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Martucci KT. Neuroimaging of opioid effects in humans across conditions of acute administration, chronic pain therapy, and opioid use disorder. Trends Neurosci 2024; 47:418-431. [PMID: 38762362 PMCID: PMC11168870 DOI: 10.1016/j.tins.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/01/2024] [Accepted: 04/21/2024] [Indexed: 05/20/2024]
Abstract
Evidence of central nervous system (CNS) exogenous opioid effects in humans has been primarily gained through neuroimaging of three participant populations: individuals after acute opioid administration, those with opioid use disorder (OUD), and those with chronic pain receiving opioid therapy. In both the brain and spinal cord, opioids alter processes of pain, cognition, and reward. Opioid-related CNS effects may persist and accumulate with longer opioid use duration. Meanwhile, opioid-induced benefits versus risks to brain health remain unclear. This review article highlights recent accumulating evidence for how exogenous opioids impact the CNS in humans. While investigation of CNS opioid effects has remained largely disparate across contexts of opioid acute administration, OUD, and chronic pain opioid therapy, integration across these contexts may enable advancement toward effective interventions.
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Affiliation(s)
- Katherine T Martucci
- Human Affect and Pain Neuroscience Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Center for Translational Pain Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Institute for Brain Sciences, Duke University, Durham, NC, USA.
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2
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Hecht JS, Moore KLJ, Roberts RF. Individuals With Prior Chronic Pain and Long-Term Opioid Treatment May Experience Persistence of That Pain Even After Subsequent Complete Cervical Spinal Cord Injury: Suggestions From a Prospective Case-Controlled Study. Arch Rehabil Res Clin Transl 2024; 6:100338. [PMID: 39006114 PMCID: PMC11240028 DOI: 10.1016/j.arrct.2024.100338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Objective To determine whether chronic pain persists after complete spinal cord injury (SCI). Design Prospective observational study regarding the outcome of pre-existent chronic pain of inpatients admitted with new clinically diagnosed complete cervical SCI. For patients who acknowledged chronic pain of ≥3 years duration before the SCI, further questions explored whether they still experienced that pain, whether they were experiencing current posttraumatic pain, and whether they had any past exposure to opioids. The included patients were identified during the initial consultation in the trauma center for treatment of the SCI. Setting Level I trauma center. Participants From a total of 49 participants with acute cervical SCI with clinically diagnosed complete motor and sensory tetraplegia admitted between 2018 and 2020, 7 were selected on the basis of a history of chronic pain. Intervention Collected complete history and performed physical examination with serial follow-ups during the acute hospital stay until death or discharge. Main Outcome Measures The primary outcome was a finding of chronic pain experienced before new clinical diagnosis of complete SCI, compared with whether or not that pain continued after the SCI injury. The secondary outcome was the relation of persistent pain with opioid use; it was formulated after data collection. Results Among 49 patients with clinically diagnosed complete cervical SCIs, 7 had experienced prior chronic pain. Four participants experienced a continuation of the prior pain after their complete tetraplegia (4/7), whereas 3 participants did not (3/7). All the participants with continued pain had been previously treated with opioids, whereas those whose pain ceased had not received chronic opioid therapy. Conclusions There may be a unique form of chronic pain that is based in the brain, irrespective of peripheral pain or spinal mechanisms. Otherwise healthy people with longstanding antecedent chronic pain whose pain persists after acute clinically complete SCI with tetraplegia may provide a new model for evaluation of brain-based pain. Opioids may be requisite for this type of pain.
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Affiliation(s)
- Jeffrey S. Hecht
- Division of Surgical Rehabilitation, Department of Surgery, University of Tennessee, Knoxville, Knoxville, Tennessee, United States
| | - Kyle L. Johnson Moore
- Office of Research, University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Roy F. Roberts
- Division of Trauma, Department of Surgery, University of Tennessee, Knoxville, Knoxville, Tennessee, United States
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3
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Koller D, Friligkou E, Stiltner B, Pathak GA, Løkhammer S, Levey DF, Zhou H, Hatoum AS, Deak JD, Kember RL, Treur JL, Kranzler HR, Johnson EC, Stein MB, Gelernter J, Polimanti R. Pleiotropy and genetically inferred causality linking multisite chronic pain to substance use disorders. Mol Psychiatry 2024:10.1038/s41380-024-02446-3. [PMID: 38355787 DOI: 10.1038/s41380-024-02446-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Abstract
Individuals suffering from chronic pain develop substance use disorders (SUDs) more often than others. Understanding the shared genetic influences underlying the comorbidity between chronic pain and SUDs will lead to a greater understanding of their biology. Genome-wide association statistics were obtained from the UK Biobank for multisite chronic pain (MCP, Neffective = 387,649) and from the Million Veteran Program and the Psychiatric Genomics Consortium meta-analyses for alcohol use disorder (AUD, Neffective = 296,974), cannabis use disorder (CanUD, Neffective = 161,053), opioid use disorder (OUD, Neffective = 57,120), and problematic tobacco use (PTU, Neffective = 270,120). SNP-based heritability was estimated for each of the traits and genetic correlation (rg) analyses were performed to assess MCP-SUD pleiotropy. Bidirectional Mendelian Randomization analyses evaluated possible causal relationships. Finally, to identify and characterize individual loci, we performed a genome-wide pleiotropy analysis and a brain-wide analysis using imaging phenotypes available from the UK Biobank. MCP was positively genetically correlated with AUD (rg = 0.26, p = 7.55 × 10-18), CanUD (rg = 0.37, p = 8.21 × 10-37), OUD (rg = 0.20, p = 1.50 × 10-3), and PTU (rg = 0.29, p = 8.53 × 10-12). Although the MR analyses supported bi-directional relationships, MCP had larger effects on AUD (pain-exposure: beta = 0.18, p = 8.21 × 10-4; pain-outcome: beta = 0.07, p = 0.018), CanUD (pain-exposure: beta = 0.58, p = 2.70 × 10-6; pain-outcome: beta = 0.05, p = 0.014) and PTU (pain-exposure: beta = 0.43, p = 4.16 × 10-8; pain-outcome: beta = 0.09, p = 3.05 × 10-6) than the reverse. The genome-wide analysis identified two SNPs pleiotropic between MCP and all SUD investigated: IHO1 rs7652746 (ppleiotropy = 2.69 × 10-8), and CADM2 rs1248857 (ppleiotropy = 1.98 × 10-5). In the brain-wide analysis, rs7652746 was associated with multiple cerebellum and amygdala imaging phenotypes. When analyzing MCP pleiotropy with each SUD separately, we found 25, 22, and 4 pleiotropic variants for AUD, CanUD, and OUD, respectively. To our knowledge, this is the first large-scale study to provide evidence of potential causal relationships and shared genetic mechanisms underlying MCP-SUD comorbidity.
