Enhancement of morphine analgesia after acute and chronic haloperidol

Sigma-1 receptors and animal studies centered on pain and analgesia

INTRODUCTION

Neuropathic pain is difficult to relieve with standard analgesics and tends to be resistant to opioid therapy. Sigma-1 receptors activated during neuropathic injury may sustain pain. Neuropathic injury activates sigma-1 receptors, which results in activation of various kinases, modulates the activity of multiple ion channels, ligand activated ion channels and voltage-gated ion channels; alters monoamine neurotransmission and dampens opioid receptors G-protein activation. Activation of sigma-1 receptors tonically inhibits opioid receptor G-protein activation and thus dampens analgesic responses. Therefore, sigma-1 receptor antagonists are potential analgesics for neuropathic and adjuvants to opioid therapy.

AREAS COVERED

This article reviews the importance of sigma-1 receptors as pain generators in multiple animal models in order to illustrate both the importance of these unique receptors in pathologic pain and the potential benefits to sigma-1 receptor antagonists as analgesics.

EXPERT OPINION

Sigma-1 receptor antagonists have a great potential as analgesics for acute neuropathic injury (herpes zoster, acute postoperative pain and chemotherapy induced neuropathy) and may, as an additional benefit, prevent the development of chronic neuropathic pain. Antagonists are potentially effective as adjuvants to opioid therapy when used early to prevent analgesic tolerance. Drug development is complicated by the complexity of sigma-1 receptor pharmacodynamics and its multiple targets, the lack of a specific sigma-1 receptor antagonist, and potential side effects due to on-target toxicities (cognitive impairment, depression).

The role of antipsychotics in the management of fibromyalgia

Fibromyalgia is a syndrome characterized by chronic generalized pain associated with different somatic symptoms, such as sleep disturbances, fatigue, stiffness, balance problems, hypersensitivity to physical and psychological environmental stimuli, depression and anxiety. It has been estimated to affect roughly the 2-4% of the general population in most countries studied, and it has been shown to be much more prevalent in women than in men. Although its pathophysiology is not yet fully understood, it is known that both genetic and environmental factors are involved in its development. Fibromyalgia shares a high degree of co-morbidity with other conditions, including chronic headache, temporomandibular disorder, irritable bowel syndrome, major depression, anxiety disorders and chronic fatigue syndrome. Therefore, this is a syndrome difficult to treat for which multimodal treatments including physical exercise, psychological therapies and pharmacological treatment are recommended. Although different kinds of drugs have been studied for the treatment of fibromyalgia, the most widely used drugs that have the higher degree of evidence for efficacy include the α(2)δ ligands pregabalin and gabapentin, and the tricyclic antidepressants (TCAs) and serotonin noradrenaline (norepinephrine) reuptake inhibitors (SNRIs). However, there is a need to look for newer additional therapeutic pharmacological options for the treatment of this complex and disabling disease. First- and second-generation antipsychotics have shown analgesic properties both in an experimental setting and in humans, although most of the available evidence for the treatment of human pain concerns older antipsychotics and involves clinical trials performed several decades ago. In addition, several second-generation antipsychotics, risperidone, olanzapine and quetiapine, have shown efficacy in the treatment of some anxiety disorders. Some second-generation antipsychotics, mainly quetiapine, aripiprazole and amisulpride, have demonstrated antidepressant activity, with quetiapine approved for the treatment of bipolar depression and refractory major depression, and aripiprazole approved as an adjunctive treatment for major depressive disorder. Finally, several old and new antipsychotics, including promethazine, levopromazine, olanzapine, quetiapine and ziprasidone, have been shown to improve sleep parameters in healthy subjects. Each of these properties suggests that antipsychotics could represent a new potential alternative for the treatment of fibromyalgia syndrome. To date, most of the published studies on the use of antipsychotics in the treatment of fibromyalgia syndrome have been uncontrolled, either case reports or case series, dealing with olanzapine, quetiapine, ziprasidone, levopromazine and amisulpride. The studies on olanzapine and quetiapine have suggested therapeutic efficacy although, in the case of olanzapine, hampered by tolerability problems. A double-blind controlled trial, published in 1980, showed that chlorpromazine increased slow-wave sleep and improved pain and mood disturbances. More recently, four double-blind controlled studies have explored the efficacy of quetiapine, either alone or as an add-on treatment, in fibromyalgia management. None of these trials has yet been published, although two of them have been presented as congress communications, both of them suggesting that quetiapine could be a potential alternative treatment for fibromyalgia. In summary, the current available evidence suggests that at least some antipsychotics, specifically quetiapine, could be useful for the treatment of fibromyalgia and that further studies on the efficacy of these compounds are worth pursuing.

