Relationship between hypothalamic-pituitary-adrenal activity and blockade of tolerance to morphine analgesia by pain: a strain comparison

Understanding the toolbox: A mixed methods study of attitudes, barriers and facilitators in parental intervention of children's cancer pain at home

Children with cancer experience pain throughout their cancer trajectory. Pain has short- and long-term negative consequences for children physically and psychologically. Children with cancer spend more time at home with their families and less time in hospital. While this has benefits for quality of life, it shifts responsibility for pain management from healthcare professionals to parents. Little is known about parents' pain management abilities in this setting. This study aimed to understand how parents of children with cancer manage their child's pain at home. A convergent, parallel, mixed methods design including pain diaries, surveys and interviews was used. Participants were parents of children with cancer on active treatment recruited from one tertiary cancer centre. Each data collection method was analysed separately and then integrated. Parents frequently under-medicate their child's pain at home. Practical barriers including the analgesic context and children finding medications unpalatable led parents to prefer non-pharmacological interventions. Attitudinal and practical barriers result in parents having an "empty toolbox" of pharmacological interventions. Consequently non-pharmacological interventions are essential to parents managing their child's cancer pain at home.

The analgesic efficacy of morphine varies with rat strain and experimental pain model: implications for target validation efforts in pain drug discovery

Background

Translating efficacy of analgesic drugs from animal models to humans remains challenging. Reasons are multifaceted, but lack of sufficiently rigorous preclinical study design criteria and phenotypically relevant models may be partly responsible. To begin to address this fundamental issue, we assessed the analgesic efficacy of morphine in three inbred rat strains (selected based on stress reactivity and affective/pain phenotypes), and outbred Sprague Dawley (SD) rats supplied from two vendors.

Methods

Sensitivity to morphine (0.3–6.0 mg/kg, s.c.) was evaluated in the hot plate test of acute thermal nociception, the Complete Freund's Adjuvant (CFA) model of inflammatory‐induced mechanical hyperalgesia, and in a locomotor motility assay in male rats from the following strains; Lewis (LEW), Fischer (F344), Wistar Kyoto (WKY), and SD's from Envigo and Charles River.

Results

F344 and SD rats were similarly sensitive to morphine in hot plate and CFA‐induced inflammatory hyperalgesia (Minimum Effective Dose (MED) = 3.0 mg/kg). WKY rats developed a less robust mechanical hypersensitivity after CFA injection, and were less sensitive to morphine in both pain tests (MED = 6.0 mg/kg). LEW rats were completely insensitive to morphine in the hot plate test, in contrast to the reversal of CFA‐induced hyperalgesia (MED = 3.0 mg/kg). All strains exhibited a dose‐dependent reduction in locomotor activity at 3.0–6.0 mg/kg.

Conclusion

Sensory phenotyping in response to acute thermal and inflammatory‐induced pain, and sensitivity to morphine in various inbred and outbred rat strains indicates that different pathophysiological mechanisms are engaged after injury. This could have profound implications for translating preclinical drug discovery efforts into pain patients.

Significance

The choice of rat strain used in preclinical pain research can profoundly affect the outcome of experiments in relation to (a) nociceptive threshold responses, and (b) efficacy to analgesic treatment, in assays of acute and tonic inflammatory nociceptive pain.

Chronic inflammatory pain does not attenuate the development of tolerance to chronic morphine in adult male rats

The overall impact of chronic pain on the response to opioids is ambiguous in the literature, and comparisons between human and animal studies are complicated by vast differences between the manner and dosage of opioids given to humans treated for pain in comparison to rodents as well as a lack of healthy participant studies examining the impact of chronic opioids. The purpose of this study was to evaluate the impact of chronic pain on the development of tolerance to morphine and to assess how the concentration of drug affects this process. Twenty-four hours after the injection of CFA or normal saline in the left hind paw, the level of mechanical hypersensitivity was assessed and animals were randomly assigned to a morphine dose (1, 3 or 8 mg/kg or saline). Morphine was administered by subcutaneous injection twice a day for 5 days. On Day 6, animals were challenged with a single dose of 3 mg/kg morphine prior to formalin testing. Evidence of tolerance was mixed, and the results varied widely among the conditions. Analysis of mean paw withdrawal thresholds indicated that the analgesic efficacy of subcutaneous morphine diminished following repeated dosing. The presence of the chronic inflammatory pain condition during the morphine dosing period produced an increase in formalin pain behaviors compared to saline controls, such that animals given any dose of morphine during the 5-day dosing period showed higher responding to formalin following the 3 mg/kg dose than animals that had received saline injections. These results indicate that chronic pain does influence the development of opioid tolerance, but it does not prevent this phenomenon from occurring as suggested by some researchers.

A prospective randomized study of corticosteroids as adjuvant drugs to opioids in advanced cancer patients

This randomized controlled study evaluated the role of corticosteroids as adjuvants to opioid therapy in 76 advanced cancer patients with pain who requiring strong opioids. Patients were divided in 2 groups. Group O received conventional opioid treatment. Group OS received dexamethasone (8 mg orally) along with conventional treatment. Pain and symptom intensity, sense of well-being, and opioid escalation index and distress score were recorded at weekly intervals until death. No differences in pain intensity, opioid consumption, and opioid escalation index were found in 66 patients who survived 33 to 37 days. Corticosteroids did not provide significant additional analgesia to opioids, but persistently decreased opioid-related gastrointestinal symptoms for the patients with limited survival and improved the sense of well-being for some weeks. Corticosteroid-related toxicity was minimal. Further studies with an increased sample size are necessary to detect any minimal difference in analgesia between the two groups.

