Opioid administration is one of the most common methods of managing moderate to severe pain in patients of all ages. All opioids induce adverse effects that include opioid tolerance and/or hyperalgesia, which are characterized in relation to analgesic approach, sex, and age. Marked sex differences in the magnitude of opioid effects upon hyperalgesia have been described in humans and in animal models for reasons that remain unclear (Barrett et al. 2003; Holtman and Wala 2005; Bodnar and Kest 2010; Wasserman et al. 2015). NMDA receptor antagonists are shown to block hyperalgesia generated by high-dose opioid exposure in male mice, while melanocortin-1 receptor antagonists are found to block hyperalgesia in female mice. (Juni et al. 2010). Prolactin inhibition prevented the occurrence of OIH in a female-selective manner (Chen et al. 2020). Interestingly, several male-specific genes have been implicated in the regulation of peripheral and spinal nociceptive processing during OIH (unpublished data, manuscript in preparation). For research continuity, our team attempted to delineate the molecular basis underlying male sensitivity to opioid antinociception. The aim was to better understand the distinct mechanisms of hyperalgesia between gender and clinical and therapeutic consequences.
The use of opioids has increased in adolescents undergoing surgical procedures (Kotzer 2000; Maxwell et al. 2005; Engelhardt et al. 2008; Tripi et al. 2015). Most relevant studies on OIH emphasized the need to explore the mechanistic basis exclusively in adult subjects. Instead, our research highlights the molecular underpinnings in adolescents. For this, rats at postnatal days 28-35 (P28-35) were used in all the experiments. The rostroventral medulla (RVM) of the brainstem has a powerful excitatory effect on spinal nociception from birth up to P21 in rats. Subsequently (P28 to adult), the influence of the RVM shifts to biphasic facilitation-inhibition (Hathway et al. 2009). The pain control system, which decreases the facilitation of spinal nociception rather than suppressing pain transmission in the preadolescent rat (P21), is mediated by mu-opioid receptor pathways in the RVM (Hathway et al. 2012). Naloxone, an opioid receptor antagonist, can prevent the most common opioid-induced side effects in children and adolescents being treated for acute postoperative pain (Maxwell et al. 2005). After pediatric scoliosis surgery, an intraoperative infusion of the NMDA receptor antagonist ketamine was reportedly unable to prevent the development of remifentanil-induced tolerance and decreased postoperative morphine consumption. Intraoperative infusion of the NMDA receptor antagonist ketamine reportedly could not prevent the development of remifentanil-induced tolerance and decreased postoperative morphine consumption after pediatric scoliosis surgery (Engelhardt et al. 2008; Tripi et al. 2015). The present finding demonstrates that the use of an mGluR1 antagonist in adolescents may increase the pain threshold during OIH in an animal model. Further studies will be informative to elucidate the clinical efficacy and significance of this approach.
The amygdala is located in the medial temporal lobe and is comprised of the lateral-basolateral complex (LA/BLA), intercalated cell mass (ITC), and central nucleus (CeA). The LA/BLA neurons receive polymodal sensory signals from the cortical and thalamic regions. ITC cells receive excitatory inputs from the medial prefrontal cortex (mPFC) (Thompson and Neugebauer 2017; Neugebauer et al. 2020). Nociceptive information can be delivered to the CeA, which serves as the major output nucleus, and glutamatergic synaptic responses are involved in pain transmission (Tully et al. 2007; Neugebauer et al. 2004). CeLC, defined as the nociceptive amygdala, has been identified as a target of the spino-parabrachio-amygdaloid tract. The CeLC receives affect-related inputs from the LA/BLA and contributes critically to pain modulation via projections to the brainstem (Gauriau and Bernard 2002; Carrasquillo and Gereau 2007; Ji and Neugebauer 2008). Paradoxical hyperalgesia can be induced by the mu-opioid agonist endomorphin-2 administered in the centromedial amygdala of rats (Terashvili et al. 2007). The CeLC may serve as a central site for the modulation of pain perception in the OIH process.
