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Elshebiney SA, Elgohary RA, El-Shamarka ME, Mabrouk M, Beheri HH. A novel tramadol-polycaprolactone implant could palliate heroin conditioned place preference and withdrawal in rats: behavioral and neurochemical study. Behav Pharmacol 2024:00008877-990000000-00091. [PMID: 38900102 DOI: 10.1097/fbp.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Drug dependence is a chronic brain disease characterized by craving and recurrent episodes of relapse. Tramadol HCl is a promising agent for withdrawal symptoms management, considering its relatively low abuse potential and safety. Oral administration, however, is not preferred in abstinence maintenance programs. Introducing an implantable, long-lasting formula is suggested to help outpatient abstinence programs achieve higher rates of treatment continuation. Tramadol implants (T350 and T650) were prepared on polycaprolactone polymer ribbons by the wet method. Male Wistar rats were adapted to heroin-conditioned place preference (CPP) at escalating doses (3-30 mg/kg, intraperitoneally, for 14 days). Implants were surgically implanted in the back skin of rats. After 14 days, the CPP score was recorded. Naloxone (1 mg/kg, intraperitoneally) was used to induce withdrawal on day 15, and symptoms were scored. Elevated plus maze and open field tests were performed for anxiety-related symptoms. Striata were analyzed for neurochemical changes reflected in dopamine, 3,4-dihydroxyphenyl acetic acid, gamma-aminobutyric acid, and serotonin levels. Brain oxidative changes including glutathione and lipid peroxides were assessed. The tramadol implants (T350 and T650) reduced heroin CPP and limited naloxone-induced withdrawal symptoms. The striata showed increased levels of 3,4-dihydroxyphenyl acetic acid, and serotonin and decreased levels of gamma-aminobutyric acid and dopamine after heroin withdrawal induction, which were reversed after implanting T350 and T650. Implants restore the brain oxidative state. Nonsignificant low naloxone-induced withdrawal score after the implant was used in naive subjects indicating low abuse potential of the implants. The presented tramadol implants were effective at diminishing heroin CPP and withdrawal in rats, suggesting further investigations for application in the management of opioid withdrawal.
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Affiliation(s)
- Shaimaa A Elshebiney
- Narcotics, Ergogenics, and Poisons Department, Medical Research and Clinical Studies Institute, National Research Centre (NRC)
| | - Rania A Elgohary
- Narcotics, Ergogenics, and Poisons Department, Medical Research and Clinical Studies Institute, National Research Centre (NRC)
| | - Marwa E El-Shamarka
- Narcotics, Ergogenics, and Poisons Department, Medical Research and Clinical Studies Institute, National Research Centre (NRC)
| | - Mostafa Mabrouk
- Refractories, Ceramics and Building Materials Department, Advanced Materials, Technology and Mineral Resources Research Institute, National Research Centre (NRC), Giza, Egypt
| | - Hanan H Beheri
- Refractories, Ceramics and Building Materials Department, Advanced Materials, Technology and Mineral Resources Research Institute, National Research Centre (NRC), Giza, Egypt
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2
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Contreras KM, Buzzi B, Vaughn J, Caillaud M, Altarifi AA, Olszewski E, Walentiny DM, Beardsley PM, Damaj MI. Characterization and validation of a spontaneous acute and protracted oxycodone withdrawal model in male and female mice. Pharmacol Biochem Behav 2024:173795. [PMID: 38834159 DOI: 10.1016/j.pbb.2024.173795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024]
Abstract
Opioid use disorder (OUD) is a serious health problem that may lead to physical dependence, in addition to affective disorders. Preclinical models are essential for studying the neurobiology of and developing pharmacotherapies to treat these problems. Historically, chronic morphine injections have most often been used to produce opioid-dependent animals, and withdrawal signs indicative of dependence were precipitated by administering an opioid antagonist. In the present studies, we have developed and validated a model of dependence on oxycodone (a widely prescribed opioid) during spontaneous withdrawal in male and female C57BL/6J mice. Dependence was induced by chronically administering oxycodone through osmotic minipumps at different doses for 7 days. Somatic withdrawal signs were measured after 3, 6, 24, and 48 h following minipump removal. Additionally, sensitivity to mechanical, thermal, and cold stimuli, along with anxiety-like behavior, were also measured. Our results indicated that spontaneous withdrawal following discontinuation of oxycodone produced an increase in total withdrawal signs after 60 and 120 mg/kg/day regimens of oxycodone administration. These signs were reversed by the administration of clinically approved medications for OUD. In general, both female and male mice showed similar profiles of somatic signs of spontaneous withdrawal. Spontaneous withdrawal also resulted in mechanical and cold hypersensitivity lasting for 24 and 14 days, respectively, and produced anxiety-like behaviors after 2 and 3 weeks following oxycodone removal. These results help validate a new model of oxycodone dependence, including the temporally distinct emergence of somatic, hyperalgesic, and anxiety-like behaviors, potentially useful for mechanistic and translational studies of opioid dependence.
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Affiliation(s)
- Katherine M Contreras
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Belle Buzzi
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Julian Vaughn
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Martial Caillaud
- Nantes Université, INSERM, UMR1235-TENS, The Enteric Nervous System in Gut and Brain Diseases, Nantes, France
| | - Ahmad A Altarifi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Emily Olszewski
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - D Matthew Walentiny
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Patrick M Beardsley
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA; Center for Biomarker Research & Precision Medicine, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - M Imad Damaj
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA; Translational Research Initiative for Pain and Neuropathy at Virginia Commonwealth University, Richmond, VA, USA.
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3
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Hastings LE, Frye EV, Carlson ER, Chuong V, Matthews AN, Koob GF, Vendruscolo LF, Marchette RCN. Cold nociception as a measure of hyperalgesia during spontaneous heroin withdrawal in mice. Pharmacol Biochem Behav 2024; 235:173694. [PMID: 38128767 PMCID: PMC10842911 DOI: 10.1016/j.pbb.2023.173694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
Opioids are powerful analgesic drugs that are used clinically to treat pain. However, chronic opioid use causes compensatory neuroadaptations that result in greater pain sensitivity during withdrawal, known as opioid withdrawal-induced hyperalgesia (OWIH). Cold nociception tests are commonly used in humans, but preclinical studies often use mechanical and heat stimuli to measure OWIH. Thus, further characterization of cold nociception stimuli is needed in preclinical models. We assessed three cold nociception tests-thermal gradient ring (5-30 °C, 5-50 °C, 15-40 °C, and 25-50 °C), dynamic cold plate (4 °C to -1 °C at -1 °C/min, -1 °C to 4 °C at +1 °C/min), and stable cold plate (10 °C, 6 °C, and 2 °C)-to measure hyperalgesia in a mouse protocol of heroin dependence. On the thermal gradient ring, mice in the heroin withdrawal group preferred warmer temperatures, and the results depended on the ring's temperature range. On the dynamic cold plate, heroin withdrawal increased the number of nociceptive responses, with a temperature ramp from 4 °C to -1 °C yielding the largest response. On the stable cold plate, heroin withdrawal increased the number of nociceptive responses, and a plate temperature of 2 °C yielded the most significant increase in responses. Among the three tests, the stable cold plate elicited the most robust change in behavior between heroin-dependent and nondependent mice and had the highest throughput. To pharmacologically characterize the stable cold plate test, we used μ-opioid and non-opioid receptor-targeting drugs that have been previously shown to reverse OWIH in mechanical and heat nociception assays. The full μ-opioid receptor agonist methadone and μ-opioid receptor partial agonist buprenorphine decreased OWIH, whereas the preferential μ-opioid receptor antagonist naltrexone increased OWIH. Two N-methyl-d-aspartate receptor antagonists (ketamine, MK-801), a corticotropin-releasing factor 1 receptor antagonist (R121919), a β2-adrenergic receptor antagonist (butoxamine), an α2-adrenergic receptor agonist (lofexidine), and a 5-hydroxytryptamine-3 receptor antagonist (ondansetron) had no effect on OWIH. These data demonstrate that the stable cold plate at 2 °C yields a robust, reliable, and concise measure of OWIH that is sensitive to opioid agonists.
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Affiliation(s)
- Lyndsay E Hastings
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Emma V Frye
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Erika R Carlson
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Vicky Chuong
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA; Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Intitute on Drug Abuse, Intramural Research Program, and National Institute on Alcohol Abuse and Alcoholism, Division of Intramural Clinical and Biological Research, Baltimore, MD, USA
| | - Aniah N Matthews
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - George F Koob
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA
| | - Leandro F Vendruscolo
- Stress and Addiction Neuroscience Unit, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, and National Institute on Alcohol Abuse and Alcoholism, Division of Intramural Clinical and Biological Research, Baltimore, MD, USA
| | - Renata C N Marchette
- Neurobiology of Addiction Section, Integrative Neuroscience Research Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USA.
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Dunn KE. Iteration is not solving the opioid crisis, it's time for transformation. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:151-158. [PMID: 36920881 DOI: 10.1080/00952990.2023.2170807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Opioid use disorder (OUD) produces exceedingly high rates of morbidity and mortality in the United States and throughout the world. Almost 90% of persons qualifying for treatment do not enter treatment and 72% of those who initiate treatment leave within 60 days. This Perspective posits that over the past decade our OUD treatment system has produced only small iterative gains in treatment access because, in part, it is founded in a series of top-down regulatory policies dating back more than 100 years. These policies prioritized restricting persons with OUD from having access to opioid agonists over empirical discovery of treatment best practice. It further suggests that for persons who are not already responding positively to our existing treatments, we may need to fundamentally transform care to enact true, meaningful change. Four potential considerations are outlined: expanding beyond long-acting opioids for treatment, embracing safe use as a viable therapeutic target, ending closed medication distribution systems, and partnering with our patients. The overarching aim of this discussion is to motivate broader thinking about new solutions for the patients for whom the existing strategies are not working and who may benefit from more transformative approaches. Though efforts to-date to expand existing treatment systems and find new ways to promote existing MOUDs have been important, these efforts have represented iterative changes. For us to meet our goal of substantially reducing opioid-related harms, it may be time to consider strategies that represent true transformation.
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Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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5
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Kay A, Shmuts R, Beck M. Understanding and co-managing medication treatment options for opioid use disorder. Intern Emerg Med 2022; 17:2159-2165. [PMID: 35138549 DOI: 10.1007/s11739-022-02936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
The number of patients with opioid use disorder (OUD) has increased dramatically. Substance use disorders in general are thought to occur in one in five patients in primary care. However, despite this prevalence, there is a dearth of training in undergraduate and continuing medical education to manage OUDs, and internal medicine doctors need to have an understanding of the basic physiology and treatment options for this illness. Expanding knowledge of OUD treatments will allow internists to use their skills and strong patient-doctor relationships to ensure the trust of their patients with OUD, leading to better outcomes and increased chances of recovery. It will also allow clinicians to appropriately refer their patients for lifesaving specialized care and help them prevent dangerous medical complications often seen as a result of addiction. There are three FDA-approved medications to treat OUD disorder, known collectively as medication-assisted treatment (MAT). In this paper, the three medications-methadone, naltrexone, and buprenorphine-are presented, compared, contrasted, and clinically reviewed.
