Selective REM Sleep Deprivation Improves Expectation-Related Placebo Analgesia

The placebo effect is a neurobiological and psychophysiological process known to influence perceived pain relief. Optimization of placebo analgesia may contribute to the clinical efficacy and effectiveness of medication for acute and chronic pain management. We know that the placebo effect operates through two main mechanisms, expectations and learning, which is also influenced by sleep. Moreover, a recent study suggested that rapid eye movement (REM) sleep is associated with modulation of expectation-mediated placebo analgesia. We examined placebo analgesia following pharmacological REM sleep deprivation and we tested the hypothesis that relief expectations and placebo analgesia would be improved by experimental REM sleep deprivation in healthy volunteers. Following an adaptive night in a sleep laboratory, 26 healthy volunteers underwent classical experimental placebo analgesic conditioning in the evening combined with pharmacological REM sleep deprivation (clonidine: 13 volunteers or inert control pill: 13 volunteers). Medication was administered in a double-blind manner at bedtime, and placebo analgesia was tested in the morning. Results revealed that 1) placebo analgesia improved with REM sleep deprivation; 2) pain relief expectations did not differ between REM sleep deprivation and control groups; and 3) REM sleep moderated the relationship between pain relief expectations and placebo analgesia. These results support the putative role of REM sleep in modulating placebo analgesia. The mechanisms involved in these improvements in placebo analgesia and pain relief following selective REM sleep deprivation should be further investigated.     

Emotional regulation of pain: the role of noradrenaline in the amygdala

The perception of pain involves the activation of the spinal pathway as well as the supra-spinal pathway,which targets brain regions involved in affective and cognitive processes.Pain and emotions have the capacity to influence each other reciprocally;negative emotions,such as depression and anxiety,increase the risk for chronic pain,which may lead to anxiety and depression.The amygdala is a key-player in the expression of emotions,receives direct nociceptive information from the parabrachial nucleus,and is densely innervated by noradrenergic brain centers.In recent years,the amygdala has attracted increasing interest for its role in pain perception and modulation.In this review,we will give a short overview of structures involved in the pain pathway,zoom in to afferent and efferent connections to and from the amygdala,with emphasis on the direct parabrachio-amygdaloid pathway and discuss the evidence for amygdala’s role in pain processing and modulation.In addition to the involvement of the amygdala in negative emotions during the perception of pain,this brain structure is also a target site for many neuromodulators to regulate the perception of pain.We will end this article with a short review on the effects of noradrenaline and its role in hypoalgesia and analgesia.     

Patients' direct experiences as central elements of placebo analgesia

Placebo analgesic effects appear to be related to patients' perception of the therapeutic intervention. In this paper, we review quantitative findings of how the relationship with the physician and the verbal suggestions given for relief may influence patients' perception of a treatment and how patients' expectations and emotional feelings may affect treatment outcome. We also present qualitative data from interviews with patients who have experienced pain relief following a placebo or an active treatment. A special focus is given to the temporal development of placebo analgesia at psychological and neurophysiological levels. Finally, we discuss the extent to which the quantitative and qualitative findings supplement or contrast with each other, and we touch upon possible implications of patients' direct experience as central for placebo analgesia.     

The Effect of Opioid Receptor Blockade on the Neural Processing of Thermal Stimuli

The endogenous opioid system represents one of the principal systems in the modulation of pain. This has been demonstrated in studies of placebo analgesia and stress-induced analgesia, where anti-nociceptive activity triggered by pain itself or by cognitive states is blocked by opioid antagonists. The aim of this study was to characterize the effect of opioid receptor blockade on the physiological processing of painful thermal stimulation in the absence of cognitive manipulation. We therefore measured BOLD (blood oxygen level dependent) signal responses and intensity ratings to non-painful and painful thermal stimuli in a double-blind, cross-over design using the opioid receptor antagonist naloxone. On the behavioral level, we observed an increase in intensity ratings under naloxone due mainly to a difference in the non-painful stimuli. On the neural level, painful thermal stimulation was associated with a negative BOLD signal within the pregenual anterior cingulate cortex, and this deactivation was abolished by naloxone.     

