A comparison of the antinociceptive effects of imipramine, tramadol and anpirtoline

Tricyclic Antidepressants in Nociceptive and Neuropathic Pain: A Review of Their Analgesic Properties in Combination With Opioids

Objectives: To determine the efficacy and safety of commonly prescribed tricyclic antidepressants (TCAs) as analgesics for nociceptive and neuropathic pain in combination with opioids. Data Sources: A comprehensive literature review was conducted with the assistance of a medical reference librarian on PubMed, MEDLINE, Scopus, and Web of Science using the following search terminology: "Amitriptyline" OR "Doxepin" OR "Desipramine" OR "Imipramine" OR "Nortriptyline" OR "Clomipramine" OR "Trimipramine" AND "Analgesia." Reports of adult patients who received any TCA as an adjunctive analgesic to opioids were included. Study Selection and Data Extraction: A total of 293 results were obtained from the initial database inquiries, following which exclusion criteria were applied and 6 articles were included in this review. Three of the reports detailed the use of TCAs in the perioperative setting, whereas the remaining 3 evaluated their effect on different etiologies of neuropathic pain. Data Synthesis: Tricyclic antidepressants were found to have modest, yet not insignificant, independent analgesic properties, although the ability to provide pain relief was relegated to a select few agents. Desipramine has the most data available for use in nociceptive, postoperative pain through its ability to potentiate and prolong the analgesic effects of opioids and was not associated with adverse drug effects. Conclusions: The efficacy of TCAs for neuropathic pain was not corroborated by this review, and the anticholinergic adverse effects associated with this drug class were found to be significant. Further research is needed to quantify the efficacy of TCAs in the management of nociceptive pain.

Effect of single-dose imipramine on chronic low-back and experimental pain. A randomized controlled trial

Antidepressants are frequently prescribed as co-analgesics in chronic pain. While their efficacy is well documented for neuropathic pain, the evidence is less clear in musculoskeletal pain conditions. The present study therefore evaluated the effect of the tricyclic antidepressant imipramine on chronic low-back pain in a randomized, double-blinded placebo-controlled design. To explore the mechanisms of action and the influence of drug metabolism, multimodal quantitative sensory tests (QST) and genotyping for cytochrome P450 2D6 (CYP2D6) were additionally performed. A single oral dose of imipramine 75 mg was compared to active placebo (tolterodine 1 mg) in 50 patients (32 females) with chronic non-specific low-back pain. Intensity of low-back pain was assessed on a 0–10 numeric rating scale at baseline and every 30 minutes after drug intake. Multimodal QST were performed at baseline and in hourly intervals for 2 hours. Pharmacogenetic influences of cytochrome P450 were addressed by CYP2D6 genotyping. No significant analgesic effect was detected neither on low-back pain nor on any of the sensory tests in the overall analyses. However, evidence for an interaction of the imipramine effect and CYP2D6 genotype was found for electrical and for pressure pain detection thresholds. Intermediate but not extensive metabolizers had a 1.20 times greater electrical pain threshold (95%-CI 1.10 to 1.31) and a 1.10 times greater pressure pain threshold (95%-CI 1.01 to 1.21) 60 minutes after imipramine than after placebo (p<0.001 and p = 0.034, respectively). The present study failed to demonstrate an immediate analgesic effect of imipramine on low-back pain. Anti-nociceptive effects as assessed by quantitative sensory tests may depend on CYP2D6 genotype, indicating that metabolizer status should be accounted for when future studies with tricyclic antidepressants are undertaken.

Serotonergic targets for the treatment of L-DOPA-induced dyskinesia

Dopamine (DA) replacement therapy with L-3,4-dihydroxyphenylalanine (L-DOPA) continues to be the gold-standard treatment for Parkinson's disease (PD). Despite clear symptomatic benefit, long-term L-DOPA use often results in the development of L-DOPA-induced dyskinesia (LID), significantly reducing quality of life and increasing costs for PD patients and their caregivers. Accumulated research has demonstrated that several pre- and post-synaptic mechanisms contribute to LID development and expression. In particular, raphe-striatal hyperinnervation and unregulated DA release from 5-HT terminals is postulated to play a central role in LID manifestation. As such, manipulation of the 5-HT system has garnered considerable attention. Both pre-clinical and clinical research has supported the potential of modulating the 5-HT system for LID prevention and treatment. This review discusses the rationale for continued investigation of several potential anti-dyskinetic strategies including 5-HT stimulation of 5-HT1A and 5-HT1B receptors and blockade of 5-HT2A receptors and SERT. We present the latest findings from experimental and clinical investigations evaluating these 5-HT targets with the goal of identifying those with translational promise and the challenges associated with each.

Electroencephalography and analgesics

To assess centrally mediated analgesic mechanisms in clinical trials with pain patients, objective standardized methods such as electroencephalography (EEG) has many advantages. The aim of this review is to provide the reader with an overview of present findings in analgesics assessed with spontaneous EEG and evoked brain potentials (EPs) in humans. Furthermore, EEG methodologies will be discussed with respect to translation from animals to humans and future perspectives in predicting analgesic efficacy. We searched PubMed with MeSH terms 'analgesics', 'electroencephalography' and 'evoked potentials' for relevant articles. Combined with a search in their reference lists 15 articles on spontaneous EEG and 55 papers on EPs were identified. Overall, opioids produced increased activity in the delta band in the spontaneous EEG, but increases in higher frequency bands were also seen. The EP amplitudes decreased in the majority of studies. Anticonvulsants used as analgesics showed inconsistent results. The N-methyl-D-aspartate receptor antagonist ketamine showed an increase in the theta band in spontaneous EEG and decreases in EP amplitudes. Tricyclic antidepressants increased the activity in the delta, theta and beta bands in the spontaneous EEG while EPs were inconsistently affected. Weak analgesics were mainly investigated with EPs and a decrease in amplitudes was generally observed. This review reveals that both spontaneous EEG and EPs are widely used as biomarkers for analgesic drug effects. Methodological differences are common and a more uniform approach will further enhance the value of such biomarkers for drug development and prediction of treatment response in individual patients.