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Affiliation(s)
- Abigail Kay
- Department of Psychiatry and Human Behavior-Division of Substance Abuse, The Sidney Kimmel Medical College at Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rachel Shmuts
- Department of Psychiatry, Rowan University School of Osteopathic Medicine, Mount Laurel, NJ, USA.
| | - Melanie Beck
- Cooper Medical School of Rowan University at AtlantiCare Regional Medical Center, Atlantic City, NJ, USA
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Guillou Landreat M, Dany A, Challet Bouju G, Laforgue EJ, Cholet J, Leboucher J, Hardouin JB, Bodenez P, Grall-Bronnec M, Guillou-Landreat M, Le Geay B, Martineau I, Levassor P, Bolo P, Guillet JY, Guillery X, Dano C, Victorri Vigneau C, Grall Bronnec M. How do people who use drugs receiving Opioid Medication Therapy perceive their treatment ? A multicentre study. Harm Reduct J 2022; 19:31. [PMID: 35346219 PMCID: PMC8961988 DOI: 10.1186/s12954-022-00608-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 03/04/2022] [Indexed: 01/04/2023] Open
Abstract
Abstract
Background
The resurgence of heroin use and the misuse of pharmaceutical opioids are some of the reasons for a worldwide increase in opioid dependence. Opioid Medication Therapies (OMT) have amply demonstrated their efficacy. From a medical point of view, the main objectives of OMT concern medical and social outcomes, centred on risk reduction and the cessation of opioid use. But patient points of view can differ and few studies have explored opioid-dependent patient viewpoints on their OMT. This variable seems important to consider in a patient-centred approach. The aim of our study was to explore points of view of people who use drugs (PWUD) treated with OMT, in a large multicentre sample.
Method
A cross-sectional multicentre study explored the points of view of PWUD with Opioid Use Disorder following OMT. Data regarding the patients’ points of view were collected using a self-administered questionnaire developed by the scientific committee of the study. A descriptive analysis and an exploratory factor analysis were performed to explore the structure of items exploring patient viewpoints.
Results
263 opioid dependent PWUD were included, a majority were men consuming heroin prior to being prescribed OMT. 68% were on methadone, 32% were on buprenorphine. Most PWUD identified a positive impact on their lives, with 92.8% agreeing or strongly agreeing that OMT had changed a lot of things in their lives. The exploratory factor analysis identified three factors: (F1) items related to points of views concerning the objectives and efficacy of OMT; (F2) items related to the legitimacy of OMT as a treatment compared to a drug, (F3) items related to experiences and relationships with OMT.
Conclusion
Patient viewpoints on efficacy were correlated with the pharmacological benefits of OMT and with the associated psychosocial measures. The implications of OMT in relationships, such as the feeling of being judged, concerned a majority. Points of view were ambivalent concerning the role of OMT as a treatment or as a drug. Involving patient points of view in therapeutic strategies decisions could help enhance positive views among PWUD on OMT and help PWUD towards their recovery.
Trial registration: OPAL study was registered: (NCT01847729).
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METZGER IF, THOMAS AE, EVRARD CA, JONES DR, MASTERS AR, HAAS DM, HANELINE LS, QUINNEY SK. Stereoselective Analysis of Methadone and EDDP in Laboring Women and Neonates in Plasma and Dried Blood Spots and Association with Neonatal Abstinence Syndrome. Am J Perinatol 2021; 38:968-975. [PMID: 32052397 PMCID: PMC9393850 DOI: 10.1055/s-0040-1701505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This pilot study evaluated the relationship between maternal and neonatal R- and S-methadone and R- and S-2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) exposure and the severity of neonatal abstinence syndrome (NAS). The use of dried blood spots (DBS) as an alternative for plasma in assessing methadone and EDDP was also assessed. STUDY DESIGN Women receiving methadone for medication assisted treatment of opioid use disorder during pregnancy were eligible for recruitment. Plasma and DBS samples were collected from mothers during labor, from cord blood, and from newborns during genetic screen. R-/S-methadone and EDDP were measured by high-performance liquid chromatography tandem mass spectrometry (HPLC/MS/MS). Associations between methadone exposure, neonatal morphine requirements, and severity of NAS were examined. RESULTS Twenty women and infants completed the study. Maternal methadone dose at delivery was 112 mg/day (range = 60-180 mg/day). Sixteen neonates experienced NAS requiring morphine; three also required phenobarbital. Higher cord blood concentrations of R-methadone, R- and S-EDDP were associated with higher maximum doses of morphine (p < 0.05). CONCLUSION Maternal methadone and cord blood concentration at delivery are variable and may be potential markers of neonatal abstinence syndrome.
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Affiliation(s)
- Ingrid F. METZGER
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA,Present address University of Barilia, Brasilia, Brazil
| | - Anna E. THOMAS
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cindy A. EVRARD
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David R. JONES
- Division of Clinical Pharmacology - Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea R. MASTERS
- Clinical Pharmacology Analytical Core - Indiana University Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David M. HAAS
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA,Division of Clinical Pharmacology - Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura S. HANELINE
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sara K. QUINNEY
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA,Division of Clinical Pharmacology - Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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The Use of the Methadone/Metabolite Ratio (MMR) to Identify an Individual Metabolic Phenotype and Assess Risks of Poor Response and Adverse Effects: Towards Scientific Methadone Dosing. J Addict Med 2021; 14:431-436. [PMID: 32032212 DOI: 10.1097/adm.0000000000000620] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Significant genetic variability of metabolism confounds reliable clinical use of methadone because physicians have no way of identifying individual patient metabolism. The methadone/metabolite ratio (MMR), the numerical ratio of serum methadone to its inactive metabolite ethylidine-dimethyl-diphenypyrrolidine (EDDP), represents the net expression of the genes controlling metabolism. The MMR has been adapted to four established pharmacogenetic metabolic categories: ultra-rapid (URM), extensive (EM, normal), intermediate (IM), and ultra-slow (USM). METHODS This study reports on the analysis of 1700 paired peak and trough serum samples for methadone and EDDP. The MMR data were stratified by metabolic category. The reliability of these categories and the relationship of the MMR to 2 other laboratory assessments, a peak/trough ratio (PTR) and a methadone half-life, was tested. Additionally, peak and trough serum levels were analyzed by MMR category. RESULTS Each category of MMR identified significantly different mean serum levels (peak and trough), peak/trough ratios, and half-lives. When serum levels were analyzed, evidence of subtherapeutic serum levels were found, predominantly in the URM and EM categories. Seventeen percent of peak serum levels were greater than 1000 ng (a level indicating potential toxicity) with a range up to 2384 ng, predominantly in the IM and USM categories. CONCLUSIONS The MMR measures an individual's phenotype for methadone metabolism. The data suggested underdosing in the URM category, as well as evidence of excessive dosing in IM and USM categories. The MMR provides a guide to safe and effective dosing, an alternative to the pharmacokinetically 'blind' dosing algorithms currently in use.
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Chalabianloo F, Fadnes LT, Høiseth G, Ohldieck C, Vold JH, Aas C, Løberg EM, Johansson KA, Bramness JG. Subjective symptoms and serum methadone concentrations: what should guide dose adjustments in methadone maintenance treatment? A naturalistic cohort study from Norway. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2021; 16:39. [PMID: 33941217 PMCID: PMC8091668 DOI: 10.1186/s13011-021-00367-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 05/11/2023]
Abstract
BACKGROUND There is little evidence-based guidance on how to optimize methadone dosages among patients with opioid addiction undergoing methadone maintenance treatment (MMT). This study aims to investigate whether self-perceived opioid withdrawal symptoms, adverse effects, and self-reported substance use in patients on MMT are related to serum methadone concentrations and the role that these variables could play in clinical decisions on dose adjustments. METHODS This naturalistic prospective cohort study included clinical and laboratory measurements from 83 patients undergoing MMT in outpatient clinics in Bergen, Norway, from May 2017 to January 2020. Information on age, gender, methadone daily doses and serum concentrations, subjective opioid withdrawal symptoms using 16 items Subjective Opioid Withdrawal Scale (SOWS) questionnaire, self-reported adverse effects, and substance use was obtained. Linear mixed modelling was used for analyzing the data. RESULTS The mean age of the participants was 45 years, and 33% were women. Almost half reported mild to moderate subjective opioid withdrawal symptoms, and all had experienced at least one subjective adverse effect. The use of at least one substance was reported by 88% of the participants. Serum concentration-to-dose ratios were lower among those who had reported subjective opioid withdrawal symptoms (p) = 0.039). The total SOWS score (p < 0.001); the specific subjective withdrawal symptoms of anxiety (p = 0.004), bone and muscle aches (p = 0.003), restlessness (p = 0.017), and (slightly) shaking (p = 0.046), also use of heroin (p = 0.015) and alcohol (p = 0.011) were associated with lower methadone concentrations. Cannabis use was slightly related to higher methadone concentrations (p = 0.049). CONCLUSIONS The findings suggest that the patient's self-perceived symptoms and current clinical condition are related to the serum concentrations of methadone. This interpretation supports dose adjustments based on patient-reported symptoms. In some aberrant cases, measurement of serum concentrations together with other individual assessments may be considered to support the clinical decision.
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Affiliation(s)
- Fatemeh Chalabianloo
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Lars Thore Fadnes
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Gudrun Høiseth
- Department of Forensic Medicine, Oslo University Hospital, Oslo, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Norwegian Center for Addiction Research, University of Oslo, Oslo, Norway
| | - Christian Ohldieck
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway
| | - Jørn Henrik Vold
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Christer Aas
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Else-Marie Løberg
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Psychology, University of Bergen, Bergen, Norway.,Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Kjell Arne Johansson
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jørgen G Bramness
- Institute of Clinical Medicine, UiT - Norway's Arctic University, Tromsø, Norway.,Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
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10
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Tang F, Ng CM, Bada HS, Leggas M. Clinical pharmacology and dosing regimen optimization of neonatal opioid withdrawal syndrome treatments. Clin Transl Sci 2021; 14:1231-1249. [PMID: 33650314 PMCID: PMC8301571 DOI: 10.1111/cts.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022] Open
Abstract
In this paper, we review the management of neonatal opioid withdrawal syndrome (NOWS) and clinical pharmacology of primary treatment agents in NOWS, including morphine, methadone, buprenorphine, clonidine, and phenobarbital. Pharmacologic treatment strategies in NOWS have been mostly empirical, and heterogeneity in dosing regimens adds to the difficulty of extrapolating study results to broader patient populations. As population pharmacokinetics (PKs) of pharmacologic agents in NOWS become more well‐defined and knowledge of patient‐specific factors affecting treatment outcomes continue to accumulate, PK/pharmacodynamic modeling and simulation will be powerful tools to aid the design of optimal dosing regimens at the patient level. Although there is an increasing number of clinical trials on the comparative efficacy of treatment agents in NOWS, here, we also draw attention to the importance of optimizing the dosing regimen, which can be arguably equally important at identifying the optimal treatment agent.
