2.3. Evaluation of Treatments in Pain Models
This study investigated the efficacy of subchronic treatment using a combination of Cannabis sativa extract with a high cannabidiol content and the nutraceuticals Chronic® and Chronic In®, developed from the phytocomplex oil extract of Bixa orellana L., to alleviate pain in animals. We assessed the analgesic activity using four distinct methods: the acetic acid-induced writhing test, the formalin test, the hot plate test, and the cold-water tail withdrawal test.
The acetic acid-induced writhing technique is commonly employed to assess the efficacy of peripheral analgesic agents or visceral inflammatory pain management (Bunman et al., 2022). Acetic acid triggers an inflammatory response in the abdominal cavity, activating the nociceptor (Foss et al., 2021a). This model of visceral pain, induced by acetic acid nociception, is non-specific and peripheral, susceptible to modulation by various therapeutic agents, including anti-inflammatories, opioid analgesics, and other centrally acting compounds (Foss et al., 2021a; Silva et al., 2021).
The pain-inducing action of acetic acid arises from its chemical stimulation in the peritoneal cavity, leading to the release of inflammatory mediators such as interleukins IL-1, IL-6, IL-8, tumor necrosis factor α (TNF-α), as well as chemokines, histamine, serotonin, and bradykinin. These substances promote the increased synthesis of lipoxygenase (LOX) and cyclooxygenase (COX) enzymes, resulting in the production of leukotrienes and prostaglandins, notably prostaglandin E2 (PGE2) and F2α (PGF2α) (Menezes et al., 2021; Silva et al., 2021). Additionally, pro-inflammatory cytokines such as IL-8, IL-1β, and TNF-α, released by macrophages and basophils, amplify the release of aspartate, glutamate, and other endogenous mediators that activate visceral nociceptive neurons (Batista et al., 2016).
Several recent studies have investigated the therapeutic potential of cannabidiol (CBD) in managing acetic acid-induced abdominal pain, consistently demonstrating its ability to significantly reduce abdominal writhing compared to placebo groups (Bunman et al., 2022; Foss et al., 2021a; Neelakantan et al., 2015; Silva et al., 2021). Neelakantan et al. (2015) and Foss et al. (2021a) report that CBD decreases the production of various inflammatory markers, such as TNF-α, IL-6, and COX-2, through mechanisms that do not involve CB1 or CB2 cannabinoid receptors. Thus, the antinociceptive effects of CBD observed in the acetic acid-induced writhing test may be attributed to its potent anti-inflammatory properties.
Furthermore, earlier studies have corroborated the therapeutic efficacy of Bixa orellana in this same test. Aktary et al. (2019) and Shilpi et al. (2006) suggest that the antinociceptive activity observed in Bixa orellana extract may result from its ability to interfere with the synthesis and release of endogenous substances induced by acetic acid, such as prostacyclin (PGI2) and other prostanoids. Additionally, the desensitization of sensory C fibers may be involved in pain transmission.
Regarding the number of abdominal writhing induced by acetic acid (
Figure 2), a statistically significant reduction was observed in all experimental groups, with a p-value < 0.001. Notably, the groups subjected to the combined administration of CSE (40 mg/kg, oral) + CHR OR (400 mg/kg, oral), as well as those receiving this combination together with naloxone (2 mg/kg, intraperitoneal), showed results comparable to the standard drug (morphine).
Considering that the acetic acid-induced abdominal writhing test is a non-specific model and does not allow for determining the exact nociceptive pathways through which a drug may act, other procedures were employed to elucidate possible mechanisms of antinociception (Silva et al., 2021). The formalin test stands out from conventional pain models as it evaluates an animal's response to continuous and moderate pain from tissue injury. It is considered more representative of clinical pain than tests that use short-duration mechanical or thermal stimuli (Tj et al., 1992).
Two distinct phases characterize the nociceptive response to formalin. The first phase, known as the neurogenic phase, occurs immediately after formalin injection and lasts approximately 10 minutes. It is marked by releasing substances P, glutamate, bradykinin, and nitric oxide, which stimulate C-type nerve fibers and some Aδ fibers. The second phase, known as the inflammatory phase, begins 15-20 minutes after injection and can last for over 60 minutes, with the release of inflammatory mediators such as histamine, serotonin, bradykinin, and prostaglandins (Bannon & Malmberg, 2007; Bunman et al., 2022; Menezes et al., 2021). Central-acting analgesics, such as opioids, inhibit both phases of the response, while peripherally-acting anti-inflammatory drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids (SAIDs), inhibit only the second phase (Silva et al., 2021).
