Sunday, November 2, 2014

Opiates in a nasal spray?

     Has anyone heard of nasal sprays for opiates?  Maciejeweski (2012) found there were off-label uses of agonistic opioids that included intra-articular and intranasal routes of administration as well as peripheral nerve blocks.   According to Steenblik et al. (2012), intranasal (IN) applications of an opioid called sufentanil has been effectively utilized in clinics at winter resorts, urgent care facilities and emergency rooms for its rapid analgesic impact on acute injuries.  They found that although most IN research was performed in the pediatric population, IN was actively being utilized in adult populations in spite of the higher volume of medication required to produce an effective analgesia.  Kendall, Maconochie, Wong & Howard (2014) also found an atomized opioid called diamorphine that was quite effective in the rapid relief of moderate to severe pain as in case of fracture and burns. 
     Sufentanil (Sufenta) is a synthetic opioid that is similar in action to fentanyl, but is better suited for IN administration due to its higher potency, lower cost and tendency to cause less adverse effects within a wide dose range (Steenblik et al., 2012).  Diamorphine is made from a semisynthetic derivative of morphine, is highly lipid soluble and crosses the blood brain barrier better than morphine, therefore producing a more rapid and intense central nervous system (CNS) response that is desired for analgesia in acute injuries ( Kendall, Maconochie, Wong & Howard, 2014). These authors also reported this medication has the sedation and gastrointestinal issues of nausea or vomiting oftentimes seen with other opioids, as well as a mild nasal irritation or burning sensation correlating with the volume of spray.
     Sufentanil’s action occurs as it binds to opioid receptors of the CNS, thus diminishing the response to pain and depressing the CNS (Ciccone, 2013).  He went on further to state that sufentanil is mostly metabolized in the liver, although some metabolism occurs in the small intestine and it has an intravenous bioavailability of 100%.  He also noted that the most dangerous side effects were apnea and thoracic rigidity, cardiac arrest, laryngospasm and anaphylaxis (p. 1022).  The most fatal drug to drug interaction is the combination with MAO inhibitors within a 2 week time frame, and less severe reactions may occur in the presence of other CNS depressants like alcohol, sedatives, antidepressants or other opioids.
     According to Kendall, Maconochie, Wong & Howard (2014), there are benefits to opiate nasal spray with its fast action compared to oral medications, plus it is as effective as an intravenous administration, but with quicker implementation in fast paced situations.  These authors felt this nasal spray demonstrated a good safety profile, but with that said, their study was limited to the pediatric population, an unfortunate limitation in this study. 
Ciccone, C. D. (2013). Drug guide for rehabilitation professionals. Philadelphia, PA: F. A.  Davis Company.
Kendall J., Maconochie, I., Wong, I. C. K. & Howard, R. (2014).  A novel multipatient intranasal diamorphine spray for use in acute pain in children: pharmacovigilance data from an observational study. Emerg Med J, 0,1-5.  doi:10.1136/emermed-2013-203226
Maciejewski, D. (2012). Sufentanil in anaesthersiology and intensive therapy.  Anaesthesiology Intensive Therapy, 44, 35-41.
Steenblik, J., Goodman, M., Davis, V., Gee, C., Hopkins, C., Stephen, R., & Madsen, T. (2012). Intranasal sufentanil for the treatment of acute pain in a winter resort clinic. American Journal Of Emergency Medicine, 30(9), 1817-1821. doi:10.1016/j.ajem.2012.02.019

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