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We observed that increasing the copy number of COR alone (e.g., 1:3:1) or together with T6ODM (e.g., 2:2:1) decreased morphine production while increasing neomorphine production, such that overall opiate production was similar but differed in the ratio of end products (Fig. For example, the control 1:1:1 strain produced 2.5 mg/L morphine and 3.7 mg/L neomorphine, a total of 6.2 mg/L end product opiates. 2010-8-25 ('To Eliminate the Opiate,'Vol. 87) In 1756, Jacob Frank and his followers were excommunicated by the rabbis. Antelman says the Sabbateans were behind the Reform, Liberal and Revolutionary movements of the Nineteenth century. They were also behind the Reform and Conservative movements in Judaism, including the 'Haskalah' i.e.

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Published online 2012 May 29. doi: 10.5114/wo.2012.28792

PMID: 23788866

This article has been cited by other articles in PMC.

Abstract

Opioid-induced bowel dysfunction (OIBD) comprises gastrointestinal symptoms such as constipation, anorexia, nausea, vomiting, gastro-oesophageal reflux, delayed digestion, abdominal pain, bloating, hard stool and incomplete evacuation that significantly deteriorate patients’ quality of life and compliance. Approximately one third of patients treated with opioids do not adhere to the opioid regimen or simply quit the treatment due to OIBD. Several strategies are undertaken to prevent or treat OIBD. Traditional oral laxatives are used but their effectiveness is limited and they display adverse effects. Other possibilities comprise opioid switch or changing the administration route. New therapies target opioid receptors in the gut that seem to be the main source of OIBD. One is a combination of an opioid and opioid antagonist (oxycodone/naloxone) in prolonged-release tablets, and another is a purely peripherally acting opioid receptor antagonist (methylnaltrexone) available in subcutaneous injections. The aim of this article is to review the pathomechanism and possible treatment strategies of OIBD.

Keywords: constipation, opioid analgesics, opioid-induced bowel dysfunction, opioid receptor antagonists, treatment

Introduction

Opioid analgesics are commonly and in most cases effectively used in chronic pain management of moderate to severe intensity. However, apart from analgesia opioids exert numerous adverse effects which may limit their effectiveness and patients’ compliance. These effects also appear in the gastrointestinal (GI) tract. Opioid-induced bowel dysfunction (OIBD) is a common adverse effects syndrome associated with the chronic use of opioid analgesics [1]. The OIBD comprises several symptoms including constipation, anorexia, nausea and vomiting, gastro-oesophageal reflux, delayed digestion, abdominal pain, flatulence, bloating, hard stool, straining during bowel movement and incomplete evacuation. In the case of long-term opioid therapy these symptoms may lead to the development of more serious complications such as bowel faecal impaction with overflow diarrhoea and faecal incontinence, pseudo-obstruction (which may cause anorexia, nausea and vomiting), disturbance of drug absorption, urine retention and urine incontinence. Opioid-induced bowel dysfunction may lead to inappropriate opioid dosing and in consequence insufficient analgesia. Opioid-induced bowel dysfunction also significantly deteriorates patients’ quality of life and compliance. Approximately one third of patients treated with opioid analgesics does not adhere to the prescribed opioid regimen or simply quit the treatment due to OIBD symptoms [].

Outline of pathomechanism of opioid-induced bowel dysfunction

The pathomechanism of OIBD is complex. It seems that the peripheral opioid effect on µ-opioid receptors in the gut wall plays the main role here, but the central effects are also important []. High density of µ-opioid receptors was found in neurons of the myenteric and submucosal plexus and immune cells in the lamina propria []. Opioid receptors (predominantly µ, also κ and δ) are located in the gut wall in the myenteric plexus and in the submucosal plexus. The former are responsible for GI motility and the latter for secretion. The µ-opioid receptors are activated in the wall of the stomach and the small and large intestine by both endogenous (e.g. enkephalins, endorphins and dynorphins) and exogenous (e.g. morphine, oxycodone, methadone) opioids and modify GI function. Activation of µ-opioid receptors inhibits excitatory and inhibitory neural pathways within the enteric nervous system that coordinates motility. Inhibition of excitatory neural pathways depresses peristaltic contractions. On the other hand, the blockade of inhibitory neural pathways increases GI muscle activity, and elevates resting muscle tone, spasm and non-propulsive motility patterns. These mechanisms are responsible for delayed gastric emptying and slowing the intestinal transit [].

Activation of opioid receptors in the submucosa inhibits water and electrolyte secretion into the gut lumen and increases fluid absorption from the intestine and blood flow in the gut wall []. Opioids increase activity in the sympathetic nervous system and thereby decrease the secretion. Endocrine cells located in the epithelium might play a role in regulating motor activity and secretion in the gut. Studies performed in mice indicate that peripheral µ-opioid receptors inhibit the transit independently of central µ-receptors []. Moreover, opioids increase ileocaecal and anal sphincter tone and impair the defecation reflex through reduced sensitivity to distension and increased internal anal sphincter tone [8]. Morphine administration leads to sphincter contraction and to decreased emptying of pancreatic juice and bile [9], which may cause delayed digestion. Anal sphincter dysfunction is an important factor in the sensation of anal blockage [, 11].

The central mechanism of opioid effects on the GI tract is supported by the results of experimental studies in which intracerebroventricular administration of morphine in rats inhibited gastrointestinal propulsion []. This effect was reversed by intracerebroventricular administration of naloxone [] and vagotomy []. Intrathecal administration of morphine reduced gastroduodenal motility and intramuscular morphine gave additional effects. It seems that both central and peripheral opioid effects play a role in opioid GI effects []. Indirect evidence of both central and peripheral components of opioid effects on bowel function may be the observed 50-60% response rate to the treatment of OIBD with methylnaltrexone (MNTX), which displays only a peripheral µ-opioid receptor antagonist effect in the treatment of patients with OIBD [, ]. Opioid-induced bowel dysfunction is the consequence of reduced GI motility, increased absorption of fluids from the gut and decreased epithelial secretion. The stool remains in the gut lumen for a longer time; therefore, more fluid is reabsorbed and the stool becomes hard and dry. The above effects are also associated with opioids’ inhibition of secretomotor neurons in the epithelium of the gut [].

Possible interventions in opioid-induced bowel dysfunction

Oral and rectal laxatives

General measures to be taken in patients with OIBD and constipation include the assessment and application of prophylactic measures matched to the patient's general condition [19]. Change of diet (increased food and fluid intake), more physical activity, sitting position during bowel movement and privacy during the defecation process are recommended []. Patients treated with opioids should be considered for prokinetic administration (metoclopramide, domperidone, itopride, prucalopride) [, ]. Any reversible causes such as hypercalcaemia should also be treated. Discontinuing or decreasing doses of drugs that may be responsible for development of constipation (e.g. tricyclics, neuroleptics, anticholinergics) should also be considered. Patients and families should be educated about the ways of prevention and treatment of OIBD [9].

