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Baby SM, May WJ, Getsy PM, Coffee GA, Nakashe T, Bates JN, Levine A, Lewis SJ. Fentanyl activates opposing opioid and non-opioid receptor systems that control breathing. Front Pharmacol 2024; 15:1381073. [PMID: 38698814 PMCID: PMC11063261 DOI: 10.3389/fphar.2024.1381073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/08/2024] [Indexed: 05/05/2024] Open
Abstract
Fentanyl elicits profound disturbances in ventilatory control processes in humans and experimental animals. The traditional viewpoint with respect to fentanyl-induced respiratory depression is that once the effects on the frequency of breathing (Freq), tidal volume (TV), and minute ventilation (MV = Freq × TV) are resolved, then depression of breathing is no longer a concern. The results of the present study challenge this concept with findings, as they reveal that while the apparent inhibitory effects of fentanyl (75 μg/kg, IV) on Freq, TV, and MV in adult male rats were fully resolved within 15 min, many other fentanyl-induced responses were in full effect, including opposing effects on respiratory timing parameters. For example, although the effects on Freq were resolved at 15 min, inspiratory duration (Ti) and end inspiratory pause (EIP) were elevated, whereas expiratory duration (Te) and end expiratory pause (EEP) were diminished. Since the effects of fentanyl on TV had subsided fully at 15 min, it would be expected that the administration of an opioid receptor (OR) antagonist would have minimal effects if the effects of fentanyl on this and other parameters had resolved. We now report that the intravenous injection of a 1.0 mg/kg dose of the peripherally restricted OR antagonist, methyl-naloxone (naloxone methiodide, NLXmi), did not elicit arousal but elicited some relatively minor changes in Freq, TV, MV, Te, and EEP but pronounced changes in Ti and EIP. In contrast, the injection of a 2.5 mg/kg dose of NLXmi elicited pronounced arousal and dramatic changes in many variables, including Freq, TV, and MV, which were not associated with increases in non-apneic breathing events such as apneas. The two compelling conclusions from this study are as follows: 1) the blockade of central ORs produced by the 2.5 mg/kg dose of NLXmi elicits pronounced increases in Freq, TV, and MV in rats in which the effects of fentanyl had apparently resolved, and 2) it is apparent that fentanyl had induced the activation of two systems with counter-balancing effects on Freq and TV: one being an opioid receptor inhibitory system and the other being a non-OR excitatory system.
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Affiliation(s)
- Santhosh M. Baby
- Department of Drug Discovery, Galleon Pharmaceuticals, Inc., Horsham, PA, United States
| | - Walter J. May
- Pediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Paulina M. Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Gregory A. Coffee
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Tej Nakashe
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - James N. Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IO, United States
| | - Alan Levine
- Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, OH, United States
| | - Stephen J. Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United States
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2
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Baby SM, May WJ, Young AP, Wilson CG, Getsy PM, Coffee GA, Lewis THJ, Hsieh YH, Bates JN, Lewis SJ. L-cysteine ethylester reverses the adverse effects of morphine on breathing and arterial blood-gas chemistry while minimally affecting antinociception in unanesthetized rats. Biomed Pharmacother 2024; 171:116081. [PMID: 38219385 PMCID: PMC10922989 DOI: 10.1016/j.biopha.2023.116081] [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: 09/01/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 01/16/2024] Open
Abstract
L-cysteine ethylester (L-CYSee) is a membrane-permeable analogue of L-cysteine with a variety of pharmacological effects. The purpose of this study was to determine the effects of L-CYSee on morphine-induced changes in ventilation, arterial-blood gas (ABG) chemistry, Alveolar-arterial (A-a) gradient (i.e., a measure of the index of alveolar gas-exchange), antinociception and sedation in male Sprague Dawley rats. An injection of morphine (10 mg/kg, IV) produced adverse effects on breathing, including sustained decreases in minute ventilation. L-CYSee (500 μmol/kg, IV) given 15 min later immediately reversed the actions of morphine. Another injection of L-CYSee (500 μmol/kg, IV) after 15 min elicited more pronounced excitatory ventilatory responses. L-CYSee (250 or 500 μmol/kg, IV) elicited a rapid and prolonged reversal of the actions of morphine (10 mg/kg, IV) on ABG chemistry (pH, pCO2, pO2, sO2) and A-a gradient. L-serine ethylester (an oxygen atom replaces the sulfur; 500 μmol/kg, IV), was ineffective in all studies. L-CYSee (500 μmol/kg, IV) did not alter morphine (10 mg/kg, IV)-induced sedation, but slightly reduced the overall duration of morphine (5 or 10 mg/kg, IV)-induced analgesia. In summary, L-CYSee rapidly overcame the effects of morphine on breathing and alveolar gas-exchange, while not affecting morphine sedation or early-stage analgesia. The mechanisms by which L-CYSee modulates morphine depression of breathing are unknown, but appear to require thiol-dependent processes.
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Affiliation(s)
- Santhosh M Baby
- Department of Drug Discovery, Galleon Pharmaceuticals, Inc., Horsham, PA, USA
| | - Walter J May
- Pediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex P Young
- Pediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Christopher G Wilson
- Basic Sciences, Division of Physiology, School of Medicine, Loma Linda University, USA
| | - Paulina M Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Gregory A Coffee
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | | | - Yee-Hee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - James N Bates
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Stephen J Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA; Department of Pharmacology, Case Western Reserve University, Cleveland, OH, USA.
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Mathew DM, Fusco PJ, Varghese KS, Awad AK, Vega E, Mathew SM, Polizzi M, George J, Mathew CS, Thomas JJ, Calixte R, Ahmed A. Opioid-free anesthesia versus opioid-based anesthesia in patients undergoing cardiovascular and thoracic surgery: a meta-analysis and systematic review. Semin Cardiothorac Vasc Anesth 2023; 27:162-170. [PMID: 37300532 DOI: 10.1177/10892532231180227] [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] [Indexed: 06/12/2023]
Abstract
BACKGROUND Despite their extensive clinical use, opioids are characterized by several side effects. These complications, coupled with the ongoing opioid epidemic, have favored the rise of opioid-free-anesthesia (OFA). Herein, we perform the first pairwise meta-analysis of clinical outcomes for OFA vs opioid-based anesthesia (OBA) in patients undergoing cardiovascular and thoracic surgery. METHODS We comprehensively searched medical databases to identify studies comparing OFA and OBA in patients undergoing cardiovascular or thoracic surgery. Pairwise meta-analysis was performed using the Mantel-Haenszel method. Outcomes were pooled as risk ratios (RR) or standard mean differences (SMD) and their 95% confidence intervals (95% CI). RESULTS Our pooled analysis included 919 patients (8 studies), of whom 488 underwent surgery with OBA and 431 with OFA. Among cardiovascular surgery patients, compared to OBA, OFA was associated with significantly reduced post-operative nausea and vomiting (RR, 0.57; P = .042), inotrope need (RR .84, P = .045), and non-invasive ventilation (RR, .54; P = .028). However, no differences were observed for 24hr pain score (SMD, -.35; P = .510) or 48hr morphine equivalent consumption (SMD, -1.09; P = .139). Among thoracic surgery patients, there was no difference between OFA and OBA for any of the explored outcomes, including post-operative nausea and vomiting (RR, 0.41; P = .025). CONCLUSION Through the first pooled analysis of OBA vs OFA in a cardiothoracic-exclusive cohort, we found no significant difference in any of the pooled outcomes for thoracic surgery patients. Although limited to 2 cardiovascular surgery studies, OFA was associated with significantly reduced postoperative nausea and vomiting, inotrope need, and non-invasive ventilation in these patients. With growing use of OFA in invasive operations, further studies are needed to assess their efficacy and safety in cardiothoracic patients.
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Affiliation(s)
| | | | | | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eamon Vega
- CUNY School of Medicine, New York, NY, USA
| | | | | | - Jerrin George
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | | | | | - Rose Calixte
- Epidemiology and Biostatistics, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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Danaf J, da Silveira Scarpellini C, Montandon G. βγ G-proteins, but not regulators of G-protein signaling 4, modulate opioid-induced respiratory rate depression. Front Physiol 2023; 14:1043581. [PMID: 37089428 PMCID: PMC10117644 DOI: 10.3389/fphys.2023.1043581] [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: 09/13/2022] [Accepted: 03/24/2023] [Indexed: 04/09/2023] Open
Abstract
Opioid medications are the mainstay of pain management but present substantial side-effects such as respiratory depression which can be lethal with overdose. Most opioid drugs, such as fentanyl, act on opioid receptors such as the G-protein-coupled µ-opioid receptors (MOR). G-protein-coupled receptors activate pertussis toxin-sensitive G-proteins to inhibit neuronal activity. Binding of opioid ligands to MOR and subsequent activation G proteins βγ is modulated by regulator of G-protein signaling (RGS). The roles of G-proteins βγ and RGS in MOR-mediated inhibition of the respiratory network are not known. Using rodent models to pharmacologically modulate G-protein signaling, we aim to determine the roles of βγ G-proteins and RGS4. We showed that inhibition of βγ G-proteins using gallein perfused in the brainstem circuits regulating respiratory depression by opioid drugs results in complete reversal of respiratory depression. Blocking of RGS4 using CCG55014 did not change the respiratory depression induced by MOR activation despite co-expression of RGS4 and MORs in the brainstem. Our results suggest that neuronal inhibition by opioid drugs is mediated by G-proteins, but not by RGS4, which supports the concept that βγ G-proteins could be molecular targets to develop opioid overdose antidotes without the risks of re-narcotization often found with highly potent opioid drugs. On the other hand, RGS4 mediates opioid analgesia, but not respiratory depression, and RGS4 may be molecular targets to develop pain therapies without respiratory liability.
