Methadone poisoning due to accidental contamination of prescribed medication.

Two infants presented with fever and signs of brainstem dysfunction, including impaired consciousness, miosis, absence of oculocephalic responses, respiratory depression and a very peculiar tremor of the tongue and floor of the mouth. They were found to have methadone poisoning caused by accidental contamination of prescribed antibiotics in the same pharmacy, which was a dispensing centre for a methadone maintenance program. They recovered with supportive treatment only.     

Understanding Heroin Overdose: A Study of the Acute Respiratory Depressant Effects of Injected Pharmaceutical Heroin

Opioids are respiratory depressants and heroin/opioid overdose is a major contributor to the excess mortality of heroin addicts. The individual and situational variability of respiratory depression caused by intravenous heroin is poorly understood. This study used advanced respiratory monitoring to follow the time course and severity of acute opioid-induced respiratory depression. 10 patients (9/10 with chronic airflow obstruction) undergoing supervised injectable opioid treatment for heroin addiction received their usual prescribed dose of injectable opioid (diamorphine or methadone) (IOT), and their usual prescribed dose of oral opioid (methadone or sustained release oral morphine) after 30 minutes. The main outcome measures were pulse oximetry (SpO₂%), end-tidal CO₂% (ETCO₂%) and neural respiratory drive (NRD) (quantified using parasternal intercostal muscle electromyography). Significant respiratory depression was defined as absence of inspiratory airflow >10s, SpO₂% < 90% for >10s and ETCO₂% per breath >6.5%. Increases in ETCO₂% indicated significant respiratory depression following IOT in 8/10 patients at 30 minutes. In contrast, SpO₂% indicated significant respiratory depression in only 4/10 patients, with small absolute changes in SpO₂% at 30 minutes. A decline in NRD from baseline to 30 minutes post IOT was also observed, but was not statistically significant. Baseline NRD and opioid-induced drop in SpO₂% were inversely related. We conclude that significant acute respiratory depression is commonly induced by opioid drugs prescribed to treat opioid addiction. Hypoventilation is reliably detected by capnography, but not by SpO₂% alone. Chronic suppression of NRD in the presence of underlying lung disease may be a risk factor for acute opioid-induced respiratory depression.     

Reversal of morphine, methadone and heroin induced effects in mice by naloxone methiodide

Opioid overdose, which is commonly associated with opioid induced respiratory depression, is a problem with both therapeutic and illicit opioid use. While the central mechanisms involved in the effects of opioids are well described, it has also been suggested that a peripheral component may contribute to the effects observed. This study aimed to further characterise the effects of the peripherally acting naloxone methiodide on the respiratory, analgesic and withdrawal effects produced by various opioid agonists. A comparison of the respiratory and analgesic effects of morphine, methadone and heroin in male Swiss-Albino mice was conducted and respiratory depressive ED(80) doses of each opioid determined. These doses (morphine 9 mg/kg i.p., methadone 7 mg/kg i.p., and heroin 17 mg/kg i.p.) were then used to show that both naloxone (3 mg/kg i.p.) and naloxone methiodide (30-100 mg/kg i.p.) could reverse the respiratory and analgesic effects of these opioid agonists, but only naloxone precipitated withdrawal. Further investigation in female C57BL/6J mice using barometric plethysmography found that both opioid antagonists could reverse methadone induced decreases in respiratory rate and increases in tidal volume. Its effects do not appear to be strain or sex dependent. It was concluded that naloxone methiodide can reverse the respiratory and analgesic actions of a variety of opioid agonists, without inducing opioid withdrawal.     

AN EVALUATION OF OBSTETRICAL ANALGESIA

Relief of pain and safety of mother and child are fundamentals in obstetrical analgesia. Elimination of those drugs which are ineffective or dangerous is the best guide to proper medication. Morphine, codeine, or similar opium derivatives should be avoided as they depress fetal respiration. Barbiturates have the same fault, despite their popularity.Demerol in small dosage is safe and effective. Scopolamine yields excellent results with safety. Magnesium sulfate potentiates and reinforces the action of scopolamine and involves no danger. This combination of drugs may be used by any competent general practitioner in the home or hospital.     