In the majority of patients with OIBD, laxatives need to be administered. The general recommendation is to combine oral administration of osmotic agents (usually lactulose or macrogol) which have an osmotic effect in the colon [] with stimulants activating neurons in the myenteric and submucosal plexus in the colon and reducing absorption of water and electrolytes from the intraluminal contents: anthracenes (senna), polyphenolics (bisacodyl) or sodium picosulphate []. However, these drugs display limited efficacy in patients suffering from OIBD; moreover, they may cause several adverse effects and must be administered on a regular basis []. Other groups of laxatives are faecal lubricants (liquid paraffin), and stool softeners (surfactants: sodium docusate); however, they are usually ineffective when administered alone [24]. The use of bulk-forming agents such as fibre, bran, methylcellulose and psyllium seeds has a limited role in patients with advanced disease as enough fluids (at least 2 l per day) should be co-administered to avoid intestinal obstruction through viscous mass development in the bowel [25–]. Castor oil is not recommended due to its sudden stimulating effect on bowel motility and the risk of developing strong abdominal cramps [28]. If the oral laxatives are found to be ineffective, rectal treatment is considered. The dose of oral laxatives should be titrated to achieve bowel movement unless adverse effects appear. If there is more than 3 days since last bowel action rectal measures (suppositories e.g. bisacodyl 10 mg and glycerine 4 g or a micro-enema) may be added to the oral regimen. Rectal measures may be administered alone in those patients who are unable to swallow oral laxatives and suffer from nausea and vomiting; they might be useful in patients with neurological deficits e.g. spinal cord compression [29].

Rectal laxatives comprise suppositories increasing intestinal motility through direct stimulation of the nerve endings in the myenteric ganglia of the colon, thus inducing peristalsis (bisacodyl), or using osmotic drugs (glycerol) that act by irritation of the mucosa in the rectum, which also enhances the motility of the colon and subsequently triggers the defecation reflex. The next step to be taken after these agents are found to be ineffective is rectal enema with normal saline (100-200 ml) or phosphates (120-150 ml).

In case of faecal impaction the management depends on the severity of symptoms (rectal pain, abdominal colicky pain, protruding hard faeces and faecal leakage). If the symptoms are not severe in case of soft faeces stimulating agents such as senna or bisacodyl 10-20 mg once daily orally or rectally may be administered until bowel movement is achieved. If hard faeces are present glycerol suppositories or osmotic enemas may be administered. Enema of arachis oil (130 ml) or of decussate sodium (100 ml) may be appropriate. Macrogols reduce the need for digital disimpaction. However, in cases of severe symptoms, when neither oral nor rectal treatment gives a desired effect and faecal impaction is not relieved causing significant distress, it may be necessary to perform digital stool evacuation [30]. As the procedure is painful and distressing it should be performed with caution. Patients should be sedated with midazolam; for effective pain relief systemic opioids should be given along with topical administration of local anaesthetics.

Opioid switch

The possibility of opioid switch in the treatment of OIBD should be considered as one of the available treatment options. Opioids which seem to be more often associated with constipation are codeine and dihydrocodeine (opioids for mild to moderate pain), morphine, oxycodone and hydromorphone (opioids for moderate to severe pain). These opioids may be switched to other opioids belonging to the same group but having less constipating effect: codeine or dihydrocodeine may be switched to tramadol; morphine, oxycodone or hydromorphone to transdermal opioids (fentanyl, buprenorphine) or to methadone [, 32]. The most evidence supporting the benefits of the opioid switch as regards constipation relief was accumulated for the morphine to transdermal fentanyl switch [–]. Tassinari et al. performed a meta-analysis comparing 3 randomized trials of transdermal opioids (fentanyl and buprenorphine) with slow-release oral morphine in the treatment of moderate-severe cancer pain in 425 patients. A significant difference in favour of transdermal opioids was observed for constipation (OR = 0.38; p < 0.001) and patients’ preference (OR = 0.43; p = 0.014, in the three trials investigating transdermal fentanyl) [].

However, in contrast to clinical studies, observational surveys that reflect a more real life conditions do not provide evidence for advantages of transdermal fentanyl over other opioid analgesics with respect to bowel function. In a large (2324 patients), multicentre, observational study, morphine (89.6%) and transdermal fentanyl (74.1%) more often induced OIBD in comparison to oxycodone and transdermal buprenorphine (59.3% each). Age over 70, cancer-related pain and transdermal fentanyl were the risk factors for the development of OIBD symptoms []. In another large study 4040 patients were analysed with respect to the level of constipation. A similar constipation intensity was found among patients treated with controlled-release (CR) morphine, CR oxycodone and transdermal fentanyl; no difference between cancer and non-cancer patients was found [].

In some studies similar or less intense constipating effect was observed in patients treated with transdermal buprenorphine (1.2%) in comparison to CR morphine (6.7%) [39]. Retrospective studies highlight the benefits of less intense constipation after switch from morphine to methadone; however these studies were performed in a small number of patients [, ]. A prospective study demonstrated constipation relief in 80% of treated patients after the switch from morphine to methadone []. Some studies point to the benefits of administering tramadol rather than small morphine doses [–45] or dihydrocodeine [46] with respect to the constipation intensity. In contrast to the above-mentioned trials stand the results of an open study performed in 174 patients with cancer pain No differences were found in constipation that developed in patients treated with transdermal opioids (buprenorphine and fentanyl) and oral CR hydromorphone. A possible explanation of this observation could be higher doses of amitriptyline administered to patients treated with buprenorphine and fentanyl and higher activity of patients treated with hydromorphone. A possible explanation of this observation could be higher doses of amitryptyline administered to patients treated with buprenorphine and fentanyl and higher activity of patients treated with hydromorphone. No differences in the consumption of laxatives or in the intensity of nausea were found between the patient groups. The patients treated with hydromorphone experienced more intense vomiting than those treated with transdermal opioids. The cause of vomiting apart from the opioid administered could be attributed to the primary tumour location, as patients treated with hydromorphone more often had an abdominal site diagnosed [].

Targeted treatment of opioid-induced bowel dysfunction

Few clinical studies have compared the efficacy of different laxatives [48], with controlled studies lacking []. However, traditional laxatives do not target the cause of OIBD, which is predominantly associated with opioid analgesics binding and activating µ-opioid receptors in the GI tract []. If the oral laxatives are found to be ineffective, rectal measures are usually introduced. Another approach involves treatment directed at the cause of OIBD. This method involves either using a combination of opioid analgesics with opioid receptor antagonists, which act both centrally and peripherally, or administering opioid receptor antagonists, which act exclusively peripherally. An important advantage of this approach is the fact that it is targeted treatment of OIBD and that it may be combined with oral laxatives, if necessary; finally, this approach may eliminate the need for rectal measures, which are poorly tolerated by patients.

Apart from opioid antagonists with exclusively peripheral effects, opioid receptor antagonists which also have a central mode of action should be listed: naloxone, naltrexone and nalmefene. The majority of studies performed so far refer to the use of an immediate-release formulation of oral naloxone (IR naloxone). In spite of high IR naloxone efficacy in the treatment of OIBD, in some patients opioid withdrawal symptoms and attenuation of analgesia were observed, rendering IR naloxone less useful when administered alone [–]. Similar results were obtained in the studies on nalmefene [] and nalmefene glucuronide [].

