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Martucci KT. Neuroimaging of opioid effects in humans across conditions of acute administration, chronic pain therapy, and opioid use disorder. Trends Neurosci 2024:S0166-2236(24)00063-8. [PMID: 38762362 DOI: 10.1016/j.tins.2024.04.005] [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: 10/30/2023] [Revised: 04/01/2024] [Accepted: 04/21/2024] [Indexed: 05/20/2024]
Abstract
Evidence of central nervous system (CNS) exogenous opioid effects in humans has been primarily gained through neuroimaging of three participant populations: individuals after acute opioid administration, those with opioid use disorder (OUD), and those with chronic pain receiving opioid therapy. In both the brain and spinal cord, opioids alter processes of pain, cognition, and reward. Opioid-related CNS effects may persist and accumulate with longer opioid use duration. Meanwhile, opioid-induced benefits versus risks to brain health remain unclear. This review article highlights recent accumulating evidence for how exogenous opioids impact the CNS in humans. While investigation of CNS opioid effects has remained largely disparate across contexts of opioid acute administration, OUD, and chronic pain opioid therapy, integration across these contexts may enable advancement toward effective interventions.
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Affiliation(s)
- Katherine T Martucci
- Human Affect and Pain Neuroscience Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Center for Translational Pain Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Institute for Brain Sciences, Duke University, Durham, NC, USA.
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2
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Warner NS, Hanson AC, Schulte PJ, Kara F, Reid RI, Schwarz CG, Benarroch EE, Graff-Radford J, Vemuri P, Jack CR, Petersen RC, Warner DO, Mielke MM, Kantarci K. Prescription Opioids and Brain Structure in Community-Dwelling Older Adults. Mayo Clin Proc 2024; 99:716-726. [PMID: 38702125 PMCID: PMC11081533 DOI: 10.1016/j.mayocp.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE To evaluate the associations between prescription opioid exposures in community-dwelling older adults and gray and white matter structure by magnetic resonance imaging. METHODS Secondary analysis was conducted of a prospective, longitudinal population-based cohort study employing cross-sectional imaging of older adult (≥65 years) enrollees between November 1, 2004, and December 31, 2017. Gray matter outcomes included cortical thickness in 41 structures and subcortical volumes in 6 structures. White matter outcomes included fractional anisotropy in 40 tracts and global white matter hyperintensity volumes. The primary exposure was prescription opioid availability expressed as the per-year rate of opioid days preceding magnetic resonance imaging, with a secondary exposure of per-year total morphine milligram equivalents (MME). Multivariable models assessed associations between opioid exposures and brain structures. RESULTS The study included 2185 participants; median (interquartile range) age was 80 (75 to 85) years, 47% were women, and 1246 (57%) received opioids. No significant associations were found between opioids and gray matter. Increased opioid days and MME were associated with decreased white matter fractional anisotropy in 15 (38%) and 16 (40%) regions, respectively, including the corpus callosum, posterior thalamic radiation, and anterior limb of the internal capsule, among others. Opioid days and MME were also associated with greater white matter hyperintensity volume (1.02 [95% CI, 1.002 to 1.036; P=.029] and 1.01 [1.001 to 1.024; P=.032] increase in the geometric mean, respectively). CONCLUSION The duration and dose of prescription opioids were associated with decreased white matter integrity but not with gray matter structure. Future studies with longitudinal imaging and clinical correlation are warranted to further evaluate these relationships.
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Affiliation(s)
- Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Andrew C Hanson
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Firat Kara
- Department of Radiology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michelle M Mielke
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC
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Dagher M, Alayoubi M, Sigal GH, Cahill CM. Unveiling the link between chronic pain and misuse of opioids and cannabis. J Neural Transm (Vienna) 2024; 131:563-580. [PMID: 38570361 DOI: 10.1007/s00702-024-02765-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/10/2024] [Indexed: 04/05/2024]
Abstract
Over 50 million Americans endure chronic pain where many do not receive adequate treatment and self-medicate to manage their pain by taking substances like opioids and cannabis. Research has shown high comorbidity between chronic pain and substance use disorders (SUD) and these disorders share many common neurobiological underpinnings, including hypodopaminergic transmission. Drugs commonly used for self-medication such as opioids and cannabis relieve emotional, bothersome components of pain as well as negative emotional affect that perpetuates misuse and increases the risk of progressing towards drug abuse. However, the causal effect between chronic pain and the development of SUDs has not been clearly established. In this review, we discuss evidence that affirms the proposition that chronic pain is a risk factor for the development of opioid and cannabis use disorders by outlining the clinical evidence and detailing neurobiological mechanisms that link pain and drug misuse. Central to the link between chronic pain and opioid and cannabis misuse is hypodopaminergic transmission and the modulation of dopamine signaling in the mesolimbic pathway by opioids and cannabis. Moreover, we discuss the role of kappa opioid receptor activation and neuroinflammation in the context of dopamine transmission, their contribution to opioid and cannabis withdrawal, along with potential new treatments.
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Affiliation(s)
- Merel Dagher
- MacDonald Research Laboratory Building, Department of Psychiatry and Biobehavioral Sciences, Shirley and Stefan Hatos Center for Neuropharmacology, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, 675 Charles E Young Drive South, Office 2774, Los Angeles, CA, 90095, USA
| | - Myra Alayoubi
- MacDonald Research Laboratory Building, Department of Psychiatry and Biobehavioral Sciences, Shirley and Stefan Hatos Center for Neuropharmacology, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, 675 Charles E Young Drive South, Office 2774, Los Angeles, CA, 90095, USA
- Neuroscience Interdepartmental Program, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Gabriella H Sigal
- Department of Integrative Biology and Physiology, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Catherine M Cahill
- MacDonald Research Laboratory Building, Department of Psychiatry and Biobehavioral Sciences, Shirley and Stefan Hatos Center for Neuropharmacology, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, 675 Charles E Young Drive South, Office 2774, Los Angeles, CA, 90095, USA.
- Neuroscience Interdepartmental Program, University of California Los Angeles, Los Angeles, CA, 90095, USA.
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4
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Gao Y, Su B, Ding L, Qureshi D, Hong S, Wei J, Zeng C, Lei G, Xie J. Association of Regular Opioid Use With Incident Dementia and Neuroimaging Markers of Brain Health in Chronic Pain Patients: Analysis of UK Biobank. Am J Geriatr Psychiatry 2024:S1064-7481(24)00320-8. [PMID: 38702251 DOI: 10.1016/j.jagp.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVES We aimed to investigate the association of regular opioid use, compared with non-opioid analgesics, with incident dementia and neuroimaging outcomes among chronic pain patients. DESIGN The primary design is a prospective cohort study. To triangulate evidence, we also conducted a nested case-control study analyzing opioid prescriptions and a cross-sectional study analyzing neuroimaging outcomes. SETTING AND PARTICIPANTS Dementia-free UK Biobank participants with chronic pain and regular analgesic use. MEASUREMENTS Chronic pain status and regular analgesic use were captured using self-reported questionnaires and verbal interviews. Opioid prescription data were obtained from primary care records. Dementia cases were ascertained using primary care, hospital, and death registry records. Propensity score-matched Cox proportional hazards analysis, conditional logistic regression, and linear regression were applied to the data in the prospective cohort, nested case-control, and cross-sectional studies, respectively. RESULTS Prospective analyses revealed that regular opioid use, compared with non-opioid analgesics, was associated with an increased dementia risk over the 15-year follow-up (Hazard ratio [HR], 1.18 [95% confidence interval (CI): 1.08-1.30]; Absolute rate difference [ARD], 0.44 [95% CI: 0.19-0.71] per 1000 person-years; Wald χ2 = 3.65; df = 1; p <0.001). The nested case-control study suggested that a higher number of opioid prescriptions was associated with an increased risk of dementia (1 to 5 prescriptions: OR = 1.21, 95% CI: 1.07-1.37, Wald χ2 = 3.02, df = 1, p = 0.003; 6 to 20: OR = 1.27, 95% CI: 1.08-1.50, Wald χ2 = 2.93, df = 1, p = 0.003; more than 20: OR = 1.43, 95% CI: 1.23-1.67, Wald χ2 = 4.57, df = 1, p < 0.001). Finally, neuroimaging analyses revealed that regular opioid use was associated with lower total grey matter and hippocampal volumes, and higher white matter hyperintensities volumes. CONCLUSION Regular opioid use in chronic pain patients was associated with an increased risk of dementia and poorer brain health when compared to non-opioid analgesic use. These findings imply a need for re-evaluation of opioid prescription practices for chronic pain patients and, if further evidence supports causality, provide insights into strategies to mitigate the burden of dementia.