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Affiliation(s)
- Dora Koller
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA.
- Department of Genetics, Microbiology, and Statistics, Faculty of Biology, University of Barcelona, Catalonia, Spain.
| | - Eleni Friligkou
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
| | - Brendan Stiltner
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
| | - Gita A Pathak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
| | - Solveig Løkhammer
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- NORMENT, Department of Clinical Science, University of Bergen, Bergen, Norway
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway
| | - Daniel F Levey
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
| | - Hang Zhou
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
| | - Alexander S Hatoum
- Department of Psychological and Brain Sciences, Washington University in Saint Louis, St. Louis, MO, USA
| | - Joseph D Deak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
| | - Rachel L Kember
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Mental Illness Research, Education and Clinical Center, Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Jorien L Treur
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henry R Kranzler
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Mental Illness Research, Education and Clinical Center, Veterans Integrated Service Network 4, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Emma C Johnson
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, USA
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Joel Gelernter
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
- Wu Tsai Institute, Yale University, New Haven, CT, USA
| | - Renato Polimanti
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
- Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA.
- Wu Tsai Institute, Yale University, New Haven, CT, USA.
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4
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Gerrans P. Pain suffering and the self. An active allostatic inference explanation. Neurosci Conscious 2024; 2024:niae002. [PMID: 38348334 PMCID: PMC10860504 DOI: 10.1093/nc/niae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 01/06/2024] [Accepted: 01/16/2024] [Indexed: 02/15/2024] Open
Abstract
Distributed processing that gives rise to pain experience is anchored by a multidimensional self-model. I show how the phenomenon of pain asymbolia and other atypical pain-related conditions (Insensitivity to Pain, Chronic Pain, 'Social' Pain, Insensitivity to Pain, Chronic Pain, 'Social' Pain, empathy for pain and suffering) can be explained by this idea. It also explains the patterns of association and dissociation among neural correlates without importing strong modular assumptions. It treats pain processing as a species of allostatic active inference in which the mind co-ordinates its processing resources to optimize basic bodily functioning at different time scales. The self is inferred to be source and target of regulation in this process. The self-modelling account reconciles conflicting deaffectualization and depersonalization accounts of pain asymbolia by showing how depersonalization and pain asymbolia arise at different levels of hierarchical self modelling.
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Affiliation(s)
- Philip Gerrans
- Department of Philosophy, University of Adelaide, Adelaide, SA, Australia
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5
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Komisaruk BR, Del Cerro MCR, Goldstein I. Orgasm utilizes the pain pathway: is orgasm "nonaversive pain"? Sex Med Rev 2023; 11:291-295. [PMID: 37635366 DOI: 10.1093/sxmrev/qead037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023]
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6
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Rigatti M, Chapman B, Chai PR, Smelson D, Babu K, Carreiro S. Digital Biomarker Applications Across the Spectrum of Opioid Use Disorder. COGENT MENTAL HEALTH 2023; 2:2240375. [PMID: 37546179 PMCID: PMC10399596 DOI: 10.1080/28324765.2023.2240375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/17/2023] [Indexed: 08/08/2023]
Abstract
Opioid use disorder (OUD) is one of the most pressing public health problems of the past decade, with over eighty thousand overdose related deaths in 2021 alone. Digital technologies to measure and respond to disease states encompass both on- and off-body sensors. Such devices can be used to detect and monitor end-user physiologic or behavioral measurements (i.e. digital biomarkers) that correlate with events of interest, health, or pathology. Recent work has demonstrated the potential of digital biomarkers to be used as a tools in the prevention, risk mitigation, and treatment of opioid use disorder (OUD). Multiple physiologic adaptations occur over the course of opioid use, and represent potential targets for digital biomarker based monitoring strategies. This review explores the current evidence (and potential) for digital biomarkers monitoring across the spectrum of opioid use. Technologies to detect opioid administration, withdrawal, hyperalgesia and overdose will be reviewed. Driven by empirically derived algorithms, these technologies have important implications for supporting the safe prescribing of opioids, reducing harm in active opioid users, and supporting those in recovery from OUD.
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Affiliation(s)
- Marc Rigatti
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Brittany Chapman
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Peter R Chai
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - David Smelson
- Department of Psychiatry, UMass Chan Medical School, Worcester, MA, USA
| | - Kavita Babu
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Stephanie Carreiro
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA, USA
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7
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Swain JE, Ho SS. Brain circuits for maternal sensitivity and pain involving anterior cingulate cortex among mothers receiving buprenorphine treatment for opioid use disorder. J Neuroendocrinol 2023; 35:e13316. [PMID: 37491982 DOI: 10.1111/jne.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 07/27/2023]
Abstract
Opioid-induced deficits in maternal behaviors are well-characterized in rodent models. Amid the current epidemic of opioid use disorder (OUD), prevalence among pregnant women has risen sharply. Yet, the roles of buprenorphine replacement treatment for OUD (BT/OUD) in the brain functions of postpartum mothers are unclear. Using functional magnetic resonance imaging (fMRI), we have developed an evolutionarily conserved maternal behavior neurocircuit (MBN) model to study human maternal care versus defensive/aggressive behaviors critical to mother-child bonding. The anterior cingulate gyrus (ACC) is not only involved in the MBN for mother-child bonding and attachment, but also part of an opioid sensitive "pain-matrix". The literature suggests that prescription opioids produce physical and emotional "analgesic" effects by disrupting specific resting-state functional connectivity (rs-FC) of ACC to regions related to MBN. Thus, in this longitudinal study, we report findings of overlapping MBN and pain matrix circuits, for mothers with chronic exposure of BT/OUD. A total of 32 mothers were studied with 6 min rs-FC at 1 month (T1) and 4 months postpartum (T2), including seven on BT/OUD and 25 non-BT/OUD mothers as a comparison group. We analyzed rs-FC between the insula, putamen, and the dorsal anterior cingulate cortex (DACC) and rostral ACC (RACC), as the regions of interest that mediate opioid analgesia. BT/OUD mothers, as compared to non-BT/OUD mothers, showed less left insula-RACC rs-FC but greater right putamen-DACC rs-FC at T1, with these between-group differences diminished at T2. Some of these rs-FC results were correlated with the scores of postpartum parental bonding questionnaire. We found time-by-treatment interaction effects on DACC and RACC-dependent rs-FC, potentially identifying brain mechanisms for beneficial effects of BT, normalizing dysfunction of maternal brain and behavior over the first four months postpartum. This study complements recent studies to ascertain how BT/OUD affects maternal behaviors, mother-child bonding, and intersubjectivity and reveals potential MBN/pain-matrix targets for novel interventions.
