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Fipps DC, Oesterle TS, Kolla BP. Opioid Maintenance Therapy: A Review of Methadone, Buprenorphine, and Naltrexone Treatments for Opioid Use Disorder. Semin Neurol 2024. [PMID: 38848746 DOI: 10.1055/s-0044-1787571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
The rates of opioid use and opioid related deaths are escalating in the United States. Despite this, evidence-based treatments for Opioid Use Disorder are underutilized. There are three medications FDA approved for treatment of Opioid Use Disorder: Methadone, Buprenorphine, and Naltrexone. This article reviews the history, criteria, and mechanisms associated with Opioid Use Disorder. Pertinent pharmacology considerations, treatment strategies, efficacy, safety, and challenges of Methadone, Buprenorphine, and Naltrexone are outlined. Lastly, a practical decision making algorithm is discussed to address pertinent psychiatric and medical comorbidities when prescribing pharmacology for Opioid Use Disorder.
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Affiliation(s)
- David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Tyler S Oesterle
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Bhanu P Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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Liu P, Korthuis PT, Buchheit BM. Novel Therapeutic and Program-Based Approaches to Opioid Use Disorders. Annu Rev Med 2024; 75:83-97. [PMID: 37827194 DOI: 10.1146/annurev-med-050522-033924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Opioid use disorder continues to drive overdose deaths in many countries, including the United States. Illicit fentanyl and its analogues have emerged as key contributors to the complications and mortality associated with opioid use disorder. Medications for opioid use disorder treatment, such as methadone and buprenorphine, are safe and substantially reduce opioid use, infectious complications, and mortality risk, but remain underutilized. Polysubstance use and emerging substances such as xylazine and designer benzodiazepines create additional treatment challenges. Recent clinical and policy innovations in treatment delivery, including telemedicine, bridge clinics, and expanded models for accessing methadone have the potential to increase access to life-saving care for people living with opioid use disorder.
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Affiliation(s)
- Patricia Liu
- Section of Addiction, Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA;
| | - P Todd Korthuis
- Section of Addiction, Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA;
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Bradley M Buchheit
- Section of Addiction, Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA;
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Bremer PT, Burke EL, Barrett AC, Desai RI. Investigation of monoclonal antibody CSX-1004 for fentanyl overdose. Nat Commun 2023; 14:7700. [PMID: 38052779 PMCID: PMC10698161 DOI: 10.1038/s41467-023-43126-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
The opioid crisis in the United States is primarily driven by the highly potent synthetic opioid fentanyl leading to >70,000 overdose deaths annually; thus, new therapies for fentanyl overdose are urgently needed. Here, we present the first clinic-ready, fully human monoclonal antibody CSX-1004 with picomolar affinity for fentanyl and related analogs. In mice CSX-1004 reverses fentanyl antinociception and the intractable respiratory depression caused by the ultrapotent opioid carfentanil. Moreover, toxicokinetic evaluation in a repeat-dose rat study and human tissue cross-reactivity study reveals a favorable pharmacokinetic profile of CSX-1004 with no safety-related issues. Using a highly translational non-human primate (NHP) model of respiratory depression, we demonstrate CSX-1004-mediated protection from repeated fentanyl challenges for 3-4 weeks. Furthermore, treatment with CSX-1004 produces up to a 15-fold potency reduction of fentanyl in NHP respiration, antinociception and operant responding assays without affecting non-fentanyl opioids like oxycodone. Taken together, our data establish the feasibility of CSX-1004 as a promising candidate medication for preventing and reversing fentanyl-induced overdose.
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Affiliation(s)
| | - Emily L Burke
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Behavioral Biology Program, Integrative Neurochemistry Laboratory, McLean Hospital, Belmont, MA, USA
| | | | - Rajeev I Desai
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Behavioral Biology Program, Integrative Neurochemistry Laboratory, McLean Hospital, Belmont, MA, USA
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Opheim A, Benth JŠ, Solli KK, Kloster PS, Fadnes LT, Kunøe N, Gaulen Z, Tanum L. Risk of relapse to non-opioid addictive substances among opioid dependent patients treated with an opioid receptor antagonist or a partial agonist: A randomized clinical trial. Contemp Clin Trials 2023; 135:107360. [PMID: 37865138 DOI: 10.1016/j.cct.2023.107360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/24/2023] [Accepted: 10/15/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND AND OBJECTIVE First study to assess any compensatory increase in use of non-opioid illicit substances and alcohol in opioid dependent patients randomized to treatment with extended-release naltrexone (XR-NTX) or buprenorphine-naloxone (BP-NLX) and in longer term treatment with extended-release naltrexone. METHOD A multicenter, outpatient, open-label randomized clinical trial where patients received intramuscular extended-release naltrexone hydrochloride, 380 mg/month, or daily sublingual buprenorphine-naloxone 8-24/2-6 mg for 12 weeks, and an option to continue with extended-release naltrexone for an additional 36 week follow-up. The study was conducted at five urban addiction clinics and detoxification units in Norway between November 2012, and July 2016. RESULTS Among the 143 patients, 106 men and 37 women, there were no significant differences between those randomized to XR-NTX or BP-NLX in the risk of first relapse to alcohol (HR 1.31; 0.68-2.53), amphetamines (HR 0.88; 0.43-1.80), benzodiazepines (HR 1.24; 0.74-2.09) or cannabis (HR 1.55; 0.83-2.89). Also in the 36-week (12-48 weeks) follow-up period we found no significant differences between patients continuing with XR-NTX compared to those switching to XR-NTX after the randomized period in risk of first relapse to any non-opioid substance. In both study periods, the mean time in the study were longer among those relapsing to non-opioid addictive substances than those who did not. There was no significant association between first relapse to illicit opioids and first relapse to non-opioid addictive substances. CONCLUSION There was no increase in the risk of relapse to non-opioid addictive substances neither in short term nor longer-term treatment with extended-release naltrexone. Trial registrationclinicaltrials.gov Identifier: NCT01717963.
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Affiliation(s)
- Arild Opheim
- Department of Addiction Medicine, Haukeland University Hospital, Norway; Institute of Global Public Health and Primary Care, University of Bergen, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, P.O.Box 1171, 0318 Blindern, Norway; Health Services Research Unit, Akershus University Hospital, P.O. Box 1000, 1478 Lorenskog, Norway
| | - Kristin Klemmetsby Solli
- Norwegian Centre for Addiction Research, University of Oslo, 0315 Oslo, Norway,; Department of Research and Development in Mental Health Services, Akershus University Hospital, 1478 Lorenskog, Norway; Vestfold Hospital Trust, 3116 Tonsberg, Norway
| | - Pia S Kloster
- Department of Addiction Medicine, Haukeland University Hospital, Norway
| | - Lars Thore Fadnes
- Department of Addiction Medicine, Haukeland University Hospital, Norway; Institute of Global Public Health and Primary Care, University of Bergen, Norway
| | - Nikolaj Kunøe
- Lovisenberg Diaconal Hospital, P.O. Box 4970, 0440 Oslo, Norway
| | - Zhanna Gaulen
- Department of Addiction Medicine, Haukeland University Hospital, Norway; Department of Clinical Dentistry, University of Bergen, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health Services, Akershus University Hospital, 1478 Lorenskog, Norway; Faculty for Health Science, Oslo Metropolitan University, Pilestredet 32, 0167 Oslo, Norway
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Patients' experiences of continued treatment with extended-release naltrexone: a Norwegian qualitative study. Addict Sci Clin Pract 2022; 17:36. [PMID: 35850782 PMCID: PMC9290197 DOI: 10.1186/s13722-022-00317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background The opioid antagonist extended-release naltrexone (XR-NTX) in the treatment of opioid use disorder (OUD) is effective in terms of safety, abstinence from opioid use and retention in treatment. However, it is unclear how patients experience and adjust to losing the possibility of achieving an opioid effect. This qualitative study is the first to explore how people with opioid dependence experience XR-NTX treatment, focusing on the process of treatment over time. Methods Using a purposive sampling strategy, semi-structured interviews were undertaken with 19 persons with opioid use disorder (15 men, four women, 22–55 years of age) participating in a clinical trial of XR-NTX in Norway. The interviewees had received at least three XR-NTX injections. Qualitative content analysis with an inductive approach was used. Findings Participants described that XR-NTX treatment had many advantages. However they still faced multiple challenges, some of which they were not prepared for. Having to find a new foothold and adapt to no longer gaining an effect from opioids due to the antagonist medication was challenging. This was especially true for those struggling emotionally and transitioning into the harmful use of non-opioid substances. Additional support was considered crucial. Even so, the treatment led to an opportunity to participate in society and reclaim identity. Participants had strong goals for the future and described that XR-NTX enabled a more meaningful life. Expectations of a better life could however turn into broken hopes. Although participants were largely optimistic about the future, thinking about the end of treatment could cause apprehension. Conclusions XR-NTX treatment offers freedom from opioids and can facilitate the recovery process for people with OUD. However, our findings also highlight several challenges associated with XR-NTX treatment, emphasizing the importance of monitoring emotional difficulties and increase of non-opioid substances during treatment. As opioid abstinence in itself does not necessarily equal recovery, our findings underscore the importance of seeing XR-NTX as part of a comprehensive, individualized treatment approach. Trial registration: Clinicaltrials.gov # NCT03647774, first Registered: Aug 28, 2018.
