1
|
Toikumo S, Vickers-Smith R, Jinwala Z, Xu H, Saini D, Hartwell EE, Pavicic M, Sullivan KA, Xu K, Jacobson DA, Gelernter J, Rentsch CT, Stahl E, Cheatle M, Zhou H, Waxman SG, Justice AC, Kember RL, Kranzler HR. A multi-ancestry genetic study of pain intensity in 598,339 veterans. Nat Med 2024; 30:1075-1084. [PMID: 38429522 DOI: 10.1038/s41591-024-02839-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 01/27/2024] [Indexed: 03/03/2024]
Abstract
Chronic pain is a common problem, with more than one-fifth of adult Americans reporting pain daily or on most days. It adversely affects the quality of life and imposes substantial personal and economic costs. Efforts to treat chronic pain using opioids had a central role in precipitating the opioid crisis. Despite an estimated heritability of 25-50%, the genetic architecture of chronic pain is not well-characterized, in part because studies have largely been limited to samples of European ancestry. To help address this knowledge gap, we conducted a cross-ancestry meta-analysis of pain intensity in 598,339 participants in the Million Veteran Program, which identified 126 independent genetic loci, 69 of which are new. Pain intensity was genetically correlated with other pain phenotypes, level of substance use and substance use disorders, other psychiatric traits, education level and cognitive traits. Integration of the genome-wide association studies findings with functional genomics data shows enrichment for putatively causal genes (n = 142) and proteins (n = 14) expressed in brain tissues, specifically in GABAergic neurons. Drug repurposing analysis identified anticonvulsants, β-blockers and calcium-channel blockers, among other drug groups, as having potential analgesic effects. Our results provide insights into key molecular contributors to the experience of pain and highlight attractive drug targets.
Collapse
Affiliation(s)
- Sylvanus Toikumo
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rachel Vickers-Smith
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Epidemiology and Environmental Health, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Zeal Jinwala
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Heng Xu
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Divya Saini
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily E Hartwell
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mirko Pavicic
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Kyle A Sullivan
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Ke Xu
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel A Jacobson
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Joel Gelernter
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher T Rentsch
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- London School of Hygiene & Tropical Medicine, London, UK
| | - Eli Stahl
- Regeneron Genetics Center, Tarrytown, NY, USA
| | - Martin Cheatle
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hang Zhou
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen G Waxman
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale University School of Public Health, New Haven, CT, USA
| | - Rachel L Kember
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henry R Kranzler
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA.
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
2
|
Toikumo S, Vickers-Smith R, Jinwala Z, Xu H, Saini D, Hartwell E, Venegas MP, Sullivan KA, Xu K, Jacobson DA, Gelernter J, Rentsch CT, Stahl E, Cheatle M, Zhou H, Waxman SG, Justice AC, Kember RL, Kranzler HR. The genetic architecture of pain intensity in a sample of 598,339 U.S. veterans. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.09.23286958. [PMID: 36993749 PMCID: PMC10055465 DOI: 10.1101/2023.03.09.23286958] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Chronic pain is a common problem, with more than one-fifth of adult Americans reporting pain daily or on most days. It adversely affects quality of life and imposes substantial personal and economic costs. Efforts to treat chronic pain using opioids played a central role in precipitating the opioid crisis. Despite an estimated heritability of 25-50%, the genetic architecture of chronic pain is not well characterized, in part because studies have largely been limited to samples of European ancestry. To help address this knowledge gap, we conducted a cross-ancestry meta-analysis of pain intensity in 598,339 participants in the Million Veteran Program, which identified 125 independent genetic loci, 82 of which are novel. Pain intensity was genetically correlated with other pain phenotypes, level of substance use and substance use disorders, other psychiatric traits, education level, and cognitive traits. Integration of the GWAS findings with functional genomics data shows enrichment for putatively causal genes (n = 142) and proteins (n = 14) expressed in brain tissues, specifically in GABAergic neurons. Drug repurposing analysis identified anticonvulsants, beta-blockers, and calcium-channel blockers, among other drug groups, as having potential analgesic effects. Our results provide insights into key molecular contributors to the experience of pain and highlight attractive drug targets.
Collapse
Affiliation(s)
- Sylvanus Toikumo
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rachel Vickers-Smith
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Epidemiology, University of Kentucky College of Public Health; Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Zeal Jinwala
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Heng Xu
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Divya Saini
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily Hartwell
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mirko P. Venegas
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Kyle A. Sullivan
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Ke Xu
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Joel Gelernter
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Christopher T. Rentsch
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Eli Stahl
- Regeneron Genetics Center, Tarrytown, NY, USA
| | - Martin Cheatle
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hang Zhou
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Stephen G. Waxman
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Amy C. Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
- Yale University School of Public Health, New Haven, CT, USA
| | - Rachel L. Kember
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henry R. Kranzler
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
3
|
Serrano A, Gálvez R, Paremés E, Navarro A, Ochoa D, Pérez C. Off-label pharmacological treatment for neuropathic pain: A Delphi study by the Spanish Pain Society Neuropathic Pain Task Force. Pain Pract 2023; 23:167-179. [PMID: 36308490 DOI: 10.1111/papr.13176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/23/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The use of off-label pharmacotherapies for neuropathic pain (NP) is growing relating to the many unmet needs of patients. However, clinical guidelines fail to address it, and the available evidence is sparse and fragmented. We arranged a formal expert consensus to address this controversial issue and provide some guidance on judicious use. METHODS A two-round standard Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 40-item questionnaire prepared by the authors. Consensus on each statement was defined as at least either 80% endorsement or rejection after the second round. RESULTS Forty-three and thirty-seven panelists participated in the first and second round, respectively. Consensus was reached in 34 out of 40 statements. Endorsed alternatives for unresponsive patients include non-gabapentinoid antiepileptics (oxcarbazepine and eslicarbazepine), venlafaxine, intravenous lidocaine (when doses can be optimized), and some vaporized cannabinoids (under appropriate surveillance). In addition, lacosamide, low-dose naltrexone, propofol, or ketamine could prove beneficial if subjected to more research. Other options were rejected, and there was controversy about the usefulness of topical preparations. DISCUSSION For patients who do not respond to standard NP treatments, some other viable pharmacological options can be attempted before advancing to other therapeutic stages. This may help patients who are reluctant to or have some contraindication for interventional therapies.