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Affiliation(s)
- Yaqing Gao
- Nuffield Department of Population Health (YG, DQ), University of Oxford, Oxford, UK
| | - Binbin Su
- School of Population Medicine and Public Health (BS), Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Lei Ding
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases (LD), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Danial Qureshi
- Nuffield Department of Population Health (YG, DQ), University of Oxford, Oxford, UK
| | - Shenda Hong
- National Institute of Health Data Science (SH), Peking University, Beijing, China; Institute of Medical Technology (SH), Peking University Health Science Center, Beijing, China
| | - Jie Wei
- Department of Orthopaedics (JW, CZ, GL), Xiangya Hospital, Central South University, Changsha, China
| | - Chao Zeng
- Department of Orthopaedics (JW, CZ, GL), Xiangya Hospital, Central South University, Changsha, China
| | - Guanghua Lei
- Department of Orthopaedics (JW, CZ, GL), Xiangya Hospital, Central South University, Changsha, China.
| | - Junqing Xie
- Centre for Statistics in Medicine and NIHR Biomedical Research Centre Oxford, NDORMS (JX), University of Oxford, Oxford, UK.
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Mei YD, Gao H, Chen WF, Zhu W, Gu C, Zhang JP, Tao JM, Hua XY. Research on the multidimensional brain remodeling mechanisms at the level of brain regions, circuits, and networks in patients with chronic lower back pain caused by lumbar disk herniation. Front Neurosci 2024; 18:1357269. [PMID: 38516315 PMCID: PMC10956359 DOI: 10.3389/fnins.2024.1357269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/21/2024] [Indexed: 03/23/2024] Open
Abstract
Introduction Chronic lower back pain (cLBP), frequently attributed to lumbar disk herniation (LDH), imposes substantial limitations on daily activities. Despite its prevalence, the neural mechanisms underlying lower back pain remain incompletely elucidated. Functional magnetic resonance imaging (fMRI) emerges as a non-invasive modality extensively employed for investigating neuroplastic changes in neuroscience. In this study, task-based and resting-state fMRI methodologies are employed to probe the central mechanisms of lower back pain. Methods The study included 71 chronic lower back pain patients (cLBP group) due to LDH and 80 age, gender, and education-matched healthy volunteers (HC group). The subjects are mainly middle-aged and elderly individuals. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association Scores (JOA) were recorded. Resting-state and task-based fMRI data were collected. Results/discussion No significant differences were observed in age, gender, and education level between the two groups. In the cLBP group during task execution, there was diffuse and reduced activation observed in the primary motor cortex and supplementary motor area. Additionally, during resting states, notable changes were detected in brain regions, particularly in the frontal lobe, primary sensory area, primary motor cortex, precuneus, and caudate nucleus, accompanied by alterations in Amplitude of Low Frequency Fluctuation, Regional Homogeneity, Degree Centrality, and functional connectivity. These findings suggest that chronic lower back pain may entail reduced excitability in sensory-motor areas during tasks and heightened activity in the sensory-motor network during resting states, along with modified functional connectivity in various brain regions.
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Affiliation(s)
- Yuan-Dong Mei
- Department of Hand Surgery, the Second People’s Hospital of Changshu, Changshu, China
| | - Hang Gao
- Department of Rehabilitation, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wei-Fei Chen
- Department of Hand Surgery, the Second People’s Hospital of Changshu, Changshu, China
| | - Wei Zhu
- Department of Hand Surgery, the Second People’s Hospital of Changshu, Changshu, China
| | - Chen Gu
- Department of Hand Surgery, the Second People’s Hospital of Changshu, Changshu, China
| | - Jun-Peng Zhang
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ji-Ming Tao
- Department of Rehabilitation, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xu-Yun Hua
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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6
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Lai P, Cheng S, Chen X, Cheng F, Cheng J, Xin M, Zhu D, Li Z, Wu X, Zeng F. The Emotion Regulation of Acupuncture in Chronic Low Back Pain: A Clinical Neuroimaging Protocol. J Pain Res 2024; 17:817-825. [PMID: 38444878 PMCID: PMC10913808 DOI: 10.2147/jpr.s450589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/23/2024] [Indexed: 03/07/2024] Open
Abstract
Introduction Acupuncture is effective for patients with chronic low back pain (CLBP), which can relieve pain intensity and regulate negative emotional states such as pain-related anxiety and depression. Previous studies mainly discuss the analgesic mechanism of acupuncture treatment of CLBP, but there are multiple dimensions to pain, including sensation, emotion and cognition. Therefore, this study aims to investigate the central mechanism of acupuncture for CLBP from the perspective of emotional regulation by functional magnetic resonance imaging (fMRI). Methods and Analysis A total of 72 patients with CLBP will be recruited in the study and randomly assigned to the verum acupuncture group or the sham acupuncture group. The trail will last for 18 weeks including a 2-week baseline, a 4-week treatment and a 12-week for follow-up period. The primary outcomes are the visual analog scale (VAS) and the Japanese Orthopaedic Association Scores (JOA) score. The secondary outcomes are the 12-item short form health survey (SF-12), the state trait anxiety inventory (STAI), the self-rating anxiety scale (SAS) and self-rating depression scale (SDS). The VAS, JOA, STAI SAS and SDS will be collected at baseline, week 2, week 4, and after follow-up. The SF-12 will be evaluated at baseline, week 2 and week 4. Functional magnetic resonance imaging (MRI) data will be collected at baseline and the end of treatment. Emotion-related brain regions will be chosen as regions of interest (ROIs). The gray matter volume (GMV), amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), functional connectivity (FC), and large-scale functional brain network based on these ROIs will be analyzed within and between the two groups. Discussion This study will verify the emotional regulation of acupuncture and explore the mechanism of acupuncture for emotion regulation in patients with CLBP. Trial Registration Number https://www.chictr.org.cn/showproj.html?proj=195486, identifier: ChiCTR2300070557.
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Affiliation(s)
- Peng Lai
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
- Acupuncture & Brain Research Center, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
| | - Shirui Cheng
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
- Acupuncture & Brain Research Center, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
| | - Xingyao Chen
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
| | - Fangdong Cheng
- Geriatric Diseases Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Department of Orthopedic, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
| | - Jun Cheng
- Geriatric Diseases Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Department of Orthopedic, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
| | - Ming Xin
- Geriatric Diseases Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Department of Rehabilitation, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
| | - Deliang Zhu
- Geriatric Diseases Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
- Department of Rehabilitation, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan, People’s Republic of China
| | - Zhengjie Li
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
- Acupuncture & Brain Research Center, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
| | - Xi Wu
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
| | - Fang Zeng
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
- Acupuncture & Brain Research Center, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People’s Republic of China
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Baliki MN, Vigotsky AD, Rached G, Jabakhanji R, Huang L, Branco P, Cong O, Griffith J, Wasan AD, Schnitzer TJ, Apkarian AV. Neuropsychology of chronic back pain managed with long-term opioid use. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.07.24302408. [PMID: 38370783 PMCID: PMC10871381 DOI: 10.1101/2024.02.07.24302408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Chronic pain is commonly treated with long-term opioids, but the neuropsychological outcomes associated with stable long-duration opioid use remain unclear. Here, we contrasted the psychological profiles, brain activity, and brain structure of 70 chronic back pain patients on opioids (CBP+O, average opioid exposure 6.2 years) with 70 patients managing their pain without opioids. CBP+O exhibited moderately worse psychological profiles and small differences in brain morphology. However, CBP+O had starkly different spontaneous brain activity, dominated by increased mesocorticolimbic and decreased dorsolateral-prefrontal activity, even after controlling for pain intensity and duration. These differences strongly reflected cortical opioid and serotonin receptor densities and mapped to two antagonistic resting-state circuits. The circuits' dynamics were explained by mesocorticolimbic activity and reflected negative affect. We reassessed a sub-group of CBP+O after they briefly abstained from taking opioids. Network dynamics, but not spontaneous activity, reflected exacerbated signs of withdrawal. Our results have implications for the management and tapering of opioids in chronic pain.