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Brenna IH, Marciuch A, Birkeland B, Veseth M, Røstad B, Løberg EM, Solli KK, Tanum L, Weimand B. 'Not at all what I had expected': Discontinuing treatment with extended-release naltrexone (XR-NTX): A qualitative study. J Subst Abuse Treat 2021; 136:108667. [PMID: 34865937 DOI: 10.1016/j.jsat.2021.108667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/08/2021] [Accepted: 11/19/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX), an opioid antagonist, has demonstrated equal treatment outcomes, in terms of safety, opioid use, and retention, to the recommended OMT medication buprenorphine. However, premature discontinuation of XR-NTX treatment is still common and poorly understood. Research on patient experiences of XR-NTX treatment is limited. We sought to explore participants' experiences with discontinuation of treatment with XR-NTX, particularly motivation for XR-NTX, experiences of initiation and treatment, and rationale for leaving treatment. METHODS We conducted qualitative, semi-structured interviews with participants from a clinical trial of XR-NTX. The study participants (N = 13) included seven women and six men with opioid dependence, who had received a minimum of one and maximum of four injections of XR-NTX. The study team analyzed transcribed interviews, employing thematic analysis with a critical realist approach. FINDINGS The research team identified three themes, and we present them as a chronological narrative: theme 1: Entering treatment - I thought I knew what I was going into; theme 2: Life with XR-NTX - I had something in me that I didn't want; and theme 3: Leaving treatment - I want to go somewhere in life. Patients' unfulfilled expectations of how XR-NTX would lead to a better life were central to decisions about discontinuation, including unexpected physical, emotional, or mental reactions as well as a lack of expected effects, notably some described an opioid effect from buprenorphine. A few participants ended treatment because they had reached their treatment goal, but most expressed disappointment about not achieving this goal. Some also expressed renewed acceptance of OMT. The participants' motivation for abstinence from illegal substances generally remained. CONCLUSION Our findings emphasize that a dynamic understanding of discontinuation of treatment is necessary to achieve a long-term approach to recovery: the field should understand discontinuation as a feature of typical treatment trajectories, and discontinuation can be followed by re-initiation of treatment.
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Affiliation(s)
- Ida Halvorsen Brenna
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway.
| | - Anne Marciuch
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Department of Medicine, University of Oslo, Oslo, Norway
| | - Bente Birkeland
- Department of Psychosocial Health, Faculty of Health and Sports Science, University of Agder, Kristiansand, Norway
| | - Marius Veseth
- Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Bente Røstad
- RIO-a Norwegian users' association in the field of alcohol and drugs, Oslo, Norway
| | - Else-Marie Løberg
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway; Department of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Kristin Klemmetsby Solli
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway; Vestfold Hospital Trust, Toensberg, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Faculty for Health Science, Oslo Metropolitan University, Oslo, Norway
| | - Bente Weimand
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Department of Health, Social and Welfare Studies, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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Perez-Macia V, Martinez- Cortes M, Mesones J, Segura-Trepichio M, Garcia-Fernandez L. Monitoring and Improving Naltrexone Adherence in Patients with Substance Use Disorder. Patient Prefer Adherence 2021; 15:999-1015. [PMID: 34040354 PMCID: PMC8140930 DOI: 10.2147/ppa.s277861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/09/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Naltrexone is an opioid antagonist used for the treatment of patients with opioid use disorder and alcohol use disorder. This population often presents problems of follow-up and therapeutic efficacy related to adherence to treatment. The purpose of our study is to provide an exhaustive summary of the current evidence regarding naltrexone adherence in people with substance use disorders and to identify possible variables that may influence adherence to naltrexone. METHODS Two searches were performed in bibliographic databases (PubMed, Embase), and studies included in the systematic review were those published from January 1, 2011 to September 2020, with participants over 18 years of age, evaluating treatment with naltrexone in alcohol use disorder and opioid use disorder. From the total of 133 articles initially selected, 36 were included and analyzed in the systematic review. RESULTS Naltrexone has not demonstrated superiority over other available treatments in terms of adherence and abstinence, although reinforcement systems have obtained favorable results as an additional strategy to improve adherence. CONCLUSION It is necessary to study other psychosocial variables involved in improving adherence, in addition to taking patient preferences into account in order to improve the external validity of the results.
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Affiliation(s)
- Virginia Perez-Macia
- Vinalopó University Hospital, Elche, Spain
- Psychology and Psychiatry Department, Catholic University of Murcia, Murcia, Spain
- Correspondence: Virginia Perez-Macia 36 Vicente Fuentes Sansano Road, Elche (Alicante), 03205, SpainTel +34 675550722 Email
| | | | - Jesus Mesones
- Vinalopó University Hospital, Elche, Spain
- Psychology and Psychiatry Department, Catholic University of Murcia, Murcia, Spain
| | | | - Lorena Garcia-Fernandez
- University Hospital of San Juan, Alicante, Spain
- Clinical Medicine Department, Miguel Hernández University, Alicante, Spain
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Raleigh MD, Accetturo C, Pravetoni M. Combining a Candidate Vaccine for Opioid Use Disorders with Extended-Release Naltrexone Increases Protection against Oxycodone-Induced Behavioral Effects and Toxicity. J Pharmacol Exp Ther 2020; 374:392-403. [PMID: 32586850 DOI: 10.1124/jpet.120.000014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/18/2020] [Indexed: 12/19/2022] Open
Abstract
Opioid use disorders (OUDs) and opioid-related fatal overdoses are a significant public health concern in the United States and worldwide. To offer more effective medical interventions to treat or prevent OUD, antiopioid vaccines are in development that reduce the distribution of the targeted opioids to brain and subsequently reduce the associated behavioral and toxic effects. It is of critical importance that antiopioid vaccines do not interfere with medications that treat OUD. Hence, this study tested the preclinical proof of concept of combining a candidate oxycodone vaccine [oxycodone-keyhole limpet hemocyanin (OXY-KLH)] with an FDA-approved extended-release naltrexone (XR-NTX) depot formulation in rats. The effects of XR-NTX on oxycodone-induced motor activity and antinociception were first assessed in nonvaccinated naïve rats to establish a baseline for subsequent studies. Next, OXY-KLH and XR-NTX were coadministered to determine whether the combination would affect the efficacy of each individual treatment, and it was found that the combination of OXY-KLH and XR-NTX offered greater efficacy in reducing oxycodone-induced motor activity, thigmotaxis, antinociception, and respiratory depression over a range of repeated or escalating oxycodone doses in rats. These data support the feasibility of combining antibody-based therapies with opioid receptor antagonists to provide greater or prolonged protection against opioid-related toxicity or overdose. Combining antiopioid vaccines with XR-NTX may provide prophylactic measures to subjects at risk of relapse and accidental or deliberate exposure. Combination therapy may extend to other biologics (e.g., monoclonal antibodies) and medications against substance use disorders. SIGNIFICANCE STATEMENT: Opioid use disorders (OUDs) remain a major problem worldwide, and new therapies are needed. This study reports on the combination of an oxycodone vaccine [oxycodone-keyhole limpet hemocyanin (OXY-KLH)] with a currently approved OUD therapy, extended-release naltrexone (XR-NTX). Results demonstrated that XR-NTX did not interfere with OXY-KLH efficacy, and combination of low doses of XR-NTX with vaccine was more effective than each individual treatment alone to reduce behavioral and toxic effects of oxycodone, suggesting that combining OXY-KLH with XR-NTX may improve OUD outcomes.
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Affiliation(s)
- Michael D Raleigh
- Departments of Pharmacology (M.D.R., M.P.) and Medicine (M.P.), Center for Immunology (M.P.), Medical School, University of Minnesota, Minneapolis, Minnesota; Universita' degli Studi di Milano, Socrates Program, Milano, Italy (C.A.); and Hennepin Healthcare Research Institute, Minneapolis, Minnesota (M.P.)
| | - Claudia Accetturo
- Departments of Pharmacology (M.D.R., M.P.) and Medicine (M.P.), Center for Immunology (M.P.), Medical School, University of Minnesota, Minneapolis, Minnesota; Universita' degli Studi di Milano, Socrates Program, Milano, Italy (C.A.); and Hennepin Healthcare Research Institute, Minneapolis, Minnesota (M.P.)
| | - Marco Pravetoni
- Departments of Pharmacology (M.D.R., M.P.) and Medicine (M.P.), Center for Immunology (M.P.), Medical School, University of Minnesota, Minneapolis, Minnesota; Universita' degli Studi di Milano, Socrates Program, Milano, Italy (C.A.); and Hennepin Healthcare Research Institute, Minneapolis, Minnesota (M.P.)
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Townsend EA, Bremer PT, Faunce KE, Negus SS, Jaster AM, Robinson HL, Janda KD, Banks ML. Evaluation of a Dual Fentanyl/Heroin Vaccine on the Antinociceptive and Reinforcing Effects of a Fentanyl/Heroin Mixture in Male and Female Rats. ACS Chem Neurosci 2020; 11:1300-1310. [PMID: 32271538 DOI: 10.1021/acschemneuro.0c00064] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Opioid-targeted vaccines represent an emerging treatment strategy for opioid use disorder. To determine whether concurrent vaccination against two commonly abused opioids (fentanyl and heroin) would confer broader spectrum opioid coverage, the current study evaluated dual fentanyl/heroin conjugate vaccine effectiveness using a warm water tail-withdrawal and a fentanyl/heroin-vs-food choice procedure in male and female rats across a 105-day observation period. Vaccine administration generated titers of high-affinity antibodies to both fentanyl and heroin sufficient to decrease the antinociceptive potency of fentanyl (25-fold), heroin (4.6-fold), and a 1:27 fentanyl/heroin mixture (7.5-fold). Vaccination did not alter the antinociceptive potency of the structurally dissimilar opioid agonist methadone. For comparison, continuous treatment with a naltrexone dose (0.032 mg/kg/h) shown previously to produce clinically relevant plasma-naltrexone levels decreased the antinociceptive potency of fentanyl, heroin, and the 1:27 fentanyl/heroin mixture by approximately 20-fold. Naltrexone treatment also shifted the potency of 1:27 fentanyl/heroin mixture in a drug-vs-food choice self-administration procedure 4.3-fold. In contrast, vaccination did not attenuate 1:27 fentanyl/heroin mixture self-administration in the drug-vs-food choice procedure. These data demonstrate that a vaccine can simultaneously attenuate the thermal antinociceptive effects of two structurally dissimilar opioids. However, the vaccine did not attenuate fentanyl/heroin mixture self-administration, suggesting a greater magnitude of vaccine responsiveness is required to decrease opioid reinforcement relative to antinociception.