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Affiliation(s)
- Fei Tang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Chee M Ng
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA.,NewGround Pharmaceutical Consulting LLC, Foster City, California, USA
| | - Henrietta S Bada
- Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Markos Leggas
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
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11
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Naji-Talakar S, Sharma S, Martin LA, Barnhart D, Prasad B. Potential implications of DMET ontogeny on the disposition of commonly prescribed drugs in neonatal and pediatric intensive care units. Expert Opin Drug Metab Toxicol 2021; 17:273-289. [PMID: 33256492 PMCID: PMC8346204 DOI: 10.1080/17425255.2021.1858051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Introduction: Pediatric patients, especially neonates and infants, are more susceptible to adverse drug events as compared to adults. In particular, immature small molecule drug metabolism and excretion can result in higher incidences of pediatric toxicity than adults if the pediatric dose is not adjusted.Area covered: We reviewed the top 29 small molecule drugs prescribed in neonatal and pediatric intensive care units and compiled the mechanisms of their metabolism and excretion. The ontogeny of Phase I and II drug metabolizing enzymes and transporters (DMETs), particularly relevant to these drugs, are summarized. The potential effects of DMET ontogeny on the metabolism and excretion of the top pediatric drugs were predicted. The current regulatory requirements and recommendations regarding safe and effective use of drugs in children are discussed. A few representative examples of the use of ontogeny-informed physiologically based pharmacokinetic (PBPK) models are highlighted.Expert opinion: Empirical prediction of pediatric drug dosing based on body weight or body-surface area from the adult parameters can be inaccurate because DMETs are not mature in children and the age-dependent maturation of these proteins is different. Ontogeny-informed-PBPK modeling provides a better alternative to predict the pharmacokinetics of drugs in children.
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Affiliation(s)
- Siavosh Naji-Talakar
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Sheena Sharma
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Leslie A. Martin
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Derek Barnhart
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Bhagwat Prasad
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
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van Hoogdalem MW, McPhail BT, Hahn D, Wexelblatt SL, Akinbi HT, Vinks AA, Mizuno T. Pharmacotherapy of neonatal opioid withdrawal syndrome: a review of pharmacokinetics and pharmacodynamics. Expert Opin Drug Metab Toxicol 2020; 17:87-103. [PMID: 33049155 DOI: 10.1080/17425255.2021.1837112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Neonatal opioid withdrawal syndrome (NOWS) often arises in infants born to mothers who used opioids during pregnancy. Morphine, methadone, and buprenorphine are the most common first-line treatments, whereas clonidine and phenobarbital are generally reserved for adjunctive therapy. These drugs exhibit substantial pharmacokinetic (PK) and pharmacodynamic (PD) variability. Current pharmacological treatments for NOWS are based on institutional protocols and largely rely on empirical treatment of patient symptoms. AREAS COVERED This article reviews the PK/PD of NOWS pharmacotherapies with a focus on the implication of physiological development and maturation. Body size-standardized clearance is consistently low in neonates, except for methadone. This can be ascribed to underdeveloped metabolic and elimination pathways. The effects of pharmacogenetics have been clarified especially for morphine. The PK/PD relationship of medications used in the treatment of NOWS is generally understudied. EXPERT OPINION Providing an appropriate opioid dose in neonates is challenging. Advancements in quantitative pharmacology and PK/PD modeling approaches facilitate identification of key factors driving PK/PD variability and characterization of exposure-response relationships. PK/PD model-informed simulations have been widely employed to define age-appropriate pediatric dosing regimens. The model-informed approach holds promise to aid more rational use of medications in the treatment of NOWS.
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Affiliation(s)
- Matthijs W van Hoogdalem
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,James L. Winkle College of Pharmacy, University of Cincinnati , Cincinnati, OH, USA
| | - Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,School of Medicine Greenville, University of South Carolina , Greenville, SC, USA
| | - David Hahn
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Scott L Wexelblatt
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
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Sohrevardi SM, Pournamdari M, Salimi R, Sarrafzadeh F, Ahmadinejad M. Comparing the Efficacy of Methadone and Tincture of Opium in Controlling Agitation Caused by Withdrawal Syndrome in Opium-Addicted Patients in the Intensive Care Unit: A Randomized Trial Study. ADDICTION & HEALTH 2020; 12:69-76. [PMID: 32782729 PMCID: PMC7395929 DOI: 10.22122/ahj.v12i2.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/18/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Few studies have been conducted regarding the comparison of the efficacy of methadone and tincture of opium (TOP) in controlling agitation induced by withdrawal syndrome. Therefore, the current randomized trial study is carried out with the aim to evaluate comparisons on the efficacy of methadone and TOP in controlling agitation caused by withdrawal syndrome in opium addicted patients in the intensive care units (ICUs). METHODS This clinical trial study was conducted on 60 patients admitted to ICU of Shahid Bahonar Hospital, Kerman, Iran. After classification of the patients into two groups, the first and second groups consumed methadone syrup (5 mg/ml) and TOP (10 mg/ml), respectively. Agitation in these patients was assessed through the Richmond Agitation-Sedation Scale (RASS). Vital signs were also assessed. Paired sample t-test and independent t-test were used for data analysis. FINDINGS In the current study, the administered dose of methadone and TOP was 36.17 ± 26.99 and 112.67 ± 102.74 mg, respectively (P < 0.010). Methadone administration led to a significant decrease of the patients' vital signs, including systolic blood pressure, heart rate, respiratory rate, and Glasgow Coma Scale (GCS) (P < 0.05). Though TOP administration decreased systolic blood pressure and GCS significantly (P < 0.05), it had no effect on patients' diastolic blood pressure, body temperature, heart rate, and respiratory rate (P > 0.05). In total, no significant difference was detected between two groups regarding vital signs (P > 0.05). However, a significant difference was seen between methadone and TOP groups in terms of RASS score (P < 0.01). CONCLUSION According to the results of the current study, lower dose of methadone, compared to TOP, could control agitation caused by opium withdrawal symptoms.
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Affiliation(s)
- Seyed Mojtaba Sohrevardi
- Robarts Research Institute, University of Western Ontario, Ontario, Canada AND Pharmaceutical Sciences Research Center AND Department of Clinical Pharmacy, School of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mostafa Pournamdari
- Pharmaceutics Research Center AND Department of Medical Chemistry, School of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
| | - Razieh Salimi
- Pharmaceutics Research Center AND Department of Medical Chemistry, School of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
| | - Farhad Sarrafzadeh
- Department of Internal Medicine, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Ahmadinejad
- Department of Anesthesia, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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15
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Neuropsychological functioning and chronic methadone use: A systematic review and meta-analysis. Neurosci Biobehav Rev 2017; 73:23-38. [DOI: 10.1016/j.neubiorev.2016.11.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 11/06/2016] [Accepted: 11/09/2016] [Indexed: 11/21/2022]
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16
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Fischer IW, Hansen TM, Lelic D, Brokjaer A, Frøkjær J, Christrup LL, Olesen AE. Objective methods for the assessment of the spinal and supraspinal effects of opioids. Scand J Pain 2016; 14:15-24. [PMID: 28850426 DOI: 10.1016/j.sjpain.2016.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 09/30/2016] [Accepted: 10/03/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Opioids are potent analgesics. Opioids exert effects after interaction with opioid receptors. Opioid receptors are present in the peripheral- and central nervous system (CNS), but the analgesic effects are primarily mediated via receptors in the CNS. Objective methods for assessment of opioid effects may increase knowledge on the CNS processes responsible for analgesia. The aim of this review was to provide an overview of the most common objective methods for assessment of the spinal and supraspinal effects of opioids and discuss their advantages and limitations. METHOD The literature search was conducted in Pub Med (http://www.ncbi.nlm.nih.gov/pubmed) from November 2014 to June 2016, using free-text terms: "opioid", "morphine" and "oxycodone" combined with the terms "pupillometry," "magnetic resonance spectroscopy," "fMRI," "BOLD," "PET," "pharmaco-EEG", "electroencephalogram", "EEG," "evoked potentials," and "nociceptive reflex". Only original articles published in English were included. RESULTS For assessment of opioid effects at the supraspinal level, the following methods are evaluated: pupillometry, proton magnetic resonance spectroscopy, functional resonance magnetic imaging (fMRI), positron emission tomography (PET), spontaneous electroencephalogram (EEG) and evoked potentials (EPs). Pupillometry is a non-invasive tool used in research as well as in the clinical setting. Proton magnetic resonance spectroscopy has been used for the last decades and it is a non-invasive technique for measurement of in vivo brain metabolite concentrations. fMRI has been a widely used non-invasive method to estimate brain activity, where typically from the blood oxygen level-dependent (BOLD) signal. PET is a nuclear imaging technique based on tracing radio labeled molecules injected into the blood, where receptor distribution, density and activity in the brain can be visualized. Spontaneous EEG is typically quantified in frequency bands, power spectrum and spectral edge frequency. EPs are brain responses (assessed by EEG) to a predefined number of short phasic stimuli. EPs are quantified by their peak latencies and amplitudes, power spectrum, scalp topographies and brain source localization. For assessment of opioid effects at the spinal level, the following methods are evaluated: the nociceptive withdrawal reflex (NWR) and spinal EPs. The nociceptive withdrawal reflex can be recorded from all limbs, but it is standard to record the electromyography signal at the biceps femoris muscle after stimulation of the ipsilateral sural nerve; EPs can be recorded from the spinal cord and are typically recorded after stimulation of the median nerve at the wrist. CONCLUSION AND IMPLICATIONS The presented methods can all be used as objective methods for assessing the centrally mediated effects of opioids. Advantages and limitations should be considered before implementation in drug development, future experimental studies as well as in clinical settings. In conclusion, pupillometry is a sensitive measurement of opioid receptor activation in the CNS and from a practical and economical perspective it may be used as a biomarker for opioid effects in the CNS. However, if more detailed information is needed on opioid effects at different levels of the CNS, then EEG, fMRI, PET and NWR have the potential to be used. Finally, it is conceivable that information from different methods should be considered together for complementary information.
