratory depression.
Ketamine is available in a generic form as either
10 mg/mL or 100 mg/mL solution. It is inexpensive,
and widely available. It can be used either as an adjunct
to the use of opioids or alone, and certainly has an
opioid-sparing effect by all routes of administration.
Ketamine caries the Pregnancy Risk Classification
A, and is compatible with breast feeding according to
the WHO. The Thompson Lactation Rating, however,
does not rule out risk to infants.
Nephrotoxicity or hepatotoxicity have not been
reported.
Although no human studies exist, the use of ketamine
beyond the recommended doses carries some risk.
The LD50 in rats for intraperitoneal ketamine is 100
times the typical intravenous dose and 20 times the
typical human intramuscular dose.
Concomitant ketamine and neuromuscular blocking agent administration causes increased neuromuscular blockade. The use of metrizamide or theophylline
Chapter 77 Memantine
and ketamine increases seizure risk, and use of St Johns

Wart can potentially lead to hypotension and delayed
emergence. The combination of tramadol and ketamine
has the potential for respiratory and central nervous
system depression.

Ketamine can certainly cause tachycardia, systemic and
pulmonary hypertension, and an increased vascular
resistance if not attenuated by appropriate drugs. It can
cause injection site pain and a transient rash, and
hyperglycemia. Anorexia, nausea, and emesis are relatively common after administration of the drug, but
their incidence can be significantly reduced by the concomitant use of propofol. Salivary and tracheobronchial secretions can be well managed by premedication
with an anticholinergic. Ketamine can cause skeletal
muscle hyperactivity, and myoclonus, twitching, vocalization, fasciculations, and rigidity are not uncommon.
Emergence reactions such as vivid dreams, hallucinations, delirium, and confusion are common, and can be
prevented by premedication with a benzodiazepine or
barbiturate, or stopped after their occurrence.
Section 7
Chapter
77
The effect of ketamine on intracranial pressure

remains controversial, but the drug should certainly
be avoided in patients with refractory intracranial
hypertension. Ketamine may cause nystagmus, diplopia, and lacrimation. It may transiently increase intraocular pressure.
It is a potent bronchodilator, but there have been
few cases of laryngospasm.
Ketamine is considered to be a drug of potential
abuse, and is listed as a Schedule III narcotic.
References

Evaluations, Thompson Healthcare. Ketamine, 2009. h
ttp://www.thomsonhc.com/hcs/librarian/ND_T/HCS/
ND_PR/Main/CS/C37C33/DUPLICATIONSHIELDS
YNC/88B073/ND_PG/PRIH/ND_B/HCS/SBK/2/
ND_P/Main/PFPUI/U41ex6J2SR7kKR/PFActionId/
hcs.common.RetrieveDocumentCommon/DocId/
0425/ContentSetId/31#all.
2. Suzuki M. Role of NMDA receptor antagonists for
postoperative pain management. Pending
publication.
NMDA Antagonists
Memantine
Generic Name: memantine hydrochloride

Proprietary Names: Nemenda, Abixa (Lundbeck, Philipp.), Akatinol
Drug Class: N-methyl-d-aspartate (NMDA)
receptor antagonist
Manufacturers: Forest Pharmaceuticals, St Louis,
MO; Grunenthal GmbH 52099 Aachen, Germany

Chemical Name: 1-amino-3,5-dimethyladama
ntane hydrochloride
Chemical Formula: C12H21N; molecular wt 179.3
Introduction
Memantine was first synthesized in the 1960s and
found to antagonize the NMDA receptor in the 1980s.
319
NH2 HCl
Figure 77.1.
CH3
H 3C
Ketamine is one of the most widely known and medically used NMDA receptor antagonists (NMDAR)
and memantine is similar in that it is a noncompetitive NMDA antagonist but is better tolerated in
patients because of multiple theorized properties
including the ability to bind only (or preferentially) to
open channels; the tendency to inhibit faster, or with
higher affinity, at higher agonist concentrations; a
relatively low affinity of inhibition; being an open
channel blocker with a fast off-rate compared with
ketamine [1,2].
Mode of activity
Major sites of action: blockade of current flow through
the NMDA receptor channel.
Minor sites of action: at high concentrations
memantine affects many CNS targets, including
serotonin and dopamine uptake, nicotinic acetylcholine receptors (nAChRs), serotonin receptors,
sigma-1 receptors, and voltage-activated Na+ channels [2,3].

and elimination
Memantine is completely absorbed from the gastrointestinal (GI) tract with maximal plasma concentration
occurring between 3 and 8 hours after oral administration. Food does not influence the bioavailability of
memantine [2]. Approximately 80% of the administered dose remains as the parent drug. The mean terminal elimination half-life is 60100 h.
Indications
Memantine has Food and Drug Administration
approval for Alzheimers disease (moderate to severe),
but has been used in painful medical conditions such
as neuropathic pain.
320
Contraindications
Hypersensitivity to memantine hydrochloride.
1. Concomitant use of drugs that make the urine
alkaline
2. Concomitant use of other NMDA antagonists
3. Genitourinary conditions that raise urine pH;
may increase plasma levels of memantine
4. Moderate to severe renal impairment
5. Seizure disorder
Common doses
The recommended initial dose of memantine hydrochloride for the treatment of moderate to severe
dementia of Alzheimers type is 5 mg orally once daily.
The dose should be increased in 5 mg increments to 10
mg/day (given as 5 mg twice daily), 15 mg/day (given
twice daily in separate doses of 5 mg and 10 mg), and
20 mg/day (given as 10 mg twice daily). The minimum
recommended interval between dose increases is 1
week. The recommended maintenance dose is 10 mg
twice daily (20 mg/day). There is not an established
dose for the treatment of chronic pain states, but case
reports and medication trials have started at 510 mg
BID and increases at 1 week intervals to 30 mg/day
have been examined [35].
Clinical use in neuropathic pain

Early placebo-controlled trials of memantine for patients
with established chronic neuropathic pain demonstrated limited effectiveness. In a randomized, crossover
study on 15 patients with chronic pain for 128 yr after
amputation, the analgesic efficacy of memantine could
not be demonstrated at a dose of 20 mg/day versus placebo on any of the measured outcomes: pain scale and
allodynia [4]. In contrast, a more recent randomized,
double-blind, placebo-controlled trial with memantine
2030 mg/day initiated immediately after upper limb
amputation (n = 19) for 4 weeks post-operatively demonstrated a nearly four-fold decrease in the incidence of
phantom limb pain at 6 months from 38% to 10% [6].
After cessation of ropivacaine infusion, patients maintained on memantine 30 mg/day had reduced intensity
(0100 mm visual analog scale [VAS] scoring) of phantom limb pain at 4 weeks (VAS of 3 mm in the memantine group vs. 24 in the placebo group) and 6 months
(VAS of 7 in the memantine group vs. 17 in the placebo
group). This trial exemplifies the benefit of preventive
administration of memantidine, and that intervention
may be best initiated before surgery.
Chapter 78 Dextromethorphan
Ketamine causes memory deficits; reproduces with
impressive accuracy the symptoms of schizophrenia;
is widely abused; and induces vacuoles in neurons at
moderate concentrations and cell death at higher
concentrations. Memantine, on the other hand, is well
tolerated; although instances of psychotic side effects
have been reported, in placebo-controlled clinical
studies the incidence of side effects is remarkably
low. Memantine improves memory in Alzheimer
dementia patients and in some (but not all) studies
in animals [1].

In a randomized double-blind trial for the treatment
of Alzheimer dementia, the most common adverse
events were agitation, insomnia, diarrhea, and urinary
incontinence and infection. Additionally hypertension and tachycardia have been reported with the use
of memantine [5].
Section 7
Chapter
78
References
1. Johnson JW, Kotermanski SE. Mechanism of action of

memantine. Curr Opin Pharmacol 2006;6(1):6167.
Evaluations, Thompson Healthcare. Memantine; 2009.
3. Jarvis B, Figgitt DP. Memantine. Drugs Aging
2003;20(6):465476; discussion 477468.
4. Wiech K, Kiefer RT, Topfner S, et al. A placebocontrolled randomized crossover trial of the
N-methyl-D-aspartic acid receptor antagonist,
memantine, in patients with chronic phantom limb
pain. Anesth Analg 2004;98(2):408413.
5. Sinis N, Birbaumer N, Gustin S, et al. Memantine
treatment of complex regional pain syndrome: a
preliminary report of six cases. Clin J Pain
2007;23(3):237243.
6. Hackworth RJ, Tokarz KA, Fowler IA, Wallace SC,
Stedje-Larsen ET. Profound pain reduction after
induction of memantine treatment in two patients
with severe phantom limb pain. Anesth Analg
2008;107:13771379.
NMDA Antagonists
Dextromethorphan
Muhammad Anwar
Generic Names: dextromethorphan, dextro

methorphan hydrobromide
Brand Names/Trade Names: Tussionex, Polist
irex Extended Release suspension, Robitussin DM
Manufacturer: Covidien Pharmaceuticals (a
division of Malinckrodt), 15 Hampshire Street,
Mansfield, MA 02048; Wyeth Healthcare, P.O.
Box 26609, Richmond, VA 232616609
Drug Class: antitussive, N-methyl-d-aspartate
(NMDA) receptor antagonist

Chemical Name: 3-methoxy-17-methyl-9
(alpha),13(alpha),14(alpha)-morphinan hydrobromide monohydrate
Chemical Formula: C18H25NOHBr H2O; molecular Wt 271; dextromethorphan is the d isomer
of levophenol; it occurs as white crystals, is
sparingly soluble in water, and freely soluble in
alcohol
321
OCH3
Figure 78.1.
H 3C
Introduction
Dexromethorphan is a synthetically produced substance that is chemically related to codeine and

morphine. It is not classified as an opioid, is nonhabituating, and is not associated with respiratory
depression. The FDA approved this drug as a cough
suppressant in 1954 and it has gradually replaced
codeine as the most widely used cough suppressant in
the USA. Dextromethorphan is currently an ingredient in more than 140 over-the-counter cough and
cold medications.. It is marketed alone or in combination with other drugs such as analgesics (e.g. acetaminophen), antihistamine (e.g. chlorpheniramine),
decongestants (e.g. pseudo-ephedrine) and/or expectorants (e.g. guaifenesin). Experimental evidence suggests that dextromethorphan is a low-affinity NMDA
receptor antagonist and may provide relief of somatic
and neuropathic pain.
Mode of activity
322
Neuropathic pain often presents a management

dilemma for patients and their caregivers, because of
its severity, chronicity, and resistance to conventional
analgesics. Important pathophysiological mechanisms
associated with neuropathic pain include sodium and
calcium channel up-regulation, spinal hyperexcitability, facilitation of noxious transmission and aberrant
sympathetic nervous system activity. Central sensitization is the result of NMDA receptor activation in
the central nervous system and is triggered by barrages of noxious input from the periphery. Hence, one
strategy for relieving post-operative pain is to block
NMDA receptors before the induction of central
sensitization.
Several studies have provided evidence that NMDA
antagonists, alone or in combination with opioids,
attenuate sensitization induced by noxious stimulation, and result in improved pain relief with few side
effects. Nonspecific NMDA receptor antagonists such
as ketamine have been shown to reduce the intensity
of post-operative pain and certain neuropathic pain

conditions. Like ketamine, dextromethorphan is a
low-affinity, nonspecific NMDA receptor antagonist
that also has weak affinity for the opioid receptor.
Controversy exists as to whether dextromethorphan is
as effective as ketamine, since some clinical trials demonstrate reductions in pain intensity and opioid
requirements while others have failed to demonstrate
measurable analgesic effects.
Dextromethorphan is usually taken orally and is
well absorbed from the gastrointestinal tract. It is
metabolized in the liver by various hepatic enzymes
and subsequently undergoes O-demethylation into an
active metabolite dextrophan, N-demethylation, and
partial conjugation with glucuronic acid and sulfate
ions. One well-known metabolic catalyst involved is a
specific cytochrome P450 enzyme known as 2D6, or
CYP2D6. The therapeutic activity of dextromethorphan
is believed to be caused by both the drug and this
metabolite. Dextromethorphan and its metabolites
are excreted via kidney.
Efficacy in acute and chronic pain

Recent human and animals studies have found that
dextromethorphan reduces the intensity of post-surgical pain [14]. A meta-analysis of preemptive administration of dextromethorphan for acute post-operative
pain management demonstrated proof of efficacy
(reduction in opioid requirements) [1]. A study performed by Henderson and coworkers [4] found that
dextromethorphan reduces post-operative pain intensity and morphine dose requirements in patients recovering from abdominal hysterectomy. Fifty patients
were randomized to receive a preemptive oral dose of
dextromethorphan 40 mg, then 40 mg three times per
day for the next 2 days, or placebo solution at identical
times. Median pain scores at rest were significantly
lower at 48 and 72 hrs and mean IV-PCA morphine
consumption was reduced in the dextromethorphan
group (1.1 vs 1.5 mg/h); P = 0.54.
Chia and coworkers [5] evaluated the effectiveness
of dextromethorphan in 60 patients recovering from
major abdominal surgery. Thirty patients received an
IV infusion of dextromethorphan 5 mg/kg before
anesthetic induction (Pre group), whereas the remaining 30 patients received the same volume of saline
solution, followed by a post-operative IV infusion of
dextromethorphan 5 mg/kg (Post group). Patients in
the Pre group received the same volume of saline solution post-operatively. All patients were then treated
Chapter 78 Dextromethorphan
with IV-PCA morphine. The mean visual analog pain

score during cough or movement and at rest were similar in the two groups in the first 3 days post-operatively.
However, Post group patients consumed more morphine than Pre group patients during the first 2 days
(P < 0.01). The sedation scores, patient satisfaction,
and the incidence of morphine-related side effects
were similar between the two groups. The authors
concluded that the pre-operative administration of
dextromethorphan 5 mg/kg reduces post-operative
morphine consumption compared with post-operative
administration.
A randomized double-blind study on day-surgery
patients examined the effects of pre-incisional oral
dextromethorphan and epidural lidocaine for postoperative pain reduction and morphine sparing. Dextromethorphan-treated patients reported significantly
(P < 0.05) less pain and sedation, and reported greater
satisfaction with their pain control [6].
In nonsurgical settings, patients suffering neuropathic and cancer pain treated with dextromethorphan had a reduced need for morphine and experienced
less sedation. Dextromethorphan was found to be
effective in patients presenting with neuropathic pain;
however, dose requirements are high [7,8]. Carlsson
and coworkers [7] found that a single dose of dextromethorphan (270 mg) was effective in treating
post-traumatic neuropathic pain; however, the effect
varied among test subjects and was determined to be
useful only in patients who could experience the painrelieving effect without significant side effects.
Nelson and co-workers [8] also evaluated high
doses of dextromethorphan in patients with neuropathic pain. They performed two randomized, doubleblind, crossover trials comparing 6 weeks of oral
dextromethorphan to placebo in two groups of
patients with painful neuropathy (14 patients with
one distal symmetrical diabetic neuropathy and 18
with post-herpetic neuralgia). Dextromethorphan
dose was titrated in each patient to the highest level
reached without disrupting normal activities; mean
doses were 381 mg/day in diabetics and 439 mg/day in
post-herpetic neuralgia patients. In diabetic neuropathy, dextromethorphan decreased pain by a mean of
24% (95% CI: 6% to 42%, P = 0.011), relative to placebo. In post-herpetic neuralgia, dextromethorphan
did not reduce pain (10% decrease in pain, P = 0.72).
Five of 31 patients who took dextromethorphan
dropped out due to sedation or ataxia during dose
escalation.
Contraindications
Dextromethorphan is contraindicated in patients
taking selective serotonin reuptake inhibitors and
monoamine oxidase inhibitors.
Alcohol and CNS depressants should not be used
with dextromethorphan.
Dextromethorphan should not be taken for persistent or chronic cough or when cough is accompanied with excessive secretions such as in COPD.
Dextromethorphan may be associated with
release of histamine and should not be used in atopic
children.
Common doses/uses
Adults: oral doses of 20 to 40 mg every 4 hours or
3060 mg every 6 to 8 hours not to exceed 180 mg
daily. Long-acting preparation: 60 mg twice a day. The
extended-release oral Polistirex suspension delivers
dextromethorphan from an ion-exchange complex
over a period of 9 to 12 hours. One 60-mg dose of
Polistirex suspension delivers a plasma concentration similar to two 30-mg doses of immediate-release
dextromethorphan given every 6 hours. For preemptive surgical pain control doses between 90 and 120
mg have been used in different clinical trials. Doses
employed for control of neuropathic pain are considerably higher (200300 mg) as tolerated.
Children: dextromethorphan is not generally recommended in children less than 2 years of age unless
under medical supervision. Children aged 2 to 6 years
2.5 to 5.0 mg every 4 hours or 7.5 mg every 6 to 8
hours not to exceed 30 mg daily. Children aged 6 to 12
years may be given 5 to 10 mg every 4 hours or 15 mg
every 6 to 8 hours, not to exceed 60 mg daily.
Dextromethorphan is available in different forms
such as capsule, liquid, liquid gelatin capsule, lozenge,
tablets, intramuscular, as well as in powdered forms
(available on the internet).
Although dextromethorphan is not a potent analgesic drug, it may be useful as an adjunct drug as a
part of multimodality treatment in chronic neuropathic as well as in acute pain management. There
does not appear to be any evidence of physical
dependence or habit-forming from this drug when
used in therapeutic doses. The advantage of dextromethorphan preparation over those containing
323
codeine was the lack of physical addiction potential

and sedative side effects, although, as with most
cough suppressants, studies show that its effectiveness is highly debatable.
Adverse events are very uncommon with therapeutic
doses (40160 mg); however, dextromethorphan can
cause some side effects such as dizziness, drowsiness,
lightheadedness, nervousness, restlessness, nausea
and vomiting, and stomach pain.
There is also an illicit use of dextromethorphan.
Teenagers and young adults commonly abuse this
drug. When dextromethorphan is abused in higher
doses, it acts as a dissociative anesthetic, similar to
PCP and ketamine. Slang terms for dextromethorphan
include DM, DXM, Dex, skittles, Triple C, Tussin,
robo, rojo, and velvet.
Poison control experts point to a four-fold
increase in abuse cases since 2000, mostly involving
school-aged youth and young adults, particularly
among those who are part of the dance club or rave
scenes. Intoxications come from swallowing large
doses of cough syrup or cough-suppressant pills.
Visual and/or auditory hallucinations, euphoria,
disorientation, insomnia, confusion, dizziness, double or blurred vision, slurred speech, impaired physical coordination, abdominal pain, nausea, and
vomiting have been reported. In children there are
cases of ataxia, stupor, transient fever, lethargy,
tachycardia, high blood pressure, headache, numbness of fingers and toe, loss of consciousness, seizures, and nystagmus. The main target organ is the
central nervous system. Coma and death have also
been reported with high-dose abuse. Dextromethorphan is not an illegal or controlled drug; nevertheless,
increasing reports of abuse and intoxification have
resulted in monitoring by the DEA, and the drug
could be added to the Controlled Substances Act if
warranted.
Drug interactions
324
Concomitant use of monoamine oxidase inhibitors

has caused toxicity leading to coma and death. There
are serious life-threatening serotonergic syndrome
interactions between dextromethorphan and serotonin reuptake inhibitors. Alcohol and other CNS
depressant drugs should be avoided when taking
dextromethorphan.
Treatment of acute poisoning

Oral ingestion is the most common route of acute
poisoning. The most common clinical effects involve the
central nervous system. General principles are assessment
and support of airway, ventilation, and circulation.
Naloxone may antagonize respiratory depression and
CNS effects of dextromethorphan. Patients with respiratory depression may require admission to an intensive
care unit. Other patients can be observed in the emergency facility for 4 to 6 hours and then discharged. Patients
with minor symptoms may be sent home under supervision. Children who have ingested a long-acting preparation should be hospitalized for 24 hours observation.
Gastric decontamination is recommended for a
recent ingestion of more than 10 mg/kg. If a long-
acting dextromethorphan preparation has been
ingested, whole bowel lavage may be considered.
References
1. Helmy SAK, Bali A. The effects of the preemptive use

of the NMDA receptor antagonist dextromethorphan
on postoperative analgesic requirements. Anesth Analg
2001;92(3):739744.
2. Aoki T, Yamagauchi H, Naito H, Shiiki K, Ota Y,
Kaneko A. Dextromethorphan premedication reduced
postoperative analgesic consumption in patients after
oral surgery. Oral Surg Oral Med Oral Pathol Oral
Radiol Endodontology 2006;102(5);591595.
3. Talakoub R, Molaeinasab F. Premedication with
oral dextromethorphan reduces intra-operative morphine
requirement. J Res Med Sci 2005;10(5);281284.
4. Henderson DJ, Withington BS, Wilson JA, et al.
Perioperative dextromethorphan reduces
postoperative pain after hysterectomy. Anesth Analg
1999;89:399.
5. Chia YY, Liu K, Chow LH, et al. The preoperative
administration of intravenous dextromethorphan
reduces postoperative morphine consumption. Anesth
Analg 1999;89:748753.
6. Weinbroum AA. Dextromethaphan reduces
immediate and late postoperative analgesic
requirement and improves patients subjective scoring
after epidural lidocaine and general anesthesia. Anesth
Analg 2002;94(6):15471552.
7. Carlsson KC, Hoem NO, Moberg ER. The effect of
Dextromethorphan in neuropathic pain. Acta
Anesthesiologica Scand 2004;48:328336.
8. Nelson, KA, Park KM, Robinovitz, E et al. High-dose
oral dextromethorphan versus placebo in painful
diabetic neuropathy and postherpetic neuralgia.
Neurology 1997;48:12121218.
Section 7
Chapter
79
NMDA Antagonists
NMDA antagonists: magnesium

and amantadine
Clinton Kakazu, John Charney and Yaw Wu
Generic Name: magnesium, Epsom salts

Trade/Generic Name: magnesium sulfate injectable, topical gel
Manufacturer: HOSPIRA, Inc., Chicago, IL
Chemical Name: magnesium sulfate
Chemical Formula: MgSO4 molecular wt 120.3
Generic Name: amantadine, see Figure 79.2
Trade/Proprietary Name: Symmetrel
Manufacturer: Endo Pharmaceuticals, Inc.,
Chadds Ford, PA
Chemical Name: adamantan-1-amine
Chemical Formula: C10H17N; molecular wt 159
Introduction
Magnesium and amantidine are nonspecific inhibitors
of the NMDA receptors. Both have been advocated as
analgesic adjuvants for pain management. Several
small-scale studies have demonstrated measurable
efficacy as well as safety in selected settings.
Magnesium: mode of activity

Magnesium (Mg2+) has multiple mechanisms of action.
At the neurocellular level within the CNS, Mg2+ acts
as a noncompetitive antagonist of the N-methyl-d-
aspartate (NMDA) receptor and its associated ion
channels in a voltage-dependent manner. It has been postulated that NMDA receptor activation is one of the
mechanisms causing central sensitization, and inhibition
of its primary agonist (i.e. glutamate and aspartate) by
Mg2+ may attenuate peripheral hypersensitive nocioception. While intravenous (IV) Mg2+ has been demonstrated
to attenuate post-operative pain [1,3], its ability to effectively cross the bloodbrain barrier remains unclear [2].
A study by Tramer et al. [1] demonstrated no

increase in CSF Mg2+ concentration with peri-operative
IV Mg2+ infusion, and conversely, no post-operative
analgesic effects. Thus, there are limitations of IV Mg2+
for modulation of antinocioception via central NMDA
blockade due to insufficent Mg2+ transference into the
CNS at effective concentrations.
Direct Mg2+ administration into the CNS intrathecally (IT) has been demonstrated to augment fentanyl
spinal analgesia [4].
In addition to NMDA blockade, Mg2+ has calcium
channel blockade properties resulting in direct effects
on smooth muscle causing peripheral vasodilatation,
bronchial dilatation, and uterine relaxation.
At the neuromuscular junction Mg2+ reduces the
amount of acetylcholine release, thus explaining its
role in treatment of convulsions and seizures by blocking neuromuscular transmission.
Indications
While not FDA-approved, IV and IT Mg2+ has been
studied as an analgesic adjuvant and does not have the
equianalgesic potency of narcotics. IT Mg2+ slightly
prolongs the duration of spinal narcotics.
Topical Mg2+ in gel (Epsom gel) or solution form
has anecdotal evidence for use in minor myalgias and
arthalgias in osteoarthritis, osteoperosis, rheumatoid
arthritis and fibromyalgia.
Contraindications
IV Mg2+ is contraindicated in patients with heart block
or myocardial damage.
Doses
IV
The original study claiming analgesic adjuvant activity
was at loading doses of 50 mg/kg pre-operatively, with
8 mg/kg per h given intra-operatively [1].
325
Figure 79.1.
O
O
O-
O-
Mg++
Figure 79.2.
O
OMg
S
++
O
-
NH2
Figure 79.3.
Increase in serum magnesium concentrations

may lead to less desirable effects intra-operatively such
as prolongation of muscle relaxants, peripherial
vasodilatation, cardiac conductivity disorders, and
gastric hypomotility.
Related adverse events

GI: diarrhea
Skeletal muscle: muscle weakness, delayed deep
tendon reflex
Cardiac effects: cardiac arrhythmia, congestive
heart failure
Respiratory effects: respiratory depression,
bronchodilation, pulmonary edema
CNS effects: antiseizure, sedation, stupor, coma
Amantadine: mode of activity

IT
As an adjuvant for spinal narcotics the original study
used 50 mg of Mg2+in 3 mL of preservative-free 0.9%
sodium chloride [4].
Intra-operative IV Mg2+ is also associated with imp
roved patient comfort and better quality of sleep but
without increased adverse effects [1].
IV Mg2+ has many other potential advantages
which can benefit patients with other co-existing disease states such as: treatment of psychiatric illness
(depression, bipolar disease); obstetrics (preeclampsia,
tocolytic); cardiac ventricular dysrhythmias (torsade
de pointes).
Moreover, in animal models, Mg2+ has been shown
to improve neurological outcome in brain and spinal
cord injury. Studies demonstrating neuroprotective
effects in humans are ongoing. The basis for neuroprotection is the ability of Mg2+ to block both the
NMDA receptor and calcium ion channels, thereby
reducing the excitatory amino acid stimulatory effect
and calcium ion influx into the cell.
326
Mg2+ is eliminated solely by renal excretion and plasma

concentration is directly proportional to glomerular
filtration rate. Thus, in patients with renal dysfunction
caution is advised. Unintentional high levels of serum
magnesium may be obtained.
Amandatine is an N-methyl-d-aspartate (NMDA)

receptor antagonist. It is an uncompetitive antagonist;
it blocks the ion channel of the receptor by accelerating
its closure. The drug exhibits substantial protein binding. Hepatic metabolism is negligible. The drug undergoes renal excretion. Its half-life is 10 to 14 hours,
which is prolonged in the event of renal failure [5].
Indications
Amantadine is indicated for the treatment of chronic
neuropathic pain related to cancer and other pathologies such as diabetes. It has also been used to treat
musculoskeletal pain and post-surgical pain [57].
Contraindications
Absolute: amantadine is contraindicated for patients
with a history of hypersensitivity to the drug.
Relative: amantadine is relatively contraindicated
for use in patients with a history of seizures, substance
abuse, or psychiatric illness since the drug may exacerbate symptoms related to these disorders.
Doses
Amantadine hydrochloride is available in tablet form
(100 mg/tablet) and as an oral suspension (10 mg/mL).
The usual dose for the treatment of pain is one tablet
per day for 7 to 14 days.
An intravenous solution of amantadine sulfate (PK
Merz), 200 mg in 500 mL of normal saline, is not
approved for use in the USA.
Chapter 79 NMDA antagonists: magnesium and amantadine
Amantadine is generally well tolerated. The drug can
be used either as monotherapy or as an adjunct to
other pain medications.
Since its hepatic metabolism is minimal amantadine would not be expected to interact with other
drugs. However, it has been shown to increase morphine levels, probably by interfering with 3-glucuronidation in the kidneys. Thus, amantadine may reduce
the dosage of morphine required for pain relief when
administered with this opioid.
Amantadine may exacerbate central nervous system
effects in disorders. Dosages must be adjusted for
patients with renal disease or congestive heart failure.
Since amantadine interacts with morphine caution is
required when these two drugs are administered
together.
Related adverse events

Adverse reactions related to the administration of
amantadine include:
1. Central nervous system: insomnia, depression,
anxiety, ataxia, hallucinations
2. Gastrointestinal: nausea, diarrhea, constipation
3. Cardiovascular: arrhythmias, orthostatic
hypotension, cardiac arrest
4. Other: dizziness, neuroleptic malignant syndrome
References
1. Tramer MR, et al. Role of magnesium sulfate in

postoperative analgesia. Anesthesiology 1996;84:
340347.
2. Seong-Hoon Ko, et al. Magnesium sulfate does not
reduce postoperative analgesic requirements.
3. Koinig H, Wallner T, Marhofer P, Andel H, Hrauf K,
Mayer N. Magnesium sulfate reduces intra- and
postoperative analgesic requirements. Anesth Analg
1998;87:206210.
4. Buvanendran A, et al. Intrathecal magnesium
prolongs fentanyl analgesia: a prospective,
randomized, controlled trial. Anesth Analg
2002;95:661666.
5. Blanpied T, Clark R, Johnson J. Amandatine inhibits
NMDA receptors by accelerating channel closure
during channel block J Neurosci 2005;25(13):
33123322.
6. Pud E, Eisenberg E, Spitzer A, et al. The NMDA
antagonist amantadine reduces surgical neuropathic
pain in cancer patients: a double blind, randomized,
placebo controlled trial. Pain 1998;75(23):
349354.
7. Snijdelaar D, Koren G, Katz J. Effects of perioperative
oral amantadine on postoperative pain and morphine
consumption in patients after radical prostatectomy:
results of a preliminary study. Anesthesiology
2004;100(1):134141.
327
Section 8
Chapter
80
Alpha-Adrenergic Analgesics
Overview of adrenergic and serotoninergic

pain suppression
Frederick Conlin and Shamsuddin Akhtar
Introduction
Norepinephrine and serotonin are ubiquitous endogenous neurotransmitters in the human body. They
exert their effect via their receptors and are intricately
involved in nociception and antinociception pathways. Both the adrenergic and serotoninergic systems
consist of numerous distinct receptor subtypes that
are located throughout the periphery, the spinal cord,
and supraspinally. Stimulation of the same receptor at
different locations in the body can lead to dramatically different effects. While activation and inhibition
at each of these sites play an important role in the perception of pain, it is in the descending inhibitory pain
pathways where these transmitters appear to have
their most significant influence. The understanding
of these interactions and anatomic pathways affords
the clinician the opportunity to utilize various methods of pharmacological interventions to alleviate
pain.
Descending pain pathways
328
The descending modulation of pain involves many

neurotransmitters, neuromodulators and pathways.
Descending pathways arise from a number of brainstem structures that include periaqueductal gray matter (PAG), nucleus raphe magnus (NRM), nucleus
paragigantocellularis and locus coerulus (LC). The
frontal lobes and the amygdala also exert a descending
influence via their projections to the PAG and the
hypothalamus. The interactions are varied and complex. In animals, stimulation of the PAG has long been
recognized to produce analgesia. It has large concentrations of opioid receptors and appears to modulate
pain through both opioid and non-opioid (serotoninergic) induced antinociception. Receiving input from
the frontal and insular cortex, thalamus, cerebellum,
and limbic system, the PAG projects to NRM in the
medulla. The NRM then projects to the dorsal horn
via serotoninergic fibers in the dorsolateral funiculus.
Similar to the PAG, stimulation of the NRM can

produce analgesia, confirming its importance in
descending inhibition.
Activation of the serotoninergic, or 5-hydroxytryptamine (5-HT), receptors in the dorsal horn can
inhibit nociception. Indeed, intrathecally administered serotonin has been shown to possess some analgesic properties. These beneficial results are most
probably achieved by serotonin-induced release of
spinal GABA and opioids, and not via direct action of
serotonin itself, as the degree of antinociception was
diminished when 5-HT agonists were given in the
presence of naloxone or a GABA antagonist. The
effect of intrathecal serotonin is not exclusively antinociceptive and it may have pro-nociceptive effects in
some situations. The potential explanation of this
observation is that there are seven different families of
serotonin receptors. While the serotonin receptors
share many common properties, the unique qualities
of each receptor and its location (presynaptic versus
postsynaptic), may contribute to the variable response
to serotonin.
The locus coeruleus, which contains large concentrations of adrenergic neurons, also contributes
to descending inhibition of nociception. Serving as
the adrenergic center of the brain it communicates
with the dorsal horn of the spinal cord (substantia
gelatinosa) through the descending bulbospinal
noradrenergic pathway. Stimulation of the bulbospinal pathway leads to the release of norepinephrine,
which acts on the alpha-2-adrenergic receptors
located on the primary afferents (C and A-delta fibers) and second-order neurons. Activation of the
alpha-2-adrenergic receptors inhibits the release of
primary afferent neurotransmitters and hyperpolarizes the second-order neurons, resulting in decreased
pain transmission and antinociception. These
actions serve as the basis for the analgesic properties
seen with neuraxial use of alpha-2-adrenergic agonists such as clonidine. It should be pointed out that
Chapter 80 Overview of adrenergic and serotoninergic pain suppression
these effects can be amplified when opioids are

present but may also be seen independent of concomitant opioid administration. The locus coeruleus
also projects to the cerebral cortex, thalamus,
hypothalamus, hippocampus, amygdala, and PAG.
Stimulation of cortical -1 receptors regulates attention and wakefulness, while -2 agonism there
results in sedation. Conversely, noradrenergic fibers
traveling from the locus coeruleus and terminating
in the PAG may actually promote nociception when
stimulated, further highlighting the complexity of
the system.
Serotonin
As discussed above, serotonin has many different

receptor subtypes to which it may bind. The seemingly
contradictory properties of serotonin have made it
difficult to develop specific pharmacological agents
that carry out the desired effect on the intended receptor subtype. However, selective serotonin reuptake
inhibitors and tricyclic antidepressants are two classes
of medications that can be used clinically to modulate
pain. It is believed that at least some of the analgesic
properties displayed by tricyclic antidepressants and
serotonin reuptake inhibitors are through potentiation of the serotoninergic pathways described earlier.
The antinociceptive properties of tricyclic antidepressants, which have noradrenergic and anticholinergic
effects as well, are more profound than the modest
analgesia seen with primarily serotonin reuptake
inhibition. Further complicating the issue is that, in
the periphery, serotonin functions largely as a pronociceptive transmitter. Injury to peripheral tissue
causes platelets to release their serotonin stores, which
then stimulates nociceptors and initiates pain signals.
In addition, serotonin is involved in the inflammatory response to injury, which may further contribute
to pain, further demonstrating the dual effects of
serotonin.
Norepinephrine
Pain is modulated by norepinephrine via its effect on

alpha-adrenergic receptors, specifically the alpha-2adrenergic receptor. The adrenergic system consists
of alpha and beta receptors with multiple subtypes
within each class. While there may be a role for modulating the receptor to produce analgesia this is
currently not widely accepted. However, recent years
have seen increasing attention being given to the ability of the alpha receptor, and more specifically the
alpha-2-adrenergic receptor, to modulate nociception. The alpha-2-adrenergic receptor is found

throughout the body and the response to its stimulation differs based on location. Centrally it results in
analgesia and sedation as discussed above, while in
the periphery it can yield bradycardia, diuresis, and
vasoconstriction or vasodilatation. Clinically, the
alpha-2 agonists clonidine and dexmedetomidine are
available and can be utilized systemically or intrathecally (clonidine) for their analgesic and sedative
properties. A second mechanism whereby descending noradrenergic pathways can be employed to
enhance spinal and supraspinal analgesia is to inhibit
the synaptic reuptake, thereby increasing local concentrations of norepinephrine. Norepinephrine
released at synaptic endings of descending fibers
binds to alpha-2-adrenergic receptors located on
postsynaptic pain transmission cells. Activation of
these receptors inhibits neuronal depolarization and
pain transmission. The effects of norepinephrine are
short-lived since molecules either diffuse away from
the synapse or are actively taken up by a norepinephrine reuptake protein. Tricyclic antidepressants
described above provide measurable antinociception
by blocking this key protein and increasing concentrations of norepinephrine at the pain transmission
synapse.
We have described above the mechanisms by
which alpha-2-adrenergic stimulation can produce
both sedation and spinal and supraspinal analgesia.
However, alpha-1-adrenergic stimulation at sites in
the medulla and the periphery may be responsible for
some opposing actions, which may actually facilitate
nociception. After injury to a peripheral nerve, alphaadrenergic stimulation can increase the frequency of
impulses by the surrounding nerves leading to pain,
and actually potentiate the development of chronic
pain states. Oddly enough, there appears to be both
alpha-1- and alpha-2-adrenergic contributions to this
phenomenon. The pronociceptive properties of the
adrenergic system can also be seen in CRPS, which
is mediated by the reaction to an elevated adrenergictone.
References
1. Terman GW, Bonica JJ. Chapter 4: Spinal mechanisms

and their modulation. In Loeser JD, Butler SH,
Chapman R, Turk DC, eds. Bonicas Management of
Pain, 3rd ed. Philadelphia: Lippincott Williams &
Wilkins, 2001, pp. 125138.
329
Alpha-Adrenergic Analgesics Section 8
2. Lubenow TR, Ivankovich AD, Barkin RL. Chapter 55:

Management of acute postoperative pain.
In Barash PG, Cullen BF, Stoelting RK, eds. Clinical
Anesthesia, 5th ed. Philadelphia: Lippincott, Williams
& Wilkins, 2006, pp. 14071416.
3. Carroll I, Mackey S, Gaeta R. The role of adrenergic
receptors and pain: the good, the bad, and the
unknown. Semin Anesth Periop Med Pain 2007;
26:1721.
Section 8
Chapter
81
5. Chiari A, et al. Clonidine as the sole analgesic agent

during first stage of labor: a dose-response study.
Clonidine (transdermal and parenteral)

Anahat Kaur Dhillon
Generic Name: clonidine hydrochloride

Trade Names: Catapres, Catapres-TTS
Manufacturer: Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT 06877
Description
330
4. Giordano J, Schultea T. Serotonin 5-HT3 receptor

mediation of pain and anti-nociception: implications
for clinical therapeutics. Pain Physician 2004;7:
141147.
Clonidine is an alpha-2-adrenoreceptor agonist as

well as an imidazoline. Ahlquists 1948 classification
of adrenoreceptors into alpha and beta receptors was
followed by a description of receptors that decrease
the release of neurotransmitters that were labeled
alpha-2 and thought to be presynaptic. Clonidine was
initially synthesized in 1962 as a nasal decongestant.
When tested in the first human, intranasal clonidine
caused hypotension, significant bradycardia and
reportedly the subject was asleep for 24 hours. Since
then clonidine has played an important role in the
treatment of hypertension and a smaller role for
anesthesia and analgesia. It produces sedation, anxiolysis, potent analgesia, hemodynamic stability as well
as a reduction in post-operative shivering and nausea

and vomiting.
Mode of activity
Major and minor sites of action: alpha-2-adrenoreceptors in the CNS and periphery, as well as nonadrenergic imidazoline binding sites.
Receptor interactions: clonidine interacts at the G
protein-coupled alpha receptors with a greater affinity
for the alpha-2 receptors. The activation of the alpha-2
receptors results in decreased cAMP, K+ efflux as well
as Ca2+ entry into the nerve terminals. Activation of
receptors in the sympathetic nerve endings and in the
noradrenergic neurons in the CNS inhibits release of
norepinephrine and may release acetylcholine. The
locus coeruleus is an important modulator of alertness
and may be the major site for the hypnotic effects of
clonidine. Additionally, the G protein pathway has a
similar transduction pathway to the opioids, explaining some of the cross-tolerance and synergy between
the two classes of drugs.
Clonidine also binds to the imidazole receptors
found in the brain, kidney and pancreas. These receptors
Chapter 81 Clonidine (transdermal and parenteral)
Cl
H
N
Figure 81.1.
Cl
N
H
Clonidine
mediate a central hypotensive and anti-arrhythmogenic response.

Metabolic pathways/drug clearance and elimination: clonidine is highly lipophilic and has excellent
bioavailability. Peak plasma levels are achieved in
6090 minutes after oral administration. Transdermal
preparations take 24 hours to achieve levels. It is less
than 50% metabolized in the liver with the remaining
drug excreted unchanged in the kidney. The elimination half-life is 620 hours.
Surgical acute pain: although not FDA-approved, clonidine is a potent analgesic and has been used for postoperative pain control. Pre-operative administration
provides anxiolysis and some sparing effect on anesthetics. This effect can translate into decreased postoperative pain and use of opioids.
Medical pain: clonidine is a potent analgesic and
may be particularly helpful in the management of
patients with opioid tolerance. It can be used as an
adjunct or monotherapy.
Chronic non-malignancy pain: oral or transdermal clonidine is less commonly used in the chronic
setting for pain control due to the increased level of
sedation. However, it may be helpful in managing
patients who have been on high-dose narcotics as it
has some efficacy in withdrawal syndromes. It can also
be used for migraines.
Contraindications
reactions to clonidine.
Relative: use with caution in patients with preexisting bradycardia or sinus node dysfunction, hypotension, cerebrovascular disease, chronic renal
impairment.
Common doses
Clonidine has excellent bioavailability, making the
oral and parenteral doses almost equivalent.
Oral: tablets are supplied in 0.1 mg, 0.2 mg and 0.3

mg forms. Starting doses of 2 g/kg with titration up
to 5 g/kg are recommended.
Parenteral: in one study 150 g of clonidine was
equivalent to 5 mg of morphine for pain control. Starting with 2 g/kg and careful titration is suggested.
Transdermal patches are generally started at the
0.1 mg dose and titrated over several days.
Monotherapy: the combination of anxiolysis and
potent analgesia is very desirable in some patients.
Multimodal therapy: clonidine seems to have a
synergistic effect with opioids. This provides for more
intense analgesia with the minimization of some of
the adverse effects of either class of drugs. There is
some cross-tolerance with opioids; however, for
patients with high opioid tolerance clonidine is an
excellent adjunct.
Cost and availability: relatively inexpensive generic
versions are readily available at most hospitals.
Reduction in adverse side effects: one of the major
advantages of clonidine is its minimal effect on respiratory drive. Additionally, the bradycardia and
decrease in sympathetic outflow can be protective in
patients with cardiac disease.
Significant sedation can occur with clonidine. While
direct respiratory depression is not common, sedation
can result in hypopnea and subsequent hypoxemia.
Another limiting factor in its use has been the hemodynamic profile that includes initial hypertension followed by hypotension and bradycardia. Orthostatic
hypotension in particular can limit its use in both the
acute and chronic settings.

Common/serious adverse events: central nervous
system mediated sedation, dizziness and fatigue are
common. Xerostomia is a common side effect that
can be prohibitive in some patients. Patients should
also be monitored for hypothermia, bradycardia
and hypotension.
Less common adverse events: respiratory depression and apnea are not common but have been reported
with large doses. Sinus and AV node blocks are also
rare but serious side effects seem to occur more frequently with the transdermal administration.
331
Treatment of adverse events: the treatment is generally supportive. Volume resuscitation, norepinephrine,
and atropine are effective for management of hypotension and bradycardia. The initial hypertension noted
with administration is generally transient and should
be treated cautiously with short acting medications.
Naloxone does not seem to be effective in reversing the sedative effects but may be helpful if opioids
have been co-administered.
Section 8
Chapter
82
1. Khan Z, Ferguson C, Jones R. Alpha-2

and imidazoline receptor agonists: their
pharmacology and therapeutic role. Anaesthesia
1999;54:146165.
Evaluations, Thompson Healthcare.
Clonidine.
Neuraxial clonidine hydrochloride

Richard W. Hong
Generic Names: clonidine-HCl

Brand Name: Duraclon
Manufacturer: Roxane Laboratories, Inc.,
Columbus, OH
Drug Class: analgesic agent
Chemical Name: N-(2,6-dichlorophenyl)-4,5dihydro-1H-imidazol-2-amine
Description
332
References
Alpha-adrenergic mechanisms had been unknowingly utilized for analgesia since the first forays into
neuraxial analgesia were made by August Bier in the
late 1800s. However, more focused explorations into
the effects of alpha-2 agonism in the CNS only
started to gain serious momentum late last century,
as effective adjuncts to more commonly employed
regional anesthetics were sought. Gradually, it
became known that clonidine appears to be safe for
neuraxial use in humans, is most potent when given
spinally, and is more potent epidurally than intravenously or intramuscularly [1]. In larger doses, or in
combination with other analgesics, neuraxial clonidine can provide profound analgesia. However, safe
doses of neuraxial clonidine employed as a monotherapy have not been found adequate for surgical
anesthesia.
Mode of activity
Major and minor sites of action: alpha-2-adrenorecep
tors, non-adrenergic imidazoline-preferring binding
sites.
Receptor interactions: clonidine acts at postsynaptic alpha-2-adrenoreceptors in the CNS, mimicking the effects of norepinephrine to produce analgesia
in animals and humans. Clonidine also stimulates
release of the inhibitory neurotransmitters acetylcholine and norepinephrine in the dorsal horn. Stimulation of postsynaptic alpha-2-adrenoceptors in the
brainstem and sympathetic preganglionic neurons in
the spinal cord decreases sympathetic outflow, causing hypotension and bradycardia depending on the
extent of spread. Alpha-2-adrenergic activity in the
Chapter 82 Neuraxial clonidine hydrochloride
Cl
Figure 82.1.
H
N
H
N
N
Cl
periphery, the result of systemic uptake, may cause

vasorelaxation. Non-adrenergic activity in the lateral
reticular nucleus may also produce hypotension.
Sedation can result from effects in the locus coeruleus
of the brainstem. Clonidines neuraxial effects differ
from its effects on peripheral nerves, which are devoid
of alpha-2-adrenergic receptors, where clonidine
instead appears to have a direct effect on nerve
conduction [1].
Metabolic pathways: due to its lipophilicity, epidural clonidine is quickly absorbed into systemic circulation, with peak arterial concentrations after 10
minutes, peak venous concentrations after 3045
minutes, and peak CSF concentrations after 3060
minutes. The liver is responsible for metabolism of
50% of clonidine into inactive metabolites. Approximately two-thirds of clonidine, metabolized and
unmetabolized, are excreted renally. While the effects
of epidural clonidine may last only 35 hours, elimination takes longer. The plasma elimination half-life
of clonidine is 22 15 hours and can be prolonged in
renal failure [1,2].
Indications
Black-box warning: clonidine-HCl is not recommended
for routine obstetrical, post-partum or peri-operative
pain management due to risk of hemodynamic instability, especially hypotension and bradycardia, from
epidural administration. However, in rare obstetrical,
post-partum or peri-operative patients, the potential
benefits may outweigh the risks.
Cancer pain: neuraxial clonidine can be utilized as
an analgesic for patients with intractable cancer pain,
particularly neuropathic pain [1,2]. Clonidine is less
likely to be effective for diffuse, visceral or poorly
localized pain secondary to cancer. Preservative-free
clonidine-HCl (Duraclon) has an orphan drug designation and has only been approved by the FDA for
epidural administration in cancer patients with intractable pain.
Surgical acute pain: neuraxial clonidine is not
approved for but can be used to relieve intra-operative and post-operative pain, as an adjunct or as
monotherapy.
Labor pain: epidural clonidine has been shown to

have a dose-sparing effect on local anesthetic requirements of laboring women but there are insufficient
data to determine adverse neonatal effects.
Chronic pain: because its activity differs from that
of opioids, neuraxial clonidine is potentially useful as
an analgesic adjunct to opioids or as monotherapy in
patients developing opioid tolerance. In limited studies, there is no histopathological evidence against its
use; however, there are insufficient data regarding
long-term clonidine administration in chronic pain
patients.
Contraindications
reaction or hypersensitivity.
Relative: anticoagulant therapy, bleeding diathesis,
infection at the site of injection, and any other relative
contraindication to placement of neuraxial analgesia;
epidural use above the C4 dermatome (insufficient
data regarding safety).
Common doses
Black-box warning: the 500 g/mL strength product
should be diluted in sterile, preservative-free 0.9%
sodium chloride to a final concentration of 100 g/mL
prior to use.
Adjunct, cancer pain, epidural infusion, adult:
30g/h infusion titrated up to 40 g/h
(experience is limited with infusion rates
exceeding 40 g/h)
Adjunct, cancer pain, epidural infusion, pediatric:
0.5 g/kg per h, titrated to response
Adjunct, pain, epidural bolus, adult: 75700 g
Adjunct, labor pain, patient-controlled epidural
analgesia, adult: bupivacaine 0.0625% with fentanyl
2 g/mL + clonidine 4.5 g/mL
Adjunct, post-operative pain following total knee
arthroplasty, intrathecal bolus, adult: bupivacaine
15 mg + clonidine 75 g or bupivacaine 15 mg +
clonidine 25 g + morphine 250 g
Adjunct, post-operative pain following coronary
artery bypass graft, intrathecal bolus, adult:
clonidine 1 g/kg + morphine 4 g/kg
Monotherapy: neuraxial clonidine has not been associated with sensory or motor blockade when used as a
333
single agent. The sedative and hemodynamic effects

are sometimes desirable, depending on the clinical
situation.
Adjunct therapy: epidural clonidine as an analgesic adjunct enhances both sensory and motor block
caused by local anesthetics (mechanism unclear). It
also enhances the effect of other spinal analgesics,
including intrathecal opioids. Both quality and duration are enhanced when clonidine is combined with
these other neuraxial analgesics
Reduction in adverse events: the dose-sparing effect
of clonidine on other neuraxial medications can potentially minimize the overall side effects of the analgesic
regimen. Micturation is not delayed by neuraxial clonidine as it is with the most commonly used neuraxial
analgesics, namely local anesthetics and opioids.
Adverse events: sedation is frequently a limiting side
effect of neuraxial clonidine, particularly in the larger
doses necessary for epidural analgesia. Significant,
direct respiratory depression is not common, but significant sedation can result in transient decreases in
oxygen saturation during sleep, encouraging continuous pulse oximetry when larger (epidural) doses are
given. As stated in the black-box warning, hemodynamic effects may preclude its use in laboring patients
(to preserve uteroplacental perfusion) and in
peri-operaive patients for whom hemodynamic stability is of great concern. (That being said, some
centers successfully employ epidural clonidine as an
intra-operative/post-operative analgesic monotherapy
for thoracoabdominal aortic aneurysm surgery.)
Limited approved indications: despite safety and
efficacy demonstrated in a variety of neuraxial applications, most of clonidines neuraxial potential uses
are not FDA-approved, and it remains a Pregnancy
Class C drug.
334

Common adverse events: clonidine has a centrally
mediated sedative effect. Other CNS depressants, such
as benzodiazepines and opioids, may enhance the sedative effects of clonidine. Neuraxial clonidine can also
affect the sympathetic nervous system, resulting in
hypotension and bradycardia. When clonidine is used
as a neuraxial adjunct analgesic, its hemodynamic
effects may be enhanced by other neuraxial medications, particularly as local anesthetics. All effects are
dose-dependent.
Less common adverse events: serious respiratory depression appears to be rare, and the documented arrhythmogenic effects of clonidine (most
notably bradyarrhythmias and atrioventricular
block) are unlikely to result from appropriate neuraxial dosing.
Treatment of adverse events: for co-administration
of clonidine with other agents, one or both doses
should be reduced as necessary to avoid adverse
events. Treatment of these adverse events is typically
supportive, though it should be noted that intrathecal
neostigmine appears to counteract clonidine-induced
spinal hypotension and that yohimbine has been used
to counteract clonidine-induced sedation in postoperative patients. Hemodialysis is not likely to be
effective for complications from neuraxial clonidine
administration.
References
1. Product information: Duraclon, clonidine

hydrochloride injection. Roxane Laboratories, Inc.,
Columbus, OH, 2000.
2. Eisenach J, De Cock M, Klimscha, W. Alpha 2
adrenergic agonists for regional anesthesia: a
clinical review of clonidine (19841995).
Section 8
Chapter
83
Dexmedetomidine
David Burbulys and Kianusch Kiai
Generic Name: dexmedetomidine hydrochloride

Proprietary Name: Precedex
Manufacturers: Abbott Laboratories, Hospira
and InterMed
Class: selective 2-adrenergic agonist with sedative, hypnotic, anxiolytic, analgesic and sympatholytic effects
Chemical Name: (S)-4-[1-(2,3-dimethylphenyl)
ethyl]-1H-imidazole monohydrochloride
Mode of activity
Precedex, dexmedetomidine hydrochloride, is a
selective 2-adrenergic agonist with sedative, hypnotic, anxiolytic, and analgesic properties as well as
marked sympatholytic effects with little or no respiratory depression. It is an imidazole derivative and the
refined active d-isomer of medetomidine, an agent
used in veterinary medicine as an anesthetic.
Its mechanism of action is not well understood,
but probably resembles the central effects of clonadine. Compared to clonadine, it binds more selectively
to the 2 over the 1 receptor and has approximately
eight times the affinity. Like clonadine, it produces
sedation, reduced salivation and initially raises and
then significantly lowers the heart rate and blood pressure. This is probably due to the overall stimulation of
both the central and peripheral pre- and postsynaptic
1 and 2 receptors. The 1-mediated hypotension
and bradycardia may be pronounced with large doses
or rapid infusions. It also has marked intrinsic anesthetic and analgesic properties that clonadine does
not possess. This is probably due to the enhanced
stimulation of central and spinal postsynaptic 2
receptors as well as peripheral antinociception via
release of an enkephalin-like substance. It has been

shown that the anesthetic effects are blocked by the
centrally acting 2 antagonist atipamexole but not a
peripherally acting analog. The analgesic effects have
been shown to be blocked by antipamezole but not
naloxone.
It is highly protein-bound and has a very large volume of distribution. In animal studies, it has been
shown to cross the placenta and is distributed into
breast milk. It undergoes almost complete hepatic
biotransformation with direct glucuronidation,
aliphatic hydroxylation and N-methylation via the
CYP2A6 and P450 systems. The metabolites are then
excreted in the urine. In patients with hepatic dysfunction mean clearance values are reduced 50 to 75%
and doses should be adjusted accordingly. Patients
with significant renal insufficiency may experience
the accumulation of metabolites and long-term infusions should be avoided.
Indications
Dexmedetomidine was approved in 1999 by the FDA
for the sedation of mechanically ventilated adult
patients in the critical care setting for 24 hours or less.
Subsequently, it has received approval for procedural
sedation in non-intubated adult patients.
Despite its recent FDA approval, it has also been
studied and used off label in several other circumstances. Peri-operatively, it has been beneficial in the
management of critically ill patients and patients at
high cardiovascular risk undergoing vascular surgery,
in bariatric patients, in patients to facilitate awake
fiberoptic intubation or during awake craniotomy, and
in pediatric patients. It also has potential to be used as
an anesthetic adjunct to decrease dosages of other
common anesthetic agents. Its use reduces intraocular
pressure, attenuates the tachycardic response to
endotracheal intubation, and blunts the adverse anesthetic shivering reaction. It has been used to treat
post-operative pain, cyclical vomiting syndrome, and
335
CH3
NH
Figure 83.1.
CH3
CH3
various drug withdrawal states. It may have potential

as a neuroprotective agent and as an adjunct to extend
peripheral nerve block.
Contraindications
Absolute: Precedex is contraindicated in patients
with known allergy to dexmedetomidine.
Relative: avoid use during pregnancy, breast-feeding or if pregnancy is planned. Use with caution in
geriatric patients or in patients with advanced heart
block, significant hypertension, severe ventricular
dysfunction, diabetes mellitus, hypovolemia, hepatic
or renal insufficiency.
Common doses and uses
336
Dexmedetomidine is commonly administered by the

IV route. Intramuscular, transdermal or intranasal
routes have also been described. It has a rapid onset
of action with sedative effects observed within 5 minutes of IV administration and a terminal half-life of
approximately 2 hours.
It is supplied as a preservative-free concentrate of
100 g/mL in a 2 mL clear glass vial. This should be
diluted in 48 mL normal saline prior to its use. It is
compatible with most commonly administered IV
drugs and infusions, with the exception of amphotericin B and diazepam. It should not be infused through
the same IV line as blood or plasma.
Sedation for intubated and mechanically ventilated patients is generally achieved with a loading dose
of 1 g/kg infused over 10 minutes followed by a continuous infusion 0.2 to 0.7 g/kg per h. Over this
range, dexmedetomidine exhibits linear effects and
pharmacokinetics when administered for up to 24
hours in individuals with normal hepatic and renal
function.
Procedural sedation in non-intubated patients is
generally achieved with a loading dose of 1 g/kg
infused over 10 minutes followed by a continuous
infusion 0.6 g/kg per h. Less stimulating procedures may only require 0.5 g/kg as a loading dose.
The continuous infusion may be titrated to the
desired clinical effect with doses ranging from 0.2 to
1 g/kg per h.
As a general anesthesia adjunct, 0.50.6 g/kg may

be given as a bolus over 1 minute, in 510 mL of
normal saline, 10 to 15 minutes prior to induction.
Glycopyrrolate is often used to minimize the bradycardic effects. Alternatively, an IM dose of 0.51.5 g/
kg may be administered 60 minutes prior to induction. With IM dosing sedation may be prolonged and
significant bradycardia has been observed with higher
doses (11.5 g/kg).
Awake fiberoptic intubation may be facilitated
with a loading dose of 1 g/kg infused over 10 minutes
followed by a continuous infusion 0.7 g/kg per h
until intubation is achieved.
Dexmedetomidine does not alter respiratory rate or
oxygen saturation at the recommended dosages and
it is not necessary to discontinue the drug prior to
extubation.
Its use attenuates sympathetic activity and leads to
a dose-dependent decrease in systolic and diastolic
blood pressure and heart rate during its use and in the
immediate post-operative period. This is related to
both the dose and rate of administration.
There are no clinically important effects on neuromuscular blockade and, despite being highly protein-bound, there is little displacement of other highly
protein-bound agents such as digoxin, fentanyl, lidocaine, NSAIDS, phenytoin, theophylline, or warfarin.
It has potential as an anesthetic adjunct to decrease
dosages of other common anesthetic agents. It can
reduce intraocular pressure, decrease intracranial
pressure, be neuroprotective, attenuate the tachycardic
response to endotracheal intubation, and blunt the
adverse anesthetic shivering reaction.
It has an excellent safety profile.
Transient hypertension has been reported with IV
loading doses and IM administration but treatment is
generally not required.
Hypotension and bradycardia are more pronounced in geriatric patients or those with hypovolemia, diabetes mellitus, or chronic hypertension.
Consider lower initial loading and maintenance infusion doses in these patients. If treatment is required,
consider slowing or stopping the dexmedetomidine
infusion, increasing IV fluids and/or administering
vasopressors or anticholinergic agents to modify
vagal tone.
Chapter 83 Dexmedetomidine
Bradycardia and sinus arrest have been reported in

young, healthy adults with high vagal tone and with
large or rapid IV administration. Safety and efficacy
have not been established in children under 18 years
of age. Despite this, numerous trials have shown its
use in pediatric patients.
Supraventricular and ventricular tachycardia,
atrial fibrillation, extrasystoles, and cardiac arrest have
been rarely reported. These generally respond to
standard therapies and discontinuation of dexmedetomidine. Dexmedetomidine should be used with caution in patients with advanced heart block or severe
ventricular dysfunction.
It has been shown to have additive effects when
used with other anesthetic agents, narcotics, benzodiazepines, vasodilators, and negative chronotropic
agents. Reduced dosage should be considered when
used with these agents.
Potential withdrawal manifestations such as
nervousness, agitation, insomnia, tremor, palpitations, headaches, rapid rise in blood pressure, and
elevated plasma catecholamine levels are possible
with prolonged administration (>24 hours) and
abrupt discontinuation of therapy. Despite this
warning, dexmedetomidine has been used for
longer periods of time with little withdrawal or tolerance noted.
Cortisol response to corticotropin stimulation has
been shown to be decreased by 40% in animals following continuous infusion for 1 week but no changes
have been observed with single-dose administration.
The effects on cortisol response have not been well

studied in humans.
Dexmedetomidine is a Pregnancy Category C
agent and its use during pregnancy, labor and delivery,
including cesarean section deliveries, is not recommended. It is also excreted into milk in animal studies
and caution should be used in nursing women.

Hypotension (28%), hypertension (16%), bradycardia
(7%), tachycardia (3%), atrial fibrillation (4%), hypoxia
(4%), nausea (11%), vomiting (4%), xerostomia (4%),
fever (5%), and anemia (3%).
References
1. Abbott Laboratories. Precedex (dexmedetomidine)

injection prescribing information. North Chicago, IL,
2008.
2. Khan ZP, Ferguson CN, Jones RM. Alpha-2 and
imidazoline receptor agonists. Anaesthesia
1999;54:146165.
3. Kamibayashi T, Harawawa K, Maze M. Alpha-2
adrenergic agonists. Canad J Anaesth
1997;44:R13R18.
4. DynaMed, EBSCO Publishing. Dexmedetomidine,
2009.
5. MicromedexHealthcare Series, DrugDex
Evaluations, Martindale The Complete Drug
Reference, and Posindex, Tompson Healthcare.
Dexmedetomidine, 2009.
337
Section 9
Chapter
84
Antidepressants
Overview and use of antidepressant

analgesics in pain management
Paul M. Peloso
Introduction
338
It is evident from the literature that pain and depression commonly coexist in the setting of severe postsurgical pain and chronic pain [1,2]. Given that pain
represents the number one reason that patients visit
general practitioners, with 45% of visits related to
pain, and that depression is the most common mental health disorder, with 1015% of all clinic visits
having depression present, and further that both
increase with age, their co-occurrence would not be
surprising. In fact, pain and depression co-exist in
3050% of those with either disorder, and their
adverse effects are additive in terms of healthcare
outcomes and reduced quality of life. However, as
clinicians managing chronic pain can attest, pain
leads to depression and depression leads to pain.
Recent evidence, which will be briefly reviewed, also
corroborates the clinical impression that managing
either well requires managing the other well concurrently. Further, antidepressants have pain-relieving
properties, in addition to their mood-altering properties, as will also be discussed.
The monoamine inhibitors and the tricylic antidepressants were first discovered in the 1950s and
were not originally intended for the treatment of
depression. The name tricyclic refers to the chemical structure of this class, consisting of two benzene
rings joined by a seven-member ring, containing
nitrogen, oxygen, and carbon. Since the tricyclic
antidepressants (TCA) family includes drugs with
tetracyclic structures, some prefer the term heterocyclics although tricyclics and TCA are deeply
embedded within the physicians lexicon. Given their
serendipitous discovery, it is not surprising that
TCAs interact with a wide variety of brain receptors,
including norepinephrine, serotonin, histamine 1,
muscarinic, cholinergic and alpha-2-adrenergic
receptors, to varying degrees, with slight differences
in side effects related to this. Major adverse events
include QT prolongation, conduction abnormalities,

hypotension, dry mouth, urinary retention, weight
gain, sedation, lowered seizure threshold and given
their narrow therapeutic margin, a risk of overdose
(Table 84.1).
The monoamine oxidase inhibitors (MAOIs)
work through augmented activity of dopamine, as
monoamine oxidase normally degrades norepinephrine and serotonin. The MAOIs are rarely used
clinically due to their adverse effects, notably orthostatic hypotension, peripheral edema, myoclonic
jerks, weakness, and insomnia. Hypertensive crisis
can result when combined with sympathomimetics,
including over-the-counter products such as ephedrine and pseudoephedrine. Further, MAOIs are
known to contribute to the serotonin syndrome and
use of meperidine must be avoided in such patients.
Patients on MAOI need to restrict tyramine-rich
foods, as well [1,2].
The selective serotonin reuptake inhibitors (SSRIs)
are highly selective agents, with limited off-target activity, and are among the most commonly prescribed antidepressants, due to the superior tolerability. It is
worthwhile to point out that no single class of antidepressants appears to have superior efficacy, and newer
agents are preferred principally for enhanced tolerability. The most frequent adverse event is nausea, typically
occurring on initiation of therapy. Following that, sexual side effects tend to predominate. Inhibition of platelet function can lead to clinically important
gastrointestinal bleeding, and interactions with NSAIDs
and warfarin do occur. There is also a risk of serotonin
syndrome, which consists of mental status changes,
autonomic abnormalities (elevated pulse, blood pressure, and temperature) and neuromuscular hyperactivity, with rigidity, clonus, and heightened reflexes.
The Hunter criteria for serotonin syndrome have
an 84% sensitivity and 96% specificity for the diagnosis, and require exposure to a drug known to cause the
syndrome and at least one of (a) spontaneous clonus,
Chapter 84 Overview and use of antidepressant analgesics in pain management
Table 84.1. Common drug interactions for the antidepressants

Tricyclic antidepressants (TCA)
Examples
Amitryptyline, desipramine, imipramine, doxepine, nortyptiline maprotyline.
Major actions
Serotonin and norepiphrine, reuptake inhibitors with additional effects via

anticholinergic and alpha-2 antagonism.
Primary metabolism
Multiple CYP pathways, with the CYP2D6 pathway being the major route.
Potential interactions and clinical result
Acetylcholinesterase inhibitors can have diminished effects.

May enhance QTc effects with alfuzosin, ciprofloxacin, cisapride, dronedaron,
lumefantrine, nilotinib, quinidine, tetrabenazine: thioridazine, ziprasidone.
Alpha-/beta-agonists may have enhanced vasopressor effects.
Aspirin, NSAIDs, COX-2 inhibitors: may enhance antiplatelet effects and increase
anticoagulation (including with vit K antagonists).
May decrease TCA metabolism with terbinafine, cimetidine.
Lithium can enhance neurotoxic effects.
May enhance CNS effects, including propoxyphene.
Sulfonylureas can have enhanced hypoglycemic effects.
Tramadol can further enhance seizure potential.
Selective serotonin reuptake inhibitors (SSRI)

Examples
Citralopram, fluoxetine, paroxetine, sertraline.
Major actions
Inhibit serotonin reputake.
Primary metabolism
Citralopram - CYP2C19 is a major path.

Fluoxetine - CYP2C9 CYP2D6 and other CYP.
Paroxetine - CYP2D6.
Sertraline - CYP2C19 CYP2D6.
ASA, NSAIDs, COX-2 selective inhibitors, pentoxifylline, drotrecogin alfa,

pentosan polysulfate sodium, omega-3-acid ethyl ester can have enhanced
antiplatelet effects and increased bleeding.
Beta-blockers may have enhanced bradycardic effects.
Selective serotonin reuptake inhibitors may decrease metabolism of alpha/beta
blockers, benzodiazepines, carbamazepine, cimetidine, clozapine, fesoterodine,
haloperidol, methadone, mexiletine, phenytoin, propafenone, respiradone,
tamoxifen, galantamine, respiradone, thioridazine.
May enhance the adverse effect of other CNS depressants, like
methotrimeprazine.
Cyproheptadine can compete with binding sites and limit the therapeutic
effects.
Macrolide antibiotics can decrease the metabolism of SSRI.
Desmopressin, dextromethorphan may enhance adverse effects.
Tramadol can enhance lowered seizure thresholds.
Disulfiram can enhance adverse effects of sertraline, due to alcohol content.
Selective norepinephrine and serotonin reuptake inhibitors (SNRI)

Examples
Duloxetine, venlafaxine
Major actions
Serotonin and norepinephrine reuptake inhibitor.
Primary metabolism
Duloxetine - CYP1A2, CYP2D6.

Venlafaxine - multiple CYP, mostly CYP2D6 CYP3A4.
Alpha/beta-agonists: may enhance tachycardic, vasopressor effects.
339
Antidepressants Section 9
Table 84.1. (cont.)

Alpha 2 agonists: may have diminished antihypertensive effects.
Aspirin, NSAIDs, COX-2 inhibitors - can enhance antiplatelet effects and
anticoagulant effects (vit K antagonists).
Dasatinib, voriconazole - may increase serum concentration of venlafaxine.
Can enhance orthostatic effects of the MAOI.
May enhance CNS depressant effects of other CNS depressants.
Metoclopramide can increase risk of serotonin syndrome.
Propafenone: may increase serum levels of venlafaxine.
Buproprion
Major Actions
Dopamine, norepinephrine uptake inhibitor.
Primary metabolism
CYP2B6.
Buproprion: can decrease TCA metabolism.

Can enhance other CNS depressants effects, including with methotrimeprazine.
Mirtazapine
Major actions
5-hydroxy-tryptophan 2A receptor antagonist.
Primary metabolism
CYP2D6, CYP1A1, CYP2C19
May diminish hypotensive effect of alpha2-agonists.

Darunavir - may increase serum concentration of CYP2D6 substrates.
May enhance CNS depressive effects of other CNS depressants, including
methotrimeprazine.
Monoamine oxidase inhibitors (MAOI)

Examples
Phenelzine, trancylcypromine, isocarboxazid, moclobemide, seleginline.
Major actions
Monoamine oxidase blocked (reversibly or irreversibly), with inhibition of

dopamine and norepinephrine action.
Primary metabolism
Substrates or inhibitors of various CYP enzymes, metabolism not well studied.

Tranylcypromine is a relatively potent inhibitor of CYP2C19.
Moclobemide inhibits CYP2D6, CYP2C19, CYP1A2.
Acetylcholinesterase inhibitors can have reduced effects.

Succinylcholine: phenelzine may enhance neuromuscular blockade.
Alpha/beta-agonists have enhanced vasopressor effects.
May enhance orthostatic effects of altretamine-antihypertensives.
May enhance hypertensive effects of buspirone, levodopa, methylphenidate,
and the rauwolfia alkaloids.
May enhance neurotoxic and central effects of atomoxetine, buproprion,
tapentadol.
tramadol, may further lowered seizure-threshold.
Drugs must be weaned off to avoid syndrome.
340
Table 84.2. Commonly used drugs implicated in the serotonin syndrome
Drug implicated
Purported mechanism
Monoamine oxidase inhibitors
Inhibits serotonin metabolism
Buspirone
Direct serotonin agonist
Triptans (e.g. sumatriptan)
Ergot alkaloids
Fentanyl
Sibutramine
Cocaine, ecstasy
Impairs reuptake
Meperidine
Selective serotonin reuptake inhibitors
Serotonin norepinephrine reuptake inhibitors
Tricyclic antidepressants
St. Johns wort
Ondansetron, granisetron
Dextromethorphan
Trazadone
Emergency consultation with a medical toxicologist available at US Poison Control Network 18002221222, or find a poison control
center at the World Health Organizations list of international poison centers at www.who.int/ipcs/poisons/centre/directory/en.
(b) inducible clonus plus agitation or diaphoresis, (c)

ocular clonus plus agitation or diaphoresis, (d) tremor
and hyperreflexia, (e) hypertonia, or (f) temperature
above 38C plus ocular clonus or inducible clonus.
Table 84.2 outlines those drugs that might contribute
to the development of serotonin syndrome and which
may be used concurrently with antidepressant therapy.
The serotonin and norepinephrine reuptake inhibitors, or SNRIs, have both serotonin and norepinephrine inhibition, and are less selective than the SSRIs.
They also have nausea as a common adverse event on
initiation, and can have dizziness, drowsiness, sweating, and dry mouth, as well as sexual dysfunction, as
occur with the SSRI and have been associated with
serotonin syndrome.
Caregivers prescribing antidepressant medications
should consider the following key questions:
1. How good is the clinical evidence for
antidepressant effects on pain?
2. Are there differences among the antidepressant
classes with respect to pain control?
3. What has the recent evidence taught us about the
intersection of pain and depression?
4. Does recognizing and treating depression have
any impact on the acute post-operative period,
with respect to pain control, morbidity and

mortality?
In order to address these questions, focused literature reviews were carried out in Medline through
2009. In keeping with the established hierarchy of
clinical evidence, meta-analyses of randomized controlled trials and large randomized controlled trials
were afforded the highest level of evidence, and are
preferentially represented here. Large, well-controlled
cohort designs were considered of lesser, but important, evidence. Cohort studies are far more common
designs than randomized trials when the clinical questions are concerned with prognosis. The reader should
be aware that there is a large and growing literature on
these key questions, and this chapter cannot represent
all of it, in its entirety. The interested reader is referred
to the references herein and to the primary literature
for greater detail.
How good is the clinical evidence for

antidepressant effects on pain?
Clinical experience and randomized trial evidence
shows that antidepressant medications have pain-
relieving properties [14]. Is this pain relief related to
341
Table 84.3. Evidence for effectiveness of antidepressants in musculoskeletal and neuropathic pain conditions
OA
CLBP
FMS
Diabetic PN
PHN
Painful
polyneur
TCA
n.t.
MA
MA
MA
MA
MA
SSRI
n.t.
Neg
Neg.
Contra
n.t.
Contra
Venlafaxine
RCT
nt
nt
RCT
Neg.
RCT
Duloxetine
RCT
RCTa
MA
RCT
n.t.
RCT
Milnacipran
n.t.
n.t.
RCT
n.t.
n.t.
n.t.
TCA, tricyclic antidepressants; multiple tested include amitriptyline, desipramine, imipramine, nortryptiline, maprotyline; SSRI, selective
serotonin reuptake inhibitors (tested are citralopram, paroxetine, fluoxetine); Venlafaxine, Duloxetine, Milnacipran (selective serotonin
norepinephrine reuptake inhibitors, SNRIs).
RCT, randomized controlled trial with positive results; MA, metaanalysis of RCTs with positive results; OA, osteoarthritis; CLBP, chronic
low back pain; FMS, fibromyalgia syndrome; Diabetic PN = diabetic peripheral neuropathy; PHN, post-herpetic neuralgia; Painful polyneur,
painful polyneuropathy; n.t., not tested; Neg., negative results in 1 RCT; Contra, contradictory evidence.
a
Short-term effects on pain and sleep, but not sustained longer-term.
342
mood alteration (i.e. amelioration of depressive symptoms), or to direct pain-relieving properties? This
question was unanswerable when the TCAs alone
were used for pain, but the advent of the SSRIs and the
SNRIs allows an ability to probe this issue further.
Since the SSRIs are highly effective antidepressants,
yet appear to have limited analgesic effects, modulation of mood is probably not sufficient. The SNRIs,
with inhibition of both serotonin and norepinephrine
reuptake, and demonstrated efficacy for depression
and multiple pain states, suggested that modulation of
multiple receptor targets is necessary for pain relief.
Some authors suggest that inhibition of norepinephrine reuptake may be required for pain relief, since
TCAs and SNRIs both inhibit NE reuptake, while others have suggested that fully adequate doses of SSRIs
for pain have not been tested. The quality and consistency of evidence for antidepressants as pain-relieving
agents is reviewed, in brief, in Table 84.3.
Several high quality meta-analyses of randomized
controlled trials have been published on the value of
antidepressants and pain control, in a variety of
chronic painful musculoskeletal conditions, including
low back pain, fibromyalgia, osteoarthritis, etc. [24].
The SNRIs continue to be developed for pain indications. There is clear evidence of benefit for antidepressants in fibromyalgia, for the TCAs and the SNRIs
(duloxetine, milnacipran), osteoarthritis (duloxetine,
venlafaxine), and low back pain (TCAs, duloxetine).
In the setting of chronic musculoskeletal pain, such
as osteoarthritis and low back pain, most guidelines
recommend beginning with acetaminophen/paracetamol or nonsteroidal anti-inflammatory agents. If these
agents are not sufficient, antidepressants can be added
or substituted. Opiates are recommended only after

failure of multiple other agents. In fibromyalgia, where
NSAIDs have limited utility, the TCA and SNRI antidepressants are preferred therapy, where multiple randomized trials demonstrate the effects of TCAs and
SNRIs, including duloxetine, venlafaxine, and milnacipran. If these agents are not effective, there is some
evidence of effectiveness of tramadol, whereas opiates
are not recommended for fibromyalgia (Table84.3).
In the setting of neuropathic pain, there are multiple randomized trials demonstrating the effectiveness
of TCAs and the SNRIs, venlafaxine and duloxetine
[5,6]. Efficacy is demonstrated for TCAs and SNRIs in
several neuropathic pain subtypes, including diabetic
peripheral neuropathy, post-herpetic neuropathy and
painful polyneuropathy, as reviewed in Table 84.3.
Milnacipran, an SNRI, has not been tested in the setting of neuropathic pain. As reviewed in Sindrup et al,
[5], the tricyclic antidepressants can have important
treatment effects, with numbers-needed-to-treat (NNT)
in the range of 1.2 to 2.4, where any NNT less than 4 is
generally regarded as having important pain effects
beyond placebo. SNRIs such as venlafaxine and
duloxetine also have effects, with NNT in the range of
5 to 7. The SSRIs citalopram, fluoxetine and paroxetine have also been tested in painful polyneuropathy,
and it would appear in small trials that these agents do
have some efficacy, although this effect is less predictable and further studies are clearly needed to fully
quantify the role of SSRIs in neuropathic pain states.
Recent US guidelines support the use of TCAs and
SNRIs antidepressants as first-line agents in the treatment of neuropathic pain, prior to the use of opioid
agents, for instance [6].
Are there differences among the

antidepressant classes for pain control?
As reviewed above, there is strong evidence of efficacy
for the TCAs and for the SNRIs in fibromyalgia, osteoarthritis, low back pain, diabetic neuropathy, and
chronic neuropathic pain. Deciding whether there
might be differences among agents or classes is not
straightforward. There are few head-to-head trials,
and proper studies examining the dose-response relationship for pain have not been conducted for the
TCAs or the SSRIs. In addition, TCA dosing is often
limited by tolerability. For instance, it is not clear
whether TCAs, as they are currently used, are being
under-dosed for pain. In short, deciding on what
doses to contrast in head to head trials, among TCAs,
SSRIs and SNRIs, is not a trivial undertaking. Some
have suggested that the SSRIs are not effective in pain,
yet others argue that the proper doses for SSRIs in
pain have not been established. Unfortunately, there
is limited clinical trial information with the SSRIs.
This is disappointing in part, since pain is a common
symptom accompanying depression, and it can be part
of the diagnostic criteria, yet pain in the depression
trials was not well quantified, limiting the opportunity
to draw pain efficacy conclusions. The prior discussion notwithstanding, the limited data that are available suggest that SSRIs, like fluoxetine, are not effective
analgesics per se, although some trials do demonstrate
positive effects with paroxetine.
However, managing depression is integral to managing pain well. Thus if the goal is to manage pain in
patients who do not have concomitant depression,
then the TCAs or the SNRIs are preferred for their
demonstrated pain-relieving qualities. If the goal is to
manage depression in someone with concurrent pain,
then the SSRIs or the SNRIs are both sensible choices,
and preferred over the TCAs for their superior tolerability profiles.
What has the recent evidence

taught us about the intersection
of pain and depression?
Recent experimental evidence suggests that pain and
depression share common biological pathways. The
excellent systematic review by Kroenke and colleagues
outlines the evidence, in detail, that suggests depression and pain follow the same descending pathways of
the CNS [1,2,4]. Focus has been on the descending
system
of pain modulation. Several areas appear to be
key to pain modulation and in particular the periaqueductal gray (PAG). The amygdala, hypothalamus, and
frontal neocortex all send fibers there, with further
relays into the pons and medulla. These relay systems
contain serotonergic neurons in the rostral ventromedial medulla, and norepinephrine neurons in the dorsolateral pontine tegmentum. The rostral ventromedial
medulla has two types of cells, on cells which facilitate pain transmission, and off cells which inhibit it,
and serve to modulate peripheral sensory input. Interestingly, opiates tend to excite off cells and inhibit on
cells, dampening peripheral nociceptive input. With
the attendant reductions in serotonin and norepinephrine that accompany depression, minor peripheral
signals can be amplified, and this is consistent with the
observation that patients with depression often
describe multiple symptoms, including unexplained
pain. Of note, serotonin and norepinephrine administered intrathecally can block pain transmission. As
reviewed in Perrot et al. [3], some studies have suggested peripheral mechanisms for TCAs in pain reduction for musculoskeletal pain, including inhibition of
local nitric oxide and prostaglandin production.
It is well appreciated clinically that current and persistent pain can lead to depression. What is not clear is,
what is the chicken, and what is the egg? Is there
clinical research evidence to suggest that pain leads to
depression, supporting the clinical experience? Does
depression lead to pain? Are both events predicted by
the presence of the other? There is evidence from a
variety of sources that acute trauma and its associated
pain can lead to future depression. To cite one example, a 2000 New England Journal of Medicine publication reported on a population-based cohort of 7463
individuals who had whiplash post motor vehicle collision and who were then followed until symptom resolution [7]. Pain severity, size of body area with pain,
and depressive symptomatology were strongly related
with both time to recovery and probability of recovery.
Those individuals who had whiplash pain but who did
not report being depressed prior to the whiplash event
were followed for future symptoms of depression,
using the Epidemiological Studies Depression Scale
[8]. In this follow-up, 42% of whiplash subjects who
had not been previously depressed met the definition
for depression over the next 6 weeks. The majority
(60%) of these 42% experienced resolution within the
subsequent year, with a median recovery time of 92
days, whereas 19% experienced recurrent bouts of
343
344
depression and 19% experienced persistent depression

throughout the next one year. Kroenke and coworkers
[1,2,4], in their systematic review, show that 2% to
100% of patients attending specialized pain clinics
have depression and, when population-based studies
and general practitioner clinics are considered, a
median of 20% of patients in pain are depressed. Differences in rates depend on the clinical setting, the
underlying pain condition, and the instrument used to
detect depression. However, in sum, there is strong,
consistent evidence from cohort studies that pain leads
to depression.
Several, large, general-practice-based randomized
controlled trials have been completed, examining the
effect of managing with both pain and depression, on
depression outcomes. The Stepped Care for Affective
Disorders and Musculoskeletal Pain (SCAMP) conducted a randomized trial in general medicine clinics in
250 patients with low back, hip, or knee pain and moderate depression severity [2]. Patients were randomized
to a 12 week, three-step program of optimized antidepressant therapy (step 1) then a 12 week pain self-management program (step 2), followed by 6 months of
ongoing therapy continuation (step 3). This three-step
program was contrasted with usual care. At 12 months,
37.4% of those in the three-step program had a 50% or
greater reduction in depression severity, compared to
baseline, as contrasted with 16.5% reduction in the usual
care patients. Importantly, a clinically significant reduction in pain, defined as 30% reduction from baseline,
occurred in 41.5% of patients in the three-step program, as compared to 17.3% in usual care. Combining
improvement in both depression and pain, 26.0% in the
three-step program improved versus 7.9% in the usual
care group. There was a variety of antidepressants used
in the study, including the SNRIs, the SSRIs, buproprion, mirtazipine and the TCAs. Therefore the effects
on pain improvement cannot be ascribed solely to the
choice of antidepressant alone, but are more likely to
reflect the benefit of good depression management.
In another study, conducted in the US Veterans
Affairs healthcare system, in adults over 60 years with
depression, an examination of whether pain severity
and interference with normal work activities moderated the effects of depression treatment response was
undertaken [9]. In this study, patients were randomized
to integrated care (care delivered in the primary care
clinic, by a mental health professional) versus
enhanced specialty referral care (care delivered in the
subspecialty clinic office) and results were examined
at 3, 6, and 12 months. The trial showed that both

groups had improvement in their depression symptomatology, but that higher levels of pain severity and
interference with work activities blunted the improvements in depressive symptoms. The authors concluded
that pain interference accounted for the moderating
effects of pain severity on changes in depressive symptoms over time.
In a randomized controlled trial, designed to
examine whether enhancing the care for depression
improves pain and functional outcomes in older adults
with concomitant osteoarthritis, a total of 1001
patients were randomized to antidepressant medications with or without an additional six to eight
psychotherapy sessions [10]. Both groups had
improvement in depressive symptoms from baseline.
The group receiving antidepressants and psychotherapy had lower mean (SE) scores for pain intensity
(5.62 [0.16] vs. 6.15 [0.16]) measured on a 010
numerical rating scale; less interference with daily
activities due to arthritis (4.40 [0.18] vs. 4.99 [0.17]) as
measured on a 010 numerical rating scale, and less
interference with daily activities due to pain (2.92
[0.07] vs. 3.17 [0.07]) as measured by two questions
from the SF-12, on a 04 scale. A variety of antidepressants were allowed, and 66% of the enhanced care
group and 52% of the usual care group used
antidepressants over the 12 months. The authors concluded that in a diverse population of older adults
with osteoarthritis and comorbid depression, benefits
of improved depression care extended beyond reduced
depressive symptoms and included decreased pain as
well as improved functional status and quality of life.
In summary, these recent trials illustrate that
enhancing depression care has important impacts on
pain control, independently of the antidepressant class.
Interference with function, related to pain, appears to
be a major determinant of depression response. There
is a tight intertwining of response to both pain and
depression, based on improving both simultaneously.
Does recognizing and treating

depression have any impact on the
acute post-operative period, with
respect to pain control, morbidity
and mortality?
Finally, we will consider evidence that depression has an
influence on the outcome of major illnesses, including
recovery in the post-operative setting. It has been long

understood that depression has an influence on coronary artery bypass grafting. This continues to be an
area of active investigation. In a 2008 study, 1319
patients who had 2496 grafts had baseline angiography and were then followed up angiographically, over
a median of 4.2 years [11]. Those who were depressed,
as assessed by a Centers for Epidemiologic Studies
Depression scale (CES-D) score 16, were statistically
more likely to have graft progression (OR 1.50, 95% CI
1.08 to 2.10, P < 0.02), after adjusting for age, gender,
race, treatment, and years since surgery. Additional
statistical adjustment for past medical history, blood
pressure, and renal function did not materially alter
these results. These authors conclude that depressive
symptoms are associated with a higher risk of atherosclerotic progression among patients with saphenous
vein grafts.
In a 2009 study, 1238 patients scheduled for
CABG were assessed for depression using the Patient
Health Questionnaire (PHQ-9) [12]. Of these, 21.6%
had elevated depression scores. Predictors for preoperative depression were dyspnea at rest and exertion, previous myocardial infarction, multiple
comorbidities, as well as younger age, female gender,
lower educational attainment, and living alone. This
study demonstrated that active screening of pre-operative depression is feasible, and can be suspected
based on clinical features. Knowledge of depression
status could lead to improved post-operative management.
Oncologists believe that psychological variables
influence the course of cancer. A 2009 meta-analysis
evaluated the literature on depression and mortality
in cancer patients [13]. The 25 studies included in
this meta-analysis showed that mortality rates were
up to 39% higher in depressed patients (RR = 1.39;
95% CI, 1.101.89; P < 0.03). This analysis also
showed that adjusting for known clinical prognostic
factors had no influence on the predictive ability of
depression on mortality, suggesting that the relationship between depression and cancer mortality could
be cause and effect. While few would deny the value
of treating pain and depression in the setting of cancer, managing depression could influence the ultimate prognosis.
Data that depression can influence disease outcome are just beginning to appear in the setting of
total knee replacement (TKR). In a 2009 cohort study
43 patients undergoing TKR were followed for 12
months post-operatively [14]. Depression was studied

as a prospective predictor of post-operative pain. The
authors reported that depressive symptoms predicted
global pain complaints, and postulated that interventions designed to reduce depressive symptoms have
the potential to improve joint replacement outcomes.
In a 2003 cohort study designed to identify factors
predicting excessive post-operative pain, 116 patients
were followed for 1 year [15]. Importantly, greater
pre-operative pain predicted greater post-operative
pain, and pre-operative depression and anxiety were
associated with elevated pain levels at 1 year. The study
also showed that one in eight patients report moderate
to severe pain 1 year after surgery, with no evidence of
abnormalities on clinical exam or radiographs. The
authors recommend that office-based pre-operative
screening for depression could improve patient-perceived outcomes.
Although the evidence is not presented in its
entirety, it is clear that post-operative depression can
influence disease outcome, as illustrated in the setting
of CABG, and cancer mortality, as well as post-operative recovery, as shown in the setting of TKR. It is
also increasingly apparent that pre-operative depression can predict post-operative pain control, and
authors are increasingly advocating depression
screening. To this end, a simple, four-item instrument, the Ultra-Brief Screening Scale for Anxiety and
Depression, Patient Health Questionnaire, PHQ-4, is
presented with its scoring schema [16]. This instrument has two questions focused on anxiety and two
on depression, and has shown validity in populationbased samples. As argued, given the structured preoperative assessment process, an assessment of
depression would facilitate planning for the postoperative recovery.
References
1. Bair MJ, Robinson RL, Katon W, Kroenke K.