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Affiliation(s)
- James E Swain
- Department of Psychiatry and Behavioral Health, Renaissance School Of Medicine at Stony Brook University, Stony Brook, New York, USA
- Department of Psychology, Program in Public Health, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
- Department of Obstetrics, Gynecology and Reproductive Medicine, Program in Public Health, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - S Shaun Ho
- Department of Psychiatry and Behavioral Health, Renaissance School Of Medicine at Stony Brook University, Stony Brook, New York, USA
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8
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Deng M, Zou W. Noncoding RNAs: Novel Targets for Opioid Tolerance. Curr Neuropharmacol 2023; 21:1202-1213. [PMID: 36453497 PMCID: PMC10286586 DOI: 10.2174/1570159x21666221129122932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 10/12/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022] Open
Abstract
As a global health problem, chronic pain is one of the leading causes of disability, and it imposes a huge economic and public health burden on families and society. Opioids represent the cornerstone of analgesic drugs. However, opioid tolerance caused by long-term application of opioids is a major factor leading to drug withdrawal, serious side effects caused by dose increases, and even the death of patients, placing an increasing burden on individuals, medicine, and society. Despite efforts to develop methods to prevent and treat opioid tolerance, no effective treatment has yet been found. Therefore, understanding the mechanism underlying opioid tolerance is crucial for finding new prevention and treatment strategies. Noncoding RNAs (ncRNAs) are important parts of mammalian gene transcriptomes, and there are thousands of unique noncoding RNA sequences in cells. With the rapid development of high-throughput genome technology, research on ncRNAs has become a hot topic in biomedical research. In recent years, studies have shown that ncRNAs mediate physiological and pathological processes, including chromatin remodeling, transcription, posttranscriptional modification and signal transduction, which are key regulators of physiological processes in developmental and disease environments and have become biomarkers and potential therapeutic targets for various diseases. An increasing number of studies have found that ncRNAs are closely related to the development of opioid tolerance. In this review, we have summarized the evidence that ncRNAs play an important role in opioid tolerance and that ncRNAs may be novel targets for opioid tolerance.
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Affiliation(s)
- Meiling Deng
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wangyuan Zou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
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9
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Jin Y, Mao Y, Chen D, Tai Y, Hu R, Yang CL, Zhou J, Chen L, Liu X, Gu E, Jia C, Zhang Z, Tao W. Thalamocortical circuits drive remifentanil-induced postoperative hyperalgesia. J Clin Invest 2022; 132:158742. [PMID: 36519547 PMCID: PMC9754001 DOI: 10.1172/jci158742] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022] Open
Abstract
Remifentanil-induced hyperalgesia (RIH) is a severe but common postoperative clinical problem with elusive underlying neural mechanisms. Here, we discovered that glutamatergic neurons in the thalamic ventral posterolateral nucleus (VPLGlu) exhibited significantly elevated burst firing accompanied by upregulation of Cav3.1 T-type calcium channel expression and function in RIH model mice. In addition, we identified a glutamatergic neuronal thalamocortical circuit in the VPL projecting to hindlimb primary somatosensory cortex glutamatergic neurons (S1HLGlu) that mediated RIH. In vivo calcium imaging and multi-tetrode recordings revealed heightened S1HLGlu neuronal activity during RIH. Moreover, preoperative suppression of Cav3.1-dependent burst firing in VPLGlu neurons or chemogenetic inhibition of VPLGlu neuronal terminals in the S1HL abolished the increased S1HLGlu neuronal excitability while alleviating RIH. Our findings suggest that remifentanil induces postoperative hyperalgesia by upregulating T-type calcium channel-dependent burst firing in VPLGlu neurons to activate S1HLGlu neurons, thus revealing an ion channel-mediated neural circuit basis for RIH that can guide analgesic development.
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Affiliation(s)
- Yan Jin
- Stroke Center and Department of Neurology and,Department of Anesthesiology and Pain Medicine, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, USTC, Hefei, China
| | - Yu Mao
- Stroke Center and Department of Neurology and,Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Danyang Chen
- Department of Anesthesiology and Pain Medicine, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, USTC, Hefei, China
| | - Yingju Tai
- Department of Anesthesiology and Pain Medicine, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, USTC, Hefei, China
| | - Rui Hu
- Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chen-Ling Yang
- Department of Physiology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Jing Zhou
- Department of head, neck, and breast Surgery, Western district of the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, USTC, Hefei, China
| | - Lijian Chen
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xuesheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Erwei Gu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chunhui Jia
- Department of Anesthesiology and Pain Medicine, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, USTC, Hefei, China
| | - Zhi Zhang
- Department of Anesthesiology and Pain Medicine, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, USTC, Hefei, China
| | - Wenjuan Tao
- Stroke Center and Department of Neurology and,Department of Physiology, School of Basic Medical Sciences, Anhui Medical University, Hefei, China
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10
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Tan LL, Kuner R. Neocortical circuits in pain and pain relief. Nat Rev Neurosci 2021; 22:458-471. [PMID: 34127843 DOI: 10.1038/s41583-021-00468-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 02/07/2023]
Abstract
The sensory, associative and limbic neocortical structures play a critical role in shaping incoming noxious inputs to generate variable pain perceptions. Technological advances in tracing circuitry and interrogation of pathways and complex behaviours are now yielding critical knowledge of neocortical circuits, cellular contributions and causal relationships between pain perception and its abnormalities in chronic pain. Emerging insights into neocortical pain processing suggest the existence of neocortical causality and specificity for pain at the level of subdomains, circuits and cellular entities and the activity patterns they encode. These mechanisms provide opportunities for therapeutic intervention for improved pain management.
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Affiliation(s)
- Linette Liqi Tan
- Institute of Pharmacology, Heidelberg University, Heidelberg, Germany.
| | - Rohini Kuner
- Institute of Pharmacology, Heidelberg University, Heidelberg, Germany.
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11
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Gan Z, Li H, Naser PV, Oswald MJ, Kuner R. Suppression of neuropathic pain and comorbidities by recurrent cycles of repetitive transcranial direct current motor cortex stimulation in mice. Sci Rep 2021; 11:9735. [PMID: 33958647 PMCID: PMC8102487 DOI: 10.1038/s41598-021-89122-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/12/2021] [Indexed: 11/16/2022] Open
Abstract
Transcranial, minimally-invasive stimulation of the primary motor cortex (M1) has recently emerged to show promise in treating clinically refractory neuropathic pain. However, there is a major need for improving efficacy, reducing variability and understanding mechanisms. Rodent models hold promise in helping to overcome these obstacles. However, there still remains a major divide between clinical and preclinical studies with respect to stimulation programs, analysis of pain as a multidimensional sensory-affective-motivational state and lack of focus on chronic phases of established pain. Here, we employed direct transcranial M1 stimulation (M1 tDCS) either as a single 5-day block or recurring blocks of repetitive stimulation over early or chronic phases of peripherally-induced neuropathic pain in mice. We report that repeated blocks of stimulation reverse established neuropathic mechanical allodynia more strongly than a single 5-day regime and also suppress cold allodynia, aversive behavior and anxiety without adversely affecting motor function over a long period. Activity mapping revealed highly selective alterations in the posterior insula, periaqueductal gray subdivisions and superficial spinal laminae in reversal of mechanical allodynia. Our preclinical data reveal multimodal analgesia and improvement in quality of life by multiple blocks of M1 tDCS and uncover underlying brain networks, thus helping promote clinical translation.