Combined opioid receptor agonists with antagonists

One method to decrease the frequency of constipation in patients requiring strong opioids is to use a formulation composed of an opioid and an opioid receptor antagonist. The formulation combining oxycodone and naloxone is available in the form of prolonged-release (PR) tablets containing both drugs in the ratio of 2 : 1 (PR oxycodone/PR naloxone 5 mg/2.5 mg, 10 mg/5 mg, 20 mg/10 mg, 40 mg/20 mg) []. The optimal 2 : 1 ratio of PR oxycodone/PR naloxone tablets was demonstrated in a phase II study rendering effective analgesia and improvement in bowel function with good treatment toleration in patients with severe chronic pain [] PR oxycodone/PR naloxone is registered for the indication of severe pain which may only be successfully treated with opioid analgesics; naloxone counteracts the development of OIBD through inhibition of oxycodone's effect on opioid receptors in the gut wall [58]. The starting PR oxycodone/PR naloxone doses in opioid-naive patients is 5 mg/2.5 mg b.i.d. Patients unsuccessfully treated with opioids for mild to moderate pain (tramadol, codeine, dihydrocodeine) may start with the dose of 10 mg/5 mg b.i.d. When rotating from other opioids for moderate to severe pain to PR oxycodone/PR naloxone, the starting dose is established individually depending on the amount of previously administered opioid, analgesia and adverse effects. The maximal daily dose of PR oxycodone/PR naloxone recommended equals is 40 mg/20 mg twice daily. However, in some studies higher daily doses up to 120 mg/60 mg were explored [].

Following oral administration, oxycodone displays high bioavailability (60-87%) [] and provides effective analgesia [61]. Naloxone exhibits low bioavailability after oral administration (< 2%) and undergoes extensive first-pass metabolism in the liver with the formation of naloxone-3-glucuronide []. The analgesic effect is not reversed by naloxone and no symptoms of opioid withdrawal are observed []. The effect of orally administered naloxone depends on normal liver function, so any hepatic impairment should be carefully considered; in patients suffering from liver failure, PR oxycodone/PR naloxone administration is not recommended. There is a clinically observed difference between the administration of IR and PR formulations of naloxone. IR naloxone in some patients may attenuate analgesia or induce opioid withdrawal symptoms []. The PR naloxone formulation prevents saturation of the hepatic enzyme system responsible for naloxone metabolism and reduces the risk of opioid antagonism in the central nervous system [].

PR oxycodone/PR naloxone provides similar analgesic efficacy to oxycodone [] with improvement in bowel function expressed by better results of the Bowel Function Index (BFI) [63] and the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaires and more frequent spontaneous bowel movements: 62.1% vs. 23.3% [] and 65% vs. 39%, respectively []. Lower consumption of laxatives during treatment with PR oxycodone/PR naloxone in comparison to PR oxycodone therapy was also observed [63–]. Long-term analysis (over a period of up to 52 weeks of therapy) of two phase III studies [63, ] in patients with chronic pain demonstrated that the treatment with PR oxycodone/PR naloxone in daily doses up to 80 mg/40 mg was effective and safe []. In a large, observational study PR oxycodone/PR naloxone (in the daily dose range of 20 mg/10 mg to 40 mg/20 mg) was an effective analgesic and improved bowel function measured by BFI and quality of life over the period of 4 weeks of the treatment in 1488 patients with severe neuropathic non-malignant pain [].

A randomized, double-blind study with the use of higher PR oxycodone/PR naloxone doses (converted from oxycodone 60–80 mg per day and allowed to titrate the dose up to 120 mg/day) demonstrated significant improvement in bowel function assessed by BFI (p < 0.0001), increase in spontaneous bowel movements per week (median 3.0 vs. 1.0) and lower laxative intake in patients treated with PR oxycodone/PR naloxone in comparison to PR oxycodone administered alone []. Adverse effects of PR oxycodone/PR naloxone and PR oxycodone are similar; the frequency of diarrhoea is slightly higher in PR oxycodone/PR naloxone in comparison to PR oxycodone administered alone (5.2% vs. 2.6%) []. However, PR oxycodone/PR naloxone less frequently induces nausea (6.3% vs. 10.5%), vomiting (1.3% vs. 4.3%), abdominal pain (1.3%, vs. 4.3%) and dyspepsia (0.6% vs. 2.5%) in comparison to PR oxycodone administered alone []. These differences might be explained by naloxone's antagonist effect on gastric and gut opioid receptors and in consequence naloxone's prokinetic properties [].

Recently the results of a randomized, double-blind, multicentre study, which assessed PR oxycodone/PR naloxone efficacy and tolerance in comparison to PR oxycodone in patients with moderate to severe cancer pain and their impact on constipation, have been published. A total of 185 patients were randomized to receive up to 120 mg per day of PR oxycodone/PR naloxone or PR oxycodone over 4 weeks. After 4 weeks mean BFI and PAC-SYM scores were significantly lower with PR oxycodone/PR naloxone and the mean total laxative intake was 20% lower in this patient group compared to PR oxycodone. The mean BPI-SF (Brief Pain Inventory-Short Form) scores were similar for both treatments and the consumption of rescue analgesics was low and comparable between the two patient groups. Quality of life (assessed by the EORTC QLQ-C30 and the EuroQoL) results showed better scores with respect to constipation-related symptoms in the group treated with PR oxycodone/PR naloxone. Adverse effects were similar in both patient groups. Specifically, no difference in scores of the modified Subjective Opiate Withdrawal Scale was found between the two patient groups. The results suggest that PR oxycodone/PR naloxone in doses up to 120 mg/60 mg per day may provide effective analgesia and improve bowel function [].

In an open, uncontrolled study 26 patients with advanced cancer received different opioids due to severe pain. The former opioid treatment was switched to PR oxycodone/PR naloxone at a maximum daily dose of 40 mg/20 mg, administered for a period of 14 days. Bowel function was assessed by BFI, the Bristol Stool Form Scale (BSFS) and the Patient Global Impression of Change Scale (PGIC). In 21 patients constipation improved as measured by BFI, BSFS and PGIC, while adequate analgesia was provided. The most frequent adverse effects were nausea in 9 patients and abdominal pain in 5 patients. Two patients experienced diarrhoea. Two patients experienced diarrhoea. Opioid withdrawal symptoms were not observed In a recent study the cost-effectiveness and quality of life were compared for PR oxycodone/PR naloxone and PR oxycodone in patients with moderate-to-severe non-malignant pain and opioid-induced constipation. Although the direct treatment cost of PR oxycodone/PR naloxone compared to oxycodone PR was slightly higher, when analysing constipation treatment costs and benefits of PR oxycodone/PR naloxone in terms of improved quality-adjusted life-years, PR oxycodone/PR naloxone was a cost-effective option in the UK []. However, in contrast to PR oxycodone, PR oxycodone/PR naloxone tablets are not reimbursed, and thus they are of limited availability for patients with chronic cancer and non-cancer pain in Poland [].

The contraindications for PR oxycodone/PR naloxone comprise bowel obstruction, acute abdominal conditions, diarrhoea and allergy to the drug. It should be noted that PR oxycodone/PR naloxone studies were performed mainly in patients with chronic, non-malignant pain [63–, , ]. PR oxycodone/PR naloxone is available in several European countries including Poland. One pack contains 60 PR oxycodone/PR naloxone tablets of 5 mg/2.5 mg, 10 mg/5 mg, 20 mg/10 mg, 40 mg/20 mg strength. In a recent study a cost-effectiveness and quality of life was compared for PR oxycodone/PR naloxone and PR oxycodone in patients with moderate-to-severe non-malignant pain and opioid-induced constipation. Although PR oxycodone/PR naloxone direct treatment cost compared to oxycodone PR was slightly higher, when analysing constipation treatment costs and benefits of PR oxycodone/PR naloxone in terms of improved quality-adjusted life-year PR oxycodone/PR naloxone was a cost-effective option in the UK []. However, in contrast to PR oxycodone, PR oxycodone/PR naloxone tablets are not reimbursed of and thus available to a limited extent for patients with chronic cancer and non-cancer pain in Poland.

