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Abstract
Substance use disorders (SUD) present a worldwide challenge with few effective therapies except for the relative efficacy of opioid pharmacotherapies, despite limited treatment access. However, the proliferation of illicit fentanyl use initiated a dramatic and cascading epidemic of lethal overdoses. This rise in fentanyl overdoses regenerated an interest in vaccine immunotherapy, which, despite an optimistic start in animal models over the past 50 years, yielded disappointing results in human clinical trials of vaccines against nicotine, stimulants (cocaine and methamphetamine), and opioids. After a brief review of clinical and selected preclinical vaccine studies, the "lessons learned" from the previous vaccine clinical trials are summarized, and then the newest challenge of a vaccine against fentanyl and its analogs is explored. Animal studies have made significant advances in vaccine technology for SUD treatment over the past 50 years, and the resulting anti-fentanyl vaccines show remarkable promise for ending this epidemic of fentanyl deaths.
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Affiliation(s)
- Thomas R Kosten
- Waggoner Professor of Psychiatry, Pharmacology, Neuroscience, Immunology, Baylor College of Medicine, Houston
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2
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Walsh SL, Comer SD, Zdovc JA, Sarr C, Björnsson M, Strandgården K, Hjelmström P, Tiberg F. Pharmacokinetic-pharmacodynamic analysis of drug liking blockade by buprenorphine subcutaneous depot (CAM2038) in participants with opioid use disorder. Neuropsychopharmacology 2024; 49:1050-1057. [PMID: 38200140 PMCID: PMC11039630 DOI: 10.1038/s41386-023-01793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024]
Abstract
Buprenorphine is used to treat opioid use disorder (OUD). Weekly and monthly subcutaneous long-acting buprenorphine injections (CAM2038) provide more stable buprenorphine plasma levels and reduce the treatment burden, misuse, and diversion associated with sublingual transmucosal buprenorphine formulations. To characterize the pharmacokinetic/pharmacodynamic (PK/PD) relationship, a maximum inhibition (Imax) model was developed relating CAM2038 buprenorphine plasma concentration to drug liking maximum effect (Emax) visual analog scale (VAS; bipolar) score after intramuscular hydromorphone administration. Data included time-matched observations of buprenorphine plasma concentration and drug liking Emax VAS score after hydromorphone 18 mg administration in 47 non-treatment-seeking adults with moderate to severe OUD in a phase 2 study. Analysis used non-linear mixed-effects modeling (NONMEM®). The final Imax model adequately described the PK/PD relationship between buprenorphine plasma concentration and drug liking Emax VAS score. Simulations showed drug liking was effectively blocked at low buprenorphine plasma concentrations (0.4 ng/mL) where the upper 95% confidence interval of the drug liking Emax VAS score was below the pre-defined 11-point complete blockade threshold. The buprenorphine plasma concentration required to achieve 90% of the maximal effect (IC90) of drug liking was 0.675 ng/mL. Interindividual variability in responses to buprenorphine was observed; some participants experienced fluctuating responses, and a few did not achieve drug liking blockade even with higher buprenorphine plasma concentrations. This affirms the need to individualize treatment and titrate doses for optimal treatment outcomes. PK/PD models were also developed for desire to use VAS and Clinical Opiate Withdrawal Scale (COWS) scores, with results aligned to those for drug liking.
