levorphanol and Opioid-Related-Disorders

Methadone has unique characteristics that make it an attractive agent for the treatment of chronic pain and opioid drug dependence. However, methadone prescription requires more clinical experience and close monitoring of patients to avoid its undesirable side effects. Recently, levorphanol has emerged as "a forgotten opioid" with a similar profile as methadone. Levorphanol has no impact on QTc prolongation and considerably less drug-drug interactions as compared to methadone. Lack of commercial availability, providers' unfamiliarity, and limited clinical data on its effectiveness remain practical issues. The objective of this article is to review and compare the safety considerations for methadone and levorphanol use.

Topics: Analgesics, Opioid; Central Nervous System; Chronic Pain; Dose-Response Relationship, Drug; Humans; Levorphanol; Methadone; Opioid-Related Disorders; Therapeutic Equivalency

Earlier studies have suggested that the acute administration of an opiate can result in the development of supersensitive dopamine receptors. The present study was undertaken to determine whether the supersensitive dopamine receptors can modify the development of opiate tolerance and dependence. Administration of morphine (100 mg/kg s.c.) 6 or 24 hr before apomorphine (i.p.) potentiated apomorphine-induced climbing behavior in mice. Administration of levorphanol (12 mg/kg s.c.) 3 or 6 hr, but not 24 hr, before apomorphine also potentiated apomorphine-induced climbing behavior. Coadministration of 5 mEq/kg of LiCl with morphine or levorphanol attenuated the increased sensitivity developed to apomorphine after either opiate. Acute tolerance and dependence was induced by administration of 100 mg/kg of morphine or 12 mg/kg of levorphanol. Lithium enhanced the development of acute tolerance when coadministered with morphine 3, 6 or 24 hr before test doses of morphine, or with levorphanol 3 hr before test doses of levorphanol. Administration of apomorphine 5 min before naloxone significantly decreased the naloxone ED50 for inducing withdrawal jumping in mice that had been pretreated with morphine or levorphanol. Although coadministration of lithium with morphine or levorphanol had no significant effect on naloxone-induced withdrawal jumping, it attenuated the ability of apomorphine to decrease naloxone ED50. Morphine (100 mg/kg s.c.) increased the number of whole brain [3H]spiroperidol binding sites 3 and 6 hr after administration of morphine. This increase was no longer present 24 hr after morphine administration. Levorphanol (12 mg/kg s.c.) also increased the number of binding sites 3 hr after administration. Coadministration of lithium with morphine attenuated the increase in [3H]spiroperidol binding sites.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Animals; Apomorphine; Behavior, Animal; Drug Interactions; Drug Tolerance; Levorphanol; Lithium; Male; Mice; Morphine; Naloxone; Narcotics; Opioid-Related Disorders; Receptors, Dopamine; Spiperone; Substance Withdrawal Syndrome

Thirty-eight patients maintained on opioid analgesics for non-malignant pain were retrospectively evaluated to determine the indications, course, safety and efficacy of this therapy. Oxycodone was used by 12 patients, methadone by 7, and levorphanol by 5; others were treated with propoxyphene, meperidine, codeine, pentazocine, or some combination of these drugs. Nineteen patients were treated for four or more years at the time of evaluation, while 6 were maintained for more than 7 years. Two-thirds required less than 20 morphine equivalent mg/day and only 4 took more than 40 mg/day. Patients occasionally required escalation of dose and/or hospitalization for exacerbation of pain; doses usually returned to a stable baseline afterward. Twenty-four patients described partial but acceptable or fully adequate relief of pain, while 14 reported inadequate relief. No patient underwent a surgical procedure for pain management while receiving therapy. Few substantial gains in employment or social function could be attributed to the institution of opioid therapy. No toxicity was reported and management became a problem in only 2 patients, both with a history of prior drug abuse. A critical review of patient characteristics, including data from the 16 Personality Factor Questionnaire in 24 patients, the Minnesota Multiphasic Personality Inventory in 23, and detailed psychiatric evaluation in 6, failed to disclose psychological or social variables capable of explaining the success of long-term management. We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.

Topics: Adult; Aged; Analgesics, Opioid; Female; Humans; Levorphanol; Male; Methadone; Middle Aged; Opioid-Related Disorders; Oxycodone; Pain, Intractable; Personality Assessment; Personality Inventory; Retrospective Studies; Risk; Time Factors

The use of clonidine in the management of opiate abstinence is presented in a patient dependent upon levorphanol tartrate given for chronic pain. Use of levorphanol was abruptly discontinued, and the patient was monitored for signs and symptoms of opiate withdrawal. He manifested a significant increase in pulse and blood pressure and had perspiration, agitation, and opiate-seeking behavior. Clonidine effectively abolished these signs and symptoms. The mechanism by which clonidine prevents the opiate abstinence syndrome is discussed. Clonidine is a safe and inexpensive means of achieving rapid opiate withdrawal.

Topics: Adult; Chronic Disease; Clonidine; Humans; Levorphanol; Male; Opioid-Related Disorders; Pain; Substance Withdrawal Syndrome

Met-enkephalin and beta-endorphin levels were determined in the pituitary and brain of rats after treatment for several weeks with either agonists of high receptor affinity, such as levorphanol and etorphine, or with the narcotic antagnoist naloxone. Long-term activation of opiate receptors failed to change the endorphin levels in restricted areas of brain and pituitary, although a high degree of tolerance/dependence is apparent in those animals. Chronic blockade of opiate receptors by naloxone also fails to affect endorphin levels in the pituitary, but selectively increases metenkephalin levels in the striatum. The present data do not support the notion of negative feedback mechanisms to regulate endorphingergic functions during the development of opiate tolerance/dependence.

Topics: Animals; Brain; Dextrorphan; Drug Tolerance; Endorphins; Etorphine; Feedback; Humans; Levorphanol; Loperamide; Male; Naloxone; Opioid-Related Disorders; Pituitary Gland; Rats; Receptors, Opioid