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Affiliation(s)
- Jamil Danaf
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | | | - Gaspard Montandon
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Difrancesco S, van Baardewijk JU, Cornelissen AS, Varon C, Hendriks RC, Brouwer AM. Exploring the use of Granger causality for the identification of chemical exposure based on physiological data. FRONTIERS IN NETWORK PHYSIOLOGY 2023; 3:1106650. [PMID: 37007435 PMCID: PMC10053028 DOI: 10.3389/fnetp.2023.1106650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/22/2023] [Indexed: 03/17/2023]
Abstract
Wearable sensors offer new opportunities for the early detection and identification of toxic chemicals in situations where medical evaluation is not immediately possible. We previously found that continuously recorded physiology in guinea pigs can be used for early detection of exposure to an opioid (fentanyl) or a nerve agent (VX), as well as for differentiating between the two. Here, we investigated how exposure to these different chemicals affects the interactions between ECG and respiration parameters as determined by Granger causality (GC). Features reflecting such interactions may provide additional information and improve models differentiating between chemical agents. Traditional respiration and ECG features, as well as GC features, were extracted from data of 120 guinea pigs exposed to VX (n = 61) or fentanyl (n = 59). Data were divided in a training set (n = 99) and a test set (n = 21). Minimum Redundancy Maximum Relevance (mRMR) and Support Vector Machine (SVM) algorithms were used to, respectively, perform feature selection and train a model to discriminate between the two chemicals. We found that ECG and respiration parameters are Granger-related under healthy conditions, and that exposure to fentanyl and VX affected these relationships in different ways. SVM models discriminated between chemicals with accuracy of 95% or higher on the test set. GC features did not improve the classification compared to traditional features. Respiration features (i.e., peak inspiratory and expiratory flow) were the most important to discriminate between different chemical’s exposure. Our results indicate that it may be feasible to discriminate between chemical exposure when using traditional physiological respiration features from wearable sensors. Future research will examine whether GC features can contribute to robust detection and differentiation between chemicals when considering other factors, such as generalizing results across species.
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Affiliation(s)
- S. Difrancesco
- Department Systems Biology, The Netherlands Organisation for Applied Scientific Research (TNO), Leiden, Netherlands
| | - J. U. van Baardewijk
- Department Human Performance, The Netherlands Organisation for Applied Scientific Research (TNO), Soesterberg, Netherlands
| | - A. S. Cornelissen
- Department CBRN Protection, The Netherlands Organisation for Applied Scientific Research (TNO), Rijswijk, Netherlands
| | - C. Varon
- Circuits and Systems (CAS) Group, Delft University of Technology, Delft, Netherlands
- Centre for Research and Engineering in Space Technologies—CREST, Université Libre de Bruxelles, Brussels, Belgium
| | - R. C. Hendriks
- Circuits and Systems (CAS) Group, Delft University of Technology, Delft, Netherlands
| | - A. M. Brouwer
- Department Human Performance, The Netherlands Organisation for Applied Scientific Research (TNO), Soesterberg, Netherlands
- *Correspondence: A. M. Brouwer,
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6
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Lewis TH, May WJ, Young AP, Bates JN, Baby SM, Getsy PM, Ryan RM, Hsieh YH, Seckler JM, Lewis SJ. The ventilatory depressant actions but not the antinociceptive effects of morphine are blunted in rats receiving intravenous infusion of L-cysteine ethyl ester. Biomed Pharmacother 2022; 156:113939. [DOI: 10.1016/j.biopha.2022.113939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
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Russell T, Gangotia D, Barry G. Assessing the potential of repurposing ion channel inhibitors to treat emerging viral diseases and the role of this host factor in virus replication. Biomed Pharmacother 2022; 156:113850. [DOI: 10.1016/j.biopha.2022.113850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/25/2022] [Accepted: 10/06/2022] [Indexed: 12/03/2022] Open
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8
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Getsy PM, Baby SM, May WJ, Bates JN, Ellis CR, Feasel MG, Wilson CG, Lewis THJ, Gaston B, Hsieh YH, Lewis SJ. L-cysteine methyl ester overcomes the deleterious effects of morphine on ventilatory parameters and arterial blood-gas chemistry in unanesthetized rats. Front Pharmacol 2022; 13:968378. [PMID: 36249760 PMCID: PMC9554613 DOI: 10.3389/fphar.2022.968378] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
We are developing a series of thiolesters that produce an immediate and sustained reversal of the deleterious effects of opioids, such as morphine and fentanyl, on ventilation without diminishing the antinociceptive effects of these opioids. We report here the effects of systemic injections of L-cysteine methyl ester (L-CYSme) on morphine-induced changes in ventilatory parameters, arterial-blood gas (ABG) chemistry (pH, pCO2, pO2, sO2), Alveolar-arterial (A-a) gradient (i.e., the index of alveolar gas-exchange within the lungs), and antinociception in unanesthetized Sprague Dawley rats. The administration of morphine (10 mg/kg, IV) produced a series of deleterious effects on ventilatory parameters, including sustained decreases in tidal volume, minute ventilation, inspiratory drive and peak inspiratory flow that were accompanied by a sustained increase in end inspiratory pause. A single injection of L-CYSme (500 μmol/kg, IV) produced a rapid and long-lasting reversal of the deleterious effects of morphine on ventilatory parameters, and a second injection of L-CYSme (500 μmol/kg, IV) elicited pronounced increases in ventilatory parameters, such as minute ventilation, to values well above pre-morphine levels. L-CYSme (250 or 500 μmol/kg, IV) also produced an immediate and sustained reversal of the deleterious effects of morphine (10 mg/kg, IV) on arterial blood pH, pCO2, pO2, sO2 and A-a gradient, whereas L-cysteine (500 μmol/kg, IV) itself was inactive. L-CYSme (500 μmol/kg, IV) did not appear to modulate the sedative effects of morphine as measured by righting reflex times, but did diminish the duration, however, not the magnitude of the antinociceptive actions of morphine (5 or 10 mg/kg, IV) as determined in tail-flick latency and hindpaw-withdrawal latency assays. These findings provide evidence that L-CYSme can powerfully overcome the deleterious effects of morphine on breathing and gas-exchange in Sprague Dawley rats while not affecting the sedative or early stage antinociceptive effects of the opioid. The mechanisms by which L-CYSme interferes with the OR-induced signaling pathways that mediate the deleterious effects of morphine on ventilatory performance, and by which L-CYSme diminishes the late stage antinociceptive action of morphine remain to be determined.
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Affiliation(s)
- Paulina M. Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
- *Correspondence: Paulina M. Getsy,
| | | | - Walter J. May
- Pediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - James N. Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Christopher R. Ellis
- United States Army CCDC Chemical Biological Center, Aberdeen Proving Ground, MD, United States
| | - Michael G. Feasel
- United States Army CCDC Chemical Biological Center, Aberdeen Proving Ground, MD, United States
| | - Christopher G. Wilson
- Department of Basic Sciences, Division of Physiology, School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Tristan H. J. Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Benjamin Gaston
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Stephen J. Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United States
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Getsy PM, Baby SM, May WJ, Lewis THJ, Bates JN, Hsieh YH, Gaston B, Lewis SJ. L-NAC reverses of the adverse effects of fentanyl infusion on ventilation and blood-gas chemistry. Biomed Pharmacother 2022; 153:113277. [PMID: 35724513 PMCID: PMC9458628 DOI: 10.1016/j.biopha.2022.113277] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022] Open
Abstract
There is an urgent need for development of drugs that are able to reverse the adverse effects of opioids on breathing and arterial blood-gas (ABG) chemistry while preserving opioid analgesia. The present study describes the effects of bolus injections of N-acetyl-L-cysteine (L-NAC, 500 μmol/kg, IV) on ventilatory parameters, ABG chemistry, Alveolar-arterial (A-a) gradient, sedation (righting reflex) and analgesia status (tail-flick latency assay) in unanesthetized adult male Sprague Dawley rats receiving a continuous infusion of fentanyl (1 μg/kg/min, IV). Fentanyl infusion elicited pronounced disturbances in (1) ventilatory parameters (e.g., decreases in frequency of breathing, tidal volume and minute ventilation), (2) ABG chemistry (decreases in pH, pO2, sO2 with increases in pCO2), (3) A-a gradient (increases that were consistent with reduced alveolar gas exchange), and (4) sedation and analgesia. Bolus injections of L-NAC given 60 and 90 min after start of fentanyl infusion elicited rapid and sustained reversal of the deleterious effects of fentanyl infusion on ventilatory parameters and ABG chemistry, whereas they did not affect the sedative or analgesic effects of fentanyl. Systemic L-NAC is approved for human use, and thus our findings raise the possibility that this biologically active thiol may be an effective compound to combat opioid-induced respiratory depression in human subjects.
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Affiliation(s)
- Paulina M Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Santhosh M Baby
- Galleon Pharmaceuticals, Inc., 213 Witmer Road, Horsham, PA 19044, USA.
| | - Walter J May
- Pediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Tristan H J Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, USA
| | - James N Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Benjamin Gaston
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Stephen J Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, USA; Department of Pharmacology, Case Western Reserve University, Cleveland, OH 44106, USA.
