The role of central versus peripheral opioid receptors in fentanyl-induced brain hypoxia

Naloxone is the prototypical opioid receptor antagonist, while naloxone-methiodide, a quaternary naloxone analog, is widely used as a peripherally restricted antagonist based on the assumption that it does not cross the blood-brain barrier. This assumption has been central to arguments that peripheral opioid receptors contribute to fentanyl-induced respiratory depression. However, mass spectrometry studies show that although naloxone-methiodide has very limited permeability, it is detectable in brain tissue at a ~1:50 concentration ratio compared to naloxone. Even such small amounts may be sufficient to act on brain receptors, raising the possibility of central involvement. To test this hypothesis, we used oxygen sensors coupled with amperometry in freely moving rats to examine the roles of central versus peripheral opioid receptors in fentanyl-induced brain hypoxia. We compared naloxone with naloxone-methiodide on oxygen responses in the brain and subcutaneous space following intravenous fentanyl administration (30 μg/kg). Naloxone-methiodide at a dose of 2.0 mg/kg (but not 0.2 mg/kg) blocked fentanyl-induced hypoxia. Naloxone-methiodide’s effect was weaker and shorter than that produced by 0.2 mg/kg naloxone. Additionally, naloxone at doses 50- and 250-times lower (0.04 and 0.008 mg/kg), but not 1000-times lower (0.002 mg/kg), also blocked fentanyl-induced hypoxia, mimicking the effect of 2.0 mg/kg naloxone-methiodide. These findings suggest that naloxone-methiodide is not a strictly peripheral antagonist. At moderate to high doses, naloxone-methiodide’s ability to reverse fentanyl-induced hypoxia may be at least partly mediated by the drug’s action on central opioid receptors.