antinociception

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antinociceptive

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2013/02/01 21:19:45」(JST)

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"Painkiller" redirects here. For other uses, see Painkiller (disambiguation).

An analgesic is any member of the group of drugs used to achieve analgesia, relief from pain. The word analgesic derives from Greek αν - ("without") and άλγος - ("pain").

Commonly known as painkillers, analgesic drugs act in various ways on the peripheral and central nervous systems. They are distinct from anesthetics, which reversibly eliminate sensation, and include paracetamol (known in the US as acetaminophen or simply APAP), the non-steroidal anti-inflammatory drugs (NSAIDs) such as the salicylates, and opioid drugs such as morphine and opium.

In choosing analgesics, the severity and response to other medication determines the choice of agent; the World Health Organization (WHO) pain ladder specifies mild analgesics as its first step.

Analgesic choice is also determined by the type of pain: for neuropathic pain, traditional analgesics are less effective, and there is often benefit from classes of drugs that are not normally considered analgesics, such as tricyclic antidepressants and anticonvulsants.

Major classes

Paracetamol and NSAIDs

Main article: Non-steroidal anti-inflammatory drug

The exact mechanism of action of paracetamol/acetaminophen is uncertain but appears to act centrally in the brain rather rather than peripherally in nerve endings. Aspirin and the other non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenases, leading to a decrease in prostaglandin production. In contrast to paracetamol and the opioids, this not only reduces pain but inflammation as well.^{[citation needed]}

Paracetamol has few side effects and is regarded as generally safe, although excess or sustained use can lead to potentially life-threatening liver damage and occasionally kidney damage. While paracetamol is usually taken orally or rectally, an intravenous preparation introduced in 2002 has been shown to improve pain relief and reduce opioid consumption in the perioperative setting.

NSAIDs predispose to peptic ulcers, renal failure, allergic reactions, and occasionally hearing loss, and they can increase the risk of hemorrhage by affecting platelet function. The use of aspirin in children under 16 suffering from viral illness has been linked to Reye's syndrome, a rare but severe liver disorder.

COX-2 inhibitors

Main article: COX-2 inhibitor

These drugs have been derived from NSAIDs. The cyclooxygenase enzyme inhibited by NSAIDs was discovered to have at least 2 different versions: COX1 and COX2. Research suggested that most of the adverse effects of NSAIDs were mediated by blocking the COX1 (constitutive) enzyme, with the analgesic effects being mediated by the COX2 (inducible) enzyme. The COX2 inhibitors were thus developed to inhibit only the COX2 enzyme (traditional NSAIDs block both versions in general). These drugs (such as rofecoxib, celecoxib and etoricoxib) are equally effective analgesics when compared with NSAIDs, but cause less gastrointestinal hemorrhage in particular.

After widespread adoption of the COX-2 inhibitors, it was discovered that most of the drugs in this class increased the risk of cardiovascular events by 40% on average. This led to the withdrawal of rofecoxib and valdecoxib, and warnings on others. Etoricoxib seems relatively safe, with the risk of thrombotic events similar to that of non-coxib NSAID diclofenac.

Opiates and morphinomimetics

Main articles: Opioid and Opiate

Morphine, the archetypal opioid, and various other substances (e.g. codeine, oxycodone, hydrocodone, dihydromorphine, pethidine) all exert a similar influence on the cerebral opioid receptor system. Buprenorphine is thought to be a partial agonist of the opioid receptor, and tramadol is an opiate agonist with SNRI properties.^{[citation needed]} Tramadol is structurally closer to venlafaxine than to codeine and delivers analgesia by not only delivering "opiate-like" effects (through mild agonism of the mu receptor) but also by acting as a weak but fast-acting serotonin releasing agent and norepinephrine reuptake inhibitor. Dosing of all opioids may be limited by opioid toxicity (confusion, respiratory depression, myoclonic jerks and pinpoint pupils), seizures (tramadol), but there is no dose ceiling in patients who accumulate tolerance.^{[citation needed]}

Opioids, while very effective analgesics, may have some unpleasant side-effects. Patients starting morphine may experience nausea and vomiting (generally relieved by a short course of antiemetics such as phenergan). Pruritus (itching) may require switching to a different opioid. Constipation occurs in almost all patients on opioids, and laxatives (lactulose, macrogol-containing or co-danthramer) are typically co-prescribed.

