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Lemen PM, Garrett DP, Thompson E, Aho M, Vasquez C, Park JN. High-dose naloxone formulations are not as essential as we thought. Harm Reduct J 2024; 21:93. [PMID: 38741224 PMCID: PMC11089786 DOI: 10.1186/s12954-024-00994-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 03/31/2024] [Indexed: 05/16/2024] Open
Abstract
Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.
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Affiliation(s)
- Paige M Lemen
- Tennessee Harm Reduction, 1989 Madison Avenue, 7, Memphis, TN, 38104, USA.
- University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Daniel P Garrett
- Tennessee Harm Reduction, 1989 Madison Avenue, 7, Memphis, TN, 38104, USA
| | - Erin Thompson
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
| | - Megan Aho
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
| | - Christina Vasquez
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
- The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Ju Nyeong Park
- Harm Reduction Innovation Lab, Rhode Island Hospital, Providence, RI, USA
- The Warren Alpert Medical School, Brown University, Providence, RI, USA
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2
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Bates JN, Getsy PM, Coffee GA, Baby SM, MacFarlane PM, Hsieh YH, Knauss ZT, Bubier JA, Mueller D, Lewis SJ. Lipophilic analogues of D-cysteine prevent and reverse physical dependence to fentanyl in male rats. Front Pharmacol 2024; 14:1336440. [PMID: 38645835 PMCID: PMC11026688 DOI: 10.3389/fphar.2023.1336440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/31/2023] [Indexed: 04/23/2024] Open
Abstract
We examined whether co-injections of the cell-permeant D-cysteine analogues, D-cysteine ethyl ester (D-CYSee) and D-cysteine ethyl amide (D-CYSea), prevent acquisition of physical dependence induced by twice-daily injections of fentanyl, and reverse acquired dependence to these injections in freely-moving male Sprague Dawley rats. Injection of the opioid receptor antagonist, naloxone HCl (NLX, 1.5 mg/kg, IV), elicited a series of withdrawal phenomena that included cardiorespiratory and behavioral responses, and falls in body weight and body temperature, in rats that received 5 or 10 injections of fentanyl (125 μg/kg, IV), and the same number of vehicle co-injections. Regarding the development of physical dependence, the NLX-precipitated withdrawal phenomena were markedly reduced in fentanyl-injected rats that had received co-injections of D-CYSee (250 μmol/kg, IV) or D-CYSea (100 μmol/kg, IV), but not D-cysteine (250 μmol/kg, IV). Regarding reversal of established dependence to fentanyl, the NLX-precipitated withdrawal phenomena in rats that had received 10 injections of fentanyl (125 μg/kg, IV) was markedly reduced in rats that received co-injections of D-CYSee (250 μmol/kg, IV) or D-CYSea (100 μmol/kg, IV), but not D-cysteine (250 μmol/kg, IV), starting with injection 6 of fentanyl. This study provides evidence that co-injections of D-CYSee and D-CYSea prevent the acquisition of physical dependence, and reverse acquired dependence to fentanyl in male rats. The lack of effect of D-cysteine suggests that the enhanced cell-penetrability of D-CYSee and D-CYSea into cells, particularly within the brain, is key to their ability to interact with intracellular signaling events involved in acquisition to physical dependence to fentanyl.
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Affiliation(s)
- James N. Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Paulina M. Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Gregory A. Coffee
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Santhosh M. Baby
- Section of Biology, Galleon Pharmaceuticals, Inc., Horsham, PA, United States
| | - Peter M. MacFarlane
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Zackery T. Knauss
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | | | - Devin Mueller
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Stephen J. Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United States
- Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, OH, United States
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3
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Aziz R, Nguyen L, Ruhani W, Nguyen A, Zachariah B. The Optimal Initial Dose and Route of Naloxone Administration for Successful Opioid Reversal: A Systematic Literature Review. Cureus 2024; 16:e52671. [PMID: 38380203 PMCID: PMC10878679 DOI: 10.7759/cureus.52671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
This systematic literature review aims to determine the optimal initial dose of naloxone for successful opioid overdose reversal across different administration routes. Types of participants included adults who have opioid overdoses and adults who are suspected to have opioid overdoses. Pregnant women, children, animals, and populations outside the US were excluded. The interventions included were intranasal (IN), intramuscular (IM), and intravenous (IV) naloxone administration. The data collected for this systematic review were studies from PubMed, CINAHL, PsyINFO, and Cochrane Central Register of Controlled Trials registers between January 2015 and July 2021. The risk of bias was assessed via the Review Manager application. Six studies met the inclusion criteria. A meaningful statistical analysis was unable to be conducted with such few studies. The studies reveal 2 mg IN as the most popular dosing for initial naloxone for successful opioid reversal. The most common route of naloxone administration for successful reversal could not be studied but most studies revealed successful initial naloxone dosing in IN equivalents. With minimal studies emerging from our review, further research is warranted in naloxone dosing for optimal opioid reversal in order to fully treat patients. Healthcare workers must be vigilant of potential withdrawal from high naloxone dosing as well as the inefficiency of lower naloxone dosing for adequate opioid overdose reversal in order to treat patients with opioid overdoses properly.