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Affiliation(s)
- Iben W Fischer
- Mech-Sense, Department of Gastroenterology &Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark.,Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tine M Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dina Lelic
- Mech-Sense, Department of Gastroenterology &Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Anne Brokjaer
- Mech-Sense, Department of Gastroenterology &Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Jens Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lona L Christrup
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne E Olesen
- Mech-Sense, Department of Gastroenterology &Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark.,Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Gayman C, Pietras C. Laboratory Measures of Aggression in Methadone Patients Pre- and Postdose. PSYCHOLOGICAL RECORD 2016. [DOI: 10.1007/s40732-016-0206-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Jiang H, Hillhouse M, Du J, Pan S, Alfonso A, Wang J, Zhou Z, Yuan W, Ling W, Zhao M. Dose, Plasma Level, and Treatment Outcome Among Methadone Patients in Shanghai, China. Neurosci Bull 2016; 32:538-544. [PMID: 27612968 DOI: 10.1007/s12264-016-0059-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022] Open
Abstract
The purpose of this study was to investigate the blood levels of methadone in participants receiving methadone for the treatment of opioid dependence. After stabilization on methadone for four weeks, blood samples from 95 participants were collected between treatment weeks 4 and 12, before and after receiving doses of methadone, and its blood levels were measured. A multiple linear regression model was used to examine the association between methadone blood levels and the outcomes of methadone maintenance treatment (MMT). Outcome differences between participants who had high (≥2) or low (<2) peak-to-trough ratios were also compared using an independent sample t-test. The blood level of methadone was not correlated with the clinical outcome of MMT with the moderate range of doses given. However, the retention of patients who had a free peak-to-trough ratio >2 was significantly poorer than those whose ratio was <2. Thus, monitoring plasma methadone levels is unlikely to be effective for guiding dosing decisions in situations where compliance with MMT is already very high or when the methadone dose is no longer the dominant factor in determining the clinical outcome. However, monitoring plasma methadone levels is still helpful for guiding the dosage for patients with a rapid metabolism.
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Affiliation(s)
- Haifeng Jiang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Maureen Hillhouse
- Department of Psychiatry, Integrated Substance Abuse Program, University of California at Los Angeles, Los Angeles, CA, 90025, USA
| | - Jiang Du
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Shujun Pan
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Ang Alfonso
- Department of Psychiatry, Integrated Substance Abuse Program, University of California at Los Angeles, Los Angeles, CA, 90025, USA
| | - Jun Wang
- Shanghai Yangpu District Mental Health Center, Shanghai, 200093, China
| | - Zhirong Zhou
- Shanghai Xuhui District Mental Health Center, Shanghai, 200232, China
| | - Weijun Yuan
- Shanghai Hongkou District Mental Health Center, Shanghai, 200083, China
| | - Walter Ling
- Department of Psychiatry, Integrated Substance Abuse Program, University of California at Los Angeles, Los Angeles, CA, 90025, USA
| | - Min Zhao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.
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Wedam EF, Haigney MC. The Impact of Opioids on Cardiac Electrophysiology. Curr Cardiol Rev 2016; 12:27-36. [PMID: 26818485 PMCID: PMC4807715 DOI: 10.2174/1573403x1201160126122405] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 11/17/2015] [Accepted: 11/20/2015] [Indexed: 11/22/2022] Open
Abstract
Synthetic opioid agents have been used in modern medicine for over a century and for opioid addiction treatment for over a half-century. Liberal use of opioids in the United States has been attended by an extraordinary increase in opioid-related mortality, with over 16,000 deaths in 2012. As there have been advances in opioid agents for pain and addiction, so have there been advances in our understanding of the cardiac effects of these agents. In the last 10 years, significant data regarding electrophysiologic effects of these agents have been collected. We aim in this review to discuss the effects on cardiac electrophysiology of the various opioid agents currently in use and the evidence that these effects are contributing to the rise in opioid-related mortality.
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Affiliation(s)
| | - Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, A3060, USUHS, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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20
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Sheynin J, Moustafa AA, Beck KD, Servatius RJ, Casbolt PA, Haber P, Elsayed M, Hogarth L, Myers CE. Exaggerated acquisition and resistance to extinction of avoidance behavior in treated heroin-dependent men. J Clin Psychiatry 2016; 77:386-94. [PMID: 27046310 PMCID: PMC4822714 DOI: 10.4088/jcp.14m09284] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 05/04/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Addiction is often conceptualized as a behavioral strategy for avoiding negative experiences. In rodents, opioid intake has been associated with abnormal acquisition and extinction of avoidance behavior. Here, we tested the hypothesis that these findings would generalize to human opioid-dependent subjects. METHOD Adults meeting DSM-IV criteria for heroin dependence and treated with opioid medication (n = 27) and healthy controls (n = 26) were recruited between March 2013 and October 2013 and given a computer-based task to assess avoidance behavior. For this task, subjects controlled a spaceship and could either gain points by shooting an enemy spaceship or hide in safe areas to avoid on-screen aversive events. Hiding duration during different periods of the task was used to measure avoidance behavior. RESULTS While groups did not differ on escape responding (hiding) during the aversive event, heroin-dependent men (but not women) made more avoidance responses during a warning signal that predicted the aversive event (analysis of variance, sex × group interaction, P = .007). Heroin-dependent men were also slower to extinguish the avoidance response when the aversive event no longer followed the warning signal (P = .011). This behavioral pattern resulted in reduced opportunity to obtain reward without reducing risk of punishment. Results suggest that, in male patients, differences in avoidance behavior cannot be easily explained by impaired task performance or by exaggerated motor activity. CONCLUSIONS This study provides evidence for abnormal acquisition and extinction of avoidance behavior in opioid-dependent patients. Interestingly, data suggest that abnormal avoidance is demonstrated only by male patients. Findings shed light on cognitive and behavioral manifestations of opioid addiction and may facilitate development of therapeutic approaches to help affected individuals.
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Affiliation(s)
- Jony Sheynin
- Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Ann Arbor, MI 48109 ,
| | - Ahmed A. Moustafa
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, NJ, USA,Marcs Institute for Brain and Behaviour, University of Western Sydney, Sydney, NSW, Australia,School of Social Sciences and Psychology, University of Western Sydney, Sydney, NSW, Australia
| | - Kevin D. Beck
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, NJ, USA,Joint Biomedical Engineering Program, New Jersey Institute of Technology and Graduate School of Biomedical Sciences, Rutgers, The State University of New Jersey, Newark, NJ, USA,Stress & Motivated Behavior Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Richard J. Servatius
- Joint Biomedical Engineering Program, New Jersey Institute of Technology and Graduate School of Biomedical Sciences, Rutgers, The State University of New Jersey, Newark, NJ, USA,Stress & Motivated Behavior Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, USA,Department of Veterans Affairs, Veterans Affairs Medical Center, Syracuse, NY, USA
| | - Peter A. Casbolt
- School of Social Sciences and Psychology, University of Western Sydney, Sydney, NSW, Australia
| | - Paul Haber
- Drug Health Services, Addiction Medicine, Central Clinical School, Royal Prince Alfred Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Mahmoud Elsayed
- Drug Health Services, Addiction Medicine, Central Clinical School, Royal Prince Alfred Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Lee Hogarth
- School of Psychology, University of New South Wales, Sydney, NSW, Australia,School of Psychology, University of Exeter, Exeter, UK
| | - Catherine E. Myers
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, NJ, USA,Joint Biomedical Engineering Program, New Jersey Institute of Technology and Graduate School of Biomedical Sciences, Rutgers, The State University of New Jersey, Newark, NJ, USA,Stress & Motivated Behavior Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, USA
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Methadone’s effect on nAChRs—a link between methadone use and smoking? Biochem Pharmacol 2015; 97:542-549. [DOI: 10.1016/j.bcp.2015.07.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/23/2015] [Indexed: 12/17/2022]
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Graziani M, Nisticò R. Gender differences in pharmacokinetics and pharmacodynamics of methadone substitution therapy. Front Pharmacol 2015; 6:122. [PMID: 26106330 PMCID: PMC4460328 DOI: 10.3389/fphar.2015.00122] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/25/2015] [Indexed: 12/17/2022] Open
Abstract
Gender-related differences in the pharmacological effects of drug are an emerging topic. This review examines gender differences in both pharmacokinetic and pharmacodynamic aspects of methadone, a long-acting opioid agonist that is prescribed as a treatment for opioid dependence and the management of chronic pain. Method: We performed a search in the Medline database from 1990 to 2014 in order to find published literature related to gender differences in pharmacokinetics (PK) and pharmacodynamics (PD) of methadone. Results: None of the studies were carried out with the primary or secondary aim to identify any gender differences in the pharmacokinetic profile of methadone. Importantly; high inter-subjects variability in PK parameters was found also intra female population. The reported differences in volume of distribution could be ascribed to the physiological differences between men and women in body weight and composition, taking into account that the dose of methadone was established irrespective of body weight of patients (Peles and Adelson, 2006). On the other hand, the few studies present in literature found no gender difference in some direct pharmacodynamic parameters. Some reports have suggested that female gender is associated with an increased risk for long-QT-related cardiac arrhythmias in methadone maintenance subjects. Conclusion: Even though it may be too simplistic to expect variability only in one parameter to explain inter-individual variation in methadone response, we believe that a better knowledge of gender-related differences might have significant implications for better outcomes in opioid dependence substitution therapy in women.
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Affiliation(s)
- Manuela Graziani
- Vittorio Erspamer School of Physiology and Pharmacology, Sapienza University of Rome Rome, Italy ; Drug Addiction and Clinical Pharmacology Unit, University Hospital Umberto I, Sapienza University of Rome Rome, Italy
| | - Robert Nisticò
- Department of Biology, University of Rome Tor Vergata Rome, Italy
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Meissner K, Blood J, Francis AM, Yermolenka V, Kharasch ED. Cyclosporine-inhibitable cerebral drug transport does not influence clinical methadone pharmacodynamics. Anesthesiology 2015; 121:1281-91. [PMID: 25072223 DOI: 10.1097/aln.0000000000000391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Interindividual variability and drug interaction studies suggest that blood-brain barrier drug transporters mediate human methadone brain biodistribution. In vitro and animal studies suggest that methadone is a substrate for the efflux transporter P-glycoprotein, and that P-glycoprotein-mediated transport influences brain access and pharmacologic effect. This investigation tested whether methadone is a transporter substrate in humans [corrected]. METHODS Healthy volunteers received oral (N=16) or IV (N=12) methadone in different crossover protocols after nothing (control) or the validated P-glycoprotein inhibitor cyclosporine (4.5 mg/kg orally twice daily for 4 days, or 5 mg/kg IV over 2 h). Plasma and urine methadone and metabolite concentrations were measured by mass spectrometry. Methadone effects were measured by miosis and thermal analgesia (maximally tolerated temperature and verbal analog scale rating of discreet temperatures). RESULTS Cyclosporine marginally but significantly decreased methadone plasma concentrations and apparent oral clearance, but had no effect on methadone renal clearance or on hepatic N-demethylation. Cyclosporine had no effect on miosis or on R-methadone concentration-miosis relationships after either oral or IV methadone. Peak miosis was similar in controls and cyclosporine-treated subjects after oral methadone (1.4±0.4 and 1.3±0.5 mm/mg, respectively) and IV methadone (3.1±1.0 and 3.2±0.8 mm, respectively). Methadone increased maximally tolerated temperature, but analgesia testing was confounded by cyclosporine-related pain. CONCLUSIONS Cyclosporine did not affect methadone pharmacodynamics. This result does not support a role for cyclosporine-inhibitable transporters mediating methadone brain access and biodistribution.