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Bajaj A, Blum K, Bowirrat A, Gupta A, Baron D, Fugel D, Nicholson A, Fitch T, Downs BW, Bagchi D, Dennen CA, Badgaiyan RD. DNA Directed Pro-Dopamine Regulation Coupling Subluxation Repair, H-Wave® and Other Neurobiologically Based Modalities to Address Complexities of Chronic Pain in a Female Diagnosed with Reward Deficiency Syndrome (RDS): Emergence of Induction of “Dopamine Homeostasis” in the Face of the Opioid Crisis. J Pers Med 2022; 12:jpm12091416. [PMID: 36143203 PMCID: PMC9503998 DOI: 10.3390/jpm12091416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/27/2022] [Accepted: 08/27/2022] [Indexed: 11/16/2022] Open
Abstract
Addiction is a complex multifactorial condition. Established genetic factors can provide clear guidance in assessing the risk of addiction to substances and behaviors. Chronic stress can accumulate, forming difficult to recognize addiction patterns from both genetic and epigenetic (environmental) factors. Furthermore, psychological/physical/chemical stressors are typically categorized linearly, delaying identification and treatment. The patient in this case report is a Caucasian female, aged 36, who presented with chronic pain and partial disability following a surgically repaired trimalleolar fracture. The patient had a history of unresolved attention deficit disorder and an MRI scan of her brain revealed atrophy and functional asymmetry. In 2018, the patient entered the Bajaj Chiropractic Clinic, where initial treatment focused on re-establishing integrity of the spine and lower extremity biomechanics and graduated into cognitive behavior stabilization assisted by DNA pro-dopamine regulation guided by Genetic Addiction Risk Severity testing. During treatment (2018–2021), progress achieved included: improved cognitive clarity, focus, sleep, anxiety, and emotional stability in addition to pain reduction (75%); elimination of powerful analgesics; and reduced intake of previously unaddressed alcoholism. To help reduce hedonic addictive behaviors and pain, coupling of H-Wave with corrective chiropractic care seems prudent. We emphasize the importance of genetic assessment along with attempts at inducing required dopaminergic homeostasis via precision KB220PAM. It is hypothesized that from preventive care models, a new standard is emerging including self-awareness and accountability for reward deficiency as a function of hypodopaminergia. This case study documents the progression of a patient dealing with the complexities of an injury, pain management, cognitive impairment, anxiety, depression, and the application of universal health principles towards correction versus palliative care.
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Affiliation(s)
- Anish Bajaj
- Bajaj Chiropractic Clinic, New York, NY 10010, USA
| | - Kenneth Blum
- Division of Addiction Research & Education, Center for Psychiatry, Medicine, and Primary Care, (Office of the Provost), Western University Health Sciences, Pomona, CA 91766, USA
- The Kenneth Blum Institute on Behavior & Neurogenetics, Austin, TX 78701, USA
- Correspondence:
| | - Abdalla Bowirrat
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Ashim Gupta
- Future Biologics, Lawrenceville, GA 30043, USA
| | - David Baron
- Division of Addiction Research & Education, Center for Psychiatry, Medicine, and Primary Care, (Office of the Provost), Western University Health Sciences, Pomona, CA 91766, USA
| | - David Fugel
- Bajaj Chiropractic Clinic, New York, NY 10010, USA
| | | | - Taylor Fitch
- Bajaj Chiropractic Clinic, New York, NY 10010, USA
| | - B. William Downs
- Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, Long School of Medicine, University of Texas Medical Center, San Antonio, TX 78229, USA
| | - Debasis Bagchi
- Department of Pharmaceutical Sciences, Southern University College of Pharmacy, Houston, TX 77004, USA
| | - Catherine A. Dennen
- The Kenneth Blum Institute on Behavior & Neurogenetics, Austin, TX 78701, USA
| | - Rajendra D. Badgaiyan
- Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, Long School of Medicine, University of Texas Medical Center, San Antonio, TX 78229, USA
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Panagiotoglou D. Evaluating the population-level effects of overdose prevention sites and supervised consumption sites in British Columbia, Canada: Controlled interrupted time series. PLoS One 2022; 17:e0265665. [PMID: 35316284 PMCID: PMC8939833 DOI: 10.1371/journal.pone.0265665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/04/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND On 14 April 2016, British Columbia's Provincial Medical Health Officer declared the overdose crisis a public health emergency, sanctioning the implementation of new overdose prevention sites (OPS) and supervised consumption sites (SCS) across the province. METHODS We used the BC Centre for Disease Control's Provincial Overdose Cohort of all overdose events between 1 January 2015 and 31 December 2017 to evaluate the population-level effects of OPSs and SCSs on acute health service use and mortality. We matched local health areas (LHA) that implemented any site with propensity score matched controls and conducted controlled interrupted time series analysis. RESULTS During the study period, twenty-five OPSs and SCSs opened across fourteen of British Columbia's 89 LHAs. Results from analysis of LHAs with matched controls (i.e. excluding Vancouver DTES) were mixed. Significant declines in reported overdose events, paramedic attendance, and emergency department visits were observed. However, there were no changes to trends in monthly hospitalization or mortality rates. Extensive sensitivity analyses found these results persisted. CONCLUSIONS We found OPSs and SCSs reduce opioid-related paramedic attendance and emergency department visit rates but no evidence that they reduce local hospitalization or mortality rates.
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Affiliation(s)
- Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Abstract
Opiates, such as morphine, and synthetic opioids, such as fentanyl, constitute a class of drugs acting on opioid receptors which have been used therapeutically and recreationally for centuries. Opioid drugs have strong analgesic properties and are used to treat moderate to severe pain, but also present side effects including opioid dependence, tolerance, addiction, and respiratory depression, which can lead to lethal overdose if not treated. This chapter explores the pathophysiology, the neural circuits, and the cellular mechanisms underlying opioid-induced respiratory depression and provides a translational perspective of the most recent research. The pathophysiology discussed includes the effects of opioid drugs on the respiratory system in patients, as well as the animal models used to identify underlying mechanisms. Using a combination of gene editing and pharmacology, the neural circuits and molecular pathways mediating neuronal inhibition by opioids are examined. By using pharmacology and neuroscience approaches, new therapies to prevent or reverse respiratory depression by opioid drugs have been identified and are currently being developed. Considering the health and economic burden associated with the current opioid epidemic, innovative research is needed to better understand the side effects of opioid drugs and to discover new therapeutic solutions to reduce the incidence of lethal overdoses.
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13
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Charkhgard N, Razaghi E. Opiates Possibly Boosted Human Civilization. IRANIAN JOURNAL OF PSYCHIATRY AND BEHAVIORAL SCIENCES 2021; 15. [DOI: 10.5812/ijpbs.114491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/24/2021] [Accepted: 08/17/2021] [Indexed: 09/01/2023]
Abstract
: Testosterone is a fundamental biological drive for human survival. Evidence documents an association between the evolutionary suppression of testosterone and the civilization processes, especially their socialization and family colonization abilities, among early humans. Interestingly, opiates suppress testosterone as a side effect. However, in clinical practice, clients undergoing opioid substitution therapy have subnormal, normal, or even above-normal testosterone. This paper discusses a possibility indicating that opiates promoted civilization processes among early humans. We further suggest that modern humans might have inherited the positive impact of opiates on early humans as a biological propensity for using opioids. Some users may use opioids for self-medication to decrease their extraordinarily high testosterone levels.
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14
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Baby SM, Discala JF, Gruber R, Getsy PM, Cheng F, Damron DS, Lewis SJ. Tempol Reverses the Negative Effects of Morphine on Arterial Blood-Gas Chemistry and Tissue Oxygen Saturation in Freely-Moving Rats. Front Pharmacol 2021; 12:749084. [PMID: 34630119 PMCID: PMC8493249 DOI: 10.3389/fphar.2021.749084] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/03/2021] [Indexed: 12/14/2022] Open
Abstract
We have reported that pretreatment with the clinically approved superoxide dismutase mimetic, Tempol (4-hydroxy-2,2,6,6-tetramethylpiperidine-N-oxyl), blunts the cardiorespiratory depressant responses elicited by a subsequent injection of fentanyl, in halothane-anesthetized rats. The objective of the present study was to determine whether Tempol is able to reverse the effects of morphine on arterial blood-gas (ABG) chemistry in freely-moving Sprague Dawley rats. The intravenous injection of morphine (10 mg/kg) elicited substantial decreases in pH, pO2 and sO2 that were accompanied by substantial increases in pCO2 and Alveolar-arterial gradient, which results in diminished gas-exchange within the lungs. Intravenous injection of a 60 mg/kg dose of Tempol 15 min after the injection of morphine caused minor improvements in pO2 and pCO2 but not in other ABG parameters. In contrast, the 100 mg/kg dose of Tempol caused an immediate and sustained reversal of the negative effects of morphine on arterial blood pH, pCO2, pO2, sO2 and Alveolar-arterial gradient. In other rats, we used pulse oximetry to determine that the 100 mg/kg dose of Tempol, but not the 60 mg/kg dose elicited a rapid and sustained reversal of the negative effects of morphine (10 mg/kg, IV) on tissue O2 saturation (SpO2). The injection of morphine caused a relatively minor fall in mean arterial blood pressure that was somewhat exacerbated by Tempol. These findings demonstrate that Tempol can reverse the negative effects of morphine on ABG chemistry in freely-moving rats paving the way of structure-activity and mechanisms of action studies with the host of Tempol analogues that are commercially available.