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Affiliation(s)
- Marwan N Baliki
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
- Shirley Ryan AbilityLab, Chicago, Illinois
| | - Andrew D Vigotsky
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Biomedical Engineering and Statistics & Data Science, Northwestern University, Chicago, Illinois
| | - Gaelle Rached
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Department of Neuroscience, Northwestern University, Chicago, Illinois
| | - Rami Jabakhanji
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Department of Neuroscience, Northwestern University, Chicago, Illinois
| | - Lejian Huang
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Department of Neuroscience, Northwestern University, Chicago, Illinois
| | - Paulo Branco
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Department of Neuroscience, Northwestern University, Chicago, Illinois
- Department of Anesthesia, Northwestern University, Chicago, Illinois
| | - Olivia Cong
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Department of Neuroscience, Northwestern University, Chicago, Illinois
| | - James Griffith
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Medical and Social Sciences, Northwestern University, Chicago, Illinois
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas J Schnitzer
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Department of Anesthesia, Northwestern University, Chicago, Illinois
- Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
| | - A Vania Apkarian
- Center for Translational Pain Research, Northwestern University, Chicago, Illinois
- Department of Neuroscience, Northwestern University, Chicago, Illinois
- Department of Anesthesia, Northwestern University, Chicago, Illinois
- Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
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8
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Jeddi HM, Busse JW, Sadeghirad B, Levine M, Zoratti MJ, Wang L, Noori A, Couban RJ, Tarride JE. Cannabis for medical use versus opioids for chronic non-cancer pain: a systematic review and network meta-analysis of randomised clinical trials. BMJ Open 2024; 14:e068182. [PMID: 38171632 PMCID: PMC10773353 DOI: 10.1136/bmjopen-2022-068182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/27/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE The objective of this study is to evaluate the comparative benefits and harms of opioids and cannabis for medical use for chronic non-cancer pain. DESIGN Systematic review and network meta-analysis. DATA SOURCES EMBASE, MEDLINE, CINAHL, AMED, PsycINFO, PubMed, Web of Science, Cannabis-Med, Epistemonikos and the Cochrane Library (CENTRAL) from inception to March 2021. STUDY SELECTION Randomised trials comparing any type of cannabis for medical use or opioids, against each other or placebo, with patient follow-up ≥4 weeks. DATA EXTRACTION AND SYNTHESIS Paired reviewers independently extracted data. We used Bayesian random-effects network meta-analyses to summarise the evidence and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to evaluate the certainty of evidence and communicate our findings. RESULTS Ninety trials involving 22 028 patients were eligible for review, among which the length of follow-up ranged from 28 to 180 days. Moderate certainty evidence showed that opioids provide small improvements in pain, physical functioning and sleep quality versus placebo; low to moderate certainty evidence supported similar effects for cannabis versus placebo. Neither was more effective than placebo for role, social or emotional functioning (all high to moderate certainty evidence). Moderate certainty evidence showed there is probably little to no difference between cannabis for medical use and opioids for physical functioning (weighted mean difference (WMD) 0.47 on the 100-point 36-item Short Form Survey physical component summary score, 95% credible interval (CrI) -1.97 to 2.99), and cannabis resulted in fewer discontinuations due to adverse events versus opioids (OR 0.55, 95% CrI 0.36 to 0.83). Low certainty evidence suggested little to no difference between cannabis and opioids for pain relief (WMD 0.23 cm on a 10 cm Visual Analogue Scale (VAS), 95% CrI -0.06 to 0.53) or sleep quality (WMD 0.49 mm on a 100 mm VAS, 95% CrI -4.72 to 5.59). CONCLUSIONS Cannabis for medical use may be similarly effective and result in fewer discontinuations than opioids for chronic non-cancer pain. PROSPERO REGISTRATION NUMBER CRD42020185184.
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Affiliation(s)
- Haron M Jeddi
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute of Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute of Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Mitchell Levine
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Michael J Zoratti
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
| | - Li Wang
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute of Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Atefeh Noori
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Hand Program, Division of Plastic, Reconstructive and Aesthetic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
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Baker AK, Park SH, Weber KA, Martucci KT. Reduced Spinal Cord Gray Matter in Patients with Fibromyalgia Using Opioids Long-term. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.02.23289401. [PMID: 37205383 PMCID: PMC10187444 DOI: 10.1101/2023.05.02.23289401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Objective Chronic pain involves alterations in brain gray matter volume (GMV). Moreover, opioid medications are known to reduce GMV in numerous brain regions involved in pain processing. However, no research has evaluated (1) chronic pain-related GMV alterations in the spinal cord or (2) the effect of opioids on spinal cord GMV. Accordingly, this study evaluated spinal cord GMV in health controls and patients with fibromyalgia who were using and not using opioids long-term. Methods We analyzed average C5 - C7 GMV of the spinal cord dorsal and ventral horns in separate female cohorts of healthy controls (HC, n = 30), fibromyalgia patients not using opioids (FMN, n = 31), and fibromyalgia patients using opioids long-term (FMO, n = 27). To assess the effect of group on average dorsal and ventral horn GMV, we conducted a one-way multivariate analysis of covariance. Results After controlling for age, we observed a significant effect of group on ventral horn GMV (p = 0.03, η2 = 0.09), and on dorsal horn GMV (p = 0.05, η2 = 0.08). Tukey's posthoc comparisons showed that, compared to HC participants, FMOs had significantly lower ventral (p = 0.01) and dorsal (p = 0.02) GMVs. Among FMOs only, ventral horn GMV was significantly positively associated with pain severity and interference, and both dorsal and ventral GMVs were significantly positively associated with cold pain tolerance. Conclusion Long-term opioid use may impact sensory processing in fibromyalgia via gray matter changes within the cervical spinal cord.
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Affiliation(s)
- Anne K. Baker
- Human Affect and Pain Neuroscience Laboratory, Department of Anesthesiology, Duke University School of Medicine, Durham NC 27710
- Center for Translational Pain Medicine, Duke University Medical Center, Durham NC 27710
| | - Su Hyoun Park
- Human Affect and Pain Neuroscience Laboratory, Department of Anesthesiology, Duke University School of Medicine, Durham NC 27710
- Center for Translational Pain Medicine, Duke University Medical Center, Durham NC 27710
| | - Kenneth A. Weber
- Systems Neuroscience and Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School fo Medicine, Palo Alto, CA 94304
| | - Katherine T. Martucci
- Human Affect and Pain Neuroscience Laboratory, Department of Anesthesiology, Duke University School of Medicine, Durham NC 27710
- Center for Translational Pain Medicine, Duke University Medical Center, Durham NC 27710
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10
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Tajerian M, Amrami M, Betancourt JM. Is there hemispheric specialization in the chronic pain brain? Exp Neurol 2022; 355:114137. [PMID: 35671801 PMCID: PMC10723052 DOI: 10.1016/j.expneurol.2022.114137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022]
Abstract
Organismal bilateral symmetry is associated with near-identical halves of the central nervous system, with certain functions displaying specialization through one brain hemisphere. The processing of pain in the brain as well as brain plasticity in the context of painful injuries have garnered much attention in recent decades. Noninvasive brain imaging studies in pain-free human subjects have identified multiple brain regions that are linked to the sensory and affective components of pain. Longlasting adaptations in brains of chronic pain sufferers have likewise been described, suggesting a mechanism for pain chronification. Invasive molecular and biochemical studies in animal models have expanded on these findings, with added emphasis on the role of specific genes and molecules involved. To date, the extent of hemispheric asymmetry in the context of pain is not well-understood. This topical review evaluates the evidence of hemispheric specialization observed in humans and rodent models of pain and compares it to findings where such asymmetry is absent. Our review shows conflicting information regarding the existence of pain-related asymmetry, and if so, the side to which it can be localized. This could be due to the heterogeneity of pain processing pathways, heterogeneity in study parameters, as well as differences in data reporting. With the advent of progressively sophisticated non-invasive tools that can be used in human subjects, in addition to more precise methods to visualize and control specific brain regions or neuronal ensembles in animal models, we predict that the next few decades will witness a better understanding of the supraspinal control and processing of chronic pain, including the role of each of its hemispheres.