Pharmacokinetics of tramadol following intravenous and oral administration in male rhesus macaques (Macaca mulatta)

Recently, tramadol and its active metabolite, O-desmethyltramadol (M1), have been studied as analgesic agents in various traditional veterinary species (e.g., dogs, cats, etc.). This study explores the pharmacokinetics of tramadol and M1 after intravenous (IV) and oral (PO) administration in rhesus macaques (Macaca mulatta), a nontraditional veterinary species. Rhesus macaques are Old World monkeys that are commonly used in biomedical research. Effects of tramadol administration to monkeys are unknown, and research veterinarians may avoid inclusion of this drug into pain management programs due to this limited knowledge. Four healthy, socially housed, adult male rhesus macaques (Macaca mulatta) were used in this study. Blood samples were collected prior to, and up to 10 h post-tramadol administration. Serum tramadol and M1 were analyzed using liquid chromatography-mass spectrometry. Noncompartmental pharmacokinetic analysis was performed. Tramadol clearance was 24.5 (23.4-32.7) mL/min/kg. Terminal half-life of tramadol was 111 (106-127) min IV and 133 (84.9-198) min PO. Bioavailability of tramadol was poor [3.47% (2.14-5.96%)]. Maximum serum concentration of M1 was 2.28 (1.88-2.73) ng/mL IV and 11.2 (9.37-14.9) ng/mL PO. Sedation and pruritus were observed after IV administration.

Who are Prone to Develop Adverse Effects with Oral Tramadol? a Retrospective Cohort Study

Objective

Oral tramadol is a commonly prescribed analgesic in Hong Kong. Significant adverse effects are frequently observed in our locality. Our study aims to describe the rate of significant adverse effect that warrant discontinuation of oral tramadol and identify the risk factors for development of adverse effect.

Design

Retrospective cohort study.

Methods

Adult patients aged greater than 18 years old admitted to the emergency medicine ward of a large-scale local hospital in Hong Kong being prescribed with oral tramadol during in-hospital stay were recruited. Significant adverse effects during the hospital stay were observed as the outcome of interest.

Results

A total of 575 subjects were recruited. 29.9% experienced significant adverse effects likely related to tramadol. Age (p=0.006; odds ratio [OR] = 1.017, 95% confidence interval [CI] = 1.005-1.029) and sex (p=0.006; OR=1.696, 95% CI= 1.166-2.465) were statistically significant predictors of adverse effects after oral tramadol.

Conclusion

Our study suggests that female and increasing age patients are significant predictors for the development of adverse effect after taking oral tramadol. Possible adverse effects should be explained to the patients careful especially the higher risk groups. (Hong Kong j. emerg.med. 2014;21:3-9)

Clinical pharmacology of analgesics assessed with human experimental pain models: bridging basic and clinical research

The medical impact of pain is such that much effort is being applied to develop novel analgesic drugs directed towards new targets and to investigate the analgesic efficacy of known drugs. Ongoing research requires cost-saving tools to translate basic science knowledge into clinically effective analgesic compounds. In this review we have re-examined the prediction of clinical analgesia by human experimental pain models as a basis for model selection in phase I studies. The overall prediction of analgesic efficacy or failure of a drug correlated well between experimental and clinical settings. However, correct model selection requires more detailed information about which model predicts a particular clinical pain condition. We hypothesized that if an analgesic drug was effective in an experimental pain model and also a specific clinical pain condition, then that model might be predictive for that particular condition and should be selected for development as an analgesic for that condition. The validity of the prediction increases with an increase in the numbers of analgesic drug classes for which this agreement was shown. From available evidence, only five clinical pain conditions were correctly predicted by seven different pain models for at least three different drugs. Most of these models combine a sensitization method. The analysis also identified several models with low impact with respect to their clinical translation. Thus, the presently identified agreements and non-agreements between analgesic effects on experimental and on clinical pain may serve as a solid basis to identify complex sets of human pain models that bridge basic science with clinical pain research.

Human experimental pain models for assessing the therapeutic efficacy of analgesic drugs

Pain models in animals have shown low predictivity for analgesic efficacy in humans, and clinical studies are often very confounded, blurring the evaluation. Human experimental pain models may therefore help to evaluate mechanisms and effect of analgesics and bridge findings from basic studies to the clinic. The present review outlines the concept and limitations of human experimental pain models and addresses analgesic efficacy in healthy volunteers and patients. Experimental models to evoke pain and hyperalgesia are available for most tissues. In healthy volunteers, the effect of acetaminophen is difficult to detect unless neurophysiological methods are used, whereas the effect of nonsteroidal anti-inflammatory drugs could be detected in most models. Anticonvulsants and antidepressants are sensitive in several models, particularly in models inducing hyperalgesia. For opioids, tonic pain with high intensity is attenuated more than short-lasting pain and nonpainful sensations. Fewer studies were performed in patients. In general, the sensitivity to analgesics is better in patients than in healthy volunteers, but the lower number of studies may bias the results. Experimental models have variable reliability, and validity shall be interpreted with caution. Models including deep, tonic pain and hyperalgesia are better to predict the effects of analgesics. Assessment with neurophysiologic methods and imaging is valuable as a supplement to psychophysical methods and can increase sensitivity. The models need to be designed with careful consideration of pharmacological mechanisms and pharmacokinetics of analgesics. Knowledge obtained from this review can help design experimental pain studies for new compounds entering phase I and II clinical trials.