Purely peripherally acting opioid receptor antagonists

Methylnaltrexone (MNTX) is a derivative of naltrexone, a peripheral µ-opioid receptor antagonist which does not cross the blood-brain barrier []. As MNTX has low oral bioavailability it is administered subcutaneously or intravenously and is rapidly absorbed []. However, studies in healthy volunteers demonstrated the efficacy of oral MNTX in the prevention of delay in oro-caecal transit time after intravenous morphine administration []. The MNTX plasma half-life equals 105 to 140 minutes, protein binding is approximately 11-15%. Methylnaltrexone is excreted unchanged in 50% to the urine. Methylnaltrexone is a weak CYP2D6 inhibitor with no significant drug interactions [77]. Methylnaltrexone is used in the treatment of opioid-induced constipation in advanced diseases in adult patients when constipation does not respond to conventional oral laxatives. The drug is available in ampoules containing 12 mg MNTX bromide in the volume of 0.6 ml and is applied via subcutaneous injections. A single MNTX dose equals 8 mg in patients with body weight 38-61 kg or 12 mg if the body mass is 62-114 kg [].

Patients falling outside of this range should receive a dose of 0.15 mg/kg. In patients with mild to moderate hepatic or renal impairment no dose adjustment is necessary. However, in patients with severe renal failure (creatinine clearance < 30 ml/min) the MNTX dose should be reduced by one-half []. A bowel movement within 4 h after MNTX injection is observed in 50-60% patients (the median time to bowel movement after the drug administration is 30 minutes). If no therapeutic effect is observed, the injection may be repeated every other day. Methylnaltrexone is recommended for the treatment of OIBD in adults with advanced illness. In Poland MNTX is available in ampoules (12 mg) and the drug is not reimbursed. Methylnaltrexone adverse effects comprise abdominal pain (28% of patients), flatulence (13%), nausea (11%), dizziness (7%) and diarrhoea (5%) which usually have mild to moderate intensity and are associated with the defecation act []. However, the administration of MNTX may be associated with an increased risk of gastrointestinal perforation in patients with diseases that decrease gut wall integrity (cancer, peptic ulceration and Ogilvie's syndrome) or concomitant medications (NSAIDs, bevacizumab). The majority of GI perforation cases indicate different possible locations (duodenum, small and large bowel). A possible contributing factor might be the prokinetic effect of MNTX. It is not known if the dose and duration of the treatment with MNTX relate to this complication []. As MNTX does not cross the blood-brain barrier, the attenuation of analgesia or opioid withdrawal symptoms are not observed []. The use of MNTX is contraindicated in patients with mechanical bowel obstruction, in acute abdominal conditions and in case of allergy to the drug. Methylnaltrexone may be used in palliative care patients with OIBD not amenable to the treatment with oral laxatives. Several clinical studies have demonstrated the effectiveness of MNTX in patients with advanced diseases and with OIBD [, , , , –].

In a systematic review on the use of laxatives in palliative care patients no differences were found between different regimens through analysis of 4 randomised controlled trials. The only exception was a combination of lactulose with senna that was superior to dantron combined with poloxamer. Overall limited efficacy of traditional laxatives was demonstrated, with a lack of randomised controlled trials []. However, in a recent controlled, open-label study polyethylene glycol and sodium picosulphate were more effective than lactulose in opioid-induced constipation in cancer pain patients [].

Two systematic reviews assessed the efficacy and safety of peripherally active opioid receptor antagonists in the treatment of OIBD in 2352 patients [] and in 2871 patients [] who took part in randomized, controlled trials of µ-opioid receptor antagonists. Alvimopan (8 and 9 studies respectively), MNTX (6 trials), naloxone (7 studies) and nalbuphine (1 study) were studied. MNTX and alvimopan which is not registered for the treatment of OIBD in patients with chronic diseases [] were better than placebo in reversing opioid-induced increased gastrointestinal time and constipation. Alvimopan was safe and effective in the treatment of postoperative ileus []. The incidence of adverse events was similar to placebo and of mild to moderate intensity. Effects of naloxone and nalbuphine were not demonstrated. Long-term efficacy and safety of opioid antagonists were not clearly established. A recent systematic review confirmed MNTX efficacy in opioid-induced constipation but its long-term efficacy could not be clearly established. The efficacy and differences among traditional laxatives in palliative care patients with constipation could not be established due to limited number of randomized studies [].

In conclusion: OIBD in patients diagnosed with chronic diseases is a clinical problem that is difficult and often underestimated by medical staff. This is an important issue especially in the case of patients regularly receiving opioids for pain or other indications. Thanks to newly introduced drugs that target the cause of OIBD, a more effective therapy is available. The experience with MNTX and PR oxycodone/PR naloxone in patients suffering from OIBD is promising. Benefits were demonstrated from the use of a new prokinetic agent prucalopride in non-cancer patients suffering from OIBD. However, further clinical studies should be undertaken to develop more effective guidelines for the management of OIBD and to establish more precisely the role of opioid receptor antagonists in the treatment of OIBD. The role of opioid receptor antagonists as potential antiemetic and prokinetic agents should be further explored, as suggested by the results of experimental studies in animals. High costs of new therapies should be carefully considered, although overall resources may also be saved on traditional laxative use. The most important advantage of targeted therapies is the decrease of patients’ suffering associated with OIBD and substantial reduction in the need to perform invasive rectal procedures and in consequence improvement in patients’ quality of life.

References

1. Ueberral MA, Mueller-Schwefe G. Opioid-induced constipation – a frequent and distressing side effect in daily practice affecting oral and transdermal opioid applications. Eur J Pain. 2006;10:S172.[Google Scholar]

2. Bell TJ, Panchal SJ, Miaskowski C, Bolge SC, Milanova T, Williamson R. The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1) Pain Med. 2009;10:35–42. [PubMed] [Google Scholar]

3. Reimer K, Hopp M, Zenz M, et al. Meeting the challenges of opioid-induced constipation in chronic pain management – a novel approach. Pharmacology. 2009;83:10–7. [PubMed] [Google Scholar]

4. Davis MP. The opioid bowel syndrome: a review of pathophysiology and treatment. J Opioid Manage. 2005;1:153–61. [PubMed] [Google Scholar]

5. Holzer P. Treatment of opioid-induced gut dysfunction. Expert Opin Investig Drugs. 2007;16:181–94. [PubMed] [Google Scholar]

6. Holzer P. Opioids and opioid receptors in the myenteric nervous system: from a problem in opioid analgesia to a possible new prokinetic therapy in humans. Neurosci Lett. 2004;361:192–5. [PubMed] [Google Scholar]

7. Shook JE, Pelton JT, Hruby VJ, Burks TF. Peptide opioid antagonist separates peripheral and central opioid antitransit effects. J Pharmacol Exp Ther. 1987;243:492–500. [PubMed] [Google Scholar]

8. Sykes NP. Constipation and diarrhoea. In: Doyle D, Hanks G, Cherny N, Calman K, editors. Oxford textbook of palliative medicine. Oxford: Oxford University Press; 2004. pp. 483–96. [Google Scholar]

9. Basta S, Anderson DL. Mechanisms and management of constipation in the cancer patient. J Pharmaceut Care Pain Symptom Control. 1998;6:21–40.[Google Scholar]