Toxicology and pathology of deaths related to methadone: retrospective review

Objectives To clarify the mechanisms and risk factors of methadone toxicity and to describe the findings of deaths related to methadone use Design Retrospective review of case notes in the records of the San Francisco Medical Examiner comparing the findings in cases where methadone was deemed the cause of death with findings in decedents where methadone was an incidental finding, and with 50 age-matched, disease and drug free, trauma victims. Results 38 cases out of the 3317 processed by our office during 1997-1998 were identified in which methadone had been detected. Cases were mostly male 28/38 (74%) and white, 28/38 (74%). In 17 of 38 cases death was deemed to have been caused by methadone toxicity. For the group the mean blood methadone concentration for all 38 patients, was 957 ng/ml SD =.681, SE =.14). The mean blood concentration of the main methadone metabolite (EDDP) was 253 ng/ml, SD = 529 ng/ml, SE =.089. The mean ratio of methadone in the blood to EDDP in the blood was 13.6:1 Values were not significantly different between cases in which methadone toxicity was the cause of death and in those in which it was an incidental finding. Cocaine, or the cocaine metabolite benzoylecgonine, was detected in the blood or urine of 16/38 cases (42%); morphine in one-third (13/38) and methamphetamine in only one. Pulmonary edema was evident in all cases, coronary artery disease in 9/38 (24%) and cirrhosis in 7/38 (18%) of the methadone users. Necrotizing fasciitis was the cause of death in 4 of the 38 methadone users (11%). Nationally, a sizeable percent of methadone deaths are from drugs diverted from treatment programs. Conclusions The presence of methadone is often an incidental finding during postmortem examination which is unrelated to the cause of death. Postmortem measurements of methadone or its metabolite, or both, cannot be used in isolation to identify which deaths are associated with methadone toxicity.The Office on National Drug Control Policy is commited to making methadone treatment programs more widely available; deaths related to heroin use fall when where methadone replacement programs are available.^{1, 2, 3} Unfortunately, methadone is toxic. A total of 552 methadone-related deaths were reported to the government in 1996, making methadone the seventh most frequent cause of drug-related death in the United States (nearly 4000 deaths related to heroin were reported during that same period).⁴Most deaths that are related to methadone occur during the first few weeks of maintenance treatment; they are often the result of the dosage having been increased so quickly that fatal respiratory depression occurs.^5,6 The relative risk of fatal respiratory depression occurring during the first 2 weeks of methadone maintenance treatment is nearly seven times higher than that in untreated heroin addicts and 97.8 times higher than for patients who have been on methadone maintenance for more than 2 weeks.^3,7New opiate users who are using illicitly obtained methadone are also at risk. The amount of methadone diverted from treatment programs, and by inference the number of deaths occurring as a result, is limited because the number of heroin users actually enrolled in methadone programs is comparatively small. There are an estimated 810,000 heroin addicts in the United States but only 115,000 participate in maintenance programs.⁴ If methadone becomes more widely available opportunities for diversion from treatment programs will increase and so will the number of deaths.¹ Some of these deaths might be prevented, especially if the underlying cause of death was better understood. Little is known about the pharmacokinetics of methadone in opiate users. The data that have been published are largely derived from studies of single doses given to healthy volunteers or intravenous doses given to patients with cancer. Whether such studies are relevant to the pharmacokinetics in chronic heroin users is not known. Furthermore, nearly all of these studies were undertaken before differences in the tissue distribution of methadone isomers were understood,⁸ before methadone metabolites could be routinely measured, before chiral (special chemical techniques used to separate dextro- from levo- isomers of the same molecule) separation of methadone isomers was possible ⁹ and before the problem of determining the redistribution of drugs after death was appreciated.¹⁰     