Responses to olfactory and intranasal trigeminal stimuli: relation to the respiratory cycle

The aim of the study was to investigate whether the perception of intranasal chemosensory stimuli changes in relation to the respiratory cycle. We investigated 40 healthy subjects with normal olfactory function who participated in four sessions. The first session was used to adapt subjects to the experimental conditions, and, specifically, to train a certain breathing technique (velopharyngeal closure) which prevents intranasal respiratory air-flow. In each of the following three sessions one of three stimulants was tested, namely phenyl ethyl alcohol (PEA), hydrogen sulfide (H(2)S), or the trigeminal stimulant carbon dioxide (CO(2)). The sequence of testing the three stimulants was randomized across all participants. Sessions were separated by at least 1 day. Chemosensory event-related potentials (ERP) were recorded in response to 80 stimuli each. Following each stimulus subjects rated its intensity using a computerized visual analogue scale. Respiration was recorded using a probe in front of the subjects' mouth. While presentation of chemosensory stimuli was performed independent of the respiratory cycle, responses were averaged off-line according to the subjects' respiratory phase when the stimuli had been presented. Intensity of olfactory or trigeminal stimuli did not differ significantly in relation to the respiratory cycle. Olfactory ERP to phenylethyl alcohol were larger when stimuli were presented during inspiration. Similarly, responses to H(2)S tended to be larger when stimuli were presented during inspiratory phases. In addition, responses to CO(2) were larger when stimuli were presented during inspiration. Differences in relation to the respiratory cycle were found specifically for early ERP components. It is important to note that the changes of chemosensory information processing were found in the absence of changes of intranasal airflow. These data indicate on an electrophysiological level that there is priming of both olfactory and trigeminally mediated sensations in relation to the respiratory cycle.

Assessing efficacy of non-opioid analgesics in experimental pain models in healthy volunteers: an updated review

AIM

Experimental pain models may help to evaluate the mechanisms of analgesics and target the clinical indications for their use. This review, the second in a series of two, addresses how the efficacy of non-opioid analgesics have been assessed in human volunteers using experimental pain models.

METHODS

A literature search was completed for randomized controlled studies that included human experimental pain models, healthy volunteers and non-opioid analgesics.

RESULTS

Nonsteroidal anti-inflammatory drugs worked against various types of acute pain as well as in hyperalgesia. Analgesia from paracetamol was difficult to detect in experimental pain and the pain needed to be assessed with very sensitive methods like evoked brain potentials. The N-methyl-D-aspartate antagonists exemplified by ketamine generally needed strong, long-lasting or repeated pain in the skin for detectable analgesia, whereas pain in muscle and viscera generally was more easily attenuated. Gabapentin worked well in several models, particularly those inducing hyperalgesia, whereas lamotrigine was weak in modulation of experimental pain. Imipramine attenuated pain in most experimental models, whereas amitriptyline had weaker effects. Delta-9-tetrahydrocannabinol attenuated pain in only a few models.

CONCLUSIONS

Pain induction and assessment are very important for the sensitivity of the pain models. Generally, experimental pain models need to be designed with careful consideration of the pharmacological mechanisms and pharmacokinetics of analgesics. The drawback with the different study designs is also discussed. This knowledge can aid the decisions that need to be taken when designing experimental pain studies for compounds entering Phase I and II trials.

Assessing analgesic actions of opioids by experimental pain models in healthy volunteers - an updated review

AIM

Experimental pain models may help to evaluate the mechanisms of action of analgesics and target the clinical indications for their use. This review addresses how the efficacy of opioids can be assessed in human volunteers using experimental pain models. The drawback with the different study designs is also discussed.

METHOD

A literature search was completed for randomized controlled studies which included human experimental pain models, healthy volunteers and opioids.

RESULTS

Opioids with a strong affinity for the micro-opioid receptor decreased the sensation in a variety of experimental pain modalities, but strong tonic pain was attenuated more than short lasting pain and non-painful sensations. The effects of opioids with weaker affinity for the micro-opioid receptor were detected by a more narrow range of pain models, and the assessment methods needed to be more sensitive.

CONCLUSION

The way the pain is induced, assessed and summarized is very important for the sensitivity of the pain models. This review gives an overview of how different opioids perform in experimental pain models. Generally experimental pain models need to be designed with careful consideration of pharmacological mechanisms and pharmacokinetics of analgesics. This knowledge can aid the decisions needed to be taken when designing experimental pain studies for compounds entering phase 1 clinical trials.

FLUOXETINE ALTERS MU OPIOID RECEPTOR EXPRESSION IN OBESE ZUCKER RAT EXTRAHYPOTHALAMIC REGIONS

The aim of this article was to describe the effects of chronic fluoxetine on mu opioid receptor expression in obese Zucker rat extrahypothalamic regions. Male obese Zucker (fa/fa) rats were administered with fluoxetine (10 mg/kg; i.p.) daily for two weeks. Brain regional immunostaining for mu opioid receptor was carried out. An increase in the numbers of neural cells immunostained for mu opioid receptor in caudatus-putamen, dentate gyrus, lateral septum, amygdala, and frontal, parietal, and piriform cortices was observed. Increased mu opioid receptor expression in the central amygdaloid nuclei suggests a decreased opioidergic tone at this level that could be involved in fluoxetine anorectic action.

Interactions between olfaction and the trigeminal system: what can be learned from olfactory loss

The olfactory and the trigeminal systems have a close relationship. Most odorants also stimulate the trigeminal nerve. Further, subjects with no sense of smell exhibit a decreased trigeminal sensitivity with unclear underlying mechanisms. Previous studies indicated that single stages of trigeminal processing may differently be affected by olfactory loss. A better knowledge of adaptive and compensatory changes in the trigeminal system of subjects with acquired anosmia (AA) will improve the understanding of interactive processes between the 2 sensory systems. Thus, we aimed to assess trigeminal function on different levels of processing in subjects with AA. Subjects with AA showed larger electrophysiological responses to irritants obtained from the mucosa than healthy controls. On central levels, however, they exhibited smaller event-related potentials and psychophysical measures to irritants. Over 9 months, they exhibited an increase in trigeminal sensitivity. Subjects with recovering olfactory function showed an even more increased peripheral responsiveness to irritants. These data suggest dynamic mechanisms of mixed sensory adaptation/compensation in the interaction between the olfactory and trigeminal systems, where trigeminal activation is increased on mucosal levels in subjects with AA and amplified on central levels in subjects with a functioning olfactory system.

