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Opioid Neurotoxicity: Fentanyl Dose-Response Effects in Rats

Kofke, W. Andrew MD, FCCM; Garman, Robert H. DVM; Stiller, Richard L. PhD; Rose, Marie E. BA; Garman, Rosalyn

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Abstract

Administered in large doses, alfentanil produces limbic system (hippocampus, amygdala, septal nucleus, cingulate and entorhinal cortices, dentate gyrus, and association areas) hypermetabolism, seizure, and histopathologic alterations (i.e., brain damage) in rats [1]. We previously demonstrated that the neurotoxicity associated with administration of a large dose (i.e., approximately equivalent to a "stress-free" anesthetizing dose) of alfentanil is also shared by fentanyl and sufentanil [2]. In these prior studies, two doses of opioids were administered: a dose thought to be appropriate for basal analgesia in rats, and a dose 10- to 20-fold larger to simulate a cardiac anesthesia dosing scheme used in humans. Whether even larger doses of opioids are required to produce brain damage in these models is unknown, although rats receiving small doses (i.e., <or=to 400 micro g/kg) occasionally sustain limbic system injury [2].

The objectives of this investigation were to determine: (a) the relationship between opioid dose and severity and frequency of brain damage, and (b) whether, and to what extent, opioid neurotoxicity depends on electrographic activation.

Methods

Approval of the institutional animal care and use committee was obtained for all the experiments. Forty male Sprague-Dawley rats weighing 335-440 g were allowed access to food and water overnight. Anesthesia was induced with 4% halothane in 70% N2 O and 30% O2, the trachea was intubated with a 14-gauge Teflon catheter, and 0.6 mg of pancuronium bromide was injected intramuscularly and then intravenously as often as needed to maintain neuromuscular block. The lungs were mechanically ventilated (Analytical Specialties Ventilator, St. Louis, MO) for the duration of the opioid administration and up to 3 h afterward, and inspired and expired O2 and CO2 were continuously monitored by infrared spectrometry (Hewlett Packard, Waltham, MA). Mechanical ventilation was adjusted to maintain PaCO2 approximately 35 mm Hg. Biparietal stainless steel electroencephalogram (EEG) needle electrodes and rectal temperature probe were inserted. A femoral vein and artery were cannulated and arterial blood pressure was continually monitored. Anesthesia during surgery consisted of 1% halothane in O2/N2 O 30%/70% and after surgery sedation was maintained with O2/N2 O 30%/70% without halothane for 1 h. After 1 h, each rat received 1 mL of 8.4% sodium bicarbonate and was randomly assigned to one of eight groups: Control = 0.9% normal saline solution (NSS) loading dose (LD) 4 mL/kg maintenance dose (MD) 4.0 mL [centered dot] kg-1 [centered dot] h-1 NSS; 50-2 = fentanyl LD 50 micro g/kg, MD 2.0 micro g [centered dot] kg-1 [centered dot] min-1; 100-4 = fentanyl LD 100 micro g/kg, MD 4.0 micro g [centered dot] kg-1 [centered dot] min-1; 200-8 = fentanyl LD 200 micro g/kg, MD 8.0 micro g [centered dot] kg-1 [centered dot] min-1; 400-16 = fentanyl LD 400 micro g/kg, MD 16.0 micro g [centered dot] kg-1 [centered dot] min-1; 800-32 = fentanyl LD 800 micro g/kg, MD 32.0 micro g [centered dot] kg-1 [centered dot] min-1; 1600-64 = fentanyl LD 1600 micro g/kg, MD 64.0 micro g [centered dot] kg-1 [centered dot] min-1; and 3200-128 = fentanyl LD 3200 micro g/kg, MD 128.0 micro g/kg.

In each group (n = 5), the LD was administered over 1-2 min. In all groups receiving opioid, the fentanyl was lyophilized before the experiment and reconstituted in NSS to permit a LD of 4 mL/kg and MD of 4 mL [centered dot] kg-1 [centered dot] h-1. During the infusions, opioid-treated rats received O2/N2 30%/70% and control animals received 0.4% halothane in O2/N2 O 30%/70%. After 2 h of anesthetic or saline, all rats received 100% O2 and underwent tracheal extubation when alert. They were placed in an O2-infused enclosure for 1 h and then moved to a cage overnight.