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Affiliation(s)
| | | | - Ryan Gruber
- Galleon Pharmaceuticals Inc, Horsham, PA, United states
| | - Paulina M Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United states
| | - Feixiong Cheng
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United states
| | - Derek S Damron
- Department of Biological Sciences, School of Biomedical Sciences, Kent State University, Kent, OH, United states
| | - Stephen J Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United states.,Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United states
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15
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Baertsch NA, Bush NE, Burgraff NJ, Ramirez JM. Dual mechanisms of opioid-induced respiratory depression in the inspiratory rhythm-generating network. eLife 2021; 10:e67523. [PMID: 34402425 PMCID: PMC8390004 DOI: 10.7554/elife.67523] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/14/2021] [Indexed: 12/20/2022] Open
Abstract
The analgesic utility of opioid-based drugs is limited by the life-threatening risk of respiratory depression. Opioid-induced respiratory depression (OIRD), mediated by the μ-opioid receptor (MOR), is characterized by a pronounced decrease in the frequency and regularity of the inspiratory rhythm, which originates from the medullary preBötzinger Complex (preBötC). To unravel the cellular- and network-level consequences of MOR activation in the preBötC, MOR-expressing neurons were optogenetically identified and manipulated in transgenic mice in vitro and in vivo. Based on these results, a model of OIRD was developed in silico. We conclude that hyperpolarization of MOR-expressing preBötC neurons alone does not phenocopy OIRD. Instead, the effects of MOR activation are twofold: (1) pre-inspiratory spiking is reduced and (2) excitatory synaptic transmission is suppressed, thereby disrupting network-driven rhythmogenesis. These dual mechanisms of opioid action act synergistically to make the normally robust inspiratory rhythm-generating network particularly prone to collapse when challenged with exogenous opioids.
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Affiliation(s)
- Nathan A Baertsch
- Center for Integrative Brain Research, Seattle Children’s Research InstituteSeattleUnited States
- Department of Pediatrics, University of WashingtonSeattleUnited States
| | - Nicholas E Bush
- Center for Integrative Brain Research, Seattle Children’s Research InstituteSeattleUnited States
| | - Nicholas J Burgraff
- Center for Integrative Brain Research, Seattle Children’s Research InstituteSeattleUnited States
| | - Jan-Marino Ramirez
- Center for Integrative Brain Research, Seattle Children’s Research InstituteSeattleUnited States
- Department of Pediatrics, University of WashingtonSeattleUnited States
- Department Neurological Surgery, University of WashingtonSeattleUnited States
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16
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Liu S, Kim DI, Oh TG, Pao GM, Kim JH, Palmiter RD, Banghart MR, Lee KF, Evans RM, Han S. Neural basis of opioid-induced respiratory depression and its rescue. Proc Natl Acad Sci U S A 2021; 118:e2022134118. [PMID: 34074761 PMCID: PMC8201770 DOI: 10.1073/pnas.2022134118] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Opioid-induced respiratory depression (OIRD) causes death following an opioid overdose, yet the neurobiological mechanisms of this process are not well understood. Here, we show that neurons within the lateral parabrachial nucleus that express the µ-opioid receptor (PBL Oprm1 neurons) are involved in OIRD pathogenesis. PBL Oprm1 neuronal activity is tightly correlated with respiratory rate, and this correlation is abolished following morphine injection. Chemogenetic inactivation of PBL Oprm1 neurons mimics OIRD in mice, whereas their chemogenetic activation following morphine injection rescues respiratory rhythms to baseline levels. We identified several excitatory G protein-coupled receptors expressed by PBL Oprm1 neurons and show that agonists for these receptors restore breathing rates in mice experiencing OIRD. Thus, PBL Oprm1 neurons are critical for OIRD pathogenesis, providing a promising therapeutic target for treating OIRD in patients.
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Affiliation(s)
- Shijia Liu
- Peptide Biology Laboratories, The Salk Institute for Biological Studies, La Jolla, CA 92037
- Section of Neurobiology, Division of Biological Sciences, University of California San Diego, La Jolla, CA 92093
| | - Dong-Il Kim
- Peptide Biology Laboratories, The Salk Institute for Biological Studies, La Jolla, CA 92037
| | - Tae Gyu Oh
- Gene Expression Laboratory, The Salk Institute for Biological Studies, La Jolla, CA 92037
| | - Gerald M Pao
- Molecular and Cellular Biology Laboratories, The Salk Institute for Biological Studies, La Jolla, CA 92037
| | - Jong-Hyun Kim
- Peptide Biology Laboratories, The Salk Institute for Biological Studies, La Jolla, CA 92037
| | - Richard D Palmiter
- HHMI, University of Washington, Seattle, WA 98195
- Department of Biochemistry, School of Medicine, University of Washington, Seattle, WA 98195
| | - Matthew R Banghart
- Section of Neurobiology, Division of Biological Sciences, University of California San Diego, La Jolla, CA 92093
| | - Kuo-Fen Lee
- Peptide Biology Laboratories, The Salk Institute for Biological Studies, La Jolla, CA 92037
- Section of Neurobiology, Division of Biological Sciences, University of California San Diego, La Jolla, CA 92093
| | - Ronald M Evans
- Gene Expression Laboratory, The Salk Institute for Biological Studies, La Jolla, CA 92037
- HHMI, The Salk Institute for Biological Studies, La Jolla, CA 92037
| | - Sung Han
- Peptide Biology Laboratories, The Salk Institute for Biological Studies, La Jolla, CA 92037;
- Section of Neurobiology, Division of Biological Sciences, University of California San Diego, La Jolla, CA 92093
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17
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Peppin JF, Pergolizzi Jr JV, Fudin J, Meyer TA, Raffa RB. History of Respiratory Stimulants. J Pain Res 2021; 14:1043-1049. [PMID: 33889020 PMCID: PMC8057823 DOI: 10.2147/jpr.s298607] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/02/2021] [Indexed: 11/24/2022] Open
Abstract
The interest in substances that stimulate respiration has waxed and waned throughout the years, intensifying following the introduction of a new class of drugs that causes respiratory depression, and diminishing when antidotes or better drug alternatives are found. Examples include the opioids--deaths increasing during overprescribing, diminishing with wider availability of the opioid receptor antagonist naloxone, increasing again during COVID-19; the barbiturates--until largely supplanted by the benzodiazepines; propofol; and other central nervous system depressants. Unfortunately, two new troubling phenomena force a reconsideration of the status-quo: (1) overdoses due to highly potent opioids such as fentanyl, and even more-potent licit and illicit fentanyl analogs, and (2) overdose due to polysubstance use (the combination of an opioid plus one or more non-opioid drug, such as a benzodiazepine, sedating antidepressant, skeletal muscle relaxant, or various other agents). Since these now represent the majority of cases, new solutions are again needed. An interest in respiratory stimulants has been revived. This interest can be informed by a short review of the history of this interesting class of medications. We present a short history of the trajectory of advances toward more selective and safer respiratory stimulants.
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Affiliation(s)
- John F Peppin
- Marian University College of Osteopathic Medicine, Indianapolis, IN, USA
- Pikeville University College of Osteopathic Medicine, Pikeville, KY, USA
| | - Joseph V Pergolizzi Jr
- Enalare Therapeutics Inc., Princeton, NJ, USA
- NEMA Research Inc., Naples, FL, USA
- Neumentum Inc., Summit, NJ, USA
| | - Jeffrey Fudin
- Western New England College of Pharmacy, Springfield, MA, USA
- Albany College of Pharmacy & Health Sciences Union University, Albany, NY, USA
- Remitigate Therapeutics, Delmar, NY, USA
| | | | - Robert B Raffa
- Enalare Therapeutics Inc., Princeton, NJ, USA
- Neumentum Inc., Summit, NJ, USA
- University of Arizona College of Pharmacy, Tucson, AZ, USA
- Temple University School of Pharmacy, Philadelphia, PA, USA
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18
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Zaig S, da Silveira Scarpellini C, Montandon G. Respiratory depression and analgesia by opioid drugs in freely behaving larval zebrafish. eLife 2021; 10:63407. [PMID: 33720013 PMCID: PMC8060028 DOI: 10.7554/elife.63407] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 03/11/2021] [Indexed: 12/24/2022] Open
Abstract
An opioid epidemic is spreading in North America with millions of opioid overdoses annually. Opioid drugs, like fentanyl, target the mu opioid receptor system and induce potentially lethal respiratory depression. The challenge in opioid research is to find a safe pain therapy with analgesic properties but no respiratory depression. Current discoveries are limited by lack of amenable animal models to screen candidate drugs. Zebrafish (Danio rerio) is an emerging animal model with high reproduction and fast development, which shares remarkable similarity in their physiology and genome to mammals. However, it is unknown whether zebrafish possesses similar opioid system, respiratory and analgesic responses to opioids than mammals. In freely-behaving larval zebrafish, fentanyl depresses the rate of respiratory mandible movements and induces analgesia, effects reversed by μ-opioid receptor antagonists. Zebrafish presents evolutionary conserved mechanisms of action of opioid drugs, also found in mammals, and constitute amenable models for phenotype-based drug discovery. When it comes to treating severe pain, a doctor’s arsenal is somewhat limited: synthetic or natural opioids such as morphine, fentanyl or oxycodone are often one of the only options available to relieve patients. Yet these compounds can make breathing slower and shallower, quickly depriving the body of oxygen and causing death. This lethal side-effect is particularly devastating as opioids misuse has reached dangerously high levels in the United States, creating an ‘opioid epidemic’ which has claimed the lives of over 80,000 Americans in 2020. It is therefore crucial to find safer drugs that do not have this effect on breathing, but this research has been slowed down by the lack of animal models in which to study the effect of new compounds. Zebrafish are small freshwater fish that reproduce and develop fast, yet they are also remarkably genetically similar to mammals and feature a complex nervous system. However, it is not known whether the effect of opioids on zebrafish is comparable to mammals, and therefore whether these animals can be used to test new drugs for pain relief. To investigate this question, Zaig et al. exposed zebrafish larvae to fentanyl, showing that the fish then exhibited slower lower jaw movements – a sign of decreased breathing. The fish also could also tolerate a painful stimulus for longer, suggesting that this opioid does reduce pain in the animals. Together, these results point towards zebrafish and mammals sharing similar opioid responses, demonstrating that the fish could be used to test potential pain medications. The methods Zaig et al. have developed to establish these results could be harnessed to quickly assess large numbers of drug compounds, as well as decipher how pain emerges and can be stopped.