Effects of long-term exposure to volatile irritants on sensory thresholds, negative mucosal potentials, and event-related potentials

This study examined whether repetitive exposure to an irritant stimulant leads to desensitization and whether such modulation influences the psychological or the physiological response to that chemical. Subjects were exposed to acetic acid vapor in their home environment. Before, during, and after 3 weeks of daily exposure, the authors obtained electrophysiological recordings at peripheral and central levels in combination with psychophysical responses to acetic acid and acetone. Responses to acetic acid decreased during and following exposure. This did not generalize to the control irritant. Thresholds measured 1 year following exposure returned to baseline levels. In summary, repetitive exposure to an irritant vapor results in a specific desensitization to irritancy from that chemical, which appears to originate at a peripheral level.

Effects of anpirtoline on regional serotonin synthesis in the rat brain: an autoradiographic study

Anpirtoline has been described as an agonist at 5-HT1B receptors with a relatively high potency. It also acts as an agonist at 5-HT1A receptors, but has a lower potency than at the 5-HT1B sites. There is very little known about the mechanism by which anpirtoline influences regional 5-HT synthesis. The aim of the present study was to investigate the effects of acutely and chronically administered anpirtoline on 5-HT synthesis in the rat brain using the autoradiographic alpha-[14C]methyl-L-tryptophan method. In the acute study, anpirtoline (2.0 mg/kg) was administered intraperitoneally 30 min before the tracer injection. The control rats were injected with the same volume of saline. In the chronic study, anpirtoline (2 mg/kg per day) was injected subcutaneously in saline once a day for 10 days. There were no significant differences between the plasma-free and total tryptophan concentrations between the anpirtoline treatment and the respective control groups. In the acute experiment, 5-HT synthesis rates in all of the brain areas investigated were significantly decreased by anpirtoline when compared to the saline-treated group. In the chronic anpirtoline experiment, 5-HT synthesis rates of almost all of the projection areas, as well as the raphe nuclei, were normalized or had a tendency to be normalized. These results suggest that it is likely that the terminal 5-HT1B receptors are involved in the regulation of 5-HT synthesis in the projection areas and that 5-HT synthesis, in the raphe, is likely influenced by anpirtoline's 5-HT1A and/or 5-HT1B agonistic properties.

Gustatory stimulation influences the processing of intranasal stimuli

OBJECTIVES

Taste and smell interact. The aim of this study was to examine this interaction using gustatory and olfactory stimuli applied at the same time, which exhibited perceptual compatibility and incompatibility.

METHODS

Thirty-two, young, healthy normosmic subjects (16 men, 16 women) took part in two randomized sessions. Event-related potentials (ERP) were recorded in response to vanillin, or gaseous CO2. These two conditions were combined with three "taste conditions" including sweet taste, sour taste, and the intraoral presentation of an empty taste dispenser.

RESULTS

Vanillin responses were largest for the "sweet" condition, while they were smaller for the "sour condition". In contrast, responses to CO2 were largest under the "sour" condition, and smallest under the "sweet" condition. Moreover, during the "sweet" condition the latencies of P1 and N1 were shorter than in the "sour" condition, which was the other way around for CO2.

CONCLUSIONS

Results of the present investigation suggested that (1) the early processing of intranasal chemosensory stimuli is modulated through concomitant gustatory stimulation, and that (2) this modulation may depend, at least in part, on the contextual compatibility between intranasal and intraoral stimuli.

Sex differentiated responses to intranasal trigeminal stimuli

The aim of the study was to address sex-related hemispheric differences in trigeminal event-related potentials while controlling for the subjects' olfactory sensitivity. Event-related potentials to lateralized stimulation using the trigeminal stimulant CO(2) were recorded in 28 healthy young subjects (16 women). There was no sex-related difference in olfactory sensitivity. Results indicated a sex-differentiated response to trigeminally induced pain. Women were found to have generally higher amplitudes and shorter latencies of the late positive component than men. Moreover, men and women exhibited different hemispheric activations in that women expressed shorter latencies over the left hemisphere than men. The pronounced sex-related difference of the late positive component suggests a cognitive/emotional impact on the processing of intranasal pain as indicated by others.

The influence of stimulus duration on the reliability of pain ratings after nociceptive stimulation of the nasal mucosa with CO2

Nociceptive stimuli consisting of short pulses of gaseous CO(2) applied to the nasal mucosa were investigated in 12 healthy volunteers (six males, six females) with respect to trial-to-trial variability. A statistical rather than a psychophysical approach was employed, focusing on test-retest reliability. According to a randomized, volunteer-blind crossover design, two repeated measurements for each of four stimulus durations (200, 400, 800 and 1600 ms) were performed on eight different days. During measurements, a total of 80 stimuli of 16 concentrations of CO(2) (40-70% v/v in 2% steps) was applied with an interstimulus interval at 30 s. The interday variability of the pain ratings was lowest at a stimulus duration of 400 ms and highest at 200 ms. The results show that stimulus duration may affect the statistical outcome of studies on pain, and should be considered when setting up an experimental pain model.

Effects of the form of glasses on the perception of wine flavors: a study in untrained subjects

Many wine connoisseur claim that the glass shape has a direct impact on wine aroma. This hypothesis was investigated in healthy volunteers (85 m, 96 f; age 19-73 years); 89 subjects received red wine, 92 subjects white wine. Subjects compared three glasses with a white wine and three glasses with a red. Glasses were of different shape but of the same height and of comparable opening diameter. All glasses had elegant stems; two glasses of 'tulip' and 'beaker'-like shapes were used in sessions with red and white wines. Different bulbous glasses were used in either red or white wine sessions. Subjects were blinded whether they received one or more wines. Intensity, hedonic tone, and quality of the wines were rated repeatedly before and after drinking. Ratings of wine odors from different glasses were influenced by glass shape. Importantly, this appeared not to relate to the esthetic impression the glasses made. Thus, the present data indicate that the shape of glasses seems to influence the perception of wine odors.

Age-related decline of intranasal trigeminal sensitivity: is it a peripheral event?