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Affiliation(s)
- E. Andrew Townsend
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, Virginia 23298, United States
| | - Paul T. Bremer
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, California 92037, United States
| | - Kaycee E. Faunce
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, Virginia 23298, United States
| | - S. Stevens Negus
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, Virginia 23298, United States
| | - Alaina M. Jaster
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, Virginia 23298, United States
| | - Hannah L. Robinson
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, Virginia 23298, United States
| | - Kim D. Janda
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, California 92037, United States
| | - Matthew L. Banks
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, Virginia 23298, United States
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Thomas I. A Brief Overview of Identification and Management of Opiate Use Disorder in the Primary Care Setting. Nurs Clin North Am 2019; 54:495-501. [PMID: 31703775 DOI: 10.1016/j.cnur.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This article offers a brief review geared toward primary care providers of the most critical aspects of the management of opiate use disorder, including screening, brief intervention, and referral to treatment as well as medication-assisted treatment and the alarming trends and dangers of illicitly produced fentanyl.
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Affiliation(s)
- Ian Thomas
- Carondelet Health Network, 2656 North Sahuara Place, Tucson, AZ 85712, USA.
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11
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Schwienteck KL, Blake S, Bremer PT, Poklis JL, Townsend EA, Negus SS, Banks ML. Effectiveness and selectivity of a heroin conjugate vaccine to attenuate heroin, 6-acetylmorphine, and morphine antinociception in rats: Comparison with naltrexone. Drug Alcohol Depend 2019; 204:107501. [PMID: 31479865 PMCID: PMC6878171 DOI: 10.1016/j.drugalcdep.2019.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/09/2019] [Accepted: 06/10/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND One emerging strategy to address the opioid crisis includes opioid-targeted immunopharmacotherapies. This study compared effectiveness of a heroin-tetanus toxoid (TT) conjugate vaccine to antagonize heroin, 6-acetylmorphine (6-AM), morphine, and fentanyl antinociception in rats. METHODS Adult male and female Sprague Dawley rats received three doses of active or control vaccine at weeks 0, 2, and 4. Vaccine pharmacological selectivity was assessed by comparing opioid dose-effect curves in 50 °C warm-water tail-withdrawal procedure before and after active or control heroin-TT vaccine. Route of heroin administration [subcutaneous (SC) vs. intravenous [IV)] was also examined as a determinant of vaccine effectiveness. Continuous naltrexone treatment (0.0032-0.032 mg/kg/h) effects on heroin, 6-AM, and morphine antinociceptive potency were also determined as a benchmark for minimal vaccine effectiveness. RESULTS The heroin-TT vaccine decreased potency of SC heroin (5-fold), IV heroin (3-fold), and IV 6-AM (3-fold) for several weeks without affecting IV morphine or SC and IV fentanyl potency. The control vaccine did not alter potency of any opioid. Naltrexone dose-dependently decreased antinociceptive potency of SC heroin, and treatment with 0.01 mg/kg/h naltrexone produced similar, approximate 8-fold decreases in potencies of SC and IV heroin, IV 6-AM, and IV morphine. The combination of naltrexone and active vaccine was more effective than naltrexone alone to antagonize SC heroin but not IV heroin. CONCLUSIONS The heroin-TT vaccine formulation examined is less effective, but more selective, than chronic naltrexone to attenuate heroin antinociception in rats. Furthermore, these results provide an empirical framework for future preclinical opioid vaccine research to benchmark effectiveness against naltrexone.
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Affiliation(s)
- Kathryn L. Schwienteck
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - Steven Blake
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Paul T. Bremer
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Justin L. Poklis
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - E. Andrew Townsend
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - S. Stevens Negus
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
| | - Matthew L. Banks
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298 USA
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Tenney RD, Blake S, Bremer PT, Zhou B, Hwang CS, Poklis JL, Janda KD, Banks ML. Vaccine blunts fentanyl potency in male rhesus monkeys. Neuropharmacology 2019; 158:107730. [PMID: 31369740 PMCID: PMC6745253 DOI: 10.1016/j.neuropharm.2019.107730] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/25/2019] [Accepted: 07/28/2019] [Indexed: 11/30/2022]
Abstract
One proposed factor contributing to the increased frequency of opioid overdose deaths is the emergence of novel synthetic opioids, including illicit fentanyl and fentanyl analogues. A treatment strategy currently under development to address the ongoing opioid crisis is immunopharmacotherapies or opioid-targeted vaccines. The present study determined the effectiveness and selectivity of a fentanyl-tetanus toxoid conjugate vaccine to alter the behavioral effects of fentanyl and a structurally dissimilar mu-opioid agonist oxycodone in male rhesus monkeys (n = 3-4). Fentanyl and oxycodone produced dose-dependent suppression of behavior in an assay of schedule-controlled responding and antinociception in an assay of thermal nociception (50 °C). Acute naltrexone (0.032 mg/kg) produced an approximate 10-fold potency shift for fentanyl to decrease operant responding. The fentanyl vaccine was administered at weeks 0, 2, 4, 9, 19, and 44 and fentanyl or oxycodone potencies in both behavioral assays were redetermined over the course of 49 weeks. The vaccine significantly and selectively shifted fentanyl potency at least 10-fold in both assays at several time points over the entire experimental period. Mid-point titer levels correlated with fentanyl antinociceptive potency shifts. Antibody affinity for fentanyl as measured by a competitive binding assay improved over time to approximately 3-4 nM. The fentanyl vaccine also increased fentanyl plasma levels approximately 6-fold consistent with the hypothesis that the vaccine sequesters fentanyl in the blood. Overall, these results support the continued development and evaluation of this fentanyl vaccine in humans to address the ongoing opioid crisis.
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Affiliation(s)
- Rebekah D Tenney
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, 23298, USA
| | - Steven Blake
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Paul T Bremer
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Bin Zhou
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Candy S Hwang
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Justin L Poklis
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, 23298, USA
| | - Kim D Janda
- Departments of Chemistry and Immunology and Microbial Science, Skaggs Institute for Chemical Biology, Worm Institute for Research and Medicine, The Scripps Research Institute, La Jolla, CA, 92037, USA.
| | - Matthew L Banks
- Department of Pharmacology and Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA, 23298, USA.
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13
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Jarvis BP, Holtyn AF, DeFulio A, Koffarnus MN, Leoutsakos JMS, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. The effects of extended-release injectable naltrexone and incentives for opiate abstinence in heroin-dependent adults in a model therapeutic workplace: A randomized trial. Drug Alcohol Depend 2019; 197:220-227. [PMID: 30852374 PMCID: PMC6440824 DOI: 10.1016/j.drugalcdep.2018.12.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/29/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
AIM To determine whether extended-release injectable naltrexone (XR-NTX), incentives for opiate abstinence, and their combination reduce opiate use compared to a usual care control and whether the combination reduces opiate use compared to either treatment alone. DESIGN Randomized 2 × 2 single-site controlled trial conducted from November 2012 through May 2016. After a detoxification and oral naltrexone induction, participants were assigned to a Usual Care, Abstinence Incentives, XR-NTX, or XR-NTX plus Abstinence Incentives group for a six-month intervention period. SETTING A model therapeutic workplace where participants could work on automated computer programs that targeted job-skills training for 4 h every weekday for 24 weeks and earn about $10 per hour. PARTICIPANTS 84 heroin-dependent adults who were unemployed and medically approved for naltrexone. Most participants were male (71.4%), African American (80.1%), and cocaine dependent (71.4%). MEASUREMENTS The primary outcome measure was the percentage of urine samples negative for opiates that were collected at once weekly assessments (24 per participant) that were not part of the intervention and for which participants were paid $10 for completing. INTERVENTION Participants who attended the workplace provided thrice-weekly urine samples. Abstinence Incentives participants had to provide opiate-free urine samples to maintain maximum pay. XR-NTX participants received one injection every 4 weeks and were required to take injections in order to work and to maintain maximum pay. Usual Care participants were not offered XR-NTX and opiate urinalysis results did not affect pay. FINDINGS A large percentage (65 of 149; 43.6%) of individuals failed the induction protocol required for randomization and to be eligible to receive XR-NTX. When missing urine samples were considered positive, there was no significant interaction between XR-NTX and Abstinence Incentives. XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (81.3%, SD 39.0%) than XR-NTX participants (64.5%, SD 47.9%; aOR 10.4, 95% CI 1.3-85.5; P = .030). When urine samples were not replaced, there was a significant interaction between XR-NTX and Abstinence Incentives (aOR 77.0, 95% CI 1.3-4432;P = 0.036); XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (99.6%, SD 0.1%) than XR-NTX participants (85.0%, SD 35.7%; aOR 147.6, 95% CI 6.3-3472; P = 0.002), Abstinence Incentives participants (91.9%, SD 27.3%; aOR 121.7, 95% CI 4.8-3067; P =0.004), and Usual Care participants (78.7%, SD 41.0%; aOR 233.4, 95% CI 9.4-5814; P <.001). No other group differences were significant. CONCLUSION XR-NTX plus incentives for opiate abstinence increased opiate abstinence, but XR-NTX alone did not. XR-NTX can promote opiate abstinence when it is combined with incentives for opiate abstinence in a model therapeutic workplace.