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Affiliation(s)
- Shenhab Zaig
- Keenan Research Centre for Biomedical Sciences. St. Michael's Hospital Unity Health Toronto, Toronto, Canada
| | | | - Gaspard Montandon
- Keenan Research Centre for Biomedical Sciences. St. Michael's Hospital Unity Health Toronto, Toronto, Canada
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19
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Zeng F, Zhang Q, Liu Y, Sun G, Li A, Talay RS, Wang J. AMPAkines potentiate the corticostriatal pathway to reduce acute and chronic pain. Mol Brain 2021; 14:45. [PMID: 33653395 PMCID: PMC7923831 DOI: 10.1186/s13041-021-00757-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
The corticostriatal circuit plays an important role in the regulation of reward- and aversion-types of behaviors. Specifically, the projection from the prelimbic cortex (PL) to the nucleus accumbens (NAc) has been shown to regulate sensory and affective aspects of pain in a number of rodent models. Previous studies have shown that enhancement of glutamate signaling through the NAc by AMPAkines, a class of agents that specifically potentiate the function of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, reduces acute and persistent pain. However, it is not known whether postsynaptic potentiation of the NAc with these agents can achieve the full anti-nociceptive effects of PL activation. Here we compared the impact of AMPAkine treatment in the NAc with optogenetic activation of the PL on pain behaviors in rats. We found that not only does AMPAkine treatment partially reconstitute the PL inhibition of sensory withdrawals, it fully occludes the effect of the PL on reducing the aversive component of pain. These results indicate that the NAc is likely one of the key targets for the PL, especially in the regulation of pain aversion. Furthermore, our results lend support for neuromodulation or pharmacological activation of the corticostriatal circuit as an important analgesic approach.
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Affiliation(s)
- Fei Zeng
- Department of Pain, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, People's Republic of China
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Qiaosheng Zhang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Yaling Liu
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Guanghao Sun
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Anna Li
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Robert S Talay
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA.
- Department of Neuroscience & Physiology, New York University School of Medicine, New York, NY, USA.
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20
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Talay RS, Liu Y, Michael M, Li A, Friesner ID, Zeng F, Sun G, Chen ZS, Zhang Q, Wang J. Pharmacological restoration of anti-nociceptive functions in the prefrontal cortex relieves chronic pain. Prog Neurobiol 2021; 201:102001. [PMID: 33545233 DOI: 10.1016/j.pneurobio.2021.102001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/14/2021] [Accepted: 01/24/2021] [Indexed: 12/30/2022]
Abstract
Chronic pain affects one in four adults, and effective non-sedating and non-addictive treatments are urgently needed. Chronic pain causes maladaptive changes in the cerebral cortex, which can lead to impaired endogenous nociceptive processing. However, it is not yet clear if drugs that restore endogenous cortical regulation could provide an effective therapeutic strategy for chronic pain. Here, we studied the nociceptive response of neurons in the prelimbic region of the prefrontal cortex (PL-PFC) in freely behaving rats using a spared nerve injury (SNI) model of chronic pain, and the impact of AMPAkines, a class of drugs that increase central glutamate signaling, on such response. We found that neurons in the PL-PFC increase their firing rates in response to noxious stimulations; chronic neuropathic pain, however, suppressed this important cortical pain response. Meanwhile, CX546, a well-known AMPAkine, restored the anti-nociceptive response of PL-PFC neurons in the chronic pain condition. In addition, both systemic administration and direct delivery of CX546 into the PL-PFC inhibited symptoms of chronic pain, whereas optogenetic inactivation of the PFC neurons or administration of AMPA receptor antagonists in the PL-PFC blocked the anti-nociceptive effects of CX546. These results indicate that restoration of the endogenous anti-nociceptive functions in the PL-PFC by pharmacological agents such as AMPAkines constitutes a successful strategy to treat chronic neuropathic pain.
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Affiliation(s)
- Robert S Talay
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States
| | - Yaling Liu
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States; Department of Pain, The Third Xiangya Hospital and Institute of Pain Medicine, Central South University, Changsha, 410013, Hunan Province, China
| | - Matthew Michael
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States
| | - Anna Li
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States
| | - Isabel D Friesner
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States
| | - Fei Zeng
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States
| | - Guanghao Sun
- Department of Psychiatry, New York University Langone Health, New York, NY 10016, United States
| | - Zhe Sage Chen
- Department of Psychiatry, New York University Langone Health, New York, NY 10016, United States; Neuroscience Institute, New York University Langone Health, New York, NY 10016, United States
| | - Qiaosheng Zhang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States.
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY 10016, United States; Neuroscience Institute, New York University Langone Health, New York, NY 10016, United States; Department of Neuroscience and Physiology, New York University Langone Health, New York, NY 10016, United States.
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21
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Willner MJ, Xiao Y, Kim HS, Chen X, Xu B, Leong KW. Modeling SARS-CoV-2 infection in individuals with opioid use disorder with brain organoids. J Tissue Eng 2021; 12:2041731420985299. [PMID: 33738089 PMCID: PMC7934045 DOI: 10.1177/2041731420985299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/13/2020] [Indexed: 01/10/2023] Open
Abstract
The COVID-19 pandemic has aggravated a preexisting epidemic: the opioid crisis. Much literature has shown that the circumstances imposed by COVID-19, such as social distancing regulations, medical and financial instability, and increased mental health issues, have been detrimental to those with opioid use disorder (OUD). In addition, unexpected neurological sequelae in COVID-19 patients suggest that COVID-19 compromises neuroimmunity, induces hypoxia, and causes respiratory depression, provoking similar effects as those caused by opioid exposure. Combined conditions of COVID-19 and OUD could lead to exacerbated complications. With limited human in vivo options to study these complications, we suggest that iPSC-derived brain organoid models may serve as a useful platform to investigate the physiological connection between COVID-19 and OUD. This mini-review highlights the advances of brain organoids in other neuropsychiatric and infectious diseases and suggests their potential utility for investigating OUD and COVID-19, respectively.
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Affiliation(s)
- Moshe J Willner
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Yang Xiao
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Hye Sung Kim
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
- Institute of Tissue Regeneration Engineering, Dankook University, Cheonan, Republic of Korea
- Department of Regenerative Dental Medicine, College of Dentistry, Dankook University, Cheonan, Republic of Korea
- Cell & Matter Institute, Dankook University, Cheonan, Republic of Korea
| | - Xuejing Chen
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
- Department of Physics, Tsinghua University, Beijing, China
| | - Bin Xu
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| | - Kam W Leong
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
- Department of Systems Biology, Columbia University Irving Medical Center, New York, NY, USA
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22
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So R, Al Hamarneh Y, Barnes M, Beazely MA, Boivin M, Laroche J, Patel H, Sihota A, Smith T, Tsuyuki RT. The status of naloxone in community pharmacies across Canada. Can Pharm J (Ott) 2020; 153:352-356. [PMID: 33282025 PMCID: PMC7689620 DOI: 10.1177/1715163520958435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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23
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Webster LR, Karan S. The Physiology and Maintenance of Respiration: A Narrative Review. Pain Ther 2020; 9:467-486. [PMID: 33021707 PMCID: PMC7648809 DOI: 10.1007/s40122-020-00203-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/26/2020] [Indexed: 01/12/2023] Open
Abstract
Chronic pain is one of the most common reasons adults seek medical care and is often managed with opioid analgesics; however, opioids may cause respiratory depression by suppressing various components of respiration. Respiration is the physiological process that facilitates gas exchange and is mediated through the proper function of and communication among central neural control (respiratory drive), sensory input systems, the lungs, and the muscles involved in respiration. Normal respiratory function can be dampened with the use of central nervous system (CNS) depressants and/or underlying health conditions. Patients with chronic pain are often exposed to CNS depressants other than opioids, including benzodiazepines, barbiturates, nonbenzodiazepine sedative-hypnotics, and ethanol, which can function synergistically with opioids to increase the risk of respiratory depression. Some patients may also have underlying health issues, such as obstructive sleep apnea, that can be exacerbated with the use of opioids and other CNS depressants and further contribute to respiratory depression. Clinicians should have a thorough understanding of respiration, recognize how various CNS depressants suppress it, and take necessary steps to mitigate the risk of opioid-induced respiratory depression by collaborating with a multidisciplinary team (i.e., sleep and pain specialists), choosing appropriate medications, and educating patients on the proper use and storage of opioids.