Seven days after fentanyl infusion, the rats were anesthetized with halothane and underwent cerebral perfusion fixation with 10% neutral buffered formalin via thoracotomy with left ventricular cannulation. The calvaria were removed and the exposed brains were further immersion-fixed in neutral buffered formalin for at least 24 h before their removal. The brain was sliced at approximately 3-mm intervals and the slices were embedded in paraffin by routine techniques. Six-micrometer sections of each brain block were prepared, stained with hematoxylin and eosin, and evaluated by light microscopy. Fifty brain areas were examined. Degrees of neuropathologic alterations within a given anatomic region were scored based on subjective assessment of number and distribution of eosinophilic neurons and severity of tissue edema. Scores, assigned by a pathologist who was unaware of the experimental treatment, are: 0 = none; 1 = minimal; 2 = mild; 3 = moderate; 4 = marked; and 5 = severe. These grades are also semiquantitative in that they reflect the approximate number of degenerating neurons present in the affected neuroanatomic areas as follows: 1, less than 5%; 2, 6%-20%; 3, 21%-50%; 4, 51%-75%; and 5, 76%-100% dead neurons. An overall neuropathologic score was calculated for each rat by summating the pathologic scores for all brain areas examined.

Arterial blood pH, PO2, PCO2, and glucose were determined immediately before opioid infusion, five times during the 2-h opioid infusion, and 30 min after infusion.

EEG data were digitized and recorded using Labtech Notebook[R] (Laboratory Technologies Corp., Wilmington, MA) and underwent post-hoc Fourier processing. Total power was derived over the 30 min immediately before opioid infusion, during the 2 h of opioid infusion, and over the 15 min immediately after the end of opioid infusion. Using time-stamped EEG data, average power spectra were calculated for each group.

Arterial fentanyl concentrations were measured by radioimmunoassay using rabbit antifentanyl antibody. Arterial blood gases and pH measurements were made on 100-micro L samples with a Corning 178 pH/blood gas ionizer (CIBA Corning Diagnostics Corporation, Medfield, MA). Whole arterial blood glucose assays were performed on 25-micro L samples with a Yellow Springs Instruments, Model 23A glucose analyzer (Yellow Springs, OH).

Physiologic, EEG data, and plasma fentanyl concentrations were analyzed by analysis of variance (ANOVA), followed by post-hoc least significant difference testing where P < 0.05 on ANOVA. Neuropathologic scores observed for each brain area were tabulated. Due to constraints of performing multiple comparisons over many groups and brain areas, these data did not undergo statistical analysis. Rather, for each rat the pathologic grades for all brain areas examined were summated, resulting in an overall neuropathologic score for each rat. This variable was analyzed by Kruskal-Wallis ANOVA across all groups, followed by one-tailed Wilcoxon's signed rank test, comparing treatment groups with the control group, if P < 0.05 on ANOVA. Spearman correlation coefficients were calculated for the relationships between plasma fentanyl concentration, power on spectral analysis of EEG, and overall neuropathologic grade.

Results

Physiologic variables measured during baseline and opioid infusion in rats are listed in Table 1. During the baseline period the only difference between groups was with the 200-8 group where PaO2 was lower (110 +/- 10 mm Hg) than in the control group. The lowest PaO2 in the 200-8 group was 99 mm Hg. With the LD of fentanyl, lowest mean arterial pressure was 99 +/- 4 mm Hg, occurring in the 100-4 group. However, there were no statistically significant between-group differences in post-LD maximum or minimum blood pressures. With opioid infusion several statistically significant differences from the control group occurred in PaO2, mean arterial pressure, rectal temperature, and blood glucose. Opioid infusion was associated with moderate increases in blood pressure throughout the infusion period. After 30 min of opioid infusion, blood glucose was higher than the control group in the fentanyl larger dose groups, although this difference was not present by the end of the infusion. In addition, PaO2 continued to be lower in the 200-8 group than in the control group with the lowest individual PaO2 93 mm Hg. By the end of the opioid infusion, there was a moderate increase in rectal temperature in the 100-4 and 200-8 groups, compared to the control group.

Table 1
Table 1:
Physiologic Variables

Fentanyl concentration increased progressively with each sequential increase in infusion rate (Table 2). Significant differences from the control group occurred in the 200-8, 800-32, 1600-64, and 3200-128 groups.

