Baclofen as an adjuvant analgesic

Baclofen-induced excessive perspiration: A case report and review of literature

This report highlights an unexpected baclofen side effect, a medication known for its safety profile. The rarity of excessive perspiration as a side effect distinguishes this case from typical baclofen adverse reactions. Documenting uncommon reactions is vital for physicians to broaden their awareness of baclofen's side effects and improve care.

Direct Formation of Amide-Linked C-Glycosyl Amino Acids and Peptides via Photoredox/Nickel Dual Catalysis

Glycoproteins account for numerous biological processes including those associated with diseases and infections. The advancement of glycopeptides has emerged as a promising strategy for unraveling biological pathways and discovering novel medicines. In this arena, a key challenge arises from the absence of efficient synthetic strategies to access glycopeptides and glycoproteins. Here, we present a highly concise approach to bridging saccharides with amino acids and peptides through an amide linkage. Our amide-linked C-glycosyl amino acids and peptides are synthesized through cooperative Ni-catalyzed and photoredox processes. The catalytic process generates a glycosyl radical and an amide carbonyl radical, which subsequently combine to yield the C-glycosyl products. The saccharide reaction partners encompass mono-, di-, and trisaccharides. All 20 natural amino acids, peptides, and their derivatives can efficiently undergo glycosylations with yields ranging from acceptable to high, demonstrating excellent stereoselectivities. As a substantial expansion of applications, we have shown that simple C-glycosyl amino acids can function as versatile building units for constructing C-glycopeptides with intricate spatial complexities.

Migraine Care Challenges and Strategies in US Uninsured and Underinsured Adults: A Narrative Review, Part 2

OBJECTIVE

To review the challenges and potential solutions in treatment options for quality migraine care in adult patients who are under or uninsured.

BACKGROUND

The Affordable Care Act has improved access to health care for many; however, those who are underserved continue to face treatment disparities and have inadequate access to appropriate migraine management.

METHODS

This manuscript is the second of a 2-part narrative review which was performed after a series of discussions within the Underserved Populations in Headache Medicine Special Interest Section meetings of the American Headache Society. Literature was reviewed for key concepts underpinning conceptual boundaries and a broad overview of the subject matter. Published guidelines, state-specific Medicaid websites, headache quality measurement sets, literature review, and expert opinion were used to tailor suggested treatment options and therapeutic strategies. In this second part of our narrative review, we explored migraine care strategies and considerations for underserved and vulnerable adult populations with migraine.

RESULTS

Although common, migraine remains untreated, particularly among those of low socioeconomic status. Low socioeconomic status may play an important role in the disease progression, prescription of hazardous medications such as opioids, outcomes, and quality of life of patients with migraine and other headache disorders. There are some evidence-based and guideline supported treatment options available at low cost that include prescription medications and supplements, though approved devices are costly. Resources available online and simple nonpharmacological strategies may be particularly useful in the underserved migraine population.

CONCLUSIONS

We identified and discussed migraine treatment barriers that affect underserved populations in the US and summarized practical, cost-effective strategies to surmount them. However, more research is needed to identify the best cost-effective measures for migraine management in underserved and vulnerable patients who are uninsured or underinsured.

GABAB receptor activation attenuates inflammatory orofacial pain by modulating interleukin-1β in satellite glial cells: Role of NF-κB and MAPK signaling pathways

Orofacial inflammation could activate satellite glial cells (SGCs) in the trigeminal ganglion (TG) to produce interleukin 1β (IL-1β) which plays crucial roles in the development of inflammatory pain. Recent studies have shown that gamma-amino butyric acid-B (GABA_B) receptor could modulate the expression of inflammatory cytokines in microglia and astrocytes in the spinal cord. The objective of this study was to investigate whether GABA_B receptors in TG SGCs attenuate inflammatory facial pain via mediating IL-1β following inflammation and its mechanisms. Complete Freund's adjuvant (CFA) was injected into the whisker pad of rats to induce inflammation in vivo. Lipopolysaccharide (LPS) was added to culture medium to activate SGCs in vitro. Behavioral measures showed that microinjection of baclofen (a selective GABA_B receptor agonist) into the TG ameliorated the mechanical allodynia of CFA-treated rats. Interestingly, baclofen pretreatment inhibited SGC activation and IL-1β production, however, preserved the decreased expression of GABA_B receptors in SGCs activated by CFA in vivo and LPS in vitro. In addition, baclofen suppressed the increased expression of p-NF- κ B p65, p-I κ Bα, and p-p38 MAPK, while reversed the decreased production of I κ Bα, and further enhanced the increased expression of p-ERK(1/2) in LPS-treated SGCs in vitro. Finally, those effects of baclofen were abolished by saclofen (a specific GABA_B receptor antagonist) co-administration. Altogether, these results demonstrated for the first time that activation of GABA_B receptor might inhibit IL-1β production by suppressing NF- κ B and p38 MAPK signaling pathway activation and restore GABA_B receptor expression in SGCs to attenuate inflammatory facial pain.

Managing Chronic Pain in the Elderly: An Overview of the Recent Therapeutic Advancements

A majority of the elderly suffer from chronic pain that significantly alters their daily activities and imposes an enormous burden on health care. Multiple comorbidities and the risk of polypharmacy in the elderly make it a challenge to determine the appropriate drug, dosage, and maintenance of therapy. Opioids are the most commonly used agents for this purpose in the elderly. The aim of this article is to discuss both the current well-established therapies used for managing chronic pain in the elderly and also the emerging newer therapies.

