Prescription Opioid Misuse: Comparison
Please note this is a comparison between Version 4 by Maria Carla Gerra and Version 3 by Camila Xu.

Prescription opioids are used for some chronic pain conditions. However, generally, long-term therapy has unwanted side effects which may trigger addiction, overdose, and eventually cause deaths. Opioid addiction and chronic pain conditions have both been associated with evidence of genetic and epigenetic alterations. Despite intense research interest, many questions about the contribution of epigenetic changes to this typology of addiction vulnerability and development remain unanswered. The aim of this review was to summarize the epigenetic modifications detected in specific tissues or brain areas and associated with opioid prescription and misuse in patients who have initiated prescribed opioid management for chronic non-cancer pain. The review considers the effects of opioid exposure on the epigenome in central and peripheral tissues in animal models and human subjects and highlights the mechanisms in which opioid epigenetics may be involved. This will improve our current understanding, provide the basis for targeted, personalized pain management, and thus balance opioid risks and benefits in managing chronic pain.

  • epigenetics
  • prescription opioids
  • pain

1. Introduction

Chronic pain represents significant public health concerns and prescription opioids are a common treatment option for cancer pain management, for end-of-life treatment, in relation to surgery, and for short-term use in severe acute/chronic pain conditions not related to cancer [1]. The non-medical use of opioids and their negative health consequences among people who use drugs have been studied since 2007 after the spread of the opioid crisis. However, in the last few years, we have witnessed a new opioid crisis, even among young people and categories of workers, particularly in North America, the Middle East, Asia, and Africa. This crisis is related to the non-medical use of prescription opioids that can result in opioid misuse, defined as “use contrary to the directed or prescribed pattern of use, regardless of the presence or absence of harm or adverse effects” [2]. Signs of an increase in methadone, buprenorphine, fentanyl, codeine, morphine, tramadol, and oxycodone misuse and the increased prescription rates for opioids for pain management have also been observed in Europe resulting in an increase of vulnerable cohorts of long-term opioid users [3]. The central issue is that long-term opioid therapy is associated with many side effects such as addiction, development of tolerance, and opioid-induced hyperalgesia. In addition, in 2018 more than one-third of overdose deaths involved pharmaceutical opioids with the number of overdose deaths rising from 3442 in 1999 to 17,029 in 2017 [4][5].

Opioid drugs act not only in nociceptive processes but also in modulating gastrointestinal, endocrine, and autonomic functions, as well as in affecting cognition and reward systems [6]. The relationship between pain states and substance abuse/misuse has been recently examined. Opioids carried an increased susceptibility to abuse even during initial exposure for pain treatment; in particular, when too many opioid drugs are prescribed for conditions not supposed to be treated by opioids or if healthcare systems are not set up to control the number of opioid prescriptions to an individual patient (doctor shopping) [7][8][9].

Nevertheless, it is important to note that the lack of consistent findings regarding the identification of personal risk factors that may predict opioid misuse in chronic pain patients was recently evidenced in the literature [10]. Among the possible risk factors, the individual genetic variability in conjunction with chronic pain, both affecting stress and reward systems, lead to differential responses to opioids and may determine the transition risk from therapeutic use to opioid addiction. Addiction is a multifactorial condition as both genetics and psychosocial factors can trigger opioid addictive behaviors. Polymorphisms in the μ -opioid receptor 1 ( OPRM1 ), the cytochrome P450 2D6 ( CYP2D6 ), the catechol-O-methyl transferase ( COMT ) genes and in the ATP-binding cassette family genes have been found to be associated with differences in morphine consumption and metabolization process [11]. The main environmental factors important for developing opioid/substance abuse are described as psychiatric medication prescriptions, mood disorders, specific mental health diagnoses, and adverse childhood experiences [12][13].

The aim of this review was to report the collected data from published studies on the identified epigenetic modifications associated with opioid prescription and misuse in patients who have initiated prescribed opioids for pain.

2. Specifics

All the publications collected in the literature search phase underwent abstract screening to determine eligibility for full-text data extraction. To be eligible for data extraction, studies met the following inclusion criteria: (1) the selected publications were in English language only; (2) the samples were composed of animal models to study chronic pain or human subjects with chronic noncancer pain (persistent pain lasting longer than 3 months), (3) participants were exposed to or were using prescription opioids, (4) the abstract listed one or more of the following terms in reference to potential epigenetic changes: DNA methylation, histone, chromatin, non-coding RNAs, microRNAs, gene or protein expression. Studies related to genetic polymorphisms, which are changes in the DNA sequence, were excluded from the review.

Finally, to identify potentially relevant studies not detected through the main screening, a few articles were selected from other reviews.