Compared to younger subjects, older people have a reduced sensitivity of the intranasal trigeminal system which responds to irritation of the nasal cavity. It is unclear whether the cause of this difference relates to age-dependent changes in the periphery of the system. The aim of the present study was the comparison of intranasal trigeminal thresholds assessed through electrophysiological measurements in eight young (four women, four men; mean age 25 years) and eight older subjects (four women, four men; mean age 62 years). The negative mucosa potential (NMP), a peripheral correlate of trigeminal activation, was recorded from the nasal mucosa in response to stimulation with varying concentrations of the mixed olfactory/trigeminal stimulants menthol and linalool. Thresholds were estimated as the strongest concentration which did not elicit a NMP response. Older subjects were found to have higher thresholds for menthol when compared to younger subjects. Furthermore, an explorative analysis indicated that the increase of response amplitudes to increasing stimulus concentrations was shallower in older subjects. These findings indicate that age related loss of intranasal trigeminal sensitivity seems to take place, at least to some degree, in the periphery of the intranasal trigeminal system.

A symbolic-connectionist theory of relational inference and generalization

The authors present a theory of how relational inference and generalization can be accomplished within a cognitive architecture that is psychologically and neurally realistic. Their proposal is a form of symbolic connectionism: a connectionist system based on distributed representations of concept meanings, using temporal synchrony to bind fillers and roles into relational structures. The authors present a specific instantiation of their theory in the form of a computer simulation model, Learning and Inference with Schemas and Analogies (LISA). By using a kind of self-supervised learning, LISA can make specific inferences and form new relational generalizations and can hence acquire new schemas by induction from examples. The authors demonstrate the sufficiency of the model by using it to simulate a body of empirical phenomena concerning analogical inference and relational generalization.

Assessment of pharyngeal sensitivity to mechanical stimuli using psychophysical and electrophysiological techniques

The investigation was aimed to assess pharyngeal sensitivity by means of intensity ratings and event-related potentials (ERPs) to mechanical stimulation. Twenty healthy subjects participated (14 female, mean age 23.6 years). Both intensity ratings and ERP were obtained in response to three intensities of mechanical stimuli (air puffs) applied to the nasal cavity or the pharynx. Test-retest reliability was investigated for two sessions performed on different days. The study provided the following: (1) intensity ratings of nasal or pharyngeal stimuli increased with increasing stimulus intensity (P < 0.001); (2) they also exhibited a significant test-retest reliability (r </= 0.78) which was best for higher stimulus intensities; (3) ERP amplitudes increased and latencies shortened with increasing stimulus intensity (factor 'intensity': P < 0.013); (4) test-retest reliability was best at centro-frontal recording sites where significant correlations were found for both ERP amplitudes and latencies; (5) ERP to pharyngeal stimulation correlated significantly with perceived stimulus intensity (e.g., latency N1 at Cz: r = -0.73, P = 0.001). In conclusion, mechanical stimulation of the pharynx can be applied to reliably elicit ERPs which are related to both stimulus intensity and intensity ratings. This model may be useful in the investigation of cough-related changes in pharyngeal sensitivity.

Peripheral and central nervous changes in patients with rheumatoid arthritis in response to repetitive painful stimulation

It has been observed that patients with rheumatoid arthritis (RA) respond differently to repetitive painful stimulation. The present study investigated whether this is related to the peripheral or central nervous nociceptive system. EEG-derived potentials and the negative mucosal potential (NMP) from the respiratory epithelium were recorded in response to painful intranasal stimulation with gaseous CO(2). Differences between groups (12 RA patients, 12 controls) were found when stimuli were presented at short intervals. While the NMP did not differ between groups, patients had larger cortical responses to the first stimuli of a series of painful stimuli. This may indicate that in RA central nervous changes of nociceptive processing are present.

Assessment of intranasal trigeminal function

Intranasal trigeminal function is more and more understood as an integral part of human chemosensory perception. Sensations like burning, stinging, warmth, coolness, or itching are produced by almost all odorants so that they can be perceived by anosmics. Electrophysiological responses to trigeminal stimuli allow the specific assessment of trigeminally mediated information at different levels of processing including the periphery or the cortex. Information regarding the localization of these processes can be derived from magnetoencephalographic recordings or functional imaging data. When using these techniques in combination with psychophysical measures, it seems to be possible to specifically describe how and where the processing of irritation takes place, how it may interact with olfactory mediated sensations, and how it is modulated, e.g. by environmental influences or analgesic drugs.

Novel strategies for pharmacotherapy of depression

Modulating monoamine activity as a therapeutic strategy continues to dominate antidepressant research, with a recent emphasis on agents with multiple targets, including combined serotonin/noradrenaline re-uptake inhibitors and numerous serotonin receptor ligands. An important new development has been the emergence of potential novel mechanisms of action, notably modulation of the activity of neuropeptides substance P and corticotrophin-releasing factor, and the intracellular messenger cyclic adenosine monophosphate. Efforts in this area have recently been rewarded by the demonstration of antidepressant efficacy of the substance P receptor antagonist MK-0869.

Effects of fluoxetine administration on mu-opoid receptor immunostaining in the rat forebrain

Fluoxetine is a selective serotonin reuptake inhibitor. Analysis of mu-opioid receptor immunostaining after chronic fluoxetine administration in rats revealed an increase in the density of cells expressing mu-opioid receptors in the caudatus-putamen, the dentate gyrus, the lateral septum and the frontal, parietal and piriform cortices. These data suggest that mu-opioid receptor expression in the rat forebrain is altered by in vivo chronic fluoxetine treatment.

Olfactory function in acute rhinitis

This study was performed to investigate the effects of the common cold on olfactory function, which was assessed using chemosensory event-related potentials (CSERP, in response to both olfactory [H2S] and trigeminal [CO2] stimuli) and psychophysical measures (intensity ratings, odor discrimination, butanol threshold); nasal volume was assessed by means of acoustic rhinometry. The investigation was performed in 36 subjects (18 women, 18 men). After onset of the rhinitis (day 0) measurements were performed on days 2, 4, 6 and 35. The cold produced a decrease of the volume of the anterior nasal cavity accompanied by an increase of mucus secretion, an increase of olfactory thresholds, a decrease of intensity ratings and a decrease of N1 CSERP amplitudes to olfactory and trigeminal stimuli. When mucus secretion of the contralateral nasal cavity was controlled with oxymetazoline, N1 amplitudes to olfactory stimuli were still affected by the cold as indicated by the significant increase of amplitudes as subjects recovered; this phenomenenon was not found for responses to trigeminal stimuli. This indicates that the common cold has a small effect on olfactory function which may be independent of nasal congestion.