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Affiliation(s)
- Brantley P. Jarvis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, Unites States
| | - August F. Holtyn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, Unites States
| | - Anthony DeFulio
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, Unites States
| | - Mikhail N. Koffarnus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, Unites States
| | - Jeannie-Marie S. Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, Unites States
| | - Annie Umbricht
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, Unites States
| | - Michael Fingerhood
- Department of Medicine, Johns Hopkins University School of Medicine. Baltimore, MD, United States
| | - George E. Bigelow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, Unites States
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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14
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Sofuoglu M, DeVito EE, Carroll KM. Pharmacological and Behavioral Treatment of Opioid Use Disorder. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2018. [PMCID: PMC9175946 DOI: 10.1176/appi.prcp.20180006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: Opioid use disorder (OUD) in the United States has surged, with an estimated 2.5 million needing treatment. The aim of this article is to provide a clinical overview of the key pharmacological and behavioral treatments for OUD. Methods: A nonsystematic review of the literature was conducted to investigate OUD treatments, including their mechanism of action, efficacy, clinical guidelines in the United States, and consideration of frequently occurring comorbid conditions. Results: Food and Drug Administration (FDA)–approved pharmacotherapies for OUD include methadone, buprenorphine, and naltrexone, each of which has different actions on opioid receptors. Although these medications all show efficacy in some dosages and formulations, barriers to accessibility may be most pronounced for methadone, whereas treatment retention poses greater challenges for naltrexone and, to a lesser extent, buprenorphine. Lofexidine, an α2‐adrenergic agonist, has recently been approved by the FDA for treatment of opioid withdrawal symptoms. OUD is commonly treated with medication‐assisted treatment (MAT), which offers pharmacotherapy in the context of counseling and/or behavioral treatments. Behavioral therapies, rarely offered as stand‐alone treatments for OUD, are generally used in the context of MAT, in structured settings or to prevent relapse after detoxification and stabilization. The aim of behavioral interventions is to improve medication compliance and target problems not addressed with medication alone. Individuals with OUD commonly have other comorbid psychiatric and substance use conditions, which are not exclusionary for initiating MAT but should be carefully evaluated and monitored because they may reduce treatment effectiveness. Conclusions: MAT is the first‐line treatment for patients with OUD and should be provided in combination with behavioral interventions. Treatment retention remains challenging in this population. Future studies should focus on approaches that will serve the complex needs of patients with OUD, including those with comorbid psychiatric and substance use conditions.
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Affiliation(s)
- Mehmet Sofuoglu
- Yale University School of MedicineDepartment of Psychiatry
- VA Connecticut Healthcare SystemWest HavenCT
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15
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Carroll KM, Nich C, Frankforter TL, Yip SW, Kiluk BD, DeVito EE, Sofuoglu M. Accounting for the uncounted: Physical and affective distress in individuals dropping out of oral naltrexone treatment for opioid use disorder. Drug Alcohol Depend 2018; 192:264-270. [PMID: 30300800 PMCID: PMC6203294 DOI: 10.1016/j.drugalcdep.2018.08.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/14/2018] [Accepted: 08/14/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The theoretical benefits of naltrexone as a treatment for opioid use disorder (e.g., safety, non-addictive, low risk of diversion) stand in sharp contrast to its disappointing record on retention in most samples. The relationship of uncomfortable physical and dysphoric symptoms to retention on naltrexone is a controversial and under-studied issue. METHODS Using data from a randomized controlled trial of voucher-based contingency management and support from a significant other to enhance retention on oral naltrexone, we compared self-reported somatic and dysphoric symptoms, measured weekly, for individuals who were retained on naltrexone through the 12-week trial (n = 50) versus those who dropped out (n = 70). RESULTS There were no differences between participants who completed treatment and those who dropped out on multiple baseline characteristics, including somatic or affective symptoms prior to treatment. However, whether analyzed cross-sectionally or over time, participants who dropped out consistently reported higher rates of somatic symptoms, particularly difficulty sleeping, as well as affective symptoms, including multiple indicators of depression, anxiety, and anhedonia. CONCLUSIONS Although the smaller group of participants who were retained on oral naltrexone for 12 weeks reported decreasing physical and affective discomfort over time, there was substantial evidence that those who dropped out experienced continued and significant levels of distress. Individuals who report physical or affective distress while taking naltrexone may be at higher risk of dropout.
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Affiliation(s)
- Kathleen M Carroll
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, 40 Temple Street, New Haven, CT, 06510, USA.
| | - Charla Nich
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, 40 Temple Street, New Haven, CT, 06510, USA.
| | - Tami L Frankforter
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, 40 Temple Street, New Haven, CT, 06510, USA.
| | - Sarah W Yip
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, 40 Temple Street, New Haven, CT, 06510, USA.
| | - Brian D Kiluk
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, 40 Temple Street, New Haven, CT, 06510, USA.
| | - Elise E DeVito
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, 40 Temple Street, New Haven, CT, 06510, USA.
| | - Mehmet Sofuoglu
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, 40 Temple Street, New Haven, CT, 06510, USA; West Haven Veterans Affairs MIRECC, 950 Campbell Avenue, Building 35, West Haven, CT, 06516, USA.
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16
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Solli KK, Latif ZEH, Opheim A, Krajci P, Sharma-Haase K, Benth JŠ, Tanum L, Kunoe N. Effectiveness, safety and feasibility of extended-release naltrexone for opioid dependence: a 9-month follow-up to a 3-month randomized trial. Addiction 2018; 113:1840-1849. [PMID: 29806872 DOI: 10.1111/add.14278] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/18/2018] [Accepted: 05/23/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM This is a follow-up study of a previously published randomized clinical trial conducted in Norway that compared extended-release naltrexone (XR-NTX) to buprenorphine-naloxone (BP-NLX) over 3 months. At the conclusion of the trial, participants were offered their choice of study medication for an additional 9 months. While BP-NLX was available at no cost through opioid maintenance treatment programmes, XR-NTX was available only through study participation, accounting for why almost all participants chose XR-NTX in the follow-up. The aim of this follow-up study was to compare differences in outcome between adults with opioid dependence continuing XR-NTX and those inducted on XR-NTX for a 9-month period, on measures of effectiveness, safety and feasibility. DESIGN In this prospective cohort study, participants were either continuing XR-NTX, changed from BP-NLX to XR-NTX or re-included into the study and inducted on XR-NTX treatment. SETTING Five urban, out-patient addiction clinics in Norway. PARTICIPANTS Opioid-dependent adults continuing (n = 54) or inducted on (n = 63) XR-NTX. INTERVENTION XR-NTX administrated as intramuscular injections (380 mg) every fourth week. MEASUREMENTS Data on retention, use of heroin and other illicit substances, opioid craving, treatment satisfaction, addiction-related problems and adverse events were reported every fourth week. FINDINGS Nine-month follow-up completion rates were 51.9% among participants continuing XR-NTX in the follow-up and 47.6% among those inducted on XR-NTX. Opioid abstinence rates were, respectively, 53.7 and 44.4%. No significant group differences were found in use of heroin and other opioids. CONCLUSIONS Opioid-dependent individuals who elect to switch from buprenorphine-naltrexone treatment after 3 months to extended-release naltrexone treatment for 9 months appear to experience similar treatment completion and abstinence rates and similar adverse event profiles to individuals who had been on extended-release naltrexone from the start of treatment.
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Affiliation(s)
| | - Zill-E-Huma Latif
- Department of Research and Development in Mental Health, Akershus University Hospital, Loerenskog, Norway
| | - Arild Opheim
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,The University of Bergen, Bergen, Norway
| | - Peter Krajci
- Department of Addiction Medicine, Oslo University Hospital, Oslo, Norway
| | - Kamni Sharma-Haase
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway.,Vestfold Hospital Trust, Toensberg, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Blindern, Norway.,Health Services Research Unit, Akershus University Hospital, Loerenskog, Norway
| | - Lars Tanum
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway.,Department of Research and Development in Mental Health, Akershus University Hospital, Loerenskog, Norway
| | - Nikolaj Kunoe
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
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17
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Jarvis BP, Holtyn AF, Subramaniam S, Tompkins DA, Oga EA, Bigelow GE, Silverman K. Extended-release injectable naltrexone for opioid use disorder: a systematic review. Addiction 2018; 113:1188-1209. [PMID: 29396985 PMCID: PMC5993595 DOI: 10.1111/add.14180] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/18/2017] [Accepted: 01/26/2018] [Indexed: 12/14/2022]
Abstract
AIMS To review systematically the published literature on extended-release naltrexone (XR-NTX, Vivitrol® ), marketed as a once-per-month injection product to treat opioid use disorder. We addressed the following questions: (1) how successful is induction on XR-NTX; (2) what are adherence rates to XR-NTX; and (3) does XR-NTX decrease opioid use? Factors associated with these outcomes as well as overdose rates were examined. METHODS We searched PubMed and used Google Scholar for forward citation searches of peer-reviewed papers from January 2006 to June 2017. Studies that included individuals seeking treatment for opioid use disorder who were offered XR-NTX were included. RESULTS We identified and included 34 studies. Pooled estimates showed that XR-NTX induction success was lower in studies that included individuals that required opioid detoxification [62.6%, 95% confidence interval (CI) = 54.5-70.0%] compared with studies that included individuals already detoxified from opioids (85.0%, 95% CI = 78.0-90.1%); 44.2% (95% CI = 33.1-55.9%) of individuals took all scheduled injections of XR-NTX, which were usually six or fewer. Adherence was higher in prospective investigational studies (i.e. studies conducted in a research context according to a study protocol) compared to retrospective studies of medical records taken from routine care (6-month rates: 46.7%, 95% CI = 34.5-59.2% versus 10.5%, 95% CI = 4.6-22.4%, respectively). Compared with referral to treatment, XR-NTX reduced opioid use in adults under criminal justice supervision and when administered to inmates before release. XR-NTX reduced opioid use compared with placebo in Russian adults, but this effect was confounded by differential retention between study groups. XR-NTX showed similar efficacy to buprenorphine when randomization occurred after detoxification, but was inferior to buprenorphine when randomization occurred prior to detoxification. CONCLUSIONS Many individuals intending to start extended-release naltrexone (XR-NTX) do not and most who do start XR-NTX discontinue treatment prematurely, two factors that limit its clinical utility significantly. XR-NTX appears to decrease opioid use but there are few experimental demonstrations of this effect.