A thorough screening of the collected papers was conducted based on the inclusion criteria and quality of the experiments (methods typology to detect the epigenetic changes, adequate description of study methodology, sample size, and inclusion/exclusion criteria). Analyzing the identified papers, three main categories were evidenced and grouped in Table 1 , Table 2 and Table 3 , respectively: (i) studies investigating epigenetic changes in animal models (16), (ii) studies involving human subjects (3), and (iii) studies related to intergenerational or transgenerational prescribed opioid effects (5). Among the three studies on human subjects, one was related to cancer pain patients [14]. Nevertheless, it was included because considered relevant.

Table 1. Epigenetic changes after prescribed opioid exposure in experimental models.
OpioidsTissues/SampleEpigenetic MethodsChangeAnimalsFindingsPMIDAuthors
Table 2. Epigenetic changes after prescribed opioid exposure in humans.
OpioidsTissuesFindingsPMIDAuthors
]
Table 3. Intergenerational/transgenerational prescribed opioid effects.
OpioidsEpigenetic MethodsChangeTissues/SampleEpigenetic MethodsChangeSampleOrganismFindingsPMIDAuthors
MorphineBrain tissues

(PAG, PFC, temporal lobe, and ventral striatum)
Microarray gene expression profiling and pattern matching
OpioidsWhole bloodBisulfite modification and Array-based genome-wide DNA methylation assayGene expressionAdult male miceThe development of tolerance is influenced by a region in OPRM1 gene. The genes epigenetically modified by chronic morphine administration are mainly related to neuroadaptation.DNA methylation at specific CpG sites19386926140 opioid dependence cases and 80 opioid-exposed controlsThree genome-wide significant differentially methylated CpGs map to genes involved in chromatin remodeling, DNA binding, cell survival, and cell projection (PARG, RERE, and CFAP77 genes).Tapocik et al., 2009 [15]
31801960Montalvo-Ortiz et al., 2019
OxycodoneRat brains[31]
Quantitative RT-PCRGene expressionTimed pregnant Sprague-Dawley ratsExposed rat pups have lower birth weight and postnatal weight gain and greater congenital malformations. Endothelin B receptor expression is altered in the brain of oxycodone-treated rat pups indicating a possible delay in CNS(central nervous system) development.26676852Devarapalli et al., 2016 [33]MorphineNAcChromatin immunoprecipitation followed by massive parallel sequencingH3K9me2 distribution in NAc in the absence and presence of chronic morphineOpioid medication self-administration (hydrocodone, oxycodone, and codeine: 5–30 mg)9 to 11-week-old C57BL/6J male mice or G9afl/fl miceSaliva collected at 3 time pointsGenome-wide DNA methylation assay and candidate approachDNA methylation at OPRM1 gene promoterChronic morphine decreases G9a expression and H3K9me2 at global level and in specific loci in mouse NAc.2319773633 opioid-naïve participants who underwent standard dental surgeryHypermethylation of the OPRM1 promoter is measured in response to opioid use, and such epigenetic restructuring can be induced even by short-term use of therapeutic opioids.Sun et al., 2012 [3249346116]
Sandoval-Sierra et al., 2020 [32]
Methadone or buprenorphineCord blood or salivaSequencing of bisulfite-treated DNADetermination of Percent DNA Methylation86 infants with Neonatal Abstinence Syndrome from mothers receiving methadone or buprenorphine during pregnancyHigh methylation of three specific CpG sites of the OPRM1 promoter identified is associated with a worse outcome for Neonatal Abstinence Syndrome.24996986Wachman et al., 2014 [34]MorphineCentral nucleus of amygdalaChromatin immunoprecipitationGene and protein expressionFemale mice with persistent and acute painPersistent pain and repeated morphine upregulate the transcriptional regulator MeCP2. MeCP2 enhances BDNF expression and represses G9a action and its repressive mark H3K9me2 in CeA.24990928Zhang et al., 2014 [17]
Remifentanil, oxycodone, codeineWhole bloodBrain-derived extracellular vesiclePyrosequencing at specific CpG sites and LINE1 (global genome-wide DNA methylation assay)RNA sequencingMicroRNA expressionMale and female Sprague Dawley ratsDistinct miRNA signatures are identified in brain-derived extracellular vesicle at a key stage of brain development in offspring that were in utero and postnatal oxycodone-exposed.31861723Shahjin et al. 2019 [35]MorphineCentral nucleus of amygdalaChromatin immunoprecipitationGene expressionRat model of morphine self-administrationThe repression of GluA1 function by MeCp2 is proposed as a mechanism for morphine-seeking behavior in pain experience.25716866Hou et al., 2015 [18]