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Affiliation(s)
- Konrad Meissner
- From the Department of Anesthesiology, Universitätsmedizin Greifswald, Greifswald, Germany (K.M.); and Departments of Anesthesiology (K.M., J.B., A.M.F., V.Y., E.D.K.) and of Biochemistry and Molecular Biophysics (E.D.K.), Washington University in St. Louis, St. Louis, Missouri
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Gamage TF, Ignatowska-Jankowska BM, Muldoon PP, Cravatt BF, Damaj MI, Lichtman AH. Differential effects of endocannabinoid catabolic inhibitors on morphine withdrawal in mice. Drug Alcohol Depend 2015; 146:7-16. [PMID: 25479915 PMCID: PMC4295928 DOI: 10.1016/j.drugalcdep.2014.11.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/16/2014] [Accepted: 11/16/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inhibition of endocannabinoid catabolic enzymes fatty acid amide hydrolase (FAAH) and/or monoacylglycerol lipase (MAGL) reduces somatic morphine withdrawal signs, but its effects on aversive aspects of withdrawal are unknown. The present study investigated whether Δ(9)-tetrahydrocannabinol (THC), the MAGL inhibitor JZL184, the FAAH inhibitor PF-3845, or the dual FAAH/MAGL inhibitor SA-57 would reduce acquisition of morphine withdrawal-induced conditioned place avoidance (CPA) and jumping. METHODS Mice were implanted with placebo or 75 mg morphine pellets, 48 h later injected with naloxone or saline and placed in the conditioning apparatus, and assessed for CPA at 72 h. Subjects were also observed for jumping behavior following naloxone challenge. RESULTS Naloxone (0.056 mg/kg) produced robust CPA in morphine-pelleted, but not placebo-pelleted, mice. Morphine pretreatment prevented the occurrence of withdrawal CPA and withdrawal jumping, while clonidine (an α2 adrenergic receptor agonist) only blocked withdrawal CPA. THC, JZL184, and SA-57 significantly reduced the percentage of mice that jumped during the conditioning session, but did not affect acquisition of withdrawal CPA. PF-3845 did not reduce morphine withdrawal CPA or jumping. Finally, neither THC nor the endocannabinoid catabolic enzyme inhibitors in non-dependent mice elicited a conditioned place preference or aversion. CONCLUSIONS These findings suggest that inhibiting endocannabinoid catabolic enzymes reduces somatic morphine withdrawal signs, but not aversive aspects as inferred in the CPA paradigm. The observation that non-dependent mice administered inhibitors of endocannabinoid degradation did not display place preferences is consistent with the idea that that endocannabinoid catabolic enzymes might be targeted therapeutically, with reduced risk of abuse.
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Affiliation(s)
- Thomas F. Gamage
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Kontos Medical Sciences Building, 1217 East Marshall Street, Richmond, VA, 23298
| | - Bogna M. Ignatowska-Jankowska
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Kontos Medical Sciences Building, 1217 East Marshall Street, Richmond, VA, 23298
| | - Pretal P. Muldoon
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Kontos Medical Sciences Building, 1217 East Marshall Street, Richmond, VA, 23298
| | - Benjamin F. Cravatt
- The Skaggs Institute for Chemical Biology and Department of Chemical Physiology, The Scripps Research Institute, 10550 N. Torrey Pines Rd. La Jolla, CA 92037
| | - M. Imad Damaj
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Kontos Medical Sciences Building, 1217 East Marshall Street, Richmond, VA, 23298
| | - Aron H. Lichtman
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Kontos Medical Sciences Building, 1217 East Marshall Street, Richmond, VA, 23298
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The impact of recent cocaine use on plasma levels of methadone and buprenorphine in patients with and without HIV-infection. J Subst Abuse Treat 2014; 51:70-4. [PMID: 25480096 DOI: 10.1016/j.jsat.2014.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 10/08/2014] [Accepted: 10/27/2014] [Indexed: 11/21/2022]
Abstract
Cocaine decreases methadone and buprenorphine plasma concentrations. HIV infection and/or antiretroviral medication use may impact these relationships. We sought to determine the association between recent cocaine use and methadone and buprenorphine concentrations in HIV-infected and uninfected subjects in clinical care. R- and S-methadone or buprenorphine and norbuprenorphine concentrations were assessed at 0.5, 1, 2, and 24 hours after dosing in subjects with confirmed cocaine use and abstinence. We compared methadone and buprenorphine concentrations for cocaine use vs. abstinence, by HIV status in 16 subjects receiving methadone (6 HIV-infected) and 17 receiving buprenorphine (8 HIV-infected). With recent cocaine use, peak R-methadone (244 vs. 297 ng/mL, p = 0.03) and peak S-methadone (285 vs. 339 ng/mL); p = 0.03 concentrations were lower in HIV-uninfected subjects only. Peak buprenorphine and norbuprenorphine concentrations were unchanged regardless of cocaine use or HIV status. Cocaine may decrease methadone concentrations in HIV-uninfected subjects. HIV infection or its treatment may attenuate cocaine's effect on methadone.
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Bell J. Pharmacological maintenance treatments of opiate addiction. Br J Clin Pharmacol 2014; 77:253-63. [PMID: 23210630 DOI: 10.1111/bcp.12051] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 11/21/2012] [Indexed: 12/18/2022] Open
Abstract
For people seeking treatment, the course of heroin addiction tends to be chronic and relapsing, and longer duration of treatment is associated with better outcomes. Heroin addiction is strongly associated with deviant behaviour and crime, and the objectives in treating heroin addiction have been a blend of humane support, rehabilitation, public health intervention and crime control. Reduction in street heroin use is the foundation on which all these outcomes are based. The pharmacological basis of maintenance treatment of dependent individuals is to minimize withdrawal symptoms and attenuate the reinforcing effects of street heroin, leading to reduction or cessation of street heroin use. Opioid maintenance treatment can be moderately effective in suppressing heroin use, although deviations from evidence-based approaches, particularly the use of suboptimal doses, have meant that treatment as delivered in practice may have resulted in poorer outcomes than predicted by research. Methadone treatment has been 'programmatic', with a one-size-fits-all approach that in part reflects the perceived need to impose discipline on deviant individuals. However, differences in pharmacokinetics and in side-effects mean that many patients do not respond optimally to methadone. Injectable diamorphine (heroin) provides a more reinforcing medication for some 'nonresponders' and can be a valuable option in the rehabilitation of demoralized, socially excluded individuals. Buprenorphine, a partial agonist, is a less reinforcing medication with different side-effects and less risk of overdose. Not only is it a different medication, but also it can be used in a different paradigm of treatment, office-based opioid treatment, with less structure and offering greater patient autonomy.
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Affiliation(s)
- James Bell
- Kings Health Partners, London, SE5 8RS, UK
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Muldoon PP, Jackson KJ, Perez E, Harenza JL, Molas S, Rais B, Anwar H, Zaveri NT, Maldonado R, Maskos U, McIntosh JM, Dierssen M, Miles MF, Chen X, De Biasi M, Damaj MI. The α3β4* nicotinic ACh receptor subtype mediates physical dependence to morphine: mouse and human studies. Br J Pharmacol 2014; 171:3845-57. [PMID: 24750073 PMCID: PMC4128047 DOI: 10.1111/bph.12741] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 04/04/2014] [Accepted: 04/15/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Recent data have indicated that α3β4* neuronal nicotinic (n) ACh receptors may play a role in morphine dependence. Here we investigated if nACh receptors modulate morphine physical withdrawal. EXPERIMENTAL APPROACHES To assess the role of α3β4* nACh receptors in morphine withdrawal, we used a genetic correlation approach using publically available datasets within the GeneNetwork web resource, genetic knockout and pharmacological tools. Male and female European-American (n = 2772) and African-American (n = 1309) subjects from the Study of Addiction: Genetics and Environment dataset were assessed for possible associations of polymorphisms in the 15q25 gene cluster and opioid dependence. KEY RESULTS BXD recombinant mouse lines demonstrated an increased expression of α3, β4 and α5 nACh receptor mRNA in the forebrain and midbrain, which significantly correlated with increased defecation in mice undergoing morphine withdrawal. Mice overexpressing the gene cluster CHRNA5/A3/B4 exhibited increased somatic signs of withdrawal. Furthermore, α5 and β4 nACh receptor knockout mice expressed decreased somatic withdrawal signs compared with their wild-type counterparts. Moreover, selective α3β4* nACh receptor antagonists, α-conotoxin AuIB and AT-1001, attenuated somatic signs of morphine withdrawal in a dose-related manner. In addition, two human datasets revealed a protective role for variants in the CHRNA3 gene, which codes for the α3 nACh receptor subunit, in opioid dependence and withdrawal. In contrast, we found that the α4β2* nACh receptor subtype is not involved in morphine somatic withdrawal signs. CONCLUSION AND IMPLICATIONS Overall, our findings suggest an important role for the α3β4* nACh receptor subtype in morphine physical dependence.