10. Potter J, Wagg A. Management of bowel problems in older people: an update. Clin Med. 2005;5:289–95.[PMC free article] [PubMed] [Google Scholar]

11. Mumford SP. Can high fibre diets improve the bowel function in patients on radiotherapy ward? In: Twycross RG, Lack SA, editors. Control of alimentary symptoms in far advanced cancer. Edinburgh: Churchill Livingstone; 1986. p. 183. [Google Scholar]

12. Porecca F, Cowan A, Raffa RB, Tallarida RJ. Ketazocines and morphine: effects on gastrointestinal transit after central and peripheral administration. Life Sci. 1983;32:1785–90. [PubMed] [Google Scholar]

13. Parolado D, Sala M, Gori E. Effect of intracerebroventricular administration of morphine upon intestinal motility in rat and its antagonism with naloxone. Eur J Pharmacol. 1977;46:329–38. [PubMed] [Google Scholar]

14. Stewart JJ, Weisbrodt NW, Burks TF. Central and peripheral action of morphine on intestinal transit. J Pharmacol Exp Ther. 1978;205:547–55. [PubMed] [Google Scholar]

15. Thörn SE, Wattwil M, Lindberg G, Säwe J. Systemic and central effects of morphine on gastrointestinal motility. Acta Anaesthesiol Scand. 1996;40:177–86. [PubMed] [Google Scholar]

16. Thomas J, Karver S, Cooney GA, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med. 2008;358:2332–43. [PubMed] [Google Scholar]

17. Slatkin N, Thomas J, Lipman AG, et al. Methylnaltrexone for Treatment of opioid-induced constipation in advanced illness patients. J Support Oncol. 2009;7:39–46. [PubMed] [Google Scholar]

18. Wood JD, Galligan JJ. Function of opioids in the enteric nervous system. Neurogastroenterol Motil. 2004;16(suppl. 2):181–94. [PubMed] [Google Scholar]

19. Benson AB, Stein R. Diarrhoea and constipation: supportive oncology management. In: Ettinger DS, editor. Supportive Care in Cancer Therapy. New York: Humana Press; 2009. pp. 213–25. [Google Scholar]

20. Klaschik E, Nauck F, Ostgathe C. Constipation – modern laxative therapy. Support Care Cancer. 2003;11:679–85. [PubMed] [Google Scholar]

21. Bruera E, Brenneis C, Michand M, MacDonald N. Continuous subcutaneous infusion of metoclopramide for treatment of narcotic bowel syndrome. Cancer Treat Rep. 1987;71:1121–2. [PubMed] [Google Scholar]

22. Sloots CE, Rykx A, Cools M, Kerstens R, De Pauw M. Efficacy and safety of prucalopride in patients with chronic noncancer pain suffering from opioid-induced constipation. Dig Dis Sci. 2010;55:2912–21.[PMC free article] [PubMed] [Google Scholar]

23. Larkin PJ, Sykes NP, Centeno C, et al. The management of constipation in palliative care: clinical practice recommendations. Palliat Med. 2008;22:796–807. [PubMed] [Google Scholar]

24. Leppert W. Postępowanie u chorych z objawami ze strony przewodu pokarmowego w medycynie paliatywnej. Terapia. 2011;19:59–66.[Google Scholar]

25. Mancini I, Bruera E. Constipation. In: Ripamonti C, Bruera E, editors. Gastrointestinal symptoms in advanced cancer patients. Oxford: Oxford University Press; 2004. pp. 193–206. [Google Scholar]

26. Sykes NP. Current approaches to the management of constipation. Cancer Surv. 1994;21:137–46. [PubMed] [Google Scholar]

27. Mancini I, Bruera E. Constipation in advanced cancer patients. Support Care Cancer. 1998;6:356–64. [PubMed] [Google Scholar]

28. Leppert W, Dzierżanowski T, Ciałkowska-Rysz A, Jarosz J, Pyszkow-ska J, Stachowiak A. Postępowanie u chorych z zaparciem stolca w medycynie paliatywnej – zalecenia Grupy Roboczej Ekspertów Polskiego Towarzystwa Medycyny Paliatywnej. Med Paliat. 2009;1:1–10.[Google Scholar]

29. Daeninck P, Crawford G. Laxatives. In: Walsh D, Caraceni AT, Fainsinger R, Foley K, Glare P, Goh C, Lloyd-Williams M, Núńez Olarte J, Radbruch L, editors. Palliative Medicine. Philadelphia: Elsevier; 2009. pp. 767–70. [Google Scholar]

30. Twycross R, Wilcock A, Toller CS. Constipation. In: Twycross R, Wilcock A, Toller CS, editors. Symptom Management in Advanced Cancer. Nottingham: Palliativedrugs.com Ltd; 2009. pp. 111–20. [Google Scholar]

31. Mercadante S, Bruera E. Opioid switching: a systematic and critical review. Cancer Treat Rev. 2006;32:304–15. [PubMed] [Google Scholar]

32. Leppert W. Postępy w leczeniu farmakologicznym bólu nowotworowego analgetykami opioidowymi. Wspolczesna Onkol. 2009;13:66–73.[Google Scholar]

33. Ahmedzai S, Brooks D. Transdermal fentanyl versus sustained-release oral morphine in cancer pain: preference, efficacy and quality of life. J Pain Symptom Manage. 1997;13:254–61. [PubMed] [Google Scholar]

34. Haazen L, Noorduin H, Megens A, Meert T. The constipation-inducing potential of morphine and transdermal fentanyl. Eur J Pain. 1999;3(Suppl. A):9–15.[Google Scholar]

35. Hunt R, Fazekas B, Thorne D, Brooksbank M. A comparison of subcutaneous morphine and fentanyl in hospice cancer patients. J Pain Symptom Manage. 1999;18:111–9. [PubMed] [Google Scholar]

36. Tassinari D, Sartori S, Tamburini E, Scarpi E, Raffaeli W, Tombesi P, Maltoni M. Adverse effects of transdermal opiates treating moderate-severe cancer pain in comparison to long-acting morphine: A meta-analysis and systematic review of the literature. J Palliat Med. 2008;11:492–502. [PubMed] [Google Scholar]

37. Rosti G, Gatti A, Costantini A, Sabato AF, Zucco F. Opioid-related bowel dysfunction: prevalence and identification of predictive factors in a large sample of Italian patients on chronic treatment. Eur Rev Med Pharmacol Sci. 2010;14:1045–50. [PubMed] [Google Scholar]

38. Weschules DJ, Bain KT, Reifsnyder J, McMath JA, Kupperman DE, Gallagher RM, Hauck WW, Knowlton CH. Toward evidence-based prescribing at end of life: a comparative analysis of sustained-release morphine, oxycodone, and transdermal fentanyl, with pain, constipation, and caregiver interaction outcomes in hospice patients. Pain Med. 2006;7:320–9. [PubMed] [Google Scholar]

39. Bach V, Kamp-Jensen M, Jensen NH, Eriksen J. Buprenorphine and sustained release oral morphine – effect and side-effects in chronic use. Pain Clin. 1991;4:87–93.[Google Scholar]

40. Mancini IL, Hanson J, Neumann CM, Bruera E. Opioid type and other clinical predictors of laxative dose in advanced cancer patients: a retrospective study. J Palliat Med. 2000;3:49–56. [PubMed] [Google Scholar]

