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Pande LJ, Arnet RE, Piper BJ. An Examination of the Complex Pharmacological Properties of the Non-Selective Opioid Modulator Buprenorphine. Pharmaceuticals (Basel) 2023; 16:1397. [PMID: 37895868 PMCID: PMC10610465 DOI: 10.3390/ph16101397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
The goal of this review is to provide a recent examination of the pharmacodynamics as well as pharmacokinetics, misuse potential, toxicology, and prenatal consequences of buprenorphine. Buprenorphine is currently a Schedule III opioid in the US used for opioid-use disorder (OUD) and as an analgesic. Buprenorphine has high affinity for the mu-opioid receptor (MOR), delta (DOR), and kappa (KOR) and intermediate affinity for the nociceptin (NOR). Buprenorphine's active metabolite, norbuprenorphine, crosses the blood-brain barrier, is a potent metabolite that attenuates the analgesic effects of buprenorphine due to binding to NOR, and is responsible for the respiratory depressant effects. The area under the concentration curves are very similar for buprenorphine and norbuprenorphine, which indicates that it is important to consider this metabolite. Crowding sourcing has identified a buprenorphine street value (USD 3.95/mg), indicating some non-medical use. There have also been eleven-thousand reports involving buprenorphine and minors (age < 19) at US poison control centers. Prenatal exposure to clinically relevant dosages in rats produces reductions in myelin and increases in depression-like behavior. In conclusion, the pharmacology of this OUD pharmacotherapy including the consequences of prenatal buprenorphine exposure in humans and experimental animals should continue to be carefully evaluated.
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Affiliation(s)
- Leana J. Pande
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 18509, USA; (L.J.P.); (R.E.A.)
- Touro College of Osteopathic Medicine, Middletown, NY 10027, USA
| | - Rhudjerry E. Arnet
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 18509, USA; (L.J.P.); (R.E.A.)
| | - Brian J. Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 18509, USA; (L.J.P.); (R.E.A.)
- Center for Pharmacy Innovation and Outcomes, Danville, PA 17821, USA
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Bozinoff N, Tardelli V, Rubin-Kahana DS, Le Foll B. Patterns of use and adverse events reported among persons who regularly inject buprenorphine: a systematic review. Harm Reduct J 2022; 19:113. [PMID: 36229831 PMCID: PMC9559254 DOI: 10.1186/s12954-022-00695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/30/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Aims Given the ongoing opioid crisis, novel interventions to treat severe opioid use disorder (OUD) are urgently needed. Injectable opioid agonist therapy (iOAT) with diacetylmorphine or hydromorphone is effective for the treatment of severe, treatment-refractory OUD, however barriers to implementation persist. Intravenous buprenorphine for the treatment of OUD (BUP iOAT) has several possible advantages over traditional iOAT, including a safety profile that might enable take-home dosing. We aimed to characterize injecting practices among real-world populations of persons who regularly inject buprenorphine, as well as associated adverse events reported in order to inform a possible future BUP iOAT intervention. Methods We conducted a systematic review. We searched MEDLINE, EMBASE, and PsycINFO from inception through July 2020 and used backwards citation screening to search for publications reporting on dose, frequency among persons who regularly inject the drug, or adverse events associated with intravenous use of buprenorphine. The review was limited to English language publications and there was no limitation on study type. Study quality and risk of bias was assessed using the Mixed Methods Appraisal Tool. Narrative synthesis was used in reporting the results. Results Eighty-eight studies were included in our review. Regular injection of buprenorphine was identified across diverse settings world-wide. Daily dose of oral buprenorphine injected was < 1–12 mg. Frequency of injection was 0–10 times daily. Adverse events could be characterized as known side effects of opioids/buprenorphine or injection-related complications. Most studies were deemed to be of low quality. Conclusions Extramedical, intravenous use of buprenorphine, continues to be documented. BUP iOAT may be feasible and results may inform the development of a study to test the efficacy and safety of such an intervention. Future work should also examine acceptability among people with severe OUD in North America. Our review was limited by the quality of included studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12954-022-00695-5.
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Affiliation(s)
- Nikki Bozinoff
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, ON, Toronto, Canada. .,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada. .,Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
| | - Vitor Tardelli
- Departamento de Psiquiatria, Universidade Federal de Sao Paulo, São Paulo, Brazil.,Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Dafna Sara Rubin-Kahana
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Child, Youth, and Family Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.,Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
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Paola AD, Taweh N, Biondi BE, Foray A, Frank CA, Shaw A, Springer SA. Gender differences among persons entering medication treatment for opioid use disorder in the community. Am J Addict 2022; 31:390-395. [PMID: 35652902 PMCID: PMC9463117 DOI: 10.1111/ajad.13304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND AND OBJECTIVES We evaluated gender differences among persons initiating medications for opioid use disorder (MOUD). METHODS Analyses of baseline assessments for a study evaluating the impact of MOUD on outcomes included: demographics, DSM-5 diagnoses, depression severity, quality of life (QoL), and medication history (N = 125). RESULTS When compared to men, women had a greater prevalence of generalized anxiety and posttraumatic stress disorders; and worse psychological QoL. Women were less likely to be prescribed psychiatric medications. DISCUSSION AND CONCLUSIONS Women may benefit from tailored multidisciplinary programs with MOUD. SCIENTIFIC SIGNIFICANCE This study identified that women with OUD seeking MOUD in the community had greater sedative hypnotic nonprescribed medication use and psychiatric comorbidity than men, all of which can contribute to poorer retention on MOUD and higher risk of morbidity and mortality. Thus, concurrent psychiatric disorder screening and treatment integrated with MOUD may improve retention on MOUD, opioid relapse and overdose for women.
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Affiliation(s)
- Angela Di Paola
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT
| | - Noor Taweh
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT
- University of Connecticut, Storrs, CT
| | - Breanne E. Biondi
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Ariadna Foray
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Cynthia A. Frank
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT
| | - Albert Shaw
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT
| | - Sandra A. Springer
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT
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4
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Ansari M, Rostam-Abadi Y, Baheshmat S, Hamzehzadeh M, Gholami J, Mojtabai R, Rahimi-Movaghar A. Buprenorphine abuse and health risks in Iran: A systematic review. Drug Alcohol Depend 2021; 226:108871. [PMID: 34214882 DOI: 10.1016/j.drugalcdep.2021.108871] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Buprenorphine maintenance treatment (BMT) is widely used in Iran, and its use is growing continuously. We reviewed studies on buprenorphine use, non-prescribed use, use disorder and treatment-seeking for it, buprenorphine-associated poisoning, and mortality in Iran in the current systematic review. METHODS An Iranian database (Scientific Information Database; SID) and three International electronic databases (PubMed, Scopus, and Web of Science) were searched for publications up to August 2020 for the relevant data. Opportunistic methods (Contact with experts and backward citation tracking) were also used for this purpose. Identified records were screened for eligibility criteria, and data of included studies were extracted. For context, the trend of BMT in the country was also examined. RESULTS Ten studies were found on the prevalence of non-prescribed buprenorphine use, seven were on the regular use and use disorder, and two studies on buprenorphine poisoning. The last 12-month prevalence of non-prescribed use was lower than 0.5 % in the general population, university, and high school students. The indicator was 2.5 % among persons who use drugs in a 2018 national study. The proportion of buprenorphine poisoning was 4.9 % among all illicit substance poisoning cases admitted to a hospital. The proportion of buprenorphine poisoning cases among all acute pediatric drug poisoning cases increased from 1.2 % to 2.5 % in a 3-year study. CONCLUSION Despite the expansion of BMT in Iran in the last decade, the adverse health consequences associated with buprenorphine are infrequent, when compared to other opioids used in Iran, suggesting the safety of BMT for future expansion.
