title: Levorphanol use: past, present and future.
abstract: Levorphanol is a potent opioid analgesic that was first approved for use in the United States in 1953. Levorphanol is approved for use in moderate to severe pain where an opioid analgesic is appropriate. Levorphanol has a wide range of activities including mu opioid agonism, delta agonism, kappa1 and kappa3 receptor agonism, N-methyl-d-aspartate receptor antagonism and reuptake inhibition of both norepinephrine and serotonin. This multimodal profile might prove effective for pain syndromes that are refractory to other opioid analgesics, such as central and neuropathic pain and opioid-induced hyperalgesia. Levorphanol is well suited as a first-line opioid and can also be used during opioid rotation. It has no known effect on the cardiac QT interval or drug-drug interactions involving hepatic cytochrome P450s enzymes. In these regards, levorphanol may offer a superior safety profile over methadone and other long-acting opioids. Despite its prospective value of multiple mechanisms of action and the potential for treating various types of pain, levorphanol use has been largely supplanted by other recently approved opioids. Its waning use over the years has caused it to be referred to as the "Forgotten Opioid" and resulted in what some consider its underutilization. In fact, levorphanol is relatively unfamiliar to most prescribers. The purpose of this review is to inform practitioners about the attributes of this opioid and reintroduce it to clinicians as an option for treating moderate to severe pain when alternative treatment options are inadequate, not indicated or contraindicated.
authors.affiliation: a Pain Management and Palliative Care , Englewood Hospital and Medical Center , Englewood , NJ , USA.|b Department of Anesthesiology , Icahn School of Medicine at Mount Sinai , New York , NY , USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Gudin
authors.affiliation: c Professional Practice Division, Albany College of Pharmacy and Health Sciences , Albany , NY , USA.|d Professional Practice Division, Western New England University College of Pharmacy , Springfield , MA , USA.|e PGY2 Pain Residency and Clinical Pharmacy, Pain Management Stratton VA Medical Center , Albany , NY , USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Fudin
authors.affiliation: f International Clinical Research Institute , Overland Park , KS , USA.|g Department of Pharmaceutical Sciences, Temple University School of Medicine , Philadelphia , PA , USA.
authors.forename: Srinivas
authors.initials: S
authors.lastname: Nalamachu
mesh_terms: D000284:Administration, Oral; D000701:Analgesics, Opioid / Q000737:chemistry / Q000493:pharmacokinetics / Q000494:pharmacology / Q000627:therapeutic use*; D004334:Drug Administration Schedule; D006801:Humans; D007981:Levorphanol / Q000737:chemistry / Q000493:pharmacokinetics / Q000494:pharmacology / Q000627:therapeutic use*; D010146:Pain / Q000188:drug therapy*; D012720:Severity of Illness Index
chemical_list: D000701:Analgesics, Opioid; D007981:Levorphanol
keywords: Analgesic; Kappa opioid receptor; Levorphanol; Mu opioid receptor; N-methyl-d-aspartate; NMDA; Opioid; Opioid rotation