41. Daeninck PJ, Bruera E. Reduction in constipation and laxative requirements following opioid rotation to methadone: a report of four cases. J Pain Symptom Manage. 1999;18:303–9. [PubMed] [Google Scholar]

42. Mercadante S, Casuccio A, Fulfaro F, Groff L, Boffi R, Villari P, Gebbia V, Ripamonti C. Switching from morphine to methadone to improve analgesia and tolerability in cancer patients: a prospective study. J Clin Oncol. 2001;19:2898–904. [PubMed] [Google Scholar]

43. Grond S, Radbruch L, Meuser T, Loick G, Sabatowski R, Lehmann KA. High-dose tramadol in comparison to low-dose morphine for cancer pain relief. J Pain Symptom Manage. 1999;18:174–9. [PubMed] [Google Scholar]

44. Duggan AK. The cost of constipation in morphine patients and the economic possibilities with tramadol. Br J Med Econom. 1995;9:21–9.[Google Scholar]

45. Leppert W. Analgesic efficacy and side effects of oral tramadol and morphine administered orally in the treatment of cancer pain. Nowo-twory. 2001;51:257–66.[Google Scholar]

46. Leppert W, Majkowicz M. Ocena analgezji i objawow niepozadanych tramadolu i dihydrokodeiny o kontrolowanym uwalnianiu u chorych z bolem nowotworowym – na podstawie zmodyfikowanej skali ESAS. (Assessment of analgesia and adverse effects of controlled release tramadol and dihydrocodeine in patients with cancer pain – based on a modified ESAS) Wspolczesna Onkol. 2008;12:246–54.[Google Scholar]

47. Wirz S, Witmmann M, Schenk M, et al. Gastrointestinal symptoms under opioid therapy: A prospective comparison of oral sustained-release hydromorphone, transdermal fentanyl, and transdermal buprenorphine. Eur J Pain. 2009;13:737–43. [PubMed] [Google Scholar]

48. Sykes NP. A clinical comparison of laxatives in a hospice. Palliat Med. 1991;5:307–14.[Google Scholar]

49. Miles CL, Fellowes D, Goodman ML, Wilkinson S. Laxatives for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2006;4:CD003448. [PubMed] [Google Scholar]

50. Holzer P, Ahmedzai SH, Niederle N, Leyendecker P, Hopp M, Bosse B, Spohr I, Reimer K. Opioid-induced bowel dysfunction in cancer-related pain: causes, consequences, and a novel approach for its management. J Opioid Manage. 2009;5:145–95. [PubMed] [Google Scholar]

51. Sykes NP. An investigation of the ability of oral naloxone to correct opioid-related constipation in patients with advanced cancer. Palliat Med. 1996;10:135–44. [PubMed] [Google Scholar]

52. Liu M, Wittbrodt E. Low-dose oral naloxone reverses opioid-induced constipation and analgesia. J Pain Symptom Manage. 2002;23:48–53. [PubMed] [Google Scholar]

53. Meissner W, Schimdt U, Hartmann M, et al. Oral naloxone reverses opioid-induced constipation. Pain. 2000;84:105–9. [PubMed] [Google Scholar]

54. Glass PS, Jhaveri RM, Smith LR. Comparison of potency and duration of action of nalmefene and naloxone. Anesth Analg. 1994;78:536–41. [PubMed] [Google Scholar]

55. Cheskin LJ, Chami TN, Johnson RE, et al. Assessment of nalmefene glucuronide as a selective gut opioid antagonist. Drug Alcohol Depend. 1995;39:151–4. [PubMed] [Google Scholar]

56. Nadstawek J, Leyendecker P, Hopp M, Ruckes C, Wirz S, Fleischer W, Reimer K. Patient assessment of a novel therapeutic approach for the treatment of severe, chronic pain. Int J Clin Pract. 2008;62:1159–67.[PMC free article] [PubMed] [Google Scholar]

57. Leyendecker P, Hopp M, Bosse B, et al. Bowel function index (BFI), a new validated questionnaire for assessing opioid induced constipation; Proceedings of the IASP Congress on Pain; 2008. [Google Scholar]

58. Anonim. Oxycodone/naloxone prolonged release tablets, questions and answers; 2009. Feb, Paineurope supplement. [Google Scholar]

59. Ahmedzai SH, Nauck F, Bar-Sela G, Bosse B, Leyendecker P, Hopp M. A randomized, double-blind, active-controlled, double-dummy, parallel-group study to determine the safety and efficacy of oxycodone/naloxone prolonged-release tablets in patients with moderate/severe, chronic cancer pain. Palliat Med. 2012;26:50–60.[PMC free article] [PubMed] [Google Scholar]

60. Kalso E. Oxycodone. J Pain Symptom Manage. 2005;29(5S):S47–56. [PubMed] [Google Scholar]

61. Biancofiore G. Oxycodone controlled release in cancer pain management. Therap Clinic Risk Manage. 2006;2:228–34.[Google Scholar]

62. Fishman J, Roffwarg H, Helman L. Disposition of naloxone-7,8-3H in normal and narcotic-dependent men. J Pharmacol Exp Ther. 1973;187:575–80. [PubMed] [Google Scholar]

63. Müller-Lissner S, Leyendecker P, Hopp M, Ruckes C, Fleischer W, Reimer K. Oral prolonged release (PR) oxycodone/naloxone combination reduces opioid-induced bowel dysfunction (OIBD) in patients with severe chronic pain. Eur J Pain. 2007;11(S82) abstract 189. [Google Scholar]

64. Vondrackova D, Leyendecker P, Meissner W, et al. Analgesic efficacy and safety of oxycodone in combination with naloxone as prolonged release tablets in patients with moderate to severe chronic pain. J Pain. 2008;9:1144–54. [PubMed] [Google Scholar]

65. Simpson K, Leyendecker P, Hopp M, et al. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe noncancer pain. Curr Med Res Opin. 2008;24:3503–12. [PubMed] [Google Scholar]

66. Sandner-Kiesling A, Leyendecker P, Hopp M, et al. Long-term efficacy and safety of combined prolonged-release oxycodone and naloxone in the management of non-cancer chronic pain. Int J Clin Pract. 2010;64:763–74.[PMC free article] [PubMed] [Google Scholar]

67. Hermanns K, Junker U, Nolte T. Prolonged-release oxycodone/naloxone in the treatment of neuropathic pain – results from a large observational study. Exp Opin Pharmacother. 2012;13:299–311. [PubMed] [Google Scholar]

68. Löwenstein O, Leyendecker P, Hopp M, et al. Combined prolonged release oxycodone and naloxone improves bowel function in patients receiving opioids for moderate-to-severe non-malignant chronic pain: a randomized controlled trial. Expert Opin Pharmacother. 2009;10:531–53. [PubMed] [Google Scholar]

69. Schang JC, Devroede G. Beneficial effects of naloxone in a patient with intestinal pseudoobstruction. Am J Gastroenterol. 1985;80:407–11. [PubMed] [Google Scholar]

70. Clemens KE, Quednau I, Klaschik E. Bowel function during pain therapy with oxycodone/naloxone prolonged-release tablets in patients with advanced cancer. Int J Clin Pract. 2011;65:472–8. [PubMed] [Google Scholar]

71. Mercadante S, Ferrera P, Adile C. High doses of oxycodone-naloxone combination may provide poor analgesia. Support Care Cancer. 2011;19:1471–2. [PubMed] [Google Scholar]

