Opioid-induced respiratory depression (OIRD) can result in fatal respiratory arrest. The current gold standard for intervention is opioid displacement using high affinity opioid receptor antagonists, like naloxone (NLX), which reverse OIRD and, undesirably, opioid analgesia. We recently reported in rats that the most lethal clinically used opioid fentanyl (60 nmol/kg, i.v.) causes OIRD that is reversed by systemic NLX (2.5 µmol/kg, i.v.). Multiple reports indicate that systemic NLX rapidly triggers release of the analgesic neuropeptide oxytocin (OXTN) from the hypothalamic paraventricular nucleus (PVN) both in opioid-dependent and opioid-naïve rats. Given that OXTN microinjections into specific nodes of the respiratory network can stimulate breathing, we hypothesized that OXTN can reverse fentanyl OIRD. We recorded phrenic nerve activity (PNA) to index neural inspiration in anesthetized (urethane/chloralose), vagotomized, paralyzed and artificially ventilated rats and determined that systemic peptide and non-peptide activation of OXTN receptors robustly reversed PNA arrest by fentanyl (60 nmol/kg, i.v.) (P<0.0001, n=4-6). Because nearly all systemic NLX-induced OXTN release is from the PVN, we tested the possibility that PVN NLX could counteract OIRD.PVN NLX (3 nmol/kg, 50 nL) not only reversed PNA arrest by fentanyl (60 nmol/kg, i.v.) (P=0.0238, n=3), but prevented it altogether (P=0.0107, n=3-4). To determine whether direct stimulation of PVN OXTN neurons could reverse fentanyl OIRD, we used an optogenetic approach. Mice with channelrhodopsin selectively expressed in OXTN neurons were anesthetized (ketamine-acepromazine-xylazine) and instrumented with arterial and venous catheters along with an optical fiber cannula dorsal to PVN. While spontaneously breathing, expired CO2 was used to monitor rhythmic ventilation and to quantify bradypnea during OIRD. Following systemic fentanyl (60 nmol/kg, i.v.), blue light (473 nm, 12 mW) pulses (10 ms, 20 Hz) were delivered to the PVN using a 5 s On/1 s Off pattern for 3 min. Photo-stimulation, which did not stimulate basal respiration rate (P=0.9056), prevented lethal effects of fentanyl OIRD (P<0.0001, n=3). Whereas dummy pulses during fentanyl OIRD permitted apneas as long as 51.1±16.5 s and proved to be lethal, optogenetic stimulation significantly attenuated apneas to a maximum 2.9±1.6 s (P<0.0001) and resulted in respiratory rate progressively recovering to 60.7±0.4% of baseline by the end of photo-stimulation. Although the expired CO2 increase post-fentanyl was similar (P=0.0334-P<0.0001) prior to PVN photo-stimulation between cohorts receiving blue light and dummy pulses (P=0.2171), the latter failed to prevent lethal respiratory arrest (P<0.0001). Findings indicate that systemic treatment with OXTN receptor agonists and activation of PVN OXTN neurons, both previously demonstrated to be analgesic, can reverse fentanyl overdose in rodents without requiring analgesia-reversing opioid receptor antagonism.
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