微电泳给予单胺类受体阻断剂对兔孤束区呼吸性单位的吗啡诱发抑制效应的影响

实验在46只局部麻醉、肌肉麻痹和切断双侧颈迷走神经的家兔上进行。记录延髓孤束区的单位放电活动。观察微电泳单胺类受体阻断剂对呼吸性单位的吗啡诱发抑制效应的影响。全身应用吗啡前,在86个吸气性单位中,妥拉苏林引起阻遏的只有9个,在92个吸气性单位中,赛庚啶引起兴奋的只有1个。而在全身应用吗啡诱发单位活动抑制的背景上,在59个吸气性单位中,妥拉苏林引起阻遏的有42个,在74个吸气性单位中,赛庚啶引起兴奋的有12个。但两者对非呼吸性单位的影响,吗啡应用前后均无明显差别。这些结果进一步支持下述假设,即在吗啡所致的呼吸抑制效应中,5-HT 可能起着抑制性递质的作用,而 NE 起着兴奋性递质的作用。     

White matter abnormalities correlating with memory and depression in heroin users under methadone maintenance treatment

Methadone maintenance treatment (MMT) has elevated rates of co-morbid memory deficit and depression that are associated with higher relapse rates for substance abuse. White matter (WM) disruption in MMT patients have been reported but their impact on these co-morbidities is unknown. This study aimed to investigate changes in WM integrity of MMT subjects using diffusion tensor image (DTI), and their relationship with history of heroin and methadone use in treated opiate-dependent individuals. The association between WM integrity changes from direct group comparisons and the severity of memory deficit and depression was also investigated. Differences in WM integrity between 35 MMT patients and 23 healthy controls were evaluated using DTI with tract-based spatial statistical analysis. Differences in DTI indices correlated with diminished memory function, Beck Depression Inventory, duration of heroin use and MMT, and dose of heroin and methadone administration. Changes in WM integrity were found in several WM regions, including the temporal and frontal lobes, pons, cerebellum, and cingulum bundles. The duration of MMT was associated with declining DTI indices in the superior longitudinal fasciculus and para-hippocampus. MMT patients had more memory and emotional deficits than healthy subjects. Worse scores in both depression and memory functions were associated with altered WM integrity in the superior longitudinal fasciculus, para-hippocampus, and middle cerebellar peduncle in MMT. Patients on MMT also had significant WM differences in the reward circuit and in depression- and memory-associated regions. Correlations among decreased DTI indices, disease severity, and accumulation effects of methadone suggest that WM alterations may be involved in the psychopathology and pathophysiology of co-morbidities in MMT.     

中缝大核在臂旁内侧核区注射吗啡所致呼吸抑制效应中的作用

实验在33只浅麻醉、肌肉麻痹、人工呼吸及切断双侧颈迷走神经的家兔上进行。观察中缝大核区电解损毁或微量注射利多卡因对呼吸活动及臂旁内侧核区微量注射吗啡所致呼吸抑制效应的影响。结果是:电解损毀中缝大核区,使呼吸频率增加,膈神经放电的幅度和频率均无明显变化,而臂旁内侧核区微量注射吗啡抑制呼吸的程度减轻;中缝大核区微量注射利多卡因,则部分消除臂旁内侧核区微量注射吗啡的呼吸抑制效应。中缝大核旁网状结构电解损毁或微量注射利多卡因,不影响吗啡的呼吸抑制效应。上述结果提示,中缝大核区可能在脑桥臂旁内侧核区微量注射吗啡抑制呼吸的机制中起一定作用。     

微电泳U—50488对大鼠疑核呼吸相关单位电活动的影响

本工作观察了微电泳给予 U-50488对大鼠延髓疑核呼吸相关单位自发放电活动的影响。在96个单位中,呈抑制效应的51个,兴奋效应的11个,先抑制后兴奋的3个,先兴奋后抑制的6个,其余25个单位的自发放电活动无明显变化。在16个 U-50488产生抑制效应的单位中,12个单位的抑制效应能被纳洛酮对抗。2个 U-50488 表现为兴奋效应的单位,纳洛酮也显出拮抗效应。U-50488产生抑制效应持续的时间明显长于兴奋效应持续的时间。本工作的结果提示,k 受体可能也参与呼吸调控作用,并且介导 U-50488抑制效应的阿片受体亚型可能不同于介导兴奋效应的阿片受体亚型。     

Inhibition of mitochondrial NADH:ubiquinone oxidoreductase by ethoxyformic anhydride