The drug candidate, ADX71441, is a novel, potent and selective positive allosteric modulator of the GABAB receptor with a potential for treatment of anxiety, pain and spasticity

Positive allosteric modulation of the GABA_B receptor is a promising alternative to direct activation of the receptor as a therapeutic approach for treatment of addiction, chronic pain, anxiety, epilepsy, autism, Fragile X syndrome, and psychosis. Here we describe in vitro and in vivo characterization of a novel, potent and selective GABA_B positive allosteric modulator (PAM) N-(5-(4-(4-chloro-3-fluorobenzyl)-6-methoxy-3,5-dioxo-4,5-dihydro-1,2,4-triazin-2(3H)-yl)-2-fluorophenyl)acetamide (ADX71441). In vitro, Schild plot and reversibility tests at the target confirmed PAM properties of the compound. In mice and rats ADX71441 is bioavailable after oral administration and is brain penetrant. A single dose of ADX71441 had an anxiolytic-like profile in the mouse marble burying test (minimum effective dose; MED 3 mg/kg) as well as in the elevated plus maze test in mice and rats (both MED 3 mg/kg). Also, in mice, acute administration of ADX71441 reduced visceral pain-associated behaviors in the acetic acid-induced writhing test. ADX71441 dose-dependently reduced time on rotarod in rats (MED 10 mg/kg) indicative of muscle-relaxant qualities. ADX71441 reduced locomotor activity in mice (10 mg/kg) and rats (3 mg/kg) after single dose; however, following sub-chronic administration in mice, 30 mg/kg ADX71441 was associated with normal locomotor activity. While acute administration of ADX71441 reduced body temperature in rats and mice (both MED 10 mg/kg), the effect in the former was transient, rapidly returning to normal levels despite high concentrations of the compound remaining in plasma. Thus, the GABA_B PAM ADX71441 represents a valid therapeutic approach for development of novel treatment of anxiety, pain and spasticity.

Therapeutics in the Management of Spasticity

Spasticity is commonly defined as a velocity-dependent increase in tonic stretch re flexes that results from a variety of disorders affecting the brain and spinal cord. Treat ment of spasticity is generally considered when the increase in tone interferes with functional activities, such as positioning, mobility, or daily cares, when it is painful, or when it leads to complications such as contractures or skin breakdown. This re view discusses the pathophysiology of spasticity and details the various treatments avail able, including physical and occupational therapy modalities, use of splints and or thoses, oral and intrathecal medications, nerve blocks, botulinum toxin injections, and orthopedic and neurosurgical interventions.

Trigeminal neuralgia (part II): Factors affecting early pharmacotherapeutic outcome

Aims

We conducted a cohort study to examine demographic and clinical features associated with the pharmacotherapeutic outcome in classical trigeminal neuralgia (CTN) patients.

Methods

Patients with a clinical profile indicating a diagnosis of CTN, as per the International Headache Society’s published classification, were enrolled prospectively. Demographic and pain-related characteristics were carefully collected. For the purposes of the study, patients with features such as autonomic signs and longer attack duration were included. All patients were then initiated on a standardised and accepted stepped pharmacotherapeutic protocol for the management of CTN. Initial pain scores and prospectively collected pain scores from pain diaries were used to assess the treatment outcome, with a ≥50% reduction considered significant.

Results

A total of 86 patients were seen, of whom five had an underlying disorder that could account for the pain. The study cohort therefore consisted of 81 patients, and based on attack duration these were divided into short (≤2 minutes, n = 61) and long (>2 minutes, n = 20) groups, for further analysis. The features of these patients and a discussion on the differential diagnosis have been presented in part 1 of this report. Employing an accepted stepped pharmacotherapeutic protocol for the management of CTN, significant improvement was more frequent in the short (74%) than in the long attack group (50%, p = 0.05). In the short attack group there were statistically significant associations between a poor treatment response and longer disease duration, the presence of autonomic signs and atypical pain descriptors for pain quality ( p < 0.05).

Conclusion

This report supports previous findings that prolonged disease duration and autonomic signs are negative prognostic indicators. The present study now adds long attack duration as a further negative prognostic sign.

Evaluation of peripheral versus central effects of GABA(B) receptor activation using a novel, positive allosteric modulator of the GABA(B) receptor ADX71943, a pharmacological tool compound with a fully peripheral activity profile

BACKGROUND AND PURPOSE

The GABA(B) receptor agonist, baclofen, has shown promising effects in patients suffering from pain, post-traumatic stress disorder, alcoholism, overactive bladder and gastroesophageal reflux disease. However, baclofen's short duration of action and side effects limit its wider use. Here we characterized a novel, GABA(B) receptor positive allosteric modulator (PAM) ADX71943.

EXPERIMENTAL APPROACH

In vitro, ADX71943 was assessed for pharmacological activity and selectivity using recombinant and native GABA(B) receptors. In vivo ADX71943 was assessed in the acetic acid-induced writhing (AAW) test in mice and formalin tests (FTs) in mice and rats. Marble burying (MB) and elevated plus maze (EPM) tests, rotarod, spontaneous locomotor activity (sLMA) and body temperature (BT) tests in mice and rats were used to investigate centrally-mediated effects.

KEY RESULTS

In vitro, in the presence of GABA, ADX71943 increased the potency and efficacy of agonists and showed selectivity at the GABA(B) receptor. ADX71943 reduced pain-associated behaviours in AAW; an effect blocked by GABA(B) receptor antagonist CGP63360. ADX71943 reduced pain in the FT in mice and rats, but was inactive in the MB and EPM despite reaching high concentrations in plasma. ADX71943 had no effect on BT, rotarod and sLMA.

CONCLUSIONS AND IMPLICATIONS

ADX71943 showed consistent and target-related efficacy in tests of disorders that have a significant peripheral component (acute and chronic pain), while having no effect in those associated with centrally-mediated anxiety-like reactivity and side effects. Thus, ADX71943 is a useful pharmacological tool for delineation of peripherally- versus centrally-mediated effects of GABA(B) receptor activation.

Activation of spinal GABAB receptors normalizes N-methyl-D-aspartate receptor in diabetic neuropathy

N-methyl-D-aspartate receptor (NMDAR) activity is increased, while GABAB receptor is downregulated in the spinal cord dorsal horn in diabetic neuropathy. In this study, we determined the interaction of NMDARs and GABAB receptors in streptozotocin (STZ)-induced diabetic neuropathy. The paw withdrawal threshold (PWT) was significantly lower in STZ-treated rats than in vehicle-treated rats. Intrathecal injection of baclofen, a GABAB receptor agonist, significantly increased the PWT in STZ-treated rats, an effect that was abolished by pre-administration of the GABAB receptor specific antagonist CGP55845. Spinal NR2B, an NMDA receptor subunit, protein and mRNA expression levels were significantly higher in STZ-treated rats than in vehicle-treated rats. Intrathecal baclofen significantly reduced the NR2B protein and mRNA expression levels in STZ-treated rats. Intrathecal administration of CGP55845 eliminated baclofen-induced reduction of NR2B protein and mRNA levels in STZ-treated rats. In addition, the phosphorylated cAMP response element-binding (CREB) protein level was significantly higher in the spinal cord dorsal horn in STZ-treated rats compared with vehicle-treated rats. Intrathecal injection of baclofen significantly decreased phosphorylated CREB protein level in STZ-treated rats; an effect was blocked by CGP55845. These data suggest that activation of GABAB receptors in the spinal cord dorsal horn normalizes NMDAR expression level in diabetic neuropathic pain.