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Affiliation(s)
- Maral Tajerian
- Department of Biology, Queens College, City University of New York, Queens, NY 11367, USA; The Graduate Center, City University of New York, New York, NY 10016, USA.
| | - Michael Amrami
- Department of Biology, Queens College, City University of New York, Queens, NY 11367, USA
| | - John Michael Betancourt
- Neuroscience Graduate Program, Graduate School of Medical Sciences, Weill Cornell Medicine, New York, NY 10021, USA
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11
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Warner NS, Mielke MM, Verdoorn BP, Knopman DS, Hooten WM, Habermann EB, Warner DO. Pain, Opioid Analgesics, and Cognition: A Conceptual Framework in Older Adults. PAIN MEDICINE 2022; 24:171-181. [PMID: 35913452 PMCID: PMC9890310 DOI: 10.1093/pm/pnac113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/06/2023]
Abstract
Chronic pain is highly prevalent in older adults and is associated with poor functional outcomes. Furthermore, opioid analgesics are commonly utilized for the treatment of pain in older adults despite well-described adverse effects. Importantly, both chronic pain and opioid analgesics have been linked with impairments in cognitive function, though data are limited. In this manuscript we summarize the evidence and critical knowledge gaps regarding the relationships between pain, opioid analgesics, and cognition in older adults. Furthermore, we provide a conceptual framework to guide future research in the development, implementation, and evaluation of strategies to optimize analgesic outcomes in older adults while minimizing deleterious effects on cognition.
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Affiliation(s)
- Nafisseh S Warner
- Correspondence to: Nafisseh S. Warner, MD, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. Tel: (507)284-2511; Fax: (507)266-7732; E-mail:
| | - Michelle M Mielke
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David S Knopman
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - William M Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA,Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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12
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Comparative benefits and harms of individual opioids for chronic non-cancer pain: a systematic review and network meta-analysis of randomised trials. Br J Anaesth 2022; 129:394-406. [PMID: 35817616 DOI: 10.1016/j.bja.2022.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Most systematic reviews of opioids for chronic pain have pooled treatment effects across individual opioids under the assumption they provide similar benefits and harms. We examined the comparative effects of individual opioids for chronic non-cancer pain through a network meta-analysis of randomised controlled trials. METHODS We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials to March 2021 for studies that enrolled patients with chronic non-cancer pain, randomised them to receive different opioids, or opioids vs placebo, and followed them for at least 4 weeks. Certainty of evidence was evaluated using the GRADE approach. RESULTS We identified 82 eligible trials (22 619 participants) that evaluated 14 opioids. Compared with placebo, several opioids showed superiority to others for analgesia and improvement in physical function; however, when restricted to pooled-effect estimates supported by moderate certainty evidence, no differences between opioids were evident. Among opioids with moderate certainty evidence, all increased the risk of gastrointestinal adverse events compared with placebo, although no opioids were more harmful than others. Low to very low certainty evidence suggests that extended-release vs immediate-release opioids may provide similar benefits for pain relief and physical functioning, and gastrointestinal harms. CONCLUSIONS Our findings support the pooling of effect estimates across different types and formulations of opioids to inform effectiveness for chronic non-cancer pain.
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13
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Nury E, Schmucker C, Nagavci B, Motschall E, Nitschke K, Schulte E, Wegwarth O, Meerpohl JJ. Efficacy and safety of strong opioids for chronic noncancer pain and chronic low back pain: a systematic review and meta-analyses. Pain 2022; 163:610-636. [PMID: 34326292 DOI: 10.1097/j.pain.0000000000002423] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/22/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT In recent years, long-term prescribing and use of strong opioids for chronic noncancer pain (CNCP) has increased in high-income countries. Yet existing uncertainties, controversies, and differing recommendations make the rationale for prolonged opioid use in CNCP unclear. This systematic review and meta-analyses compared the efficacy, safety, and tolerability of strong opioids with placebo or nonopioid therapy in CNCP, with a special focus on chronic low back pain (CLBP). Systematic literature searches were performed in 4 electronic databases (MEDLINE, Web of Science, Cochrane Library, and CINAHL) in July 2019 and updated by regular alerts until December 2020. We included 16 placebo-controlled randomized controlled trials for CLBP and 5 studies (2 randomized controlled trials and 3 nonrandomized studies) of opioids vs nonopioids for CNCP in the quantitative and qualitative synthesis. Random effects pairwise meta-analyses were performed for efficacy, safety, and tolerability outcomes and subgroup analyses for treatment duration, study design, and opioid experience status. Very low to low certainty findings suggest that 4 to 15 weeks (short or intermediate term) opioid therapy in CLBP (compared with placebo) may cause clinically relevant reductions in pain but also more gastrointestinal and nervous system adverse events, with likely no effect on disability. By contrast, long-term opioid therapy (≥6 months) in CNCP may not be superior to nonopioids in improving pain or disability or pain-related function but seems to be associated with more adverse events, opioid abuse or dependence, and possibly an increase in all-cause mortality. Our findings also underline the importance and need for well-designed trials assessing long-term efficacy and safety of opioids for CNCP and CLBP.
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Affiliation(s)
- Edris Nury
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Blin Nagavci
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Edith Motschall
- Institute of Medical Biometry and Statistics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kai Nitschke
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erika Schulte
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Odette Wegwarth
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Max Planck Institute for Human Development, Center for Adaptive Rationality, Berlin, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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14
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Su Y, Meng X, D'Arcy C. Does Gender Moderate the Relationship Between Chronic Pain and Substance Use Disorder? Insights From a National Canadian Population Survey. Front Psychiatry 2022; 13:799655. [PMID: 35308886 PMCID: PMC8924112 DOI: 10.3389/fpsyt.2022.799655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Though it has been shown that men have a higher lifetime prevalence of substance use disorder and a lower prevalence of chronic pain than women, there is little research to date focusing on gender differences in the relationship between chronic pain and substance use disorder. This study examined whether gender moderates the relationship of chronic pain and substance use disorder. We also sought to examine the gender differences in the associations between specific pain types-arthritis, migraine, and back pain, and substance use disorder. METHODS The data were drawn from the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH 2012) with individuals aged 20 years and older living in the 10 Canadian provinces (N = 23,089). A two-level logistic mixed effects model was used to account for provincial differences. RESULTS Our findings indicated gender moderated the association between arthritis as well as migraine, and substance use disorder. However, no moderation effect of gender on the relationship between back pain and substance use disorder was found. Specifically, the strength of the association between arthritis and substance use disorder was stronger among men (ORinteraction = 0.62, 95% CI: 0.53 to 0.73), whereas the strength of the association between migraine and substance use disorder was stronger among women (ORinteraction = 1.45, 95% CI: 1.18 to 1.79). In addition, geographical location was found to explain a small proportion (2.3%-2.4%) of the overall variance in SUD. CONCLUSIONS The results suggest that gender moderated the relations between arthritis as well as migraine, and substance use disorder, respectively. Treatment programs for pain and substance misuse might benefit from an approach tailored to gender differences.
