Spinal Opioid Tolerance Depends upon Platelet-Derived Growth Factor Receptor-β Signaling, Not μ-Opioid Receptor Internalization

Opioids are some of the most potent analgesics available. However, their effectiveness is limited by the development of analgesic tolerance. Traditionally, tolerance was thought to occur by termination of μ-opioid receptor (MOR) signaling via desensitization and internalization. Contradictory findings led to a more recent proposal that sustained MOR signaling caused analgesic tolerance. However, this view has also been called into question. We recently discovered that the platelet-derived growth factor receptor(PDGFR)-β signaling system is both necessary and sufficient to cause opioid tolerance. We therefore propose a completely new hypothesis: that opioid tolerance is mediated by selective cellular signals and is independent of MOR internalization. To test this hypothesis, we developed an automated software-based method to perform unbiased analyses of opioid-induced MOR internalization in the rat substantia gelatinosa. We induced tolerance with either morphine, which did not cause MOR internalization, or fentanyl, which did. We also blocked tolerance by administering morphine or fentanyl with the PDGFR-β inhibitor imatinib. We found that imatinib blocked tolerance without altering receptor internalization induced by either morphine or fentanyl. We also showed that imatinib blocked tolerance to other clinically used opioids. Our findings indicate that opioid tolerance is not dependent upon MOR internalization and support the novel hypothesis that opioid tolerance is mediated by intracellular signaling that can be selectively targeted. This suggests the exciting possibility that undesirable opioid side effects can be selectively eliminated, dramatically improving the safety and efficacy of opioids. SIGNIFICANCE STATEMENT: Classically, it was thought that analgesic tolerance to opioids was caused by desensitization and internalization of μ-opioid receptors (MORs). More recently, it was proposed that sustained, rather than reduced, MOR signaling caused tolerance. Here, we present conclusive evidence that opioid tolerance occurs independently of MOR internalization and that it is selectively mediated by platelet-derived growth factor receptor signaling. This novel hypothesis suggests that dangerous opioid side effects can be selectively targeted and blocked, improving the safety and efficacy of opioids.

Abused Drugs Modulate RGS4 mRNA Levels in Rat Brain: Comparison Between Acute Drug Treatment and a Drug Challenge after Chronic Treatment

While different classes of abused drugs interact with distinct signaling substrates, it appears that all utilize receptors in the mesolimbic dopamine system to mediate their reinforcing effects. The regulator of G-protein signaling (RGS) proteins modulate G-protein coupled receptor (GPCR) signaling by increasing the rate of GTP hydrolysis of G proteins. This study was undertaken to determine whether morphine, cocaine, or amphetamine would modulate RGS4 mRNA levels in relevant brain regions. Acute administration of morphine and cocaine decreased levels of RGS4 mRNA in the reticulotegmental pontine nucleus (RtTg) and locus coeruleus (LC). Increases in RGS 4 mRNA levels were observed in the nucleus accumbens (NAc) and dorsal central gray (CGD). Acute drug challenge after chronic drug administration increased RGS4 mRNA in the CGD and decreased RGS4 levels in the red nucleus and RtTg. Interestingly, the LC exhibited biphasic modulation, with decreased RGS4 mRNA levels after acute administration and increased levels after chronic administration. These findings indicate that RGS4 mRNA levels are modulated in a similar manner by different drugs of abuse and imply that a common substrate could mediate some effects of abused drugs.

The biologic basis of fatigue

In spite of many remarkable advances in our understanding of the mechanisms of cancer biology, very little attention has been directed toward mechanisms underlying cancer-induced symptoms. Although fatigue is a widely prevalent complication of cancer, there is a paucity of both basic and clinical research in this area. This article details our current knowledge of mechanisms causing cancer-related fatigue and briefly discusses currently available therapeutic options. A framework for addressing gaps in our knowledge and recommendations for future research directions are proposed.

Use of transcutaneous electrical nerve stimulation in a young child with pain from open perineal lesions

Transcutaneous electrical nerve stimulation (TENS) has been shown to be an effective treatment modality in adults experiencing pain associated with a variety of conditions. Therapeutic measures that are effective with adults can often be used with children. However, the benefit of TENS for children has not been well established since few research or clinical data have been published in the literature. This case report of a 4-year-old female with open perineal skin lesions who received TENS as an adjuvant therapy for painful dressing changes illustrates that TENS can be an effective treatment in children. In addition to the pain reduction seen in our patient, TENS therapy also had an opioid-sparing effect.