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Affiliation(s)
- Mina Ansari
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
| | - Yasna Rostam-Abadi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
| | - Shahab Baheshmat
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran.
| | - Marziyeh Hamzehzadeh
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran.
| | - Jaleh Gholami
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
| | - Ramin Mojtabai
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
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Phillips SJ, Oliveto A, Mancino MJ, Hendrickson HP. Development and validation of a rapid liquid chromatography/tandem mass spectrometry method to quantitate gabapentin and buprenorphine in human serum. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2021; 35:e9104. [PMID: 33860565 PMCID: PMC8959393 DOI: 10.1002/rcm.9104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 06/12/2023]
Abstract
RATIONALE Gabapentin has shown initial promise as an opioid-sparing medication in pain patients as well as a treatment for opioid withdrawal and liquid chriomatography/tandem mass spectrometry (LC/MS/MS) is often used for clinical monitoring. Despite reports of validated tandem mass spectrometric methods for the determination of gabapentin and buprenorphine, mechanisms for the collision-induced fragmentation have not been adequetely described. METHODS A rapid analytical method has been developed to determine gabapentinoid, gabapentin, and the partial opioid agonist, buprenorphine, in 20 μL of human serum using LC/MS/MS with a chromatographic run time of 2 min. A simplified sample cleanup procedure using methanol precipitation of serum proteins/lipids followed by evaporation and reconstitution in mobile phase was demonstrated. Gabapentin and buprenorphine were detected following positive ion electrospray ionization using multiple-reaction monitoring. The internal standard approach was used for quantitation with labeled gabapentin-D10 and buprenorphine-D4 serving as internal standards. Using organic reaction principals and stable isotope labels, collision-induced fragmentation mechanisms for both gabapentin and buprenorphine are proposed. The method was validated according to the FDA Guidance for Industry - Bioanalytical Method Validation. RESULTS Accuracy was demonstrated by error values ≤15% for buprenorphine and ≤6% for gabapentin. The inter-day precision was ≤4.88% and 15.59% for gabapentin and buprenorphine and the intra-day precision was ≤5.20% and 11.65% for gabapentin and buprenorphine. The lower limit of quantitation corresponded to 10 ng/mL for gabapentin and 1 ng/mL for buprenorphine in serum. Recoveries were 104 ± 2.55% and 85 ± 2.03% for gabapentin and buprenorphine, respectively. CONCLUSIONS Concentrations of gabapentin and buprenorphine were determined for five authentic human serum samples to further validate the utility of the method and applicable to therapeutic drug monitoring beyond its use as a drug screening assay. Furthermore, new mechanisms for the collision-induced dissociation of gabapentin and buprenorphine have been proposed.
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Affiliation(s)
- Sarah J Phillips
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Alison Oliveto
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Michael J Mancino
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Howard P Hendrickson
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
- Department of Pharmaceutical Social and Administrative Sciences, McWhorter School of Pharmacy, Samford University, Birmingham, AL, 35229, USA
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6
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Bishop-Freeman SC, Friederich LW, Feaster MS, Hudson JS. Buprenorphine-Related Deaths in North Carolina from 2010-2018. J Anal Toxicol 2021; 45:780-791. [PMID: 34145443 DOI: 10.1093/jat/bkab073] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/11/2021] [Accepted: 06/18/2021] [Indexed: 12/16/2022] Open
Abstract
Buprenorphine is a commonly prescribed medication for the treatment of opioid-use disorder. As prescriptions increase in North Carolina, buprenorphine is more frequently encountered statewide in routine postmortem casework. Between 2010 and 2018, there were 131 select cases investigated by the Office of the Chief Medical Examiner where buprenorphine was detected in peripheral blood and considered a primary cause of death, with no other opioids present and no other non-opioid substances found in the lethal range. The decedents ranged in age from 14 to 64 years, with 67% male. The mean/median peripheral blood concentrations were 4.1/2.1 ng/mL for buprenorphine and 7.8/3.4 ng/mL for the metabolite, norbuprenorphine. These postmortem blood concentrations overlap antemortem therapeutic concentrations in plasma reported in the literature for opioid-dependent subjects receiving sublingual maintenance therapy. The pathologist considered scene findings, prescription history, autopsy findings, toxicological analysis, and decedent behavior prior to death to conclude a drug-related cause of death. Many of the deaths were complicated by the presence of other central nervous system depressants along with contributory underlying cardiovascular and respiratory disease. The three most prevalent additive substances were alprazolam, ethanol, and gabapentin, found in 67, 36, and 32 cases out of 131, respectively. Interpreting buprenorphine involvement in a death is complex, and instances may be under-estimated in epidemiological data because of the lack of a defined toxic or lethal range in postmortem blood along with its good safety profile. As expansion to access of opioid-use disorder treatment becomes a priority, awareness of the challenges of postmortem interpretation is needed as increased use and diversion of buprenorphine are inevitable.
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Affiliation(s)
- Sandra C Bishop-Freeman
- Office of the Chief Medical Examiner, Raleigh, NC, USA.,UNC Department of Pathology and Laboratory Medicine, Chapel Hill, NC, USA
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Darke S, Duflou J, Larance B, Farrell M, Lappin J. Characteristics and circumstances of death related to buprenorphine toxicity in Australia. Drug Alcohol Depend 2021; 218:108360. [PMID: 33268226 DOI: 10.1016/j.drugalcdep.2020.108360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Buprenorphine is a semi-synthetic opioid used in the treatment of opioid dependence and chronic pain. The current study aimed to determine the characteristics and circumstances of all recorded cases of buprenorphine-related toxicity death in Australia; determine toxicology and organ pathology; and compare these profiles to cases of death due to buprenorphine-related traumatic injury. METHODS All cases of buprenorphine-related drug toxicity death were retrieved from the National Coronial Information System (2000-2019), as were all cases of buprenorphine-related traumatic injury. Information was collected on cause of death, case characteristics, toxicology and major organ pathology. RESULTS A total of 314 cases of drug toxicity and 55 of traumatic injury were identified. Toxicity cases were significantly older (40.5 v 36.1 years), more likely to have a history of chronic pain (OR 2.95), less likely to have a history of injecting drug use (OR 0.09), but more likely to have injected buprenorphine proximal to death (OR 4.90). There were no group differences in buprenorphine or norbuprenorphine toxicology. Toxicity cases were more likely to have hypnosedatives (OR 2.08) and other opioids (OR 4.69) present, but less likely to have psychostimulants (OR 0.26) and THC (OR 0.45). Toxicity cases were more likely to be obese (OR 4.05), have pre-existing cardiovascular disease (OR 4.02) and heavier hearts (412.1 v 355.2 g). CONCLUSIONS Buprenorphine-related toxicity death cases differed from trauma deaths in their characteristics, toxicology and disease. Fatal buprenorphine toxicity is associated with older age, concurrent use of depressants and cardiovascular disease.
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Affiliation(s)
- Shane Darke
- National Drug & Alcohol Research Centre, University of New South Wales, NSW, Australia.
| | - Johan Duflou
- National Drug & Alcohol Research Centre, University of New South Wales, NSW, Australia; Sydney Medical School, University of Sydney, NSW, Australia
| | - Briony Larance
- National Drug & Alcohol Research Centre, University of New South Wales, NSW, Australia; School of Psychology, University of Wollongong, NSW, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, NSW, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - Julia Lappin
- National Drug & Alcohol Research Centre, University of New South Wales, NSW, Australia; School of Psychiatry, University of New South Wales, NSW, Australia
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8
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Park TW, Larochelle MR, Saitz R, Wang N, Bernson D, Walley AY. Associations between prescribed benzodiazepines, overdose death and buprenorphine discontinuation among people receiving buprenorphine. Addiction 2020; 115:924-932. [PMID: 31916306 PMCID: PMC7156323 DOI: 10.1111/add.14886] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/23/2019] [Accepted: 10/29/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Benzodiazepines are commonly prescribed to patients with opioid use disorder receiving buprenorphine treatment, yet may increase overdose risk. However, prescribed benzodiazepines may improve retention in care by reducing buprenorphine discontinuation and thus may prevent relapse to illicit opioid use. We aimed to test the association between benzodiazepine prescription and fatal opioid overdose, non-fatal opioid overdose, all-cause mortality and buprenorphine discontinuation. DESIGN AND SETTING This was a retrospective cohort study using five individually linked data sets from Massachusetts, United States government agencies. PARTICIPANTS We studied 63 389 Massachusetts residents aged 18 years or older who received buprenorphine treatment between January 2012 and December 2015. MEASUREMENTS Filled benzodiazepine prescription during buprenorphine treatment was the main independent variable. The primary outcome was time to fatal opioid overdose. Secondary outcomes were time to non-fatal opioid overdose, all-cause mortality and buprenorphine discontinuation. We defined buprenorphine discontinuation as having a 30-day gap without another prescription following the end date of the previous prescription. We used Cox proportional hazards models to calculate hazards ratios that tested the association between receipt of benzodiazepines and all outcomes, restricted to periods during buprenorphine treatment. FINDINGS Of the 63 345 individuals who received buprenorphine, 24% filled at least one benzodiazepine prescription during buprenorphine treatment. Thirty-one per cent of the 183 deaths from opioid overdose occurred when individuals received benzodiazepines during buprenorphine treatment. Benzodiazepine receipt during buprenorphine treatment was associated with an increased risk of fatal opioid overdose adjusted hazard ratio (HR) = 2.92, 95% confidence interval (CI) = 2.10-4.06, non-fatal opioid overdose, adjusted HR = 2.05, 95% CI, 1.68-2.50, all-cause mortality, adjusted HR = 1.90, 95% CI, 1.48-2.44 and a decreased risk of buprenorphine discontinuation, adjusted HR = 0.87, 95% CI, 0.85-0.89. CONCLUSIONS Benzodiazepine receipt appears to be associated with both increased risk of opioid overdose and all-cause mortality and decreased risk of buprenorphine discontinuation among people receiving buprenorphine.