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Affiliation(s)
- Rida Aziz
- Pain Management, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Lan Nguyen
- Pain Management, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Washika Ruhani
- Pain Management, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - An Nguyen
- Pain Management, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Brian Zachariah
- Emergency Medicine, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
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4
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Bates JN, Getsy PM, Coffee GA, Baby SM, MacFarlane PM, Hsieh YH, Knauss ZT, Bubier JA, Mueller D, Lewis SJ. L-cysteine ethyl ester prevents and reverses acquired physical dependence on morphine in male Sprague Dawley rats. Front Pharmacol 2023; 14:1303207. [PMID: 38111383 PMCID: PMC10726967 DOI: 10.3389/fphar.2023.1303207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 12/20/2023] Open
Abstract
The molecular mechanisms underlying the acquisition of addiction/dependence on morphine may result from the ability of the opioid to diminish the transport of L-cysteine into neurons via inhibition of excitatory amino acid transporter 3 (EAA3). The objective of this study was to determine whether the co-administration of the cell-penetrant L-thiol ester, L-cysteine ethyl ester (L-CYSee), would reduce physical dependence on morphine in male Sprague Dawley rats. Injection of the opioid-receptor antagonist, naloxone HCl (NLX; 1.5 mg/kg, IP), elicited pronounced withdrawal phenomena in rats which received a subcutaneous depot of morphine (150 mg/kg) for 36 h and were receiving a continuous infusion of saline (20 μL/h, IV) via osmotic minipumps for the same 36 h period. The withdrawal phenomena included wet-dog shakes, jumping, rearing, fore-paw licking, 360° circling, writhing, apneas, cardiovascular (pressor and tachycardia) responses, hypothermia, and body weight loss. NLX elicited substantially reduced withdrawal syndrome in rats that received an infusion of L-CYSee (20.8 μmol/kg/h, IV) for 36 h. NLX precipitated a marked withdrawal syndrome in rats that had received subcutaneous depots of morphine (150 mg/kg) for 48 h) and a co-infusion of vehicle. However, the NLX-precipitated withdrawal signs were markedly reduced in morphine (150 mg/kg for 48 h)-treated rats that began receiving an infusion of L-CYSee (20.8 μmol/kg/h, IV) at 36 h. In similar studies to those described previously, neither L-cysteine nor L-serine ethyl ester (both at 20.8 μmol/kg/h, IV) mimicked the effects of L-CYSee. This study demonstrates that 1) L-CYSee attenuates the development of physical dependence on morphine in male rats and 2) prior administration of L-CYSee reverses morphine dependence, most likely by intracellular actions within the brain. The lack of the effect of L-serine ethyl ester (oxygen atom instead of sulfur atom) strongly implicates thiol biochemistry in the efficacy of L-CYSee. Accordingly, L-CYSee and analogs may be a novel class of therapeutics that ameliorate the development of physical dependence on opioids in humans.