MorphineNAcQuantitative RT-PCRGene expressionFemale Sprague-Dawley ratsIncreased expression of KOR (K opioid receptor gene) and DRD2 (Dopamine 2 receptor gene) in response to repeated administration of quinpirole (a D2/D3 receptors agonist) in the progeny of females exposed to opiates during adolescence (also observed in the F2 generations).MorphineDorsal root ganglia and spinal cord tissuesQuantitative RT-PCR, Western Immunoblotting and ChIP-PCRGene and protein expression, histone modifications analysisMale Sprague-Dawley rats SNL (spinal nerve ligation) modelG9a contributes to transcriptional repression of MORs in primary sensory neurons in neuropathic pain. G9a inhibitors: potential treatment of chronic neuropathic pain26917724Zhang et al., 2016 [19]
MorphineDorsal root gangliaQuantitative RT-PCR and Western BlotGene and protein expressionAdult male CD-1 miceNeuropathic pain increases C/EBPβ expression. C/EPBβ activates the G9a gene, that epigenetically silences Kv1.2 and MOR genes. Blocking the induced increase in C/EBPβ in the DRG, morphine analgesia after CCI is improved.28698219Li et al., 2017 [20]
MorphineBasolateral amygdalaQuantitative RT-PCR and Western BlotGene and protein expressionMale Sprague–DawleyIncrease in H3K14ac together with upregulation of the BDNF and FosB; and CREB activation.24829091Wang et al., 2015 [21]
MorphineRat brain regionsPyrosequencingDNA methylation (5mC) and global DNA 5-hydroxymethylation (5hmC)Male Wistar ratsAcute and chronic exposure is associated with significantly decreased/increased 5mC at specific genes (BDNF, IL1B, IL6, NR3C1, COMT). Global 5hmC levels increase in the cerebral cortex, hippocampus, and hypothalamus, but decrease in the midbrain.29111854Barrow et al., 2017 [22]
23314440Morphine, phentaylHippocampusRNAseqGene and protein expressionMice chronically treated with μ-opioid agonistsThe increased expression of MiR-339-3p inhibits intracellular MOR biosynthesis and acts as a negative feedback modulator of MOR signals.23085997Wu et al., 2013 [23]
Byrnes et al., 2013 MorphineDorsal root gangliaQuantitative RT-PCR and Western BlotGene and protein expressionMale CD-1 mice treated with morphine to establish systemic chronic tolerance to morphine anti-nociception[24]
DNA methylation140 women with persistent pain after breast cancer surgeryThe global DNA methylation is shown to be a pain predictive biomarker, providing useful information to allocate the patients to either a “persistent pain” or “non-persistent pain” phenotype.[36]
Morphine self-administrationNAcRNA deep sequencing and qPCRGene expressionFemale adolescent Sprague Dawley ratsGenes related to synaptic plasticity and the myelin basic protein are dysregulated; some effects persisted into the subsequent generation.27729240MorphineDorsal root gangliaQuantitative RT-PCR and Western BlotGene and protein expressionMale CD-1 mice injected with morphine to elicit morphine toleranceThe increased BDNF expression is regulated by the miR-375 and JAK2/STAT3 pathway. Inhibition of this pathway decreases BDNF production, and thus, attenuated morphine tolerance.28603428Li et al., 2017 [25]
31775878Kringel et al., 2019 [14Vassoler et al., 2017 [37]MiR-219 contributes to the development of chronic tolerance to morphine analgesia by targeting CaMKIIγ and enhancing CaMKIIγ-dependent brain-derived neurotrophic factor expression.27599867Hu et al., 2016 OxycodoneVentral tegmental area of the developing brainQuantitative RT-PCR and chromatin immunoprecipitationGene expression and histone modifications analysisMale offspring of C57Bl/6NTac miceAdolescent oxycodone exposure increases the repressive mark H3K27me3, at key dopamine-related genes.33325096Carpenter et al., 2020 [26]
OxycodoneStriatum (NAc and CPu)RNAseqGene expressionMice following extended 14-day oxycodone self-administrationAlterations in the expression of

heterodimer receptor, integrins, semaphorins, semaphorin receptors, plexins, selective axon guidance genes.
29946272Yuferov et al., 2018 [27]
Oxycodone
OxycodoneDorsal striatum and ventral striatumRNAseqGene expressionAdult male C57BL/6J mice underwent a 14-day oxycodone self-administrationInflammation/immune genes have altered expression during chronic self-administration of oxycodone28653080Zhang et al., 2017 [28]
OxycodoneHippocampusDNA ELISA Kit for total 5mC; quantitative RT-PCRGlobal 5mC levels and gene expressionMale Sprague-Dawley ratsThe global DNA hypomethylation induced by oxycodone can be reversed through oxytocin and could significantly attenuate the oxycodone rewarding effects.31526808Fan et al., 2019 [29]
OxycodoneVentral tegmental areaDNA ELISA Kit for total 5mC and OneStep qMethyl™ kit for gene-specific 5mC, quantitative RT-PCR, Western blottingGlobal and specific 5mC levels and gene expressionSprague-Dawley ratsDown-regulation of DNMT1 and up-regulation of TET1-3 lead to a decrease in global 5mC levels and differential demethylation at exon 1 of SYN and exon 2 of PSD95.31735530Fan et al., 2019 [30]