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Affiliation(s)
- Zheng Gan
- Institute of Pharmacology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany
| | - Han Li
- Institute of Pharmacology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany
| | - Paul Vincent Naser
- Institute of Pharmacology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany
| | - Manfred Josef Oswald
- Institute of Pharmacology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany
| | - Rohini Kuner
- Institute of Pharmacology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.
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12
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An Investigation into Proteomic Constituents of Cerebrospinal Fluid in Patients with Chronic Peripheral Neuropathic Pain Medicated with Opioids- a Pilot Study. J Neuroimmune Pharmacol 2020; 16:634-650. [PMID: 33219474 DOI: 10.1007/s11481-020-09970-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/30/2020] [Indexed: 12/25/2022]
Abstract
The pharmacodynamics of opioids for chronic peripheral neuropathic pain are complex and likely extend beyond classical opioid receptor theory. Preclinical evidence of opioid modulation of central immune signalling has not been identified in vivo in humans. Examining the cerebrospinal fluid (CSF) of patients medicated with opioids is required to identify potential pharmacodynamic mechanisms. We compared CSF samples of chronic peripheral neuropathic pain patients receiving opioids (n = 7) versus chronic peripheral neuropathic pain patients not taking opioids (control group, n = 13). Baseline pain scores with demographics were recorded. Proteome analysis was performed using mass spectrometry and secreted neuropeptides were measured by enzyme-linked immunosorbent assay. Based on Gene Ontology analysis, proteins involved in the positive regulation of nervous system development and myeloid leukocyte activation were increased in patients taking opioids versus the control group. The largest decrease in protein expression in patients taking opioids were related to neutrophil mediated immunity. In addition, notably higher expression levels of neural proteins (85%) and receptors (80%) were detected in the opioid group compared to the control group. This study suggests modulation of CNS homeostasis, possibly attributable to opioids, thus highlighting potential mechanisms for the pharmacodynamics of opioids. We also provide new insights into the immunomodulatory functions of opioids in vivo.
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Gerrans P. Pain Asymbolia as Depersonalization for Pain Experience. An Interoceptive Active Inference Account. Front Psychol 2020; 11:523710. [PMID: 33192765 PMCID: PMC7658103 DOI: 10.3389/fpsyg.2020.523710] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/10/2020] [Indexed: 02/05/2023] Open
Abstract
"Mineness," also called "subjective presence" or "personalization," is the feeling that experiences belong to a continuing self. This article argues that mineness is produced by processes of interoceptive active inference that model the self as the underlying cause of continuity and coherence in affective experience. A key component of this hierarchical processing system and hub of affective self-modeling is activity in the anterior insula cortex. I defend the account by applying it to the phenomenon of pain asymbolia, a condition in which nociceptive signals (of bodily damage) are not attributed to the self. Thus, pain asymbolia is a form of "depersonalization for pain" as Klein puts it. The pain is experienced as happening to my body but is not experienced as mine. Thus, we can describe it as loss of subjective presence or "mineness" for the experience of pain.
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Affiliation(s)
- Philip Gerrans
- Department of Philosophy, University of Adelaide, Adelaide, SA, Australia
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14
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Response to “Treating patients rather than their functional neuroimages” (Br J Anaesth 2018; 121: 969–71). Br J Anaesth 2019; 123:e166-e171. [DOI: 10.1016/j.bja.2019.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/14/2019] [Accepted: 01/21/2019] [Indexed: 11/23/2022] Open
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15
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Calvo F, Almada RC, Dos Anjos-Garcia T, Falconi-Sobrinho LL, Paschoalin-Maurin T, Bazaglia-de-Sousa G, Medeiros P, Silva JAD, Lobão-Soares B, Coimbra NC. Panicolytic-like effect of µ 1-opioid receptor blockade in the inferior colliculus of prey threatened by Crotalus durissus terrificus pit vipers. J Psychopharmacol 2019; 33:577-588. [PMID: 30663473 DOI: 10.1177/0269881118822078] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The endogenous opioid peptide system has been implicated in the neural modulation of fear and anxiety organised by the dorsal midbrain. Furthermore, previous results indicate a fundamental role played by inferior colliculus (IC) opioid mechanisms during the expression of defensive behaviours, but the involvement of the IC µ1-opioid receptor in the modulation of anxiety- and panic attack-related behaviours remains unclear. Using a prey-versus-snake confrontation paradigm, we sought to investigate the effects of µ1-opioid receptor blockade in the IC on the defensive behaviour displayed by rats in a dangerous situation. METHODS Specific pathogen-free Wistar rats were treated with microinjection of the selective µ1-opioid receptor antagonist naloxonazine into the IC at different concentrations (1.0, 3.0 and 5.0 µg/0.2 µL) and then confronted with rattlesnakes ( Crotalus durissus terrificus). The defensive behavioural repertoire, such as defensive attention, flat back approach (FBA), startle, defensive immobility, escape or active avoidance, displayed by rats either during the confrontations with wild snakes or during re-exposure to the experimental context without the predator was analysed. RESULTS The blockade of µ1-opioid receptors in the IC decreased the expression of both anxiety-related behaviours (defensive attention, FBA) and panic attack-related responses (startle, defensive immobility and escape) during the confrontation with rattlesnakes. A significant decrease in defensive attention was also recorded during re-exposure of the prey to the experimental apparatus context without the predator. CONCLUSION Taken together, these results suggest that a decrease in µ1-opioid receptor signalling activity within the IC modulates anxiety- and panic attack-related behaviours in dangerous environments.
