Medical Cannabis in Patients with Chronic Pain: Effect on Pain Relief, Pain Disability, and Psychological aspects. A Prospective Non randomized Single Arm Clinical Trial.

BACKGROUND: There is an increasing interest in the medical use of cannabis, particularly in the treatment of chronic pain. OBJECTIVES: The aim is to evaluate the effects of cannabis use and the associated benefits reported by patients with various chronic pain diagnoses. MATERIAL AND METHODS: A total of 338 patients with different chro- nic pain conditions were treated with a Cannabis Flos 19% decoction for 12 months, in addition to their pharmacological therapy. Baseline levels for pain medications, pain intensity, pain disability, anxiety and depression were recorded at 1, 3, 6 and 12 months. RESULTS: Pain intensity records a statistically significant reduction from Baseline to 12 months follow up (X² 61.375; P<0,001); the im- provements from Baseline to 12 months follow up are also recorded in pain disability (X² 39.423; P<0,001) and in anxiety and depression symptoms (X²30.362; P<0,001; X²27.786; P<0,001). CONCLUSIONS: Our study suggest that Cannabis therapy, as an adjun- ct a traditional analgesic therapy, can be an efficacious tool to make more effective the management of chronic pain and its consequences on functional and psychological dimension. Further randomized, controlled trials are needed to confirm our conclusions.

Treatment of neck pain with type A botulinum toxin evaluated by Neck Pain Questionnaire (NPQ).

AIMS: To investigate the effects of a treatment with botulinum toxin in patients suffering of cervical pain can be defined as a painful condition of the upper region of the spinal column affecting neck and shoulders. It is one of the most frequent complaints and estimates suggest it affects 7 out of 10 people, with varying degrees of intensity. Although there is a number of causes, most often muscular contraction is involved as a probable consequence of a variety of irritative phenomena. MATERIALS AND METHODS: In our study 26 patients suffering from cervical pain were treated (21 women and 5 men, mean age 60.8 years, range 37-88). Three scales were used to evaluate pain: the Visual Analogue Scale (VAS), the Verbal Scale (VS) and the Neck ad Pain Questionnaire (NPQ). Scoring on all three of these scales was carried out at time 0 (T0) prior to treatment and at time 1 (T1) after 4 months. Patients were treated with 500 MU of Type A Dysport Toxin (Ipsen SpA), made up with 2.5 ml of sodium chloride solution at 0.9%, giving 20 units of toxin in 1 ml. An average of 180 units of toxin were administered to each patient, equivalent to 0.9 ml per point/unit (range 40- 360 units). Patients were given from 1 to 4 units at each session with an average of 2 units. The most common muscles injected were splenius cervicis, the sternocleidomastioid, trapetius, paravertebral and levator scapulae. of patients with cervical pain treated with botulinum toxin were as follows: the mean score on the Visual analogue scale (VAS) at T0 was 6.31, while at T1 it fell to 2.65, i.e. a decrease of 3.66 scores, equivalent to 58%. On the verbal scale (VS), the mean score at T0 was 2, which dropped to 0.8 at T1, a decrease of 1.2 scores, equivalent to 60%. By the Neck Pain Questionnaire (NPQ) the mean T0 score was 12.76, a figure which fell to 7.62 at T1, a drop of 5.14 points, equivalent to 40.28%. The statistical analysis shows that between T0 and T1 the decrease in the VAS, VA and NPQ scores was highly significant (p< 0.01). CONCLUSIONS: The administration of botulinum toxin appears to be a useful therapy for the treatment of muscular-skeletal pain. Technically, the therapeutic use and efficacy of botulinum toxin principally consists in the practical possibility of delivering the toxin principally remains in the target structures. If performed by qualified personnel, the treatment with botulinum toxin can be carried out in day surgery and it appears to be safe, with few risks and a minimum of side effects. To conclude, the main goals in the treatment of muscular-skeletal pain with botulinum toxin are in the breaking of the vicious circle of contraction pain -contraction, in stopping the pain from becoming chronic and achieving a valid alternative therapy.

Role of α1- and α2-GABA(A) receptors in mediating the respiratory changes associated with benzodiazepine sedation.