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Affiliation(s)
- Yingying Su
- School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada.,Department of Psychiatry, McGill, University and the Douglas Research Centre, Montreal, QC, Canada
| | - Xiangfei Meng
- Department of Psychiatry, McGill, University and the Douglas Research Centre, Montreal, QC, Canada
| | - Carl D'Arcy
- School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada.,Department of Psychiatry, University of Saskatchewan, Saskatoon, SK, Canada
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15
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Upadhyay J, Verrico CD, Cay M, Kodele S, Yammine L, Koob GF, Schreiber R. Neurocircuitry basis of the opioid use disorder-post-traumatic stress disorder comorbid state: conceptual analyses using a dimensional framework. Lancet Psychiatry 2022; 9:84-96. [PMID: 34774203 DOI: 10.1016/s2215-0366(21)00008-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/11/2020] [Accepted: 01/06/2021] [Indexed: 12/17/2022]
Abstract
Understanding the interface between opioid use disorder (OUD) and post-traumatic stress disorder (PTSD) is challenging. By use of a dimensional framework, such as research domain criteria, convergent and targetable neurobiological processes in OUD-PTSD comorbidity can be identified. We hypothesise that, in OUD-PTSD, circuitry that is implicated in two research domain criteria systems (ie, negative valence and cognitive control) underpins dysregulation of incentive salience, negative emotionality, and executive function. We also propose that the OUD-PTSD state might be systematically investigated with approaches outlined within a neuroclinical assessment framework for addictions and PTSD. Our dimensional analysis of the OUD-PTSD state shows how first-line therapeutic approaches (ie, partial μ-type opioid receptor [MOR1] agonism) modulate overlapping neurobiological and clinical features and also provides mechanistic rationale for evaluating polytherapeutic strategies (ie, partial MOR1 agonism, κ-type opioid receptor [KOR1] antagonism, and α-2A adrenergic receptor [ADRA2A] agonism). A combination of these therapeutic mechanisms is projected to facilitate recovery in patients with OUD-PTSD by mitigating negative valence states and enhancing executive control.
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Affiliation(s)
- Jaymin Upadhyay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA, USA.
| | - Christopher D Verrico
- Department of Psychiatry and Behavioral Sciences and Department of Pharmacology, Baylor College of Medicine, Houston, TX, USA
| | - Mariesa Cay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA, USA
| | - Sanda Kodele
- Faculty of Psychology and Neuroscience, Section Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, Netherlands
| | - Luba Yammine
- Louis A Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - George F Koob
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Rudy Schreiber
- Faculty of Psychology and Neuroscience, Section Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, Netherlands
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16
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Martucci KT, Weber KA, Mackey SC. Spinal Cord Resting State Activity in Individuals With Fibromyalgia Who Take Opioids. Front Neurol 2021; 12:694271. [PMID: 34421798 PMCID: PMC8371264 DOI: 10.3389/fneur.2021.694271] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/28/2021] [Indexed: 11/24/2022] Open
Abstract
Chronic pain coincides with myriad functional alterations throughout the brain and spinal cord. While spinal cord mechanisms of chronic pain have been extensively characterized in animal models and in vitro, to date, research in patients with chronic pain has focused only very minimally on the spinal cord. Previously, spinal cord functional magnetic resonance imaging (fMRI) identified regional alterations in spinal cord activity in patients (who were not taking opioids) with fibromyalgia, a chronic pain condition. Here, in patients with fibromyalgia who take opioids (N = 15), we compared spinal cord resting-state fMRI data vs. patients with fibromyalgia not taking opioids (N = 15) and healthy controls (N = 14). We hypothesized that the opioid (vs. non-opioid) patient group would show greater regional alterations in spinal cord activity (i.e., the amplitude of low frequency fluctuations or ALFF, a measure of regional spinal cord activity). However, we found that regional spinal cord activity in the opioid group was more similar to healthy controls, while regional spinal cord activity in the non-opioid group showed more pronounced differences (i.e., ventral increases and dorsal decreases in regional ALFF) vs. healthy controls. Across patient groups, self-reported fatigue correlated with regional differences in spinal cord activity. Additionally, spinal cord functional connectivity and graph metrics did not differ among groups. Our findings suggest that, contrary to our main hypothesis, patients with fibromyalgia who take opioids do not have greater alterations in regional spinal cord activity. Thus, regional spinal cord activity may be less imbalanced in patients taking opioids compared to patients not taking opioids.
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Affiliation(s)
- Katherine T. Martucci
- Human Affect and Pain Neuroscience Laboratory, Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Kenneth A. Weber
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, United States
| | - Sean C. Mackey
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, United States
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17
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Merhar SL, Kline JE, Braimah A, Kline-Fath BM, Tkach JA, Altaye M, He L, Parikh NA. Prenatal opioid exposure is associated with smaller brain volumes in multiple regions. Pediatr Res 2021; 90:397-402. [PMID: 33177677 PMCID: PMC8110593 DOI: 10.1038/s41390-020-01265-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/14/2020] [Accepted: 10/23/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND The impact of prenatal opioid exposure on brain development remains poorly understood. METHODS We conducted a prospective study of term-born infants with and without prenatal opioid exposure. Structural brain MRI was performed between 40 and 48 weeks postmenstrual age. T2-weighted images were processed using the Developing Human Connectome Project structural pipeline. We compared 63 relative regional brain volumes between groups. RESULTS Twenty-nine infants with prenatal opioid exposure and 42 unexposed controls were included. The groups had similar demographics, except exposed infants had lower birth weights, more maternal smoking and maternal Hepatitis C, fewer mothers with a college degree, and were more likely non-Hispanic White. After controlling for sex, postmenstrual age at scan, birth weight, and maternal education, exposed infants had significantly smaller relative volumes of the deep gray matter, bilateral thalamic ventrolateral nuclei, bilateral insular white matter, bilateral subthalamic nuclei, brainstem, and cerebrospinal fluid. Exposed infants had larger relative volumes of the right cingulate gyrus white matter and left occipital lobe white matter. CONCLUSIONS Infants with prenatal opioid exposure had smaller brain volumes in multiple regions compared to controls, with two regions larger in the opioid-exposed group. Further research should focus on the relative contributions of maternal opioids and other exposures. IMPACT Prenatal opioid exposure is associated with developmental and behavioral consequences, but the direct effects of opioids on the developing human brain are poorly understood. Prior small studies using MRI have shown smaller regional brain volumes in opioid-exposed infants and children. After controlling for covariates, infants with prenatal opioid exposure scanned at 40-48 weeks postmenstrual age had smaller brain volumes in multiple regions compared to controls, with two regions larger in the opioid-exposed group. This adds to the literature showing potential impact of prenatal opioid exposure on the developing brain.
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Affiliation(s)
- Stephanie L Merhar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
| | - Julia E Kline
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Adebayo Braimah
- Imaging Research Center, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Mekibib Altaye
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Lili He
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Nehal A Parikh
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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18
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Martel MO, Bruneau A, Edwards RR. Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities. Transl Res 2021; 234:114-128. [PMID: 33676035 DOI: 10.1016/j.trsl.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 12/27/2022]
Abstract
Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.
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Affiliation(s)
- Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Montreal, Canada; Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Alice Bruneau
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Robert R Edwards
- Department of Anesthesiology & Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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19
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Khera T, Rangasamy V. Cognition and Pain: A Review. Front Psychol 2021; 12:673962. [PMID: 34093370 PMCID: PMC8175647 DOI: 10.3389/fpsyg.2021.673962] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/26/2021] [Indexed: 01/14/2023] Open
Abstract
Cognition is defined as the brain's ability to acquire, process, store, and retrieve information. Pain has been described as an unpleasant sensory or emotional experience, and for experiencing pain consciously, cognitive processing becomes imperative. Moreover, evaluation of pain strongly depends on cognition as it requires learning and recall of previous experiences. There could be a possible close link between neural systems involved in cognition and pain processing, and studies have reported an association between pain and cognitive impairment. In this narrative review, we explore the available evidence that has investigated cognitive changes associated with pain. We also examine the anatomical, biochemical, and molecular association of pain and neuro-cognition. Additionally, we focus on the cognitive impairment caused by analgesic medications. There is a need to improve our understanding of pathophysiology and cognitive impairment mechanisms associated with chronic pain and its treatment. This area provides a diverse opportunity for grounding future research, aiding institution of timely interventions to prevent chronic pain and associated cognitive decline, ultimately improving patient care.