The Effect of Low-level Laser Therapy on Trigeminal Neuralgia: A Review of Literature

The effect of low intensity laser radiation in the treatment of acute and chronic pain is now established in many studies. Tri-geminal neuralgia is a pain passes through nerve's branches and its trigger is located in skin or mucosa that could lead to pain with a trigger stimulus. The pain involved branches of trigeminal nerve that sometimes has patients to seek the treatment for several years. Nowadays different treatments are used for relief of pain that most of them cause tolerance and various side effects. This paper reviews and summarizes scientific papers available in English literature publishedin PubMed, Scopus, Science Direct, Inter science, and Iran Medex from 1986 until July 2011 about the effect of these types of lasers on trigeminal neuralgia which is one of the most painful afflictions known. In different studies, the effect of laser therapy has been compared with placebo irradiation or medicinal and surgical treatment modalities. Low-level laser therapy (LLLT) is a treatment strategy which uses a single wavelength light source. Laser radiation and monochromatic light may alter cell and tissue function. However, in most studies laser therapy was associated with significant reduction in the intensity and frequency of pain compared with other treatment strategies, a few studies revealed that between laser and placebo group there was not any significant difference according to the analgesic effect. Low-level laser therapy could be considered in treatment of trigeminal neuralgia without any side effects.

GABA pharmacology: the search for analgesics

Decades of research have been devoted to defining the role of GABAergic transmission in nociceptive processing. Much of this work was performed using rigid, orthosteric GABA analogs created by Povl Krogsgaard-Larsen and his associates. A relationship between GABA and pain is suggested by the anatomical distribution of GABA receptors and the ability of some GABA agonists to alter nociceptive responsiveness. Outlined in this report are data supporting this proposition, with particular emphasis on the anatomical localization and function of GABA-containing neurons and the molecular and pharmacological properties of GABAA and GABAB receptor subtypes. Reference is made to changes in overall GABAergic tone, GABA receptor expression and activity as a function of the duration and intensity of a painful stimulus or exposure to GABAergic agents. Evidence is presented that the plasticity of this receptor system may be responsible for the variability in the antinociceptive effectiveness of compounds that influence GABA transmission. These findings demonstrate that at least some types of persistent pain are associated with a regionally selective decline in GABAergic tone, highlighting the need for agents that enhance GABA activity in the affected regions without compromising GABA function over the long-term. As subtype selective positive allosteric modulators may accomplish these goals, such compounds might represent a new class of analgesic drugs.

Downregulation of GABAB receptors in the spinal cord dorsal horn in diabetic neuropathy

Diabetic neuropathic pain is a common clinical problem and remains difficult to treat with classic analgesics. Spinal dorsal horn neurons are important in mediating nociceptive signaling, and the hyperactivity of these neurons is critical in diabetic neuropathy. In this study, we determined the GABA(B) receptor expression level in dorsal horn neurons in streptozotocin (STZ)-induced diabetes in rats by using reverse-transcription polymerase chain reaction (RT-PCR) and western blot analyses. Mean blood glucose concentrations were significantly higher and the paw withdrawal threshold was significantly lower in STZ-treated rats than in saline-treated rats. Immunohistochemical staining showed that the GABA(B) receptor was extensively expressed in the spinal dorsal horn neurons. The GABA(B1) mRNA level decreased in a time-dependent manner in STZ-treated rats compared with saline-treated controls. Furthermore, the protein expression level revealed by western blot analysis was lower in STZ-treated rats than in saline-treated rats. These data suggest that GABA(B) receptors are downregulated in the spinal dorsal horn in this model of STZ-induced diabetic neuropathic pain. The reduction of GABA(B) expression may contribute to the hyperactivity of spinal dorsal horn neurons and diabetic neuropathic pain.

Baclofen as an adjuvant analgesic for cancer pain

PURPOSE

Baclofen is a g-aminobutyric acid receptor agonist commonly used for managing many types of neuropathic pain. The effect of baclofen on cancer pain has not previously been studied. This retrospective study evaluated the efficacy of baclofen in patients with cancer pain.

METHODS

We reviewed the medical records of all patients given baclofen orally as an analgesic for cancer at 5 institutions.

RESULT

Twenty-five patients received 10 to 40 mg of baclofen for cancer pain relief. Twenty patients have undergone neuropathic pain such as paroxysmal or lancing, sharp, or like an electric shock. Baclofen was effective in 21 of 25 patients and significantly reduced Numeric Rating Scale (pain score, 0-10; P < .0001). Nine patients reported mild adverse events: none of these 9 patients had to discontinue baclofen due to adverse events.

CONCLUSION

Our findings suggest that baclofen may be a useful adjuvant analgesic in the treatment of cancer pain.

Modulation of pain transmission by G-protein-coupled receptors

The heterotrimeric G-protein-coupled receptors (GPCR) represent the largest and most diverse family of cell surface receptors and proteins. GPCR are widely distributed in the peripheral and central nervous systems and are one of the most important therapeutic targets in pain medicine. GPCR are present on the plasma membrane of neurons and their terminals along the nociceptive pathways and are closely associated with the modulation of pain transmission. GPCR that can produce analgesia upon activation include opioid, cannabinoid, alpha2-adrenergic, muscarinic acetylcholine, gamma-aminobutyric acidB (GABAB), groups II and III metabotropic glutamate, and somatostatin receptors. Recent studies have led to a better understanding of the role of these GPCR in the regulation of pain transmission. Here, we review the current knowledge about the cellular and molecular mechanisms that underlie the analgesic actions of GPCR agonists, with a focus on their effects on ion channels expressed on nociceptive sensory neurons and on synaptic transmission at the spinal cord level.

Management of neuropathic orofacial pain

Current management of painful trigeminal neuropathies relies on pharmacological (topical and systemic), surgical, and complementary modalities. There is, however, a lack of quality research relating to the effectiveness of these modalities. In this review we analyze the available data that relates to the therapy of trigeminal neuralgia, postherpetic neuralgia, and posttraumatic neuropathies and provide clinical guidelines. The review focuses on medical management, as well as surgical and other interventions for painful neuropathies.