When used appropriately, opioids and similar narcotic analgesics are otherwise safe and effective, however risks such as addiction and the body becoming used to the drug (tolerance) can occur. The effect of tolerance means that frequent use of the drug may result in its diminished effect so, when safe to do so, the dosage may need to be increased to maintain effectiveness. This may be of particular concern regarding patients suffering with chronic pain.^{[citation needed]}

Flupirtine

Flupirtine is a centrally acting K+ channel opener with weak NMDA antagonist properties. It is used in Europe for moderate to strong pain and migraine and its muscle relaxant properties. It has no anticholinergic properties and is believed to be devoid of any activity on dopamine, serotonin or histamine receptors. It is not addictive and tolerance usually does not develop. However, tolerance may develop in single cases.

Specific agents

In patients with chronic or neuropathic pain, various other substances may have analgesic properties. Tricyclic antidepressants, especially amitriptyline, have been shown to improve pain in what appears to be a central manner.^{[citation needed]} Nefopam is used in Europe for pain relief with concurrent opioids. The exact mechanism of carbamazepine, gabapentin and pregabalin is similarly unclear, but these anticonvulsants are used to treat neuropathic pain with differing degrees of success. Anticonvulsants are most commonly used for neuropathic pain as their mechanism of action tends to inhibit pain sensation.^{[citation needed]}

Specific forms and uses

Combinations

Analgesics are frequently used in combination, such as the paracetamol and codeine preparations found in many non-prescription pain relievers. They can also be found in combination with vasoconstrictor drugs such as pseudoephedrine for sinus-related preparations, or with antihistamine drugs for allergy sufferers.

While the use of paracetamol, aspirin, ibuprofen, naproxen and other NSAIDS concurrently with weak to mid-range opiates (up to about the hydrocodone level) has been said to show beneficial synergistic effects by combatting pain at multiple sites of action, several combination analgesic products have been shown to have few efficacy benefits when compared to similar doses of their individual components. Moreover, these combination analgesics can often result in significant adverse events, including accidental overdoses, most often due to confusion which arises from the multiple (and often non-acting) components of these combinations.

Topical or systemic

Topical analgesia is generally recommended to avoid systemic side-effects. Painful joints, for example, may be treated with an ibuprofen- or diclofenac-containing gel; capsaicin also is used topically. Lidocaine, an anesthetic, and steroids may be injected into painful joints for longer-term pain relief. Lidocaine is also used for painful mouth sores and to numb areas for dental work and minor medical procedures.

Psychotropic agents

Tetrahydrocannabinol (THC) and some other cannabinoids, either from the Cannabis sativa plant or synthetic, have analgesic properties, although the use of cannabis derivatives is currently illegal in many countries. A recent study finds that inhaled cannabis is effective in alleviating neuropathy and pain resulting from e.g. spinal injury and multiple sclerosis. Other psychotropic analgesic agents include ketamine (an NMDA receptor antagonist), clonidine and other α₂-adrenoreceptor agonists, and mexiletine and other local anaesthetic analogues.

Atypical, adjuvant analgesics & potentiators

Drugs which have been introduced for uses other than analgesics are also used in pain management. Both first-generation (such as amitriptyline) and newer anti-depressants (such as duloxetine) are used alongside NSAIDs and opioids for pain involving nerve damage and similar problems. Other agents directly potentiate the effects of analgesics, such as using hydroxyzine, promethazine, carisoprodol or tripelennamine to increase the pain-killing ability of a given dose of opioid analgesic.

Adjuvant analgesics, also called atypical analgesics, include nefopam, orphenadrine, pregabalin, gabapentin, cyclobenzaprine, scopolamine, and other drugs possessing anticonvulsant, anticholinergic and/or antispasmodic properties, as well as many other drugs with CNS actions. These drugs are used along with analgesics to modulate and/or modify the action of opioids when used against pain, especially of neuropathic origin.

Dextromethorphan has been noted to slow the development of tolerance to opioids and exert additional analgesia by acting upon the NMDA receptors; some analgesics such as methadone and ketobemidone and perhaps piritramide have intrinsic NMDA action.

High-alcohol liquor, two forms of which were in the US Pharmacopoeia up until 1916 and in common use by physicians well into the 1930s, has been used in the past as an agent for dulling pain, due to the CNS depressant effects of ethyl alcohol, a notable example being the American Civil War. However, the ability of alcohol to relieve severe pain is likely inferior to many analgesics used today (e.g. morphine, codeine). As such, the idea of alcohol for analgesia is generally considered a primitive practice in virtually all industrialized countries today.