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Affiliation(s)
- Sharon L Walsh
- Behavioral Science, Pharmacology, Psychiatry and Pharmaceutical Sciences Departments, University of Kentucky College of Medicine and Pharmacy, Kentucky, KY, USA
| | - Sandra D Comer
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | | | | | | | - Peter Hjelmström
- Camurus AB, Lund, Sweden
- Uppsala Monitoring Centre, Uppsala, Sweden
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Jansen S, Dahan A. Opioid-induced respiratory depression. BJA Educ 2024; 24:100-106. [PMID: 38375496 PMCID: PMC10874713 DOI: 10.1016/j.bjae.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 02/21/2024] Open
Affiliation(s)
- S.C. Jansen
- Leiden University Medical Centre, Leiden, The Netherlands
| | - A. Dahan
- Leiden University Medical Centre, Leiden, The Netherlands
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Mariani JJ, Dobbins RL, Heath A, Gray F, Hassman H. Open-label investigation of rapid initiation of extended-release buprenorphine in patients using fentanyl and fentanyl analogs. Am J Addict 2024; 33:8-14. [PMID: 37936553 DOI: 10.1111/ajad.13484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Synthetic opioids, including fentanyl and fentanyl analogs, account for over 70,000 annual overdose deaths in the United States, but there is limited information examining methods of induction and maintenance outcomes for buprenorphine treatment of patients with opioid use disorder (OUD) using these opioids. METHODS A secondary analysis of results grouped by fentanyl use status was completed for an open-label study with rapid induction of extended-release buprenorphine in the inpatient research unit. Eligible participants received a single 4 mg dose of transmucosal buprenorphine (BUP-TM) followed by an extended-release buprenorphine 300 mg injection ([BUP-XR]) after approximately 1 h. An extension study continued follow-up up to 6 months (6 monthly injections). RESULTS Among participants with fentanyl-positive urine samples (FEN+; n = 19), all received BUP-TM, 17 received BUP-XR, 13 elected to receive a second BUP-XR injection, and 10 received all six scheduled injections. Among participants with fentanyl-negative samples (FEN-; n = 7), all received BUP-TM and BUP-XR, four elected to receive a second injection, and two participants received all six scheduled injections. Induction day clinical opioid withdrawal scale (COWS) scores were similar for FEN+ and FEN- groups. In the FEN+ group, mean COWS scores fell to below 5 within 24 h of BUP-XR injection. DISCUSSION AND CONCLUSIONS The treatment of individuals with OUD using fentanyl with a rapid 1-day induction to BUP-XR 300 mg injection is feasible and well-tolerated. SCIENTIFIC SIGNIFICANCE A prospective trial of participants grouped by fentanyl use status at induction demonstrates comparable patient retention and clinical response following single-day induction of BUP-XR in participants who are FEN+ and FEN-.
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Affiliation(s)
- John J Mariani
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert L Dobbins
- Global Medicines Development, Indivior Inc., Richmond, Virginia, USA
| | - Amy Heath
- Global Medicines Development, Indivior Inc., Richmond, Virginia, USA
| | - Frank Gray
- Global Medicines Development, Indivior Inc., Richmond, Virginia, USA
| | - Howard Hassman
- Hassman Research Institute, CenExel, Berlin, New Jersey, USA
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Gui YK, Zeng XH, Xiao R, Xi WF, Zhang D, Liu Y, Zhu SH, Da X, Shi DW, Hu XD, Xu GH. The Effect of Dezocine on the Median Effective Dose of Sufentanil-Induced Respiratory Depression in Patients Undergoing Spinal Anesthesia Combined with Low-Dose Dexmedetomidine. Drug Des Devel Ther 2023; 17:3687-3696. [PMID: 38090026 PMCID: PMC10712329 DOI: 10.2147/dddt.s429752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/19/2023] [Indexed: 12/18/2023] Open
Abstract
Purpose The application of sedation and analgesia in spinal anesthesia has many benefits, but the risk of respiratory depression (RD) caused by opioids cannot be ignored. We aimed to observe the effect of dezocine, a partial agonist of μ-receptor, on the median effective dose (ED50) of sufentanil-induced RD in patients undergoing spinal anesthesia combined with low-dose dexmedetomidine. Patients and Methods Sixty-two patients were randomly assigned to dezocine group (DS) and control group (MS). After spinal anesthesia, mask oxygen (5 L/min) and dexmedetomidine (0.1 ug/kg) were given. Five minutes later, patients in the DS group received an Intravenous (IV) bolus of sufentanil and 0.05mg/kg dezocine, while patients in the MS group only received an IV bolus of sufentanil. Results ED50 of DS group was 0.342 ug/kg, 95% confidence interval (CI) was (0.269, 0.623) ug/kg, and the ED50 of MS group was 0.291 ug/kg, 95% CI was (0.257, 0.346) ug/kg. There was no difference in the type and treatment measures of RD and hemodynamic changes between the two groups, and no serious adverse reactions occurred in either group. Conclusion Dezocine can improve RD induced by sufentanil in patients with spinal anesthesia combined with low-dose dexmedetomidine, and increase the safety window of sufentanil use.