Placebo in emotional processing--induced expectations of anxiety relief activate a generalized modulatory network

Placebo analgesia and reward processing share several features. For instance, expectations have a strong influence on the subsequent emotional experience of both. Recent imaging data indicate similarities in the underlying neuronal network. We hypothesized that placebo analgesia is a special case of reward processing and that placebo treatment could modulate emotional perception in the same way as does pain perception. The behavioral part of this study indicates that placebo treatment has an effect on how subjects perceive unpleasant pictures. Furthermore, event-related fMRI demonstrated that the same modulatory network, including the rostral anterior cingulate cortex and the lateral orbitofrontal cortex, is involved in both emotional placebo and placebo analgesia. These effects were correlated with the reported placebo effect and were predicted by the amount of treatment expectation induced on a previous day. Thus, the placebo effect may be considered to be a general process of modulation induced by the subjects' expectations.     

Comparison of Transversus Abdominis Plane Infiltration with Liposomal Bupivacaine versus Continuous Epidural Analgesia versus Intravenous Opioid Analgesia

Epidural analgesia is considered the standard of care but cannot be provided to all patients Liposomal bupivacaine has been approved for field blocks such as transversus abdominis plane (TAP) blocks but has not been clinically compared against other modalities. In this retrospective propensity matched cohort study we thus tested the primary hypothesis that TAP infiltration are noninferior (not worse) to continuous epidural analgesia and superior (better) to intravenous opioid analgesia in patients recovering from major lower abdominal surgery. 318 patients were propensity matched on 18 potential factors among three groups (106 per group): 1) TAP infiltration with bupivacaine liposome; 2) continuous Epidural analgesia with plain bupivacaine; and; 3) intravenous patient-controlled analgesia (IV PCA). We claimed TAP noninferior (not worse) over Epidural if TAP was noninferior (not worse) on total morphine-equivalent opioid and time-weighted average pain score (10-point scale) within first 72 hours after surgery with noninferiority deltas of 1 (10-point scale) for pain and an increase less of 20% in the mean morphine equivalent opioid consumption. We claimed TAP or Epidural groups superior (better) over IV PCA if TAP or Epidural was superior on opioid consumption and at least noninferior on pain outcome. Multivariable linear regressions within the propensity-matched cohorts were used to model total morphine-equivalent opioid dose and time-weighted average pain score within first 72 hours after surgery; joint hypothesis framework was used for formal testing. TAP infiltration were noninferior to Epidural on both primary outcomes (p<0.001). TAP infiltration were noninferior to IV PCA on pain scores (p = 0.001) but we did not find superiority on opioid consumption (p = 0.37). We did not find noninferiority of Epidural over IV PCA on pain scores (P = 0.13) and nor did we find superiority on opioid consumption (P = 0.98). TAP infiltration with liposomal bupivacaine and continuous epidural analgesia were similar in terms of pain and opioid consumption, and not worse in pain compared with IV PCA. TAP infiltrations might be a reasonable alternative to epidural analgesia in abdominal surgical patients. A large randomized trial comparing these techniques is justified.     

心理护理对腹腔镜胆囊切除术患者焦虑心理的影响

目的:探讨心理护理对腹腔镜胆囊切除术患者焦虑心理的影响。方法:将84例腹腔镜手术患者随机分为2组:对照组23例,给予常规护理;心理护理组61例,给予常规护理+心理护理,其中文化程度<高中的患者34例,文化程度≥高中的患者27例。采用焦虑自评量表(SAS)评价焦虑状态,采用疼痛视觉模拟标尺评估患者疼痛情况,以及评估患者情绪情感、恐惧程度及对治疗满意度。结果:与对照组比较,心理护理组患者焦虑程度、恐惧程度、疼痛评分、显著下降(P<0.05);与文化程度<高中比较,文化程度≥高中的患者焦虑评分显著降低(P<0.05),情绪情感的评分显著增加(P<0.05);术后第1-2天疼痛评分无显著差异(P>0.05),术后第3天疼痛评分有显著差异(P<0.05);心理护理组的满意度明显升高(P<0.05)。结论:腹腔镜手术患者存在明显的焦虑、恐惧症状,心理护理干预能有效缓解患者焦虑心理,减轻疼痛程度,减少疼痛时间,提高患者对医疗服务满意度,可有效提高临床护理质量与效率。     