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Affiliation(s)
- Tae Woo Park
- Department of Psychiatry, Boston University School of Medicine and Boston Medical Center,Grayken Center for Addiction, Boston Medical Center
| | - Marc R. Larochelle
- Grayken Center for Addiction, Boston Medical Center,Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine and Boston Medical Center
| | - Richard Saitz
- Grayken Center for Addiction, Boston Medical Center,Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine and Boston Medical Center,Department of Community Health Sciences, Boston University School of Public Health
| | - Na Wang
- Biostatistics, Epidemiology, and Data Analytics Center, Boston University School of Public Health
| | - Dana Bernson
- Office of Population Health, Massachusetts Department of Public Health
| | - Alexander Y. Walley
- Grayken Center for Addiction, Boston Medical Center,Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine and Boston Medical Center
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Gerak LR, Maguire DR, France CP. Behavioral Pharmacology of Drugs Acting at Mu Opioid Receptors. Handb Exp Pharmacol 2020; 258:127-145. [PMID: 31451969 DOI: 10.1007/164_2019_265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Despite the therapeutic utility of opioids for relieving pain, other behavioral effects, including their potential for abuse and overdose, can be quite detrimental to individuals as well as society and have contributed to the ongoing opioid crisis. The dramatic escalation in overdose deaths over the last 15 years was initially driven by abuse of prescription opioids, although abuse of heroin, fentanyl, and fentanyl analogs has been increasing, largely due to increased availability and lower cost compared with prescription opioids. All of these opioids share pharmacological properties, acting as agonists at mu opioid receptors, and produce similar behavioral effects, including abuse-related, pain-relieving, dependence-producing, and respiratory-depressant effects. Despite their similarities, opioids are not pharmacologically identical. In fact, drugs that act at mu opioid receptors, including abused opioids, can vary on a number of dimensions, including pharmacological efficacy, drug-receptor interactions, receptor selectivity, and pharmacokinetics. Overall, these differences impact behavioral effects of drugs acting at mu opioid receptors, and this chapter describes variations in those behavioral effects and how these differences continue to provide new strategies that can be developed to address the ongoing opioid epidemic.
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Affiliation(s)
- Lisa R Gerak
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Addiction Research, Treatment and Training Center of Excellence, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - David R Maguire
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Addiction Research, Treatment and Training Center of Excellence, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Charles P France
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
- Addiction Research, Treatment and Training Center of Excellence, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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Cohier C, Salle S, Fontova A, Mégarbane B, Roussel O. Determination of buprenorphine, naloxone and phase I and phase II metabolites in rat whole blood by LC-MS/MS. J Pharm Biomed Anal 2019; 180:113042. [PMID: 31865207 DOI: 10.1016/j.jpba.2019.113042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/09/2019] [Accepted: 12/09/2019] [Indexed: 11/19/2022]
Abstract
Buprenorphine and buprenorphine/naloxone combination are maintenance treatments used worldwide. However, since their marketing, despite ceiling respiratory effects, poisonings and fatalities have been attributed to buprenorphine misuse and overdose. Therefore, to better understand the mechanisms of buprenorphine-related toxicity in vivo, experimental investigations have been conducted, mainly in the rat. We developed a liquid chromatographic-tandem mass spectrometric (LC-MS/MS) method with electrospray ionization for the simultaneous quantification of buprenorphine, naloxone and their metabolites (norbuprenorphine, buprenorphine glucuronide, norbuprenorphine glucuronide and naloxone glucuronide) in rat whole blood. Compounds were extracted from whole blood by protein precipitation and chromatographically separated using gradient elution of aqueous ammonium formate and methanol in a Raptor Biphenyl core-shell column (100 mm x 3,0 mm x 2,7 μm). Following electrospray ionization, quantification was carried out in the multiple reaction monitoring (MRM) mode by the tandem mass spectrometer API 3200 system. The LC-MS/MS method was validated according to the currently accepted criteria for bioanalytical method validation. The method required small sample volumes (50 μL) and was sensitive with limits of quantification of 6.9, 6.2, 3.6, 3.3, 1.3 and 57.7 ng/mL for buprenorphine, norbuprenorphine, buprenorphine glucuronide, norbuprenorphine glucuronide, naloxone and naloxone glucuronide respectively. The upper limit of quantification was 4000 ng/ml for all the studied compounds. Trueness (88-115 %), repeatability and intermediate precision (both <15%) were in accordance with the international recommendations. The procedure was successfully used to quantify these compounds in the whole blood sample from one rat 24 h after the intravenous administration of buprenorphine/naloxone (30.0/7.5 mg/kg).
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Affiliation(s)
- Camille Cohier
- Inserm, U1144, Paris, France; Paris-Descartes University, UMR-S 1144, Paris, France; Paris-Diderot University, UMR-S 1144, Paris, France; Forensic Toxicology Unit, Forensic Sciences Institute of the French Gendarmerie, Pontoise, France
| | - Sophie Salle
- Forensic Toxicology Unit, Forensic Sciences Institute of the French Gendarmerie, Pontoise, France
| | - Anne Fontova
- Forensic Toxicology Unit, Forensic Sciences Institute of the French Gendarmerie, Pontoise, France
| | - Bruno Mégarbane
- Inserm, U1144, Paris, France; Paris-Descartes University, UMR-S 1144, Paris, France; Paris-Diderot University, UMR-S 1144, Paris, France; Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris, France.
| | - Olivier Roussel
- Inserm, U1144, Paris, France; Paris-Descartes University, UMR-S 1144, Paris, France; Paris-Diderot University, UMR-S 1144, Paris, France; Forensic Toxicology Unit, Forensic Sciences Institute of the French Gendarmerie, Pontoise, France
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Gerak LR, Minervini V, Latham E, Ghodrati S, Lillis KV, Wooden J, Disney A, Husbands SM, France CP. Methocinnamox Produces Long-Lasting Antagonism of the Behavioral Effects of µ-Opioid Receptor Agonists but Not Prolonged Precipitated Withdrawal in Rats. J Pharmacol Exp Ther 2019; 371:507-516. [PMID: 31439807 DOI: 10.1124/jpet.119.260331] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/19/2019] [Indexed: 01/10/2023] Open
Abstract
A novel µ-opioid receptor antagonist, methocinnamox (MCAM), attenuates some abuse-related and toxic effects of opioids. This study further characterized the pharmacology of MCAM in separate groups of rats using procedures to examine antinociception, gastrointestinal motility, and withdrawal in morphine-dependent rats. Antinociceptive effects of opioid receptor agonists were measured before and after MCAM (1-10 mg/kg) using warm water tail withdrawal and sensitivity to mechanical stimulation in inflamed paws (complete Freund's adjuvant). Before MCAM, morphine, fentanyl, and the κ-opioid receptor agonist spiradoline dose dependently increased tail-withdrawal latency from 50°C water; MCAM attenuated the antinociceptive effects of morphine and fentanyl, but not spiradoline. Morphine increased sensitivity to mechanical stimulation and decreased gastrointestinal motility, and MCAM blocked both effects. These antagonist effects of 10 mg/kg MCAM were persistent, lasting for 2 weeks or longer. Withdrawal emerged after discontinuation of morphine treatment or administration of 10 mg/kg MCAM or 17.8 mg/kg naloxone; other than the day of antagonist administration when withdrawal signs were greater in rats that received antagonist compared with rats that received vehicle, there was no difference among groups in directly observable withdrawal signs or decreased body weight. These results confirm that MCAM is a selective µ-opioid receptor antagonist with an exceptionally long duration of action, likely due to pseudoirreversible binding. Despite its sustained antagonist effects, the duration of withdrawal precipitated by MCAM is not different from that precipitated by naloxone, suggesting that the long duration of antagonism provided by MCAM could be particularly effective for treating opioid abuse and overdose. SIGNIFICANCE STATEMENT: The opioid receptor antagonist MCAM attenuates some abuse-related and toxic effects of opioids. This study demonstrates that MCAM selectively antagonizes multiple effects mediated by µ-opioid receptor agonists for 2 weeks or longer, and like naloxone, MCAM precipitates withdrawal in morphine-dependent rats. Despite this persistent antagonism, withdrawal signs precipitated by MCAM are not significantly different from signs precipitated by naloxone or occurring after discontinuation of morphine, suggesting that using MCAM for opioid abuse or overdose would not produce sustained withdrawal.
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Affiliation(s)
- Lisa R Gerak
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Vanessa Minervini
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Elizabeth Latham
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Saba Ghodrati
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Katherine V Lillis
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Jessica Wooden
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Alex Disney
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Stephen M Husbands
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
| | - Charles P France
- Departments of Pharmacology (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.) and Psychiatry (C.P.F.), and Addiction Research, Treatment & Training Center of Excellence (L.R.G., V.M., E.L., S.G., K.V.L., J.W., C.P.F.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; and Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom (A.D., S.M.H.)