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Affiliation(s)
| | - Suzanne Karan
- University of Rochester Medical Center, Rochester, NY, USA
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24
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Falcão LF, da Silva Pontes L, Afonso da Silva BG, Vieira da Silva Franco KM, Costa LA, Barbosa Rocha RS, Simões Quaresma JA. The complexity of respiratory disease associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection: From immunopathogenesis to respiratory therapy. Rev Med Virol 2020. [DOI: 10.1002/rmv.2167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Luiz Fábio Falcão
- Center for Biological and Health Sciences State University of Pará Belém Pará Brazil
| | | | | | | | - Luiz Adriano Costa
- Center for Biological and Health Sciences State University of Pará Belém Pará Brazil
| | | | - Juarez Antônio Simões Quaresma
- Center for Biological and Health Sciences State University of Pará Belém Pará Brazil
- Evandro Chagas Institute Ministry of Health Ananindeua Pará Brazil
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25
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Selvanathan J, Peng PWH, Wong J, Ryan CM, Chung F. Sleep-disordered breathing in patients on opioids for chronic pain. Reg Anesth Pain Med 2020; 45:826-830. [PMID: 32928994 DOI: 10.1136/rapm-2020-101540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/23/2020] [Accepted: 07/02/2020] [Indexed: 11/03/2022]
Abstract
The past two decades has seen a substantial rise in the use of opioids for chronic pain, along with opioid-related mortality and adverse effects. A contributor to opioid-associated mortality is the high prevalence of moderate/severe sleep-disordered breathing, including central sleep apnea and obstructive sleep apnea, in patients with chronic pain. Although evidence-based treatments are available for sleep-disordered breathing, patients are not frequently assessed for sleep-disordered breathing in pain clinics. To aid healthcare providers in this area of clinical uncertainty, we present evidence on the interaction between opioids and sleep-disordered breathing, and the prevalence and predictive factors for sleep-disordered breathing in patients on opioids for chronic pain. We provide recommendations on how to evaluate patients on opioids for risk of moderate/severe sleep-disordered breathing in clinical care, which could lead to earlier use of therapeutic interventions for opioid-associated sleep-disordered breathing, such as opioid cessation or positive airway pressure therapy. This would improve quality of life and well-being of patients with chronic pain.
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Affiliation(s)
- Janannii Selvanathan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Philip W H Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Clodagh M Ryan
- Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada .,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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High Efficacy by GAL-021: A Known Intravenous Peripheral Chemoreceptor Modulator that Suppresses BK Ca-Channel Activity and Inhibits IK(M) or Ih. Biomolecules 2020; 10:biom10020188. [PMID: 31991782 PMCID: PMC7072225 DOI: 10.3390/biom10020188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/25/2022] Open
Abstract
GAL-021 has recently been developed as a novel breathing control modulator. However, modifications of ionic currents produced by this agent remain uncertain, although its efficacy in suppressing the activity of big-conductance Ca2+-activated K+ (BKCa) channels has been reported. In pituitary tumor (GH3) cells, we found that the presence of GAL-021 decreased the amplitude of macroscopic Ca2+-activated K+ current (IK(Ca)) in a concentration-dependent manner with an effective IC50 of 2.33 μM. GAL-021-mediated reduction of IK(Ca) was reversed by subsequent application of verteporfin or ionomycin; however, it was not by that of diazoxide. In inside-out current recordings, the addition of GAL-021 to the bath markedly decreased the open-state probability of BKCa channels. This agent also resulted in a rightward shift in voltage dependence of the activation curve of BKCa channels; however, neither the gating charge of the curve nor single-channel conductance of the channel was changed. There was an evident lengthening of the mean closed time of BKCa channels in the presence of GAL-021, with no change in mean open time. The GAL-021 addition also suppressed M-type K+ current with an effective IC50 of 3.75 μM; however, its presence did not alter the amplitude of erg-mediated K+ current, or mildly suppressed delayed-rectifier K+ current. GAL-021 at a concentration of 30 μM could also suppress hyperpolarization-activated cationic current. In HEK293T cells expressing α-hSlo, the addition of GAL-021 was also able to suppress the BKCa-channel open probabilities, and GAL-021-mediated suppression of BKCa-channel activity was attenuated by further addition of BMS-191011. Collectively, the GAL-021 effects presented herein do not exclusively act on BKCa channels and these modifications on ionic currents exert significant influence on the functional activities of electrically excitable cells occurring in vivo.
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Sun X, Thörn Pérez C, Halemani D N, Shao XM, Greenwood M, Heath S, Feldman JL, Kam K. Opioids modulate an emergent rhythmogenic process to depress breathing. eLife 2019; 8:e50613. [PMID: 31841107 PMCID: PMC6938398 DOI: 10.7554/elife.50613] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 12/11/2019] [Indexed: 12/13/2022] Open
Abstract
How mammalian neural circuits generate rhythmic activity in motor behaviors, such as breathing, walking, and chewing, remains elusive. For breathing, rhythm generation is localized to a brainstem nucleus, the preBötzinger Complex (preBötC). Rhythmic preBötC population activity consists of strong inspiratory bursts, which drive motoneuronal activity, and weaker burstlets, which we hypothesize reflect an emergent rhythmogenic process. If burstlets underlie inspiratory rhythmogenesis, respiratory depressants, such as opioids, should reduce burstlet frequency. Indeed, in medullary slices from neonatal mice, the μ-opioid receptor (μOR) agonist DAMGO slowed burstlet generation. Genetic deletion of μORs in a glutamatergic preBötC subpopulation abolished opioid-mediated depression, and the neuropeptide Substance P, but not blockade of inhibitory synaptic transmission, reduced opioidergic effects. We conclude that inspiratory rhythmogenesis is an emergent process, modulated by opioids, that does not rely on strong bursts of activity associated with motor output. These findings also point to strategies for ameliorating opioid-induced depression of breathing.
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Affiliation(s)
- Xiaolu Sun
- Department of NeurobiologyDavid Geffen School of Medicine at UCLALos AngelesUnited States
| | - Carolina Thörn Pérez
- Department of NeurobiologyDavid Geffen School of Medicine at UCLALos AngelesUnited States
| | - Nagaraj Halemani D
- Department of Cell Biology and AnatomyChicago Medical School, Rosalind Franklin University of Medicine and ScienceNorth ChicagoUnited States
| | - Xuesi M Shao
- Department of NeurobiologyDavid Geffen School of Medicine at UCLALos AngelesUnited States
| | - Morgan Greenwood
- RFUMS/DePaul Research Internship ProgramRosalind Franklin University of Medicine and ScienceNorth ChicagoUnited States
| | - Sarah Heath
- Department of NeurobiologyDavid Geffen School of Medicine at UCLALos AngelesUnited States
| | - Jack L Feldman
- Department of NeurobiologyDavid Geffen School of Medicine at UCLALos AngelesUnited States
| | - Kaiwen Kam
- Department of Cell Biology and AnatomyChicago Medical School, Rosalind Franklin University of Medicine and ScienceNorth ChicagoUnited States
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Ayad S, Khanna AK, Iqbal SU, Singla N. Characterisation and monitoring of postoperative respiratory depression: current approaches and future considerations. Br J Anaesth 2019; 123:378-391. [DOI: 10.1016/j.bja.2019.05.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/06/2019] [Accepted: 05/24/2019] [Indexed: 01/19/2023] Open
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Kassick AJ, Allen HN, Yerneni SS, Pary F, Kovaliov M, Cheng C, Pravetoni M, Tomycz ND, Whiting DM, Nelson TL, Feasel M, Campbell PG, Kolber B, Averick S. Covalent Poly(lactic acid) Nanoparticles for the Sustained Delivery of Naloxone. ACS APPLIED BIO MATERIALS 2019; 2:3418-3428. [PMID: 31497753 PMCID: PMC6731033 DOI: 10.1021/acsabm.9b00380] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The opioid epidemic currently plaguing the United States has been exacerbated by an alarming rise in fatal overdoses as a result of the proliferated abuse of synthetic mu opioid receptor (MOR) agonists, such as fentanyl and its related analogues. Attempts to manage this crisis have focused primarily on widespread distribution of the clinically approved opioid reversal agent naloxone (Narcan); however, due to the intrinsic metabolic lability of naloxone, these measures have demonstrated limited effectiveness against synthetic opioid toxicity. This work reports a novel polymer-based strategy to create a long-acting formulation of naloxone with the potential to address this critical issue by utilizing covalent nanoparticle (cNP) drug delivery technology. Covalently loaded naloxone nanoparticles (Nal-cNPs) were prepared via the naloxone-initiated, ring-opening polymerization (ROP) of l-lactide in the presence of a bifunctional thiourea organocatalyst with subsequent precipitation of the resulting naloxone-poly(l-lactic acid) polymer. This protocol afforded well-defined nanoparticles possessing a drug loading of approximately 7% w/w. The resulting Nal-cNPs demonstrated excellent biocompatibility, while exhibiting sustained linear release kinetics in vitro and blocking the effects of high dose (10 mg/kg) acute morphine for up to 98 h in an in vivo rodent model of neuropathic pain.