Table 2
Table 2:
Plasma Fentanyl Concentrations

Fentanyl administration was associated with activation of EEG in rats, with power generally increasing with larger doses (P = 0.01 on ANOVA) during opioid infusion, and correlating with the plasma fentanyl concentrations (P < 0.001) (Figure 1). EEG power normalized to baseline was significantly greater in the 400-16 and 1600-64 groups compared to the control group during fentanyl infusion (P < 0.05) (Figure 2). Total power during (P < 0.01) and after (P < 0.001) opioid infusion correlated with the overall neuropathologic score.

Figure 1
Figure 1:
A, Averaged compressed spectral arrays for the control dose group. Using the loading dose (LD) as the zero time point, Fourier transformed data were averaged at corresponding points before and after the LD. The large scaling spike at the LD is 107 micro V2, placed on each Figure at17 Hz on the horizontal axis. Note that this spike indicates different scales between the figures. This was done to appropriately fit the spectra in each plot. Each Figure includes2 h of infusion after the LD. B, Averaged compressed spectral arrays for the 800-32 dose group. The format is the same as in Figure 1A. (Group names are defined in text, based on the loading dose (LD, micro g/kg) and maintenance dose (MD, micro g [centered dot] kg-1 [centered dot] min-1).
Figure 2
Figure 2:
Summated and averaged power spectra. For each rat, power spectra were averaged over the following time periods: 30 min before loading dose (baseline), after 2 h of fentanyl infusion (opioid period), and 15 min after infusion was completed (postopioid). Averaged spectra were then transformed as a percentage of baseline (+/- SEM) for each group of animals and plotted as shown. * P < 0.05 versus the control group. The groups are based on fentanyl loading dose (LD) and maintenance dose (MD); e.g., 50-2 = LD 50 micro g/kg-MD 2 micro g [centered dot] kg-1 [centered dot] min-1.

There were no lesions observed in the brains of any of the control or 200-8 group rats (Table 3 and Figure 3). Statistically significant differences from the control group's overall neuropathologic score occurred in the 400-16, 800-32, 1600-64, and 3200-28 groups. Plasma fentanyl concentrations correlated with the overall neuropathologic score (P = 0.03 and P = 0.02 for samples drawn after 15 and 120 min of fentanyl infusion, respectively).

Table 3
Table 3:
Neuropathologic Data
Figure 3
Figure 3:
Fentanyl-induced brain damage. The number of animals with normal histology is noted as a function of progressively increasing fentanyl dose for each brain area. n = 5 per group. LD = loading dose; MD = maintenance dose. Group names are defined in text based on LD and MD.

One of the rats in the 50-2 group had foci of mild eosinophilic neuron degeneration and neuropil vacuolation within the cerebellar cortex, but this neuroanatomic area was not affected in any other rat from any group. One of the five rats in the 100-4 group had mild to moderate degrees of neuron degeneration within at least four limbic system regions. Several rats in each of the 400-16 and larger dose groups also had evidence of neuropathologic change within the limbic system, with the greatest degree of effect being evident within the 800-32 group.

The primary histopathologic alteration seen in the fentanyl-dosed rats was one of acute eosinophilic neuron degeneration. On low magnification, the degenerating (necrotic) neurons were characterized by nuclear pyknosis and by the presence of perineuronal retraction spaces (Figure 4A, Figure 4B, and Figure 4C). In areas of marked neuron degeneration, secondary vacuolation of the neuropil, malacia, or hemorrhage were occasionally present (Figure 4B). On higher power examination, the necrotic neurons were found to have brightly stained eosinophilic cytoplasm (Figure 5B). Lesions were primarily confined to the limbic system and its associated areas and were most consistently present within the piriform and entorhinal cortices and within the hippocampus. For the hippocampus, the large pyramidal neurons (Figure 5A and Figure 5B) were more frequently affected than the granular neurons of the dentate gyrus (Figure 6A and Figure 6B), but both areas were affected in some animals.