Collapse
Affiliation(s)
- Ancor Serrano
- Pain Clinic, Department of Anesthesia and Reanimation, Hospital Universitari de Bellvitge, L'Hospital et de Llobregat, Spain
| | - Rafael Gálvez
- Pain Clinic, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Elena Paremés
- Pain Clinic, Department of Anesthesia and Reanimation, Hospital Povisa, Vigo, Spain
| | - Ana Navarro
- Centro de Salud Puerta del Ángel, Madrid, Spain
| | - Dolores Ochoa
- Clinical Pharmacology, Hospital de la Princesa, Madrid, Spain
| | | |
Collapse
|
4
|
Pain Management in Older Adults with Chronic Wounds. Drugs Aging 2022; 39:619-629. [PMID: 35829959 DOI: 10.1007/s40266-022-00963-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/03/2022]
Abstract
Older people often suffer from different types of ulcers, with the most prevalent being chronic leg ulcers (CLUs) and diabetic foot ulcers. There are major issues in the current medical approach because these ulcers are hard to heal, and, in the case of CLUs, very painful and with a high frequency of relapse. Older people complain of pain more frequently than young people, frequently due to a combination of painful chronic wounds with other comorbidities (e.g. arthritis, peripheral arterial disease, vertebrogenic pain syndrome). However, chronic pain appears to be managed better by older people because the pain sensitivity is downregulated and the pain threshold is higher in older people. Pain management of chronic wounds is often insufficient, especially in older individuals. It is highly important to use non-traumatic wound dressings and pay attention to patients' feelings and fears because pain in chronic ulcers can impair wound healing. Key factors include good preparation for dressing change and adequate analgesia, ideally a combination of topical and oral agents.
Collapse
|
5
|
Edinoff AN, Derise OC, Sheppard AJ, Miriyala S, Virgen CG, Kaye AJ, Niakan M, Cornett EM, Kaye AD. The Influence of Analgesic Modalities on Postoperative Cancer Recurrence. Anesth Pain Med 2022; 12:e123463. [PMID: 35433388 PMCID: PMC8995873 DOI: 10.5812/aapm.123463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/20/2022] [Indexed: 11/16/2022] Open
Abstract
The potential for cancer cells to grow and to metastasize depends on complex interactions between inflammatory signals and pathways, immune cells, and elements of the stromal tissue in which they invade. Related to the nature of many cancers, the probability of recurrence can potentially be quite high for some patients. Immunology, lifestyle modifications, timing of disease, genetics, age, gender, and race are only a handful of ways the likelihood of cancer recurrence can be influenced. The quantity, or density, of certain immunological cells or factors, plays a role in the propagation of cancer cells. Opioids are often used in cancer patients for acute postoperative and chronic pain management. While they can produce significant pain relief, the type of analgesic utilized is important, as it may influence cancer propagation. In this regard, certain opioids have been found to increase T regulatory cells while suppressing NK cell function. Morphine may promote tumor neovascularization and expansion. Fentanyl administration significantly diminishes NK-cells and CD8+ cytotoxic T-cells. In a recent meta-analysis, propofol-based anesthesia improved both cancer-free survival and overall survival. COX inhibitors have also shown promise in persevering cancer immune function, as in literature involving ketorolac and celecoxib. In summary, inhaled anesthesia and opioids may contribute to a pro-tumor metastasis environment also known as cancer propagation; whereas propofol and COX inhibitors may provide a better alternative to reduce cancer recurrence and propagation.
Collapse
Affiliation(s)
- Amber N. Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA, USA
- Corresponding Author: Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA, USA.
| | - Olivia C. Derise
- School of Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA, USA
| | - Aaron J. Sheppard
- School of Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA, USA
| | - Sumitra Miriyala
- School of Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA, USA
| | - Celina G. Virgen
- College of Medicine-Phoenix, University of Arizona, Phoenix, AZ, USA
| | - Aaron J. Kaye
- Department of Anesthesiology, Medical University of South Carolina, Charleston, SC, USA
| | - Mohammad Niakan
- Pain Research Center, Department of Anesthesiology Intensive Care and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Research Center, Department of Anesthesiology Intensive Care and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA, USA
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA, USA
| |
Collapse
|