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Affiliation(s)
- Andrew J. Kassick
- Neuroscience Disruptive Research Lab, Allegheny Health Network Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
- Neuroscience Institute, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Heather N. Allen
- Department of Biological Sciences and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania 15282, United States
| | - Saigopalakrishna S. Yerneni
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213, United States
| | - Fathima Pary
- Department of Chemistry, Oklahoma State University, Stillwater, Oklahoma 74078, United States
| | - Marina Kovaliov
- Neuroscience Disruptive Research Lab, Allegheny Health Network Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
- Neuroscience Institute, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Cooper Cheng
- Neuroscience Institute, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Marco Pravetoni
- Department of Pharmacology, University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Nestor D. Tomycz
- Neuroscience Institute, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Donald M. Whiting
- Neuroscience Institute, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
| | - Toby L. Nelson
- Department of Chemistry, Oklahoma State University, Stillwater, Oklahoma 74078, United States
| | - Michael Feasel
- Chemical Biological Center, APG, U.S. Army Combat Capabilities Development Command, Edgewood, Maryland 21010, United States
| | - Phil G. Campbell
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213, United States
- Engineering and Engineering Research Accelerator, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213, United States
| | - Benedict Kolber
- Department of Biological Sciences and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania 15282, United States
| | - Saadyah Averick
- Neuroscience Disruptive Research Lab, Allegheny Health Network Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
- Neuroscience Institute, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, United States
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30
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Solving the Opioid Crisis: Respiratory Depression by Opioids as Critical End Point. Chest 2019; 156:653-658. [PMID: 31194974 DOI: 10.1016/j.chest.2019.05.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/20/2019] [Accepted: 05/27/2019] [Indexed: 11/24/2022] Open
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Ahmad-Molaei L, Hassanian-Moghaddam H, Farnaghi F, Tomaz C, Haghparast A. Delay-Dependent Impairments in Memory and Motor Functions After Acute Methadone Overdose in Rats. Front Pharmacol 2018; 9:1023. [PMID: 30250433 PMCID: PMC6139438 DOI: 10.3389/fphar.2018.01023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 08/23/2018] [Indexed: 11/21/2022] Open
Abstract
Methadone is used as a substitution drug for the treatment of opioid dependence and chronic pain. Despite its widespread use and availability, there is a serious concern with respect to the relative safety of methadone. The purpose of this study was to characterize how acute methadone overdose affects the cognitive and motor performance of naïve healthy rats. The methadone overdose was induced by administering an acute toxic dose of methadone (15 mg/kg; ip; the equivalent dose of 80% of LD50) to adolescent rats. Resuscitation using a ventilator pump along with a single dose of naloxone (2 mg/kg; ip) was administered following the occurrence of apnea. The animals which were successfully resuscitated divided randomly into three apnea groups that evaluated either on day 1, 5, or 10 post-resuscitation (M/N-Day 1, M/N-Day 5, and M/N-Day 10 groups) in the Y-maze and novel object memory recognition tasks as well as pole and rotarod tests. The data revealed that a single toxic dose of methadone had an adverse effect on spontaneous behavior. In addition, Recognition memory impairment was observed in the M/N-Day 1, 5, and 10 groups after methadone-induced apnea. Further, descending time in the M/N-Day 5 group increased significantly in comparison with its respective Saline control group. The overall results indicate that acute methadone-overdose-induced apnea produced delay-dependent cognitive and motor impairment. We suggest that methadone poisoning should be considered as a possible cause of delayed neurological disorders, which might be transient, in some types of memory or motor performance in naïve healthy rats.
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Affiliation(s)
- Leila Ahmad-Molaei
- Neuroscience Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Farnaghi
- Department of Pediatric Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Carlos Tomaz
- Neuroscience Research Program, CEUMA University, São Luís, Brazil
| | - Abbas Haghparast
- Neuroscience Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Pergolizzi JV, LeQuang JA, Taylor R, Ossipov MH, Colucci D, Raffa RB. Designing safer analgesics: a focus on μ-opioid receptor pathways. Expert Opin Drug Discov 2018; 13:965-972. [DOI: 10.1080/17460441.2018.1511539] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Michael H. Ossipov
- Department of Pharmacology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Daniel Colucci
- Department of Bioengineering, Northeastern University, Boston, MA, USA
| | - Robert B. Raffa
- University of Arizona College of Pharmacy, Tucson, AZ, USA
- Temple University School of Pharmacy, Philadelphia, PA, USA
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33
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Strickler J, James A, Oʼleary S, Dube-Clark G. Portrait of an epidemic: acute opioid intoxication in adults. Nursing 2018; 48:40-43. [PMID: 30134319 DOI: 10.1097/01.nurse.0000541389.52104.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Jeff Strickler
- At University of North Carolina Hospitals in Chapel Hill, N.C., Jeff Strickler is a vice president, Ashley James is a lead pharmacist, Suzy O'Leary is an ED nurse manager, and Gigi Dube-Clark is a clinical nurse
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Ryan SA, Dunne RB. Pharmacokinetic properties of intranasal and injectable formulations of naloxone for community use: a systematic review. Pain Manag 2018; 8:231-245. [DOI: 10.2217/pmt-2017-0060] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aim: To assess the pharmacokinetic properties of community-use formulations of naloxone for emergency treatment of opioid overdose. Methods: Systematic literature review based on searches of established databases and congress archives. Results: Seven studies met inclusion criteria: two of US FDA-approved intramuscular (im.)/subcutaneous (sc.) auto-injectors, one of an FDA-approved intranasal spray, two of unapproved intranasal kits (syringe with atomizer attachment) and two of intranasal products in development. Conclusion: The pharmacokinetics of im./sc. auto-injector 2 mg and approved intranasal spray (2 and 4 mg) demonstrated rapid uptake and naloxone exposure exceeding that of the historic benchmark (0.4 mg im.), indicating that naloxone exposure was adequate for reversal of opioid overdose.
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Affiliation(s)
- Shawn A Ryan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, 45267 USA
- BrightView Health, Cincinnati, OH, 45206 USA
| | - Robert B Dunne
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, 48202 USA
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35
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Liang X, Yong Z, Su R. Inhibition of protein kinase A and GIRK channel reverses fentanyl-induced respiratory depression. Neurosci Lett 2018; 677:14-18. [PMID: 29679681 DOI: 10.1016/j.neulet.2018.04.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/07/2018] [Accepted: 04/16/2018] [Indexed: 02/08/2023]
Abstract
Opioid-induced respiratory depression is a major obstacle to improving the clinical management of moderate to severe chronic pain. Opioids inhibit neuronal activity via various pathways, including calcium channels, adenylyl cyclase, and potassium channels. Currently, the underlying molecular pathway of opioid-induced respiratory depression is only partially understood. This study aimed to investigate the mechanisms of opioid-induced respiratory depression in vivo by examining the effects of different pharmacological agents on fentanyl-induced respiratory depression. Respiratory parameters were detected using whole body plethysmography in conscious rats. We show that pre-treatment with the protein kinase A (PKA) inhibitor H89 reversed the fentanyl-related effects on respiratory rate, inspiratory time, and expiratory time. Pre-treatment with the G protein-gated inwardly rectifying potassium (GIRK) channel blocker Tertiapin-Q dose-dependently reversed the fentanyl-related effects on respiratory rate and inspiratory time. A phosphodiesterase 4 (PDE4) inhibitor and cyclic adenosine monophosphate (cAMP) analogs did not affect fentanyl-induced respiratory depression. These findings suggest that PKA and GIRK may be involved in fentanyl-induced respiratory depression and could represent useful therapeutic targets for the treatment of fentanyl-induced ventilatory depression.
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Affiliation(s)
- Xiaonan Liang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Key Laboratory of Neuropsychopharmacology, Beijing Institute of Pharmacology and Toxicology, 27 Taiping Road, Beijing 100850, China
| | - Zheng Yong
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Key Laboratory of Neuropsychopharmacology, Beijing Institute of Pharmacology and Toxicology, 27 Taiping Road, Beijing 100850, China.
| | - Ruibin Su
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Key Laboratory of Neuropsychopharmacology, Beijing Institute of Pharmacology and Toxicology, 27 Taiping Road, Beijing 100850, China.
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36
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Ahmad T, Valentovic MA, Rankin GO. Effects of cytochrome P450 single nucleotide polymorphisms on methadone metabolism and pharmacodynamics. Biochem Pharmacol 2018; 153:196-204. [PMID: 29458047 DOI: 10.1016/j.bcp.2018.02.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/14/2018] [Indexed: 01/11/2023]
Abstract
Methadone is a synthetic, long-acting opioid with a single chiral center forming two enantiomers, (R)-methadone and (S)-methadone, each having specific pharmacological actions. Concentrations of (R)- and (S)-methadone above therapeutic levels have the ability to cause serious, life-threatening, and fatal side effects. This toxicity can be due in part to the pharmacogenetics of an individual, which influences the pharmacokinetic and pharmacodynamic properties of the drug. Methadone is primarily metabolized in the liver by cytochrome P450 (CYP) enzymes, predominately by CYP2B6, followed by CYP3A4, 2C19, 2D6, and to a lesser extent, CYP2C18, 3A7, 2C8, 2C9, 3A5, and 1A2. Single nucleotide polymorphisms (SNPs) located within CYPs have the potential to play an important role in altering methadone metabolism and pharmacodynamics. Several SNPs in the CYP2B6, 3A4, 2C19, 2D6, and 3A5 genes result in increases in methadone plasma concentrations, decreased N-demethylation, and decreased methadone clearance. In particular, carriers of CYP2B6*6/*6 may have a greater risk for detrimental adverse effects, as methadone metabolism and clearance are diminished in these individuals. CYP2B6*4, on the other hand, has been observed to decrease plasma concentrations of methadone due to increased methadone clearance. The involvement, contribution, and understanding the role of SNPs in CYP2B6, and other CYP genes, in methadone metabolism can improve the therapeutic uses of methadone in patient outcome and the development of personalized medicine.
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Affiliation(s)
- Taha Ahmad
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA
| | - Monica A Valentovic
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA
| | - Gary O Rankin
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA.
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37
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Chen Z, Zhao H, Fu N, Chen L. The diversified function and potential therapy of ectopic olfactory receptors in non-olfactory tissues. J Cell Physiol 2017; 233:2104-2115. [PMID: 28338216 DOI: 10.1002/jcp.25929] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/22/2017] [Indexed: 12/28/2022]
Abstract
Olfactory receptors (ORs) are mainly distributed in olfactory neurons and play a key role in detecting volatile odorants, eventually resulting in the production of smell perception. Recently, it is also reported that ORs are expressed in non-olfactory tissues including heart, lung, sperm, skin, and cancerous tissues. Interestingly, ectopic ORs are associated with the development of diseases in non-olfactory tissues. For instance, ectopic ORs initiate the hypoxic ventilatory responses and maintain the oxygen homeostasis of breathing in the carotid body when oxygen levels decline. Ectopic ORs induce glucose homeostasis in diabetes. Ectopic ORs regulate systemic blood pressure by increasing renin secretion and vasodilation. Ectopic ORs participate in the process of tumor cell proliferation, apoptosis, metastasis, and invasiveness. Ectopic ORs accelerate the occurrence of obesity, angiogenesis and wound-healing processes. Ectopic ORs affect fetal hemoglobin levels in sickle cell anemia and thalassemia. Finally, we also elaborate some ligands targeting for ORs. Obviously, the diversified function and related signal pathway of ectopic ORs may play a potential therapeutic target in non-olfactory tissues. Thus, this review focuses on the latest research results about the diversified function and therapeutic potential of ectopic ORs in non-olfactory tissues.