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Affiliation(s)
- James N. Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Paulina M. Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Gregory A. Coffee
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Santhosh M. Baby
- Section of Biology, Galleon Pharmaceuticals, Inc., Horsham, PA, United States
| | - Peter M. MacFarlane
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Zackery T. Knauss
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | | | - Devin Mueller
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Stephen J. Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United States
- Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, OH, United States
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Marks KR, Oyler DR, Strickland JC, Jaggers J, Roberts MF, Miracle DK, Barnes C, Lei F, Smith A, Mackin E, Martin MC, Freeman PR. Bystander preference for naloxone products: a field experiment. Harm Reduct J 2023; 20:171. [PMID: 38017424 PMCID: PMC10685501 DOI: 10.1186/s12954-023-00904-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Bystander administration of naloxone is a critical strategy to mitigate opioid overdose mortality. To ensure bystanders' willingness to carry and administer naloxone in response to a suspected overdose, it is critical to select products for community distribution with the highest likelihood of being utilized. This study examines bystanders' preference for and willingness to administer three naloxone products approved by the FDA for bystander use and identify product features driving preference. METHODS The population was a convenience sample of individuals who attended the Kentucky State Fair, August 18-28, 2022, in Louisville, Kentucky. Participants (n = 503) watched a standardized overdose education and naloxone training video, rated their willingness to administer each of three products (i.e., higher-dose nasal spray, lower-dose nasal spray, intramuscular injection), selected a product to take home, and rated factors affecting choice. RESULTS After training, 44.4% chose the higher-dose nasal spray, 30.1% chose the intramuscular injection, and 25.5% chose the lower-dose nasal spray. Factors most influencing choice on a 10-point Likert scale were ease of use (9 [7-10]), naloxone dose (8 [5-10]), and product familiarity (5 [5-9]). CONCLUSIONS Bystanders expressed high willingness to administer all studied formulations of naloxone products. Product choice preference varied as a function of product features. As the number and variety of available products continue to increase, continuous evaluation of formulation acceptability, in addition to including individuals with lived experience who are receiving and administering overdose reversal agents, is critical to support adoption and save lives.
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Affiliation(s)
- Katherine R Marks
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY, USA.
- Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services, 275 E. Main Street, Frankfort, KY, 40621, USA.
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jody Jaggers
- Kentucky Pharmacy Education and Research Foundation, Frankfort, KY, USA
| | - Monica F Roberts
- Substance Use Priority Research Area, University of Kentucky, Lexington, KY, USA
| | - Dustin K Miracle
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Chase Barnes
- Kentucky Department for Public, Health Division of Public Health Protection & Safety, Frankfort, KY, USA
| | - Feitong Lei
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Amanda Smith
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Eric Mackin
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Martika C Martin
- Kentucky Pharmacy Education and Research Foundation, Frankfort, KY, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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7
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Yugar B, McManus K, Ramdin C, Nelson LS, Parris MA. Systematic Review of Naloxone Dosing and Adverse Events in the Emergency Department. J Emerg Med 2023; 65:e188-e198. [PMID: 37652808 DOI: 10.1016/j.jemermed.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/29/2023] [Accepted: 05/26/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Experts recommend using the lowest effective dose of naloxone to balance the reversal of opioid-induced respiratory depression and avoid precipitated opioid withdrawal, however, there is no established dosing standards within the emergency department (ED). OBJECTIVES The aim of this review was to determine current naloxone dosing practice in the ED and their association with adverse events. METHODS We conducted a systematic review by searching PubMed, Cochrane, Embase, and EBSCO from 2000-2021. Articles containing patient-level data for initial ED dose and patient outcome had data abstracted by two independent reviewers. Patients were divided into subgroups depending on the initial dose of i.v. naloxone: low dose ([LD], < 0.4 mg), standard dose ([SD], 0.4-2 mg), or high dose ([HD], > 2 mg). Our outcomes were the dose range administered and adverse events per dose. We compared groups using chi-squared difference of proportions or Fisher's exact test. RESULTS The review included 13 articles with 209 patients in the results analysis: 111 patients in LD (0.04-0.1 mg), 95 in SD (0.4-2 mg), and 3 in HD (4-12 mg). At least one adverse event was reported in 37 SD patients (38.9%), compared with 14 in LD (12.6%, p < 0.0001) and 2 in HD (100.0%, p = 0.16). At least one additional dose was administered to 53 SD patients (55.8%), compared with 55 in LD (49.5%, p < 0.0001), and 3 in HD (100.0%, p = 0.48). CONCLUSIONS Lower doses of naloxone in the ED may help reduce related adverse events without increasing the need for additional doses. Future studies should evaluate the effectiveness of lower doses of naloxone to reverse opioid-induced respiratory depression without causing precipitated opioid withdrawal.