Interestingly, there is evidence to suggest pain-related hemispheric lateralization in the amygdala. There is no discernible difference in pain sensation in both the right and left amygdala under normal conditions, whereas a predominant involvement of the right amygdala has been observed in nociceptive responses to inflammatory and neuropathic pain stimuli (Thompson and Neugebauer 2017). An inhibitor of protein kinase A decreased the activity of right CeLC neurons after the induction of arthritis (Ji and Neugebauer 2009). ERK activation occurs in the right CeA and plays a dominant role in inflammation-induced peripheral hypersensitivity (Carrasquillo and Gereau 2008). Engagement of opioid receptor signaling in the right CeA contributes to pain responses produced by morphine (Nation et al. 2018; Navratilova et al. 2020). This agrees with the previous finding that the modulation of pain by mGluR1 activation is functionally lateralized to the right hemisphere.
Although the mechanism of OIH is unclear, it is conceivable that the activation of the glutamatergic system is involved. Glutamate is a major excitatory neurotransmitter in the mammalian nervous system. The compound is important in pain pathways, where it participates in transmitting nociceptive signals from the peripheral nociceptors to the central nervous system. There are two types of glutamate receptors: the ionotropic type (iGluRs) and the metabotropic type (mGluRs). To date, eight subtypes of mGluR have been identified in the nervous system. They include group I mGluR1/mGluR5, group II mGluR2/mGluR3, group III mGluR4, and mGluR6-8(Palazzo et al. 2019).
Group I mGluR-induced nociceptive processing in amygdala neurons participates in emotional-affective pain modulation through a mechanism that involves reactive oxygen species (Ji and Neugebauer 2010). There are the enhanced synaptic transmission at the nociceptive parabrachial (PB)→CeA synapse and the increased excitability which results in the altered output from the CeA in the arthritis model. The enhanced synaptic transmission and altered excitability in the CeA neurons were accompanied by the upregulation of mGluR1 and mGluR5(Neugebauer et al. 2003). Blocking mGluR1 rather than mGluR5 can reverse pain-related alterations in excitatory and inhibitory transmission in CeLC neurons from arthritic rats(Ren and Neugebauer 2010). Rescue of impaired endocannabinoid-dependent mGluR5 facilitation can restore mPFC output, which inhibits pain behaviors in arthritic rats (Kiritoshi et al. 2016). Activation of group II mGluR2 and mGluR3 subtypes can decrease neurotransmitter release in the synaptic cleft and inhibit spinal nociceptive processing in arthritis pain model (Mazzitelli and Neugebauer 2019; Mazzitelli et al. 2018). Recent evidence revealed that group III mGluR7 (pain enhancing) acts as a gatekeeper to regulate the flow of information to CeLC neurons under normal circumstances, but not during pain. Presynaptic mGluR8 (pain inhibiting) inhibits excitatory transmission in the CeLC in the state of pain (Ren et al. 2011). The data also suggest that mGluR8 and mGluR5 counteract the neuroprotective effect of ultra-micronized palmitoylethanolamide on long-term potentiation in conditions of neuropathic pain (Boccella et al. 2019).
In this study, the potential role of mGluR1 in the OIH process was explored. A proportion of the cellular glutamate pool was stored in the synaptic gap, and the protein expression of mGluR1 was increased after fentanyl exposure. We noticed that application of A841720 reduced glutamate content both under the normal condition and in OIH, suggesting unknown influences on normal mGluR1-mediated function in the amygdala when mGluR1 antagonist was used in the treatment of OIH. The potential side effects should be closely investigated. The increase and decrease in mGluR1 levels depended on the dynamic balance of its production and internalization. Presynaptic function was measured by mEPSC frequency and postsynaptic responsiveness was determined by mEPSC amplitude. CeLC cells displayed significantly increased mEPSC frequency and amplitude in the OIH process, which could be restored by blockade of mGluR1 using A841720. It’s not common that mGluR1 blockade reduces both the frequency and amplitude of mEPSCs. There are some similar cases. The mEPSC frequency and amplitude recorded in anterior cingulate cortex neurons were obviously increased after peripheral nerve ligation (Xu et al. 2008). Tumor necrosis factor-alpha significantly increased mEPSC frequency and amplitude in the immature superficial dorsal horn neurons after the spared nerve injury (Li et al. 2009). Our findings indicated that CeLC mGluR1 may upregulate presynaptic neurotransmitter release and postsynaptic responsiveness as well to induce behavioral hyperalgesia.
The collective findings indicate the involvement of mGluR1 in the fentanyl-induced behavioral hyperalgesia, which may be related to the enhanced synaptic transmission in the right CeLC. Further prospective data are needed, which may help patients recover from OIH.