Opioids and Antidepressants for Pain Control in Musculoskeletal Disease

Park Se-Jin; Sub Kim Woo; Jang Taedong

doi:10.4055/jkoa.2020.55.1.1

Journal List > J Korean Orthop Assoc > v.55(1) > 1142182

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Se-Jin, Woo, and Taedong: Opioids and Antidepressants for Pain Control in Musculoskeletal Disease

Original Article

J Korean Orthop Assoc 2020;55(1):1-8.

DOI: https://doi.org/10.4055/jkoa.2020.55.1.1

Opioids and Antidepressants for Pain Control in Musculoskeletal Disease

Park Se-Jin, M.D., Sub Kim Woo, M.D., Jang Taedong, M.D.

Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Se-Jin Park, M.D. Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea TEL: +82-2-2001-2415 FAX: +82-2-2001-2176 E-mail: qortn97@naver.com ORCID: https://orcid.org/0000-0002-3941-1857

Received 31 May 201920 October 2019 Accepted 23 October 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The progression of aging and the increase in musculoskeletal diseases have led to an increase in invasive treatment methods, including various surgical methods, but conservative treatment should be attempted before surgical treatment in musculoskeletal diseases. Medication for pain control, such as acetaminophen, non-steroidal anti-inflammatory drugs, steroid, opioids, antidepressants, etc., is one of the most popular methods for pain control. If the pain receptors on peripheral organ are stimulated, pain is transmitted to the brain by the ascending pathway, and the brain then secretes endogenous opioids, such as endorphin, by the descending pathway for pain control. Opioids are substances that act on the opioid receptors, and there are three receptors for opioids. The affinity for each receptor varies according to the tissue and the patient’s systemic status. Antidepressants work on the synapses in the central nervous system and its main mechanism is regulation of the ascending pathway. This is mainly effective in chronic pain and neuropathic pain, which is similar in effectiveness to opioids. This review focuses on the effectiveness, method of use, and side effects of opioids and antidepressants.

Keywords: musculoskeletal system, opioid, antidepressive agent

References

1. Hoy D, Bain C, Williams G. . A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012. 64:2028–37.

2. Podichetty VK, Mazanec DJ, Biscup RS. Chronic non-malignant musculoskeletal pain in older adults: clinical issues and opioid intervention. Postgrad Med J. 2003. 79:627–33.

3. Tauben D. Nonopioid medications for pain. Phys Med Rehabil Clin N Am. 2015. 26:219–48.

4. Attal N, Cruccu G, Baron R. . European Federation of Neurological Societies. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010. 17:1113–23. e67–88.

5. Kieffer BL. Recent advances in molecular recognition and signal transduction of active peptides: receptors for opioid peptides. Cell Mol Neurobiol. 1995. 15:615–35.

6. Megale RZ, Deveza LA, Blyth FM. . Efficacy and safety of oral and transdermal opioid analgesics for musculoskeletal pain in older adults: a systematic review of randomized, placebo-controlled trials. J Pain. 2018. 19:475.e1–475.e24.

7. Pasternak GW. Opioids and their receptors: are we there yet? Neuropharmacology. 2014. 76 Pt B:198–203.

8. Carnide N, Hogg-Johnson S, Côté P. . Early prescription opioid use for musculoskeletal disorders and work outcomes: a systematic review of the literature. Clin J Pain. 2017. 33:647–58.

9. Stein C, Hassan AH, Lehrberger K, Giefing J, Yassouridis A. Local analgesic effect of endogenous opioid peptides. Lancet. 1993. 342:321–4.

10. Stein C, Pflüger M, Yassouridis A. . No tolerance to peripheral morphine analgesia in presence of opioid expression in inflamed synovia. J Clin Invest. 1996. 98:793–9.

11. Takeba Y, Suzuki N, Kaneko A, Asai T, Sakane T. Endorphin and enkephalin ameliorate excessive synovial cell functions in patients with rheumatoid arthritis. J Rheumatol. 2001. 28:2176–83.

12. Spetea M. Opioid receptors and their ligands in the musculoskeletal system and relevance for pain control. Curr Pharm Des. 2013. 19:7382–90.

13. Chou R, Fanciullo GJ, Fine PG. . American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009. 10:113–30.

14. Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007. 129:355–62.

15. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007. 8:573–82.