Neuropathic pain in soft tissue complaints

Many soft tissue complaints are associated with the development of neuropathic pain. This pain is produced by pathophysiological processes that are different to the processes involved in the generation of the inflammatory or nociceptive pain more commonly encountered in soft tissue disorders. One of the consequences of this is that neuropathic pain can often be less responsive to standard analgesic therapies. The use of alternative analgesic strategies may be necessary if we are to treat neuropathic pain successfully. This chapter aims to outline some of the clinical features associated with neuropathic pain, the aetiological factors leading to its development and the evidence base (or lack) behind current treatment strategies. It will try to provide a rational approach to the management of neuropathic pain in patients with soft tissue disorders, particularly focusing on pharmacological management. Neuropathic pain is the focus of much current research activity, particularly pharmacological research, and this chapter will attempt to identify gaps in our clinical knowledge and highlight opportunities for further research.

Altered synaptic input and GABAB receptor function in spinal superficial dorsal horn neurons in rats with diabetic neuropathy

Hyperactivity of spinal dorsal horn neurons plays an important role in the development of diabetic neuropathic pain. However, little is known as to whether synaptic input to spinal dorsal horn neurons is altered in diabetic neuropathy. Also, the function of GABAB receptors in the control of synaptic input to dorsal horn neurons in diabetes remains poorly understood. To determine the changes in synaptic input to dorsal horn neurons and the GABAB)receptor function in streptozotocin-induced diabetes, we performed whole-cell recording (GDP-beta-S included in the internal solution) on lamina II neurons in rat spinal cord slices. The frequency of glutamatergic mEPSCs and the amplitude of monosynaptic EPSCs evoked from the dorsal root were significantly higher in diabetic than in control rats. On the other hand, the basal frequency and amplitude of GABAergic spontaneous IPSCs and mIPSCs and those of glycinergic spontaneous IPSCs and mIPSCs did not differ significantly between control and diabetic rats. The GABAB agonist baclofen produced a significantly greater reduction in dorsal root-evoked EPSCs and the frequency of mEPSCs in control than in diabetic rats. However, the inhibitory effect of baclofen on GABAergic and glycinergic spontaneous IPSCs and mIPSCs was not significantly different in the two groups. These findings suggest that increased glutamatergic input from primary afferents to dorsal horn neurons may contribute to synaptic plasticity and central sensitization in diabetic neuropathic pain. Furthermore, the function of presynaptic GABAB receptors at primary afferent terminals, but not that on GABAergic and glycinergic interneurons, in the spinal cord is reduced in diabetic neuropathy.

Subarachnoid Transplant of a Human Neuronal Cell Line Attenuates Chronic Allodynia and Hyperalgesia After Excitotoxic Spinal Cord Injury in the Rat

The relief of neuropathic pain after spinal cord injury (SCI) remains daunting, because pharmacologic intervention works incompletely and is accompanied by multiple side effects. Transplantation of human cells that make specific biologic agents that can potentially modulate the sensory responses that are painful would be very useful to treat problems such as pain. To address this need for clinically useful human cells, the human neuronal NT2 cell line was used as a source to isolate a unique human neuronal cell line that synthesizes and secretes/releases the inhibitory neurotransmitters gamma-aminobutyric acid (GABA) and glycine. This new cell line, hNT2.17, expresses an exclusively neuronal phenotype, does not incorporate bromodeoxyuridine during differentiation, and does not express the tumor-related proteins fibroblast growth factor 4 and transforming growth factor-alpha during differentiation after 2 weeks of treatment with retinoic acid and mitotic inhibitors. The transplant of predifferentiated hNT2.17 cells was used in the excitotoxic SCI pain model, after intraspinal injection of the mixed AMPA/metabotropic receptor agonist quisqualic acid (QUIS). When hNT2.17 cells were transplanted into the lumbar subarachnoid space, tactile allodynia and thermal hyperalgesia induced by the injury were quickly and potently reversed. Control cell transplants of nonviable hNT2.17 cells had no effect on the hypersensitivity induced by QUIS. The effects of hNT2.17 cell grafts appeared 1 week after transplants and did not diminish during the 8-week course of the experiment when grafts were placed 2 weeks after SCI. Immunohistochemistry and quantification of the human grafts were used to ensure that many grafted cells were still present and synthesizing GABA at the end of the study. These data suggest that the human neuronal hNT2.17 cells can be used as a "biologic minipump" for antinociception in models of SCI and neuropathic pain.

PERSPECTIVE

This study describes the initial characterization and use of a human-derived cell line to treat neuropathic pain that would be suitable for clinical application, once further tested for safety and approved by the Food and Drug Administration. A dose of these human cells could be delivered with a spinal tap and affect the intrathecal spinal environment for sensory system modulation.

Pain management

This article provides information regarding treatments for the management of moderate to severe pain in patients who are at the end of life. Discussion focuses on the use of strong opioids and adjuvant analgesics. Special attention also is given to the most frequently used forms of interventional pain management. Although pain in terminally ill patients is not always related to cancer, many of the studies cited in this article were performed in cancer patients, a model that informs much of what is presented.

Trigeminal neuralgia

Trigeminal Neuralgia (TN) is a well recognized syndrome characterized by lancinating attacks of severe facial pain. The diagnosis of TN is based on a history of characteristic pain attacks that are consistent with specific widely accepted criteria for the diagnosis. TN pain attacks may result from physiologic changes induced by a chronic partial injury to the brainstem trigeminal nerve root from a variety of causes. An early and accurate diagnosis of TN is important, because therapeutic interventions can reduce or eliminate pain attacks in the large majority of TN patients.

