Tapentadol
Tapentadol, sold under the brand names Nucynta and Palexia among others, is a synthetic opioid analgesic with a dual mode of action as a highly selective full agonist of the μ-opioid receptor and as a norepinephrine reuptake inhibitor. Tapentadol is used medically for the treatment of moderate to severe pain. It is highly addictive and is a commonly abused drug.
Frequently reported adverse effects include euphoria, constipation, nausea, vomiting, headaches, loss of appetite, drowsiness, dizziness, itching, dry mouth, and sweating. More severe adverse reactions can occur, including addiction and dependence, substance abuse, respiratory depression, and an elevated risk of serotonin syndrome. Concurrent use of tapentadol with serotonergic drugs or central nervous system depressants – including alcohol, cannabis, benzodiazepines, and other opioids – can heighten the risks of excessive serotonin accumulation, profound sedation, dangerously slowed breathing and death.
Analgesia occurs within 32 minutes of oral administration, and lasts for 4–6 hours. Tapentadol is taken by mouth, and is available in immediate-release and controlled-release formulations. Tapentadol's combined mechanism of action is often compared to that of tramadol. Unlike tramadol, tapentadol is not metabolised by cytochrome P450 enzymes, but rather through glucuronidation. Due to this, tapentadol has fewer interactions with other medications and fewer side effects when compared with tramadol.
Like tramadol, tapentadol affects both the opioid system and the norepinephrine system to relieve pain. Unlike tramadol, it has only weak effects on the reuptake of serotonin and is a significantly more potent opioid with no known active metabolites. The potency of tapentadol is somewhere between that of tramadol and morphine, with an analgesic efficacy comparable to that of oxycodone despite a lower incidence of side effects. The CDC Opioid Guidelines Calculator estimates a conversation rate of 50mg of tapentadol equaling 10 mg of oral oxycodone in terms of opioid receptor activation.
In the late 1980s, Grünenthal developed tapentadol to improve on tramadol, which they had created in 1962. Their goal was to design a molecule that minimized serotonin activity, strongly activated the μ-opioid receptor, inhibited norepinephrine reuptake, and worked without metabolic activation. The result was tapentadol. Due to the high risk of addiction, substance misuse, and dependence, tapentadol is a Schedule II controlled substance in the United States, a Schedule 8 controlled drug in Australia, and a Class A controlled substance in the United Kingdom.
Medical use
Tapentadol is used for the treatment of moderate to severe pain for both acute and chronic musculoskeletal pain. It is also specifically indicated for controlling the pain of diabetic neuropathy when around-the-clock opioid medication is required.Extended-release formulations of tapentadol are not indicated for use in the management of acute pain and are instead indicated only for the relief of severe, disabling pain, that is long-term in nature and cannot be controlled by any other pharmacological means.
Tapentadol is pregnancy category C. There are no adequate and well-controlled studies of tapentadol in pregnant women, and tapentadol is not recommended for use in women during and immediately prior to labor and delivery.
There are no adequate and well-controlled studies of tapentadol in children.
Contraindications
Tapentadol is contraindicated in people with epilepsy or who are otherwise prone to seizures. It raises intracranial pressure so should not be used in people with head injuries, brain tumors, or other conditions which increase intracranial pressure. It increases the risk of respiratory depression so should not be used in people with asthma.As with other μ-opioid agonists, tapentadol may cause spasms of the sphincter of Oddi, and is therefore discouraged for use in patients with biliary tract disease such as both acute and chronic pancreatitis. People who are rapid or ultra rapid metabolizers for the CYP2C9, CYP2C19, and CYP2D6 enzymes may not respond adequately to tapentadol therapy. Due to reduced clearance, tapentadol should be administered with caution to people with moderate liver disease and not at all in people with severe liver disease.
Adverse effects
The most commonly reported side effects of tapentadol therapy are constipation, nausea, vomiting, headaches, loss of appetite, drowsiness, dizziness, itching, dry mouth, and sweating. Tapentadol has also been noted to induce feelings of relaxation and euphoria, and it may cause serious side effects such as respiratory depression, serotonin syndrome, addiction and substance dependence.Several studies have found that tapentadol causes less constipation and nausea compared with oxycodone. It has been noted that due to this, treatment adherence may be improved, with fewer people discontinuing tapentadol.