Morphine sparing with droperidol in patient-controlled analgesia

STUDY OBJECTIVE

To determine if droperidol has a morphine-sparing effect when coadministered with morphine via patient-controlled analgesia (PCA) for postoperative pain management.

DESIGN

A randomized, double-blind clinical study.

SETTING

Department of Anesthesiology, Kaohsiung Veterans General Hospital, Taiwan.

PATIENTS

One hundred seventy-nine American Society of Anesthesiologists physical status 1 and 2 female patients undergoing abdominal hysterectomy.

INTERVENTIONS

At the end of surgery, patients in the droperidol group received PCA, with the device programmed to deliver a bolus dose of 1 mg morphine and 50 mug droperidol on demand. Patients in the control group received 1 mg morphine on demand. For both groups, PCA lockout was 5 minutes between boluses, with a 4-hour morphine limit of 30 mg.

MEASUREMENTS AND MAIN RESULTS

Pain intensity at rest or on movement and relative sedation score were evaluated and recorded at 6, 12, 24, 48, and 72 hours after surgery. Related side effects were also evaluated and recorded on postoperative days 1, 2, and 3. Morphine use was significantly lower for the droperidol group than the control group during the postoperative 72-hour period (33.9 +/- 9.8 and 54.9 +/- 12.1 mg, respectively), with significantly decreased pain intensity levels for the former relative to the latter at 48 hours (pain intensity on movement: 3.9 +/- 1.2 vs 4.3 +/- 0.9, respectively; P = .049) and 72 hours (pain intensity on movement: 3.0 +/- 1.1 vs 3.6 +/- 0.5, respectively; P = .003; pain intensity at rest: 1.3 +/- 1.0 vs 1.6 +/- 0.7, respectively; P = .033) subsequent to surgery. Control subjects demonstrated a greater frequency of postoperative nausea and vomiting than did their droperidol counterparts on postoperative day 1.

CONCLUSION

Coadministration of 50 mug droperidol and 1 mg morphine on demand via PCA provides a morphine-sparing effect and reduces the frequency of postoperative nausea and vomiting.

Involvement of dopamine D2 receptor-mediated functions in the modulation of morphine-induced antinociception in diabetic mouse

The effects of the dopamine agonists and antagonists on morphine-induced antinociception in diabetic mice were studied. The antinociceptive effect of morphine (5 mg/kg, s.c.) in diabetic mice was significantly less than that in non-diabetic mice. The antinociceptive effect of morphine in diabetic mice, but not that in non-diabetic mice, was significantly enhanced following pretreatment with sulpiride, a selective dopamine D2 antagonist, (30 mg/kg, s.c.). Pretreatment with quinpirole, a selective dopamine D2 agonist, (100 nmol, i.c.v.), markedly increased the antinociceptive effect of morphine in diabetic mice, but not in non-diabetic mice. There was no significant difference in the antinociceptive effect of morphine (5 mg/kg, s.c.) between the quinpirole-treated diabetic mice and saline-treated non-diabetic mice. A higher dose of quinpirole (300 nmol, i.c.v.) had no significant effect on morphine-induced antinociception in diabetic mice. On the other hand, the antinociceptive effect of morphine was significantly reduced by pretreatment with quinpirole (300 nmol, i.c.v.) in non-diabetic mice. Quinpirole (100 and 300 nmol, i.c.v.) dose-dependently increased total locomotor activity in non-diabetic mice. In contrast, a lower dose of quinpirole (100 nmol, i.c.v.) significantly reduced spontaneous locomotor activity in diabetic mice, while a higher dose of quinpirole had no significant effect on the spontaneous locomotor activity. The dopamine turnover ratio in the limbic forebrain and midbrain in diabetic mice were significantly greater than those in non-diabetic mice. When mice were pretreated with quinpirole (100 and 300 nmol, i.c.v), this enhanced dopamine turnover ratio was not observed in either the limbic forebrain or the midbrain of diabetic mice. These findings suggest that the attenuation of morphine-induced antinociception and dopamine D2 receptor-mediated function in diabetic mice may somehow be related.