A Bayesian Perspective on Sensory and Cognitive Integration in Pain Perception and Placebo Analgesia

The placebo effect is a component of any response to a treatment (effective or inert), but we still ignore why it exists. We propose that placebo analgesia is a facet of pain perception, others being the modulating effects of emotions, cognition and past experience, and we suggest that a computational understanding of pain may provide a unifying explanation of these phenomena. Here we show how Bayesian decision theory can account for such features and we describe a model of pain that we tested against experimental data. Our model not only agrees with placebo analgesia, but also predicts that learning can affect pain perception in other unexpected ways, which experimental evidence supports. Finally, the model can also reflect the strategies used by pain perception, showing that modulation by disparate factors is intrinsic to the pain process.     

Predicting Adolescent Anxiety Ratings From Infant Behavioral Style in Response to Expectancy Violation

Nearly 15 years after infants participated in an operant conditioning task, contact was once again established with the former participants to determine relations between infant behavior in response to expectancy violation during mobile conjugate reinforcement and reported anxiety ratings during adolescence. Shifting infants from a high-stimulation reinforcement contingency to a low-stimulation contingency violated expectancy during the learning task, which elicited negative reactivity, crying, in a number of infants. Original participants and 1 parent were later asked to complete a behavioral assessment questionnaire. Results were consistent with studies that have established relations between early negative reactivity and later internalizing behavior. Infant negative reactivity and poor environmental regulation together significantly contributed to the prediction of higher ratings on a later anxiety scale. Also, infant fear and crying were related and higher fear predicted higher anxiety. Findings also suggested fear is a distinct negative emotional reaction and even early in development can be differentiated from other negative reactivity styles.     

Differential effects of selective opioid peptide antagonists on the acquisition of pavlovian fear conditioning.

Pretreatment with opioid antagonists enhances acquisition of Pavlovian fear conditioning. The present experiments attempted to characterize the type of opioid receptor responsible for this effect using a procedure that assessed the fear of rats to a chamber previously associated with electric shock (1 mA, 0.75 s). Freezing, a species-typical immobility, was employed as an index of fear. Two mu opioid antagonists, CTOP (40 ng) and naloxonazine (10 micrograms), enhanced conditioning. On the other hand, the kappa antagonist nor-binaltorphimine reduced conditioning. Two delta antagonist treatments (16-methyl cyprenorphine and naltrindole) had no reliable effect on acquisition. Thus the enhancement of conditioning appears to be mediated by mu receptors. Previous research has shown that the conditional fear produced by these procedures caused an analgesia that is also mediated by mu receptors. It is argued that the enhancement effect occurs because of an antagonism of this analgesia and that the analgesia normally acts to regulate the level of fear conditioning.     

Objective assessment of clonidine analgesia in man and influence of naloxone

Experimental data indicate that clonidine can induce marked analgesia. We characterized this effect in healthy volunteers and investigated possible links with the opioid peptide system by means of naloxone antagonism. According to a cross-over, double-blind, placebo-controlled design, 10 subjects received oral and i.v. placebo or clonidine (0.2 mg p.o.) or clonidine and naloxone (2.8 mg i.v. in 5 h). Analgesia was assessed by measurement of the subjective pain threshold (visual analog scale) and the objective nociceptive flexion reflex (R III) threshold after transcutaneous electrical stimulations. A correlation was observed between subjective and objective thresholds (r: 0.78). Oral clonidine alone or with naloxone increased subjective and objective pain thresholds for at least 4 hours (p less than 0.01, ANOVA). Naloxone tended to reinforce clonidine analgesia. Only moderate and well tolerated side-effects were observed.     