Depression and pain comorbidity. A literature review.
Arch Intern Med 2003;163:24332445.
2. Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of
chronic pain: a synthesis of recommendations from
systematic reviews Gen Hosp Psychiatry 2009;31:
206219.
3. Perrot S, Javier RM, Marty M, et al. and the CEDR
(Cercle dEtude de la Douleur en Rhumatologie
France), French Rheumatological Society, Pain Study
Section. Is there any evidence to support the use of
345
anti-depressants in painful rheumatological

conditions? Systematic review of pharmacological
and clinical studies. Rheumatology 2008;47:
11171123.
4. Kroenke K, Bair MJ, Damush TM, Wu J. Optimized
antidepressant therapy and pain self-management in
primary care patients with depression and
musculoskeletal pain: a randomized controlled trial.
JAMA 2009;301(20):20992110.
5. Sindrup SH, Otto1 M, Nanna B, et al. Antidepressants
in the treatment of neuropathic pain. Basic Clin
Pharmacol Toxicol 2005;96:399409.
6. OConnor, AB, Dworkin RH. Treatment of
neuropathic pain: an overview of recent guidelines.
Am J Med 2009;122: S22S32.
7. Cassidy JD, Carroll LJ, Cote P, et al. Effect of
eliminating compensation for pain and suffering on
the outcome of insurance claims for whiplash injury.
N Engl J Med 2000;342:11791186.
8. Carroll LJ, Cassidy JD, Cote P. Frequency, timing, and
course of depressive symptomatology after whiplash.
SPINE 2006;31(16): E551E556.
9. Mavandadi S, Ten Have TR, Katz IR, Nalla U, Durai B,
Krahn DD, Llorente MD, Kirchner JA, Olsen EJ, Van
Stone WW, Cooley SL, Oslin DW. Effect of depression
treatment on depressive symptoms in older
adulthood: the moderating role of pain. J Am Geriatr
Soc 2007;55:202211.
10. Lin EHB, Katon W, Von Korff M, Tang l., Williams Jr
JW, Kroenke K, Hunkeler E, Harpole L, Hegel M,
346
Arean P, Hoffing M, Della Penna R, Langston C,

Unutzer J, for the IMPACT Investigators. Effect of
improving depression care on pain and functional
outcomes among older adults with arthritis: a
randomized controlled trial. JAMA 2003;290:24282434.
11. Wellenius GA, Mukamal KJ, Kulshreshtha A, et al.
Depressive symptoms and the risk of atherosclerotic
progression among patients with coronary artery
bypass grafts. Circulation 2008;117:23132319.
12. Dunkel A, Kendel F, Lehmkuhl E, et al. Predictors of
preoperative depressive risk in patients undergoing
coronary artery bypass graft surgery. Clin Res Cardiol
2009;98:643650.
13. Jillian R, Satin JR, Linden W, Phillips MJ. Depression
as a predictor of disease progression and mortality in
cancer patients: a meta-analysis. Cancer 2009;
53495361.
14. Edwards RR, Haythornthwaite JA, Smith MT.
Catastrophizing and depressive symptoms as
prospective predictors of outcomes following total
knee replacement. Pain Res Manag 2009;14(4):
307311.
15. Brander VA, Stulberg SD, Adams AD, et al. Predicting
total knee replacement pain: a prospective, obser
vational study. Clinic Orthop Rel Res 2003;416:2736.
16. Lwe B, Wahl I, Rose M, et al. A 4-item measure of
depression and anxiety: validation and standard
ization of the Patient Health Questionnaire-4 (PHQ-4)
in the general population. J Affect Disord 2009. http://
dx.doi.org/10.1016/j.jad.2009.06.019.
Section 9
Chapter
85
Antidepressants
Tricyclic antidepressants
Carly Miller and Alan Miller
Tertiary Amines
Generic Name: amitriptyline-HCl
Trade Name: Elavil
Manufacturer: Astra Zeneca Pharmaceuticals,
Wilmington, DE
Generic Name: doxepin-HCl
Trade Name: Sinequan
Manufacturer: Pfizer U.S. Pharmaceuticals,
New York, NY
Generic Name: imipramine-HCl
Trade Name: Tofranil
Manufacturer: Novartis Pharmaceuticals, East
Hanover, NJ
Secondary Amines
Generic Name: desipramine-HCl
Trade Name: Norpramin
Manufacturer: Aventis Pharmaceuticals, Inc.,
Bridgewater, NJ
Generic Name: nortriptyline-HCl
Trade Name: Pamelor
Manufacturer: Novartis Pharmaceuticals, East
Hanover, NJ
Generic Name: protriptyline-HCl
Trade Name: Vivactil
Manufacturer: Odyssey Pharmaceuticals, East
Hanover, NJ
Chemical Structure: tertiary amine (amitriptyline), see Figure 85.1; secondary amine (nortri
ptyline), see Figure 85.2
Description
Tricyclic antidepressants (TCAs) can be effective mono

therapy for pain, or as an adjuvant to other analgesics
[1]. They are particularly effective for neuropathic pain

and their efficacy for post-herpetic neuralgia may be
greater than that of the newer pregabalin [2]. Tricyclics
are commonly used to treat headaches, fibromyalgia,
neck and low back pain. The mechanism of the antinociceptive activity of the tricyclic antidepressants is
largely unknown, and appears to be distinct from their
antidepressant properties. It may be related to sodium
channel blockade. Analgesic effects are achieved with
lower doses and quicker onset than antidepressant
effects.
Traditionally the tertiary amine amitriptyline has
been favored for pain management over nortriptyline,
despite increased side effects and interactions and no
proven analgesic benefit of tertiary amines over secondary amines.
Mode of activity
Major sites of action: serotonin and norepinephrine
receptors in the CNS.
Minor sites of action: cholinergic (muscarinic),
alpha-1- and alpha-2-adrenergic, histaminic-1 and
dopaminergic receptors; CNS and cardiac sodium
channels.
Receptor interactions: the tricyclic antidepressants inhibit the postsynaptic reuptake of serotonin
and norepinephrine, and increase concentrations
in the spinal cord. Norepinephrine binds to, and
activates, postsynaptic alpha-adrenergic receptors,
thereby suppressing pain transmission. Norepinephrine reuptake blocks dopamine activity in the
frontal cortex, and by inhibiting this process tricyclics increase dopaminergic activity in this area.
Depending on the tricyclic agent, there is postsynaptic blockade of histamine-1, dopaminergic, cholinergic, alpha-1-adrenergic and alpha-2-adrenergic
receptors (concentrated in CNS and cardiac tissue
due to high lipophilicity). This activity is largely
responsible for side effects and drug interactions of
these medications.
347
Figure 85.1.
CH3
N
CH3
Figure 85.2.
H
N
CH3
Metabolic pathways/drug clearance and elimination: there is significant first-pass effect, with roughly
50% bioavailability. Most tricyclics are greater than
90% plasma-bound. The mean half-lives of amitriptyline and nortriptyline (an active metabolite of
amitriptyline) are about 21 and 32 hours, respectively.
Peak levels occur from 2 to 12 hours, although analgesic effects are not achieved for at least 3 to 10 days.
Elimination is 98% renal for amitriptyline and 67%
renal for nortriptyline. Tricyclic antidepressants are
substrates of the cytochrome P450 2D6 system, which
is inhibited by several medications, including selective
serotonin reuptake inhibitors. Interactions may lead
to significant increases in plasma concentration.
Indications (non-approved)
348
Tricyclic antidepressants are not FDA-approved for

any pain indications.
Surgical acute pain: amitriptyline may be beneficial for adjunctive use for pain control as well as nighttime sedation. Patients recovering from amputation,
traumatic or surgical nerve injuries (intercostal nerves,
branches of the brachial plexus, inguinal and genitofemoral nerve, etc.). Consider starting dose of
12.525 mg qhs and increase to 50 mg as tolerated.
Monitor for urinary retention/constipation that may
coincide with post-operative symptoms. Consider
nortriptyline or desipramine to reduce side effects.
Medical and chronic non-malignant pain:

amitriptyline and nortryptiline are useful for controlling diabetic neuropathic pain, post-herpetic neuralgia, neck and back radicular pain, as well as pain from
conditions including HIV, complex regional pain syndrome (CRPS; RSD), and autoimmune disorders (RA,
SLE). Migraine and tension headaches, fibromyalgia,
temporomandibular joint disorder, interstitial cystitis,
irritable bowel syndrome, premenstrual, pelvic and
phantom limb pain may also respond to tricyclics.
Consider starting amitriptyline 2550 mg qhs and
increase to 300 mg qhs as side effects (dry mouth, constipation, daytime sedation, urinary retention, etc.)
permit. Titrate with weekly dosage increases. As the
active metabolite of amitriptyline, consider starting
nortriptyline at 25 mg. Consider discontinuing
amitriptyline if no pain benefits by 150 mg or
nortriptyline if no benefit by 75 mg. Again, fewer side
effects occur with nortriptyline (Table 85.1), although
amitriptyline is sometimes preferred for its sedative
effects. Use caution prescribing TCAs for patients with
fibromyalgia and interstitial cystitis where agents such
as SSRIs are commonly used.
Cancer pain: tricyclic antidepressants may be a
helpful adjuvant in treating visceral and neuropathic
pain of malignancy. Consider using them alone or as
adjuncts to opioid analgesics for neuropathic symptoms in cancer pain such as burning, tingling, electric
shock and sharp sensations. If minimal medical
comorbidities are present, consider a rapid titration to
maximum effective dose with tolerable side effects
(150 mg/day for amitriptyline or nortriptyline).
Contraindications
Absolute: documented allergy to tricyclics, recent
myocardial infarction, history of QTc prolongation or
cardiac arrhythmia, and unstable heart failure. Do not
use in conjunction with substances known to significantly prolong QTc such as thioridazine, pimozide,
certain antiarrhythmics, and fluoroquinolones.
Relative: history of seizure disorder, bipolar disorder (may induce mania), urinary retention, narrowangle glaucoma, delirium, hyperthyroidism, bradycardia
(or drugs that cause bradycardia), or electrolyte disturbance (esp. K+ or Mg2+). Use caution in conjunction
with other antidepressants (including MAOIs and
SSRIs), other anticholinergic medications, drugs that
increase plasma levels (phenothiazines, haloperidol,
cimetidine), or drugs that lower seizure threshold (esp.
tramadol). Use caution in elderly, children/adolescents,
Tablet: 10, 25,

50, 75, 100, 150
parenteral:
10mg/mL
Capsule: 25, 50, 75
Tablet: 10, 25, 50

parenteral: 25
mg/2 mL
Amitriptyline (active
metabolite: nortriptyline)
Clomipramine
(active metabolite:
desmethylclomipramine)
Imipramine (active
metabolite: desipramine)
Capsule: 10, 25,

50, 75 Oral sln:
10mg/5 mL
Tablet: 10, 25, 50,
75, 100, 150
Nortriptyline
Desipramine
Secondary amines
Capsule: 10, 25, 50,

100, 150 oral sln:
10 mg/mL
Formulations (mg)
Doxepin (active
metabolite:
desmethyldoxepin)
Tertiary amines
Generic name
300
150
300
250
300
300
Maximum
daily dose
(mg)
Memory loss
Tachycardia
++
+++
+++
++++
++++
++++
Dry mouth
Dizziness
++
++
+++
+++
++++
+++
Constipation
Urinary
retention
Blurred vision
Cholinergic
blockade
Orthostatic
hypotension
-1
blockade
Side effects
Prolactin
elevation
EPS
Dopamine
blockade
++
++
+++
+++
++++
Weight gain
Sedation
Histamine
blockade
++++
+++
++
++
++
Anxiety
Sweating
Norepinephrine
reuptake
blockade
+/-
+/-
++
+++
++
Nausea
Diarrhea
Serotonin
reuptake
blockade
Table 85.1. Tricyclic antidepressant formulations, side effects, active metabolites and plasma levels (in descending order by side effect profile)[3]
n/a
150
350
300
160
200
Upper limit
of therapeutic plasma
level (ng/mL)
Chapter 85 Tricyclic antidepressants
349
pregnant/nursing women, and those with renal, hepatic,

or cardiac impairment.
Common doses
Doses of tricyclic antidepressants are generally lower
for pain than therapeutic ranges for depression. Most
tricyclics can be started at 1025 mg and titrated 25
mg at weekly intervals to therapeutic level (typically
75 mg for pain, maximum 150 mg) [1]. Nortriptyline
is typically effective at about half the dose of amitriptyline. Although not routinely recommended, plasma
concentration may be measured to ensure nontoxic
levels.
Oral and parenteral dosing: refer to Table 85.1 for
formulations.
Tricyclics are not narcotics and are not addictive. They
are easily prescribed and widely available in pharmacies and hospital formularies. Less caution is needed
in low analgesic doses.
Cost: inexpensive generics are widely available and
often covered by insurance.
As monotherapy: may be effective for some types
of pain.
As used for multimodal analgesia: often a useful
analgesic adjunct to other therapeutic interventions;
may also improve mood and sleep.
Toxicity: supratherapeutic plasma concentrations
(Table 85.1) can cause severe, life-threatening toxicity
resulting in cardiac arrhythmia/arrest, seizures (rare),
hepatic failure, paralytic ileus, and hyperthermia
(both due to anticholinergic toxicity).
Drug interactions: extreme caution with concomitant MAOIs or SSRIs, cimetidine, haloperidol,
or phenothiazines (all increase plasma levels). Avoid
QT-prolonging or potentially proarrhythmic agents,
350
sodium channel blocking agents such as type 1a and

1c antiarrhythmics, cardiac glycosides, cocaine, or
amphetamines. Agents that precipitate bradycardia
(-blockers, clonidine, calcium channel blockers),
or lower serum magnesium or potassium levels (diuretics, stimulant laxatives, parenteral amphotericin
B, glucocorticoids) all may potentiate QTc prolongation. Use caution in conjunction with drugs that
lower seizure threshold or have anticholinergic
properties.
Adverse events, tolerability: side effects may limit
tolerability (Table 85.1).

Common adverse events: include sedation, weight
gain, dry mouth, and constipation (Table 85.1). Abrupt
discontinuation should be avoided.
Serious adverse events: related to cardiac effects of
QTc prolongation and drug interactions described.
Treatment of adverse events: some common side
effects may resolve over time or with lower doses. In
addition to supportive therapy, the mainstay of treatment for severe toxicity is serum alkalinization with
sodium bicarbonate to increase protein binding and
decrease QRS interval. Although no reversal agent
exists, substances that may reverse cardiotoxicity are
being studied.
References
1. McQuay HJ, Moore RA. Antidepressants in chronic

pain. BMJ 1997;314:763764.
2. OConnor AB, Noyes K, Holloway RG. A costeffectiveness comparison of desipramine, gabapentin,
and pregabalin for treating postherpetic neuralgia. J
Am Geriatr Soc 2007;55(8):11761184.
3. Adapted from Maxmen J, Ward N. Psychotropic Drugs:
Fast Facts, 3rd ed. New York: W.W. Norton &
Company, 2002, and respective drug package inserts.
Section 9
Chapter
86
Antidepressants
Trazodone
JinLei Li
Generic Name: trazodone HCl

Proprietary Name: Desyrel
Drug Class: tetracyclic antidepressant
Manufacturer: Bristol-Myers Squibb, 345 Park
Ave, New York, NY; Apothecon, P.O. Box 4500,
Princeton, NJ; Labopharm, 480 Armand-
Frappier Blvd, LAVAL, Quebec H7V 4B4
(extended-release formula)
Chemical Name: 2-[3-[4-(3-chlorophenyl)-1piperazinyl]propyl]-1,2,4-triazolo[4,3-a]
pyridin-3(2H)-one hydrochloride
Chemical Formula: C19H22ClN5OHCl
Introduction
Trazodone is a tetracyclic atypical antidepressant that
also provides analgesic effects at supraspinal and
spinal levels in the central nervous system (CNS).
Mode of activity
Trazodone is a modulator that augments the serotonin
(5-HT) system and increases the excitatory effects of
this neurotransmitter. It inhibits reuptake of serotonin
and induces significant changes in 5-HT presynaptic
receptor [1]. It may also act as a serotonin agonist via an
active metabolite. Additionally it has a minor inhibitory
effect on the catecholamine system through decreasing
norepinephrine uptake, alpha-1 receptor blockage,
beta-receptor subsensitivity and decreased beta-receptor density. Thirdly trazodone also blocks histamine
(H1) receptors and has minor anti-cholinergic effects.

and elimination
Trazodone is currently available in standard and
extended-release oral formula. Transdermal preparation
and suppository delivery are under development for pain

control. The serum concentration of standard-release
trazodone tablets peaks at around 30100 minutes,
which can be significantly delayed with food for up to
2.5 hours. In blood trazodone is highly protein-bound,
85% to 95%. It is metabolized by liver extensively to an
active metabolite, m-chlorophenylpiperazine (mCPP),
through CYP3A4 (major) and CYP2D6 (minor). Trazodone metabolism is biphasic with the half-life of redistribution around 1 hour and half-life of elimination
around 1012 hours [2,3]. Trazodone is excreted primarily in urine 75% (<1% unchanged), with feces excretion
accounting for about 20%. Trazodones anti-insomnia
effect may be noted within 13 hours following administration. The precise time to onset of its analgesic effects
in patients suffering chronic pain is variable and may be
delayed. Theoretically the onset of trazodones anti-neuropathic effects may occur around the same time as that
of its antidepression effects, around 13 weeks [3].
Indications
Trazodone was approved by the FDA in 1982 for
depression, and while it is not approved for chronic
pain management it has been advocated for use in
multimodal analgesic regimens. In acute pain settings
its ability to quickly restore a normal sleeping pattern
contributes to better overall pain control. Trazodone is
most effective in treating chronic neuropathic pain: its
ability to inhibit serotonin and norepinephrine uptake
provides measurable analgesic and mood elevation
effects [35]. Okuda and coworkers [4] evaluated the
analgesic effect of trazodone on thermal hyperalgesia
in a chronic constriction injury of the sciatic nerve in
rats. They also examined the effects of lesions in the
descending and ascending serotonergic system upon
trazodones antihyperalgesic effects. Trazodone showed
a clear dose dependency, and lesion studies suggested
that the serotonergic descending pain control pathway
is primarily responsible for its analgesic effect.
351
N
N CH2 CH2 CH2 N
N
HCI
Cl
Figure 86.1.
Trazodone is effective in pain states associated with

anxiety, depression, insomnia, and adrenergic hyperactivity [3]. It is also useful in settings where tricyclic antidepressants are contraindicated, not tolerated or
ineffective. Ventafridda and colleagues [5] compared
the analgesic effects of trazodone and amitriptyline for
the treatment of chronic deafferentation pain in 45
patients with oncological peripheral nerve lesions. The
therapeutic effectiveness of trazodone in terms of pain
intensity, hours of sleep, hours standing and lying,
mood, anxiety, and weakness was equivalent to that provided by amitripyline, although side effects were less
pronounced. Trazodone 100150 mg daily has also been
shown to be effective in chest pain secondary to esophageal mobility abnormalities. In pediatrics, trazodone
has also been used in childrens migraine headache.
Contraindications
Absolute: patients allergic to trazodone or nefazodone
or any components of the formulation.
Relative: avoid using in patients taking sodium
oxybate as their central nervous system and respiratory-depressant effects are synergistic. Avoid using
together with linezolid or MAOIs for the risk of serotonin syndrome. Avoid using in patients with recent
suicidal ideations or attempts as trazodone may
increase risk of suicide especially at the start of treatment or with dose escalation. Avoid using in the setting of a recent heart attack as trazodone increases
heart rate and therefore adds to stress on the heart.
Common doses
Oral: take it after a meal or a snack to reduce the risk of
dizziness and vomiting. It comes in preparations of 50,
100, 150, and 300 mg. Oral adult initial dose is 2550 mg
daily and final dose 25150 mg daily. In general, trazodone is effective for pain control at an overall dose lower
than that required for treatment of depression.
352
As an oral antidepressant, trazodone is easy to use, with

good absorption and bioavailability, well tolerated and
affordable. Trazodone has little of the aminergic properties of tricyclics or monoamine oxidase inhibitors. This
results in its low cardiotoxicity with almost no effect on
cardiac conduction and little anticholinergic effect. Trazodone is therefore used in neuropathic pain patients
when tricyclics are contraindicated, not tolerated, or
ineffective, such as cardiac patients, especially patients
with arrythmias, Alzheimers, and the elderly. Trazodone
is the first antidepressant that does not cause death with
overdose as compared with the lethal effects of tricyclic
overdose. Trazodone is available as low-cost generic
preparations. The extended-release formula has just been
approved by the FDA. In summary trazodone has opioid-sparing effects in chronic pain control, restores sleep
patterns, has a low side-effect profile, and no death has
been reported for overdose.
Major drug interactions: trazodone interacts with
MAOIs with the risk of serotonin syndrome. When
switching between trazodone and an MAOI, a 2-week
no-trazodone no-MAOI gap is necessary to safely stop
and start treatment. Trazodone should not be stopped
abruptly. Trazodone interacts with alcohol with worsening sedation. Tegretol decreases blood levels while
Nizoral and Norvir increase blood levels of trazodone.
Co-administration of trazodone can increase blood concentrations of digoxin and phenytoin. Trazodone may
also pass into breast milk and affect a nursing baby.

Common/serious adverse events: dizziness, headache,
sedation, nausea, xerostomia, blurred vision.
Less common adverse events: syncope, hypo/hypertension, edema, confusion, decreased concentration,
diarrhea/constipation, tremor, myalgia, nasal congestion.
Rare but important events: agitation, allergic reactions, alopecia, anxiety, bradycardia/tachycardia,
extrapyramidal symptoms, hepatitis, priapism (i.e.
prolonged or constant penile erection that can be
painful), rash, seizure, speech impairment, urinary
retention, risk of suicidal ideations or attempts.
Disease-related concerns
Use cautiously in patients with cardiovascular disease
especially during the acute recovery phase of MI.
Possible dose adjustment in patients with hepatic or
renal dysfunctions, seizure disorders, head trauma,
alcoholism, schizophrenia, or bipolar manic depression.
Use with caution in patients with drug abuse history.
Chapter 87 Duloxetine
Overdose
Symptoms vary from person to person and are also
influenced by co-injection of alcohol or other sedative/psycoative medications. Overdose of trazodone
may cause an increase in incidence or severity of any
of the reported adverse reactions, with drowsiness and
vomiting being the most common ones, followed by
hypotension, breathing difficulty, seizures, priapism,
and arrhythmia. There is the potential for loss of life
but it has not been reported. There is no specific antidote for trazodone. Any patient suspected of having
taken an overdose should be admitted to hospital as
soon as possible. Acute management is geared to promote elimination and avoid further absorption such
as activated charcoal, gastric lavage, and forced diuresis when indicated. Ipecac is contraindicated. In the
meantime proper monitoring of cardiac, respiratory,
neurological status, and NPO may be warranted. Treat
symptomatically, such as IVF/dopamine/norepenephrine for hypotension, benzodiazepines/barbiturates
for seizure, cyproheptadine for serotonin syndrome.
Conclusion
Trazodone provides useful analgesia for patients suffering chronic neuropathic pain, although it is not
Section 9
Chapter
87
formally
approved for this condition. It does not
appear to offer efficacy advantages over amitriptyline
and other TCAs but may provide improved
tolerability.
References
1. Stoelting RK, Hillier SC. Chapter 19: Drugs used for

psychopharmacologic therapy. In Pharmacology and
Physiology in Anesthetic Practice, 4th ed. pp.
398406.
2. Ansari A. The efficacy of newer antidepressants in
the treatment of chronic pain: a review of current
literature. Harv Rev Psychiatry: 2000;7(5):257277.
3. Ventafridda V, et al. Antidepressants for cancer pain
and other painful syndromes with deafferentation
component: comparison of amitriptyline and
trazodone. Ital J Nerurol Sci 1987;8:579587.
4. Okuda K, Takanishi T, Yoshimoto K, et al. Trazodone
hydrochloride attenuates thermal hyperalgesia in a
chronic constriction injury rat model. Eur Acad
Anaesthesiol 2003;20:409414.
5. Ventafridda V, Caraceni A, Saita L, et al. Trazodone
for deafferentation pain. Comparison with
amitriptyline. Psychopharmacology 1988;
95:S44S49.
Antidepressants
Duloxetine
Eric S. Hsu
Generic Name: duloxetine-HCl

Proprietary Name: Cymbalta Delayed-Release
Capsules for Oral Use
Manufacturer: Eli Lilly and Company, Indianapolis, IN 46285

Chemical Name: (+)-(S)-N-methyl--(1-naph
thyloxy)-2 thiophenepropylamine hydrochloride
Empirical Formula: C18H19NOSHCl; molecular
wt 333.88
353
Description
Indications
Duloxetine is a selective serotonin and norepinephrine

reuptake inhibitor (SNRI). Duloxetine is available as
delayed-release capsules for oral route.
1 .
2.
3.
4.
Mode of activity
Proposed mechanism of action: the potentiation of
serotonergic and noradrenergic activity in the CNS
may attribute to the clinical efficacy.
Receptor interactions: preclinical studies have shown
that duloxetine is a potent inhibitor of serotonin and
norepinephrine reuptake and a less potent inhibitor of
dopamine reuptake. Duloxetine has no significant affinity for dopaminergic, adrenergic, cholinergic, histaminergic, opioid, glutamate, and GABA receptors. Duloxetine
does not inhibit monoamine oxidase (MAO).
Pharmacokinetics: duloxetine has an elimination
half-life of about 12 hours and its pharmacokinetics is
dose-proportional over the therapeutic range. Patients
may reach steady-state plasma concentrations after
dosing for 3 days. Elimination of duloxetine is mainly
through hepatic metabolism involving two P450 isozymes, CYP1A2 and CYP2D6.
Absorption and distribution: oral duloxetine is
well absorbed with maximal plasma concentrations in
6hours. Food delays the time to reach peak concentration from 6 to 10 hours and decreases 10% of
absorption. There is a 3 hour delay in absorption and
a one-third increase in apparent clearance of duloxetine after an evening dose as compared to a morning
dose.
Metabolism and elimination: duloxetine undergoes extensive metabolism to numerous inactive
metabolites. The major biotransformation pathways
for duloxetine involve oxidation of the naphthyl ring
followed by conjugation and further oxidation. Both
CYP1A2 and CYP2D6 catalyze the oxidation of the
naphthyl ring in vitro. Most (about 70%) of the duloxetine dose appears in the urine as metabolites of duloxetine; about 20% is excreted in the feces.
Figure 87.1.
O
S
354
NH HCI
CH3
Major depressive disorder

Generalized anxiety disorder
Diabetic peripheral neuropathy
Fibromyalgia
Contraindications
Patients taking monoamine oxidase inhibitors. The
potential interactions with serotonergic drugs may
include hyperthermia, rigidity, myoclonus, autonomic
instability with possible rapid fluctuations of vital
signs. Mental status changes may involve extreme agitation and then progress to delirium and coma resembling neuroleptic malignant syndrome.
Patients have uncontrolled narrow-angle glaucoma. There was an increased risk of mydriasis associated with use of duloxetine.
Warnings and precautions

1 .
2.
3.
4.
5.
6.
Clinical worsening and suicide risk

Activation of mania/hypomania
Hepatotoxicity
Orthostatic hypotension and syncope
Effect on blood pressure
Serotonin syndrome or neuroleptic malignant
syndrome (NMS-like reactions)
7. Seizures
8. Abnormal bleeding
9. Hyponatremia
10. Urinary hesitation and retention
Common doses
There is no standard recommendation for laboratory
tests while patients take duloxetine. Patients may take
duloxetine without regard to meals or fasting.
It should be swallowed whole and not chewed or
crushed as this may affect the enteric coating of
duloxetine.
Initial treatment
Diabetic peripheral neuropathic pain: patients may
start duloxetine with 60 mg or a lower dose and gradually titrate due to the concern of common renal
insufficiency in patients with diabetes.
Fibromyalgia: start with 30 mg once daily for 1
week and allow patients to adjust to duloxetine before
considering increasing to 60 mg daily or higher dose.
Chapter 87 Duloxetine
Maintenance treatment
Diabetic peripheral neuropathic pain: the effectiveness of duloxetine must be assessed carefully based on
the progress of diabetic peripheral neuropathy.
Fibromyalgia: the efficacy of duloxetine in fibromyalgia was demonstrated in placebo-controlled trials up to 12 weeks. Efficacy up to 6 months has also
been documented in placebo-controlled studies after
FDA approval.
Discontinuing duloxetine
A gradual reduction in the dose rather than abrupt
cessation is recommended whenever possible. At least
14 days should pass between discontinuation of an
MAOI and initiation of therapy with duloxetine. In
addition, at least 5 days after stopping duloxetine
should be allowed before switching to an MAOI.
Diabetic peripheral neuropathic pain
The efficacy of duloxetine in pain management of diabetic peripheral neuropathy was recognized in two
randomized, 12-week, double-blind, placebo-controlled, fixed-dose studies. These were adult patients with
at least 6 months history of peripheral neuropathic
pain due to diabetes.
Both studies compared duloxetine 60 mg once
daily or twice daily with the placebo. Duloxetine 60
mg once or twice a day provided statistically significant improvement of endpoint mean pain scores from
baseline. The proportion of patients with at least a
50% reduction in pain score was higher in the treatment group than in the placebo.
Fibromyalgia
The efficacy of duloxetine for pain management of
fibromyalgia was well established in two randomized,
double-blind, placebo-controlled, fixed-dose studies.
These adult patients all met the American College of
Rheumatology criteria for fibromyalgia (a history of
widespread pain for 3 months, and pain present at 11
or more of the 18 specific tender point sites).
Both studies compared duloxetine 60 mg once
daily or 120 mg daily (given in divided doses in Study
1 and as a single daily dose in Study 2) with the placebo. The treatments using duloxetine 60 mg once or
twice daily resulted in statistically significant improvements of endpoint mean pain scores from baseline.
The proportion of patients with at least a 50% reduction in their pain score was higher in the treatment
group than in the placebo.
In addition, those nonresponders with less than
30% pain reduction after 8 weeks of duloxetine were
no more likely to meet response criteria at the end of
60 weeks of treatment even if blindly titrated to 120
mg as compared to those continued on 60 mg.
Duloxetine may cause significant drugdrug interactions. Both liver P450 isozymes CYP1A2 and CYP2D6
are accountable for the metabolism of duloxetine.
Simultaneous use with inhibitors of CYP1A2 and 2D6
resulted in higher levels of duloxetine. Duloxetine is
an inhibitor of CYP1A2 and 2D6. The desipramine (a
CYP2D6 substrate) level was increased by three-fold
when administered together with duloxetine 120 mg/
day. The concomitant use of duloxetine with other
SSRIs, SNRIs, or tryptophan is not recommended due
to the potential for serotonin syndrome.
Drugs that raise the gastrointestinal pH may lead
to an earlier release of duloxetine. Co-administration
of duloxetine with another highly protein-bound drug
may cause higher free levels and potential adverse
reactions.
Serotonin release by platelets plays an important role in hemostasis. Psychotropic drugs that
interfere with serotonin reuptake may increase the
occurrence of upper gastrointestinal bleeding with
concurrent use of an NSAID or aspirin. Altered
anticoagulant effects have been reported when either
SSRIs or SNRIs are co-administered with warfarin.
Hemostasis in warfarin therapy should be carefully
monitored whenever duloxetine is initiated or discontinued.

The most commonly observed adverse reactions associated with duloxetine were nausea, constipation,
decreased appetite, dry mouth, somnolence, and
hyperhidrosis. Patients in DPNP trials also reported
dizziness and asthenia.

Abuse
In animal studies, duloxetine did not demonstrate
any barbiturate-like (depressant) abuse potential.
355
While duloxetine has not been systematically studied

in humans for abuse potential, there was no suggestion of any drug-seeking behavior in the clinical trials. Physicians should carefully evaluate and follow
up patients with a history of drug abuse while on
duloxetine.
Dependence
Duloxetine did not demonstrate dependence-producing potential in studies using a rat model.
Overdosage
Signs and symptoms
In postmarketing experience, fatal outcomes have
been reported for acute overdoses, primarily with
mixed overdoses, but also with duloxetine only, at
doses as low as 1000 mg. Signs and symptoms of overdose on duloxetine included somnolence, coma, serotonin syndrome, seizures, syncope, tachycardia,
hypotension, hypertension, and vomiting.
Management of overdose
There is no specific antidote to duloxetine, but if serotonin syndrome ensues, specific treatment (such as
with cyproheptadine and/or temperature control)
may be considered. In a case of acute overdose, treatment should consist of general measures employed in
the management of overdose with any drug.
Clinical pearls
It is mandatory to set up a realistic goal prior to initiating pain management. Duloxetine, as an adjuvant
analgesic, may contribute to pain relief gradually but
not instantaneously. Previous studies have demonstrated mild to moderate pain relief in patients who
responded to duloxetine treatment. The efficacy and
timeline with duloxetine were quite different than
analgesics such as opioids or NSAIDs that were not
FDA approved for DPN and/or fibromyalgia.
356
It is an empirical decision whether to start with

duloxetine or anti-epileptics for neuropathic pain
management. Vigilant follow-up and patient education on drugdrug interactions are crucial to a
successful launch of duloxetine. It is prudent to start
with a low dose (2030 mg) of duloxetine and titrate
cautiously to balance the risk and benefit ratio.
Duloxetine doses higher than 60 mg failed to provide
any additional pain relief yet caused more adverse
events and withdrawals according to previous clinical
studies.
Russell et al. demonstrated that duloxetine at dosages of 60 mg/day and 120 mg/day for up to 6 months
was safe and effective in the treatment of fibromyalgia
with or without major depressive disorder [3]. They also
provided more robust assessment efficacy of duloxetine in fibromyalgia than most previous published
studies that were only for 3 months duration.
Potential synergistic effects in pain management
with other FDA-approved agents such as pregabalin
warrant further clinical research. It is crucial to validate the current strategy with multimodal analgesia
including duloxetine to improve outcome in fibromyalgia and diabetic peripheral neuropathy.
References
1. Duloxetine (Cymbalta) Prescription Information,

February 16, 2009. Eli Lilly and Company,
Indianapolis, IN 46285, USA.
2. Sultan A, Gaskell H, Derry S, Moore RA. Duloxetine
for painful diabetic neuropathy and fibromyalgia pain:
systemic review of randomized trials. BMC Neurology
2008;8:29.
3. Russell IJ, Mease PJ, Smith TR, Kajdasz DK,
Wohlreich MM, Detke MJ, Walker DJ, Chappell AS,
Arnold LM. Efficacy and safety of duloxetine
for treatment of fibromyalgia in patients with
or without major depressive disorder: results
from a 6-month, randomized, double-blind,
placebo-controlled, fixed-dose trial. Pain
2008;136:432444.
Section 9
Chapter
88
Antidepressants
Milnacipran
Kristin L. Richards
Generic Name: milnacipran

Trade/Proprietary Name: Savella
Manufacturer: Forest Pharmaceuticals, a subsidiary of Forest Laboratories, Professional
Affairs Department, 13600 Shoreline Drive, St
Louis, MO 63045
Drug Class: serotonin norepinephrine reuptake
inhibitor (SNRI)
Chemical Formula: C15H22N2O; molecular wt
246.3
Introduction
Milnacipran, although relatively new on the market in
the USA, has been in use in Europe since 1996. It was
first approved for the treatment of major depression in
France in December 1996 and is currently marketed
under the brand name Ixel in over 45 countries worldwide and under the brand name Toledomin in Japan.
Milnacipran has been compared to imipramine, SSRIs,
TCAs, and additional antidepressant medications.
When comparing milnacipran with TCAs, both are
equally efficacious; however, significantly fewer side
effects were experienced with milnacipran. As with
other antidepressant medications, 1 to 3 weeks may
elapse before significant antidepressant action
becomes clinically evident. In January 2009 the US
Food and Drug Administration (FDA) approved milnacipran (under the brand name Savella) for the treatment of fibromyalgia, making it the third medication
approved for this purpose in the USA.
Pharmacology
Milnacipran is both a serotonin and a norepinephrine
reuptake inhibitor, in a 2:1 ratio and therefore exhibits a
balanced action upon both transmitters. The serotonin
reuptake inhibition is likely to improve depression,

while the norepinephrine reuptake inhibition is likely
to be effective in treating chronic pain. Milnacipran
has no direct action on opioid receptors.
Pharmacokinetics
Milnacipran is effective when given orally and has a
bioavailability of 85%. Peak plasma concentrations are
reached 2 hours after oral dosing and the elimination
half-life of 8 hours is not changed in the elderly but is
increased by significant renal disease. With a creatinine clearance of 29 mL/min the maintenance dose
should be decreased by 50%, with a max of 100 mg/
day. The medication should be avoided with a creatinine clearance of less than 5 mL/min.
Milnacipran is conjugated to the inactive glucuronide and is then excreted in the urine as the unchanged
drug and conjugate, after which only traces of the
active metabolites are found. Enzymes of the CYP
class do not play a role in the metabolism of milnacipran and therefore the risk of interactions with drugs
metabolized by CYP enzymes is minimal.
Adverse effects
According to the FDA, the most frequently occurring
adverse reactions (5% and greater than placebo)
were nausea, headache, constipation, dizziness,
insomnia, hot flush, hyperhidrosis, vomiting, palpitations, heart rate increased, dry mouth, and hypertension. In contrast to several antidepressant medications,
milnacipran does not appear to have sexual side
effects. In a study of over 3000 patients, the incidence
of cardiovascular and anticholinergic side effects was
significantly lower compared to TCAs. Elevation of
liver enzymes, without signs of symptomatic liver disease, has rarely occurred.
It is important to monitor these patients for the
development of rapid mood swings to mania as this
has also been seen and then dictates termination of
357
Figure 88.1.
O
N
Cl
treatment. In psychotic patients emergence of delirium has been noticed as well.

In depressed patients, milnacipran has a low incidence of sedation but improves sleep with regard to
both duration and quality. In agitated patients or those
with suicidal thoughts additive sedative/anxiolytic
treatment is usually indicated.
Interactions
As previously discussed, milnacipran is both a serotonin and a norepinephrine reuptake inhibitor and
therefore is a medication that has the potential to
cause serotonin syndrome when administered with
MAOIs or lithium. The development of hyperserotonergia (serotonin syndrome) can cause a potentially
lethal hypertensive crisis.
Additional medication interactions include:
5-HT1 receptor agonists when taken with
milnacipran can cause coronary vasoconstriction
with the risk of angina pectoris and even possible
myocardial infarction
Epinephrine and norepinephrine including local
anesthetics with these medications when used in
patients taking milnacipran can cause a
hypertensive crisis and/or cardiac arrhythmias
MDA, MDMA or other serotonergic
amphetamines hyperserotonergia, hyperthermia
and potentially lethal hypertensive crisis
Clonidine antihypertensive action of clonidine
may be antagonized
Digitalis when milnacipran is administered to
patients currently taking digitalis the hemodynamic
actions of the digitalis can be increased
Alcohol no interactions known. However, as with
all patients with significant alcohol abuse it is
important to monitor liver function.
Contraindications
358
Administration of milnacipran should be avoided in

the following circumstances.
As with all medications, known hypersensitivity to

the medication is an absolute contraindication.
Patients under 15 years of age should not receive
the medication secondary to insufficient clinical data.
Concomitant treatment with irreversible MAO
inhibitors, phenelzine, (l)-deprenyl, digitalis glycosides, or 5-HT1D agonists (e.g. sumatriptan) is an
absolute contraindication.
As previously stated, caution is advised when
administering milnacipran in patients concurrently
receiving parenteral epinephrine, norepinephrine, or
with patients taking clonidine or reversible MAO-A
inhibitors (moclobemide, toloxatone).
Advanced renal disease requires dosage adjustment based on creatinine clearance.
Caution should also be used in patients with
benign prostatic hypertrophy, with hypertension and
heart disease as well as with open-angle glaucoma.
There are insufficient clinical data regarding the
administration of milnacipran in pregnancy and during lactation and therefore it should not be used in
these patients.
Indications and dosage

In Europe, milnacipran is indicated for both the treatment of major depressive disorder and the management of patients with fibromyalgia. However, in the
USA the only approved indication is the management
of fibromyalgia.
There have been several studies regarding the most
effective dosage regimen. The consensus appears to be
that the recommended dose for depression is 50 mg/
day (given as 25 mg 2 times daily), with a starting
period of 4 days on 25 mg/day. The dose should be
decreased in patients with renal disease. The recommended dose for fibromyalgia is 100 mg/day (after an
initial upwards titration period) which may be increased
to 200 mg/day based on the patients response.
Clinical results: fibromyalgia

Fibromyalgia is a systemic disease affecting 24% of
the general population in developed countries and the
exact etiology and pathophysiology remain unexplained. However, the most recent studies provide
increasing evidence that the pain is due to a dysfunction of pain processing within the CNS. This results in
patients experiencing allodynia and hyperalgesia.
In order to establish criteria for the diagnosis
the American College of Rheumatology established
Chapter 88 Milnacipran
classification criteria in 1990; however, these criteria

focus only on pain and not on the additional issues
that fibromyalgia patients experience: for example,
fatigue, cognitive disturbances, impaired memory,
sleep abnormalities, and depression. Additionally
many of these patients also experience conditions
such as IBS, migraine headaches, and chronic fatigue.
The treatment of this condition has proved to be
difficult and is usually accomplished with antidepressant medications. However, anticonvulsants, antispasticity, anxiolytics, sedatives, opioids, and NSAIDS
have been used as well. The most effective results
have been seen with antidepressants and specifically
TCAs.
Placebo-controlled trials involving a total of over
2000 patients have shown milnacipran, at both 100
and 200 mg/day, to be significantly more effective than
placebo in treating both pain and the broader syndrome of fibromyalgia. Additionally data show that
the therapeutic effects of milnacipran were sustained
for at least 1 year of therapy. Response rates with milnacipran were similar in patients with and without
comorbid depression.
In closing, milnacipran, although relatively new
to the market in the USA, is providing the opportunity to more effectively manage patients with fibromyalgia. These patients have historically proved to be
difficult for clinicians to adequately treat and as the
data continue to evolve on milnacipran hopefully
more patients will have the opportunity for relief of
their symptoms of not only fibromyalgia but also
clinical depression.
References
1. Briley M, Prost JF, Moret C. Preclinical pharmacology of

milnacipran. Int Clin Psychopharmacol 1996;11:S914.
2. Kasper S, Pletan Y, Solles A, Tournoux A.
Comparative studies with milnacipran and tricyclic
antidepressants in the treatment of patients with

major depression: a summary of clinical trial
results. Int Clin Psychopharmacol 1996;11(Suppl
4):3539.
3. Lopez-Ibor J, Guelfi JD, Pletan Y, Tournoux A, Prost
JF. Milnacipran and selective serotonin reuptake
inhibitors in major depression. Int Clin
Psychopharmacol 1996;11(Suppl 4):4146.
4. Clauw DJ, Mease P, Palmer RH, Gendreau RM,
Wang Y. Milnacipran for the treatment of
fibromyalgia in adults: a 15-week, multicenter,
randomized, double-blind, placebo-controlled,
multiple-dose clinical trial. Clin Ther
2008;30(11):19882004.
5. Mease PJ, Clauw DJ, Gendreau RM, Rao SG, Kranzler
J, Chen W, Palmer RH. The efficacy and safety of
milnacipran for treatment of fibromyalgia. a
randomized, double-blind, placebo-controlled trial. J
Rheumatol 2009;36(2):398409.
6. Moret C, Charveron M, Finberg JP, Couzinier JP,
Briley M. Biochemical profile of midalcipran (F 2207),
1-phenyl-1-diethyl-aminocarbonyl-2-aminomethylcyclopropane (Z) hydrochloride, a potential fourth
generation antidepressant drug. Neuropharmacology
1985;24(12):12111219.
7. Nakagawa A, Watanabe N, Omori IM, Barbui C,
Cipriani A, McGuire H, Churchill R, Furukawa TA.
Milnacipran versus other antidepressive agents for
depression. Cochrane Database Syst Rev
2009;8(3):CD006529.
8. Papakostas GI, Fava M. A meta-analysis of clinical
trials comparing milnacipran, a serotonin
norepinephrine reuptake inhibitor, with a
selective serotonin reuptake inhibitor for the
treatment of major depressive disorder. Eur
Neuropsychopharmacol J Eur Coll
Neuropsychopharmacol 2007;17(1):3236.
9. Puozzo C, Panconi E, Deprez D. Pharmacology and
pharmacokinetics of milnacipran. Int Clin
Psychopharmacol 2002;17:S2535.
359
Section 10
Chapter
89
360
Muscle Relaxants
Overview of muscle relaxants in pain

David A. Lindley
Unlike many categories of pharmaceutical agents, the

group muscle relaxants has no reference to a common structure or mechanism of action. Whereas
local anesthetics indicates a group of pharmaceutical agents with similar structure and mechanism of
action, the approximately ten drugs of the muscle
relaxants category have virtually no shared structure
and no shared mechanism of action.
This chapter will present the evolution of muscle
relaxants in the chronological order they appeared in
the clinical setting, a brief overview of structure,
mechanism of action, and efficacy. The chapter will
conclude with a brief discussion of prescribing considerations as well as a more detailed description and
discussion of each muscle relaxant.
Our chronology of muscle relaxants starts
strangely enough in 1952 with the expectorant guaifenesin (Figure 89.1). Although this medication was
marketed as an expectorant, it was associated with
reports of pain relief. In fact, guaifenesin has been
studied for its use in treatment of fibromyalgia. In
1957, guaifenesin was modified with a carbamate
group, making a guaifenesin prodrug called methocarbamol. This drug was, and continues to be, marketed as a muscle relaxant under the brand name
Robaxin.
Although some opine that guaifenesin and its prodrugs have discrete analgesic and muscle relaxant
activities, the March 2008 Prescribing Information
indicates the mechanism of action of methocarbamol
(Figure 89.2) as a muscle relaxant has not been established and may be related to general CNS depression. Of course, any drug that causes general sedation
will have the secondary effect of muscle relaxation.
The package insert goes on to state that methocarbamol has no direct action on the contractile mechanism of striated muscle, the motor end plate or the
nerve fiber [1,2].
Several other drugs to follow were also marketed
as muscle relaxants and share the CNS depression
mechanism of action. Some of these drugs are marketed as centrally acting muscle relaxants to distinguish them from direct muscle relaxants [3].
Guaifensin (1952) and methocarbamol

(Robaxin) (1957)
Efficacy: very limited or inconsistent data supporting
efficacy for peripheral spasm.
No studies supporting evaluating efficacy in central spasticity [4].
Chlorzoxazone (Parafon Forte DSC)

(1958)
Chlorzoxazone (Figure 89.3) is said to act primarily
at the level of the spinal cord and subcortical
areas of the brain where it inhibits multisynaptic
reflex arcs involved in producing and maintaining
skeletal muscle spasm of varied etiology. Some studies state the mechanism is mediated via calcium-
activated potassium channels, whereas other studies
state the mechanism is not mediated via potassium
channels [68].
Efficacy: There is very limited or inconsistent data
regarding the effectiveness of [chlorzoxazone] compared to placebo in patients with musculoskeletal
conditions. Not investigated for efficacy in central
spasticity [4].
In 1955, meprobamate (Figure 89.4) was introduced as a mild tranquilizer. It gained the epithet
Happy Pills and was associated with abuse and
habituation. In 1959, the drug was modified with
an isopropyl group and marketed as a muscle
relaxant, carisoprodol (Soma). Carisoprodol (Figure 89.5) is metabolized to meprobamate. Carisoprodol, like meprobamate, has addictive properties.
Carisoprodol has been ranked number 14 of the 20
most abused mood-altering drugs in the USA
[9,10].
Chapter 89 Overview of muscle relaxants in pain
and meprobamate (metabolite) at GABA-A receptors

[12]. Meprobamate impairs cerebellar function prior
to producing muscle relaxation [17].
Efficacy: fair evidence compared to placebo for
treatment of peripheral spasm [4]. The drug is indicated for short-term use up to 3 weeks, and has not
been tested for chronic use for central spasticity
[4,11].
Figure 89.1.
O
O
OH
H2N
Carbamate Group
Figure 89.2.
O
O
The next drug marketed with a muscle relaxant indication is a structural analog of diphenhydramine
(Benadryl) (Figure 89.6). Consider this structural
similarity when thinking of its mechanism of action
and side-effect profile.
OH
Figure 89.3.
H
N
Cl
O
O
O
H
NH2
Meprobamate
(Miltown)
O
N
Figure 89.4.
O
O
O
O
Orphenadrine (Norflex) (1959)
Mechanism of action
Orphenadrine does not cause direct skeletal muscle
relaxation. Proposed mechanisms of action of orphenadrine include H1 receptor antagonist [5,13,14],
NMDA receptor antagonist and muscarinic antagonist [5,13] activities. Recent evidence also demonstrates orphenadrine has a sodium channel blockade
effect which has been attributed to the analgesic characterisics of the drug (as well as proarrhythmic and
proconvulsive effects) [13].
Efficacy: orphenadrine has been shown to be
superior to placebo for the treatment of pain of musculoskeletal etiology [9,15]. Orphenadrine was determined to have fair evidence compared to placebo for
treatment of peripheral spasm, but not central spasticity, in another review [4].
Figure 89.5.
NH2
Carisoprodol
(Soma)
Carisoprodol (Soma) (1959)

Although not fully understood, the mechanism of
action of carisoprodol has been attributed to the
effects of the metabolite meprobamate, including
inhibition of interneuronal activity at the descending
reticular formation and spinal cord [9,11]. There is no
direct skeletal muscle relaxation. Recent evidence
indicates the mechanism of action is due to a
barbiturate-like effect of both carisoprodol (parent)
Metaxalone (Skelaxin) (1962)

Mechanism of action
Metaxalone (Figure 89.7) has no direct relaxation
effect on skeletal muscle, the motor end plate, or the
nerve fiber. The mechanism of action of metaxalone
may be due to general CNS depression.
Efficacy: one review found it is difficult to determine the effectiveness of this medication in the
treatment of muscle spasm, citing the paucity of
studies and the poor design of available studies,
such as the failure to control for physical therapy
[9]. Another review found metaxalone has very
limited or inconsistent data for treatment of peripheral spasm and no evidence for treatment of central
spasticity [4].
361
Muscle Relaxants Section 10
Figure 89.6.
Diphenhydramine
(Benadryl)
Not Substituted
H 3C
Methyl
Substitution
Diazepam (Figure 89.8) binds to and stabilizes the GABAA receptor in a conformation that is more sensitive to
GABA binding. This increases the frequency of Cl channel opening and hyperpolarizes the cell [17,18].
Efficacy: statistically similar improvement in
spasms and stiffness as dantrolene [17].
N
H
Figure 89.8.
Diazepine Ring
O-
O
N
Amitriptyline
Single Bond
362
N+
O
Figure 89.10.
Dantrolene (1975) See Figure 89.9

Mechanism of action
Inhibits the ryanodine receptor complex thereby limiting its activation by calmodulin and calcium and
inhibiting the voltage-dependent activation of calcium
release in skeletal muscle [20].
Benzene Ring
Cl
H
N
Diazepam (Valium) (1963)

Mechanism of action
Figure 89.7.
CH3
Figure 89.9.
Cyclobenzaprine (Flexeril)
(Amrix) (1977)
Compare the structures of amitriptyline (Figure
89.10) and cyclobenzaprine (Figure 89.11) to see their
similarities. Cyclobenzaprine has another double
bond, giving it a cycloheptene ring compared to
amitriptylines cycloheptane ring.
Mechanism of action
Tricyclic analogs, including cyclobenzaprine and
amitriptyline, inhibit 5-HT2 receptors in the ventral spinal cord, thereby inhibiting the tonic alpha-motorneuron
excitation produced by descending serotonergic pathways from the medullary raphe to the ventral horn of the
spinal cord [21]. The mechanism of action of cyclobenzaprine is independent of sedation [9].
treatment of peripheral spasm [4].
Chapter 89 Overview of muscle relaxants in pain
Figure 89.11.
Cyclobenzaprine
Double Bond
Tizanidine (Zanaflex) (1996)

Structure: very similar structure to clonidine. See differences in Figures 89.13 (tizanidine) and 89.14
(clonidine).
Mechanism of action
N
OH
H2N
Baclofen is a GABA analog.
Cl
Figure 89.12.
Cl
Figure 89.13.
H
N
H
N
N
N
N
Some prescribing considerations
S
Tizanidine
Cl
Figure 89.14.
H
N
Cl
Tizanidine and clonidine are both alpha-2 agonists.

As evidenced by their differing effects on blood pressure, the specific pharmacodynamic profiles of the
two drugs differ somewhat. This may be due to variation in the agonist activity at the specific alpha-2
receptor subtypes A, B, and C [26,27].
As an alpha-2 agonist, tizanidine decreases presynaptic excitatory neurotransmitter release and postsynaptic neurotransmitter effectiveness. Alpha-2 receptor
agonists attenuate monosynaptic and polysynaptic
reflexes in the spinal cord [25]. Tizanidine decreases
excitatory neurotransmitter release and Substance P
release from small sensory afferents [28]. Tizanidine
decreases locus coeruleus activity, thereby modulating
descending motor regulatory pathways [28]. Tizanidine decreases activity of both alpha and gamma motor
neurons [28].
central spasticity and peripheral spasm.
H
N
N
Clonidine
Baclofen (1977)
Mechanism of action
Baclofen (Figure 89.12) is a presynaptic and postsynaptic GABA-B receptor agonist. When activated, a G
protein second-messenger system stimulates opening
of K+ channels, thereby hyperpolarizing the neuron
[23,24].
central spasticity [4].
Very limited or inconsistent data for peripheral
spasm [4].
Know the mechanism of action of your muscle

relaxant. If the patient is already taking tramadol or
tapentadol as well as amitriptyline, consider your
rationale for adding a third agent with serotonergic
activity such as cyclobenzaprine, as well as the
increased risk of serotonin syndrome. Do not use
cyclobenzaprine within 2 weeks of the last dose of
an MAOI. Some MAOIs include isocarboxazid
(Marplan), tranylcypromine (Parnate), phenelzine
(Nardil), selegiline (Eldepryl, Emsam),
Utilize rational drug prescribing. Does the muscle
relaxant have an independent mechanism of
action for muscle relaxation, or does it rely on
CNS depression/sedation to secondarily cause
muscle relaxation?
Does the muscle relaxant you are considering
have high potential for habituation or addiction?
Is your patient particularly at risk for habituation,
compulsive use, or addiction?
What is the indication for prescribing a muscle
relaxant? Is it central spasticity such as from
stroke, spinal cord injury, or multiple sclerosis?
363
Table 89.1. Compromises of liver or kidney
Drug
Caution with compromise of:
Chlorzoxazone (Parafon Forte DSC)
liver
Methocarbamol (Robaxin)
liver or kidneys
Carisoprodol (Soma)
liver or kidneys
Orphenadrine (Norflex)
liver or kidneys
Metaxalone (Skelaxin)
liver or kidneys
Diazepam (Valium)
liver
Dantrolene
liver
Cyclobenzaprine (Flexeril) (Amrix)
liver
Baclofen
kidneys
Tizanidine (Zanaflex)
liver or kidneys
Is it peripheral spasm? What is the evidence of

your muscle relaxant choice for the patients
etiology?
Are there contraindications to concomitant drug
use? For instance, tizanidine is contraindicated in
patients with concomitant use of CYP450 1A2
inhibitors such as fluvoxamine, amiodarone,
mexiletine, propafenone, cimetidine,
fluoroquinolones (ciprofloxacin, norfloxacin),
rofecoxib, oral contraceptives, and ticlopidine [27].
Consider the anticholinergic side effects of
various muscle relaxants, and use caution when
prescribing, especially in the elderly. For instance,
methocarbamol has clinically significant
anticholinergic side effects.
Know the metabolism and clearance of your
muscle relaxant choice. Does your patient have
liver or kidney compromise (Table 89.1)?
References
1. Methocarbamol prescribing information, March 2008.

2. http://web.mit.edu/london/www/guai.html. Accessed
July 5, 2009.
3. http://www.whocc.no/atcddd/. Accessed July 5, 2009.
4. Chou et al. Comparative efficacy and safety of skeletal
muscle relaxants for spasticty and musculoskeletal
conditions: a systematic review. J Pain Symptom
Manage 2004;28(2);140.
364
7. Cao et al. Modulation of recombinant smallconductance Ca2-activated K+ channels by the muscle

relaxant chlorzoxazone and structurally related
compounds. J Pharmacol Exp Ther 2001;296(3):683.
8. Dong et al. Chlorzoxazone inhibits contraction of rat
thoracic aorta. Eur J Pharmacol 2006;545:161.
9. Toth et al. Commonly used muscle relaxant therapies
for acute low back pain: a review of carisoprodol,
cyclobenzaprine hydrochloride, and metaxalone. Clin
Ther 2004;26(9)13551367.
10. Rosenbaum R, Pagliaro LA, Pagliaro AM.
Psychologists Psychotropic Drug Reference. Psychology
Press, 1998, p. 338.
11. Carisoprodol prescribing information, MedPointe
Healthcare Inc., Somerset, NJ. 08873, Rev. 9/2007.
12. Gonzalez et al. Carisoprodol-mediated modulation of
GABAA receptors: in vitro and in vivo studies. J
Pharmacol Exp Ther 2009;329(2)827.
13. Desaphy J-F, et al. Involvement of voltage-gated
sodium channels blockade in the analgesic effects of
orphenadrine. Pain 2009;142:225235.
14. Orphenadrine prescribing information, 1/2006,
Akorn, Inc., Buffalo Grove, IL 60089.
15. Valtonen. A controlled clinical trial of chlormezanone,
orphenadrine, orphenadrine/paracetamol and placebo
in the treatment of painful skeletal muscle spasms.
Ann Clin Res 1975;7(2):85.
16. Meprobamate prescribing information, 2008, King
Pharmaceuticals, Inc., Bristol, TN 37620.
5. http://www.neurotransmitter.net/muscle_
drug_reference.html. Accessed July 5, 2009.
17. Schmidt et al. Comparison of dantrolene sodium and

diazepam in the treatment of spasticity. J Neurol
Neurosurg Psychiatry 1976;39:350356.
6. Chlorzoxazone Prescribing Information, August 2000,

Ortho-McNeil Pharmaceutical, Inc., Raritan, NJ 08869.
18. Valium prescribing information, 1998, Hoffmann-LA

Roche Limited, Ontario.
Chapter 90 Diazepam and lorazepam
19. Dantrolene prescribing information, 2007, Proctor &

Gamble Pharmaceuticals, TM owner.
20. Fruen et al. Dantrolene inhibition of sarcoplasmic
reticulum Ca2+ release by direct and specific action at
skeletal muscle ryanodine receptors. J Biol Chem
1997;272(43):26965.
21. Honda et al. Tricyclic analogs cyclobenzaprine,
amitriptyline and cyproheptadine inhibit the spinal
reflex transmission through 5-HT2 receptors. Eur J
Pharmacol 2003;458:91.
24. Newberry et al. Direct hyperpolarizing action of

baclofen on hippocampal pyramidal cells. Nature
1984;308(5958):450.
25. Tanabe et al. Spinal 1- and 2-adrenoreceptors
mediate facilitation and inhibition of spinal motor
transmission, respectively. Japan J Pharmacol
1990;54:69.
26. Zanaflex package insert. Acorda Therapeutics,
Hawthorne NY, July 2006.
22. Day et al. Serotonin syndrome in a patient taking

Lexapro and Flexeril: a case report. Am J Emerg Med
2008;26:1069.
27. Philipp. Physiological significance of 2-adrenergic

receptor subtype diversity: one receptor is not enough.
Am J Physiol Regul Integrat Compar Physiol
2002;283:R287.
23. Baclofen prescribing information, Upsher-Smith

Laboratories, Inc., 2002.
28. Coward. Tizanidine. Neuropharmacology and

mechanism of action. Neurology 1994;44(Suppl 9):S6.
Section 10
Chapter
90
Muscle Relaxants
Diazepam and lorazepam

Mirjana Lovrincevic and Mark J. Lema
Generic (proprietary) Names: diazepam (Valium, Diastat)

Manufacturer: Roche Laboratories (Valium),
340 Kingsland Street, Nutley, NJ 071101199
Generic (proprietary) Names: lorazepam (Ativan, Temesta)
Manufacturer: Baxter Healthcare Corporation,
Deerfield, IL 60015
Class: benzodiazepines (BNZs)
Chemical Structure: diazepam, see Figure 90.1;
lorazepam, see Figure 90.2
Mode of activity
Major and minor sites of action: GABAA receptors in
the brain and spinal cord.
Receptor interactions: benzodiazepines enhance

the actions of the neurotransmitter gamma-aminobutyric acid (GABA) on its receptor by modulating the
GABA system in the brain, through the presence of
high-affinity binding receptors [1,2]. Interaction of
benzodiazepines with GABAA receptors opens chloride ion channels, and enhances the frequency of chloride channel opening. It has been shown that in order
to elicit the different effect, a different degree of GABAA
receptor occupation is necessary. For instance, full
agonists are able to elicit an anxiolytic or anticonvulsant effect at a low overall receptor occupation. Partial
agonists, because of their lower intrinsic efficacy for
enhancement of GABAergic transmission, need a
higher receptor occupation to produce the same effect.
However, the weak enhancement of GABAergic transmission by a partial agonist is not sufficient to induce
sedative/hypnotic and muscle relaxant actions, since
even full agonists need a rather high receptor
365
H3C
N
Figure 90.1. Diazepam
Cl
Figure 90.2. Lorazepam
O
OH
HN
N
Cl
Cl
occupation in order to produce these effects. As an example, the benzodiazepine agonistic receptor occupancy
was found to differ among the various physiological
responses in the following order: antipanic > anticonvulsion > sedation > muscle relaxation [3]. This graded
response explains why only pure agonists of GABA
receptors are able to display muscle relaxant properties,
and why the price for that is always prominent sedation.

and elimination (Diazepam)
Diazepam is primarily metabolized by hepatic cytochrome enzyme responsible for S-mephenytoin hydroxylation, with very little unchanged drug eliminated in
the urine [1,2]. Hepatic N-demethylation results in the
formation of the active metabolite desmethyldiazepam.
This metabolite is hydroxylated to form oxazepam.
Another minor active metabolite is temazepam. The
half-life (t1/2)of diazepam ranges from approximately 24
hours to more than 48 hours. With chronic dosing,
steady-state concentrations of diazepam are achieved
between 5 days and 2 weeks. The half-life is prolonged in
the elderly and in patients with cirrhosis or hepatitis.

and elimination (Lorazepam)
366
Elimination of lorazepam occurs by metabolism

within the liver and renal excretion of the metabolites.
Glucuronidation to form lorazepam-glucuronide is
the major pathway for metabolism. Minor metabolites
include a hydroxylated derivative, a quinazolinone
derivative and a quinazoline carboxylic acid. Seventy
to seventy-five percent of the dose is excreted as the

glucuronide compound in the urine. All the metabolites
of lorazepam are inactive. Lorazepam is readily and
completely absorbed from the gastrointestinal tract
after oral absorption. Peak plasma levels are reached
at approximately 2 hours. Its half-life (t1/2) is between
10 and 20 hours, with 14 hours often cited [2,3].
Diazepam approved uses: treatment of anxiety, acute
alcohol withdrawal, seizures and muscle spasms. Also
used as a sedative/hypnotic/amnesic.
Lorazepam approved uses: treatment of anxiety,
panic attacks, insomnia, chemotherapy-induced nausea and vomiting, alcohol withdrawal, treatment of
seizures. Non-approved: muscle spasms.
There have been several studies assessing the effectiveness of diazepam in prevention of succinylcholineinduced myalgia after general anesthesia. While some
older studies concluded that diazepam significantly
reduced post-operative myalgia other randomized,
controlled studies have found no such effect. Diazepam
is also effective in alleviating symptoms of muscle
contraction headache, but its sedation side effect precludes its routine use to treat this condition. Spasticity
associated with cerebral palsy is generally treated with
high doses of diazepam. Side effects, including habituation, memory impairment, and dyscoordination, are
very common and often intolerable. Stiff-person syndrome, a rare neurological disorder with autoimmune
features characterized by progressive, severe muscle
rigidity and stiffness affecting mostly the spine and
lower extremities, has been successfully treated with
diazepam plus immunomodulation therapy.
Benzodiazepines are also being used in the symptomatic treatment of dystonias with prominent muscle spasms.
Contraindications
Absolute: myasthenia gravis, known allergy to BNZ,
less than 6 months old, severe respiratory failure.
Relative: pregnancy (teratogenesis), acute intoxication, sleep apnea, ataxia, acute narrow-angle glaucoma.
Common doses/uses
Diazepam
Oral: 210 mg, 34 times daily for muscle spasm (up
to 30 mg/day).
Chapter 90 Diazepam and lorazepam
Tablets 2 mg, 5 mg, 10 mg.

Capsules, time-release 15 mg (marketed by
Roche as Valrelease).
Liquid solution 1 mg/mL in 500 mL containers
and unit-dose (5 mg and 10 mg); 5 mg/mL in 30
mL dropper bottle (marketed by Roxane as
Diazepam Intensol).
Parenteral: 210 mg IV/IM every 34 hours
Solution for IV/IM injection 5 mg/mL. 2 mL
ampoules and syringes; 1 mL, 2 mL, 10 mL vials;
2 mL Tel-E-Ject; also contains 40% propylene
glycol, 10% ethyl alcohol, 5% sodium benzoate and
benzoic acid as buffers, and 1.5% benzyl alcohol as
a preservative.
Neuraxial: none.
Lorazepam
Oral: 26 mg/day, given in two or three divided
doses.
Tablets 0.5 mg,1 mg, 2 mg.
Parenteral: (IM/IV) 26 mg/day, given in two or
three divided doses.
Solution for IM/IV injection 2 mg/mL in either
1 mL or 10 mL vials, 4 mg/mL in either 1 mL or
10 mL vials.
Neuraxial: none.
Ease of use, tolerability, opioid-sparing: both drugs
are available for oral as well as parenteral use.
Injectable doses can cause irritation to veins and
can lead to thrombophlebitis. Both drugs should be
used with caution with opioids as they can enhance
the opioid effects of respiratory depression and
somnolence.
Cost/availabilty: both drugs come in generic form
and are widely available. Since they are a schedule
C-IV drug, prices can be inflated due to extra handling. Diazepam per tablet 2 mg ($0.18), 5 mg
($0.16), 10 mg ($0.17), 2 mg solution ($0.34); injectable 10 mL of 5mg/mL dose ($1.84). Lorazepam per
tablet 0.5 mg ($2.50), 1 mg ($2.90), 2 mg ($4.50);
injectable per 1mL ($3.44).
As monotherapy: these drugs are often used alone
for muscle spasm and are interchangeable. Lorazepam
has a longer therapeutic half-life even though

diazepam metabolizes over 24 hours.
As used for multimodal analgesia: cyclobenzaprine (Flexeril), carisoprodol (Soma), oral steroids,
opioids, and NSAIDs can all be used in combination
therapy with caution, based on the severity and onset
of symptoms.
Toxicity: BNZs are known to cause unconsciousness,
seizures, respiratory failure, and profound hypotension but are rarely lethal.
Drug interactions: sedatives/hypnotics, opioids,
barbiturates, antihistamines, alcohol, neuroleptics,
anticonvulsants, and SSRIs can all enhance the sedative effects of BNZs.

Common adverse events: sedation, dizziness, weakness, unsteadiness, irritation on injection, respiratory
depression, hypoventilation (IV), hypotension.
Serious adverse events: dependency, abuse, withdrawal syndrome, respiratory failure, seizures, depression, hypersensitivity reaction.
Less common adverse events: suicidality, anaphylactoid reactions, blood dyscrasias, hepatic encephalopathy exacerbation.
Treatment of adverse events: flumazenil (Romazicon) may be of some benefit in reversing sedation or
respiratory depression. Treatments for other causes
are largely symptomatic and may necessitate observation in an ICU.
References
1. Duka T, Hollt V, Herz A. In vivo receptor occupation

by benzodiazepines: correlation with pharmacological
effect. Brain Res 1979;179:147156.
2. Haefely W, Kyburz E, Gerecke M, Mohler H. Recent
advances in the molecular pharmacology of
benzodiazepine receptors and in the structure-activity
relationships of their agonists and antagonists. In
Testa B, ed. Advances in Drug Research, vol. 14.
London: Academic Press, 1985, pp. 165322.
3. Sieghart W. Pharmacology of benzodiazepine
receptors: an update. J Psychiatr Neurosci 1994;19:
2429.
367
Section 10
Chapter
91
Muscle Relaxants
Methocarbamol
Martha Zegarra
Generic Name: methocarbamol

Proprietary Name: Robaxin
Deerfield, IL 60015
Class: muscle relaxant
Chemical Name: 2-hydroxy-3-(2-methoxyphenoxy)propyl carbamate
Introduction
Methocarbamol is a central-acting muscle relaxant
used to treat skeletal muscle spasms and pain related
to severe muscle spasm. It is also associated with significant sedative properties.
Mode of activity
Methocarbamols mechanism of action in humans has
not been established, but may be related to general
central nervous system (CNS) depression. It has no
direct action on the contractile mechanism of striated
muscle, the motor end plate, or the nerve fiber.
Methocarbamol is metabolized via dealkylation
and hydroxylation. Conjugation of methocarbamol
also is likely. Essentially all methocarbamol metabolites
are eliminated in the urine. Small amounts of unchanged
methocarbamol also are excreted in the urine.
In healthy volunteers, the plasma clearance of
methocarbamol ranges between 0.20 and 0.80 L/h per
kg, the mean plasma elimination half-life ranges
between 1 and 2 hours, and the plasma protein binding ranges between 46% and 50%.
368
discomfort
associated with acute, painful musculoskeletal conditions, including acute back injury, acute discogenic back pain with related muscular spasm, and
muscle spasm associated with severe post-operative
abdominal and back pain.
There is clinical evidence which suggests that metho
carbamol may have a beneficial effect in the control of
the neuromuscular manifestations of tetanus. It does
not, however, replace the usual management of tetanus.
Contraindications
Absolute: methocarbamol is contraindicated in
patients hypersensitive to methocarbamol or to any of
the tablet components.
Relative: methocarbamol may inhibit the effect of
pyridostigmine bromide. Therefore, methocarbamol
should be used with caution in patients with myasthenia gravis receiving anticholinesterase agents.
Safe use of methocarbamol has not been established with regard to possible adverse effects upon
fetal development. Thus, methocarbamol should not
be used in women who are or may become pregnant
and particularly during early pregnancy unless in the
judgment of the physician the potential benefits outweigh the possible hazards.
Methocarbamol may cause a color interference in
certain screening tests for 5-hydroxyindoleacetic acid
(5-HIAA) using nitrosonaphthol reagent and in
screening tests for urinary vanillylmandelic acid
(VMA) using the Gitlow method.
Common doses/uses
Methocarbamol tablets (Robaxin) USP, 500 mg are
white, round, bisected tablets, debossed with LAN
over 1302, supplied in bottles of 100 and 500 tablets.
Oral dosing
Methocarbamol is indicated as an adjunct to rest, physical therapy, and other measures for the relief of
500 mg tablets: adults: initial dosage: 3 tablets QID.

Maintenance dosage: 2 tablets QID.
Chapter 91 Methocarbamol
Figure 91.1.
OH
O
OCH3
NH2
750 mg tablets: adults: initial dosage: 2 tablets QID.