Imipramine inhibits soluble enkephalin-degrading aminopeptidase activity in vitro

Considerable evidence has appeared recently connecting the mechanism of action of some antidepressant drugs with the inhibition of the enzymes responsible for enkephalin degradation. Imipramine in vitro inhibits the enkephalin-degrading aminopeptidase MII and interacts with the enzyme in a mixed competitive-noncompetitive manner. The present work shows that imipramine in vitro also inhibits reversibly soluble enkephalin-degrading aminopeptidase activity in rat brain. Kinetic analysis showed that this enzyme has two different binding sites for the drug, and that imipramine interacts with the enzyme in a mixed noncompetitive-acompetitive way.

Interaction mechanisms of imipramine and desipramine with enkephalin-degrading aminopeptidases in vitro

In the last few years, considerable evidence has appeared concerning the importance of the opioid systems in the action mechanism of some antidepressant drugs. This action mechanism could be mediated through the inhibition of the enzymes responsible for enkephalin degradation. In this sense, imipramine treatment in vivo increases the enkephalin levels, and this effect is enhanced by inhibitors of enkephalin-degrading enzymes. The present work shows the effects in vitro of imipramine and its active metabolite desipramine on the activities of two membrane-bound enkephalin-degrading aminopeptidases present in rat brain. Imipramine and desipramine in vitro do not affect the aminopeptidase M activity, but they reversibly inhibits the aminoeptidase MII. The enzyme kinetic analysis shows that this enzyme molecule has two different binding sites for each drug, which exert a mixed type enzyme inhibition.

Neurogenic inflammation: with additional discussion of central and perceptual integration of nonneurogenic inflammation

The Working Group on Neurogenic Inflammation proposed 11 testable hypotheses in the three domains of neurogenic inflammation, perceptual and central integration, and nonneurogenic inflammation. The working group selected the term people reporting chemical sensitivity (PRCS) to identify the primary subject group. In the domain of neurogenic inflammation, testable hypotheses included: PRCS have an increased density of c-fiber neurons in symptomatic tissues; PRCS produce greater quantities of neuropeptides and prostanoids than nonsensitive subjects in response to exposure to low-level capsaicin or irritant chemicals; PRCS have an increased and prolonged response to exogenously administered c-fiber activators such as capsaicin; PRCS demonstrate augmentation of central autonomic reflexes following exposure to agents that produce c-fiber stimulation; PRCS have decreased quantities of neutral endopeptidase in their mucosa; exogenous neuropeptide challenge reproduces symptoms of PRCS. In the domain of perceptual and central integration, testable hypotheses included: PRCS have alterations in adaptation, habituation, cortical representation, perception, cognition, and hedonics compared to controls; the qualitative and quantitative interactions between trigeminal and olfactory systems are altered in PRCS; higher integration of sensory inputs is altered in PRCS. In the domain of nonneurogenic inflammation, testable hypotheses included: increased inflammation is present in PRCS in symptomatic tissues and is associated with a heightened neurosensory response; PRCS show an augmented inflammatory response to chemical exposure. The working group recommended that studies be initiated in these areas.

An evaluation of antidepressants in rheumatic pain conditions

In a randomized, double-blind, parallel study, fluoxetine and amitriptyline were compared with placebo in the treatment of chronic rheumatic pain. A total of 59 patients were evaluated during 4 wk of treatment and received 20 mg fluoxetine, 25 mg amitriptyline, or placebo daily. Pain intensity, pain relief, vital variables, and global evaluation were used to assess efficacy. To evaluate safety variables, the incidence of side effects was noted. Both amitriptyline and fluoxetine significantly reduced pain intensity compared with placebo. Similarly, pain relief was greater with both amitriptyline and fluoxetine than with placebo. At the end of the fourth week, fluoxetine was superior in efficacy to amitriptyline. The incidence of adverse effects was significantly greater with amitriptyline; dryness of the mouth was the most predominant side effect. We conclude that fluoxetine is an effective analgesic with fewer side effects.

Dose dependent time course of the analgesic effect of a sustained-release preparation of tramadol on experimental phasic and tonic pain

1. The aim of this study was to investigate the analgesic effect and its duration of a new sustained-release preparation of tramadol in an experimental pain model based on pain-related chemosomatosensory evoked potentials (CSSEPs) and subjective intensity estimates of painful phasic and tonic stimuli. 2. Twenty volunteers participated in a randomised, double-blind, three-fold cross-over study. Measurements were obtained before and 0.5, 1, 4, 6, and 12 h after administration of the drug (100 mg, 200 mg and placebo orally). CSSEPs were recorded after stimulation of one nostril with phasic, painful CO2 pulses. The other nostril was stimulated with a constant stream of dry air, which produced a tonic painful sensation. Subjects rated the perceived intensity of phasic and tonic stimuli via visual analogue scales. In order to test for nonspecific effects, acoustic evoked potentials (AEPs) were recorded, the spontaneous EEG was analysed in the frequency domain, the subject's vigilance was assessed in a tracking task, and the side effects of the drug were monitored. 3. The sustained-release preparation of tramadol produced a significant dose-related decrease in CSSEP amplitudes when compared with placebo. The reduction in amplitudes outlasted the observation period of 12 h, demonstrating the prolonged duration of the analgesic effect. 4. A dose-related significant decrease could be observed for the estimates of tonic pain. Similar to the decrease of amplitudes of the CSSEP, the reduction of the ratings of tonic pain outlasted the observation period of 12 h. The observed slight decrease in the estimates of phasic pain under medication did not reach a statistically significant level when compared with placebo. No significant effect could be demonstrated for the perception of the phasic and the tonic pain as determined by the McGill-Questionnaire. 5. A significant dose-related increase in the estimates of the side effects 'drowsiness', 'vertigo' and 'sickness' but not for 'tiredness' could be demonstrated.

Analgesic effects of propyphenazone in comparison to its combination with caffeine

OBJECTIVE

The aim of the study was to investigate whether the analgesic effect of propyphenazone (PROP) was increased when it was administered in combination with caffeine (CAFF).