Figure 4
Figure 4:
A, Medium-power photomicrograph of a normal-appearing piriform cortex. This micrograph is of the posterior portion of the piriform cortex present on the lateral aspect of the temporal lobe (control group rat; hematoxylin and eosin x100). B, Medium-power photomicrograph of the same portion of the piriform cortex as is shown inFigure 4A. However, this micrograph is of a rat in Group 400-16. The majority of the neurons are surrounded by haloes, indicating cell retraction and, therefore, cell death. A slight degree of malacia is present within the outer layer of the cortex (bottom edge of tissue). The adjacent meningeal layer is expanded and moderately cellular, and mild multifocal acute perivascular hemorrhage is also present (Group 400-16 rat; hematoxylin and eosin x100). C, Medium-power photomicrograph of the anterior portion of the piriform cortex of a rat in Group 400-16. In contrast to the diffuse neuronal degeneration evident within Figure 4B, damage within this area is patchy, and the contrast between undamaged and damaged regions of the cortex is, therefore, more readily apparent. The neurons at the lower right are relatively normal in appearance. However, within the left and central portions of the micrograph, the neurons are shrunken and have pyknotic nuclei and perineuronal retraction spaces. The cytoplasm of the necrotic neurons is eosinophilic, but this cannot be appreciated in this black and white micrograph (Group 400-16 rat; hematoxylin and eosin x100). (Note: Perineuronal retraction spaces represent an artifact of tissue processing, but this histologic change is enhanced by the presence of cell death and should not be present in perfusion-fixed tissues.)
Figure 5
Figure 5:
A, High-power photomicrograph of the hippocampal CA4 regional of a control group rat. The pyramidal neurons are normal in appearance (hematoxylin and eosin x430). B, High-power photomicrograph of the hippocampal CA4 region of a rat in Group 400-16. The majority of the pyramidal neurons have shrunken pyknotic nuclei. The cytoplasm surrounding these nuclei is retracted and, on sections stained with hematoxylin and eosin, is brightly eosinophilic. Scattered microglial cells (with elongated, irregularly contoured nuclei) are also present (Group 400-16 rat; hematoxylin and eosin x430).
Figure 6
Figure 6:
A, Medium-power photomicrograph of a normal-appearing dentate gyrus from the dorsal portion of the hippocampus of a control group rat (hematoxylin and eosin x100). B, Medium-power photomicrograph of the dentate gyrus from the dorsal portion of the hippocampus of a rat in Group 400-16. The lower and right-hand portions of the gyrus are relatively normal, but a focus of marked neuron degeneration is present within the central and upper portions. As in other areas of the brain, the process of neuron degeneration is characterized by neurons which have shrunken pyknotic nuclei and retracted eosinophilic cytoplasm. An influx of microglial cells contributes to the hypercellular appearance of the lesioned areas (Group 400-16 rat; hematoxylin and eosin x100).

Discussion

Previous studies have indicated that opioids can produce limbic system hypermetabolism and brain damage [1-4]. However, in each study the neurotoxic doses of opioid were rather large, equal to or exceeding what might be considered "cardiac" or full-anesthetizing doses in rats. Therefore, it has become important to determine whether opioids can produce brain damage at smaller doses which might be considered to mimic in rats the dose ranges used in humans. Moreover, it is helpful to ascertain whether there might be a submaximal dose associated with the most extensive brain damage, as such information may give hints regarding the mechanism of neurotoxicity.

Our data confirm that fentanyl produces brain lesions in rats across a range of doses. Moreover, because the rats in our experiments underwent perfusion-fixation seven days after opioid infusion, it is likely that the lesions were not a transient abnormality. Kissin et al. [5] assessed fentanyl effects in rats over a range of end points which model basal analgesia, hypnosis, and stress-free anesthesia. Their data indicate 50% effective dose values for fentanyl in Sprague-Dawley rats as follows: tail clamp 10 micro g/kg, loss of righting reflex 25 micro g/kg, and lack of tachycardia to tail clamp 366 micro g/kg. Our 400-16 group corresponds to their largest dose group. Two of the five rats in this group sustained marked to severe damage in some brain areas (Table 3). Plasma fentanyl levels were similar at the beginning and end of the infusion, ensuring that a stress-free dose was maintained throughout the infusion. If Kissin et al.'s largest dose group corresponds to a stress-free large-dose opioid paradigm commonly used in humans, our data may indicate that opioid neurotoxicity can occur in rats at doses comparable to those used clinically.