Maintenance dosage: 1 tablet q4h or 2 tablets TID.
Six grams a day are recommended for the first 48
to 72 hours of treatment (for severe conditions 8 g a
day may be administered). Thereafter, the dosage can
be reduced to approximately 4 g a day.
Parenteral (IV/IM): adults moderate pain: one
dose of 1 g may be adequate. Ordinarily this injection
need not be repeated, as the administration of the oral
form will usually sustain the relief initiated by the
injection.
Adults severe pain/post-op pain: additional doses
of 1 g may be repeated every 8 hours up to a maximum
of 3 g/day for no more than 3 consecutive days.
Total adult parenteral dosage should not exceed 3
g/day for more than 3 consecutive days except in the
treatment of tetanus. If the condition persists, a similar course may be repeated after a drug-free interval of
48 hours.
Safety and effectiveness of methocarbamol in pediatric patients below the age of 16 have not been established.
Methocarbamol can be used alongside rest and physical therapy as well as combined with other medications as part of multimodal analgesia in the treatment
of musculoskeletal pain. Since it may possess a general CNS depressant effect, caution is advised when
used in combination with other CNS depressants.
Methocarbamol is available as a generic medication.
Potential disadvantages, drug-related

adverse events
Adverse reactions reported coincident with the
administration of methocarbamol include:
Generalized: anaphylactic reaction, angioneurotic

edema, fever, headache
Cardiovascular system: bradycardia, flushing,
hypotension, syncope, thrombophlebitis
GI system: dyspepsia, jaundice (including
cholestatic jaundice), nausea and vomiting
Hematological and lymphatic system: leukopenia
Immune system: hypersensitivity reactions
Nervous system: amnesia, confusion, diplopia,
dizziness or lightheadedness, drowsiness,
insomnia, mild muscular incoordination,
nystagmus, sedation, seizures (including grand
mal), vertigo
Skin and special senses: blurred vision,
conjunctivitis, nasal congestion, metallic taste,
pruritus, rash, urticaria.
Limited information is available on the acute toxicity of methocarbamol. Overdose of methocarbamol
has been reported in conjunction with alcohol, psychotropic drugs, or other CNS depressants and
includes the following symptoms: nausea, drowsiness,
blurred vision, hypotension, seizures, coma, and
death.
Management of overdose includes symptomatic
and supportive treatment. Supportive measures
include maintenance of an adequate airway, monitoring urinary output and vital signs, and administration
of intravenous fluids if necessary. The usefulness of
hemodialysis in managing overdose is unknown.
Cost: average price ranges $50$99 per 30 day supply and is generally covered by prescription drug
insurance.
References
1. http://www.drugs.com/methocarbamol.htm.
2. http://www.fda.gov/downloads/Drugs/InformationOn
Drugs/UCM086233.pdf. Orange Book Cumulative
Supplement 05 May 2009 (Approved Drug Products
with Therapeutic Equivalence Evaluations). Accessed
June 18, 2009.
3. http://www.rxlist.com/methocarbamol-drug.htm.
369
Section 10
Chapter
92
Muscle Relaxants
Cyclobenzaprine
Martha Zegarra
Generic Name: cyclobenzaprine

Proprietary Name: Flexeril
Class: central-acting muscle relaxant/anticholinergic
Manufacturer: Merck & Co. Inc., West Point,
PA 19486
Chemical Name: (5H-dibenzo[a,d]cyclohepten5-ylidene)-N,N-dimethyl-1-propanamine
Molecular Formula: C20H21N
Introduction
370
Cyclobenzaprine is a central-acting muscle relaxant

that is commonly used to treat pain from injury, muscle spasms, and other painful musculoskeletal con
ditions. It is structurally related to first-generation
tricyclic antidepressants such as imipramine and
amitriptyline and appears to inhibit the uptake of
norepinephrine in the locus coeruleus. Tricyclic compounds with norepinephrine reuptake-inhibiting
properties have been shown to exert analgesic effects
in chronic nerve and muscle pain by acting primarily
within the central nervous system at brainstem as
opposed to spinal cord levels, although their action on
the latter may contribute to their overall skeletal muscle relaxant activity. The exact mechanism of action of
cyclobenzaprine is unknown.
Cyclobenzaprine is extensively metabolized by the
liver via glucoronide conjugation and N-demethylation and is excreted primarily by the kidneys. Estimates of mean oral bioavailability of cyclobenzaprine
range from 33% to 55%. It is highly bound to plasma
proteins. Cyclobenzaprine is eliminated quite slowly,
with an effective half-life of 18 hours, and has a plasma
clearance of 0.7 L/min.
Cyclobenzaprine is indicated as an adjunct to rest and
physical therapy for relief of muscle spasm associated
with acute, painful musculoskeletal conditions. Like
other tricyclic antidepressants, it is also prescribed
off-label for the treatment of fibromyalgia and as a
sleep aid.
Cyclobenzaprine should be used for up to 23
weeks as there is lack of adequate evidence of effectiveness for more prolonged use. Generally, muscle
spasm associated with acute, painful musculoskeletal
conditions is of short duration and specific therapy for
longer periods is seldom warranted.
Cyclobenzaprine has not been found effective in
the treatment of spasticity associated with cerebral or
spinal cord disease, or in children with cerebral palsy.
Contraindications
Absolute
Cyclobenzaprine is contraindicated in patients hypersensitive to cyclobenzaprine or to any of the tablet
components.
Concomitant use of monoamine oxidase inhibitors (MAOIs) or within 14 days after their discontinuation is contraindicated as hyperpyretic crisis, seizures,
and deaths have occurred in patients receiving
cyclobenzaprine (or structurally similar tricyclic antidepressants) and MAOIs.
Cylcobenzaprine is contraindicated in the acute
recovery phase of myocardial infarction, and in patients
with arrhythmias, heart block or conduction disturbances, congestive heart failure, or hyperthyroidism.
Relative
Because of its atropine-like action, cyclobenzaprine
should be used with caution in patients with a history
of urinary retention, angle-closure glaucoma,
increased intraocular pressure, and in patients taking
Chapter 92 Cyclobenzaprine
Figure 92.1.
CH3
CH3
anticholinergic medication. Cyclobenzaprine may

also enhance the effects of alcohol, barbiturates, and
other CNS depressants.
The plasma concentration of cyclobenzaprine is
generally higher in the elderly and in patients with
hepatic impairment, thus it should be used with
caution in subjects with mild hepatic impairment.
Due to the lack of data in subjects with more severe
hepatic insufficiency, the use of cyclobenzaprine in
subjects with moderate to severe impairment is not
recommended.
Tricyclic antidepressants and structurally similar
drugs may block the antihypertensive action of
guanethidine and may enhance the seizure risk in
patients taking tramadol.
Common doses/uses
Oral: Flexeril 5 mg adults: recommended dosage: 1
tablet TID or QID.
Based on individual patient response, the dose
may be increased to 10 mg three times a day. Use of
Flexeril for periods longer than 23 weeks is not recommended.
Less frequent dosing should be considered for
hepatically impaired or elderly patients.
The safety and effectiveness of cyclobenzaprine
in pediatric patients below 15 years of age and in
pregnant and nursing women have not been established.
Cyclobenzaprine is indicated as an adjunct to rest and
physical therapy for relief of muscle spasm and it has
been shown to have an opioid-sparing effect when used
alongside weak and intermediate-strength painkillers
such as codeine, dihydrocodeine, and hydrocodone.
Cyclobenzaprine is available as a generic medication and is relatively inexpensive.
Cost: average price is $60 per 30 tablets and is generally covered by prescription drug insurance.
Potential disadvantages, drug-related

adverse events
Side effects are common and are generally dose-dependent. They include drowsiness, fatigue, dry mouth,
headache, and dizziness. Other less common side
effects are respiratory depression, blurred vision,
pharyngitis, and decreased functionality in various
muscles. A thorough medical history should be
assessed prior to prescribing this medication. Patients
with a medical history which includes a recent heart
attack, congestive heart failure, heart rhythm problems, heart block, thyroid problems, or a substance
abuse problem may not be able to take cyclobenzaprine or may require careful monitoring while undergoing drug therapy with this medication. Agitation is
a common side effect observed especially in the elderly. Long-term use has been associated with vision
damage.
Overdose
The most common CNS effects associated with
cyclobenzaprine overdose are drowsiness and tachycardia. Less frequent manifestations include tremor,
agitation, coma, ataxia, hypertension, slurred speech,
confusion, dizziness, nausea, vomiting, and hallucinations. Rare but potentially critical manifestations of
overdose are cardiac arrest, chest pain, cardiac dysrhythmias, severe hypotension, seizures, and neuroleptic malignant syndrome and stroke. Changes in
the electrocardiogram, particularly in QRS axis or
width, are clinically significant indicators of cyclobenzaprine toxicity.
Although rare, deaths may occur from overdosage,
particularly with multiple drug ingestion (including
opioids and alcohol). Patients should be instructed to
contact the prescribing caregiver if symptoms such as
severe drowsiness, fast heartbeat, slurred speech, hallucinations, chest pain, seizures, increased muscle
stiffness with fever and sweating of overdose are experienced. If overdose is suspected, dosing should be
discontinued immediately. As management of overdose is complex and changing, it is recommended that
the physician contact the US national poison hotline
at 18002221222 for current information on treatment.
Conclusion
Muscle relaxants such as cyclobenzaprine should be
considered for the multimodal management of acute
371
musculoskeletal injuries. When combined with a

nonsteroidal anti-inflammatory drug and occasional
doses of an opioid-acetaminophen compound, patients
often experience reductions in pain and associated
skeletal muscle spasm, and may also benefit from
improvements in functionality. The downside of central-acting muscle relaxants is their sedating and cognitive effects, which can be particularly troublesome
in elderly patients.
Cyclobenzaprine is not appropriate for children
under 12 years of age. Patients who have taken an
MAOI in the previous 14 days should not take this
medication.
The American Food and Drug Administration
rated this medication as a Pregnancy Risk Category B.
This medication is not expected to cause harm or
birth defects in unborn babies. It has yet to be determined whether or not Flexeril will pass into the
mothers breast milk and affect a nursing baby. The
prescribing physician should discuss whether the
benefits outweigh the risks before prescribing this
medication to a pregnant or nursing woman.
Section 10
Chapter
93
372
There is a risk of side effects associated with Flexeril, some of which are severe. A patient who is experiencing a serious side effect or an allergic reaction
should seek immediate emergency medical attention.
An allergic reaction will present with symptoms which
include facial swelling, including swelling of the lips,
mouth, throat, or tongue, hives, and difficulty breathing. Other serious side effects which require emergency medical attention include symptoms such as
chest pain or heaviness that involves the arm, fast
heart rate, uneven heart rhythm.
References
1. http://www.drugs.com/cyclobenzaprine.htm.
2. http://www.fda.gov/ucm/groups/fdagovpublic/@fdagov-drugs-gen/documents/document/
ucm071436.pdf (Approved Drug Products with
Therapeutic Equivalence Evaluations) 29th ed.
Accessed June 18, 2009.
3. http://www.rxlist.com/cyclobenzaprine-drug.htm.
Muscle Relaxants
Metaxalone
Eric S. Hsu
Generic Name: metaxalone

Proprietary Name: Skelaxin
Distributor: King Pharmaceuticals, Inc., Bristol,
TN 37620
Manufacturer: Mallinckrodt Inc., Hobart, NY
13788. Each oval, scored tablet contains 800 mg
metaxalone
Chemical Name: 5-[(3, 5-dimethylphenoxy)

methyl]-2-oxazalidinone
Empirical Formula: C12H15NO3; molecular wt
221.25
Mode of activity
In contrast to neuromuscular blocking agents used in
anesthesia, there is no direct action by metaxalone on
Chapter 93 Metaxalone
Figure 93.1.
CH3
CH2
CH2
CH
NH
O
C
CH3
the contractile mechanism of striated muscle, motor

end plate, or the nerve fiber.
Although the exact mechanism of action of
metaxalone has not been well established, it may be
related to the general depression of the central nervous system in the human or modification of signals
conducted through polysynaptic fibers controlling
passive stretch.

and elimination
The potential increase in metaxalone exposure and a
reduction in half-life may be attributed to the more
complete absorption of metaxalone associated with a
high-fat meal. The bioavailability of metaxalone under
fasting conditions increases with age. Metaxalone is
metabolized by the liver and excreted in the urine as
some unidentified metabolites. There could be extensive distribution in various tissues according to the
apparent volume of distribution and lipophilicity of
metaxalone.
Hepatic cytochrome P450 enzymes CYP1A2,
CYP2D6, CYP2E1, CYP3A4, CYP2C8, CYP2C9, and
CYP2C19 may all contribute to the metabolism of
metaxalone. However, metaxalone does not significantly
inhibit or induce major CYP enzymes such as CYP1A2,
CYP2D6, CYP2E1, and CYP3A4. There is a gender difference in the pharmacokinetics of metaxalone. The
mean half-life is 11.1 hours in females and 7.6 hours in
males. The data show the bioavailability of metaxalone is
significantly higher in females than males.
Metaxalone should be prescribed with precaution
in all patients with hepatic and/or renal impairment
due to unknown impact of disease and dysfunction on
the pharmacokinetics.
Indications
Metaxalone is a muscle relaxant for relieving pain
caused by strains, sprains, and other musculoskeletal
conditions. Metaxalone may be prescribed as an
adjuvant
to rest, physical therapy, and alternative
modalities to reduce acute musculoskeletal pain.
Metaxalone does not directly relax any tense skeletal
muscles in human. The mode of action of metaxalone
has not been clearly identified, but may be related to
general CNS depression and sedation.
Contraindications
1. Known hypersensitiviy to any components of
metaxalone.
2. Known tendency to drug-induced, hemolytic, or
other anemias.
3. Significantly impaired renal or hepatic function.
Warnings
Metaxalone may impair mental and/or physical abilities required for performance of hazardous tasks, such
as operating machinery or driving a motor vehicle.
Patients must refrain from these tasks especially while
taking metaxalone together with either alcohol or
Common doses
The recommended dose of metaxalone for adults and
children over 12 years of age is 800 mg three to four
times a day as needed.
How supplied
Skelaxin (metaxalone) is available as an 800 mg oval, scored
pink tablet inscribed with 8667 on the scored side and S
on the other. Available in bottles of 100 (NDC 60793
13601) and in bottles of 500 (NDC 6079313605).
Store at controlled room temperature, between
15C and 30C (59F and 86F).
Metaxalone was approved by the FDA in 1964 as an
adjuvant therapy to rest, physical therapy, and other
measures for relief of discomfort associated with acute
painful musculoskeletal conditions. There were two
double-blind studies of similar design in the mid-1960s
that demonstrated the safety and efficacy of metaxalone
compared to placebo. The treatment with metaxalone
resulted in marked or moderate improvement of acute
low back syndrome (either pain or spasm) or acute
exacerbation of chronic low back disorders. Metaxalone
373
was also found to be effective for treating acute involuntary muscle spasm in a later double-blind placebocontrolled study published by Dent et al. in 1975 [4].
Metaxalone (Skelaxin) is commonly considered as
a moderately strong muscle relaxant and does not
have any significant drugdrug interactions. Although
cases of polydrug fatality involving metaxalone were
reported, metaxalone is usually well tolerated with
variable incidence of side effects.
It is hard to interpret the previous studies on metaxa
lone due to many study limitations. There were only
200 patients recruited in the two mid-1960s trials that
led to FDA approval. However, there was no clear
description of the duration and type of back pain and
treatment before enrollment. Whether there were concomitant analgesics, sedatives, hypnotics, and/or physical therapy had not been elucidated clearly. Although
Dent et al. illuminated the use of associated medications before and during their trial, there were only 228
patients enrolled in the study published in 1975.
The inadequacy of accessible data and exclusion of
metaxalone from the Cochrane Review could further
compromise the clinical application of metaxalone in
the management of acute or chronic low back pain.
The absolute bioavailability from metaxalone tablets is not known. The precise impact of a patients age,
gender, hepatic, and renal disease on the pharmacokinetics of metaxalone has not been determined yet.
Skelaxin should always be used with caution particularly in the elderly and any patient with hepatic and/or
renal impairment.
Drug interactions: metaxalone may augment the
effects of alcohol, opioids, benzodiazepines, barbiturates, and other CNS depressants.
374
Metaxalone treatment was linked with rare instances

of hepatic enzyme elevation and anemia based on a
false-positive hepatic assay using the cepalin flocculation test. Serial liver function studies should be considered for close follow-up. Metaxalone may fabricate
a false-positive Benedicts tests, due to an unknown
reducing substance. A glucose-specific test, alternatives to urine glucose testing, will be helpful to differentiate clinical findings. Metaxalone should be
administered with great care to patients with any preexisting liver and renal disease.
Adverse reactions
The most frequent reactions to metaxalone include:
1. CNS: drowsiness, dizziness, headache, and
nervousness or irritability
2. Digestive: nausea, vomiting, and gastrointestinal
upset
3. Immune system: hypersensitivity reaction, rash
with or without pruritus
4. Hematological: leukopenia, hemolytic anemia
5. Hepatobiliary: jaundice
6. Anaphylactic reactions have been reported with
metaxalone.
Overdosage
Deaths by deliberate or accidental overdose have
occurred with muscle relaxants including metaxalone,
particularly in combination with any antidepressants
and/or alcohol. When determining the LD50 in rats
and mice, progressive sedation, hypnosis, and finally
respiratory failure were noted as the dosage increased.
In dogs, no LD50 could be determined as the higher
doses produced an emetic action in 15 to 30 minutes.
Treatment: gastric lavage and supportive therapy
should be initiated. Urgent consultation with a regional
poison control center is highly recommended .
Clinical pearls
Metaxalone is often introduced as less sedating in
comparison with other muscle relaxants such as Flexeril or Soma. However, patients should always start
with only half a tablet (400 mg) and adjust dose with
precaution. The full dose (800 mg) may then be considered after careful assessment of side effects and
clinical improvement.
Metaxalone, like any other muscle relaxants,
should be prescribed for regular usage only in the
acute phase of persistent musculoskeletal spasm and
pain. Metaxalone may be considered in a case of acute
flare-up in patients with chronic musculoskeletal
pain.
Patients need to be warned about common side
effects of dizziness and drowsiness that apply to muscle
relaxants including metaxalone. There is no available
head-to-head comparison of muscle relaxants to establish that any one muscle relaxant is superior to another.
Clinicians may select a muscle relaxant of choice based
on a patients specific need, risks and benefits ratio,
drugdrug interaction, and potential risk of abuse.
Chapter 94 Tizanidine
References
1. Metaxalone (Skelaxin) Prescribing Information April

2008. King Pharmaceuticals, Inc., Bristol, TN 37620.
2. Toth PP, Urtis J. Commonly used muscle relaxant
therapies for acute low back pain: a review of
carisoprodol, cyclobenzaprine hydrochloride, and
metaxalone. Clin Ther 2004;26:13551367.
Section 10
Chapter
94
3. Chou R, Peterson K, Helfand M. Comparative efficacy

and safety of skeletal muscle relaxants for spasticity
and musculoskeletal conditions: a systemic review.
J Pain Symptom Manage 2004;28(2):140175.
4. Dent RW, Ervin DK. A study of metaxalone (Skelaxin)
vs. placebo in acute musculoskeletal disorders: a
cooperative study. Curr Ther Res Clin Exp
1975;18:433440.
Muscle Relaxants
Tizanidine
Tariq Malik
Generic Name: tizanidine

Trade/Proprietary Names: Zanaflex Sirdalud,
Ternelin, Tizanidinu
Drug Class: skeletal muscle relaxant, centrally
acting
Manufacturer: Elan Pharma International, Ltd,
Athlone, Ireland
Generic Manufacturers: Alpha Pharm PTY,
Ltd; Barr Laboratories Inc, 223 Quaker Road
Pomona, NY; Mylan Pharmaceuticals, 1500
Corporate Drive, Canonsburg, PA
Chemical Name: 5-chloro-4-(2- imidazoline-2ylamino)-2,1,3-benzothiodaizole hydrochloride
Formula: C9H8CIN5 S-HCl
Introduction
Tazanidine is a centrally acting muscle relaxant prescribed for skeletal muscle spasm and associated pain.
It is supplied as a white crystalline powder that is
slightly soluble in water. Aqueous solubility decreases
with increase in pH. It is supplied as tablets and capsules, both of which have different pharmacokinetics
and are not totally bioequivalent. It was approved by
the FDA in 1996 as an oral anti-spastic agent [1].
Mode of action
The exact mechanism of action of tizanidine is
unknown. It acts in the CNS at different sites, both at
spinal and supraspinal level, which accounts for its
anti-spastic effect. Its main affect is via its alpha-2 agonism though its affect on imidazoline receptors may
also play a role, as shown by reversal of its anti-spastic
effects by alpha-2 antagonists such as yohimbine and
idazoxan in animals [1,2].
Tazanidine acts predominantly at presynaptic
level, reducing the release of the excitatory amino
acids glutamate and aspartate from the presynaptic
terminals of spinal cord interneurons. It may also
facilitate the action of the inhibitory neurotransmitter
glycine. At the supraspinal level tizanidine inhibits the
facilitatory descending noradrenergic system (from
the locus coeruleus) on the spinal interneurons.
Spasticity is defined as velocity-dependent increase
in muscle tone which could be due to a number of different mechanisms. The pathways involved are both
375
Figure 94.1.
N
S
N
Cl
HCI
HN
HN
mono- and polysynaptic at the spinal level. Tizanidine

has been found to be more effective in reducing the
magnitude of polysynaptic excitation vs. monosynaptic excitation, unlike baclofen, which is more effective
on monosynaptic pathways [13].
Clinical effects
Muscle relaxation: in animal models tizanidine
reduces drug-induced rigor, decerebrate rigidity and
reflex muscle activity. In clinical trials it reduced muscle tone in most of the patients in a dose-dependent
manner which peaked at 23 h and lasted for 6 h. It is
a short-acting drug.
Cardiovascular effect: by virtue of its affinity for
imidazoline receptors and alpha-2 receptors, tazanidine causes bradycardia, a decrease in SBP and DBP of
about 715% from the baseline. The effect is due to
central sympatholytic activity similar to clonidine,
albeit of lower magnitude. Change is dose-dependent
and peaks at 90120 minutes after oral intake [1].
Antinociceptive effect: in animal models a dosedependent analgesic activity is seen which appears to
be mediated by alpha-2 receptors at the spinal level.
Tizanidine attenuates the abstinence syndrome precipitated by giving nalaxone to rats addicted to
morphine.
GI effects: tizanidine slows GI motility and transit
time. It inhibits stimulated gastric secretion and offers
some protection against drug-induced ulcers in rats.
Miscellaneous effects: the drug has shown anticonvulsant activity and hypothermic effects in animals. In
one healthy volunteers study 6 mg and 12 mg doses
reduced oxygen consumption from baseline by 38%.
Mean energy consumption also decreased by 59%
from baseline.
Pharmacokinetics
376
Absorption: it is rapidly absorbed with peak plasma

concentration reached in 45120 minutes. The absorption ratio is 0.53 to 0.66 but due to the extensive
first-pass effect through the liver bioavailability is only

21% of the dose. Dose and plasma levels are dosedependent over the dose range studied (220 mg).
There is little doseplasma level variability within the
same person but significant variability between individuals. Only 30% of the drug is protein-bound.
Metabolism: 95% of the drug is metabolized by the
cytochrome P450 system, primarily by the CYP1A2
isoenzyme. Metabolism is via oxidation of the imidazoline part of the molecule. There are three main metabolites and four minor identified in humans, all of which
are pharmacologically inactive. Tizanidine is extensively metabolized by the liver with only 3% excreted
unchanged in the urine. The drug is eliminated from
the body mostly in the urine (66%) and the rest (23%)
in the feces. Elimination half-life is 24 hours [13].
Renal impairment: drug clearance is reduced in
patients with renal impairment (CrCl < 25 mL/min)
with elimination half time increasing to 13.6 h from
24 h.
Tizanidine tablets vs. capsules

The capsule is a multi-particulate formulation of the
drug. In different studies it has been shown that food
facilitates drug uptake (both increasing bioavailability
and peak drug level) when the drug is taken as a tablet
but significantly impairs drug uptake when taken in
capsular form. The effect is quite significant (about
2240%) in magnitude. Sprinkling the capsule on food
also increases drug absorption by 1015%. Therefore
patients should be cautioned when switching from one
formulation to another or changing their intake in
relation to food. Patients should be consistent in how
and when they take the drug in relation to food [1].
Indications
FDA-labeled: spasticity
The efficacy of tizanidine as a muscle relaxant was
established in several pivotal randomized trials [13].
Dosage used in these trials ranged from 18 to 36 mg
per day in three daily doses. Improvement in Ashworth scale occurred by 3.94.7 points. Functional
improvement was not significant compared to placebo. Nance et al. in 1997 [4] studied 142 MS patients
in a well done study and found a high degree of interpatient variability and found no relation between
plasma level and Ashworth score. In general higher
doses resulted in higher plasma levels and more side
effects. The authors concluded that each patient will
Improvement In Ashworth
Score
Chapter 94 Tizanidine
Figure 94.2. Graph shows dose

dependence improvement in Ashworth
score after single dose, but irrespective
of dose effect wears off by 6 h.
-5
-4
16 mg tizanidine
-3
-2
8 mg tizanidine
-1
placebo
0
1
0
3
Hours Post-Dose
require individual titration to the optimum dose for

maximum benefit. Dosage up to 36 mg per day does
not decrease any muscle strength. In double-blind
comparative studies, tizanidine up to 36 mg/day
improved the muscle tone comparable to baclofen
6090 mg/day or diazepam 30 mg/day when studied
in people with MS or cerebrospinal injury. The duration of treatment was about 48 weeks in the trials.
Long-term treatment of spasticity with tizanidine for
8 to 36 months was found to be effective in controlling
symptoms with minimal or no upward adjustment of
dosage during that period [1,3] (Figure 94.2)
Non-FDA-labeled indications
As adjunct therapy for headache disorders and acute
back pain. In many small clinical trials tizanidine has
improved chronic tension headache and facial pain
from TMJ, and shown transient improvement in pain
of trigeminal neuralgia and low back pain. All these
studies are small and short-term. Doses used in these
trials were low, mostly 2 mg twice a day. It also may
have a role in helping patients wean off narcotics by
minimizing withdrawal symptoms.
Side effects
Most common reported side effects are fatigue, somnolence, dry mouth, dizziness, and hypotension, happening in 35% of patients and the most common
reason to stop the medication. They are dose-dependent and peak at 23 h post-ingestion and clearly correlate with the peak plasma level of the medication
[13]. Infrequent side effects are liver function abnormalities, constipation and vomiting, feeling nervous
or depression, speech disorder or visual hallucination
or blurred vision and UTI. Formed visual hallucinations were reported in 5/170 patients (3%) in two
North American clinical trials. It happened within
6 weeks of initiation and resolved after stopping the

drug but in one person it took 2 weeks for complete
resolution of the symptoms.
There is no known case of drug abuse.
Drug interactions
Most of the interactions are due to its primary dependence on P450 CYP1A2 for metabolism. Any inhibition
or potentiation of this isoenzyme dramatically alters
the drug level and clearance from the body. Fluvoxmine and ciprofloxacin are potent inhibitors of
CYP1A2. Hence giving tizanidine to patients taking
any of these drugs will increase the peak level by seven
to ten fold and increase half-life by three fold. This will
result in a very high incidence of side effects and/or
complications such as too much sedation or significant hypotension.
Acetaminophen delays the peak plasma level by 16
minutes. Alcohol increases the AUC of tizanidine by
20%, resulting in more side effects [1]. Other sedatives
will have a synergistic sedative effect with tizanidine.
Any CNS depressant is going to potentiate the sedative effect of tizanidine. In a study of healthy volunteers, tizanidines half-life was 10% lower and the AUC
(0) was 33% less in male smokers when compared
to male nonsmokers. Oral contraceptives decrease
clearance of the drug, resulting in a three- to four-fold
higher peak level and higher AUC (0). Tizanidine
has been known to cause severe hypotension when
given to patients taking ACE inhibitors. In controlled
clinical trials drug use has resulted in elevated liver
enzymes (3 the baseline) in 5% of subjects. The
enzyme elevation normalizes on cessation of therapy.
A case of death due to liver injury has been reported.
Periodic monitoring of the LFT is recommended for
the first 6 months (0, 1, 3, 6 months) and periodically
thereafter. Due to its extensive hepatic metabolism,
377
the drug should be avoided or used with extreme caution in patients with liver dysfunction.
Dosing guidelines
The most effective dose for each individual is determined by dose titration due to the great inter-patient
pharmacokinetic and pharmacodynamic variability.
The starting dose is usually 4 mg unless the patient is
elderly or has renal insufficiency (CrCl < 25 mL/min),
when it is started at 2 mg. The dose is repeated every
68 h. The dose can be increased every 24 days. In
clinical trials final doses ranged from 2 to 36 mg per
day. The dose can be titrated up to a daily dose of 36
mg per day unless the optimal effect appears at a lower
dose or side effects limit upward titration. It is given in
three divided doses. No single dose should be more
than 12 mg though a single dose as high as 16 mg has
been studied; but such a high single dose can cause too
many side effects. If a single dose is causing too much
sedation or drowsiness it can be given four times a day
in smaller individual doses. Frequency as often as six
times per day has been suggested to overcome individual dose side effects.
Contraindications
Absolute: allergy, co-administration of ciprofloxacin,
co-administration of fluvoxmine. Relative : renal failure, liver insufficiency.
Toxicology
The minimum toxic dose has not been established. An
adult survived ingestion of 360 mg of tizanidine
though he required intubation for loss of airway
reflexes [2]. Overdose with tizanidine results in exaggerated pharmacological effects of the drug. It affects
predominantly the CNS and CVS. Clinical effects
include lethargy, bradycardia, hypotension, agitation,
confusion, vomiting, and coma. Therapy is primarily
supportive and includes use of activated charcoal for
gut decontamination, support of CV with fluid, pressors and atropine for bradycardia.
Comparative standing
In general all muscle relaxants are equally efficacious.
They just differ in their side-effect profile and cost.
378
Tizanidine
is in general better tolerated by patients
compared with baclofen and diazepam. In a comparative review of different muscle relaxants, Chou et al.
[5] reviewed 101 trials and concluded that baclofen
and tizanidine are equally effective in treating patients
with spasticity, though tizanidine is more often associated with dry mouth, while baclofen causes increased
weakness.
Supplied as
Zanaflex capsule: 2 mg, 4 mg, 6 mg
Zanaflex tablet: 2 mg, 4 mg
Generic oral tablet: 2 mg, 4 mg
Buccal formulation (non-commercial formulation)
Slow release formulation (Sirdalud MR 6 mg and
12 mg available in Europe).
Drug cost: Zanaflex capsules are more expensive
than comparable doses of generic tizanidine [6].
Zanaflex: 2 mg (150): $266.18, 4 mg (150): $360.62,
6 mg (150): $500.58
Tizanidine capsules: 2 mg (90) $19.99, 4 mg (90):
$81.99
References
1. http://tizanidine.org/.
2. Henney HR, Runyan DJ. A clinically relevant review
of Tizanidine hydrochloride dose relationships to
pharmacokinetics, drug safety and dose effectiveness
in healthy subjects and patients. Int J Clin Pract
2008;62(2):314324.
3. Wagstaff AJ, Bryson HM. Tizanidine: a review of its
pharmacology, clinical efficacy and tolerability in the
management of spasticity associated with cerebral and
spinal disorders. Drugs 1997;53(3):435452.
4. Nance PW, Sheremata WA, Lynch SG, et al.
Relationship of the antispasticity effect of Tizanidine
to plasma concentration in patients with multiple
sclerosis. Arch Neurol 1997;54:731736.
5. Chou, et al. J Pain Symptom Manage 2004;28(2):
141175.
6. Cost taken from www.drugstore.com.
Section 10
Chapter
95
Muscle Relaxants
Baclofen
Marisa Lomanto
Generic Name: baclofen

Brand Names: Lioresal, Lioresal intrathecal
Drug Class: skeletal muscle relaxant
Manufacturers: Novartis Pharmaceuticals, East
Hanover, NJ; Medtronic Neurological, Minneapolis, MN; Aligen Independent Laboratories,
Jackson, WY; Allscripts Healthcare Solutions,
Libertyville, IL; American Health Packaging,
Columbus, OH; Auro Pharmaceutical, Phila,
PA; Barr Laboratories Inc, Pomona, NY
Chemical Name: 4-amino-3-(4-chlorophenyl)
butanoic acid
Introduction
Baclofen is a centrally acting skeletal muscle relaxant
that is used to treat spasticity. It is a chemical analog of
gamma-aminobutyric acid (GABA), an inhibitory
neurotransmitter, and is a specific agonist at GABA-B
receptors.
Mode of activity
Although the exact mechanism of action is not completely known, it is thought to bind to presynaptic and
postsynaptic GABA-B receptors. Baclofen works
mainly at the spinal cord level to inhibit monosynaptic
and polysynaptic reflexes by interfering with the release
of excitatory neurotransmitters. Activity at supraspinal
sites may also contribute to its clinical effect.

and elimination
Oral administration: baclofen is rapidly absorbed from
the GI tract. Its oral bioavailability is approximately
70%. It is approximately 30% plasma protein-bound.

Peak plasma concentrations occur 0.5 to 3 hours after
an oral dose. Approximately 70 to 85% is excreted in
the urine unchanged and about 15% is metabolized by
deamination in the liver. Its elimination half-life is 2 to
4 hours in plasma. Baclofen crosses the bloodbrain
barrier in small amounts after an oral dose, with concentrations in CSF approximately 12% of that in plasma.
Baclofen crosses the placenta and is also found in breast
milk.
Intrathecal administration: plasma concentrations of intrathecally administered baclofen are
thought to be low. Limited data suggest that baclofen
injected into the lumbar CSF travels cephalad, producing a lumbarcisternal baclofen concentration
gradient of approximately 4:1 during continuous
intrathecal infusion. CSF elimination of baclofen
probably occurs by bulk flow removal of CSF and
approximates CSF turnover. Its elimination half-life
is approximately 1.5 hours after a 50 to100 g intrathecal loading dose.
FDA-labeled indications
Baclofen is approved for the treatment of reversible
spasticity and its associated pain in a variety of neurological conditions of both spinal cord and cerebral origin, such as multiple sclerosis, amyotrophic lateral
sclerosis, and spinal cord injuries. It can be administered orally or intrathecally. Intrathecal baclofen is
used to manage chronic intractable spasticity in
patients who are unresponsive, or who have intolerable side effects, to a minimum 6 week course of oral
therapy. There must be a positive response to a test
dose of intrathecal baclofen prior to implantation of a
continuous infusion pump. The safety and efficacy of
baclofen have not been established in the pediatric
population.
379
OH
Figure 95.1.
H2N
Cl
Non-FDA-labeled indications
Oral baclofen, in daily divided doses of 15 to 80 mg,
has been found to be effective in treating neuropathic
pain; it has been used alone and as an adjuvant for the
treatment of trigeminal neuralgia. Oral baclofen, in
similar doses, has been used to treat intractable hiccups. In addition, though not a conventional analgesic
itself, it may potentiate opioid analgesia. Continuous
intrathecal baclofen infusion of 1 to 2 mg daily for the
management of tetanus has been reported.
Contraindications
380
Absolute: hypersensitivity to baclofen or any component of the product.

Relative/precautions:
Baclofen increases gastric acid secretion; use with
caution in patients with a history of peptic ulcer
disease.
Baclofen may exacerbate severe psychiatric or
seizure disorders. Patients with cerebrovascular
disease may also tolerate baclofen poorly.
Severe renal impairment may cause baclofen
toxicity. Patients with renal insufficiency or
those ungerdoing hemodialysis require a
reduced dose.
Baclofen may increase blood glucose
concentrations; use with caution in patients with
diabetes.
Baclofen should be used with caution in patients
who require their spasticity to maintain posture
or function.
Baclofen is considered unsafe in patients with
porphyria.
Baclofen may precipitate bronchospasm and
should be used with caution in patients with
respiratory impairment.
Baclofen may cause alterations in liver function
tests; monitor in patients with hepatic disease.
The safety and efficacy of baclofen have not been

established in the pediatric population.
Small children may be unable to accommodate an
implantable baclofen pump.
Baclofen is classified as Pregnancy Category C.
The concentrations of baclofen found in breast
milk are low; the American Academy of
Pediatrics considers baclofen acceptable with
breast-feeding.
Adverse effects may be more common in the
elderly.
Baclofen may enhance the effects of alcohol and
Common doses
Baclofen can be administered orally or intrathecally.
Intrathecal administration is accomplished by means
of an intrathecal catheter and a surgically implanted
refillable pump. Intrathecal administration is often
preferred in patients with severe spasticity, as very little of the oral dose actually reaches the CSF. These
patients may be unresponsive to oral baclofen and/or
intolerant of its side effects at high doses. While
intrathecal administration may minimize side effects,
it poses the risk of potentially severe CNS depression.
How supplied:
oral tablet: 10 mg, 20 mg
Lioresal intrathecal test solution : 0.05 mg/mL
Lioresal intrathecal refill solution: 0.5 mg/mL,
2mg/mL
Oral: baclofen is given in divided doses, preferably
with or after food. The initial dose is 5 mg three times
a day for 3 days, increased to 10 mg a day for 3 days,
then titrated up in a similar manner until a therapeutic effect is obtained or a maximum daily dose of 80
mg is reached. Doses of more than 80 mg daily are
usually not recommended. If there is no clinical
response within 6 weeks of achieving the maximum
dose, the drug should be gradually withdrawn. Elderly
patients should receive lower initial doses. Patients
with renal insufficiency or those undergoing hemodialysis should receive reduced doses; 5 mg daily has
been recommended.
Intrathecal: before starting intrathecal baclofen,any
existing anti-spastic therapy should be gradually withdrawn. Initial intrathecal test doses are given to determine clinical response. If there is a positive response,
an intrathecal catheter is placed and connected to a
subcutaneously implanted pump whose reservoir can
Chapter 95 Baclofen
be refilled by percutaneous injection. Intrathecal test

doses start at 25 to 50 g, given over at least 1 minute,
and are increased by 25 g every 24 hours until a dose
of 100 g is reached or a positive response of 4 to 8
hours is obtained. A positive response is considered a
reduction in muscle spasm, passive limb movement,
and/or pain relief. Patients who do not respond to a
test dose of up to 100 g are not candidates for intrathecal treatment. For those with a positive response lasting longer than 8 hours, the test dose required to
produce that response is then given as a 24-hour infusion. If the response to the test dose lasted 8 hours or
less, a dose equivalent to twice the test dose is given as
a 24-hour infusion. Daily dosage can then be adjusted
as needed. Maintenance doses range from 10 g to 2
mg daily, depending on the cause of spasticity, with
most patients requiring 300 to 800 g daily. Most
patients require a gradual increase in dose over time
to maintain an optimal response (Table 95.1).
Significant tolerance does not seem to occur and
baclofen retains its therapeutic effects after many years
of use.
Baclofen, like other GABA agonists, can produce CNS
depression. In addition, the intrathecal pump systems
are complex and expensive. Like most implantantable
devices they carry the risk of infection. Their subcutaneous position makes them vulnerable to damage
with the potential for release of the entire baclofen
dose. Inadvertent intrathecal overdose may also occur
secondary to pump malfunction or dispensing errors.
In approximately 5% of patients, the intrathecal route
has no effect.

Common adverse events: drowsiness, dizziness, weakness, nausea, vomiting, constipation (intrathecal 100%).
Less common adverse events: fatigue, headache,
elevated liver enzymes, elevated blood glucose, urinary
retention, incontinence, euphoria, depression, paresthesias, xerostomia, taste alteration, anorexia, abdominal
pain, diarrhea, constipation, respiratory depression, cardiovascular depression, chest pain, syncope, paradoxical increase in spasticity, impotence/inability to ejaculate
(intrathecal), asceptic meningitis (intrathecal).

Withdrawal: abrupt discontinuation of baclofen can
result in withdrawal symptoms, which may include
hyperthermia, tachycardia, seizures, hallucinations,
psychosis, agitation, and exaggerated rebound spasticity. In rare cases this may progress to rhabdomyolysis,
multiple organ-system failure, and death. With the
exception of serious adverse events, baclofen should
be gradually reduced over 1 to 2 weeks before discontinuing, especially in those patients on chronic highdose therapy. The FDA has issued a black-box warning
advising against the abrupt withdrawal of intrathecal
baclofen.
Toxicity: weakness, drowsiness, confusion, agitation,
delirium, hallucinations, nausea and vomiting are common in mild to moderate toxicity. Respiratory depression, hypotension, bradycardia, hypotonia, hypothermia,
seizures, and coma may occur in severe toxicity. Rare
events include status epilepticus, rhabdomyolysis, and
first-degree AV block. Oral doses of 200 mg or more and
intrathecal doses of 1.5 mg or more often produce significant toxicity.
Treatment of adverse events: adverse events are
often transient and dose-related. Mild side effects can
Table 95.1. Adult baclofen dosing for spasticity

Oral
5 mg PO TID; increase by 15 mg/day q 3 days to maximum dose 80 mg/day
Intrathecal test dose
2550 g in 1 mL intrathecal over 1 min; increase by 25 g q24 h until maximum dose 100 g
or 48 h sustained clinical response. Must respond to a single bolus dose of 100 g/2 mL to be
a candidate for infusion pump therapy.
Initial intrathecal infusion rate
If test dose response < 8 h: initial daily dose = 2 test dose intrathecally over 24 h. If test dose
response > 8 h: initial daily dose = test dose intrathecally over 24 h.
Intrathecal infusion titration
For spinal cord spasticity: after first 24 h, may increase dosage by 1030% q24 h. For cerebral
origin spasticity: after first 24 h, may increase dosage 515% q24h.
Intrathecal pump refill
For spinal cord spasticity: may increase daily dose by 1040% (max) or reduce daily dose by
1020% PRN during pump refill. For cerebral origin spasticity: may increase daily dose by 520%
(max) or reduce daily dose by 1020% PRN during pump refill.
381
generally be minimized by increasing doses gradually

or controlled by a decrease in dose. Serious adverse
events usually require intervention, as described
below.
Withdrawal: manage withdrawal from oral
baclofen by resuming the usual dose. Manage withdrawal from intrathecal baclofen by either resuming
the infusion or administering by lumbar puncture.
Give oral baclofen if intrathecal administration is not
possible. Supplement with IV benzodiazepines if
needed. Cyproheptadine may also be useful; the initial
dose is 12 mg orally, then 2 mg every 2 hours as
needed, to a maximum dose of 32 mg/day.
Toxicity: management of mild to moderate toxicity usually requires only supportive care. Management
of severe toxicity may require more aggressive intervention. Monitor the need for airway management,
including endotracheal intubation in patients with
CNS depression or recurrent seizures. Treat seizures
with IV benzodiazepines and barbiturates. Treat hypotension with fluids and vasopressors. Atropine may be
used to treat hypotension associated with bradycardia.
382
For patients who have ingested more than 100 mg,

and who are alert or have a protected airway, activated
charcoal may be administered. Hemodialysis may be
particularly useful in patients with impaired renal
function. In the event of intrathecal overdose, immediately empty the remaining baclofen solution from
the pump reservoir. If not contraindicated, withdraw
approximately 40 mL of CSF through the access port
or by lumbar puncture. Frequently monitor mental
status, cardiopulmonary status, urine output, and the
ability to protect the airway. Monitor CPK in patients
with prolonged or recurrent seizures.
References
1. http://www.onlinedrugtest.info. july 12, 2009.

2. http://en.wikipedia.org/wiki/Baclofen. July 12, 2009.
3. MICROMEDEX Healthcare Series: DRUGDEX
Drug Point. May 15, 2009.
4. MICROMEDEX Healthcare Series: Martindale The
Complete Drug Reference. Copyright 2008.
5. http://www.drugs.com/mmx/apo-baclofen.html. May
19, 1999.
Section 11
Chapter
96
Adjuvant Analgesics and Antiemetics
Corticosteroids: intravenous, neuraxial,

and articular
Johan Raeder
Indroduction
The corticosteroids (Figure 96.1) are naturally occurring hormones in the body, with a diurnal variation in
circulating levels and increased circulating levels during trauma and stress. Typically about 2550 mg of
cortisone is secreted during a normal 24 hour period.
The clinical analgesic effect of stress hormones has
long been acknowledged, for instance during combat
situations where the pain threshold seems to be significantly elevated, possibly partly due to corticosteroids and other stress hormones. It has also been shown
that animals with elevated levels of endogenous corticosteroids experience less pain than others. Potential
analgesic and clinical benefits of corticosteroids are
outlined in Table 96.1.
Mechanisms of action
Corticosteroids act by binding to a class of nuclear
receptors (corticosteroid receptors). Upon binding to
the receptor transfer (chaperone) protein, the drug
receptor complex diffuses into the nucleus of the cell
and binds to DNA. Then production of proteins and
enzymes with subsequent clinical effects are initiated.
Traditional pharmacokinetic parameters are not appropriate for describing corticosteroid pharmacodynamics, since genetic activation is associated with significant
latency to effect. For this reason, onset is typically
delayed, with maximum effects observed after 34
hours or more. For the same reason, the duration of
clinical effect is prolonged and does not correlate with
plasma concentrations of drug. In general, effects on
cellular processes will continue for hours to days,
despite complete clearance of drug from plasma. Some
direct cellular membrane effects of corticosteroids have
also been suggested. The rapid membrane stabilization
from glucocorticoids during anaphylactoid reactions
and a study showing analgesic effect within 1 hour of
administration are clinically supportive of these nonDNA mediated effects of corticosteroids.
Molecular mechanisms of
corticosteroids
The family of steroid molecules includes potent hormones, necessary for normal homeostasis and growth
of the human body. Basically both mineralocorticoids
and glucocorticoids are subclasses of the corticosteroid family, but for analgesia and the rest of this chapter only the glucocorticoids will be discussed. The
glucocorticoids have virtually no sex hormonal properties, but some of them may still have slight mineralcorticoid effects (Table 96.2) resulting in renal sodium
and water retention. There are also some reports of
increased blood sugar levels, especially in diabetic
patients. The major effects of the glucocorticoid subclass of steroid hormones are linked with the inflammatory response; including inhibition of inflammatory
gene expression and stimulation of anti-inflammatory
gene expression. Important mediators include TNF
inhibition and leukocyte inhibition in the peripheral
injured tissue. COX-2 inhibition is seen both in the
periphery, in the spinal dorsal horn and in the central
nervous system. As a part of this general anti-inflammatory action, glucocorticoids also have direct effects
on blood capillaries, with decreased permeability and
reduced vasodilatation.
A general anti-inflammatory action may be very
important for pain reduction per se, by reducing local
tissue pressure and limiting the release of potent pain
mediators. The glucocorticoids have also been shown
to have direct effects on pain neurons and receptors.
They reduce neuropeptide release, inhibit signal transmission in C fibers and stimulate the secretion of
endogenous endorphins.
Clinical actions of glucocorticoids

The well-known clinical effects of glucocorticoids
include anti-inflammation, anti-edema, anti-allergic
and antipyrexia. Also, analgesia and antiemetic effects
383
Adjuvant Analgesics and Antiemetics Section 11
21
18
HO
11
19
CH3
1
2
10
A
3
12
20
CH3
17
13
14
OH
CH3
HO
16
OH
CH3
(a) Hydrocortisone (cortisol)
CH2OH
(b) Prednisolone
C
CH3
O
HO
CH2OCC2H5
C
OH
CH3
CH3
O
OCC2H5
CH3
CH3
15
HO
Figure 96.1. The chemical structure of

glucocorticoids and other steroid
hormones.
CH2OH
CH2OH
F
O
CH3
CI
O
(c) Beclomethasone dipropionate
(d) Dexamethansone
Table 96.1. Clinical effects of glucocorticoid actions

Anti-inflammatory
Anti-edema
Analgesia
Antiemesis
Antipyretic
Euphoria
Increased alertness
Increased energy
Restlessness
Increased appetite
384
are well documented, although the mechanism especially of antiemesis is less well understood. The glucocorticoids frequently induce a slight feeling of euphoria
and alertness, being documented in the post-operative
setting as less sedation when these drugs are used
(Table 96.1). The patient may sometimes describe a
sensation of more energy and also increased appetite
may be beneficial in this setting. On the other hand,
there are also reports of restlessness, dysphoria, and
even rare cases of abrupt psychosis, when glucocorti-
coids are used for analgesia. Less post-operative shivering has been observed and fewer cardiac arrhythmias.
Antiarrhythmic effect is only shown in some studies,
whereas others have not demonstrated this effect.
With prolonged use of these drugs there is a very
long list of non-beneficial effects, resulting from a
generalized reduction in tissue growth, deprived cellular activation and wound healing. The clinical manifestations may be: wound rupture, non-fusion of
fractures, gastric ulceration and perforation, skin vulnerability and wound formation, poor infection control. Also, hormonal side-effects may develop, such as
moon-face appearance, sexual hormone dysfunction,
mental disturbances, and hyperglycemia. Some
adverse events associated with long-term glucocorticoid exposure are outlined in Table 96.3.
Clinical analgesic action after

systemic injection
The analgesic effect of glucocorticoids has been well
documented, especially in the post-operative setting.
Compared with other analgesics, the onset of clinical
effect is generally delayed. In this investigators experience, no analgesic effect was evident during the first 4
hours following IV administration of 16 mg dexamethasone to patients recovering from breast surgery. This
Chapter 96 Corticosteroids: intravenous, neuraxial, and articular
Table 96.2. Steroid pharmocokinetic/dynamic characteristics
Drug
Half-life
(hr)
Equivalent
dose (mg)
Antiinflammatory
potency
Mineral
corticoid
potency
Na+retaining
potency
20
25
0.8
0.8
0.8
0.8
0.8
Short-acting
Hydrocortisone
812
Cortisone
812
Intermediate
Prednisolone
1836
Prednisone
1836
0.8
0.8
Methylprednisone
1836
0.5
0.8
Triamcinolone
1836
Long-acting
Dexamethasone
3654
0.75
25
Endogenous cortisone production: 2550 mg/day 12 mg dexamethasone. Modified from Salerno A, Hermann R. J Bone Joint Surg
2006:88:13611372.
Table 96.3. Steroid side effects

Dermatological
Endocrine
Skin thinning
Diabetes
Alopecia
Adrenal-pituitary insufficiency
Hirsuitism
Acne
Striae
Bone
Gastrointestinal
Osteoporosis
Gastritis
Avascular necrosis
Peptic ulcer disease

Bowel perforation
Muscle
Neuropsychiatric
Myopathy
Euphoria
Dysphoria
Renal
Psychosis
Fluid volume shifts
Insomnia
Hyperkalemia
Cardiovascular
Reproductive
Hypertension
Amenorrhea
Cardiomyopathy
Infertility
Immunological
Increased risk of infection
Herpes zoster
correlates with previous reports of delayed onset of

effect. However, there are reports of onset of post-surgical analgesia provided by 125 mg IV methylprednisolone, evident at 60 min after administration. This is
in accordance with experimental and clinical evidence

suggesting that glucocorticoids may have rapid and
direct, non-genomic actions on cellular membranes.
The duration of analgesic effect provided by single
doses of IV glucocorticoid may be prolonged for at
least 3 days. The plasma elimination half-life of dexamethasone is only about 6 h, thus there seem to be
ongoing drug effects for a significant period after drug
clearance from the plasma. Both the slow onset and
prolonged effect from a single dose may be explained
by the assumed basic major effect mechanisms of glucocorticoid.
The optimal dose for glucocorticoid analgesic
effect is not established, as controlled dose-finding
studies have not been performed. For the antiemetic
effect, a dexamethasone dose of 34 mg seems to be
optimal, whereas for analgesia 816 mg seems to be
necessary in adults.
Although glucocorticoids have been shown to
inhibit the cyclooxygenase 2 (COX-2) enzyme system,
much like NSAIDs, they also have hormonal effects
and act on a variety of other enzyme systems. Thus, it
is of interest to elucidate how the analgesic effect compares with other analgesics in placebo-controlled
models. Paracetamol seems to have more analgesic
efficacy during the first 34 hours after administration, whereas dexamethasone provides delayed analgesia. Patients treated with a single IV dose NSAID
(i.e. ketorolac) experienced a more rapid onset of
analgesia, while those treated with methylprednisolone required significantly less rescue analgesics
during post-operative days 2 and 3.
385
An important question that must be addressed is

whether or not the glucocorticoids provide measurable analgesic effects when they are administered in
multimodal analgesic regimens.
In one placebo-controlled study, the analgesic
effect of dexamethasone, 8 mg, was effective in addition to a regimen of local wound anesthesia, paracetamol and ketorolac. Similarly, in another study, the
analgesic effect of a glucocorticoid was additive to that
provided by local anesthesia, paracetamol and codeine.
Several studies have shown that the specific analgesic
effects of a glucocorticoid plus an NSAID or coxib is
better than NSAID or coxib alone, also when paracetamol is included in the control group.
Neuraxial glucocorticoids
386
Neuraxial glucocorticoids are used for pain management associated with acute and chronic localized low
back pain as well as radiating pain, such as with ischialgia. The concept is to benefit from the local, peripheral effect of the glucocorticoid on inflamed or
edematous tissue as well as blocking some of the
actions of activated cytokines and immunological
mediators in the tissue structures which are believed
to be involved with the etiology of the pain. Whether
or how much such effect from a localized high concentration is achieved by neuraxial injection different
from simple intravenous or oral systemic administration is still debated. There are some data suggesting
that glucocorticoids hardly penetrate the dura and
thus should not be expected to reach elevated, nonsystemic concentrations around the nerveroots. Still,
other data show that efficacy may be achieved with
virtually no measurable glucocorticoid in the systemic
circulation. In some studies, a transforaminal technique with aid of fluoroscopy has been used, in order
to ensure deposition of drug closer to the painful
structures than with conventional epidural technique.
Still, with all controversies as to mode of administration, choice of drug, dose, concentration or adjuvants, there seems to be proper documentation of
analgesic effect from neuraxial glucocorticoids during
acute episodes of low back pain and radiating pain.
The effect may be evident within a few hours and may
last for 13 weeks and up to 36 months in some studies. However, the analgesic effect does not seem to be
superior to placebo when evaluated beyond this timeframe, or in terms of outcome or risk of recurrence.
With chronic or subacute pain, the data provide far
less, but still mostly positive, evidence for analgesia
with neuraxial glucorticoids. However, the potential

risks of these neuraxial injections should be noted:
headache from accidental dura puncture, nerve injury,
hematoma, or localized infection.
Articular glucocorticoid
As with neuraxial injections, the concept of articular
injection is to provide a high concentration of drug
proximal to the location of the suspected origin of
pain. Although intra-articular deposition certainly
will produce a high concentration inside the joint,
there is still a debate as to whether this is the major
relevant site for pain treatment, as much of articular
pain is believed to be mediated from structures outside the joint cavity, such as tendons, connective tissue, capsules, and muscle. Also, there is a concern that
high concentration of intra-articular corticosteroid
may have deleterious effects on cartilage and bone, as
reported in some rare cases.
The joints most commonly studied for intra-articular glucocorticoid injection include the knee joint
and the shoulder joint. In recent meta-analyses of
knee joint injections, there was a significant analgesic
effect of corticosteroids during the first week, lasting
for 34 weeks in many patients, but not beyond. Similar effect and profile have been demonstrated for subacromial and other joint injections. No significant
deleterious effects on cartilage or bone have been
demonstrated after single injections in prospective
studies. The injections seem to be more efficacious in
patients with joint effusion or flares.
Other clinical effects and side effects

Glucocorticoids may also have beneficial effects on minimizing nausea and vomiting, and improving alertness,
appetite, and mood. Potential adverse effects include
hyperglycemia, flushing, restlessness, impaired wound
healing, gastrointestinal ulceration, and increased infection risk. Increased alertness has also been described,
which may be beneficial in a post-operative setting with
more rapid clearheaded recovery and discharge. Adverse
effects are unlikely following single-dose administration, but may increase with repeated doses.
In a meta-analysis of adverse effects after single-dose
administration, no significant side effects were demonstrated in the 17 studies of 941 patients receiving dexamethasone. Even more impressive is the absence of side
effects revealed in the meta-analyses of a much higher
dose of mehylprednisolone (i.e. 1530 mg/kg) used for
Chapter 96 Corticosteroids: intravenous, neuraxial, and articular
chest-trauma care. In more than 2000 patients from 51

single studies, the only significant effect found was an
improvement of pulmonary function with glucocorticoid.
However, there have been intermittent reports of psychotic reactions after a single, high-dose administration
of glucocorticoids. Also, in studies of dexamethasone
515 mg, a 2040% non-dose-dependent increase in
post-operative blood sugar has been noted.
Conclusion: glucocorticoids for

analgesic injection
The glucocorticoids have analgesic effect with delayed
onset of 14 h and prolonged duration for at least 13
days after a single IV dose. The analgesic peak potency
seems to be comparable to the effects provided by
optimal doses of NSAIDs and paracetamol. The combination of a glucocorticoid plus NSAIDs provides
additive anti-inflammatory effects and analgesia. In
addition, the glucocorticoids may offer a safe and useful substitute for patients with known contraindications to NSAIDs (asthma, allergy, renal failure,
bleeding tendency).
For injection of glucocorticoids into neuraxial and
joint structures, there seems to be the best analgesic
effect with acute pain, lasting for some weeks; whereas
the documentation of benefit declines with the increasing chronicity of pain and when observations beyond
23 months are done.
There seems to be minor difference in the effect of
different glucocorticoids, although few comparative
studies on equipotent doses of different drugs have
been done. Still, for injection into delicate structures
such as joints and peri-neuraxial tissue, there is a
debate about which drug, formulation, and particle

size is optimal.
References
1. Raeder J, Dahl V. Clinical application of

glucocorticoids, anti-neuropathics and other analgesic
adjuvants for acute pain management. In Sinatra R
et al., eds. Acute Pain Management. Cambridge
2. Salerno A, Hermann R. Efficacy and safety of steroid
use for post-operative pain relief. Update and review
of the medical literature. J Bone Joint Surg Am
2006;88:13611372.
3. Abdi S, Datta S, Trescot AM, et al. Epidural steroids in
the management of chronic spinal pain: a systematic
review. Pain Physician 2007;10:185212.
4. Arroll B, Goodyear-Smith F. Corticosteroid injections
for painful shoulder: a meta-analysis. Br J Gen Pract
2005;55:224228.
5. Bellamy N, Campbell J, Robinson V, et al.
Intraarticular corticosteroid for treatment of
osteoarthritis of the knee. Cochrane Database Syst Rev
2005;CD005328.
6. Gruson KI, Ruchelsman DE, Zuckerman JD.
Subacromial corticosteroid injections. J Shoulder
Elbow Surg 2008;17:118S130S.
7. Staal JB, de Bie RA, de Vet HC, et al. Injection
therapy for subacute and chronic low back pain: an
updated Cochrane review. Spine (Phila Pa 1976)
2009;34:4959.
8. Stafford MA, Peng P, Hill DA. Sciatica: a review of
history, epidemiology, pathogenesis, and the role of
epidural steroid injection in management. Br J
Anaesth 2007;99:46173.
387
Section 11
Chapter
97
Oral corticosteroids
Kianusch Kiai and David Burbulys
Numerous preparations are available including:

Generic Name: dexamethasone
Chemical Name: 9-fluoro-11,17,21-trihy
droxy-16-methylpregna-1,4-diene-3,20-dione
Proprietary Names: Decadron, DexPak, Maxidex, Baycadron, Ozurdex and several others
in the USA and other countries
Manufacturers: Merck and several others in the
USA and other countries
Class: corticosteroid, adrenal glucocorticoid,
synthetic glucocorticoid
Generic Name: prednisone
Chemical Name: 17,21-dihydroxypregna-1,4diene-3,11,20-trione
Proprietary Names: Deltasone, Deltacortisone, Deltadehydrocortisone, Orasone, Prednisone and several others in the USA and other
countries
Manufacturers: Bristol-Myers-Squibb, Merck,
Novartis, Pharmacia & Upjohn and several others in the USA and other countries
Class: corticosteroid, adrenal glucocorticoid,
synthetic glucocorticoid
Chemical Structure: dexamethasone, see Figure
97.1; prednisone, see Figure 97.2
Mode of activity
388
Oral corticosteroids have many properties which may

be beneficial in acute and chronic pain relief. They are
principally anti-inflammatory or immunosuppressant
agents that are derived from adrenal steroids and have
primarily glucocorticoid activity with limited or no
mineralocorticoid activity.
At the molecular level, unbound glucocorticoids
easily cross the cell membrane and bind to specific
cytoplasmic
receptors. This modifies transcription and
protein synthesis of many enzyme systems to achieve
the drugs goal. These include stabilizing leukocyte lysosomal membranes, preventing the release of destructive
acid hydrolases from leukocytes, reducing leukocyte
adhesion to capillary endothelium, inhibiting macrophage accumulation in inflamed areas, reducing
capillary wall permeability and edema formation, antagonizing histamine activity and the release of kinins from
substrates, reducing the inflammatory response to bacterial endotoxins and cell-wall components, reducing
the release of cytokines, reducing activity and volume of
the lymphatic system producing lymphocytopenia,
decreasing the activity of tissue to antigenantibody
complexes and depressing immunoglobulin and complement concentrations and passage of immune complexes through basement membranes.
The anti-inflammatory actions are thought to involve
phospholipase A2 inhibitory proteins. These, in turn, control many of the mediators of inflammation such as prostaglandins and leukotrienes by inhibiting the release of
the precursor molecule arachidonic acid. This reduction
in inflammation, edema, and tumor burden is especially
beneficial in reducing bone pain, neuropathic pain from
infiltration or compression of structures, spinal cord
compression, pain from bowel obstruction or organ capsule distention, pain from lymphedema, and headache
pain associated with increased intracranial pressure.
In addition to these anti-inflammatory and
immunosuppressive activities of pain control, oral
corticosteroids have several other properties that
make them useful as multipurpose adjuvant analgesics, especially in patients with pain associated with
chronic disease or cancer. The mechanisms of these
effects are less well worked out but corticosteroids
also stimulate the erythroid cells of bone marrow
and prolong the survival time of erythrocytes and
platelets. They promote gluconeogenesis and protein
catabolism, They reduce chemotherapy-induced
nausea and vomiting, and alleviate dyspnea, effusion
Chapter 97 Oral corticosteroids
OH
Figure 97.1.
There are several, though, which may be considered

adjuvant analgesia uses. These include treating:
cerebral edema associated with primary or
metastatic brain tumor, craniotomy or head injury
hypercalcemia of malignancy
inflammatory disorders of the musculoskeletal
system
palliative management of leukemia and
lymphoma.
Figure 97.2.
Off-label uses
CH3
HO
OH
CH3
CH3
O
HO
O
OH
or hypercalcemia, stimulate appetite and improve

malaise and mood, and lead to a sense of well-being.
Corticosteroids have also been shown to have use
as an adjunctive treatment for acute post-operative
neuropathic pain in several animal studies. This most
probably involves inhibiting the production of proinflammatory cytokines secreted at or near the site of
nerve injury and reducing the development and maintenance of central sensitization and neuropathic pain.
Further research is needed, however, in this area.
Prednisone and dexamethasone are rapidly
absorbed across the GI mucosa following oral administration. Peak effects are observed in 12 hours. The
circulating drugs bind extensively to plasma albumen
and transcortin. Unbound drug is quickly distributed
into the kidneys, intestine, skin, liver, and muscle
where dexamethasone has its active effects. Prednisone
undergoes hepatic metabolism to its active metabolite,
prednisolone, prior to redistribution to the tissues for
its effects. Both drugs are further metabolized by the
liver to inactive compounds which are then excreted
in the urine. Prednisone has a plasma half-life of
approximately 1 hour but has a biological half-life of
1836 hours. Dexamethasone has a biological half-life
of 23 days. Corticosteroids are well distributed into
breast milk and easily cross the placenta.
Indications
FDA-approved uses
Oral corticosteroids have several FDA-approved indications; none of which is for primary pain management.
Several studies have suggested that oral corticosteroids may also have benefit in the direct or adjuvant
relief of acute or chronic pain associated with:
headache (migraine, cluster, acute mountain
sickness)
cancer (leukemia, lymphoma, myeloma)
complications of cancer (edema, inflammation,
effusions, treatment complications, hollow
viscous obstruction, solid organ capsule
distension, nausea and vomiting, loss of appetite,
and depressed mood)
post-operative nausea and vomiting
AIDS wasting syndrome and cachexia
various inflammatory, infectious or autoimmune
disorders.
Contraindications
Absolute: hypersensitivity to the drug or any other
component of the product. Active or suspected ocular
or periocular infection (herpes simplex keratitis, vaccinia, varicella, mycobacterial disease or fungal infection), systemic fungal infections, advanced glaucoma
or concurrent administration of live vaccines in
patients receiving immunosuppressive doses.
Relative: active or latent peptic ulcer disease, recent
intestinal anastomoses, nonspecific ulcerative colitis
(increased risk of perforation), diabetes, adrenocortical
insufficiency (may persist for months after discontinuing therapy), active or latent tuberculosis, cerebral
malaria, chicken pox, measles, latent amebiasis or
strongyloides infection, inactivated viral or bacterial
vaccines where antibody response may not be induced,
cirrhosis, congestive heart failure, renal failure or hypertension (increased risk of sodium retention, edema and
potassium loss), hypokalemia or hypocalcemia, emotional instability or psychotic tendencies, hypothyroidism, growth retardation in infants and children,
389
myasthenia gravis (risk of acute myopathy), optic neuritis, osteoporosis, pregnancy, breast feeding, birth control (may reduce effectiveness), and recent myocardial
infarction (may increase risk of wall rupture).
Common doses and uses

Oral corticosteroids are generally administered in either
a high- or low-dose regimen depending on the indication. A high-dose regimen of dexamethasone, up to
80100 mg/day in four divided doses, is often used for
spinal cord compression or an acute episode of severe
pain that cannot be reduced with opioids. For prevention
of chemotherapy-induced nausea and vomiting, 20 mg
of dexamethasone is often given followed by 8 mg twice
a day for 3 days. A 10 mg loading dose, followed by 4 mg
every 6 hours, is often used for acute cerebral edema due
to primary or metastatic brain tumor. These doses are
generally tapered rapidly over a few days once the symptoms improve or other therapy is instituted. Lower-dose
regimens of 24 mg once or twice a day of dexamethasone may be used for patients with advanced cancer who
continue to have moderate pain despite optimal dosing
of opioid drugs. Similar dosing may also be beneficial for
intractable nausea and vomiting or to improve appetite
and malaise. Five mg of prednisone is equivalent to 0.75
mg of dexamethasone. Because the therapeutic effects of
corticosteroids are of longer duration than the metabolic
effects, intermittent treatment (every other day) may
allow the metabolic rhythm of the body to become reestablished while maintaining the therapeutic value.
As part of multimodal analgesia they are a useful
adjunctive agent to relieve pain through their anti-
inflammatory and immunosuppressant properties.
This is especially beneficial for pain associated with
arthritis or other chronic inflammatory processes, cancer, AIDS, and other chronic painful disease states. In
addition to modulating pain, they have the added benefit of reducing swelling, edema, effusions, and inflammation and improving appetite, controlling nausea and
vomiting, and promoting a sense of general well-being.
They are easily prescribed, inexpensive, non-addictive,
widely available, and in oral formulation.
390
Side effects
Mineralocorticoid adverse effects include hypertension, sodium and water retention, potassium and cal-
cium depletion, hypokalemic alkalosis, edema and

potentially congestive heart failure in susceptible individuals. Glucocortocorticoid adverse effects include
mobilization of calcium and phosphorus leading to
osteoporosis and spontaneous fractures, avascular
necrosis of bone, muscle wasting, hyperglycemia, peptic ulceration, lypolysis and fat redistribution, hirsutism, bruising, striae, acne, thromboembolic
complications, impaired tissue repair and delayed
wound healing, impaired immune function and
increased susceptibility to infection, masking and early
dissemination of infection, skin thinning, the development of glaucoma and cataracts, mental and neurological disturbances, and secondary adrenocortical
insufficiency which may persist for months or years.
Drug interactions
Corticosteroids interact with many drugs and classes
including amphotericin B (may worsen severe hypokalemia), hepatic P450 enzyme inducers (increases
metabolism of corticosteroids), antacids (decreases
bioavailability), digoxin (increases digoxin toxicity
due to hypokalemia), diuretics (increases diuretic
effects, worsens hypokalemia), insulin and other oral
hypoglycemic agents (corticosteroids worsen glucose
intolerance), NSAIDS (increased risk of GI bleeding),
and vaccines (increases risk of disseminated infection
with live virus and reduces effectiveness of attenuated
or killed vaccines).

There are no commonly reported specific drug-related
adverse effects with oral corticosteroids, but there are
numerous significant effects and side effects (listed
above), many of which may be life-threatening.
References
1. DynaMed, EBSCO Publishing. Dexamethasone, 2009.

2. DynaMed, EBSCO Publishing. Prednisone, 2009.
3. MicromedexHealthcare Series, DrugDex
Evaluations, Martindale The Complete Drug
Reference, and Posindex, Tompson Healthcare.
Dexamethasone, 2009.
4. MicromedexHealthcare Series, DrugDex Evaluations,
Martindale The Complete Drug Reference, and
Posindex, Tompson Healthcare. Prednisone, 2009.
5. Knotkova H, Pappagallo M. Adjuvant analgesics.
Anesthesiol Clin North Am 2007:27:775786.
6. Lussier D, Huskey A, Portenoy R. Adjuvant analgesics
in cancer pain management. Oncologist 2004;9:571591.
Section 11
Chapter
98
Antihistamines
Sharon Lin
Antihistamines
First-generation H1 antihistamines
Generic Name (proprietary name): chlorpheniramine (Aller-chlor, Ahist, Chlor-Trimeton),
diphenhydramine hydrochloride (Benadryl),
hydroxyzine (Vistaril)
Manufacturer: Pfizer Inc., New York, NY
Generic Name (proprietary name): promethazine (Phenergan)
Manufacturer: Baxter Healthcare, Deerfield, IL
Second-generation H1 antihistamines
Generic Name (proprietary name): acrivastine
(Semprex-D)
Manufacturer: UCB Pharma, Inc., Smyrna, GA
Generic Name (proprietary name): cetirizine
(Zyrtec), desloratadine (Clarinex)
Manufacturer: Schering-Plough, Kenilworth,
NJ
Generic Name (proprietary name): fexofenadine (Allegra)
Manufacturer: Sanofi-Aventis U.S. LLC, Bridgewater, NJ
Generic Name (proprietary name): levocetirizine (Xyzal)
Manufacturer: UCB Pharma, Inc., Smyrna, GA;
Sanofi-Aventis U.S., LLC, Bridgewater, NJ
Generic Name (proprietary name): loratadine
(Claritin, Alavert)
Manufacturer: Shering-Plough HealthCare
Products Inc. Division of Merck & Co., Inc.,1
Merck Dr, Whitehouse Station, NJ
H2 antihistamines
Generic Name (proprietary name): cimetidine
(Tagamet), famotidine (Pepcid)
Manufacturer: Merck & Co., Inc., Whitehouse
Station, NJ
Generic Name (proprietary name): nizatidine
(Axid), ranitidine (Zantac)
Manufacturer: GlaxoSmithKline, Philadelphia,
PA
Chemical Structure: diphenhydramine hydrochloride, see Figure 98.1; fexofenadine hyd
rochloride, see Figure 98.2
Description
More than 40 H1 antihistamines are available and are
among the most widely used medications. The most
common use of antihistamines is to suppress allergic
inflammation in the mucous membranes and other
body organs, preventing symptoms such as itching,
congestion, rhinorrhea, tearing, sneezing, flushing,
and urticaria. Antihistamine medications have also
been used for antiemetic effects, as a peri-operative
sedative, and for the treatment of insomnia. With the
beneficial anti-inflammatory effects, antihistamines
have been utilized as an adjunct agent to promote
analgesia in patients with an inflammatory component to pain (post-surgical or infectious etiology).
First-generation H1 antihistamines cross the blood
brain barrier and are seldom the drugs of choice due
to sedation, while second-generation H1 antihistamines do not cross the bloodbrain barrier to any
appreciable extent and are popular because they are
less sedating. H2 antihistamines are used primarily to
inhibit gastric acid secretion in patients with gastroesophageal reflux disease, dyspepsia, or peptic ulcer
disease.
391
Figure 98.1.
CH3
N
CH3
HCI
serotonin receptors, and cardiac ion channels, resulting in decreased inflammatory mediator release. H2
antihistamines bind H2 receptors in the gastric parietal cells, inhibiting acid secretion and decreasing
vascular permeability.
Metabolic pathways
H 3C
CO2H
CH3
HO
N
OH
HCI
Figure 98.2.
Mode of activity
Major and minor sites of action: the major sites of
action include the H1 and H2 receptors, which are
widely expressed throughout the body. The H1 receptors are expressed in neurons, smooth muscle of airways, and vasculature, while H2 receptors are primarily
expressed in gastric mucosa parietal cells, smooth
muscle, and cardiac cells. Although H3 and H4 receptors have been discovered in histaminergic neurons
and bone marrow, respectively, currently there are no
inverse agonists available for clinical use.
392
Antihistamines are classified as inverse agonists,

which bind and stabilize the inactive form of the histamine receptor. H1 antihistamines act on endothelial
cells to decrease postcapillary venule permeability and
leakage of plasma protein, decreasing the size of wheal
and flare response. The effect of H1 antihistamines in
airway smooth muscle histamine receptors is bronchodilatation. In the central nervous system, firstgeneration H1 antihistamines cross the bloodbrain
barrier and bind with the H1 receptors, resulting in
sedation and antiemetic effects via blockade of the histaminergic signal from the vestibular nucleus to the
vomiting center in the medulla. As second-generation
H1 antihistamines do not significantly penetrate the
bloodbrain barrier and are highly specific for the H1
receptor, they are non-sedating and without significant side effects. H1 antihistamines also interact with
muscarinic receptors, alpha-adrenergic receptors,
The onset of action of most second-generation oral

antihistamines is within 13 hours, with peak serum
levels in 23 hours and dosing once to twice daily. Antihistamines are absorbed well orally due to the liposolubility of these molecules, facilitating their bioavailability.
The typical elimination half-life of H1 antihistamines
ranges from 2 hours for acrivastine to 27 hours for
desloratadine. The residual effects of H1 antihistamines
may persist for days after discontinuation of the drug. If
allergen skin tests are to be performed, most H1 antihistamines need to be discontinued 56 days prior to
testing. Second-generation H1 antihistamines are
extensively metabolized by the hepatic cytochrome
P450 (CYP450) system and are largely excreted
unchanged in the urine and feces.
Surgical acute pain: oral and parenteral doses of antihistamines are used as an adjunct to decrease inflammation to promote analgesia. Following noxious
stimulation, an inflammatory response occurs and
locally released neurotransmitters such as substance P
and tachykinins promote vasodilatation and histamine release from blood cells. Additional histamine is
released in response to tissue damage and activation
of mast cells. Antihistamines in combination with
opioids have been found to provide superior pain
relief compared to equivalent doses of opioids alone,
therefore antihistamines may have an opioid-sparing
effect. However, one study found no difference in pain
relief with a single dose of terfenadine (withdrawn by
FDA in 1997) after oral surgery.
Medical pain: H1 antihistamines appear to be
effective in treating renal colic pain, one of the most
severe forms of pain. The mechanism involves the
inhibition of renal vasodilatation in the occluded ureter, the inhibition of prostaglandin release, and prevention of spontaneous urethral contractions. H2
receptor antagonists are used for the treatment and
maintenance of gastroesophageal reflux disease, peptic
ulcer disease, and dyspepsia.
Chronic non-malignancy pain: antihistamines
may be helpful in patients with myofascial pain, as one
Chapter 98 Antihistamines
of the possible mechanisms of pain is believed to be

associated with stimulation of H1 receptors on sensory nerve terminals resulting in arterial vasodilatation and increased capillary permeability.
Cancer pain: currently, there is no well-defined
role for H1 antihistamines in treating cancer pain.
Contraindications
Absolute: hypersensitivity or documented severe allergic reaction.
Relative: patients with hepatic or renal dysfunction may require dose adjustment.
Common doses
See Tables 98.198.3.
Ease of use, tolerability: second-generation H1 antihistamines are better tolerated by patients compared
to first-generation H1 antihistamines because they are
less sedating and have fewer side effects. Although
there is no pharmacological tolerance to antihistamines, some first-generation H1 antihistamines have
been drugs of abuse.
Table 98.1. First-generation H1 antihistamines
Drug
Dose
Preparations
Duration
of action
Common
adverse
reactions
Considerations
Chlorpheniramine
(Aller-chlor,
Ahist, ChlorTrimeton)
4 mg PO q4hq6h or sustained
release 812 mg PO
q8h-q12h, maximal
oral dose 24 mg/
day; 540 mg IM,
IV or SC as a single
dose, maximum
parenteral dose 40
mg/day
4 mg (AllerChlor), 12 mg
(Ahist, ChlorTrimeton), SR 8
mg and 12 mg
tablets (PO); 10
mg/mL (IV)
36 hours
Cardiac
dysrhythmias,
constipation,
drowsiness,
dizziness, epigastric
discomfort,
hypotension,
increased bronchial
secretions,
urinary retention,
somnolence
No specific
advantages, available
without prescription
Diphenhydramine
hydrochloride
(Benadryl)
2550 mg PO q4hq6h, maximal oral

dose 300 mg/day;
1050 mg IV/ IM or
IV q2h-q3h, maximal
parenteral dose 400
mg/day
25 mg, 50 mg
tablets (PO); 50
mg/mL (IV)
46 hours
Dizziness,
drowsiness,
photosensitivity,
paradoxical
excitement,
tachycardia,
thickened bronchial
secretions, urinary
retention
Most sedating
antihistamine,
useful for insomnia,
available without
prescription
Hydroxyzine
(Vistaril)
25 mg PO TID-QID;
25100 mg IM
q46h
10 mg, 25 mg, 50
mg tablets (PO);
50 mg/mL (IM)
46 hours
Agitation,
drowsiness,
dizziness, dry
mouth, weakness
IV route not
recommended
due to digital
gangrene, possible
psychological effects
of withdrawal,
requires prescription
Cyproheptadine
(generic)
4 mg PO TID- QID,
maximal dose 0.5
mg/kg per day
4 mg tablets (PO)
69 hours
Abdominal
discomfort,
dry mouth
diarrhea, nausea,
rash, urticaria,
photosensitivity,
weight gain
Serotonin antagonist,
Promethazine
(Phenergan)
6.2512.5 mg PO
QD; 12.525 mg IV
q4h-q6h
12.5 mg, 25 mg, 50

mg tablets (PO);
25 mg/mL (IV)
46 hours
Drowsiness,
dermatitis,
photosensitivity,
somnolence
Effective antiemetic
and adjunct for
post-operative pain,
393
Table 98.2. Second-generation H1 antihistamines
394
Drug
Dose
Preparations
Duration
of action
Common adverse reactions
Considerations
Acrivastine
(Semprex-D)
8 mg acrivastine
one tablet PO TID,
maximal dose 4
tablets/day
8 mg acrivastine/
60 mg
pseudoephedrine
tablets (PO)
12 hours
Blurred vision,
dizziness, dry
mouth, excitability,
headache,
hypertension,
palpitations,
somnolence,
thickened bronchial
secretions
Usually
combined with
pseudoephedrine;
relatively nonsedating, requires
prescription
Cetirizine
(Zyrtec)
510 mg PO QD
5 mg, 10 mg tablets
(PO)
24 hours
Abdominal pain,
diarrhea, dizziness,
drowsiness,
headache, dry
mouth, nausea
Once-daily
dosing, favorable
side-effect
profile, relatively
non-sedating,
available without
prescription,
expensive
Desloratadine
(Clarinex)
5 mg PO QD
5 mg tablets (PO)
24 hours
Dry mouth,
dizziness,
dyspepsia,
headache,
myalgia, nausea,
somnolence
Once daily dosing,

prescription
Fexofenadine
(Allegra)
60 mg PO BID or
180mg PO QD
30 mg, 60 mg, 180

mg tablets (PO)
1224 hours
Diarrhea, dizziness,
dyspepsia,
headache, myalgia,
somnolence
Relatively
non-sedating,
favorable sideeffect profile,
expensive,
requires
prescription
Levocetirizine
(Xyzal)
5 mg PO QD
5 mg tablets (PO)
32 hours
Dry mouth,
epistaxis,
nasopharyngitis,
somnolence,
weakness
Active Renantiomer of
cetirizine with
higher affinity
for H1 receptor,
unclear clinical
relevance,
prescription
Loratadine
(Claritin, Alavert)
10 mg PO QD
10 mg tablets (PO)
2448 hours
Abdominal
pain, diarrhea,
drowsiness,
headache, dry
mouth, paradoxical
excitement
Relatively
non-sedating,
favorable sideeffect profile,
available without
prescription
Cost: inexpensive over-the-counter formulations

are available for both H1 antihistamines and H2 antihistamines. Second-generation H1 antihistamines are
generally more expensive than first-generation and
may not be covered by insurance carriers due to the
availability of over-the-counter formulations.
Availability: over-the-counter and prescription
antihistamines are available in virtually all pharmacies.
As monotherapy: while H1 antihistamines have

the potential to decrease opioid requirement and
enhance analgesia, these medications are rarely used
as monotherapy.
As used for multimodal analgesia: H1 antihistamines have been reported to decrease morphine and
acetaminophen requirement for post-operative pain.
When H1 antihistamines are given in combination
Chapter 98 Antihistamines
Table 98.3. H2 antihistamines
Drug
Dose
Preparations
Duration of
action
Common
adverse
reactions
Considerations
Cimetidine
(Tagamet)
300 mg PO
QID;300 mg IV/IM
q6h-q8h, maximal
oral and IV dose is
2400 mg/day
200 mg, 300 mg,

400 mg, 800 mg
tablets (PO); 150
mg/mL (IV/ IM)
48 hours (PO),
45 hours (IV)
Confusion, diarrhea,
dizziness, elevated
LFTs, gynecomastia,
headache,
drowsiness, nausea,
rash
May cause
confusion
in geriatric
patients,
multiple drug
interactions
due to hepatic
microsomal
enzyme
inhibition
(CYP3A4,
CYP2D6), some
formulations
require
prescription
Famotidine
(Pepcid)
20 mg PO BID; 20
mg IV BID
10 mg, 20 mg, 40
mg tablets (PO); 10
mg/mL (IV)
912 hours (PO);

1012 hours (IV)
Constipation,
diarrhea dizziness,
headache
More potent
than cimetidine
and ranitidine,
requires
prescription
Nizatidine (Axid)
150 mg PO BID
75 mg tablets (PO)
10 hours
Abdominal
pain, agitation,
constipation,
dizziness, dyspepsia,
elevated LFTs,
headache, nausea,
somnolence
Highest
bioavailability,
least hepatic
metabolism,
available
without
prescription
Ranitidine
(Zantac)
150 mg PO BID; 50
mg IV/IM q6h-q8h
75 mg, 150 mg, 300

mg tablets (PO); 25
mg/mL (IV)
412 hours (PO);

68 hours (IV)
Diarrhea, dizziness,
dry mouth,
constipation,
headache, myalgias,
nausea, rash, vertigo
Useful for
patients
unresponsive
to cimetidine,
available
without
prescription
with opioids, there is higher analgesic efficacy compared to equivalent doses of opioids alone.
Toxicity: H1 antihistamines exert effects on cardiac ion
channels independently of the H1 receptor, resulting in
prolonged QT intervals. Terfenadine (Seldane) and
astemizole (Hismanal), first-generation H1 antihistamines which have been withdrawn by the FDA and
replaced by second-generation H1 antihistamines,
inhibit the potassium rectifier currents resulting in
slower repolarization and rarely ventricular arrhythmias such as torsades de pointes. Diphenhydramine
and other first-generation H1 antihistamines may result
in supraventricular arrhythmias, and dose-related
QT prolongation and sinus tachycardia. There have
been no reported cardiotoxic effects of second-generation H1 antihistamines. Patients at increased risk of

cardiotoxicity include patients with organic heart disease, cardiac arrhythmias, or electrolyte imbalance
(hypocalcemia, hypokalemia, hypomagnesemia). The
effects of H1 antihistamines on alpha-adrenergic receptors may result in hypotension, dizziness, and reflex
tachycardia. Large doses of antihistamines may cause
seizure activity; however, it has been suggested that H1
receptors are clustered around epileptogenic foci in the
brain and inhibit generalized seizure activity. H2 antihistamines may result in rare renal or hepatotoxicity,
polymyositis, interstitial nephritis, or myelosuppression with thrombocytopenia, anemia and neutropenia.
H2 antihistamines are associated with confusion,
restlessness, somnolence, agitation, headaches, and
395
dizziness. Rapid infusion of a H2 antihistamine may

result in sinus bradycardia, hypotension, prolonged
QT interval, AV block, and cardiac arrest.
Drug interactions
Concomitant use of drugs or alcohol with CNS depressant effects may increase the risk of adverse reactions
with H1 antihistamines. H2 antihistamines have
numerous effects including increasing the metabolism
of drugs metabolized by CYP2B6, decreasing the
absorption of antifungal medications, increasing the
serum concentration of fentanyl via CYP3A4 inhibition, and decreasing the metabolism of selective serotonin reuptake inhibitors (SSRIs), amiodarone,
anticonvulsants, benzodiazepines, and carvedilol.

Common adverse events
First-generation H1 antihistamines commonly result in
sedation and impaired cognitive and psychomotor performance due to decreased CNS neurotransmission.
Some first-generation H1 antihistamines have been associated with accidental or intentional overdose and have
been drugs of abuse. Second-generation H1 antihistamines are less sedating and have few toxic effects in the
setting of overdose. The effects on muscarinic receptors
Section 11
Chapter
99
396
may cause urinary retention, sinus tachycardia and dry

eyes, dry mouth, constipation, diplopia, and hypotension. The effects on both the H1 receptor and the serotonin receptor may stimulate appetite and weight gain.

