O uso de opióides no tratamento da dor crônica não oncológica: o papel da metadona

Sady Ribeiro; André Prato Schmidt; Sérgio Renato Guimarães Schmidt

doi:10.1590/S0034-70942002000500015

Review Article

O uso de opióides no tratamento da dor crônica não oncológica: o papel da metadona

Opioids for treating non malignant chronic pain: the role of methadone

Sady Ribeiro; André Prato Schmidt; Sérgio Renato Guimarães Schmidt

http://dx.doi.org/10.1590/S0034-70942002000500015 Braz J Anesthesiol, vol.52, n5, p.644-651, 2002

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Resumo

JUSTIFICATIVA E OBJETIVOS: O uso de opióides em dor oncológica já é bastante difundido e comprovado por diversos ensaios clínicos bem controlados. Entretanto, há uma grande controvérsia em relação ao uso em longo prazo de opióides em dor crônica de origem não oncológica, que tem se intensificado de forma importante nos últimos anos. Neste estudo, objetivamos avaliar criticamente as informações disponíveis na literatura a respeito do uso de opióides para tratamento de dor crônica não oncológica e o papel da metadona como opção terapêutica. CONTEÚDO: Os estudos disponíveis ainda são limitados, mas demonstram que determinadas subpopulações de pacientes portadores de dor crônica podem alcançar analgesia importante, com pouca tolerância e baixo potencial para adição, principalmente aqueles refratários aos esquemas terapêuticos convencionais. Morfina é o opióide padrão, mas outras alternativas podem ser utilizadas como oxicodona, hidromorfona ou fentanil. Metadona é um opióide sintético, inicialmente utilizado para prevenir síndrome de abstinência em paciente dependentes, que também constitui uma importante opção no tratamento da dor crônica não oncológica, principalmente dor neuropática. CONCLUSÕES: Apesar do conhecimento crescente sobre o uso de opióides em dor crônica não oncológica, novos estudos melhor controlados ainda são necessários para uma discussão mais científica a respeito do assunto. A metadona administrada por via oral apresenta uma boa relação custo-benefício, representando uma alternativa efetiva para um melhor controle da dor em alguns pacientes.

Palavras-chave

ANALGÉSICOS, ANALGÉSICOS, DOR

Abstract

BACKGROUND AND OBJECTIVES: The use of opioids for cancer pain has already well established by several well-controlled clinical trials. However, there is a major controversy about long-term use of opioids in non-malignant chronic pain, which has been significantly intensified in the last few years. This study aimed at evaluating available data on the use of opioids for treating non-malignant chronic pain and the role of methadone as a therapeutic alternative. CONTENTS: There are few available studies, but they show that some subpopulations of chronic pain patients may achieve sustained analgesia with minor tolerance and low addiction potential, mainly those refractory to conventional therapy. Morphine is the standard opioid, but other alternatives may be used such as oxycodone, hydromorphone or fentanyl. Methadone is a synthetic opioid, initially used to prevent withdrawal syndrome in addicted patients, which may be an important alternative for treating non-malignant chronic pain, especially neuropathic pain. CONCLUSIONS: Although the growing knowledge on the use of opioids for treating non-malignant chronic pain, new better controlled studies are still needed to allow a more scientific discussion about this subject. Oral methadone is cost-effective and an effective alternative for a better pain control in certain patients.

Keywords

ANALGESICS, ANALGESICS, PAIN

Referencias

Loeser JD, Melzack R. Pain: an overview. Lancet. 1999;353:1607-1609.

Millan MJ. The induction of pain: an integrative review. Prog Neurobiol. 1999;57:1-164.

Carr DB, Goudas LC. Acute pain. Lancet. 1999;353:2051-2058.

Besson JM. The neurobiology of pain. Lancet. 1999;353:1610-1615.

Thomsen AB, Sorensen J, Sjogren P. Economic evaluation of multidisciplinary pain management in chronic pain patients: a qualitative systematic review. J Pain Symptom Manage. 2001;22:688-698.

Ashburn MA, Staats PS. Management of chronic pain. Lancet. 1999;353:1865-1869.

MacPherson RD. The pharmacological basis of contemporary pain management. Pharmacol Ther. 2000;88:163-185.

Barkin RL, Fawcett J. The management challenges of chronic pain: the role of antidepressants. Am J Ther. 2000;7:31-47.

Tremont-Lukats IW, Megeff C, Backonja MM. Anticonvulsants for neuropathic pain syndromes: mechanisms of action and place in therapy. Drugs. 2000;60:1029-1052.

Guay DR. Adjunctive agents in the management of chronic pain. Pharmacotherapy. 2001;21:1070-1081.

Fisher K, Coderre TJ, Hagen NA. Targeting the N-methyl- D-aspartate receptor for chronic pain management: Preclinical animal studies, recent clinical experience and future research directions. J Pain Symptom Manage. 2000;20:358-373.

Weinbroum AA, Rudick V, Paret G. The role of dextromethorphan in pain control. Can J Anaesth. 2000;47:585-596.

McQuay H. Opioids in pain management. Lancet. 1999;353:2229-2232.

Allen RM, Dykstra LA. Role of morphine maintenance dose in the development of tolerance and its attenuation by an NMDA receptor antagonist. Psychopharmacology. 2000;148:59-65.

Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11:203-217.

Dellemijn P. Are opioids effective in relieving neuropathic pain?. Pain. 1999;80:453-462.

Bruera E, Macmilian K. The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain. 1989;39:13-16.

Dickenson AH. Evidence for a role of the NMDA receptor in the frequency dependent potentiation of deep dorsal horn nociceptive neurons following C fiber stimulation. Neuropharmacology. 1987;26:1235-1238.

Elliot K, Hynansky A. Dextromethrphan attenuates and reverses analgesic tolerance to morphine. Pain. 1994;59:361-368.

Fisbain DA, Rosomoff HL. Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain. 1992;8:77-85.

Haddox JD, Joranson D. The use of opioids for the treatment of chronic pain. Clin J Pain. 1997;13:6-8.

Garrido MJ, Troconiz IF. Methadone: a review of its pharmacokinetic/pharmacodynamic properties. J Pahrmacol Toxicol. 1999;42:61-66.

Codd E, Shank R. Serotonin and norepinephrine uptake inhibiting activity of centrally acting analgesics: structural determinants and role in antinociception. J Pharmacol Exp Ther. 1995;274:1263-1270.

Oxenham D, Farrer K. Methadone: opioid, N-methyl-D- aspartate antagonist or both?. Palliat Med. 1998;12:302.

Davis MP, Walsh D. Methadone for relief of cancer pain: a review of pharmacokinetics, pharmacodynamics, drug interactions and protocols of administration. Support Care Cancer. 2001;9:73-83.

Pereira J, Lawlor P, Vigano A. Equianalgesic dose ratios for opioids: A critical review and proposals for long-term dosing. J Pain Symptom Manage. 2001;22:672-687.

Kristensen K, Blemmer T, Angelo HR. Stereoselective pharmacokinetics of methadone in chronic pain patients. Ther Drug Monit. 1996;18:221-227.

Inturrisi CE, Colburn WA, Kaiko RF. Pharmacokinetics and pharmacodynamics of methadone in patients with chronic pain. Clin Pharmacol Ther. 1987;41:392-401.

Kreek MJ. Long-term methadone maintenance therapy: effects on liver function. Annals of Internal Medicine. 1972;77:598-602.

Novick DM, Kreek MJ. Methadone disposition in patients with chronic liver disease. Clin Pharmacol Ther. 1981;30:353-362.

Wojnar-Horton RE, Kristensen JH. Methadone distribution and excretion into breast milk of clients in a methadone maintenance program. Br J Clin Pharmacol. 1997;44:543-547.

Wang EC. Methadone treatment during pregnancy. J Obstet Gynecol Neonatal Nurs. 1999;28:615-622.

Sullivan HR. Quantitative determination of methadone concentration in human blood, plasma and urine by gas chromatography. Res Comm Chem Pathol Pharmacol. 1972;3:467-478.

Schlatter J, Madras J. Drug interactions with methadone. Presse Med. 1999;28:1381-1384.

McCance-Katz EF, Rainey PM. Methadone effects on zidovudine disposition (AIDS Clinical Trials Group 262). J Acquir Immune Defic Syndr. 1998;18:435-443.

Richelson E. Pharmacokinetic drug interactions of new antidepressants: a review of the effects on the metabolism of other drugs. Mayo Clin Proc. 1997;72:835-847.

Swerdon M. Anticonvulsant drugs and chronic pain. Clin Neuropharmacol. 1984;7:51-87.

Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain. 1986;25:171-86.

Manfredi PL, Gonzales GR, Cheville AL. Methadone analgesia in cancer pain patients on chronic methadone maintenance therapy. J Pain Symptom Manage. 2001;21:169-174.

Gagnon B, Bruera E. Differences in the ratios of morphine to methadone in patients with neuropathic pain versus non-neuropathic pain. J Pain Symptom Manage. 1999;18:120-125.

Gardner-Nix JS. Oral methadone for managing chronic nonmalignant pain. J Pain Symptom Manage. 1996;11:321-328.

Jamison RN, Kauffman J, Katz NP. Characteristics of methadone maintenance patients with chronic pain. J Pain Symptom Manage. 2000;19:53-62.

Hagen NA, Wasylenko E. Methadone: outpatient titration and monitoring strategies in cancer patients. J Pain Symptom Manage. 1999;18:369-375.

McQuay H. Opioids in chronic non-malignant pain. BMJ. 2001;322:1134-1135.

Susman E. Methadone safe and effective for treating cancer pain. The Lancet Oncology. 2001;2:329.

Verhaak PFM, Kerssens JJ, Dekker J. Prevalence of chronic benign pain disorder among adults: a review of the literature. Pain. 1998;77:231-239.

Fainsinger R, Schoeller T. Methadone in the management of cancer pain: a review. Pain. 1993;52:137-147.

Levy MH. Pharmacologic treatment of cancer pain. N Engl J Med. 1996;335:1124-1132.

O uso de opióides no tratamento da dor crônica não oncológica: o papel da metadona

Opioids for treating non malignant chronic pain: the role of methadone

Sady Ribeiro; André Prato Schmidt; Sérgio Renato Guimarães Schmidt

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