METHODS

For assessment of analgesia a model was chosen based on chemo-somatosensory event-related potentials (CSSERP) elicited by stimulation of the nasal mucosa. Twenty healthy volunteers participated in the experiments. The study followed a placebo-controlled, randomised, double-blind, 5-fold cross-over design. Each of the 5 medications (400 mg PROP, 600 mg PROP, 400 mg PROP + 100 mg CAFF, 600 mg PROP + 150 mg CAFF, placebo) was orally administered. Experiments were separated by at least 5 days. In addition to assessment of CSSERP, subjects estimated the intensity of the stimulus. Drug effects unrelated to nociception were monitored, and in addition, the plasma levels of PROP were also analysed.

RESULTS

While 400 mg PROP did not significantly reduce the amplitude of CSSERP in comparison to placebo, all other medications produced a significant decrease in amplitudes. For both dosages of PROP, there was a significant amplification of the antinociceptive effect of PROP by CAFF, as indicated by the decrease in CSSERP amplitude. A significant effect of the factor "drug" was also found in the spontaneous EEG, indicating an arousal reaction after CAFF. No significant differences between plasma levels of PROP were found when applied either alone or in combination with CAFF.

CONCLUSION

The significant increase in the antinociceptive effect of PROP when administered together with caffeine appears to be related either to amplification of PROP's antinociceptive actions by CAFF or an atinociceptive effect of CAFF itself.

Effects of azapropazone on pain-related brain activity in human subjects

1. The dose-related effects of azapropazone on (i) event-related and spontaneous EEG-activity and (ii) the subjects' pain ratings were investigated using an experimental human pain model based on both chemo-somatosensory event-related potentials (CSSERP) and subjects' pain ratings. 2. Healthy subjects (n = 20) participated in a placebo-controlled, randomized, double-blind, four-way cross-over study. Single doses of azapropazone (300 mg, 600 mg and 1200 mg) and placebo were administered intravenously. Each experiment consisted of five sessions (before and 1, 2, 4 and 8 h after administration of the medication). Each session lasted for approximately 40 min. In the first 20 min, pain was induced by short CO2-stimuli presented to the right nostril (phasic pain; interstimulus interval 30 s) and EEG was recorded from five positions. CSSERPs were obtained in response to painful CO2-stimuli. In the following 20 min period, tonic pain was induced by a constant stream of dry air introduced in the left nostril. Subjects rated the intensity of both phasic and tonic pain by means of a visual analogue scale. Additionally, a frequency analysis of the spontaneous EEG was performed. 3. Azapropazone reduced the pain-related CSSERP-amplitudes at frontal and parietal recording positions. This topographical pattern was observed in previous studies with opioids, while NSAIDs such as flurbiprofen and ketoprofen exerted effects at frontal and central positions. In contrast to other NSAIDs, administration of azapropazone resulted in a reduction of the frequency bands alpha 1, delta and theta of the spontaneous EEG. At the subjective level, analgesic effects of azapropazone were observed in the ratings of tonic pain. 4. Analgesic properties of azapropazone were demonstrated in man. The topographical pattern of the changes in the CSSERPs and the effects on EEG background activity suggest a central component of the analgesic action of azapropazone.

Tonic versus phasic pain: dose-related effects of ketoprofen

Only recently has a new experimental technique been developed which combines tonic and phasic painful stimulation. By means of this technique the non-steroidal anti-inflammatory drug (NSAID) ibuprofen has been shown to produce a dose-related decrease in heterotopically applied phasic and tonic pain. The present study aimed to investigate the dose-related effects of the NSAID ketoprofen (50, 100, and 150 mg i.v.) when tonic and phasic stimuli were applied homotopically. Eighteen healthy volunteers participated in the double-blind, randomized, placebo-controlled study. After an initial training session subjects took part in four experiments, each of which was divided into three sessions (before, 30, and 120 min after drug administration). During each session 45 painful phasic CO2 stimuli of three concentrations were presented to the left nostril in randomized order (duration 200 ms; interval 40 s; 45%, 52%, and 59% v/v CO2). The left nostril was additionally stimulated with a constant stream of dry air, which produced a tonic painful sensation described as dull and burning. Subjects rated the intensity of the painful stimuli by means of visual analogue scales. Chemosomatosensory event-related potentials (CSSERPs) were recorded in response to phasic painful CO2 stimuli. Ketoprofen reduced the subjects' estimates of tonic pain in a dose-related manner. In contrast, given the special conditions of homotopic application of tonic and phasic painful stimuli, estimates of phasic pain increased significantly, corresponding to a significant increase in CSSERP amplitudes. An explanation of this inverse effect of the drug on responses to tonic and phasic pain may be a lateralized interaction between both C-fiber and A delta-fiber systems at a spinal or peripheral level.

Effects of flurbiprofen enantiomers on pain-related chemo-somatosensory evoked potentials in human subjects

1. The aim of the study was to investigate the analgesic effects of flurbiprofen enantiomers using an experimental pain model based on both chemo-somatosensory event-related potentials (CSSERP) and subjective pain ratings. 2. Healthy female volunteers (n = 16, age 23-36 years) participated in a placebo-controlled, randomised, double-blind, four-way crossover study. Single doses of (S)-flurbiprofen (50 mg), (R)-flurbiprofen (50 and 100 mg) and placebo were administered orally. Measurements were taken before and 2 h after administration of the medications. During each measurement, 32 painful stimuli of gaseous carbon dioxide (200 ms duration, interval approximately 30 s) of two concentrations (60 and 65% CO2 v/v) were applied to the right nostril. EEG was recorded from five positions and CSSERP were obtained in response to the painful CO2- stimuli. Additionally, subjects rated the perceived intensity of the painful stimuli by means of a visual analogue scale (VAS). 3. The CSSERP-amplitude P2, a measure of analgesic effect, decreased after administration of both (R)- and (S)-flurbiprofen, while it increased after placebo. This was statistically significant at recording positions C4 (P < 0.01) and Fz (P < 0.05). The analgesia-related decreases in evoked potential produced by (R)-flurbiprofen were dose-dependent. Comparing similar doses of (R)- and (S)-flurbiprofen, the decrease in CSSERP-amplitudes produced by the (S)-enantiomer was somewhat more pronounced, indicating a higher analgesic potency. 4. The present data indicate that both enantiomers of flurbiprofen produce analgesic effects. Since (R)-flurbiprofen caused only little toxicity in rats as compared with the (S)-enantiomer or the racemic compound, a reduction of the quantitatively most important side effects in the gastrointestinal tract might be achieved by employing (R)-flurbiprofen in pain therapy.