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Affiliation(s)
- Yong-Kang Gui
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Xiao-Hui Zeng
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Rui Xiao
- Department of Anesthesiology, Fuyang Hospital of Anhui Medical University, Fuyang, Anhui, 236113, People’s Republic of China
| | - Wen-Feng Xi
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Department of Anesthesiology, Fuyang Hospital of Anhui Medical University, Fuyang, Anhui, 236113, People’s Republic of China
| | - Dan Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Department of Anesthesiology, Fuyang Hospital of Anhui Medical University, Fuyang, Anhui, 236113, People’s Republic of China
| | - Yang Liu
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Si-Hui Zhu
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Xin Da
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - De-Wen Shi
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Xu-Dong Hu
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
| | - Guang-Hong Xu
- Department of Anesthesiology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
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Marsden J, Kelleher M, Gilvarry E, Mitcheson L, Bisla J, Cape A, Cowden F, Day E, Dewhurst J, Evans R, Hardy W, Hearn A, Kelly J, Lowry N, McCusker M, Murphy C, Murray R, Myton T, Quarshie S, Vanderwaal R, Wareham A, Hughes D, Hoare Z. Superiority and cost-effectiveness of monthly extended-release buprenorphine versus daily standard of care medication: a pragmatic, parallel-group, open-label, multicentre, randomised, controlled, phase 3 trial. EClinicalMedicine 2023; 66:102311. [PMID: 38045803 PMCID: PMC10692661 DOI: 10.1016/j.eclinm.2023.102311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 12/05/2023] Open
Abstract
Background Daily methadone maintenance or buprenorphine treatment is the standard-of-care (SoC) medication for opioid use disorder (OUD). Subcutaneously injected, extended-release buprenorphine (BUP-XR) may be more effective-but there has been no superiority evaluation. Methods This pragmatic, parallel-group, open-label, multi-centre, effectiveness superiority randomised, controlled, phase 3 trial was conducted at five National Health Service community-based treatment clinics in England and Scotland. Participants (adults aged ≥ 18 years; all meeting DSM-5 diagnostic criteria for moderate or severe OUD at admission to their current maintenance treatment episode) were randomly assigned (1:1) to receive continued daily SoC (liquid methadone (usual dose range: 60-120 mg) or sublingual/transmucosal buprenorphine (usual dose range: 8-24 mg) for 24 weeks; or monthly BUP-XR (Sublocade;® two injections of 300 mg, then four maintenance injections of 100 mg or 300 mg, with maintenance dose selected by response and preference) for 24 weeks. In the intent-to-treat population (senior statistician blinded to blinded to treatment group allocation), and with a seven-day grace period after randomisation, the primary endpoint was the count of days abstinent from non-medical opioids between days 8-168 (i.e., weeks 2-24; range: 0-161 days). Safety was reported for the intention-to- treat population. Adopting a broad societal perspective inclusive of criminal justice, NHS and personal social service costs, a trial-based cost-utility analysis estimated the Incremental Cost-effectiveness Ratio (ICER) per quality-adjusted life year (QALY) of BUP-XR versus SoC at the National Institute for Health and Care Excellence threshold. The study was registered EudraCT (2018-004460-63) and ClinicalTrials.gov (NCT05164549), and is completed. Findings Between Aug 9, 2019 and Nov 2, 2021, 314 participants were randomly allocated to receive SoC (n = 156) or BUP-XR (n = 158). Participants were abstinent from opioids for an adjusted mean of 104.37 days (standard error [SE] 9.89; range: 0-161 days) in the SoC group and an adjusted mean of 123.43 days (SE 4.76; range: 24-161 days) in the BUP-XR group (adjusted incident rate ratio [IRR] 1.18, 95% confidence interval [CI] 1.05-1.33; p-value 0.004). The incidence of any adverse event was higher in the BUP-XR group than the SoC group (128 [81.0%] of 158 participants versus 67 [42.9%] of 156 participants, respectively-most commonly rapidly-resolving (mild-moderate range) pain from drug administration in the BUP-XR group (121 [26.9%] of 450 adverse events). There were 11 serious adverse events (7.0%) in the 158 participants in the BUP-XR group, and 18 serious adverse events (11.5%) in the 156 participants in the SoC group-none judged to be related to study treatment. The BUP-XR treatment group had a mean incremental cost of £1033 (95% central range [CR] -1189 to 3225) and was associated with a mean incremental QALY of 0.02 (95% CR 0.00-0.05), and an ICER of £47,540 (0.37 probability of being cost-effective at the £30,000/QALY gained willingness-to-pay threshold). However, BUP-XR dominated the SoC among participants who were rated more severe at study baseline, and among participants in maintenance treatment for more that 28 days at study enrolment. Interpretation Evaluated against the daily oral SoC, monthly BUP-XR is clinically superior, delivering greater abstinence from opioids, and with a comparable safety profile. BUP-XR was not cost-effective in a base case cost-utility analysis using the societal perspective, but it was more effective and less costly (dominant) among participants with more severe OUD, or those whose current treatment episode was longer than 28 days. Further trials are needed to evaluate if BUP-XR is associated with better clinical and health economic outcomes over the longer term. Funding Indivior.