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Affiliation(s)
- Fabrício Calvo
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,2 Department of Pharmacology, São Lucas College, Porto Velho (RO), Brazil.,3 Aparício Carvalho Integrative College (FIMCA), Porto Velho (RO), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil
| | - Rafael Carvalho Almada
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil
| | - Tayllon Dos Anjos-Garcia
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,6 NAP-USP-Neurobiology of Emotions Research Centre (NuPNE), University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil
| | - Luiz Luciano Falconi-Sobrinho
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil.,6 NAP-USP-Neurobiology of Emotions Research Centre (NuPNE), University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil
| | - Tatiana Paschoalin-Maurin
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil
| | - Guilherme Bazaglia-de-Sousa
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil.,6 NAP-USP-Neurobiology of Emotions Research Centre (NuPNE), University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil
| | - Priscila Medeiros
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil
| | - Juliana Almeida da Silva
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil.,6 NAP-USP-Neurobiology of Emotions Research Centre (NuPNE), University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil
| | - Bruno Lobão-Soares
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil.,7 Department of Biophysics and Pharmacology, Federal University of Rio Grande do Norte (UFRN), Natal (RN), Brazil
| | - Norberto Cysne Coimbra
- 1 Department of Pharmacology, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil.,4 Ophidiarium LNN-FMRP-USP/INeC, University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brasil.,5 Behavioural Neurosciences Institute (INeC), Ribeirão Preto (SP), Brazil.,6 NAP-USP-Neurobiology of Emotions Research Centre (NuPNE), University of São Paulo (FMRP-USP), Ribeirão Preto (SP), Brazil
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Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia-when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Lancet 2019; 393:1558-1568. [PMID: 30983591 DOI: 10.1016/s0140-6736(19)30430-1] [Citation(s) in RCA: 268] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/21/2018] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
Abstract
Opioids are a mainstay of acute pain management but can have many adverse effects, contributing to problematic long-term use. Opioid tolerance (increased dose needed for analgesia) and opioid-induced hyperalgesia (paradoxical increase in pain with opioid administration) can contribute to both poorly controlled pain and dose escalation. Hyperalgesia is particularly problematic as further opioid prescribing is largely futile. The mechanisms of opioid tolerance and hyperalgesia are complex, involving μ opioid receptor signalling pathways that offer opportunities for novel analgesic alternatives. The intracellular scaffold protein β-arrestin-2 is implicated in tolerance, hyperalgesia, and other opioid side-effects. Development of agonists biased against recruitment of β-arrestin-2 could provide analgesic efficacy with fewer side-effects. Alternative approaches include inhibition of peripheral μ opioid receptors and blockade of downstream signalling mechanisms, such as the non-receptor tyrosine kinase Src or N-methyl-D-aspartate receptors. Furthermore, it is prudent to use multimodal analgesic regimens to reduce reliance on opioids during the perioperative period. In the third paper in this Series we focus on clinical and mechanism-based understanding of tolerance and opioid-induced hyperalgesia, and discuss current and future strategies for pain management.
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Affiliation(s)
- Lesley A Colvin
- Division of Population Health and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
| | - Fiona Bull
- Institute for Academic Anaesthesia, Division of Systems Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Tim G Hales
- Institute for Academic Anaesthesia, Division of Systems Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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Abstract
Persistent, in particular neuropathic pain affects millions of people worldwide. However, the response rate of patients to existing analgesic drugs is less than 50%. There are several possibilities to increase this response rate, such as optimization of the pharmacokinetic and pharmacodynamic properties of analgesics. Another promising approach is to use prognostic biomarkers in patients to determine the optimal pharmacological therapy for each individual. Here, we discuss recent efforts to identify plasma and CSF biomarkers, as well as genetic biomarkers and sensory testing, and how these readouts could be exploited for the prediction of a suitable pharmacological treatment. Collectively, the information on single biomarkers may be stored in knowledge bases and processed by machine-learning and related artificial intelligence techniques, resulting in the optimal pharmacological treatment for individual pain patients. We highlight the potential for biomarker-based individualized pain therapies and discuss biomarker reliability and their utility in clinical practice, as well as limitations of this approach.
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18
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Lin WY, Chu WH, Chao THH, Sun WZ, Yen CT. Longitudinal FDG-PET scan study of brain changes in mice with cancer-induced bone pain and after morphine analgesia. Mol Pain 2019; 15:1744806919841194. [PMID: 30868934 PMCID: PMC6492350 DOI: 10.1177/1744806919841194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/14/2019] [Accepted: 02/20/2019] [Indexed: 01/21/2023] Open
Abstract
Morphine is the most commonly used drug for treating physical and psychological suffering caused by advanced cancer. Although morphine is known to elicit multiple supraspinal analgesic effects, its behavioral correlates with respect to the whole-brain metabolic activity during cancer-induced bone pain have not been elucidated. We injected 4T1 mouse breast cancer cells into the left femur bone marrow cavity of BALB/c mice. All mice developed limb use deficits, mechanical allodynia, and hypersensitivity to cold, which were effectively suppressed with morphine. Serial 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) was performed for each mouse before cancer induction (0 day), after cancer-induced bone pain was established (14 days), and during effective morphine treatment (16 days). The longitudinal FDG-PET imaging analysis demonstrated that cancer-induced bone pain increased glucose uptake in the insular cortex and hypothalamus and decreased the activity of the retrosplenial cortex. Morphine reversed the activation of the insular cortex and hypothalamus. Furthermore, morphine activated the amygdala and rostral ventromedial medulla and suppressed the activity of anterior cingulate cortex. Our findings of hypothalamic and insular cortical activation support the hypothesis that cancer-induced bone pain has strong inflammatory and affective components in freely moving animals. Morphine may provide descending inhibitory and facilitatory actions in the treatment of cancer-induced bone pain in a clinical setting.