16. Ives TJ, Chelminski PR, Hammett-Stabler CA. . Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006. 6:46.

17. Kastelic N, Farless H, Pericak A. Guidelines for the chronic use of opioid analgesics [Internet]. Euless (TX): The Federation of State Medical Boards; 2017 Apr [updated 2017 Aug 10; cited 2019 Jan 15]. Available from: http://sciencepolicy. duke.edu/content/guidelines-chronic-use-opioid-analge-sics-model-policy.

18. Hwang IC, Shim JY. Opioids use for chronic noncancer pain. J Korean Med Assoc. 2013. 56:711–7.

19. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006. 174:1589–94.

20. Lee YW. Opioid therapy for chronic nonmaliganat pain. Hanyang Med Rev. 2011. 31:70–5.

21. Obata H. Analgesic mechanisms of antidepressants for neuropathic pain. Int J Mol Sci. 2017. 18:E2483.

22. Barakat A, Hamdy MM, Elbadr MM. Uses of fluoxetine in nociceptive pain management: a literature overview. Eur J Pharmacol. 2018. 829:12–25.

23. Onuţu AH. Duloxetine, an antidepressant with analgesic properties - a preliminary analysis. Rom J Anaesth Intensive Care. 2015. 22:123–8.

24. Beal BR, Wallace MS. An overview of pharmacologic management of chronic pain. Med Clin North Am. 2016. 100:65–79.

25. Binder A, Baron R. The pharmacological therapy of chronic neuropathic pain. Dtsch Arztebl Int. 2016. 113:616–25.

26. Shah S, Kapoor S, Durkin B. Analgesic management of acute pain in the opioid-tolerant patient. Curr Opin Anaesthesiol. 2015. 28:398–402.

27. Açikalin A, Satar S, Avc A, Topal M, Kuvandk G, Sebe A. QTc intervals in drug poisoning patients with tricyclic antidepressants and selective serotonin reuptake inhibitors. Am J Ther. 2010. 17:30–3.

28. Jasiak NM, Bostwick JR. Risk of QT/QTc prolongation among newer non-SSRI antidepressants. Ann Pharmacother. 2014. 48:1620–8.

29. Beach SR, Kostis WJ, Celano CM. . Meta-analysis of selective serotonin reuptake inhibitor-associated QTc prolongation. J Clin Psychiatry. 2014. 75:e441–9.

Table 1.

Types and Effects of Opioids

Opioid	Conversion factor
Codeine (mg)	0.15
Fentanyl transdermal (mg/h)	2.4
Hydrocodone (mg)	1
Hydromorphone (mg)	4
Methadone (mg)
1–20 mg/d	4
21–40 mg/d	8
41–60 mg/d	10
≥61–80 mg/d	12
Morphine (mg)	1
Oxycodone (mg)	1.5
Oxymorphone (mg)	3
Tapentadol (mg)	0.4

Table 2.

Type, Specificity, and Distribution of Opioid Receptor

Receptor type	Receptor distribution (musculoskeletal system)	Specificity
m-opioid receptor	Synovium, articular cartilage	The main receptor on which opioid work. The action of morphine and narcotic analgesics used clinically in moderate, severe, acute and chronic pain is the major agonist of mu receptors.
d-opioid receptor	Synovium	The expression of d-opioid receptor in the synovium of knee joints from patients with RA and OA was demonstrated. The density of d-opioid receptor immunoreactive nerve fibers was significantly greater in RA and OA synovium than on normal synovium.
k-opioid receptor	Synovium	k-opioid receptor were detected in normal human fibroblast-like synoviocytes. Although there is still limited information on the occurrence and distribution of k-opioid receptor in musculoskeletal tissues, pharmacological evidence on the presence and activation of peripheral k-opioid receptor located in arthritic joint tissues comes from preclinical studies. than on normal synovium.

RA, rheumatoid arthritis; OA, osteoarthritis.

Table 3.

Types and Dose of Antidepressants

Antidepressants	Dose
TCAs
Amitriptyline	10–75 mg at bedtime
Nortriptyline	10–50 mg at bedtime
Imipramine	10–50 mg at bedtime
Desipramine	10–50 mg at bedtime
Doxepin	10–75 mg at bedtime
SNRI
Milnacipran	25–50 mg twice a day
Duloxetine	Maximum 30 mg twice a day
SSRI
Fluoxetine	5 mg/Kg/d

TCAs, tricyclic antidepressants; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.

TOOLS

Similar articles