72. Meissner W, Leyendecker P, Meuller-Lissner S, et al. A randomised controlled trial with prolonged-release oral oxycodone and naloxone to prevent and reverse opioid-induced constipation. Eur J Pain. 2009;13:56–64. [PubMed] [Google Scholar]

73. Dunlop W, Uhl R, Khan I, Taylor A, Barton G. Quality of life benefits and cost impast of prolonged release oxycodone/naloxone versus prolonged release oxycodone in patients with moderate-to-severe non-malignant pain and opioid-induced constipation: a UK cost-utility analysis. J Med Econ. 2012;15:564–75. [PubMed] [Google Scholar]

74. Shaiova L, Rim F, Friedman D, Jahdi M. A review of methylnaltrexone, a peripheral opioid receptor antagonist, and its role in opioid-induced constipation. Palliat Support Care. 2007;5:161–6. [PubMed] [Google Scholar]

75. Yuan CS. Clinical status of methylnaltrexone. A new agent to prevent and manage opioid-induced side effects. J Support Oncol. 2004;2:111–22. [PubMed] [Google Scholar]

76. Yuan CS, Foss JF, Osinski J, Toledano A, Roizen MF, Moss J. The safety and efficacy of oral methylnaltrexone in preventing morphine-induced delay in oral-cecal transit time. Clin Pharmacol Ther. 1997;61:467–5. [PubMed] [Google Scholar]

77. Abarca FM, Saclarides TJ, Brand MI. A review of the treatment of opioid-induced constipation with methylnaltrexone bromide. Clinical Medicine Insights: Therapeutics. 2010;2:53–60.[Google Scholar]

78. Portenoy RK, Thomas J, Moehl Boatwright ML, Tran D, Galasso FL, Stambler N, Von Gunten CF, Israel RJ. Subcutaneous methylnaltrexone for the treatment of opioid-induced constipation in patients with advanced illness: a double-blind, randomized, parallel group, dose-ranging study. J Pain Symptom Manage. 2008;35:458–68. [PubMed] [Google Scholar]

79. Chamberlain BH, Cross K, Winston JL, et al. Methylnaltrexone treatment of opioid-induced constipation in patients with advanced illness. J Pain Symptom Manage. 2009;38:683–90. [PubMed] [Google Scholar]

80. Corken A, Green L, Greene P, Avigan M. Methylnatrexone and Gastrointestinal Perforation. J Pain Symptom Manage. 2010;40:e1–e3. [PubMed] [Google Scholar]

81. Becker G, Galandi D, Blum HE. Peripherally acting opioid antagonists in the treatment of opiate-related constipation: a systematic review. J Pain Symptom Manage. 2007;34:547–65. [PubMed] [Google Scholar]

82. Yuan CS. Methylnaltrexone mechanisms of action and side effects on opioid bowel dysfunction and of the opioid adverse effects. Ann Pharmacother. 2007;41:984–93. [PubMed] [Google Scholar]

83. Yuan CS, Foss JF, O'Connor M, et al. Methylnaltrexone for reversal of constipation due to chronic methadone use: a randomized controlled trial. JAMA. 2000;283:367–72. [PubMed] [Google Scholar]

84. Miles CL, Fellowes D, Goodman ML, Wilkinson S. Laxatives for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;1:CD003448. [PubMed] [Google Scholar]

85. Wirz S, Nadstawek J, Elsen C, Junker U, Wartenberg HC. Laxative management in ambulatory cancer patients on opioid therapy: a prospective, open-label investigation of polyethylene glycol, sodium picosulphate and lactulose. Eur J Cancer Care. 2012;21:131–40. [PubMed] [Google Scholar]

86. McNicol E, Boyce DB, Schumann R, Carr D. Efficacy and safety of mu-opioid antagonists in the treatment of opioid-induced bowel dysfunction: systematic review and meta-analysis of randomized controlled trials. Pain Med. 2008;9:634–59. [PubMed] [Google Scholar]

87. McNicol ED, Boyce D, Schumann R, Carr DB. Mu-opioid antagonists for opioid-induced bowel dysfunction. Cochrane Database Syst Rev. 2008;2:CD006332. [PubMed] [Google Scholar]

88. Paulson DM, Kennedy DT, Donovick RA, et al. Alvimopan: An oral, peripherally acting, mu-opioid receptor antagonist for the treatment of opioid-induced bowel dysfunction – a 21-day treatment-randomized trial. J Pain. 2005;6:184–92. [PubMed] [Google Scholar]

89. Leppert W. The role of opioid receptor antagonists in the treatment of opioid-induced constipation – a review. Adv Ther. 2010;27:714–30. [PubMed] [Google Scholar]

90. Candy B, Jones L, Goodman ML, Drake R, Tookman A. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;1:CD003448. [PubMed] [Google Scholar]

Articles from Contemporary Oncology are provided here courtesy of Termedia Publishing

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Comprehensive sourcebook focuses on mythology anthropology, religion, and sexuality to uncover precisely what other encyclopedias leave out or misrepresent. The Woman’s Encyclopedia presents the fascinating stories behind word origins, legends, superstitions, and customs.

Mythology’s Last Gods is a comprehensive history of the development of Judaeo-Christian god-mythology. Harwood traces the beginning of the “god” concept, the evolution of Judaism to the first century, and the evolution of Christianity from its monotheistic beginnings to its emergence as a three-god creed in A.D. 325.

A classic one-volume study Bible in the King James Version. Helps include 198 appendices, including explanations of Hebrew words and their uses; charts; parallel passages; maps; lists of proper names; calendars; and timelines.

This book is the first ever to advocate that the medium is not reformable. Its problems are inherent in the technology itself and are so dangerous — to personal health and sanity, to the environment, and to democratic processes — that TV ought to be eliminated forever.

Dr. Rabbi Antelman presents in a very easy read the history behind the various schisms in Judaism, when they happened, for what reason and by whom. “To Eliminate the Opiate” is the “From Time Immemorial” of untold Jewish History.

The Historical (Jewish) Jesus and the Mythical (Egyptian) Christ; Paul as a Gnostic Opponent, not the Apostle of Historic Christianity; The Logia of the Lord; or the Pre-Christian Sayings ascribed to Jesus the Christ; Gnostic and Historic Christianity; The Hebrew and other Creations fundamentally explained; The Devil of Darkness; or Evil in the Light of Evolution; Luniolatry; Ancient and Modern; Man in search of his Soul, during Fifty Thousand Years, and how he found it; The Seven Souls of Man, and their Culmination in the Christ; and The Coming Religion.

A WORK OF RECLAMATION AND RESTITUTION IN TWELVE BOOKS Vol. I and 2. It may have been a million years ago The Light was kindled in the Old Dark Land With which the illumined Scrolls are all aglow, That Egypt gave us her mummied hand: This was the secret of that subtle smile Inscrutable upon the Sphinx’s face, Now told from sea to sea, from isle to isle; The revelation of the Old Dark Race and more!

The Natural Genesis is based on Massey’s study of hieroglyphic inscriptions, bone-caves, and cuneiform tablets of ancient Egypt. The findings from Massey’s years of dedicated research are carefully documented here and encompass such broad areas as religion and the occult, etomology, astrology, and mythology.

Containing an attempt to recover and reconstitute the lost origins of the myths and mysteries, types and symbols, religion and language, with Egypt for the mouthpiece and Africa as the birthplace. The significance of this work was not recognized in its own time over 100 years ago.