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Affiliation(s)
- Tanvi Khera
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Valluvan Rangasamy
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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20
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Mill RD, Winfield EC, Cole MW, Ray S. Structural MRI and functional connectivity features predict current clinical status and persistence behavior in prescription opioid users. NEUROIMAGE-CLINICAL 2021; 30:102663. [PMID: 33866300 PMCID: PMC8060550 DOI: 10.1016/j.nicl.2021.102663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/24/2021] [Accepted: 04/02/2021] [Indexed: 01/10/2023]
Abstract
Prescription opioid use disorder (POUD) has reached epidemic proportions in the United States, raising an urgent need for diagnostic biological tools that can improve predictions of disease characteristics. The use of neuroimaging methods to develop such biomarkers have yielded promising results when applied to neurodegenerative and psychiatric disorders, yet have not been extended to prescription opioid addiction. With this long-term goal in mind, we conducted a preliminary study in this understudied clinical group. Univariate and multivariate approaches to distinguishing between POUD (n = 26) and healthy controls (n = 21) were investigated, on the basis of structural MRI (sMRI) and resting-state functional connectivity (restFC) features. Univariate approaches revealed reduced structural integrity in the subcortical extent of a previously reported addiction-related network in POUD subjects. No reliable univariate between-group differences in cortical structure or edgewise restFC were observed. Contrasting these mixed univariate results, multivariate machine learning classification approaches recovered more statistically reliable group differences, especially when sMRI and restFC features were combined in a multi-modal model (classification accuracy = 66.7%, p < .001). The same multivariate multi-modal approach also yielded reliable prediction of individual differences in a clinically relevant behavioral measure (persistence behavior; predicted-to-actual overlap r = 0.42, p = .009). Our findings suggest that sMRI and restFC measures can be used to reliably distinguish the neural effects of long-term opioid use, and that this endeavor numerically benefits from multivariate predictive approaches and multi-modal feature sets. This can serve as theoretical proof-of-concept for future longitudinal modeling of prognostic POUD characteristics from neuroimaging features, which would have clearer clinical utility.
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Affiliation(s)
- Ravi D Mill
- Center for Molecular and Behavioral Neuroscience, Rutgers University, Newark, NJ 07102, USA
| | - Emily C Winfield
- Center for Molecular and Behavioral Neuroscience, Rutgers University, Newark, NJ 07102, USA
| | - Michael W Cole
- Center for Molecular and Behavioral Neuroscience, Rutgers University, Newark, NJ 07102, USA
| | - Suchismita Ray
- Department of Health Informatics, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ 07103, USA.
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Examining opioid prescribing trends for non-cancer pain using an estimated oral morphine equivalence measure: a retrospective cohort study between 2005 and 2015. BJGP Open 2020; 5:bjgpopen20X101122. [PMID: 33172848 PMCID: PMC7960521 DOI: 10.3399/bjgpopen20x101122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice. Aim To use an estimated oral morphine equivalent (OMEQe) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status. Design & setting A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank. Method An OMEQe measure was developed and used to describe trends in opioid burden over the study period. OMEQe burden was stratified by eight drug groups, which was based on usage and deprivation. Results An estimated 643 436 843 milligrams (mg) OMEQe was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQe per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQe prescribed than the least deprived over the study period. Conclusion Over the study period, OMEQe burden nearly doubled, with disproportionate OMEQe prescribed in the most deprived communities. Using OMEQe provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.
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Meyer E, Morawa E, Nacak Y, Rösch J, Doerfler A, Forster C, Erim Y. Insular Cortical Thickness in Patients With Somatoform Pain Disorder: Are There Associations With Symptom Severity and Childhood Trauma? Front Psychiatry 2020; 11:497100. [PMID: 33132923 PMCID: PMC7513830 DOI: 10.3389/fpsyt.2020.497100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 08/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies show significant alterations in insular cortical thickness in patients with somatoform pain disorder (SPD). Additionally, associations between childhood maltreatment and morphometric alterations in insular cortex have been observed. Since patients with SPD often report about adverse childhood experiences, we were interested in the interrelationship of exposure to childhood maltreatment and insular cortical thickness in patients with SPD. METHODS Fifteen adult patients with SPD (ICD-10 F 45.40/41, DSM-Code 307.80) and thirteen healthy adult controls underwent T1-weighted MR brain imaging. In the voxel-based morphometry (VBM) analysis we compared whole brain cortical thickness between patients and controls using a Student's two-sampled t-test (p < .05). Then we performed a secondary analysis to detect differences in cortical thickness levels in the insular cortex between both groups. For further analysis of differences in insular cortical thickness we used gender, age, depressive symptoms [Patient Health Questionnaire (PHQ)-9], and whole brain cortical thickness as nuisance covariates. Subsequently we explored associations between insular cortical thickness, symptom severity (PHQ-15) and past experiences of childhood maltreatment (CTQ) in both groups. RESULTS Patients showed reduced insular cortical thickness in a subregion of right Brodmann area (BA) 13 (anterior part of the insular cortex), whereas whole brain cortical thickness did not differ between groups. The between-group difference in the identified insular subregion of right BA 13 was not diminished by any of the covariates. This implies that the reduction in cortical thickness in the identified insular subregion might be due to a specific group effect. The effect sizes indicate that the group of patients experienced more childhood maltreatment than the control group. Nonetheless, significant correlations of insular cortical thickness with symptom severity and childhood maltreatment in the total collective could not be demonstrated for the group of patients. CONCLUSIONS Our data suggest that alterations in the identified insular subregion of right BA 13 are associated with somatoform pain, independent of gender, age, or coincident depression levels. To identify significant associations of insular cortical thickness and experiences of childhood maltreatment in patients with SPD investigations within larger samples are highly recommended.
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Affiliation(s)
- Elisabeth Meyer
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Eva Morawa
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Yeliz Nacak
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Julie Rösch
- Department of Neuroradiology, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Clemens Forster
- Institute of Physiology and Pathophysiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Yesim Erim
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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MacMillan KDL. Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes. Clin Perinatol 2019; 46:817-832. [PMID: 31653310 DOI: 10.1016/j.clp.2019.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of neonatal abstinence syndrome owing to prenatal opioid exposure has grown rapidly in recent decades and it disproportionately affects rural, non-white, and public insurance-dependent populations. Treatment consists of pharmacologic and nonpharmacologic interventions with wide variability in approaches across the United States. Standardizing clinical assessment, minimizing unnecessary interruptions, and prioritizing nonpharmacologic and family-centered care seems to improve hospital outcomes. Neonatal abstinence syndrome may have long-term developmental and biological effects, but understanding is limited owing in part confounding biosocial factors. Early intervention and longitudinal support of the infant and family promote better outcomes.
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Affiliation(s)
- Kathryn Dee Lizcano MacMillan
- Division of Neonatology and Newborn Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA; Division of Pediatric Hospital Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA.
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Caritis SN, Panigrahy A. Opioids affect the fetal brain: reframing the detoxification debate. Am J Obstet Gynecol 2019; 221:602-608. [PMID: 31323217 DOI: 10.1016/j.ajog.2019.07.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/26/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
Abstract
Medication-assisted treatment is recommended for individuals with an opioid use disorder, including pregnant women. Medication-assisted treatment during pregnancy provides benefits to the mother and fetus, including better pregnancy outcomes, reduced illicit drug use, and improved prenatal care. An alternative approach, medically supervised withdrawal (detoxification), has, in recent reports, demonstrated a low risk of fetal death and low rates of relapse and neonatal abstinence syndrome. The rates of relapse and neonatal abstinence syndrome are questioned by many who view medically supervised withdrawal as unacceptable based on the concern for the potential adverse consequences of relapse to mother and baby. The impact of opioids on the fetal brain have not been integrated into this debate. Studies in animals and human brain tissues demonstrate opioid receptors in neurons, astroglia, and oligodendrocytes. Age-specific normative data from infants, children, and adults have facilitated investigation of the impact of opioids on the human brain in vivo. Collectively, these studies in animals, human neural tissue, adult brains, and the brains of children and newborns demonstrate that opioids adversely affect the human brain, primarily the developing oligodendrocyte and the processes of myelinization (white matter microstructure), connectivity between parts of the brain, and the size of multiple brain regions, including the basal ganglia, thalamus, and cerebellar white matter. These in vivo studies across the human lifespan suggest vulnerability of specific fronto-temporal-limbic and frontal-subcortical (basal ganglia and cerebellum) pathways that are also likely vulnerable in the human fetal brain. The long-term impact of these reproducible changes in the fetal brain in vivo is unclear, but the possibility of lasting injury has been suggested. In light of the recent data on medically supervised withdrawal and the emerging evidence suggesting adverse effects of opioids on the developing fetal brain, a new paradigm of care is needed that includes the preferred option of medication-assisted treatment but also the option of medically supervised opioid withdrawal for a select group of women. Both these treatment options should offer mental health and social services support throughout pregnancy. More research on both opioid exposure on the developing human brain and the impact of medically supervised withdrawal is required to identify appropriate candidates, optimal dose reduction regimens, and gestational age timing for initiating medically supervised withdrawal.