Effects of carrageenan and morphine on acute inflammation and pain in Lewis and Fischer rats

The present study used inbred, histocompatible Fischer 344 (FIS) and Lewis (LEW) rats to begin to explore the role of the hypothalamic-pituitary-adrenal (HPA) axis in the immune processes and pain behavior associated with the carrageenan model of acute hindpaw inflammation. Because the HPA axis contributes in part to morphine's analgesic and immunomodulatory properties, the present study also assessed the effects of morphine in carrageenan-inflamed LEW and FIS rats. The results showed that carrageenan-induced hindpaw swelling and pain behavior were greater in FIS than in LEW rats. The enhanced hindpaw swelling in FIS rats correlated with an increase in myeloperoxidase (MPO; a measure of neutrophils) in the inflamed hindpaw. FIS rats showed lower circulating levels of TNFalpha, higher IL-6 levels, and similar IL-1beta and nitric oxide levels, when compared to LEW rats. Morphine produced a significant decrease in carrageenan-induced hindpaw swelling and MPO in both strains, but morphine did not significantly alter circulating cytokine/mediator levels. Morphine's analgesic effects were greater in the inflamed than the noninflamed hindpaw, and they did not correlate with morphine's anti-inflammatory effects. In fact, low doses of morphine produced a mechanical allodynia and hyperalgesia in the noninflamed hindpaw of FIS, but not LEW, rats. These results suggest a positive relationship between HPA axis activity and acute inflammation and inflammatory pain. In contrast, little evidence is provided for HPA axis involvement in morphine's anti-inflammatory or analgesic effects.

Dexamethasone mimics the inhibitory effect of chronic pain on the development of tolerance to morphine analgesia and compensates for morphine induced changes in G proteins gene expression

It is previously reported that the HPA axis plays role in the inhibitory effect of pain on tolerance development to analgesic effect of opioids. The present study was designed to investigate whether the chronic co-administration of dexamethasone as a glucocorticoid is also able to prevent or reverse analgesic tolerance to morphine and to compare the expression of G(alphai/o) and G(beta) subunits of G proteins in the context of chronic dexamethasone, development of morphine tolerance and their combination. Analgesic tolerance to morphine was induced by chronic intraperitoneally (i.p.) administration of morphine 20 mg/kg to male Wistar rats weighing 200-240 g within 4 consecutive days and analgesia was assessed using tail-flick test. Chronic dexamethasone was applied using 4 daily i.p. injections. Lumbar spinal tissues were assayed for the expression of G(alphai/o) and G(beta) proteins using "semiquantitative PCR" normalized to beta-actin gene expression. Results showed that chronic administration of dexamethasone could reduce and reverse the development of tolerance in rats that received chronic i.p. injections of morphine. Chronic administration of dexamethasone significantly increased the expression of G(alphai/o), while chronic administration of morphine did not change its expression. The expression of G(beta), however, was increased after the chronic administration of morphine, but did not change after the administration of chronic dexamethasone. None of these increases were observed when morphine and dexamethasone were co-administered. We conclude that the development of tolerance to analgesic effect of morphine could be prevented and reversed by dexamethasone co-administration. The increase in G(alphai/o) genes expression produced by chronic dexamethasone may facilitate the opioid signaling pathway and compensate for morphine-induced tolerance.

Inflammation-Susceptible Lewis Rats Show Less Sensitivity Than Resistant Fischer Rats in the Formalin Inflammatory Pain Test and With Repeated Thermal Testing

Comparisons between Lewis and Fischer inbred strains of rats are used frequently to study the effect of inherent differences in function of the hypothalamic-pituitary-adrenal axis on pain-relevant traits, including differential susceptibility to chronic inflammatory disease and differential responsiveness to analgesic drugs. Increasing use of genetic models including transgenic knockout mice and inbred strains of rodents has raised our awareness of, and the importance of, thorough characterization (or phenotyping) of the strains of rodents being compared. Furthermore, genetic variability in analgesic sensitivity is correlated with, and may be caused by, genetically determined baseline sensitivity. Thus in this study, baseline inflammatory and thermal nociceptive sensitivities were measured in awake male and female Lewis and Fischer rats to examine whether the results could explain relevant strain differences reported in the literature. The effect of maternal separation was also examined and no effect was found on nociceptive sensitivity, corticosterone responses, or the development of adjuvant-induced arthritis, a model of rheumatoid arthritis. Lewis rats and female rats were more sensitive to thermal nociception in the tail withdrawal test (mean of 3 trials) than Fischer rats and male rats, respectively. Unexpectedly, the more inflammation-susceptible Lewis rats were less sensitive in the formalin inflammatory nociception test, and showed a significant decrease in sensitivity with repeated thermal nociceptive testing, whereas Fischer rats did not. These results affect the interpretation of previously observed results. Further study of the underlying mechanisms and the relevance to differential susceptibility to chronic inflammation is warranted.

Changes in G proteins genes expression in rat lumbar spinal cord support the inhibitory effect of chronic pain on the development of tolerance to morphine analgesia

There are some reports regarding the inhibitory effect of pain on tolerance development to analgesic effect of opioids. The present study was designed to investigate whether the chronic formalin induced pain is able to reverse analgesic tolerance to morphine and to evaluate the expression of G(alpha i/o) and G(beta) subunits of G proteins in the context of chronic pain, development of morphine tolerance and their combination. Morphine tolerance was induced by chronic systemic (intraperitoneally, i.p.) or spinal (intrathecally, i.t.) administration of morphine to male Wistar rats weighing 200-240 g and analgesia was assessed using tail flick test. Chronic pain was induced by 4 daily intraplantar injections of 50 microl of 5% formalin. Lumbar spinal tissues were assayed for the expression of G(alpha i/o) and G(beta) proteins using "semiquantitative PCR" normalized to beta-actin gene expression. Results showed that chronic formalin induced pain could reduce and reverse the development of tolerance in rats that had received chronic (i.p. or i.t.) administration of morphine. Chronic administration of morphine did not change G(alpha i/o) gene expression, while chronic pain significantly increased its expression. The expression of G(beta), however, was increased after the chronic administration of morphine, but did not change after the induction of chronic pain. None of these increases were observed when morphine and formalin were administered at the same time. Due to synchronous development of morphine tolerance and changes in expression of G(beta), it may be concluded that the development of tolerance to analgesic effect of morphine is partially mediated by increase in G(beta) gene expression. The increase in G(alpha i/o) genes expression produced by chronic pain may facilitate the opioid signaling pathway and compensate for morphine-induced tolerance.