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Affiliation(s)
- Wen-Ying Lin
- Department of Life Science, National Taiwan University,
Taipei
- Department of Anesthesiology, National Taiwan University
Hospital, Taipei
- National Taiwan University Cancer Center, National Taiwan
University College of Medicine, Taipei
| | - Wen-Hua Chu
- Department of Life Science, National Taiwan University,
Taipei
| | | | - Wen-Zen Sun
- Department of Anesthesiology, National Taiwan University
Hospital, Taipei
| | - Chen-Tung Yen
- Department of Life Science, National Taiwan University,
Taipei
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20
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Allegri N, Mennuni S, Rulli E, Vanacore N, Corli O, Floriani I, De Simone I, Allegri M, Govoni S, Vecchi T, Sandrini G, Liccione D, Biagioli E. Systematic Review and Meta‐Analysis on Neuropsychological Effects of Long‐Term Use of Opioids in Patients With Chronic Noncancer Pain. Pain Pract 2018; 19:328-343. [DOI: 10.1111/papr.12741] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 09/05/2018] [Accepted: 10/05/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Nicola Allegri
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
| | | | - Eliana Rulli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Nicola Vanacore
- IRCCS Mondino Foundation Pavia Italy
- National Centre of Epidemiology National Institute of Health Rome Italy
| | - Oscar Corli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Irene Floriani
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Irene De Simone
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Massimo Allegri
- Pain Therapy Service Policlinico Monza Monza Italy
- Italian Pain Group Milan Italy
| | - Stefano Govoni
- Department of Drug Sciences University of Pavia Pavia Italy
| | - Tomaso Vecchi
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
- IRCCS Mondino Foundation Pavia Italy
| | - Giorgio Sandrini
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
- IRCCS Mondino Foundation Pavia Italy
| | - Davide Liccione
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
| | - Elena Biagioli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
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Webster L, Diva U, Tummala R, Sostek M. Treatment with Naloxegol Versus Placebo: Pain Assessment in Patients with Noncancer Pain and Opioid-Induced Constipation. Pain Pract 2017; 18:505-514. [PMID: 28898536 DOI: 10.1111/papr.12640] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/18/2017] [Accepted: 09/06/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To summarize results from pain and opioid use assessments with naloxegol in adults with opioid-induced constipation (OIC) and chronic noncancer pain. METHODS Two phase 3 randomized, double-blind, 12-week studies evaluated the efficacy and safety of oral naloxegol (12.5 or 25 mg daily) in adults (18 to < 85 years) with confirmed OIC and chronic noncancer pain: KODIAC-04 (NCT01309841) and KODIAC-05 (NCT01323790). Pain level was assessed daily (11-point numeric rating scale [NRS]; 0 = no pain, 10 = worst imaginable pain). Changes from baseline in mean weekly pain scores and opioid dose (weeks 1 through 12) were analyzed using mixed-model repeated measures. RESULTS At baseline, mean daily NRS average pain scores ranged from 4.5 to 4.8 for all groups in KODIAC-04 (N = 652) and were 4.6 for each group in KODIAC-05 (N = 700). Respective mean ± SD changes from baseline average pain for placebo, naloxegol 12.5 mg, and naloxegol 25 mg were -0.2 ± 1.07, -0.3 ± 1.05 (P = 0.773 vs. placebo), and 0.2 ± 0.95 (P = 0.837 vs. placebo; KODIAC-04) and -0.1 ± 0.94, -0.1 ± 0.87 (P = 0.744), and 0.0 ± 1.18 (P = 0.572; KODIAC-05). At baseline, mean daily opioid doses ranged from 135.6 to 143.2 morphine equivalent units (MEUs)/day in KODIAC-04, and from 119.9 to 151.7 MEUs/day in KODIAC-05. Respective mean ± SD changes from baseline dose were -1.8 ± 30.19, -2.3 ± 20.52 (P = 0.724 vs. placebo), and 0.4 ± 13.01 (P = 0.188 vs. placebo; KODIAC-04) and -0.3 ± 17.14, -1.3 ± 17.11 (P = 0.669 vs. placebo), and 0.1 ± 8.54 (P = 0.863 vs. placebo; KODIAC-05). Changes in maintenance opioid dose were few; reasons for such changes were similar across treatment groups. CONCLUSION Centrally mediated opioid analgesia was maintained during treatment with naloxegol in patients with noncancer pain and OIC.
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Affiliation(s)
- Lynn Webster
- PRA Health Sciences, Salt Lake City, Utah, U.S.A
| | - Ulysses Diva
- Bioinformatics and Information Sciences, AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland, U.S.A
| | - Raj Tummala
- Global Medicines Development, AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland, U.S.A
| | - Mark Sostek
- Global Medicines Development, AstraZeneca Pharmaceuticals LP, Gaithersburg, Maryland, U.S.A
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DosSantos MF, Moura BDS, DaSilva AF. Reward Circuitry Plasticity in Pain Perception and Modulation. Front Pharmacol 2017; 8:790. [PMID: 29209204 PMCID: PMC5702349 DOI: 10.3389/fphar.2017.00790] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 10/19/2017] [Indexed: 12/30/2022] Open
Abstract
Although pain is a widely known phenomenon and an important clinical symptom that occurs in numerous diseases, its mechanisms are still barely understood. Owing to the scarce information concerning its pathophysiology, particularly what is involved in the transition from an acute state to a chronic condition, pain treatment is frequently unsatisfactory, therefore contributing to the amplification of the chronic pain burden. In fact, pain is an extremely complex experience that demands the recruitment of an intricate set of central nervous system components. This includes cortical and subcortical areas involved in interpretation of the general characteristics of noxious stimuli. It also comprises neural circuits that process the motivational-affective dimension of pain. Hence, the reward circuitry represents a vital element for pain experience and modulation. This review article focuses on the interpretation of the extensive data available connecting the major components of the reward circuitry to pain suffering, including the nucleus accumbens, ventral tegmental area, and the medial prefrontal cortex; with especial attention dedicated to the evaluation of neuroplastic changes affecting these structures found in chronic pain syndromes, such as migraine, trigeminal neuropathic pain, chronic back pain, and fibromyalgia.
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Affiliation(s)
- Marcos F. DosSantos
- Laboratório de Morfogênese Celular, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Brenda de Souza Moura
- Programa de Pós-Graduação em Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alexandre F. DaSilva
- Headache and Orofacial Pain Effort, Department of Biologic and Materials Sciences, School of Dentistry, Center for Human Growth and Development, Molecular and Behavioral Neuroscience Institute, University of Michigan, Ann Arbor, MI, United States
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Goulooze SC, Krekels EH, van Dijk M, Tibboel D, van der Graaf PH, Hankemeier T, Knibbe CA, van Hasselt JC. Towards personalized treatment of pain using a quantitative systems pharmacology approach. Eur J Pharm Sci 2017; 109S:S32-S38. [DOI: 10.1016/j.ejps.2017.05.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 02/08/2023]
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Manhapra A, Arias AJ, Ballantyne JC. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Subst Abus 2017; 39:152-161. [PMID: 28929914 DOI: 10.1080/08897077.2017.1381663] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In response to the opioid epidemic and new guidelines, many patients on high-dose long term opioid therapy (LTOT) for chronic pain are getting tapered off opioids. As a result, a unique clinical challenge is emerging: while many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking. METHODS We offer a commentary with our perspective on possible mechanisms involved in this clinical phenomena and offer practical management guidance, supported by available evidence. RESULTS It is not well recognized that allostatic opponent process involved in development of opioid dependence can cause worsening pain, functional status, sleep and psychiatric symptoms over time, and significant fluctuation of pain and other affective symptoms due to their bidirectional dynamic interaction with opioid dependence ('affective dynamism'). These elements of complex persistent dependence (CPD), the grey area between simple dependence and addiction, can lead to escalating and labile opioid need, often generating aberrant behaviors. Opioid tapering, a seemingly logical intervention in this situation, may lead to worsening of pain, function and psychiatric symptoms due to development of protracted abstinence syndrome. We offer practicing clinicians management principles and practical guidance focused on management of CPD in addition to chronic pain in these difficult clinical scenarios. CONCLUSION Awareness of the science of the neuroplasticity effects of repeated use of opioids is necessary to better manage these patients with complex challenges.