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Affiliation(s)
- P P Muldoon
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
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Raffa RB, Pergolizzi JV. Opioid-Induced Hyperalgesia: Is It Clinically Relevant for the Treatment of Pain Patients? Pain Manag Nurs 2013; 14:e67-83. [DOI: 10.1016/j.pmn.2011.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 04/12/2011] [Accepted: 04/13/2011] [Indexed: 11/15/2022]
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Ramesh D, Gamage TF, Vanuytsel T, Owens RA, Abdullah RA, Niphakis MJ, Shea-Donohue T, Cravatt BF, Lichtman AH. Dual inhibition of endocannabinoid catabolic enzymes produces enhanced antiwithdrawal effects in morphine-dependent mice. Neuropsychopharmacology 2013; 38:1039-49. [PMID: 23303065 PMCID: PMC3629394 DOI: 10.1038/npp.2012.269] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Inhibition of the endocannabinoid catabolic enzymes, monoacylglycerol lipase (MAGL) or fatty acid amide hydrolase (FAAH) attenuates naloxone-precipitated opioid withdrawal signs in mice via activation of CB1 receptors. Complete FAAH inhibition blocks only a subset of withdrawal signs, whereas complete MAGL inhibition elicits enhanced antiwithdrawal efficacy, but is accompanied with some cannabimimetic side effects. Thus, the primary objective of the present study was to determine whether combined, full FAAH inhibition and partial MAGL represents an optimal strategy to reduce opioid withdrawal. To test this hypothesis, we examined whether combined administration of high-dose of the FAAH inhibitor PF-3845 and low-dose of the MAGL inhibitor JZL184, as well as the novel dual FAAH-MAGL inhibitor SA-57, which is 100-fold more potent in inhibiting FAAH than MAGL, would prevent spontaneous withdrawal in morphine-dependent mice, a model with greater face validity than precipitating withdrawal with μ-opioid receptor antagonists. Strikingly, a combination of low-dose JZL184 and high-dose PF-3845 as well as the dual inhibitor SA-57 reduced all abrupt withdrawal signs (ie, platform jumping, paw flutters, head shakes, diarrhea, and total body weight loss), but did not elicit any cannabimimetic side effects. In addition, JZL184 or PF-3845 blocked naloxone-precipitated hypersecretion in morphine-dependent small intestinal tissue. Collectively, these results are the first to show that endocannabinoid catabolic enzyme inhibitors reduce abrupt withdrawal in morpine-dependent mice and are effective in a novel in vitro model of opioid withdrawal. More generally, these findings support the idea that joint MAGL and FAAH inhibition represents a promising approach for the treatment of opioid dependence.
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Affiliation(s)
- Divya Ramesh
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA
| | - Thomas F Gamage
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium,Mucosal Biology Research Center, University of Maryland, Baltimore (MD), Baltimore, MD, USA
| | - Robert A Owens
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA
| | - Rehab A Abdullah
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA
| | - Micah J Niphakis
- Department of Chemical Physiology and the Skaggs Institute for Structural Biology, The Scripps Research Institute, La Jolla, CA, USA
| | - Terez Shea-Donohue
- Mucosal Biology Research Center, University of Maryland, Baltimore (MD), Baltimore, MD, USA
| | - Benjamin F Cravatt
- Department of Chemical Physiology and the Skaggs Institute for Structural Biology, The Scripps Research Institute, La Jolla, CA, USA
| | - Aron H Lichtman
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA,Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA, USA,Department of Pharmacology and Toxicology, Virginia Commonwealth University, PO Box 980613, Richmond, VA 23298-0613, USA, Tel: +1 804 828 8480, Fax: +1 804 828 2117, E-mail:
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Salisbury AL, Coyle MG, O’Grady KE, Heil SH, Martin PR, Stine SM, Kaltenbach K, Weninger M, Jones HE. Fetal assessment before and after dosing with buprenorphine or methadone. Addiction 2012; 107 Suppl 1:36-44. [PMID: 23106925 PMCID: PMC4277183 DOI: 10.1111/j.1360-0443.2012.04037.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To determine pre- and post-dosing effects of prenatal methadone compared to buprenorphine on fetal wellbeing. DESIGN A secondary analysis of data derived from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study, a double-blind, double-dummy, randomized clinical trial. SETTING Six United States sites and one European site that provided comprehensive opioid-dependence treatment to pregnant women. PARTICIPANTS Eighty-one of the 131 opioid-dependent pregnant women completing the MOTHER clinical trial, assessed between 31 and 33 weeks of gestation. MEASUREMENTS Two fetal assessments were conducted, once before and once after study medication dosing. Measures included mean fetal heart rate (FHR), number of FHR accelerations, FHR reactivity in the fetal non-stress test (NST) and biophysical profile (BPP) score. FINDINGS Significant group differences were found for number of FHR accelerations, non-reactive NST and BPP scores (all Ps < 0.05). There were no significant group differences before time of dosing. Significant decreases (all Ps < 0.05) occurred from pre- to post-dose assessment for mean FHR, FHR accelerations, reactive NST and fetal movement. The decrease in accelerations and reactive NST were significant only for fetuses in the methadone group, and this resulted in a significantly lower likelihood of a reactive NST compared to fetuses in the buprenorphine group. CONCLUSION Buprenorphine compared with methadone appears to result in less suppression of mean fetal heart rate, fetal heart rate reactivity and the biophysical profile score after medication dosing and these findings provide support for the relative safety of buprenorphine when fetal indices are considered as part of the complete risk-benefit ratio.
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Affiliation(s)
- Amy L. Salisbury
- Department of Pediatrics and Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
| | - Mara G. Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University
| | | | - Sarah H. Heil
- Departments of Psychiatry and Psychology, University of Vermont
| | - Peter R. Martin
- Departments of Psychiatry and Pharmacology and Addiction Center, Vanderbilt University School of Medicine
| | - Susan M. Stine
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine
| | - Karol Kaltenbach
- Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University
| | - Manfred Weninger
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna
| | - Hendrée E. Jones
- Department of Psychiatry and Behavioral Sciences and Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Substance Abuse Treatment Evaluations and Interventions Program, RTI International
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Pharmacokinetic-pharmacodynamic modeling of mood and withdrawal symptoms in relation to plasma concentrations of methadone in patients undergoing methadone maintenance treatment. J Clin Psychopharmacol 2012; 32:666-71. [PMID: 22926601 DOI: 10.1097/jcp.0b013e3182664ecd] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aims of the present study were to characterize the relationship between plasma racemic methadone and its enantiomers' concentrations with respect to their pharmacodynamic effects and to investigate the influence of potential covariates on the pharmacodynamic parameters in patients on methadone maintenance treatment (MMT). Eighty-eight regular subjects at the Sheffield Care Trust Substance Misuse Services were studied. Samples of blood and urine were collected before the daily dose of methadone. Blood samples were taken up to 5 hours after dose. Total plasma concentrations of (RS)-methadone and total and unbound plasma concentrations of both enantiomers were measured by liquid chromatography-mass spectrometry. The Total Mood Disturbance Score (TMDS), the Objective Opioid Withdrawal Scale (OOWS), and the Subjective Opioid Withdrawal Scale (SOWS) were used as measures of mood and withdrawal. Population pharmacokinetic/pharmacodynamic analysis and subsequent multiple regression analysis were used to determine the factors influencing the pharmacodynamic effects of methadone. Significant decreases (P ≤ 0.04) were observed in the scores for the TMDS, SOWS, and OOWS for 5 hours after methadone dosage. The TMDS had returned to baseline by 10 hours after dose (P = 0.98), at which time the SOWS remained significantly below baseline (P = 0.001). Multiple regression analysis revealed that 33% of the overall variation in unbound (R)-methadone EC50 was explained by 3 variables, namely CYP3A activity (9%), age (16%), and sex (8%). Age also accounted for 8% and 9% of the variation in total (rac)- and (R)-methadone EC50. The present study has confirmed that the duration of mood change in the present study was shorter than the effect of methadone in stabilizing withdrawal symptoms. Thus, it is likely that a once-daily dose of methadone, albeit effective for preventing withdrawal, may not be sufficient to improve mood in some patients. Finally, it was established that CYP3A activity, years of dependent use, sex, and age are major determinants of methadone EC50 with respect to TMDS.
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Barratt DT, Coller JK, Hallinan R, Byrne A, White JM, Foster DJR, Somogyi AA. ABCB1 haplotype and OPRM1 118A > G genotype interaction in methadone maintenance treatment pharmacogenetics. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2012; 5:53-62. [PMID: 23226062 PMCID: PMC3513228 DOI: 10.2147/pgpm.s29272] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Genetic variability in ABCB1, encoding the P-glycoprotein efflux transporter, has been linked to altered methadone maintenance treatment dose requirements. However, subsequent studies have indicated that additional environmental or genetic factors may confound ABCB1 pharmacogenetics in different methadone maintenance treatment settings. There is evidence that genetic variability in OPRM1, encoding the mu opioid receptor, and ABCB1 may interact to affect morphine response in opposite ways. This study aimed to examine whether a similar gene-gene interaction occurs for methadone in methadone maintenance treatment. METHODS Opioid-dependent subjects (n = 119) maintained on methadone (15-300 mg/day) were genotyped for five single nucleotide polymorphisms of ABCB1 (61A > G; 1199G > A; 1236C > T; 2677G > T; 3435C > T), as well as for the OPRM1 118A > G single nucleotide polymorphism. Subjects' methadone doses and trough plasma (R)-methadone concentrations (C(trough)) were compared between ABCB1 haplotypes (with and without controlling for OPRM1 genotype), and between OPRM1 genotypes (with and without controlling for ABCB1 haplotype). RESULTS Among wild-type OPRM1 subjects, an ABCB1 variant haplotype group (subjects with a wild-type and 61A:1199G:1236C:2677T:3435T haplotype combination, or homozygous for the 61A:1199G:1236C:2677T:3435T haplotype) had significantly lower doses (median ± standard deviation 35 ± 5 versus 180 ± 65 mg/day, P < 0.01) and C(trough) (78 ± 22 versus 177 ± 97 ng/mL, P < 0.05) than ABCB1 wild-type subjects. Among subjects with the most common ABCB1 haplotype combination (wild-type with 61A:1199G:1236T:2677T:3435T), the OPRM1 118 A/G genotype was associated with a significantly higher C(trough) than 118 A/A (250 ± 126 versus 108 ± 36 ng/mL, P = 0.016). No ABCB1 haplotype group or OPRM1 genotype was associated with dose or C(trough) without taking into account confounding genetic variability at the other locus. Therefore, two interacting pharmacogenetic determinants of methadone maintenance treatment response were identified, ie, ABCB1, where variants are associated with lower methadone requirements, and OPRM1, where the variant is associated with higher methadone requirements. CONCLUSION These opposing pharmacogenetic effects therefore need to be considered in combination when assessing methadone maintenance treatment pharmacogenetics.
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Affiliation(s)
- Daniel T Barratt
- Discipline of Pharmacology, School of Medical Sciences, University of Adelaide, Adelaide, South Australia
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Abstract
AIMS Opioids have been implicated in emotion regulation. Opioid users report decreased negative emotional response, but there has been no formal study on the effect of opioid administration on emotional reactivity. The aim of this study was to investigate the effect of methadone on emotional reactivity in methadone-maintained patients. DESIGN Velten's mood induction procedures were used to induce elative and depressive emotional reactions in the subjects. Each group was administered both induction procedures at 0 hour and 3 hours (corresponding with trough and peak plasma methadone concentrations in methadone subjects). SETTING A drug treatment clinic with an out-patient methadone maintenance treatment programme. PARTICIPANTS Twenty-one subjects currently on methadone maintenance treatment and 21 controls with no history of opioid dependence. MEASUREMENTS Emotional reactivity was measured using mood visual analogue scales. FINDINGS At 0 hour, methadone and control subjects showed similar elation (methadone 13.2 ± 3.1 mean ± standard error of the mean [SEM], control 14.4 ± 3.7) and depression reactivity (methadone 23.6 ± 5.0, control 25.1 ± 5.0). However, at 3 hours repeated measures showed that methadone subjects had significantly decreased depression reactivity (methadone 18.5 ± 4.6, control 36.7 ± 5.7; P = 0.021) and elation reactivity (methadone 4.4 ± 1.9, control 19.0 ± 2.4) compared to controls. CONCLUSIONS Opioid addicts on methadone maintenance appear to be less reactive to mood induction at times of peak plasma methadone concentration than non-addict controls; this suggests that methadone blunts both elative and depressive emotional reactivity.