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Power J, Salmon AM, Latimer J, Jauncey M, Day CA. Overdose Risk and Client Characteristics Associated With the Injection of Buprenorphine at a Medically Supervised Injecting Center in Sydney, Australia. Subst Use Misuse 2019; 54:1646-1653. [PMID: 30973286 DOI: 10.1080/10826084.2019.1600147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Buprenorphine and buprenorphine/naloxone (BNX) were developed to improve the safety profile of opioid substitution treatment (OST) and reduce diversion and injection, yet continue to be injected, despite the risk of harm. Previous studies examining injection of these substances have relied on self-reported injection and overdose. Using data from the Uniting Medically Supervised Injecting Center (MSIC) in Sydney, this study aimed to assess the overdose risk associated with the use of buprenorphine and BNX and identify factors associated with injecting. Methods: Client data routinely collected from MSIC, a drug consumption room where clients can legally inject drugs under supervision, was used. Odds ratios (OR) to assess the risk of overdose and their associated 95% confidence intervals (95%CI) were calculated and compared to other substances. Univariate analysis using χ-square and multivariate logistic regressions were used to determine characteristics associated with buprenorphine and BNX injection. Results: Data from 1,020,782 injections by 15,832 individuals were analyzed. Risk of overdose was low for buprenorphine compared to other substances (OR 0.16; 95%CI: 0.07-0.19) and no overdoses occurred when BNX was injected. Injection of both buprenorphine and BNX was associated with male gender, homelessness, no income/reliance upon government payments, and prior imprisonment. Conclusions: Buprenorphine and BNX continue to be injected, albeit in small numbers. This is the first study to report on injection and overdose risk using direct observation, and has confirmed the lower overdose risk. MSIC clients who inject buprenorphine and BNX tend to be marginalized and may benefit from targeted harm reduction measures.
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Affiliation(s)
- Joseph Power
- a The Sydney Central Clinical School, Faculty of Medicine and Health , University of Sydney , Sydney , NSW , Australia
| | - Allison M Salmon
- b Uniting Medically Supervised Injecting Centre , Kings Cross , NSW , Australia
| | - Julie Latimer
- b Uniting Medically Supervised Injecting Centre , Kings Cross , NSW , Australia
| | - Marianne Jauncey
- a The Sydney Central Clinical School, Faculty of Medicine and Health , University of Sydney , Sydney , NSW , Australia.,b Uniting Medically Supervised Injecting Centre , Kings Cross , NSW , Australia
| | - Carolyn A Day
- a The Sydney Central Clinical School, Faculty of Medicine and Health , University of Sydney , Sydney , NSW , Australia.,b Uniting Medically Supervised Injecting Centre , Kings Cross , NSW , Australia
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13
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14
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High buprenorphine-related mortality is persistent in Finland. Forensic Sci Int 2018; 291:76-82. [DOI: 10.1016/j.forsciint.2018.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 11/22/2022]
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15
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Abstract
Opioid maintenance treatment is the first-line approach in opioid dependence. Both the full opioid agonist methadone (MET) and the partial agonist buprenorphine (BUP) are licensed for the treatment of opioid dependence. BUP differs significantly from MET in its pharmacology, side effects, and safety issues. For example, the risk of respiratory depression is lower than with MET. The risk of diversion and injection of BUP have been reduced by also making it available as a tablet containing the opioid antagonist naloxone. This review summarizes the clinical effects of BUP and examines possible factors that can support decisions regarding the use of BUP or MET in opioid-dependent people.
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Affiliation(s)
- Michael Soyka
- Medical Park Chiemseeblick, Bernau, Germany; Psychiatric Hospital, University of Munich, Munich, Germany
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16
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Wang T, Ma J, Wang R, Liu Z, Shi J, Lu L, Bao Y. Poly-Drug Use of Prescription Medicine among People with Opioid Use Disorder in China: A Systematic Review and Meta-Analysis. Subst Use Misuse 2018; 53:1117-1127. [PMID: 29281497 DOI: 10.1080/10826084.2017.1400066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Opioid use disorder (OUD) causes substantial public health and social problems worldwide. Poly-drug use is common in people with OUD and increases morbidity and mortality. Investigation of the patterns and characteristics of poly-drug use of prescription medicine among opioid users is needed to develop appropriate prevention and intervention strategies. OBJECTIVES To estimate the prevalence of poly-drug use of prescription medicine among people with OUD in China using meta-analysis. METHODS We searched relevant epidemiological studies published before February 2017 in English and Chinese databases. The quality of included studies was assessed using the Agency for Healthcare Research and Quality scale. The pooled prevalences of prescription medicine use among people with OUD were estimated. RESULTS We included 80 eligible studies in the meta-analysis. The main prescription medicines were benzodiazepines (BZDs) and prescription opioid analgesics. The pooled prevalence of unclassified BZDs and prescription opioids was 40.6% and 23.2%, respectively. Diazepam was the most frequently co-used BZD (32.6%), followed by triazolam (32.1%), and estazolam (9.2%). Tramadol was the most commonly used prescription opioid (27.3%), followed by methadone (16.8%), buprenorphine (12.6%), pethidine (8.9%), morphine (6.5%), dihydroetorphine (3.9%), and codeine-containing cough syrup (3.7%). BZDs were mainly used for self-medication (56.1%), whereas prescription opioids were primarily coused for nonmedical purposes (69.4%). CONCLUSIONS The results demonstrate that prescription medicine use is widespread among opioid users in China. There needs to be more consideration of poly-drug use, and early interventions and management strategies are needed to prevent poly-drug use among opioid users in China.
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Affiliation(s)
- Tongyu Wang
- a National Institute on Drug Dependence , Peking University , Beijing , China.,b School of Public Health , Peking University , Beijing , China.,d Beijing Center for Diseases Prevention and Control , Beijing , China
| | - Jun Ma
- a National Institute on Drug Dependence , Peking University , Beijing , China.,b School of Public Health , Peking University , Beijing , China
| | - Rujia Wang
- a National Institute on Drug Dependence , Peking University , Beijing , China.,b School of Public Health , Peking University , Beijing , China
| | - Zhimin Liu
- a National Institute on Drug Dependence , Peking University , Beijing , China
| | - Jie Shi
- a National Institute on Drug Dependence , Peking University , Beijing , China
| | - Lin Lu
- a National Institute on Drug Dependence , Peking University , Beijing , China.,c Institute of Mental Health, National Clinical Research Center for Mental Disorders, Key Laboratory of Mental Health and Peking University Sixth Hospital , Peking University , Beijing , China
| | - Yanping Bao
- a National Institute on Drug Dependence , Peking University , Beijing , China.,e National Drug and Alcohol Research Centre , University of New South Wales Australia , Sydney , NSW , Australia
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18
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Ho RCM, Chen KY, Broekman B, Mak A. Buprenorphine prescription, misuse and service provision: a global perspective. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.108.005975] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryBuprenorphine, a partial μ-opioid agonist and κ-opioid antagonist, is recommended as safe and effective maintenance treatment for opioid dependence. It offers the possibility of management in primary care settings. However, its prescription has led to diversion for illicit recreational use and resulted in medical complications and, rarely, fatal overdose in combination with other sedatives. The outcome of buprenorphine maintenance programmes varies from country to country and it is determined by the local therapeutic traditions, regulatory restrictions and existing service provision for opioid misusers. This article addresses the pharmacology of buprenorphine, the benefits and drawbacks of its prescription, service provision for opioid misuse around the world, policy recommendations, and prescribing training requirements.
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Taikato M, Kidd B, Baldacchino A. What every psychiatrist should know about buprenorphine in substance misuse. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.29.6.225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Buprenorphine is prescribed as a treatment for opioid dependence (Barnett et al, 2001; Lintzeris et al, 2002). Methadone substitute prescribing is the primary maintenance treatment in Britain and is well established (Ward, 1997). Despite the advantages of methadone maintenance there are associated disadvantages, including potential death following overdose, the inconvenience of daily dosing, the risk of the drug being used by others and stigma (Walsh, 1994).
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20
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Høiseth G, Arnestad M, Karinen R, Morini L, Rogde S, Sempio C, Vindenes V, Øiestad ÅML. Is Hair Analysis Useful in Postmortem Cases? J Anal Toxicol 2017; 42:49-54. [DOI: 10.1093/jat/bkx077] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 08/28/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Gudrun Høiseth
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Center for psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | - Marianne Arnestad
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | - Ritva Karinen
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | - Luca Morini
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Sidsel Rogde
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | - Cristina Sempio
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Vigdis Vindenes
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway
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21
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Partanen A, Mäki J. Buprenorphine more common as a problem drug in Finland. NORDIC STUDIES ON ALCOHOL AND DRUGS 2017. [DOI: 10.1177/145507250402101s17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Airi Partanen
- Special planning officer, STAKES–The National Research and Development Centre for Welfare and Health, POB 220, FIN-00531 Helsinki
| | - Jukka Mäki
- Managing director, Probation Foundation Finland, Kinaporinkatu 2 E 39, FIN-00500 Helsinki
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22
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Vadivelu N, Kai AM, Kodumudi V, Zhu R, Hines R. Pain Management of Patients with Substance Abuse in the Ambulatory Setting. Curr Pain Headache Rep 2017; 21:9. [PMID: 28251524 DOI: 10.1007/s11916-017-0610-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction. RECENT FINDINGS Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA.
| | - Alice M Kai
- Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Vijay Kodumudi
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Richard Zhu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Roberta Hines
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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23
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Richards S, Torre L, Lawther B. Buprenorphine-Related Complications in Elderly Hospitalised Patients: A Case Series. Anaesth Intensive Care 2017; 45:256-261. [DOI: 10.1177/0310057x1704500217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a case series of buprenorphine-related respiratory and neurological depression in opioid-naïve elderly hospitalised patients who received buprenorphine for acute pain management at our institution over a 24-month period. All six patients had risk factors for respiratory depression such as advanced age, concurrent comorbidities, or the ingestion of other potential central nervous system depressants. All patients required escalation of management with additional monitoring, with some transferred to a high dependency or intensive care unit. Five patients had attempted naloxone reversal with varying results. Our cases highlight the fact that while buprenorphine has been demonstrated to have a ceiling effect in relation to respiratory depression in healthy volunteers, it remains an important side-effect and may result in significant respiratory depression in patients with reduced respiratory or neurological reserve. Difficulties with buprenorphine's reversal using naloxone are described. We recommend additional caution when considering buprenorphine for acute pain management in elderly opioid-naïve patients, especially if they have comorbidities or are taking other central nervous system depressants. When buprenorphine is used in patients with risk factors, we recommend additional monitoring and education about potential adverse respiratory effects and their management.