The NADH:ubiquinone, but not the NADH:ferricyanide, reductase activity of mitochondrial complex I (NADH:ubiquinone oxidoreductase) is inhibited by incubation of the enzyme at pH 6.0 and 0 degree C with ethoxyformic anhydride (EFA), and the inhibition is partially reversed by subsequent incubation of EFA-treated complex I with hydroxylamine. These results and spectral changes of EFA-treated complex I in the u.v. region are consistent with modification of essential histidyl or tyrosyl residues between the primary NADH dehydrogenase and the site of ubiquinone reduction. Treatment of complex I with EFA in the presence of high concentrations of Seconal or Demerol did not protect against EFA inactivation, suggesting that the site of EFA modification may not be the same as the inhibiton sites of Seconal and Demerol. However, the presence of NADH during incubation of complex I with EFA greatly enhanced the inhibition rate, indicating that the reduced conformation of complex I is more susceptible to attack by EFA.     

Antagonism of morphine-induced central respiratory depression by donepezil in the anesthetized rabbit

Morphine is often used in cancer pain and postoperative analgesic management but induces respiratory depression. Therefore, there is an ongoing search for drug candidates that can antagonize morphine-induced respiratory depression but have no effect on morphine-induced analgesia. Acetylcholine is an excitatory neurotransmitter in central respiratory control and physostigmine antagonizes morphine-induced respiratory depression. However, physostigmine has not been applied in clinical practice because it has a short action time, among other characteristics. We therefore asked whether donepezil (a long-acting acetylcholinesterase inhibitor used in the treatment of Alzheimer's disease) can antagonize morphine-induced respiratory depression. Using the anesthetized rabbit as our model, we measured phrenic nerve discharge as an index of respiratory rate and amplitude. We compared control indices with discharges after the injection of morphine and after the injection of donepezil. Morphine-induced depression of respiratory rate and respiratory amplitude was partly antagonized by donepezil without any effect on blood pressure and end-tidal C02. In the other experiment, apneic threshold PaC02 was also compared. Morphine increased the phrenic nerve apnea threshold but this was antagonized by donepezil. These findings indicate that systemically administered donepezil partially restores morphine-induced respiratory depression and morphine-deteriorated phrenic nerve apnea threshold in the anesthetized rabbit.     

Self-administration of heroin, acetylmethadol, morphine, and methadone in rhesus monkeys.

Heroin, α-$\text{l}$-acetylmethadol (LAAM), morphine, and methadone each maintained self-administration in rhesus monkeys. The order of relative potency was heroin ≥ LAAM > morphine ≥ methadone. Total daily drug intake increased as dose per injection increased; maximum daily intake was inversely related to relative potency. At high doses, self-injection of methadone and LAAM caused stupor and/or respiratory failure in some monkeys. These toxic effects were partly or completely reversible by naloxone.     

Modulation of respiration during brain hypoxia

This review is a summary of the effects of brain hypoxia on respiration with a particular emphasis on those studies relevant to understanding the cellular basis of these effects. Special attention is given to mechanisms that may be responsible for the respiratory depression that appears to be the primary sequela of brain hypoxia in animal models. Although a variety of potential mechanisms for hypoxic respiratory depression are considered, emphasis is placed on changes in the neuromodulator constituency of the respiratory neuron microenvironment during hypoxia as the primary cause of this phenomenon. Hypoxia is accompanied by a net increase in neuronal inhibition due to both decreased excitatory and increased inhibitory neuromodulator levels. A survey of hypoxia-tolerant cellular systems and organisms suggests that hypoxic respiratory depression may be a manifestation of the depression of cellular metabolism, which appears to be a major adaptation to limited oxygen availability in these systems.     

Calcium as a counteractive agent to streptomycin induced respiratory depression: an in vivo electrophysiological observation.