"Anxiebo", placebo, and postoperative pain

Background

Surgical treatment and its consequences expose patients to stress, and here we investigated the importance of the psychological component of postoperative pain based on reports in the clinical literature.

Discussion

Postoperative pain remains a significant clinical problem. Increased pain intensity with increased demand for opioid medication, and/or a relative unresponsiveness to pain treatment was reported both when the analgesia was administered by means of conventional nurse injection regimes and patient-controlled analgesia (PCA). Both the quality of the analgesia, and the sensitivity of postoperative models for assessing analgesic efficacy could be significantly influenced. The findings could be explained by increased penetration of an algesic anxiety-related nocebo influence (which we chose to call "anxiebo") relative to its analgesic placebo counterpart. To counteract this influence, the importance of psychological effects must be acknowledged, and doctors and attending nurses should focus on maintaining trustful therapist-patient relationships throughout the treatment period. The physical mechanism of anxiebo should be further explored, and those at risk for anxiebo better characterized. In addition, future systemic analgesic therapies should be directed towards being prophylactic and continuous to eliminate surgical pain as it appears in order to prevent the anxiebo effect. Addressing anxiebo is the key to developing reproducible models for measuring pain in the postoperative setting, and to improving the accuracy of measurements of the minimum effective analgesic concentration.

Summary

Anxiebo and placebo act as counterparts postoperatively. The anxiebo state may impair clinical analgesia and reduce the sensitivity of analgesic trials. Ways to minimize anxiebo are discussed.     

Naloxone increases pain perception in rats and mice.

Rats and mice manifest hyperalgesia when treated with low doses of naloxone. These doses are sufficient to block morphine analgesia. The results are consistent with the hypothesis that there is physiological release of an endogenous opioid which modulates pain sensitivity.     

Nonopioid placebo analgesia is mediated by CB1 cannabinoid receptors

Placebo analgesia is mediated by both opioid and nonopioid mechanisms, but so far nothing is known about the nonopioid component. Here we show that the specific CB1 cannabinoid receptor antagonist 5-(4-chlorophenyl)-1-(2,4-dichloro-phenyl)-4-methyl-N-(piperidin-1-yl)-1H-pyrazole-3-carboxamide (rimonabant or SR141716) blocks nonopioid placebo analgesic responses but has no effect on opioid placebo responses. These findings suggest that the endocannabinoid system has a pivotal role in placebo analgesia in some circumstances when the opioid system is not involved.     

On the role of endogenous opioid peptides: failure of naloxone to influence shock escape threshold in the rat.

Rats treated with doses of naloxone sufficient to block morphine analgesia showed no change in the threshold for escape from foot shock. The data offer no support to the hypothesis that an endogenous opioid modulates responsiveness to pain and discomfort.     

The effect of gonadal hormones and gender on anxiety and emotional learning

Disorders of anxiety and fear dysregulation are highly prevalent. These disorders affect women approximately 2 times more than they affect men, occur predominately during a woman's reproductive years, and are especially prevalent at times of hormonal flux. This implies that gender differences and sex steroids play a key role in the regulation of anxiety and fear. However, the underlying mechanism by which these factors regulate emotional states in either sex is still largely unknown. This review discusses animal studies describing sex-differences in and gonadal steroid effects on affect and emotional learning. The effects of gonadal hormones on the modulation of anxiety, with particular emphasis on progesterone's ability to reduce the responsiveness of female rats to corticotropin releasing factor and the sex-specific effect of testosterone in the reduction of anxiety in male rats, is discussed. In addition, gonadal hormone and gender modulation of emotional learning is considered and preliminary data are presented showing that estrogen (E2) disrupts fear learning in female rats, probably through the antagonistic effect of ERalpha and ERbeta activation.     