(-)-Pentazocine analgesia in mice: interactions with a sigma receptor system

(-)-Pentazocine is active in the tailflick assay in CD-1 mice, although it shows a biphasic dose-response curve with a peak effect of only 30%. Co-administration of haloperidol shifts the dose-response curve to the left and elevates the maximal response to 70% through a blockade of sigma 1 receptors, but the curve remains biphasic. (+)-Pentazocine is inactive in all antinociceptive assays, either alone or with haloperidol. The analgesic actions of (-)-pentazocine are readily reversed by nor-binaltorphimine, but not by the mu-selective opioid receptor antagonist beta-funaltrexamine, implying a kappa 1-opioid receptor mechanism of action. This conclusion is supported by the ability of antisense oligodeoxynucleotides directed against the KOR-1 clone, which encodes the kappa 1-opioid receptor, to block (-)-pentazocine analgesia.

The neuroleptics as adjuvant analgesics

The role of neuroleptic drugs as adjuvant analgesics has been a subject of longstanding controversy. Despite frequent claims of efficacy, evidence from controlled trials supports neither claims of intrinsic analgesic properties nor the routine use of the neuroleptics as a means to reliably induce clinically useful analgesia. Methotrimeprazine is unique in that there is evidence for reliable dose-related analgesia that is comparable to opioid-mediated analgesia, although routine use is not recommended. Despite probable interaction with opioid receptors, there is insufficient evidence to support a role for the butyrophenone category of neuroleptics as adjuvant analgesics. Limited trials of the neuroleptics may be considered for pain that has been unresponsive to more conventional pharmacologic approaches, especially when associated with headache, nerve injury, or psychological distress. The neuroleptics have an important role in the symptomatic management of agitation, delirium, and nausea, particularly in patients with cancer.

Opposite dopaminergic activity in lateral and median hypothalamic nuclei in relation to the feeding effect of D-Ser2-Leu-Enk-Thr6 (DSLET)

The Leu-enkephalin analogue D-Ser2-Leu-Enk-Thr6 (DSLET) had been shown to enhance feeding in rats, increase dopaminergic activity in the striatum like other opiate agonists, and particularly to decrease dopaminergic activity in the hypothalamus. In this study, the latter effect was found to be localized in the hypothalamic nuclei involved in the regulation of feeding such as the paraventricular (PVN), ventromedian (VMH), dorsomedian (DMH) nuclei and the lateral hypothalamus (LH). DSLET produced the same decrease in dopaminergic activity in the LH as in the whole hypothalamus. In the median nuclei (PVN and VMH and to a lesser extent in the DMH), an opposite effect was observed, resembling that in the striatum. The relevance of these opposite variations with regard to the feeding effect of DSLET is discussed. The decreased dopaminergic activity in the LH would appear to be the most specifically related to the behavioural effect given the known role of dopamine in this region. These data reconcile apparently contradictory aspects of the role of dopamine and the functional opposition between the lateral and median hypothalamus in food intake control.

Evaluation of selective actions of dopamine D-1 and D-2 receptor agonists and antagonists on opioid antinociception

The effect of the selective dopamine receptor agonists SKF 38393 (D-1) and quinpirole (D-2) on nociception was studied in the mouse tail immersion test. The D-1 receptor agonist induced mild hyperalgesia whereas the D-2 agonist produced antinociception. Pretreatment with either the selective D-1 receptor antagonist SCH 23390 or the D-2 receptor antagonist (-)-sulpiride converted the hyperalgesia produced by the D-1 agonist into an antinociceptive response whereas the effect of the D-2 receptor agonist was significantly antagonised. The antinociceptive response of selective opioid agonists was also studied in combination with selective dopamine receptor agonists and antagonists. Sufentanil (mu-opioid) antinociception was enhanced in animals pretreated with (-)-sulpiride but not SCH 23390. In animals co-administered sufentanil with SKF 38393 there was a reduced antinociceptive effect whilst quinpirole enhanced the action of sufentanil. Likewise, antinociception induced by the kappa-opioid agonist U50,488H was unaltered in animals pretreated with SCH 23390, increased by (-)-sulpiride, and reduced by SKF 38393. delta-Opioid antinociception induced by [D-Ala2,D-Leu5]enkephaline remained unmodified following pretreatment with either (-)-sulpiride or SCH 23390 but was potentiated in animals which received both the delta-agonist and the D-2 receptor agonist. It is concluded that D-2 receptor agonists not only have intrinsic antinociceptive activity, but can also potentiate opioid-induced antinociception. Similarly, dopamine D-2 receptor antagonists appear to potentiate opioid-induced antinociception in this nociceptive model.