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Affiliation(s)
- John Marsden
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Mike Kelleher
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Eilish Gilvarry
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Luke Mitcheson
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Jatinder Bisla
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Angela Cape
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Fiona Cowden
- NHS Tayside and Dundee Health and Social Care Partnership, Scotland, United Kingdom
| | - Edward Day
- Birmingham and Solihull Mental Health, NHS Foundation Trust, Birmingham, United Kingdom
| | - Jonathan Dewhurst
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Rachel Evans
- School of Health Sciences, Bangor University, Wales, United Kingdom
| | - Will Hardy
- Clinic for Health Economics and Medicines Evaluation, Bangor University, Wales, United Kingdom
| | - Andrea Hearn
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Joanna Kelly
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Natalie Lowry
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Martin McCusker
- Lambeth Service User Council, South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Caroline Murphy
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Robert Murray
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Tracey Myton
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Sophie Quarshie
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Rob Vanderwaal
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - April Wareham
- Patient and Public Involvement and Engagement Representative, United Kingdom
| | - Dyfrig Hughes
- Clinic for Health Economics and Medicines Evaluation, Bangor University, Wales, United Kingdom
| | - Zoë Hoare
- School of Health Sciences, Bangor University, Wales, United Kingdom
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Lee K, Zhao Y, Merali T, Fraser C, Kozicky JM, Mormont MC, Conway B. Real-world Evidence for Impact of Opioid Agonist Therapy on Nonfatal Overdose in Patients with Opioid Use Disorder during the COVID-19 Pandemic. J Addict Med 2023; 17:e374-e381. [PMID: 37934531 DOI: 10.1097/adm.0000000000001213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
OBJECTIVES The primary objectives of this study were to describe the demographics and clinical characteristics of patients who were treated with buprenorphine extended-release versus buprenorphine-naloxone sublingual tablets versus methadone in a real-world setting and to evaluate the difference in nonfatal overdose events between treatment cohorts. METHODS This study was a retrospective chart review of patients with opioid use disorder initiating opioid agonist therapy in Canada during the outset of the COVID-19 pandemic (March 11, 2020 to October 31, 2021). Three treatment cohorts were defined by the initial prescribed opioid agonist therapy regimen: buprenorphine extended-release, buprenorphine-naloxone sublingual tablets, and methadone. Baseline characteristics, as well as treatment status, overdose events, and substance use 6 months after treatment initiation were collected using a standardized form. RESULTS Nine clinics provided data on 379 patient cases. The incidence rate (number of events per 100 person-years) for a self-reported nonfatal overdose was 46.8 (n = 18), 19.3 (n = 10), and 1.7 (n = 1) in the methadone, buprenorphine-naloxone sublingual tablets, and buprenorphine extended-release cohorts, respectively. The risk-adjusted difference for the proportion of patients with nonfatal overdose was 8.59% (95% confidence interval, 3.10-14.08%; P = 0.0022) for methadone versus buprenorphine extended-release and 6.51% (95% confidence interval, 1.46-11.56%; P = 0.0115) for buprenorphine-naloxone sublingual tablets versus buprenorphine extended-release. CONCLUSIONS Buprenorphine extended-release was associated with lower rates of nonfatal overdose events compared with daily opioid agonist therapy. Given the limitations of this naturalistic, retrospective design, further prospective studies are needed to validate these findings and demonstrate the potential for long-acting opioid agonist therapy in addressing the opioid crisis.