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Affiliation(s)
- Steven M Savvas
- Discipline of Pharmacology, University of Adelaide, South Australia, Australia.
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Therapeutic drug monitoring for drugs used in the treatment of substance-related disorders: literature review using a therapeutic drug monitoring appropriateness rating scale. Ther Drug Monit 2012; 33:561-72. [PMID: 21912330 DOI: 10.1097/ftd.0b013e31822fbf7c] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The efficacy of drugs for the treatment of substance-related disorders is moderate at best. Therapeutic drug monitoring (TDM) could be an instrument to improve outcomes. Because TDM for most of those drugs is not established, the authors reviewed the literature and built a rating scale to detect the potential added value of TDM for these pharmacologic agents. METHODS A literature search was performed for acamprosate, bupropion, buprenorphine, clomethiazole, disulfiram, methadone, naltrexone, and varenicline. The rating scale included 22 items and was divided in five categories: efficacy, toxicity, pharmacokinetics, patient characteristics, and cost-effectiveness. Three reference substances with established TDM were similarly assessed for comparison: clozapine, lithium, and nortriptyline. The three reference substances achieved scores of 15, 12, and 14 points, respectively. RESULTS Drugs for treatment of substance-related disorders achieved 3 to 17 points, 17 for methadone, 11 for buprenorphine, 10 for disulfiram, also 10 for naltrexone for the indication opioid-dependence and 9 for the indication alcohol dependence as well as bupropion, 7 points for acamprosate, 6 points for clomethiazole, and 3 for varenicline. CONCLUSIONS It is concluded that systematic evaluation of drug- and patient-related variables with the new rating scale can estimate the appropriateness of TDM. Because their rating revealed similar scores as the three reference drugs, it is proposed that TDM should be established for bupropion, buprenorphine, disulfiram or a metabolite, methadone, and naltrexone. An objective rating of drug- and patient-related characteristics could help laboratories focus their method development on the most likely drugs to require TDM along with a thorough drug use evaluation.
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Ramesh D, Ross GR, Schlosburg JE, Owens RA, Abdullah RA, Kinsey SG, Long JZ, Nomura DK, Sim-Selley LJ, Cravatt BF, Akbarali HI, Lichtman AH. Blockade of endocannabinoid hydrolytic enzymes attenuates precipitated opioid withdrawal symptoms in mice. J Pharmacol Exp Ther 2011; 339:173-85. [PMID: 21719468 DOI: 10.1124/jpet.111.181370] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Δ(9)-Tetrahydrocannbinol (THC), the primary active constituent of Cannabis sativa, has long been known to reduce opioid withdrawal symptoms. Although THC produces most of its pharmacological actions through the activation of CB(1) and CB(2) cannabinoid receptors, the role these receptors play in reducing the variety of opioid withdrawal symptoms remains unknown. The endogenous cannabinoids, N-arachidonoylethanolamine (anandamide; AEA) and 2-arachidonylglycerol (2-AG), activate both cannabinoid receptors but are rapidly metabolized by fatty acid amide hydrolase (FAAH) and monoacylglycerol lipase (MAGL), respectively. The objective of this study was to test whether increasing AEA or 2-AG, via inhibition of their respective hydrolytic enzymes, reduces naloxone-precipitated morphine withdrawal symptoms in in vivo and in vitro models of opioid dependence. Morphine-dependent mice challenged with naloxone reliably displayed a profound withdrawal syndrome, consisting of jumping, paw tremors, diarrhea, and weight loss. THC and the MAGL inhibitor 4-nitrophenyl 4-(dibenzo[d][1,3]dioxol-5-yl(hydroxy)methyl)piperidine-1-carboxylate (JZL184) dose dependently reduced the intensity of most measures through the activation of CB(1) receptors. JZL184 also attenuated spontaneous withdrawal signs in morphine-dependent mice. The FAAH inhibitor N-(pyridin-3-yl)-4-(3-(5-(trifluoromethyl)pyridin-2-yloxy)benzyl)-piperdine-1-carboxamide (PF-3845) reduced the intensity of naloxone-precipitated jumps and paw flutters through the activation of CB(1) receptors but did not ameliorate incidence of diarrhea or weight loss. In the final series of experiments, we investigated whether JZL184 or PF-3845 would attenuate naloxone-precipitated contractions in morphine-dependent ilea. Both enzyme inhibitors attenuated the intensity of naloxone-induced contractions, although this model does not account mechanistically for the autonomic withdrawal responses (i.e., diarrhea) observed in vivo. These results indicate that endocannabinoid catabolic enzymes are promising targets to treat opioid dependence.
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Affiliation(s)
- Divya Ramesh
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia 23298-0613, USA
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Abstract
Opioids are the most potent drugs for treatment of acute and chronic pain. However, accumulating evidence suggests that opioids may paradoxically also enhance pain, often referred to as opioid-induced hyperalgesia. Opioid-induced hyperalgesia is defined as an increased sensitivity to pain or a decreased pain threshold in response to opioid therapy. Several mechanisms have been proposed to support opioid-induced hyperalgesia. However, it remains unclear whether opioid-induced hyperalgesia develops during continuous chronic application of opioids or on their withdrawal. This review provides a comprehensive summary of clinical research concerning opioid-induced hyperalgesia and the molecular mechanisms of opioid withdrawal and opioid tolerance and other potential mechanisms which might induce hyperalgesia during opioid therapy will be discussed. The status quo of our knowledge will be summarized and the clinical relevance of opioid-induced hyperalgesia will be discussed.
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Affiliation(s)
- C Zöllner
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Deutschland.
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Mood Disturbance and Withdrawal Severity in Substitution Treatment for Opioid Dependence. ADDICTIVE DISORDERS & THEIR TREATMENT 2010. [DOI: 10.1097/adt.0b013e318194fff6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Elkader AK, Brands B, Callaghan R, Sproule BA. Exploring the relationship between perceived inter-dose opioid withdrawal and patient characteristics in methadone maintenance treatment. Drug Alcohol Depend 2009; 105:209-14. [PMID: 19713051 DOI: 10.1016/j.drugalcdep.2009.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 05/15/2009] [Accepted: 07/02/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite clinical optimization of methadone doses, as many as 53% of patients experience significant and unacceptable levels inter-dose opioid withdrawal some of the time. Little is known about the relationship between perceived inter-dose opioid withdrawal and patient characteristics in methadone maintenance treatment. METHODS Ninety stabilized MMT patients were recruited and divided into three satisfaction groups (holders (H), partial holders (PH), and nonholders (NH)) based on their perceived opioid withdrawal as assessed by a guided self-report process. A battery of subjective assessments was administered during the approximate trough methadone condition. The primary measures were the Subjective Opioid Withdrawal Scale (SubOWS), Hopkins Symptom Checklist-90 (SCL-90), Obsessive-Compulsive Drug Use Survey (OCDUS), Profile of Mood States (POMS), and Neo Personality Inventory (NEO). RESULTS Nonholders experienced more opioid withdrawal (SubOWS-NH: 22.0+/-8.8 vs. PH: 12.2+/-8.2 vs. H: 9.3+/-10.0, p<0.001) and craving (OCDUS-NH: 11.4+/-8.8 vs. PH: 6.4+/-6.9 vs. H: 6.5+/-6.2, p=0.016). Holders experienced less Obsessive/Compulsive psychological distress (SCL-90-NH: 15.3+/-8.1 vs. PH: 12.3+/-7.3 vs. H: 6.6+/-5.1, p<0.001), Depression/Dejection (POMS-NH: 19.7+/-13.7 vs. PH: 17.2+/-13.2 vs. H: 7.9+/-10.4, p=0.002), and neurotic personality (NEO-NH: 63.3+/-12.3 vs. PH: 60.9+/-10.0 vs. H: 54.0+/-8.8, p=0.006). Partial holders had a less agreeable personality (NEO-NH: 44.2+/-8.6 vs. PH: 38.0+/-10.6 vs. H: 47.6+/-11.7, p=0.002). CONCLUSIONS Physical opioid withdrawal is an important factor in understanding patient satisfaction with MMT. However, patient characteristics, such as level of psychological distress and negative mood, may also need to be considered because of their relationship with perceived inter-dose opioid withdrawal symptoms and patient satisfaction.
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Affiliation(s)
- Alex K Elkader
- Centre for Addiction and Mental Health, 33 Russell St., Toronto, ON, Canada M5S 2S1
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Cannabis and benzodiazepines as determinants of methadone trough plasma concentration variability in maintenance treatment: a transnational study. Eur J Clin Pharmacol 2009; 65:1113-20. [DOI: 10.1007/s00228-009-0706-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 06/20/2009] [Indexed: 11/25/2022]
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Kharasch ED, Walker A, Whittington D, Hoffer C, Bedynek PS. Methadone metabolism and clearance are induced by nelfinavir despite inhibition of cytochrome P4503A (CYP3A) activity. Drug Alcohol Depend 2009; 101:158-68. [PMID: 19232844 PMCID: PMC3582041 DOI: 10.1016/j.drugalcdep.2008.12.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 11/15/2008] [Accepted: 12/06/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Methadone plasma concentrations are decreased by nelfinavir. Methadone clearance and the drug interactions have been attributed to CYP3A4, but actual mechanisms of methadone clearance and the nelfinavir interaction are unknown. We assessed nelfinavir effects on methadone pharmacokinetics and pharmacodynamics, intestinal and hepatic CYP3A4/5 activity, and intestinal P-glycoprotein transport activity. CYP3A4/5 and transporters were assessed using alfentanil and fexofenadine, respectively. METHODS Twelve healthy HIV-negative volunteers underwent a sequential crossover. On three consecutive days they received oral alfentanil plus fexofenadine, intravenous alfentanil, and intravenous plus oral methadone. This was repeated after nelfinavir. Plasma and urine analytes were measured by mass spectrometry. Opioid effects were measured by pupil diameter change (miosis). RESULTS Nelfinavir decreased intravenous and oral methadone plasma concentrations 40-50%. Systemic clearance, hepatic clearance, and hepatic extraction all increased 1.6- and 2-fold, respectively, for R- and S-methadone; apparent oral clearance increased 1.7- and 1.9-fold. Nelfinavir stereoselectively increased (S>R) methadone metabolism and metabolite formation clearance, and methadone renal clearance. Methadone bioavailability and P-glycoprotein activity were minimally affected. Nelfinavir decreased alfentanil systemic and apparent oral clearances 50 and 76%, respectively. Nelfinavir appeared to shift the methadone plasma concentration-effect (miosis) curve leftward and upward. CONCLUSIONS Nelfinavir induced methadone clearance by increasing renal clearance, and more so by stereoselectively increasing hepatic metabolism, extraction and clearance. Induction occurred despite 50% inhibition of hepatic CYP3A4/5 activity and more than 75% inhibition of first-pass CYP3A4/5 activity, suggesting little or no role for CYP3A in clinical methadone disposition. Nelfinavir may alter methadone pharmacodynamics, increasing clinical effects.