Figure 3 graphically presents the results obtained in this study for both test phases regarding the treatments with the orally administered nutraceutical Chronic
®, either alone or in combination with
Cannabis sativa extract rich in cannabidiol (CSE). In both the early and late phases, all treated groups showed significant differences from the control group, which received distilled water (4 ml/kg), with p-values < 0.001.
Regarding the results of the formalin test in the groups that received Chronic In
®, administered intramuscularly, all groups showed significant differences compared to the control group (p < 0.001) in both the early and late phases (
Figure 4). However, significant differences were observed between the experimental groups CSE + CHR IN and CHR IN alone in the early phase (p < 0.05) and the late phase (p < 0.01), with the Group receiving the combination of treatments yielding the best results. This suggests that the combination of
Cannabis sativa extract rich in cannabidiol may enhance the analgesic effects of Bixa orellana.
Additionally, in the late (inflammatory) phase, the combination of naloxone with CSE and CHR IN had a significantly negative impact (p < 0.05), increasing the nociceptive behavior of the animals. This effect was not reported when naloxone was combined with CSE and CHR OR, suggesting that the relevance of this interaction in the opioid pathway is still unclear. Therefore, further studies are necessary to elucidate this issue.
The findings of this study align with previous research highlighting the efficacy of CBD (Bunman et al., 2022; Razavi et al., 2021; Silva et al., 2021) and Bixa orellana (Aktary et al., 2019) in this pain model. It is worth noting that CBD demonstrated a more pronounced influence in the inflammatory phase than in the neurogenic phase in all these studies.
Several studies corroborate the anti-inflammatory effects of CBD. Costa et al. (2004) reported that in a carrageenan-induced paw edema experiment, CBD significantly reduced tissue cyclooxygenase activity, plasma levels of prostaglandin E2, and the production of oxygen free radicals and nitric oxide. Atalay et al. (2020) affirmed that CBD acts as an agonist of the PPARγ receptor, modulating inflammation by suppressing the expression of pro-inflammatory genes, including cyclooxygenase (COX2), and various pro-inflammatory mediators such as TNF-α, IL-1β, and IL-6. Additionally, Urits et al. (2020) documented that, in combination with THC, even low concentrations of CBD can interact with CB2 receptors, inhibiting the inflammatory response, especially by suppressing mast cell degranulation and neutrophil migration to areas near pain centers. Therefore, the enhanced efficacy of CBD during the late phase of the formalin test could be attributed to its anti-inflammatory effects.
As for the action of Bixa orellana extract in the formalin test, its analgesic properties can also be associated with its anti-inflammatory characteristics (Aktary et al., 2019). As mentioned earlier, tocotrienols exhibit significant anti-inflammatory and antioxidant activity, reducing the secretion of critical pro-inflammatory mediators involved in pain sensitization and providing protection against tissue injury (Aggarwal et al., 2019; Ranasinghe et al., 2022; Tejpal Singh et al., 2023). Geranylgeraniol is another compound found in B. orellana, which demonstrates anti-inflammatory properties. Batista et al. (2022) indicate that geranylgeraniol inhibits the expression of interleukin-1 receptor-associated kinase-1 (IRAK1) and tumor necrosis factor receptor-associated factor 6 (TRAF6), preventing excessive NF-κB activation in response to lipopolysaccharide-induced inflammation in THP-1 cells.
The hot plate and tail withdrawal tests are widely recognized as effective for evaluating central antinociceptive activity (Aktary et al., 2019). In this assay, the nociceptive experience is mediated by the activation of vanilloid receptors and the stimulation of C-type and Aδ-type nociceptive fibers (Menezes et al., 2021). Preliminary studies suggest that centrally acting drugs, such as NMDA receptor antagonists, opioids, and tricyclic antidepressants, show significant efficacy in this model. At the same time, anti-inflammatory agents like indomethacin, dexamethasone, and nimesulide do not exhibit relevant efficacy (Bannon & Malmberg, 2007).
