Ils défrayent la chronique ces dernières années pour le nombre de morts par overdose que leur surconsommation a pu provoquer. Que sont les opioïdes, dont la prise doit être surveillée de près par les médecins ? Y a-t-il une différence avec les opiacés ? En tant que patients confrontés à la douleur, nous rencontrerons à un moment ou à un autre de notre vie cette classe de médicaments. En voici une présentation succincte.
Des comprimés d’Oxycodone
DES COMPRIMÉS D’OXYCODONE. LEUR ACTION ANTALGIQUE EST SIMILAIRE À CELLE DE LA MORPHINE. L’EFFET THÉRAPEUTIQUE EST PRINCIPALEMENT ANALGÉSIQUE, ANXIOLYTIQUE, ANTITUSSIF ET SÉDATIF. L’OXYCODONE EST UTILISÉE DANS LA PRISE EN CHARGE DES DOULEURS INTENSES ET DES DOULEURS CANCÉREUSES. L’OXYCODONE EST DÉRIVÉ DE LA THÉBAÏNE, UN ALCALOÏDE DE L’OPIUM.
Quand la douleur ne peut plus être soulagée par du paracétamol ou des anti-inflammatoires, une autre classe pharmacologiques est prescrite : les antalgiques opioïdes.
Mais ces médicaments sont à prendre avec autant de précaution que toute autre classe de médicaments car leur prise répétée provoque des comportements d’addiction, d’accoutumance du corps à leurs effets et de ce fait, le besoin d’en augmenter les prises et les quantités.
Opioïdes, opiacés, quelle différence?
Opiacés et opioïdes sont des termes renvoyant à la même classe pharmacologique. En France, le mot opioïde tend à se généraliser et semble englober le terme opiacé dans les usages linguistiques courants comme savants (chimie organique et pharmacologie). Les opioïdes pourraient être décrits comme des substances pouvant se lier aux récepteurs opiacés de notre cerveau.
Le terme opiacé renvoie à des molécules naturelles présentes dans l’opium qui est la résine blanche (ou latex) obtenue à partir de l’incision des capsules encore vertes du pavot (Papaver somniferum), une fleur plus grande que notre coquelicot des champs, originaire d’Asie. Les composés naturellement présents dans l’opium sont : la morphine, la codéine, la narcotine, la laudanosine, la thébaïne, la papavérine, la narcotine, la noscapine, etc.
D’autres opiacés composés, obtenus à partir des substances naturellement présentes dans l’opium (par hémisynthèse), sont également désignés par le terme générique d’opioïdes : l’héroïne, l’hydromorphone, l’oxymorphone, l’hydrocodone, l’oxycodone…
Dans la catégorie des opioïdes, sont plus souvent citées des substances entièrement synthétiques : fentanyl, péthidine, méthadone, propoxyphène…
Enfin, le terme opioïde renvoie également à des substances que notre corps fabrique, les opioïdes endogènes. Les substances opiacés et opioïdes prescrites aux patients miment et renforcent notre propre système opioïde.
Dans quels cas les opioïdes sont-ils prescrits ?
Avant toute chose, il faut garder à l’esprit que les opioïdes ne sont pas les antalgiques les plus couramment prescrits en France. Les antidouleurs les plus consommés restent le paracétamol, l’aspirine et les anti-inflammatoires non stéroïdiens (AINS), qui représentent tout de même 78% des médicaments antalgiques (à noter que ces AINS ne sont pas non plus sans danger).
Ces opioïdes sont connus pour soulager les douleurs, mais ils ont d’autres usages thérapeutiques : ce sont des antitussifs, antidiarrhéiques et ils peuvent servir de substitution dans le cadre d’un sevrage. Ces médicaments sont surveillés de très près car ils exposent à de nombreux effets indésirables, d’ordre digestif (constipation, nausées et vomissements) ou neuropsychique (sédation, somnolences, vertiges, perte de la vigilance), mais aussi, plus grave encore, à des phénomènes d’addiction qui interviennent en cas de prise répétée ou à des dépressions respiratoires en cas de prise aiguë.
On distingue les opioïdes dits faibles des opioïdes dits forts. L’OMS a mis au point une classification faisant correspondre intensité de la douleur et niveau d’efficacité des antalgiques. Il existe trois paliers : I, II et III. A noter que cette gradation liée à l’intensité douloureuse ne fait plus assez sens pour les cliniciens, du fait des connaissances nouvelles sur les mécanismes de la douleur.
Opioïdes dits faibles (codéine, poudre d’opium, tramadol, dextropropoxyphène…)
palier II de l’OMS
prescrits en cas de douleurs chroniques en France, inscrits sur la liste des substances vénéneuses et disponibles uniquement sur ordonnance.
Opioïdes dits forts : buprénorphine, fentanyl, hydromorphone, morphine, oxycodone, péthidine
palier III de l’OMS
la morphine seule est indiquée pour les « douleurs persistantes intenses ou rebelles » (douleurs aiguës et chroniques) aux antalgiques de niveau plus faible.
la buprénorphine, le fentanyl, l’hydromorphone et l’oxycodone sont réservés aux douleurs cancéreuses intenses en France, ces opioïdes forts sont inscrits sur la liste des substances stupéfiantes.
Pourtant, qu’ils soient faibles ou forts, tous ces opioïdes exposent à des risques de dépression respiratoire ou à un phénomène d’accoutumance. Les prescriptions et les délivrances en pharmacie des opioïdes faibles sont donc soumises également à des règles strictes.
En raison de cette balance défavorable du rapport bénéfices/risques, les médecins ont pour consigne de ne pas prescrire en première intention cette classe d’antalgique. C’est le cas pour certaines douleurs intenses : douleurs dentaires, lombalgie aiguë, traumatismes simples du rachis, « coup du lapin », entorses ou blessures mineures des membres sans signes de lésions des tissus, colique néphrétique.
Dans le cas de céphalées et migraines résistant aux antalgiques de palier I, les opioïdes ne seront pas prescrits, même pour un traitement de seconde intention.
sciencesetavenir
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