Comparison of the antinociceptive effect of morphine, methadone, buprenorphine and codeine in two substrains of Sprague-Dawley rats

Sprague-Dawley rats from two different vendors, Möllegård, Denmark and B&K Universal, Sweden, have been tested for the antinociceptive effect of morphine, methadone, buprenorphine and codeine on the hot plate. Morphine and methadone had significantly weaker effect in Möllegård rats compare to B&K rats. In contrast, the effect of buprenorphine was stronger in Möllegård rats than in B&K rats and the effect of codeine was similar in the two substrains. Plasma levels of morphine, morphine-6-glucuronide, morphine-3-glucuronide, buprenorphine and norbuprenorphine were determined at two time points after drug injection. Möllegård rats had significantly lower mean plasma level of morphine and significantly higher ratio of morphine-3-glucuronide/morphine at 30 min, compared to B&K rats. No difference was seen for the metabolism of buprenorphine in the two substrains. The results suggest that Möllegård rats metabolize morphine to morphine-3-glucuronide to a greater extent than B&K rats, and this may at least partly underlie the substrain difference in the effect of morphine. It is also suggested that the antinociceptive mechanisms of buprenorphne may be different from those of morphine and methadone.

Dexamethasone modulates the development of morphine tolerance and expression of glutamate transporters in rats

We recently demonstrated an increase in spinal cerebrospinal fluid (CSF) excitatory amino acids (EAAs) in morphine-tolerant rats after morphine challenge. The present study examined whether co-infusion of the glucocorticoid dexamethasone (DEX) co-infusion inhibited morphine tolerance and the morphine challenge-induced EAAs increase after long-term morphine infusion. Intrathecal (i.t.) catheters and one microdialysis probe were implanted to male Wistar rats. Rats were divided into four groups: i.t. morphine (15 microg/h), saline (1 microl/h), DEX (2 microg/h), or DEX (2 microg/h) plus morphine (15 microg/h) infusion for 5 days. Tail-flick responses were examined before drug infusion and daily after the start of infusion for 5 days. Moreover, on day 5 after morphine challenge (50 microg, i.t.), CSF EAAs was also measured. Rat spinal cords were removed on day 5, and prepared for Western blot analysis of different glutamate transporters (GTs). The AD50 (analgesic dose) on day 5 was 1.33 microg in saline-infused rats, 83.84 microg in morphine-tolerant rats, and 10.15 microg in DEX plus morphine co-infused rats. Single DEX (2 microg, i.t.) injection did not enhance morphine's antinociceptive effect in either naïve or morphine-tolerant rats. No difference in CSF EAA level was observed in all groups between baseline (before drug infusion) and on day 5 after tolerance developed. Surprisingly, on day 5, after morphine challenge, an increase in glutamate and aspartate (284+/-47% and 201+/-18% of basal) concentration was observed, and morphine lost its antinociceptive effect (maximum percent effect, MPE = 41+/-12%), whereas DEX/morphine co-infusion inhibited morphine-evoked EAA increase with a MPE = 97+/-2%. DEX co-infusion prevented the downregulation of glial glutamate transporters (GLAST (Glu-Asp transporter) and GLT-1 (Glu transporter-1)), but not the neuronal GT EAAC1 (excitatory amino acid carrier). Upregulation of GLT-1 was also observed (204+/-20% of basal). DEX co-infusion inhibits the morphine-challenge induced EAA increase and prevents the loss of morphine's antinociceptive effect after long-term morphine infusion.

Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial

BACKGROUND

Opioid analgesia is commonly used during neonatal intensive care. We undertook the Neurologic Outcomes and Pre-emptive Analgesia in Neonates (NEOPAIN) trial to investigate whether pre-emptive morphine analgesia decreases the rate of a composite primary outcome of neonatal death, severe intraventricular haemorrhage (IVH), and periventricular leucomalacia (PVL) in preterm neonates.

METHODS

Ventilated preterm neonates (n=898) from 16 centres were randomly assigned masked placebo (n=449) or morphine (n=449) infusions. After a loading dose (100 microg/kg), morphine infusions (23-26 weeks of gestation 10 microg kg(-1) h(-1); 27-29 weeks 20 microg kg(-1) h(-1); 30-32 weeks 30 microg kg(-1) h(-1)) were continued as long as clinically justified (maximum 14 days). Open-label morphine could be given on clinical judgment (placebo group 242/443 [54.6%], morphine group 202/446 [45.3%]). Analyses were by intention to treat.

FINDINGS

Baseline variables were similar in the randomised groups. The placebo and morphine groups had similar rates of the composite outcome (105/408 [26%] vs 115/419 [27%]), neonatal death (47/449 [11%] vs 58/449 [13%]), severe IVH (46/429 [11%] vs 55/411 [13%]), and PVL (34/367 [9%] vs 27/367 [7%]). For neonates who were not given open-label morphine, rates of the composite outcome (53/225 [24%] vs 27/179 [15%], p=0.0338) and severe IVH (19/219 [9%] vs 6/189 [3%], p=0.0209) were higher in the morphine group than the placebo group. Placebo-group neonates receiving open-label morphine had worse rates of the composite outcome than those not receiving open-label morphine (78/228 [34%] vs 27/179 [15%], p<0.0001). Morphine-group neonates receiving open-label morphine were more likely to develop severe IVH (36/190 [19%] vs 19/219 [9%], p=0.0024).

INTERPRETATION

Pre-emptive morphine infusions did not reduce the frequency of severe IVH, PVL, or death in ventilated preterm neonates, but intermittent boluses of open-label morphine were associated with an increased rate of the composite outcome. The morphine doses used in this study decrease clinical signs of pain but can cause significant adverse effects in ventilated preterm neonates.

Strain differences in pain sensitivity and expression of preprodynorphin mRNA in rats following peripheral inflammation

The experience of pain is highly variable among individuals, which may be due in part to the effects of genetic factors on the central transmission and modulation of noxious inputs. This study examined behavioral responses and the expression of preprodynorphin (PPD) mRNA at the spinal level during complete Freund's adjuvant-induced inflammation of the unilateral hind paw in male Fischer 344 (F344), Sprague-Dawley (SD), and Lewis (LEW) rats. Experiments showed that F344 rats exhibited stronger hind paw hyperalgesia and greater spinal PPD mRNA induction than SD or LEW rats. These results indicate that genetic factors that determine the spinal PPD mRNA and dynorphin production underlie strain-dependent differences in pain perception.