Effect of streptomycin on respiratory function in cats was studied. It was observed that streptomycin at a dose of 40 mg/kg body weight intravenously (i.v.) caused respiratory failure or streptomycin induced respiratory depression (SIRD). This respiratory failure is not linked with Herring-Breuer stretch receptors because the effect remained unaltered in artificially ventilated cats. The involvement of central structures in SIRD can be discarded since intracarotid and intraventricular administration of streptomycin failed to produce any change in respiration. Studies on monosynaptic reflex, dorsal and ventral root activities of spinal phrenic and intercostal nerves, and on fusimotor and alpha-motor neuron activities of spinal intercostal and phrenic nerves in decerebrated cats indicated clearly that respiratory depression is not only due to blockade at neuromuscular junction but due to functional depression at the level of muscle receptors and spinal cord motor neurons. The respiratory depression induced by streptomycin was more or less completely reversed when calcium was administered intravenously from external source. It is speculated that streptomycin induced respiratory depression may be mediated through calcium inhibition which can be treated with external calcium in conjunction with artificial respiration.     

Interindividual variability of methadone response: impact of genetic polymorphism

Methadone, an opioid analgesic, is used clinically in pain therapy as well as for substitution therapy in opioid addiction. It has a large interindividual variability in response and a narrow therapeutic index. Genetic polymorphisms in genes coding for methadone-metabolizing enzymes, transporter proteins (p-glycoprotein; P-gp), and mu-opioid receptors may explain part of the observed interindividual variation in the pharmacokinetics and pharmacodynamics of methadone. Cytochrome P450 (CYP) 3A4 and 2B6 have been identified as the main CYP isoforms involved in methadone metabolism. Methadone is a P-gp substrate, and, although there are inconsistent reports, ABCB1 genetic polymorphisms also contribute slightly to the interindividual variability of methadone kinetics and influence dose requirements. Genetic polymorphism is the cause of high interindividual variability of methadone blood concentrations for a given dose; for example, in order to obtain methadone plasma concentrations of 250 ng/mL, doses of racemic methadone as low as 55 mg/day or as high as 921 mg/day can be required in a 70-kg patient without any co-medication. The clinician must be aware of the pharmacokinetic properties and pharmacological interactions of methadone in order to personalize methadone administration. In the future, pharmacogenetics, at a limited level, can also be expected to facilitate individualized methadone therapy.     

家兔延髓腹侧区在吗啡抑制呼吸机制中的作用

实验在36只麻醉、制动和人工通气的家兔上进行。探讨了延髓腹侧区在吗啡引起呼吸抑制机制中的作用。结果观察到:将浸透吗啡药液的滤纸片敷贴于延髓腹侧面的S区,可以引起膈神经放电抑制;将纳洛酮置于同一区域可翻转吗啡的效应;谷氨酸钠用于S区可引起膈神经放电加强;脑桥臂旁内侧核(NPBM)微量注射吗啡引起的膈神经放电抑制效应可被钠洛酮用于S区所预防;电刺激NPBM 主要引起延髓腹侧区单位放电的抑制反应,在这些出现抑制反应的单位中,大部分对微电泳给予吗啡也表现为放电的抑制。上述结果表明,家兔延髓腹侧区存在能激活膈神经放电的神经元;将吗啡微量注射于 NPBM,可通过激活延髓腹侧区的阿片受体使该区域某些神经元抑制,进而引起膈神经放电的抑制。     

A general model for aerobic yeast growth: continuous culture

A general model for the aerobic growth of yeast in continuous culture is presented. The model is capable of simulating the complete range of metabolic responses observed for yeast growth in continuous culture including respiratory repression, saturated respiratory capacity, and respiratory depression.It is postulated that respiratory depression is the result of the adaptation (increase in capacity of the respiratory intermediate transport proteins located at the mitochondrial membrane). Respiratory repression and subsequent saturated respiratory capacity is postulated to be the result of the gradual transfer of biosynthetic intermediates provision from the mitochondrion to the cytoplasm or, possibly, the adaptation (increase) in the capacity of the cell to excrete ethnol. It is difficult to provide a definitive experimental verification of these postulates.Irrespective of the biochemical basis of respiratory repression and depression, the model described is capable of simulating the complete range of metabolic responses obtained for yeast growth in continuous culture. It is the only model reported in the literature capable of achieving this.     