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Affiliation(s)
- Evan D. Kharasch
- Department of Anesthesiology, and Department of Biochemistry and Molecular Biophysics, Washington University in St. Louis, St. Louis, MO, 63110 USA
| | - Alysa Walker
- Department of Anesthesiology, University of Washington. Seattle, WA, 98195 USA
| | - Dale Whittington
- Department of Anesthesiology, University of Washington. Seattle, WA, 98195 USA
| | - Christine Hoffer
- Department of Anesthesiology, University of Washington. Seattle, WA, 98195 USA
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Somogyi AA, Larsen M, Abadi RM, Jittiwutikarn J, Ali R, White JM. Flexible dosing of tincture of opium in the management of opioid withdrawal: pharmacokinetics and pharmacodynamics. Br J Clin Pharmacol 2009; 66:640-7. [PMID: 19032172 DOI: 10.1111/j.1365-2125.2008.03277.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS The aim was to evaluate the clinical effectiveness, pharmacodynamics and pharmacokinetics of a range of Tincture of Opium (TOP) doses in the management of opioid withdrawal. METHODS Forty-five opium-dependent Thai subjects were allocated to three dosing groups (6.66, 13.3 and 20 mg morphine equivalents, twice daily) depending on their self-reported prior opium use. On day 5 of dosing subjects underwent an interdosing interval study where blood, withdrawal scores, heart rate and blood pressure (BP) were collected at 0, 1, 3 and 8 h. Plasma morphine concentrations were quantified by high-performance liquid chromatography, and plasma morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) concentrations by LCMS. RESULTS Thirty-two subjects completed the study. Withdrawal scores were low for all subjects (range 9-23% of maximum response). There were dose-dependent changes in both systolic and diastolic BP (P = 0.021 and P = 0.01, respectively), but these were not considered clinically significant. There were no effects of dose on respiratory rate. Plasma morphine concentrations changed significantly across the interdosing interval (P = 0.0001), rising to a maximum at 1 h after dosing. Plasma morphine concentrations also differed according to dose (P < 0.05). The mean ratios of the morphine glucuronides were found to be: M3G/M6G = 7.7, M3G/morphine = 35.6 and M6G/morphine = 4.9, values comparable to those previously reported. CONCLUSION The management of opioid withdrawal can be achieved, with minimal adverse effects, by using flexible dosing of TOP.
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Affiliation(s)
- Andrew A Somogyi
- Discipline of Pharmacology, School of Medical Sciences, University of Adelaide, Adelaide, Australia.
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Major depressive disorder and patient satisfaction in relation to methadone pharmacokinetics and pharmacodynamics in stabilized methadone maintenance patients. J Clin Psychopharmacol 2009; 29:77-81. [PMID: 19142113 DOI: 10.1097/jcp.0b013e318192eb00] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many patients enrolled in methadone maintenance treatment experience significant interdose opioid withdrawal. Mood states have been related to patient satisfaction with treatment and may influence how methadone patients experience opioid withdrawal. The objective of this study was to investigate the influence of major depressive disorder on response to methadone in patients on methadone maintenance treatment. Seventeen methadone patients (7 depressed and 10 not depressed) had pharmacokinetic and pharmacodynamic assessments (opioid withdrawal, drug effects, and mood) over one 24-hour dosing interval. Subjects were also divided based on their satisfaction with methadone treatment: 12 holders and 5 nonholders. Depressed subjects experienced more dysphoric opioid effects as measured by the Addiction Research Centre Inventory (area under the effect versus time curve, 14 +/- 32 vs -31 +/- 47, P < 0.04) and had higher scores on the Subjective Opioid Withdrawal Scale (area under the effect versus time curve, 33 +/- 97 vs -74 +/- 67, P < 0.02) over the dosage interval. Hamilton Depression scores significantly correlated with trough subjective opioid withdrawal scale scores (r = 0.7, P < 0.004). Nonholders had significantly higher exposure to unbound (S)-methadone compared with holders, specifically: trough concentration (6.1 +/- 2.7 ng/mL vs 2.7 +/- 1.7 ng/mL, P < 0.01), average steady-state concentration (7.6 +/- 4.0 ng/mL vs 4.1 +/- 2.5 ng/mL, P < 0.05), maximum concentration (14.6 +/- 7.1 ng/mL vs 7.5 +/- 4.2 ng/mL, P < 0.04), and area under the curve (183 +/- 95 h*ng/mL vs 99 +/- 61 h*ng/mL, P < 0.05). Study findings suggest that (S)-methadone may relate to patients' dissatisfaction with methadone treatment. Depressed methadone patients may be more sensitive to negative opioid effects and opioid withdrawal.
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The effect of stress on craving for methadone depends on the timing of last methadone dose. Behav Res Ther 2008; 46:1170-5. [DOI: 10.1016/j.brat.2008.05.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 03/28/2008] [Accepted: 05/13/2008] [Indexed: 11/18/2022]
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Compton PA, Ling W, Torrington MA. Lack of effect of chronic dextromethorphan on experimental pain tolerance in methadone-maintained patients. Addict Biol 2008; 13:393-402. [PMID: 18507735 DOI: 10.1111/j.1369-1600.2008.00112.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Good evidence exists to suggest that individuals on opioid maintenance for the treatment of addiction (i.e. methadone) are less tolerant of experimental pain than are matched controls or ex-opioid addicts, a phenomenon theorized to reflect opioid-induced hyperalgesia (OIH). Agonist activity at the excitatory ionotropic N-methyl-D-aspartate (NMDA) receptor on dorsal horn neurons has been implicated in the development of both OIH and its putative expression at the clinical level-opioid tolerance. The aim of this study was to evaluate the potential utility of the NMDA-receptor antagonist, dextromethorphan (DEX), to reverse or treat OIH in methadone-maintenance (MM) patients. Utilizing a clinical trial design and double-blind conditions, changes in pain threshold and tolerance [cold pressor (CP) and electrical stimulation (ES)] following a 5-week trial of DEX (titrated to 480 mg/day) in comparison with placebo was evaluated in a well-characterized sample of MM patients. The sample (n = 40) was 53% male and ethnically diverse (53% Latino, 28% African American, 10% White, 9% other), with a mean age of 48.0 years (SD = 6.97). Based on t-test analyses, no difference was found between groups on CP pain threshold, CP pain tolerance, ES pain threshold or ES pain tolerance, both pre- and postmedication. Notably, DEX-related changes significantly differed by gender, with women tending to show diminished tolerance for pain with DEX therapy. These results support that chronic high-dose NMDA antagonism does not improve tolerance for pain in MM patients, although a gender effect on DEX response is suggested.
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Affiliation(s)
- Peggy A Compton
- Acute Care Section, School of Nursing, University of California at Los Angeles, Factor Building 4-246, Box 956918, Los Angeles, CA 90095-6918, USA.
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Li Y, Kantelip JP, Gerritsen-van Schieveen P, Davani S. Interindividual variability of methadone response: impact of genetic polymorphism. Mol Diagn Ther 2008; 12:109-24. [PMID: 18422375 DOI: 10.1007/bf03256276] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Methadone, an opioid analgesic, is used clinically in pain therapy as well as for substitution therapy in opioid addiction. It has a large interindividual variability in response and a narrow therapeutic index. Genetic polymorphisms in genes coding for methadone-metabolizing enzymes, transporter proteins (p-glycoprotein; P-gp), and mu-opioid receptors may explain part of the observed interindividual variation in the pharmacokinetics and pharmacodynamics of methadone. Cytochrome P450 (CYP) 3A4 and 2B6 have been identified as the main CYP isoforms involved in methadone metabolism. Methadone is a P-gp substrate, and, although there are inconsistent reports, ABCB1 genetic polymorphisms also contribute slightly to the interindividual variability of methadone kinetics and influence dose requirements. Genetic polymorphism is the cause of high interindividual variability of methadone blood concentrations for a given dose; for example, in order to obtain methadone plasma concentrations of 250 ng/mL, doses of racemic methadone as low as 55 mg/day or as high as 921 mg/day can be required in a 70-kg patient without any co-medication. The clinician must be aware of the pharmacokinetic properties and pharmacological interactions of methadone in order to personalize methadone administration. In the future, pharmacogenetics, at a limited level, can also be expected to facilitate individualized methadone therapy.
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Affiliation(s)
- Yongfang Li
- Department of Clinical Pharmacology and Toxicology, University Hospital Besançon, Besançon, France
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Cao YJ, Smith PF, Wire MB, Lou Y, Lancaster CT, Causon RC, Bigelow GE, Martinez E, Fuchs EJ, Radebaugh C, McCabe S, Hendrix CW. Pharmacokinetics and Pharmacodynamics of Methadone Enantiomers After Coadministration with Fosamprenavir-Ritonavir in Opioid-Dependent Subjects. Pharmacotherapy 2008; 28:863-74. [DOI: 10.1592/phco.28.7.863] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. DIALOGUES IN CLINICAL NEUROSCIENCE 2008. [PMID: 18286804 PMCID: PMC3202507 DOI: 10.31887/dcns.2007.9.2/hkleber] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
While opioid dependence has more treatment agents available than other abused drugs, none are curative. They can, however, markedly diminish withdrawal symptoms and craving, and block opioid effects due to lapses. The most effective withdrawal method is substituting and tapering methadone or buprenorphine, α-2 Adrenergic agents can ameliorate untreated symptoms or substitute for agonists if not available. Shortening withdrawal by precipitating it with narcotic antagonists has been studied, but the methods are plagued by safety issues or persisting symptoms. Neither the withdrawal agents nor the methods are associated with better long-term outcome, which appears mostly related to post-detoxification treatment. Excluding those with short-term habits, the best outcome occurs with long-term maintenance on methadone or buprenorphine accompanied by appropriate psychosocial interventions. Those with strong external motivation may do well on the antagonist naltrexone. Currently, optimum duration of maintenance on either is unclear. Better agents are needed to impact the brain changes related to addiction.
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Affiliation(s)
- Herbert D Kleber
- Columbia University College of Physicians & Surgeons, New York, NY 10032, USA.
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