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Affiliation(s)
- S. Richards
- Intensivist, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - L. Torre
- Intensive Care, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - B. Lawther
- Anaesthetic Consultant, Director of Acute Pain Service, Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western
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24
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Saleem M, Martin H, Tolya A, Coates P. Do all screening immunoassay positive buprenorphine samples need to be confirmed? Ann Clin Biochem 2017; 54:707-711. [PMID: 28121168 DOI: 10.1177/0004563216688489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Interference from opiates in the Microgenics CEDIA® Buprenorphine assay is known to produce false-positive buprenorphine screening immunoassay results necessitating confirmatory buprenorphine testing by chromatography/mass spectrometry methods. Method We reviewed data on falsely positive buprenorphine immunoassay screen (cut-off ≥ 5 µg/L) but negative for buprenorphine by gas chromatography mass spectrometry (cut-off ≥ 5 µg/L) and had a positive opiate immunoassay result (cut-off ≥ 300 µg/L). The results were collected over three months, and the data were evaluated to determine whether there is an opiate immunoassay screen concentration below which a false-positive buprenorphine result will not occur. Results We found that cross-reactivity in the CEDIA® buprenorphine immunoassay by opiates at concentrations <2000 µg/L will not cause a false-positive buprenorphine result. After changing our practice to not proceed with confirmatory buprenorphine gas chromatography mass spectrometry assay when the opiate screening concentration is below an even more conservative cut-off of <1500 µg/L, we estimate a potential cost-saving of AU$ 17,810 per year without compromising clinical care. Conclusion Samples with CEDIA® opiate immunoassay result <2000 µg/L and a positive CEDIA® buprenorphine immunoassay screen do not require confirmatory testing for buprenorphine.
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Affiliation(s)
- Mohamed Saleem
- Chemical Pathology Directorate, South Australia Pathology, Adelaide, Australia
| | - Helen Martin
- Chemical Pathology Directorate, South Australia Pathology, Adelaide, Australia
| | - Anne Tolya
- Chemical Pathology Directorate, South Australia Pathology, Adelaide, Australia
| | - Penny Coates
- Chemical Pathology Directorate, South Australia Pathology, Adelaide, Australia
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Donroe JH, Holt SR, Tetrault JM. Caring for patients with opioid use disorder in the hospital. CMAJ 2016; 188:1232-1239. [PMID: 27647616 PMCID: PMC5135493 DOI: 10.1503/cmaj.160290] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Joseph H Donroe
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn.
| | - Stephen R Holt
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Jeanette M Tetrault
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
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Cohier C, Chevillard L, Salle S, Risède P, Roussel O, Mégarbane B. Editor’s Highlight: Neurorespiratory Effects of Buprenorphine and Ethanol in Combination: A Mechanistic Study of Drug–Drug Interactions in the Rat. Toxicol Sci 2016; 155:389-399. [DOI: 10.1093/toxsci/kfw221] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lagard C, Chevillard L, Malissin I, Risède P, Callebert J, Labat L, Launay JM, Laplanche JL, Mégarbane B. Mechanisms of tramadol-related neurotoxicity in the rat: Does diazepam/tramadol combination play a worsening role in overdose? Toxicol Appl Pharmacol 2016; 310:108-119. [PMID: 27641627 DOI: 10.1016/j.taap.2016.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/30/2016] [Accepted: 09/14/2016] [Indexed: 11/29/2022]
Abstract
Poisoning with opioid analgesics including tramadol represents a challenge. Tramadol may induce respiratory depression, seizures and serotonin syndrome, possibly worsened when in combination to benzodiazepines. Our objectives were to investigate tramadol-related neurotoxicity, consequences of diazepam/tramadol combination, and mechanisms of drug-drug interactions in rats. Median lethal-doses were determined using Dixon-Bruce's up-and-down method. Sedation, seizures, electroencephalography and plethysmography parameters were studied. Concentrations of tramadol and its metabolites were measured using liquid-chromatography-high-resolution-mass-spectrometry. Plasma, platelet and brain monoamines were measured using liquid-chromatography coupled to fluorimetry. Median lethal-doses of tramadol and diazepam/tramadol combination did not significantly differ, although time-to-death was longer with combination (P=0.04). Tramadol induced dose-dependent sedation (P<0.05), early-onset seizures (P<0.001) and increase in inspiratory (P<0.01) and expiratory times (P<0.05). The diazepam/tramadol combination abolished seizures but significantly enhanced sedation (P<0.01) and respiratory depression (P<0.05) by reducing tidal volume (P<0.05) in addition to tramadol-related increase in respiratory times, suggesting a pharmacodynamic mechanism of interaction. Plasma M1 and M5 metabolites were mildly increased, contributing additionally to tramadol-related respiratory depression. Tramadol-induced early-onset increase in brain concentrations of serotonin and norepinephrine was not significantly altered by the diazepam/tramadol combination. Interestingly neither pretreatment with cyproheptadine (a serotonin-receptor antagonist) nor a benserazide/5-hydroxytryptophane combination (enhancing brain serotonin) reduced tramadol-induced seizures. Our study shows that diazepam/tramadol combination does not worsen tramadol-induced fatality risk but alters its toxicity pattern with enhanced respiratory depression but abolished seizures. Drug-drug interaction is mainly pharmacodynamic but increased plasma M1 and M5 metabolites may also contribute to enhancing respiratory depression. Tramadol-induced seizures are independent of brain serotonin.
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Affiliation(s)
- Camille Lagard
- Inserm, U1144, Paris, France; UMR-S 1144, Paris-Descartes University, Paris, France; UMR-S 1144, Paris-Diderot University, Paris, France.
| | - Lucie Chevillard
- Inserm, U1144, Paris, France; UMR-S 1144, Paris-Descartes University, Paris, France; UMR-S 1144, Paris-Diderot University, Paris, France.
| | - Isabelle Malissin
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Medical and Toxicological Critical Care, Paris, France.
| | - Patricia Risède
- Inserm, U1144, Paris, France; UMR-S 1144, Paris-Descartes University, Paris, France; UMR-S 1144, Paris-Diderot University, Paris, France.
| | - Jacques Callebert
- Inserm, U1144, Paris, France; UMR-S 1144, Paris-Descartes University, Paris, France; UMR-S 1144, Paris-Diderot University, Paris, France; Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Laboratory of Biochemistry and Molecular Biology, Paris, France.
| | - Laurence Labat
- Inserm, U1144, Paris, France; UMR-S 1144, Paris-Descartes University, Paris, France; UMR-S 1144, Paris-Diderot University, Paris, France; Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Laboratory of Toxicology, Paris, France.
| | - Jean-Marie Launay
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Laboratory of Biochemistry and Molecular Biology, Paris, France; Inserm, U942, Paris, France.
| | - Jean-Louis Laplanche
- Inserm, U1144, Paris, France; UMR-S 1144, Paris-Descartes University, Paris, France; UMR-S 1144, Paris-Diderot University, Paris, France; Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Laboratory of Biochemistry and Molecular Biology, Paris, France.
| | - Bruno Mégarbane
- Inserm, U1144, Paris, France; UMR-S 1144, Paris-Descartes University, Paris, France; UMR-S 1144, Paris-Diderot University, Paris, France; Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Medical and Toxicological Critical Care, Paris, France.