There is no specific antidote for antihistamine overdose. The treatment is primarily supportive therapy.
Activated charcoal, cardiovascular monitoring when
appropriate, and benzodiazepines for convulsions
may be used to treat antihistamine overdose.
References
1. Simons FE. Advances in H1-antihistamines. N Engl J

Med 2004;351(21):22032217.
2. Yilmaz E, Ertan B, Deniz T, et al. Histamine 1 receptor
antagonist in symptomatic treatment of renal colic
accompanied by nausea: two birds with one stone?
Urology 2009;73(1):3236.
Evaluations.
4. Berthold CW, Dionne RA. Clinical evaluation of
H1-receptor and H2-receptor antagonists for acute
postoperative pain. J Clin Pharmacol 1993;33:944948.
5. Simons FE. H1-antihistamines: more relevant than
ever in the treatment of allergic disorders. J Allergy
Clin Immunol 2003;112(4):S42S52.
Parenteral antiemetics
Zhuang T. Fang
Nausea and vomiting are common side effects of opioids and volatile anesthetics. Opioid use is identified as
one of the four major anesthetic risk factors (female
gender, non-smoker, history of PONV and post-
operative opioids) for post-operative nausea and vomiting (PONV). It is estimated as many as one-third of
patients who receive opioids for post-operative pain

will experience nausea and vomiting. PONV can lead
to significant morbidity; including dehydration and
electrolyte abnormality, damage to wound closure,
prolonged hospital stay or unanticipated hospital
admission following ambulatory surgery, aspiration
Chapter 99 Parenteral antiemetics
Hypoxia:
hypotension; pain;
increased intracranial
pressure;
unpleasant sights,
smells, and emotions
Vestibular center
H1, M1
CTZ
D2, 5-HT3, M1, H1
opioid, NK1
Figure 99.1. Pathways and

neurotransmitters involved in postoperative nausea and vomiting. (With
permission from Am J Health-Syst Pharm,
2005.)
Cortical afferent nerves
VOMITING CENTER
Afferent nerves from

periphery (vagal and
glossopharyngeal nerves,
Gl-tract nerves,
pharyngeal nerves)
5-HT3, D2, NK1
pneumonia, and patient dissatisfaction. Prevention

and treatment of PONV is an important part of the
practice of modern anesthesia.
The precise mechanisms of nausea and vomiting
are not clearly delineated. However, several receptors,
including serotonin type 3 (5-hydroxytryptamine
[5H-T3]), dopamine type 2 (D2), acetylcholine, histamine, and substance P have been identified in the
chemoreceptor trigger zone (CTZ), nuclei tractus solitarii (NTS) and gastrointestinal (GI) tract. All are
thought to play important roles in the afferent and
efferent neurological process of nausea and vomiting.
Activation of these receptors can lead to nausea and
vomiting by delaying gastric emptying peripherally,
and increasing emetic signaling at the CTZ and the
vomiting center centrally (Figure 99.1). Opioid-induced nausea and vomiting (OINV) has not been
studied alone extensively due to the challenge in separating nausea and vomiting induced by opioids per se
from that caused by PONV, chemotherapy, or radiation. OINV may be due to the direct effects on the
CTZ and vomiting center, decrease of pyloric tone
leading to the delayed gastric emptying as well as the
enhanced vestibular sensitivity. The experience of
nausea and vomiting from all the causes (PONV,
OINV, chemotherapy, radiation, etc.) may involve
multiple receptors. Physiologically, vomiting is a reflex
mediated by both the autonomic and somatic nervous

systems and coordinated by the vomiting center in the
brainstem. The dorsal and ventral respiratory groups
are also involved in the process by regulating the
phrenic nerve, leading to contraction of the diaphragm
during vomiting. Drugs that are designed to inhibit
these receptors significantly reduce post-operative
and opioid-induced nausea and vomiting.
Ondansetron is the most popular drug currently
used in the treatment and prevention of PONV.
Ondansetron inhibits 5H-T3 receptors in the CTZ as
well as the GI tract. It is most efficacious when given
immediately before the end of surgery for the prophylaxis of PONV. It is more effective in preventing
vomiting than nausea. When used alone, ondansetron is superior to conventional antiemetic agents,
such as droperidol and metoclopramide, in the prevention of PONV with minimal adverse effects. In
certain surgical procedures where PONV must be
avoided, including retinal, brain, head and neck, gastrointestinal and facial plastic surgeries, ondansetron
is the drug of choice. An oral form of ondansetron is
also available, but it is more commonly prescribed for
the treatment of nausea and vomiting caused by
chemotherapy or radiation therapy. Although it is not
a common practice, 8 to 16 mg oral ondansetron
given I hour before the induction of general anesthesia
397
can significantly reduce the incidence of PONV in

high-risk patients.
Although used extensively for the past several decades, droperidol and metoclopramide are less commonly used today because of their potential severe
adverse effects, the black-box warning from the FDA
for both drugs, and the comparable price of the generic
ondansetron. Possible prolongation of the QT interval
leading to torsade de pointes following droperidol use
and tardive dyskinesia associated with metoclopramide use limit their use. However, there is little
evidence
to show that antiemetic doses (0.625 to
1.25 mg) of droperidol trigger this potentially fatal
dysrhythmia. On the other hand, the tardive dyskinesia is usually associated with chronic (>3 months)
use of metoclopramide for certain medical conditions,
such as diabetic gastroparesis and symptomatic gastroesophageal reflux disease (GERD). Because of these
concerns, both drugs should be reserved for patients
who do not respond to or cannot tolerate other treatments. Both droperidol and metoclopramide are
mainly the antagonists of D2 receptors. Droperidol is
Table 99.1. General information
Agents
Ondansetron
Droperidol
Metoclopramide
Generic Name
Ondansetron
Droperidol
Metoclopramide
Chemical name
9-Methyl-3-[(2methylimidazol-1-yl)methyl]2,3-dihydro-1H-carbazol-4one
3-[1-[4-(4-Fluorophenyl)-4oxobutyl]-3,6-dihydro-2Hpyridin-4-yl]-1H-benzimidazol2-one
4-Amino-5-chloro-N-(2diethylaminoethyl)-2methoxybenzamide
Proprietary name
Zofran
Droleptan
Reglan
Manufacturer and address
Baxter, One Baxter Parkway,

Deerfield, IL 600154625
American Regent, Inc., One

Luitpold Drive, P.O. Box 9001,
Shirley, NY 11967
Hospira, Inc., 275 North Field

Drive, Dept. 051M, Bldg.
H12S, Lake Forest, IL 60045
Class
5HT3 antagonist
Dopamine 2 antagonist
Dopamine 2 antagonist and

GI stimulant
Agents
Ondansetron
Droperidol
Metoclopramide
Major site of action
Chemoreceptor trigger zone
Gastrointestinal tract
Minor site of action
Ondansetron is a selective
serotonin 5-HT3 receptor
antagonist. It blocks 5-HT3
receptors in the central CTZ
and peripheral vagus nerve
resulting in the reduction of
vomiting reflex
Droperidol strongly
antagonizes the effect of
dopaminergic D2 receptors
in the CTZ and weakly
antagonizes the cholinergic
action leading to ganglionic
blockage and reduction of
afferent pathway of nausea
and vomiting
It inhibits peripheral
dopamine D2 receptors
resulting in increased
GI motility and tone. Its
antagonism of the central D2
receptors raises the threshold
of activity in the CTZ and
decreases the sensitivity of
visceral nerves supplying
afferents to the vomiting
center. It also antagonizes
5- HT3 receptors at high dose
Metabolic pathways, drug

clearance and elimination
Ondansetron is 7076%
protein-bound. It is
metabolized by the hepatic
cytochrome P450 and
excreted in the urine and
feces. Less than 10% of the
dose is unchanged in the
urine. Its half-life is 5.7 hours
Droperidol is 90% proteinbound. Its volume of

distribution is 2.5 L/kg.
Droperidol is extensively
metabolized in the liver.
75% of the metabolites are
excreted in the urine with 22%
in the feces. Its elimination
half-life is about 2 hours
Metoclopramide is 1020%
protein-bound. Its volume
of distribution is 23.5 L/kg.
Metoclopramide is mainly
metabolized in the liver
and its major metabolite is
sulfate derivative; 80% of
metoclopramide is excreted
in the urine and 20% of that
is unchanged. Its elimination
half-life is 2.55 hours
Table 99.2. Pharmacology
398
Chapter 99 Parenteral antiemetics
Table 99.3. Clinical use of the agents
Agents
Ondansetron
Droperidol
Metoclopramide
Indications
Post-operative and
chemotherapy-induced
nausea and vomiting
Nausea and vomiting in

surgical and diagnostic
procedures; hiccups
Gastroesophageal reflux
disease (GERD), PONV
Contraindications
Known hypersensitivity to
the drug
Known hypersensitivity to the

drug; known or suspected QT
prolongation
Known hypersensitivity;
patients receiving other
drugs which may cause EPSs;
epileptics; GI tract obstruction,
perforation or hemorrhage;
pheochromocytoma
Doses/uses (IV)
4 mg, IV
0.6251.25 mg IV
10 mg, slow IV
It is a most effective and safe

drug for the prophylaxis and/
or prevention of PONV. More
effective for vomiting than
nausea. Its side effects are
mild. It is easy to administer
and tolerated well
It is effective in the treatment

of PONV. More effective in
nausea than vomiting
It is easy to administer and

tolerated well. It is effective if
nausea and vomiting is due to
gastric stasis
Although it is a concern, no
sufficient data to support
dose adjustment in patients
receiving P450 inducer or
inhibitor
FDA black-box warning for

QT prolongation and torsade
de pointes. It can cause
oversedation in patients
receiving opioids. It can
also cause hypotension and
neuroleptic effects
FDA black-box warning for

EPSs in chronic users. It can
also cause neuroleptic effects
Toxicity
May lead to low blood

pressure and fainting,
sudden blindness and severe
constipation
May cause extrapyramidal

reactions (EPSs) and
abnormalities of liver function
tests
May cause EPSs and increase

in prolactin production
Drug interactions
See additional information
Cost
$0.29 per vial of 4 mg
Headache, constipation,
elevated liver enzymes and
short-lasting QT prolongation,
which is transient and usually
self eliminated
Sedation, dizziness, anxiety,

hypotension, QT prolongation
and EPSs
Drowsiness, diarrhea and EPSs
Closely monitoring and

supportive measure
Patients receiving droperidol

should be monitored by EKG
for 2 to 3 hours. If torsades
de pointes should occur,
ACLS protocol should start
immediately
Slow IV push and

administration of anxiolytics
might reduce the incidence
of EPSs. EPSs can also be
prevented and treated
by diphenhydramine and
benzodiazepam
more effective in women than men. A small dose

(0.6251.25 mg) of droperidol and short term use of
metoclopramide is still safe in carefully selected and
monitored patients when the use of these drugs is
indicated (i.e. treatment failure with ondansetron and/
or dexamethasone). An oral form of metoclopramide
is also available, but rarely used in the prophylaxis or
the treatment of PONV or OINV.
In high-risk patients for PONV, combinations of
drugs from different classes (5-HT3 antagonists, anti-
dopaminergics, anticholinergics, antihistamines and

steroids) given peri-operatively are more effective, and
therefore recommended. The antiemetic effect from
the combination of ondansetron and droperidol is
superior to the single use of either drug. It was estimated that the frequency of PONV in patients who
carried all four risk factors decreased from 80% without antiemetics to 59%, 44% and 32% and 24% when
one, two, three or four drugs (ondansetron, dexamethasone, droperidol and propofol) were administrated,
399
respectively. However, patients receiving combined

therapy could potentially face combined side effects
as well. Acute cardiac dysrhythmia associated with the
simultaneous or close administration of ondansetron
and metoclopramide has been reported. For low-risk
patients, it is not recommended to treat PONV prophylactically since the gain in benefit (the number
needed to treat is about 40) does not outweigh the
expense and risk of treatment. The efficacy of
antiemetic treatment critically depends on surgical
patients baseline risk.
Post-operative pain is one of the major stressors
leading to patients discomfort and morbidity. Opioid
analgesia, administrated by the intravenous (bolus
injection or patient controlled analgesia [PCA]), oral,
intramuscular, or epidural routes, is the main stream
of management for surgical patients pain control.
However, the opioid-induced nausea and vomiting
may limit their usefulness. IV ondansetron (4 mg) was
very effective in the treatment of nausea and vomiting
in patients who underwent surgery with regional
anesthesia (spinal, epidural, plexus, or peripheral
nerve blocks) and required opioids (by IV or epidural
injection) for pain post-operatively. It provided not
only a 6-hour period free of nausea and vomiting but
also significant reduction of nausea and vomiting in
the 24-hour period compared to the placebo group.
The addition of droperidol to the PCA with morphine
in a dose of 0.0170.17 mg droperidol/mg of morphine prevented nausea or vomiting in one in every
three patients, with only an infrequent incidence of
excessive drowsiness or extrapyramidal reactions. On
the other hand, mixing metoclopramide with morphine for the use of PCA had insignificant effectiveness in reducing nausea and vomiting. However, the
prokinetic effect of metoclopramide could be useful if
patients nausea and vomiting is partially caused by
the delay of gastric emptying from opioid use, by
enhancing pyloric and lower esophageal sphincter
tone, especially after the failure of other antiemetic
treatment. Special caution should be exercised in
patients who undergo bowel surgery (due to obstruction, perforation, or hemorrhage) since the stimulation of gastrointestinal motility from metoclopramide
could potentially lead to the rupture of the bowel
anastomosis.
General information, pharmacology, and clinical use
of the three drugs are summarized in Tables 99.199.3.
400
Additional information
Drug interaction with ondansetron
Potent P450 inducers, including phenytoin, rifampicin,
and carbamazepine, can significantly increase the clearance and decrease the blood concentration of ondansetron. However, there are not sufficient data to support
dosage adjustment for patients taking these drugs.
Ondansetron may be associated with an increase
in patient-controlled administration of tramadol.
Drug interaction with droperidol

CNS depressant drugs, including barbiturates,
benzodiazepines, opioids, and general anesthetics,
can increase or potentiate the sedative effect of
droperidol.
Drug interaction of metoclopramide

Absorption of digoxin in the stomach may be diminished. Absorption of oral medication (e.g. acetaminophen, levodopa, tetracycline, and ethanol) in the
small bowel may be increased. Insulin dosage may
require adjustment because the action of metoclopramide will influence the delivery of food to the intestines and thus the rate of absorption. Metoclopramide
increases the effect of succinylcholine and the serum
levels of cyclosporine.
References
1. Gan TJ, Meyer TA, Apfel CC, et al. Society for

Ambulatory Anesthesia guidelines for the
management of postoperative nausea and vomiting
(special article). Anesth Analg 2007;105:16151628.
2. Golembiewski J, Chernin E, Chopra T. Prevention and
treatment of postoperative nausea and vomiting. Am J
Health Syst Pharm 2005;62:12471260.
3. Domino KB, Anderson EA, Polissar NK, et al.
Comparative efficacy and safety of ondansetron,
droperidol, and metoclopramide for preventing
postoperative nausea and vomiting: a meta-analysis.
Anesth Analg 1999;88:13701379.
4. Rung GW, Claybon L, Hord A, et al. The intravenous
ondansetron for postsurgical opioid-induced nausea
and vomiting. Anesth Analg 1997;84:832838.
5. Apfel CC, Korttila K, et al. A factorial trial of six
interventions for the prevention of postoperative
nausea and vomiting. NEJM 2004;350(24):24412451.
Section 11
Chapter
100
Oral antiemetics aprepitant

Philip F. Morway
Aprepitant, a new class of antiemetics known as neurokin-1 (NK-1) receptor antagonists, was developed and
marketed by Merck & Co. under the brand name Emend.
It was initially approved in March of 2003 by the US
Food and Drug Administration (FDA) as an oral medication for use in the prevention of acute and delayed
chemotherapy-induced nausea and vomiting (CINV).
By July of 2006 the FDA amended its initial recommendation to include aprepitant for use in the prevention
of post-operative nausea and vomiting (PONV). In
January of 2008, Merk & Co applied for and gained FDA
approval for the use fosaprepitant, trade name Ivemend,
an intravenously administered prodrug of aprepitant.
Chemical Structure: aprepitant, see Figure
100.1; fosaprepitant, see Figure 100.2
Systematic (IUPAC) Names: aprepitant: 5([(2R,3S)-2-((R)-1-[3,5-bis(trifluoromethyl)phenyl]
ethoxy)-3-(4-f luorophenyl)morpholino]
methyl)1H-1,2,4-triazol-3(2H)-one; fosaprepitant:
[3-{[(2R,3S)-2-[(1R)-1-[3,5-bis
(trifluoromethyl)phenyl]ethoxy]-3-(4-fluorophenyl)morpholin-4-yl]methyl}-5-oxo-2H-1,2,4-triazol-1-yl]phosphonic acid
Description
Aprepitant is the first member of this new class of
antiemetic drugs which is a potent, selective, CNSpenetrant oral nonpeptide antagonist of the NK1
receptor. NK1 receptors are located throughout the GI
tract, by way of vagal afferents, and the central nervous
system. When stimulated by the neurotransmitter substance P, the vomiting reflex may be directly initiated.
Like other antiemetic agents which exert their effects
by blocking the action of specific neurotransmitters,
aprepitant exerts its antiemetic effect by blocking the
action of substance P on the NK1 receptor.
The study and development of aprepitant was initially focused on obtaining a more effective treatment
for CINV. Following the administration of cytotoxic

chemotherapeutic agents, such as cisplatin, more than
80% of patients experience chemotherapy-induced
emesis, which appears to consist of both an acute and
a delayed phase. Prior to the use of aprepitant the
acute phase emesis responded well to 5-HT3 antagonists while the delayed phase was poorly controlled.
With the advent of the NK1 receptor antagonist aprepitant, both the acute and delayed phase of CINV are
well controlled. The control of the delayed phase of
CINV may be due in part to the prolonged elimination half-life exhibited by aprepitant (9 to 13 hours
compared to the elimination half-life of 3.8 to 4 hours
for ondansetron, a 5HT3 receptor antagonist).
One of the fundamental features of aprepitant, and
a major advantage it has over other chemotherapyinduced side-effect treatments, is that while it successfully antagonises the NK1 receptors it has very little
affinity over other receptors such as serotonin,
dopamine, and corticosteroids. It is estimated that
aprepitant is at least 3000 times more selective of NK1
receptors compared to the other well-known neurotransmitter antagonists.
Mode of action
The mechanism of action of aprepitant is to block the
neurotransmitter substance P from stimulating the
NK1 receptor, thereby disrupting the vomiting reflex.
NK1 receptors are located throughout both the central and peripheral nervous systems. Within the CNS,
the majority of NK1 receptors are located within the
medulla oblongata, most notably in the area postrema
(AP) and in the nucleus tractus solitarius (NTS).
These regions of the brainstem along with the dorsal
motor vagal nucleus (DMVN) comprise what is
referred to as the vomiting center. In the PNS the
NK1 receptors involved in promoting emesis are
located within the vagal afferent fibers which originate in the GI tract and migrate directly to the
401
O
O
Summary:
N
NH
N
F
N
H
O
F
F
F
Aprepitant
Figure 100.1.
O
P
N
N
Pharmacokinetic data
OH
OH
N
O
N
H
Drug is absorbed orally with a tmax of 4 hours

Bioavailability 6065%
Protein binding > 95%
Volume of distribution (Vdss) 70 L in humans
Half-life 913 hours
Metabolism hepatic, mostly mediated by
CYP3A4
Minor metabolism by CYP1A2 and CYP2C19
In healthy young adults, aprepitant accounts for
approximately 24% of the radioactivity in plasma over
72 hours following a single oral 300-mg dose of [14C]
aprepitant, indicating a substantial presence of metabolites in the plasma. Seven metabolites of aprepitant,
which are only weakly active, have been identified in
human plasma.
F
F
F
Fosaprepitant
Figure 100.2.
402
vomiting
center in the medulla. The neurotransmitter
substance P can be found in high concentrations
within the vomiting center of the CNS, the gastrointestinal vagal afferent fibers of the PNS as well as
stored in the enterochromaffin cells of the gastric
mucosa.
The release of substance P can be elicited by the
administration of certain cytotoxic agents used in
chemotherapy as well as various anesthetic agents.
Following the release of substance P within the CNS,
the NK-1 receptors of the vomiting center can be
directly stimulated, initiating the vomiting reflex. The
vagal afferents of the GI tract can also be stimulated by
substance P when it is released from the enterochromaffin cells of the GI tract following their destruction
by these cytotoxic agents.
The use of aprepitant has also been shown to
increase the activity of the 5-HT3 receptor antagonist
ondansetron and the corticosteroid dexamethasone,
which are also used to prevent the acute phase of
CINV caused by chemotherapy.
Aprepitant, in combination with other antiemetic agents,

is indicated for the prevention of acute and delayed nausea and vomiting associated with initial and repeat
courses of highly emetogenic cancer chemotherapy
including high-dose cisplatin, and the prevention of nausea and vomiting associated with initial and repeat
courses of moderately emetogenic cancer chemotherapy.
Aprepitant is indicated for the prevention of postoperative nausea and vomiting.
Contraindications
Absolute: aprepitant is contraindicated in patients who
are hypersensitive to any component of the product.
Aprepitant is a weak-to-moderate (dose-dependent)
cytochrome P450 isoenzyme 3A4 (CYP3A4) inhibitor. Aprepitant should not be used concurrently with
pimozide, terfenadine, astemizole, or cisapride. Dosedependent inhibition of CYP3A4 by aprepitant could
result in elevated plasma concentrations of these
drugs, potentially causing serious or life-threatening
ventricular arrhythmias.
Precautions and drug interactions

Precautions
1. Aprepitant is a dose-dependent inhibitor of
CYP3A4, and should be used with caution in
Chapter 100 Oral antiemetics aprepitant
patients receiving concomitant medications

that are primarily metabolized through
CYP3A4.
2 . Moderate inhibition of CYP3A4 by aprepitant,
125 mg/80 mg regimen, could result in elevated
plasma concentrations of these concomitant
medications.
3. Weak inhibition of CYP3A4 by a single 40 mg
dose of aprepitant is not expected to alter the
plasma concentrations of concomitant
medications that are primarily metabolized
through CYP3A4 to a clinically significant
degree.
4. When aprepitant is used concomitantly with
another CYP3A4 inhibitor, aprepitant plasma
concentrations can also be elevated
Drug interactions
Effects of aprepitant on:
1. Corticosteroids: noted an increase in plasma
levels of dexamethasone or methylprednisolone
when given concurrently with aprepitant.
Corticosteroids are substrates for CYP3A4 and
the inhibition of this enzyme by high-dose
aprepitant leads to raised plasma levels of
corticosteroids.
2. Benzodiazepines: midazolam is also metabolized
by the isoenzyme CYP3A4, which when inhibited
by high-dose aprepitant will lead to an increase in
plasma levels for any given dose.
3. Warfarin: decrease in plasma levels of warfarin
are seen due to the induction of the metabolic
enzyme CYP2C9 by concomitant administration
of aprepitant
4. Oral contraceptives: the co-administration of
aprepitant may reduce the efficacy of hormonal
contraceptives during and for 28 days after
administration of the last dose of aprepitant.
Alternative or backup methods of contraception
should be used during treatment with aprepitant
and for 1 month following the last dose of
aprepitant.
Effects of drugs on aprepitant:
1. Ketoconazole, a strong inhibitor of CYP3A4,
increases the effective half-life of aprepitant three
fold.
2. Rifampin, a strong CYP3A4 inducer, effectively
decreases the effective half-life of aprepitant three
fold.
3. Diltiazem effectively doubles aprepitants halflife while simultaneously decreasing its own
efficacy.
4. Paroxetine, when given simultaneously with
aprepitant, effectively decreases both agents
effective half-life.
Common doses
For the prevention of post-operative nausea and vomiting, 40 mg of aprepitant is given orally 3 hours prior
to the induction of anesthesia.
When used for the treatment of chemotherapyinduced nausea and vomiting, aprepitant is given over
3 days as part of a combination antiemetic regimen
that also includes a 5HT3 antagonist as well as a corticosteroid. The recommended dose is 125 mg orally 1
hour before chemotherapy on day 1 and 80 mg orally
each morning on days 2 and 3.
Fosaprepitant, a prodrug of aprepitant, is rapidly
converted in hepatic and extrahepatic tissues to aprepitant. When used for the treatment of CINV, 115 mg
of fosaprepitant reconstituted in normal saline should
be administered over 15 minutes 1 hour prior to
chemotherapy. It has been determined that 115 mg of
injectable fosaprepitant is equivalent to 125 mg of oral
aprepitant.
To date, intravenous dosing has not been established for the prevention of PONV.
A combined analysis of the two studies demonstrates
that both aprepitant doses (40 and 125 mg) improved
protection against nausea and vomiting and reduced
the need for rescue therapy, compared with ondansetron. The 40 mg aprepitant dose also was found to be
superior to ondansetron for the prevention of nausea,
vomiting, and the need to use rescue therapy in the
same patient.
Cost: the cost of one unit 40 mg dose of aprepitant
used for the prevention of PONV is $47.84, whereas
the cost for a 3-day course of aprepitant for use in
the treatment of CINV (total dosage given over 3
days equals 285 mg of aprepitant) is approximately
$250.00.
Currently, the most expensive drug for chemotherapy-induced nausea and vomiting is aprepitant
since the generic version of ondansetron became
available in 2007. A 4 mg dose of ondansetron may
now cost the patient less than $20.00. The addition of
aprepitant to this standard regimen increases the cost
403
of antiemetic therapy more than 30 times but can

increase the quality of life by reducing vomiting and
nausea and decreasing the costs of additional antiemetics for rescue therapy.
Monotherapy: as noted above, for the treatment of
PONV, aprepitant when used as a single antiemetic
agent was superior to ondansetron in preventing nausea and vomiting as well as decreasing the need for
rescue therapy.
Multimodal therapy: the addition of aprepitant to
the combined ondansetron and dexamethasone regimen demonstrated a decrease in both the acute and
delayed phases of chemotherapy-induced emesis.
Toxicity: specific information regarding the toxicity
of aprepitant has not been fully investigated. Single
doses of up to 600 mg of aprepitant are well tolerated
by healthy subjects with no subjective or objective
side effects noted. This is also seen when 375 mg of
aprepitant was administered daily for up to 42 days.
Drowsiness and headache were reported in one
patient who ingested 1440 mg of aprepitant. In the
event of overdose, aprepitant should be discontinued
and supportive treatment provided. Due to the
antiemetic effect of aprepitant, drug-induced emesis
may not be effective. Aprepitant cannot be removed
by hemodialysis.
404

The results of various clinical trials indicated that the
incidence of adverse events was similar in the aprepitant group compared with the group which received
only standard regimen of ondansetron and dexamethasone. The most commonly observed side effects with
aprepitant treatment were asthenia, hiccups, diarrhea,
gastritis, elevation in liver function tests, and dizziness. There are also reports of thrombocytopenia and
dehydration.
References
1. Roila F, Fatigoni S. New antiemetic drugs. Ann Oncol

2006;(supplement 2):96100.
2. Girish C, Manikandan S. Indian J Cancer 2007;44:
530.
3. Sood M, et al. Aprepitant in PONV. Clin Pharmacol
2007;23(4):395398.
4. Gan T, et al. A randomized, double-blind comparison
of the NK1-antagonist, aprepitant, versus ondansetron
for the prevention of postoperative nausea and
vomiting. Anesth Analg 2007;104:10821089.
5. Aprepitant Oral: AHFS detailed monograph.
Aprepitant/Fosaprepitant Dimeglumine http://cme.me
dscape.com/druginfo/monograph. Class Antiemetics,
miscellaneous (56:22.92).
6. Product information: Aprepitant capsules (Emend
Merk) 2006.
Section 11
Chapter
101
Transdermal scopolamine
Joe C. Hong
Generic Name: transdermal scopolamine

Proprietary Name: Transderm Scop
Class: antiemetic, antimuscarinic
Manufacturer: ALZA Corporation, Mountain
View, CA; distributed by Norvartis Consumer
Health, Inc., Parsippany, NJ
Chemical Name: 9-methyl-3-oxa-9-azatricyclo
[3.3.1.02,4]non-7-yl ester
303.3
Introduction
Transdermal scopolamine is a muscarinic receptor
antagonist used for the prevention of post-operative
nausea and vomiting. It is supplied as a circular
adhesive patch (0.2 mm thick and 2.5 cm2) applied to
the post-auricular skin. Each patch contains 1.5 mg
of the belladonna alkaloid programmed to continuously release in vivo approximately 1.0 mg over 72
hours. The patch consists of four distinctive layers.
Going from visible surface to the surface adherent to
the skin, these layers are: (1) backing layer; (2) drug
reservoir of scopolamine; (3) microporous polypropylene membrane that controls the rate of scopolamine delivery; (4) adhesive contact surface with
the skin.
Mode of activity
Major site of action: muscarinic-type acetylcholine
receptors in the chemoreceptor trigger zone. In terms
of nausea and vomiting prophylaxis, scopolamine is a
competitive inhibitor of muscarinic acetylcholine
receptors in the chemoreceptor trigger zone which
communicates with the emetic center within the
reticular formation of the brainstem. Outside the
chemoreceptor
trigger zone, scopolamine is also a
competitive inhibitor at postganglionic muscarinic
receptors in the parasympathetic nervous system.
Antagonism of the parasympathetics is responsible
for anticholinergic symptoms such as inhibition of
salivation and perspiration, decreased gastrointestinal
secretions and motility, drowsiness, mydriasis, and
tachycardia.
Absorption and metabolism: circulating plasma
levels of the percutaneously absorbed scopolamine are
detected within 4 hours after applying the patch. Due
to the tertiary amine structure of scopolamine (nonionized), it readily crosses the bloodbrain barrier as
well as the placenta.
Scopolamine is extensively metabolized hepatically by the cytochrome P450 system. Less than 10%
of the total transdermal dose is excreted in the urine
as the parent compound or metabolites. The elimination half-life of scopolamine is 4.8 hours.
Indications
Transdermal scopolamine has current FDA indication only for the prevention of nausea and vomiting
associated with motion sickness and recovery from
anesthesia and surgery in adults. There is currently
no FDA approval for use in the pediatric setting. A
single 1.5 mg transdermal scopolamine patch should
only be applied to the hairless area of the skin over
lying the mastoid process. Only one patch should be
worn at any time. The patch should not be cut or
altered in any way as this will disrupt the delivery
process.
In the peri-operative setting, the manufacturer
currently recommends applying a single patch onto
the post-auricular area the evening prior to the scheduled surgery. Alternatively, the patch can also be
applied at least 4 hours before the antiemetic effect is
required. In the obstetrics setting, the manufacturer
recommends applying the patch 1 hour prior to cesarean
405
CH3
Figure 101.1.
CH2OH
OOCCH
C6H5
section to minimize exposure of the newborn baby to

the drug. The patch may be safely removed 24 hours
after surgery.
tan-colored patch
Contraindications
Absolute: transdermal scopolamine is absolutely contraindicated in patients with documented hypersensitivity to scopolamine or belladonna alkaloids.
Hypersensitivity to the inactive components within
the delivery system, which includes mineral oil and
polyisobutylene, is also contraindicated. Patients with
angle-closure (narrow-angle) glaucoma, myasthenia
gravis, and intestinal bowel obstruction should not
receive scopolamine. Patients scheduled for MRIs
should have the patch removed as the aluminized
backing may cause burn injury.
Relative: transdermal scopolamine may cause
mydriasis leading to an increase in intraocular pressure in patients with chronic open-angle (wide-angle)
glaucoma and should be used with caution. Patients
with known liver or kidney dysfunction should use
scopolamine patch with caution. Patients with history
of psychosis or seizures should also avoid transdermal
scopolamine.
Common doses
406
General: transdermal scopolamine is only available as

a 1.5 mg patch designed to deliver approximately 1.0
mg of scopolamine over a 72 hour period. The patch
must not be ingested, cut, divided, or altered in any
way as this will disrupt the delivery system.
Peri-operative use: transdermal scopolamine can
be applied to the post-auricular skin either the evening
prior to scheduled surgery or 4 hours prior to the time
of the desired antiemetic effect (Figure 101.2). In the
obstetric setting, the patch should be applied 1 hour
prior to delivery by cesarean section to minimize
exposure to the newborn. The patch should be kept in
place for 24 hours following surgery, at which time it
should be removed and discarded.
Motion sickness: transdermal scopolamine should
be applied 4 hours prior to the time of the desired
antiemetic effect. The patch may be left on for up to 72
Figure 101.2. Placement of the transdermal scopolamine patch.
hours as needed to prevent motion sickness. Should

therapy be needed for greater than 72 hours, the initial
patch must be removed prior to the application of a
new patch.
Transdermal scopolamine has multiple advantages
over its parenteral compound. The ability to deliver
scopolamine transdermally results in needle-free
administration and therefore a less-invasive therapy
as well as improved safety for the healthcare provider.
Blood concentration of transdermal scopolamine also
tends to remain at or above the defined therapeutic
level over time compared to the variable plasma concentrations with high peaks and low troughs with
parenteral scopolamine. The lower continuous dose of
transdermal scopolamine also minimizes the dosedependent antimuscarinic side effects. Lastly, transdermal scopolamine provides a much longer duration of
action (up to 72 hours) compared to 4 hours with
parenteral scopolamine. Ambulatory patients therefore can continue to receive post-operative nausea and
vomiting prevention from hospital to home.
Common adverse events: common adverse events of
transdermal scopolamine are related to its antimuscarinic effects outside the chemoreceptor trigger zone.
The most common side effects are dryness of the
mouth followed by drowsiness, dizziness, and transient impairment of eye accommodation resulting in
blurred vision and dilatation of the pupils.
Serious adverse events: rare but serious adverse
events of transdermal scopolamine are also antimuscarinic in nature. Signs and symptoms of severe
Chapter 102 Topical capsaicin
antimuscarinic toxicity include lethargy, somnolence,

coma, confusion, agitation, hallucination, convulsion, decreased GI motility, urinary retention, tachycardia, hypotension, and supraventricular arrhythmias.
Scopolamine should therefore be used with caution
in patients with suspected bowel obstruction, urinary
bladder neck obstruction, history of seizures, or
psychosis. Because scopolamine relies mostly on
hepatic metabolism and to a lesser extent renal elimination, it should be used with caution in the elderly
or patients with known or suspected liver or kidney
dysfunction due to the increased likelihood of drug
accumulation.

Drug interactions: because of the CNS depressant
effect of transdermal scopolamine, caution needs to
be excercised if the patient is concomitantly taking
other CNS depressants such as alcohol, benzodiazepines, antihistamines, and opioid-based pain medications. The concomitant use of opioids may also
increase the risk of decreased gastric motility and
delayed gastric emptying.
Treatment of adverse events: in the presence of
excess antimuscarinic side effects, the scopolamine
patch must immediately be removed. Simple removal
Section 11
Chapter
102
of the patch should resolve most cases of toxicity.

However, in the setting of serious antimuscarinic toxicity, the patient must be continuously monitored and
vital signs taken regularly. Continuous EKG monitoring is recommended as well as establishing intravenous access. Physostigmine may be titrated as needed
to offset the antimuscarinic effects of scopolamine
toxicity.
References
1. Kotelko DM, et al. Transdermal scopolaine decreases

nausea and vomiting following cesarean section in
patients receiving epidural morphine. Anesthesiology
1989;71:675678.
2. Gan TJ, et al. Society for Ambulatory Anesthesia
guidelines for the management of postoperative
nausea and vomiting. Anesth Analg 2007;105(6):
16151628.
3. Clissold SP, et al. Transdermal hyoscine (scopo
lamine): a prelimary review of its pharmacodynamic
properties and therapeutic efficacy. Drugs
1985;29:189207.
4. Cronin CM, et al. Transdermal scopolamine in
motion sickness. Pharmacotherapy 1982;2:2931.
5. Transderm Scopolamine (package insert). Deerfield,
IL: Baxter Healthcare Corporation; 2003.
Topical capsaicin
Jure Marijic
Description
Capsaicin is the main ingredient in the hot chili
peppers that produces a hot, burning sensation when
peppers are ingested and irritates eyes when they are

exposed to the substance. Capsaicin is also the active
ingredient in a number of creams that are marketed
as over-the-counter remedies for topical pain control,
pepper spray used by police for crowd control or
individuals for self-defense, as well as more recently in
some nasal decongestant and sinus medications.
407
Table 102.1. Commonest indications for capsaicin
HO
Post-herpetic neuralgia
H
N
Pain in osteoarthritis
O
O
Figure 102.1.
Mode of activity and pharmacology

Capsaicin is used topically for symptomatic relief
of pain. Unlike other pain medications that decrease
inflammation (NSAIDs) or prevent transmission (local
anesthetics) and perception of pain (narcotics), capsaicin works on a special type of nociceptors at the origin
of the pain signal. Capsaicin activates the capsaicin or
vaniloid 1 receptor, which is a special type of temperature-sensitive transient receptor potential (TRP) nonselective ion channel (TTRP1). Capsaicin also induces
release of substance P, which is responsible for runny
nose, watery eyes, sweating, and gastric juice production. Capsaicin also releases endorphins; however, it
appears that this does not play a major role in pain
relief by capsaicin.
Pain relief by capsaicin is not immediate. In fact it
usually takes several days to several weeks to get pain
relief. Patients with arthritis can typically expect relief
after 12 weeks of treatment, while with patients with
neuralgias it may take twice as long (24 weeks).
Patients with head and neck neuralgias may have to
apply capsaicin for a much longer period of time to
get pain relief. For this group of patients it may take
over 6 weeks to get pain relief. The long time needed
for capsaicin-induced pain relief appears to be due to
the fact that capsaicin attenuates pain by producing
neuroplastic changes in medullar dorsal horn and
spinal cord nociceptive neurons.
In addition to its analgesic effect capsaicin has
many other beneficial effects including a nasal
decongestant effect, a topical anti-inflammatory
effect and even an effect on cancer cell growth and
death, cardiovascular disease, asthma, and bacterial
infections.
How to use capsaicin in pain

management
408
Capsaicin is used topically for symptomatic relief of

pain. The medicine is applied to the painful area and
gently rubbed in. Capsaicin is applied topically three
or four times daily. It should be applied on clean dry
Diabetic neuropathy pain

Nondiabetic chronic polyneuropathy
Stump pain
Painful neuroma
Primary headaches
Pain from cancer infiltrating skin
Pain in oral mucositis
Postmastectomy pain syndrome
skin and should not be used if skin is damaged, irritated, or infected. If capsaicin is used for treatment of
pain associated with herpes zoster it should not be
used until herpetic lesions have healed over. Care
should be taken not to get capsaicin into the patients
eyes since it will cause pain and irritation. Therefore it
is recommended to wash hands with soap and warm
water after applying capsaicin to remove any medication from the hands and prevent eye irritation. A
problem arises when the targets of treatment are
hands and hand joints. In that case it is recommended
not to wash the hands for as long as possible and at a
minimum 30 minutes. In patients with painful
osteoarthritis addition of glyceryl trinitrate enhances
the analgesic effect of capsaicin. The mechanism of
this enhancement is not clear. In certain patients with
post-herpetic neuralgia (PHN) great symptomatic
relief can be obtained from topical capsaicin; however,
only 20% of patients get significant relief. Despite the
lack of dramatic effect several pain societies still recommend topical capsaicin in treatment of PHN. Other
indications for use of capsaicin include painful
diabetic neuropathy and HIV-associated distal sensory neuropathy.
Capsaicin is available from many manufacturers
and in many different concentrations ranging from
0.025 to 0.1%. A new experimental patch containing
8% capsaicin has been shown in two studies to be
more effective than regular-dose (0.04%) capsaicin in
treatment of post-herpetic neuralgia.
Capsaicin is not recommended for children
younger than 2 years. For children 2 years or older
topical capsaicin is believed to work in a similar
way as for adults; however, caution should be used
and this medicine should be used only under the
Chapter 102 Topical capsaicin
supervision
of a pediatric pain specialist. When used
in the geriatric population its effectiveness, safety
profile, and complications are believed to be similar
to those in the adult population although there are
no specific studies comparing different age groups
(Table 102.1).
Side effects
When capsaicin is first applied to skin a warm stinging
and sometimes burning sensation is felt by a majority
of patients. With time (usually 24 weeks or in some
patients longer) this sensation is diminished and most
of the time completely disappears (tolerance). It seems
that the higher the dose and the shorter the interval
between applications of capsaicin the faster is the disappearance of the local sensations. Bathing in warm
water, heat, humidity, and sweating will increase the
sensation or may lead to reappearance of symptoms
after they have disappeared. Since very little capsaicin
is absorbed systemically there is little chance of interaction with systemically administered medication or a
systemic effect of capsaicin. As preparations with
higher concentrations (up to 8%) of capsaicin become
available there is an increasing chance of systemic
effects and interaction with other medications.
Bioavailability after topical administration of capsaicin is very low. The blood capsaicin levels are much
lower than after ingestion of peppers and are not sufficient to produce systemic effects.
Capsaicin is a natural product (extract from hot peppers) that is easy to use, delivered directly to the site of
pain, with minimal systemic absorption and very low
risk of toxicity and drugdrug interactions. There is
also no need to titrate the dosage.
Capsaicin is seldom effective in conditions associated
with moderate to severe pain when used alone. Studies show no significant difference between capsaicin
and placebo when used as a sole analgesic in cases of
PHN or other causes of neuropathic pain.
Contraindications
The only known absolute contraindication is allergy to
capsaicin. Capsaicin should not be used if skin is damaged, irritated, or infected.
References
1. Pittler MH, Ernst E. Complementary therapies for

neuropathic and neuralgic pain. Clin J Pain
2008;24:731733.
2. Caterina MJ, Leffler A, Malmberg AB, Martin WJ,
Trafton J, Petersen-Zeitz KR, Koltzenburg M,
Basbaum AI, Julius D. Impaired nociception and pain
sensation in mice lacking the capsaicin receptor.
Science 2000;288:241242.
3. Honda K, Kitagawa J, Sessle BJ, Kondo M, Tsuboi Y,
Yonehara Y, Iwata K. Mechanisms involved in
an increment of multimodal excitability of
medullary and upper cervical dorsal horn neurons
following cutaneous capsaicin treatment. Mol Pain
2008;4:59.
4. Backonja M, Wallace MS, Blonsky ER, Cutler BJ,
Malan P Jr, Rauck R, Tobias J. NGX-4010, a
high-concentration capsaicin patch, for the
treatment of postherpetic neuralgia: a randomised,
double-blind study. Lancet Neurol 2008;7:
11061112.
5. Knotkova H, Pappagallo M, Szallasi A. Capsaicin
(TRPV1 agonist) therapy for pain relief: farewell or
revival? Clin J Pain 2008;24:142154.
409
Section 11
Chapter
103
Topical salicylates
Jeremy M. Wong
Generic Name: methyl salicylate

Chemical Name: methyl O-hydroxybenzoate
Proprietary Formulations: Oil of wintergreen
(98%), Icy Hot Extra Strength Cream (30%),
Bayer Muscle Joint Pain Relief Cream (30%),
Muscle Rub Extra Strength Cream (30%), BenGay Extra Strength Cream (30%), Tiger Balm
Liniment (28%), Ben-Gay Original Cream
(18.3%), Pain Bust-R II Ointment (17%), TheraGesic Cream (15%), Banalg Hospital Strength
Lotion (4.9%), asian herbal remedies (1567%)
Generic Name: trolamine salicylate
Chemical Name: 2-(bis(2-hydroxyethyl)amino)
ethanol; 2-hydroxybenzoic acid
Proprietary Formulations: Aspercreme Cream
(10%), Myoflex Cream (10%), Mobisyl Crme
(10%), Sportscreme Pain Relieving Rub (10%)
Generic Name: diethylamine salicylate
Chemical Name: diethylazanium; 2-hydroxybenzoate
Proprietary Formulations: Algesal (10%)
Manufacturers: Pfizer, Chattem, Bayer, B F
Ascher & Co., others
Class: external analgesic
Chemical Structure: methyl salicylate, see Figure 103.1; trolamine salicylate, see Figure 103.2
Mode of activity
410
Salicylate can be applied to the skin as un-ionized

salicylic acid (normally for its keratolytic activity), as a
salicylate salt (most commonly trolamine salicylate),
as esters such as methyl salicylate and, rarely, as aspirin. In the form most often used in topical products,
salicylates work primarily as rubefacients. Rubefacients are compounds that work by counter-irritation,
causing skin irritation, local vasodilatation, and a feeling of warmth when applied to the skin surrounding
soft tissue injuries. With this surface stimulation, an
analgesic effect is achieved by masking the perception
of pain. This is in contrast to topical NSAIDs (such as
topical diclofenac), which act by inhibiting cyclooxygenase enzymes responsible for development of
inflammatory processes.
Like topical NSAIDs, topical salicylates permeate
the skin and are absorbed to a depth of 34 mm. The
effect of rubefacients is thought to be due to the activation of A fibers, which modulate pain signals
transmitted by C fibers to the dorsal horn of the spinal cord. This prevents pain signals reaching the
brain. The action of rubbing the skin also increases
the penetration of rubefacient into the skin, disperses
local tissue pain mediators, and results in the activation of A fibers, thus enhancing the analgesic effect
of rubefacients.
As well as being counter-irritants, salicylate compounds are hydrolyzed in the dermal and subcutaneous tissues to salicylic acid and have an
anti-inflammatory action, although the exact mechanism of action of topical salicylates is still unclear.
Salicylates may interfere with the activity of transcription factors and kinases involved in inflammatory
processes, but do not appear to work through COX
inhibition. In fact, data suggest that salicylates are
approximately 100-fold less potent as inhibitors of
COX-2 relative to ASA.
The salicylate compounds used topically share
with aspirin the common metabolic breakdown
product, free salicylate (see section on aspirin earlier
in this text), which is primarily responsible for the
toxicity observed. On average, 1220% of the dose of
methyl salicylate is absorbed through the skin.
Methyl salicylate is readily hydrolyzed to salicylate,
although some methyl salicylate is found in blood.
Some unchanged methyl salicylate is excreted in
urine as hydrolysis is relatively slow in humans.
Chapter 103 Topical salicylates
Figure 103.1.
OH
HO
OH
H+
N
OH
OH
Figure 103.2.
Absorption of methyl salicylate from the skin depends

on the pharmaceutical formulation (i.e. the type and
quantity of vehicle), the area covered, the time and
site of application, skin blood flow, temperature, and
hydration, but in all cases studied the absorption of
salicylate has been incomplete. For example, when
creams and an ointment containing methyl salicylate
were applied to 50 cm2 areas of the forearm, only
1220% of the methyl salicylate was absorbed over a
10-hour period, even though the skin was covered.
The plasma levels of salicylate were low, at less than
10 mg/l. Nevertheless, substantial amounts of methyl
salicylate are absorbed when applied to large areas of
skin, especially when covered.
In contrast, percutaneous absorption of a salicylate
salt (i.e. trolamine salicylate) is only about 1%, and
the concentrations in the dermis and subcutaneous
tissue are much lower than after application of methyl
salicylate.
Aspirin is slowly absorbed from the skin. Very low
levels of ASA are found in the blood after topical
application (about 2 M), but still sufficient to reduce
prostaglandin synthesis in the GI tract with consequent gastric damage.
Diffusion of salicylate salts from skin into synovial
fluid has only been studied in the knee, where the concentrations are too low for significant anti-inflammatory effect. Direct diffusion from skin into the synovial
fluid appears insignificant, although these agents may
still be effective for soft tissue rheumatism, which is
frequently superficial.
Indicated for the temporary relief of minor aches and
pains of muscles, tendons, and joints such as those
associated with strains, arthritis, simple backache,
sprains, etc.
Acute surgical pain: topical salicylates are not

often used for the treatment of acute surgical pain as
they should not be applied to broken skin nor should
they be covered with a dressing. These compounds
can also potentially contribute to bleeding as evidence
suggests they can interfere with platelet aggregation
(see below).
Medical pain and chronic non-malignancy pain:
efficacy estimates for rubefacients are unreliable
because, while there are numerous case reports of
efficacy of topical salicylates for the treatment of both
acute and chronic pain, there is a lack of good clinical
trials. The trials that have been performed are limited
by number, size, quality, and validity. The only systematic review available of rubefacients containing salicylates concluded, from the limited information
available, that these agents may be efficacious in acute
pain and moderately to poorly efficacious in chronic
arthritic and rheumatic pain. In acute conditions, the
number needed to treat was 2.1 for at least 50% pain
relief compared with placebo at 7 days. For chronic
conditions, the number needed to treat for topical
salicylate compared with placebo was 5.3. Of note,
however, high-validity trials of chronic pain showed
significantly less analgesic effect than low-validity trials. Interestingly, while it is thought that topical analgesics owe much of their efficacy to rubbing during
application, a high placebo response rate has not been
observed in the available clinical studies.
Although further study is needed, topical aspirin
(local aspirin applied in a suitable solvent) has been
found in some studies to be as effective as lidocaine for
the treatment of post-herpetic neuralgia, with over 70%
of patients responding to both treatments. In these
studies, significantly more pain relief was provided by
topical aspirin as compared to oral aspirin. The local
levels of acetylsalicylate were 80100-fold higher than
after oral aspirin and circulating levels much lower.
Cancer pain: topical salicylates are unlikely to be
beneficial for the treatment of anything other than
localized cancer pain as the area of application must
be limited to avoid toxicity.
Contraindications
Absolute: allergy to salicylate or sensitivity to any of
its components.
Relative: patients with preexisting coagulation
abnormalities (or taking warfarin) should use topical
salicylates cautiously. Because of the risk of systemic
absorption, also consider contraindications to aspirin.
411
Common doses/uses
If ingested or used improperly, there is a risk of salicylate toxicity. Evidence exists that topical salicylates
can impair coagulation, by impairing platelet aggregation as well as by potentiating the warfarin effect.
There is a small risk of local irritant or allergic contact
dermatitis, as well as anaphylaxis. Topical salicylates
have questionable efficacy, especially for the treatment
of chronic pain conditions.
ingestion include vomiting, abdominal pain, and

occasional hematemesis. Symptoms of acute systemic
toxicity include hyperpnea, tachypnea, tinnitus, deafness, hyperpyrexia, diaphoresis, lethargy, confusion,
coma, and seizures. Complications of salicylate
poisoning include dehydration, electrolyte disturbances, mixed and complex acidbase disturbances,
gastrointestinal ulcers, hepatitis, cerebral edema, CSF
glucopenia, and noncardiogenic pulmonary edema.
Salicylates rarely produce spontaneous hemorrhage,
but even topically applied salicylates can impair platelet function and potentiate the effect of warfarin by
inhibiting the vitamin K-dependent synthesis of factors VII, IX, and X. Symptoms of chronic salicylate
poisoning are similar to those of acute poisoning, but
GI symptoms may be less pronounced, patients appear
more severely ill, and CNS symptoms may be more
prominent. These findings can include agitation,
confusion, slurred speech, hallucinations, seizures,
and coma.
If skin irritation occurs, use of the product should
be stopped and the skin washed thoroughly with soap
and water. Professional advice should be obtained for
ingestion of topical salicylate products, or immediate
medical care for evidence of systemic toxicity. Emesis
should not be induced for ingestion of salicylates, but
activated charcoal may be helpful. Supportive care
may be required, including intubation and ventilation,
treatment of acidbase and electrolyte abnormalities,
anticonvulsants, and vasopressors.
For ocular exposure, the eye(s) should be irrigated
with room-temperature tap water for 15 minutes. If
after irrigation the patient is having pain, decreased
visual acuity, or persistent irritation, referral for an
ophthalmological examination is indicated.
References
Topical preparations should only be used externally

on the skin. The compound is applied liberally to the
painful area and massaged until absorbed. The total
number of applications is recommended not to exceed
three or four applications per day. The product should
not be used on irritated or broken skin, and not covered with a tight bandage or used with a heating pad
as this may cause skin damage. Use near the eyes or
mucous membranes is advised against, and hands
should be washed thoroughly after applying.
Rubefacients can be used as adjuvants to oral analgesic
therapy, support bandages, rest, ice, and compression,
and may be useful in patients who cannot tolerate oral
analgesics. They are often used in combination with massage therapy, with the rubbing action also contributing
to the local heat and rubefacient effect. Depending on
the type of compounds used, either a warm or cold
sensation can be produced after topical administration.
These compounds are easy to use, relatively inexpensive,
available over the counter, well-tolerated by most, and
may be efficacious for treatment of acute pain.
412
Contact dermatitis or anaphylaxis can occur from local

application. Absorption through the skin is increased by
large areas of application, repeated application, exercise,
heat, broken skin, or covering the area with a bandage,
and is higher with methyl salicylate preparations.
Systemic salicylate toxicity is possible with excess
percutaneous absorption or after oral ingestion. The
signs and symptoms of salicylate intoxication are
related to local irritation of the GI tract (after oral
ingestion), direct stimulation of the CNS respiratory
center, stimulation of the metabolic rate, disturbance
of carbohydrate and lipid metabolism, and interference with hemostasis. Typical GI symptoms of acute
1. Rainsford KD. Aspirin and Related Drugs. Illustrated.

Boca Raton: CRC Press, 2004.
2. Mason et al. Systematic review of efficacy of topical
rubefacients containing salicylates for the treatment of
acute and chronic pain. BMJ 2004;328; 995.
3. Altman et al. Topical therapy for osteoarthritis:
clinical and pharmacologic perspectives. Postgrad Med
2009;121(2):139147.
4. Chyka PA, et al. Salicylate poisoning: an evidencebased consensus guideline for out-of-hospital
management. Clin Toxicol 2007;45:95131.
5. Davis JE. Are one or two dangerous? Methyl salicylate
exposure in toddlers. J Emerg Med 2007;32(1):6369.
Section 11
Chapter
104
Pamidronate
Rex Cheng and Zoreh Steffens
Class: analgesic agent

Generic Name: pamidronate, pamidronate disodium
Proprietary Name: Aredia
Manufacturer: Bedford Laboratories, Bedford,
OH; several other manufacturers produce generic
version of this medication
Description
Aredia, pamidronate disodium (APD), is a bone-
resorption inhibitor used to treat hypercalcemia associated with malignancy and osteolytic bone lesions
associated with multiple myeloma, metastatic breast
cancer, and moderate to severe Pagets disease of bone.
Aredia, a member of the group of chemical compounds known as bisphosphonates, is an analog
of pyrophosphate. Pamidronate disodium is designated chemically as phosphonic acid (3-amino-1-
hydroxypropylidene) bis-, disodium salt, pentahydrate,
(APD).
Pamidronate disodium is a white powder with
inactive ingredients mannitol, USP, and phosphoric
acid (for adjustment to pH 6.5 prior to lyophilization).
Pamidronate is not metabolized and is exclusively
eliminated by renal excretion.
Mode of activity
Pamidronate disodium is a bisphosphonate which
binds irreversibly to hydroxyapatite in bone. It is a
strong inhibitor of bone resorption, reducing osteoclast or osteoclast precursor activity. Bisphosphonates
inhibit bone resorption by selective adsorption to
mineral surfaces and subsequent internalization by
bone-resorbing osteoclasts.
Pamidronate is one of the first drugs that has been
proven to reduce the incidence of skeletal complications of metastatic breast cancer and prostate cancer. It
also relieves bone pain caused by metastatic bone
lesions. Other indications include treatment of osteolytic
bone lesions of multiple myeloma, moderate-to-severe
hypercalcemia of malignancy, and moderate-to-severe
bone lesions due to Pagets disease.
Non-approved uses include treatment of pediatric
osteoporosis and treatment of osteogenesis imperfecta. It has also been used to treat refractory pain of
lumbar degenerative spinal stenosis.
Contraindications
Absolute: hypersensitivity to pamidronate, other
bisphosphonates or any component of the formulation.
Relative: avoid use during pregnancy, breast-feeding
or if conception is planned. Use caution when using in
renally impaired patients.
Common doses
Pamidronate is poorly absorbed following oral administration, therefore IV treatment is preferred. Dilute
prior to administration and infuse over at least 2
hours. Dosing intervals vary by treatment protocol.
Pamidronate is available in two doses:
Vials 30 mg each contains 30 mg of sterile,
lyophilized pamidronate disodium and 470 mg of
mannitol, USP
Vials 90 mg each contains 90 mg of sterile,
lyophilized pamidronate disodium and 375 mg of
mannitol, USP.
Due to the risk of deterioration of renal function,
which may progress to renal failure, single doses of
Pamidronate should not exceed 90 mg.
413
Figure 104.1.
O
O
H
H
P
P
O
O
O
H
Dosing should be adjusted for use in the elderly

and in patients with renal impairment.
Pamidronate has been shown to decrease pain associated with bone resorption of Pagets disease. Reductions of 3050% in analgesic requirements have been
documented with use of pamidronate in bone metastasis patients.
Skeletal complications, including pathological
fractures, the need for radiation to bone or bone surgery, spinal cord compression, and hypercalcemia
have been reduced in patients receiving pamidronate.
Pamidronate has several drug interactions. Aminoglycosides may result in enhanced hypocalcemia. NSAIDs
may enhance GI and nephrotoxicity. Phosphate supplements may enhance hypocalcemia. Thalidomide
may result in increased nephrotoxicity.
Pamidronate may interfere with diagnostic imaging agents such as technetium-99m-diphosphonate in
bone scans.
414

Central nervous system: fatigue, fever, headache,
insomnia, somnolence, psychosis, seizure
Endocrine and metabolic: hypophosphatemia,
hypokalemia/hyperkalemia, hypomagnesemia,
hypocalcemia, hypernatremia, hypothyroidism
Cardiovascular: atrial fibrillation/flutter,
hypertension/hypotension, syncope, tachycardia,
CHF, edema, anaphylactic shock
Gastrointestinal: nausea, vomiting, anorexia,
abdominal pain, dyspepsia, constipation,
gastrointestinal bleeding, diarrhea, stomatitis
Genitourinary: UTI
Hematological: anemia, granulocytopenia,
leucopenia, neutropenia, thrombocytopenia
Local: infusion site reaction
Neuromuscular and skeletal: weakness, myalgia,
arthralgia, osteonecrosis of the jaw, back pain, bone
pain
Renal: increased serum creatinine, uremia, acute
renal failure
Respiratory: dyspnea, cough, URI, sinusitis, rales,
pleural effusion, rhinitis, ARDS, bronchospasm
References
1. Katzung BG. Basic & Clinical Pharmacology, 10th ed.

New York: McGraw-Hill.
2. McPhee SJ, Papdakis MA. Current Medical Diagnosis
& Treatment. New York: McGraw-Hill, 2009.
3. Clezardin P, Gligorov J, Delma, P. Mechanisms of
action of bisphosphonates on tumor cells and
prospects for use in the treatment of malignant
osteolysis. Joint Bone Spine 2000;67(1): 2229.
Section 11
Chapter
105
Ziconotide
Sunil J. Panchal
Generic Name: ziconotide

Trade/Proprietary Name: Prialt
Drug Class: conopeptide analgesic
Manufacturer: Elan Pharmaceuticals, South San
Francisco, CA 94080
Chemical Formula: C102H172N36O32S7; molecular
Wt 2639; ziconotide is a 25 amino acid, polybasic peptide containing three disulfide bridges
Introduction
Ziconotide is a synthetic equivalent of a naturally
occurring conopeptide found in the piscivorous marine
snail, Conus magus. Ziconotide binds to N-type voltage-gated calcium channels located on the primary
nociceptive (A and C) afferent nerves in the superficial layers (Rexed laminae I and II) of the dorsal horn
in the spinal cord. It was approved for use in the USA
in 2004 for control of severe chronic pain.
Mode of activity
The exact mechanism of action of ziconotide has
not been established in humans. Results in animals
suggest that its binding blocks N-type voltage-gated
calcium channels on the spinal terminals of primary
afferent noxious fibers. Blockade of these channels
inhibits the release of glutamate, substance P and
other excitatory neurotransmitters from the central
terminals of primary noxious fibers, and suppression
of second-order spinal cell depolarization.
Metabolism
Ziconotide is cleaved by endopeptidases and exopeptidases at multiple sites on the peptide. Following passage
from the CSF into the systemic circulation during
continuous
IT administration, ziconotide is expected to
be susceptible to proteolytic cleavage by various peptidases/proteases present in most organs (e.g. kidney, liver,
lung, muscle, etc.), and thus readily degraded to peptide
fragments and their individual constituent free amino
acids. Human and animal CSF and blood exhibit minimal hydrolytic activity toward ziconotide in vitro. The
biological activity of the various expected proteolytic degradation products of ziconotide has not been assessed.
Elimination
Minimal amounts of ziconotide (< 1%) were recovered
in human urine following IV infusion. The terminal
half-life of ziconotide in CSF after an IT administration was around 4.6 hours (range 2.96.5 hours). Mean
CSF clearance (CL) of ziconotide approximates adult
human CSF turnover rate (0.30.4 mL/min).
Approved indication: ziconotide intrathecal infusion
is indicated for the management of severe chronic
pain in patients for whom intrathecal therapy is
warranted, and who are intolerant of or refractory to
other treatment, such as systemic analgesics, adjunctive therapies, or intrathecal morphine.
Contraindications
Contraindications: Prialt is contraindicated in patients
with a known hypersensitivity to ziconotide or any of
its formulation components and in patients with any
other concomitant treatment or medical condition
that would render intrathecal administration hazardous. Patients with a preexisting history of psychosis
should not be treated with ziconotide. Contraindi
cations to the use of intrathecal analgesia include
conditions such as the presence of infection at the
microinfusion injection site, uncontrolled bleeding
diathesis, and spinal canal obstruction that impairs
circulation of CSF.
415
weeks. This recommendation to be more conservative

was based on concerns of reducing the risk of adverse
events and improving patient tolerability.
Availability: available for purchase from the manufacturer for injection into an intrathecal pump reservoir by a physician or designee.
Cost: approximately $7.00 per microgram.
Ziconotide provides powerful and prolonged analgesia for patients suffering chronic intractable pain that
is poorly responsive to conventional opioid and nonopioid analgesics. An important advantage of ziconotide is the avoidance of opioid-induced adverse events
such as GI issues, pruritus, decreased testosterone levels, opioid-induced hyperalgesia, as well as behavioral
issues.
H Cys Lys Gly
Lys
Ala
Gly
Cys
H2N
Cys
Lys
Cys
Asp Tyr
Thr
Cys
Lys
Gly
Ser
Gly
Ser Arg
Cys
Ser Arg
Leu Met
Figure 105.1.
Common doses
416
Ziconotide is approved as a neuraxial (intrathecal)

analgesic for chronic pain. It is not approved for postoperative analgesia or for labor and delivery analgesia.
The manufacturer recommends that intrathecal
ziconotide should be initiated at no more than 2.4 g/
day (0.1 g/h) and titrated to patient response. Doses
may be titrated upward by up to 2.4 g/day (0.1 g/h)
at intervals of no more than two or three times per
week, up to a recommended maximum of 19.2 g/day
(0.8 g/h) by day 21. Dose increases in increments of
less than 2.4 g/day (0.1 g/h) and increases in dose
less frequently than two or three times per week may
be used. However, at a consensus conference of 30
international experts in intrathecal therapy, a majority
recommended that therapy be initiated at 0.5 g/ day,
and slowly titrated in 0.5 g increments every 12
Toxicity: elevation of serum creatine kinase (CKMM). In clinical studies (mostly open label), 40% of
patients had serum creatine kinase (CK) levels above
the upper limit of normal (ULN), and 11% had CK
levels that were three times the ULN or more. In cases
where CK was fractionated, only the muscle isoenzyme (MM) was elevated. The time to occurrence was
sporadic, but the greatest incidence of CK elevation
was during the first 2 months of treatment. Elevated
CKs were more often seen in males, in patients who
were being treated with antidepressants or anti-epileptics, and in patients treated with intrathecal morphine. Most patients who experienced elevations in
CK, even for prolonged periods of time, did not have
limiting side effects. However, one case of symptomatic myopathy with EMG findings and two cases of
acute renal failure associated with rhabdomyolysis
and extreme CK elevations (17 00027 000 IU/L) have
been reported. It is recommended that physicians
monitor serum CK in patients undergoing treatment
with ziconotide periodically.
Drug interactions
Formal PK drugdrug interaction studies have not
been performed with Prialt. As ziconotide is a peptide, it is expected to be completely degraded by
endopeptidases and exopeptidases (Phase I hydrolytic
enzymes) widely located throughout the body, and
not by other Phase I biotransformation processes
(including the cytochrome P450 system) or by Phase
Chapter 105 Ziconotide
II conjugation reactions. Thus, intrathecal administration, low plasma ziconotide concentrations, and
metabolism by ubiquitous peptidases make metabolic
interactions of other drugs with ziconotide unlikely.
Further, as ziconotide is not highly bound in plasma
(approximately 50%) and has low plasma exposure
following IT administration, clinically relevant plasma
protein displacement reactions involving ziconotide
and co-administered medications are unlikely.
Adverse events
Ziconotide has been associated with CNS-related
adverse events, including psychiatric symptoms, cognitive impairment, and decreased alertness/unresponsiveness. The dose should be reduced or discontinued
if signs or symptoms of cognitive impairment develop,
but other contributing causes should also be considered. Some patients have become unresponsive or stuporous while receiving ziconotide.
Adverse reactions: the most frequently reported
adverse events (25%) in the 1254 patients (662 patient
years) in clinical trials were dizziness, nausea, confusional state, and nystagmus. Serious adverse events
and discontinuation of ziconotide for adverse events
are less frequent when the drug is slowly titrated.

Common/serious adverse events: dizziness, nausea,
confusional state, and nystagmus.
Less common adverse events: vertigo, blurred
vision, diarrhea, nausea, vomiting, asthenia, abnormal
gait, pyrexia, rigors, sinusitis, anorexia, muscle spasms,
pain in limb, amnesia, ataxia, dizziness, dysarthria,
dysgeusia, headache, memory impairment, nystagmus, somnolence, tremor, anxiety, confusional state,
insomnia, urinary retention, pruritus, sweating.
At less than 2% in the clinical investigations: acute

renal failure, atrial fibrillation, cerebrovascular accident, sepsis, meningitis, psychotic disorder, suicidal
ideation, respiratory distress, rhabdomyolysis, electrocardiogram abnormal, stupor, loss of consciousness, incoherent, clonic convulsion and grand mal
convulsion. Rare instances of fatal pneumonia aspiration and suicide attempt were reported (<1%).
Treatment of adverse events: there is not an antagonist available for ziconotide. For mild adverse events,
the clinician may either monitor the patient to see
whether there is improvement with time, or reduce
the dose. For severe adverse events, it is recommended
that the delivery of ziconotide be discontinued, and
that the drug is completely removed from the intrathecal pump by aspirating and rinsing the reservoir with
preservative-free saline, as well as aspirating the
pumps side port, to remove drug from the intrathecal
catheter. The clinician will need to provide supportive
care until the adverse effects stop, which may take up
to several days.
References
1. Product insert, revised 10/08.

2. Deer T, Krames E, Hassenbusch S, Burton A, Caraway
D, Dupen S, Eisenach J, Erdek M, Grigsby E, Kim P,
Levy R, McDowell G, Mekhail N, Panchal SJ, Prager J,
Rauck R, Saulino M, Sitzman T, Staats P, StantonHicks M, Stearns L, Willis KD, Witt W, Follett K,
Huntoon M, Liem L, Rathmell J, Wallace M, Buchser
E, Cousins M, Ver Donck A. Polyanalgesic Consensus
Conference 2007: Recommendations for the
management of pain by intrathecal (intraspinal) drug
delivery: report of an interdisciplinary expert panel.
Neuromodulation 2007;10(4):300328.
417
Section 11
Chapter
106
Methylnaltrexone
Kathleen Ji Park, Anthony DePlato and Jill Zafar
Generic Name: methylnaltrexone bromide

Trade/Proprietary Name: Relistor
Drug Class: peripheral -opioid-receptor antagonist
Manufacturer: Wyeth Corporation, Madison, NJ
Chemical Name: (R)-N-(cyclopropylmethyl)nor
oxymorphone methobromide
Description
Methylnaltrexone is a peripherally acting mu-opioidreceptor antagonist. It is a quaternary ammonium
derivative of naltrexone that binds selectively to peripheral mu opioid receptors. Due to its low lipid solubility
and an addition of a polar methyl group, methylnaltrexone cannot cross the bloodbrain barrier, in contrast to
naltrexone, a central-acting, uncharged, opioid antagonist. Methylnaltrexone exerts peripheral blockade of
mu opioid receptors in the gastrointestinal tract, and it
is used to relieve the gastrointestinal-related adverse
effects of opioids while maintaining centrally based
analgesia. The drug was FDA-approved in April 2008
for administration via subcutaneous injection in the
treatment of patients who develop opioid-induced constipation with advanced illnesses. Unlike naltrexone,
methylnaltrexone does not induce opioid withdrawal.
Mode of activity
418
Major and minor sites of action: methylnaltrexone

is a peripheral opioid-receptor antagonist. It is also
a partial agonist at mu, delta, and kappa opioid
receptors.
Receptor interactions: the primary effects of methyl
naltrexone are mediated by antagonism of mu opioid
receptors in the gastrointestinal tract. These receptors
are primarily concentrated in neural cells and termi-
nal endings located in the myenteric plexus. Oral,

parenteral and, to a lesser degree, neuraxial opioids
bind to and activate these receptors. Neurons within
the myenteric plexus are stimulated, resulting in constriction of circular smooth muscle, decreased secretion, decreased gastrointestinal motility, and delayed
transit time (Figure 106.2). Methylnaltrexone blocks
these opioid receptor mediated effects.
Metabolic pathways: following subcutaneous injection, the drug is absorbed rapidly and reaches peak
plasma concentration after about 30 minutes with a halflife of 8 hours. Up to 15% of the drug is protein-bound.
Methylnaltrexone undergoes metabolism to multiple
compounds. The most frequent metabolite is methyl-6naltrexol (5%). N-Demethylation of methylnaltrexone
to produce naltrexone is not significant. Up to 85% of
the drug is excreted unchanged in the urine or feces.
Indications (approved)
Methylnaltrexone is FDA-approved for subcutaneous
injection in the treatment of opioid-induced constipation in patients with advanced illness who are receiving palliative care and are insufficiently responding to
laxative therapy.
Multiple clinical trials are currently under way
to investigate methylnaltrexone, orally or subcutaneously, in healthy chronic pain patients as a treatment
for constipation and opioid-induced bowel dysfunction. Intravenous methylnaltrexone is being investigated to treat and prevent post-operative ileus;
however, the drug has not yet received approval for
these indications. Chronic use of methylnaltrexone
for greater than 4 months has not been studied.
Contraindications
Absolute contraindications: methylnaltrexone is
absolutely contraindicated in known or suspected
Chapter 106 Methylnaltrexone
CH3
N+ Br -
Figure 106.1.
OH
HO
mechanical gastrointestinal obstruction and in patients

with severe allergic reaction to methylnaltrexone.
Relative contraindications: the drug is listed as a
Pregnancy Category B drug. It is unknown whether
the drug is secreted via lactation. The drug has not
been studied in patients with end-stage renal disease
or severe hepatic dysfunction.
Methylnaltrexone should be used with caution in
patients with recent histories of bowel surgery, colonoscopy, colon cancer, or active diverticulitis.
Common dosage
Adult doses are adjusted according to body weight
and are administered subcutaneously in the upper
arm, thigh, or abdomen. The typical dosing schedule
is every other day as needed. The maximum dose is
once a day. Usual dosing is 8 mg for patients between
38 and 61 kg and 12 mg for patients between 62 and
114 kg. For weights outside the previously described
ranges, dosing is calculated as 0.15 mg/kg.
Elderly dosing is the same as adult dosing.
Pediatric dosing is currently unavailable.
No dosing adjustment is required in mild to moderate renal impairment. For severe renal impairment with
creatinine clearance of less than 30 mL/minute, the recommended dosing is 50% of normal adult dose. Patients
with end-stage renal disease have not been studied.
No dosing adjustment is needed for patients with
mild to moderate hepatic dysfunction. Severe hepatic
impairment has not been studied with respect to
methylnaltrexone.
Methylnaltrexone is a drug that is well tolerated
and offers a treatment in relieving opioid-induced constipation. It was found to be effective in causing laxation in almost 50% of patients within 4 hours after one
dose (Figure 106.3). The drug does not affect central
analgesia or precipitate opioid withdrawal. There are
no known significant drug interactions with methyl
naltrexone. Patients can easily and safely administer
self-injections. Methylnaltrexone can improve patients
symptoms and possibly their quality of life.
Finally, caregivers must recognize that, unlike nonselective antagonists, methynaltrexone will not reverse
excessive sedation, respiratory depression, and other
symptoms associated with central opioid toxicity.
The toxicity of the drug is low, with less than 1% of
patients suffering from life-threatening complications.
Cost may be an issue to patients as there is no generic
Decreased
gastric
emptying
Constipation
Incomplete
evacuation
Formation of
hard stools
Spasms
Opioid-induced Bowel
Dysfunction
Abdominal
distension
Figure 106.2. Opioid-induced bowel

dysfunction (OBD). Opioids increase
intestinal fluid absorption, inhibit
intestinal secretions and peristalsis, and
block propulsive movements in the
colon. Constipation and other symptoms
associated with OBD occur in 1590% of
cancer patients and may be more
distressful and debilitating than pain.
Tolerance rarely develops to these
symptoms and traditional therapy
including stimulants, lubricants, and bulk
laxatives may not be effective.
Bloating
Abdominal
cramping
419
Placebo
MNTX 0.15 mg/kg
MNTX 0.30 mg/kg
100
80
++
60
Serious reaction is severe diarrhea and common reactions are abdominal pain, flatulence, dizziness, nausea
and vomiting.
40
20
0
4 hours
24 hours
Time of Evaluation
Figure 106.3. Patients with advanced illness and opioid-induced
constipation who experienced laxation within 4 and 24 hours after
receiving methylnaltrexone or placebo. *P < 0.0001 vs. placebo; +P
< 0.0004 vs. placebo, ++P < 0.0014 vs. placebo With permission
from: Thomas J, et al. J Clin Oncol. ASCO Meeting Proceedings
2005;23(16S):abstract 8003.
alternative to the brand name methylnaltrexone Relistor. Methylnaltrexone is new to the market, and clinical trials are still under way to investigate its efficacy
and safety in other clinical settings.
Section 11
Chapter
107
420
Patients who are suffering from severe persistent

diarrhea, as well as other known adverse reactions, are
advised to discontinue methylnaltrexone and immediately notify the prescribing healthcare worker.
References
1. Thomas J, et al. Methylnaltrexone for opioid-induced

constipation in advanced illness. N Engl J Med
2008;358:23322343.
2. Relistor subcutaneous injection package insert. Wyeth
2008. http://www.wyeth.com/hcp/relistor/prescribinginformation.
3. Viscusi E, et al. Peripherally acting mu-opioid
receptor antagonists and postoperative ileus:
mechanisms of action and clinical applicability. Anesth
Analg 2009;108:18111822.
Alvimopan
Victor A. Filadora II and Sidney Allison
Generic Name: alvimopan

Trade Name: Entereg
Drug Class: peripheral opioid antagonist
Manufacturer: Adolor Corporation, Exton, PA
193411127
Chemical Name: [[2(S)-[[4(R)-(3-hydroxyp
henyl)-3(R),4-dimethyl-1-piperidinyl]methyl]1-oxo-3-phenylpropyl]amino]acetic acid dihydrate
Chemical Formula: C25H32N2O42H2O; molecular wt 460.6
Description
Alvimopan is a peripheral opioid receptor antagonist. It was first synthesized at Lilly Research Laboratories, and introduced in May 2008 by Adolor
Corporation and GlaxoSmithKline under the brand
name Entereg. Its indication is to accelerate upper and
lower gastrointestinal recovery time following partial
large or small bowel resection surgery with primary
anastomosis. It is the first pharmacotherapy approved
by the US FDA for this application [13].
Alvimopans activity is peripherally restricted
because at physiological pH, its large zwitterionic
Chapter 107 Alvimopan
2H2O
HO
O
+
N
H
N
H
Figure 107.1.
form and polarity limit gastrointestinal absorption

and prevent passage through the bloodbrain barrier.
It competitively antagonizes the effects of morphine
on gastrointestinal contractility without reversing the
central analgesic effects of opioid agonists [1,2]. No
dosage adjustments are required in patients with coadministration of morphine or acid blockers. Patients
with recent exposure to opioids are more sensitive to
opioid receptor antagonists. This sensitivity is limited to gastrointestinal tract discomfort, which may
include abdominal pain, nausea and vomiting, and
diarrhea.
Mode of activity
As an opioid antagonist, alvimopan interacts selectively with gastrointestinal opioid receptors with no
central nervous system activity. It has not shown affinity for non-opioid receptors such as adrenergic,
dopaminergic, histaminergic, GABAergic, or cholinergic receptors [1,2,4].
Metabolic pathways
After multiple oral doses, the mean terminal-phase
half-life of alvimopan ranges from 10 to 17 hours. It
is absorbed systemically and its oral bioavailability
in humans is estimated at only 6%. After 5 days of
oral administration of alvimopan 12 mg twice daily,
its mean peak plasma concentration is 10.98 6.43
ng/mL with a time to reach this peak concentration
of 1.5 to 3 hours. Alvimopan is converted to its
active metabolite, ADL 080011, via amide hydrolysis as a product of intestinal flora activity, not by
hepatic metabolism. After 36 hours of standard dosing of alvimopan, the mean peak plasma concentration of the metabolite is 35.73 35.29 ng/mL.
Cytochrome P450 isoenzyme metabolism, glucuronidation, and sulfation are not involved in alvimopan metabolism [1].
Alvimopan does not affect concomitant administration of acid blockers or antibiotics. The plasma
concentrations of metabolite, however, are lower in
patients receiving acid blockers and pre-operative oral

antibiotics. Since the metabolite is not required for
efficacy of alvimopan, no dosage adjustments are
required.
Alvimopan does not affect co-administration of
morphine and its metabolite, morphone-6-glucuronide, when morphine is intravenously administered.
No dosage adjustments of intravenous morphine are
necessary.
Excretion pathways
The primary elimination pathway of alvimopan is via
biliary secretion, with renal excretion accounting for
approximately 35% of its clearance. Alvimopans
metabolites undergo systemic absorption and firstorder elimination. These metabolites and other glucuronidated conjugates are eliminated unchanged in
the feces and urine.
Alvimopan is indicated to prevent post-operative
ileus by accelerating the time to upper and lower gastrointestinal recovery following partial large or small
bowel resection surgery with primary anastomosis
[1,2].
Contraindications
Alvimopan is contraindicated in patients who have
taken opioids for more than 7 consecutive days immediately prior to taking alvimopan.
Common doses
Capsule: 12 mg. For short-term use in hospitals that
have registered in and successfully met all of the
requirements for EASE (Entereg Access Support and
Education) program.
Adult: a maximum of 15 doses is indicated. The
first dose of 12 mg is administered orally between 30
minutes and 5 hours prior to surgery. Subsequent dosage is 12 mg twice daily after surgery for a maximum
of 7 days or until discharge.
Administration of alvimopan to patients receiving
more than three doses of an opioid a week prior to
surgery was not studied in the post-operative ileus
clinical trials and should be closely monitored.
Geriatric use: although the bioavailability and oral
clearance of alvimopan decrease with age, this has
minor clinical significance. Therefore, no dosage
adjustment based on increased age is necessary.
421
Pediatric use: safety and effectiveness in children

have not been established.
Hepatic impairment: although there is a potential
for higher plasma concentration of alvimopan in
patients with mild-to-moderate hepatic impairment,
no dosage adjustment is necessary. A high alvimopan
or metabolite level, however, may cause possible
adverse effects, such as diarrhea, gastrointestinal pain,
and cramping. These patients should be closely monitored for these effects. If adverse events occur, discontinue administration of alvimopan.
Alvimopan is not recommended for use in patients
with severe hepatic impairment.
Renal impairment: although no dosage adjustment
is necessary in patients with mild-to-severe renal
impairment, those with severe renal impairment
should be closely monitored for possible adverse
effects, such as diarrhea, gastrointestinal pain, and
cramping. These effects could indicate high alvimopan or metabolite levels. Discontinue alvimopan if
adverse events occur.
Alvimopan has not been studied in patients with
end-stage renal disease and is not recommended for
use in these patients.
Bowel obstruction: patients undergoing surgery
for correction of complete bowel obstruction are not
recommended for administration with alvimopan.
Alvimopan has low systemic absorption and limited
ability to enter the central nervous system. Since it is
peripherally restricted, it does not reduce the pain
relief of therapeutic opioids. As a result, patients may
have pain control and improved bowel motility.
Because alvimopan reverses the adverse effects of
opioids on the gastrointestinal tract, it accelerates gastrointestinal recovery in patients following colorectal
or small-bowel resection surgery. This potentially
improves patient comfort while reducing healthcare
expenditure due to extended hospitalization.
Alvimopan also has no known potential for
dependence or abuse.
Toxicity
422
Intravenous administration of alvimopan up to 10

mg/kg per day in female mice (about 3.4 to 6.8
times the recommended human oral dose) did not
produce adverse effects on fertility and reproductive
performance.
Oral administration of alvimopan at 4000 mg/kg

per day for 104 weeks in female mice (about 674 times
the recommended human dose) increased incidences
of fibroma, skin fibrosarcoma and sarcoma, and
osteoma/osteosarcoma. In rats, however, oral administration of alvimopan up to 500 mg/kg per day for
104 weeks (about 166 times the recommended human
dose) did not produce any tumor [1,2].
In the Ames test, mouse lymphoma cell (L5178Y/
TK+/) forward mutation test, Chinese Hamster Ovary
(CHO) cell chromosome aberration test, and mouse
micronucleus test, alvimopan was not found genotoxic. Its metabolite was negative in the Ames test, CHO
cell chromosome aberration test, and mouse micronucleus test.
Drug interactions
Alvimopan can be co-administered with morphine or
acid blockers without dosage adjustments.

Although alvimopan is generally well tolerated, its
most common side effects include nausea, vomiting,
abdominal distention, constipation, dyspepsia, and
flatulence.
Patients with long-term or intermittent opioid
therapy, including any opioid use a week prior to
administration of alvimopan, could be more sensitive
to its adverse effects. These effects, such as abdominal
pain, nausea and vomiting, as well as diarrhea, are
limited to the gastrointestinal tract.
No causal relationship between alvimopan and
myocardial infarctions has been established. In a
12-month study of patients treated with opioids for
chronic pain, incidences of myocardial infarctions in
patients treated with alvimopan 0.5 mg twice daily
were reported to be higher than those treated with
placebo. The majority of myocardial infarctions
occurred between 1 and 4 months after the first treatment of alvimopan.
Patients with severe hepatic impairment are not
recommended for treatment with alvimopan. The
plasma level of drug was found to be potentially
10-fold higher than in a healthy control volunteer. No
studies have been established for alvimopan administration in patients with severe hepatic impairment.
Other adverse reactions that were reported in
nine worldwide placebo-controlled alvimopan trials in
1650 patients include anemia, hypokalemia, back pain,
and urinary retention. Although hypokalemia was
Chapter 107 Alvimopan
more common with bowel resection patients, it was

less frequent in the overall surgical population [1,4].

No specific antidote has been indicated for overdosage
with alvimopan. Patients should be managed with
appropriate supportive therapy.
2. Delaney CP, Yasothan U, Kirkpatrick P. Alvimopan.