Opioids produce seizures in both in vivo and in vitro preparations [1-4,6-9]. However, there have been disparate observations. For example, in one investigation, intracerebroventricular administration of morphine produced seizure activity, which was abolished by intravenous administration of morphine [9]. Opioids are thought to produce seizures by inhibition of inhibitory neurons producing, in effect, disinhibition of glutamatergic excitatory neurons [6,8]. In addition, there are some reports of micro opioids having glutamatergic effects through other mechanisms [10]. At the membrane level, however, opioids appear to have a uniform hyperpolarizing effect on neuronal membranes [7]. There is a suggestion in our data that there may be dose-related disparate effects of opioids. Inspection of Figure 3 and Table 3 suggests a nonlinear relationship, with possibly a decrease in opioid neurotoxity at the largest doses. Perhaps opioid inhibitory effects may first occur in the interneurons, thereby disinhibiting glutamatergic cells, followed by hyperpolarization of all cells with larger doses and thus, inhibition of the glutamatergic cells.

Many anesthetics have both proconvulsant and anticonvulsant properties [11]. It is thus congruent with these observations, therefore, that fentanyl also may have dose-related variable effects on seizure activity. Taken altogether, studies of these various anesthetics suggest that the brain exists in a delicate equilibrium between excitation and inhibition and, depending on the circumstances, any anesthetic may alter the equilibrium to elicit either excitation, manifest as seizure activity (possibly risking brain injury if sustained), or inhibition, manifest as EEG suppression and a hypnotic state.

Kofke et al. [1] in a previous study, reported that large-dose alfentanil produced (a) epileptiform activity on scalp and hippocampal EEG recordings, (b) increased glucose utilization in the ventral hippocampus, and (c) limbic system lesions with particular susceptibility in amygdala. Our neuropathologic and scalp EEG observations with progressively increasing fentanyl doses are qualitatively similar to those in this earlier alfentanil report. Given the prior report of fentanyl-induced hippocampal hypermetabolism in rats [4] and our pathologic data, it seems likely that limbic system epileptiform activity and hypermetabolism occurred in the rats we studied. It is unclear whether the epileptiform activity and the hypermetabolism, either jointly or singly, are essential components of the pathogenesis of opioid-induced brain damage. We have recently observed phenytoin-mediated amelioration of opioid-induced brain damage, but without complete ablation of epileptiform activity on scalp EEG [12].

We chose to use total power as an electrographic quantitative indicator of activation with concurrent qualitative observation of unprocessed EEG. This is a procedure which has not undergone scrutiny to determine its specificity for activation due to seizure versus increased power due to high-amplitude slowing. It is thus possible that nonspecific, nonepileptiform slowing contributed to the statistically significant electrographic effects we observed.

Fentanyl-treated rats, particularly those receiving larger doses, exhibited higher blood glucose concentration and blood pressure. This has been discussed in a prior report [2]. Prior studies indicate no effect of glucose on seizure-induced brain damage [13,14]. It is thus unlikely that the modest hyperglycemia we observed with fentanyl administration contributed to brain damage. If hypermetabolism is important in the pathogenesis of opioid neurotoxicity, increased blood glucose should be protective. However, this is a complex notion, as we observed a protective effect with blood pressure reduction [2]. The protective effect we observed in this earlier study was likely due in part to ganglionic blockade with its attendant catecholamine-reducing side effects [15].

It is noteworthy that another substance, domoic acid, produces a pattern of brain injury in rats [16,17], similar to that seen with opioids. Additionally, it has been given to subhuman primates [18], and has been ingested by humans [19,20] with a pattern of injury quite similar to that seen in rats. Such observations indicate that it is possible that a limbic system convulsant, which activates the limbic system in rats, can have similar effects in humans. It is thus of interest that fentanyl administered to monkeys in preliminary experiments increased qualitative glucose utilization in the temporal lobes, similar to that seen in rodents [21]. Epileptiform activity has been observed with opioids administered to both epileptic [22,23] and nonepileptic [24] humans. It is unclear whether such intermittent spiking activity, such as these reports describe, is deleterious.

In many animal models, sustained seizures without hypoxemia produce brain damage [1,2,25,26]. Evidence suggests that sustained seizures also produce brain damage in humans [27]. However, it is unknown whether such sustained seizure activity can occur in opioid-treated humans, or whether it would be neurotoxic if it did occur in humans. Thus, although there is ample circumstantial evidence that some deleterious opioid effects seen in animals occur in primates, at this time the clinical relevance of these observations can only be a source of speculation.

The authors gratefully acknowledge the assistance of Margaret Morriello, Cynthia Hladik, and Carol Campbell in manuscript preparation and Francie Siegfried for editorial review.

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