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Paone D, Tuazon E, Stajic M, Sampson B, Allen B, Mantha S, Kunins H. Buprenorphine infrequently found in fatal overdose in New York City. Drug Alcohol Depend 2015; 155:298-301. [PMID: 26305073 DOI: 10.1016/j.drugalcdep.2015.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Buprenorphine is an opioid agonist medication that is both safe and effective in the treatment of opioid use disorders and the prevention of opioid overdoses. Despite this, media coverage has highlighted public concerns about the potential safety consequences of buprenorphine misuse and diversion. To address the possible contribution of buprenorphine to overdose mortality, we systematically tested post mortem blood specimens from decedents who had died of an unintentional drug overdoses in 2013. METHODS We retrospectively tested consecutive drug overdose cases that occurred from June through October 2013. Cases with available blood specimens were tested for buprenorphine and norbuprenorphine using liquid chromatography-tandem mass spectrometry. Toxicology results were linked to death certificates and case files from New York City Vital Statistics and New York City Office of the Chief Medical Examiner. RESULTS Of the 98 unintentional drug overdose fatalities tested, only 2 (2.0%) tested positive for buprenorphine metabolites. All 98 unintentional fatalities involved multiple substances. CONCLUSIONS Buprenorphine was infrequently found in drug overdose deaths in New York City. Since the safety and efficacy of buprenorphine are well documented, and overdoses resulting from buprenorphine treatment or diversion are very rare, facilitating access to buprenorphine treatment is strongly recommended.
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Affiliation(s)
- Denise Paone
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States.
| | - Ellenie Tuazon
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
| | - Marina Stajic
- New York City Office of the Chief Medical Examiner, 520 First Avenue, New York, NY 10016, United States
| | - Barbara Sampson
- New York City Office of the Chief Medical Examiner, 520 First Avenue, New York, NY 10016, United States
| | - Bennett Allen
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
| | - Shivani Mantha
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
| | - Hillary Kunins
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
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A review of pharmacogenetic studies of substance-related disorders. Drug Alcohol Depend 2015; 152:1-14. [PMID: 25819021 PMCID: PMC4458176 DOI: 10.1016/j.drugalcdep.2015.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/05/2015] [Accepted: 03/02/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Substance-related disorders (SRDs) are a major cause of morbidity and mortality worldwide. Family, twin, and adoption studies have demonstrated the substantial heritability of SRDs. To determine the impact of genetic variation on risk for SRD and the response to treatment, researchers have conducted a number of secondary data analyses and quasi-experimental studies that target one or more candidate gene variants. METHODS This review examines studies in which candidate polymorphisms were examined as mediator variables to identify pharmacogenetic effects on subjective responses to drug administration or cues or outcomes of medication trials for SRDs. Efforts to use a meta-analytic approach to quantify these effects are premature because the number of available studies using similar methods and outcomes is limited, so the present review is qualitative. RESULTS Findings from these studies provide preliminary evidence of clinically relevant pharmacogenetic effects. However, independent replication of these findings has been sparse. CONCLUSIONS Although this growing body of literature has produced conflicting results, improved statistical controls may help to clarify the findings. Additionally, the use of empirically derived sub-phenotypes (i.e., which serve to differentiate distinct groups of affected individuals) may also help to identify genetic mediators of pharmacologic response in relation to SRDs. The identification of genetic mediators can inform clinical care both by identifying risk factors for SRDs and predicting adverse events and therapeutic outcomes associated with specific pharmacotherapies.
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Gharavi R, Hedrich W, Wang H, Hassan HE. Transporter-Mediated Disposition of Opioids: Implications for Clinical Drug Interactions. Pharm Res 2015; 32:2477-502. [PMID: 25972096 DOI: 10.1007/s11095-015-1711-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/06/2015] [Indexed: 01/08/2023]
Abstract
Opioid-related deaths, abuse, and drug interactions are growing epidemic problems that have medical, social, and economic implications. Drug transporters play a major role in the disposition of many drugs, including opioids; hence they can modulate their pharmacokinetics, pharmacodynamics and their associated drug-drug interactions (DDIs). Our understanding of the interaction of transporters with many therapeutic agents is improving; however, investigating such interactions with opioids is progressing relatively slowly despite the alarming number of opioids-mediated DDIs that may be related to transporters. This review presents a comprehensive report of the current literature relating to opioids and their drug transporter interactions. Additionally, it highlights the emergence of transporters that are yet to be fully identified but may play prominent roles in the disposition of opioids, the growing interest in transporter genomics for opioids, and the potential implications of opioid-drug transporter interactions for cancer treatments. A better understanding of drug transporters interactions with opioids will provide greater insight into potential clinical DDIs and could help improve opioids safety and efficacy.
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Affiliation(s)
- Robert Gharavi
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, 20 N Pine Street, Rooms: N525 (Office), Baltimore, Maryland, 21201, USA
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Nahar LK, Andrews R, Paterson S. Validated Method for the Quantification of Buprenorphine in Postmortem Blood Using Solid-Phase Extraction and Two-Dimensional Gas Chromatography–Mass Spectrometry. J Anal Toxicol 2015; 39:519-25. [DOI: 10.1093/jat/bkv051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bretteville-Jensen AL, Lillehagen M, Gjersing L, Andreas JB. Illicit use of opioid substitution drugs: prevalence, user characteristics, and the association with non-fatal overdoses. Drug Alcohol Depend 2015; 147:89-96. [PMID: 25543167 DOI: 10.1016/j.drugalcdep.2014.12.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Diversion of opioid substitution drugs (OSD) is of public concern. This study examined the prevalence, frequency, and predictors of illicit OSD use in a group of injecting drug users (IDUs) and assessed if such use was associated with non-fatal overdoses. METHODS Semi-annual cross-sectional interviews conducted in Oslo, Norway (2006-2013), from 1355 street-recruited IDUs. Hurdle, logistic, and multinomial regression models were employed. RESULTS Overall, 27% reported illicit OSD use in the past four weeks; 16.8% methadone, 12.5% buprenorphine, and 2.9% both drugs. Almost 1/10 reported at least one non-fatal overdose in the past four weeks, and roughly 1/3 reported such experience in the past year. Use of additional drugs tended to be equally, or more prevalent among illicit OSD users than other IDUs. In terms of illicit OSD use being a risk factor for non-lethal overdoses, our results showed significant associations only for infrequent buprenorphine use (using once or less than once per week). Other factors associated with non-fatal overdoses included age, education, homelessness, as well as the benzodiazepines, stimulants, and heroin use. CONCLUSIONS Users of diverted OSD may represent a high-risk population, as they used more additional drugs and used them more frequently than other IDUs. However, illicit OSD use may be less harmful than previously assumed. After accounting for an extensive set of covariates, only infrequent illicit buprenorphine use, but not methadone use, was associated with non-fatal overdoses.
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Affiliation(s)
| | - Mats Lillehagen
- Norwegian Institute for Alcohol and Drug Research (SIRUS), PB 565 Sentrum, 0105 Oslo, Norway
| | - Linn Gjersing
- Norwegian Institute for Alcohol and Drug Research (SIRUS), PB 565 Sentrum, 0105 Oslo, Norway
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Soyka M. New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone. Subst Abuse Rehabil 2015; 6:1-14. [PMID: 25610012 PMCID: PMC4293937 DOI: 10.2147/sar.s45585] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Opioid maintenance therapy is a well-established first-line treatment approach in opioid dependence. Buprenorphine, a partial opioid agonist, has been found by numerous studies to be an effective and safe medication in the treatment of opioid dependence. At present, buprenorphine is available as a monodrug or in a fixed 4:1 ratio combination with naloxone. A diminished risk of diversion and abuse for the buprenorphine-naloxone combination is likely but not firmly established. Conventional formulations are given sublingually to avoid the hepatic first-pass effect. A novel film tablet is available only in the US and Australia. Other novel, sustained-release formulations (implant, depot) are currently being developed and tested. Recent studies, including a Cochrane meta-analysis, suggest that the retention with buprenorphine is lower than for methadone, but that buprenorphine may be associated with less drug use. Higher doses of buprenorphine are associated with better retention rates. Buprenorphine has a ceiling effect at the opioid receptor with regard to respiratory depression, and may cause fewer fatal intoxications than methadone. Possible antidepressant effects of buprenorphine and its use in comorbid psychiatric patients has not been studied in much detail. Clinical implications are discussed.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität, Munich, Germany
- Private Hospital Meiringen, Meiringen, Switzerland
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Darke S. Opioid overdose and the power of old myths: what we thought we knew, what we do know and why it matters. Drug Alcohol Rev 2014; 33:109-14. [PMID: 24589077 DOI: 10.1111/dar.12108] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Darke S, Farrell M. Would legalizing illicit opioids reduce overdose fatalities? Implications from a natural experiment. Addiction 2014; 109:1237-42. [PMID: 24456133 DOI: 10.1111/add.12456] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/18/2013] [Accepted: 12/06/2013] [Indexed: 11/29/2022]
Abstract
Overdose is the leading cause of premature mortality among heroin users. We examine whether the provision of regulated and quality-controlled heroin to users in specified doses would reduce heroin overdose rates. We also address this in the context of the epidemic of prescription opioid use and deaths seen in recent years in the United States and internationally. We explore the extent to which any change in legal access to heroin would affect overdose rates, and note that this depends upon the validity of the two main assumptions that variations in illicit drug purity and/or the presence of drug contaminants are major causes of overdose. Toxicological and demographic data from studies of heroin overdose deaths do not support these assumptions. The surge in the use of pharmaceutical opioids provides an example of the legal delivery of opioids of known dosage and free of contaminants, where overdose deaths can be examined to test these assumptions. Rates of fatal opioid overdose have escalated, with increased rates of prescribing of pharmaceutical opioids. On the basis of the experience with prescription opioids, unregulated legal heroin access would not reduce overdose rates.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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Comparison of toxicity associated with nonmedical use of benzodiazepines with buprenorphine or methadone. Drug Alcohol Depend 2014; 138:118-23. [PMID: 24629782 DOI: 10.1016/j.drugalcdep.2014.02.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/05/2014] [Accepted: 02/07/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Polysubstance use is prevalent in individuals using buprenorphine or methadone nonmedically, with benzodiazepines being a common co-ingestant. The objective of this study was to compare the severity of buprenorphine and methadone toxicity with concomitant use of benzodiazepines. METHODS A retrospective analysis of buprenorphine and methadone cases from November 1, 2002 to December 31, 2010 reported to the American Association of Poison Control Centers' National Poison Data System (NPDS) was conducted. INCLUSION CRITERIA age ≥ 18 years, nonmedical use of methadone with benzodiazepines (methadone-BZD) or buprenorphine with benzodiazepines (BUP-BZD), and case followed to a documented outcome. Cases with co-ingestants other than benzodiazepines were excluded. Clinical effects, treatments, disposition and final medical outcomes were evaluated. RESULTS There were 692 methadone-BZD cases and 72 BUP-BZD cases. Clinical effects in methadone-BZD and BUP-BZD groups were lethargy (71.1%, 59.7%), respiratory depression (29.0%, 15.3%), coma (22.4%, 5.6%), respiratory arrest (4.5%, 0), hypotension (11.8%, 2.8%) and cardiac arrest (1.9%, 0), respectively. Patients in the methadone-BZD group were four-times more likely to receive naloxone (60.4% vs 15.3%) or be intubated (16.3% vs 4.2%) than in the BUP-BZD group. Hospitalization rates were highest for methadone-BZD patients with 67.3% receiving medical admissions compared to 43.3% of BUP-BZD patients. Outcomes were more serious for methadone-BZD cases (p<0.0001); while there were no BUP-BZD deaths, exposure to methadone-BZD yielded 16 deaths. CONCLUSIONS Nonmedical use of benzodiazepines with methadone is associated with higher hospitalization rates, greater ICU utilization rates and considerably worse medical outcomes when compared to nonmedical use of benzodiazepines with buprenorphine.