Differences of mu-opioid receptors between Lewis and F344 rats

F344 and Lewis rats show different responses to opioids in several experimental paradigms. In this study we have used the specific mu-opioid agonist DAMGO to find out if these differences could be attributed to heterogeneity of mu-opioid receptors. The density of [H3]DAMGO binding sites was similar in the brain cortex and spinal cord of both strains, but DAMGO affinity for mu-opioid receptors was higher in F344 tissues. Moreover, a parallel study of the effects of DAMGO on electrically-evoked twitches of isolated vasa deferentia revealed that this drug was also more effective in F344 preparations. These results suggest that mu-opioid receptors of F344 rats are more sensitive to pharmacological stimulation in vitro, which could be related to a higher drug affinity.

The role of contextual cues on counterirritation in the development process of analgesic tolerance to morphine

Tolerance to morphine analgesia was determined by daily exposing rats either to the same box or different boxes during repeated administration of formalin (2.5%, 0.4 mL/body, sc) and morphine (5 mg/kg, sc). The analgesic effect was determined daily for four consecutive days by exposing rats to either the same box or different boxes, and the process of tolerance development was assessed by a hot plate test (52.5 degrees C). The rats were divided into four groups: one group received formalin and morphine in the same context (Group FM-Same), one group in the different context (Group FM-Diff), one group received saline and morphine in the same context (Group SM-Same), two groups received formalin in the same or different contexts (Groups FS-Same or FS-Diff), and one group received saline in the same context (Group SS-Same). The response latency of Group SM-Same was decreased from Day 2 to a level similar to that of Group SS-Same on Day 4, while that of FM-Same decreased more slowly. The latency of Group FM-Diff maintained the level of Day 2 until Day 4, being significantly longer than that of FM-Same. In the Extinction Phase, all rats received formalin and saline injections in the same box they had been exposed to on Day 1. On the first day, hyperalgesia was evident in Group SM-Same alone. In the Re-test Phase, the rats underwent a second morphine injection, and showed recovery from tolerance. These results indicate that formalin-induced chronic stress pain reduces tolerance development to morphine, and the mutual influence of pain, counterirritation, between formalin and hot-plate, facilitates the effect of contextual cues by inhibiting an associative learning.

Differential antinociception by morphine and methadone in two sub-strains of Sprague-Dawley rats and its potentiation by dextromethorphan

The antinociceptive effect of morphine and methadone was tested in two substrains of Sprague-Dawley (SD) rats, from B&K Universal, Sweden (BK) and Mollegård, Denmark (DK). In both sub-strains of SD rats subcutaneous morphine or methadone produced dose-dependent antinociception on the hot plate test. However, the effect of the opioids was less in DK-SD than BK-SD rats, particularly for morphine as it failed to produce maximal antinociception even at high doses. Dextromethorphan, a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist, potentiated the antinociceptive effect of morphine and methadone in the DK-SD rats. The potentiation of morphine by dextromethorphan was significantly greater than its effect on methadone at equipotent doses. The results showed that there is a sub-strain difference for SD rats in the response to the antinociceptive effect of opioids, which may be due to greater NMDA receptor activity in DK-SD than in BK-SD rats. The higher efficacy of methadone may be derived from its proposed NMDA receptor blocking property and/or high intrinsic activity.

Neurobiology of nitrous oxide-induced antinociceptive effects

Nitrous oxide (N2O), or laughing gas, has been used for clinical anesthesia for more than a century and is still commonly used. While the anesthetic/hypnotic mechanisms of N2O remain largely unknown, the underlying mechanisms of its analgesic/antinociceptive effects have been elucidated during the last several decades. Evidence to date indicate that N2O induces opioid peptide release in the periaqueductal gray area of the midbrain leading to the activation of the descending inhibitory pathways, which results in modulation of the pain/nociceptive processing in the spinal cord. The types of opioid peptide induced by N2O and the subtypes of opioid receptors that mediate the antinociceptive effects of N2O appear to depend on various factors including the species and/or strain, the regions of the brain, and the paradigms of behavior testing used for the experiments. Among three types of descending inhibitory pathways, the descending noradrenergic inhibitory pathway seems to play the most prominent role. The specific elements involved are now being resolved.

The hypothalamic-pituitary-adrenal axis in the pathogenesis of rheumatic diseases

Many studies have demonstrated altered HPA axis activity in patients with rheumatic diseases. In the case of autoimmune inflammatory diseases, circumstantial evidence suggests that failure of the neuroendocrine-immune regulatory loop may lead to insufficient production of endogenous glucocorticoid. Nevertheless, in human autoimmune disease, it is not possible to determine if altered HPA axis activity predates the onset of chronic inflammation. Animal studies and some early genetic studies in RA patients lend credibility to the argument that insufficient HPA axis response to inflammatory stimuli may increase susceptibility to, or severity of, these diseases. Most patients with rheumatic diseases complain of musculoskeletal pain. There is evidence of HPA axis involvement in acute and chronic pain. In the case of FM, pain cannot be explained on the basis of inflammation or altered musculoskeletal anatomy. This has led to the hypothesis that central nervous system mechanisms contribute to the symptom of somatic pain. Again, it is unclear if the observed HPA axis abnormalities reflect pre-existing vulnerability to the FM spectrum of disease, or whether chronic somatic symptoms alter HPA axis activity. Availability of technology to study better central components of the HPA axis may shed further light on its role in the pathogenesis of inflammatory autoimmune rheumatic diseases and musculoskeletal pain syndromes.