Nature Rev 2008;7:727728.
3. Ludwig K, Enker WE, Delaney CP, Wolff BG, Du W,
Fort JG, Cherubini M, Cucinotta J, Techner L.
Gastrointestinal tract recovery in patients undergoing
bowel resection. Arch Surg 2008;143(11):10981105.
4. Udeh E, Goldman M. Alvimopan. Formulary
2005;40:176183.
References
1. Bream-Rouwenhorst HR, Cantrell MA. Alvimopan

for postoperative ileus. Am J Health-System Pharm
2009;66:12671277.
423
Section 12
Chapter
108
New and Emerging Analgesics
Overview: novel targets for

new analgesics
Ian W. Rodger and Peter G. Lacouture
Introduction
424
Novel targets for new analgesics may be described in

several different ways. One could consider new applications for existing compounds including route of
administration (nasal, pulmonary, transdermal, intraosseous, etc.) or delivery technologies (extended-release, iontophoresis, etc.). Many of these new
approaches, or products, are discussed in the chapters
that follow, including the TRP channel blockers
(Chapter 128), the cannabinoid agonists (Chapters
125 and 126), and the NMDA-receptor antagonists
(neramexane, Chapter 129). In addition, chapters
preceding this section describe relatively new targets
including agonists (tapentadol, Chapters 31 and
115), NMDA antagonists (Section 6), -adrenergic
receptor agonists (clonidine, Chapter 81; dexmeditomidine, Chapter 83), calcium channel blockers (2subunit antagonists, Chapter 70), and some biological
products such as ziconotide (Chapter 105).
This overview will not revisit the above topics in
detail, but will place them in an appropriate perspective as future targets. Many of these targets have
been identified previously. However, recent emerging information on mechanisms of action continues
to shed new light on novel areas for analgesic development. Novel targets can be discussed as mechanism-based or as chemical (drug)-based. The
chapters that follow in this section of the textbook
are drug-based discussions, so this introductory
chapter will focus on mechanism-based principles.
The objective of this chapter is to provide a scientific
foundation for modification or repurposing of existing drugs as well as identifying pathways for new
drug therapies.
This overview has been divided into four families;
ion channels, enzymes, receptors, and cytokines. Where
appropriate each targeted family has been subdivided
into members that reflect the mechanistic theme.
While the basis of this chapter is highly scientific
and clinical, we would be remiss if, at the outset, we
did not examine the future development of any of

these novel therapies based on commercial considerations. Table 108.1 presents one perspective on the
potential sales for these new treatments projected
from 2018 to 2023.
In both of these time segments, the growth factor
modulators and the CGRP antagonists show the greatest economic return (estimates in excess of $1 billion/
year). It is also worth noting that all of these targets
show meaningful growth over the 5 year period
reviewed. The groups showing at least a doubling of
sales include the cannabinoid modulators, the ion
channel modulators, the CGRP antagonists and the
cytokine modulators.
Ion channel families

Acid-sensing ion channels (ASICs)
Acid-sensing ion channels are a family of transmembrane-spanning proteins that form ion channels in nociceptors that are uniquely sensitive to the
action of H+ ions (see Figure 108.1). Thus, any reduction in the pH (increase in H+) of tissues, such as
that which occurs during inflammation, will cause
activation of ASICs leading to a reduction in the
excitation threshold of the nociceptor and enhanced
sensory nerve activation. The growing awareness
of the importance of ASICs in regulating sensory
nerve activation is currently the subject of intense
research investigation. However, to date, there are
no selective agents that have the selectivity of action
necessary for them to assume the status of clinical
candidates.
Transient receptor potential (TRP) channels

Arguably one of the most interesting targets in the
past decade has been the family known as the transient receptor potential (TRP) channels (Figure
108.1). They compose a superfamily of ion channels that play important roles in the transmission
Chapter 108 Overview: novel targets for new analgesics
Table 108.1.
Sales of Emerging Novel Drug Classes, 2018 and 2023
5
500
Vanilloid receptor agonists
650
6
2018
150
1
Vanilloid receptor antagonists
2023
3
300
2
250
Cannabinoid modulators
600
60
2,000
2
Growth factor modulators
3
3,000
25
250
Subtype-specific
ion-channel modulators
600
6
Calcitonin gene-related peptide

receptor antagonists
1,200
1
,
3
3,000
250
2
Cytokine modulators
75
750
300
3
Other inflammatory modulators
4
400
300
300
Glutamate receptor modulators
500
5
Purinergic receptor modulators

Subtype-selective nicotinic
acetylcholine receptor agonists
200
400
40
Kinase modulators
0
500
1,000
1,500
2,000
Sales ($MM)
2,500
3,000
3,500
Note: Sales represents sales across the seven major markets that we cover (United States, France, Germany, Italy, Spain,
United Kingdom, and Japan).
Decision Resources, Inc., 2008

Source: Decision Resources, Inc.
of sensory input through the nerve cell. They are

strictly cationic channels (admitting Na+, K+ and
Ca2+) and frequently nonselective in that they will
permit entry of more than one cation. These channels, expressed in primary afferent fibers, are of
interest because they are involved in the transduction of noxious stimuli. The principal interest in
these channels has focused on TRPV1 (Chapters 96

and 128). While the majority of research has focused
on antagonists of TRPV1 there is certain interest in
low molecular weight agonists that desensitize the
cationic channel. Both approaches have been shown
to be effective in neuropathic and inflammatory
pain states
.
425
New and Emerging Analgesics Section 12
Ca2+
Na+
Bradykinin
TRPV1
TrkA
H+
AEA
PI3K-Src
Gq
Na+
Nav1.8
Gs
Gi
PGE2
P2X3
CB1
ASIC
Sodium (Na+) channels
426
Figure 108.1. Diagrammatic

representation of the nociceptor
(adapted from Julius and Basbaum, 2001
[8]). The elements shown in the figure
that are known to modulate the
nociceptors in an excitatory manner are
tyrosine kinase A (TrkA), the receptor for
nerve growth factor, the transient
receptor potential channel (TRP) V1,
bradykinin receptor(s), the tetrodotoxinresistant, sensory neuron-specific Na+
channel (Nav1.8), the acid-sensing ion
channels (ASIC), the adenosine P2X3
receptor, and prostaglandin (PG)E2
receptors. Inhibitory modulation of the
nociceptor is achievable via stimulation
of the cannabinoid type 1 receptors
(CB1).
Peripheral nociceptors are the sensory anatomical

detectors of painful stimuli. The nociceptors transduce the initial stimuli by creating action potentials
that are largely a consequence of the entry of sodium
ions (Na+) into the neuron. There are several types of
voltage-gated Na+ channels that can be classified according to their sensitivity to tetrodotoxin (TTX) and
their primary structure. A variety of Na+ channels are
involved in regulating nociceptor excitability. They
are the TTX-sensitive Nav1.3 and 1.7 channels and
the TTX-insensitive Nav1.8 and 1.9 channels. However, it is the latter two sodium channels that are of
particular importance. While both these TTX-resistant channels are present in the nociceptor membrane
the Nav1.8 sub-type is of greatest interest (Figure
108.1). These channels are primarily expressed in
slow-conducting sensory C fibers. Nav1.8 channel
opening leads directly to the generation of action
potentials that pass up through the dorsal root ganglion to the dorsal horn of the spinal cord. Furthermore, the expression and biological properties of
these Nav1.8 channels can be modulated by ongoing
nociceptor activity and further enhanced by inflammatory events or injury occurring locally. The Nav1.8
channel is solely responsible for the detection of pain
induced by noxious cold.
There has been a concerted effort to identify
drugs that selectively block the Nav1.8 and/or Nav1.9
channels. To date, however, there is but one report of
such a selective blocker, A-803467. A-803467 is more
than 100-fold more selective for the human Nav1.8
expressed in recombinant cell lines compared with other

Nav channels (1.2, 1.3, 1.5, and 1.7). It is highly effective
in animal models of both inflammatory and neuropathic
pain. The effects of A-803467 are dose-dependent and
reversible and, in contrast to classical sodium channel
blockers such as the local anesthetics (see Section 5), the
ability to block the Nav1.8 current was not frequencydependent. Interestingly, while A-803467 was highly
effective in the different chronic pain models it was ineffective in blocking acute pain, suggesting that this Nav1.8
may not be involved in physiological nociception.
Calcium (Ca2+) channels
Ca2+ entry into the presynaptic terminal of the primary

sensory neuron is essential for the release of the neurotransmitters necessary for conveying the wave of excitation upwards to the central nervous system. In the
dorsal horn this is achieved via the opening of specific
N-type, voltage-gated Ca2+ channels that have been
designated Cav2.2 (Figure 108.2). Given the importance
of this channel there has been significant effort directed
towards the discovery of antagonists of Cav2.2. A key
consideration in targeting Cav2.2 is to design a molecule that would inhibit Ca2+ entry during conditions in
which the primary sensory neuron is firing rapidly, as is
the case in painful conditions, as opposed to the lowerfrequency discharge that occurs under normal, physiological conditions. In essence, what one seeks is a
so-called use-dependent inhibitor of Cav2.2. Today
there are both preclinical and clinical data to support
the involvement of the Cav2.2 channels since inhibition
of this channel is associated with analgesic effects in
both chronic and neuropathic pain syndromes.
Mast cell or
neutrophil
Substance
Tissue
injury
Histamine
Bradykinin
NGF
5-HT
Prostaglandin
ATP
H+
Stimulus
Representative
receptor
NGF
Bradykinin
Serotonin
ATP
H+
Lipids
Heat
Pressure
TrKA
BK2
5-HT3
P2X3
ASIC3/VR1
PGE2/CB1/VR1
VR1/VRL-1
DEG/ENaC
C-
fib
DRG cell body
er
Cav2.2
ter
mi
na
CGRP
Substance P
GLU
Cav2.2
CGRP
Blood
vessel
Substance P
Spinal cord
Spinal dorsal horn
Figure 108.2. Schematic representation of events occurring after tissue injury leading ultimately to the perception of pain. The initial injury
releases a chemical soup that alters the peripheral nociceptors to enhance their sensitivity to stimuli by lowering their threshold for
stimulation. This soup contains growth factors, lipids, H+, ATP, and a host of humoral mediators including cytokines. The end result is
enhanced firing of the sensory neuron sending impulses via the dorsal root ganglion to the dorsal horn of the spinal cord. Neurochemical
transmission at this junction is achieved via Ca2+ entry through Cav2.2 channels and the release of glutamate, substance P, and CGRP.
(Adapted from Julius and Basbaum, 2001 [8].)
The Cav2.2 channel, like all ion channels, is composed of numerous subunits. A critical component of
the Cav2.2 is the 2-subunit (see Chapter 70), which
is known to be up-regulated in animal models of neuropathic pain and it is this subunit that is the proposed
target of the GABA analogs gabapentin and pregabalin (see Chapters 71 and 72). Additionally, gabapentin
has also been shown to down-regulate channel expression as well as conformationally altering the channel
structure. Both these compounds are used for the
treatment of chronic pain syndromes although their
side-effect profile is poorer than one would have anticipated. In all likelihood this is a consequence of the
2 subunit not being the exclusive province of the
Cav2.2 channel, with it being expressed in a wide variety of other voltage-gated Ca2+ channels. A gabapentin
prodrug, XP13512 (GSK), is currently in phase II clinical development.
The small-molecule approach of Neuromed led to
the discovery of NMED 160, which showed selective,
use-dependent inhibition of Cav2.2 in a wide range

of animal pain models. Beyond the developments
mentioned above, this compound provides substantial validation of the approach to targeting Cav2.2 as
a novel mechanism for providing analgesic efficacy.
This compound, renamed MK-6721, has been studied in a phase II clinical trial but is not regarded as a
candidate for further clinical development. An alternative approach to generation of small-molecule,
selective inhibitors of Cav2.2 has been based upon
the key structural features of cone snail -conotoxins.
The snail conopeptide, ziconotide (Prialt from Elan/
Eisai; see Chapter 105) is an example of this
approach. This peptide (which has to be administered intrathecally) has been shown in several clinical studies to have substantial analgesic efficacy
in both chronic and severe pain states even in
patients who were unresponsive to morphine. The
downside to ziconotide is that either by intrathecal
or systemic routes of administration it is associated
427
with orthostatic hypotension and a litany of neurological side effects.

Notwithstanding some of the developmental difficulties the Cav2.2 channel remains a viable and attractive target for novel analgesic drugs that would have
therapeutic benefit in both inflammatory and neuropathic pain conditions.
Potassium (K+) channels

Clearly, the cationic pathways of the sodium and calcium channels are the most well-recognized and have
been explored to a greater degree than any other channels of this type. However, there is evidence that in
certain conditions, modulation of the K+ channel may
have merit as a therapeutic agent. A less well-known
member (at least for pain) of this ion channel family of
the potassium channel modulators is KCNQ (Kv7).
Five sub-groups of this channel exist. Four family
members (KCNQ25) are primarily associated with
the nervous system but KCNQ2/3 are most relevant in
relation to neuropathic pain. What is fascinating is
that while nerve injury increases expression of certain
Na+ channels the exact opposite occurs with K+ channels. Thus, decreased expression of K+ channels occurs
after injury in both A and C fibers, contributing to an
exaggerated sensory response.
Retigabine (Valeant) has been explored in this area
and in particular the KCNQ2/3 channel. Retigabine is
classified as a potassium channel activator. It is structurally similar to the analgesic flupirtine developed by
Asta Medica. These products have been targeted for
acute, neuropathic, and migraine pain.
While the potassium channel modulation may play
an important role in the future of pain management
particularly in neuropathic states, this potential has yet
to be realized. The existing family representative (flupirtine) has shown limited utility and currently
research and interest in this area is somewhat low.
Chloride (Cl) channels
428
Chloride channels represent the only anionic channel

of interest for analgesic development. These channels
often play an important role in neural excitability and
therefore are important in the roles of several neurotransmitters including GABA and glycine. Hyperpolarization of the post-synaptic cell body leads to a less
excitable nerve fiber and the resultant loss of sensory
transmission through select fibers. Through several
cascading events, interactions at the Cl channel result
in a hyperpolarization by the inward rush of Cl.
Therefore, the enhanced movement of Cl into the

neural cell results in hyperpolarization and decreased
excitability of the membrane while the cancellation of
Cl movement into the cell results in an increase in
nerve membrane excitability. Thus molecules which
enhance chloride movement into the sensory nerve
will potentially demonstrate analgesic activity. These
channels also play important roles with respect to the
neurotrophins (see BDNF receptors) and the nonsteroidal anti-inflammatory analgesic drugs (see mPGES-1
below).
At the present time, targets for analgesic potential
have not been realized. However, their role in modulating neural membrane excitability makes them a
promising target for future development. Specific
chloride channel modulators in development for the
treatment of pain are not known but are often contributors to action of other transmitters such as GABA
and glycine.
Enzyme families
Microsomal prostaglandin E synthase-1
(mPGES-1)
Prostaglandins (PGs), in particular PGE2, have long
been known as pivotal mediators of inflammation and
the pain associated with inflammatory events (see Figure 108.2). PGE2 is the product of the cyclooxygenase
(COX) pathways, both COX-1 and COX-2. Drugs
that inhibit these pathways in a nonselective fashion
have been available for some time. These are the socalled nonsteroidal anti-inflammatory drugs (NSAIDs)
(see Section 4). Within this class of drugs there are
those that are nonselective for the cyclooxygenase
enzymes COX-1 and COX-2, typified by ibuprofen
and naproxen, and those that are selective inhibitors
of COX-2, typified by celecoxib and etoricoxib. Both
nonselective and selective NSAIDs are highly effective at reducing pain and inflammation but, not
surprisingly, only in those settings where there is a
PG-dependent mechanism involved. Thus, at best, they
have limited efficacy in neuropathic pain conditions. A
further complication is that NSAIDs have a side-effect
profile that is less than desirable. The nonselective
agents, through COX-1 inhibition, cause gastrointestinal complications and fluid retention. The selective
COX-2 inhibitors cause fluid retention and have been
associated with potentially serious cardiovascular side
effects when used for extended periods of time.
In an attempt to obviate the cardiovascular side

effects of the selective COX-2 inhibitors attention has
been directed towards inhibition of prostaglandin
biosynthesis at a point further down the pathway leading to PGE2. COX-2 is responsible for the conversion
of arachidonic acid to the cyclic endoperoxides and
ultimately to a variety of prostanoids (thromboxane,
PGD, PGE, and prostacyclin). It has been postulated
that a component of the cardiovascular side effects of
selective COX-2 inhibition is a consequence of the
reduction in the formation of the vascularly protective
substance prostacyclin. To circumvent this effect
attention has been focused on the biosynthetic step
that occurs after COX-2, namely the conversion of the
cyclic endoperoxides by microsomal PGE synthase-1
(mPGES-1) to PGE2. The rationale underlying this
approach is that by allowing the formation of the
cyclic endoperoxides some of that substrate can be
converted to prostacyclin thereby allowing for the vascular benefits to remain unaffected. Such a targeted
approach to inhibit the formation of PGE2 at the
mPGES-1 step is an attractive way of creating analgesic and anti-inflammatory agents that have the undeniable efficacy of NSAIDs but with much diminished
cardiovascular risk profiles. Currently there are no
candidate molecules in clinical development but several companies have significant preclinical programs
underway
.
Kinase modulators
The kinase family of enzymes participates in many
pathways contributing to the modulation of pain
responses. Many of these roles are described in the
neurotrophin family (see Neurotrophin receptors)
and in the actions of GABA and glycine. They are
ubiquitous enzymes acting in many different cells.
However, their particular activity in neural sensory
cells is highly relevant to analgesic development.
One group of compounds that is of particular
interest for future development is the p38 kinase
inhibitors. This group is particularly interesting
because of the extensive research that has described
them as a potential treatment focused on inflammatory pain mechanisms. P38 kinase has long been
known to play an important role in inflammation
especially in joint-related pathologies. Briefly, these
kinases are thought to exhibit their therapeutic benefit
by inhibiting many of the pro-inflammatory cytokines
such as TNF, IL-6 and IL-1 (see Cytokine family).
BMS has advanced a candidate as an orally active
inhibitor targeted for the treatment of rheumatoid

arthritis. BIRB-796 (Boehringer-Ingelheim) has also
advanced in the clinic, but very few data are available.
VX-745 (Vertex) was dropped from development on
toxicity grounds; however, VX-702 has advanced to
patient trials.
While activity after the turn of the century has
markedly increased in this area, no lead candidates
have made significant progress in the clinic. Many
have been discontinued after demonstrating hepatotoxicity and CNS effects characterized as dysphoria. It
does, however, remain an important target for the
future in inflammatory pain as better selectivity,
potency, and oral activity are identified. The hope is
that somewhere in this family of compounds a specific
disease-modifying product for immune-based pathologies such as RA will develop.
Nitric oxide synthase

Nitric oxide synthase (NOS) is an enzyme that produces
nitric oxide from arginine. Nitric oxide is then utilized in
the communication between neurons, in effects on the
immune system, and in contributing to vasodilatation.
There are three known important isoforms; endothelial
NOS (eNOS), neuronal NOS (nNOS), and inducible
NOS (iNOS). iNOS plays a role in immune and inflammatory responses, while nNOS is an important modulator of pain and neuronal sensitization. Several
compounds have been advanced by Neuraxon in this
arena. NXN-188, a selective nNOS inhibitor and 5HT
agonist, devoid of cardiovascular side effects, is targeted
for migraine headache. Since iNOS plays an important
role in inflammation and nNOS plays a role in central
sensitization, the development of a dual inhibitor of
iNOS and nNOS may be found in the near future. Early
testing in headache is promising for this family and a
possible beneficial role in neuropathic pain is evolving.
In addition, a potential role in poorly managed visceral
pain has merit. Juxtaposed to compounds decreasing the
production of nitric oxide is AZD-3582/HCT-3012
(Naproxcinod), which acts as a nitric oxide donor. However, this product has focused on the beneficial actions
of nitric oxide to reduce severe cardiovascular (stroke/
heart attack) and possibly gastrointestinal toxicities
.
Receptor families
Purinoceptors
Receptors preferentially activated by adenosine triphosphate (ATP) are termed purinoceptors. There are
429
two distinct classes of purinoceptor that have been

designated P2X and P2Y. In the context of pain mechanisms and analgesic control of pain, the P2X receptors are the ones that have been most studied. Two
particular sub-types of the P2X receptor are worthy of
mention; P2X3 and P2X4.
P2X3 receptors
The purine P2X3 receptor is a specific sub-type of

ATP-gated ion channel which is found on peripheral nociceptors (Figure 108.1). While its role in
modulating the peripheral nociceptor is not clearly
understood, it has been suggested that it may well
be the receptor that is responsive to pressure or tissue deformation/distension/damage. The rationale
underlying this thesis is that ATP is released by
these types of stimuli and because small-diameter C
fibers express the P2X3 receptor for which ATP is
the natural ligand. Some support for this notion
comes from experiments where filling and stretching of the urinary bladder is known to cause the
release of ATP from the stratified columnar epithelial cells and activation of P2X3 to induce bladder
emptying. Thus, the release of ATP could be
regarded as a signal that enables immediate detection by nociceptors of tissue damage or distension.
While there is considerable interest in this potential
therapeutic target there are no molecules that are
currently in clinical development.
P2X4 receptors
430
Microglia have long been known for their specific

homeostatic scavenging functions within the central
nervous system. However, it has been recognized
that they, along with satellite cells, play a much wider
role. For example, nerve injury activates microglia
in the spinal cord and these cells are implicated in
the induction of neuropathic pain. Until relatively
recently, however, it was not known whether activated microglia were a cause or a consequence of the
altered pain states. It is now recognized that they are
a contributing factor. In injured and certain inflammatory states microglia are stimulated by the local
release of ATP in the spinal cord that acts upon the
purinoceptor, P2X4. This action induces the formation, and release, of a small neuronal modulating
protein termed brain-derived neurotrophic factor
(BDNF) from the microglia. BDNF, in turn, diffuses
from the microglia to exert its effect (see Neurotrophin receptors) predominantly on the post-synaptic
cell in the dorsal horn of the spinal cord. The end

result is the disinhibition of the GABA-ergic and
glycinergic control of synaptic function. The fact
that today BDNF is recognized to play a pivotal role
in the development of neuropathic pain states makes
the P2X4 receptor a fascinating target for novel analgesics since blockade at this point would impede the
induction and release of BDNF.
Adenosine receptor agonists/antagonists

Adenosine receptors are found throughout the body
and mediate a number of biological functions. Adenosine has an important role in the function of
nerve cells, it has a role in cell proliferation, and it
acts as a signal of inflammation. Basically, there are
four adenosine receptors, A1, A2a and b, and A3.
These receptors are linked to G protein-coupled
receptors and the complex functions that they
orchestrate. A1 receptors are closely linked to cardiac function, A3 is inextricably linked to cell
growth and cell death and A2b is probably linked to
airway function. However, it is the A2a receptor that
is a major driver of inflammatory events by sensing
excessive tissue inflammation and enhancing neural
communications.
A2a receptors have defined roles in Parkinsons
disease, schizophrenia, pain states, and possibly
Alzheimers disease, and A2a agonists are in clinical
trials as anti-inflammatory agents. However, interestingly, A1a agonists are in clinical trials for neuropathic pain. In fact, recent evidence suggests that
two A1 receptor agonists (GR79236 and GR190178)
have potential as treatments for migraine headache
via effects on CGRP. Hence the roles and activities
of these adenosine agonists have far-reaching
effects.
There are few compounds in development as adenosine agonists. However, two such compounds have
advanced to the clinic. GW-493838 (GSK) has been
examined as an adenosine agonist and has advanced
to phase 2 trials in neuropathic pain. Also T-62 (King
Pharmaceutical) has begun early studies with a similar agonist for neuropathic pain. It is also of interest to
note that while the A2a agonists have attracted the
most attention for pain, an A2b antagonist has
advanced as an enhancer for opioid analgesia. Clearly,
the success of future candidates will require further
development and understanding of these ubiquitous
receptors with broad actions.
Bradykinin receptors
Bradykinin has long been recognized as one of the G
protein-coupled receptors that can modulate both
pain and inflammation (see Figures 108.1 and
108.2). Two receptor types have been described: B1
and B2. The B2 receptor is expressed constitutively
in a wide variety of tissues including nociceptive
neurons whereas the B1 receptor lies dormant. In
inflammatory states the B1 receptor is induced/activated and can generate both pain and inflammation.
Stimulation of the bradykinin receptor leads to activation of a phosphoinositide signaling pathway, the
release of intracellular calcium ions, and activation
of a kinase system. This ultimately opens TRPV1
channels in the sensory nerve membranes, so
enhancing nociception.
While the potential role of bradykinin antagonists
is significant, years of research have not been able to
adequately define the type of bradykinin receptor that
is responsible for pain and inflammation in humans.
A B2 antagonist (HOE140; Icatibant) was evaluated
clinically but failed to alleviate acute pain. To date
there is no B1 antagonist and a clear clinical candidate
for B2 is not on the horizon. Nevertheless, the proven
involvement of bradykinin in inflammatory pain
renders an antagonist of the relevant B-receptor a
worthwhile target.
CGRP exerts a number of effects in the human

body, but one of the most significant is its role in
arterial vasodilatation (see Figure 108.2). Sensory
nerve fibers that contain CGRP innervate small
arteries and have the ability to control vasomotor
activity. CGRP also causes vascular relaxation
through a nitric oxide pathway (see Nitric oxide
synthase) affecting vascular smooth muscle. In a
migraine attack, vasodilatation in the intra-cranial
and extra-cranial arteries is believed to cause the
headache phase of migraine. Neurogenic inflammation mediated by activation of the trigeminal C fibers
known to trigger migraines is completely abolished
by CGRP antagonists. Furthermore, this effect has
also been seen with cluster headaches. It is of interest
to note that the existing anti-migraine treatments
(ergot, triptans) inhibit CGRP release.
Early discovery of a peptide antagonist showed
promise in animal models, but it had poor penetration through the bloodbrain barrier because of
its peptide nature. Shortly thereafter, telcagepant
(MK-0974 from Merck) was shown to be orally active
and effective in relieving headache. Key to success in
this area will be the design of a molecule which can be
administered by convenient routes (oral, sub-lingual,
intranasal) providing a rapid onset of action. BMS694153 could be just such a molecule in that it is
potent, water-soluble, has good intranasal bioavailability and favorable toxicology
.
Calcitonin gene-related peptide (CGRP)

receptors
Glutamates receptor agonists/antagonists
CGRP is one of a family of substances believed to

play a meaningful role in the condition referred to as
neurogenic inflammation. This peptide is released
from the terminals of primary sensory neurons in
almost all tissues with particular density in perivascular, dorsal root, vagal, and trigeminal ganglia (Figure 108.2). Sensory nerve stimulation, subsequent
extravasation, and vasodilatation, which are all considered part of the migraine attack, were initially
thought to be inhibited by neurokinin receptor
(NK1) antagonists. However, since these blockers
failed to change the direction of these painful conditions, CGRP antagonists were tested and found to
block the neurogenic vasodilatation and the subsequent migraine headache. In addition, it has been
suggested that CGRP antagonists could play a role in
other painful conditions as well as opioid-induced
tolerance and dependence.
The excitatory neurotransmitter glutamate (Figure

108.2) has a variety of family members that have been
evaluated as targets for analgesic development especially in the initiation and maintenance of neuropathic
pain resulting from central injury (spinal cord),
peripheral injury (PDN, radiculopathy), and inflammatory injury (arthritis).
There is added excitement around this neurotransmitter family because they have been suggested to be
involved in three significant problems with pain
hyperalgesia, allodynia, and spontaneous pain generation. Furthermore, glutamatergic signaling is involved
in the process of central sensitization. Glutamate receptors are classified into ionotropic and metabotropic
receptors. Generally, glutamate, NMDA, AMPA and
kainate-selective agonists are pro-nociceptive, while
metabotropic glutamate attenuates pain. Therefore,
antagonists of NMDA, AMPA and kainate as well as
431
agonists of metabotropic glutamate are potentially

analgesic.
Ionotropic receptors
NMDA
NMDA antagonists are probably the most recognized
glutamate modulators. In animal models, these molecules have shown significant activity as analgesics,
but have also shown concerning side effects and
therefore have a weak therapeutic index. Ketamine is
a specific dissociative anesthetic which acts through
NMDA pathways but has poor efficacy and a myriad
side effects including hallucinations and sedation.
MK801 (dizocipine) showed similar short-comings,
but did lead to the development of a lower affinity
channel blocker such as memantidine (see Chapter
77), which has shown limited success in the clinic.
However, antagonists of the NMDA sub-types (NR1
and NR2) have been evaluated to enhance efficacy
and reduce toxicity with this class of compounds.
These compounds are directed at the strychnineinsensitive glycineB regulatory site of the NMDA
channel. One specific NR1-glycine antagonist
(GV196771), however, has not shown meaningful
pain relief with reduced side effects probably due to
inadequate penetration into the CNS. Another candidate (NR2B) has been suggested to have very specific sensory distribution and therefore a target for
specific antagonist development. Many of these compounds that interact through NR1 and 2 have been
evaluated in ischemic stroke and cognition, but there
is possible activity in neuropathic pain exemplified
by RGH896 (Gideon Richter), EV101 (Evotec), and
CP101606 (Pfizer).
432
AMPA
AMPA receptors are a family of proteins that line
sodium ion channels expressed in the brain, spinal
cord, dorsal root, and periphery. These receptors
transmit both sensory and nociceptive stimuli. Transmission mediated by AMPA is believed to play an
important role in wind-up and central plasticity. Thus,
it is an important component in persistent pain states.
Antagonists of the AMPA receptor have significant
analgesic potential; however, the well-known side
effects of ataxia and sedation have hampered their
development.
Torrey-Pines has advanced the development of a specific AMPA-kinase antagonist (NGX426/tezampanel)
for pain. However, poor bioavailability (it has only been

evaluated as an injectable) and several side effects are
problematic. Development of an orally active prodrug
have, however, resurrected interest in this compound.
NS-1209 (NeuroSearch) has also advanced into Phase 1
clinical trials.
Kainate receptors
This receptor family is very similar to NMDA and
AMPA. These receptors are largely distributed in both
the central and peripheral nervous systems. They are
localized in dendrites, postsynaptic membranes, nerve
fibers, and synapses. They generally play an excitatory
role in the postsynaptic membrane of excitatory neurons. They can also modulate GABA release from
inhibitory neurons and also sensory ganglia within
the dorsal horn.
The focus of several compounds in development
has focused on the GLUk5 subunit. LY382884 has been
advanced as a treatment for peripheral neuropathy
and LY 466195 for migraine; however, neither has
gone deep into the clinic.
Metabotropic receptors
This sub-family of glutamate receptors has been
extensively researched. The receptors are separated
into three groups: Group I includes mGluR1 and 5
and their variants; Group II includes mGluR2 and 3;
and Group III includes mGluR4, 6, 7, and 8. Group I
receptors generally couple G protein receptors, while
Groups II and III generally couple with adenyl
cyclase.
In particular, mGluR1 and 5 have shown promise
in the modulation of central excitability in chronic
pain, but minimal effects in acute pain. Activation of
mGluR1 receptors plays a critical role in the induction and maintenance of central sensitization induced
by inflammation. Therefore, antagonists of these
pathways are targets for persistent inflammatory
pain. LY367385, a specific antagonist has been shown
to have analgesic effects in multiple models of inflammatory pain which is apparently mediated by both
central and peripheral targets. Further studies have
also suggested a role in attenuating persistent neuropathic pain. Peripheral mGluR5 receptors have
been suggested to modify pain and several antagonists (MPEP and SIB 1747) have shown activity in
animal models of neuropathic pain. ADX10059 and
ADX4861 (Addex) have proven clinically effective in
both migraine and fibromyalgia and AZD2066 and
AZD9272 (Astra Zeneca) are in phase 1 and 2 clinical trials.

mGluR2 and 3 have been evaluated for their
effects on pain transmission. There is emerging information that suggests that these pathways and receptors are involved in the central sensitization in the
dorsal horn and spinal cord. mGluR2 is located in
sensory nerves and believed to play an important
role in reversing allodynia whereas mGluR3 is
located in several sites in the brain as well as in the
spinal dorsal horn after nerve injury. Several agonists, LY379268, LY354740 and LV389795, have
been shown to support the development of persistent pain following inflammatory reactions. Furthermore, antagonists of these mGluR2/4 receptors have
shown reversal or prevention of these outcomes.
While there is significant analgesic potential with
antagonists of these receptors clinical development is
very slow.
Nicotinic receptor agonists/antagonists

Neuronal nicotinic receptors (NNRs) have been investigated for years as part of the very complex ligandgated ion channel family. Basically, there are five
subunit proteins that form this channel expressing
both and sites. While the definition of these units
and binding sites continues to evolve, their potential
role in pain modulation has garnered significant interest, particularly with regard to neuropathic states.
Models of chronic pain secondary to nerve injury have
demonstrated an overexpression of several of these
subunits. Interestingly, both agonists and antagonists
of these NNRs have been evaluated for therapeutic
potential.
Abbott developed one of the early agonists (ABT594), which was a selective agonist of subunits 4
and 2 demonstrating anti-nociceptive activity, but
not acceptable tolerability. ABT-894 was subsequently advanced as a candidate and has shown significant potential. TC-6499 (GSK/Targacept),
classified as a neuronal nicotinic receptor agonist,
has also advanced into the clinic. On the antagonist
side, ACV-1 (Metabolic Pharmaceuticals), which
was discovered from the Australian marine cone
snail, has entered phase 1 trials for neuropathic pain.
While its effectiveness in neuropathic pain models is
well-defined, it may also be effective in certain
inflammatory pain states. The seemingly paradoxical
effect of this antagonist is believed to be based on the
different NNR subtypes. Significant interest in this

conopeptide exists because it appears to have no
effect on motor coordination, can be delivered subcutaneously or by inhalation, and possibly demonstrates the ability to assist in the repair of damaged
nerves.
Cannabinoid receptors
There are two cannabinoid receptors of interest to
pain: CB-1 and CB-2. Their present development for
analgesia is described in Chapters 125 (general agonists) and 126 (peripheral agonists). The significant
interest in these receptors is driven by the finding that
the CB receptor is found in both the central and
peripheral nervous systems. Essentially, it is the CB-1
receptor which has been defined as the target for
future development (see Figures 108.1 and 108.2). The
earliest agonist candidate (THC) demonstrated analgesic effectiveness in neuropathic pain, but widespread
nonspecific binding of CB-1 and CB-2 resulted in distressing side effects.
At least three candidates have since been advanced
in the clinic. One of the first (Sativa, GW Pharma) was
approved as a nasal spray for MS pain and allodynia.
KDS2000 (Kadmus Pharma) has advanced their candidate into patients with PDN and PHN using a topical formulation. Astra Zeneca has also made significant
progress with a selective CB-2 agonist (AZD 1940).
Neurotrophin receptors
Neurotrophins are a family of related proteins that
contain the following family members: nerve growth
factor (NGF), brain-derived neurotrophic factor
(BDNF), neurotrophin-3 (NT-3), and NT-4/5. All
neurotrophins are synthesized as proforms that are
cleaved to release the active, mature forms. Each neurotrophin binds with high affinity to one of the tyrosine receptor kinase (trk) family of transmembrane
receptors; NGF to trkA, BDNF and NT-4/5 to trkB
and NT-3 to trkC. The neurotrophins all act on trks
that are expressed on sensory nerve terminals, the end
result being enhanced sensitivity of the nociceptors.
The two neurotrophins that have been most intimately
linked to both injury-induced nociceptive and neuropathic pain are NGF and BDNF.
NGF
NGF is one of the most intensively studied of the neurotrophins. Its increased expression and release is a
433
434
hallmark event associated with injury and a wide variety of inflammatory conditions. It is intimately
involved in modulation of peripheral nociceptors
(Figures 108.1 and 108.2). Once NGF activates its
receptor, trkA, it turns on the phosphoinositide 3-kinase (PI3K)-src kinase signaling pathway leading to
the phosphorylation of intracellular TRPV1 stores
which ultimately leads to their enhanced insertion
into the nociceptor membrane. The upshot is a marked
reduction in the threshold of stimulation of the TRPV1
complex and consequent enhanced nociceptor activation. Furthermore, NGF activation of trkA significantly influences several other nociceptor modulating
systems notably P2X3 and bradykinin receptors, acidsensing ion channels (ASICs) and the TTX-insensitive
Nav1.8 channels. By virtue of trkA phosphorylation all
of these systems markedly enhance nociceptor sensitivity to provoking stimuli.
Few NGF/TrkA antagonists/inhibitors have been
reported to date. However, the therapeutic concept
of blocking NGFs actions has been established
through use of the humanized anti-NGF monoclonal antibodies RN624 (Tanezumab; Pfizer) and
AMG403(Amgen). Additionally, in rodent models
of chronic pain the NGF antagonist ALE-0540 has
shown anti-allodynic properties. Also, several antibodies to NGF from Sanofi-Aventis/Regeneron and
Abbott/PanGenetics (PG110) have entered clinical
trials.
BDNF has also been linked with a direct effect on

neuronal excitability as well as enhancement of
NMDA receptor activation, both mediated via trkB
phosphorylation.
At the present time there are no molecules that
selectively interfere with the action of BDNF at its
trkB receptor site. However, the realization that microglia, and BDNF in particular, have an important role
to play in the development of chronic and neuropathic
pain states makes them a very logical target for novel
analgesic agents.
BDNF
IL-1
The receptor for BDNF is trkB, which is located in

close proximity to both the GABA and glycine receptor, chloride ion (Cl) channel complexes on the
post synaptic cell body of the second order sensory
neurons in the dorsal horn of the spinal cord. Once
activated trkB phosphorylates the GABA and glycine complexes in such a manner that the normal
inward movement of Cl (which hyperpolarizes the
membrane) is reversed. The outward movement of
Cl creates a depolarized membrane and sensitization of the cell. Thus, BDNF from the activated
microglia is capable of disrupting the very necessary
inhibitory actions of both GABA and glycine that
are normally released from the descending interneurons. It has been suggested that this action of BDNF
may well be a critical component of the spinal windup phenomenon that can convert acute pain into
more chronic, possibly even neuropathic, pain.
This cytokine is released primarily by monocytes and

macrophages as well as fibroblasts and endothelial
cells during injury or inflammation. Nearly a decade
ago it was discovered that IL-1 was expressed in
nociceptive DRG neurons. It is expressed after peripheral crush injuries and CNS trauma (microglia and
astrocytes). Following injection into the body this
cytokine produces hyperalgesia and is found to
increase the production of substance P and PGE2 in a
number of neural cells. Administration of a specific
receptor blocker (IL-1ra) has been shown to prevent
or attenuate cytokine-mediated hyperalgesia and
mechanical allodynia.
AV-411 (Ibudilast), manufactured by Avigen, is
currently in clinical trials for pain associated with
diabetic neuropathy. It has been described as an
IL-1 and IL-6 inhibitor as well as a cytokine glial
attenuator.
Cytokine family
There are several members of the family of cytokines
that play important roles in the inflammatory
responses in the central and peripheral nervous
systems. Certain cytokines when secreted following
injury to the spinal cord, the dorsal root ganglion
(DRG), or other injured nerves lead to pain generated from abnormal spontaneous activity in the
injured nerve or in compressed or inflamed DRGs.
These cytokines are small proteins secreted by cells
that control communication among cells. The subgroups include lymphokines, monokines, chemokines, and interleukins. The network and interactions
of cytokines are extremely complicated, but the
family members associated with inflammatory
pain seem to be largely limited to IL-1, IL-6, and
TNF.
IL-6
The promise of genetics
This cytokine has been shown to play a central role in

the neuronal reaction following nerve injury. It is
closely involved with microglial and astrocytic activation and neuropeptide expression. There is significant information that indicates that IL-6 is intimately
connected to the development of neuropathic pain
after peripheral nerve injury. Also, intrathecal
administration of IL-6 induces tactile allodynia and
thermal hyperalgesia in rats.
Antagonism of IL-6 by AV-411 is currently
under investigation (see IL-1 above). In addition,
Sanofi-Aventis/Regeneron have advanced a humanized antibody for RA into the clinic.
Probably the most significant novel targets for the

future are those driven by genetic variability to pain.
It is this variability that has generated the hopes for
personalized medicines in the future. Unfortunately,
these targets are probably the furthest off. The thrust
for the present and future growth of pain genetics
rests at two levels. The first is to understand the
genetic basis of the pathophysiology of acute and
chronic pain and the resultant differences in pain
sensitivity and variability and the second is how to
effectively control these players. Currently most of
the interest in this area is describing genes that code
for specific pain-related pathways. Certain genes
related to insensitivities to pain have been found to
encode for specific voltage-gated sodium channels
and neurotrophin tyrosine-kinase receptors. Also,
genes defining sodium channels (SCN1A) and calcium channels (CACNL1A4) in migraine sufferers
have been identified. Furthermore, genes encoding
for opioid receptors (OPRM1), ion channels
(TRPV1), bioamines and nitric oxide (GHC1),
adrenergic and dopaminergic transmission (COMT
472), and endogenous signaling lipids (FAAH) have
been described. However, study designs, heterogeneity, sample sizes, phenotype complexities, and statistical approaches have weaknesses that must be
addressed before the value of genetic intervention
can be fully appreciated.
TNF
This cytokine has a long history of involvement in a
number of inflammatory pain pathways. TNF receptors are present in numerous tissues including neurons and glia. It has been shown to play important
roles in both inflammatory and neuropathic hyperalgesia. In animals, intraplantar injection of complete
Freunds adjuvant results in significant release of
TNF with a resultant hyperalgesia. This effect is
delayed by the administration of an anti-TNF
antiserum.
As with all of the cytokine proinflammatory
proteins, their effects can be prevented or reversed
by specific antibodies; however, they can also be
managed by the anti-inflammatory cytokines. These
cytokines can be utilized for future analgesic properties. For instance, the cytokine IL-10 has been
shown to antagonize the inflammatory properties
of IL-1, IL-6, and TNF. In addition, IL-10 can
up-regulate anti-inflammatory cytokines such as
IL-4, IL-11, and IL-13 or down-regulate the production of IL-1, IL-6, and TNF. Direct administration of IL-10 has been shown to reduce peripheral
neuritis, spinal cord excitotoxicity, and other
peripheral nerve dysfunction. Similarly, IL-4 has
been shown to exhibit antihyperalgesic effects in
neuropathic pain. All of this work has been conducted in animal models, but it does leave an open
door for commercial development. Interestingly,
minocyline, a tetracycline derivative, inhibits IL-1
converting enzyme and NO up-regulation. It prevents glial cell proliferation and activation of p38
kinase.
Additional target considerations

It is impossible in a chapter of this nature to cover all
the novel targets that are being pursued with the intention of developing novel analgesics. Thus, in Table
108.2 we have provided a list of several novel drugs
that are in different phases of commercial development, the mechanism(s) that are being targeted and
anticipated clinical indication.
Concluding remarks
Today we have a far greater understanding of how
pain is perceived and how that perception can be
modulated, both up and down. We understand far
more about the humoral and neurochemical mechanisms that occur at both peripheral and central sites
within the nervous system. As a consequence of the
assembly of all this new knowledge there is clear evidence that points us at ion channels, receptors,
435
Table 108.2. Additional targets
Drug
Company
Mechanism
Indication
AGN-199981
Allergan
2b-Adrenergic agonist
Phase 2
Neuropathic pain
Bicifadine
DOV
5-HT, NA reuptake inhibitor,

glutamate antagonist
Phase 2
Neuropathic pain
Desvenlafaxine
Wyeth
5-HT, NA reuptake inhibitor
Phase 3
PDN
Radaxafine
GSK
NA, dopamine reuptake inhibitor
Phase 1
Neuropathic pain
Reboxetine
Pfizer
Selective NA reuptake inhibitor
Phase 2
PHN
Lacosamide
Schwarz
Amino acid anticonvulsant, Nav

blocker
Phase 3
Neuropathic pain
Ralfinamide
Newron
Na and Ca channel blocker
Phase 2b
Neuropathic pain
IP-751
Manhattan
Pharmaceuticals
Cannabinoid derivative; TNF

antagonist; LO inhibitor; IL
antagonist
Phase 2
Spinal and nerve injury

pain
XPI3512
GSK / Xenoport
Pro-gabapentin
Phase 2
Neuropathic pain
NGD8243
Merck / Neurogen
TRPV1 antagonist
Phase 2
Post-op dental
GRC-6211
Lilly / Glenmark
TRPV1 antagonist
Phase 2
Neuropathic pain,
osteoarthritis
AZDI386
AstraZeneca
TRPV1 antagonist
Phase 1
Unknown
enzymes, and cytokines that have the potential to be

targets for novel, effective analgesics. Throughout this
chapter we have attempted to tease out some of the
most attractive of these novel targets, ones which hold
the promise that, through selective intervention at
these specific points, therapeutic modalities may result
that could revolutionize the management of the most
intractable pain states.
References
1. Rodger IW. Analgesic targets: today and tomorrow.

Inflammopharmacology 2009;17:151161.
2. Dray A. Neuropathic pain: emerging treatments.
Br J Anaesth 2008;101:4858.
436
Phase
3. Rice ASC, Hill GG. New treatments for neuropathic

pain. Annu Rev Med 2006;57:535551.
4. Bevan S, Andersson DA. TRP channel antagonists for
pain opportunities beyond TRPV1. Curr Opin Invest
Drugs 2009;10:655663.
5. Bleakman D, Alt A, Nisenbaum ES. Glutamate
receptors and pain. Semin Cell Dev Biol 2006;17:592
604.
6. Pezet S, McMahon SB. Neurotrophins: mediators and
modulators of pain. Annu Rev Neurosci 2006;29:507
538.
7. Fields RD. New culprits in chronic pain. Sci Am
2009;301:5057.
8. Julius D, Basbaum AI. Molecular mechanisms of
nociception. Nature 2001;413:203210.Figure 108.3.
Figure reproduced from Fields (2009) [7] with permission.
Section 12
Chapter
109
Intranasal morphine
Denis V. Snegovskikh
Generic Name: intranasal morphine (morphine

mesylate/chitosan)
Trade Name: Rylomine
Manufacturer: Javelin Pharmaceuticals, 125
Cambridge Park Drive Cambridge, MA 02140;
Javelin was recently acquired by Hospira, Lake
Forest, IL
Chemical Name: (5,6)-7,8-didehydro-4,5epoxy-17-methyl morphinian-3,6-diol
285.34
Introduction
Intranasal (IN) morphine (Rylomine) is a patientcontrolled nasal spray that delivers a single, metered
dose of Morphine. Rylomine is currently in phase 3
clinical development and may have use as a rapid-acting analgesic in both acute and chronic pain settings.
Description
Intranasal morphine provides rapid analgesic onset
(comparable to IV) together with a simple and
non-invasive way to control moderate to severe pain.
It consists of a combination of active ingredient morphine mesylate and ChiSys delivery system. ChiSys is
based on the use of chitosan to evenly disperse and
improve morphine absorption through the nasal
mucosa.
Chitosan is a cationic linear polysaccharide, composed of two monosaccharides: N-acetyl-d-glucosamine and d-glucosamine linked together by
glucosidic bonds [2]. Chitosan is obtained from partial deacetylation of chitin, which originates from
shells of crustaceans (e.g. crabs and prawns) and
forms positively charged salts when dissolved in
inorganic and organic acids [2,11]. Glutamate salt of
chitosan with a mean molecular weight of around
200 kDa and a degree of deacetylation of 8090% is
used for nasal delivery of drugs [2].
Mode of activity
Oral formulations of morphine are associated with
slow and variable onset of action, and provide unreliable analgesia in patients recovering from surgery.
Clinicians often rely on injectable or IV-PCA morphine to ensure rapid and effective pain relief. Injection of morphine often requires professional
assistance or hospitalization. Therefore, alternative
formulations of morphine that are easy to administer
by a patient or caregiver and deliver rapid onset of
action may provide significant medical benefits.
Morphine is a hydrophilic molecule that has very
low bioavailability when administered intranasally
(about 10% compared with IV administration) [2].
Limiting factors of nasal absorption are the polar
nature of molecules [5], drastic changes in pH of
local environment, and the presence of the enzymatic
system [8,9]. Mucociliary clearance mechanism is
another very important limiting factor that significantly decreases the amount of time during which
morphine is available for absorption [10]. Chitosan
can significantly improve transmucosal absorption
of morphine through different mechanisms:
Positively charged chitosan reacts with negatively
charged sialic acid residues of mucin of nasal
mucus (bioadhesive mechanism) [1]. As a result of
this strong interaction with nasal mucus layer and
epithelial cells, chitosan formulation slows
437
HO
Figure 109.1.
Me
HO
clearance of morphine by the mucociliary system,

providing a longer time for drug transport across
the nasal membrane [2].
In Caco-2 cell culture studies chitosan opened
transiently the tight junctions between cells, which
enables hydrophilic drug to pass through the
membrane by the paracellular route [2].
438
Median time to peak concentration (tmax) after

intranasal administration of morphine/chitosan combination is 1327 min and dose-dependent absolute
bioavailability is 60% to 83% (oral immediate-release
morphine: tmax 1 hour and absolute bioavailability 25%
to 35%) [3].
The pharmacokinetic profile of intranasal morphine is similar to that of IV morphine with respect
to plasma concentration of the drug and its metabolites [2]. Morphine plasma levels typically associated with analgesic efficacy (2040 ng/mL) are
attained as early as 510 minutes following intranasal administration [4]. Christensen et al. in a study
of 225 post-surgical dental patients (third molar
extraction) found that efficacy profile (onset, level
of analgesia, and duration of effect) of intranasal
morphine 15 mg was similar to that of IV morphine
7.5 mg. Analgesic superiority of IN morphine 15 mg
over placebo was evident 5 minutes after administration and persisted for 6 hours [5]. The duration
of analgesic effect (time to rescue medication) in
that study was 34 hours, similar in IN and IV
groups. Stoker et al. in a study of 187 post-surgical
patients found that IN morphine showed a significant linear dose response, and that a 3.75 mg dose
was not efficacious and a 30 mg dose caused excessive adverse events typical of systemically administered opioids (nausea, vomiting, hypotension and
oxygen desaturation) [3].
The metabolite profile obtained after IN administration of the chitosan-morphine combination and IV
morphine was essentially identical (M3G about 85%
and M6G about 15%). The level of both morphine-3glucoronide and morphine-6-glucoronide were only
about 25% of that found after oral administration of
morphine [2].
After administration of IN morphine every 6 hours
for 7 days the pharmacokinetics of morphine and its
metabolites were linear within each dose. Mean
plasma concentrations of morphine on day 7 were
comparable to those on day 1, indicating no significant accumulation. Steady-state plasma concentrations of morphine, M6G and M3G were reached after
48 to 72 hours of dosing [6].
Each nostril can hold only 150200 L of administered drug. It requires approximately 15 minutes for
the drug to clear the nasal passages. So attempting to
introduce additional drug will result in the drug either
being swallowed or dripping out of the nose [3,7].
Indications
Proposed indications for IN morphine are acute moderate-to-severe pain, including post-operative pain
(orthopedic [3], dental [5]) and breakthrough pain in
cancer and chronic non-cancer pain patients.
Contraindications
Proposed contraindication to IN morphine are similar to those for IV morphine.
No study was done on patients with acute upper
respiratory tract infection, allergic rhinitis, or chronic
nasal congestion.
Doses
A single-spray unit dose device delivers 7.5 mg of morphine mesylate intranasally in a 0.1 mL metered dose.
Based upon the results of the trial of IN morphine for
post-operative pain control in orthopedic patients [3]
the following doses can be recommended:
7.5 mg every 12 hours
15 mg every 23 hours
A 7.5 mg dose was better tolerated, but had inferior efficacy [3].
A second metered dose cannot be given earlier
than 15 minutes after the first dose [7].
1. Rapid onset, comparable to IV morphine
pharmacokinetics.
Chapter 109 Intranasal morphine
2. Non-invasive, simple way of administration. No

need for dedicated equipment and specialized
support.
3. Avoids GI metabolism, fewer GI side effects,
lower level of metabolites.
4. Safe, no significant accumulation after 1 week of
use, single-dose device limits abuse potential.
Currently is in phase 3 clinical development in the
USA; not approved by FDA.
Limited experience. Nasal administration may be
associated with irritation and congestion, and epistaxis.

Local adverse events
Dysgeusia (transient bitter taste), rhinitis, rhinorrhea
and nasal and throat discomfort, mostly mild to moderate in intensity [3].
Severity of symptoms is dose-dependent [2,3]. The
majority of symptoms occur at 5 and 15 minutes postdose, with few reported by 1 hour after IN dosing [3].
Systemic opioid-related adverse events

Similar to those seen with IV morphine, including
oxygen desaturation, nausea, vomiting, dizziness, and
hypotension. Oxygen desaturation after a single
dose (that was corrected with oxygen via nasal canula)
happened only after a 30 mg dose. All other symptoms
were mostly mild in intensity and showed a dose-
dependent pattern [3].
In the study of post-surgical dental patients who
were otherwise healthy, doses of IN morphine of
7.515 mg did not cause any changes in respiratory
rate or blood pressure. Only a mild transient decrease
in oxygen saturation relative to baseline was observed.
No patients required oxygen therapy [5].
References
1. Illium L, Dodane V, Iqbal K. Drug Deliv Technonol

2002;2(2):4043.
2. Illum L, Watts P, et al. Intranasal delivery of morphine.
J Pharmacol Exp Ther 2002;301:391400.
3. Stoker DG, et al. Analgesic efficacy and safety of
morphine-chitosan nasal solution in patients with
moderate-to-severe pain following orthopedic surgery.
Pain Med 2008;9:312.
4. Fisher A, Green G, et al. A Phase I Absorption Study of
Intranasal Morphine in Normal Volunteers. Javelin
Pharmaceuticals, Inc.
5. Christensen KS, et al. The analgesic efficacy and
safety of novel intranasal morphine formulation
(morphine plus chitosan), immediate release oral
morphine, intravenous morphine and placebo in a
postsurgical dental pain model. Pain Med 2008;
107(6):20182024.
6. Albin R, Green G, et al. A Phase I Single- and
Multiple-Dose Pharmacokinetic Study of Intranasal
Morphine in Healthy Volunteers. Javelin
Pharmaceuticals, Inc.
7. Sheckler MT, et al. Nasal Delivery of Analgesics. 2005.
Available at: http://www.ondrugdelivery.com/publicati
ons/NASAL%20FINAL%20Lo-res.pdf.
8. Hussain A, Faraj J, et el. Hydrolysis of leucine
enkephalin in the nasal cavity of the rat a possible
factor in the low bioavailability of nasally
administered peptides. Biochem Biophys Res Commun
1985;133:923928.
9. Lee VH. Enzymatic barriers to peptide and protein
absorption. Crit Rev Ther Drug Carrier Syst 1988:5:
6997.
10. Schipper NG, Verhoef JC, Merkus FW. The nasal
mucociliary clearance: relevance to nasal drug
delivery. Pharm Res 1991;8:807814.
11. Muzzarelli RAA. Chitin. In Muzzarelli RAA, ed.
Natural Chelating Polymers: Alginic Acid, Chitin and
Chitosan. New York: Pergamon Press, 1973, pp.
83252.
439
Section 12
Chapter
110
Intranasal ketamine
Generic Name: ketamine hydrochloride (for

intranasal administration)
Brand Name: Ereska
Drug Class: central-acting analgesic, NMDA
antagonist
Manufacturer: Javelin Pharmaceuticals, Inc.,
Cambridge, MA; Javelin was recently acquired
by Hospira, Lake Forest, IL
Molecular Formula: C13H16ClNO[HCl]
Description
Javelin Pharmaceuticals, Inc. (Cambridge, MA) has

conducted late-stage clinical trials evaluating Ereska
(intranasal [IN] ketamine HCl 150 mg/mL) as a sole
analgesic agent for acute pain and cancer breakthrough pain (BTP) in patients on chronic opioid
therapy. Ereska is an aqueous solution of 15% w/v
ketamine hydrochloride (equivalent to 13% w/v ketamine base), with an antimicrobial preservative. It is
administered using a bi-dose nasal delivery device
that delivers two sprays per device (one spray in each
nostril, 90 seconds between sprays) for a total unit
dose of 0.2 mL or 30 mg of ketamine hydrochloride
(equivalent to 26 mg ketamine base) (Figure 110.2).
Mode of activity
440
Ketamine is a rapid-acting dissociative anesthetic first

approved 40 years ago for animals and humans,
and in continuous use since. At anesthetic doses (several mg/kg) it produces a cataleptic state with nystagmus and intact corneal and light reflexes, and
maintenance of ventilatory drive as well as blood pressure even in hypovolemic subjects [1]. The latter properties make it a potentially attractive alternative to
morphine or other opioids in civilian emergency, mass
casualty, or military settings. Soon after ketamines

introduction into clinical practice it was observed that
analgesia often persists long after its anesthetic effects
subside, and can be achieved in awake subjects given
subanesthetic doses (0.250.5 mg/kg). More recent
investigations have indicated that plasma ketamine
concentrations in the range of 50150 ng/mL are
analgesic and also potentiate opioid analgesia with little
or no psychological effects [2]. For additional information, please refer to the chapter on injectable ketamine.
The physiology of the nasal mucosa makes it an
ideal environment for rapid, non-invasive delivery
of systemic drugs. Its large surface area, uniform
temperature, vascularity, and high permeability
facilitate rapid and predictable absorption of drugs
into the bloodstream. A number of drugs in current
clinical use are effective when administered IN. To
provide analgesia by delivering subanesthetic doses
of ketamine via the IN route requires a suitable drug
formulation and metered dose delivery system.
Using such a system, clinical trials of intranasal ketamine have demonstrated that close to half of a 30 mg
IN dose is bioavailable. Once absorbed into the
bloodstream, ketamine is rapidly distributed into
brain and other highly perfused tissues, in which it
may reach levels 4- to 5-fold higher than plasma. The
initial distribution phase from plasma to peripheral
tissues occurs with a half-life of 711 minutes. The
plasma half-life is between 2 and 3 hours. Norketamine is the primary active metabolite of ketamine,
and produces effects similar to those of ketamine
although with only about 1/5 to 1/3 the potency of
the parent compound.
Ketamine, a non-opioid, inhibits the excitatory
effects of the endogenous excitatory amino acid neurotransmitter glutamate upon the NMDA receptor. The
NMDA receptor plays a key role in the development of
sensitization, hyperalgesia, and tolerance to the analgesic effects of opioids, as well as in certain preclinical
models of neurotoxicity. We have demonstrated that
Chapter 110 Intranasal ketamine
our proprietary formulation can minimize or avert

neurotoxicity observed in animal models in response
to various NMDA receptor antagonists including conventionally formulated ketamine. The pharmacology
and analgesic mechanisms of ketamine, the indications
and contraindications for the approved injectable formulation, and its potential for neurotoxicity are
reviewed elsewhere in this volume. Novel, intriguing
mechanisms of ketamines actions currently under
exploration include anti-inflammatory properties as
well as acute, beneficial effects upon CNS systems that
regulate mood.
Since our intranasal ketamine product candidate

delivers subanesthetic doses, emergence reactions
observed in some patients following general anesthesia with high doses of injectable ketamine are not
expected nor have been observed in clinical studies to
date. Indeed, the Side Effects Rating Scale for Dissociative Anesthetics, an instrument used to characterize dissociative effects (fatigue, dizziness, nausea,
headache, feeling of unreality, change in hearing,
change in vision, mood change, generalized discomfort, and hallucination), has been applied during the
early clinical development of IN ketamine. Most subjects reported no dissociative effects post-dosing and
of those who did, the majority were weak or modest in
severity. Local nasal effects of IN ketamine have likewise been mild and transient. On the other hand, caution should be used whenever ketamine or any other
scheduled drug is administered via any route to
patients with a history of substance abuse.
Indications/contraindications
Efficacy and safety
Figure 110.1.
CH3
NH
HCl
O
Cl
Substantial published literature ranging from cases

and case series through meta-analyses of randomized
controlled trials describes the parenteral administration of subanesthetic doses of ketamine to provide
analgesia in patients with acute pain such as burn
pain, chronic pain such as neuropathic pain, and cancer-related pain as both a stand-alone analgesic as well
as an adjuvant to opioids [5].
At anesthetic or analgesic doses, ketamine has a wide

margin of safety and has little impact upon cardiovascular and respiratory function even in physiologically
compromised populations. Preservation, even stimulation, of blood pressure and pulse rate are seen with
high doses of ketamine; such changes are minimal
when very low doses are given. This pattern contrasts
with the hypotension and/or bradycardia often seen
Figure 110.2. Bi-Dose Nasal Spray
System prototypes for ketamine nasal
delivery.
441
with exposure to volatile anesthetizing agents, barbiturates, benzodiazepines, and opioids. Ketamine is
effective for alleviating pain refractory to opioids, such
as acute or chronic neuropathic pain, and compared
with opioids its use is less likely to be associated with
issues of tolerance and physical dependence. The clinical literature on multimodal analgesia indicates that
besides NSAIDs, only ketamine is proven to decrease
pain intensity while simultaneously reducing the
requirement for opioids sufficiently to decrease opioid-related side effects.
The bi-dose delivery system for our intransal ketamine product candidate provides non-invasive (i.e.
needle-free) administration compared to IV or IM
injections, via a rugged, simple to use device that can
be patient-administered if necessary. Each disposable device delivers a total of 30 mg ketamine with
well-characterized, predictable pharmacokinetics.
This approach to delivering subanesthetic doses of
ketamine may be particularly advantageous in emergency situations where convenience, speed of drug
delivery/onset, and avoidance of accidental needle
sticks in healthcare providers are desirable. In addition, our intranasal ketamine product candidate was
formulated to minimize neurotoxicity, a question
that has been raised regarding the differently formulated ketamine product currently approved for
anesthesia.
Our intranasal ketamine product candidate is
being developed for the management of acute moderate to severe pain, as well as BTP in patients on
chronic opioid therapy. Pilot studies in both of these
pain models, using the exploratory formulation of
Ereska, have yielded encouraging results for safety
and efficacy. A randomized, double-blind, singledose parallel study [3] tested 10, 30 and 50 mg IN
doses in 40 patients with acute post-operative pain

following surgical removal of 24 impacted third
molars (see Table 110.1). Dose-dependent analgesia,
statistically superior to placebo, was observed over a
3-hour period. Analgesia was rapid (< 10 minutes)
and meaningful pain relief was achieved within 15
minutes of the 50 mg dose. Safety was evaluated
through adverse event reporting, vital signs, pulse
oximetry, nasal assessments, and a standard dissociative side effects questionnaire. The majority of adverse
events were mild/weak and transient. No untoward
effects were observed on vital signs, pulse oximetry,
and nasal examination. At the doses tested, no significant dissociative effects were evident using the
Side Effects Rating Scale for Dissociative Anesthetics.
Comparing results from this study and a separate
study of morphine analgesia in the same molar extraction model, we estimated that 30 mg of IN ketamine
had approximately the same analgesic effect as 5 mg
IV morphine (Table 110.1).
A second exploratory study [4] found encouraging
results in 20 patients with BTP chronically treated
with opioids (> 60 mg/day of morphine or equivalent).
Each patient had two BTP episodes at least 48 hours
apart treated in a double-blind fashion with IN ketamine or placebo in a randomized, crossover design.
Patients reported significantly greater declines in BTP
pain intensity with IN ketamine than IN placebo (P <
0.0001), with pain relief evident within 10 minutes of
dosing and persisting during the full 60 minutes of
post-dose observation. Table 110.2 shows other key
findings of this study. Repeated IN dosing has been
shown to be feasible in our more recent unpublished
clinical trials, although acute IN drug dosing is limited by the absorptive capacity of the nasal mucosa
(acutely, about 400 L).
Table 110.1. Intranasal ketamine for acute pain after extraction of impacted molars: TOTPAR scores across 1 and 3 hours (with
permission from reference 3)
442
TOTPAR1 (VAS)
TOTPAR3 (VAS)
Placebo
8.5 + 8.1
10.8 + 10.4
IN ketamine 10 mg
24.3 + 27.3
91.6 +109.1
IN ketamine 30 mg
24.4 + 26.3
61.7 + 71.0
IN ketamine 50 mg
46.0 + 28.4
122.3 + 97.7
All values reported as mean SD. VAS, visual analog scale.

For TOTPAR1, intergroup differences were significant (P = 0.013 by ANOVA). The 50 mg dose separated from placebo (P < 0.01 by Dunnetts,
Tukeys, and Duncans tests).
For TOTPAR3, intergroup differences were significant (P = 0.028 by ANOVA). The 10 and 50 mg doses separated from placebo (P < 0.05 by
Duncans test).
Chapter 110 Intranasal ketamine
Table 110.2. Intranasal ketamine decreased breakthrough pain in 20 patients on chronic (>6 weeks) opioid therapy (with
permission from reference 4)
Endpoint
IN ketamine
IN placebo
Pain intensity decrease (mean + SD)
2.65 + 1.87
0.81 + 1.01
P < 0.0001
40% decrease in pain intensity
45%
5%
P = 0.0078
Rescue medication use during testing session
0%
35%
P = 0.0135
Pain intensity assessed using a 010 numerical scale
In summary, subanesthetic doses of ketamine are

now used increasingly in anesthesia practice as part of
multimodal regimens for acute pain, as well as add-on
therapy in selected patients with chronic pain. Our
intranasal ketamine product candidate provides a
simple, non-invasive alternative to the present invasive (IM, IV) methods of systemic administration of
low-dose ketamine, and has the potential to make this
agent available on a broader scale. However, it is still
under development and the final assessment of its
benefits and risks will await completion and integration of the results of its entire clinical investigative
program.
References
Acknowledgments
4. Carr DB, Goudas LC, Denman WT, et al. Safety and

efficacy of intranasal ketamine for the treatment of
breakthrough pain in patients with chronic pain: a
randomized, double-blind, placebo-controlled,
crossover study. Pain 2004;108:1727.
The clinical studies described herein were supported

in part by a contract from the United States Department of Defense (DAMD 1700-11712; acute pain)
and a grant from the NIH/NCI (1-R43-CA-8663001;
breakthrough pain).
1. White PF, Way WL, Trevor AJ. Ketamine its

pharmacology and therapeutic uses. Anesthesiology
1982;56:119136.
2. Tucker AP, Kim YI, Nadeson R, Goodchild CS.
Investigation of the potentiation of the analgesic
effects of fentanyl by ketamine in humans: a doubleblinded, randomized, placebo controlled crossover
study of experimental pain. BioMed Central
Anesthesiol 2005;5:2.
3. Christensen K, Rogers E, Green GA, Hamilton DA,
Mermelstein F, Liao E, Wright C, Carr DB. Safety and
efficacy of intranasal ketamine for acute postoperative
pain. Acute Pain 2007;9:183192.
5. Visser E, Schug SA. The role of ketamine in pain

management. Biomed Pharmacol 2006;60:341348.
443
Section 12
Chapter
111
Inhaled fentanyl
Dana Oprea
Generic Name: inhaled (transpulmonary) fentanyl

Proprietary Name: AeroLEF; Fentanyl
TAIFUN
Class: opioid analgesic
Manufacturers: YM Biosciences, 5045 Orbitor
Drive, Building 11, Suite 400, Mississauga,
Ontario; Akela Pharma Inc (Formally LAB
Pharma), 11501 Domain Drive, Suite 130 Austin, TX 78758
Chemical Name:N-phenyl-N-(1-(2-phenylethyl)4-piperidinyl) propanamide
Chemical Formula: C22H28N2O; molecular wt
336.4
Introduction
Fentanyl is a synthetic opioid analgesic, introduced in
the 1950s, that has enhanced analgesic activity and
potency and fewer adverse effects compared with morphine or meperidine. Structurally related to meperidine, fentanyl gained wide popularity as an intra-operative
anesthetic adjunct as well as an effective analgesic for
the management of acute and chronic pain.
Description
444
Fentanyl is highly lipophillic, has a rapid onset of

action, and does not release histamine. It has a dosedependent duration of action, with small bolus doses
providing 30 minutes of pain relief and large boluses
and continuous infusions providing highly extended
durations of activity. Fentanyl is 100 to 300 times more
potent than morphine, allowing a low therapeutic
blood concentration of approximately 0.6 to 3 ng/mL
for analgesia [1]. Given its stable cardiovascular profile, fentanyl became popular in many settings including critically ill patients. Its high lipid solubility and a
pattern of rapid and extensive redistribution make it

an ideal agent to be delivered through alternate routes
other than the traditional intravenous or intramus
cular ones. Alternative delivery methods include
transdermal, buccal, intranasal, and sublingual
administration for maintenance and breakthrough
management of chronic pain. A new method of fentanyl administration, termed inhaled or transpulmonary administration, may offer the benefits of
extremely rapid onset, convenience, and reliability for
acute pain and sudden onset breakthrough pain in
chronic pain settings.
Pharmacokinetics of inhaled fentanyl

Higgins et al. [2] assessed the effects of three concentrations of inhaled nebulized fentanyl citrate solution
given for post-operative pain relief. Among the 30
studied patients, the patients inhaling a more concentrated solution of fentanyl citrate over 9 minutes
showed a moderate analgesic response within 5 min of
inhalation. In this study inhaled fentanyl did not prove
more effective than the other parenteral formulations.
Inhalation of 300 g of fentanyl from the nebulizer
produced a peak concentration of 0.4 ng/mL at 2 min
and a plateau concentration of 0.1 ng/mL at 15 min,
while with inhalation of 100 g, blood levels remained
stable at 0.02 ng/mL.
Another small study assessed the effectiveness of
fentanyl delivered by aerosol for post-operative analgesia. The seven patients receiving 300 pg of inhaled
fentanyl had a significant improvement versus patients
receiving 100 pg. There were no adverse effects such as
respiratory depression, bronchospasm, nausea or
drowsiness reported in this study [3].
Mather et al. [4] also studied the use of aerosolized
pulmonary fentanyl in healthy volunteers using
SmartMist. In this study, plasma concentrations from
SmartMist were similar to those from the intravenous injection, with a bioavailability averaging ~100%
within 5 minutes of delivery.
Chapter 111 Inhaled fentanyl
Figure 111.1.
CH3
O
provides very rapid increases in plasma concentrations and appropriate therapeutic plasma concentrations (0.5 to 2 ng/mL) are achieved during inhalation
dosing (Figure 111.3). Fentanyl TAIFUN is a fastacting fentanyl formulation delivered using the
TAIFUN dry powder inhaler platform.
Indications
Acute pain
Based on these prior studies, a liposome-encapsulated drug carrier system has been developed in order
to overcome fentanyls short duration of action. Liposomes are microscopic vesicles composed of an aqueous compartment surrounded by a phospholipid
bilayer that acts as a permeable barrier to entrap molecules. Incorporation of a drug within a liposome provides a controlled, sustained release system.
In Hungs preliminary study [5] comparing nebulizer and intravenous administration of fentanyl,
delivery of 2000 g of a nebulized mixture of free
(50%) and liposomal-encapsulated (50%) fentanyl
(FLEF) to volunteers resulted in a peak plasma concentration of 1.15 ng/mL at 22 min. One important
feature of the FLEF was that the plasma concentration
decreased slowly after the single 2000 g dose. At 8
and 24 h after inhalation, fentanyl concentration values were 0.25 0.14 ng/mL and 0.12 0.16 ng/mL,
respectively (Figure 111.2).
In a subsequent study by the same author, five
doses of 4000 g FLEF were administered at 12-h
intervals. The time to reach the peak concentration
after each administration ranged from 12.5 to 19.2
min and the fentanyl concentration was maintained
within the analgesic therapeutic concentration (0.63
ng/mL). The bioavailability of inhaled FLEF is 1220%,
which is consistent with the bioavailability of most
drugs administered via the pulmonary system
(1020%).
Two inhaled fentanyl preparations are currently
under investigation. AeroLEF is mixture of free and
liposome-encapsulated fentanyl delivered through
breath-actuated nebulizers. It is designed to rapidly
achieve therapeutic concentrations through absorption of the free component, followed by release of fentanyl from liposomes and continued pulmonary
absorption to extend the duration of action. Inhalation of small doses of free fentanyl in AeroLEF
AeroLEF has been specifically designed by YM Biosciences to provide rapid and extended analgesia. It is
currently in development for the treatment of moderate to severe acute pain. AeroLEF is an investigational
drug in late-stage clinical development and has already
undergone phase I and phase II trials. During the
phase I trial, ten healthy, non-smoking, opiate-naive
volunteers received an intravenous (IV) dose of 200
g fentanyl in the first arm of the study and a 3 mL
dosage of AeroLEF (500 g/mL) delivered by the
AeroEclipse breath-actuated nebulizer in a subsequent arm of the study with a washout period separated by at least 1 week.
Following the initiation of AeroLEF inhalation,
plasma concentrations of fentanyl rapidly entered the
therapeutic range within minutes, with the majority of
subjects attaining maximum plasma concentrations in
10 minutes.
Administration of 1500 g of AeroLEF and 200
g of IV fentanyl achieved similar fentanyl concentrations; the achievement of maximal concentration of
fentanyl within the dosing period allows subjects to
safely administer therapeutic doses of fentanyl with
AeroLEF and offers the potential for the patient to
individualize the consumed dose of AeroLEF
matched to their perception of meaningful analgesia
during dosing.
Preliminary data from an eight-center, two-part
phase IIb open label study suggests that AeroLEF is
superior to placebo for providing post-operative pain
relief in opioid-naive patients following orthopedic
surgery. AeroLEF met the primary endpoint of the
study, showing a statistically significant difference in
SPRID4 (sum of combined changes in pain relief and
pain intensity reported over the first 4 hours following
initiation of dosing) from placebo.
A median time of onset of effective analgesia of 9.0
to 23.4 minutes was seen in patients with moderate to
severe pain following a range of orthopedic surgeries
across eight different clinical trial sites.
445
12
Figure 111.2. Rate of absorption of

fentanyl after inhalation of the mixture of
free and liposome-encapsulated fentanyl.
(With permission from Hung OR, Whynot
SC, Varvel JR, Shafer SL, Mezei M.
Anesthesiology. 83(2):277284, August
1995.) [5]
12
10
Rate of Absorption of Fentanyl (ug/min)
10
8
6
4
2
0
-2
15
30
45
60
-2
60
120
180
240
300
1500
Time (min)
Proprietary
AeroLEF
Formulation
TM
Anesthesiology
Rapid and
Extended
Plasma Levels
Patient
Inhalation by
Nebulization
Plasma Fentanyl (ng/ml)
(Free + Encapsulated Fentanyl)
2.5
2
1.5
1
0.5
0
10
20
30
40
Time (minutes)
50
60
Figure 111.3. Uptake of fentanyl using the AeroLEF formulation.
446
Achievement of effective analgesia was the reason

for stopping AeroLEF dosing in 88% of treated pain
episodes.
A two-center, open-label study of 19 patients who
had undergone anterior cruciate ligament surgery
reported that 18 out of 19 subjects (95%) had reported
a decrease in pain intensity at the end of dosing.

Patients were allowed access to up to two nebulizers,
each containing a 3 mL dosage of AeroLEF (500 g/mL).
AeroLEF self-administration achieved plasma fentanyl concentrations within the normal therapeutic
range. The free fentanyl led rapidly to analgesic effects
Chapter 111 Inhaled fentanyl
(mean time of 5 minutes) and liposomal fentanyl

allowed for long-lasting analgesia in most patients
(mean time of 3.7 hours).
Breakthrough cancer pain

Fentanyl TAIFUN was developed for treatment of
breakthrough cancer pain. When compared with
other dosage forms used for the treatment of breakthrough pain, the inhalation route offers greater convenience and a more rapid onset of pain relief.
The results support clinical efficacy already at the
lowest dose of 100 g and a trend of dose-response
relationship. The safety of Fentanyl TAIFUN was
similar to that of placebo, with the exception of an
increase in mild to moderate somnolence. The
TAIFUN metered inhaler is depicted in Figure 111.4.
The multi-centered, randomized, double-blind,
placebo-controlled, parallel group trial of 122 cancer
patients on maintenance opioid therapy was undertaken to establish formal dose-response data of Fentanyl TAIFUN. The primary variables were the time to
significant pain relief and the degree of pain relief.
Fentanyl TAIFUN was administered at doses of 100,
200, and 400 g per dose during two episodes of
breakthrough pain with rescue medication available
upon request.
The time to significant pain relief was achieved on
average in 7.8 to 11.6 minutes, depending on the dose.
The difference from placebo was statistically significant
with the 100 g and 400 g doses of Fentanyl TAIFUN.
Similarly, the degree of pain relief measured as the
Sum of Pain Intensity Difference (SPID) was significantly better with Fentanyl TAIFUN compared to
placebo.
Preliminary data suggest positive results from the
open-label arm of its Fentanyl TAIFUN phase IIb
clinical trial. The results from 24 patients demonstrated successful dose titration resulting in effective
control of breakthrough pain episodes.
All 24 patients were successfully titrated to a dose

of 400 g or less. From these first 24 patients, nine
patients titrated to 100 g, ten patients titrated to 200
g and only five patients titrated to 400 g. The patients
experienced significant pain relief in 95% of the pain
episodes treated. The estimate of the median time to
significant pain relief was 7 minutes. Based on the
interim adverse event data, Fentanyl TAIFUN doses
have been well tolerated and adverse events recorded
were in accordance with previously disclosed Fentanyl
TAIFUN clinical trial data, therefore suggesting high
tolerability of Fentanyl TAIFUN in opioid-tolerant
cancer patients.
The phase III trials are ongoing.
Inhaled fentanyl offers certain advantages:
(1) simple and non-invasive route of administration;
(2) rapid onset of analgesia from rapid pulmonary
absorption of free fentanyl;
(3) extended analgesia from continued release of
liposome entrapped fentanyl (AeroLEF);
(4) personalized, self-titratable dosing.
In addition, the problems inherent in delivering
analgesia to a patient with difficult intravenous
access, to a patient who would not need an intravenous line except to receive pain medication, or in the
out-of-hospital setting make the idea of having an
effective inhaled analgesic very attractive. Inhaled
fentanyl may also be able to be given more quickly
than intravenous analgesia and the equipment costs
of nebulizers compare favorably with the cost of the
supplies needed for intravenous administration.
Inhaled fentanyl also proved to be beneficial in the
pediatric population, where it is easy to administer
and does not cause additional pain or distress to the
child.
Figure 111.4. The TAIFUN metereddose intrapulmonary fentanyl inhaler.
447
Dyspnea, which occurs in 70% of terminally ill

cancer patients, may be significantly improved by
inhaled nebulized fentanyl citrate, as well as the respiratory rate and oxygen saturation.
Inhaling medications has certain limitations. Patients
may find nebulizers cumbersome, noisy, and timeconsuming and some dislike the face mask. Nebulization is also an inefficient way of administering drugs,
although the dose can be increased (200 mg fentanyl
citrate can be delivered in 4 mL of solution).
Side effects
Fentanyl inhalation does not cause any clinically significant adverse events and is comparable to intravenous fentanyl in terms of safety, tolerance, and
preservation of pulmonary function.
Subjects reported feelings of sedation, relaxation,
difficulty concentrating, tiredness, lightheadedness,
vagueness, mild disorientation, heaviness in limbs,
mental slowness, and pruritus after both routes of
Section 12
Chapter
112
448
fentanyl
administration: these side effects are typical
of fentanyl. After the intrapulmonary route, there are
reports of an unpleasant taste in the mouth and dryness of the mouth. Both side effects and subjective
effects increased as the dose increased.
References
1. Peng PW, Sandler AN. A review of the use of fentanyl

analgesia in the management of acute pain in adults.
2. Higgins MJ, Asbury AJ, Brodie MJ. Inhaled nebulised
fentanyl for postoperative analgesia. Anaesthesia
1991;46(11):973976.
3. Worsley MH, MacLeod AD, Brodie MJ, Asbury AJ,
Clark C. Inhaled fentanyl as a method of analgesia.
Anaesthesia 1990;45(6):449451.
4. Mather LE, Woodhouse A, Ward ME, Farr SJ,
Rubsamen RA, Eltherington LG. Pulmonary
administration of aerosolised fentanyl:
pharmacokinetic analysis of systemic delivery.
Br J Clin Pharmacol 1998;46(1):3743.
5. Hung OR, Whynot SC, Varvel JR, Shafer SL, Mezei M.
Pharmacokinetics of inhaled liposome-encapsulated
fentanyl. Anesthesiology 1995;83(2):277284.
Hydromorphone extended-release
Ira Whitten
Generic Name: hydromorphone extended release

(ER)
Proprietary/Trade Names: Pallidone, Exalgo
Drug Class: opioid analgesic, class II
Manufacturers: Purdue Pharma Inc, 1 Stamford
Forum, Stamford, CT; Neuromed Pharmaceuticals Inc; Covidien (a division of Mallinckrodt)
15 Hampshire Street, Mansfield, MA 02048
Chemical Name: 4,5-epoxy-3-hydroxy-17

methylmorphinan-6-one hydrochloride
Introduction
Hydromorphone is a potent semi-synthetic opioid
analgesic that is available in oral, rectal, and parenteral
formulations for control of moderate to severe pain.
Chapter 112 Hydromorphone extended-release
CH3
N
Figure 112.1.
CH2
H
CH2
OH
HCl
It is prescribed as an analgesic for both acute postoperative pain and for chronic pain. Refer to chapter
for additional information regarding use of immediate release preparations in pain medicine.
Mode of action
Hydromorphone binds to opioid receptors in the
central nervous system to produce dose-dependent
analgesia. Binding at receptors is also responsible for
many of its its side effects including euphoria, pruritus,
nausea, decreased GI motility, and constipation. Respiratory depression, the most troubling adverse event
associated with hydromorphone, can be reversed with
opioid antagonists such as naloxone.
Hydromorphone is similar in structure to morphine, yet it has higher lipid solubility and four to six
times greater oral and parenteral analgesic potency.
Hydromorphone has been available for many years in
an oral immediate-release (IR) formulation for the
treatment of acute and chronic pain, yet this form
requires repeated dosing throughout a 24 hour period.
Immediate-release oral formulations of hydromorphone have high oral bioavailability (62%), an onset of
effect within 30 minutes and a peak effect within 1
hour of ingestion. Hydromorphone is 20% proteinbound and its respective plasma and tissue distribution half-lives are 1.3 and 14.7 minutes. Hydromorphone
is primarily metabolized in the liver by conjugation to
form the metabolites hydromorphone-3-glucoronide,
dihydroiosmorphine, and dihydromorphine. Excretion of the drug occurs via the kidneys, where approximately 13% is excreted as the unchanged parent
compound and 2251% as conjugated hydromorphone metabolites. Total body clearance is 1.66 L/min,
resulting in an elimination half-life that is 2.5 hours
for the oral immediate-release formulation, which
necessitates repeated administration every 46 hours
[13].
Recently two new formulations of extended-release
hydromorphone, Palladone and Exalgo, have been
developed for the treatment of chronic pain in opioidtolerant patients. Extended-release hydromorphone
may offer dosing convenience over IR preparations,
and a more potent alternative to extended-release
morphine and oxycodone.
Extended-release hydromorphone
formulations
Two formulations of extended-release hydromorphone have been evaluated and filed for FDA approval
in the USA. These formulations have been marketed
under the names Palladone, manufactured by Purdue Pharma Inc., and Exalgo, produced by Neuromed Pharmaceuticals Inc. Palladone was initially
approved for sale in the USA in 2004, but was voluntarily withdrawn from the market due to safety concerns. Exalgo is currently in the final stages of FDA
approval as a once-daily administered analgesic for
the management of chronic pain.
Palladone capsules are formulated using a controlled-release melt extrusion technology combining
hydromorphone HCl with polymers to form pellets,
which are then loaded into gelatin capsules. The capsules are designed to provide uniform, controlled
release of hydromorphone over a 24 hour period and
are produced in 12, 16, 24, and 32 mg dosages. Pharmacokinetic studies of Palladone demonstrated that a
steady-state level is reached in 2 to 3 days and the formulation has an elimination half-life of approximately
18.6 hours.
In clinical trials, Palladone dosages were shown
to be equivalent to cumulative dosages of immediaterelease hydromorphone. When a 12 mg dose Palladone capsule given every 24 hours was compared to a
3 mg dose of immediate-release hydromorphone given
every 6 hours the two drug formulations were found
to be equivalent and Palladone showed lower steadystate peak levels, higher trough levels, and a reduction
in plasma level fluctuation (Figure 112.2) [3]. The distribution pharmacokinetics following administration
of Palladone show a biphasic level of drug in which
there is a rapid plasma peak of drug followed by a prolonged broad second peak at therapeutic levels. The
advantage to this form of dosing over immediate-
release hydromorphone is that this extended-release
formulation achieves a prolonged steady therapeutic
level without the peak and trough effects of 6 hour
dosing.
Palladone was initially approved by the FDA in
2004 for use in opioid-tolerant patients who required
449
Concentration, ng/mL
Figure 112.2. The pharmacokinetic

profile of Palladone shows that at
steady-state this formulation provides a
constant therapeutic level of drug with
less pronounced peak and trough levels
compared to immediate-release
hydromorphone.
0
0
10
Immediate-release
hydromorphone 3 mg q6h
450
12
14
Hours
16
18
20
22
24
PalladoneTM 12 mg q24h
prolonged therapy for chronic pain. Subsequent

research by the manufacturer showed that when Palladone is combined with alcohol in vitro there is
increased breakdown of the capsules resulting in rapid
release of the hydromorphone salt. It was proposed
that if this were to occur in patients that this dose
dumping could lead to respiratory depression and
death [6]. A subsequent study in healthy volunteers
showed that when this extended-release formulation
was taken with a solution of 40% alcohol there was on
average a 5.5-fold maximum systemic exposure [7].
While no ethanol-related overdose events were found
to have occurred in post-marketing surveillance, the
manufacturer voluntarily withdrew the medication
from the market. It is unclear at this time whether Palladone will be modified, reapproved, or remarketed.
Exalgo is an extended-release formulation of
hydromorphone HCl manufactured by Covidien in
conjunction with Neuromed Pharmaceuticals. This
preparation is currently in the final stages of FDA
approval for sale in the USA. Exalgo employs the
OROS push-pill oral osmotic delivery system to
accurately deliver hydromorphone at a constant rate
over a 24 hour period. Osmotic delivery of hydromorphone has been shown to deliver consistent amounts
of drug over a 24 hour period and to achieve steadystate drug levels within 48 hours of initial dosing.
Exalgo will be available in 8, 16, 32, and 64 mg dosages for once-daily administration.
A study comparing the conversion of morphine
sulfate to OROS ER hydromorphone in patients with
chronic cancer pain showed that patients were able to

successfully convert from morphine to hydromorphone over a short time period and that the long-acting formulation provided adequate 24 hour pain relief
with lower overall pain scores [8]. Patients were easily
converted using a morphine-to-hydromorphone conversion ratio of 5:1, and without prior conversion to
immediate-release hydromorphone. Follow-up studies also demonstrated ease of conversion, safety, and
efficacy of extended-release hydromorphone in the
treatment of non-malignant chronic pain [8,9].
Exalgo, like Palladone, provides stable plasma concentrations with less fluctuation in drug level compared to immediate-release formulations that are
dosed every 46 hours [89]. The pharmacokinetic
profile of the OROS push-pill hydromorphone formulation has also been shown to be independent of
whether the patient takes the medication with food or
not [10]. Initial studies of OROS hydromorphone
show that taking this medication with alcohol has only
a minimal effect on drug release and no dose dumping was observed in volunteers [11]. With the
approval of Exalgo, practitioners will have a true
once-daily medication for the treatment of chronic
pain with less danger of rapid drug release.
Indications
The Exalgo formulation of hydromorphone ER is
proceeding toward FDA approval for the treatment of
moderate to severe chronic pain in opioid-tolerant
Chapter 112 Hydromorphone extended-release
patients. Extended- release hydromorphone may be

indicated for the treatment of chronic pain secondary
to cancer, back pain, osteoarthritis, and other medical
conditions [310].
Studies of patient medication compliance have
shown that complex administration schedules or use
of a medication requiring repeated dosing throughout
the day significantly decreases the level of patient
compliance. The advantage of extended-release hydromorphone over immediate-release hydromorphone is
the convenience of once-daily dosing compared to
repeated dosing every 46 hours. Extended release
hydromorphone also offers the ability to achieve a
prolonged therapeutic level of drug while avoiding
fluctuations in plasma/CNS concentrations. This may
reduce the incidence of adverse events seen with peak
plasma levels and avoid increasing pain noted with
trough levels [3,4].
Contraindications
This medication is absolutely contraindicated in
patients who have a hypersensitivity or allergy to
hydromorphone or other opioids. Hydromorphone is
relatively contraindicated in those with acute or severe
asthma or COPD, conditions in which there is
decreased ventilatory function, intracranial lesions or
conditions associated with increased ICP, known or
suspected paralytic ileus, or conditions resulting in
respiratory depression or impairment. Patients with
severe renal and/or hepatic impairment should be
closely monitored for signs of respiratory depression
as severe organ dysfunction may lead to poor drug
metabolism and increase drug levels [3].
Adverse effects
The adverse effects of extended-release hydromorphone are similar to other opioid medications; with
constipation, nausea, vomiting, pruritus, and urticaria
being common. Other possible side effects include
confusion, somnolence, euphoria, and respiratory
depression. Respiratory depression is the most dangerous side effect of hydromorphone as it may result
in hypoxia, coma, and death. Hydromophone should
be used with caution in patients taking other CNS
depressant medications. High doses of hydromorphone can result in the accumulation of neuroexcitatory metabolites which may cause seizures and
myoclonus. One advantage over morphine is that
hepatic metabolites of hydromorphone have minimal
analgesic or respiratory depressant activity.
Extended-release hydromorphone, like other opioid-based medications, has a strong risk of physical
dependence and abuse. In this regard the FDA labels
hydromorphone as a Category C [3].
This medication should only be used in opioidtolerant patients for the treatment of moderate to
severe chronic pain. Patients must be instructed not to
crush or adulterate the preparation as this could lead
to acute toxicity.
References
1. Barash PG, ed. Clinical Anesthesia, 6th ed. Philadelphia:

Lippincott Williams & Wilkins, 2005, pp. 465497.
2. Weinstein SM. A new extended release formulation
(OROS) of hydromorphone in the management of
pain. Ther Clin Risk Manage 2009:5 7580.
3. Palladone medication guide.
www.purduepharma.com.
4. Drover DR, Angst MS, Valle M, Ramaswamy B, Naidu S,
Stanski DR, Verotta D. Input characteristics and
bioavailability after administration of immediate and a
new extended-release formulation of hydromorphone in
healthy volunteers. Anesthesiology 2002;97(4):82736.
5. Angst MS, Drover DR, Lotsch J, et al.
Pharmacodynamics of orally administered sustainedrelease hydromorphone in humans. Anesthesiology
2001;94(1):6373.
6. FDA alert: Alcohol-Palladone Interaction;
www.fda.gov.
7. Walden M, Nicholls FA, Smith KJ. The effect of
ethanol on the release of opioids from oral prolongedrelease preparations. Drug Dev Industr Pharm
2007;33:11011111.
8. Vashi V, Harris S, El-Tahtawy A, Wu D, Cipriano A.
Clinical pharmacology and pharmacokinetics of
once-daily hydromorphone hydrochloride extendedrelease capsules. J Clin Pharmacol 2005;45(5):547554.
9. Palangio M, Northfelt DW, Portenoy RK, Brookoff D,
Doyle RT Jr, Dornseif BE, Damask MC. Dose
conversion and titration with a novel, once daily,
OROS osmotic technology, extended-release
formulation in the treatment of chronic malignant or
nonmalignant pain. J Pain Symptom Manage
2002;23(5):355368.
10. Sathyan G, Xu E, Thipphawong J, Gupta SK.
Pharmacokinetic profile of a 24-hour controlled-release
OROS formulation of hydromorphone in the presence
and absence of food. BMC Clin Pharmacol 2007;7:2.
11. Sathyan G, Sivakumar K, Thipphawong J.
Pharmacokinetic profile of a 24-hour controlled-release
OROS formulation of hydromorphone in the presence
of alcohol. Curr Med Res Opin 2008;24(1):297305.
451
Section 12
Chapter
113
Hydrocodone extended-release
Thomas Wong
Generic Name: hydrocodone bitartrate/acetaminophen (HC/APAP)

Trade Name: Vicodin Controlled Release,
Vicodin CR
Manufacturer: Abbott Laboratories, Abbott
Park, IL
Chemical Structure of hydrocodone: see Figure
113.1
Chemical Name: 4,5-epoxy-3-methoxy-17methylmorphinan-6-one
299.3
Introduction
Hydrocodone is a well-recognized opioid analgesic,
widely prescribed for acute and chronic pain management. It is a semi-synthetic opioid analgesic derived
from codeine and thebaine that was synthesized in
Germany in 1920 and approved by the FDA in 1943.
Hydrocodone and compounds containing hydrocodone have become the most frequently prescribed
opioids in the USA [1,2]. Reasons for its popularity
include high efficacy, patient tolerability, low cost, and
less controlled schedule III labeling.
Description
452
While primarily employed as an analgesic, hydromorphone is an excellent cough suppressant and is associated with less histamine release and pruritus than
codeine. Hydrocodone is only available for oral
administration, as either a tablet, capsule, or syrup
formulation, and is usually combined with acetaminophen or ibuprofen. Standard immediate-release
tablets provide 46 h of analgesia for patients with
moderate to moderately severe pain. A new, controlled-release formulation that contains acetaminophen
is pending FDA approval and has an extended 12 hour
duration of effect [24].
Mode of activity
Major and minor sites of action: hydrocodone activates supraspinal and spinal opioid receptors. It has
agonistic effects at mu, kappa, and delta subtypes and
provides dose-dependent analgesia, euphoria, reduced
GI motility, and respiratory depression. Its effects can
be reversed by naloxone.
Hydrocodone has a half-life of 3.8 hours, peak
effect at 1.3 hours, and a duration of 4.6 hours. It is
metabolized by the liver and excreted primarily in
urine. Hydrocodone is oxidized to hydromorphone by
cytochrome P450 2D6. The extended-release formulation has measurably different pharmacokinetics: following a single dose of 1, 2 or 3 HC/APAP CR tablet(s),
the mean maximum plasma concentration (Cmax)
ranged from 13.3 to 36.8 ng/mL for HC and 2.01 to
6.68 ng/mL for APAP. The mean time to reach Cmax
(Tmax) was 6.06.7 hours for HC and 1.11.3 hours for
APAP. Following twice-daily dosing of 2 HC/APAP
CR tablets for 3 days, steady-state HC/APAP concentrations were attained by 24 hours [3,4]. The mean
Cmax on day 3 was 37.0 ng/mL for HC and 4.96 ng/mL
for APAP. Systemic exposures of HC and APAP demonstrated a dose-proportional increase from one to
three tablets. Steady-state concentrations were reached
by 24 hours with minimal accumulation following
twice-daily administration. Thus, it can be taken every
12 hours [4].
Indications
The extended-release formulation has been submitted for consideration and is pending FDA approval.
The new preparation will offer a more prolonged
and uniform duration of activity; however, like
Chapter 113 Hydrocodone extended-release
HO
placebo. The most common adverse events were nausea, vomiting, headache, dizziness, somnolence, pruritus, and pain.
Figure 113.1.
Me
Chronic low back pain
H
O
other sustained-release opioids it will probably be

approved as a more controlled schedule II narcotic,
which may influence its prescription and use. The new
drug application for Vicodin CR contains confidential
information and at this time it remains unclear whether
it will be approved as a schedule II or III analgesic.
Surgical acute pain: dosing will be based on investigational trials and guidance from the FDA. The
efficacy and safety of controlled-release hydrocodone
15 mg/acetaminophen 500 mg (HC/APAP CR) was
recently evaluated in patients recovering from bunionectomy [5]. Two hundred and twelve subjects were
randomized to receive either one HC/APAP CR tablet plus placebo (n = 70), two HC/APAP CR tablets
(n = 70), or two placebo tablets (n = 72) upon onset of
moderate or severe pain following surgery. Subjects
were treated for 3 days; however, the primary endpoint was the sum of pain relief over the first 12 hours.
Patients treated with HC/APAP CR experienced
statistically significant improvement in all efficacy
variables (Table 113.1). One or two tablets of controlled-release HC 15 mg/APAP 500 mg provided significantly better pain relief for acute bunionectomy pain
than placebo tablets. Two tablets provided consistently superior relief to one tablet. Time to perceptible
pain relief was < 40 minutes. As might be expected,
the incidence of adverse events was significantly
higher for subjects receiving HC/APAP CR versus
The efficacy of HC/APAP extended-release was

assessed in patients with moderate to severe chronic
low back pain in a double-blind, placebo-controlled
trial [6]. At the end of the open-label titration period,
511 patients entered the 12-week double-blind portion
of the study and were randomized to receive one tablet
of HC/APAP extended release, two tablets HC/APAP
extended release, or placebo twice daily. The primary
efficacy endpoint was measured as change in patients
assessments of pain intensity based on a visual analog
scale, and compared to baseline. Back pain intensity
was significantly lower in patients receiving either one
or two tablets taken twice daily of HC/APAP extended
release compared to those taking placebo (8.6, two tablets, P = 0.001; 13.3, one tablet, P = 0.002 versus 22.2,
placebo). The most common adverse events in any
treatment group were nausea, constipation, diarrhea,
and headache. In the two-tablet HC/APAP controlled
release group, 53% of patients reported adverse events,
as compared to 44% in the one-tablet group [6].
Medical pain
Hydrocodone/acetaminophen may be used to treat
moderate to moderately severe pain with greater convenience and possibly better patient compliance since
it is dosed twice a day (q12 hours) instead of the usual
36 hours. The long-term efficacy of extended-release
hydrocodone/acetaminophen was evaluated for osteo
arthritic pain management [7]. Pain and quality of
life were assessed using Brief Pain Inventory (BPI),
Work Productivity and Activity Impairment (WPAI),
and SF-36 questionnaires that occurred at baseline,
Table 113.1. HC/APAP CR bunionectomy trial efficacy results
Group minutes
TOTPAR score
mean (SE)
Perceived pain
relief (n (%))
Meaningful pain
relief (n (%))
Time to rescue
medication (min)
11/70 (16%)
101
Placebo (n = 72)
2.2 (0.98)
28/70 (40%)
One tablet HC/APAP CR

(n = 70)
6.4 (0.99)a
52 (74%)a
28 (40%)a
131a
Two tablets HC/APAP CR

(n = 70)
13.3 (1.00) a,b
60 (86%)a
45 (64%)a,b
251a,b
P < 0.01 vs. placebo, bP < 0.01 vs. one tablet. With permission from- Desjardins P, Diamond E, Clark F. Treatment of acute pain with 12-hour
controlled-release hydrocodone-acetaminophen tablets following bunionectomy: a randomized, double-blind, placebo-controlled study.
The American Academy of Pain Medicine Annual Meeting, 23rd Annual Meeting, February 710, 2007, New Orleans, LA.
453
weeks 24 and 56 [7]. Patients treated with (HC/APAP

CR) showed improvement in all BPI pain assessments
at each evaluation period. Patients had less sleep
interference (decreased ~4050%) and less interference in walking ability due to pain (decreased
~3040%) from baseline to weeks 4, 12, 24, 40, and
56. Overall impairment due to health decreased 17.5%
at week 24 and 15.8% at week 56. The most commonly
reported treatment-emergent AEs (10% of patients)
were constipation, nausea, headache, and somnolence. The incidence and prevalence of these common
AEs generally decreased over time. One hundred and
twenty-four (29%) patients discontinued due to AE(s).
The most common AEs that led to discontinuation
were nausea, somnolence, constipation, dizziness,
vomiting, headache, and fatigue
Chronic cancer pain

Hydrocodone/acetaminophen CR has not been
approved but may be used to relieve moderate to moderately severe malignancy-related pain. It may be useful for control of both somatic and visceral pain
symptoms.
Contraindications
Absolute: history of previous severe allergic reaction
to hydrocodone or acetaminophen. Relative: head
injury, increased intracranial pressure, elderly patient,
severe liver or renal impairment, acute abdominal
conditions, hypothyroidism, Addisons disease, prostatic hypertrophy, urethral stricture, history of drug
abuse, and patients with respiratory depression [8].
Common doses/uses
Controlled-release HC/APAP is only formulated as an
oral preparation containing a standard dose of hydromorphone 15 mg and acetaminophen 500 mg, to be
administered every 12 hours. Phase 3 study data indicate that 12-hour dosing provided effective pain relief
for patients with moderate to severe acute and chronic
pain. The drug should not be crushed or tampered
with as that will change the pharmacokinetics of the
extended-release hydrocodone. At this time, the manufacturer has not disclosed whether HC/APAP CR will
be manufactured in a tamper-resistant formulation.
454
Ease of use, tolerability, and efficacy: this new controlled-release formulation of hydrocodone offers the
promise of greater analgesic uniformity and a more

extended duration of effect than that provided by
immediate release formulations. As monotherapy HC/
APAP CR can be used for management of moderate to
moderately severe pain. As used for multimodal analgesia HC/APAP CR can be combined with other
immediate-release opioids and adjuvant analgesics for
pain control.
Cost: N/A.
Availability: pending FDA approval possibly in
2010.
Toxicity: limited by acetaminophen (not to exceed 4 g
acetaminophen total dose per day), and potential for
hydrocodone overdose.
Diversion and abuse: similar to other CR opioids,
12 h CR dose may be adulterated for immediate use.
Abuse or excessive use is also associated with the risk
of acetaminophen overdose.
Drug interactions: other narcotics, antihistamines,
benzodiazepines, antipsychotics, antianxiety agents,
or other CNS depressants. Use of MAO inhibitors or
tricyclic antidepressants can increase the effect of
hydrocodone. It is not recommended for pediatric
use; Pregnancy Category C [1,2,8].