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Ma LL, Freret T, Lange M, Bourgine J, Coquerel A, Lelong-Boulouard V. Benzodiazepines increase the reward effects of buprenorphine in a conditioned place preference test in the mouse. Fundam Clin Pharmacol 2014; 28:681-9. [DOI: 10.1111/fcp.12072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 02/12/2014] [Accepted: 03/06/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Lin-Lin Ma
- Normandie University; CS 14032 Cedex 5 Caen France
- UCBN; COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
- Inserm; U 1075 COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
| | - Thomas Freret
- Normandie University; CS 14032 Cedex 5 Caen France
- UCBN; Groupe Mémoire et Plasticité comportementale (GMPc) EA 4259; UFR des Sciences Pharmaceutiques, Boulevard Becquerel; 14032 Caen France
| | - Mathilde Lange
- CHU de Caen, Service de Pharmacologie; Avenue de la Côte de Nacre 14033 Caen France
| | - Joanna Bourgine
- Normandie University; CS 14032 Cedex 5 Caen France
- UCBN; COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
- Inserm; U 1075 COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
- CHU de Caen, Service de Pharmacologie; Avenue de la Côte de Nacre 14033 Caen France
| | - Antoine Coquerel
- Normandie University; CS 14032 Cedex 5 Caen France
- UCBN; COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
- Inserm; U 1075 COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
- CHU de Caen, Service de Pharmacologie; Avenue de la Côte de Nacre 14033 Caen France
- Centres régionaux de pharmacovigilance et d'addictovigilance; CHU Caen; 14033 Caen France
| | - Véronique Lelong-Boulouard
- Normandie University; CS 14032 Cedex 5 Caen France
- UCBN; COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
- Inserm; U 1075 COMETE; UFR de Médecine; Avenue de la Côte de Nacre CS 14032 Cedex 5 Caen France
- CHU de Caen, Service de Pharmacologie; Avenue de la Côte de Nacre 14033 Caen France
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Wikner BN, Öhman I, Seldén T, Druid H, Brandt L, Kieler H. Opioid-related mortality and filled prescriptions for buprenorphine and methadone. Drug Alcohol Rev 2014; 33:491-8. [PMID: 24735085 DOI: 10.1111/dar.12143] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 03/18/2014] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND AIMS To assess opioid-related mortality and correlation with filled prescriptions for buprenorphine and methadone. DESIGN AND METHODS A register study, including data from the Swedish Forensic Pathology and Forensic Toxicology databases 2003-2010, the Prescribed Drug Register and the National Patient Register. RESULTS A total of 1301 deaths, assessed as related to buprenorphine, methadone or heroin, or a combination of them, were studied. The largest number of fatalities was related to intake of heroin (n = 776), followed by methadone (n = 342) and buprenorphine (n = 168). The total annual number of fatal cases related to the studied drugs more than doubled (116 to 255) during the study period. There were increases in mortality related to both buprenorphine and methadone: from 1 to 49 cases for buprenorphine, and from 19 to 81 cases for methadone. Only one-fifth of the fatal cases had a filled prescription for the maintenance drug assessed as the cause of death. DISCUSSION AND CONCLUSION This study showed that most fatalities were not related to filled prescriptions of maintenance drugs, and a substantial illicit use of buprenorphine and methadone resulting in deaths was revealed. To prevent opioid toxicity deaths it is important to make efforts not only to reduce drug diversion from maintenance programs, but also to improve the control of drug trafficking and other illegal sources.
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Affiliation(s)
- Birgitta N Wikner
- Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institute, Stockholm, Sweden
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Chiadmi F, Schlatter J. Buprenorphine and norbuprenorphine determination in mice plasma and brain by gas chromatography-mass spectrometry. ANALYTICAL CHEMISTRY INSIGHTS 2014; 9:9-16. [PMID: 24653644 PMCID: PMC3956859 DOI: 10.4137/aci.s13515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/18/2013] [Accepted: 12/20/2013] [Indexed: 11/18/2022]
Abstract
A gas chromatography tandem mass spectrometry method for quantification of buprenorphine (BUP) and norbuprenorphine (NBUP) in brain and plasma samples from mice was developed and validated. Analytes were extracted from the brain or plasma by solid phase extraction and quantified within 20 minutes. Calibration was achieved by linear regression with a 1/x weighting factor and d4-buprenorphine internal standard. All products were linear from 1 to 2000 ng/mL with a correlation of determination >0.99. Assay accuracy and precision of back-calculated standards were within ±10%. The lower limit of quantification for both BUP and NBUP from the brain and plasma was 1 ng/mL. This sensitive and specific method can be used for the investigation of BUP mechanism of action and clinical profile.
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Affiliation(s)
- Fouad Chiadmi
- Laboratoire de toxicologie de médecine légale, Hôpital Jean Verdier - APHP, Bondy, France
| | - Joël Schlatter
- Laboratoire de toxicologie de médecine légale, Hôpital Jean Verdier - APHP, Bondy, France
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Barnett V, Twycross R, Mihalyo M, Wilcock A. Opioid antagonists. J Pain Symptom Manage 2014; 47:341-52. [PMID: 24512968 DOI: 10.1016/j.jpainsymman.2013.12.223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 11/10/2013] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Mary Mihalyo
- Mylan School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania, USA
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Uosukainen H, Kauhanen J, Bell JS, Ronkainen K, Tiihonen J, Föhr J, Onyeka IN, Korhonen MJ. Mortality among clients seeking treatment for buprenorphine abuse in Finland. Drug Alcohol Depend 2013; 133:391-7. [PMID: 23896305 DOI: 10.1016/j.drugalcdep.2013.06.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/24/2013] [Accepted: 06/24/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND It is unclear whether buprenorphine abuse is associated with a similar risk of death to other substance abuse. This study examined all-cause mortality rates and causes of deaths among clients seeking treatment for buprenorphine abuse. METHODS Structured clinical interviews were conducted with 4685 clients between January 1998 and August 2008. Records of deaths that occurred among these clients were extracted from the Official Causes of Death Register in Finland. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were computed using national mortality rates over a 13-year follow-up to examine excess mortality. Kaplan-Meier survival analysis was used to compare survival between buprenorphine and other clients. RESULTS Sixty-one of 780 (7.8%) clients who sought treatment for buprenorphine abuse and 408 of 3905 (10.4%) other clients died during the 13-year follow-up period. The most common cause of death was drug-related in buprenorphine (n=25, 41.0%) and other clients (n=142, 34.8%). Survival rates were similar among buprenorphine and other clients (log-rank χ[df=1](2)=0.215, p=0.643). The SMR was 3.0 (95% CI 2.3-3.8) and 3.1 (95% CI 2.8-3.4) for buprenorphine and other clients, respectively. Excess mortality was highest among women aged 20-29 years, and more pronounced in buprenorphine clients (SMR 27.9 [95% CI 12.6-49.0]) compared to other clients (SMR 14.0 [95% CI 9.3-19.6]). CONCLUSIONS Clients seeking treatment for buprenorphine abuse had a three times higher mortality rate than the national average, with the excess risk highest among female clients. Overall mortality rates were similar among clients seeking treatment for buprenorphine and other substance abuse.