Adjunctive pharmacological management of persistent, nonmalignant pain in older individuals

Chronic or persistent pain is a common comorbidity of aging, primarily due to the relatively high frequency of pain-associated disorders in this population (e.g., inflammatory and noninflammatory musculoskeletal disease, zoster infection, diabetes, stroke, and peripheral and central neurological diseases). Acetaminophen, nonsteroidal anti-inflammatory drugs and opioids are important long-term analgesics in this age group. However, adjunctive agents are also important in the management of persistent pain in the elderly, especially neuropathic pain. Oral antiepileptic drugs, mexiletine, baclofen, tricyclic antidepressants, selective serotonin–norepinephrine dual reuptake inhibitors and intranasal/injectable calcitonin are the subjects of this review of the management of persistent, nonmalignant pain in the elderly. While some of these agents are considered narrow-spectrum analgesics (e.g., baclofen in trigeminal neuralgia and calcitonin in bone pain), most are broad-spectrum analgesics, useful in neuropathic pain syndromes of multiple etiologies. Within the antiepileptic drug class, gabapentin and carbamazepine can be considered first-line agents, followed by lamotrigine and pregabalin as second-line agents, and the other most recently approved drugs as third-line or ‘salvage’ agents. The tricyclic antidepressants have numerous precautions/contraindications and tolerability issues in this population, thus reducing their utility. Duloxetine and venlafaxine are the only useful analgesics among the modern antidepressants. Challenges for the future include not only the search for more effective and less toxic adjunctive analgesics for the elderly, but also translating our knowledge of current and future analgesics into effective therapies in the ‘real world’ community and institutional settings where elderly people live. There is no justification in our society today for anyone to live with untreated or undertreated persistent pain.

The pharmacotherapy of chronic pain: a review

The past two decades have contributed a large body of preclinical work that has assisted in our understanding of the underlying pathophysiological mechanisms that cause chronic pain. In this context, it has been recognized that effective treatment of pain is a priority and that treatment often involves the use of one or a combination of agents with analgesic action. The current review presents an evidence-based approach to the pharmacotherapy of chronic pain. Medline searches were done for all agents used as conventional treatment in chronic pain. Published papers up to June 2005 were included. The search strategy included randomized, controlled trials, and where available, systematic reviews and meta-analyses. Further references were found in reference sections of papers located using the above search strategy. Agents for which there were no controlled trials supporting efficacy in treatment of chronic pain were not included in the present review, except in cases where preclinical science was compelling, or where initial human work has been positive and where it was thought the reader would be interested in the scientific evidence to date.

The Role of GABA in the Mediation and Perception of Pain

A great deal of effort has been expended in attempting to define the role of GABA in mediating the transmission and perception of pain. Pursuit of this question has been stimulated by the fact that GABAergic neurons are widely distributed throughout the central nervous system, including regions of the spinal cord dorsal horn known to be important for transmitting pain impulses to the brain. In addition, GABA neurons and receptors are found in supraspinal sites known to coordinate the perception and response to painful stimuli and this neurotransmitter system has been shown to regulate control of sensory information processing in the spinal cord. The discovery that GABA receptor agonists display antinociceptive properties in a variety of animal models of pain has provided an impetus for developing such agents for this purpose. It has been shown that GABA receptor agonists, as well as inhibitors of GABA uptake or metabolism, are clinically effective in treating this symptom. However, even with an enhanced understanding of the relationship between GABAergic transmission and pain, it has proven difficult to exploit these findings in designing novel analgesics that can be employed for the routine management of pain. Work in this area has revealed a host of reasons why GABAergic drugs have, to date, been of limited utility in the management of pain. Chief among these are the side effects associated with such agents, in particular sedation. These limitations are likely due to the simultaneous activation of GABA receptors throughout the neuraxis, most of which are not involved in the transmission or perception of pain. This makes it difficult to fully exploit the antinociceptive properties of GABAergic drugs before untoward effects intervene. The discovery of molecularly and pharmacologically distinct GABAA receptors may open the way to developing subtype selective agents that target those receptors most intimately involved in the transmission and perception of pain. The more limited repertoire of GABAB receptor subunits makes it more difficult to develop subtype selective agents for this site. Nonetheless, a GABAB agonist, CGP 35024, has been identified that induces antinociceptive responses at doses well below those that cause sedation (Patel et al., 2001). It has also been reported that, unlike baclofen, tolerance to antinociceptive responses is not observed with CGP 44532, a more potent GABAB receptor agonist (Enna et al., 1998). While the reasons for these differences in responses to members of the same class remain unknown, these findings suggest it may be possible to design a GABAB agonist with a superior clinical profile than existing agents. Besides the challenges associated with identifying subtype selective GABAA and GABAB receptor agonists, the development of GABA analgesics has been hindered by the fact that the responsiveness of these receptor systems appear to vary with the type and duration of pain being treated and the mode of drug administration. Further studies are necessary to more precisely define the types of pain most amenable to treatment with GABAergic drugs. Inasmuch as the antinociceptive responses to these agents in laboratory animals are mediated, at least in part, through activation or inhibition of other neurotransmitter and neuromodulator systems, it is conceivable that GABA agonists will be most efficacious as analgesics when administered in combination with other agents. The results of anatomical, biochemical, molecular, and pharmacological studies support the notion that generalized activation of GABA receptor systems dampens the response to painful stimuli. The data leave little doubt that, under certain circumstances, stimulation of neuroanatomically discreet GABA receptor sites could be of benefit in the management of pain. Continued research in this area is warranted given the limited choices, and clinical difficulties, associated with conventional analgesics.

GABA(B) receptor function and subunit expression in the rat spinal cord as indicators of stress and the antinociceptive response to antidepressants

Experiments were undertaken to examine whether once daily i.p. administration of either of two antidepressants used for the treatment of neuropathic pain, amitriptyline (10 mg/kg) and fluoxetine (5 mg/kg), to rats for 7 days modifies GABA(B) receptor function and subunit expression in the lumbar spinal cord. The results indicate that, as previously reported for desipramine, both amitriptyline and fluoxetine increase the pain threshold to a thermal stimulus, the expression of GABA(B(1)) subunits, and baclofen-stimulated [35S]GTPgammaS binding, a measure of GABA(B) receptor function. The effects of antidepressant administration on GABA(B(1b)) and GABA(B(2)) subunit expression in spinal cord are more variable than for GABA(B(1a)). It was also discovered that repeated daily exposure to a thermal stimulus or immobilization stress increases GABA(B(1a)) expression in the lumbar spinal cord, with no commensurate change in thermal pain threshold or GABA(B) receptor sensitivity. These results support a relationship between GABA(B) receptors and the action of antidepressants. The findings demonstrate that drug-induced increases in GABA(B) receptor function can occur independently of any change in GABA(B) receptor subunit expression and are consistent with the notion that GABA(B) receptor subunits have multiple functions, only one of which is dimerization to form GABA(B) receptors. The data also suggest that GABA(B) subunit gene expression may serve as a preclinical marker of antidepressant efficacy and of drug- or stress-induced modifications in central nervous system activity.