Mu and kappa opioid receptors in periaqueductal gray and rostral ventromedial medulla

The periaqueductal gray (PAG) and rostral ventromedial medulla (RVM) are important brain stem pain modulating regions. Recent evidence suggests that kappa opioids antagonize the effects of mu opioids in the RVM. However, the anatomical relationship between mu and kappa opioid receptors in PAG and RVM is not well characterized. This study examined relationships between mu and kappa opioid receptor immunoreactivity (IR) and mRNA in PAG and RVM. Brain slices were processed for either immunocytochemistry or in situ hybridization. We found considerable anatomical overlap of mu and kappa opioid IR and mRNA in the RVM and PAG. These results provide an anatomical basis for recent behavioral and electrophysiological findings in RVM, and suggest modulatory interactions between mu and kappa opioids in PAG.

Pattern of c-fos mRNA induction in rat brain by acute morphine

Initially, opioid signaling had been thought to be mainly inhibitory in nature. However, it has been shown that opioids can activate specific signaling pathways and induce immediate early gene (IEG) transcription in brain. IEGs can then regulate the transcription of other genes, leading to changes in neuronal function in response to extracellular stimuli. This study was designed to identify brain regions that demonstrate specific induction of the IEG c-fos, a component of the AP-1 transcription factor, in response to acute morphine, and to contrast this induction with the stressful effects of the injection itself. Rats received either 10 mg/kg morphine or an equivalent volume of saline injected subcutaneously. Animals were then sacrificed 15, 30, or 60 min after injection. Specific induction of c-fos mRNA by morphine was seen in dorsomedial caudate-putamen, paraventricular nucleus of the thalamus, central and intralaminar thalamic nuclei, dorsal central grey, superior colliculus, lateral parabrachial nucleus, inferior olivary complex, and caudal nucleus tractus solitarius. These findings represent the first complete anatomical mapping of c-fos induction in rat brain, and show that acute morphine administration alters gene expression in several areas related to known functional properties of opioids. However, regions showing c-fos induction are not all classically associated with opioid receptors and opioid-mediated effects. These findings are considered in the context of the effects of opioids on neural circuitry as well as direct, receptor-mediated effects of morphine on neural cells.

Opioid effects on mitogen-activated protein kinase signaling cascades

BACKGROUND

The molecular mechanisms underlying both beneficial and undesirable opioid actions are poorly understood. Recently, the three currently known mammalian mitogen-activated protein kinase (MAPK) signaling cascades (extracellular signal-related kinase [ERK], stress-activated protein kinase, and p38 kinase) were shown to play important roles in transducing receptor-mediated signaling processes.

METHODS

To determine whether any of these kinase cascades were activated by opioids, mu, delta, or kappa opioid receptors were transiently introduced into COS-7 cells together with MAPKs tagged to allow recognition by specific antibodies, and then exposed to opioids. Mitogen-activated protein kinase activation was determined by an in vitro MAPK activation assay. In addition, C6 glioma cells with either mu, delta, or kappa receptors stably introduced were exposed to opioids and MAPK activation determined by in vitro activation assay or antibody detection of activated forms.

RESULTS

Transient experiments in COS cells revealed potent stimulation of ERK by mu and delta receptor activation, weak stimulation of stress-activated protein kinase by all receptor types, and no activation of p38. In stably transfected C6 glioma cells, only ERK activation was observed. Extracellular signal-related kinase induction was rapid, peaking 5 min after stimulation, and its activation was receptor-type specific. Mu and delta receptor stimulation activated ERK, but kappa stimulation did not.

CONCLUSIONS

These results show that acute opioid signaling is not only inhibitory, but can strongly activate an important signaling cascade. Extracellular signal-related kinase activation may contribute to desirable responses to opioids, such as analgesia and sedation, and also to undesirable adaptive responses, such as tolerance, physical dependence, and possibly addiction. Further study of this system could provide greater insight into the molecular mechanisms underlying these clinical problems.

Cancellation of pediatric outpatient surgery: economic and emotional implications for patients and their families

STUDY OBJECTIVE

To determine the cause and timing of case cancellation in a pediatric outpatient surgical population, and to examine the economic and emotional impact of such cancellations on patients and their families.