Influences of electrical lesions of the dopaminergic system on morphine- and U-50,488H-induced analgesia in rats

The effects of electrical lesions of brain areas containing dopamine cell bodies and terminals on morphine analgesia were investigated and compared with those of a selective kappa-opioid agonist, U-50,488H. The analgesic effect of morphine 10 mg/kg IP was potentiated significantly in substantia nigra (SN)- or caudate-putamen-lesioned rats, but not by ventral tegmental area (VTA) or nucleus accumbens lesions. However, electrical lesions of neither SN nor VTA affected the analgesic activity of U-50,488H 32 mg/kg IP. Although the tolerance to morphine analgesia developed in all four of the lesioned groups as well as in sham-lesioned rats, a significant analgesic effect in the SN-lesioned group prevailed during chronic treatment for 14 days as compared with that of sham-lesioned rats. From these results, it is suggested that morphine analgesia is potentiated by dysfunction of the nigro-striatal dopaminergic system, but not by that of the mesolimbic dopaminergic system, the central dopaminergic system is not involved in the appearance of U-50,488H analgesia and is not basically related to the development of tolerance to morphine analgesia.

The effect of chronic haloperidol treatment on some cardiovascular parameters in cats

Blood pressure, heart rate and evoked cardiovascular reflexes were examined in cats following chronic treatment with haloperidol, at a dose of 1 mg kg-1 per day, orally for 23 days. Five days after the final dose the animals were anaesthetized and tested for their reaction to various cardiovascular stimuli and to a number of agonist and antagonist drugs, given both intravenously and into the vertebral artery. It was found that treatment with haloperidol caused hypertension in the cats, as well as a potentiation of the pressor response to bilateral carotid occlusion. The response to 30 degrees head-up tilting was also altered so that in treated cats, the blood pressure returned to normal more rapidly during the tilt. There was no difference in the heart rate of the two groups of cats, nor in the pressor response to intravenous noradrenaline or angiotensin II or to afferent brachial nerve stimulation, nor was the depressor action of bradykinin altered. Hexamethonium reduced the blood pressure in both control and treated cats to approximately the same level. Blood O2, CO2, pH and bicarbonate levels were also unaltered by the treatment, as was plasma renin activity. Of the drugs given into the vertebral artery, only noradrenaline, prazosin, ketanserin and haloperidol caused a significantly greater fall in blood pressure in treated than in control cats, while clonidine and St91 were equally effective in both groups. These results suggest that haloperidol treatment has caused a greater modulation of central alpha 1- than of alpha 2-adrenoceptors.

Similarities of the cataleptic state induced by beta-endorphin and morphine

A variety of behavioral tests were used to characterize the cataleptic state induced by various treatments. Besides catalepsy, posture, locomotion, rigidity and the presence of reflexive responses were assessed. Measures of analgesia and body temperature were taken. The behavioral profiles of beta-endorphin, morphine, etonitazene, haloperidol, arecoline and GABA were compared at the time maximal catalepsy scores were obtained. Results indicated that, for an equivalent degree of catalepsy, the profile of beta-endorphin was similar to that of opiates, except for changes in body temperature; beta-endorphin's profile differed markedly from that of haloperidol, arecoline and GABA. Catalepsy was less pronounced with the latter two drugs. There were similarities in the behavioral profile of haloperidol and arecoline.

Neuroleptic and analgesic interactions upon pain and activity measures

Previous data in rats indicate that while dopamine receptor blockers like haloperidol (HAL) potentiate opiate analgesia, dopamine receptor stimulants like apomorphine reduce cold-water swim (CWS) and 2-deoxy-D-glucose (2-DG) analgesia. Yet recently, HAL and chlorpromazine (CBZ) have been shown to reduce heat and immobilization analgesia. To address these differences, the present study investigated whether HAL (10, 50, 100 microgram/kg) or CPZ (1, 3, 5 mg/kg) would potentiate or reduce the effects of morphine (MOR), CWS, 2-DG and chlordiazepoxide (CDP) upon analgesia and activity. While HAL increased jump thresholds in a dose-dependent manner, CPZ doses exerted erratic effects. MOR analgesia was potentiated by the two higher CPZ doses and by the highest HAL dose. 2-DG analgesia was potentiated by only the highest HAL dose while CDP analgesia was potentiated by the moderate CPZ dose. While all CPZ doses potentiated CWS-induced increases in jump thresholds, the lowest HAL dose reduced this effect. These effects are considered in terms of the analgesic manipulation and its magnitude of effect, the neuroleptic and its dose, the pain test, and possible concurrent effects upon activity.