BACKGROUND AND PURPOSE: The molecular substrates underlying the respiratory changes associated with benzodiazepine sedation are unknown. We examined the effects of different doses of diazepam and alprazolam on resting breathing in wild-type (WT) mice and clarified the contribution of α1- and α2-GABA(A) receptors, which mediate the sedative and muscle relaxant action of diazepam, respectively, to these drug effects using point-mutated mice possessing either α1H101R- or α2H101R-GABA(A) receptors insensitive to benzodiazepine. EXPERIMENTAL APPROACH: Room air breathing was monitored using whole-body plethysmography. Different groups of WT mice were injected i.p. with diazepam (1-100 mg·kg(-1) ), alprazolam (0.3, 1 or 3 mg·kg(-1) ) or vehicle. α1H101R and α2H101R mice received 1 or 10 mg·kg(-1) diazepam or 0.3 or 3 mg·kg(-1) alprazolam. Respiratory frequency, tidal volume, time of expiration and time of inspiration before and 20 min after drug injection were analysed. KEY RESULTS: Diazepam (10 mg·kg(-1) ) decreased the time of expiration, thereby increasing the resting respiratory frequency, in WT and α2H101R mice, but not in α1H101R mice. The time of inspiration was shortened in WT and α1H101R mice, but not in α2H101R mice. Alprazolam (1-3 mg·kg(-1) ) stimulated the respiratory frequency by shortening expiration and inspiration duration in WT mice. This tachypnoeic effect was partially conserved in α1H101R mice while absent in α2H101R mice. CONCLUSIONS AND IMPLICATIONS: These results identify a specific role for α1-GABA(A) receptors and α2-GABA(A) receptors in mediating the shortening by benzodiazepines of the expiratory and inspiratory phase of resting breathing respectively.

A reduction in hippocampal GABAA receptor alpha5 subunits disrupts the memory for location of objects in mice.

The memory for location of objects, which binds information about objects to discrete positions or spatial contexts of occurrence, is a form of episodic memory particularly sensitive to hippocampal damage. Its early decline is symptomatic for elderly dementia. Substances that selectively reduce alpha5-GABA(A) receptor function are currently developed as potential cognition enhancers for Alzheimer's syndrome and other dementia, consistent with genetic studies implicating these receptors that are highly expressed in hippocampus in learning performance. Here we explored the consequences of reduced GABA(A)alpha5-subunit contents, as occurring in alpha5(H105R) knock-in mice, on the memory for location of objects. This required the behavioral characterization of alpha5(H105R) and wild-type animals in various tasks examining learning and memory retrieval strategies for objects, locations, contexts and their combinations. In mutants, decreased amounts of alpha5-subunits and retained long-term potentiation in hippocampus were confirmed. They exhibited hyperactivity with conserved circadian rhythm in familiar actimeters, and normal exploration and emotional reactivity in novel places, allocentric spatial guidance, and motor pattern learning acquisition, inhibition and flexibility in T- and eight-arm mazes. Processing of object, position and context memories and object-guided response learning were spared. Genotype difference in object-in-place memory retrieval and in encoding and response learning strategies for object-location combinations manifested as a bias favoring object-based recognition and guidance strategies over spatial processing of objects in the mutants. These findings identify in alpha5(H105R) mice a behavioral-cognitive phenotype affecting basal locomotion and the memory for location of objects indicative of hippocampal dysfunction resulting from moderately decreased alpha5-subunit contents.

[The chemical neuromodulation of pain: a review]. / La neuromodulazione chimica del dolore: una rassegna.

The chronic pain is a true emergency. In fact, the study "Pain in Europe 2005" showed that 26% of the Italian population is suffering by it. Chronic pain can be benign, when caused by a tissular damage, or malignant when cancer-related. The study of the pain has made a lot of progress in the last years. An example is the chemical neuromodulation, that interferes with the transmission of the pain afferences toward the brain, through the administration of chemical substances in the spinal or cranial compartment in well selected patients. This allows the use of doses lower than those required for other ways of administration, with less collateral effects and a more rapid response.