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Neuroimaging of Pain: Human Evidence and Clinical Relevance of Central Nervous System Processes and Modulation. Anesthesiology 2019; 128:1241-1254. [PMID: 29494401 DOI: 10.1097/aln.0000000000002137] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neuroimaging research has demonstrated definitive involvement of the central nervous system in the development, maintenance, and experience of chronic pain. Structural and functional neuroimaging has helped elucidate central nervous system contributors to chronic pain in humans. Neuroimaging of pain has provided a tool for increasing our understanding of how pharmacologic and psychologic therapies improve chronic pain. To date, findings from neuroimaging pain research have benefitted clinical practice by providing clinicians with an educational framework to discuss the biopsychosocial nature of pain with patients. Future advances in neuroimaging-based therapeutics (e.g., transcranial magnetic stimulation, real-time functional magnetic resonance imaging neurofeedback) may provide additional benefits for clinical practice. In the future, with standardization and validation, brain imaging could provide objective biomarkers of chronic pain, and guide treatment for personalized pain management. Similarly, brain-based biomarkers may provide an additional predictor of perioperative prognoses.
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Martucci KT, MacNiven KH, Borg N, Knutson B, Mackey SC. Apparent Effects of Opioid Use on Neural Responses to Reward in Chronic Pain. Sci Rep 2019; 9:9633. [PMID: 31270360 PMCID: PMC6610070 DOI: 10.1038/s41598-019-45961-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/17/2019] [Indexed: 11/09/2022] Open
Abstract
Neural responses to incentives are altered in chronic pain and by opioid use. To understand how opioid use modulates the neural response to reward/value in chronic pain, we compared brain functional magnetic resonance imaging (fMRI) responses to a monetary incentive delay (MID) task in patients with fibromyalgia taking opioids (N = 17), patients with fibromyalgia not taking opioids (N = 17), and healthy controls (N = 15). Both groups of patients with fibromyalgia taking and not taking opioids had similar levels of pain, psychological measures, and clinical symptoms. Neural responses in the nucleus accumbens to anticipated reward and non-loss outcomes did not differ from healthy controls in either fibromyalgia group. However, neural responses in the medial prefrontal cortex differed, such that patients with fibromyalgia not taking opioids demonstrated significantly altered responses to anticipated rewards and non-loss outcomes compared to healthy controls, but patients with fibromyalgia taking opioids did not. Despite limitations including the use of additional non-opioid medications by fibromyalgia patients taking opioids, these preliminary findings suggest relatively "normalized" neural responses to monetary incentives in chronic pain patients who take opioids versus those who do not.
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Affiliation(s)
- Katherine T Martucci
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University School of Medicine, Stanford, California, USA.
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kelly H MacNiven
- Department of Psychology, Symbiotic Project on Affective Neuroscience Laboratory, Stanford University, Stanford, California, USA
| | - Nicholas Borg
- Department of Psychology, Symbiotic Project on Affective Neuroscience Laboratory, Stanford University, Stanford, California, USA
| | - Brian Knutson
- Department of Psychology, Symbiotic Project on Affective Neuroscience Laboratory, Stanford University, Stanford, California, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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Smallwood RF, Price LR, Campbell JL, Garrett AS, Atalla SW, Monroe TB, Aytur SA, Potter JS, Robin DA. Network Alterations in Comorbid Chronic Pain and Opioid Addiction: An Exploratory Approach. Front Hum Neurosci 2019; 13:174. [PMID: 31191279 PMCID: PMC6548857 DOI: 10.3389/fnhum.2019.00174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/13/2019] [Indexed: 12/17/2022] Open
Abstract
The comorbidity of chronic pain and opioid addiction is a serious problem that has been growing with the practice of prescribing opioids for chronic pain. Neuroimaging research has shown that chronic pain and opioid dependence both affect brain structure and function, but this is the first study to evaluate the neurophysiological alterations in patients with comorbid chronic pain and addiction. Eighteen participants with chronic low back pain and opioid addiction were compared with eighteen age- and sex-matched healthy individuals in a pain-induction fMRI task. Unified structural equation modeling (SEM) with Lagrange multiplier (LM) testing yielded a network model of pain processing for patient and control groups based on 19 a priori defined regions. Tests of differences between groups on specific regression parameters were determined on a path-by-path basis using z-tests corrected for the number of comparisons. Patients with the chronic pain and addiction comorbidity had increased connection strengths; many of these connections were interhemispheric and spanned regions involved in sensory, affective, and cognitive processes. The affected regions included those that are commonly altered in chronic pain or addiction alone, indicating that this comorbidity manifests with neurological symptoms of both disorders. Understanding the neural mechanisms involved in the comorbidity is crucial to finding a comprehensive treatment, rather than treating the symptoms individually.
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Affiliation(s)
- Rachel F Smallwood
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Larry R Price
- Metholology, Measurement and Statistical Analysis, Texas State University, San Marcos, TX, United States
| | - Jenna L Campbell
- Department of Communication Sciences and Disorders, University of New Hampshire, Durham, NH, United States
| | - Amy S Garrett
- Department of Psychiatry, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - Sebastian W Atalla
- College of Nursing, The Ohio State University, Columbus, OH, United States
| | - Todd B Monroe
- College of Nursing, The Ohio State University, Columbus, OH, United States
| | - Semra A Aytur
- Department of Health Management and Policy, University of New Hampshire, Durham, NH, United States
| | - Jennifer S Potter
- Department of Psychiatry, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - Donald A Robin
- Department of Communication Sciences and Disorders, University of New Hampshire, Durham, NH, United States.,Interdisciplinary Program in Neuroscience and Behavior, University of New Hampshire, Durham, NH, United States
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Iriah SC, Trivedi M, Kenkel W, Grant SE, Moore K, Yee JR, Madularu D, Kulkarni P, Ferris CF. Oxycodone Exposure: A Magnetic Resonance Imaging Study in Response to Acute and Chronic Oxycodone Treatment in Rats. Neuroscience 2018; 398:88-101. [PMID: 30550747 DOI: 10.1016/j.neuroscience.2018.11.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 11/16/2022]
Abstract
The present study was designed to use blood-oxygen-level dependent (BOLD) imaging to "fingerprint" the change in activity in response to oxycodone (OXY) in drug naïve rats before and after repeated exposure to OXY. It was hypothesized that repeated exposure to OXY would initiate adaptive changes in brain organization that would be reflected in an altered response to opioid exposure. Male rats exposed to OXY repeatedly showed conditioned place preference, evidence of drug-seeking behavior and putative neuroadaptation. As these studies were done on awake rats we discovered it was not possible to image rats continuously exposed to OXY due to motion artifact judged to be withdrawal while in the scanner. To circumvent this problem manganese-enhanced MRI (MEMRI) was used to map the distributed integrated activity pattern resulting from continuous OXY exposure. Rats were administered OXY (2.5 mg/kg, i.p.) during image acquisition and changes in BOLD signal intensity were recorded and the activation and deactivation of integrated neural circuits involved in olfaction and motivation were identified. Interestingly, the circuitry of the mesencephalic dopaminergic system showed little activity to the first exposure of OXY. In the MEMRI study, rats received OXY treatments (2.5 mg/kg, twice daily) for four consecutive days following intraventricular MnCl2. Under isoflurane anesthesia, T1-weighted images were acquired and subsequently analyzed showing activity in the forebrain limbic system, ventral striatum, accumbens, amygdala and hippocampus. These results show brain activity is markedly different when OXY is presented to drug naïve rats versus rats with prior, repeated exposure to drug.