Effect of a selective GABAB receptor agonist baclofen on the μ-opioid receptor agonist-induced antinociceptive, emetic and rewarding effects

The management of excessive adverse effects of opioids is a major clinical problem. The present study was undertaken to investigate the effect of a selective gamma-aminobutyric acid (GABA)(B) receptor agonist baclofen on the mu-opioid receptor agonist-induced antinociceptive, emetic and rewarding effects. Either morphine or fentanyl produced a dose-dependent antinociceptive effect in both ferrets using Randall-Selitto test and mice using tail-flick test. Under these conditions, pretreatment of baclofen produced an additive antinociception induced by morphine or fentanyl. Furthermore, the augmentation of antinociception induced by systemic administration of baclofen with morphine or fentanyl was completely abolished by either i.c.v. or i.t. pretreatment with the selective GABA(B) receptor antagonist CGP 35348 in mice. We next investigated the emetic response induced by mu-opioid receptor agonist in ferrets. Morphine at lower doses than that used for antinociceptive assay produced both retching and vomiting, whereas fentanyl failed to produce the retching and vomiting in ferrets. Here we reported for the first time that baclofen significantly suppressed the retching and vomiting induced by morphine, indicating the involvement of GABA(B) receptor in emetic control pathway. Furthermore, baclofen also inhibited place preference elicited morphine or fentanyl in rats. Taken together, these results suggest that co-administration of baclofen with mu-opioid receptor agonist produced a potentiation of antinociceptive effect, whereas an untoward effect was completely blocked.

Management of cancer pain

There are four basic approaches to cancer pain control: modify the source of pain, alter central perception of pain, modulate transmission of pain to the central nervous system, and block transmission of pain to the central nervous system. Systemic pharmacologic management aimed at the first three of these approaches is the cornerstone of the treatment of most cancer patients with moderate to severe pain. Optimal pharmacologic management of cancer pain requires selection of the appropriate analgesic drug; prescription of the appropriate dose; administration of the analgesic by the appropriate route; scheduling of the appropriate dosing interval; prevention of persistent pain and relief of breakthrough pain; aggressive titration of the dose of the analgesic; prevention, anticipation, and management of analgesic side effects; consideration of sequential trials of opioid analgesics; and use of appropriate co-analgesic drugs for specific pain syndromes. Most clinicians should be able to control most of the pain in most of their cancer patients. Collaboration with pain and hospice/palliative care experts should help the rest. No cancer patient should live or die with unrelieved pain.

GABA(B) receptor alterations as indicators of physiological and pharmacological function

Given the widespread distribution of GABA(B) receptors throughout the central nervous system, and within certain peripheral organs, it is likely their selective pharmacological manipulation could be of benefit in the treatment of a variety of disorders. Studies aimed at defining the clinical potential of GABA(B) receptor agonists and antagonists have included gene deletion experiments, examination of changes in receptor binding, subunit expression and function in diseased tissue, as well as after the chronic administration of drugs. The results indicate that a functional GABA(B) receptor requires the combination of GABA(B(1)) and GABA(B(2)) subunits, that receptor function does not always correlate with subunit expression and receptor binding, and that GABA(B) receptor modifications may be associated with the clinical response to antidepressants, mood stabilizers, and GABA(B) receptor agonists and antagonists. Moreover, changes in GABA(B) binding or expression suggest this receptor may be involved in mediating symptoms associated with chronic pain, epilepsy and schizophrenia. This, together with results from other types of studies, indicates the potential therapeutic value of developing drugs capable of selectively activating, inhibiting, or modulating GABA(B) receptor function.

Adjuvant Analgesics in Cancer Pain Management

Adjuvant analgesics are defined as drugs with a primary indication other than pain that have analgesic properties in some painful conditions. The group includes numerous drugs in diverse classes. Although the widespread use of these drugs as first-line agents in chronic nonmalignant pain syndromes suggests that the term "adjuvant" is a misnomer, they usually are combined with a less-than-satisfactory opioid regimen when administered for cancer pain. Some adjuvant analgesics are useful in several painful conditions and are described as multipurpose adjuvant analgesics (antidepressants, corticosteroids, alpha(2)-adrenergic agonists, neuroleptics), whereas others are specific for neuropathic pain (anticonvulsants, local anesthetics, N-methyl-D-aspartate receptor antagonists), bone pain (calcitonin, bisphosphonates, radiopharmaceuticals), musculoskeletal pain (muscle relaxants), or pain from bowel obstruction (octreotide, anticholinergics). This article reviews the evidence supporting the use of each class of adjuvant analgesic for the treatment of pain in cancer patients and provides a comprehensive outline of dosing recommendations, side effects, and drug interactions.

Activaton of GABAB receptor inhibits the excitability of rat small diameter trigeminal root ganglion neurons

A selective GABA(B) receptor agonist, baclofen, is known to suppress neuropathic pain. In the present study, we investigated the effect of baclofen on the excitability of trigeminal root ganglion (TRG) neurons by using the whole cell and perforated patch-clamp recording techniques. Under voltage-clamp (V(h)=-60 mV), voltage-dependent K(+) currents were recorded in the small diameter TRG neurons (<30 microm) and isolated by blocking Na(+) and Ca(2+) currents with appropriate ion replacement. Separation of the K(+) current components was achieved by the response to variation in the conditioning voltage. Two distinct K(+) current components, a transient (I(A)) and a sustained (I(k)), were identified. Baclofen significantly increased I(A) by 74.8% (50 microM) and in a dose-dependent manner (1-50 microM). Similarly, I(K) was also enhanced by baclofen administration (41.8%: 50 microM). The relative amplitude of potentiation of I(A) was significantly higher than that of I(K) (P<0.05). Baclofen-sensitive I(A) and I(K) currents were antagonized by K(+) channel blockers, 4-aminopyridine (4-AP) and tetraethylammonium (TEA). The augmentation of K(+) currents was antagonized by 3-amino-2-(4-chlorophenyl)-2-hydroxypropylsulfonic acid (saclofen; GABA(B) antagonist). In the current clamp mode, the resting membrane potential was -62+/-1.6 mV (n=24). Hyperpolarization of the membrane potential was elicited by baclofen (10-50 microM), and the response was associated with a decrease in the input resistance. Baclofen induced-hyperpolarization was blocked by saclofen (100 microM). In the presence of both 4-AP and TEA, no significant changes in membrane potential induced by baclofen application were observed. In the presence of BaCl(2), baclofen-evoked hyperpolarization with decreased resistance was observed. During application of baclofen, the firing rate of the action potentials by depolarizing step pulses was decreased. Application of baclofen reduced action potential duration evoked by a depolarization current pulse.These results indicated that activation of GABA(B) receptors inhibits the excitability of rat small diameter TRG neurons and this inhibitory action is mediated by potentiation of voltage-dependent K(+) currents. We therefore concluded that modification of nociceptive transmission in the trigeminal system by activation of GABA(B) receptors occurs at the level of small TRG neuron cell bodies and/or their primary afferent terminals, which are potential targets of analgesia by baclofen.