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Affiliation(s)
- Bianca Yugar
- Rutgers New Jersey Medical School, Newark, New Jersey.
| | - Kelly McManus
- Rutgers New Jersey Medical School, Newark, New Jersey
| | - Christine Ramdin
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Mehruba Anwar Parris
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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Lemen PM, Garrett DP, Thompson E, Aho M, Vasquez C, Park JN. High-Dose Naloxone Formulations Are Not as Essential as We Thought. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.07.23293781. [PMID: 37645849 PMCID: PMC10462226 DOI: 10.1101/2023.08.07.23293781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Naloxone is a U.S. Food and Drug Administration (FDA) approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public, and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review aimed to improve understanding regarding the adequacy of the regularly distributed two doses of low-dose IM or IN naloxone in effectively reversing fentanyl overdoses and whether high-dose naloxone formulations (HDNF) formulations are an optimal solution to this problem. Moreover, our initiative incorporated the perspectives and experiences of people who use drugs (PWUD), enabling a more practical and contextually-grounded analysis. We began by discussing the knowledge and perspectives of Tennessee Harm Reduction, a small peer-led harm reduction organization. A comprehensive literature review was then conducted to gather relevant scholarly works on the subject matter. The evidence indicates that, although higher doses of naloxone have been administered in both clinical and community settings, the vast majority of fentanyl overdoses can be successfully reversed using standard IM dosages with the exception of carfentanil overdoses and other more potent fentanyl analogs, which necessitate three or more doses for effective reversal. Multiple studies documented the risk of precipitated withdrawal using high doses of naloxone. Notably, the possibility of recurring overdose symptoms after resuscitation exists, contingent upon the half-life of the specific opioid. Considering these findings and the current community practice of distributing multiple doses, we recommend providing at least four standard doses of IN or IM naloxone to each potential bystander, and training them to continue administration until the recipient achieves stability, ensuring appropriate intervals between each dose. Based on the evidence, we do not recommend HDNF in the place of providing four doses of standard naloxone due to the higher cost, risk of precipitated withdrawal and limited evidence compared to standard IN and IM. All results must be taken into consideration with the inclusion of the lived experiences, individual requirements, and consent of PWUD as crucial factors. It is imperative to refrain from formulating decisions concerning PWUD in their absence, as their participation and voices should be integral to the decision-making process.
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Danaf J, da Silveira Scarpellini C, Montandon G. βγ G-proteins, but not regulators of G-protein signaling 4, modulate opioid-induced respiratory rate depression. Front Physiol 2023; 14:1043581. [PMID: 37089428 PMCID: PMC10117644 DOI: 10.3389/fphys.2023.1043581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/24/2023] [Indexed: 04/09/2023] Open
Abstract
Opioid medications are the mainstay of pain management but present substantial side-effects such as respiratory depression which can be lethal with overdose. Most opioid drugs, such as fentanyl, act on opioid receptors such as the G-protein-coupled µ-opioid receptors (MOR). G-protein-coupled receptors activate pertussis toxin-sensitive G-proteins to inhibit neuronal activity. Binding of opioid ligands to MOR and subsequent activation G proteins βγ is modulated by regulator of G-protein signaling (RGS). The roles of G-proteins βγ and RGS in MOR-mediated inhibition of the respiratory network are not known. Using rodent models to pharmacologically modulate G-protein signaling, we aim to determine the roles of βγ G-proteins and RGS4. We showed that inhibition of βγ G-proteins using gallein perfused in the brainstem circuits regulating respiratory depression by opioid drugs results in complete reversal of respiratory depression. Blocking of RGS4 using CCG55014 did not change the respiratory depression induced by MOR activation despite co-expression of RGS4 and MORs in the brainstem. Our results suggest that neuronal inhibition by opioid drugs is mediated by G-proteins, but not by RGS4, which supports the concept that βγ G-proteins could be molecular targets to develop opioid overdose antidotes without the risks of re-narcotization often found with highly potent opioid drugs. On the other hand, RGS4 mediates opioid analgesia, but not respiratory depression, and RGS4 may be molecular targets to develop pain therapies without respiratory liability.