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Affiliation(s)
- Brantley P. Jarvis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine,Public Health Research and Translational Science, Battelle Memorial Institute
| | - August F. Holtyn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Shrinidhi Subramaniam
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - D. Andrew Tompkins
- Department of Psychiatry, University of California, San Francisco School of Medicine
| | - Emmanuel A. Oga
- Public Health Research and Translational Science, Battelle Memorial Institute
| | - George E. Bigelow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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18
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Toyama K, Furuie H, Kuroda K, Ishizuka H. Pharmacokinetic Bioequivalence Studies of an Extended-Release Oxycodone Hydrochloride Tablet in Healthy Japanese Subjects Under Fasting and Fed Conditions Without an Opioid Antagonist. Drugs R D 2017; 17:363-370. [PMID: 28516342 PMCID: PMC5629125 DOI: 10.1007/s40268-017-0184-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Oxycodone is a semisynthetic opioid used for the treatment of moderate to severe pain. Two separate studies were conducted to assess the pharmacokinetic bioequivalence of a newly formulated oxycodone hydrochloride extended-release tablet to a marketed oxycodone product in Japan under fasting and fed conditions. Each study was a randomized, open-label, single-dose, single-center, two-period, two-way crossover study. Healthy male Japanese subjects received the oxycodone 10-mg products under fasting and fed conditions. Blood samples were collected at specified time intervals, and plasma concentrations of oxycodone were analyzed using a validated liquid chromatography tandem mass spectrometry assay method. The pharmacokinetic parameters were determined via non-compartmental analysis. Pharmacokinetic metrics used for bioequivalence assessment were the maximum observed plasma concentration (C max) and the area under the concentration-time curve up to the last sampling time (AUC t ). A total of 24 healthy subjects were enrolled in each study. One subject withdrew after completion of the first sequence under fed conditions. The ratios of geometric least square means for C max and AUC t under fasting conditions were 1.1110 (90% confidence interval [CI] 1.0562-1.1687) and 0.9946 (90% CI 0.9670-1.0231), respectively. The ratios of geometric least square means for C max and AUCt under fed conditions were 1.1417 (90% CI 1.0959-1.1895) and 1.0135 (90% CI 0.9810-1.0470), respectively. The 90% CIs were within the predefined range (0.80-1.25). Both treatments were well tolerated when taken without an opioid antagonist in healthy Japanese subjects. Pharmacokinetic bioequivalence between test and reference formulations under fasting and fed conditions was concluded in terms of both rate and extent of absorption.
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Affiliation(s)
- Kaoru Toyama
- Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., 1-2-58, Hiromachi, Shinagawa, Tokyo, 140-8710, Japan.
| | - Hidetoshi Furuie
- Osaka Pharmacology Clinical Research Hospital, 4-1-29 Miyahara, Yodogawa-ku, Osaka-shi, Osaka, 532-0003, Japan
| | - Kana Kuroda
- Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., 1-2-58, Hiromachi, Shinagawa, Tokyo, 140-8710, Japan
| | - Hitoshi Ishizuka
- Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., 1-2-58, Hiromachi, Shinagawa, Tokyo, 140-8710, Japan
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19
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Rudolf G, Walsh J, Plawman A, Gianutsos P, Alto W, Mancl L, Rudolf V. A novel non-opioid protocol for medically supervised opioid withdrawal and transition to antagonist treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:302-309. [PMID: 28795846 DOI: 10.1080/00952990.2017.1334209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The clinical feasibility of a novel non-opioid and benzodiazepine-free protocol was assessed for the treatment of medically supervised opioid withdrawal and transition to subsequent relapse prevention strategies. METHODS A retrospective chart review of DSM-IV diagnosed opioid-dependent patients admitted for inpatient medically supervised withdrawal examined 84 subjects (52 males, 32 females) treated with a 4-day protocol of scheduled tizanidine, hydroxyzine, and gabapentin. Subjects also received ancillary medications as needed, and routine counseling. Primary outcomes were completion of medically supervised withdrawal, and initiation of injectable extended release (ER) naltrexone treatment. Secondary outcomes included the length of hospital stay, Clinical Opiate Withdrawal Scale (COWS) scores, and facilitation to substance use disorder treatment intervention. Ancillary medication use and adverse effects were also assessed. RESULTS A total of 79 (94%) of subjects completed medically supervised withdrawal. A total of 27 (32%) subjects chose to pursue transition to ER naltrexone, and 24 of the 27 (89%) successfully received the injection prior to hospital discharge. The protocol subjects had a mean length of hospital stay of 3.6 days, and the mean COWS scores was 3.3, 3.4, 2.8, and 2.4 on Day 1, 2, 3, and 4, respectively. Furthermore, 71 (85%) engaged in an inpatient or outpatient substance use disorder (SUD) treatment program following protocol completion. CONCLUSION This retrospective chart review suggests the feasibility of a novel protocol for medically supervised opioid withdrawal and transition to relapse prevention strategies, including injectable ER naltrexone. This withdrawal protocol does not utilize opioid agonists or other controlled substances..
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Affiliation(s)
- Gregory Rudolf
- a Department of Pain Services , Swedish Medical Center , Seattle , WA , USA
| | - Jim Walsh
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
| | - Abigail Plawman
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
| | - Paul Gianutsos
- c Department of Family Medicine , Swedish Medical Center Cherry Hill Campus , Seattle , WA , USA
| | - William Alto
- c Department of Family Medicine , Swedish Medical Center Cherry Hill Campus , Seattle , WA , USA
| | - Lloyd Mancl
- d Department of Biostatistics , University of Washington , Seattle , WA , USA
| | - Vania Rudolf
- b Addiction Recovery Service, Swedish Medical Center , Seattle , WA , USA
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20
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Ray LA, Bujarski S, Shoptaw S, Roche DJO, Heinzerling K, Miotto K. Development of the Neuroimmune Modulator Ibudilast for the Treatment of Alcoholism: A Randomized, Placebo-Controlled, Human Laboratory Trial. Neuropsychopharmacology 2017; 42:1776-1788. [PMID: 28091532 PMCID: PMC5520778 DOI: 10.1038/npp.2017.10] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 01/05/2017] [Accepted: 01/10/2017] [Indexed: 02/06/2023]
Abstract
Current directions in medication development for alcohol use disorder (AUD) emphasize the need to identify novel molecular targets and efficiently screen new compounds aimed at those targets. Ibudilast (IBUD) is a neuroimmune modulator that inhibits phosphodiesterase-4 and -10 and macrophage migration inhibitory factor and was recently found to reduce alcohol intake in rats by ∼50%. To advance medication development for AUD, the present study consists of a randomized, crossover, double-blind, placebo-controlled laboratory study of IBUD in nontreatment-seeking individuals with current (ie, past month) mild-to-severe AUD. This study tested the safety, tolerability, and initial human laboratory efficacy of IBUD (50 mg b.i.d.) on primary measures of subjective response to alcohol as well as secondary measures of cue- and stress-induced changes in craving and mood. Participants (N=24) completed two separate 7-day intensive outpatient protocols that included daily visits for medication administration and testing. Upon reaching a stable target dose of IBUD (or matched placebo), participants completed a stress-exposure session (day 5; PM), an alcohol cue-exposure session (day 6; AM), and an i.v. alcohol administration session (day 6; PM). Participants stayed overnight after the alcohol administration, and discharge occurred on day 7 of the protocol. Medication conditions were separated by a washout period that was ⩾7 days. IBUD was well tolerated; however, there were no medication effects on primary measures of subjective response to alcohol. IBUD was associated with mood improvements on the secondary measures of stress exposure and alcohol cue exposure, as well as reductions in tonic levels of craving. Exploratory analyses revealed that among individuals with higher depressive symptomatology, IBUD attenuated the stimulant and mood-altering effects of alcohol as compared with placebo. Together, these findings extend preclinical demonstrations of the potential utility of IBUD for the treatment of AUD and suggest that depressive symptomatology should be considered as a potential moderator of efficacy for pharmacotherapies with neuroimmune effects, such as IBUD.