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Affiliation(s)
- Kenneth Lee
- From the London RAAM Clinic, London, ON, Canada (KL); Indivior Inc, Richmond, VA (YZ); Indivior Canada Ltd., Montreal, QC (J-MK, M-CM); Drug Intelligence Inc., Toronto, ON, Canada (TM); Cool Aid Community Health Center, Victoria, BC, Canada (CF); Novocure Inc, Portsmouth, NH (M-CM); Novocure Inc, Montreal, QC, Canada (M-CM); and Vancouver Infectious Diseases Center and Simon Fraser University, Burnaby, BC, Canada (BC)
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8
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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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van Lemmen M, Florian J, Li Z, van Velzen M, van Dorp E, Niesters M, Sarton E, Olofsen E, van der Schrier R, Strauss DG, Dahan A. Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology 2023; 139:342-353. [PMID: 37402248 DOI: 10.1097/aln.0000000000004622] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Opioids are effective analgesics, but they can have harmful adverse effects, such as addiction and potentially fatal respiratory depression. Naloxone is currently the only available treatment for reversing the negative effects of opioids, including respiratory depression. However, the effectiveness of naloxone, particularly after an opioid overdose, varies depending on the pharmacokinetics and the pharmacodynamics of the opioid that was overdosed. Long-acting opioids, and those with a high affinity at the µ-opioid receptor and/or slow receptor dissociation kinetics, are particularly resistant to the effects of naloxone. In this review, the authors examine the pharmacology of naloxone and its safety and limitations in reversing opioid-induced respiratory depression under different circumstances, including its ability to prevent cardiac arrest.
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Affiliation(s)
- Maarten van Lemmen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeffrey Florian
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Zhihua Li
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eveline van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elise Sarton
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - David G Strauss
- Division of Applied Regulatory Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Janganati V, Salazar P, Parks BJ, Gorman GS, Prather PL, Peterson EC, Alund AW, Moran JH, Crooks PA, Brents LK. Deuterated buprenorphine retains pharmacodynamic properties of buprenorphine and resists metabolism to the active metabolite norbuprenorphine in rats. Front Pharmacol 2023; 14:1123261. [PMID: 37229250 PMCID: PMC10204800 DOI: 10.3389/fphar.2023.1123261] [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: 12/13/2022] [Accepted: 04/04/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction: An active metabolite of buprenorphine (BUP), called norbuprenorphine (NorBUP), is implicated in neonatal opioid withdrawal syndrome when BUP is taken during pregnancy. Therefore, reducing or eliminating metabolism of BUP to NorBUP is a novel strategy that will likely lower total fetal exposure to opioids and thus improve offspring outcomes. Precision deuteration alters pharmacokinetics of drugs without altering pharmacodynamics. Here, we report the synthesis and testing of deuterated buprenorphine (BUP-D2). Methods: We determined opioid receptor affinities of BUP-D2 relative to BUP with radioligand competition receptor binding assays, and the potency and efficacy of BUP-D2 relative to BUP to activate G-proteins via opioid receptors with [35S]GTPγS binding assays in homogenates containing the human mu, delta, or kappa opioid receptors. The antinociceptive effects of BUP-D2 and BUP were compared using the warm-water tail withdrawal assay in rats. Blood concentration versus time profiles of BUP, BUP-D2, and NorBUP were measured in rats following intravenous BUP-D2 or BUP injection. Results: The synthesis provided a 48% yield and the product was ≥99% deuterated. Like BUP, BUP-D2 had sub-nanomolar affinity for opioid receptors. BUP-D2 also activated opioid receptors and induced antinociception with equal potency and efficacy as BUP. The maximum concentration and the area under the curve of NorBUP in the blood of rats that received BUP-D2 were over 19- and 10-fold lower, respectively, than in rats that received BUP. Discussion: These results indicate that BUP-D2 retains key pharmacodynamic properties of BUP and resists metabolism to NorBUP and therefore holds promise as an alternative to BUP.