Anesthesia for eye operations in the aged

Aged persons appear to fear eye operations. Hence both patient and surgeon are more at ease with the use of a general anesthetic, particularly if the anesthetist has visited the patient before the operation and reassured him. Early ambulation, ordinarily so desirable in the aged, is curtailed in most eye operations because the head and eyes must be completely quiet. Since barbiturates are not well tolerated by aged patients, Dramamine is used instead preoperatively. Dramamine adequately sedates but does not cause depression or hallucinations. Morphine is contraindicated because of its pupillary action; Demerol is the drug of choice for preoperative medication. Xylocaine applied directly to the pyriform fossa and vocal cords prevents laryngospasm, coughing and straining. Then, following induction with Pentothal, a Guedel airway is introduced into the oropharynx and through it a continuous flow of oxygen is maintained throughout the procedure. Relaxation of the eyelids is aided by the use of various muscle relaxants, succinylcholine being the relaxant of choice because it is rapidly eliminated. By administering narcotics intravenously during the course of the operation the amount of Pentothal needed can be held to a minimum. To prevent any slowing of the respiration, Nalline is administered in conjunction with the narcotic. In dealing with debilitated patients, Nalline is usually given in conjunction with the preoperative narcotic. Any latent slowing of the respiration can be promptly relieved by an additional dose of Nalline.     

Effects of Methadone on the Minimum Anesthetic Concentration of Isoflurane,and Its Effects on Heart Rate,Blood Pressure and Ventilation during Isoflurane Anesthesia in Hens (Gallus gallus domesticus)

The aim of this study was to measure the temporal effects of intramuscular methadone administration on the minimum anesthetic concentration (MAC) of isoflurane in hens, and to evaluate the effects of the isoflurane-methadone combination on heart rate and rhythm, blood pressure and ventilation. Thirteen healthy adult hens weighing 1.7 ± 0.2 kg were used. The MAC of isoflurane was determined in each individual using the bracketing method. Subsequently, the reduction in isoflurane MAC produced by methadone (3 or 6 mg kg^-1, IM) was determined by the up-and-down method. Stimulation was applied at 15 and 30 minutes, and at 45 minutes if the bird had not moved at 30 minutes. Isoflurane MAC reduction was calculated at each time point using logistic regression. After a washout period, birds were anesthetized with isoflurane and methadone, 6 mg kg^-1 IM was administered. Heart rate and rhythm, respiratory rate, blood gas values and invasive blood pressure were measured at 1.0 and 0.7 isoflurane MAC, and during 45 minutes after administration of methadone once birds were anesthetized with 0.7 isoflurane MAC. Fifteen minutes after administration of 3 mg kg^-1 of methadone, isoflurane MAC was reduced by 2 (-9 to 13)% [logistic regression estimate (95% Wald confidence interval)]. Administration of 6 mg kg^-1 of methadone decreased isoflurane MAC by 29 (11 to 46)%, 27 (-3 to 56)% and 10 (-8 to 28)% after 15, 30 and 45 minutes, respectively. Methadone (6 mg kg^-1) induced atrioventricular block in three animals and ventricular premature contractions in two. Methadone caused an increase in arterial blood pressure and arterial partial pressure of carbon dioxide, while heart rate and pH decreased. Methadone, 6 mg kg^-1 IM significantly reduced isoflurane MAC by 30% in hens 15 minutes after administration. At this dose, methadone caused mild respiratory acidosis and increase in systemic blood pressure.     

An investigation of the activity of opiate drug receptors located on frog skeletal muscle fibre membrane.

Extracellular and intracellular microelectrode studies were conducted to test the actions and interactions of opiate agonists, antagonists, and procaine on action potentials in frog sartorius muscles. Extracellular studies showed that morphine, methadone, propoxyphene, and procaine all depressed action potential production. Low concentrations of naloxone or naltrexone antagonized the excitability depression produced by the three opiate agonists but not the depression produced by procaine. Intracellular studies revealed that certain concentrations of the opiate agonists produced a biphasic decline in the stimulus-induced increase in sodium conductance (gNa). Naloxone or naltrexone antagonized only the second phase of this decline. These results show that part of the excitability depression produced by opiate agonists is due to an action on opiate drug receptors.