Gabapentin in the treatment of neuropathic pain

This paper reviews the pharmacology and clinical effectiveness of gabapentin in the treatment of neuropathic pain. Gabapentin has antihyperalgesic and antiallodynic properties but does not have significant actions as an anti-nociceptive agent. Its mechanisms of action appear to be a complex synergy between increased GABA synthesis, non-NMDA receptor antagonism and binding to the alpha2delta subunit of voltage dependent calcium channels. The latter action inhibits the release of excitatory neurotransmitters. Clinically, several large randomized controlled trials have demonstrated its effectiveness in the treatment of a variety of neuropathic pain syndromes. Patients with neuropathic pain can expect a mean reduction in pain score of 2.05 points on an 11 point numerical rating scale compared with a reduction of 0.94 points if they had taken the placebo. Around 30% of patients can expect to achieve more than 50% pain relief and a similar number will also experience minor adverse events; the most common of which are somnolence and dizziness. In patients with neuropathic pain due to cancer, higher response rates might be observed with gabapentin when administered with opioids because of a synergistic interaction.

Treatment of Chronic Pain

Chronic pain is a symptom associated with ongoing physical or mental illness or a combination of both that may not have a clear, identifiable pathophysiology. Assessment of chronic pain varies in the clinical presentation related to age, gender, racial, and cultural differences. Headache, low back pain, musculoskeletal pain, and neuropathic pain are the most common types of chronic pain complaints by patients. Pharmacologic therapy is based on best practice standards, published clinical trials, and guidelines by professional organizations. Current medications reviewed include opioids, anticonvulsants, antidepressants, clonidine, local anesthetics, muscle relaxants, N-methyl-D-aspartate antagonists, and nonsteroidal anti-inflammatory drugs.

Demographics, assessment and management of pain in the elderly

The prevalence of pain increases with each decade of life. Pain in the elderly is distinctly different from pain experienced by younger individuals. Cancer is a leading cause of pain; however, other conditions that cause pain such as facet joint arthritis (causing low back pain), polymyalgia rheumatica, Paget's disease, neuropathies, peripheral vascular disease and coronary disease most commonly occur in patients over the age of 50 years. Poorly controlled pain in the elderly leads to cognitive failure, depression and mood disturbance and reduces activities of daily living. Barriers to pain management include a sense of fatalism, denial, the desire to be 'the good patient', geographical barriers and financial limitations. Aging causes physiological changes that alter the pharmacokinetics and pharmacodynamics of analgesics, narrowing their therapeutic index and increasing the risk of toxicity and drug-drug interactions. CNS changes lead to an increased risk of delirium. Assessment among the verbal but cognitively impaired elderly is satisfactorily accomplished with the help of unidimensional and multidimensional pain scales. A comprehensive physical examination and pain history is essential, as well as a review of cognitive function and activities of daily living. The goal of pain management among the elderly is improvement in pain and optimisation of activities of daily living, not complete eradication of pain nor the lowest possible drug dosages. Most successful management strategies combine pharmacological and nonpharmacological (home remedies, massage, topical agents, heat and cold packs and informal cognitive strategies) therapies. A basic principle of the pharmacological approach in the elderly is to start analgesics at low dosages and titrate slowly. The WHO's three-step guideline to pain management should guide prescribing. Opioid choices necessitate an understanding of pharmacology to ensure safe administration in end-organ failure and avoidance of drug interactions. Adjuvant analgesics are used to reduce opioid adverse effects or improve poorly controlled pain. Adjuvant analgesics (NSAIDs, tricyclic antidepressants and antiepileptic drugs) are initiated prior to opioids for nociceptive and neuropathic pain. Preferred adjuvants for nociceptive pain are short-acting paracetamol (acetaminophen), NSAIDs, cyclo-oxygenase-2 inhibitors and corticosteroids (short-term). Preferred drugs for neuropathic pain include desipramine, nortriptyline, gabapentin and valproic acid. Drugs to avoid are pentazocine, pethidine (meperidine), dextropropoxyphene and opioids that are both an agonist and antagonist, ketorolac, indomethacin, piroxicam, mefenamic acid, amitriptyline and doxepin. The type of pain, and renal and hepatic function, alter the preferred adjuvant and opioid choices. Selection of the appropriate analgesics is also influenced by versatility, polypharmacy, severity and type of pain, drug availability, associated symptoms and cost.

Tender points as predictors of distress and the pharmacologic management of fibromyalgia syndrome

The object of this study was to determine the association between tender point pain ratings, tender point counts and distress in people with fibromyalgia and to review the pharmacotherapy of fibromyalgia. Demographic, psychosocial, and health status information was collected from 316 health maintenance organization members with fibromyalgia. A manual tender point exam was conducted. Tender point counts predicted 3.0%, and tender point severity ratings predicted 8.3%, of the variance in distress. Little difference was found between the variance predicted for physical versus psychologic distress. A principal components analysis of all measures produced four distinct factors: global-physical functioning, tender points, psychologic, and physical. Tender point pain ratings and counts predicted a small but significant amount of variance in distress. In addition, FMS involves at least four rather distinct factors, one of which is related to tender points. Pharmacotherapeutic management is provided on a patient-specific basis including pharmacokinetics, pharmacodynamic, pathophysiologic, and psychosocial needs designed and modulated for each individual patient.