Tapentadol has been demonstrated to reduce the seizure threshold in patients. Tapentadol should be used cautiously in patients with a history of seizures, and in patients who are also taking one or more other drugs which have also been demonstrated to reduce the seizure threshold. Patients at high risk include those using other serotogenic and adrenergic medications, as well as patients with head trauma, metabolic disorders, and those in alcohol and/or drug withdrawals.
Tapentadol has been demonstrated to potentially produce hypotension, and should be used with caution in patients with low blood pressure, and patients who are taking one or more other medications which are also known to reduce blood pressure.
Addiction and abuse
The World Health Organization determined that there was little evidence to judge the abuse potential of tapentadol when it was introduced. Although early pre-clinical animal trials suggested that tapentadol had a reduced abuse liability compared to other opioid analgesics, the US Drug Enforcement Agency placed tapentadol into Schedule II, the same category as stronger opioids more commonly used recreationally, such as morphine, oxycodone, and fentanyl. Since these initial trials, however, evidence has shown that tapentadol is commonly abused, misused and diverted, that it is addictive, and that it poses a high risk of physical and/or mental dependence.Given that tapentadol is a highly selective full agonist of the μ-opioid receptor, and given that is not a pro-drug, with no ceiling effect, studies have found that it is significantly more abusable than tramadol, and similar to hydrocodone and other full agonists of the μ-opioid receptor in terms of addiction and dependence liability. Tapentadol is water soluble, which creates the potential for further abuse of the drug. There have been reports of users crushing, chewing, inhaling or injecting immediate-release tapentadol tablets, which can lead to respiratory depression, coma and death.
Dependence and withdrawal
The risk of experiencing severe withdrawal symptoms is high if a patient has become physically or mentally dependent and discontinues tapentadol abruptly. These symptoms can range from mild discomfort to more serious health issues, making abrupt cessation dangerous. When a person has been using tapentadol regularly for an extended period of time, tapering off the drug gradually is generally recommended. This approach allows the body to adjust to lower doses over time, minimizing the risk of withdrawal symptoms and ensuring a safer transition away from tapentadol. Gradual withdrawal helps to avoid the shock to the system that comes with abrupt discontinuation, ultimately making the process more manageable for a person who has developed a dependence.The symptoms of tapentadol withdrawal are typical of other opioids and can include anxiety, restlessness, fever or chills, joint pain, nausea or vomiting, loss of appetite, runny nose, stomach cramps, sweating, tremor, or insomnia.
However, tapentadol withdrawal symptoms may be more intense and prolonged when compared with more typical opioids such as codeine or oxycodone, in some respects, due to the fact that tapentadol acts also as norepinephrine reuptake inhibitor. People withdrawing from a tapentadol dependency may experience both typical opioid withdrawal symptoms, such as fever or nausea, along with symptoms associated more commonly with the discontinuation of drugs which block the reuptake of norepinephrine.
Interactions
Combination with selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, serotonin releasing agents, and serotonin receptor agonists may lead to potentially lethal serotonin syndrome. Combination with MAOIs may also result in an adrenergic storm. Use of tapentadol with alcohol or other central nervous system depressants such as benzodiazepines, barbiturates, nonbenzodiazepines, phenothiazines, gabapentinoids and other opiates may result in increased impairment, sedation, respiratory depression, and death.Tapentadol is partially metabolized by the hepatic enzymes CYP2C9, CYP2C19, and CYP2D6 so it innately has interactions with drugs that enhance or repress the activity/expression of one or more of these enzymes, as well as with substrates of these enzymes ; some enzyme mediators/substrates require dosing adjustments to one or both medications.
The combination of tapentadol and alcohol may result in increased plasma concentrations of tapentadol and produce respiratory depression to a degree greater than the sum of the two drugs when administered separately; patients should be cautioned against alcohol consumption when taking tapentadol as the combination may be fatal.
Tapentadol should be used with caution in patients who are taking one or more anticholinergic drugs, as this combination may result in urine retention.