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Affiliation(s)
- Jamil Danaf
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | | | - Gaspard Montandon
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- *Correspondence: Gaspard Montandon,
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10
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Luba R, Jones J, Choi CJ, Comer S. Fentanyl withdrawal: Understanding symptom severity and exploring the role of body mass index on withdrawal symptoms and clearance. Addiction 2023; 118:719-726. [PMID: 36444486 PMCID: PMC9992259 DOI: 10.1111/add.16100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Fentanyl is a highly lipophilic mu opioid receptor agonist, increasingly found in heroin and other drug supplies, that is contributing to marked increases in opioid-related overdose and may be complicating treatment of opioid use disorder (OUD). This study aimed to measure the influence of body mass index (BMI) on fentanyl withdrawal and clearance. DESIGN, SETTING, PARTICIPANTS This secondary analysis, from a 10-day inpatient study on the safety and efficacy of sublingual dexmedetomidine for opioid withdrawal, includes participants with OUD (n = 150) recruited from three sites in New York, New Jersey and Florida, who were maintained on oral morphine (30 mg four times per day) for 5 days before starting study medication. Most participants (n = 118) tested positive for fentanyl on admission to the inpatient unit. MEASUREMENTS Urine toxicology and opioid withdrawal symptoms [Clinical Opioid Withdrawal Scale (COWS) and Short Opiate Withdrawal Scale (SOWS)] were assessed daily. The present analysis includes data on opioid withdrawal from days 1-5 of stabilization and urine toxicology data from days 1-10. FINDINGS Fentanyl status at admission was not significantly associated with COWS or SOWS scores after adjusting for sex, site and polysubstance use. Participants classified as overweight or obese (n = 66) had significantly higher odds of testing positive for fentanyl across days 1-10 [odds ratio (OR) = 1.65; P < 0.01] and higher SOWS maximum scores across morphine stabilization (P < 0.05) compared to those with a healthy BMI (n = 68). CONCLUSIONS Among inpatients with opioid use disorder, fentanyl status does not appear to be statistically significantly associated with Clinical Opioid Withdrawal Scale and Short Opiate Withdrawal Scale mean and maximum scores. High body mass index status (overweight or obese) appears to be an important predictor of slower fentanyl clearance and higher Short Opiate Withdrawal Scale maximum scores across the inpatient period than lower body mass index status.
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Affiliation(s)
- Rachel Luba
- Division on Substance Use Disorders, Department of Psychiatry and New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, USA
| | - Jermaine Jones
- Division on Substance Use Disorders, Department of Psychiatry and New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, USA
| | - C Jean Choi
- Division of Mental Health Data Science, New York State Psychiatric Institute, New York, NY, USA
| | - Sandra Comer
- Division on Substance Use Disorders, Department of Psychiatry and New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, USA
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Xavier J, Greer A, Crabtree A, Buxton JA. Police officers’ perceptions of their role at overdose events: a qualitative study. DRUGS: EDUCATION, PREVENTION AND POLICY 2022. [DOI: 10.1080/09687637.2022.2070057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jessica Xavier
- British Columbia Center for Disease Control, Vancouver, BC, Canada
| | - Alissa Greer
- School of Criminology, Simon Fraser University, Burnaby, BC, Canada
| | - Alexis Crabtree
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jane A. Buxton
- British Columbia Center for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Treatment of opioid overdose: current approaches and recent advances. Psychopharmacology (Berl) 2022; 239:2063-2081. [PMID: 35385972 PMCID: PMC8986509 DOI: 10.1007/s00213-022-06125-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The USA has recently entered the third decade of the opioid epidemic. Opioid overdose deaths reached a new record of over 74,000 in a 12-month period ending April 2021. Naloxone is the primary opioid overdose reversal agent, but concern has been raised that naloxone is not efficacious against the pervasive illicit high potency opioids (i.e., fentanyl and fentanyl analogs). METHODS This narrative review provides a brief overview of naloxone, including its history and pharmacology, and the evidence regarding naloxone efficacy against fentanyl and fentanyl analogs. We also highlight current advances in overdose treatments and technologies that have been tested in humans. RESULTS AND CONCLUSIONS The argument that naloxone is not efficacious against fentanyl and fentanyl analogs rests on case studies, retrospective analyses of community outbreaks, pharmacokinetics, and pharmacodynamics. No well-controlled studies have been conducted to test this argument, and the current literature provides limited evidence to suggest that naloxone is ineffective against fentanyl or fentanyl analog overdose. Rather a central concern for treating fentanyl/fentanyl analog overdose is the rapidity of overdose onset and the narrow window for treatment. It is also difficult to determine if other non-opioid substances are contributing to a drug overdose, for which naloxone is not an effective treatment. Alternative pharmacological approaches that are currently being studied in humans include other opioid receptor antagonists (e.g., nalmefene), respiratory stimulants, and buprenorphine. None of these approaches target polysubstance overdose and only one novel approach (a wearable naloxone delivery device) would address the narrow treatment window.