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Affiliation(s)
- Sade C Iriah
- Northeastern Univ., Center for Translational NeuroImaging, Boston, MA, USA
| | - Malav Trivedi
- NOVA Southeastern University, Ft. Lauderdale, FL, USA
| | - William Kenkel
- The Kinsey Institute, Indiana University, Bloomington, IN, USA
| | - Simone E Grant
- Northeastern Univ., Center for Translational NeuroImaging, Boston, MA, USA
| | - Kelsey Moore
- Northeastern Univ., Center for Translational NeuroImaging, Boston, MA, USA
| | - Jason R Yee
- Northeastern Univ., Center for Translational NeuroImaging, Boston, MA, USA
| | - Dan Madularu
- Northeastern Univ., Center for Translational NeuroImaging, Boston, MA, USA; Douglas Hospital, McGill University, Montreal, QC, Canada; Carleton University, Ottawa, ON, Canada
| | - Praveen Kulkarni
- Northeastern Univ., Center for Translational NeuroImaging, Boston, MA, USA
| | - Craig F Ferris
- Northeastern Univ., Center for Translational NeuroImaging, Boston, MA, USA.
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Fill MMA, Miller AM, Wilkinson RH, Warren MD, Dunn JR, Schaffner W, Jones TF. Educational Disabilities Among Children Born With Neonatal Abstinence Syndrome. Pediatrics 2018; 142:e20180562. [PMID: 30166364 PMCID: PMC6947655 DOI: 10.1542/peds.2018-0562] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that can occur after intrauterine opioid exposure. Adverse neurobehavioral outcomes have been documented in infants with NAS; however, educational outcomes have not been thoroughly examined. We analyzed Tennessee data to understand the need for special educational services among infants who are born with NAS. METHODS By using Tennessee Medicaid and birth certificate data, infants who were born in Tennessee between 2008 and 2011 with a history of NAS were matched (1:3) to infants who were born during the same period without a history of NAS. Groups were matched on the basis of sex, race and/or ethnicity, age, birth region of residence, and Medicaid enrollment status. Data were linked to Tennessee Department of Education special education data during early childhood (3-8 years of age). Conditional multivariable logistic regression was used to assess associations between NAS and selected special education outcomes. RESULTS A total of 1815 children with a history of NAS and 5441 children without NAS were assessed. Children with NAS were significantly more likely to be referred for a disability evaluation (351 of 1815 [19.3%] vs 745 of 5441 [13.7%]; P < .0001), to meet criteria for a disability (284 of 1815 [15.6%] vs 634 of 5441 [11.7%]; P < .0001), and to require classroom therapies or services (278 of 1815 [15.3%] vs 620 of 5441 [11.4%]; P < .0001). These findings were sustained in a multivariable analysis, with multiple models controlling for maternal tobacco use, maternal education status, birth weight, gestational age, and/or NICU admission. CONCLUSIONS Results of this novel analysis linking health and education data revealed that children with a history of NAS were significantly more likely to have a subsequent educational disability.
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Affiliation(s)
- Mary-Margaret A Fill
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia;
- Tennessee Department of Health, Nashville, Tennessee
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | | | | | | | - John R Dunn
- Tennessee Department of Health, Nashville, Tennessee
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - William Schaffner
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Timothy F Jones
- Tennessee Department of Health, Nashville, Tennessee
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
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Ignatowski TA, Spengler RN. Targeting tumor necrosis factor in the brain relieves neuropathic pain. World J Anesthesiol 2018; 7:10-19. [DOI: 10.5313/wja.v7.i2.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/28/2018] [Accepted: 06/02/2018] [Indexed: 02/06/2023] Open
Abstract
Neuropathic pain is a chronic syndrome caused by direct damage to or disease of the somatosensory nervous system. The lack of safe, adequate and sustained pain relief offered by present analgesic treatments is most alarming. While many treatment options are available to manage chronic pain, such as antidepressants, non-steroidal anti-inflammatory agents, opioids, and anticonvulsants, chronic neuropathic pain remains largely unmanaged. Compounding the dilemma of ineffective chronic pain treatments is the need to provide relief from suffering and yet not contribute to the scourge of drug abuse. A recent epidemic of addiction and accidental drug prescription overdoses parallel the increased use of opioid treatment, even though opioids are rarely an effective treatment of relieving chronic pain. To make matters worse, opioids may contribute to exacerbating pain, and side-effects such as cognitive impairment, nausea, constipation, development of tolerance, as well as their potential for addiction and overdose deaths exist. Clearly, there is an urgent need for alternative, non-opiate treatment of chronic pain. Innovative discoveries of pertinent brain mechanisms and functions are key to developing effective, safe treatments. Pioneering work has revealed the essential effects of the pleiotropic mediator tumor necrosis factor (TNF) on brain functioning. These studies establish that TNF inhibits norepinephrine release from hippocampal neurons, and show that excess TNF production within the hippocampus occurs during neuropathic pain, which mobilizes additional mechanisms that further inhibit norepinephrine release. Significantly, it has been verified that elevated levels of TNF in the brain are actually required for neuropathic pain development. Since TNF decreases norepinephrine release in the brain, enhanced TNF levels would prevent engagement of the norepinephrine descending inhibitory neuronal pain pathways. Increased levels of TNF in the brain are therefore critical to the development of neuropathic pain. Therefore, strategies that decrease this enhanced TNF expression in the brain will have superior analgesic efficacy. We propose this novel approach of targeting the pathologically high levels of brain TNF as an effective strategy in the treatment of the devastating syndrome of chronic pain.
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Affiliation(s)
- Tracey A Ignatowski
- Department of Pathology and Anatomical Sciences and Program for Neuroscience, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY 14203, United States
- NanoAxis, LLC, Clarence, NY 14031, United States
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Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Schwerdtle T, Vollmer G, Wallace H, Benford D, Calò G, Dahan A, Dusemund B, Mulder P, Németh-Zámboriné É, Arcella D, Baert K, Cascio C, Levorato S, Schutte M, Vleminckx C. Update of the Scientific Opinion on opium alkaloids in poppy seeds. EFSA J 2018; 16:e05243. [PMID: 32625895 PMCID: PMC7009406 DOI: 10.2903/j.efsa.2018.5243] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.
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Abstract
This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and CUNY Neuroscience Collaborative, Queens College, City University of New York, Flushing, NY 11367, United States.
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Anesthesia, brain changes, and behavior: Insights from neural systems biology. Prog Neurobiol 2017; 153:121-160. [PMID: 28189740 DOI: 10.1016/j.pneurobio.2017.01.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 01/19/2017] [Accepted: 01/22/2017] [Indexed: 02/08/2023]
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Brain morphology in school-aged children with prenatal opioid exposure: A structural MRI study. Early Hum Dev 2017; 106-107:33-39. [PMID: 28187337 DOI: 10.1016/j.earlhumdev.2017.01.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 01/27/2017] [Accepted: 01/30/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Both animal and human studies have suggested that prenatal opioid exposure may be detrimental to the developing fetal brain. However, results are somewhat conflicting. Structural brain changes in children with prenatal opioid exposure have been reported in a few studies, and such changes may contribute to neuropsychological impairments observed in exposed children. AIM To investigate the association between prenatal opioid exposure and brain morphology in school-aged children. STUDY DESIGN A cross-sectional magnetic resonance imaging (MRI) study of prenatally opioid-exposed children and matched controls. SUBJECTS A hospital-based sample (n=16) of children aged 10-14years with prenatal exposure to opioids and 1:1 sex- and age-matched unexposed controls. OUTCOME MEASURES Automated brain volume measures obtained from T1-weighted MRI scans using FreeSurfer. RESULTS Volumes of the basal ganglia, thalamus, and cerebellar white matter were reduced in the opioid-exposed group, whereas there were no statistically significant differences in global brain measures (total brain, cerebral cortex, and cerebral white matter volumes). CONCLUSIONS In line with the limited findings reported in the literature to date, our study showed an association between prenatal opioid exposure and reduced regional brain volumes. Adverse effects of opioids on the developing fetal brain may explain this association. However, further research is needed to explore the causal nature and functional consequences of these findings.
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