DESIGN

Questionnaire survey.

SETTING

Outpatient surgery unit of a large university children's hospital.

PARTICIPANTS

127 parents of children whose elective outpatient surgery had been cancelled.

INTERVENTIONS

A total of 200 questionnaires were mailed to the parents of children who had their outpatient surgery cancelled.

MEASUREMENTS AND MAIN RESULTS

Of those children whose surgery had been cancelled, 34.6% were due to upper respiratory infections (URIs), 30.7% for other medical reasons, and the balance for scheduling errors, because the child had not fasted, or for difficulties with transportation. The majority of surgeries (58.3%) were cancelled prior to their scheduled surgery date. However, 18.9% were cancelled on the day of surgery prior to leaving for the hospital and 22.8% were cancelled on arrival at the outpatient surgery clinic. Of those patients whose surgeries were not cancelled until they arrived at the hospital, 38.5% of mothers and 50.0% of fathers missed a day of work and, of these, 53.3% and 42.1%, respectively, went unpaid for the work day missed. The mean number of miles driven (round trip) to the hospital for a cancelled operation was 158.8 miles (range 8 to 1,350 miles). Additional testing and new appointments were ordered in 25.2% of the cancelled cases. 45% of parents and 16% of children were disappointed by the cancellation; 16% of parents were frustrated by the cancellation and 3.3% were angry.

CONCLUSIONS

This study suggests that last-minute cancellation of surgery has an important impact on patients and their families and suggests a need to review present protocols for screening patients prior to surgery.

Molecular cloning and expression analysis of rat Rgs12 and Rgs14

We report the cloning of two novel rat regulators of G-protein signaling (RGS) cDNAs using a degenerate PCR strategy. The rRgs12 and rRgs14 cDNAs encode predicted polypeptides of 1387 and 544 amino acids, respectively. We have also identified the human orthologue of rRgs12 by alignment of cosmid sequences in the database which map the human RGS12 gene to chromosome 4p16.3. Furthermore, we identified human ESTs with high homology to rRgs14 which map to human chromosome 5qter. Northern blot analysis indicates that rRgs14 is expressed at high levels in brain, lung, and spleen, whereas rRgs12 is expressed at high levels in brain and lung and lower levels in testis, heart, and spleen. Analysis of the predicted rRGS12 and rRGS14 polypeptides indicates that they are closely related and possess regions of homology outside of the conserved RGS domain. We have also identified conserved regions in RGS12 which are similar to protein domains found in mouse rhophilin and coiled-coil proteins suggesting possible interactions with ras-like G-proteins.

Lumbar epidural morphine infusions for children undergoing cardiac surgery

OBJECTIVE

To determine whether outcomes and costs in children undergoing cardiac surgery are affected by the method of postoperative pain management.

DESIGN

Retrospective, case control.

SETTING

Tertiary care children's hospital in a university setting.

PARTICIPANTS

Two groups of children undergoing cardiac surgery for palliation or repair of congenital heart disease oer a 21-month period between January 1993 and September 1994.

INTERVENTIONS

Lumbar epidural morphine infusions (LEM) in one group, and IV opioid (IVO) medication in the other for postoperative pain control.

MEASUREMENTS AND MAIN RESULTS

Hospital courses of 27 LEM patients and 27 IVO patients were analyzed. In LEM patients, epidural catheters were placed following anesthetic induction, but before anticoagulation. A bolus of 50 micrograms/kg of preservative-free morphine sulfate was administered through the catheter, followed by a continuous infusion at 3 to 4 micrograms/kg/h for 22 to 102 (median, 46) hours postoperatively. The IVO patients received 50 micrograms/kg, IV, of fentanyl before incision followed by a continuous infusion at 0.3 microgram/kg/min. The fentanyl infusion rate was decreased to 0.1 microgram/kg/min postoperatively and maintained for 24 hours. Although the LEM group was demographically similar to the IVO group, times to tracheal extubation, transfer from the intensive care unit, and resumption of regular diet were significantly shorter in LEM patients. LEM and IVO patients received similar amounts of fentanyl during surgery (10.4 +/- 19.3 micrograms/kg/h v 13.7 +/- 8.1 micrograms/kg/h, p = 0.4). However, during postoperative recovery, LEM patients who were extubated late received significantly less supplemental opioid medication than IVO patients extubated late during the first 5 postoperative days. No complications related to dural puncture, bleeding into the epidural space, or respiratory depression were encountered. Pruritus and nausea/vomiting were the most commonly reported morbidities in both groups. Fifty-six percent (15/27) of LEM patients and 41% of IVO patients reported pruritus (p = 0.4). There was no significant difference in the incidence of nausea and vomiting between the groups (34% v 30%, respectively).