The most common side effects are lightheadedness,
dizziness, drowsiness, nausea, vomiting, headache,
and constipation [1,2,8]. Other side effects listed by
system include:
CNS: agitation, dependency, CNS depression,
lethargy, restlessness, sedation
Cardiovascular: bradycardia, orthostatic
hypotension, palpitations, tachycardia
Gastrointestinal: nausea, vomiting, anorexia,
constipation, paralytic ileus, biliary spasm,
cholestatic jaundice
Genitourinary: urinary retention
Respiratory: respiratory depression, respiratory
paralysis
Dermatological: flushing, rash, urticaria, pruritus.

Tratment of adverse events is similar to that employed
for other opioid agonists: naloxone for reversal of
respiratory depression, stool softeners, laxatives or
Chapter 114 Iontophoretic transdermal fentanyl
peripheral antagonists for constipation, and ondansetron, metoclopramide, and other antiemetics for nausea and vomiting [1,2,8].
References
1. Physician Desk Reference, 63rd ed. Physician Desk

Reference Inc., 2009.
5. Desjardins P, Diamond E, Clark F. Treatment of acute

pain with 12-hour controlled-release hydrocodoneacetaminophen tablets following bunionectomy: A
randomized, double-blind, placebo-controlled study.
The American Academy of Pain Medicine Annual
Meeting, 23rd Annual Meeting, February 710, 2007,
New Orleans, LA.
3. www.accessdata.fda.gov FDA database for approved

drugs.
6. Hitt E. Efficacy and safety evaluation of 12 weeks

extended-release hydrocodone/acetaminophen
treatment in patients with chronic low back pain by
prior opioid use. American Academy of Pain
Medicine, 2008.
4. Klein CE, Liu W, Qian JX, et al. Pharmacokinetics of

12-hour controlled-release hydrocodone and
acetaminophen tablets in healthy subjects following
single- and multiple-dose(s). The American Academy
of Pain Medicine Annual Meeting, 23rd Annual
Meeting, February 710, 2007, New Orleans, LA.
8. Ellsworth et al. Mosbys Drug Consult. Elsevier, 2002.
2. Medline Plus, www.nlm.nih.gov U.S. National

Library of Medicine.
Section 12
Chapter
114
7. Webster D, Herrington D, Corser BC, et al. Effects of

12-hour, extended-release hydrocodone/
acetaminophen on pain-related physical function, work
productivity, and sleep quality: a 56-week, open-label
study AAPM annual meeting, 2008, poster #194.
Iontophoretic transdermal fentanyl

Craig T. Hartrick
Generic Name: iontophoretic transdermal fentanyl delivery system

Trade/Proprietary Name: IONSYS
Drug Class: opioid analgesic, schedule II
Manufacturer: Ortho-McNeil Pharmaceuticals,
Inc., Raritan, NJ
Chemical Name: propanamide, N-phenyl-N-[1(2-phenylethyl)-4-piperidinyl]monohydrochloride
Introduction
The analgesic effects of fentanyl are predominately
mediated via 1 opioid receptor activity. The historical
development of fentanyl and its continuous transdermal delivery are discussed elsewhere in this text
(Section 2). The iontophoretic delivery of on-demand
aliquots of fentanyl (originally called E-Trans), however, is a novel patient-activated system that employs
iontophoresis to rapidly deliver drug into the subcutaneous circulatory system.
Mode of action
While patient-controlled intravenous delivery of opioids has often been a standard therapy for moderatesevere acute pain management, this needleless system
allows for rapid delivery of drug across intact skin,
without the need for an intravenous line or pump
(Figure 114.2). Using iontophoresis, an imperceptible
current generates an electric field that repulses the
455
Figure 114.1.
O
N
N
Figure 114.2. Fentanyl iontophoretic delivery system (Ionsys).
456
positively charged drug from a reservoir at the anode,

forcing it through the dermis. Drug is also transported
by electro-osmotic bulk flow of the solvent. Each
system contains fentanyl HCl 10.8 mg in a hydrogel
composed of cetylpyridinium chloride, citric acid,
polacrilin, polyvinyl alcohol, sodium citrate, sodium
chloride, sodium hydroxide, and purified water.
Dosing: the system is attached to the intact hairless
skin of the chest or upper outer arm. When a patient
activates the system by depressing a button on its surface twice within 3 seconds, a 3-V lithium battery generates a current density of 62 microamperes/cm2 in the
skin beneath the system. This current results in the
delivery of a fixed dose of fentanyl (40 g; equivalent
to 44.4 g fentanyl HCl) proportional to the current
applied (170 microamperes). The delivery takes place
over a 10-minute lock-out period, during which time
the system cannot be reactivated. Blood levels of fentanyl continue to increase for 5 minutes after completion of each 10-minute dosing period. There is minimal
passive drug delivery from the system; clinically significant drug delivery requires activation.
Approximately 40% of an administered dose is
absorbed in the first hour of therapy; however, the system reaches near 100% efficiency after 10 hours of use.
A brief audible tone sounds and a light-emitting diode

(LED) illuminates continuously during drug delivery.
If the system becomes dislodged, losing effective skin
contact, the LED flashes and a 20-second audible tone
is produced. Depressing the button only once results
in a single flash for each five successful drug deliveries,
thus providing an estimate of drug consumption.
The system remains active for up to 24 hours or 80
delivered doses.
The metabolism of fentanyl, as discussed in Section
2, is characterized primarily by phase 1 N-dealkylation
to norfentanyl and other inactive metabolites via the
cytochrome P450 enzyme CYP3A4. Since nearly 40%
of all drugs that undergo phase 1 metabolism are substrates, inhibitors, or inducers of CYP3A4, there is
considerable potential for drugdrug interaction. The
patient-controlled self-administration inherent in this
system, however, mitigates the clinical significance of
potential interactions considerably. Rising or falling
blood levels should be met with decreasing or increasing patient attempts, respectively.
Indications
Iontophoretic transdermal fentanyl (fentanyl ITS) was
FDA-approved for short-term management of acute
post-operative pain in hospitalized adults. The system
is intended to be a patient-controlled method for
maintenance of analgesia. Titration of a loading dose
with opioids to an acceptable analgesic level prior to
initiation of the system is recommended. Moreover,
since the current (and hence the dose) are not adjustable, this system is most appropriate for opioid-naive
patients and should not be preferred for opioid-tolerant
subjects or those requiring a basal infusion.
Contraindications
As with all patient-controlled systems and devices, the
patient must be capable of understanding how and
when to use the system. Consequently it is not appropriate in patients with altered levels of consciousness
or impaired cognition. The system has not been adequately studied in pediatric patients. Fentanyl is highly
lipid-soluble. It crosses the placenta to the fetus in
pregnancy and is excreted in breast milk.
Caution should be exercised in administering any
potent opioid, such as fentanyl, in subjects with sleep
apnea, severe hepatic dysfunction, head injuries, or
conditions associated with increased intracranial pressure, or in patients with impending respiratory failure.
Chapter 114 Iontophoretic transdermal fentanyl
Barriers to effective analgesia in acute pain management include pharmacokinetic, pharmacodynamic,
logistic, economic, and technical equipment-related
challenges. Rapid-acting, lipophilic agents with relatively short duration allow easier titration to effect
without inducing prolonged adverse effects commonly
associated with opioids. A pooled analysis by Viscusi et
al. of three large randomized controlled trials (n = 1941)
comparing fentanyl ITS to intravenous patient-controlled (ivPCA) morphine demonstrated comparable analgesia with both modalities. A meta-analysis examining
adverse events by Hartrick (n = 2597) conservatively
demonstrated that, compared to IV-PCA morphine,
fentanyl ITS subjects were significantly less likely to discontinue therapy due to an adverse event (odds ratio
[OR]: 1.5; 95% CI: 1.012.25, P = 0.046), had less pruritus (OR: 1.8; 95% CI: 1.32.4, P = 0.001), and, when the
fixed-effects model was applied (Mantel Haenszel), less
nausea (OR: 1.2; 95% CI: 1.011.4, P = 0.034) and less
somnolence (OR: 1.9; 95% CI: 1.033.4, P = 0.04).
Hospital care, by its nature, is labor-intensive.
Therapies requiring extra nursing and pharmacy personnel time present substantial barriers to care not
only for the patients involved, but also for other
patients whose care may be compromised due to time
constraints imposed by the increased burden on the
staff. A survey examining nursing time reported significantly less time associated with fentanyl ITS therapy compared to IV-PCA morphine. They estimated
an average saving of nearly 70 minutes of nursing time
alone for each patient, with most of the additional
time involved in set-up and discontinuation procedures. These procedures also can lead to programming
errors, resulting in accidental overdose and even
death. This has been a topic of ISMP (Institute of Safe
Medication Practices) Alerts; over 120 serious errors
were reported to the US FDA in the past 10 years, with
undoubtedly many more remaining unreported. IONSYS eliminates programming and therefore programming errors. It also eliminates the costs associated
with actual pump purchase, maintenance, and repair.
Patient and nursing satisfaction is high with fentanyl
ITS. Patients find the system convenient with no bulky
pump limiting their movement and rehabilitation
efforts. This is especially important after major orthopedic surgery. With respect to ease of care (EOC),
patients following total joint replacement reported
significantly better overall EOC compared to IV-PCA
morphine (43 vs. 27%; P < 0.001) and better move-
ment (97 vs. 71%; P < 0.001). Physical therapists (83

vs. 55%; P < 0.001) and nurses (80 vs. 55%; P < 0.001)
likewise rated the fentanyl ITS superior for EOC. A
pooled analysis (n = 1305) examining nursing timeefficiency and convenience confirmed these findings
in post-operative patients following major orthopedic
surgery, abdominal, and pelvic surgery.
Both personnel and technical issues can contribute to lapses in analgesic coverage: analgesic gaps.
System-related events leading to significant analgesic
gaps were compared in patients receiving fentanyl ITS
with patients receiving IV-PCA morphine (n = 1305).
Fentanyl ITS patients had fewer analgesic gaps (6 vs.
12; P < 0.001), shorter analgesia gaps (15 vs. 20 min.),
and faster resolution of analgesic gaps (11 vs. 20 min.)
compared with IV-PCA morphine.
While the fixed-dose system eliminates errors, it also
eliminates flexibility. The lack of programmability and
the lack of a basal infusion mode may make fentanyl
ITS unsuitable for use in many opioid-tolerant individuals. Moreover, the current design only allows an
estimation of the actual number of doses administered
(within five). Detailed history cannot be obtained
from the system to determine the number and timing
of attempts relative to deliveries.
At the end of service of the system (24 hours, or 80
doses), even if the maximal allowed drug was delivered,
there is still considerable drug remaining in the reservoir.
Disposal of the system requires disassembly by the pharmacist. The bottom housing containing the hydrogel reservoirs must be removed from the top housing, which
contains the electronics and battery, for proper waste disposal and drug destruction according to local policy.
Skin reactions, including hypersensitivity, redness,
and even prolonged hyperpigmentation, especially in
dark-skinned individuals, are potential problems with
transdermal systems. Failure of adherence of the system to the skin is an unusual but potential disadvantage. The skin should be clipped if necessary (not
shaved) to improve adherence in hirsute patients.
Currently the principal disadvantage of fentanyl
ITS is availability. Despite initial European Commission approval in January 2006 and FDA approval in
May 2006, IONSYS is not currently being produced
due to technical problems. It is likely that some design
modifications will be made prior to launch that may
include improved features for recording the number
and timing of successful drug delivery attempts.
457
References
1. Viscusi ER, Siccardi M, Damaraju CV, Hewitt DJ,

Kershaw P. The safety and efficacy of fentanyl
iontophoretic transdermal system compared with
morphine intravenous patient-controlled analgesia for
postoperative pain management: an analysis of pooled
data from three randomized, active-controlled clinical
trials. Anesth Analg 2007;105(5):14281436.
2. Hartrick CT. Patient-controlled transdermal
iontophoretic fentanyl system as an alternative to
intravenous morphine PCA: review and metaanalysis. Future Neurol 2007;2(6):621627.
3. Hartrick CT, Bourne MH, Gargiulo K, Damaraju V,
Vallow S, Hewitt DJ. Fentanyl iontophoretic
Section 12
Chapter
115
4. Lindley P, Pestano CR, Gargiulo K. Comparison of

postoperative pain management using two patientcontrolled analgesia methods: nursing perspective.
J Adv Nurs 2009;65(7):13701380.
5. Panchal SJ, Damaraju CV, Nelson WW, Hewitt DJ,
Schein JR. System-related events and analgesic
gaps during postoperative pain management
with the fentanyl iontophoretic transdermal system
and morphine intravenous patient-controlled
analgesia. Anesth Analg 2007;105(5):14371441.
Tapentadol ER
Raymond S. Sinatra
Generic Name: tapentadol extended-release

Trade Name: not yet named; possibly Nucynta
ER
Drug Class: opioid analgesic, class II; centralacting analgesic
Manufacturer: PriCara, Division of OrthoMcNeil-Janssen Pharmaceuticals, Inc., Raritan,
NJ 08869
Chemical Name: 3-[(1R,2R)-3-(dimethylamino)1-ethyl-2-methylpropyl]phenol monohydrochloride
Chemical Formula: C14H23NOHCl
458
transdermal system for acute pain management after

orthopedic surgery: a comparative study with
morphine intravenous patient-controlled analgesia.
Reg Anesth Pain Med 2006;31:546554.
Description
Tapentadol is a novel schedule II central-acting analgesic. It was initially formulated as an immediate-
release preparation and approved in 2008 for moderate
to severe acute pain. Tapentadol immediate-release,
Nucynta, is marketed as 50, 75, and 100 mg tablets
and provides analgesia (primary efficacy endpoint)
comparable to 1015 mg of immediate-release oxycodone. A sustained-duration oral formulation named
Tapentadol ER is in late-stage development for chronic
pain and the results of clinical trials, including four
phase III pivotal trials, have been submitted to the
FDA for approval.
Mode of activity
Tapentadol has dual effects in suppressing pain transmission, combining opioid receptor (MOR) agonism
as well as norepinephrine reuptake inhibition. (The
Chapter 115 Tapentadol ER
Figure 115.1.
HO
N
HCL
pharmacology of tapentadol is discussed in Chapter

31.) Tapentadol has higher binding affinity for the
norepinephrine (NE) transporter than tramadol,
although it is associated with limited inhibition of
serotonin reuptake [13]. Analgesia provided by NE
reuptake inhibition may augment the effect provided
by mu receptor agonism and contributes a proportion
of tapentadols overall analgesic effect. In animal
studies, tapentadol provided 1/3 to 1/2 the analgesic
potency of morphine despite having 18 times less
affinity for the mu receptor [2,3]. Tapentadol exists as
a single active enantiomer [13] and is metabolized
mainly by O-glucuronidation; its principal metabolite
is inactive, having no affinity for MOR or the NE
transporter. As the analgesic activity of tapentadol
resides with the parent molecule, no enzymes are
needed to convert it to an active metabolite (as is the
case with tramadol and codeine).
Tapentadol ER was specifically developed for the
management of moderate to severe chronic pain. The
controlled-release formulation provides the convenience and analgesic uniformity associated with twice
per day dosing. Tapentadols analgesic efficacy is
comparable to a classic extended-release opioid,
oxycodone CR. Based on several large-scale clinical
trials, tapentadol ER is associated with better gastrointestinal tolerability than oxycodone CR, and
there is some evidence that it may have a broader
spectrum of efficacy, particularly in patients with
neuropathic pain. It is anticipated that tapentadol ER
will be released as a schedule II opioid analgesic. In
an attempt to limit abuse, tapentadol ER will be formulated as a tamper-resistant tablet that cannot be
easily adulterated. The tablet is designed to provide
a high degree of mechanical resistance, such as to
crushing or chewing [4].
Indications
Tapentadol ER has yet to gain FDA approval. Johnson
& Johnson has submitted a New Drug Application
(NDA) to the FDA for tapentadol (ER) as an oral analgesic for the management of moderate to severe
chronic pain in patients 18 years of age or older. The
FDA submission is based on a clinical development
program that included phase 3 double-blind, randomized, active- and placebo-controlled studies that
evaluated its efficacy and safety for moderate to severe
pain in patients with chronic osteoarthritis and low
back pain, and diabetic peripheral neuropathic pain.
Tapentadol ER has also been evaluated in a 1-year,
active-control open-label phase 3 safety trial.
Clinical investigations
Osteoarthritis
In a randomized, double-blind investigation, the
efficacy and safety of tapentadol ER were compared
with placebo and oxycodone CR for the treatment of
moderate to severe osteoarthritic (OA) knee pain [5].
Following a 3-week titration phase, patients were randomized to receive adjusted doses of tapentadol ER
(100 to 250 mg), oxycodone CR (20 to 50 mg), or placebo twice daily (BID) over a 12-week maintenance
period. Primary efficacy endpoints were the change
from baseline average pain intensity at week 12. Data
from 1023 patients who received at least one dose of
study drug were analyzed. Treatment with tapentadol
ER resulted in significant reductions in average pain
intensity compared with placebo over the entire maintenance period. In contrast, oxycodone CR failed to
achieve a clinically relevant decrease in mean pain
intensity over 12 weeks compared with placebo. During the 15 weeks of treatment, discontinuations due to
AEs occurred in 6.5% of patients treated with placebo,
19.2% with tapentadol ER, and 43.0% of patients with
oxycodone CR. These findings suggest that tapentadol
ER is effective for relief of osteoarthritic pain and may
improve patient compliance because it is associated
with lower incidences of AEs leading to treatment discontinuation.
Chronic low back pain

The safety and efficacy of tapentadol ER were evaluated in 958 patients presenting with chronic low
back pain (CLBP) [6]. In blinded-randomized fashion, patients with moderate-severe pain were titrated
drugs over 3 weeks to achieve effective and tolerable
BID dose of tapentadol ER (100250 mg), oxycodone
HCl controlled-release (CR; 2050 mg), or placebo,
and then maintained at that dose for 12 weeks. Additional dose adjustments were allowed to maintain an
optimal balance of efficacy and tolerability. Pain intensity was measured twice daily on an 11 pt NRS (0 = no
pain; 10 = pain as bad as you can imagine). Efficacy
459
was measured as change from baseline in average pain

intensity at week 12 of the maintenance phase of the
trial. Two hundred and thirty-five patients in the tapentadol ER group and 199 patients in the oxycodone
CR group entered the 12-week maintenance period.
During this time interval, the average 24 h dose for
tapentadol ER was 400 mg, and the oxycodone CR
dose was 80 mg. Patients treated with tapentadol ER
reported significantly greater reductions in average
pain intensity than patients treated with placebo at
week 12 and for the overall 12-week maintenance
period. Patients treated with tapentadol ER and oxycodone CR reported a greater reduction in pain intensity than patients treated with placebo. A higher
percentage of patients completed the 15-week treatment period with tapentadol ER (54.1%) than with
oxycodone CR (43.3%), mainly because of the lower
rate of discontinuation due to GI adverse events
(16.7% with tapentadol ER vs 32.3% with oxycodone
CR). The authors concluded that tapentadol ER (100
250 mg BID) relieved moderate to severe chronic low
back pain more effectively than placebo, and with
fewer adverse event-related discontinuations than
oxycodone HCl CR (2050 mg BID) [6].
Diabetic neuropathy pain
460
The efficacy of tapentadol ER in managing moderate

to severe chronic pain was also evaluated in patients
with diabetic peripheral neuropathy [7,8]. A recent
phase III randomized-withdrawal trial evaluated diabetic patients aged 18 years or older with a diagnosis of
moderate-severe painful diabetic peripheral neuropathy and symptoms for a minimum of 6 months [7].
During the 3-week open-label period, patients
were titrated to an optimal dose of tapentadol ER (100
to 250 mg) twice daily. The majority of these patients
(79.4%) had a pain intensity rating >= 6 on the
11-point NRS.
Patients were then advanced to a double-blind
phase of the trial which consisted of a 12-week maintenance period, during which time patients study
medication. A total of 588 patients who received tapentadol ER in the open-label period had a mean
decrease in pain intensity from 7.3 (standard deviation, SD = 1.43), or severe pain, to 3.5 (SD = 1.89), or
mild pain, during open-label treatment. During the
double-blind period, the tapentadol ER group had an
average pain intensity that remained relatively constant, while the placebo group had a pain intensity
that increased in severity (P < 0.001).
Table 115.1. Long-term Safety Trial: Treatment-related adverse

events
Event
Tapentadol ER
(n = 894)
Oxycodone
CR (n = 223)
Constipation
202 (22.6)
86 (38.6)
Nausea
162 (18.1)
74 (33.2)
Vomiting
63 (7.0)
30 (13.5)
Dry mouth
81 (9.1)
10 (4.5)
Diarrhea
71 (7.9)
12 (5.4)
Dizziness
132 (14.8)
43 (19.3)
Somnolence
133 (14.9)
25 (11.2)
Headache
119 (13.3)
17 (7.6)
Fatigue
87 (9.7)
23 (10.3)
Pruritus
48 (5.4)
23 (10.3)
Values represent numbers of patients reporting an event and

percentages of patients evaluated. From: Lange C, Lange R,
Kuperwasser B, et al. Long-term safety of controlled, adjustable
doses of tapentadol extended release and oxycodone controlled
release: results of a randomized, open-label, phase 3, 1-year trial
in patients with chronic low back or osteoarthritis pain. Tenth
Annual EULAR Congress, Poster number SAT-0481, June 2009,
Copenhagen, Denmark.
During the open-label treatment phase, 20.1% of

patients experienced the onset of one or more treatmentemergent adverse events that led to discontinuation
from the study. Following advancement to the double
blind phase, only 11.2% of patients in the tapentadol ER
group and 5.7% of patients in the placebo group discontinued due to treatment-emergent adverse events. In the
open-label phase, gastrointestinal related adverse events
led to discontinuation in 10% of patients [7].
Long-term safety in patients with

chronic pain
The long-term safety and efficacy of tapentadol ER were
evaluated in a large randomized open-label trial of
patients with chronic pain (low back and osteoarthritis)
[8]. Patients (1117) were randomized in a 4:1 ratio to
receive twice-daily doses of tapentadol ER 50 mg or
oxycodone CR 10 mg for the first 3 days, after which the
dose was increased to tapentadol 100 mg BID or oxycodone 20 mg BID for the next 4 days. Patients were
maintained on these analgesics for the next 51 weeks,
although dose escalations or reductions were permitted. Use of acetaminophen was allowed during the
study at doses of up to 1000 mg/day for no more than 7
consecutive days and no more than 14 out of 30 days.
Over the 1-year study interval, reductions in average
Chapter 115 Tapentadol ER
pain intensity scores and mean total daily analgesic

doses were stable in both active groups. Patients treated
with tapentadol ER reported a lower overall incidence
of gastrointestinal treatment-related adverse events
such as nausea, vomiting, and constipation (Table
115.1). A lower percentage of patients treated with tapentadol ER experienced nausea, vomiting, constipation,
or pruritus; however, a greater number reported headache. Treatment-related adverse events led to discontinuation in 22% of patients in the tapentadol ER group
and in 36.8% of patients in the oxycodone CR group.
Contraindications
1. Tapentadol ER, like other opioids, may be
associated with significant respiratory depression,
and should not be administered to patients with
acute or severe bronchial asthma or hypercapnia
in unmonitored settings or in the absence of
resuscitative equipment.
2. Paralytic ileus (proven or suspected).
3. Patients who are receiving monoamine oxidase
(MAO) inhibitors or who have taken them within
the last 14 days due to potential additive effects
on norepinephrine levels which may result in
adverse cardiovascular events [1,3].
Warnings
Patients are at risk of developing serotonin syndrome.
The development of a potentially life-threatening serotonin syndrome may occur with use of SNRI products,
including tapentadol, particularly with concomitant
use of serotonergic drugs such as SSRIs, SNRIs, TCAs,
MAOIs, and triptans, and with drugs which impair
metabolism of serotonin (including MAOIs). This
may occur at the recommended dose. Serotonin syndrome may include mental-status changes (e.g. agitation, hallucinations, coma), autonomic instability (e.g.
tachycardia, labile blood pressure, hyperthermia), and
neuromuscular aberrations (e.g. hyperreflexia, incoordination). Since tapentadol has effects on norepinephrine reuptake, patients may experience a monoamine
syndrome of poorly characterized irritability and agitation that resembles serotonin syndrome but is not
associated with major complications [1,3].
Common doses
To be determined. In phase III tapentadol ER trials,
dosing ranged from 100 to 250 mg twice daily. No dosage adjustment is needed in mild or moderate renal
impairment. Tapentadol may be provided to opioiddependent patients [10].
1. Unlike tramadol, tapentadol is an active molecule,
it is not a prodrug and does not have to be
converted into an active form [13].
2. Tapentadol is metabolized by hepatic
glucoronidation, which is usually not saturable.
There is less individual variability because there is
no interaction with CYP-450, CYP-2D-6 enzymebased metabolism.
3. Nephrotoxicity or hepatotoxicity has not been
reported.
4. Better gastrointestinal tolerability than oxycodone
CR, specifically, less nausea and vomiting and
constipation in the osteoarthritis and CLBP
efficacy trials and 1-year safety trial [6,8,10].
5. The lower incidence of adverse events and greater
tolerability of tapentadol ER compared to
controlled-release opioids may provide a reason
to prescribe this preparation. Better tolerability
may result in a lower discontinuation rate, and
greater patient compliance with analgesic dosing.
These advantages may lead to improved analgesic
effectiveness and greater patient satisfaction with
therapy.
Risk of opioid-induced respiratory depression, nausea, vomiting, and constipation. Risk of monoamine
excitability and possible serotonin syndrome. Tapentadol should not be used during breast feeding. Like
other extended-duration opioids, the cost of tapentadol ER will probably be higher than immediate-release
opioid analgesics.

Tapentadol has an abuse potential similar to other potent
opioid agonists and is subject to criminal diversion. It is
unclear whether the tamper-resistant ER preparation
will limit diversion, adulteration, and abuse. Abrupt discontinuation of tapentadol IR after 90 days of continuous treatment was associated with mild to moderate
withdrawal symptoms in only 17% of patients [10].
Conclusion
Based on phase III clinical trials, tapentadol ER may
offer an advance over standard CR opioid preparations
461
in that it offers better tolerability that may reduce

discontinuation of therapy and improve pain intensity. Initial trials demonstrating efficacy in neuropathic pain suggests that tapentadols dual analgesic
effects may provide a broader analgesic spectrum than
typical opioid analgesics.
References

Evaluations, Thompson Healthcare. 2009.
2. Tzschentke TM, Christoph T, Ko B, et al. (1 R,2
R)-3-(3-Dimethylamino-1-ethyl-2-methyl-propyl)phenol hydrochloride (tapentadol hcl): a novel
-opioid receptor agonist/norepinephrine reuptake
inhibitor with broad-spectrum analgesic
properties. J Pharmacol Exp Ther 2007;323(1):
265276.
3. Guay D. Is Tapentadol an advance on Tramadol?
Consult Pharm 2009;24;833839.
4. http://www.jnjpharmarnd.com/jnjpharmarnd/new
s_release_12012009.html.
5. Afilalo M, Kuperwasser B, Kelly K, et al. Efficacy and
safety of tapentadol extended release (ER) for chronic
pain due to osteoarthritis of the knee: results of a
phase III study. Poster presented at the 5th World
Congress of the World Institute of Pain (WIP); March
1316, 2009; New York, New York, USA. Pain Practice
2009;9(s1):159. [Abstract PB237].
6. Buynak R, Shapiro D, Okamoto A, et al. Efficacy and
safety of tapentadol extended-release for chronic low
back pain: results of a randomized, double-blind,
462
placebo- and active-controlled phase III study. Poster

presented at the 28th Annual Scientific Meeting of the
American Pain Society (APS); May 79, 2009; San
Diego, California, USA. J Pain 2009;10(4 Suppl.
1):S50. [Poster #301]
7. Etropolski M, Shapiro D, Okamoto A, et al. Efficacy
and safety of tapentadol extended release
(ER) for diabetic peripheral neuropathic pain:
results of a randomized-withdrawal, double-blind,
placebo-controlled phase III Study. Poster presented
at the 61st Annual Meeting of the American
Academy of Neurology (AAN); April 25May 2,
2009; Seattle, Washington, USA. [Abstract
P05.047]
8. Shapiro D. Efficacy and tolerability of tapentadol
extended release for diabetic peripheral neuropathic
pain: results of a randomized-withdrawal, doubleblind, placebo-controlled phase III Study. [Abstract
113] AAPM annual meeting Feb 2010, San
Antonio.
9. Lange C, Lange R, Kuperwasser B, et al. Long-term
safety of controlled, adjustable doses of tapentadol
extended release and oxycodone controlled release:
results of a randomized, open-label, phase 3, 1year
trial in patients with chronic low back or
osteoarthritis pain. Tenth Annual EULAR Congress,
Poster number SAT-0481, June 2009, Copenhagen,
Denmark.
10. Hale M, Upmalis D, Okamato A, et al. Tolerability of
tapentadol immediate release in patients with lower
back pain or osteoarthritis of the hip or knee over 90
days: a randomized, double-blind study. Curr Med Res
Opin 2009;25(5):10951104.
Section 12
Chapter
116
Tamper-resistant opioids
Christopher Gharibo and Fleurise Montecillo
Generic Names: tamper-resistant oxycodone,

extended-release; tamper-resistant morphine,
extended-release
Trade/Proprietary Names: Remoxy, Acurox
Embeda
Manufacturers: King Pharmaceuticals, 501
Fifth Street, Bristol, TN 37620;
Acura Pharmaceuticals, Inc., 616 N. North
Court, Palatine, IL 60067; Purdue Pharma,
Stamford, CT
Introduction
Physicians generally have always been mindful of

potential for abuse and diversion when including opioids in a patients analgesic plan. Prescription drugs
are the second most commonly abused drugs in the
USA, second only to marijuana. Of these prescription
drugs of abuse, opioids make up the largest component. There is growing concern over the increasing
role prescription opioids play among the first-time
drug abusers. For example, studies of illicit drug use
among American teenagers found that new abuse of
prescription opioids from 1992 to 2003 increased over
500%. Illicit drug use includes diversion of the prescribed opioid to anyone other than the patient to
whom the drugs were prescribed, and often includes
friends or family members of patients with legitimate
prescriptions [1].
The most common form of casual abuse includes
excessive self-dosing of a prescribed drug for nonanalgesic purposes. Other methods of abuse include
crushing pills and snorting them, dissolving pills in
alcohol and drinking the mixture or solubilizing the
opioids into an injectable form. Although it may seem
snorting or injection of prescription opioids would be

a more common practice among intravenous drug
abusers seeking euphoria, a study of prescription opioid use among street drug users in New York City
found intravenous injection, inhaling, or snorting an
opioid to be an extremely rare practice. Indeed, most
prescription opioids are orally ingested when abused,
even among street drug users and those seeking purely
euphoric effects [2].
It should also be noted that a large number of
prescription opioid abusers have chronic pain conditions which often necessitated legitimate opioid prescriptions before their abusive or addictive behavior
developed. Other street drug users relied on prescription opioids to mitigate withdrawal symptoms from
other illicit drugs such as heroin. Physician responsibility in combating prescription opioid abuse should
therefore include an appropriate multi disciplinary
plan of care, a multi-mechanistic analgesic plan, careful monitoring and documentation of opioid therapy,
outcome monitoring and documentation as well as
vigilant screening of patients for mental health issues
and addictive behavior including use of urine toxicology screens [2,3].
Tamper-resistance
Recent advances to aid in combating abuse of prescription opioids have included the development of
tamper-resistant formulations that contain one or
more engineered strategies to mitigate euphoria and
combat illicit use when the opioid is consumed in a
greater amount than prescribed, crushed, snorted,
or injected (Figure 116.1). The goal of such analgesics is to be able to deliver reliable pain relief to
patients, while discouraging inappropriate use.
Currently, the products that are close to filing or
have filed a (NDA) New Drug Application with the
FDA are limited in their approach and only address
463
Figure 116.1.
Abuse Deterrent Design
Hard-to-crush capsule
Resists crushing force for

snorting
Resists dissolution for
extraction and IV injection
Gel-cap with inextricable

abusable active drug
Resists extraction for snorting or IV

injection
Freezing, crushing, or attempted
dissolution in high-proof EtOH releases
only a fraction of drug
Forms a viscous mass when tampered
with by force or attempted dissolution
464
a certain type or a limited range of abusive behavior.

However, it is predicted that the next 5 to 10 years
will yield the development of a spectrum of such
agents that combine multiple tamper-resistant technologies that protect against different types of abuse
into one product.
There are six potential approaches to tamper-resistance, and ideally these strategies may be combined
to provide a more effective tamper-resistance that
would address the different types of abuse modes
present in the community.
1. Controlled delivery devices the opioid is
contained in a robust dispenser that delivers the
programmed dose at a fixed interval. This type of
device would not prevent hoarding and would be
subject to physical breakage of the container.
2. Physical barrier the physical properties of the
pill demonstrate stability in the most demanding
physical environments. For example, an opioid
pill that is uncrushable and undissolvable in

extreme environments and in various solvents
over a prolonged period of time (e.g. Remoxy,
EDACS) (Figure 116.1).
3 . Prodrug formulation initially inactive opioid
formulation that requires activation by the
gastrointestinal milieu (e.g. cleaving by digestive
enzymes) or hepatic metabolism to deliver
analgesic or euphoric effect, rendering snorting or
injection of the prodrug form without effect.
4. Aversive component opioids containing aversive
dosages at clinically insignificant amounts such
that unpleasant effects are experienced only in the
event of overdosing or inappropriate delivery (e.g.,
Acurox).
5. Dual mechanism molecule(s) with dual
mechanism of action that activates the opioid
receptors as well as a second stimulatory CNS
mechanism (e.g. norepinephrine reuptake
Chapter 116 Tamper-resistant opioids
inhibitors) that offsets the opioid-induced CNS

euphoria (e.g. tramadol).
6. Sequestered antagonist arguably the most
robust approach, an embedded reversal agent is
only released upon tampering with the product
(e.g. Embeda).
Some drug formulations are specifically designed
to resist crushing or dissolving, therefore providing a
physical barrier to inappropriately snorting or injecting. Remoxy and Purdues modified OxyContin
represent two examples of this approach that are currently under investigation. Unlike the currently supplied OxyContin, these preparations resist dissolution
in alcohol or water in the short term, and resist extreme
crushing or freeze fragmentation.
Remoxy is an abuse-resistant oxycodone preparation based on patented ORADUR technology. ORADUR is a high-viscosity gel cap designed to gradually
dissolve in the GI tract and deliver oxycodone over 12
hours. Remoxy efficacy was evaluated in a pivotal randomized, placebo-controlled, double-blind phase III
study in 412 patients with moderate to severe chronic
pain due to osteoarthritis of the hip or knee taking
1080 mg q12h or placebo for 12 weeks after initial
titration. As expected, Remoxy was superior to placebo for decrease in pain intensity scores, quality of
analgesia and global assessment (P < 0.01). A separate
phase III study of Remoxy for moderate to severe
chronic osteoarthritis patients over a 4 week period
produced similar results with superior functional
improvement vs. placebo on the WOMAC Osteoarthritis Index pain subscale (P = 0.015), stiffness subscale
(P = 0.040), and total score (P = 0.045). In a head-tohead clinical comparison, these phase III trials have
been accepted by the FDA and the product is currently
undergoing nonclinical stability testing in common solvents before resubmission, which is anticipated in 2010.
In studies performed to date, the comparator, OxyContin, released over 200% more drug than Remoxy when
placed in high-proof alcohol. In a chewing study, OxyContin released 170% more drug than Remoxy during
the first hour of the studies (when abusers presumably
expect to get high). Purdue Pharma are also evaluating
abuse-resistant technology for extended-release oxycodone. The new formulation is designed to have resistance to extraction and adulteration.
Extruded Deterrence of Abusable Controlled
Substances (EDACS) is a patent-pending physicalbarrier technology being developed by Akela Phar
maceuticals. EDACS utilizes a hardened hot-melt
extruded matrix to deliver drugs in a difficult to adulterate form. The extruded matrix containing dispersed
drug can be shaped into hardened tablets that are
water-insoluble, slightly soluble in ethanol, nonfriable,
and noncompressable. The tablets are very difficult to
crush for inhalation and do not allow for dissolution
and injection. EDACS is being positioned as an abusedeterrent technology that could be combined with
existing, proven opioids. Using an EDACS matrix
would presumably result in extended duration of pain
relief with the added benefit of a more controlled
slow-release delivery of the drug that is much more
difficult to circumvent.
OROS is a patented technology designed for 24
hour drug delivery of drugs such as methylphenidate
and calcium channel blockers. The system involves a
patented system that requires the osmotically active
core to come in contact with gastric water before
delivering medication at a constant rate over 24 hours.
This technology has also been combined with hydromorphone, and these formulations are currently being
studied in chronic pain models. Studies investigating
OROS hydromorphone for the treatment of cancer
pain have suggest that it is a safe option for chronic
cancer pain, and possibly more effective than extendedrelease morphine. Study subjects taking this formulation with varied alcohol concentrations exhibited only
minimally increased plasma levels of hydromorphone,
suggesting that the OROS technology can maintain its
delivery rate and integrity even with alcohol-related
dose dumping attempts.
Other extended-release opioid formulations
undergoing clinical trials also provide a physical barrier to abusive drug dumping. Tramadol, a selective
opioid receptor agonist, is available in formulations
that are difficult to crush and resist alcohol extraction,
such as Tramadol ER, and Tridural extended-release
tablets. DETERx technology has been used to develop
a sustained-release oral oxycodone formulation also
known as COL-003 that when ingested and crushed
results in the same plasma profile as if it had been
swallowed as intended. Rexista is a 24 hour formulation of oxycodone that resists crushing and resists
extraction by alcohol.
AcuroxTM is a gel cap preparation of intermediate-release oxycodone with niacin and a mucosal irritant. The pills gel structure makes it difficult to dissolve
or crush, and the integrated mucosal irritant discourages snorting, inhaling, or intravenous delivery. However, when ingested, the product is metabolized by the
465
liver so that no irritation occurs during intended oral

use. The niacin dose contained in Acurox produces no
symptoms when dosed appropriately, but excessive
oral intake of the pill will also lead to increased serum
levels of niacin, triggering unpleasant symptoms typical of excessive niacin intake, including flushing,
sweats, and headache. Further studies are needed to
support the idea that the unpleasant effects of niacin
are a sufficient deterrent against purposeful overdosing, as some contend that these side effects do not
effectively counteract potential euphoric effects of the
opioid. Critics of the Acurox formulation also cite easy
strategies that abusers could use to mitigate the
unpleasant effects of niacin, such as aspirin premedication and a large meal.
A more robust strategy for abuse deterrence
includes preparations of instant or extended-release
opioid formulations combined with antagonists such
as naltrexone in their core. Tampering with such a
formulation, such as crushing or dissolving it in a solvent, releases the antagonist, substantially limiting
the analgesic and euphoric potential of the opioid, as
well as its street value, to discourage attempts at purposeful overdosing and misuse. However, such an
approach does not address the casual abuser who
simply takes a dose greater than prescribed by their
physician. EMBEDA is a product by King Pharmaceuticals that utilizes the agonist-antagonist approach.
EMBEDA combines extended-release morphine
with a naloxone core that is discussed in a separate
chapter in this textbook.
The main challenge for tamper-resistant formulations has been in proving to the Federal Drug Administration that they truly provide an effective barrier
against misuse as well as convincing the regulators
466
that availability of such formulations will not create a

false sense of security for the physicians leading to
their increased utilization. FDA is understandably
concerned about physician misperceptions that may
develop. Physician education is paramount and these
products are possibly tamper-resistant and there is no
existing or pipeline product that is tamper-proof.
Prescription opioid abuse is a serious issue that
requires a range of simultaneous strategies for prevention, detection, and treatment. Strategies to deter
inappropriate use of prescription opioids are under
development, and include inclusion of aversive components, sequestered antagonists, mechanism-based
strategies, prodrug forms, formulations that serve as
physical barriers to tampering, and controlled delivery devices. Tamper-resistant opioid formulations are
not tamper-proof. They are not a panacea for abuse,
but merely a small step towards maximizing patient
safety and discouraging illicit use. Ultimately, the physician must bear in mind that there is no formulation
that can withstand the determination of a truly desperate addict, and careful clinical vigilance is required
of any patient whose pain management strategy
includes the use of prescription opioids.
References
1. Manchikanti L. Prescription drug abuse. Pain

Physician 2006;9:287321.
2. Davis WR, Johnson BD. Prescription opioid use,
misuse, and diversion among street drug users in New
York City. Drug and Alcohol Depend 2008;92:267276.
3. Rosenblum A, Parrino M, et al.
Prescription opioid abuse among enrollees into
methadone maintenance treatment. Drug and Alcohol
Depend 2007;90:6471.
Section 12
Chapter
117
Novel sustained-release analgesics

Danielle Perret and Michael M. Kim
Hydromorphone OROS technology

Generic Name: hydromorphone extended-release
Proprietary Name: Jurnista (OROS Push-Pull
technology)
Manufacturer: ALZA Corporation, Mountain
View, CA, USA
Chemical Name: 4,5--epoxy-3-hydroxy-17methyl morphinan-6-one
Subcutaneous extended-release
sufentanil
Generic Name: sufentanil extended-release
Proprietary Name: Chronogesic
Manufacturer: DURECT Corporation, Cupertino, CA
Chemical Name: N-[4-(methoxymethyl)-1-(2thiophen-2-ylethyl) -4-piperidyl]-N-phenyl-propanamide
Transdermal extended-release
sufentanil
Generic Name: sufentanil extended-release
Proprietary Name: TRANSDUR
Manufacturer: DURECT Corporation, Cupertino, CA

Chemical name: N-[4-(methoxymethyl)-1(2-thiophen-2-ylethyl) -4-piperidyl]-N-phenylpropanamide
Introduction
There are a variety of new and emerging analgesic

options that offer the promise of prolonged and highly
uniform analgesia. On the forefront of research is new
sustained-release analgesic technology. Several sustained-release formulations have already been discussed
such as inhaled aerosolized liposome-encapsulated fentanyl, iontophoretic transdermal fentanyl, extendedrelease hydrocodone, tamper-proof oxycodone and
even transdermal local anesthetics. In this chapter we
focus on the technology behind three new emerging
sustained-release opioid formulations: extended-release
hydromorphone using the OROS system and two sufentanil formulations including DUROS implant technology and TRANSDUR transdermal technology.
Hydromorphone OROS technology

Mode of activity
Hydromorphone is a semi-synthetic mu opioid analgesic having major and minor sites of action at spinal
and supraspinal opioid receptors. It is widely prescribed for pain management in patients with moderate to severe acute and chronic pain. Hydromorphone
is extensively metabolized by the liver and its inactive
metabolite is primarily excreted in urine [1].
How it works
OROS hydromorphone utilizes the patented PushPull osmotic pump technology which provides a
steady and continuous release of drug over 24 hours,
thus providing consistent drug plasma levels and
467
HO
Figure 117.1.
Me
H
O
Figure 117.2.
O
S
N
N
O
Figure 117.3.
O
S
N
N
O
468
analgesic effects. The key behind the OROS technology is the tablet core, which is made up of a drug
layer containing the drug (hydromorphone), a push
layer made up of an osmo-polymer composition and a
semi-permeable membrane that encapsulates these
two layers [1]. This semi-permeable membrane is only
pervious to water but not to hydromorphone or the
osmotic layer [2]. A hole measuring 6.35 micrometers
in diameter is made with laser precision within this
semi-permeable membrane, allowing drug to be
released [1,3].
The driving force behind this system is the absorption of water from the gastrointestinal tract. Water
passes from the gastrointestinal tract into the push
layer at a controlled rate determined by the semipermeable membrane [1]. The absorbed water suspends hydromorphone and causes the osmotic layer
to expand. This expansion of the osmotic layer pushes
against the drug layer, which forces the hydrated
hydromorphone out through the laser-drilled orifice
(Figure 117.4) The rate of drug release is directly
proportional to the rate that water enters the tablet
core [1].
Studies have concluded that the OROS system
provides a constant stable level of release of hydro-
morphone over a 24 hour period [1,5]. Measurable

release of hydromorphone begins after about 2 hours
[1]. Thereafter the release is constant for up to 18
hours with peak plasma concentrations occurring
around 1316 hours [1]. Plasma concentrations reach
a broad and flat plateau within 6 to 8 hours and remain
at this plateau for 24 hours [1]. Steady state is achieved
in 48 hours [1]. Pharmacokinetics are linear. Gastric
pH, GI motility and the presence of food have a minimal effect on drug absorption or metabolism in
healthy patients [4].
This OROS hydromorphone technology is currently being marketed in Europe under the tradename
Jurnista. It has not yet been approved for sale in the
USA.
A search of current ongoing or pending clinical
trials involving this medication at clinicaltrials
.gov reveals the following: safety and efficacy of OROS
Hydromorphone compared with oral morphine,
OROS Hydromorphone in patients with chronic
osteoarthritis, and the use of OROS Hydromorphone
in cancer patients.
A search of completed studies also reveals the following: effectiveness and tolerability of OROS Hydromorphone and Hydromorphone IR in chronic pain,
safety and tolerability of OROS Hydromorphone in
long-term use for cancer pain, effectiveness versus
placebo for chronic low back pain, in chronic nonmalignant pain, safety and impact on quality of life,
randomized open-label for safety and effectiveness in
short-term use for post-operative pain, dose proportionality studies, OROS Hydromorphone versus
morphine in cancer patients, and safety and effectiveness in patients with osteoarthritis.
It remains unclear whether or when OROS
Hydromorphone will be approved and available for
prescription.
Common doses/uses: 8 mg, 16 mg, 32 mg, 64 mg.
Patient compliance facility of once a day dosing;
steady and long duration of analgesia; stable plasma
levels for 24 hours; reduced variability GI pH, motility, and food have minimal effect on absorption and
metabolism.
Toxicity: a previous formulation of extended-release
hydromorphone marketed under the name Palladone
utilized a distinct technology but was pulled from
Chapter 117 Novel sustained-release analgesics
Figure 117.4. OROS technology.

Laser-Drilled Hole
(point of drug release)
Rate-Controlling
Membrane
Hard Shell
(clear or colored
overcoat)
Hydromorphone
HCI
Osmotic Pump
(Push layer)
the US market secondary to drug dumping. This is

a potential concern for all extended-release drug
formulations.
Tamper-resistance: the capsule is not hardened
and drug may be extruded and adulterated, and possibly abused.
Drug interactions: same as hydromorphone.
Decreased plasma concentrations may result from
gastrointestinal hyper-motility syndromes due to
excretion before absorption.
A ghost of the outer lining of the capsule will be
passed in feces. This should be explained to patients.

Common/serious adverse events for hydromorphone:
respiratory depression, dependence, tolerance, nausea/vomiting, constipation, sedation, pruritus.
Reported adverse events for trials involving OROS
hydromorphone include: headache, asthenia, and
nausea, occurring in 31%, 28%, and 28% of patients,
respectively [5].
Subcutaneous extended-release
sufentanil
Mode of activity
Sufentanil is a potent mu opioid receptor agonist. Like
other opioids, its major and minor sites of action are
at spinal and supraspinal opioid receptors. It is primarily metabolized by the liver with a small degree of
intestinal metabolism. Although sufentanil is primarily used during induction and maintenance of general anaethesia, it can provide powerful analgesia in
acute and chronic pain settings.
How it works
Chronogesic is a subcutaneously implantable drug
dispensing osmotic pump that can provide benefits of
continuous drug delivery for several months and possibly up to 1 year [1]. The DUROS delivery system is
the technology behind Chronogesic and was FDAapproved as a drug delivery technology in March
2000. The device is a 4 44 mm rod with a titanium
housing which has a 155 microliter reservoir [6]. Similar to the OROS technology, this system works by
osmosis of water from the body. Water is slowly drawn
through a semi-permeable polyurethane poly-membrane into the osmotic engine. Salt located in the
engine compartment acts as the osmotic agent which
draws water in from the body [6]. The osmosis of the
water causes expansion of this compartment which
then exerts pressure on a piston that displaces the sufentanil located in the drug reservoir [1]. Sufentanil is
released in a continuous and highly controlled fashion
(Figure 117.5). The system can be set up to deliver
sufentanil at different concentrations from rates of
3.3 mg/day to 13.3 mg/day [1].The titanium housing
469
Figure 117.5. Sufentanil transdermal

system.
Semipermeable
Membrane
Osmotic
Engine
Piston
Drug
Reservoir
Drug
Actual Size: 4mm x 45mm
protects and stabilizes the drug inside thus allowing

delivery of medication for months. Delivery is possible for up to 1 year.
The subcutaneous sufentanil system is placed by
a physician, with recommended placement under
the patients arm. It can be done as a simple outpatient procedure in the office setting. The procedure is
easy and only local anesthetic in the desired area is
required prior to implantation. This can be done in
as quickly as a few minutes. Removal or replacement
is also simple and can be done in the office setting
[6,7].
Development of the Chronogesic subcutaneous
sufentanil system was halted during phase III clinical
trials at the discretion of DURECT Corporation secondary to a design flaw that caused a small fraction
of units to prematurely shut down delivery of the
drug prior to the end of the intended delivery period.
Clinical trials are on hold and will resume when redesign of the delivery system is complete [2]. Due to
this development, trial information is not readily
available.
Common doses/uses: subcutaneous 3.3 to 13.3
mg/day.
Prolonged analgesic delivery system; steady and long
duration of analgesia; 100% patient compliance; avoids
therapeutic troughs and peaks in plasma concentration which may potentially diminish opioid tolerance.
470
Premature shutdown in the delivery of drugs prior to

end of the intended delivery time; possibility of drug
dumping; small interventional procedure required for
implantation, small risk of infection and subcutaneous reaction.

Common/serious adverse events (sufentanil): respiratory depression, dependence, tolerance, nausea/vomiting, constipation, sedation, pruritus.
Transdermal extended-release
sufentanil
Mode of activity
Sufentanil is a potent mu opioid receptor agonist. Like
other opioids, its major and minor sites of action are
at spinal and supraspinal opioid receptors. It is currently being studied as an analgesic for use in chronic
pain settings.
How it works
Sufentanil is approximately 7.5 times more potent
than fentanyl, with greater opioid-receptor affinity.
This potency allows a dramatic decrease in transdermal patch size. TRANSDUR sufentanil has been
evaluated in phase II clinical trials by ENDO Pharmaceuticals [7]. Patients were converted from oral opioids and transdermal fentanyl to transdermal sufentanil.
Dose potency relationships and dosing titration regimens were established; safety and tolerability have
been demonstrated at these doses with documented
effective analgesia provided. Proposals for phase III
trials are undergoing FDA review. Two titration regimens are expected to be studied in phase III trials. A
conversion factor between oral morphine and
transdermal sufentanil has been established with plans
for additional testing in upcoming phase III trials [7].
Common doses/uses:
Available in dose equivalents to fentanyl:
1. 100 g/h
2. 25 g/h.
Chapter 118 Extended-duration bupivacaine
Longer duration of use 7 days (versus 3 days for fentanyl patches); smaller patch size improves patient
comfort/compliance (about 1/5 current fentanyl patch
size); improved skin adhesion (versus fentanyl
patches); improvement in skin irritation amongst
other patch technology; prolonged analgesic delivery
system; steady duration of analgesia.
Allergy/pruritus to adhesive; lack of adhesiveness
similar to transdermal fentanyl patches, patients may
have difficulty bathing, swimming, and showering.

Common/serious adverse events (sufentanil): respiratory depression, dependence, tolerance, nausea/vomiting, constipation, sedation, pruritus.
References
1. Gupta S, Sathyan G. Providing constant analgesia with

OROS hydromorphone. J Pain Symptom Manage
2007;33(2):S19S24.
Section 12
Chapter
118
2. Palangio M, Northfelt D, Portenoy R, Brookoff D,

Doyle R, Dornseif B, Damask M. Dose conversion
and titration with a novel, once-daily, OROS osmotic
technology, extended-release hydromorphone
formulation in the treatment of chronic malignant or
nonmalignant pain. J Pain Symptom Manage
2002;23(5):355368.
3. Rathbone M, Hadgraft J, Roberts M, Lane M.
Modified-Release Drug Delivery Technology,
2nd ed. Vol. 1. New York: Informa Healthcare,
2008.
Pharmacokinetic profile of the 24-hour controlled
release OROS formulation of hydromorphone in the
presence and absence of food. BMC Clin Pharmacol
2007;7:2.
Pharmacokinetic investigation of dose
proportionality with a 24 hour controlled-release
formulation of hydromorphone. BMC Clin Pharmacol
2007;7:3.
6. Wright J, Yum S, Johnson RM. DUROS
Osmotic Pharmaceutical Systems for Parenteral &
Site-Directed Therapy. Drug Deliv Technol 2003;
3:6473.
7. www.durtec.com
Extended-duration bupivacaine
Tiffany Denepitiya-Balicki and Mamatha Punjala
Generic Names: extended-duration bupivacaine,

liposomal bupivacaine
Trade/Proprietary Names: Depobupivacaine,
Exparel
Drug Class: local anesthetic
Manufacturer: Pacira Pharmaceuticlals, 5 Sylvan Way, Parsippany, NJ 07054
Chemical Name: 1-butyl-N-(2,6-dimethylphenyl) piperidine-2-carboxam

Chemical Formula: C18H28N2O
Introduction
Currently available long-acting local anesthetics
including bupivacaine and ropivacaine rarely last
over 12 hours, thereby limiting their usefulness to
471
CH2(CH2)2CH3
CH3
LA
N
HCl
COCH
H2O
Phosphatidylcholine
bilayer
Local Anesthetic
Molecule
H2O Water Molecule
LAH OLAH2O
2
H O
LA 2 LA LA LA
H2O H2O H2O
LA H O
2
CH3
Local anesthetic molecules

in solution in an aqueous carrier
Figure 118.1.
control moderate to severe post-operative pain

unless repeated administration or continuous-infusion dosing are employed. An additional limitation
of local anesthetics is the high drug plasma concentrations and systemic toxicity related to rapid absorption or intravascular injection. Development of
controlled-release delivery systems which alter local
anesthetic pharmacodynamics and pharmacokinetics offer the promise of improved extended postoperative pain management. Encapsulation of local
anesthetic molecules into a liposomal carrier provides a safe and reliable method to extend duration
of activity and improve post-operative pain management [13].
Mode of activity
472
Liposomes are bilayered lipid vesicles that are 13

m in size. As a result of the bilayer structure, a separation of environments is created with resultant
internal and external compartments (Figures 118.2
and 118.3) [3]. Lipid-soluble drugs are concentrated
within the lipid bilayer, while water-soluble drugs
can accumulate within the inner aqueous compartment [1]. Following depot injection, liposomes within
the injectate suspension slowly dissolve over time
and the entrapped medication diffuses into tissue [3].
In addition to being an excellent depot, liposomes
possess the added benefits of being biocompatible,
having the ability to be given by most routes, and
decrease the exposure of toxin agents to susceptible
tissues [1,2].
Because liposomes come in different shapes and
sizes, the performance of each varies with their structure. The liposomes that will carry analgesics should
fulfill certain criteria, including but not limited to: sterility, no neurotoxicity, no adverse effects, structural
stability, and lengthened duration of action from the
current standard [1]. While most liposomal local
anesthetics are still being tested in humans, animal
Figure 118.2. Liposome structure. (With permission from Kuzma

PJ, et al. Progress in the development of ultra-long-acting local
anesthetics. Regional Anesthesia 1997; 22:543551.)
studies provide promising results. In rabbits, liposomal bupivacaine has been shown to provide a longer
period of pain relief than plain bupivacaine, without
motor block or side effects [1,2]. A second major
advantage associated with liposomal delivery is that
tissue and plasma levels of drug are maintained for
prolonged periods while peak plasma concentrations
observed with standard immediate-release preparations are avoided (Figure 118.4). This more favorable
release kinetic profile would be expected to minimize
neuro- and cardiotoxic adverse events associated with
local anesthetics. One potential disadvantage of liposomal drug delivery is their unregulated or unpredictable dissolution rate and leakage of drug contents.
Leakage, particularly in the case of local anesthetics,
could lead to toxicity [1]. Other potential disadvantages include the low payload of analgesic and the
moderate inherent stability of the molecule secondary
to van der Waals forces among liposomes in a given
solution [3]. A recently developed liposomal preparation (DepoFoam) appears to have overcome problems associated with earlier products and offers several
advantages for sustained and highly stable drug delivery [4]. The preparation has been approved for use as
a delivery vehicle for epidural morphine (DepoDur)
and other pharmacological agents (Table 118.1). It is
currently being evaluated as a carrier vehicle for
extended-duration bupivacaine. Other liposomal carriers are being evaluated for extended-duration mepivacaine preparations [5].
Chapter 118 Extended-duration bupivacaine
Table 118.1. DepoFoam, multivesicular liposomes

1. Particles are suspended in isotonic saline
2. Liposomes are 13 m in diameter
3. Liposomes are composed of phospholipids, triglycerides,
and cholesterol
4. The solution can be injected with fine (2024 gauge) needles
5. Drug is delivered over a period of 130 days
6. Shelf life is 2 years
7. Well tolerated, few adverse or allergic reactions noted
Figure 118.3. Scanning electron microscopic image of a

drug-encapsulating liposome, DepoFoamTM l.
Microspheres
Microspheres are another modality for analgesics
to be delivered over prolonged periods of time.
Essentially, microspheres are synthetic biodegradable
(similar to suture material) entities that are larger
than liposomes. Like the liposomes, the physical characteristics of microspheres and their speed of degradation are key to release kinetics and duration of drug
effect. While most microsphere pharmacokinetic
information has been derived from animal studies,
early human application has yielded promising results.
Microspheres containing bupivacaine produce a prolonged nerve block (10 hours to 5.5 days duration). In
the study, researchers found that adding varying
amounts of dexamethasone prolonged the duration of
the nerve block; however, the mechanism by which
this occurs could not be accounted for [1]. One
adverse event associated with microspheres that may
limit their overall usefulness is inflammatory skin
reactions that may or may not be allergic in nature.
Liposomal bupivacaine
A promising example of long-acting local anesthetics
is liposomal bupivacaine (LB, DepoBupivicaine or
ExpareL). Liposomal bupivacaine (LB, Exparel) is
an extended-release liposomal injection of bupivacaine intended for single-dose administration

which can provide several days of pain management
following surgery. It is administered into the surgical
wound prior to closure of facial and skin layers. Liposomal bupivacaine is currently in phase II and phase
III trials. To date the preparation has been tested in
ten wound infiltration clinical trials involving 350
volunteers and more than 1000 patients recovering
from various types of surgery. In these trials LB had a
low adverse event profile, no toxicology signals, and
no QTc changes in doses ranging up to 750 mg [5].
In a randomized active-control phase II study the
efficacy and safety of LB were evaluated in 103
patients recovering from total knee replacement surgery [6]. Following completion of surgery, patients
received a single intra-operative dose of LB or immediate-release bupivacaine (Bup) via local infiltration.
Liposomal bupivicaine effectively controlled moderate to severe pain for more than 72 hours in dosedependent fashion, with significant reduction in
opioid rescue. The pertinent clinical findings included
the following. Patients receiving LB 450 mg reported
average pain intensity scores of 5.0 cm vs. 7.0 cm for
the Bup active control (P < 0.05). Pain intensity was
also lower, with patients treated with LB 450 mg
requiring significantly lower doses of opioid rescue
throughout the entire evaluation period, and experiencing 30% less nausea and vomiting than patients
treated with Bup. Of importance was the finding that
8% of patients treated with LB required no rescue
opioid during the study period versus 0% in the active
control group.
Two pivotal phase III placebo-controlled trials
have been conducted in patients recovering from
orthopedic and soft-tissue procedures [7]. In a
recently completed hemorrhoidectomy trial, patients
treated with 300 mg LB reported statistically signifi-
473
Figure 118.4. Bupivacaine plasma

levels: immediate-release preparation
versus a liposomal-release preparation
(DepoFoam).
Concentration
Immediate Release Bupivacaine
DepoFoam Microspheres
Containing Bupivacaine
Toxic
Level
Minimum
Therapeutic
Level
Time
Figure 118.5. Phase III

hemorrhoidectomy trial: time to first
opioid rescue.
100
75
50
25
0
2h
4h
8h
12h
Placebo
474
24h
36h
48h
60h
72h
Liposomal Bupivacaine
cant reductions in total pain intensity (NRS) in hours

072 (P < 0.001). Differences were statistically significant at 12, 24, 36, 48, 60, and 72 h following administration (P < 0.001). Opioid requirements over 72 h
were significantly reduced in the LB-treated group
(P < 0.008) (Figure 118.5). Similar analgesic benefits
were observed in a double-blind placebo-controlled
trial performed in patients recovering from bunionectomy [7]. Following completion of surgery performed under Mayo block, patients received either
LB, 120 mg (n = 93) or placebo (n = 93). Pain intensity scores during the first 36 hours were significantly
reduced in the LB-treated group when compared to
placebo (P < 0.005) (Figure 118.5). Opioid dose
requirements over 36 h were also reduced in the LB
group.
Future
The future of long-acting analgesics looks promising.
The ability to administer a single dose of local anesthetic
post-operatively may render the need for continuously
infusing catheters unnecessary. Liposomal bupivacaine
overcomes the limitations of conventional bupivacaine
formulations and may be particularly useful in procedures where post-operative pain management is
especially problematic and where prolonged analgesia
can provide a significant improvement in pain relief
and functionality. For example 534 000 patients undergo
extremely painful TKA in the USA each year and that
number is expected to increase as our population continues to age. The use of LB and other prolonged-duration local anesthetics in this and other painful surgical
procedures may be particularly efficacious. Liposomal
Chapter 119 Morphine-6-glucuronide
bupivacaine may also be useful for palliative nerve

blocks, and for control of non-surgical pain such as long
bone and rib fractures and for intra-articular injection.
While LB may be considerably more expensive than
immediate-release preparations, single-dose local
anesthetic administration offers greater patient safety
and cost-effectiveness than continuous-infusion techniques. It must be recognized that catheters are associated with potential drug-related toxicity and infection
risks and that placement and maintenance can be challenging, time-consuming, and expensive.
3. Kuzma PJ, et al. Progress in the development of

ultra-long-acting local anesthetics. Reg Anesth
1997;22:543551.
4. Mantripragada S. A lipid based depot (DepoFoam)
for sustained release drug delivery. Prog Lipid Res
2002;41:392404.
5. de Araujo DR, Cereda CM, Brunetto GB, et al.
Encapsulation of mepivacaine prolongs the analgesia
provided by sciatic nerve block in mice. Can J Anesth
2004;51:566572.
1. Grant SA. The Holy Grail: long acting local anesthetics

and liposomes. Best Pract Res Clin Anesthesiol
2002;16:345352.
6. Bramlett KW. A single administration of

DepoBupivacaine intraoperatively provides analgesia
and reduction in use of rescue opiates compared with
bupivacaine HCL in patients undergoing total knee
arthroplasty. Biennial World Congress of the
International College of Surgeons in Vienna, Austria
(Poster) December 6, 2008.
2. Holt DV, Viscusi ER, Wordell CJ. Extended-duration

agents for perioperative pain management. Curr Pain
Headache Rep 2007;11:3337.
7. Pacira Pharmaceuticals, Inc., Parsipany NJ.

http://www.pacira.com/news-events.aspx.
Unpublished data on file, 2009.
References
Section 12
Chapter
119
Morphine-6-glucuronide
Stephen M. Eskaros
Generic Name: morphine-6-glucoronide

Trade/Proprietary Name: none
Chemical Structure: formed by glucuronidation
of morphine at the C-6 position; see Figure 119.1
Chemical Formula: C23H27NO8
Introduction
Morphine remains the most widely used opioid
analgesic for acute post-operative and chronic pain.
Like all opioids, morphine exhibits a number of
undesirable and even life-threatening properties. As
such, an opioid agonist highly selective for the
analgesia-mediating receptors and devoid of morphines numerous side effects has long been sought.
One of morphines metabolites, morphine-six-glucuronide (M6G), may prove to have such a profile.
Several synthesis pathways for M6G exist and it is
currently in phase III clinical trials as an opioid
analgesic.
475
Table 119.1. Different opioid receptor types and subtypes
H3C
N
Receptors
Specific effects
Morphine
of each receptor affinity
subtype
M6G
Affinity
Sedation, euphoria
+++
Supraspinal
analgesia,
peripheral
analgesia, euphoria,
prolactin release
Spinal analgesia,
respiratory
depression,
physical
dependence,
gastrointestinal
effects, bradycardia,
pruritus, dopamine,
and growth
hormone release
Modulation of
receptor function
and dopaminergic
neurons
++
Spinal and
supraspinal
analgesia
Pharmacokinetics
Supraspinal
analgesia
It is estimated that the volume of distribution of M6G

is 510 times smaller than that of morphine. Because
it is considerably more polar than morphine and is
not metabolized (only excreted), M6G has a slower
onset and longer duration of action. Its plasma elimination half-time of 23 h is similar to that of morphine, but its blood-effect site equilibration half-time
(t1/2 Ke0) is twice as long (68 h), mainly due to its
slower passage across the bloodbrain barrier. Studies
suggest that subcutaneous M6G is completely bio
available, but bioavailability of an oral dose is less than
15%. Significant enterohepatic cycling of M6G has
been observed, and it appears that oral M6G is hydrolyzed to morphine in the gut followed by re-glucuronidation upon entering the plasma. Thus, an oral
preparation of M6G would render little advantage
over oral morphine for management of acute or
chronic pain.
Sedation,
gastrointestinal
effects
++
Spinal analgesia,
diuresis, miosis
Psychotomimesis,
dysphoria
Supraspinal
analgesia
OH
HO
HO
O OH
OH
Figure 119.1.
Metabolism
Approximately 1015% of an exogenous dose of morphine is converted to M6G by a specific glucuronosyl
transferase found primarily in the liver and brain,
though the kidneys may also play a role in its conversion. The same enzyme catalyzes the formation of
morphine-3-glucuronide (M3G), which is pharmacologically inactive and morphines most abundant
metabolite (about 50%). M6G is excreted unchanged
by the kidneys and its clearance has been shown to
correlate with creatinine clearance.
Pharmacodynamics
476
The relative potency of M6G to morphine is a topic of

much debate. Animal data suggest M6G is equally or
more potent than morphine, while it appears to be less
potent in humans by a factor of 23. Early human
studies suggested that small doses 0.1 mg/kg M6G

provided no analgesia, but doses > 0.2 mg/kg were
superior to placebo in relieving post-operative pain.
Onset time varies between 15 and 30 min with doses
0.3 mg/kg.
Potential advantages and uses

(Table 119.1)
M6G possesses many morphine-like properties, and
several preliminary studies suggest it may provide
analgesia comparable to morphine with similar onset
and longer duration of action. It appears to induce less
nausea and respiratory suppression, two of the most
troublesome side effects of opioid analgesia, than
Chapter 119 Morphine-6-glucuronide
equipotent doses of morphine. This may be a result of

lower affinity for the 2 receptor subtype, thought by
many to be largely responsible for the respiratory and
GI effects of opioids. In one study comparing morphine and M6G for post-operative pain following
abdominal surgery, morphine induced PONV in more
than twice as many subjects compared with M6G. Evidence also suggests that M6G causes less depression
of respiration and of the ventilatory response to isocapnic hypoxia. These preliminary studies suggest
M6G may prove to be equally efficacious as morphine
in relieving pain with longer duration of action and
superior safety and side-effect profiles.
Multiple routes of M6G administration have been
studied. As mentioned, bioavailability of enteral M6G
is minimal and probably precludes its use as an oral
agent. Intrathecal doses of 100125 g produce analgesia comparable to that of morphine 500 g. Nebulized M6G is poorly absorbed with bioavailability
less than 10%. However, one placebo-controlled trial
found nebulized M6G to be superior to morphine in
improving exercise tolerance in COPD patients
despite inferior plasma absorption. This may be
related to recent data suggesting the presence of opioid receptors in the lung, and possibly a local rather
than centrally mediated mechanism responsible for
inducing cough and breathlessness. Nebulized M6G
would be an ideal agent to relieve shortness of breath
if opiates act locally in the lung, as systemic toxicity

would be minimized while exposing pulmonary tissue to large amounts of drug. Another promising
finding of these initial studies is that a subcutaneous
dose of M6G displays very similar pharmacokinetics
to an intravenous dose. It is absorbed into the circulation fairly rapidly despite its large polar structure,
probably due to absence of a basement membrane in
the endothelium. Presence of basement membrane in
lung tissue probably explains the slower absorption of
nebulized M6G despite a much larger surface area.
Maximal plasma concentration occurs approximately
30 min after a SC dose and >60 min in nebulized
form.
Disadvantages
The biggest drawback of M6G is its tendency to accumulate in patients with renal dysfunction. Plasma
elimination half-time in non-dialyzed patients with
end-stage renal disease can approach 30 hours.
Another disadvantage is its slow passage across the
bloodbrain barrier, prolonging its onset of action
relative to morphine.
Randomized controlled trials

Table 119.2 summarizes the findings of randomized,
controlled clinical trials on the efficacy of M6G in
Table 119.2. Randomized, double-blind clinical trials on the efficacy of intravenous M6G for post-operative pain
Ref.
Population
Design
Placebo
Outcome
Motamed
et al. [6]
37 patients after
open knee surgery
M6G or morphine at
skin closure followed
by post-operative PCA
Yes
M6G 7 mg/70 kg was not better

than placebo
Cann et al. [2]
144 patients after

laparoscopic
gynecological surgery
M6G or morphine
bolus doses
No
M6G 8.4 mg/70 kg is as effective

as morphine with respect to
analgesia but with less nausea/
vomiting and sedation
Binning et al. [1]
68 patients following hip

replacement surgery
M6G bolus followed by

morphine PCA
No
M6G 30 mg/70 kg equivalent to

morphine 10 mg/70 kg
Hanna et al. [5]
100 patients during/after

joint replacement surgery
M6G versus morphine

bolus and PCA
No
M6G analgesia similar to

morphine
Dahan et al. [4]a
62 patients following
open abdominal surgery
M6G versus morphine

bolus and PCA
No
M6G and morphine analgesia

similar with 50% less nausea
and vomiting in the M6G group
Smith et al. [8]
170 patients after knee

replacement surgery
M6G 10, 20, or 30

mg/70 kg bolus
followed by morphine
PCA
Yes
M6G 30 mg/70 kg superior to

placebo
Single-center sub-analysis (multi-center population size = 517).

PCA, patient-controlled analgesia.
477
humans. All but one reported M6G to be better than

placebo and comparable to morphine in analgesic efficacy. M6G was generally found to produce less
systemic toxicity compared with morphine, though
no study to date has been adequately powered to compare side-effect profiles.
2. Cann C, Curran J, Milner T, Ho B. Unwanted effects of

morphine-6-glucoronide and morphine. Anaesthesia
2002;57:12001203.
Conclusions
4. Dahan A, van Dorp E, Smith T, Yassen A.

Morphine-6-glucuronide (M6G) for postoperative
pain relief. Eur J Pain 2008;12(4):403411. Review.
Many authors of clinical trials evaluating M6G believe

it is reliably effective and possesses desirable properties distinct from commercially available pain medications, warranting its availability as an opioid
analgesic. The development of a powerful opioid with
minimal risk of nausea and respiratory suppression
would undoubtedly be welcomed by physicians treating acute and chronic pain. While M6G is currently
being evaluated in phase 3 trials, larger clinical studies
are needed to further characterize its safety and efficacy.
References
1. Binning S, Coggins S, Davidson A, Millinga KR.