[Our experience in the chemical spinal neuromodulation in chronic pain from spinal collapse due to osteoporosis.]. / La nostra esperienza sulla neuromodulazione chimica spinale nel dolore cronico da collasso vertebrale di origine osteoporotica.

AIMS: Osteoporosis is a metabolic disease of the bone characterized by reduced bone mass and microstructural deterioration of bone tissue with a consequent increase in bone fragility and risk of vertebral collapse. Treatment of osteoporosis with the new molecule is effective in improving the density and quality of bone but does not provide an analgesic effect for patients with vertebral collapse. The treatment of chronic pain from vertebral collapse is difficult and may require the use of opioids, but for some patients the intake of these drugs is burdened with systemic side effects. The aim of our study is to use the way in reducing intrathecal opioid dosage and at the same time have good pain control without significant side-effects. We report our experience in the use of continuous infusion pump for intrathecal morphine in patients with chronic pain from osteoporotic vertebral collapse that can not tolerate therapy with systemic opioids because of severe side effects. MATERIALS AND METHODS: 24 patients (19 women and 5 men with average age of 73.3 years) with a diagnosis of chronic pain from vertebral collapse refractory to treatment for systemic analgesic were treated with the use of pumps for intrathecal infusion of morphine. All patients were fit the criteria for inclusion. For the measurement of pain the visual analogue scale (VAS) in three stages: T0, T1, T2 was administered to all patients. For the evaluation of the quality of life the Questionnaire of quality of life of the European Foundation for Osteoporosis (QUALEFFO) was administered in three times. RESULTS: In the one year follow-up there was a significant reduction in pain measured by VAS, from 8.5 to 1.9 in T0 to T2 in all patients. Similarly there was a reduction in the average score of QUALEFFO of all variables, from T0 equal to 114.7 to T2 equal to 79.1. With the intrathecal infusion of morphine no patient required an additional systemic treatment. CONCLUSIONS: This study demonstrates that intrathecal-morphine therapy offers patients relief from pain and a good quality of life. Continuous intrathecal infusion of morphine is a valuable therapy and is particularly suitable for those patients who show side effects with the administration of systemic opioids.

Cortical glutamatergic neurons mediate the motor sedative action of diazepam.

The neuronal circuits mediating the sedative action of diazepam are unknown. Although the motor-depressant action of diazepam is suppressed in alpha1(H101R) homozygous knockin mice expressing diazepam-insensitive alpha1-GABA(A) receptors, global alpha1-knockout mice show greater motor sedation with diazepam. To clarify this paradox, attributed to compensatory up-regulation of the alpha2 and alpha3 subunits, and to further identify the neuronal circuits supporting diazepam-induced sedation, we generated Emx1-cre-recombinase-mediated conditional mutant mice, selectively lacking the alpha1 subunit (forebrain-specific alpha1(-/-)) or expressing either a single wild-type (H) or a single point-mutated (R) alpha1 allele (forebrain-specific alpha1(-/H) and alpha1(-/R) mice, respectively) in forebrain glutamatergic neurons. In the rest of the brain, alpha1(-/R) mutants are heterozygous alpha1(H101R) mice. Forebrain-specific alpha1(-/-) mice showed enhanced diazepam-induced motor depression and increased expression of the alpha2 and alpha3 subunits in the neocortex and hippocampus, in comparison with their pseudo-wild-type littermates. Forebrain-specific alpha1(-/R) mice were less sensitive than alpha1(-/H) mice to the motor-depressing action of diazepam, but each of these conditional mutants had a similar behavioral response as their corresponding control littermates. Unexpectedly, expression of the alpha1 subunit was reduced in forebrain, notably in alpha1(-/R) mice, and the alpha3 subunit was up-regulated in neocortex, indicating that proper alpha1 subunit expression requires both alleles. In conclusion, conditional manipulation of GABA(A) receptor alpha1 subunit expression can induce compensatory changes in the affected areas. Specifically, alterations in GABA(A) receptor expression restricted to forebrain glutamatergic neurons reproduce the behavioral effects seen after a global alteration, thereby implicating these neurons in the motor-sedative effect of diazepam.

