Pain management: physiopathology, future research and endpoints

The effect of substance P1-7 amide on nociceptive threshold in diabetic mice

We previously demonstrated that intrathecal treatment with substance P metabolite substance P(1-7) induced anti-hyperalgesia in diabetic mice. In the present study, we have used a synthetic analog of this peptide, the substance P(1-7) amide, showing higher binding affinity than the native heptapeptide, for studies of the tail-flick response in diabetic and non-diabetic mice. Intrathecal injection of substance P(1-7) amide produced prolongation of the tail-flick latency in both diabetic and non-diabetic mice, an effect that was more pronounced in diabetic mice than non-diabetic mice. Moreover, the observed antinociceptive potency of the substance P(1-7) amide was higher in both diabetic and non-diabetic mice in comparison with the native substance P(1-7). The antinociceptive effect of substance P(1-7) amide was reversed by naloxone but not by the selective opioid receptor antagonist β-funaltrexamine, naltrindole or nor-binaltorphimine, selective for the μ-, δ- or κ-opioid receptor, respectively. In addition, the antinociceptive effect induced by substance P(1-7) amide was partly reversed by the σ(1) receptor agonist (+)-pentazocine, suggesting a possible involvement of the σ(1) receptor for the action of this peptide. These results suggest that the actions of substance P(1-7) amide mimic the effects of the native substance P fragment but with higher potency and that the mechanisms for its action may involve the σ(1) receptor system.

Management of Chronic Pain in the Acute Care Setting

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term. Because they are self-reinforcing, opioids may be sought and be reported to improve chronic pain, even when they may make the condition worse over time. There are many effective alternatives to opioids for the treatment of chronic pain, but their use is complicated and may require considerable time and effort to determine which ones work. Patients, particularly those who have already been prescribed opioids, may resist these alternatives. An extensive physical and psychosocial evaluation is required in the management of chronic pain, which is difficult if not impossible to achieve in the emergency or urgent care settings. Consequently, emergency and urgent care physicians should work closely with the patient's pain management specialist or personal physician. Systems should be set up in advance to identify those patients whose frequent use of acute care services for obtaining opioids may be compromising their long-term management, putting themselves at risk for psychological and tolerance-induced adverse effects of frequent opioid use. Opioids may be used in carefully selected patients in consultation with their pain management specialist or personal physician, but care must be exercised not to initiate or exacerbate psychological or tolerance-related complications of chronic pain.

Effects of morphine on formalin-induced nociception in rats

This study focused on the antinociceptive action of morphine in the formalin test in rats. Formalin-induced behaviour is characterised by two phases relevant to acute and tonic pain. Morphine (1-6 mg/kg) was administered systemically before or after the early phase, and its ability to affect the late phase was investigated. Inhibitory effects of morphine (3 mg/kg) injected immediately after the early phase were significantly stronger (32+/-9%) compared to the preemptive administration (84+/-29%, relative to saline-treated controls, 5% formaldehyde). It appears that some neural and/or behavioural changes during the early phase limit effects of morphine on the late phase. Furthermore, manipulation of stimulation intensity (2% vs. 5% formaldehyde) significantly affected the ability of morphine (3 mg/kg) to suppress early (55+/-7% and 76+/-10%, respectively) but not late phase of formalin-induced behaviours. These results agree with the previous demonstrations on the effects of acute nociceptive stimulation intensity on analgesic potency of opiate drugs. Thus, the present study revealed two factors that affect the potency of morphine in formalin test: administration regimen and formalin concentration.

Strategies for the treatment of cancer pain in the new millennium

As was the case in the era before us, in the new millennium we will continue to see an abundance of patients experiencing cancer-related pain for different reasons. Although much needless pain and suffering still affects many of those with cancer, we are presented with a medical dichotomy. With the analgesic drugs available today, and the relatively simple and effective guidelines to treat cancer pain published and disseminated by the World Health Organization, why do people with cancer continue to experience pain? As we search for the answer, the horizon may hold promising new drugs, 'old drugs' with new interest and applications, and new strategies for the field of pain therapy. Possibilities include the isolation and development of analgesics or analgesic combinations that may minimise the adverse effects which are often associated with the current therapeutic class of opioid analgesics. In addition, current research points to promising results identifying the N-methyl D-aspartate non-opioid receptor as a likely component of neuropathic pain. Drugs such as gabapentin, the mechanism of action of which is not well known, have found favour within the clinical community for their analgesic properties and good tolerability. Methadone, in a phase of resurgence, has garnered the attention of the clinical community because of its unique receptor activity and pharmacoeconomic benefits. A number of clinical studies have demonstrated that methadone has a valuable role in treating cancer pain. Perhaps, an unbalanced focus on the risks of inappropriate use, rather than the benefits, should not compromise or distract from the use of methadone as an alternative to morphine. Studies are on going to assess the potential role of methadone in treating neuropathic pain. Drugs such as cannabinoids, although currently applicable for patients with anorexia, nausea and/or vomiting, may offer benefits to patients experiencing pain. Other opportunities exist with such compounds as alpha2-adrenergic agonists, nicotine, lidocaine and ketamine. New strategies such as the switching opioids and/or their route of administration may offer improved analgesia with fewer adverse effects, thus providing therapeutic alternatives for the clinical community. In addition, there is interest in the co-administration of opioids that act on different receptors. For instance, oxycodone appears to be a kappa opioid receptor agonist and may offer enhanced analgesia when combined with morphine.