Opioid antinociception and positive reinforcement are mediated by different types of opioid receptors

Fentanyl (FEN) and diprenorphine's (DIPR) potentials for analgesia and reinforcement were assayed using rats. Analgesia was measured by the classic tail-flick test. The test germane to opioid reinforcement involved measuring pressing rates for direct electrical stimulation of the lateral hypothalamus and ventral tegmental area. FEN, as does morphine and heroin, produced strong analgesia and enhanced pressing rates for brain stimulation. DIPR produced no analgesia and antagonized FEN's analgesia. DIPR, at doses antagonizing FEN's analgesia, enhanced pressing for brain stimulation. DIPR's enhancement of pressing was antagonized by naloxone (100 micrograms/kg). When FEN and DIPR were given concurrently, pressing for brain stimulation was not reduced and was greater than after FEN alone was given. These data support a conclusion that different types of receptors are associated with opioid analgesia and reinforcement.     

Psychological evaluation of postoperative pain and its significance for treatment

The results of tests applied to two groups of the patients who underwent elective surgeries are being discussed. The patients were selected with the aid of J.C. Raven's Intelligence Quotient, H.J. Eysenck's Personality Inventory, J. Taylor's Personality Scale, and Spielberg's S.T.A.I. The patients were operated at the Casualty and Orthopaedic Surgery Department of the Surgical Institute, Military Academy of Medicine. Postoperative analgesia was achieved with i.m. pethidine (1 mg/kg b.w.) in the group of 30 patients with low intensity of neurosis and anxiety while the group of 60 patients with high level of neurosis and anxiety required three different techniques: pethidine (dose as above) intravenously, electric stimulation and placebo stimulation. The following tests were applied to all patients before surgery and on the three postoperative days: 1) evaluation of anxiety level, 2) determination and detection of pain points, 3) pain intensity determination, 4) determination of the dose of analgetic agent required for pain abolishment. Other factors determined included: 1) efficiency of both electric and placebo efficacy, 2) analgesic drug dose vs. pain intensity, 3) pain vs. anxiety ratio. The obtained results indicated that considerable oscillations of the emotional tension are observed in both pre- and postoperative periods. Intensity of pain and its compliance to the treatment are closely related to the level of anxiety. Psychological examination performed in patients preoperatively enables to foresee the postoperative pain intensity and to plan the course of therapy.     

Lessons learned from placebo groups in antidepressant trials

This comprehensive review provides an overview about placebo and nocebo phenomena in antidepressant trials. Improvements in the placebo groups may partly be explained through methodological issues such as natural course of depression and regression to the mean, but also fundamentally reflect investigators' and participants' expectations. A meta-analysis by our group of 96 randomized placebo-controlled trials showed large placebo responses to antidepressant medication. Moderator analyses revealed substantially larger placebo responses in observer ratings compared with self-report. Effect sizes in observer ratings showed strong increase with publication year while this effect was not found for patients' self-ratings. This reflects the strong influence of investigators' expectations. The analysis of 'nocebo effects', e.g. adverse effects in placebo groups of antidepressant trials also confirms the impact of expectations: nocebo symptoms reflected the typical side-effect patterns expected in the drug group, with higher symptoms rates in the placebo groups of tricyclic antidepressant trials compared with placebo groups of trials testing selective serotonin reuptake inhibitors. While the placebo response seems to be similar for women and men, gender differences were found for nocebo rates. In the conclusion, we discuss potential implications for clinical trial designs and argue for interventions aimed at optimizing positive expectations of treatment benefit while minimizing the impact of adverse effects.     

Effects of morphine and naloxone on pain sensitivity after radiation injuries in rats

Radiation in doses 150 Gy induces different changes in pain sensitivity in rats by thermal (analgesia) and electrical (hyperalgesia) stimuli. Naloxone (0.1 and 1 mg/kg) and morphine (5 mg/kg) show, that analgesia is realized due to opioid mechanisms.