HPA axis function and drug addictive behaviors: insights from studies with Lewis and Fischer 344 inbred rats

Much research supports a link between stress and its concomitant hypothalamic-pituitary-adrenal (HPA) axis responses with behavioral sensitivity to psychoactive drugs. Our research demonstrates that Lewis inbred rats more readily acquire drug self-administration than Fischer 344 (F344) inbred rats and, compared to this strain, Lewis rats have hyporesponsive HPA axis responses to stress exposure. This association appears to conflict with investigations using outbred rats and suggests that the relationship between drug sensitivity and HPA axis responsiveness is more complicated than originally thought. It is essential to better understand this relationship because of its relevance to vulnerability and relapse to drug abuse. Thus, this paper reviews the literature in which these two inbred strains have been compared. We discuss strain differences in HPA axis function, in characteristics of the mesolimbic dopamine system, and in behaviors thought to reflect emotionality. Strain differences in unconditioned and conditioned effects of psychoactive drugs are then reviewed. Next, we discuss the possible role of sex and gonadal hormones on responsiveness to psychoactive drugs in these strains. Finally, a comparison of results obtained from these strains to three other comparator groups (e.g., high and low responders) suggests that a non-monotonic relationship between behavioral sensitivity to drugs and HPA axis responsiveness can explain much of the discrepancies in the literature.

The pharmacogenetics of analgesia: toward a genetically-based approach to pain management

Interindividual differences in the experience of pain have been appreciated clinically for over a century. More recently, there has been a growing body of evidence demonstrating differences in analgesic response to various pharmacotherapies, although the source of this variability largely remains to be explained. To this end, basic science research is beginning to identify the allelic variants that underlie such antinociceptive variability using a multiplicity of animal models, and powerful genetic approaches are being exploited to accelerate this process. Although the vast majority of these studies have focused on the pharmacogenetics of opioids, owing to their prominent status as analgesics, the number of pharmacotherapies evincing genetically-based variability is rapidly expanding. In addition, analogous studies have been undertaken in humans, as a small but growing number of clinical trials have begun to evaluate prospectively the existence, if oftentimes not the origin, of interindividual differences in analgesic drug response. Importantly, with a few notable exceptions, such efforts have primarily identified differences in analgesic efficacy and/or potency between male and female human subjects. Looking toward the future development of one or more widely utilised, pharmacogenetic screens that would lead to modifications in treatment planning, at least with respect to the pharmacologic management of pain, this review will document the breadth of genetically-based variability in drug-mediated antinociception in animals. Specific examples in which the gene or genes underlying such variability have been postulated or identified will be given, while highlighting the effect of sex and its interactions with other genetic backgrounds. Finally, we will summarise and evaluate the literature on pharmacogenetic differences in human analgesic drug response, for which the influence of sex has served as one of the better studied and heuristically insightful examples.

Susceptibility to autoimmune disease and drug addiction in inbred rats. Are there mechanistic factors in common related to abnormalities in hypothalamic-pituitary-adrenal axis and stress response function?

DA and LEW inbred rats are extraordinarily susceptible to a wide range of experimental autoimmune diseases. These diseases include rheumatoid arthritis models such as collagen-induced arthritis (CIA) and adjuvant-induced arthritis (AIA), multiple sclerosis models such as myelin-basic-protein (MBP)-induced experimental autoimmune encephalomyelitis (MBP-EAE), and autoimmune uveitis models such as retinal S antigen (SAG) and interphotoreceptor-retinoid-binding-protein (IRBP)-induced experimental autoimmune uveitis (SAG-EAU and IRBP-EAU, respectively). DA and LEW rats are also addiction-prone to various drugs of abuse, such as cocaine. Moreover, they exhibit a variety of behavioral and biochemical characteristics that appear to be related to their susceptibility to addiction. By contrast, F344 and BN rats show quite different phenotypes. They are relatively resistant to CIA, AIA, MBP-EAE, SAG-EAU, and IRBP-EAU, and they are relatively resistant to addiction. Interestingly, both DA and LEW rats, in contrast to F344 and BN rats, have abnormalities in hypothalamic-pituitary-adrenal (HPA) axis function. For example, circadian production of corticosteroids is very abnormal in DA and LEW rats; that is, they exhibit minimal circadian variation in corticosterone levels. Since corticosteroids potentially have significant influences on immune function and autoimmune disease susceptibility and may also influence sensitivity to drugs of abuse, we have begun to dissect genetic control of these various phenotypic differences, focusing initially on the regulation of autoimmune disease expression. Using genomewide scanning techniques involving F2 crosses of DA x F344 (CIA and AIA), DA x BN (CIA), and LEW x F344 [IRBP-EAU and streptococcal-cell-wall arthritis (SCWA)], we have identified, to date, 14 genomic regions [quantitative trait loci (QTL)] that regulate disease expression in these crosses. Development and analysis of QTL-congenic rats involving these loci are in progress and should permit us to address the relationships among autoimmune disease susceptibility, drug addiction, and HPA axis and stress response function. These initial data, however, indicate that the genetic control of the autoimmune disease traits is highly complex.

Opioid poorly-responsive cancer pain. Part 2: basic mechanisms that could shift dose response for analgesia

Basic research in experimental pain models may illuminate the phenomenon of cancer pain that is poorly responsive to opioid drugs. Research findings can be valuable in formulating new strategies in clinical practice. This review evaluated experimental observations in terms of the events that occur in cancer patients receiving opioid therapy for pain.

Pain genes?: natural variation and transgenic mutants

Like many other complex biological phenomena, pain is starting to be studied at the level of the gene. Advances in molecular biological technology have allowed the cloning, mapping, and sequencing of genes, and also the ability to disrupt their function entirely (i.e. via transgenic knockouts). With these new tools at hand, pain researchers have begun in earnest the task of defining (a) which of the 70,000-150,000 mammalian genes are involved in the mediation of pain, and (b) which of the pain-relevant genes are polymorphic, contributing to both natural variation in responses and pathology. Although there are only a few known examples in which single gene mutations in humans are associated with pain conditions (e.g. an inherited form of migraine and congenital insensitivity to pain), it is likely that others will be identified. Concurrently, a variety of genes have been implicated in both the transmission and control of "pain" messages in animals. The present review summarizes current progress to these ends, focusing on both transgenic (gene-->behavior) and classical genetic (behavior-->gene) approaches in both humans and laboratory mice.

All the king's horses and all the king's men: pain management from hospital to home

Pain management in children with cancer continues to be less than adequate in most settings. Children in pain often have multiple caregivers, each imposing a significant risk to adequate pain management if they are uninformed about the principles of pain management and the child's specific pain management regimen. This article reviews current pain management guidelines for children, obstacles to adequate pain management, and the challenges of managing pain across care settings (hospital to home). Using the hospice model of care, case studies are presented that illustrate both threats to adequate pain control and the coordination of care necessary to ensure consistent pain management between the hospital and home. Implications for improvement in pain management between settings and future directions for advancing skills and knowledge related to pain management in children with cancer are provided.