CONCLUSIONS

Given the present methodologic limitations, the authors found improved outcomes only in LEM patients extubated late compared with IVO patients. Randomized, prospective studies to evaluate this conclusion and to determine the comparative efficacy and safety of LEM infusions are in progress.

Factors that influence an anesthesiologist's decision to cancel elective surgery for the child with an upper respiratory tract infection

STUDY OBJECTIVE

To examine factors that anesthesiologists consider when making decisions regarding elective surgery cancellation of the pediatric patient with an upper respiratory infection (URI).

DESIGN

Questionnaire survey.

SETTING

Anesthesiology departments and/or practices throughout the United States.

PARTICIPANTS

212 anesthesiologist members of the Society for Pediatric Anesthesia (SPA).

MEASUREMENTS AND MAIN RESULTS

A total of 400 questionnaires were mailed to anesthesiologists randomly selected from the membership of the SPA. Of these questionnaires, 212 (54%) were completed and returned. Of these respondents, 71 (34.5%) reported that they seldom (1% to 25% of the time) cancelled cases due to an URI, and 43 (20.9%) stated that they usually (76% to 99% of the time) cancelled in the event of an URI. Two respondents (1%) reported never cancelling due to an URI, and six (2.9%) stated that they always cancelled. Frequency of cancellation was independent of type of practice. However, anesthesiologists who had been in practice for more than 10 years were significantly more likely to cancel than those who had been in practice for less than 10 years (p < 0.05). Factors that were considered most important in making decisions regarding cancellation included the urgency of the surgery and the presence of asthma. Other important considerations included fear of complications and the anesthesiologist's previous experience anesthetizing children with URIs. Factors related to the economics and inconvenience of cancellation did not influence the decision to cancel surgery. These factors included distance traveled, cost of cancellation, attitude of the parents, fear of litigation, and pressure to complete cases expediently.

CONCLUSIONS

The results of this survey demonstrate a wide range of opinions and approaches to this enduring clinical dilemma. However, it appears that the practice of cancelling elective surgery for children with URIs may be changing over time, since younger anesthesiologists appear to cancel less often than their more experienced counterparts. It is hoped that this information will be useful to practioners in their evaluation and management of children with colds and will stimulate further investigation into this important clinical problem.

Does chronic nociceptive stimulation alter the development of morphine tolerance?

Conflicting results exist concerning the issues of whether chronic nociceptive stimulation (a) increases or decreases the effectiveness of morphine analgesia, and (b) facilitates or inhibits the development of narcotic tolerance. We carried out a series of experiments with appropriate controls in order to examine these two issues and their possible relationship. In experiment 1, rats received complete Freund's adjuvant (CFA), a chronic nociceptor, injected into a single hind paw or anesthesia without injection, together with morphine or placebo pellets in a 2 x 2 study design. The data indicate that the presence of the chronic nociceptive stimulus significantly facilitated the development of tolerance to morphine analgesia as measured using tail-flick latency (TFL) testing. Experiment 2 was designed to compare the analgetic effectiveness of an acute injection of morphine in rats experiencing chronic nociceptive stimulation and in controls. CFA was injected in the right hindpaw, and nine days later TFLs were tested after morphine doses of 1 and 2 mg/kg s.c. The data obtained showed that chronic nociceptive stimulation significantly reduced the effectiveness of morphine at the 1 mg/kg dose. However, baseline TFLs appeared to be shorter in rats treated with CFA, suggesting that the decrease in morphine effectiveness could be due to a general increase in pain sensitivity. Therefore, a third experiment was performed, using a less intense thermal stimulus to prolong baseline TFLs and accentuate any potential differences. Sixteen rats either received CFA or served as controls. TFLs were then measured at baseline and one hour after a 0.5 mg/kg dose of morphine.(ABSTRACT TRUNCATED AT 250 WORDS)

MK-801 inhibits the development of morphine tolerance at spinal sites

The N-methyl-D-aspartate (NMDA) receptor antagonist MK-801 has been shown to attenuate tolerance development in rats. In this study, we show that MK-801 inhibits tolerance to the antinociceptive effects of morphine, as assessed by the tail-flick test, in spinalized rats. These results suggest that NMDA receptor antagonists inhibit opiate tolerance at spinal sites, and also provide strong evidence that the effects of MK-801 are not due to its ability to interfere with associative learning, but instead to inhibition of non-associative mechanisms of opiate tolerance.