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Adverse events related to bystander naloxone administration in cases of suspected opioid overdose in British Columbia: An observational study. PLoS One 2021; 16:e0259126. [PMID: 34714854 PMCID: PMC8555799 DOI: 10.1371/journal.pone.0259126] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Take-Home Naloxone programs have been introduced across North America in response to rising opioid overdose deaths. There is currently limited real-world data on bystander naloxone administration, overdose outcomes, and evidence related to adverse events following bystander naloxone administration. Methods The research team used descriptive statistics from Take-Home Naloxone administration forms. We explored reported demographic variables and adverse events among people who received by-stander administered naloxone in a suspected opioid overdose event between August 31, 2012 and December 31, 2018 in British Columbia. We examined and contextualized differences across years given policy, program and drug toxicity changes. We used multivariate logistic regression to examine whether an association exists between number of ampoules of naloxone administered and the odds that the recipient will experience withdrawal symptoms. Results A large majority (98.1%) of individuals who were administered naloxone survived their overdose and 69.2% had no or only mild withdrawal symptoms. Receiving three (Adjusted Odds Ratio (AOR) 1.64 (95% Confidence Interval (CI): 1.08–2.48)) or four or more (AOR 2.19 (95% CI: 1.32–3.62)) ampoules of naloxone was significantly associated with odds of moderate or severe withdrawal compared to receiving one ampoule of naloxone. Conclusions This study provides evidence from thousands of bystander reversed opioid overdoses using Take-Home Naloxone kits in British Columbia, and suggests bystander-administered naloxone is safe and effective for opioid overdose reversal. Data suggests an emphasis on titration during bystander naloxone training in situations where the person experiencing overdose can be adequately ventilated may help avoid severe withdrawal symptoms. We identified a decreasing trend in the likelihood of moderate or severe withdrawal over the study period.
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Hill LG, Zagorski CM, Loera LJ. Increasingly powerful opioid antagonists are not necessary. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 99:103457. [PMID: 34560623 PMCID: PMC8454200 DOI: 10.1016/j.drugpo.2021.103457] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Lucas G Hill
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 2.222G, Austin, TX 78712, United States.
| | - Claire M Zagorski
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 2.222G, Austin, TX 78712, United States
| | - Lindsey J Loera
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1910, PHR 2.222G, Austin, TX 78712, United States
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Purssell R, Godwin J, Moe J, Buxton J, Kestler A, Brubacher JR. Authors' reply to Comment on Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens. Clin Toxicol (Phila) 2020; 59:80-81. [PMID: 33215939 DOI: 10.1080/15563650.2020.1846744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Roy Purssell
- British Columbia Centre for Disease Control, Drug and Poison Information Centre, Vancouver, Canada
| | - Jesse Godwin
- University of British Columbia, Vancouver, Canada.,University of Toronto, Vancouver, Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Jane Buxton
- School of Population and Public Health, The University of British Columbia, Vancouver, Canada
| | - Andrew Kestler
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
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Jefri MY, Nelson LS. Comment on Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens. Clin Toxicol (Phila) 2020; 59:79-80. [PMID: 33156706 DOI: 10.1080/15563650.2020.1838536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Mohamed Y Jefri
- Department of Emergency Medicine, Rutgers New Jersey Medical School
| | - Lewis S Nelson
- Department of Emergency Medicine, Director, Division of Medical Toxicology, Rutgers New Jersey Medical School, Chief of Service, Emergency Department, University Hospital of Newark, Senior Consultant New Jersey Poison Information and Education System
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