Comparison of Two Dosing Regimens of Morphine-6glucuronide Versus Morphine for Analgesia following
Total Hip Replacement. Prague: 4th congress of EFIC,
Abstract No. 587.T (2003).
478
3. Dahan A, van Dorp E, Sarton E. Postoperative

morphine-6-glucuronide versus morphine: equal
analgesia but reduced nausea/vomiting. Anesthesiology
2007;107:A1744.
5. Hanna MH, Elliott KM, Fung M. Randomized,

double-blind study of the analgesic efficacy of
morphine-6-glucuronide versus morphine sulphate
for postoperative pain in major surgery. Anesthesiology
2005;102:815821.
6. Motamed C, Mazoit X, Ghanouchi K, et al.
Preemptive intravenous morphine-6glucuronide is ineffective for postoperative
pain relief. Anesthesiology 2000;92:
355360.
7. Penson RT, Joel SP, Roberts M, Gloyne A, Beckwith
S, Slevin ML. The bioavailability and
pharmacokinetics of subcutaneous, nebulized and
oral morphine-6-glucuronide. Br J Clin Pharmacol
2002;53(4):347354.
8. Smith TW, Binning AR, Dahan A. Efficacy and
safety of morphine-6-glucuronide (M6G) for
postoperative pain relief: a randomized, doubleblind study. Eur J Pain 2009;13(3):293299.Epub 2008
Jun 11.
Section 12
Chapter
120
Neostigmine
Rongjie Jiang and Balazs Horvath
Generic Name: neostigmine, neostigmine methylsulfate

Trade Name: Neostigmine
Drug Class: acetylcholinesterase inhibitor
Deerfield, IL 60015
Chemical Name: dimethylcarbamate (m-hydroxyphenyl)trimethylammonium methylsulfate
Chemical Formula: C12H19N2O2; molecular wt
223.294 g/mol
Introduction
Neostigmine methylsulfate is a cholinesterase inhibitor commonly used for reversal of non-depolarizing
neuromuscular blockade. Neuraxial administration of
neostigmine as an analgesic agent is still in an experimental stage. A severe nausea side effect limits its
intrathecal application. Recent studies employing epidural neostigmine have reported effective analgesia,
opioid, and local anesthetic sparing effects, and reduction in opioid-related side effects [2].

Neostigmine is approved for the reversal of nondepolarizing neuromuscular blockade. It directly
inhibits acetylcholinesterase, the key enzyme responsible for deactivation of acetylcholine (Ach) in central and peripheral cholinergic synapses. Increased
concentration of Ach and activation of spinal cho
linergic receptors suppress pain transmission [2].
Following administration of neostigmine, the concentration of Ach expressed at spinal cholinergic
neuronal endings is increased, resulting in measurable analgesic effects. Also, perfusion of rat spinal cord
with Ach increases nitric oxide (NO) synthesis, which
may also provide analgesic effects [10]. Following

epidural administration, neostigmine concentration
in CSF is about 1/10 of that observed with intrathecal
dosing, which may explain the reduced incidence of
nausea and vomiting observed in multiple studies
when using it epidurally [6].
Receptor interaction
Neostigmine offers additive analgesic effects when
combined with opioids and alpha-2-adrenoceptor
agonists such as clonidine. Opioids and NE receptors
modulate pain via descending inhibitory fibers,
whereas Ach receptors are suppressive at local
interneurons. This addition of local modulation of
noxious transmission may explain the opioid and local
anesthetic sparing potential of neostigmine.

and elimination
Neostigmine is hydrolyzed by cholinesterase to
3-hydroxyphenyltrimethylammonia and 3-hydroxyphenyldimethylamine. It is also metabolized by microsomal enzymes in the liver to its glucuronide conjugate.
Eighty percent of neostigmine is eliminated in the
urine within 24 hours as either an unchanged form
(50%) or its inactive metabolites (30%). Renal excretion accounts for 50% of neostigmine clearance [11].
How supplied
Neostigmine injection is supplied in 10 mL multipledose vials (1mg/mL), in packages of 10. This preparation contains 1 mg/mL neostigmine methylsulfate, 1.8
mg/mL methylparaben and 0.2 mg/mL propylparaben
in sterile water.
Indications for analgesia

At present neostigmine has not been FDA-approved
for analgesia. The FDA non-approved indications
479
CH3
H3C
+
N
CH3
Figure 120.1.
CH3
Purpose
CH3
O
include use as an adjunct to peripheral nerve block,

and epidural and intrathecal administration as an
adjunct in post-operative and labor analgesia.
Recent peer-reviewed trials suggest that neostigmine
has measurable clinical efficacy; however, the studies
were small and underpowered for safety determinations.
When neostigmine given as a single bolus epidurally is
combined with epidural bupivacaine at the end of the
surgery, the analgesic effect lasts significantly longer
than bupivacaine alone [12]. In early labor, a single bolus
of 4 g/kg neostigmine with 10 mg ropivacaine provided
equivalent analgesia to 20 mg of ropivacaine [13]. When
neostigmine is administered continuously in patientcontrolled epidural analgesia during labor, it reduces
hourly bupivacaine requirement by 19% to 25% [3].
Contraindications
Absolute [1]: neostigmine is contraindicated in
patients with known hypersensitivity to neostigmine
methylsulfate, intestinal or urinary tract obstruction,
and mechanical peritonitis.
Relative [1]: neostigmine should be used cautiously in patients who have a history of asthma,
bradycardia, cardiac arrhythmias, recent coronary
occlusion, epilepsy, hyperthyroidism, peptic ulcer, or
vagotonia.
Common doses
Intrathecally administered neostigmine produces
dose-dependent side effects. At 150 g, it causes mild
nausea. At 500750 g, it causes severe nausea, vomiting, and sedation. At 750 g, it causes anxiety [8]. The
high incidence of nausea associated with neostigmine
limits its use in spinal analgesia. Epidural neostigmine
in combination with local anesthetics has a more
acceptable side-effect profile. Neuraxial neostigmine
doses evaluated in several clinical trials are presented
in Tables 120.1 and 120.2.
480
Table 120.1. Single bolus of epidural neostigmine [2]
The recent studies employing epidural neostigmine

have demonstrated significant analgesic efficacy, local
Dose
Side
(experimental) effects
Duration
Post-operative 50100 g
pain for knee (1 g/kg)
surgery
No changes ~5 hours [7]

from control
group
Post-operative
pain for
abdominal
hysterectomy
10 g/kg
combined with
bupivacaine
10 mg
No changes ~223 min

from control vs. control
group
~78 min [12]
Early labor
pain
300 g 500 g
To be
determined
(TBD)
TBD
Table 120.2. Continuous infusion of epidural neostigmine [3]
Purpose
Dose
(experimental)
Post-operative PCEA: 0.125%

pain (adjunct) bupivacaine
plus neostigmine
4 g/kg [4]
Side
effects
Duration
Epidural
TBD
neostigmine
110 g/kg
is considered
safe [5]
Labor analgesia Bolus 80 g then

Moderate
(adjunct)
continuous with 4 sedation [3]
g/mL neostigmine
in 1.25 mg/mL
bupivacaine PCEA
solution [3]
Reduces
bupivacaine
usage by
19% to 25%
anesthetic sparing effects, and an acceptable side-effect

profile. Unlike opioid analgesics, neostigmine does not
produce respiratory depression, neonatal depression,
or pruritus [1]. Theoretically, neostigmine has a potential to replace the lipophilic opioids such as fentanyl
and sufentanyl as the primary analgesic adjunct to
local anesthetic blockade. Epidural neostigmine
administered in doses of 110 g/kg is considered safe
[5]. The exact safety profile has yet to be determined.
Larger, direct comparison studies are needed.
It is unclear whether epidural neostigmine or preservatives within the vial may be associated with neurotoxicity given the limited sample size within the
existing studies. The antioxidants methyl- and propylparaben which are present in the commercially available neostigmine have not demonstrated neurotoxicity
in animals [10]. Preservative-free neostigmine is not
available in the USA. A much larger clinical trial is
needed to assess the short- and long-term safety profile of neuraxial-administered neostigmine.
Chapter 121 Buprenorphine transdermal
References
1. Neostigmine in Micromedex Healthcare Series and

DrugDex Evaluations.
2. Eisenach J. Epidural neostigmine: will it replace lipid
soluble opioids for postoperative and labor analgesia?
Anesth Analg 2009;109(2):293295.
3. Wong C. Neostigmine decreases bupivacaine use by
patient-controlled epidural analgesia during labor: a
randomized controlled study. Anesth Analg
2009;109(2):524530.
4. Tekin, S. Comparison of analgesic activity of the
addition to neostigmine and fentanyl to bupivacaine
in postoperative epidural analgesia. Saudi Med J
2006;27(8):11991203.
5. Chia YY. The acotomy. Anesth Analg 2006;102(1):201208.
6. Omais M. Epidural morphine and neostigmine for
post-operative analgesia after orthopedic surgery.
Anesth Analg 2002;95(6):16981701.
7. Lauretti GR. Postoperative analgesia by intraarticular
and epidural neostigmine following knee surgery. J
Clin Anesth 2000;12(6):444448.
Section 12
Chapter
121
8. Hood DD, Eisenach JC. Phase I safety assessment of

intrathecal neostigmine methylsulfate in humans.
9. Cronnelly R, et al. Renal function and the
pharmacokinetics of neostigmine in anesthetized
man. Anethesiology 1979;51:222226.
10. Eisenach JC, et al. Phase I human safety assessment
of intrathecal neostigmine containing methyland propylparabens. Anesth Analg 1997;85:
842846.
11. Neostigmine package insert. Baxter, Deerfield, IL,
June 2005.
12. Nakayama M, et al. Analgesic effect of epidural
neostigmine after abdominal hysterectomy. J Clin
Anesth 2001;13(2):8689.
13. Roelants F, et al. The effect of epidural neostigmine
combined with ropivacaine and sufentanil on
neuraxial analgesia during labor. Anesth Analg
2003;96(4):11611166.
Buprenorphine transdermal
Martin Hale
Generic Name: buprenorphine transdermal delivery system

Proprietary Names: Transtec (transdermal 3-day
delivery system), Norspan, BuTrans, ResTiva
(transdermal 7-day delivery systems)
Class of Drug: opioid analgesic
Manufacturers: Napp Pharmaceuticals Limited,
Cambridge Science Park,
Milton Road, Cambridge, UK; Purdue Pharma

LP, One Stamford Forum, Stamford, CT
Chemical Name: (2S)-2-[()-(5R,6R,7R,14S)9-cyclopropylmethyl-4,5
epoxy-6,14-ethano-3-hydroxy-6-methoxymorphinan-7-yl]3,3-dimethylbutan-2-ol
467.6
481
HO
Figure 121.1.
O
N
O
H
OH
Introduction
Buprenorphine is a semi-synthetic, highly lipophilic

opioid analgesic derived from thebaine, approved for
the management of moderate to severe acute and
chronic pain [1,2]. Buprenorphine has poor oral bioavailability; however, it provides effective analgesia
following parenteral, sublingual, or neuraxial administration [1,2]. Transdermal buprenorphine delivery
systems have been developed to improve convenience
compliance and analgesic uniformity. A 3-day delivery transdermal system, named Transtec, was developed and subsequently marketed in Europe in 2002,
followed in 2004 by a 7-day preparation named Norspan. Norspan is approved for use in 26 countries
worldwide, and an identical preparation named
BuTrans is currently undergoing phase III FDA trials. At the present time neither Norspan nor BuTrans
are approved or available for prescription in the USA.
482
Buprenorphines precise mechanism of analgesic

action is unknown. However, it is believed to bind and
activate spinal and supraspinal opioid receptors.
Buprenorphine has high affinity for mu opioid receptors, where it behaves as a partial agonist. At low to
moderate doses buprenorphine is 25 to 50 times more
potent than morphine; however, an analgesic ceiling
effect is noted with increasing dose [1,2]. Buprenorphine also has agonist binding properties at delta and
opioid-like receptors (ORL-1) and antagonistic effects
at kappa subtypes [1].
Buprenorphine is metabolized in the liver by
CYP3A4 and N-dealkylated to form norbuprenorphine.
It is also conjugated with glucuronic acid to form
buprenorphine-3-O-glucuronide and norbuprenor
phine-3-O-glucuronide. Approximately 2/3 of bupre
norphine is eliminated unchanged in feces [13].
Common doses/uses
Norspan/BuTrans is available in three strengths: the
patches contain 5, 10 and 20 mg of buprenorphine and
are designed to release buprenorphine at a controlled
rate of 5, 10 and 20 g/h.
Each patch provides a steady delivery of buprenorphine for up to 7 days. Steady state is achieved during
the first application. After removal of the patch,
buprenorphine concentrations decline approximately
50% in 12 hours.
Buprenorphine transdermal delivery system
(BTDS) patches have been shown to successfully treat
moderate to severe chronic pain. Double-blind studies have demonstrated its effectiveness in treating cancer pain as well as chronic lumbar pain [4] and chronic
osteoarthritis pain of the hip and knee.
Contraindications
Absolute: contraindicated in patients with hypersensitivity to buprenorphine or the patch excipients (oleyl
oleate, povidone, levulinic acid, adhesive matrix),
opioid-dependent patients for narcotic withdrawal
treatment, patients with severely impaired respiratory
function, or in patients who have used MAO inhibitors
in the past 2 weeks. BTDS has not been studied in
patients under 18 years of age.
Relative: caution should be used in patients with
convulsive disorders, head injury, shock, a reduced
level of consciousness, intracranial lesions or increased
intracranial pressure, or in patients with severe hepatic
impairment.
Overdose deaths have been reported with buprenorphine in combination with ethanol and benzodiazepines.
Transdermal buprenorphine has a latency to onset
and peak effect, and is not recommended for analgesia
in the immediate post-operative period, or when analgesic requirements are varying rapidly.
Seven-day transdermal delivery provides many benefits from the perspectives of pain management and
public health. Opioids with full mu agonist activity are
generally assumed to provide the strongest pain relief,
but also carry a higher risk of respiratory depression
and other side effects. Fentanyl is the only opioid in a
transdermal dosage form currently marketed in the
USA. The availability of a transdermal opioid with a
potentially lower side-effect profile (e.g. respiratory
depression) may offer advantages in patients with
Chapter 121 Buprenorphine transdermal
pulmonary
disease. Buprenorphine appears to have a
ceiling for cardiorespiratory and subjective effects and
a high safety margin even when taken by the IV route
[5]. Confirmed cases of overdose death in patients
taking only buprenorphine are rare. Most cases of
overdose death involve the use of buprenorphine in
combination with sedatives and/or alcohol.
Transdermal buprenorphine may provide convenience and other benefits in certain populations (e.g.
older adults who have difficulty swallowing pills and/or
have trouble opening medication bottles, and individuals dependent on others for assistance with taking
medication). The once per week, four patch changes
per month dosing schedule should facilitate adherence with the prescribed regimen of medication
administration for the control of pain [6]. No coordination is required with eating schedules because food
consumption does not affect drug delivery by the
transdermal route.
Abuse and diversion of any opioid product is of
concern. However, buprenorphine appears to have a
lower abuse liability than other morphine-like drugs,
reflected in the FDA listing of buprenorphine as a
C-III [7]. Furthermore, the transdermal system is not
particularly attractive to opioid abusers, given their
ready access to a broad range of opioids that produce
stronger euphoria and require little or no tampering
[7]. In addition, opioid abusers would be expected to
find buprenorphine less desirable than morphine-like
drugs due to its pharmacological ceiling limitation on
euphoria and the possibility that its administration
may precipitate opioid withdrawal symptoms.
of buprenorphine overdose. The risk of overdose and

death is increased with concurrent abuse of BTDS
with alcohol, benzodiazepines, sedatives, tranquilizers, antidepressants, and other substances.
Interactions: concomitant treatment with CYP3A4
inhibitors may lead to elevated plasma concentrations
with intensified efficacy of buprenorphine. Co-administration of buprenorphine and CYP3A4 enzyme
inducers could lead to increased clearance which
might result in reduced efficacy.
Patients should avoid direct exposure of the BTDS
application site to heating pads, electric blankets, heat
lamps, saunas, hot tubs, and heated water beds, because
an increase in absorption of buprenorphine may occur.
Caution should be used when treating febrile patients
as fever may increase absorption, resulting in increased
plasma concentrations of buprenorphine.
Withdrawal: buprenorphine doses should be
tapered gradually to prevent signs and symptoms of
withdrawal in the physically dependent patient; introduction of appropriate immediate-release opioid
medication should be considered.
Conclusions
Abuse: all opioids have associated risk of misuse,

abuse, addiction, and diversion. Evaluations prior to
prescribing opioids should include: (a) proper assessment of the patient, (b) proper prescribing practices,
and (c) periodic re-evaluation of therapy,
Toxicity: manifestations of acute opioid overdose
include pinpoint pupils, sedation, hypotension, res
piratory depression, and/or death. In cases of overdose, BTDS should be removed immediately. After
BTDS removal mean buprenorphine concentrations
decrease approximately 50% in 12 hours (range 1024
h), with an apparent terminal half-life of ~26 hours.
Naloxone may not be as effective in reversing respiratory depression produced by buprenorphine [13].
High doses of naloxone hydrochloride, 1035 mg/70
kg, have been reported to be used in the management

In an efficacy and safety trial of BTDS in opioid-
exposed subjects with moderate to severe low back
pain, the most frequently reported adverse events were
those typically associated with opioid therapy (e.g.
nausea, headache, vomiting, constipation, somnolence, dizziness) and application-site pruritus, typical
of a transdermal delivery system [4]. BTDS treatments
were found to be generally well-tolerated and safe.
The advantages of transdermal buprenorphine are

primarily related to the convenience and improved
compliance associated with a 7-day analgesic delivery
system. The preparation may be particularly useful in
elderly patients with moderate pain that cannot be
controlled with non-opioid analgesics and others who
are at risk for respiratory depression with pure mu
agonists.
References
1. Gutstein HB, Akil H. Chapter 23: Opioid analgesics.

In Hardman JG, Limbird LE, Gilman AG, eds.
Goodman & Gilmans The Pharmacological Basis of
Therapeutics, 10th ed. New York: McGraw-Hill, 2005,
pp. 569619.
483
2. Way WL, Fields HL, Schumaker MA. Chapter 31:

Opioid analgesics. In Katsung BG, ed. Basic & Clinical
Pharmacology, 9th ed. Lange Medical Books/
McGraw-Hill, 2004.
5. Umbricht, A, Huestis, M, Cone, E, Preston, K, Effects

of high-dose intravenous buprenorphine in
experienced opioid abusers. J Clin Psychopharmacol
2004;24(5).
3. http://emc.medicines.org.uk/ BuTrans summaries

of product characteristics.
6. Bradley C. Compliance with drug therapy. Prescribers

J 1999;39(1).
4. Steiner D, Munera, C, Hale, M, Ripa, S, Landau, C,

The efficacy and safety of buprenorphine transdermal
system (BTDS) in subjects with moderate to severe
low back pain. APS 28th Annual Meeting, San Diego,
CA. May 8, 2009.
7. http://www.fda.gov/ FDA recommendation to

reschedule buprenorphine 11/23/01.
Section 12
Chapter
122
Nicotine (transdermal)
Dmitri Souzdalnitski, Imanuel Lerman and Keun Sam Chung
Generic Name: nicotine

Trade/Proprietary Names: Nicoderm, Habitrol,
Nicorette, ProStep
Drug Class: acetylcholine receptor agonist
Manufacturer: Alza Pharmaceuticals, 1900
Charleston Road Mountain View, CA 94039;
CIBA-Geigy, Summit, NJ; generic (multiple)
Chemical Name: S-3-(1-methyl-2-pyrrolidinyl)
pyridine
Molecular Formula: C10H14N2; class: autonomic
ganglia stimulant
Introduction
484
Nicotine is a tertiary amine composed of a pyridine

and a pyrrolidine ring obtained, from the tobacco
plant (Nicotiana tabacum). It was initially identified
by Posselt and Reiman in 1828. Nicotine is a colorless
to pale yellow, freely water-soluble, oily, hygroscopic
volatile liquid, strong base with pKa = 8.5 with a characteristic pungent odor. It turns brown on exposure
to air or light. Of its two stereoisomers, S() nicotine
is the more active, and it is the prevalent form in
tobacco [1].
Mechanism of action
Nicotine functions as an agonist at a subtype of acetylcholine receptors, termed nicotinic receptors. Nicotinic acetylcholine receptors (nAChRs) are extremely
variable in their molecular structure. They are composed of five subunits to form a ligand-binding site and
an ionic pore. The variability of nAChRs subunit combinations and their location are responsible for diverse,
sometimes paradoxical, physiological and pharmacological effects of nicotine, including pain relief [1,2].
1. Nicotine is a prominent central nervous system
stimulant. Primary sites of action of nicotine in
the brain are thought to be pre-junctional,
causing the release of other neuro-transmitters.
Nicotine rewarding properties are related to its
ability to increase dopamine in the mesolimbic
system, similarly to other drugs of abuse.
Chapter 122 Nicotine (transdermal)
Figure 122.1.
N
CH3
H
N
Distribution
Delivery via a transdermal patch provides a sustained
plasma nicotine concentration, typically lower than
venous blood concentrations after tobacco smoking
(Figure 122.2). On the other hand, a nasal spray and a
vapor inhaler provide immediate 10-fold higher arterial blood concentrations immediately following inhalation compared to venous concentrations after a
nicotine patch application.
Metabolism
Figure 122.2. Nicotine patch.
2. Nicotine is known to induce -endorphin and

enkephalins, which are thought to be
fundamental for the manifestations of its
rewarding properties.
3. Morphine and other opioids produce analgesia in
part releasing acetylcholine and stimulating
nAChRs. Nicotine stimulates the same nAChRs.
4. Nicotine is a potent stimulator of stretch or
pressure mechanoreceptors of the skin,
mesentery, tongue, lung, and stomach, which may
contribute to its pain-relieving mechanisms.
5. Nicotine has anti-inflammatory properties.
6. Nicotine acts as an alpha-2 noradrenergic
receptor agonist in a way similar to clonidine,
another adjunct to pain management.
7. At the same time it promotes a discharge of
epinephrine from the adrenal medulla, as well as
discharge of catecholamines from sympathetic
nerve endings, resulting in activation of spinal
cord and brain descending inhibitory pain
pathways.
Nicotine induces nausea, vomiting, and occasionally diarrhea by both central and peripheral actions.
Future research will clarify the role and relative
contribution of specific actions of nicotine to alleviation of pain.
Pharmacokinetics
Absorption
Nicotine is easily absorbed from the respiratory tract,
buccal membranes, skin, and intestines, but not from
the stomach.
Nicotine is rapidly metabolized to cotinine, the major

metabolite of nicotine, via the cytochrome P450 pathway by cytochrome P450 (CYP2A), mainly in the liver.
Other metabolites included nicotine-1-N-oxide and
3-hydroxycotinine and conjugated metabolites, also
produced for the most part in the liver but also in the
kidney and lung. Only about 1020% of nicotine
remains unchanged. The relationship of nicotine and
CYP450 remains undiscovered. Nicotine has a halflife of about 24 hours, and cotinine has a half-life of
approximately 1620 hours. While cotinine is thought
to be an inactive metabolite it may contribute to development of tolerance to nicotine by prolonged weak stimulation of cholinergic receptors. Nicotine and its
metabolites are eliminated by the kidney. About 10%
of nicotine is excreted with urine unaltered. Nicotine
is also excreted in the milk of lactating women.
Indications (non-FDA-approved)
Acute surgical pain
Nicotine is not FDA-approved for any pain indications. Nevertheless, data obtained from recent clinical
trials suggest it may provide limited analgesic benefits
in post-surgical settings [35]. Transdermal nicotine,
5 mg, applied once immediately prior to induction of
general anesthesia for pelvic or abdominal surgical
procedures, reduced post-operative pain scores in
non-smokers. There was no increased benefit of nicotine with doses larger than 5 mg [3)] (Table 122.1).
Another recent study revealed that the pre-operative
application of a 7 mg nicotine patch resulted in a
significant (31%) reduction in opioid consumption in
non-smoking patients undergoing radical retropubic
prostatectomy [4]. Peri-operative administration of a
high-dose transdermal nicotine patch (21 mg/24
hours) for 3 days did not improve post-operative pain
control or decrease the analgesic requirement after
485
Table 122.1. Nicotine transdermal patch as an adjunct for post-operative pain control: indications and techniques
Indications
Advantages
Transdermal nicotine
patch application
Primary pain control

program
Pelvic and abdominal open

or laparoscopic surgeries [3]
Decreased pain scores by

2540%, tendency to decrease
opioid consumption
5 mg/16 h 1 patch applied

immediately before surgery to
glabrous skin away from the
surgery site. The patches to be
removed at bedtime on the
same night of surgery
Morphine PCA, NSAIDs
Radical retropubic
prostatectomy [4]
Decreased opioid
consumption by 1/3,
tendency to decrease pain
scores for the first 24 h after
the surgery
7 mg/24 h 1 patch applied

behind the ear 3060 min
before surgery
Intravenous morphine
patient-controlled analgesia
(PCA) and nonsteroidal antiinflammatory drugs (NSAIDs)
Abdominal hysterectomy [5]
Improves discharge eligibility
21 mg/24h patch applied

before, and on post-operative
days 1 and 2.
Morphine PCA
pelvic gynecological surgery. This study was different

from others in the way that it included both smokers
and non-smokers [5].
Chronic pain and cancer pain

There are no RCTs of nicotine for chronic nonmalignancy pain or cancer pain. The existing data
suggest that chronic nicotine users may actually be
more sensitive to pain than non-smokers. Symptoms
are more pronounced in smokers with more severe
nicotine dependence [6]. The association between the
intensity of pain in chronic pain states and smoking
status was explained by higher levels of substance P (P
for pain) in the cerebral spinal fluid and lower plasma
beta-endorphin levels than in non-smokers. There are
similarities between hypersensitivity to pain induced
by chronic nicotine use and opioid-induced hyperalgesia and opioid-induced tolerance in chronic pain
states. Further research is needed to explore and
explain these effects.
Adverse reactions
486
Serious reactions: nicotine dependence, fetal harm

risk.
Common reactions: nausea, local erythema, local
edema, rash, withdrawal symptoms, headache, palpitations, tachycardia, HTN, hiccups, constipation, flatulence, diarrhea, paresthesias, arthralgias, chest
discomfort, insomnia, abnormal dreams [7].
Less common adverse events: fever, hypothermia,
thirst.
Contraindications
Hypersensitivity, severe arrhythmias, acute myocardial infarction within 2 weeks, worsening or severe
angina [7].
Relative contraindications and cautions

Caution if asthma or reactive airway disease, cardiovascular, peripheral vascular diseases, hepatic impairment,
renal impairment, hyperthyroidism, pheochromocytoma, insulin-dependent diabetes mellitus, peptic ulcer
disease, or HTN are present [7].
Pregnancy: nicotine is a Pregnancy Category D
medication and should not be used by pregnant
women.
Drug abuse and dependence: there is a significant
risk of addiction associated with the use of nicotine.
Drug interactions
Combination of nicotine and dofetilide, a class III
antiarrhythmic drug, is contraindicated since it may
increase levels of both drugs with QT prolongation
and arrhythmias [7]. Combination with bupropion
may increase risk of hypertension secondary to possible additive effects. Combination with insulin may
increase insulin requirements. Combination with
metformin may increase metformin levels and risk
of lactic acidosis, and may decrease hypoglycemic
agent efficacy. Blood sugar monitoring recommended
for combinations of nicotine with some other
diabetic medications, including acarbose, miglitol,
Chapter 122 Nicotine (transdermal)
pioglitazone,
repaglinide, rosiglitazone, sitagliptin,
sulfonylureas. Combination with ergot alkaloids or
caffeine may increase risk of peripheral vasoconstriction, ischemia.
makes its use even less attractive than opioids. The fact
that nicotine induces nausea, vomiting, and sometimes diarrhea may limit its usefulness as an analgesic
as well.
Common doses
References
Adult dosing: 7 mg, 14 mg, or 21 mg24h patch [7];

renal dosing caution advised if severe impairment;
hepatic dosing caution advised if hepatic impairment; pediatric dosing is currently unavailable and
not applicable for nicotine.
Potential advantages of nicotine include its opioidsparing effect in multimodal post-operative analgesia, easy use and administration, and cost-effectiveness
[1,35]. It has been shown recently that use of
transdermal nicotine patch significantly improves
discharge eligibility scores [7]. Discharge home earlier may allow considerable savings for each treated
patient without compromising patient safety and
patient satisfaction. If confirmed, this finding may
attract a significant number of healthcare providers
and payers to nicotine use for post-operative pain
control.
Addiction potential is the main disadvantage of use of
nicotine for pain control. Public access to this drug
1. Benowitz NL. Nicotine and postoperative

management of pain. Anesth Analg 2008;107(3):
739741.
2. Trigo JM, Zimmer A, Maldonado R. Nicotine
anxiogenic and rewarding effects are decreased in
mice lacking beta-endorphin. Neuropharmacology
2009;56(8):11471153.
3. Hong D, Conell-Price J, Cheng S, Flood P.
Transdermal nicotine patch for postoperative pain
management: a pilot dose-ranging study. Anesth Analg
2008;107(3):10051010.
4. Habib AS, White WD, El Gasim MA, et al.
Transdermal nicotine for analgesia after radical
retropubic prostatectomy. Anesth Analg
2008;107(3):9991004.
5. Turan A, White PF, Koyuncu O, Karamanliodlu B,
Kaya G, Apfel CC. Transdermal nicotine patch failed
to improve post-operative pain management. Anesth
Analg 2008;107(3):10111017.
6. Weingarten TN, Moeschler SM, Ptaszynski AE,
Hooten WM, Beebe TJ, Warner DO. An assessment of
the association between smoking status, pain intensity,
and functional interference in patients with chronic
pain. Pain Physician 2008;11(5):643653.
7. http://www.epocrates.com/.
487
Section 12
Chapter
123
Local anesthetic bone paste

Vadim Tokhner and Inderjeet Singh Julka
Generic Names: methyl methacrylate cement

plus lidocaine, hemostatic putty plus lidocaine
Trade/Proprietary Names: (Simplex Bone
cement), Osteobond, Orthostat, Sterilized
lidocaine (Xylocaine)
Drug Class: local anesthetic
Manufacturers: Howmedica Osteonics Corporation, 325 Corporate Drive, Mahwah, NJ;
Zimmer Holdings, 345 Main Street, Warsaw,
IN; Orthocon, Inc., North Brunswick, NJ; Astra
Pharmaceuticals, Shrewsbury, MA; Astra Zeneca
Pharmaceuticals, Westboro, MA
Chemical Formula of Lidocaine: 2-(diet
hylamino)-N-(2,6-dimethylphenyl) ethanamide
Chemical Structure of Lidocaine: see Figure
123.1
Poly(methyl methacrylate) is an acrylic resin. It
is a clear and a rigid vinyl polymer, made by free
radical vinyl polymerization from the monomer
methyl methacrylate (Figure 123.2).
Description
488
Bone cement is used for fixation of artificial joints/

implants to the skeleton. It acts as a filler between the
bone and the implant. It consists of poly(methyl
methacrylate) (PMMA), which is a transparent thermoplastic. It is a synthetic polymer of methyl methacrylate. Addition of crystals of barium sulfate gives
it radiopacity. Incorporation of substances such as
local anesthetics [1], antibiotics, anti-inflammatory
drugs, immunomodulators, osteogenic promoters,
and diagnostic substances such as radioactive tracers
into bone cement has been attempted. The combination of a local anesthetic with methyl methacrylate
cement offers the promise of selective analgesia following surgery or injury to bone. Analgesia from
incorporated
local anesthetic is thought to be due
to the elution of the drug into the surgical site.
However, much research into the efficacy, duration
of analgesia, and side effects needs to be done. Some
elution behavior of local anesthetics has been preliminarily studied. It was found that prilocaine
eluted the fastest and bupivacaine the slowest, with
lidocaine between them [2]. Local anesthetics have
also been shown to have some anti-microbial activity [35].
Orthocon Inc. is developing a novel extendedrelease bone hemostat containing lidocaine which is
designed to stop bleeding and to provide local pain
relief. This preparation utilizes the companys proprietary Orthostat hemostatic bone putty. Orthostat
is a sterile, moldable, wax-like mixture of calcium
stearate and alkylene oxide copolymer intended to
control bleeding from the cut surface of bone. When
applied manually to surgically incised or traumatically
broken bone, the putty achieves local control of bleeding by acting as a mechanical tamponade. The new
preparation combines Orthostat putty with lidocaine. It allows the local anesthetic to be slowly eluted
and may be employed for relief of osteogenic pain following orthopedic surgery. The company expects to
initiate a pivotal clinical trial with this product in the
near future.
Mode of activity
Local anesthetic agents released from bone paste or
putty can reversibly block the fast sodium channels of
the neural cell membrane and prevent axonal depolarization. This leads to failure of noxious transmission and neuronal signaling within injured bone.
Indications
Patients undergoing orthopedic surgeries where bone
cement is utilized can be considered as potential candidates for this approach.
Chapter 123 Local anesthetic bone paste
CH3
Figure 123.1.
C2H5
NH CO CH2 N
C2H5
CH3
CH3
C=C
CH3
Vinyl polymerization
C=O
O
CH3
Methyl Methacrylate
+CH2-C}-n
C=O
O
CH3
Poly Methyl Methacrylate
Figure 123.2.
Common doses
An amount of 5% by weight of bone cement composition of a local anesthetic agent is thought to be
effective [1].
Various potential advantages may be present while
providing analgesia by this method, including ease of
use, tolerability, opioid-sparing effect, and possible
reduction in opioid-related adverse events. Familiarity with the technique by the surgeons can be a potential advantage.
Elution profiles were studied and it was concluded that the amount of lidocaine released is proportional to the amount mixed with PMMA. It was
found to peak at 6 hours and continued to elute up to
72 hours [1].
There was a 10% improvement in impact strength
upon addition of lidocaine to CMW3 bone cement
and it had little effect on compressive strength, flexural strength, or flexural modulus [1].
Various potentially significant adverse reactions may
occur due to hypersensitivity to any of the components (local anesthetics, bone cement and plastics).
Systemic reactions to local anesthetics including
cardiac arrhythmia, bradycardia, cardiovascular collapse, increased defibrillator threshold, and heart
block can occur.
Agitation, confusion, dizziness, euphoria, hallucinations, lightheadedness, seizure, slurred speech,
somnolence, and coma can occur due to central
nervous systemic effects. Dermatological manifestations such as angioedema and urticaria can be
present. Patients may complain of metallic taste,
nausea, and vomiting and present with broncho
spasm, dyspnea, respiratory depression, and resultant
respiratory arrest.
Disease-related concerns include liver dysfunction, which may lead to increased risk of local anesthetic toxicity.
Mixing lidocaine with bone cement is also found
to increase the cement setting time [1].
References
1. US patent No 6,355,705 B1: date of patent 03/12/2002.

Inventor David M Bond; John F. Rudan.
2. Bond DM, Rudan J, Kobus SM, Adams MA. Depot
local anesthetic in polymethylmethacrylate bone
cement: a preliminary study. Clin Orthop Relat Res
2004;418:242245.
3. Ravin CE, et al. In vitro effects of lidocaine on
anaerobic respiratory pathogens and strains of
Hemophilus influenzae. Chest 1977;72:439441.
4. Rosenburg PH, et al. Antimicrobial activity of
bupivacaine and morphine. Anesthesiology
1985;62:178179.
5. Schmidt RM, et al. Antimicrobial activity of local
anesthetics: lidocaine and procaine. J Infect Dis
1970;121:597607.
489
Section 12
Chapter
124
Peripheral kappa agonists

Derek Chalmers
Generic Name: peripheral kappa agonist

Trade/Proprietary Name: CR845
Manufacturer/Developer: Cara Therapeutics
Parrot Drive, Trumbull, CT
Chemical Name: d-Phe-d-Phe-d-Leu-d-Lys-[(4-N-piperidinyl)amino carboxylic acid], acetate
salt
Introduction
CR845 is a novel peripherally restricted, all-d-amino
acid tetrapeptide kappa opioid selective agonist
under development for the treatment of acute and
chronic pain. It belongs to a novel class of opioid ligands which has a reduced ability to cross the blood
brain barrier and therefore acts without inducing
central side effects [1]. It is currently available as an
intravenous formulation in a sterile isotonic 0.04 M
acetate buffer of pH 4.5 composed of acetic acid,
sodium acetate trihydrate, sodium chloride, and
water, with addition of hydrochloric acid for pH
adjustments.
Mechanism of action
490
CR845 acts to reduce pain by selectively activating

kappa opioid receptors located on peripheral nerve
terminals, and kappa receptors on certain immune
cells. CR845 has no activity at the mu or delta subtypes of opioid receptors, or other known receptors.
Stimulation of kappa receptors by CR845 results in the
initiation of an intracellular cascade that leads to the
inhibition of ion channels necessary for peripheral
nerve activity and culminates in reduced afferent
nerve activity. Activation of kappa receptors on
immune cells results in reduced release of nerve-

sensitizing pro-inflammatory molecules.
Pharmacokinetics
Absorption: intravenous CR845 is completely
absorbed after infusion with peak plasma levels at the
end of infusion.
Distribution: CR845 exhibits a low volume of distribution in humans related to its high level of solubility. Highest concentrations are found in the plasma
compartment with minimal to no exposure predicted
in the central nervous system (CNS) based on preclinical distribution analysis. CR845 has a plasma half-life
of approximately 2 hours
Metabolism: CR845 is not a substrate for hepatic
drug-metabolizing enzymes and is eliminated as an
unchanged parent compound via biliary and urinary
excretion.
Acute surgical pain: CR845 may be effective in treating visceral, inflammatory, and neuropathic pain in
the acute post-operative setting. CR845 is particularly
indicated under conditions in which surgical procedures, such as abdominal laparoscopic approaches,
are likely to induce post-operative pain with a prominent visceral pain component. In a recent randomized
double-blind evaluation performed in women recovering from laparoscopic vaginal hysterectomy,
patients treated with CR845 benefited from reductions in pain intensity and IV-PCA morphine requirements [2].
Contraindications
Hypersensitivity: at this stage of clinical development,
CR845 is contraindicated in patients with a known
hypersensitivity to any component of this product or
opioids in general.
Chapter 124 Peripheral kappa agonists
H
N
H2N
O
O
N
H
H
N
O
N
CO2H
O
NH2
NH2
HOAC
Figure 124.1.

CR845 has not been systematically studied in humans
for its potential in relation to abuse, tolerance, or
physical dependence. However, it is likely that CR845s
peripherally restricted distribution would limit its
ability to induce CNS-related responses associated
with dependence.
CR845 offers the potential advantage of opioid-like
analgesia in the absence of classical opioid side effects.
Due to CR845s lack of central nervous system activity
and pharmacological selectivity for the kappa opioid
receptor, CR845 does not produce CNS-mediated respiratory depression, nausea or vomiting, sedation, or
cognitive dysfunction. In addition, CR845s activation
of peripheral kappa opioid receptors may act to treat
visceral pain with a higher degree of efficacy than that
available with traditional opioids, such as morphine.
Moreover, the drugs lack of activity at peripheral mu
opioid receptors may result in a lack of gastrointestinal and bladder-related side effects, such as post-operative ileus and urinary retention, and lead to improved
patient recovery times. CR845 may be used in a multimodal approach with reduced doses of centrally acting opioids.
The administration of IV CR845 results in an acute
diuretic effect manifest as an increase in mean urine
flow rate and a resultant negative fluid balance.
Patients should be monitored for fluid balance on an
ongoing basis.

The most frequently reported AE after CR845 administration is facial paresthesia. This usually manifests as
mild tingling or numbness around the face and nose
and subsides within minutes after drug administration. Mild to moderate orthostatic tachycardia has
also been observed with CR845 use and is most probably secondary to negative fluid balance induced by
increased urine flow rate.
References
1. Vanderah TW, Largent-Milnes T, Lai J, et al.

Novel D-amino acid tetrapeptides produce
potent antinociception by selectively acting at
peripheral -opioid receptors. Eur J Pharmacol
2008;583:6272.
2. Cara Therapeutics, 2010. Unpublished data on file.
491
Section 12
Chapter
125
Cannabinoid agonists
Yasser F. Shaheen and Aziz M. Razzuk
Generic Names: delta-9-tetrahydrocannabinol,

dronabinol, nabilone
Proprietary Names: Marinol, Cesamet, Sativex
Manufacturer: Solvay Pharmaceuticals, Inc.,
Marietta, GA; Valeant Pharmaceuticals International; GW Pharmaceuticals, London, UK
Drug Class: central-acting analgesic
Chemical Structures: 9-THC (dronabinol;
Marinol), see Figure 125.1; nabilone (Cesamet),
see Figure 125.2; cannabidiol, see Figure 125.3
IUPAC Names: dronabinol, ()-(6aR,10aR)6,6,9-trimethyl-3-pentyl-6a,7,8,10a-tetrahydro-6
H-benzo[c]chromen-1-ol; nabilone, (6aR,10aR)1-hydroxy-6,6-dimethyl-3-(2-methyloctan-2-yl)7,8,10,10a-tetrahydro-6aH-benzo[c]
chromen-9-one; cannabidiol, 2-[(6S)-3-methyl6-prop-1-en-2-ylcyclohex-2-en-1-yl]-5-pentylbenzene-1,3-diol
Introduction
492
Cannabis sativa is the genus and species name of a

flowering plant which has been used medicinally
for thousands of years. Delta-9-tetrahydrocannabinol (9-THC) is responsible for almost all the psychoactive effects of cannabis, but is only one of
more than 60 similar compounds found in cannabis
which, together, are collectively known as cannabinoids. Cannabinoid agonists that share the basic
chemical structure of delta-9-tetrahydrocannabinol
have been increasingly studied in recent years for
potential benefits in various types of pain and pain
syndromes.
To gain FDA approval of a drug, the molecule
must be relatively safe and the doses standardized,
among other things. The inhalation of natural cannabis smoke or oral consumption of the plant parts is
either unsafe, the dose cannot be standardized practically, or both. Cannabis smoke carries similar
health risks to cigarette smoke and there are hundreds of different compounds beyond the cannabinoids that vary in concentration from plant to plant,
making dose standardization infeasible. Current
cannabinoid agonists are either synthesized 9-THC
or synthetic analogs of 9-THC or are chemical
extracts from pharmaceutically standardized cannabis plants.
To date, only two cannabinoid agonist drugs have
been approved by the FDA for use in the USA. Dronabinol is a Schedule III synthetic form of 9-THC
and is marketed as Marinol capsules. Nabilone is
marketed as Cesamet and is a Schedule II synthetic
analog of 9-THC. Neither of these drugs is approved
for pain, however. Dronabinol is approved for nausea
and vomiting associated with cancer chemotherapy
in patients for whom standard antiemetics are inadequate and for AIDS patients with anorexia and
weight loss. Nabilone is approved for treating cancer
patients with chemotherapy-induced nausea and
vomiting (CINV) for whom conventional therapy
failed. However, there are a number of clinical trials
and case reports demonstrating that dronabinol and
nabilone provide moderate analgesic effects in
humans.
One other drug, Sativex (GW Pharmaceuticals,
London, England) is currently undergoing phase IIb/
III trials in the USA for the treatment of patients with
advanced cancer whose pain is not controlled with
opioid medications. The trials were expected to be
completed by the end of 2009, after which FDA
approval will be sought by the manufacturer to market
Sativex in the USA with its partner, Otsuka Pharmaceutical Co. Ltd. Sativex is an oral mucosal spray which
delivers a mixture of 9-THC and cannabidiol. Cannabidiol is one of the phyto-cannabinoids found in
cannabis which has no psychoactivity itself, but
reduces the psychoactive side effects of 9-THC when
Chapter 125 Cannabinoid agonists
Mode of activity
CH3
9
OH
H2
C
H2
C
H
H3C
C
H2
CH3
CH3
C
H2
Figure 125.1.
O
OH
CH3
H
H3C
H2
C
O
CH3
H2
C
C
H2
H2
C
C
H2
CH3
CH3
Figure 125.2.
CH3
OH
H2
C
H
H3C
HO
CH2
C
H2
H2
C
C
H2
CH3
Figure 125.3.
administered in combination. Sativex is extracted

from pharmaceutical-grade cannabis standardized
to give a reproducible proportion of 9-THC and
cannabidiol. This cannabis is grown in a secret location by the manufacturer in the UK.
Of the four stereoisomers of 9-THC, the trans
() isomer occurs naturally in cannabis and is many
times more potent than the other isomers. Dronabinol refers specifically to this isomer. Nabilone is more
potent than dronabinol and differs in that the methyl
group has been replaced by a carbonyl group on C-9
and the alkyl side chain is branched and longer. Cannabidiol differs from dronabinol in that the pyran
ring is broken. This difference renders it essentially
devoid of psychoactivity.
The cannabinoid agonists act on cannabinoid receptors that have been found in high concentrations in
areas of the brain dealing with pain control. These
receptors are also found peripherally and are capable
of modulating nociception as well. The receptors
clearly identified thus far are designated CB1 and CB2
(for cannabinoid-1 and cannabinoid-2). CB1 is primarily found in the central nervous system but can also be
found in the peripheral nervous system. CB2 is found
in cells and tissues involved with immune function and
in microglial cells, centrally. They are both G proteincoupled receptors located on the presynaptic terminals
of neurons. Central CB1 receptors are responsible for
the psychoactive side effects of cannabinoid agonists,
which are one of the primary difficulties in the use of
cannabinoids for pain management.
CB1 and CB2 are part of the endogenous cannabinoid system known as the endocannabinoid system.
This system also includes the naturally occurring ligands (endocannabinoids) of these receptors as well as
associated metabolic enzymes. Two of these endocannabinoids are N-arachidonoyl ethanolamine or anandamide and 2-arachidonoyl glycerol or 2-AG. They
are not stored in synaptic vesicles, but rather are synthesized on demand within the postsynaptic membrane. They are then released as retrograde messengers
acting on CB1 and CB2 receptors on the presynaptic
membrane resulting in an inhibitory effect on neurotransmitter release. Although 9-THC acts on the
same receptors as anandamide and 2-AG, producing
similar effects, its chemical structure is very different
from these two endocannabinoids. The endocannabinoid system is found throughout the central and
peripheral nervous systems as well as in many other
tissues and performs a vast array of functions in a
multitude of processes. Its involvement in nociception
is still being elucidated and a variety of methods to
manipulate it for control of pain are being studied
intensively at institutions all over the world.
The absorption and metabolism of the cannabinoid agonists also impact their effectiveness in the
management of pain symptoms. Greater than 90% of
dronabinol is absorbed and then readily metabolized
hepatically via microsomal hydroxylation to a mixture
of metabolites, with 11-hydroxy-9-THC being the
main active metabolite. They begin exerting their
effect within 1 hour and within 4 hours reach peak
effect, with psychoactivity lasting up to 6 hours. Elimination is primarily biliary with more than half being
493
excreted in the feces and less than a fifth in the urine.

Complete clearance of the drug takes days to weeks
due to its highly lipid-soluble nature. Nabilone is more
potent than dronabinol, but otherwise has similar
onset of action, metabolism, and clearance.
Sativex contains approximately equal proportions
of dronabinol and cannabidiol delivered in an oral
spray providing an onset of action of only 1540 minutes with peak effect occurring similarly to the oral
drugs. The cannabidiol may decrease psychotropic
effects either by competitive inhibition for the CB1
receptor site and/or by decreasing the metabolism of
dronabinol to 11-hydroxy-9-THC, which may be
more psychoactive than 9-THC.
Indications
494
Dronabinol and nabilone have not been approved for

the treatment of pain, but there is increasing evidence
that they have a useful role and have been prescribed
in some pain states. Sativex, on the other hand, is in
late-stage clinical trials to approve its use specifically
for patients with intractable cancer pain. The literature also contains many reports of its utility in various
types of pain.
Studies of cannabinoid agonists in acute post-operative pain have been mixed, with nabilone found to
actually worsen post-operative pain in one report.
However, there is evidence for their use with opioid
drugs, adjunctively, for possible synergistic effects or
to delay the development of opioid tolerance.
Cannabinoid agonists have been found to be more
generally useful in the management of chronic pain.
The individual drugs have rarely been compared head
to head for efficacy in any single study, so it is still not
clear which drug would be more beneficial for any
particular pain syndrome. Furthermore, reported efficacy of an individual drug can vary substantially from
study to study, even of the same pain syndrome.
Dronabinol has been found to be helpful to patients
with chronic non-malignancy pain on stable dosages of
opioids with persistent pain. Ten mg of dronabinol was
as effective as 20 mg of dronabinol and had fewer side
effects. The same dosage was effective in moderately
reducing pain related to multiple sclerosis (MS). Benefit to patients with cancer pain has also been reported.
Nabilone was successful in reducing non-malignancy pain as well as cancer pain, where it also
decreased opioid usage. At 1 mg per day, it reduced
spasticity-related pain in MS. Case reports describing
its use in neuropathic pain have been positive.
Sativex has generally been found to be more effective than the currently approved cannabinoid drugs in
the management of pain. It has been reported to be
useful in chronic non-malignancy pain, intractable
cancer pain, and peripheral and central neuropathic
pain, including that related to MS. It has already been
approved in Canada for the treatment of cancer pain
refractory to opioid therapy and central neuropathic
pain in MS. Studies have shown it to help patients
with brachial plexus root avulsion and rheumatoid
arthritis.
Contraindications
Since the cannabinoid agonists are not first-line
drugs in the treatment of any of the various types
of pain or pain syndromes, any potential risk of serious consequences from their use should be considered
an absolute contraindication. Preexisting or genetic
predisposition to serious psychiatric disorders such
as schizophrenia or psychotic disorders, in general,
would be an example. Precipitation or worsening of
these and less serious psychiatric disorders has been
reported. Caution and close monitoring of patients
with less serious illnesses such as bipolar disorder,
anxiety, or depression is necessary since the symptoms
of these disorders could become manifest.
The cannabinoid agonists should be avoided in
nursing mothers and have not been studied in pregnancy, pediatrics, or geriatrics, necessitating either
avoidance in these groups, or, at least, careful consideration of risk versus benefit. In the elderly, evaluation of cardiovascular, hepatic, and renal disease
should be undertaken. These drugs can cause tachycardia and orthostatic hypotension, especially initially, increasing the risk of myocardial infarction in
patients with cardiovascular disease. Postural hypotension coupled with the common adverse effects of
increased dizziness and drowsiness could lead to falls
in the elderly.
These drugs can lower the seizure threshold in
patients with a history of seizure disorder, which raises
the concern for the potential of precipitation of seizures in this group of patients. Careful monitoring is
advised in prescribing these drugs to patients already
on other drugs that affect the CNS due to possible
additive or synergistic effects. Although the potential
risk of abuse of the cannabinoid agonists has been
found to be low, care should be taken when prescribing these drugs to patients with a prior history of substance abuse, including alcohol. Of course, these drugs
Chapter 125 Cannabinoid agonists
should be avoided in patients with known hypersensitivity to cannabinoids, the sesame oil in Marinol capsules, or the propylene glycol, ethanol, or peppermint
oil in the Sativex spray.
Common doses/uses
The cannabinoid agonists suffer from a relatively
increased adverse effect profile compared to other
drugs used to treat pain. It is, therefore, generally recommended to titrate cannabinoid-based drugs for
therapeutic effect, beginning with dosages at the lower
end of the spectrum. Dronabinol dosages often range
from 2.5 mg per day to 40 mg divided into four doses
(QID). BID and TID dosing can be used for smaller
total daily dosages. Early-morning dosing should be
avoided due to a subsequent increase in adverse effects.
Nabilone can be titrated beginning with 1 mg at bedtime or 0.5 mg for cannabinoid-naive patients and
increased to BID dosing with a maximum daily dosage of 6 mg. Each actuation of the Sativex pump delivers 100 L of an oro-mucosal spray containing 2.7 mg
of 9-THC and 2.5 mg of cannabidiol. The patient can
self-titrate the number of sprays per day for symptomatic pain relief since the onset of action is fairly
rapid. Patients usually reach a stable dosage range
within 710 days and this often amounts to about
810 sprays per day.
Cannabinoid agonists are especially advantageous in
pain management due to a relative lack of toxicity,
with reported deaths from overdose rare to nonexistent. This is attributable to their low potential for respiratory depression because of the lack of CB1 receptors
in the respiratory center of the brainstem. When used
adjunctively, they are opioid-sparing and thereby
reduce the risk of respiratory depression by opioids. In
addition, 9-THC stimulates beta endorphin production, delays development of tolerance to opioids, and
limits withdrawal symptoms from opioids.
Although the cannabinoid agonists have a side-effect profile that is significant enough to limit widespread use among clinicians, they have few serious
adverse effects. With continued usage, tolerance to the
sedative effects develops while, at the same time, there
is generally no loss of analgesic efficacy and even some
increase in pain relief over a period of weeks to
months. Dronabinol and nabilone assist with improved
sleep, which helps increase pain tolerance. Nabilone is
more potent than 9-THC and has a longer half-life,

requiring less frequent dosing. The abuse potential for
these drugs is relatively low, presumably because of
the slower rise in plasma levels due to oral intake as
opposed to the rapid rise in plasma levels attained
with smoked cannabis.
Long-term use of Sativex in a variety of pain syndromes has not demonstrated significant tolerance
development to its analgesic effects. With normal
usage, serum levels remain below the generally
accepted minimum threshold for driving impairment,
specifically, 5 ng/mL of 9-THC. Few drugdrug
interactions and virtually no withdrawal symptoms
on abrupt cessation of therapy are further advantages
to the use of Sativex.
The main disadvantages of using cannabinoid agonists
for the treatment of pain is their psychotropic side
effects and potential for intoxication while generally
providing only modest pain reduction. Patients need to
be advised to abstain from driving, operating machinery, or engaging in other hazardous activities until the
drugs effect on them is known. Caution and monitoring are required in the context of psychiatric disorders.
It is possible to become psychologically or physiologically dependent on these drugs. Special care must also
be taken with cardiac patients and the elderly.
Drug interactions include, among others, additive
CNS depression when given to patients already on
CNS depressants and additive tachycardia and/or
hypertension when given to patients taking sympathomimetic drugs, anticholinergic drugs, and tricyclic
antidepressants.
There may be issues of availability with nabilone
since it is not generally considered a formulary drug.
Also, since it is a Schedule II drug, restrictions on prescribing may complicate its use in chronic pain therapy. Sativex is a Schedule II drug in Canada, but it is
uncertain whether it will be categorized as a Schedule
II or Schedule III drug when ultimately approved in
the USA.
The cost of cannabinoid agonist therapy for chronic
pain is relatively high. Dronabinol and nabilone range
in cost from several hundred dollars per month to
even $1000$2000 or more, depending on the dosage.
It is not known what the cost of Sativex therapy will be
once approved. In Canada, it is less expensive than the
oral drugs, yet still costs up to several hundred dollars
per month for the usual dosage regimen.
495
Table 125.1. Less common adverse events of individual cannabinoid agonists
Dronabinol
Nabilone
Sativex
Weakness
Weakness
Weakness
Depersonalization
Depersonalization
Depersonalization
Confusion
Confusion
Confusion
Palpitations
Headache
Headache
Anxiety
Sleep disturbance
Anxiety
Abdominal pain
Ataxia
Abdominal pain
Paranoia
Visual disturbance
Blurred vision
Abnormal thinking
Concentration difficulties
Memory problems
Oral pain (due to spray)
Oral irritation (due to spray)
Abnormal taste (due to spray?)

Serious adverse events are uncommon with the cannabinoid agonists. Their interactions with the central
nervous system are complex and not well understood,
but include sympathomimetic effects that can lead to
tachycardia and, occasionally, postural hypotension,
which may lead to cardiac events in susceptible
patients. Psychotic reactions and seizures can be precipitated in some patients with a history or genetic
predisposition to these disorders.
The most common adverse events with cannabinoids are CNS-related, including dizziness, drowsiness, persistent appetite stimulation, conjunctival
hyperemia, dry mouth, and the euphoria associated
with the cannabinoid high. Some of the less common adverse events associated with each individual
cannabinoid agonist are listed in Table 125.1.
Treatment of minor adverse events may include
reassurance, cessation of therapy, and supportive care.
In cases of recent overdose, activated charcoal and a
saline or sorbitol cathartic should be introduced into
the stomach via nasogastric tube. Reassurance and/or
benzodiazepines may be used if psychotic reactions,
panic, or severe agitation are present. For hypotensive
reactions, intravenous fluids and Trendelenburg positioning are usually adequate without the need for
pressors or other drugs.
Summary
496
Currently, the analgesic potential of the cannabinoid

agonists is generally modest, at best, and adverse
effects can limit their potential benefit. However, for

patients with intractable or chronic pain and chronic
pain syndromes, there are often no effective treatments. The cannabinoid agonists should be considered
as alternative or adjunctive analgesics in this subset of
patients, since even modest alleviation of discomfort
and opioid-sparing helps to lessen their total pain burden.
References
1. American Hospital Formulary Service Drug

Information 2008. Bethesda, MD: American Society of
Health-System Pharmacists, 2008, pp. 30073008.
2. Ashton JC, Milligan ED. Cannabinoids for the
treatment of neuropathic pain: clinical evidence. Curr
Opin Investig Drugs 2008;9:6575.
3. A study of Sativex for pain relief in patients
with advanced malignancy. (SPRAY) ClinicalTrials.
gov website. http://clinicaltrials.gov/ct2/show/NCT00
530764?term=sativex&rank=68. Accessed July 20,
2009.
4. Canadian Agency for Drugs and Technologies in
Health website. http://www.cadth.ca/media/pdf/310
_sativex_cetap_e.pdf. September 2005. Accessed July
22, 2009.
5. Farquhar-Smith WP. Do cannabinoids have a role in
cancer pain management? Curr Opin Support Palliat
Care 2009;3:713.
6. Hosking RD, Zajicek JP. Therapeutic potential of
cannabis in pain medicine. Br J Anaesth 2008;101:
5968.
7. Narang S, Gibson D, Wasan AD, Ross EL, Michna E,
Nedelikovic SS, Jamison RN. Efficacy of dronabinol as
Chapter 126 Peripheral cannabinoid receptor agonists
an adjuvant treatment for chronic pain patients on

opioid therapy. J Pain 2008;9:254264.
8. Pertwee RG. Cannabinoid pharmacology: the first 66
years. Br J Pharmacol 2006;147:S163S171.
9. Physicians Desk Reference. 63rd ed. Montvale, NJ:
Physicians Desk Reference, Inc., 2009, pp. 31633166.
10. Regence Rx Pharmacy Benefit Management website. h
ttp://www.regencerx.com/docs/physicianRx/cesamet0
207.pdf. February 2007. Accessed July 22, 2009.
Section 12
Chapter
126
11. Russo EB. Cannabinoids in the management of

difficult to treat pain. Ther Clin Risk Manag
2008;4:245259.
12. Svendsen KB, Jensen TS, Bach FW. Does the
cannabinoid dronabinol reduce central pain in
multiple sclerosis? Randomised double blind
placebo controlled crossover trial. Br Med J
2004;329:253257.
Peripheral cannabinoid receptor

agonists
Ho Dzung and Mark J. Lema
Generic Names: anandamide (endogenous ligand); tetrahydrocannabinol

Proprietary Names: CR701; WIN-552122;
JWH-133; AM-1231
Drug Class: central- and peripheral-acting
analgesic
Manufacturer: CR701: Cara Therapeutics, Shelton
CT
Chemical Structures: see Figure 126.1
Introduction
Although cannabinoid drugs have been used recreationally and therapeutically for millennia little was
known regarding their sites of activity and mechanisms of action. In recent years the pharmacological
and behavioral properties of these molecules have
been more thoroughly defined [1,2]. Development of
ligands that preferentially bind to peripheral receptors
may offer the promise of effective analgesia without
the central nervous system effects of nonselective
cannabinoids.
Description
Delta-9-tetrahydrocanabinol (THC), the active ligand
in Cannabis sativa extract, was thought to exert its
pharmacological effects by activating cannabinoid
receptors in the central nervous system. These receptors were identified in 1988, and endogenous ligands
termed endocannabinoids were isolated in 1992. Two
major cannabinoid receptor subtypes termed CB1 and
CB2 have been characterized [24]. Central CB1 receptors are primarily localized in neocortex and the limbic system, and are responsible for many of the
behavioral and analgesic effects of cannabinoid agonists. Peripheral CB2 receptors and some CB1 subtypes
are primarily localized in immune cells such as leukocytes and mast cells, which have been shown to be
involved in pain and inflammatory responses. CB2
receptors are not present in the CNS; however, they
are also found in peripheral nerve fibers and are particularly concentrated in injured neural endings.
The first endocannabinoid, anandamide, is an arachidonoyl ethanolamine, derived from fatty acids
within the body. Its pharmacology is quite similar to
THC although its chemical structure is different.
Anandamide binds primarily to the central CB1
497
CH3
H
H
H3C
H3C
Figure 126.1.
O
CH
CH3
N
CH3
N
O
O
WIN-55212-2
THC
CH3
O
N
H
CH3
Anandamide
498
OH
H 3C
CH3
CH3
H 3C
CH3
JWH-133
subtypes,
and its potency is equivalent to THC. CB1
agonists are associated with measurable analgesic
effects; however, their behavioral effects, including
suppression of locomotion, catalepsy, and hypothermia, are often problematic.
Recently a number of highly selective CB2 receptor
agonists have been developed [46]. These peripherally acting molecules have little to no activity in the
central nervous system and minimal off-target activity
on non-cannabinoid receptors, or various channels,
transporters, and kinases [5,6]. Peripherally selective
CB2 agonists were synthesized by combining an active
ligand with non-active chemical groups that either
limit association with CB1 receptors or decrease
bloodbrain barrier penetration and access to the
CNS. Limitations in CNS access may provide important clinical advantages over nonselective cannabinoids, since the psychoactive effects of cannabinoids
are caused by their interactions at central CB1 receptors. Psychoactivity and other adverse effects including euphoria, ataxia, dizziness, and confusion have
diminished patient tolerability. Unlike nonselective
cannabinoids, peripherally selective agonists would
also be expected to have lower psychological dependency, abuse, and diversion risks. Peripheral CB2 receptors may be an appropriate target for eliciting relief of
inflammatory pain without the CNS effect. CB2 receptor agonists in development can inhibit inflammation
and inflammatory hyperalgesia and offer the promise
of providing safe and effective analgesia [7]. Synthetic

CB2 ligands have also been found to attenuate neuropathic pain and mechanical and thermal hyperalgesia
in animal nerve ligation models
A number of peripherally selective CB2 agonists,
including WIN-552122, JWH-133, HU-308, and
CR701, have been developed and are being evaluated
in early phase II safety and analgesic efficacy trials.
The compound HU-308 is highly selective for the CB2
receptor subtype, with a selectivity over 5000 times
greater for CB2 vs. CB1. A second CB2 agonist, CR701,
that has high selectivity and minimal CNS access is
being evaluated at Cara Therapeutics [6]. This compound has demonstrated efficacy in animal models of
inflammatory and neuropathic pain. A similar compound, CB-13, is a potent agonist at both the CB1 and
CB2 receptors, but has very poor bloodbrain barrier
penetration. It produces only peripheral effects at low
doses, with symptoms of central effects such as catalepsy only appearing at much higher dose ranges. It
has antihyperalgesic properties in animal studies and
has progressed to preliminary human trials. A final
compound, AM1241, appears to be particularly effective in controlling neuropathic pain. Ibrahim et al. [8]
tested the hypothesis that CB2 receptor activation
would reverse the sensory hypersensitivity observed
in neuropathic pain states. AM1241 dose-dependently
reversed tactile and thermal hypersensitivity produced by ligation of the L5 and L6 spinal nerves in
Chapter 126 Peripheral cannabinoid receptor agonists
rats. These effects were not antagonized by a CB1

receptor antagonist, suggesting that they were produced by actions of AM1241 at CB2 receptors. AM1241
was also active in blocking spinal nerve ligation-induced tactile and thermal hypersensitivity in mice
lacking CB1 receptors (CB1/ mice), confirming
that AM1241 reverses sensory hypersensitivity independent of actions at CB1 receptors.
Relative: patients with coronary risk factors (tachy

cardia and orthostatic hypotension), dementia (fall
precautions), mood disorders (anxiety, confusion,
dizziness).
Clearance and elimination pathways for peripherally

selective cannabinoids have yet to be clearly defined.
THC is metabolized to 11-OH-THC (11-hydroxyTHC) by the human body by almost exclusive firstpass hepatic metabolism. More than 50% of THC is
excreted in the feces.
When employed as analgesics, CB2 agonists may offer

improved safety by avoiding psychoactive effects commonly observed with nonselective agonists. This may
also permit use of higher and potentially more efficacious doses with greater patient tolerability. This is a
very important advantage, because despite clear analgesic effects in animal models, THC and other nonselective cannabinoids have not proven to be effective
analgesics in humans. The major factor responsible for
this lack of clinical efficacy has been a very high sideeffect profile of these agents that severely limits dose.
Proper utilization of CB2 agonists may not only eliminate psychoactive effects, but, when employed in a multimodal regimen, may also limit opiate use and their
associated side effects. Experimental cannabinoids such
as JWH-133 and CR-701 exhibit fewer adverse reactions due to more selectivity for CB2 receptors, but provide effective analgesia in animal studies. When used as
a sole analgesic, CB2 agonists are shown to alleviate
neuropathic pain and mechanical hyperalgesia. They
have not been studied as part of a multimodal regimen;
however, CB2 receptor agonists enhance the effect of
opioid receptor agonists in a variety of models of analgesia, and combinations of cannabinoids and opioids
may produce synergistic effects [9]. There is also evidence that CB2 agonists enhance the analgesic effect of
nonsteroidal anti-inflammatory drugs (NSAIDs), raising the possibility that combination therapy could
reduce NSAID dose and minimize the potential for gastrointestinal and cardiovascular disturbances [9].
There are no approved indications for peripheral cannabinoid agonists for the treatment of pain. Animal
models and clinical trials display possible use for inflammatory, visceral, and neuropathic pain. Doses for pain
management in humans have yet to be determined.
Toxicity: toxicity is extremely low with no reported

cases. Absorption is limited by serum lipids, which
can become saturated with THC, mitigating toxicity.
LD50 of THC is 1270 mg/kg for male rats and 730 mg/kg
for female rats from oral doses. Accumulation of
metabolites is directly associated with increased incidence of adverse effects.
Drug interactions: no significant drugdrug interactions are noted. Treatment for any possible interactions should include the discontinuation of
cannabinoid treatment.
Mode of activity
Peripherally selective cannabinoid agonists exert their
major and minor effects by selectively activating
peripheral CB2 receptors. Cannabinoid receptors are
Gi/o-linked seven-transmembrane-domain G proteincoupled receptors. CB2 agonists mediate analgesia by
preventing the release of noxious and inflammatory
mediators from a variety of cell types including neutrophils, macrophages, and mast cells. As mentioned
above, CB2 receptors also inhibit afferent conduction
in inflamed or injured nerve fibers. Recent data indicate that CB2 expression is up-regulated in injured
peripheral neurons and may play a role in neuropathic
pain, particularly painful neuromas. Other studies
exhibit a possible spinal location of microglia and
macrophages expressing CB2 receptors. Activation of
these receptors leads to improvement of central sensitization, hyperalgesia, and allodynia while also providing anti-inflammatory effects.
Metabolic pathways
Contraindications (based on
dronabinol usage)
Absolute: known sensitivity and allergic reactions to
cannabinoids, marijuana, or sesame oil.
499
Adverse events observed with nonselective agonists may not be as common or pronounced with
peripherally selective CB2 cannabinoids. They include
potential for abuse, confusion, ataxia, memory loss,
psychosis, dizziness, hypotension, sedation, euphoria,
paranoia, and dry mouth. Less common adverse
events include: orthostatic hypotension, abdominal
pain, nausea, vomiting, anxiety, myalgias, increased
appetite, nightmares, flushing, visual difficulties, and
headache. No specific antagonists are currently in use,
but adverse effects can be cared for individually.
Availability: due to the potential for abuse, there is
legal debate about the therapeutic use of natural cannabinoids. It is to be noted that use of cannabinoids
may be habit-forming and possibly lead to abuse of
other substances. This may not be the case for peripherally selective agonists. Currently CB2 receptor agonists are only available for experimental analgesic
trials.
References
1. Hanus L, Breuer A, Mechoulam R, Fride E. HU-308:

a specific agonist for CB(2), a peripheral cannabinoid
receptor. Proc Natl Acad Sci USA 1999;96(25):
1422814233.
Section 12
Chapter
127
3. Brownjohn PW, Ashton JC. Novel targets in pain

research: the case for CB2 receptors as a biorational
pain target. Curr Anaesth Crit Care 2009;20:198203.
4. LaBuda CJ, Koblish M, Little PJ. Cannabinoid CB2
receptor agonist activity in the hindpaw incision
model of postoperative pain. Eur J Pharmacol
2005;527:172174.
5. Gardin A, Kucher K, Kiese B, Appel-Dingemanse S.
Cannabinoid receptor agonist 13, a novel cannabinoid
agonist: first in human pharmacokinetics and safety.
Drug Metab Dispos 2009;37(4):827833.
6. Chalmers D. Cara Therapeutics, personal
communication. 2009
7. Quartilho A, Mata HP, Ibrahim MM, et al. Inhibition
of inflammatory hyperalgesia by activation of
peripheral CB2 cannabinoid receptors. Anesthesiology
2003;99:955960.
8. Ibrahim MM, Deng H, Zvonok A, et al. Activation of
CB2 cannabinoid receptors by AM1241 inhibits
experimental neuropathic pain: pain inhibition by
receptors not present in the CNS. Proc Natl Acad Sci
USA 2003;100(18):1052910533.
9. Philip Malan T Jr, Mohab M Ibrahim, Josephine Lai,
et al. CB2 agonists, analgesia without psychoactive
effects. Curr Opin Pharmacol 2003;3:6267.
Injectable capsaicin
Muhammad K. Ghori
Generic Name: injectable capsaicin

Trade Name: Adlea
Manufacturer: Anesiva Inc., San Francisco, CA;
note: Anesiva merged with a second company
on August 5, 2009, and is now called Arcion
Therapeutics Inc.
500
2. Roxane Laboratories, Inc. Q & A about therapy with

Marinol (dronabinol). Pamphlet. Columbus, OH, 1997.
Class: peripheral-acting TRPV-1 antagonisttype analgesic

Chemical Name: 8-methyl-N-vanillyl-trans-6nonenamide
305.41
Chapter 127 Injectable capsaicin
Introduction
The injectable analgesic Adlea is a concentrated and

purified form of capsaicin (8-methyl-N-vanillyl6-nonenamide). It is an unapproved preparation, currently in phase 3 trials for relief of post-surgical acute
pain, nerve trauma-induced neuropathic pain, and for
chronic musculoskeletal, tendon-related, and arthritic
pain.
Description
Capsaicin is an alkaloid derived from plants and has
been a common ingredient in food and spices for
many centuries. It is concentrated in the seeds and
inner stem of chili peppers and is the active ingredient
responsible for making them taste hot. Low-concentration capsaicin is widely available and is a frequently
used topical analgesic for patients with chronic
arthritic joint and back pain. Topical gels and creams
are often combined with NSAIDs and narcotic analgesics for severe pain due to sprains, strains, joint pains,
and for other types of arthritis. A higher-concentration topical capsaicin has also been approved for postherpetic neuralgia-related neuropathic pain [1,2].
This new injectable preparation Adlea (formerly
named ALRGX 4975 98% Pure) employs purified capsaicin in very high concentration. In October 2006 the
FDA granted orphan drug status for Adlea for the
treatment of pain related to interdigital neuroma
(Mortons neuroma).
The manufacturer is currently evaluating Adlea
for the management of acute pain following orthopedic surgery and for chronic joint pain. Currently,
long-acting, site-specific Adlea is being evaluated in
several clinical trials, including pain related to interdigital neuroma, post-traumatic neuropathic pain,
knee joint osteoarthritis pain, and post-surgical pain
following bunionectomy, total knee replacement, and
arthroscopic shoulder surgery.
Mode of activity
Capsaican is a TRPV-1 agonist. TRPV1 (also termed
the capsaican receptor) is a polymodal nociceptor
exhibiting a dynamic threshold of activation that is
markedly reduced in inflammatory conditions [3].
TRPV1 knock-out mice are devoid of post-inflammatory thermal hyperalgesia. TRPV receptors are in
abundance on unmyelinated C fiber peripheral endings and respond to a variety of noxious mediators.
Once activated these fibers transmit localized and
O
CH3O
HO
N
H
Figure 127.1.
highly intense pain impulses (gnawing pain, deep,

aching pain) to the spinal cord and higher centers.
Following local application, Adlea initially stimulates these receptors, releases additional substance P,
and causes immediate complaints of severe burning
pain. Continued exposure to capsaicin depletes
stores of substance P, and eventually destroys the terminal nerve endings, thereby minimizing or preventing subsequent C fiber activation. Adleas effects
are highly selective at C fiber TRPV1 receptors. For
this reason its application does not have any clinically measurable effects on A-delta and A-alpha fibers, and it does not block temperature or touch
sensations [3].
Potential indications
1. Post-operative pain: total knee replacement,
bunionectomy, total hip replacement,
arthroscopic shoulder surgery, hernia repair.
2. Acute and chronic pain: pain due to tendinitis
of the elbow, interdigital neuromas, moderate to
severe osteoarthritis of the knee, neuropathic
pain occurring secondary to trauma and nerve
injury [4].
3. As adjuvant therapy: clinically significant
opioid-sparing effect. It may be useful in elderly
debilitated patients in whom respiratory and CNS
depression due to narcotic overdose needs to be
avoided.
4. Limited data indicate that capsaicin may be
effective for relief of migraine headache,
cancer-related pain and diabetic and HIV
neuropathy [5].
Clinical trials and doses

1. Total knee arthroplasty: in a randomized, doubleblind, phase 3 trial (ACTIVE 1) Adlea (15 mg in
60 mL of solution, 0.25 mg /mL) was compared
with placebo in 217 patients undergoing total knee
arthroplasty. Adlea was injected into the wound at
the end of surgery. Post-operative pain
501
502
improvement from the 448 hours period was

significantly improved in the active group (P =
0.005). In a similar but more extended trial
(ACTIVE-2), reductions in post-operative pain
and improved range of motion continued for 6
weeks following surgery. There was a significant
reduction in opioid requirements during this time
period (P = 0.005).
2 . Bunionectomy: this phase 2 dose-ranging trial in
185 patients evaluated 100, 500 and 1000 g doses
of Adlea vs. placebo during the first 32 hours
following bunionectomy. Pain relief was
statistically improved and need for ketorolac
rescue reduced in the higher-dose group vs. the
two lower-dose groups and placebo during the
first 32 hours post-op. All three doses were well
tolerated with similar side effects to placebo.In a
randomized double blind phase 3 study of 301
patients, Adlea 1 mg in 4 mL solution (0.25
mg/mL) injected into the surgical wound was
compared with placebo for pain relief following
bunionectomy [6]. Study results showed less pain
in the Adlea group; however, the reduction was
not significant during the first 232 hours when
compared with placebo (P = 0.07). During this
interval a secondary endpoint (opioid
consumption) was significantly reduced in the
Adlea group (P = 0.012). Another secondary end
point, the numeric of post-operative pain rating
score from 4 to 48 hours, also showed statistically
significant reductions in the Adlea-treated group
(P = 0.004). There was no difference in wound
healing, safety profile or sensory testing around
the wound, which demonstrated the selectivity of
Adleas effect on noxious C fibers.
3. Osteoarthritis of knee joint: a small phase 2 study
(n = 12) found that patients with end-stage
osteoarthritis reported significant pain relief for 6
weeks after receiving a single injection of Adlea in
the knee joint. In an open label phase 2 study of
55 patients suffering from osteoarthritis of the
knee joint, a statistically significant reduction of
pain (P = 0.001) was noted in one of four groups
treated with stepped doses of Adlea (100 g first
week, 300 g second week and 1000 g third
week).
4. Tendinitis of the elbow joint: in a small phase 2
trial, tendinitis of the elbow was studied in 45
patients. Patients were treated with lidocaine
followed by placebo or Adlea (100 g) in painful
tendinitis of the elbow joint. Reduced pain and

increased functionality from baseline was noted
by 60% of patients treated with Adlea.
5 . Interdigital neuroma: in this double-blind,
placebo-controlled phase 2 study of 58 patients
with severe interdigital neuroma-related pain,
those treated with a single injection of Adlea
reported significant improvement in symptoms
for up to 4 weeks. The Adlea group reported 59%
less pain, which was significantly better than
placebo (36% less pain) throughout the 4-week
observation period.
Pharmacokinetics/pharmacodynamics
Subcutaneous injection of capsaicin in rats resulted in
a rise in blood concentration, reaching a maximum at
5 hours. Highest concentration was found in kidney,
and lowest in liver. Direct plasma levels of Adlea have
yet to be reported in any of the clinical trials. Plasma
levels were measured following application of the high
dose (640 g/cm2) capsaican dermal patch Qutenza
(NGX-4010). Plasma concentration from 173 patients
with post-herpetic neuralgia, HIV-related neuropathy, and painful diabetic neuropathy showed a maximum plasma concentration of 17.8 ng/mL. The
capsaicin levels declined very rapidly, with a mean
population elimination half-life of 1.64 hours. Mean
area under the curve and Cmax values after a 60 minute
application were 7.42 ng/mL and 1.86 ng/mL respectively. Application of NGX-4010 for 90 minutes
resulted in capsaicin area under the curve and Cmax
values approximately 1.78- and 2.15-fold higher than
observed in patients treated for 60 minutes. Low systemic exposure and very rapid elimination half-life of
capsaicin after NGX-4010 administration are unlikely
to result in systemic effects and support the overall
safety profile of this investigational cutaneous patch.
Mild transient increase in liver enzymes was seen
more often in the capsaicin-treated group. Metabolism and elimination data for Adlea are expected to be
similar to topical and transdermal capsaicin.
Contraindications
At this time, the only absolute contraindication for
Adlea is patient hypersensitivity to capsaicin or capsinoid products. Relative contraindications would
include patients with elevated liver enzymes, patients
showing signs of septic arthritis, age less than 2 years,
and patients on ACE inhibitors.
Chapter 127 Injectable capsaicin
Common doses
Dosing will be based on clinical trial safety and efficacy data, and contingent upon FDA approval.
Potential advantages and

disadvantages
Adlea is a selective peripheral-acting analgesic that
can be used for acute and chronic pain management
[5,6]. It may be employed in a multimodal analgesic
regimen with opioids and NSAIDs. Its long-lasting
analgesic and narcotic-sparing effect may reduce the
incidence and severity of opioid-related sedation,
nausea, vomiting, and constipation.
The NSAID-sparing effect of capsaicin can reduce
the unwanted side effects of NSAIDs such as plateletrelated aggregation abnormalities, peptic ulcer problems, or cardiovascular and renal complications. It
may be particularly useful in the elderly, who are often
intolerant to opioids and NSAIDs.
Potential disadvantages are burning stinging pain
and hyperalgesia at the injection site; possible neurotoxicity if injected directly into a nerve. Persistent redness and erythema; occasional cough with ACE
inhibitors
Pain and hyperthermia at the injection site can be
reduced by pre-administration neural blockade, and
administration during general anesthesia. Ideally,
Adlea may be applied to patients receiving anesthesia
and post-operative analgesia with epidural and peripheral neural blockade catheters. Residual pain may be
controlled with local application of ice packs, local
anesthetic infiltration, and oral acetaminophen.
In conclusion, Adlea appears to exhibit promise

as a novel analgesic in the treatment of acute surgical
pain, osteoarthritis, and conditions of chronic
neuropathic pain. It remains unclear whether or
when it will receive FDA approval. The merging of
Anesevia into a larger company may improve the
chances for funding and completion of outstanding
clinical trials.
References
1. Wong GY, Gavva NR. Therapeutic potential of

vanilloid receptor TRPV1 agonists and antagonists as analgesics: recent advances and setbacks.
Brain Res Rev 2009;60(1)267277, Epub 2008
Dec 25.
2. Aasvang EK, Hansen JB, Kehlet H. The effect of
wound instillation of a novel purified capsaicin
formulation on post herniotomy pain. Anesth Analg
2008;107(1):910.
3. Final report on capsaicin. Int J Toxicol 2007:26(suppl.
1):3106.
4. Remadevi R, Szallisi A. Adlea(ALGRX-4975) an
injectable capsaicin (TRPV1 Receptor agonist)
formulation for longstanding pain relief. IDrugs
2008;11(2):120132.
5. Babbar S, Marier JF, Bley K. Pharmacokinetic analysis
of capsaicin after topical administration of a highconcentration capsaicin patch to patients with
peripheral neuropathic pain. NeurogesX inc, San
Mateo, California 94404, USA.
6. Stoker DG, Gottleib I, Comfort S. A single instillation
of a highly purified capsaicin formulation decreases
postoperative pain after bunionectomy. IASP annual
meeting, 2008.
503
Section 12
Chapter
128
TRPV-1 ion channel blockers

Jeanette Derdemezi
Generic Names: transient receptor potential

vanilloid (TRPV) channel antagonist, capsaze
pine, iodo-resiniferatoxin (I-RTX), MK-2295
Trade/Proprietary Name: none at present
Drug Class: ion channel blocker
Manufacturer/developer: Sandoz (Novartis),
Novartis International AG, CH-4002 Basel, Swi
tzerland; Merck Pharmaceuticals, P.O. Box 100,
One Merck Drive, Whitehouse Station, NJ 08889
Chemical Name: N-[2-(4-chlorophenyl)ethyl]1,3,4,5-tetrahydro-7,8-dihydroxy-2H-2-benzazepine-2-carbothioamide
Chemical Formula: C19H21ClN2O2S
Introduction
504
Transient receptor potential vanilloid (TRPV) channel blockers (antagonists) are new drugs, which are
not currently approved for clinical use, yet have great
analgesic potential. An example of this class of drugs
is capsazepine, a synthetic analog of capsaicin [1],
which inactivates TRPV1 channels by competitively
occupying TRPV1 binding sites in sensory neurons.
Although capsazepine, the first TRPV antagonist,
exhibited certain analgesic and anti-inflammatory
properties, its effects were of low potency as well as
variable within different species. As a result, capsazepine never reached the clinical arena. It is used
now in the laboratory as an investigating tool for the
study of other TRPV antagonists. The next compound
studied was iodo-resiniferatoxin (I-RTX), an analog
of resiniferatoxin (RTX). This drug was more potent
than capsazepine and more specific for TRPV receptors but lacked consistent analgesic effects. The functional importance of the TRPV channels in pain was
further elucidated with the cloning of the vanilloid
receptor [2]. The search for the perfect TRPV antagonist has been intensified and currently there are
several drugs undergoing clinical trials. The new
generation of TRPV antagonists has structures completely different from the agonists and therefore they
are devoid of partial agonistic effect. Newer compounds that are in phase 2 clinical trials are:
SB-705498 (for migraine, made by GSK), NGD8243/MK-2295 (for acute pain, made by Neurogen/
Merck), and GRC (for acute pain, made by Glenmark/Eli Lilly). Some other compounds useful for
the treatment of chronic pain are in phase 1 clinical
trials (AMG-517, AZD-1386,ABT-102) [3].
Mode of action
Ion channels are integral membrane proteins found in
every cell. Transient receptor potential (TRP) channels are nonselective monovalent and divalent cation
channels, first described in the visual system of Drosophila. TRP channels, which got their name because
mutations in this gene cause a transient voltage
response, are important structures for Ca2+ homeostasis and other regulatory and physiological functions.
When intracellular Ca2+ stores are depleted, these
channels open, allowing extracellular Ca2+ to enter the
cell. TRP channels are classified into six families
according to their amino acid sequence and homology: TRPC (canonical), TRPM (melastatin), TRPL
(mucolilpins), TRPP (polycystins), TRPA (ankyrin),
and TRPV (vanilloid receptors) [4].
TRPV channels are further classified into six subfamilies: TRPV1, TRPV2, TRPV3, TRPV4, TRPV5,
and TRPV6. The subtypes TRPV 1, 2, 3, and 4 are
called thermo TRPs [4] since all of them are activated
by different degrees of temperature. In 1997 the
TRPV1 (capsaicin, vanilloid) receptor was cloned
from rodent posterior dorsal root ganglia [2] and since
then has been studied extensively. Activation of
TRPV1 receptors is associated with pain formation
Chapter 128 TRPV-1 ion channel blockers
HO
HO
N
Cell membrane
N
H
Intra cellular
Figure 128.1.
Brain
Nerve Terminal
Dorsal root
ganglion
A and C Fibers
Detection
Extra cellular
Propagation
Spinal cord
Transmission to CNS
Figure 128.2. Schematic representation of signal detection

propagation and transmission.
and propagation via the afferent neurons into the posterior horn of the spinal cord and other CNS locations,
where they release glutamate and other neuropeptides
Meanwhile there is release of pro-inflammatory substances from the periphery (Figure 128.2). Due to
their role in pain detection, transmission, amplification, and sensitization, TRPV channels have become
the target for the development of new analgesics.
Structure of TRPV channels

The TRPV receptor contains six transmembrane
domains designated S1S6. These domains anchor the
channel to the cellular membrane. Between S5 and S6
there is a pore. TRPV possess three ankyrin repeats.
This transmembrane protein has an extracellular surface and an intracellular surface (Figure 128.3). Factors that activate and regulate this channel act in
different domains. Antagonists of this channel may
act in different areas of the complex molecule, the
pore, the capsaicin site, the extracellular area, or the
intracellular area, leading to its inactivation.
Location: TRPV1, a nonselective cation channel
with a preference for calcium, is abundant in the
peripheral sensory and central nervous system as well
as other organ cells. TRPV channels are found in small
1 2 3 4 5
Pore
CI
Cell membrane
Figure 128.3. Schematic diagram of a TRPV1 channel.
unmyelinated (C), less myelinated (Ad) fibers of primary afferent neurons as well as in the dorsal root and
trigeminal and nodose ganglia. In addition they are
located in the dorsal horn of the spinal cord (especially in lamina I and the inner surface of lamina II),
the spinal nucleus of the trigeminal tract and in the
fibers deriving from the nodose ganglia. The expression of these receptors (channels) in the pathway of
the pain ties them closely to initiation and transduction of pain. TRPV channels have been located in
areas other than the sensory system such as the urothelial cells, the gastroesophageal junction, in the mast
cells, lymphocytes, and keratinocytes. The presence of
TRPV channels in mast cells emphasizes their role in
the inflammatory process.
TRPV1 channels are activated by many physical,
mechanical and chemical stimuli and endogenous ligands, and therefore have been described as polymodal
receptors. TRPV1 is stimulated by:
1. temperatures above 42C
2. pH less than 5.5 (protons)
3. capsaicin, piperine
4. spider venoms
5. jellyfish
6. lipids such as anandamide
7. pro-inflammatory neuropeptides, such as
prostaglandins, ATP, NGF, bradykinin, CGRP
(calcitonin gene-related peptide).
When TRPV channels are stimulated by the above
factors, the proteins undergo a configurational change
which allows Ca2+ followed by Na+ to enter the cytoplasm causing depolarization. In addition, Ca2+ entering the cytoplasm causes the release of many
neuropeptides (kinins, substance P, prostaglandins,)
which further activate the TRPV channel. TRPV1
antagonists can interfere in all these levels, thereby
decreasing inflammatory pain, acute pain, and chronic
pain.
505
In a preliminary human trial, the TRPV1 antagonist MK-2295 was administered to normal individuals for 14 days. In addition to reductions in
experimental pain and hyperalgesia, these subjects
also displayed a marked increase in threshold to
heat-related discomfort. Some patients did not
report discomfort despite exposure to unpleasant
temperatures around 48C. While this finding may
offer therapeutic benefits, it could result in thermal
injury.
Ideal TRPV1 antagonist (drug profile)

For clinical use the TRPV1 antagonists should be
able
1. to block activation of the channel (heat, proton,
ligand)
2. to be potent
3. to have bioavailability
4. to be highly selective
5. to have minor, if any, side effects
6. to be soluble.
Potential indications of TRPV1

antagonists
The new TRPV agents will be useful alone or in
combination with other agents in the following
conditions:
1. Hyperalgesia (some types)
2. Post-operative pain
3. Inflammatory pain (osteoarthritis, rheumatoid
arthritis)
4. Neuropathic pain (diabetic, AIDS neuropathy)
5. Bone cancer pain [5]
6. Visceral pain
7. Migraine pain.
Advantages of TRPV blockers

The advantage of these agents is that they act at the
nociceptor level; therefore by blocking TRPV channels
506
they can interfere with pain at the site of its formation

rather its propagation.
TRPV channels are expressed in cells outside the sensory system and therefore mediate many physiological
functions. Blocking these channels can lead to untoward effects from other systems. The following are
some well-documented and some potential side
effects.
1. Hyperthermia which is not responding to
antipyretics (TRPV channels are found in the
hypothalamus, where they may play a role in
temperature regulation).
2. Insensitivity to potentially damaging thermal
stimulation.
3. Hypertension (this is a potential untoward effect
that may occur with prolonged use).
4. Gastric ulcers.
Based on these potential risks, systemic administration of TRPV1 antagonists may be restricted;
however, topical application may offer greater safety
and analgesic effectiveness.
References
1. Bevan S, et al. Capsazepine: a competitive antagonist

of the sensory neurone excitant capsaicin: Br J
Pharmacol 1992;107:544552.
2. Caterina MJ, Schumacher MA, Tominaga M, Rosen
TA, Levine JD, Julius D. The capsaicin receptor: a
heat-activated ion channel in the pain pathway. Nature
1997;389:816824.
3. Pal M, Angaru S, Kodimuthali A, Dhingra N.
Vanilloid receptor antagonists: emerging class of novel
anti-inflammatory agents for pain management. Curr
Pharm Des 2009;15:10081026.
4. Cortright DN, Szallasi A. TRP channels and pain.
Curr Pharm Des 2009;15:17361749.
5. Nilius B, Owianik G, Voets T, Peters JA. Transient
receptor potential cation channels in disease. Physiol
Rev 2007;87:165217.
Section 12
Chapter
129
Neramexane
Dajie Wang
Generic Name: neramexane

Trade/Proprietary Name: none at present
Class of Drug: uncompetitive NMDA antagonist
Manufacturer: Forest Laboratories, Inc., 909
Third Avenue, New York, NY 10022; Merz Pharmaceuticals, Frankfurt, Germany
Chemical Name: 1-amino-1,3,3,5,5-pentamethylcyclohexane hydrochloride
Introduction
Neramexane is a central-acting N-methy-d-aspartate
receptor antagonist which first underwent preclinal
trials in Germany. In 1998, it was investigated for both
neuroprotective and alcoloholism effects. In 2001, it
continued onto phase II trials for alcoholism and a
phase I trial for pain. In 2001, Forest Laboratories Inc.
entered into an agreement with Merz & Co. (Germany)
and brought the drug to the USA [1,2]. Pre-clinical
animal models have been trialed with neramexane,
looking at its effects on various entities, including neuropathic pain [3]. A phase 1b trial revealed promising
results for treatment of neuropathic pain; however, the
subsequent phase II trial showed no superiority to
existing treatments [4,5]. A phase III trial is currently
under investigation for tinnitus [1,2].
Mode of activity
Neramexane is an open-channel blocker against the
NMDA receptor. It has moderate affinity to the NMDA
receptor, with strong voltage-dependency and fastonset blocking kinetics.
Metabolic pathways, drug clearance and elimination: in the phase I study, an oral dose (540 mg)
demonstrated a plasma half-life of approximately

2942 hours. Metabolism has not been clearly elucidated yet. After administration of a single dose,
3040% of the drug was excreted from the kidney
unchanged [3].
Indications
Specific indications have not been approved by the
FDA. Several clinical trials have used neramexane for
Alzheimers disease, tinnitus, alcohol substitution, and
pain. A phase III trial for moderate to severe Alzhei
mers disease failed to achieve significance in the end
points tested. For tinnitus, a phase III trial is ongoing.
Preliminary analgesic trials

In a rat model of diabetic neuropathic pain, treatment
with neramexane (12.3, 24.6, and 49.2 mg/kg per day)
for 2 weeks via an osmotic minipump significantly
reduced symptoms of mechanical hyperalgesia and
allodynia. Administration of memantine (20 mg/kg
per day) was comparable to gabapentin (50 mg/kg per
day) [3].
In a phase Ib human investigation the analgesic
and anti-hyperalgesic properties of neramexane were
tested in 18 subjects following intradermal capsaicin
[4]. The patients received either a single dose of neramexane (40 mg PO), flupirtine (100 mg), or placebo
in a double-blind, randomized, cross-over study. Pain
intensity following intradermal capsaicin injection as
well as pain evoked by pinpricks was significantly
reduced by neramexane (22% to 30% vs. placebo).
Dynamic mechanical allodynia (pain to light touch)
was also significantly attenuated by neramexane
(28% vs. placebo). Flupirtine showed no analgesic
or anti-hyperalgesic effect. The finding that a single
low dose of neramexane had a marked analgesic effect
in a human surrogate model of neurogenic hyperalgesia could not be duplicated in a subsequent phase II
trial [5].
507
NH2
Figure 129.1.
drug reactions. The most frequent adverse events were

fatigue, daze, and dizziness [3].
References
1. Neramexane. Drugs R D. 2002;3(1):1920.
Contraindications
Not available for clinical use.
Common doses/uses
Oral doses between 550 mg were used in the clinical
trials [3].
Potential advantages/disadvantages
This drug is not available for clinical use, although it
may be effective for neuropathic pain.