Pathophysiology and pharmacology of GABA(A) receptors.

By controlling spike timing and sculpting neuronal rhythms, inhibitory interneurons play a key role in brain function. GABAergic interneurons are highly diverse. The respective GABA(A) receptor subtypes, therefore, provide new opportunities not only for understanding GABA-dependent pathophysiologies but also for targeting of selective neuronal circuits by drugs. The pharmacological relevance of GABA(A) receptor subtypes is increasingly being recognized. A new central nervous system pharmacology is on the horizon. The development of anxiolytic drugs devoid of sedation and of agents that enhance hippocampus-dependent learning and memory has become a novel and highly selective therapeutic opportunity.

Specific GABA(A) circuits in brain development and therapy.

GABAergic interneurons are highly diverse and operate with a corresponding diversity of GABA(A) receptor subtypes in controlling behaviour. In this article, we review the significance of GABA(A) receptor heterogeneity for neural circuit development and central nervous system pharmacology. GABA(A) receptor subtypes were identified as selective targets for behavioural actions of benzodiazepines and of selected intravenous anesthetic agents using point mutations which render a specific receptor subtype insensitive to the action of the respective drugs and also by novel subtype-selective ligands. The pharmacological separation of anxiolysis and sedation guides the development of novel anxiolytics, while inverse agonism at extrasynaptic GABA(A) receptors involved in learning and memory is currently being evaluated as a novel therapeutic principle for symptomatic memory enhancement.

Contribution of the alpha1-GABA(A) receptor subtype to the pharmacological actions of benzodiazepine site inverse agonists.

A histidine-to-arginine point-mutation at position 101 in the alpha1-subunit of gamma-aminobutyric acid (GABA)(A) receptors has been shown to switch the in vitro efficacy of Ro 15-4513 from inverse agonism to agonism. In order to assess the consequences of this pharmacological switch in vivo, the motor and proconvulsant effects of Ro 15-4513 were analyzed in knock-in mice containing point-mutated alpha1(H101R)-GABA(A) receptors. Furthermore the influence of the alpha1(H101R) substitution on the efficacy of the beta-carboline inverse agonist DMCM was examined both in vitro and in vivo. Ro 15-4513 (10 mg/kg) increased baseline locomotion and potentiated the convulsant effect of pentylenetetrazole in wild type mice. In alpha1(H101R) mice, Ro 15-4513 decreased locomotion and, at a higher dose (30 mg/kg) it displayed an anticonvulsant action. In vitro, DMCM acted as an inverse agonist at recombinant alpha1beta2gamma2 receptors whereas it potentiated GABA-evoked chloride currents at alpha1(H101R)beta2gamma2 receptors. DMCM was inactive as a convulsant in alpha1(H101R) mice. In keeping with the major contribution of these receptors to the sedative and anticonvulsant properties of benzodiazepine site agonists, the present findings identify the alpha1-GABA(A) receptors as the molecular targets for the allosteric modulation by benzodiazepine site ligands in either direction with regard to the behavioral outputs, sedation/motor stimulation and anticonvulsion/proconvulsion.

Trace fear conditioning involves hippocampal alpha5 GABA(A) receptors.

The heterogeneity of gamma-aminobutyric acid type A (GABA(A)) receptors contributes to the diversity of neuronal inhibition in the regulation of information processing. Although most GABA(A) receptors are located synaptically, the small population of alpha5GABA(A) receptors is largely expressed extrasynaptically. To clarify the role of the alpha5GABA(A) receptors in the control of behavior, a histidine-to-arginine point mutation was introduced in position 105 of the murine alpha5 subunit gene, which rendered the alpha5GABA(A) receptors diazepam-insensitive. Apart from an incomplete muscle relaxing effect, neither the sedative, anticonvulsant, nor anxiolytic-like activity of diazepam was impaired in alpha5(H105R) mice. However, in hippocampal pyramidal cells, the point mutation resulted in a selective reduction of alpha5GABA(A) receptors, which altered the drug-independent behavior. In line with the role of the hippocampus in certain forms of associative learning, trace fear conditioning, but not delay conditioning or contextual conditioning, was facilitated in the mutant mice. Trace fear conditioning differs from delay conditioning in that the conditioned and unconditioned stimulus are separated by a time interval. Thus, the largely extrasynaptic alpha5GABA(A) receptors in hippocampal pyramidal cells are implicated as control elements of the temporal association of threat cues in trace fear conditioning.

