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Moreno AM, Alemán F, Catroli GF, Hunt M, Hu M, Dailamy A, Pla A, Woller SA, Palmer N, Parekh U, McDonald D, Roberts AJ, Goodwill V, Dryden I, Hevner RF, Delay L, Gonçalves Dos Santos G, Yaksh TL, Mali P. Long-lasting analgesia via targeted in situ repression of Na V1.7 in mice. Sci Transl Med 2021; 13:eaay9056. [PMID: 33692134 PMCID: PMC8830379 DOI: 10.1126/scitranslmed.aay9056] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/14/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022]
Abstract
Current treatments for chronic pain rely largely on opioids despite their substantial side effects and risk of addiction. Genetic studies have identified in humans key targets pivotal to nociceptive processing. In particular, a hereditary loss-of-function mutation in NaV1.7, a sodium channel protein associated with signaling in nociceptive sensory afferents, leads to insensitivity to pain without other neurodevelopmental alterations. However, the high sequence and structural similarity between NaV subtypes has frustrated efforts to develop selective inhibitors. Here, we investigated targeted epigenetic repression of NaV1.7 in primary afferents via epigenome engineering approaches based on clustered regularly interspaced short palindromic repeats (CRISPR)-dCas9 and zinc finger proteins at the spinal level as a potential treatment for chronic pain. Toward this end, we first optimized the efficiency of NaV1.7 repression in vitro in Neuro2A cells and then, by the lumbar intrathecal route, delivered both epigenome engineering platforms via adeno-associated viruses (AAVs) to assess their effects in three mouse models of pain: carrageenan-induced inflammatory pain, paclitaxel-induced neuropathic pain, and BzATP-induced pain. Our results show effective repression of NaV1.7 in lumbar dorsal root ganglia, reduced thermal hyperalgesia in the inflammatory state, decreased tactile allodynia in the neuropathic state, and no changes in normal motor function in mice. We anticipate that this long-lasting analgesia via targeted in vivo epigenetic repression of NaV1.7 methodology we dub pain LATER, might have therapeutic potential in management of persistent pain states.
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Affiliation(s)
- Ana M Moreno
- Department of Bioengineering, University of California San Diego, San Diego, CA 92093, USA
| | - Fernando Alemán
- Department of Bioengineering, University of California San Diego, San Diego, CA 92093, USA
| | - Glaucilene F Catroli
- Department of Anesthesiology, University of California San Diego, San Diego, CA 92093, USA
| | - Matthew Hunt
- Department of Anesthesiology, University of California San Diego, San Diego, CA 92093, USA
| | - Michael Hu
- Department of Bioengineering, University of California San Diego, San Diego, CA 92093, USA
| | - Amir Dailamy
- Department of Bioengineering, University of California San Diego, San Diego, CA 92093, USA
| | - Andrew Pla
- Department of Bioengineering, University of California San Diego, San Diego, CA 92093, USA
| | - Sarah A Woller
- Department of Anesthesiology, University of California San Diego, San Diego, CA 92093, USA
| | - Nathan Palmer
- Division of Biological Sciences, University of California San Diego , San Diego, CA 92093, USA
| | - Udit Parekh
- Department of Electrical Engineering, University of California San Diego , San Diego, CA 92093, USA
| | - Daniella McDonald
- Department of Bioengineering, University of California San Diego, San Diego, CA 92093, USA
- Biomedical Sciences Graduate Program, University of California San Diego, San Diego, San Diego, CA 92093, USA
| | - Amanda J Roberts
- Animal Models Core, Scripps Research Institute, La Jolla, CA 92037, USA
| | - Vanessa Goodwill
- Department of Neuropathology, University of California San Diego, San Diego, CA 92093, USA
| | - Ian Dryden
- Department of Neuropathology, University of California San Diego, San Diego, CA 92093, USA
| | - Robert F Hevner
- Department of Neuropathology, University of California San Diego, San Diego, CA 92093, USA
| | - Lauriane Delay
- Department of Anesthesiology, University of California San Diego, San Diego, CA 92093, USA
| | | | - Tony L Yaksh
- Department of Anesthesiology, University of California San Diego, San Diego, CA 92093, USA.
| | - Prashant Mali
- Department of Bioengineering, University of California San Diego, San Diego, CA 92093, USA.