There were no serious adverse events in all the trials
and no subjects were taken out of the trials for adverse
Section 12
Chapter
130
508
2. Goldman-Sachs Global Healthcare. Goldman Sachs

Global Healthcare Conference. Forest Laboratories
Inc., Company Presentation, 2006.
3. Chen SR, Samoriski G, Pan HI. Antinociceptive
effects of chronic administration of uncompetitive
NMDA receptor antagonists in a rat model of
diabetic neuropathic pain. Neuropharmacology
2009;57:121126.
4. Klein T, Magerl A, Hanschmann M, et al.
Antihyperalgesic and analgesic properties of the
N-methyl-d-aspartate (NMDA) receptor antagonist
neramexane in a human surrogate model of
neurogenic hyperalgesia. Eur J Pain 2008;12:1729.
5. Rammes G. Neramexane: a moderate-affinity NMDA
receptor channel blocker: new prospects and
indications. Exp Rev Clin Pharmacol 2009;2(3):
231238.
Nociceptin
Juan Jose Egas and Bijal Patel
Introduction
History
Nociceptin (orphanin FQ) is a novel neuropeptide

whose actions have yet to be completely elucidated. However, stimulation of the nociceptin receptor has been implicated in the modulation of many
neurobehavioral processes, including pain, substance
dependence, sexual behavior, anxiety, locomotor
activity, learning capacity, memory, and adaptation to
stressful stimulus [16]. Continued research in this
area has the potential to lead to a new class of drugs
for pain medicine and beyond.
Detailed characterization of opioid receptors began in

1992 with the identification and cloning of the OP1
(delta) receptor, followed by subsequent identification
and cloning of OP2 (kappa) and OP3 (mu) receptors.
All of these receptors are G-coupled proteins that have
seven transmembrane domains and share 60% of
structural homology. In 1994, a new receptor subtype
was identified and was originally given the name opioid receptor like-1 (ORL-1). This subtype has typical
opioid receptor characteristics, such as a G-coupled
Chapter 130 Nociceptin
protein, seven transmembrane domains and also sharing up to 60% of structural homology with mu opioid
receptors. This homology is particularly strong in the
transmembrane domains and less in the extracellular
domains (up to 80% in the second, third and seventh
transmembrane domains) [1]. Its gene was localized
to murine chromosome 2 and was named Oprl1 [2].
Despite this receptors close homology to the traditional opioid receptors, investigators were initially
unable to find an endogenous binding ligand, thus
leading to its original classification as an orphan
receptor [2]. However, 1 year after its discovery, an
endogenous ligand neuropeptide was found simultaneously by two groups of investigators. A French
group led by Meunier named the ligand nociceptin to
denote its presumed pronociceptive activity, while
a Swiss group led by Reinscheid named it orphanin
FQ, referring to its affinity to the orphan opioid
receptor [2].
The nociceptin/orphanin FQ
neuropeptide
Like most neuropeptides, nociceptin/orphanin FQ
(NC OF FQ) originates from a larger precursor peptide, in this case prepro-nociceptin, whose gene has
been localized to chromosome 8 (8p21). Nociceptin/
orphanin FQ is a heptadecapeptide, which also shares
some structural homologies with the classic endogenous opioid neuropeptide dynorphin A. Both neuropeptides are composed of 17 amino acids, and
contain the same last two amino acids at the carboxyl
terminus [2]. Despite these structural similarities,
both neuropeptides do not share cross affinity with
their respective ligand receptors. NC OF FQ has no
affinity to any of the traditional opioid receptors (does
not bind or compete) and its actions cannot be antagonized by nonselective antagonists of opioid receptors, such as naloxone. NC OF FQs affinity for
traditional opioid receptors can be enhanced by
replacing the alanine at position one by tyrosine.
Although the tyrosine analog interacts with the traditional opioid receptors, it still preserves some affinity
for OP4 receptors and can induce naloxone-resistant
actions [2].
Stimulation of this receptor system by an agonist
will elicit a pre-junctional inhibitory effect. It is believed
that this inhibition occurs through the same cellular
mechanisms and transduction pathways that occur
with classic opioid receptor stimulation: (a) facilitating
inward K+ currents; (b) inhibition of Ca2+ entry to the

cells through voltage-gated N-type calcium channels;
(c) suppression of adenylate cyclase with a subsequent
decrease of intracellular cAMP levels. All of these
events will lead to an inhibition of neuronal excitability and a decrease of neurotransmitter release.
Nociceptin orphanin FQ CNS

distribution
Research studies have identified the distribution of
NC OF FQ and OLR-1 through mRNA detection techniques (which is the main determinant of active
expression of the genes implicated in the synthesis of
NC OF FQ). Through these techniques, this system
was found to extend to many areas of the CNS, including the cortex, ventral forebrain, hypothalamus, amygdala, mammilary bodies, claustrum, anterior
olfactory nucleus, hippocampus, mesolimbic pathways (nucleus accumbens), periaqueductal gray, pontine nuclei, interpeduncular nucleus, substantia nigra,
raphe complex, locus coerulus, and ventral and dorsal
horns of the spinal cord [2]. Receptors have also been
found in the sympathetic, parasympathetic, and sensory nerves.
There have been conflicting data regarding the
modulatory effects of nociceptin on pain. Both antinociception and pro-nociception effects have been
noted by several authors. The route of administration
and dose administered seem to be paramount as
determinants of its predominant effect. A decrease in
the nociceptive threshold is contradictory to the general belief that stimulation of opioid receptors produces analgesia and anti-hyperalgesia. In animal
studies, intracerebroventricular (ICV) injections of
NC OF FQ provided supraspinal analgesia including
stress-induced-anti-nociception. Spinal administration of NC OF FQ produces a dose-dependent analgesia, giving a bell-shaped dose-response curve. Low
doses of intrathecal NC OF FQ produce a spontaneous pain effect similar to that elicited by intrathecal
administration of substance P and/or NMDA agonists. It is believed that this pro-nociceptive action of
low-dose NC can be in part mediated by the activation
of the substance P system [1]. The pro-nociceptive
effect is reflected by caudally directed scratching, licking, and biting behaviors in test animals, all of which
can be eliminated by pre-treatment with morphine,
capsaicin, and neurokinin-1 receptor antagonists [1].
On the other hand, high doses of intrathecal NC
509
produce
analgesia similar to that evoked by classic
opioid receptor agonists. Pre-treatment with high
intrathecal doses of NC can block the scratching, bitting, and licking behaviors induced by intrathecal
administration of substance P. Prolonged administration of NC will result in tolerance similar to that
observed with opioid; however, there is no cross-tolerance noted between NC and morphine, indicating
that the actions of the two compounds are mediated
by different receptors [1].
Supraspinal effects of NC OF FQ can be pro-nociceptive and block analgesia provided by endogenous
and exogenous opioid compounds. It can also counteract analgesia from alpha-2 receptor agonists (clonidine), GABA B receptor agonists (baclofen), and
electroacupuncture [2]. It is believed its anti-analgesic
effects are mediated through interactions at other sites
of the neuronal circuit acting as a functional antagonist rather than a direct interaction with classic opioid receptors [2]. The pro-nociceptive action of NC
OF FQ is completely absent in OP4 receptor knockout mice and, similar to the classic opioid receptors,
prolonged stimulation of OP4 will produce tolerance
to its anti-opioid effects [1]. At the same time, this
pro-nociceptive, anti-analgesic effect of NC OF FQ
has been questioned by several authors. An ICV injection may not be considered an ideal method for reproducing its true physiological role. Diffusion and spread
of this compound will be dependent on a concentration gradient limiting its spread into deeper structures. There is also a question by using this route how
it will affect populations of opioid-like receptors that
would not be normally activated by endogenously
released NC OF FQ [2].
Nociceptin/orphanin FQ in
inflammatory pain models
510
It is well known that peripheral nerve injury or inflammatory states induce neuronal plastic changes in the
spinal cord. These plasticity changes are responsible
for the production and maintainance of persistent
pain states, allodynia, and hyperalgesia occurring in
both affected areas (primary sensitization) and nonaffected areas (secondary sensitization). In inflammatory states, the NC OF FQ system is up-regulated [4].
This is reflected by increased NC levels and binding in
the spinal cord, specifically at the level of the dorsal
horns mainly limited to the superficial laminae I and
II. Inflammatory states also induce the expression of
the prepro-NC gene at the dorsal root ganglion, giving

a short-lived burst of NC levels lasting for less than 6
hours [1].
Injection of CFA or formalin will induce tissue
injury acompanied by an inflammatory state characterized by thermal hyperalgesia and mechanical
allodynia [4,5]. Both effects are induced by an upregulation of pro-inflammatory cytokines, nitric
oxide synthase, and CGRP at the level of the dorsal
root ganglion and spinal neurons [4]. It is widely
accepted that pre-treatment with mu opioid agonists can prevent or reduce the formation of secondary hyperalgesia and allodynia after tissue
injury [3]. This effect is a consequence of the inhibition of ascending excitatory nociceptive transmission pathways and activation of inhibitory systems
with decreased propagation of action potentials in
nociceptive neurons.
In animal studies using formalin for inducing
inflammatory pain, morphine was compared to nociceptin efficacy in treating several stages of pain. It was
shown that local, peripheral, and spinal morphine
pre-treatment prevented both hyperalgesia and secondary allodynia from happening with a limited efficacy in treating pain once both phenomena are well
established. Like morphine, local, peripheral, and spinal administration of nociceptin was also able to prevent or reduce both phenomena, but to a lesser extent.
Post-treatment with NC was more effective than both
morphine and pre-treatment with NC in reducing
long-term effects of formalin in pain [3]. In another
study, pre-treatment with NC produced a long-lasting
attenuation of inflammatory pain after CFA injection
by suppressing the up-regulation of inflammatory
mediators and c-fos gene expression [4]. Through
these data, we can conclude that NC OP FQ administration has the potential to both prevent the spinal
cord sensitization induced by inflammatory states and
suppress pain transmission in the spinal cord once the
neuroplastic changes associated with sensitization are
established.
Nociceptin/orphanin FQ agonists for

substance abuse
In addition to pain modulation, nociceptin/orphanin
FQ has been implicated in reducing, or even completely blocking, the rewarding effects and tolerance
of substances that have abuse and dependency potential. NC and its receptor are located throughout the
Chapter 130 Nociceptin
reward areas of the brain, including a high denisty of

receptors in the central nucleus of the amygdala [7].
Several studies have shown that NC may block the
rewarding properties of morphine. This action was
demonstrated by blocking conditioned place preference (CPP a possible indirect way to measure
reward) through the ICV administration of NC in test
animals that were given subcutaneous morphine [8].
The anti-tolerance and anti-addictive effects are limited not only to opioids, but potentially also extend to
other substances such as cocaine, alcohol, and amphetamines [1,2,6]. This anti-addiction effect could give us
the possibility of developing bifunctional opioids that
will act on both mu opioid and NC receptors that
could function as non-addictive analgesics, devoid of
any abuse potential, or even lead to medications for
treatment of drug addiction.
Theoretically, combination mu/NC agonists may
be able to balance the therapeutic and side-effect profiles of opioid analgesics by reducing the reward effect
and tolerance development. In a study using mice and
bimodal opioids with both mu and NC activity, it was
concluded that NC full agonist activity is required to
attenuate morphine-induced rewarding effects.
Between the compounds used with both NC partial
and mu partial agonist activity, it was found that these
compounds still have analgesic properties without the
rewarding and addictive effects of pure mu opioid
stimulation [6]. Likewise, kappa opioid receptor stimulation has also been implicated in reducing the
rewarding effect of mu opioid stimulation and this is
associated, as with NC receptor stimulation, to a
decrease of dopamine release in the mesolimbic
pathway (nucleus accumbens). Mixed kappa/mu
opioid ligands, such as nalbuphine, have potent antinociceptive effects and are less addictive compared to
morphine. It appears that a bifunctional compound
with NC and mu agonist activity may be useful in
decreasing opioid withdrawal and increasing compliance in addicts. Buprenorphine is a partial mu agonist
that has been succesfully used to treat chronic pain
and drug addiction, and this effect has been attributed
in part to its ability to stimulate NC receptors [6].
Nociceptin/orphanin FQ as an
anxiolytic
In animal studies, NC was shown to act as an anxiolytic
by limiting the behavioral inhibition that would be associated with stressful/anxiety-provoking situations [1,7].
It was specifically found to play a role in the response to

acute, extreme stress conditions, rather than affecting
all aspects of the response to anxiety. The mechanism of
action is not clearly understood; however, it is believed
that its impact is focused on the inhibitory effects of NC
on serotoninergic mechanisms primarily at two sites.
The first site is the dorsal raphe nucleus neurons where
NC increases K+ conductance, thereby resulting in inhibition. NC is also believed to act on the cortical serotoninergic nerve terminals through the inhibition of
5-HT release. Additional studies have demonstrated
that non-peptide OP4 agonists have anxiolytic effects,
suggesting the possibility of a new class of anxiolytic
medication without any abuse potential, such as is often
seen with drugs such as benzodiazapenes [1].
Adverse effects
With the possibility of new drugs targeting NC and its
receptor, one must consider the potential systemic
effects with such administration. NC has the potential
to effect systems such as the cardiovascular and renal
systems. IV administration of NC resulted in speciesbased cardiovascular changes in test animals, showing
transient hypotension and bradycardia in test rats, but
an increase in both heart rate and blood pressure in
sheep [1]. With regard to renal function, IV administration of NC resulted in increased water excretion
and decreased urinary sodium excretion according to
one study. This effect is probably due to the inhibition
of oxytocin and vasopressin by NC. ICV injection of
NC in test animals led to an increase in food consumption [1]. However, unlike other effects, this one was
shown to be antagonized by naloxone.
Summary
The relatively recent discovery of the neuropeptide
nociceptin/orphanin FQ, and its receptor system,
offers the possibility of future treatment modalities in
the field of pain medicine. As described, this system
can play a role in pain relief, anxiolysis, and substance
abuse associated with opioids, and other central-acting
drugs. Although much research remains, these potential effects with regard to pain, anxiety, and substance
abuse, as well as numerous other systemic effects,
encourage further work in the area.
References
1. Calo G, et al. Pharmacology of the nociceptin

receptor. Br J Pharmacol 2000;129:12611283.
511
2. Mogil J, et al. The molecular abd behavioral

pharmacology of the orphanin FQ/nociceptin peptide
and receptor family. Pharmacol Rev 2001;53:381415.
3. Ambriz-Tututi M. Role of opioid receptor in formalininduced secondary allodynia and hyperalgesia in rats.
Eur J Pharmacol 2009;619:2532.
4. Chen Y. Activation of the nociceptin opioid system in
rat sensory neurons produces antinociceptive effects
in inflammatory pain: involvement of inflammatory
mediators. J Neurosci Res 2007;85:14781488.
pain models: implications on pain processing. J

Peripher Nerv Syst 2006;11:232240.
6. Toll L. Comparison of the anti-nociceptive and
anti-rewarding profiles of novel bifunction nociceptin/
orphanin FQ receptor (NOPr)-mu opioid receptor
(MOPr) ligands: implications for theurapeutic
applications. J Pharmacol Exp Ther 2009;331(3):954
964.
7. Ciccocioppo R, et al. Nociceptin/orphanin FQ and
drugs of abuse. Peptides 2000;21:10711080.
5. Chen Y. Nociceptin and its receptor in rat dorsal root

ganglion neurons in neuropathic and inflammatory
Section 12
Chapter
131
Anti-nerve growth factor

Allison Gandey and Roger Chou
Generic Names: nerve growth factor antibodies

(anti-NGF)
Trade/Proprietary Names: Tanezumab, Antibody PG110, JNJ-42160443
Drug Class: monoclonal antibody
Manufacturers: Pfizer Pharmaceuticals, 235 East
42nd Street, New York, NY 10017; PanGenetics
BV, Heath House, Princes Mews, Royston, SG8
9RT, UK; Johnson and Johnson, One Johnson &
Johnson Plaza, New Brunswick, NJ 08933
Description
512
Management of chronic pain is often challenging since

commonly prescribed analgesics do not have direct
effects on damaged nerves, but, rather, nonspecific
effects on pain receptors and other mediators of
pain. Neurotoxins are a new class of medications that
are being evaluated as potential analgesics. Using these
medications, researchers hope to achieve pain relief by

suppressing the activity of injured nerve tissue and
directly targeting the source of some types of chronic
pain. A challenge in developing these medications is
that in addition to affecting nerves causing pain, they
could also damage other nerves, including those in
the brain and spinal cord. Neurotoxins could therefore cause serious harm related to unintended nerve
damage, and are undergoing careful testing to understand how well they selectively affect already damaged
nerves.
Anti-nerve growth factor is the first highly selective neurotoxin to be investigated for use in humans.
Discovered in the 1950s, investigators found that this
immunotoxin stunts neural growth [1]. Researchers
Rita Levi-Montalcini and Victor Hamburger observed
that a substantial increase in the size of sympathetic
ganglia coincided with the extensive branching of
sympathetic axonal terminals in tumors. They reasoned that tumors were releasing a neurotrophin a
protein that promotes the growth and development of
neurons.
Chapter 131 Anti-nerve growth factor
The researchers named this sympathetic neurotrophin nerve growth factor and found that it could
be administered to newborn mice to promote supernormal development of the sympathetic nervous
system.
Rita Levi-Montalcini with biochemist Stanley
Cohen went on to develop an immunotoxin to nerve
growth factor and discovered that it severely suppressed
growth and development of sympathetic noradrenergic
neurons. For this and related findings, they were
awarded the 1986 Nobel Prize in Medicine.
The use of anti-nerve growth factor antibodies for
pain relief is experimental. Some studies have suggested that nerve growth factors can mediate injuryinduced or inflammatory pain. Anti-nerve growth
factor antibodies may prove to be effective in posttraumatic and post-surgical analgesia. Advocates suggest the agents will provide pain relief without
impairing bone healing.
Tanezumab
Pfizers investigational drug Tanezumab is currently
being studied for the treatment of a variety of painful
conditions, such as osteoarthritis, pain associated
with bone metastases, endometriosis, and low back
pain [2].
Tanezumab is a monoclonal antibody that targets
nerve growth factor. It is administered intravenously
and has been linked to a number of adverse events,
including abnormal peripheral sensation and neuropathy with hyperesthesia. This suggests that effects of
Tanezumab are not completely selective for injured
nerve tissue. More studies are needed to understand
the frequency and severity of neuropathy, as well as
how long such drug-induced symptoms persist.
A phase 3 trial evaluating the efficacy and safety of
Tanezumab in osteoarthritis of the knee is currently
recruiting patients. A similar trial evaluating three
doses of tanezumab in osteoarthritis of the hip is also
under way.
Results from a phase 2 trial of the investigational
drug in chronic low back pain suggest it reduced pain
and improved physical function more effectively than
naproxen [3].
The 220 trial participants had chronic nonradiculopathic low back pain for at least 3 months that
required regular analgesic medication. Investigators
report a single intravenous infusion of Tanezumab
200 g/kg provided durable efficacy over a 12-week
period (Table 131.1).
Table 131.1. Patients achieving 50% treatment response
Treatment
Week 6 (%)
Week 12 (%)
Tanezumab
56.8
48.9
Naproxen
34.1
34.1
Placebo
19.5
29.3
The researchers report abnormal peripheral sensation in 12.5% of those taking Tanezumab, 3.4% of
those taking naproxen, and 2.4% of those on placebo.
There were two cases of severe hyperesthesia in the
Tanezumab group. There was also a case of peripheral
neuropathy with hyperesthesia.
The analgesic effect of Tanezumab appears promising, but more research is needed to understand how
it would be used to manage chronic pain. Even if it is
shown to be more effective than standard medications,
peripheral neuropathy is a potentially serious adverse
event that could limit its use as a first-line medication.
Also, the cost of Tanezumab has not yet been determined. In addition to the price of Tanezumab itself, an
additional cost consideration is that it is administered
intravenously [4]. Compared to other medications for
chronic pain, a potential advantage of Tanezumab is
that it is dosed infrequently.
Antibody PG110
PanGenetics Limited is investigating another nerve
growth factor inhibitor. The investigational agent
known as PG110 is being studied for the treatment of
osteoarthritis pain.
The humanized antibody is administered intravenously. A phase 1 study evaluating the safety and tolerability of PG110 is currently recruiting participants.
The randomized, double-blind, placebo-controlled,
single-ascending-dose trial will evaluate PG110 in
patients with pain from osteoarthritis of the knee.
Potential adverse events remain unknown, but,
like Tanezumab, this nerve growth factor inhibitor
may be linked to abnormal peripheral sensation, neuropathy, and hyperesthesia. PG110 is also administered intravenously.
Many questions remain about the analgesic potential of anti-nerve growth factor antibodies. The new
drugs could provide an exciting treatment alternative
affording potent analgesia without impairing bone
healing. Possible benefits will have to be weighed carefully against the risks of these powerful and potentially
harmful neurotoxins.
513
References
1. Kostrzewa RM. Evolution of neurotoxins: from

research modalities to clinical realities. Curr Protoc
Neurosci 2009; Unit 1.18.
2. ClinicalTrials.gov.
514
3. American Pain Society 28th Annual Meeting: Poster

268 presented May 7, 2009.
4. Gandey A. Tanezumab investigated for low back pain.
Medscape Medical News. http://www.medscape.com/vi
ewarticle/703204.
Index
abdominal hysterectomy
risk of persistent post-operative
pain, 46
A-beta fibers, 8, 1415
response to injury, 25
AbixaTM, 319
acetaminophen 211212
sites of analgesic activity, 59
See also tramadol plus
acetaminophen.
acetaminophen injectable 258261
acetaminophen oral and rectal 2567
acid sensing ion channels (ASICs)
ACTIQTM, 131
AcuroxTM formulation, 466
acute pain, 56, 13
addiction
See opioid dependence, 170
A-delta fibers, 3, 89, 14
adenosine receptor agonists/
antagonists,
AdleaTM, 500
Adolonta, 137
adrenergic and serotoninergic pain
suppression
adrenergic and serotoninergic
receptors, 328
descending pain pathways, 329
norepinephrine, 329
serotonin, 329
AdvilTM, 215
AeroLEFTM, 444
AhistTM, 391
Akatinol, 319
Akten, 279
AlavertTM, 391
Algix, 243
Allegra, 391
Aller-chlor, 391
AlleveTM, 221
allodynia, 5, 14, 16, 24, 30, 76
alpha-2 adrenergic agonists
alvimopan, 42022
bowel obstruction patients, 422
amantadine, 313, 3267
American Society of
Anesthesiologists Task Force on
Acute Pain Management,
211
amethocaine gel. See Ametop GelTM
Ametop GelTM,, 2837

amputation
pain, 46
Amrix, 362
AnacinTM, 252
analgesic gaps, 53
analgesic ladder (WHO), 253
analgesic sites of action, 62
analgesic targets. See novel targets for
new analgesics
analgesics and adjunct agents
interference with pain signaling, 1
variety available, 1
AnaproxTM, 221
AnesjectTM, 316
Anestacon, 279
AnorfinTM, 157
antibody PG110, 513
anticoagulants and regional
anesthesia, 210
anticoagulated patients, 205
antiplatelet agents, 207
complications in peripheral nerve
blocks, 209
direct thrombin inhibitors (DTIs),
208
fondaparinux (Arixtra), 207
heparin, 206
herbal therapies, 208
low molecular weight heparin
(LMWH), 207
oral anticoagulants (warfarin), 207
potential complications, 206
anticonvulsant analgesics, 294
adverse effects, 293
first generation drugs, 292
mechanisms of action, 292
second generation drugs, 292
anticonvulsants 3415
link between pain and
depression, 338
monoamine oxidase inhibitors
(MAOIs), 338
SNRIs, 341
SSRIs, 338
tricyclic antidepressants
(TCAs), 338
antidepressants

antiemetics, oral. See aprepitant
antiemetics, parenteral,
combined therapy, 400
droperidol, 399400
metoclopramide, 399400
ondansetron, 398, 400
opioid-induced nausea and
vomiting (OINV), 397
postoperative nausea and vomiting
(PONV), 397
anti-epileptic drugs (AED). See
anticonvulsant analgesics
antihistamines, 3916
anti-nerve growth factor, 5123
antibody PG110, 513
aprepitant, 4014
Arcoxia, 243
Aredia, 413
ArthrotecTM, 229, 231
aspirin, 252255
Astramorph/PF, 197
Ativan, 365
member 1 (ABCB1), 38
Atretol, 301
Auxib, 243
Avinza, 86
Axid, 391
baclofen, 363, 37982
Baycadron, 388
Bayer AspirinTM, 252
BeforalTM, 154
behavioral treatments, 33
Benadryl, 361
Benadryl, 391
Bextra, 213
Bier block, 270
Bier, August, 332
bradykinin, 8
bradykinin receptors,
brain-derived neurotrophic factor
(BDNF),
breast surgery
pain, 46
BrevinazeTM, 316
buffered aspirin. See aspirin
BufferinTM, 252
515
Index
516
bupivacaine, 276
adverse events, 276
chemical name, 274
chemical structure, 274
common doses, 275
contraindications, 275
drug class, 274
drug clearance and
elimination, 274
drug interactions, 275
generic name, 274
indications, 274
major and minor sites of
action, 274
manufacturer, 274
metabolic pathways, 274
mode of activity, 274
multimodal analgesia, 275
potential advantages, 275
potential disadvantages, 276
receptor interactions, 274
toxicity, 275
trade/proprietary names, 274
treatment of adverse events, 276
BuprenexTM, 157
buprenorphine, 159
acute pain relief, 158
chemical formula, 157
chemical name, 157
description, 157
drug class, 157
epidural administration, 158
generic name, 157
intrathecal administration, 158
intravenous administration, 159
manufacturers, 157
pharmacodynamics, 157
pharmacokinetics, 157
routes of administration, 159
side effects, 157
sublingual administration, 159
buprenorphine transdermal, 483
chemical name, 481
common doses/uses, 482
description, 482
drug class, 481
drug related adverse events, 483
generic name, 481
action, 482
manufacturers, 481
proprietary names, 481

risk of abuse, 483
toxicity, 483
withdrawal, 483
BuprexTM, 157
BuprineTM, 157
butalbital. See Fioricet; Fiorinal
butorphanol, 156
adverse events, 156
chemical name, 154
cost, 156
description, 154
dose guide, 155
general pharmacology, 154
generic names, 154
indications, 155
labor analgesia, 155
manufacturers, 154
mechanism of action, 154
metabolism, 155
precautions, 156
relative contraindications, 156
structure, 154
uptake and elimination, 155
use as preoperative/preanesthetic
medication, 155
use in balanced anesthesia, 155
BuTransTM, 481
C fibers, 3, 89, 14
calcitonin gene-related peptide
(CGRP), 14
(CGRP) receptors, 154155
calcium (Ca2+) channels, 429431
CaldolorTM, 218
Cannabidiol. See cannabinoid
agonists
cannabinoid agonists, 496
cannabinoids, 493
chemical names, 492
chemical structures, 492
drug class, 492
generic names, 492
indications, 494
manufacturers, 492
See also peripheral cannabinoid
receptor agonists, 496
cannabinoid receptors
Cannabis sativa, 492, 497

capsaicin. See injectable capsaicin;
topical capsaicin
carbamazepine, 293
absorption, 302
acute toxicity, 304
adverse reactions, 305
black box warning, 302
cautions, 303
chemical class, 301
chemical name, 301
common doses, 304
cost guide, 304
description, 301
dialysis, 302
distribution, 302
drug class, 301
excretion, 302
indications, 302
metabolism, 302
Carbatrol, 292, 301
cardiac effects of poorly controlled
pain, 27
carisoprodol, 361
carpal tunnel syndrome, 23
CataflamTM, 229
Catapres TM, 330
Catapres-TTS TM, 330
catecholamines
response to poorly controlled
pain, 26
catechol-O-methyl transferase
(COMT), 38
Celebrex, 213, 238
celecoxib, 213, 242
absorption, 238
circadian effects, 239
description, 238
distribution, 238
excretion, 239
generic name, 238
indications, 240
manufacturer, 238
metabolism, 239
overdosage, 242
Index

trade name, 238
Centers for Epidemiologic Studies
Depression scale (CES-D), 345
central pain, 6
central pain syndrome, 23
central sensitization, 24
Cesamet, 492
Cesarean section
pain, 46
chloride (Cl) channels, 255
Chlor-Trimeton, 391
chlorzoxazone, 360
chronic pain, 6, 14
chronic post-surgical pain See
persistent post-operative
pain
CHRONOGESICTM, 467
Clarinex, 391
Claritin, 391
classification of pain
approaches to classification, 3
neuropathic pain, 4
nociceptive pain, 34
physiological pain, 34
clinical effects of pain, 3
clinical implications of hyperalgesia, 22
clonidine (neuraxial)
See neuraxial clonidine
hydrochloride, 332
clonidine (transdermal and
parenteral), 332
chemical name, 330
common doses, 331
description, 330
drug clearance and
elimination, 331
indications (approved/
non-approved), 331
major and minor sites of action, 330
manufacturer, 330
CNS pain pathophysiology, 24
cocaine
discovery of local anesthetic
properties, 267
codeine, 100
chemical name, 98
common doses, 100
description, 99
drug class, 98
generic name, 98
indications, 99
manufacturer, 98
sites of activity, 99
codeine compounds, 99
cognitive behavior therapy (CBT), 33
cognitive therapy, 33
combination analgesics See Fioricet;
Fiorinal
CombunoxTM, 105
Contramal, 137
corticosteroids
analgesic effects of IV
glucocorticoids, 386
articular glucocorticoids, 386
clinical actions of
clinical effects of
description, 383
glucocorticoids for analgesic
injection, 387
mechanisms of action, 383
molecular mechanisms of
neuraxial glucocorticoids, 386
side effects of glucocorticoids, 387
corticosteroids, oral, 390
common doses and uses, 390
indications, 389
side effects, 390
COX (cyclooxygenase), 25
COX (cyclooxygenase) enzymes, 212
COX-2 (cyclooxygenase-2), 15, 25
COX-2 inhibitors, 214
postoperative pain
management, 212
role in multimodal analgesia, 211
role in preemptive analgesia, 212
widespread usage, 211
Cuivasal, 279
cyclobenzaprine, 362, 372
chemical name, 370

cost, 371
description, 370
drug class, 370
drug clearance and
elimination, 370
generic name, 370
non-approved), 370
manufacturer, 370
metabolism, 370
overdose, 371
proprietary name, 370
side effects, 372
cyclooxygenase (COX), 25
cyclooxygenase (COX) enzymes, 212
cyclooxygenase-2 (COX-2), 15
Cymbalta, 353
cytochrome CYP2D6
genetic variations, 39
cytokine family, 438
cytokines, 8
Damason-PTM, 112
dantrolene, 362
Decadron, 388
delta-9-tetrahydrocannabinol. See
cannabinoid agonists
Deltacortisone, 388
Deltadehydrocortisone, 388
Deltasone, 388
DemerolTM, 94
Depakene, 292
Depakon, 292
Depobupivacaine, 471
DepoDur, 194
depression and pain. See
antidepressant analgesics
descending control of pain, 12
descending pain pathways, 329
DesyrelTM, 351
DETERx technology, 465
dexamethasone
chemical name, 388
drug class, 388
generic name, 388
indications, 389
manufacturers, 388
517
Index
518

side effects, 390
dexmedetomidine, 33
chemical name, 335
drug class, 335
generic name, 335
indications, 336
manufacturers, 335
DexPak, 388
dextromethorphan, 313, 324
brand names/trade names, 321
chemical name, 321
description, 322
drug abuse, 324
drug class, 321
efficacy in acute and chronic
pain, 323
generic names, 321
manufacturers, 321
treatment of acute poisoning, 324
diabetic neuropathy, 16, 23
Diastat, 365
diazepam, 362
drug class, 365
drug clearance and
elimination, 366
generic name, 365
non-approved), 366
manufacturer, 365
sites of action, 365
toxicity, 367

diclofenac gel, 228
chemical name, 225
description, 226
drug class, 225
generic name, 225
indications, 227
manufacturer, 225
trade/proprietary name, 225
diclofenac injectable, 235
brand/proprietary name, 232
description, 232
drug class, 232
generic name, 232
indications, 233
manufacturer, 232
diclofenac oral, 231
chemical name, 229
description, 229
drug class, 229
drug clearance and
elimination, 230
generic name, 229
indications, 230
manufacturers, 229
diclofenac patch, 228
chemical name, 225
description, 226
drug class, 225
generic name, 225
indications, 227
manufacturer, 225

diclofenac plus PPI, 231
chemical name, 229
description, 229
drug class, 229
drug clearance and
elimination, 230
generic name, 229
indications, 230
manufacturers, 229
diethylamine salicylate, 410
dihydrocodeine, 99
Dilantin, 292
DilaudidTM, 115, 187
DilocolTM, 115
diphenhydramine, 361
diphenhydramine hydrochloride
Dolophine, 127
dorsal rhizotomy, 34
dorsal root ganglia (DRG), 8
dronabinol. See cannabinoid agonists
droperidol, 399400
Drug Effects Questionnaire (DEQ), 93
duloxetine, 356
absorption, 354
chemical name, 353
clinical pearls, 356
common doses, 355
description, 354
discontinuing duloxetine, 355
distribution, 354
drug abuse and dependence, 356
generic name, 353
indications, 354
manufacturer, 353
metabolism and elimination, 354
overdosage, 356
Index

precautions, 354
proposed mechanism of action, 354
trade name, 353
warnings, 354
Duncaine, 279
DuraclonTM, 332
DuragesicTM, 134
Duramorph, 181, 197
Dyloject, 232
DynastatTM, 245
dysesthesia, 16, 30
Ebov, 242
EC-NaprosynTM, 221
EcotrinTM, 252
Ecoxib, 242
ectopic foci, 24
EDACSTM technology, 465
ElavilTM, 347
EmbedaTM, 90
EMBEDATM, 466
Emend, 401
EMLA, 279
EMLATM, 285
application area and time by age and
weight, 285
description, 284
generic name, 283
how to use, 285
manufacturer, 283
mode of action, 284
pharmacology, 284
recommended maximum dose by
age and weight, 285
emotional effects of poorly controlled
pain, 28
EmpirinTM, 252
Endodan, 101
endogenous opioids, 57
endorphins, 57
enkephalins, 14, 57
EnteregTM, 420
Epidemiological Studies Depression
Scale, 343
epidural buprenorphine, 158
epidural catheter evaluation, 204
before dosing, 201
general considerations, 200
how to determine initial dosing, 201
patient in pain in Surgical Care Unit
or Intensive Care Unit, 204
patient in pain in the postoperative
care unit (PACU), 202
symptom management, 204

epidural fentanyl, 186
chemical name, 184
description of fentanyl, 184
drug class, 184
generic name, 184
indications, 185
manufacturer, 184
trade name, 184
epidural hydromorphone, 190
chemical name, 187
continuous epidural infusion, 188
description, 187
dosing, 189
drug class, 187
drug clearance and elimination, 188
epidural patient controlled analgesia
(PCA), 189
generic name, 187
indications, 188
intermittent bolus dosing, 188
manufacturer, 187
epidural morphine, 184
adverse events, 184
availability, 183
common doses, 183
drug class, 181
drug clearance and
elimination, 181
generic name, 181
historical development, 181
indications, 182
manufacturer, 181
name of analgesic agent, 181
See also extended-release epidural
morphine, 197
epidural sufentanil
chemical name, 191
chronic pain patients, 192
cost, 193
description, 191
drug class, 191
generic name, 191
indications, 192
labor and delivery, 191
manufacturer, 191
post operative pain management,
192
trade name, 191
Equetro, 301
Ereska, 440
etoricoxib, 213
chemical name, 243
common doses, 244
description, 243
drug class, 243
drug clearance and
elimination, 243
generic names, 243
indications (non-approved in the
US), 243
manufacturer, 243
Etoxib, 243
Etozox, 243
Eutectic Mixture of Local Anesthetics
See EMLATM
ExalgoTM, 448
ExparelTM, 471
extended duration bupivacaine,
475
chemical name, 471
controlled-release delivery
systems, 472
drug class, 471
generic names, 471
liposomal bupivacaine, 474
liposomal carriers, 472
519
Index
manufacturer, 471
microsphere delivery, 473
extended-release epidural
morphine, 197
approved doses, 195
availability, 196
chemical name, 194
clinically useful dosing, 195
cost, 196
description, 194
dosing, 195
drug class, 194
generic name, 194
how supplied, 195
indications, 194
manufacturer, 194
toxicity, 196
warnings, 196
extended-release morphine sulfate.
See morphine sulfate controlledrelease
Exxiv, 251
520
Felbatol, 292
fentanyl
See epidural fentanyl; inhaled
fentanyl; iontophoretic
transdermal fentanyl, 186
fentanyl oral and buccal, 134
common doses, 133
description, 131
drug class, 131
generic names, 131
non-approved), 132
manufacturer, 131
toxicity, 134
Fentanyl TAIFUN, 444
fentanyl transdermal system, 136

chemical name, 134
common doses, 135
description, 134
drug class, 134
generic name, 134
non-approved), 135
manufacturer, 134
FENTORATM, 131
fexofenadine hydrochloride
Fioricet, 265
advantages of combination
analgesics, 265
clinical studies, 264
combination analgesics, 263
description, 263
drug class, 262
drug structures, 262
generic name, 262
indications, 263
manufacturer, 262
pharmacokinetics and
precautions, 265
side effects, 265
trade name, 262
treatments for chronic headaches, 263
Fiorinal, 265
advantages of combination
analgesics, 265
clinical studies, 264
combination analgesics, 263
description, 263
drug class, 262
drug structures, 262
generic name, 262
indications, 263
manufacturer, 262
precautions, 265
side effects, 265
trade name, 262
treatments for chronic headaches, 263
FiorinolTM, 253
Flector Patch, 225
Flexeril, 362, 370, 372

flexible approach to pain
management, 71
Fosaprepitant, 401, 403
chemical name, 401
four step approach to pain
management
common sense guidelines, 69
rationale for, 67
G protein-coupled receptors, 24
GABA (-aminobutyric acid), 14
gabapentin, 292, 293, 297
common doses, 297
description, 295
drug class, 294
generic name, 294
indications, 296
manufacturer, 294
overdose and treatment, 297
precaution and instruction for
patients, 297
trade name, 294
gabapentinoids, 292 293
Gabitril, 292
genetic factors
pain, 48
genetic factors in pain response, 40
member 1 (ABCB1), 38
catechol-O-methyl transferase
(COMT), 38
cytochrome CYP2D6, 39
guanosine triphosphate
cyclohydrolase-1 (GCH1), 40
IL-1 (interleukin-1), 39
melanocortin-1-receptor (MC1R), 39
mu opioid receptor (MOR), 37
pain phenotype, 40
UGT, 40
genetics
novel analgesic targets, 254
Genpril, 215
glutamate receptor agonists/
antagonists, 459460
Gravocain, 279
guaifenesin, 360
guanosine triphosphate
cyclohydrolase-1 (GCH1), 40
Index
Habitrol, 484
Helicobacter pylori, 213
heterosensitization, 16
histamine, 8
hydrocodone, 99
See also opioid plus ibuprofen
compounds.
hydrocodone bitartrate, 112114
chemical name, 112
common doses, 114
description, 112
drug class, 112
generic names, 112
indications (approved and nonapproved), 113
major and minor sites of action,
112
manufacturers, 112
hydromorphone extended release,
455
chemical name, 448
description, 449
diversion and abuse, 451
drug class, 448
generic name, 448
indications, 451
manufacturers, 448
toxicity, 451
trade name, 448
hydromorphone (oral and
parenteral), 118
chemical name, 115
common doses, 117
description, 115
drug class, 115
generic names, 115
indications, 116
manufacturers, 115
hydromorphone epidural
See epidural hydromorphone.
hydromorphone extended release,
448451
chemical name, 448
description, 448449
drug class, 448
formulations, 449451
generic name, 448
indications, 450451
manufacturers, 448
mode of action, 447
proprietary/trade names, 448
hydromorphone OROSTM technology,
467, 469
HydroStatTM, 115
hyperalgesia, 30
allodynia, 24
clinical implications, 22
IASP definition, 17
loss of spinal inhibitory
mechanisms, 24
opioid induced, 77
primary hyperalgesia, 18
production of new nerve
fibers, 24
secondary hyperalgesia, 21
hyperalgesia, 5, 14, 24
hyperesthesia, 76
hypoalgesia, 30
hypoesthesia, 30
hysterectomy
pain, 46
Ibu, 215
IbudoneTM, 105
ibuprofen, 215217
chemical name, 215
common doses, 216
description, 215
non-approved), 216
major sites of action, 215
oral suspension, 215

topical creams and gels, 216
toxicity, 216
compounds.
ibuprofen injectable
chemical name, 218
common doses, 219
description, 218
drug class, 218
drug related adverse reactions, 221
generic name, 218
indications, 218
manufacturer, 218
precautions, 219
trade name, 218
IL-1 (interleukin-1), 15, 39
IL-1, 435
IL-6, 435
indomethacin, 229
inflammatory pain, 15
inflammatory response, 2425
Infumorph, 181, 197
inguinal hernia repair
pain, 45
inhaled fentanyl, 448
chemical name, 444
description, 444
drug class, 444
generic name, 444
manufacturers, 444
side effects, 448
inhibitory pain modulation, 11
injectable capsaicin, 503
chemical name, 500
clinical trials and doses, 502
common doses, 503
description, 501
drug class, 500
generic name, 500
manufacturer, 500
521
Index
522
pharmacokinetics/
potential advantages and
disadvantages, 503
potential indications, 501
trade name, 500
Intensol, 101
interleukins, 8
International Association for the Study
of Pain (IASP)
definition of hyperalgesia, 17
definition of neuropathic pain, 30
definition of pain, 1, 3
intracranial lesioning, 34
intranasal ketamine. See ketamine
intranasal
intranasal morphine
chemical name, 437
description, 437
doses, 438
drug class, 437
generic name, 437
indications, 438
manufacturer, 437
trade name, 437
intrathecal buprenorphine, 158
intranasal morphine, 439
intrathecal morphine, 199
analgesic agent, 197
brand names, 197
common doses, 199
description, 197
indications, 198
IONSYSTM, 455
iontophoretic transdermal fentanyl,
457
chemical name, 455
description, 455
dosing, 456
drug class, 455
generic name, 455
indications, 456
manufacturer, 455
mode of action, 456

Isicaine, 279
Ivemend, 401
JNJ-42160443, 512
JurnistaTM, 467
Kadian, 86
KeiranTM, 316
Keppra, 292
KetajectTM, 316
KetalarTM, 316
KetalinTM, 316
KetamaxTM, 316
ketamine, 312, 319
chemical name, 316
common doses, 318
description, 316
drug class, 316
drug related adverse
events, 319
generic name, 316
indications, 318
manufacturer, 316
potential disadvantages,
319
S (+) ketamine, 312
trade names, 316
ketamine intranasal, 443
brand name, 440
description, 440
drug class, 440
efficacy and safety, 443
generic name, 440
indications, 441
manufacturer, 440
KetaTM, 316
ketorolac, 237
common doses, 237
description, 236
events, 237
generic name, 235
indications, 236
manufacturer, 235
metabolic activity, 236

toxicity, 237
trade name, 235
kinase modulators,
kretos, 243
Lamictal, 292, 306
Lamictin, 306
Lamogine, 306
lamotrigine, 292293
adverse events, 308
brand/proprietary names, 306
chemical name, 306
cost, 308
description, 306
drug class, 306
generic name, 306
metabolism, 307
Leostesin, 279
LiberaximTM, 115
lidocaine, 267, 270
See also topical local anesthetics, 283
lidocaine for neural blockade, 282
adverse events, 282
chemical names, 279
chemical structure/properties, 280
differential blockade, 282
duration of action, 281
historical development, 280
indications, 282
interaction with hormone
replacement therapy, 280
manufacturers, 280
metabolism, 280
onset of action, 281
lidocaine transdermal patch, 291
caution, 290
description, 288
disposal of used patches, 291
dosing, 290
Index
generic name, 288

how to use in pain management, 289
manufacturer, 288
mode of action, 288
overdose causes and treatment, 290
pharmacology, 288
trade name, 288
use during MRI, 290
Lidoderm, 279
Lidoderm Patch 5%, 288
Lidothesin, 279
Lioresal, 379
liposomal bupivacaine, 475
LMX-4TM (liposomal lidocaine), 285
description, 285
generic name, 283
how to use, 285
manufacturer, 283
mode of action, 285
pharmacology, 285
local anesthetic bone paste, 489
common doses, 489
description, 488
drug class, 488
generic names, 488
indications, 488
manufacturers, 488
local anesthetics, 273
additive analgesic effects, 271
advantages, 272
adverse events, 273
amides, 267, 270
disadvantages, 272
dosages, 271
esters, 267, 270271
history of discovery, 267
indications, 270
local anesthetic plus opioid, 271
metabolism, 270
mode of action, 268
neuro-anatomical correlates of
noxious blockade, 270
physiochemical correlates of LA
activity, 269
topical local anesthetics, 287

uses for differential block, 268
lorazepam
drug class, 365
generic name, 365
indications (approved/nonapproved), 366
toxicity, 367
LortabTM, 118
lumiracoxib, 213
Lyrica, 292, 298
magnesium
chemical name, 325
doses, 326
generic names, 325
indications, 325
manufacturer, 325
NMDA receptor antagonist, 314,
326
trade names, 325
Marcain, 274
Marcaine, 274
Marinol, 492
Maxidex, 388
McGill Pain Questionnaire, 6
mechanical hyperalgesia, 14
medetomidine, 335
medical factors
pain, 48
mefanamic acid, 229
melanocortin-1-receptor (MC1R), 39
meloxicam
chemical name, 249
common doses, 250
description, 249
drug class, 249
generic name, 249
indications, 250
manufacturer, 249
metabolism, 250
mode of action, 249
potential indication under
investigation, 250
memantine, 314, 321
chemical name, 319
clinical use in neuropathic
pain, 320
common doses, 320
description, 320
drug class, 319
generic name, 319
indications, 320
manufacturers, 319
meperidine, 98
alpha 2 adrenergic receptor effects,
95
anticholinergic effect, 94
chemical name, 94
class of drug, 94
common doses, 97
description, 94
generic names, 94
indications, 96
manufacturers, 94
modes of administration, 97
neuraxial administration, 97
opioid receptor binding, 95
oral administration, 97
parenteral administration, 97
sites of action, 95
sodium channel blocker, 94
trade name, 94
meprobamate, 361
523
Index
524
metaxalone, 361, 374

chemical name, 372
clinical pearls, 374
common doses, 373
cost guide, 373
how supplied, 373
indications, 373
manufacturer, 372
overdose, 374
warnings, 373
methadone, 131
acute pain crisis in emergency
room, 129
adverse events, 131
chemical name, 127
description, 127
drug class, 127
generic name, 127
non-approved), 129
intraoperative use for prolonged
postoperative analgesia, 129
intrathecal and epidural neuraxial
analgesia, 130
maintenance for heroin addiction,
128
manufacturers, 127
medical pain, 128
NMDA receptor antagonist, 314
opioid conversion, 130
postoperative acute surgical pain,
129
methocarbamol, 360, 369
chemical name, 368
common doses, 369
cost, 369
description, 368
drug class, 368
drug clearance and

elimination, 368
generic name, 368
non-approved), 368
manufacturer, 368
metabolism, 368
methyl salicylate, 409
methylnaltrexone, 420
chemical name, 418
common dosage, 419
description, 418
drug class, 418
generic name, 418
non-approved), 418
action, 418
manufacturer, 418
metoclopramide, 399400
micrisimal prostglandin E synthase-1
(mPGES-1), 421-422
Midol, 215
migraine headaches, 16
milnacipran, 358
description, 357
dosage, 359
drug class, 357
generic name, 357
indications, 359
manufacturer, 357
pharmacology, 357
misoprostol, 229
drug clearance and elimination,
230
metabolic pathway, 230

See also ArthrotecTM, 231
mixed category pain, 16
MobicTM, 249
monoamine oxidase inhibitors
(MAOIs), 338
MoradolTM, 154
morphine
history of, 73
morphine (oral and parenteral), 8285
chemical name, 82
class, 82
common doses, 83
common side effects, 85
drug interaction, 85
drug related adverse effects, 85
fertility, 84
generic names, 82
indications, 83
lactation, 84
manufacturers, 82
pregnancy, 84
treatment of adverse effects, 85
morphine intranasal. See intranasal
morphine
morphine neuraxial
See epidural morphine;
extended-release epidural
morphine; intrathecal morphine
morphine sulfate controlled-release, 86
absorption, 86
common doses, 88
drug class, 86
excretion, 87
formulations, 86
generic names, 86
non-approved), 87
manufacturers, 86
metabolic pathway, 87
metabolism, 87
sites of activity, 86
Index
morphine-6-glucuronide, 478
description, 475
disadvantages, 477
drug class, 475
generic name, 475
manufacturer/developers, 475
metabolism, 476
potential advantages and uses, 477
randomized controlled trials, 478
motor cortex stimulation, 35
MotrinTM, 215
MRI
use of lidocaine transdermal patch,
290
MS Contin, 86
multidisciplinary approach
neuropathic pain management, 34
multidisciplinary pain centers, 34
acetaminophen (paracetamol), 59
alpha-2 adrenergic agonists, 62
anticonvulsants, 60
antidepressants, 62
COX-2 inhibitors, 59
local anesthetics, 59
morphine, 85
NMDA receptor antagonists, 61
NSAIDs, 58
opioids, 58
SNRIs, 62
TCAs (tricyclic antidepressants), 61
multi-segmental flexion reflexes, 5
muscle relaxants in pain management
baclofen, 363, 364
carisoprodol, 361
chlorzoxazone, 360
cyclobenzaprine, 362
dantrolene, 362
diazepam (Valium), 362
guaifenesin, 360
meprobamate, 361
metaxalone, 361
methocarbamol, 360
orphenadrine, 361
prescribing considerations, 364
tizanidine, 363
muscle spasm, 5
myelopathic pain, 6
myofascial pain, 16
Nabilone. See cannabinoid agonists
N-acetyl-para-aminophenol (APAP).
See acetaminophen
NalbufinaTM, 150
nalbuphine
abuse liability, 153
brand names, 150

chemical name, 150
description, 151
dosage, 152
drug class, 150
formulation, 153
generic name, 150
indications, 151
manufacturers, 150
NaprelanTM, 221
NaprosynTM, 221
naproxen, 225
absorption, 222
adverse events, 224
chemical name, 221
description, 222
distribution, 222
drug class, 221
generic name, 221
indications, 223
manufacturers, 221
metabolism, 222
toxicity, 225
Naropin, 276
Nasal StadolTM, 154
NemendaTM, 319
neo-spinothalamic tract (nSTT), 11
neostigmine, 480
chemical name, 479
common doses, 480
description, 479
drug class, 479
generic name, 479
how supplied, 479
indications for analgesia, 480
manufacturer, 479
receptor interaction, 479

trade name, 479
neramexane, 314, 508
chemical name, 507
description, 507
drug class, 507
generic name, 507
indications, 507
manufacturer, 507
potential advantages/
disadvantages, 508
preliminary analgesic trials, 507
nerve growth factor (NGF), 14
nerve pain. See neuropathic pain
neuraxial clonidine hydrochloride
black box warning, 333
chemical name, 332
common doses, 333
description, 332
drug class, 332
drug clearance and
elimination, 333
indications, 333
manufacturer, 332
neuraxial glucocorticoids, 386
neuroablative procedures, 34
neuroendocrine system
responses to poorly controlled
pain, 27
neurogenic inflammation, 25
neurolytic nerve block, 34
neuronal plasticity, 16, 45
Neurontin, 292, 294
neuropathic pain, 34, 1516
assessment, 30
causes, 30
diagnosis, 30
IASP definition, 30
perception abnormalities, 30
pharmacological management, 17
scales and questionnaires, 30
screening tools, 30
sensory abnormalities, 30
sensory examination, 30
types of, 30
525
Index
526
neuropathic pain management

behavioral treatments, 33
cognitive behavior therapy (CBT),
33
cognitive therapy, 33
interdisciplinary team
approach, 34
interventional management, 35
multidisciplinary treatment, 34
nerve blocks, 34
neuroablative procedures, 34
neurostimulation, 35
non-pharmacological approaches,
34
pharmacological management, 31
psychological interventions, 32
rehabilitation, 32
neurotransmitters and receptors, 10
neurotrophin receptors, 437
Nicoderm, 484
Nicorette, 484
nicotine transdermal, 484487
absorption, 485
cautions, 486
chemical name, 484
common doses, 487
description, 484
distribution, 485
drug class, 484
generic name, 484
indications (non-FDA-approved),
486
manufacturers, 484
metabolism, 485
pregnancy, 486
nicotinic receptor agonists/
antagonists, 436
nitric oxide synthase (NOS), 433
NMDA receptor antagonists, 314
amantadine, 313, 327
dextromethorphan, 313, 324
ketamine, 312, 319
magnesium, 314, 326
memantine, 314, 321
methadone, 314
neramexane, 314
NMDA receptors
clinical pharmacology, 314
description, 310
function, 312
structure, 310
nociceptin, 511
description, 508
history, 509
Nociceptin-Orphanin FQ agonists
for substance abuse, 511
Nociceptin-Orphanin FQ as an
anxiolytic, 511
Nociceptin-Orphanin FQ CNS
distribution, 510
Nociceptin-Orphanin FQ in
inflammatory pain models, 510
Nociceptin-Orphanin FQ
neuropeptide, 509
nociception, 3, 11
activation of sensory end organs
and/or nerve endings, 8
and subjective experience of
pain, 14
ascending tracts, 11
conduction of pain to the spinal
cord and medulla, 11
descending neural pathways, 12
objective measurement, 14
stages in pain transmission, 7
transmission of impulses from
spinal cord to supra-spinal
structures, 11
nociceptive nerve fibers, 8
nociceptive pain, 34, 15
nociceptors, 3
pain detection and signaling, 1
nonsteroidal anti-inflammatory drugs.
See NSAIDs
Norco TM, 112
norepinephrine, 329
Norpramin TM, 347
NorspanTM, 481
novel sustained release analgesics
hydromorphone OROSTM
technology, 467, 469
subcutaneous extended release
sufentanil, 467, 470
transdermal extended release
novel targets for new
analgesics, 423436
acid sensing ion channels (ASICs),
423
adenosine receptor agonists/
antagonists, 430
bradykinin receptors, 430
(CGRP) receptors, 430431
calcium (Ca2+) channels, 425427
cannabinoid receptors, 433
chloride (Cl) channels, 427
cytokine family, 434

economic potential, 423
enzyme families, 427429
glutamate receptor agonists/
antagonists, 430431
IL-1, 434
IL-6, 434
ion channel families, 423427
kinase modulators, 428
microsomal prostaglandin E
synthase-1 (mPGES-1),
423424
neurotrophin receptors, 433
new approaches, 423
nicotinic receptor agonists/
antagonists, 531
nitric oxide synthase (NOS), 429
potassium (K+) channels, 427
purinoceptors, 429430
receptor families, 429433
sodium (Na+) channels, 425
the promise of genetics, 434435
TNF, 434
transient receptor potential (TRP)
channels, 423425
NSAIDs, 212213
postoperative pain management,
212
role in multimodal analgesia, 211
role in preemptive analgesia, 212
See also COX-2 inhibitors, 212
sites of analgesic action, 58
widespread usage, 211
NubainTM, 150
nuclear receptors, 24
nucleus raphe magnus, 57
Nucoxia, 243
NucyntaTM, 143
Numorphan injectableTM, 119
Nuprin, 215
Nurofen Plus, 98
OfirmevTM, 258
ondansetron, 398, 400
OPANA ERTM, 123
Opana injectableTM, 119
OpidolTM, 115
opioid agonist plus antagonist
analgesics
abuse liability, 93
abuse of prescription opioids, 91
drug class, 90
future combinations, 93
generic names, 90
manufacturers, 90
morphine plus naltrexone
combination, 9293
Index
opioid agonist and antagonist

combinations, 92
opioid analgesics, 80
benefits and liabilities, 73
future directions for acute pain
treatment, 80
history of, 73
hyperalgesia, 77
opioid tolerance and
dependence, 77
oral analgesic dosing, 79
parenteral opioid therapy, 78
regulation of, 73
opioid classification, 77
opioid dependence, 76
meanings of the term, 170
pain management in dependent
patients, 170
types of patients, 165
withdrawal syndrome, 169
opioid dosing in pediatric patients,
165169
age classification for pediatric
patients, 161
general principles of pain
management, 161162
initial opiate dosage guide (patients
over 6 months old), 162164
initial opiate dosage guide (patients
under 6 months old), 164165
opioids as anesthetics (patient under
6 months old), 164165
routine postoperative analgesia, 165
opioid hyperalgesia, 171
opioid induced hyperalgesia
characteristics, 171
clinical and management
implications, 174
pathophysiology, 172
recognition of the condition, 171
opioid plus ibuprofen compounds
chemical names, 105
chemical structure of individual
drugs, 105
common doses (oral), 107
description, 105
drug class, 105
generic names, 105
manufacturers, 105
opioid-sparing effects, 107
potential advantages and
disadvantages, 107
side effects, 107
opioid receptors, 74
delta receptors (OPR3), 7374
kappa receptors (OPR2), 7374
mu receptors (OPR1), 7374
sigma-1 receptors, 74
sigma receptors, 73
opioid rotation, 179
adverse effects of opioid analgesics,
175
guidelines, 179
patient variabilities in opioid
response, 176
tolerability of opioid analgesics, 175
opioid tolerance, 77, 167
acquired tolerance, 167
addiction, 76
development of, 166
innate tolerance, 166
learned tolerance, 166
pain management in opioid tolerant
patients, 170
pharmacodynamic tolerance, 167
pharmacokinetic tolerance, 166
physical dependence, 76
pseudo-addiction, 165
psychological dependence, 76
types of, 167
types of patients, 165
opioid-induced abnormal pain, 171
sensitivity, 171
opioid-induced paradoxical pain, 171
opioids, 171
tamper resistant. See tamper
resistant opiods
ORADURTM technology, 465
oral opioid analgesics, 79
oral salicylate See aspirin
Orasone, 388
OROSTM technology, 465
Orphanin/FQ, 508
orphenadrine, 361
OXNTM, 90
Oxy IR, 101
oxycodone, 101104
chemical name, 101
description, 101
drug class, 101
generic name, 101
indications, 102
manufacturers, 101
metabolism and elimination, 101

patients with hepatic impairment,
102
patients with renal impairment, 102
respiratory depression, 102
compounds.
oxycodone compounds
generic names, 101
manufacturers, 101
oxycodone controlled release
chemical name, 108
cost/street price, 111
description, 108
dosage, 110
drug abuse and addiction, 111
drug class, 108
formulations, 111
generic name, 108
how supplied, 111
indications, 109
manufacturer, 108
toxicity, 111
Oxycontin, 108
Oxydose, 101
Oxyfast, 101
oxymorphone extended release,
123127
absorption, 124
chemical name, 123
common doses, 126
description, 124
drug class, 123
generic name, 123
indications, 125
manufacturers, 123
metabolism, 125
527
Index

routes of administration,
126
oxymorphone injectable, 122
acute pain management, 121
chemical name, 119
clinical pharmacology, 121
common doses, 121
conversion from oral OPANA to
OPANA injection, 122
cost, 122
description, 119
drug class, 119
events, 122
generic name, 119
historical overview, 120
indications, 121
IV-PCA (patient-controlled
analgesic), 121
labor analgesia, 122
manufacturers, 119
preparations, 122
uses, 121
OxytrexTM, 90
Ozurdex, 388
528
pain
effects on recovery, 3
incidence among patients, 3
reasons for minimising
discomfort, 3
pain classifications, 4
temporal classifications, 14
pain definitions
IASP definition, 1, 3
pain detection
nociceptors, 1
pain experience
and nociception, 14
pain ladder method of controlling
pain, 211
pain management
guidelines for a four step
approach, 69
moving towards a flexible
approach, 71
rationale for a four step
approach, 67
traditional three step approach, 66
pain pathophysiology
cardiac effects, 27
CNS pathophysiology, 24
definition of pathologic pain, 23

emotional and quality of life
effects, 28
humoral and hormonal
responses, 27
peripheral nervous system, 25
pulmonary effects, 27
vascular effects, 27
venous thrombotic effects, 28
pain perception
qualitative aspects, 6
pain signaling, 1
pain temporality and duration, 6
PainEase. See vapocoolant spray
(PainEase)
paleo-spinothalamic tract (pSTT), 11
PallidoneTM, 448
Pamelor TM, 347
pamidronate
common doses, 414
description, 413
drug class, 413
generic name, 413
manufacturer, 413
paracetamol. See acetaminophen
parecoxib, 213
drug class, 245
generic name, 245
manufacturer, 245
parenteral opioid therapy, 78
paresthesia, 30
pathologic pain
definition, 23
patient
pain, 47
Patient Health Questionnaire
(PHQ-9), 345
pediatric patients. See opioid dosing in
pediatric patients.
Pepcid, 391
Percocet, 101
Percodan, 101
PercodanTM, 253
Perfalgan, 258
periaqueductal gray matter, 57
peripheral cannabinoid receptor

agonists
adverse events, 500
availability, 500
description, 499
drug class, 497
generic names, 497
manufacturer, 497
toxicity, 499
peripheral kappa agonist, 491
chemical name, 490
description, 490
drug class, 490
generic name, 490
indications (non-approved), 490
manufacturer/developer, 490
peripheral nervous system pain
pathophysiology, 25
peripheral sensitization, 25
persistent post-operative pain
abdominal hysterectomy, 46
amputation, 46
breast surgery, 46
central nervous system
involvement, 43
Cesarean section, 46
consequences, 41
definition, 41
epidemiology, 41
genetic risk factors, 48
historical background, 41
identifying patients at risk, 48
inguinal hernia repair, 45
mechanisms, 45
neuronal plasticity, 45
non-nerve structures involved, 43
pain processes, 43
patient risk factors, 47
peripheral nervous system
involvement, 43
predicting, 48
Index
risk factors, 48
risk with various operative
procedures, 46
significance, 42
spinal cord involvement, 43
structures involved, 43
surgical/medical risk factors, 48
thoracic surgery, 45
persistent post-operative pain
management, 4951
future directions for treatment, 50
multimodal treatment, 50
new targets for treatments, 50
post-operative treatment, 50
pre-emptive/preventive
treatment, 49
prevention, 49
phantom limb pain, 46
pharmacological management of
neuropathic pain, 17, 31
Phenergan, 391
phenylbutazone, 229
phenytoin, 292
physiological pain, 34
plasticity
neuronal regeneration, 16
PMS HydromorphoneTM, 115
PolistirexTM, 321
poorly controlled pain
cardiac effects, 27
catecholamine responses, 26
emotional effects, 28
neuroendocrine responses, 27
pulmonary effects, 27
quality of life effects, 28
stress response to injury, 27
vascular effects, 27
venous thombotic effects, 28
postherpetic neuralgia, 23
post-operative pain
See also persistent post-operative
pain.
potassium (K+) channels, 435
Precedex, 335
prednisone
chemical name, 388
drug class, 388
generic name, 388
indications, 389
manufacturers, 388
side effects, 390
Prednisone, 388
preemptive analgesia, 212
pregabalin, 292293
chemical name, 298
description, 298
generic name, 298
indications, 300
manufacturer, 298
overdose, 300
trade name, 298
PrialtTM, 415
prilocaine, 270, See EMLATM
primary hyperalgesia, 18, 23
procaine, 267
prostaglandins (PGs), 8
ProStep, 484
protein kinase A (PKA), 25
protein kinase C (PKC), 25
pseudo-addiction, 165
pulmonary effects of poorly controlled
pain, 27
purinergic (P2X) receptors, 8
purinoceptors, 433434
Rexista, 465
Reyes syndrome, 253, 255
Robafen AC, 98
Robaxin, 368
Robaxin, 360
Robitussin A-C Syrup, 98
RobitussinTM DM, 321
rofecoxib, 213
ropivacaine, 279
absorption, 277
brand names, 276
chemical name, 276
chemical structure,
clinical recommendations, 279
description, 276
distribution, 277
dosing and timing, 279
elimination, 277
generic name, 276
indications, 278
metabolism, 277
strength descriptions, 276
toxicity, 279
warnings, 279
RoxicetTM, 101
Roxicodone, 101
Roxiprin, 101
Rucaina, 279
RylomineTM, 437
qualitative aspects of pain

perception, 6
quality of life effects of poorly
controlled pain, 28
S (+) ketamine, 312

Sabril, 292
salicylates. See topical salicylates
Sativex. See cannabinoid agonists
SavellaTM, 357
scopolamine. See transdermal
scopolamine
secondary hyperalgesia, 5, 21, 23
selective serotonin reuptake inhibitors
(SSRIs), 338
Sensorcaine, 274
serotonin, 8
serotonin and norepinephrine
reuptake inhibitors (SNRIs), 341
serotonin syndrome, 341
silent nociceptors, 15
SinequanTM, 347
SirdaludTM, 375
SkelaxinTM, 361, 372
sodium (Na+) channels, 434
SolarazeTM, 229
Soma, 360
somatic pain, 3, 14
SophidoneTM, 115
spinal cord stimulation, 35
referred pain, 3
regeneration of damaged neurons, 16
rehabilitative/convalescent pain, 5
RelistorTM, 418
remifentanil, 150
chemical name, 147
common doses, 149
description, 148
drug class, 147
generic name, 147
manufacturers, 147
trade name, 147
RemoxyTM, 465
ReprexainTM, 105
ResTivaTM, 481
529
Index
spinothalamic tract (STT), 11

splinting, 5
Stepped Care for Affective Disorders
and Musculoskeletal Pain
(SCAMP), 344
stress response to injury, 27
subcutaneous extended release
SublimazeTM, 184
sublingual buprenorphine, 159
substance P, 8, 1415
Sufenta, 191
sufentanil. See epidural sufentanil
surgical factors
pain, 48
Sylestesin, 279
Symmetrel, 325
SyneraTM, 286
description, 286
generic name, 283
how to use, 286
manufacturer, 283
mode of action, 286
pharmacology, 286
530
Tagamet, 391
tamper resistant opioids,
AcuroxTM formulation, 466
approaches to tamper resistance, 466
DETERx technology, 465
drug class, 463
EDACS, 465
EMBEDATM, 466
generic names, 463
manufacturers, 463
OROSTM technology, 465
prescription opioid abuse, 463
RemoxyTM, 465
TanezumabTM, 513
tapentadol, 143147
chemical name, 143
common doses, 146
description, 144
drug class, 143
generic name, 143
indications, 146
manufacturer, 143
relative contraindications, 146

trade name, 143
tapentadol ER, 458462
chemical name, 458
clinical investigations, 461
common doses, 461
description, 458
drug class, 458
generic name, 458
indications, 459
manufacturer, 458
trade name, 458
warnings, 461
Tauxib, 247
Tegretol, 292, 301
Temesta, 365
temporal classifications of pain, 14
acute pain, 13
chronic pain, 14
temporal summation, 24
TernelinTM, 375
tetracaine. See Ametop GelTM; SyneraTM
thermal hyperalgesia, 14
thoracic surgery
pain, 45
three step approach to pain
management, 66
tissue pain (nociceptive pain), 15
tizanidine, 363, 378
absorption, 376
chemical name, 375
clinical effects, 376
comparative standing, 378
cost, 378
description, 375
dosing guidelines, 378
drug class, 375
generic name, 375
how supplied, 378
indications, 377
manufacturers, 375
metabolism, 376
mode of action, 376
side effects, 377
tablet vs. capsule, 376
toxicology, 378

TizanidinuTM, 375
TNF, 15
Tofranil TM, 347
Topamax, 292
topical capsaicin, 408
description, 407
how to use in pain management,
409
pharmacology, 408
side effects, 409
topical local anesthetics, 285287
Ametop GelTM (amethocaine gel),
287
EMLATM (Eutectic Mixture of Local
Anesthetics), 285
generic names, 283
LMX-4TM (liposomal lidocaine),
285
manufacturers, 283
SyneraTM (lidocaine/tetracaine
topical patch), 286
vapocoolant spray (PainEase), 287
topical salicylates, 412
diethylamine salicylate, 410
non-approved), 411
methyl salicylate, 410
trolamine salicylate, 410
ToradolTM, 235
tramadol, 137
advantages, 139
adverse events, 139
chemical name, 137
description, 137
disadvantages, 139
drug class, 137
generic name, 137
indications, 139
manufacturers, 137
metabolism, 138
mode of action, 137
preparations, 139140
structural formula, 137
Index
tramadol extended release, 140143

chemical name, 140
common doses, 141
description, 141
drug class, 140
generic name, 140
indications, 141
manufacturers, 140
tramadol plus acetaminophen
adverse events, 139
description, 137
drug class, 137
generic name, 137
indications, 139
manufacturers, 137
structural formula, 137
Tramal, 137
transcutaneous electrical stimulation
(TENS), 35
Transderm ScopTM, 405
transdermal extended release
transdermal scopolamine,
absorption, 405
adverse events, 407
chemical name, 405
common doses, 406
description, 405
drug class, 405
events, 407
generic name, 405
indications, 406
major site of action, 405
manufacturer, 405
metabolism, 405
TRANSDURTM, 467
transient receptor potential (TRP)
channels, 8
TranstecTM, 481
trazodone, 351353
chemical name, 351

common doses, 352
description, 351
disease related concerns, 353
drug class, 351
generic name, 351
indications, 352
major drug interactions, 352
manufacturers, 351
overdose, 353
tricyclic antidepressants (TCAs),
338, 350
common doses, 350
description, 347
drug clearance and elimination,
348
generic names, 347
indications (non-approved), 348
action, 347
manufacturers, 347
toxicity, 350
trade names, 347
Trileptal, 292
Trodon, 137
trolamine salicylate, 410
TRPV1 ion channel blockers, 506
activation of TRPV1 channels,
506
advantages, 506
chemical name, 504
description, 504
drug class, 504
genetic names, 504
ideal TRPV1 antagonist (drug
profile), 506
location of TRPV channels, 505
manufacturer/developer, 504
mode of action, 505

potential indications, 506
structure of TRPV channels, 505
TRPV-1 receptor, 8
tumor necrosis factor-alpha (TNF),
17
TussionexTM, 321
Tylenol with Codeine, 98
Tylenol, 256
Ultiva, 147
Ultra-Brief Screening Scale for Anxiety
and Depression, Patient Health
Questionnaire, PHQ-4, 345
Ultracet, 137
Ultram, 137
Ultram ER, 140
uridine diphosphateglucuronosyltransferase 2 family
polypeptide B7 (UGT), 40
valdecoxib, 213, 245
Valium, 362, 365
vanilloid receptors (VRI), 8
vapocoolant spray (PainEase), 287
description, 287
generic name, 283
how to use, 287
manufacturer, 283
mode of action, 287
pharmacology, 287
vascular effects of poorly controlled
pain, 27
venous thrombotic effects of poorly
controlled pain, 28
Vicodin CRTM, 452
VicodinTM Controlled Release, 452
VicoprofenTM, 105
Vioxx, 213
visceral pain, 3, 14
Vistaril, 391
Vivacaine, 274
Vivactil TM, 347
Voltaren Gel, 225
VoltarenTM, 229
Voltaren-XRTM, 229
wind-up phenomenon, 9, 212
withdrawal syndrome, 169
World Health Organization (WHO)
analgesic ladder, 66, 253
pain ladder method of controlling
pain, 211
Xylestesin, 279
531
Index
Xylocaine, 279
Xylocitin, 279
Xylotox, 279
Xyzal, 391
Zanaflex, 363
ZanaflexTM, 375
Zantac, 391
Zarontin, 292
ziconotide, 415417
adverse events, 417
532

common doses, 416
description, 415
drug class, 415
elimination, 415
generic name, 415
non-approved), 415
manufacturer, 415
metabolism, 415
potential disadvantages,
417
toxicity, 416
Zonegran, 292
Zydol, 137
Zyrtec, 391

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The Essence of Analgesia and

The Essence of Analgesia and

cambridge university press

Section 2. Oral and Parenteral Opioid

Section 1. Pain Definitions

13. Opioids and opioid receptors 73

2. Pain definitions and assessment 3

14. Morphine oral and parenteral 82

26. Methadone 127

43. Epidural sufentanil 191

27. Fentanyl oral and buccal delivery

44. Extended-release epidural morphine 194

28. Fentanyl transdermal system 134

45. Intrathecal morphine 197

29. Tramadol and tramadol plus

46. Evaluating epidural catheters 200

30. Tramadol extended-release 140

33. Nalbuphine 150

48. Nonselective nonsteroidal anti-inflammatory

34. Butorphanol 154

49. Ibuprofen 215

35. Buprenorphine: intravenous neuraxial and

50. Injectable ibuprofen 218

36. Opioid dosing in pediatric patients 161

47. Anticoagulants and regional anesthesia 204

51. Naproxen 221

38. Opioid-induced hyperalgesia 171

53. Diclofenac oral and diclofenac plus

39. Opioid rotation 174

54. Diclofenac injectable 232

Section 3. Neuraxial Opioid Analgesics

55. Ketorolac 235

40. Epidural morphine 181

56. Celecoxib 238

41. Epidural fentanyl 184

57. Etoricoxib 243

42. Epidural hydromorphone 187

58. Parecoxib 245

59. Meloxicam 249

Section 5. Local Anesthetics

Section 7. NMDA Antagonists

65. Bupivacaine 274

Section 8. Alpha-Adrenergic Analgesics

66. Ropivacaine 276

80. Overview of adrenergic and serotoninergic

67. Lidocaine for neural blockade 279

81. Clonidine (transdermal and parenteral) 330

70. Overview of anticonvulsant analgesics 292

84. Overview and use of antidepressant

71. Gabapentin 294

85. Tricyclic antidepressants 347

72. Pregabalin 298

86. Trazodone 351

73. Carbamazepine 301

87. Duloxetine 353

74. Lamotrigine 306

88. Milnacipran 357

Section 10. Muscle Relaxants

106. Methylnaltrexone 418