Moreover, within the three subgroups, the articles were listed in the tables by the type of opioids (morphine, oxycodone, etc.). It thus became clear that the identified studies primarily investigated the morphine exposure effect on gene expression and chromatin modifications. Among the studies exploring oxycodone exposure in animal models, experiments measuring DNA methylation and DNA hydroxymethylation were selected. The few studies that considered these effects on human subjects were focused on DNA methylation. Interestingly, the screening revealed a group of articles related to the intergenerational and transgenerational effects of the epigenetic marks identified. Hence, the related remarkable information was described in a dedicated paragraph. In light of the few human studies identified, a paragraph about the epigenetic research related to heroin users was included to represent how these modifications have been studied in human subjects and to give future directions for the prescription opioid research related to different pain conditions.

3. Opioids

The nociceptive response was demonstrated to activate these epigenetic mechanisms by modulating pain genes and possibly mediating the transition from acute to chronic pain. Studies highlight that also opioids are involved in diverse types of epigenetic regulation and thus they might influence the analgesic effects or the increased risk of continued opioid intake and development of a substance use disorder following long-term opioid therapy [38][39].

Other studies focused on the rewarding effects of the widely abused prescription drug oxycodone, exploring related gene expression and DNA methylation changes after a period of chronic oxycodone self-administration. In particular, RNA-sequencing in the NAc and caudate-putamen (CPu) of mice following extended 14-day oxycodone self-administration revealed differential expression of the axon guidance molecule integrins, semaphorins, and ephrins, which may correspond to alterations in the axon-target connections and synaptogenesis and thus to the oxycodone-induced neuroadaptations [27]. In addition, levels of numerous glial-specific and immune cell-specific genes were also found to be altered in the CPu and NAc consistent with a previous study identifying altered expression of genes related to the inflammation and immune functions [28]. Furthermore, two interesting studies in the rat VTA and hippocampus, respectively, demonstrated that the oxycodone induction of CPP acquisition was associated with changes in gene expression and DNA methylation. Specifically, a down-regulation of DNMT1 and up-regulation of TET1-3 were observed in the VTA leading to a decrease in global DNA methylation levels and differential demethylation of the SYN and PSD95 genes with consistent higher expression of these synaptic proteins and the synaptic density [30]. In the hippocampus, global hypomethylation, higher synaptic density, and increased expression of specific synaptic genes, SYNAPSIN, SHANK2 , and GAP4 , were observed, too [29]. In addition, these studies suggested the therapeutic potential of oxytocin to prevent oxycodone addiction. In fact, oxytocin pretreatment markedly inhibited the acquisition of oxycodone CPP and restrained stress-induced reinstatement of oxycodone. Consistently, the synaptic density and the global DNA hypomethylation induced by oxycodone were normalized and the transcription of synaptic genes and DNA methylation enzyme genes was restored [29][30].

The studies investigating intergenerational and transgenerational epigenetic changes following prescription opioid exposure are reported in Table 3 .

The role of miRNAs, 18-25 nucleotide non-coding sequences with a wide range of regulatory roles in gene expression and neuronal functions, was also investigated in heroin-seeking behavior. MiR-218 was found to regulate many neuroplasticity-related genes and target the methyl CpG-binding protein 2 (Mecp2), thus inhibiting heroin-induced reinforcement [40].

  • Prescription opioids are used for some chronic pain conditions. However, generally, long-term therapy has unwanted side effects which may trigger addiction, overdose, and eventually cause deaths. Opioid addiction and chronic pain conditions have both been associated with evidence of genetic and epigenetic alterations.
  • The present review summarizes the epigenetic factors that are associated with prescription opioids used for pain (Tables 1, 2, 3 and Figures 1 and 2 at [1]).
  • Among the potential biomarkers/therapeutic targets identified, of special interest is the histone methyltransferase G9a, the role of which should be explored in detail.
  • The studies conducted in humans are insufficient for the purpose of biomarker identification and the underlying epigenetics remains poorly understood. From these studies, the first evidence of the causal relationship between therapeutic opioid administration and epigenetic changes was revealed and research should further explore the temporal dynamics of these modifications in response to both prescription opioids administration and pain.
  • Exploring these pathways could reveal the molecular mechanisms and potential therapeutic targets for preventing chronic pain and addiction.

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