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Karmali RN, Skinner AC, Trogdon JG, Weinberger M, George SZ, Hassmiller Lich K. The association between the supply of select nonpharmacologic providers for pain and use of nonpharmacologic pain management services and initial opioid prescribing patterns for Medicare beneficiaries with persistent musculoskeletal pain. Health Serv Res 2020; 56:275-288. [PMID: 33006158 DOI: 10.1111/1475-6773.13561] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To test the relationship between the supply of select nonpharmacologic providers (physical therapy (PT) and mental health (MH)) and use of nonpharmacologic services among older adults with a persistent musculoskeletal pain (MSP) episode. DATA SOURCES/STUDY SETTING Claims data from a 5 percent random sample of Medicare beneficiaries enrolled fee-for-service (2007-2014) and the Area Health Resource File (AHRF). STUDY DESIGN This retrospective study used generalized estimating equations to estimate the association between the county nonpharmacologic provider supply and individual service use with opioid prescriptions filled during Phase 1 (first three months of an episode) and Phase 2 (three months following Phase 1). DATA COLLECTION/EXTRACTION METHODS We identified beneficiaries (>65 years) with ≥2 MSP diagnoses ≥90 days apart and no opioid prescription six months before the first pain diagnosis (N = 69 456). Beneficiaries' county characteristics were assigned using the AHRF. PRINCIPAL FINDINGS About 13.9 percent of beneficiaries used PT, 1.8 percent used MH services, and 10.7 percent had an opioid prescription during the first three months of a persistent MSP episode. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT/10 000 people/county [aOR: 0.98, 95% CI: 0.97-1.00] was associated with lower odds of filling an opioid prescription in Phase 1. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT use in Phase 1 [aOR: 0.62, 95% CI: 0.58-0.67] were associated with lower odds of filling an opioid prescription in Phase 2. The associations between the supply of providers and nonpharmacologic service use in Phase 1 and Phase 1 opioid prescriptions significantly differed by metropolitan and rural counties (P-value: .019). CONCLUSIONS Limited access to nonpharmacologic services is associated with opioid prescriptions at the onset of a persistent MSP episode. Initiating PT at the onset of an episode may reduce future opioid use. Strategies for engaging beneficiaries in nonpharmacologic services should be tailored for metropolitan and rural counties.
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Affiliation(s)
- Ruchir N Karmali
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA.,Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Asheley C Skinner
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
| | - Steven Z George
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Orthopedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
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Dentino A, Medina R, Steinberg E. Pain in the Elderly: Identification, Evaluation, and Management of Older Adults with Pain Complaints and Pain-related Symptoms. Prim Care 2018; 44:519-528. [PMID: 28797377 DOI: 10.1016/j.pop.2017.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pain is a common and often underappreciated and undermanaged problem in older adults. This article addresses the scope of the issue of pain prevalence in older adults, types of pain and their characteristics, approach to and clinical workup of older adults with pain complaints and pain-related symptoms, nonpharmacologic and pharmacologic management strategies, and caveats with attention to medication side effects in the elderly.
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Affiliation(s)
- Andrew Dentino
- The Donald W. Reynolds Department of Geriatric Medicine, The University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, OK, USA.
| | - Roberto Medina
- The Donald W. Reynolds Department of Geriatric Medicine, The University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, OK, USA
| | - Eugene Steinberg
- The Donald W. Reynolds Department of Geriatric Medicine, The University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, OK, USA
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Thakral M, Shi L, Foust JB, Patel KV, Shmerling RH, Bean JF, Leveille SG. Persistence of pain quality in community-dwelling older adults with chronic non-cancer pain. Geriatr Nurs 2018; 39:450-456. [PMID: 29477646 DOI: 10.1016/j.gerinurse.2018.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/04/2018] [Accepted: 01/08/2018] [Indexed: 02/06/2023]
Abstract
Longitudinal assessment of chronic geriatric pain is complicated by an age-associated plateau in pain severity and increase in widespread pain, calling for innovative measures such as pain quality descriptors that characterize how pain may feel. We characterized persistence of pain quality and its relation to severity, activity interference and distribution of sites, in a population-based sample of adults aged≥70 years with chronic pain (n = 398). Persistent pain quality was defined as reporting descriptors within the same category: sensory, cognitive/affective, or neuropathic at baseline and 18 months. A count variable indicated number of persistent categories. Pain quality was highly persistent. Adjusted for baseline covariates, individuals endorsing 3 persistent categories were 2-2.5x more likely to experience more widespread pain at 18 months compared to fewer persistent categories. No associations were noted in changes in pain severity or interference. A comprehensive pain assessment that includes diverse pain quality descriptors may improve individualized pain management.
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Affiliation(s)
- Manu Thakral
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, WA, USA.
| | - Ling Shi
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Janice B Foust
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Kushang V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Robert H Shmerling
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Rheumatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jonathan F Bean
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Spaulding Rehabilitation Hospital, Boston, MA, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Suzanne G Leveille
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
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