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Affiliation(s)
- Lara A Ray
- Department of Psychology, University of California, Los Angeles, CA, USA,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA,Department of Psychology, University of California, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, USA, Tel: 310 794 5383, Fax: 310 206 5895, E-mail:
| | - Spencer Bujarski
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Steve Shoptaw
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA,Department of Family Medicine, University of California, Los Angeles, CA, USA
| | - Daniel JO Roche
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Keith Heinzerling
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA,Department of Family Medicine, University of California, Los Angeles, CA, USA
| | - Karen Miotto
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
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Jarvis BP, Holtyn AF, DeFulio A, Dunn KE, Everly JJ, Leoutsakos JMS, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. Effects of incentives for naltrexone adherence on opiate abstinence in heroin-dependent adults. Addiction 2017; 112:830-837. [PMID: 27936293 PMCID: PMC5382098 DOI: 10.1111/add.13724] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/15/2016] [Accepted: 12/08/2016] [Indexed: 11/29/2022]
Abstract
AIM To test whether an incentive-based intervention that increased adherence to naltrexone also increased opiate abstinence. DESIGN Post-hoc combined analysis of three earlier randomized controlled trials that showed individually that incentives for adherence to oral and to extended-release injection naltrexone dosing schedules increased naltrexone adherence, but not opiate abstinence. SETTING Out-patient therapeutic work-place in Baltimore, MD, USA. PARTICIPANTS One hundred and forty unemployed heroin-dependent adults participating from 2006 to 2010. INTERVENTIONS Participants were hired in a model work-place for 26 weeks and randomized to a contingency (n = 72) or prescription (n = 68) group. Both groups were offered naltrexone. Contingency participants were required to take scheduled doses of naltrexone in order to work and earn wages. Prescription participants could earn wages independent of naltrexone adherence. MEASURES Thrice-weekly and monthly urine samples tested for opiates and cocaine and measures of naltrexone adherence (percentage of monthly urine samples positive for naltrexone or percentage of scheduled injections received). All analyses included pre-randomization attendance, opiate use and cocaine use as covariates. Additional analyses controlled for cocaine use and naltrexone adherence during the intervention. FINDINGS Contingency participants had more opiate abstinence than prescription participants (68.1 versus 52.9% opiate-negative thrice-weekly urine samples, respectively; and 71.9 versus 61.7% opiate-negative monthly urine samples, respectively) based on initial analyses [thrice-weekly samples, odds ratio (OR) = 3.3, 95% confidence interval (CI) = 1.7-6.5, P < 0.01; monthly samples, OR = 2.6, 95% CI = 1.0-7.1, P = 0.06] and on analyses that controlled for cocaine use (thrice-weekly samples, OR = 3.9, 95% CI = 3.3-4.5, P < 0.01; monthly samples, OR = 3.4, 95% CI = 1.1-11.1, P = 0.04), which was high and associated with opiate use. The difference in opiate abstinence rates between contingency and prescription participants was reduced when controlling for naltrexone adherence (monthly samples, OR = 1.1, 95% CI = 0.7-1.7, P = 0.84). CONCLUSIONS Incentives for naltrexone adherence increase opiate abstinence in heroin-dependent adults, an effect that appears to be due to increased naltrexone adherence produced by the incentives.
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Affiliation(s)
- Brantley P. Jarvis
- Department of Psychiatry and Behavioral Sciences; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - August F. Holtyn
- Department of Psychiatry and Behavioral Sciences; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Anthony DeFulio
- Department of Psychology; Western Michigan University; Kalamazoo MI USA
| | - Kelly E. Dunn
- Department of Psychiatry and Behavioral Sciences; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Jeffrey J. Everly
- Department of Psychology; University of Pittsburgh at Greensburg; Greensburg PA USA
| | - Jeannie-Marie S. Leoutsakos
- Department of Psychiatry and Behavioral Sciences; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Annie Umbricht
- Department of Psychiatry and Behavioral Sciences; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Michael Fingerhood
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - George E. Bigelow
- Department of Psychiatry and Behavioral Sciences; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences; Johns Hopkins University School of Medicine; Baltimore MD USA
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Jarvis BP, Holtyn AF, Berry MS, Subramaniam S, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. Predictors of induction onto extended-release naltrexone among unemployed heroin-dependent adults. J Subst Abuse Treat 2017; 85:38-44. [PMID: 28449955 DOI: 10.1016/j.jsat.2017.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 04/14/2017] [Accepted: 04/17/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIM Extended-release naltrexone (XR-NTX) blocks the effects of opioids for 4weeks; however, starting treatment can be challenging because it requires 7 to 10days of abstinence from all opioids. In the present study we identified patient and treatment characteristics that were associated with successful induction onto XR-NTX. METHODS 144 unemployed heroin-dependent adults who had recently undergone opioid detoxification completed self-report measures and behavioral tasks before starting an outpatient XR-NTX induction procedure. Employment-based reinforcement was used to promote opioid abstinence and adherence to oral naltrexone during the induction. Participants were invited to attend a therapeutic workplace where they earned wages for completing jobs skills training. Participants who had used opioids recently were initially invited to attend the workplace for a 7-day washout period. Then those participants were required to provide opioid-negative urine samples and then take scheduled doses of oral naltrexone to work and earn wages. Participants who had not recently used opioids could begin oral naltrexone immediately. After stabilization on oral naltrexone, participants were eligible to receive XR-NTX and were randomized into one of four treatment groups, two of which were offered XR-NTX. Binary and multiple logistic regressions were used to identify characteristics at intake that were associated with successfully completing the XR-NTX induction. RESULTS 58.3% of participants completed the XR-NTX induction. Those who could begin oral naltrexone immediately were more likely to complete the induction than those who could not (79.5% vs. 25.0%). Of 15 characteristics, 2 were independently associated with XR-NTX induction success: legal status and recent opioid detoxification type. Participants who were not on parole or probation (vs. on parole or probation) were more likely to complete the induction (OR [95% CI]=2.5 [1.1-5.7], p=0.034), as were those who had come from a longer-term detoxification program (≥21days) (vs. a shorter-term [<21days]) (OR [95% CI]=7.0 [3.0-16.6], p<0.001). CONCLUSIONS Our analyses suggest that individuals recently leaving longer-term opioid detoxification programs are more likely to complete XR-NTX induction. Individuals on parole or probation are less likely to complete XR-NTX induction and may need additional supports or modifications to induction procedures to be successful.
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Affiliation(s)
| | | | | | | | - Annie Umbricht
- Johns Hopkins University School of Medicine, United States
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Jarvis BP, DeFulio A, Long L, Holtyn AF, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. Factors associated with using opiates while under extended-release naltrexone blockade: A descriptive pilot study. J Subst Abuse Treat 2016; 85:56-60. [PMID: 28161142 DOI: 10.1016/j.jsat.2016.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/15/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIM Extended-release naltrexone (XR-NTX) blocks the effects of opioids for 4weeks, yet many patients continue to use them. To learn more about why this occurs, we collected self-reports on subjective effects and drug use factors from participants' most recent heroin/opiate use while under XR-NTX blockade. METHODS Participants (n=38) were unemployed, heroin-dependent adults enrolled in a randomized controlled trial evaluating employment-based incentives to promote adherence to XR-NTX. A subset of participants (n=18) were asked to complete a survey about their most recent use of heroin/opiates when they provided an opiate-positive urine sample while under XR-NTX blockade. Surveys were administered weekly, and participants could complete multiple surveys throughout the trial. Participants reported how high they were (11-point scale; 0=not at all, 10=extremely), how much heroin/opiates they took (less, more, or about the same as usual before starting naltrexone), whether they used cocaine at the same time, and the routes of administration for heroin/opiates and cocaine (if used). All analyses were descriptive. RESULTS Of the 107 surveys, 75.7% indicated being "not at all" high the last time heroin/opiates were used. 75.5% of surveys reported opiate amounts that were less than usual, and only 7.5% reported amounts larger than usual. Cocaine was used at the same time as heroin for 57.9% of surveys but typically through a different route (74.2%). DISCUSSION Using heroin/opiates while under XR-NTX blockade is not strongly associated with self-reports of high, taking larger than normal amounts of opiates, or taking opiates and cocaine simultaneously via the same route. Future research should incorporate measures of naltrexone concentration and more comprehensive and frequent assessments using ecological momentary assessment.
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Affiliation(s)
| | | | - Lauren Long
- Johns Hopkins University School of Medicine, United States
| | | | - Annie Umbricht
- Johns Hopkins University School of Medicine, United States
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Ayanga D, Shorter D, Kosten TR. Update on pharmacotherapy for treatment of opioid use disorder. Expert Opin Pharmacother 2016; 17:2307-2318. [PMID: 27734745 DOI: 10.1080/14656566.2016.1244529] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Opioid Use Disorder (OUD) is a significant public health concern, negatively impacting the medical, psychological, and social domains of an individual's life as well as creating substantial burdens for society. Effective treatment interventions are necessary for reduction of OUD and its consequences. Pharmacotherapy represents a central component of management. Areas covered: This review focuses on pharmacologic strategies for OUD treatment, discussing both primary as well as adjunctive therapy modalities. We will discuss both medications used during detoxification to treat withdrawal, as well as those used as maintenance therapy. Detox medications include alpha-2 adrenergic agonists, such as clonidine, as well as the μ-opioid agonist, methadone, and the μ-opioid partial agonist, buprenorphine. Opioid maintenance treatment (OMT) is also discussed, focusing on those medications meant to substitute abused opioids and includes the agonists, methadone and buprenorphine, as well as supervised intravenous heroin, and opioid antagonist, naltrexone. Expert opinion: Medication therapy for treatment of OUD has demonstrated efficacy and is of great clinical benefit. While agonist treatment with methadone or buprenorphine remains the gold standard, there is an important place for use of long-acting antagonist therapy with naltrexone. Continued investigation into treatment paradigms and behavioral platforms which optimize medication therapy is most needed.
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Affiliation(s)
- Daniel Ayanga
- a Menninger Department of Psychiatry and Behavioral Sciences , Baylor College of Medicine , Houston , TX , USA
| | - Daryl Shorter
- b Research Service Line, Michael E. DeBakey VA Medical Center, Menninger Department of Psychiatry and Behavioral Sciences , Baylor College of Medicine , Houston , TX , USA
| | - Thomas R Kosten
- c Departments of Psychiatry; Neuroscience; Pharmacology; Immunology & Pathology , Baylor College of Medicine, Michael E. DeBakey VA Medical Center , Houston , TX , USA
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Lee JD, Friedmann PD, Kinlock TW, Nunes EV, Boney TY, Hoskinson RA, Wilson D, McDonald R, Rotrosen J, Gourevitch MN, Gordon M, Fishman M, Chen DT, Bonnie RJ, Cornish JW, Murphy SM, O'Brien CP. Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders. N Engl J Med 2016; 374:1232-42. [PMID: 27028913 PMCID: PMC5454800 DOI: 10.1056/nejmoa1505409] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited. METHODS In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78. RESULTS A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures--self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration--were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02). CONCLUSIONS In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.).