Glutamate receptors and nociception: implications for the drug treatment of pain

Evidence from the last several decades indicates that the excitatory amino acid glutamate plays a significant role in nociceptive processing. Glutamate and glutamate receptors are located in areas of the brain, spinal cord and periphery that are involved in pain sensation and transmission. Glutamate acts at several types of receptors, including ionotropic (directly coupled to ion channels) and metabotropic (directly coupled to intracellular second messengers). Ionotropic receptors include those selectively activated by N-methyl-D-aspartate, alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid and kainate. Metabotropic glutamate receptors are classified into 3 groups based on sequence homology, signal transduction mechanisms and receptor pharmacology. Glutamate also interacts with the opioid system, and intrathecal or systemic coadministration of glutamate receptor antagonists with opioids may enhance analgesia while reducing the development of opioid tolerance and dependence. The actions of glutamate in the brain seem to be more complex. Activation of glutamate receptors in some brain areas seems to be pronociceptive (e.g. thalamus, trigeminal nucleus), although activation of glutamate receptors in other brain areas seems to be antinociceptive (e.g. periaqueductal grey, ventrolateral medulla). Application of glutamate, or agonists selective for one of the several types of glutamate receptor, to the spinal cord or periphery induces nociceptive behaviours. Inhibition of glutamate release, or of glutamate receptors, in the spinal cord or periphery attenuates both acute and chronic pain in animal models. Similar benefits have been seen in studies involving humans (both patients and volunteers); however, results have been inconsistent. More research is needed to clearly define the role of existing treatment options and explore the possibilities for future drug development.

Intraplantar injection of dextrorphan, ketamine or memantine attenuates formalin-induced behaviors

The possible prophylactic effects of local injection of NMDA receptor antagonists that are currently used in humans was investigated in the present study. Intraplantar pretreatment with either 5 mM dextrorphan (DEX), 10 mM memantine (MEM) or 10 mM ketamine (KET) significantly attenuated formalin-induced lifting and licking behaviors, however flinching behavior was not effected. Control experiments indicated that these drug actions could be attributed to local and not systemic effects of the antagonists. We hypothesize that these actions result from blocking NMDA receptors present on unmyelinated sensory axons in the skin. These data suggest that peripheral NMDA receptors contribute to nociceptor activation and can be manipulated to reduce pain of peripheral origin. Since DEX, MEM and KET are currently used in humans and considered clinically safe, they have potential therapeutic value in the treatment of physiologic or pathologic pain states which are induced or maintained by peripheral nociceptor activity. Topical or local application would avoid the side effects that can accompany systemic or intrathecal injection of NMDA antagonists.

Systemic ketamine attenuates nociceptive behaviors in a rat model of peripheral neuropathy

The efficacy of ketamine (KET), a non-competitive NMDA receptor-channel blocker, was assessed in relieving nociceptive behaviors in neuropathic rats with tight ligations of the L5 and L6 spinal nerves. The antinociceptive effects of KET were dose- and time-dependent. A systemic injection of 0.01 mg/kg KET transiently (15-30 min) attenuated several nociceptive behaviors, including mechanical allodynia and hyperalgesia, cold allodynia, spontaneous pain, and cold stress-induced pain. Treatment with 1.0 mg/kg KET consistently decreased all nociceptive behaviors for 45-75 min, without noticeable side effects. Higher doses (25 and 50 mg/kg) provided longer lasting relief: however, these doses resulted in transient motor impairment which lasted for 15-30 min post-injection. Systemic KET was most effective in decreasing the behavioral signs of mechanical allodynia and hyperalgesia, followed by cold allodynia, cold stress-induced pain, and spontaneous pain. The present results demonstrate that blockade of NMDA receptors effectively alleviates nociceptive behaviors in a rat model of peripheral neuropathy, substantiating the important role of these receptors in the central sensitization that underlies the maintenance of neuropathic pain. In addition, the ability of KET to reduce significantly a variety of nocifensive behaviors suggests that this clinically safe drug could be used in pain management for neuropathic patients.

Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions

Over the last several years, compelling evidence has accumulated indicating that central hyperactive states resulting from neuronal plastic changes within the spinal cord play a critical role in hyperalgesia associated with nerve injury and inflammation. Such neuronal plastic changes may involve activation of central nervous system excitatory amino acid (EAA) receptors, subsequent intracellular cascades including protein kinase C translocation and activation as well as nitric oxide production, leading to the functional modulation of receptor-ion channel complexes. Similar EAA receptor-mediated cellular and intracellular mechanisms have now been implicated in the development of tolerance to the analgesic effects of morphine, and a site of action involved in both hyperalgesia and morphine tolerance is likely to be in the superficial laminae of the spinal cord dorsal horn. These observations suggest that hyperalgesia and morphine tolerance, two seemingly unrelated phenomena, may be interrelated by common neural substrates that interact at the level of EAA receptor activation and related intracellular events. This view is supported by recent observations showing that thermal hyperalgesia develops when animals are made tolerant to morphine antinociception and that both hyperalgesia and reduction of the antinociceptive effects of morphine occur as a consequence of peripheral nerve injury. The demonstration of interrelationships between neural mechanisms underlying hyperalgesia and morphine tolerance may lead to a better understanding of the neurobiology of these two phenomena in particular and pain in general. This knowledge may also provide a scientific basis for improved pain management with opiate analgesics.