Genetic variability in morphine sensitivity and tolerance between different strains of rats

The development of tolerance, the sensitivity to morphine and the effective morphine plasma concentrations have been studied in Sprague-Dawley (SD-U) and Wistar (W) rats. Daily administration of morphine (10 mg/kg/12 h for 9 days) in W rats produced a reduction in morphine antinociception from day 1 (12+/-0 s) to day 9 (6.7+/-1. 9 s). Morphine antinociception in the SD-U rats did not change over the period of treatment. Naloxone abolished the antinociception of morphine in both opiate naive and chronically treated SD-U rats. The pharmacokinetic parameters of morphine and morphine-3-glucuronide did not differ significantly between strains. Both naive and chronically treated SD-U rats required smaller doses of morphine than W rats to obtain a maximum antinociceptive effect. Plasma concentrations following administration of the same dose of morphine, did not differ between strains or days of treatment. The range of morphine concentrations required to obtain a maximum effect were lower in SD-U rats, both on day 1 and day 8 when compared to W rats. These results show differences between the two strains with regard to both morphine sensitivity and development of tolerance, whilst also suggesting that the differences do not have a kinetic basis.

Differential neuroendocrine responsiveness to morphine in Lewis, Fischer 344, and ACI inbred rats

Preclinical evidence suggests there is a link between the responsiveness to stress and the propensity to self-administer drugs of abuse. Our previous findings, for example, have shown a significant positive correlation between the locomotor response to novelty and the acquisition of morphine self-administration in Lewis (LEW), Fischer 344 (F344) and ACI inbred rat strains. As an extension of this work, we now report on the neuroendocrine responses (i.e., corticosterone and prolactin secretion) evoked by morphine administration in these same inbred strains. Male LEW, F344, and ACI rats were surgically prepared with indwelling jugular catheters 7 days prior to the study. Following a habituation period, rats were treated with i.p. saline or morphine (1, 5 or 10 mg/kg). Repeated blood samples were withdrawn via the catheters immediately before and at 20, 40, 60 and 120 min after injection. Plasma samples were assayed for hormone levels by radioimmunoassay. No differences in baseline corticosterone levels were found across strains. There was a significant effect of genotype on the corticosterone response to saline injection (i.e., mild stress), with F344 rats exhibiting sustained elevations in corticosterone compared to LEW and ACI rats. Morphine-induced stimulation of corticosterone release differed significantly across strains, and in this case LEW rats displayed a reduced sensitivity to morphine. Similar to the corticosterone results, LEW rats also had blunted prolactin responses to morphine when compared to F344 rats. Our data demonstrate that genotype is an important factor modulating the neuroendocrine sensitivity to morphine. It is noteworthy that LEW rats acquire self-administration more rapidly than F344 or ACI rats, yet LEW rats display reduced corticosterone responses to stress and morphine. Taking into account the particular conditions of this study (high i.p. doses used here vs. low i.v. doses in self-administration studies), our results do not suggest that corticosterone response to stress and morphine is related to vulnerability to intravenous opiate self-administration. The data, however, are consistent with the idea of that genetic factors might influence the sensitivity to the morphine-induced effects of glucocorticoids across these inbred strains.

[Mechanisms of opioid tolerance and opioid dependence]

OBJECTIVE

Prescription of opiates to non cancer chronic pain patients is controversial, partly because of the risk of tolerance and dependence development. The two objectives of that review were: a) to identify the factors which may explain the variability of tolerance and dependence in clinical practice; b) to analyse the cellular mechanisms of occurrence of those phenomenons.

DATA SOURCES AND EXTRACTION

To our own file, we added articles retrieved in the Medline database, using, alone or in combination, following key-words (opiate, tolerance, dependence, opiate receptor, pain treatment, cAMP, cGMP, NO, NMDA, protein kinase, gene). Out of nearly 450 articles, we selected less than 200.

DATA SYNTHESIS

Tolerance, defined as loss of opioid efficacy with time, is extremely variable and depends on pain mechanisms, intrinsic efficacy and administration modality of the opioid, as well as co-administration of other agents. Physical dependence is a consequence of the intrinsic and extrinsic adaptations concerning structures as locus coeruleus, paragigantocellular nucleus, spinal cord. Acute and chronic application of opiates and withdrawal give rise to cellular adaptations which depend on the nature and efficacy of the opiate, the type of receptor and second messengers, as well as the type of cell line under study. These cellular mechanisms have consequences on neuronal excitability and gene expression. They constitute a model of cellular tolerance and dependence, but cannot explain the subtelties encountered in clinical practice.

The genetic mediation of individual differences in sensitivity to pain and its inhibition

The underlying bases of the considerable interindividual variability in pain-related traits are starting to be revealed. Although the relative importance of genes versus experience in human pain perception remains unclear, rodent populations display large and heritable differences in both nociceptive and analgesic sensitivity. The identification and characterization of particularly divergent populations provides a powerful initial step in the genetic analysis of pain, because these models can be exploited to identify genes contributing to the behavior-level variability. Ultimately, DNA sequence differences representing the differential alleles at pain-relevant genes can be identified. Thus, by using a combination of "top-down" and "bottom-up" strategies, we are now able to genetically dissect even complex biological traits like pain. The present review summarizes the current progress toward these ends in both humans and rodents.