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Affiliation(s)
- Ajay Manhapra
- a VA New England Mental Illness Research and Education Center , West Haven , Connecticut , USA.,b Advanced Pact Pain Clinic, VA Hampton Medical Center , Hampton , Virginia , USA.,c Department of Psychiatry , Yale School of Medicine , New Haven , Connecticut , USA
| | - Albert J Arias
- a VA New England Mental Illness Research and Education Center , West Haven , Connecticut , USA.,c Department of Psychiatry , Yale School of Medicine , New Haven , Connecticut , USA
| | - Jane C Ballantyne
- d Department of Anesthesiology and Pain Medicine , University of Washington School of Medicine , Seattle , Washington , USA
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NALBUPHINE-INDUCED SUBMICROSCOPIC CHANGES IN THE COMPONENTS OF THE THYMUS VASCULAR BED. WORLD OF MEDICINE AND BIOLOGY 2017. [DOI: 10.26724/2079-8334-2017-4-62-111-116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kringel D, Lötsch J. Next-generation sequencing of human opioid receptor genes based on a custom AmpliSeq™ library and ion torrent personal genome machine. Clin Chim Acta 2016; 463:32-38. [PMID: 27725223 PMCID: PMC5352731 DOI: 10.1016/j.cca.2016.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/12/2016] [Accepted: 10/07/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The opioid system is involved in the control of pain, reward, addictive behaviors and vegetative effects. Opioids exert their pharmacological actions through the agonistic binding at opioid receptors and variation in the coding genes has been found to modulate opioid receptor expression or signaling. However, a limited selection of functional opioid receptor variants is perceived as insufficient in providing a genetic diagnosis of clinical phenotypes and therefore, unrestricted access to opioid receptor genetics is required. METHODS Next-generation sequencing (NGS) workflow was based on a custom AmpliSeq™ panel and designed for sequencing of human genes related to the opioid receptor group (OPRM1, OPRD1, OPRK1, SIGMA1, OPRL1) on an Ion PGM™ Sequencer. A cohort of 79 previously studied chronic pain patients was screened to evaluate and validate the detection of exomic sequences of the coding genes with 25 base pair exon padding. In-silico analysis was performed using SNP and Variation Suite® software. RESULTS The amplicons covered approximately 90% of the target sequence. A median of 2.54×106 reads per run was obtained generating a total of 35,447 nucleotide reads from each DNA sample. This identified approximately 100 chromosome loci where nucleotides deviated from the reference sequence GRCh37 hg19, including functional variants such as the OPRM1 rs1799971 SNP (118 A>G) as the most scientifically regarded variant or rs563649 SNP coding for μ-opioid receptor splice variants. Correspondence between NGS and Sanger derived nucleotide sequences was 100%. CONCLUSION Results suggested that the NGS approach based on AmpliSeq™ libraries and Ion PGM sequencing is a highly efficient mutation detection method. It is suitable for large-scale sequencing of opioid receptor genes. The method includes the variants studied so far for functional associations and adds a large amount of genetic information as a basis for complete analysis of human opioid receptor genetics and its functional consequences.
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Affiliation(s)
- Dario Kringel
- Institute of Clinical Pharmacology, Goethe - University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörn Lötsch
- Institute of Clinical Pharmacology, Goethe - University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project Group Translational Medicine and Pharmacology TMP, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.
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Hubbard CS, Becerra L, Heinz N, Ludwick A, Rasooly T, Wu R, Johnson A, Schechter NL, Borsook D, Nurko S. Abdominal Pain, the Adolescent and Altered Brain Structure and Function. PLoS One 2016; 11:e0156545. [PMID: 27244227 PMCID: PMC4886967 DOI: 10.1371/journal.pone.0156545] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 05/16/2016] [Indexed: 12/22/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder of unknown etiology. Although relatively common in children, how this condition affects brain structure and function in a pediatric population remains unclear. Here, we investigate brain changes in adolescents with IBS and healthy controls. Imaging was performed with a Siemens 3 Tesla Trio Tim MRI scanner equipped with a 32-channel head coil. A high-resolution T1-weighted anatomical scan was acquired followed by a T2-weighted functional scan. We used a surface-based morphometric approach along with a seed-based resting-state functional connectivity (RS-FC) analysis to determine if groups differed in cortical thickness and whether areas showing structural differences also showed abnormal RS-FC patterns. Patients completed the Abdominal Pain Index and the GI Module of the Pediatric Quality of Life Inventory to assess abdominal pain severity and impact of GI symptoms on health-related quality of life (HRQOL). Disease duration and pain intensity were also assessed. Pediatric IBS patients, relative to controls, showed cortical thickening in the posterior cingulate (PCC), whereas cortical thinning in posterior parietal and prefrontal areas were found, including the dorsolateral prefrontal cortex (DLPFC). In patients, abdominal pain severity was related to cortical thickening in the intra-abdominal area of the primary somatosensory cortex (SI), whereas HRQOL was associated with insular cortical thinning. Disease severity measures correlated with cortical thickness in bilateral DLPFC and orbitofrontal cortex. Patients also showed reduced anti-correlations between PCC and DLPFC compared to controls, a finding that may reflect aberrant connectivity between default mode and cognitive control networks. We are the first to demonstrate concomitant structural and functional brain changes associated with abdominal pain severity, HRQOL related to GI-specific symptoms, and disease-specific measures in adolescents with IBS. It is possible such changes will be responsive to therapeutic intervention and may be useful as potential markers of disease progression or reversal.
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Affiliation(s)
- Catherine S. Hubbard
- Center for Pain and the Brain, Boston Children’s Hospital, Waltham, Massachusetts, United States of America
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Lino Becerra
- Center for Pain and the Brain, Boston Children’s Hospital, Waltham, Massachusetts, United States of America
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Nicole Heinz
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Allison Ludwick
- Center for Pain and the Brain, Boston Children’s Hospital, Waltham, Massachusetts, United States of America
| | - Tali Rasooly
- Center for Pain and the Brain, Boston Children’s Hospital, Waltham, Massachusetts, United States of America
| | - Rina Wu
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Adriana Johnson
- Center for Pain and the Brain, Boston Children’s Hospital, Waltham, Massachusetts, United States of America
| | - Neil L. Schechter
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, United States of America
| | - David Borsook
- Center for Pain and the Brain, Boston Children’s Hospital, Waltham, Massachusetts, United States of America
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
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Rauschecker JP, May ES, Maudoux A, Ploner M. Frontostriatal Gating of Tinnitus and Chronic Pain. Trends Cogn Sci 2016; 19:567-578. [PMID: 26412095 DOI: 10.1016/j.tics.2015.08.002] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/04/2015] [Accepted: 08/07/2015] [Indexed: 12/18/2022]
Abstract
Tinnitus and chronic pain are sensory-perceptual disorders associated with negative affect and high impact on well-being and behavior. It is now becoming increasingly clear that higher cognitive and affective brain systems are centrally involved in the pathology of both disorders. We propose that the ventromedial prefrontal cortex and the nucleus accumbens are part of a central 'gatekeeping' system in both sensory modalities, a system which evaluates the relevance and affective value of sensory stimuli and controls information flow via descending pathways. If this frontostriatal system is compromised, long-lasting disturbances are the result. Parallels in both systems are striking and mutually informative, and progress in understanding central gating mechanisms might provide a new impetus to the therapy of tinnitus and chronic pain.