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Affiliation(s)
- Hanna Uosukainen
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
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Abstract
Opioid use disorder (OUD) is a major public health problem in the United States. It has resulted in devastating consequences for people with this condition, including psychosocial and legal problems, in addition to contraction of infectious diseases such as HIV and hepatitis B and C. Furthermore, this disease can cause fatalities from drug overdoses and drug-drug interactions. OUD shatters families and destroys relationships. Effective treatment is crucial in order to curtail the consequences of this condition. The objective of this article is to provide a review of the pharmacotherapies currently being used to treat OUD.
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Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med 2013; 125:115-30. [PMID: 23933900 DOI: 10.3810/pgm.2013.07.2684] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The concurrent use of opioids, benzodiazepines (BZDs), and/or alcohol poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs and/or alcohol are at higher risk for fatal/nonfatal overdose and have more aberrant behaviors. Few practice guidelines for BZD treatment are readily available, especially when they are combined clinically with opioid analgesics and other central nervous system-depressant agents. However, coadministration of these agents produces a defined increase in rates of adverse events, overdose, and death, warranting close monitoring and consideration when treating patients with pain. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documentation of medical necessity, and the adjustment of treatment to clinical changes are essential. In this article, we review the prevalence and pharmacologic consequences of BZDs and/or alcohol use among patients with pain on chronic opioid therapy, as well as the importance of urine drug testing, an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients. Regardless of risk or known aberrant drug-related behaviors, patients on chronic opioid therapy should periodically undergo urine drug testing to confirm adherence to the treatment plan.
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Affiliation(s)
- Jeffrey A Gudin
- Pain Management and Wellness Center, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA.
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Parenteral buprenorphine–naloxone abuse is a major cause of fatal buprenorphine-related poisoning. Forensic Sci Int 2013; 232:11-5. [DOI: 10.1016/j.forsciint.2013.06.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 06/18/2013] [Accepted: 06/21/2013] [Indexed: 01/03/2023]
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Guo AY, Ma JD, Best BM, Atayee RS. Urine specimen detection of concurrent nonprescribed medicinal and illicit drug use in patients prescribed buprenorphine. J Anal Toxicol 2013; 37:636-41. [PMID: 24080973 DOI: 10.1093/jat/bkt082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patients being treated with buprenorphine usually have a history of opioid dependence and may be predisposed to misuse of drugs. Concurrent drug misuse increases the risk of life-threatening drug interactions. This retrospective data analysis observed which nonprescribed and illicit drugs were most commonly detected in the urine of patients from pain management clinics taking buprenorphine with or without a prescription. GC, LC/MS and LC-MS-MS were used to quantify 20,929 urine specimens. The most prevalent illicit drug used in both the groups (prescribed and nonprescribed buprenorphine) was marijuana, followed by cocaine. The most prevalent nonprescribed medications abused by both the groups were benzodiazepines, followed by oxycodone and hydrocodone. The overall prevalence of illicit and nonprescribed drug use was significantly higher in subjects who used buprenorphine without a prescription versus prescribed use. Of the concurrent use of marijuana and cocaine with buprenorphine, cocaine is most concerning since it decreases exposure to buprenorphine (lower area under the concentration-time curve and maximum concentration). The concurrent use of nonprescribed benzodiazepines with buprenorphine can cause excess sedation leading to respiratory depression and even death. These findings highlight the importance of educating patients about these potential toxicities. Furthermore, pain providers should consider expanding the spectrum of drugs that they monitor in patients under treatment.
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Affiliation(s)
- Alexander Y Guo
- 1Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego (UC San Diego), 9500 Gilman Drive, MC 0719, La Jolla, CA 92093-0719, USA
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Su Y, Wang H, Liu J, Wei P, Cooks RG, Zheng O. Quantitative paper spray mass spectrometry analysis of drugs of abuse. Analyst 2013; 138:4443-7. [PMID: 23774310 PMCID: PMC3732448 DOI: 10.1039/c3an00934c] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
An ambient method for rapid monitoring and quantitation of drugs of abuse in dried blood spots was developed using paper spray tandem mass spectrometry (PS-MS).
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Affiliation(s)
- Yuan Su
- Weldon School of Biomedical Engineering, Purdue University, 206 South Martin Jischke Drive, West Lafayette, IN 47907, USA
| | - He Wang
- Weldon School of Biomedical Engineering, Purdue University, 206 South Martin Jischke Drive, West Lafayette, IN 47907, USA
| | - Jiangjiang Liu
- Weldon School of Biomedical Engineering, Purdue University, 206 South Martin Jischke Drive, West Lafayette, IN 47907, USA
| | - Pu Wei
- Department of Chemistry, Purdue University, 560 Oval Drive, West Lafayette, IN, 47907, USA
| | - R. Graham Cooks
- Department of Chemistry, Purdue University, 560 Oval Drive, West Lafayette, IN, 47907, USA
- Center for Analytical Instrumentation Development, Purdue University, 560 Oval Drive, West Lafayette, IN, 47907, USA
| | - Ouyang Zheng
- Weldon School of Biomedical Engineering, Purdue University, 206 South Martin Jischke Drive, West Lafayette, IN 47907, USA
- Center for Analytical Instrumentation Development, Purdue University, 560 Oval Drive, West Lafayette, IN, 47907, USA
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Moody DE. Metabolic and toxicological considerations of the opioid replacement therapy and analgesic drugs: methadone and buprenorphine. Expert Opin Drug Metab Toxicol 2013; 9:675-97. [PMID: 23537174 DOI: 10.1517/17425255.2013.783567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Methadone and buprenorphine are maintenance replacement therapies for opioid dependence; they are also used for pain management. Methadone and buprenorphine (to a lesser extent) have seen sharp increases in mortality associated with their use. They have distinct routes of metabolism (mostly cytochrome P450 dependent), and distinct pharmacologic activity of metabolites. As such, metabolism may play a role in differences in their toxicity. AREAS COVERED This article reviews peer-reviewed literature obtained from PubMed searches and literature referenced within. The review considers first an overview of drug use and mortality over the past decade. It then provides extensive detail on the in vitro and in vivo human metabolism of methadone and buprenorphine. Using both human and experimental animal studies it then presents the pharmacodynamic activity of parent drug and metabolites at the mu-opioid receptor, as P-glycoprotein substrates and plasma/brain concentration ratios, and activity at the hERG K(+) channel. Lessons learned from drug interaction studies in humans are then examined in an attempt to bring together the combined information. EXPERT OPINION The use and misuse of these drugs contributes to the epidemic in opioid-associated mortalities. A better understanding of metabolism-, transport- and co-medication-induced changes will contribute to their safer use.
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Affiliation(s)
- David E Moody
- University of Utah College of Pharmacy, Department of Pharmacology and Toxicology, Salt Lake City, UT 84108, USA.
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Schwartz RP, Gryczynski J, O'Grady KE, Sharfstein JM, Warren G, Olsen Y, Mitchell SG, Jaffe JH. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health 2013; 103:917-22. [PMID: 23488511 DOI: 10.2105/ajph.2012.301049] [Citation(s) in RCA: 205] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the association between the expansion of methadone and buprenorphine treatment and the prevalence of heroin overdose deaths in Baltimore, Maryland from 1995 to 2009. METHODS We conducted a longitudinal time series analysis of archival data using linear regression with the Newey-West method to correct SEs for heteroscedasticity and autocorrelation, adjusting for average heroin purity. RESULTS Overdose deaths attributed to heroin ranged from a high of 312 in 1999 to a low of 106 in 2008. While mean heroin purity rose sharply (1995-1999), the increasing number of patients treated with methadone was not associated with a change in the number of overdose deaths, but starting in 2000 expansion of opioid agonist treatment was associated with a decline in overdose deaths. Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P = .002). CONCLUSIONS Increased access to opioid agonist treatment was associated with a reduction in heroin overdose deaths. Implementing policies that support evidence-based medication treatment of opiate dependence may decrease heroin overdose deaths.
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Gender and strain contributions to the variability of buprenorphine-related respiratory toxicity in mice. Toxicology 2013; 305:99-108. [DOI: 10.1016/j.tox.2013.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 01/14/2013] [Accepted: 01/23/2013] [Indexed: 11/21/2022]
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