Tolerance to morphine-induced antinociception is decreased by chronic sucrose or polycose intake

Chronic intake of palatable fluids alters morphine-induced antinociception. Two experiments were conducted to evaluate how long-term access to palatable fluids alters the development of tolerance to morphine-induced antinociception. In Experiment 1, 40 adult male Long-Evans rats were used. In addition to ad lib chow and water, 10 rats were given a 0.15% saccharin solution, 10 were given a 32% sucrose solution, and 10 were given a 32% Polycose solution to drink for 3 weeks. Ten rats were given chow and water alone, and served as dietary controls. Morphine-induced antinociception was assessed using the radiant-heat tail-flick method (TF). Half of the animals in each dietary condition were given preexposure to 7.5 mg/kg morphine; the other half received saline. All rats were given a TF 30-min postinjection. To determine whether tolerance developed, a cumulative dose paradigm (0.625, 1.25, 2.5, 5.0, 10.0 mg/kg) was employed 1 week after initial morphine injections, and was repeated at weekly intervals for 3 weeks. Antinociception was significantly lower in rats preexposed to morphine relative to rats preexposed to saline. Although all rats displayed decreased antinociception relative to the first morphine injection, rats that drank saccharin showed greater reductions in morphine-induced antinociception relative to rats that drank sucrose or Polycose. Experiment 2 was conducted to determine whether initial pairing of the TF with morphine preexposure produced differences in the development of opioid tolerance. All conditions and procedures were identical to Experiment 1, except that the initial morphine and saline injections were not followed by TF. As in Experiment 1, rats that drank saccharin showed less antinociception than rats that drank sucrose or Polycose. The present results suggest that long-term intake of palatable nutritive solutions curbs tolerance to morphine-induced antinociception, whereas long-term intake of a nonnutritive, sweet saccharin solution does not.

Genetic differences in the antinociceptive effect of morphine and its potentiation by dextromethorphan in rats

The effect of the non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist dextromethorphan on morphine-induced antinociception was studied with the hot plate test in Sprague-Dawley (SD), Wistar-Kyoto (WK), Spontaneously Hypertensive (SHR) and Dark-Agouti (DA) rats. Subcutaneous morphine at 5 mg/kg induced significant antinociception in all four rats strains. Subcutaneous dextromethorphan at 15 and 45 mg/kg, but not 5 mg/kg, significantly and dose-dependently potentiated morphine-induced antinociception in SDs, WKs and SHRs, but not in DAs. In SHRs and DAs the antinociceptive effect of morphine was followed by prolonged hyperalgesia, which was reduced (SHRs) or abolished (DAs) by dextromethorphan. These results suggest that there are significant differences among rat strains in their response to morphine and in the ability of dextromethorphan to potentiate morphine-induced antinociception. These differences are possibly of genetic origin. Moreover, these data show that morphine, at least in some strains of rats, induced a delayed and NMDA receptor-dependent hyperalgesic response, supporting the notion that administration of opiates may activate NMDA receptors, leading to reduced antinociceptive effect and the development of hyperalgesia.

Central modulation of pain perception

The information presented in this article provides a basis for individual variability in the sensation of pain and the behavioral correlates associated with pain. The knowledge of pain-inhibitory and pain-facilitating pathways linked to cognitive, emotional, and stress-response systems leads to a greater understanding of the complexities of the experience of pain. Appreciation of the influence of these higher centers should lead to improvements in the clinical management of pain.

Genetic differences in morphine sensitivity, tolerance and withdrawal in rats

Significant genetic differences in the endogenous opioid system and in response to a variety of noxious stimuli are present in rodents. We now compared the response to noxious heat with the hot plate test, morphine sensitivity and the development of tolerance and dependence to morphine in spontaneously hypertensive (SHR), Wistar-Kyoto (WK) and Sprague-Dawley (SD) rats. Significant differences were observed in basal nociception among the three strains, where SHRs were hypoalgesic compared to WK and SD. The antinociceptive effect of morphine varied among strains (SD>SHR>WK) as did the rate of tolerance development (10 mg/kg morphine 2/day for 4 days) where WK>SD=SHR. SHR rats developed hyperalgesia following morphine administration during the course of tolerance development. Furthermore, although naloxone (2 mg/kg) precipitated withdrawal symptoms in all tolerant rats, the panorama of symptoms varied among the three strains. Thus, there are significant genetic differences in a variety of effect of opiates.

Chronic running-wheel activity decreases sensitivity to morphine-induced analgesia in male and female rats

The effects of exercise on morphine-induced analgesia were examined in male and female Long-Evans rats. In Experiment 1, 10 male rats were housed in standard laboratory cages, and 10 in activity wheels for 20 days prior to nociceptive testing. Pain thresholds were assessed using a tail-flick (TF) procedure. Morphine sulfate was administered using a cumulative dosing procedure (2.5, 5.0, 7.5, 10.0, 12.5, and 15.0 mg/kg). TF latencies were measured immediately prior to and 30 min following each injection. In Experiment 2, morphine-induced analgesia was examined in females in an identical manner to that of Experiment 1. Additionally, to determine if the attenuation of morphine-induced analgesia was permanent or reversible, after the initial test nociceptive test, previously active female rats were placed in standard cages, and previously inactive females placed in running wheels for 17 days prior to a second nociceptive test. Baseline TF latencies were significantly shorter in active male rats than in inactive animals. Additionally, both active male and female rats displayed decreased morphine-induced analgesia relative to inactive controls. Moreover, females that had been inactive and then were permitted to run showed a suppression in morphine-induced analgesia relative to presently inactive rats, and to their own nociceptive responses when sedentary. In contrast, morphine-induced analgesia in initially active females who were housed in standard cages during part 2 of Experiment 2 was enhanced relative to their first nociceptive test and to presently active rats. Experiment 3 examined the effects of short-term (24 h) running on antinociception. Baseline TF latencies were shorter in active rats than inactive rats. However, no differences in morphine-induced analgesia were observed as a function of short-term exposure to exercise. Experiment 4 investigated whether differences in body weight contributed to the differences in morphine-induced analgesia between chronically active and inactive animals. %MPEs did not vary among male rats maintained at 100, 85, or 77% of their free-feeding body weight. These results indicate that chronic activity can decrease morphine's analgesic properties. These effects may be due to crosstolerance between endogenous opioid peptides released during exercise and exogenous opioids.