GABA(A)-receptor subtypes: a new pharmacology.

The GABA(A) receptor is a pluripotent drug target mediating anxiolytic, sedative, anticonvulsant, muscle relaxant and amnesic activity. These drug actions have now been attributed to defined receptor subtypes. Thus, precise guidelines are available for the development of novel drugs with more selective action and less side effects than those currently in clinical use.

GABA(A) receptor subtypes: dissecting their pharmacological functions.

The enhancement of GABA-mediated synaptic transmission underlies the pharmacotherapy of various neurological and psychiatric disorders. GABA(A) receptors are pluripotent drug targets that display an extraordinary structural heterogeneity: they are assembled from a repertoire of at least 18 subunits (alpha1-6, beta1-3, gamma1-3, delta, epsilon, theta, rho1-3). However, differentiating defined GABA(A) receptor subtypes on the basis of function has had to await recent progress in the genetic dissection of receptor subtypes in vivo. Evidence that the various actions of allosteric modulators of GABA(A) receptors, in particular the benzodiazepines, can be attributed to specific GABA(A) receptor subtypes will be discussed. Such discoveries could open up new avenues for drug development.

Molecular targets for the myorelaxant action of diazepam.

Diazepam is used clinically for its myorelaxant, anxiolytic, sedative, and anticonvulsant properties. Although the anxiolytic action is mediated by alpha2 gamma-aminobutyric acid A (GABA(A)) receptors, the sedative action and in part the anticonvulsant action are mediated by alpha1 GABA(A) receptors. To identify the GABA(A) receptor subtypes mediating the action of diazepam on muscle tone, we have assessed the myorelaxant properties of diazepam in alpha2(H101R) and alpha3(H126R) knock-in mice harboring diazepam-insensitive alpha2 or alpha3 GABA(A) receptors, respectively. Whereas in alpha2(H101R) mice the myorelaxant action of diazepam was almost completely abolished at doses up to 10 mg/kg, the same dose induced myorelaxation in both wild-type and alpha3(H126R) mice. It was only at a very high dose (30 mg/kg diazepam) that alpha2(H101R) mice showed partial myorelaxation and alpha3(H126R) mice were partially protected from myorelaxation compared with wild-type mice. Thus, the myorelaxant activity of diazepam seems to be mediated primarily by alpha2 GABA(A) receptors and at high concentrations also by alpha3 GABA(A) receptors.

Mechanism of action of the hypnotic zolpidem in vivo.

Zolpidem is a widely used hypnotic agent acting at the GABA(A) receptor benzodiazepine site. On recombinant receptors, zolpidem displays a high affinity to alpha 1-GABA(A) receptors, an intermediate affinity to alpha(2)- and alpha(3)-GABA(A) receptors and fails to bind to alpha(5)-GABA(A) receptors. However, it is not known which receptor subtype is essential for mediating the sedative-hypnotic action in vivo. Studying alpha1(H101R) mice, which possess zolpidem-insensitive alpha(1)-GABA(A) receptors, we show that the sedative action of zolpidem is exclusively mediated by alpha(1)-GABA(A) receptors. Similarly, the activity of zolpidem against pentylenetetrazole-induced tonic convulsions is also completely mediated by alpha(1)-GABA(A) receptors. These results establish that the sedative-hypnotic and anticonvulsant activities of zolpidem are due to its action on alpha(1)-GABA(A) receptors and not on alpha(2)- or alpha(3)-GABA(A) receptors.

Molecular and neuronal substrate for the selective attenuation of anxiety.

