Nitric Oxide Synthase Inhibition Modulates the Ventilatory Depressant and Antinociceptive Actions of Fourth Ventricular Infusions of Morphine in the Awake Dog

Background The role of nitric oxide (NO) production, at the brain-stem level, in ventilatory control and pain perception is poorly understood. Furthermore, it is not clear whether NO synthase (NOS) inhibition can affect morphine-induced ventilatory depression or analgesia. The central hypothesis of this investigation was that NO, at supraspinal sites, can influence ventilation and nociception and can modulate the ventilatory depressant and antinociceptive actions of morphine. Using drug delivery via the fourth cerebral ventricle, the authors examined the ventilatory and nociceptive effects of an NOS inhibitor and an NO donor in the presence or absence of morphine sulfate (MS). Methods The studies were performed in awake dogs that were restrained in a stanchion using a fourth ventricle to cisterna magna perfusion system. The dogs were chronically prepared with fourth ventricle and cisterna magna guide cannulae, femoral arterial/venous catheters, and a tracheostomy. Agents were prepared in a temperature- and pH-controlled artificial cerebrospinal fluid, perfused at 1 ml/min through the fourth ventricle cannula, and permitted to flow out through the cisterna magna cannula. The authors measured PaCO2, ventilatory drive (inspiratory occlusion pressures during carbon dioxide rebreathing), and nociception (hindpaw withdrawal threshold to increasing electrical current). Study groups were organized according to the following perfusion sequences (40 min each step): (1) MS (1 microgram/ml)-->MS + the NOS inhibitor, nitro-L-arginine (L-NA; 10(-6), then 10(-5) M)-->MS + L-NA (10(-5) M) + the NO donor, S-nitroso-acetylpenicillamine (SNAP; 10(-4) M); (2) SNAP (10(-5) M)-->SNAP (10(-4) M); (3) L-NA (10(-6), then 10(-5) M)-->L-NA (10(-5) M) + MS (1 microgram/ml)-->L-NA (10(-5) M) + MS + SNAP (10(-4) M); (4) MS (1 microgram/ml)-->MS + SNAP (10(-4) M); and (5) continuous MS (1 microgram/ml) perfusion (time control). Each perfusion sequence was preceded by a 45- to 60-min perfusion with drug-free artificial cerebrospinal fluid, during which time baseline values for each measured variable were obtained. Results Nitro-L-arginine alone dose dependently and significantly reduced PaCO2 and increased the nociceptive threshold. S-nitroso-acetylpenicillamine alone did not change the ventilation or nociceptive threshold. Morphine sulfate elicited a marked increase in PaCO2, a decrease in ventilatory drive, and an increase in nociceptive threshold (P < 0.05 compared with baseline). With L-NA pretreatment (sequence 3), but not posttreatment (sequence 1), MS-induced ventilatory depression, relative to baseline, was significantly attenuated. For both the L-NA pre- and posttreatment protocols, combined MS/L-NA perfusions produced a significantly greater antinociceptive effect than seen when MS was given alone. The L-NA effects on MS-induced ventilatory depression and antinociception were reversed with SNAP coadministration. Conclusions Endogenous NO, produced at supraspinal sites, acts as a ventilatory depressant and as a nociceptive mediator. When NOS is inhibited, the ventilatory depressant actions of morphine can be reduced and the antinociceptive actions of morphine can be potentiated. However, NOS inhibitor treatment is more effective in suppressing morphine-induced ventilatory depression when given before, rather than after, morphine administration. The specific mechanisms involved in these actions remain to be identified.