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Affiliation(s)
- Zhe Chen
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang, China
| | - Hong Zhao
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang, China
| | - Nian Fu
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang, China
| | - Linxi Chen
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang, China
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38
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Side effects of pain and analgesia in animal experimentation. Lab Anim (NY) 2017; 46:123-128. [DOI: 10.1038/laban.1216] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 12/30/2016] [Indexed: 02/03/2023]
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39
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Cornelissen L, Berde C. Biomedical science: Protection for anaesthetized mice. Nature 2016; 536:36-7. [PMID: 27488795 DOI: 10.1038/536036a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Laura Cornelissen
- Department of Anesthesiology, Perioperative &Pain Medicine, Boston Children's Hospital, Boston, Massachusetts 02115, USA, and in the Department of Anaesthesia, Harvard Medical School, Boston
| | - Charles Berde
- Department of Anesthesiology, Perioperative &Pain Medicine, Boston Children's Hospital, Boston, Massachusetts 02115, USA, and in the Department of Anaesthesia, Harvard Medical School, Boston
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40
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Haji A, Kimura S, Ohi Y. Reversal of morphine-induced respiratory depression by doxapram in anesthetized rats. Eur J Pharmacol 2016; 780:209-15. [DOI: 10.1016/j.ejphar.2016.03.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/23/2016] [Accepted: 03/29/2016] [Indexed: 10/22/2022]
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41
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Richards JR, Laurin EG, Bretz SW, Traylor BR, Panacek EA. Treatment of ethanol poisoning and associated hypoventilation with doxapram. Am J Emerg Med 2016; 34:2253.e1-2253.e2. [PMID: 27233697 DOI: 10.1016/j.ajem.2016.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 04/29/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
- John R Richards
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA.
| | - Erik G Laurin
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA
| | | | - Brittany R Traylor
- Department of Pharmacy, University of California Davis Medical Center, Sacramento, CA
| | - Edward A Panacek
- Department of Emergency Medicine, University of South Alabama College of Medicine, Mobile, AL
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Haw AJ, Meyer LC, Greer JJ, Fuller A. Ampakine CX1942 attenuates opioid-induced respiratory depression and corrects the hypoxaemic effects of etorphine in immobilized goats (Capra hircus). Vet Anaesth Analg 2016; 43:528-38. [PMID: 27531058 DOI: 10.1111/vaa.12358] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 01/05/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine whether CX1942 reverses respiratory depression in etorphine-immobilized goats, and to compare its effects with those of doxapram hydrochloride. STUDY DESIGN A prospective, crossover experimental trial conducted at 1753 m.a.s.l. ANIMALS Eight adult female Boer goats (Capra hircus) with a mean ± standard deviation mass of 27.1 ± 1.6 kg. METHODS Following immobilization with 0.1 mg kg(-1) etorphine, goats received one of doxapram, CX1942 or sterile water intravenously, in random order in three trials. Respiratory rate, ventilation and tidal volume were measured continuously. Arterial blood samples for the determination of PaO2 , PaCO2 , pH and SaO2 were taken 2 minutes before and then at 5 minute intervals after drug administration for 25 minutes. RESULTS Doxapram corrected etorphine-induced respiratory depression but also led to arousal and hyperventilation at 2 minutes after its administration, as indicated by the low PaCO2 (27.8 ± 4.5 mmHg) and ventilation of 5.32 ± 5.24 L minute(-1) above pre-immobilization values. CX1942 improved respiratory parameters and corrected etorphine's hypoxaemic effects more gradually than did doxapram, with a more sustained improvement in PaO2 and SaO2 in comparison with the control trial. CONCLUSIONS CX1942 attenuated opioid-induced respiratory depression and corrected the hypoxaemic effects of etorphine in immobilized goats. CLINICAL RELEVANCE Ampakines potentially offer advantages over doxapram, a conventional treatment, in reversing etorphine-induced respiratory depression without causing unwanted side effects, particularly arousal, in immobilized animals.
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Affiliation(s)
- Anna J Haw
- Brain Function Research Group, Faculty of Health Sciences, School of Physiology, University of the Witwatersrand, Parktown, South Africa
| | - Leith Cr Meyer
- Brain Function Research Group, Faculty of Health Sciences, School of Physiology, University of the Witwatersrand, Parktown, South Africa.,Department of Paraclinical Sciences, Faculty of Veterinary Science, University of Pretoria, Onderstepoort, South Africa
| | - John J Greer
- Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Andrea Fuller
- Brain Function Research Group, Faculty of Health Sciences, School of Physiology, University of the Witwatersrand, Parktown, South Africa.,Department of Paraclinical Sciences, Faculty of Veterinary Science, University of Pretoria, Onderstepoort, South Africa
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43
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Oxygen-sensing by arterial chemoreceptors: Mechanisms and medical translation. Mol Aspects Med 2016; 47-48:90-108. [DOI: 10.1016/j.mam.2015.12.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/01/2015] [Indexed: 12/30/2022]
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44
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Chang AJ, Ortega FE, Riegler J, Madison DV, Krasnow MA. Oxygen regulation of breathing through an olfactory receptor activated by lactate. Nature 2015; 527:240-4. [PMID: 26560302 PMCID: PMC4765808 DOI: 10.1038/nature15721] [Citation(s) in RCA: 205] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/28/2015] [Indexed: 12/25/2022]
Abstract
Animals have evolved homeostatic responses to changes in oxygen availability that act on different time scales. Although the hypoxia-inducible factor (HIF) transcriptional pathway that controls long term responses to low oxygen (hypoxia) has been established1, the pathway that mediates acute responses to hypoxia in mammals is not well understood. Here we show that the olfactory receptor Olfr78 is highly and selectively expressed in oxygen-sensitive glomus cells of the carotid body, a chemosensory organ at the carotid artery bifurcation that monitors blood oxygen and stimulates breathing within seconds when oxygen declines2. Olfr78 mutants fail to increase ventilation in hypoxia but respond normally to hypercapnia. Glomus cells are present in normal numbers and appear structurally intact, but hypoxia-induced carotid body activity is diminished. Lactate, a metabolite that rapidly accumulates in hypoxia and induces hyperventilation3–6, activates Olfr78 in heterologous expression experiments, induces calcium transients in glomus cells, and stimulates carotid sinus nerve activity through Olfr78. We propose that in addition to its role in olfaction, Olfr78 acts as a hypoxia sensor in the breathing circuit by sensing lactate produced when oxygen levels decline.
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Affiliation(s)
- Andy J Chang
- Department of Biochemistry, Stanford University School of Medicine and Howard Hughes Medical Institute, Stanford, California 94305-5307, USA
| | - Fabian E Ortega
- Department of Biochemistry, Stanford University School of Medicine and Howard Hughes Medical Institute, Stanford, California 94305-5307, USA
| | - Johannes Riegler
- Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Daniel V Madison
- Department of Molecular and Cellular Physiology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Mark A Krasnow
- Department of Biochemistry, Stanford University School of Medicine and Howard Hughes Medical Institute, Stanford, California 94305-5307, USA
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Fechtner L, El Ali M, Sattar A, Moore M, Strohl KP. Fentanyl effects on breath generation in C57BL/6J and A/J mouse strains. Respir Physiol Neurobiol 2015; 215:20-9. [PMID: 25936679 DOI: 10.1016/j.resp.2015.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/20/2015] [Accepted: 04/20/2015] [Indexed: 12/29/2022]
Abstract
We examined the effect of fentanyl on chemoresponsiveness in mouse strains divergent in the expression of spontaneous and post-hypoxic pauses. Frequency and tidal volume were recorded with plethysmography in A/J and C57BL/6J (B6) male mice. Mice selected at random received an intraperitoneal (IP) injection of either saline, low dose fentanyl (LDF = 0.04 mg/kg), or high dose fentanyl (HDF = 0.4 mg/kg) under hypoxia (8% O2) or hyperoxia (100%O2). LDF produced a decrease in frequency during hypoxia in B6, but not A/J, mice. HDF significantly decreased frequency and tidal volume in both strains under hypoxia and hyperoxia (p<0.01); naloxone, an opioid antagonist, reversed this response. The acute administration of fentanyl at any dose did not promote apneas in strains of mice exhibiting regular or irregular respiratory patterns. However, higher doses depressed respiratory frequency in both strains. The B6 mice responded with a depressive response to hypoxia that did not recover with reoxygenation, but did recover with time or naloxone.
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Affiliation(s)
- Linnea Fechtner
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mazen El Ali
- Louis Stokes Department of Veteran Affairs Medical Center, Cleveland, OH, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Abdus Sattar
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael Moore
- Louis Stokes Department of Veteran Affairs Medical Center, Cleveland, OH, USA
| | - Kingman P Strohl
- Louis Stokes Department of Veteran Affairs Medical Center, Cleveland, OH, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.
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46
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Kimura S, Ohi Y, Haji A. Blockade of phosphodiesterase 4 reverses morphine-induced ventilatory disturbance without loss of analgesia. Life Sci 2015; 127:32-8. [DOI: 10.1016/j.lfs.2015.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 01/19/2015] [Accepted: 02/02/2015] [Indexed: 12/11/2022]
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