The neuropharmacology of centrally-acting analgesic medications in fibromyalgia

As demonstrated above, the anatomy and neuropharmacology of the pain pathways within the CNS, even to the level of the midbrain, are extraordinarily complex. Indeed, discussions of the effects of these agents on the neuropharmacology of the thalamus, hypothalamus, and cortex were excluded from this review owing to their adding further to this complexity. Also, the dearth of data regarding FMS pain pathophysiology necessitated a relatively generic analysis of the pain pathways. As mentioned in the introduction, the current thought is that central sensitization plays an important role in FMS. However, we see in this chapter that the behavioral state of central sensitization may be a result of alterations in either the ascending systems or in one or more descending systems. Studies to assess the presence or relative importance of such changes in FMS are difficult to perform in humans, and to date there are no animal models of FMS. Accepting these limitations, it is apparent that many drugs considered to date for the treatment of FMS do target a number of appropriate sites within both the ascending and descending pain pathways. The data regarding clinical efficacy on some good candidate agents, however, is extremely preliminary. For example, it is evident from the present analysis that SNRIs, alpha 2 agonists, and NK1 antagonists may be particularly well suited to FMS, although current data supporting their use is either anecdotal or from open-label trials [114,149]. Other sites within the pain pathways have not yet been targeted. Examples of these include the use of CCKB antagonists to block on-cell activation or of nitric oxide synthetase antagonists to block the downstream mediators of NMDA activation. Efficacy of such agents may give considerable insight into the pathophysiology of FMS. Finally, as indicated previously, FMS consists of more than just chronic pain, and the question of how sleep abnormalities, depression, fatigues, and so forth tie into disordered pain processing is being researched actively. Future research focusing on how the various manifestations of FMS relate to one another undoubtedly will lead to a more rational targeting of drugs in this complex disorder.

Supportive therapy of elderly cancer patients

Elderly cancer patients often require supportive care due to the physiologic decline of organs and apparatus linked with the aging process per se, and for the effects of tumor or of anticancer treatments. Pain and nutritional deficits are some clinical aspects requiring supportive care. Lack of studies on these latter topics does not allow an in depth analysis of the problem. The present review deals with literature concerning pain and nutritional problems in the general cancer population with emphasis on aspects typical for elderly cancer subjects. Physiologic and cancer-related changes in body composition, physical function and cognitive capacity of the elderly are presented and, when appropriate, linked with pathogenetic factors of pain and malnutrition, as well as their treatment. Pain demographic data, pain intensity evaluation and currently available techniques to provide pain relief such as etiologic treatment, analgesic pharmacotherapy and invasive analgesic procedures, are extensively discussed. Causes and assessment of malnutrition as well as available nutritional approaches such as oral, enteral and parenteral nutrition are also debated.

Adjunctive agents in the management of chronic pain

Chronic pain syndromes include cancer-related pain, postherpetic neuralgia, painful diabetic neuropathy, and central poststroke pain and are common in the elderly. Adjunctive (or adjuvant) analgesics, defined as drugs that do not contain acetaminophen and those not classified as nonsteroidal antiinflammatory or opioid agents, play a role in the management of chronic pain. The term "adjunctive" (or "adjuvant") is a misnomer as several of these agents may constitute first-line therapy for many chronic pain syndromes. Tricyclic antidepressants have formed the backbone of therapy for chronic neuropathic pain for years. However, the difficulty with using agents of this class, due to their clinically significant adverse-event potential, has led to the evaluation of other agents, most notably, the antiepileptic drugs. The most useful are gabapentin, carbamazepine, and lamotrigine. In selected patients, baclofen, mexiletine, and clonidine may be useful as well. Cancer-related pain may respond substantially to corticosteroids, and pain associated with bone metastases to parenteral bisphosphonates and strontium. Practitioners should consider these alternative agents when treating chronic pain.

GABA B receptor-mediated effects on expression of c-Fos in rat trigeminal nucleus following high- and low-intensity afferent stimulation

We examined the effects of systemic administration of a GABA(B) receptor agonist, baclofen, or antagonist, phaclofen, on the expression of c-Fos protein induced 3h after electrical stimulation of the trigeminal ganglion at low (0.1 mA) or high intensities (1.0 mA) in the urethane-anesthetized rat. In saline-treated rats, 10 min stimulation of the trigeminal ganglion induced c-Fos-immunopositive neurons throughout the full extent of the ipsilateral superficial layers of the trigeminal nucleus caudalis, and dorsal or dorsomedial part of the nuclei rostral to obex (trigeminal nucleus principalis, dorsomedial nucleus of trigeminal nucleus oralis and dorsomedial nucleus of trigeminal nucleus interpolaris). Animals stimulated at 1.0 mA induced a significantly higher number of labeled neurons in all the trigeminal sensory nuclei than animals stimulated at 0.1 mA. In rats treated with 20mg/kg i.p. baclofen and stimulated at 0.1 mA, the numbers of Fos-positive neurons in all the trigeminal sensory nuclei were significantly decreased compared to saline-treated controls. After stimulation at 1.0 mA in rats treated with baclofen, the numbers of Fos-positive neurons in all the trigeminal sensory nuclei were also significantly decreased. In rats treated with 2mg/kg i.p. phaclofen and stimulated at 1.0 mA, the numbers of Fos-positive neurons were significantly increased in all the trigeminal sensory nuclei. However, after stimulation at 0.1 mA in rats treated with phaclofen, the numbers of Fos-positive neurons were significantly decreased in the superficial layers and magnocellular zone of trigeminal nucleus caudalis and dorsomedial nucleus of trigeminal nucleus oralis. These results indicate that the expression of c-Fos in the trigeminal sensory nucleus is differentially regulated through GABAB receptors in a manner that is dependent on the nucleus and the type of primary afferents that are activated by different stimulus intensities. Systemic administration of baclofen could inhibit both nociceptive and non-nociceptive sensory activity in the trigeminal sensory nucleus. Systemic administration of phaclofen could enhance nociceptive sensory activity but not non-nociceptive activity.

Dysesthesia perceived as painful spasticity: A report of 3 cases

Lesions of the central nervous system often involve the pyramidal tracts and the sensory pathways to produce spasticity, paresthesias, and dysesthesia. Three patients with intractable spasticity were treated with intrathecal baclofen. Two had an implanted Medtronic SynchroMed pump for long-term delivery of the muscle relaxant. The third patient had undergone a screening trial in which the baclofen was delivered into the intrathecal space through a lumbar catheter. All had excellent relief of spasms on clinical examination, but they reported painful spasms particularly at night. Two of the patients were successfully treated for dysesthesia.