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Affiliation(s)
- Joshua D Lee
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Peter D Friedmann
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Timothy W Kinlock
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Edward V Nunes
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Tamara Y Boney
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Randall A Hoskinson
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Donna Wilson
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Ryan McDonald
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - John Rotrosen
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Marc N Gourevitch
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Michael Gordon
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Marc Fishman
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Donna T Chen
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Richard J Bonnie
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - James W Cornish
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Sean M Murphy
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
| | - Charles P O'Brien
- From the Departments of Population Health (J.D.L., R.M., M.N.G.), Medicine, Division of General Internal Medicine and Clinical Innovation (J.D.L.), and Psychiatry (J.R.), New York University, and the New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons (E.V.N.) - both in New York; the Division of General Internal Medicine, the Department of Medicine, Rhode Island Hospital and Alpert Medical School of Brown University, Providence (P.D.F., R.A.H., D.W.); Friends Research Institute (T.W.K., M.G., M.F.), the University of Baltimore, School of Criminal Justice (T.W.K.), and Maryland Treatment Centers (M.F.) - all in Baltimore; the University of Pennsylvania (T.Y.B., J.W.C., C.P.O.) and the Philadelphia Veterans Affairs Medical Center (J.W.C.) - both in Philadelphia; the Center for Biomedical Ethics and Humanities, School of Medicine (D.T.C.) and the School of Law (R.J.B.), University of Virginia, Charlottesville; and Washington State University, Spokane (S.M.M.)
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Jones JD, Sullivan MA, Manubay JM, Mogali S, Metz VE, Ciccocioppo R, Comer SD. The effects of pioglitazone, a PPARγ receptor agonist, on the abuse liability of oxycodone among nondependent opioid users. Physiol Behav 2015; 159:33-9. [PMID: 26455893 DOI: 10.1016/j.physbeh.2015.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 08/31/2015] [Accepted: 10/05/2015] [Indexed: 12/13/2022]
Abstract
AIMS Activation of PPARγ by pioglitazone (PIO) has shown some efficacy in attenuating addictive-like responses in laboratory animals. The ability of PIO to alter the effects of opioids in humans has not been characterized in a controlled laboratory setting. The proposed investigation sought to examine the effects of PIO on the subjective, analgesic, physiological and cognitive effects of oxycodone (OXY). METHODS During this investigation, nondependent prescription opioid abusers (N=17 completers) were maintained for 2-3weeks on ascending daily doses of PIO (0mg, 15mg, 45mg) prior to completing a laboratory session assessing the aforementioned effects of OXY [using a within-session cumulative dosing procedure (0, 10, and 20mg, cumulative dose=30mg)]. RESULTS OXY produced typical mu opioid agonist effects: miosis, decreased pain perception, and decreased respiratory rate. OXY also produced dose-dependent increases in positive subjective responses. Yet, ratings such as: drug "liking," "high," and "good drug effect," were not significantly altered as a function of PIO maintenance dose. DISCUSSION These data suggest that PIO may not be useful for reducing the abuse liability of OXY. These data were obtained with a sample of nondependent opioid users and therefore may not be applicable to dependent populations or to other opioids. Although PIO failed to alter the abuse liability of OXY, the interaction between glia and opioid receptors is not well understood so the possibility remains that medications that interact with glia in other ways may show more promise.
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Affiliation(s)
- Jermaine D Jones
- Division of Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA.
| | - Maria A Sullivan
- Division of Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Jeanne M Manubay
- Division of Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Shanthi Mogali
- Division of Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Verena E Metz
- Division of Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Roberto Ciccocioppo
- School of Pharmacy, Pharmacology Unit, University of Camerino, Via Madonna delle Carceri 9, Camerino, Macerata 62032, Italy
| | - Sandra D Comer
- Division of Substance Abuse, New York Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
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Nunes EV, Krupitsky E, Ling W, Zummo J, Memisoglu A, Silverman BL, Gastfriend DR. Treating Opioid Dependence With Injectable Extended-Release Naltrexone (XR-NTX): Who Will Respond? J Addict Med 2015; 9:238-43. [PMID: 25901451 PMCID: PMC4450918 DOI: 10.1097/adm.0000000000000125] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 01/20/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Once-monthly intramuscular extended-release naltrexone (XR-NTX) has demonstrated efficacy for the prevention of relapse in opioid dependence, providing an alternative to agonist or partial agonist maintenance (ie, methadone and buprenorphine). The question remains, for whom is this unique treatment most efficacious and can patient-treatment matching factors be identified? METHODS A moderator analysis was conducted on a previously reported 24-week, placebo-controlled, multisite, randomized controlled trial of XR-NTX (n = 126) versus placebo (n = 124) among recently detoxified opioid-dependent adults in Russia, which showed XR-NTX superior to placebo in proportion of opioid abstinent weeks. The moderator analysis examined a dichotomous indicator of good clinical response-achieving at least 90% of weeks abstinent over the 24-week trial. A series of logistic regression models were fit for this outcome as functions of treatment (XR-NTX vs placebo), each baseline moderator variable, and their interactions. The 25 baseline variables included demographics, clinical severity (Addiction Severity Index, SF-36, and Clinical Global Impression-Severity), functioning (EQ-5D), craving, and HIV serostatus (HIV+). RESULTS More XR-NTX patients achieved 90% abstinence (64/126, 51%) versus placebo (39/124, 31%; P = 0.002). There were no significant interactions between baseline variables and treatment. There was a significant main effect of Clinical Global Impression-Severity score (P = 0.02), such that higher severity score was associated with a lower rate of Good Clinical Response. CONCLUSIONS The absence of significant baseline by treatment interactions indicates that no patient-treatment matching variables could be identified. This suggests that XR-NTX was effective in promoting abstinence from opioids across a range of demographic and severity characteristics.
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Affiliation(s)
- Edward V. Nunes
- From the New York State Psychiatric Institute and Department of Psychiatry (EVN), Columbia University, New York, NY; Bekhterev Research Psychoneurological Institute and St Petersburg State Pavlov Medical University (EK), Russia; Department of Psychiatry and Biobehavioral Sciences (WL), University of California, Los Angeles, CA; Alkermes, Inc (JZ, AM, BLS), Waltham, MA; and Treatment Research Institute (DRG), Philadelphia, PA
| | - Evgeny Krupitsky
- From the New York State Psychiatric Institute and Department of Psychiatry (EVN), Columbia University, New York, NY; Bekhterev Research Psychoneurological Institute and St Petersburg State Pavlov Medical University (EK), Russia; Department of Psychiatry and Biobehavioral Sciences (WL), University of California, Los Angeles, CA; Alkermes, Inc (JZ, AM, BLS), Waltham, MA; and Treatment Research Institute (DRG), Philadelphia, PA
| | - Walter Ling
- From the New York State Psychiatric Institute and Department of Psychiatry (EVN), Columbia University, New York, NY; Bekhterev Research Psychoneurological Institute and St Petersburg State Pavlov Medical University (EK), Russia; Department of Psychiatry and Biobehavioral Sciences (WL), University of California, Los Angeles, CA; Alkermes, Inc (JZ, AM, BLS), Waltham, MA; and Treatment Research Institute (DRG), Philadelphia, PA
| | - Jacqueline Zummo
- From the New York State Psychiatric Institute and Department of Psychiatry (EVN), Columbia University, New York, NY; Bekhterev Research Psychoneurological Institute and St Petersburg State Pavlov Medical University (EK), Russia; Department of Psychiatry and Biobehavioral Sciences (WL), University of California, Los Angeles, CA; Alkermes, Inc (JZ, AM, BLS), Waltham, MA; and Treatment Research Institute (DRG), Philadelphia, PA
| | - Asli Memisoglu
- From the New York State Psychiatric Institute and Department of Psychiatry (EVN), Columbia University, New York, NY; Bekhterev Research Psychoneurological Institute and St Petersburg State Pavlov Medical University (EK), Russia; Department of Psychiatry and Biobehavioral Sciences (WL), University of California, Los Angeles, CA; Alkermes, Inc (JZ, AM, BLS), Waltham, MA; and Treatment Research Institute (DRG), Philadelphia, PA
| | - Bernard L. Silverman
- From the New York State Psychiatric Institute and Department of Psychiatry (EVN), Columbia University, New York, NY; Bekhterev Research Psychoneurological Institute and St Petersburg State Pavlov Medical University (EK), Russia; Department of Psychiatry and Biobehavioral Sciences (WL), University of California, Los Angeles, CA; Alkermes, Inc (JZ, AM, BLS), Waltham, MA; and Treatment Research Institute (DRG), Philadelphia, PA
| | - David R. Gastfriend
- From the New York State Psychiatric Institute and Department of Psychiatry (EVN), Columbia University, New York, NY; Bekhterev Research Psychoneurological Institute and St Petersburg State Pavlov Medical University (EK), Russia; Department of Psychiatry and Biobehavioral Sciences (WL), University of California, Los Angeles, CA; Alkermes, Inc (JZ, AM, BLS), Waltham, MA; and Treatment Research Institute (DRG), Philadelphia, PA
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Opioid use and dropout in patients receiving oral naltrexone with or without single administration of injection naltrexone. Drug Alcohol Depend 2015; 147:122-9. [PMID: 25555621 PMCID: PMC4435949 DOI: 10.1016/j.drugalcdep.2014.11.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 11/26/2014] [Accepted: 11/28/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Adherence to oral naltrexone has been poor and can be improved somewhat with behavioral therapy. We compared behavioral naltrexone therapy (BNT) to compliance enhancement (CE) and tested efficacy of single-dose injection naltrexone (XR-NTX; 384 mg) with behavioral therapies at further improving adherence to oral naltrexone. METHODS A 24-week, randomized, placebo-controlled trial (n=125) compared four treatment conditions following inpatient detoxification and oral naltrexone induction: (1) BNT+XR-NTX; (2) BNT+placebo injection; (3) CE+XR-NTX; and (4) CE+placebo injection. All participants were maintained on oral naltrexone throughout the trial. Primary outcome was retention in treatment. RESULTS Of 89 randomized participants, 78.7% (70/89) completed 4 weeks, 58.2% (54/89) completed 8 weeks, 47.2% (42/89) completed 12 weeks, and 25.8% (23/89) completed 24 weeks. A Cox proportional hazards regression modeled time to dropout as a function of treatment condition, baseline opioid dependence severity (bags per day of heroin use), and their interaction. Interaction of conditions by baseline severity was significant (X3(2)=9.19, p=0.027). For low-severity patients (≤ 6 bags/day), retention was highest in the BNT-XR-NTX group (60% at 6 months), as hypothesized. For high-severity (>6 bags/day) patients, BNT-XR-NTX did not perform as well, due to high early attrition. CONCLUSION For low-severity heroin users, single-dose XR-NTX improved long-term treatment retention when combined with behavioral therapy. In higher-severity opioid-dependent patients, XR-NTX was less helpful, perhaps because, combined with oral naltrexone, it produced higher blood levels and more withdrawal discomfort. When cost considerations recommend oral naltrexone following XR-NTX, the latter should be phased in slowly.