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Affiliation(s)
- Josef P Rauschecker
- Department of Neuroscience, Georgetown University Medical Center, Washington, DC, USA; Department of Neurology and TUM-Neuroimaging Center, Technische Universität München, Munich, Germany; Institute for Advanced Study, Technische Universität München, Munich, Germany.
| | - Elisabeth S May
- Department of Neurology and TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
| | - Audrey Maudoux
- Department of Neuroscience, Georgetown University Medical Center, Washington, DC, USA
| | - Markus Ploner
- Department of Neurology and TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
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Molecular switches of the κ opioid receptor triggered by 6'-GNTI and 5'-GNTI. Sci Rep 2016; 6:18913. [PMID: 26742690 PMCID: PMC4705513 DOI: 10.1038/srep18913] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 11/30/2015] [Indexed: 12/29/2022] Open
Abstract
The κ opioid receptor (κOR) is a member of G-protein-coupled receptors, and is considered as a promising drug target for treating neurological diseases. κOR selective 6'-GNTI was proved to be a G-protein biased agonist, whereas 5'-GNTI acts as an antagonist. To investigate the molecular mechanism of how these two ligands induce different behaviors of the receptor, we built two systems containing the 5'-GNTI-κOR complex and the 6'-GNTI-κOR complex, respectively, and performed molecular dynamics simulations of the two systems. We observe that transmembrane (TM) helix 6 of the κOR rotates about 4.6(o) on average in the κOR-6'-GNTI complex. Detailed analyses of the simulation results indicate that E297(6.58) and I294(6.55) play crucial roles in the rotation of TM6. In the simulation of the κOR-5'-GNTI system, it is revealed that 5'-GNTI can stabilize TM6 in the inactive state form. In addition, the kink of TM7 is stabilized by a hydrogen bond between S324(7.47) and the residue V69(1.42) on TM1.
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30
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Abuse-Deterrent Opioid Formulations: Pharmacokinetic and Pharmacodynamic Considerations. Clin Pharmacokinet 2015; 55:751-767. [DOI: 10.1007/s40262-015-0362-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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31
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Navratilova E, Atcherley CW, Porreca F. Brain Circuits Encoding Reward from Pain Relief. Trends Neurosci 2015; 38:741-750. [PMID: 26603560 PMCID: PMC4752429 DOI: 10.1016/j.tins.2015.09.003] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 01/09/2023]
Abstract
Relief from pain in humans is rewarding and pleasurable. Primary rewards, or reward-predictive cues, are encoded in brain reward/motivational circuits. While considerable advances have been made in our understanding of reward circuits underlying positive reinforcement, less is known about the circuits underlying the hedonic and reinforcing actions of pain relief. We review findings from electrophysiological, neuroimaging, and behavioral studies supporting the concept that the rewarding effect of pain relief requires opioid signaling in the anterior cingulate cortex (ACC), activation of midbrain dopamine neurons, and the release of dopamine in the nucleus accumbens (NAc). Understanding of circuits that govern the reward of pain relief may allow the discovery of more effective and satisfying therapies for patients with acute or chronic pain.
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Affiliation(s)
- Edita Navratilova
- Department of Pharmacology, Arizona Health Sciences Center, University of Arizona, Tucson, AZ 85724, USA.
| | | | - Frank Porreca
- Department of Pharmacology, Arizona Health Sciences Center, University of Arizona, Tucson, AZ 85724, USA; Deparment of Research, Mayo Clinic, Scottsdale, AZ 85453, USA.
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32
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Gorka SM, Fitzgerald DA, Angstadt M, Phan KL, Phan KL. Opioid modulation of resting-state anterior cingulate cortex functional connectivity. J Psychopharmacol 2014; 28:1115-24. [PMID: 25237122 PMCID: PMC5613932 DOI: 10.1177/0269881114548436] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Individuals misuse oxycodone, a widely prescribed opioid analgesic, in part to self-medicate physical and emotional pain. Physical and emotional pain is thought to be represented in the brain by a 'pain matrix,' consisting of the insula, thalamus, and somatosensory cortices, with processing of the affective dimension of pain in the dorsal and rostral anterior cingulate cortex (ACC). The current study examined oxycodone's effects on resting-state functional connectivity between the dorsal ACC, rostral ACC, and other regions of the pain matrix using functional magnetic resonance imaging (fMRI). In a within-subjects, randomized, double-blind, placebo-controlled, dose-response design, 14 healthy subjects completed a resting-state scan following ingestion of placebo, 10 mg, or 20 mg of oxycodone. Functional correlations between the dorsal and rostral ACC seed regions and the pain matrix were examined and compared across sessions. Both doses of oxycodone reduced functional coupling between the dorsal ACC and bilateral anterior insula/putamen and the rostral ACC and right insula relative to placebo (no differences between doses). The findings do not withstand correction for multiple comparisons, and thus should be considered preliminary. However, they are consistent with the idea that oxycodone may produce its physical and emotional 'analgesic' effects through disruption of ACC-insula and ACC-putamen connectivity.
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Affiliation(s)
- Stephanie M. Gorka
- University of Illinois – Chicago, Department of Psychology, 1007 West Harrison St. (M/C 285), Chicago, IL 60657
| | - Daniel A. Fitzgerald
- University of Illinois-Chicago, Department of Psychiatry, 1747 West Roosevelt Road, Chicago, IL 60608
| | - Mike Angstadt
- University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI 48109
| | - K. Luan Phan
- University of Illinois-Chicago, Department of Psychiatry, 1747 West Roosevelt Road, Chicago, IL 60608,University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI 48109,Jesse Brown VA Medical Center, Mental Health Service Line, 820 S. Damen Avenue, Chicago, IL 60612
| | - K Luan Phan
- Department of Psychiatry, University of Illinois-Chicago, Chicago, IL, USA Department of Psychology, University of Illinois-Chicago, Chicago, IL, USA Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA Jesse Brown VA Medical Center, Mental Health Service Line, Chicago, IL, USA
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33
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Lu H, Jenkins BG, Stein EA. Introduction to the special issue on neuroimaging in neuropharmacology. Neuropharmacology 2014; 84:63-4. [PMID: 24859606 DOI: 10.1016/j.neuropharm.2014.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Hanbing Lu
- Neuroimaging Research Branch, Intramural Research Program, National Institute on Drug Abuse, NIH, USA.
| | - Bruce G Jenkins
- MGH Martinos Center for Biomedical Imaging and Department of Radiology, Harvard Medical School, USA
| | - Elliot A Stein
- Neuroimaging Research Branch, Intramural Research Program, National Institute on Drug Abuse, NIH, USA
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