Involvement of NMDA receptors and voltage-dependent calcium channels on augmentation of long-term potentiation in hippocampal CA1 area of morphine dependent rats

The involvement of NMDA receptors and voltage-dependent calcium channels on augmentation of long-term potentiation (LTP) was investigated at the Schaffer collateral-CA1 pyramidal cell synapses in hippocampal slices of morphine dependent rats, using primed-bursts tetanic stimulation. The amplitude of population spike was measured as an index of increase in postsynaptic excitability. d, l-AP5 and nifedipine were used as NMDA receptor antagonist and voltage-dependent calcium channel blocker, respectively. The amount of LTP of orthodromic population spike amplitude was higher in slices from dependent rats. Perfusion of slices from control or dependent rats with ACSF containing either D,L-AP5 (25 microM) or nifedipine (10 microM) and delivering tetanic stimulation, showed that D,L-AP5 completely blocked LTP of OPS in slices from both control and dependent rats, while nifedipine attenuated the amount of LTP of OPS in dependent slices and had no effect on control ones. The results suggest that the enhanced LTP of OPS in the CA1 area of hippocampal slices from morphine dependent rats is primarily induced by the NMDA receptors activity and the voltage-dependent calcium channels may also be partially involved in the phenomenon.

Psychoneuroimmunological correlates of persisting sciatic pain in patients who underwent discectomy

Patients suffering from persisting sciatic pain 8 weeks following discectomy were compared with patients displaying low complaints and healthy, pain-free volunteers regarding their interleukin-6 (IL-6) levels, morning cortisol levels and degree of psychological distress. Whereas serum concentrations of IL-6 were measured by collecting blood samples between 0945 and 2400 h in intervals of 45 min, morning cortisol levels were obtained by sampling saliva on five ensuing measurements, beginning immediately after awakening. In addition, questionnaires aimed at measuring depressive mood, somatic symptoms, coping and chronic stress were filled out by the subjects. The patients with ongoing pain displayed significantly elevated IL-6 levels and an attenuated elevation of cortisol secretion after awakening compared to the two other groups. Patients with persisting pain were also suffering more frequently from depressive mood and ongoing work-related strains. In addition, maladaptive coping strategies were favoured by these patients. The presented data support the hypothesis that the persistence of pain in many of the concerned patients may significantly be related to dysfunctional reciprocal relations between neural, endocrine and immune function.

Strain differences in adrenergic sensitivity of neuropathic pain behaviors in an experimental rat model

The aim of this study was to examine and delineate the differences in adrenergic sensitivity of mechanical allodynic behavior among various strains of rats. Neuropathic injury was produced by tight ligation of the L5 and L6 spinal nerves in several strains of rats. The degree of mechanical allodynic behavior was estimated by measuring the mechanical threshold for paw flinching with von Frey filaments. Adrenergic sensitivity of the allodynic behavior was resolved by measuring changes of the mechanical threshold after intraperitoneal injection of phentolamine, an alpha-adrenergic receptor antagonist. Injection of phentolamine caused a significant but small increase in the thresholds for paw flinching in rats of most of the tested strains; however, in Lewis rats, the resulting threshold increase was extensive enough to eliminate allodynic behavior almost completely. It is concluded that there is a difference in adrenergic sensitivity to mechanical allodynic behavior among different strains of neuropathic rats. In particular, rats of the Lewis strain were extremely sensitive to systemic injection of an alpha-adrenergic receptor blocker.

Augmentation of LTP induced by primed-bursts tetanic stimulation in hippocampal CA1 area of morphine dependent rats

The effects of chronic morphine administration on the development of Long-term potentiation (LTP) were investigated at the Schaffer collateral-CA1 pyramidal cell synapses of the rat hippocampal slices using primed-bursts tetanic stimulation. Significant enhancement of orthodromic population spike (OPS) was found for all stimulus intensities after tetanic stimulation. OPS enhancement was greatest when tested with low to mid-range stimulus intensities (25 and 50 microA). There was also significant decrease in OPS delay. These responses were similar in slices from both control and morphine dependent rats. At all delivered stimulus intensities, the amount of LTP of OPS in slices from dependent rats was larger than that of control slices. However, these differences in LTP of OPS were significant at low stimulus intensities. These findings suggest that chronic morphine administration had induced changes in CA1 neurocircuitry which modulated synaptic plasticity during high frequency stimulation and appeared as augmented LTP.

The role of corticosterone in the blockade of tolerance to morphine analgesia by formalin-induced pain in the rat

We previously reported that morphine fails to produce analgesic tolerance when administered in the presence of formalin-induced pain, which may be related to activity of the hypothalamic-pituitary-adrenal axis. In the present study, we examined whether suppression of corticosterone secretion during pain prevents the blockade of tolerance to morphine analgesia. Male Long-Evans rats were injected with morphine (20 mg/kg) or saline for 4 consecutive days in the presence or absence of formalin-induced pain. To suppress corticosterone activity, some animals were injected daily with the corticosterone synthesis inhibitor, metyrapone (100 mg/kg), 24 h and 30 min before formalin injections. The analgesic effect of a test dose of morphine (10 mg/kg) was then measured in the tail-flick test 24 h after tolerance induction (i.e. day 5). The presence of pain during tolerance induction prevented the development of analgesic tolerance. Furthermore, inhibition of corticosterone synthesis by metyrapone prevented the blockade of tolerance by pain. These results suggest that the blockade of tolerance to morphine analgesia by formalin-induced pain depends on stress-induced corticosterone increases.

Blockade of tolerance to stress-induced analgesia by MK-801 in mice

The N-methyl-D-aspartate (NMDA) receptor has been implicated in mechanisms of tolerance to morphine-induced analgesia. The present study examined the role of the NMDA receptor in the development of tolerance to stress-induced analgesia (SIA). In the first experiment, mice were exposed to a stressor (a 3-min forced swim in water maintained at 32 degrees C) once daily for 15 consecutive days. Analgesia was measured 2 min after stress on the first and last day using the hot-plate test. To examine the role of the NMDA receptor in the development of tolerance to SIA mice were treated daily with the non-competitive NMDA receptor antagonist, MK-801, 15 min before swimming. Pretreatment with MK-801 was found to block both analgesia and tolerance. In a second experiment, to examine whether SIA and tolerance to SIA are mediated by similar or different mechanisms, mice were injected daily with MK-801 after analgesia had dissipated (1 h following swim). Tolerance to SIA was blocked by delayed injections of MK-801. These results suggest that the NMDA receptor is involved in mechanisms of tolerance to SIA, independent of its role in analgesia.