Analgesic effects of dihydrocodeine and tramadol when administered either in the morning or evening

The aim of the study was to investigate the analgesic effects of two opioids [dihydrocodeine (DHC) and tramadol] when administered either in the morning or evening. The experimental technique used is based on chemosomatosensory event-related potentials (CSSERPs) in response to painful chemical stimuli that are applied to the nasal mucosa. Eighteen healthy volunteers participated in the experiments. The study followed a controlled, randomized, double-blind, sixfold, cross-over design. Thus, each of the three medications (90 mg DHC, 50 mg tramadol, or placebo) was perorally administered to all subjects on different days at 08:00 or 20:00 h. Measurements were performed before and 60, 120, 240, and 360 min after administration of the medication. In addition to the assessment of CSSERP, subjects rated the intensity of the stimuli. Moreover, unspecific drug effects were monitored by means of acoustical event-related potentials and the subjects' performance in a video game. The results indicated that the painful intensity of the chemical stimuli strongly increased during evening sessions. In addition, both DHC and tramadol exerted stronger analgesic effects when administered in the evening. Thus, an inflexible scheme of prescription might produce either an increase of pain in the morning due to insufficient analgesia or the unnecessary overdosing of analgesics in the evening.

Different sensitivity of pain-related chemosensory potentials evoked by stimulation with CO2, tooth pulp event-related potentials, and acoustic event-related potentials to the tranquilizer diazepam

1. The aim of this study was to investigate the sensitivity of pain-related potentials used in experimental pain models to the non-specific effects of the tranquilizer diazepam. Pain-related potentials were recorded after painful stimulation of the nasal mucosa with CO2 and after painful stimulation of the tooth pulp. Acoustically evoked potentials were measured in order to compare their sensitivity to the tranquilizer diazepam with the sensitivity of the pain-related potentials. 2. Twenty volunteers participated in this randomised, double-blind, three-fold crossover study. Measurements were obtained before and 20 min after the administration of the drug. Event-related potentials were recorded after painful stimulation of the nasal mucosa with CO2 (two stimulus intensities: 60% v/v and 70% v/v CO2), after painful stimulation of the tooth pulp (two stimulus intensities: 2.2 x and 3.3 x detection threshold), and after non-painful acoustical stimulation of the right ear. The subjects rated the perceived intensity of the painful stimuli by means of a visual analogue scale. In addition the spontaneous EEG was analysed in the frequency domain and the vigilance of the subjects was assessed in a tracking task. 3. Diazepam reduced significantly the amplitudes of the event-related potentials after painful stimulation of the tooth pulp and after acoustical stimulation. In contrast only a small, statistically non-significant reduction could be found after painful stimulation with CO2. The pain ratings of the painful stimuli were not affected by diazepam. Diazepam reduced the performance of the tracking task. A decrease of arousal could be found in the alpha 2-range, whereas in the beta 2 and the theta-range the power density increased under diazepam. 4. We demonstrated that event-related potentials after painful stimulation of the nasal mucosa with CO2 are less affected by the nonspecific effects of the tranquilizer diazepam than event-related potentials after painful stimulation of the tooth pulp. The effects of diazepam on the tracking task, the spontaneous EEG and the event-related potentials clearly confirm its sedative properties. Diazepam had no analgesic effect measurable by pain intensity estimates.

Chemo-somatosensory event-related potentials in response to repetitive painful chemical stimulation of the nasal mucosa

The aim of the study was to investigate how chemo-somatosensory event-related potentials (CSSERPs) and pain ratings are modified by repetitive painful stimulation of the nasal mucosa (58% v/v CO2, 200 msec duration). Twenty-two subjects performed 3 experiments during which trains of stimuli were applied. The interstimulus interval (ISI) between stimuli was constant for each experiment, but varied between experiments (8, 4, and 2 sec). CSSERPs were obtained from 5 positions (Fz, C3, Cz, C4, and Pz). The subjects not only rated the overall perceived intensities but also reported the quality of the stimuli. At an ISI of 8 sec estimates decreased and only stinging sensations were reported. In contrast, at an interval of 2 sec estimates increased being accompanied by the buildup of burning pain. This phenomenon was interpreted in terms of the superposition of first (sharp and stinging pain: A delta fibers) and second pain (dull and burning pain: C fibers), respectively. However, given the special circumstances of short ISIs CSSERP amplitudes decreased the more the shorter the ISI was. In line with previous investigations it is hypothesised that CSSERPs predominantly reflect nociceptive information transmitted via A delta fibers.

Dose-related effects of ibuprofen on pain-related potentials

1. The aim of this study was to investigate the dose-related effects of ibuprofen (placebo, 400 and 800 mg rac-ibuprofen [Aktren], administered orally) on experimentally-induced tonic and phasic pain. 2. Eighteen volunteers participated in this randomized, double-blind, three-fold cross-over study. Measurements were obtained before and 90 min after administration of the drugs. Phasic pain was produced by CO2 pulses of two concentrations applied to the right nostril. The left nostril was stimulated with a constant stream of dry air which produced a tonic painful sensation described as dull and burning. Subjects rated the intensity of the painful stimuli by means of visual analogue scales. In addition, chemo-somatosensory event-related potentials (CSSERP) were also recorded in response to phasic painful CO2 stimuli. 3. While mean intensity estimates of both tonic and phasic painful stimuli showed a non-significant dose-related decrease, a statistically significant dose-related decrease was observed for CSSERP amplitudes. 4. In conclusion, in order to investigate analgesic drug effects, CSSERP appear to be a more sensitive measure compared with psychophysically obtained responses.