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Lee JD, Friedmann PD, Boney TY, Hoskinson RA, McDonald R, Gordon M, Fishman M, Chen DT, Bonnie RJ, Kinlock TW, Nunes EV, Cornish JW, O'Brien CP. Extended-release naltrexone to prevent relapse among opioid dependent, criminal justice system involved adults: rationale and design of a randomized controlled effectiveness trial. Contemp Clin Trials 2015; 41:110-7. [PMID: 25602580 DOI: 10.1016/j.cct.2015.01.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/10/2015] [Accepted: 01/12/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX, Vivitrol; Alkermes Inc.) is an injectable monthly sustained-release mu opioid receptor antagonist. XR-NTX is a potentially effective intervention for opioid use disorders and as relapse prevention among criminal justice system (CJS) populations. METHODS This 5-site open-label randomized controlled effectiveness trial examines whether XR-NTX reduces opioid relapse compared with treatment as usual (TAU) among community dwelling, non-incarcerated volunteers with current or recent CJS involvement. The XR-NTX arm receives 6 monthly XR-NTX injections at Medical Management visits; the TAU group receives referrals to available community treatment options. Assessments occur every 2 weeks during a 24-week treatment phase and at 12- and 18-month follow-ups. The primary outcome is a relapse event, defined as either self-report or urine toxicology evidence of ≥10 days of opioid use in a 28-day (4 week) period, with a positive or missing urine test counted as 5 days of opioid use. RESULTS We describe the rationale, specific aims, and design of the study. Alternative design considerations and extensive secondary aims and outcomes are discussed. CONCLUSIONS XR-NTX is a potentially important treatment and relapse prevention option among persons with opioid dependence and CJS involvement. ClinicalTrials.gov: NCT00781898.
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Affiliation(s)
- Joshua D Lee
- Department of Population Health and Division of General Internal Medicine, New York University, United States.
| | - Peter D Friedmann
- Division of General Internal Medicine, Alpert Medical School of Brown University/Rhode Island Hospital and Providence Veterans Affairs Medical Center, United States
| | | | - Randall A Hoskinson
- Division of General Internal Medicine, Alpert Medical School of Brown University/Rhode Island Hospital and Providence Veterans Affairs Medical Center, United States
| | - Ryan McDonald
- Department of Population Health and Division of General Internal Medicine, New York University, United States
| | | | - Marc Fishman
- Friends Research Institute, United States; Maryland Treatment Centers, United States
| | - Donna T Chen
- Center for Biomedical Ethics and Humanities, University of Virginia School of Medicine, United States
| | | | - Timothy W Kinlock
- Friends Research Institute, United States; University of Baltimore, School of Criminal Justice, United States
| | - Edward V Nunes
- New York State Psychiatric Institute, Columbia University, College of Physicians and Surgeons, United States
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Kunøe N, Lobmaier P, Ngo H, Hulse G. Injectable and implantable sustained release naltrexone in the treatment of opioid addiction. Br J Clin Pharmacol 2014; 77:264-71. [PMID: 23088328 DOI: 10.1111/bcp.12011] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 10/16/2012] [Indexed: 12/12/2022] Open
Abstract
Sustained release technologies for administering the opioid antagonist naltrexone (SRX) have the potential to assist opioid-addicted patients in their efforts to maintain abstinence from heroin and other opioid agonists. Recently, reliable SRX formulations in intramuscular or implantable polymers that release naltrexone for 1-7 months have become available for clinical use and research. This qualitative review of the literature provides an overview of the technologies currently available for SRX and their effectiveness in reducing opioid use and other relevant outcomes. The majority of studies indicate that SRX is effective in reducing heroin use, and the most frequently studied SRX formulations have acceptable adverse events profiles. Registry data indicate a protective effect of SRX on mortality and morbidity. In some studies, SRX also seems to affect other outcomes, such as concomitant substance use, vocational training attendance, needle use, and risk behaviour for blood-borne diseases such as hepatitis or human immunodeficiency virus. There is a general need for more controlled studies, in particular to compare SRX with agonist maintenance treatment, to study combinations of SRX with behavioural interventions, and to study at-risk groups such as prison inmates or opioid-addicted pregnant patients. The literature suggests that sustained release naltrexone is a feasible, safe and effective option for assisting abstinence efforts in opioid addiction.
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Affiliation(s)
- Nikolaj Kunøe
- The Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway; Oslo University Hospital, Oslo, Norway
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31
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Liu JC, Ma JD, Morello CM, Atayee RS, Best BM. Naltrexone metabolism and concomitant drug concentrations in chronic pain patients. J Anal Toxicol 2014; 38:212-7. [PMID: 24659754 DOI: 10.1093/jat/bku019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Naltrexone is effective in treating opioid dependence by blocking µ, κ and δ opiate receptors. Naltrexone is mainly metabolized to an active metabolite 6β-naltrexol by dihydrodiol dehydrogenase enzymes. Concomitant opioids will not be effective while patients are taking this antagonist. This was a retrospective analysis of urinary excretion data collected from patients being treated with pain between November 2011 and May 2012. Naltrexone, 6β-naltrexol and concomitant opiate concentrations were measured by liquid chromatography-tandem mass spectrometry. Interpatient variability was calculated from first-visit specimens, and intrapatient variability was calculated from patients with two or more visits. Relationships of the metabolic ratio (MR; 6β-naltrexol/naltrexone) with age, gender and urinary pH were also explored. From 88 first-visit patient specimens, the median MR was 3.28 (range 0.73-17.42). The MR was higher in women than men (5.00 vs. 3.14, P< 0.05). The MR showed no association based on age and urinary pH. Eighteen of 88 patients taking oral naltrexone tested positive for concomitant opiate use. Urinary MRs of 6β-naltrexol/naltrexone were highly variable, which may contribute to variability in efficacy, toxicity and patient willingness to take naltrexone as directed. Twenty percent of patients tested positive for opiates and naltrexone, thus showing the importance of monitoring patients taking naltrexone.
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Affiliation(s)
- Janet C Liu
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, 9500 Gilman Drive, MC 0719, La Jolla, CA 92093-0719, USA
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Abstract
This paper is the thirty-fifth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2012 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Extended-release intramuscular naltrexone (VIVITROL®): a review of its use in the prevention of relapse to opioid dependence in detoxified patients. CNS Drugs 2013; 27:851-61. [PMID: 24018540 DOI: 10.1007/s40263-013-0110-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Naltrexone is a μ-opioid receptor antagonist that blocks the euphoric effects of heroin and prescription opioids. In order to improve treatment adherence, a once-monthly, intramuscular, extended-release formulation of naltrexone (XR-NTX) [VIVITROL(®)] has been developed, and approved in the USA and Russia for the prevention of relapse to opioid dependence, after opioid detoxification. The clinical efficacy of this formulation in patients with opioid dependence was demonstrated in a 24-week, randomized, double-blind, placebo-controlled, multicentre, phase III trial (ALK21-013; n = 250). In this trial, opioid-detoxified patients receiving XR-NTX 380 mg once every 4 weeks, in combination with psychosocial support, had a significantly higher median proportion of weeks of confirmed opioid abstinence during weeks 5-24, compared with those receiving placebo (primary endpoint). A significantly higher proportion of patients receiving XR-NTX achieved total confirmed abstinence during this period than those receiving placebo. XR-NTX was also associated with a significantly greater reduction in opioid craving and a significantly longer treatment retention period than placebo. XR-NTX was generally well tolerated in the phase III trial. The most common (incidence ≥5 %) treatment-emergent adverse events that also occurred more frequently with XR-NTX than with placebo were hepatic enzyme abnormalities, nasopharyngitis, insomnia, hypertension, influenza and injection-site pain. Thus, XR-NTX is a useful treatment option for the prevention of relapse to opioid dependence, following opioid detoxification.
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