Benzodiazepine tranquilizers are used in the treatment of anxiety disorders. To identify the molecular and neuronal target mediating the anxiolytic action of benzodiazepines, we generated and analyzed two mouse lines in which the alpha2 or alpha3 GABAA (gamma-aminobutyric acid type A) receptors, respectively, were rendered insensitive to diazepam by a knock-in point mutation. The anxiolytic action of diazepam was absent in mice with the alpha2(H101R) point mutation but present in mice with the alpha3(H126R) point mutation. These findings indicate that the anxiolytic effect of benzodiazepine drugs is mediated by alpha2 GABAA receptors, which are largely expressed in the limbic system, but not by alpha3 GABAA receptors, which predominate in the reticular activating system.

Flumazenil induces benzodiazepine partial agonist-like effects in BALB/c but not C57BL/6 mice.

RATIONALE: Some anxiety disorders may be treated in a different way than normal anxiety. OBJECTIVE: This study was aimed at investigating the action of the benzodiazepine receptor antagonist flumazenil, compared to that of the benzodiazepine receptor full agonist chlordiazepoxide, in an animal model of generalised anxiety disorder (the BALB/c mouse). METHODS: Flumazenil (0.0001, 0.001, 0. 01, 0.1 and 1 mg/kg) or chlordiazepoxide (5 mg/kg) were administered to BALB/c or C57BL/6 mice subjected to the light/dark test, the elevated plus maze or a passive avoidance step-through paradigm. RESULTS: Chlordiazepoxide and flumazenil (at all doses tested in the elevated plus maze and at the doses of 0.001 and 0.01 mg/kg in the light/dark test) induced a strong anxiolytic effect in BALB/c mice. Flumazenil did not induce anxiolysis in C57BL/6 mice, whatever the behavioral test or the dose used. However, chlordiazepoxide elicited anxiolysis in this strain in both procedures. In the passive avoidance test, chlordiazepoxide was amnesic in both strains but flumazenil had no effect. CONCLUSION: Flumazenil induces partial agonist-like effects in BALB/c and not in C57BL/6 mice, suggesting a possible benzodiazepine receptor set point shift toward the agonistic direction in some pathological anxiety states such as generalised anxiety disorder.

Benzodiazepine actions mediated by specific gamma-aminobutyric acid(A) receptor subtypes.

GABA(A) (gamma-aminobutyric acid(A)) receptors are molecular substrates for the regulation of vigilance, anxiety, muscle tension, epileptogenic activity and memory functions, which is evident from the spectrum of actions elicited by clinically effective drugs acting at their modulatory benzodiazepine-binding site. Here we show, by introducing a histidine-to-arginine point mutation at position 101 of the murine alpha1-subunit gene, that alpha1-type GABA(A) receptors, which are mainly expressed in cortical areas and thalamus, are rendered insensitive to allosteric modulation by benzodiazepine-site ligands, whilst regulation by the physiological neurotransmitter gamma-aminobutyric acid is preserved. alpha1(H101R) mice failed to show the sedative, amnesic and partly the anticonvulsant action of diazepam. In contrast, the anxiolytic-like, myorelaxant, motor-impairing and ethanol-potentiating effects were fully retained, and are attributed to the nonmutated GABA(A) receptors found in the limbic system (alpha2, alpha5), in monoaminergic neurons (alpha3) and in motoneurons (alpha2, alpha5). Thus, benzodiazepine-induced behavioural responses are mediated by specific GABA(A) receptor subtypes in distinct neuronal circuits, which is of interest for drug design.

Decreased GABAA-receptor clustering results in enhanced anxiety and a bias for threat cues.

Patients with panic disorders show a deficit of GABAA receptors in the hippocampus, parahippocampus and orbitofrontal cortex. Synaptic clustering of GABAA receptors in mice heterozygous for the gamma2 subunit was reduced, mainly in hippocampus and cerebral cortex. The gamma2 +/- mice showed enhanced behavioral inhibition toward natural aversive stimuli and heightened responsiveness in trace fear conditioning and ambiguous cue discrimination learning. Implicit and spatial memory as well as long-term potentiation in hippocampus were unchanged. Thus gamma2 +/- mice represent a model of anxiety characterized by harm avoidance behavior and an explicit memory bias for threat cues, resulting in heightened sensitivity to negative associations. This model implicates GABAA-receptor dysfunction in patients as a causal predisposition to anxiety disorders.