The use of adjuvant analgesics is an important and growing part of the pain-control field and new discoveries are made practically every year. Many of these drugs combat the side effects of opioid analgesics, an added bonus. For example, antihistamines including orphenadrine combat the release of histamine caused by many opioids. Stimulants such as methylphenidate, caffeine, ephedrine, dextroamphetamine, and cocaine work against heavy sedation and may elevate mood in distressed patients as do the antidepressants. The use of medicinal cannabis remains a debated issue.

See also

• Audioanalgesia
• Pain management
• Patient-controlled analgesia
• Pain in babies
• Congenital analgesia (insensitivity to pain)

References

UpToDate Contents

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• 1. 小児における片頭痛の病態生理、臨床的特徴、および診断 pathophysiology clinical features and diagnosis of migraine in children
• 2. 成人における緊張型頭痛：予防的治療 tension type headache in adults preventive treatment

English Journal

• Ligand-biased activation of extracellular signal-regulated kinase 1/2 leads to differences in opioid induced antinociception and tolerance.

• Bobeck EN1, Ingram SL2, Hermes SM3, Aicher SA3, Morgan MM4.
• Behavioural brain research.Behav Brain Res.2016 Feb 1;298(Pt B):17-24. doi: 10.1016/j.bbr.2015.10.032. Epub 2015 Oct 20.
• Opioids produce antinociception by activation of G protein signaling linked to the mu-opioid receptor (MOPr). However, opioid binding to the MOPr also activates β-arrestin signaling. Opioids such as DAMGO and fentanyl differ in their relative efficacy for activation of these signaling cascades, but
• PMID 26497105

• Additive antinociceptive effects of mixtures of the κ-opioid receptor agonist spiradoline and the cannabinoid receptor agonist CP55940 in rats.

• Maguire DR1, France CP.
• Behavioural pharmacology.Behav Pharmacol.2016 Feb;27(1):69-72. doi: 10.1097/FBP.0000000000000184.
• Pain is a significant clinical problem, and there is a need for pharmacotherapies that are more effective with fewer adverse effects than currently available medications. Cannabinoid receptor agonists enhance the antinociceptive effects of μ-opioid receptor agonists; it is unclear whether they impa
• PMID 26292184

• Expression and physiology of opioid receptors in the gastrointestinal tract.

• Mosińska P1, Zielińska M, Fichna J.
• Current opinion in endocrinology, diabetes, and obesity.Curr Opin Endocrinol Diabetes Obes.2016 Feb;23(1):3-10. doi: 10.1097/MED.0000000000000219.
• PURPOSE OF REVIEW: Stimulation of opioid receptors elicits analgesic effect not only in the central nervous system, but also in the gastrointestinal tract, where a high concentration of opioid receptors can be found within the enteric nervous system as well as muscular and immune cells. Along with a
• PMID 26702845

Japanese Journal

• Effect of plantar subcutaneous administration of bergamot essential oil and linalool on formalin-induced nociceptive behavior in mice

• Biomedical Research 36(1), 47-54, 2015
• NAID 130004903873

• 脊髄セロトニン,αアドレナリン受容体のgabapentinによる鎮痛に及ぼす影響

• Journal of musculoskeletal pain research = 日本運動器疼痛学会誌 6(2), 144-149, 2014
• NAID 40020196779

• ラット脊髄後角第Ⅱ層ニューロンに及ぼすオキシトシンの作用 − 鎮痛作用機序

• PAIN RESEARCH 29(4), 215-231, 2014
• NAID 130004839648

Related Links

• antinociception - Wiktionary

antinociception (uncountable) An increased tolerance for pain. Related terms [edit] antinociceptive Retrieved from "http://en.wiktionary.org/w/index.php?title=antinociception&oldid=19529939" Categories: English nouns Log in ...

• Antinociception? | ChaCha

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リンク元	「抗侵害」「antinociceptive」「抗侵害受容」

「抗侵害」

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英

antinociception、antinociceptive

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抗侵害受容、抗侵害受容性

「antinociceptive」

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• 抗侵害受容性の、抗侵害の

関

antinociception

「抗侵害受容」

　　[★]

英

antinociception

関

抗侵害