In the literature, there is some disagreement regarding the expected outcomes when assessing CBD in the hot plate test. While some studies report modest or no significant analgesic activity in this assay (Foss et al., 2021b; Neelakantan et al., 2015; Sofia et al., 1975), casting doubt on the possibility of central analgesic action by CBD, other studies have found positive results for both CBD (Crivelaro do Nascimento et al., 2020) and Cannabis sativa roots (Menezes et al., 2021).
Regarding the analgesic effects of CBD in this test, Nascimento et al. (2020) demonstrated that the selective CB1 antagonist AM251 can block CBD's effect in the hot plate test. In contrast, the CB2 inverse agonist SCH 336 does not influence the antinociceptive effects of CBD, suggesting that the analgesic action of CBD in this test is mediated through the CB1 receptor rather than the CB2 receptor. Moreover, the antagonism of TRPV1 receptors amplified the antinociceptive effect of CBD. These findings indicate that CBD reduces nociception through FAAH inhibition, leading to increased levels of anandamide (AEA). Consequently, AEA may bind to both CB1 and TRPV1 receptors, which have opposing effects on pain modulation.
As for the antinociceptive effects of Bixa orellana, there is a notable gap in the literature, with few studies available. Aktary et al. (2019) demonstrated that the methanolic Extract of B. orellana showed a latency time comparable to the control group in the hot plate test, suggesting a potential central analgesic action by this plant.
In our study, as illustrated in
Figure 5, both the Group treated with CSE alone and the groups that received CSE in combination with Chronic
® or Chronic In
® exhibited statistically significant results (p < 0.001). The isolated use of CHR OR and CHR IN, although significant (p < 0.05), revealed inferior results compared to the other experimental groups, supporting the theory that
Bixa orellana has a central analgesic effect, albeit less potent than that of CBD. It is important to note that the groups treated with naloxone, an opioid antagonist, displayed altered results, suggesting a potential interaction of CSE within the opioid pathway in this pain model. Some studies have already suggested a possible action of CBD on μ and δ opioid receptors for pain regulation (Mlost et al., 2020b; Urits et al., 2020), emphasizing further research to clarify this interaction.
As previously mentioned, the tail withdrawal test is widely recognized for assessing central antinociceptive activity. Unlike the hot plate test, where the endpoint involves a complex behavior (licking of the hind paw), nociceptive stimulation by temperature on the tail produces a simple nociceptive reflex response mediated by the spinal cord (tail withdrawal) (Bannon & Malmberg, 2007). According to studies (Adams et al., 1994; Pizziketti et al., 1985), the cold-water tail withdrawal test is particularly suited for evaluating opioid-mediated antinociception. In this method, central nervous system depressants, such as antipsychotics or anxiolytics, as well as non-narcotic analgesics like aspirin and acetaminophen, are ineffective (Pizziketti et al., 1985)
In current literature, the results of the tail withdrawal test involving Cannabis sativa, particularly the phytocannabinoids CBD and THC, are conflicting. While specific studies fail to demonstrate therapeutic efficacy for CBD in this method, indicating that analgesic action is attributable solely to THC (Moore & Weerts, 2022; Sadaka et al., 2023), other studies suggest analgesic effects of CBD, as documented by Nascimento et al. (2020), who observed a significant reduction in thermal hyperalgesia in both acute and chronic CBD treatments. Regarding the action of Bixa orellana in this context, Aktary et al. (2019) identified significant neuropharmacological activity in a dose-dependent manner comparable to standard drugs.
Figure 6 presents the results of the cold-water tail immersion test, which measures the time required for tail withdrawal. The groups treated with CSE (40 mg/kg V.O.) + CHR OR (400 mg/kg V.O.) and CSE (40 mg/kg V.O.) + CHR IN (10 mg/kg V.O.), as well as their combinations with naloxone (2 mg/kg intraperitoneally), demonstrated a significant increase in response time. This increase is evidenced by p-values of < 0.001 compared to the control group and is comparable to both the positive control group (MOR) and the Group treated with CSE alone, with p < 0.001.
The Group that received CHR IN alone showed statistical significance (p < 0.05), although inferior to the groups that received the combinations. However, the Group that received CHR OR did not show significant differences compared to the control group. These results suggest that combining CSE with CHR OR or CHR IN enhances analgesic effects, while naloxone does not appear to interfere with these effects significantly.