Rather than pass through the Atlanta Federal Prison Camp gate to serve a sentence for a tax misdemeanor back in 1987, author F. Tupper Saussy chose to become a fugitive in order to freely investigate his adversary — the United States of America. Provocative and utterly compelling, Rulers of Evil analyzes the hundreds of historical clues left by the true leaders of the world. It should be read by anyone desiring to know, definitively, why America works the way it does.

This book traces the origins of a faith. What is new is the belief that a perfect secular order will emerge from forcible overthrow of traditional authority. This inherently implausible idea energized Europe in the nineteenth century, and became the most pronounced ideological export of the West to the rest of the world in the twentieth century.

The occult power behind the spear that pierced the side of Christ. How Hitler inverted the Force in a bid to conquer the world. Fascinating reading. Photographs.

JOURNEY FROM EDEN is a complete history of the sexual customs, creeds, and ceremonies among the people by whom, and about whom, the Bible was written. This fascinating and revealing book goes behind the scenes to present an in-depth, documented account of everything you were not told in Sunday School, and were afraid to ask!

For thousands of years before the beginning of recorded history — the legends tell us — a powerful civilization flourished in the middle of the Atlantic Ocean. This breathtakingly advanced island continent boasted splendid cities, golden temples, crowded seaports from which the far-reaching influence of Atlantis spread to the rest of the world, until its destruction in an overwhelming cataclysm.

This scholarly exploration of the borderlands between science and fantasy features four complete works by the redoubtable Charle Fort (1874-1932): The Book of the Damned, Lo!, Wild Talents, and New Lands. All concern the bizarre phenomena unexplained by traditional science: flying saucers, telekinesis, sudden showers of fish from the sky, stigmata, poltergeists, and spontaneous combustion.

Foremost Fortean investigator John Keel presents a book filled with evidence of the strange and stories of the unusual. He reveals theories about “ultraterrestrials,” Men In Black, glass mountains, ancient maps, and advanced civilizations predating the caveman. Are we being manipulated for someone’s amusement? For the connoisseur of Fortean phenomena as well as newcomer.

A comprehensive encyclopedia of the unexplained, with incredible eyewitness accounts of strange creatures from around the globe. Including: Angles and Demons; The Mothman; Dinosaurs that still roam the earth; Bigfoot, the Abominable Snowman, and other hairy monsters; A real-life land of the giants;The Loch Ness monster, and much more…

John Keel is one of the most interesting authors of our age. Any of his writings are worth reading.

This book provides the hidden foundations of the United Nations, plus how and why America is the way it is today. This is a MUST READ.

A comprehensive, popular history of the occult background and roots of the Nazi movement, showing how the ideas of a vast international network of late 19th- and early 20th-century occult groups influenced Nazi ideology.

In order to follow the universal revolution which we are now passing, we must realize the dual nature of the movement by studying concurrently the outward revolutionary forces of socialism, anarchism, etc., and the hidden power behind them as indicated in the chart found in this work.

This anthology is a thorough introduction to classic literature for those who have not yet experienced these literary masterworks. For those who have known and loved these works in the past, this is an invitation to reunite with old friends in a fresh new format. As an anthology that invites readers to immerse themselves in the masterpieces of the literary giants, it is must-have addition to any library.

Known to be a masterpiece of freethought literature. The World’s Sixteen Crucified Saviors has been out of print but sought after for many years. Many people are unaware that before Christianity there were 15 other religions that also had a savior who died for their sins, then arose from the dead. Graves gives all the details inside, plus much more found in common like the immaculate conception of the gods, virgin born gods, magi, shepherds and angles who visit the infant saviors, the birthday of the gods being December 25th, plus an explanation as to how Jesus began to be worshipped as a God.

Jesus and Moses are Buried in India, Birthplace of Abraham and the Hebrews! later, to what is now Israel. You’ll be surprised to find out who and what Jehovah, Abraham, Sarah, Moses, Jesus really were.

Subtitled “A Practical Guide to the Esoteric Sciences,” this volume examines the teachings of the Mystery Schools, the five steps of self-unfoldment, and how the practice of ancient disciplines can lead to a more purposeful life.

To Eliminate The Opiate Vol 2 Pdf Free Download

This work is for anyone interested in secret societies, grand conspiracy theories, and the details of world history with its interconnections between the symbols of humanity’s cultures and beliefs — from crosses and swastikas to circles and stars to eyes of Horus and crowns — as a demonstration of the universality of Freemasonry.

I think the title says it all! Historical Effects of the Discoveries. With Over One Hundred Illustrations and Maps.

This collection chronicles the fiction and non fiction classics by the greatest writers the world has ever known. The inclusion of both popular as well as overlooked pieces is pivotal to providing a broad and representative collection of classic works.

Complete in itself, this volume originated as a commentary and expansion of Manly P. Hall’s masterpiece of symbolic philosophy, The Secret Teachings of All Ages. In Lectures on Ancient Philosophy, Manly P. Hall expands on the philosophical, metaphysical, and cosmological themes introduced in his classic work, The Secret Teachings of All Ages. Hall wrote this volume as a reader’s companion to his earlier work, intending it for those wishing to delve more deeply into the esoteric philosophies and ideas that undergird the Secret Teachings.

The pageantry and beauty of the Old Testament is presented in this book which provides keys to Bible interpretation. Illustrated with many unusual vignettes from rare manuscripts, the areas discussed include the descent of the Holy Scriptures; Moses, the lawgiver of Israel; the five books of Moses; and the story of creation.

This esoteric interpretation of the New Testament presents the devotional side of the Christian faith. The life and ministry of Jesus, the Lord’s Prayer, the Beatitudes, the Sermon on the Mount, and the sacred mysteries of the Essenes are explored.

If any group, which shared in the Christian mystery, possessed the esoteric secrets of the early Church, it was the Gnostics. This order preserved to the end the high ethical and rational standards which confer honor upon a teaching. The Church therefore attacked Gnosticism vigorously and relentlessly, recognizing these mystical philosophers as being the most formidable adversaries to the temporal power of Christian theology.

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An illustrated text which explores the symbolism of The Book of Revelations.

ISIS UNVEILED was H. P. Blavatsky’s first major literary effort, a critical response to the growing materialism in both scientific and religious institutions, and a vindication of the ageless quest. Isis ‘is the fruit of a somewhat intimate acquaintance with Eastern adepts and study of their science.’

Subtitled An Outline of the Origins of Moon and Sun Worship, Astrology, Sex Symbolism, Mystic Meaning of Numbers, the Cabala, and Many Popular Customs, Myths, Superstitions and Religious Beliefs. Important information not easily found. Mythologist Jordan Maxwell was so impressed he created a three-part video series based on this material and wrote a Preface to the book.

This incredibly detailed book reveals the hidden meanings behind occult signs and symbols from ancient times, found in what should be termed stellar theology, and then carried over into our modern world. Also reveals how Freemasonry is connected to Judaism, Christianity and the Bible.

Occult Theocrasy was originally published in 1933 shortly after Edith Starr Miller’ss death. This is volume 1 of 2 and contains a wealth of information about secret societies and occult philosophy.

More of the same, completes the set. Occult Theocrasy was originally published in 1933 shortly after Edith Starr Miller’s death. This is volume 2 of 2 and contains a wealth of information about secret societies and occult philosophy.

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