Effects of chronic morphine treatment on beta-endorphin-related peptides in the caudal medulla and spinal cord

The effects of chronic morphine treatment on beta-endorphin (beta E)-immunoreactive (beta E-ir) peptide levels were determined in the rat caudal medulla and different areas of the spinal cord. Seven days of morphine pelleting had no effect on total beta E-ir peptides in the caudal medulla. In contrast, it significantly increased beta E-ir peptide concentrations in the cervical and thoracic regions of the spinal cord compared with placebo-pelleted controls, whereas in the lumbosacral region this trend did not reach statistical significance. Injections of the opiate receptor antagonist naloxone 1 h before the rats were killed had no effect on the morphine-induced increases in the cord. Chromatographic analyses revealed that enzymatic processing of beta E-related peptides in the spinal cord seemed unaffected by the morphine and/or naloxone treatments. In light of previous data showing that morphine down-regulates beta E biosynthesis in the hypothalamus, the present results suggest that the regulation of beta E-ir peptides in the spinal cord is distinct from that found in other CNS areas. These data provide support for previous results suggesting that beta E-expressing neurons may be intrinsic to the spinal cord.

Pre- and posttranslational regulation of beta-endorphin biosynthesis in the CNS: effects of chronic naltrexone treatment

There appear to be two anatomically distinct beta-endorphin (beta E) pathways in the brain, the major one originating in the arcuate nucleus of the hypothalamus and a smaller one in the area of the nucleus tractus solitarius (NTS) of the caudal medulla. Previous studies have shown that these two proopiomelanocortin (POMC) systems may be differentially regulated by chronic morphine treatment, with arcuate cells down-regulated and NTS cells unaffected. In the present experiments, we examined the effects of chronic opiate antagonist treatment on beta E biosynthesis across different CNS regions to assess whether the arcuate POMC system would be regulated in the opposite direction to that seen after opiate agonist treatment and to determine whether different beta E-containing areas might be differentially regulated. Male adult rats were administered naltrexone (NTX) by various routes for 8 days (subcutaneous pellets, osmotic minipumps, or repeated intraperitoneal injections). Brain and spinal cord regions were assayed for total beta E-ir, different molecular weight immunoreactive beta-endorphin (beta E-ir) peptides, and POMC mRNA. Chronic NTX treatment, regardless of the route of administration, reduced total beta E-ir concentrations by 30-40% in diencephalic areas (the arcuate nucleus, the remaining hypothalamus, and the thalamus) and the midbrain, but had no effect on beta E-ir in the NTS or any region of the spinal cord. At the same time, NTX pelleting increased POMC mRNA levels in the arcuate to approximately 140% of control values.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral ketamine preanesthetic medication in children

The authors sought to define a dose of oral ketamine that would facilitate induction of anesthesia without causing significant side effects. Forty-five children (ASA Physical Status 1 and 2; aged 1-7 yr) were assigned randomly in a prospective, double-blind fashion to three separate groups that received either 3 mg/kg, 6 mg/kg, or no ketamine mixed in 0.2 ml/kg cola-flavored soft drink. They also were evaluated preoperatively and postoperatively for acceptance of oral ketamine as a premedicant, reaction to separation from parents, emotional state, and emergence phenomena. The authors detected no episodes of respiratory depression, tachycardia, or arterial hemoglobin desaturation before, during, or after surgery. The 6 mg/kg dose was well accepted; provided uniform, predictable sedation within 20-25 min; and allowed calm separation from parents and good induction conditions. The 3 mg/kg dose did not always cause sedation and calm separation from parents. Neither dose of ketamine increased the incidence of laryngospasm, prolonged recovery times, or caused emergence phenomena. The authors conclude that an oral dose of 6 mg/kg ketamine is easily administered and well accepted in young children and provides predictable, satisfactory premedication without significant side effects.