Cannabinoid Receptor-2 Activation in Keratinocytes Contributes to Elevated Peripheral β-Endorphin Levels in Patients With Obstructive Jaundice

Anesth Analg. 2021 Jul 1;133(1):251-262. doi: 10.1213/ANE.0000000000005405.


Background: Cholestatic diseases are often accompanied by elevated plasma levels of endogenous opioid peptides, but it is still unclear whether central or peripheral mechanisms are involved in this process, and little is known about the change of pain threshold in these patients. The purpose of this study was to determine the preoperative pain threshold, postoperative morphine consumption, and central and peripheral β-endorphin levels in patients with obstructive jaundice. This study also tests the hypothesis that activation of the cannabinoid receptor-2 (CB2R) in skin keratinocytes by endocannabinoids is the mechanism underlying circulating β-endorphin elevation in patients with obstructive jaundice.

Methods: The electrical pain thresholds, 48-hour postoperative morphine consumption, concentrations of β-endorphin in plasma and cerebrospinal fluid, skin and liver β-endorphin expression, and plasma levels of endocannabinoids were measured in jaundiced (n = 32) and control (n = 32) patients. Male Sprague-Dawley rats and human keratinocytes (human immortalized keratinocyte cell line [HaCaT]) were used for the in vivo and in vitro experiments, respectively. Mechanical and thermal withdrawal latency, plasma level, and skin expression of β-endorphin were measured in CB2R-antagonist-treated and control bile duct-ligated (BDL) rats. In cultured keratinocytes, the effect of CB2R agonist AM1241-induced β-endorphin expression was observed and the phosphorylation of extracellular-regulated protein kinases 1/2, p38, and signal transducer and activator of transcription (STAT) pathways were investigated.

Results: This study found (1) the plasma level of β-endorphin (mean ± standard error of the mean [SEM]) was 193.9 ± 9.6 pg/mL in control patients, while it was significantly increased in jaundiced patients (286.6 ± 14.5 pg/mL); (2) the electrical pain perception threshold and the electrical pain tolerance threshold were higher in patients with obstructive jaundice compared with controls, while the 48-hour postoperative morphine consumption was lower in the jaundiced patients; (3) there was no correlation between plasma β-endorphin levels, electrical pain thresholds, and 48-hour postoperative morphine consumption in patients with obstructive jaundice; (4) the plasma level of the endogenous cannabinoid anandamide was increased in the jaundiced patients; (5) CB2R antagonist treatment of the BDL rats reduced β-endorphin levels in plasma and skin keratinocytes, while it did not alter the nociceptive thresholds in BDL and control rats; (6) the endocannabinoid anandamide-induced β-endorphin synthesis and release via CB2R in cultured keratinocytes; and (7) phosphorylation of extracellular-regulated protein kinases 1/2 is involved in the CB2R-agonist-induced β-endorphin expression in keratinocytes.

Conclusions: CB2R activation in keratinocytes by the endocannabinoid anandamide may play an important role in the peripheral elevation of β-endorphin during obstructive jaundice.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Animals
  • Arachidonic Acids / administration & dosage
  • Cannabinoid Receptor Agonists / administration & dosage*
  • Cell Line, Transformed
  • Cells, Cultured
  • Endocannabinoids / administration & dosage
  • Humans
  • Indoles / pharmacology
  • Indoles / therapeutic use
  • Jaundice, Obstructive / blood*
  • Jaundice, Obstructive / diagnosis
  • Jaundice, Obstructive / drug therapy
  • Keratinocytes / drug effects
  • Keratinocytes / metabolism*
  • Male
  • Middle Aged
  • Morphine / administration & dosage
  • Pain Measurement / drug effects
  • Pain Measurement / methods
  • Polyunsaturated Alkamides / administration & dosage
  • Rats
  • Rats, Sprague-Dawley
  • Receptor, Cannabinoid, CB2 / agonists*
  • Receptor, Cannabinoid, CB2 / blood*
  • beta-Endorphin / blood*


  • Arachidonic Acids
  • CNR2 protein, human
  • Cannabinoid Receptor Agonists
  • Endocannabinoids
  • Indoles
  • Polyunsaturated Alkamides
  • Receptor, Cannabinoid, CB2
  • beta-Endorphin
  • Morphine
  • iodopravadoline
  • anandamide