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Affiliation(s)
- Venumadhav Janganati
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Paloma Salazar
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Brian J. Parks
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Gregory S. Gorman
- Pharmaceutical Sciences Research Institute, McWhorter School of Pharmacy, Samford University, Birmingham, AL, United States
| | - Paul L. Prather
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Eric C. Peterson
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | | | - Jeffery H. Moran
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- PinPoint Testing, LLC., Little Rock, AR, United States
| | - Peter A. Crooks
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Lisa K. Brents
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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Respiratory Effects of Biased Ligand Oliceridine in Older Volunteers: A Pharmacokinetic-Pharmacodynamic Comparison with Morphine. Anesthesiology 2023; 138:249-263. [PMID: 36538359 DOI: 10.1097/aln.0000000000004473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Oliceridine is a G protein-biased µ-opioid, a drug class that is associated with less respiratory depression than nonbiased opioids, such as morphine. The authors quantified the respiratory effects of oliceridine and morphine in elderly volunteers. The authors hypothesized that these opioids differ in their pharmacodynamic behavior, measured as effect on ventilation at an extrapolated end-tidal Pco2 at 55 mmHg, V̇E55. METHODS This four-arm double-blind, randomized, crossover study examined the respiratory effects of intravenous 0.5 or 2 mg oliceridine and 2 or 8 mg morphine in 18 healthy male and female volunteers, aged 55 to 89 yr, on four separate occasions. Participants' CYP2D6 genotypes were determined, hypercapnic ventilatory responses were obtained, and arterial blood samples were collected before and for 6 h after treatment. A population pharmacokinetic-pharmacodynamic analysis was performed on V̇E55, the primary endpoint; values reported are median ± standard error of the estimate. RESULTS Oliceridine at low dose was devoid of significant respiratory effects. High-dose oliceridine and both morphine doses caused a rapid onset of respiratory depression with peak effects occurring at 0.5 to 1 h after opioid dosing. After peak effect, compared with morphine, respiratory depression induced by oliceridine returned faster to baseline. The effect-site concentrations causing a 50% depression of V̇E55 were 29.9 ± 3.5 ng/ml (oliceridine) and 21.5 ± 4.6 ng/ml (morphine), the blood effect-site equilibration half-lives differed by a factor of 5: oliceridine 44.3 ± 6.1 min and morphine 214 ± 27 min. Three poor CYP2D6 oliceridine metabolizers exhibited a significant difference in oliceridine clearance by about 50%, causing higher oliceridine plasma concentrations after both low- and high-dose oliceridine, compared with the other participants. CONCLUSIONS Oliceridine and morphine differ in their respiratory pharmacodynamics with a more rapid onset and offset of respiratory depression for oliceridine and a smaller magnitude of respiratory depression over time. EDITOR’S PERSPECTIVE
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History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100133. [PMID: 36994370 PMCID: PMC10040330 DOI: 10.1016/j.dadr.2023.100133] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
Buprenorphine-based medications were first approved by the United States Food and Drug Administration in 2002 for the treatment of opioid dependence, or opioid use disorder (OUD) as the condition is presently known. This regulatory milestone was the outcome of 36 years of research and development, which also led to the development and approval of several other new buprenorphine-based medications. In this short review, we first describe the discovery and early development stages of buprenorphine. Second, we review key steps that led to the development of buprenorphine as a drug product. Third, we explain the regulatory approval of several buprenorphine-based medications for the treatment of OUD. We also discuss these developments in the context of the evolution of regulations and policies that have progressively improved OUD treatment availability and efficacy, although challenges remain in removing system-level, provider-level, and local-level barriers to quality treatment, to integrating OUD treatment into routine care and other settings, to reducing disparities in access to treatment, and to optimizing person-centered outcomes.
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Laffont CM, Ngaimisi E, Gopalakrishnan M, Ivaturi V, Young M, Greenwald MK, Heidbreder C. Buprenorphine exposure levels to optimize treatment outcomes in opioid use disorder. Front Pharmacol 2022; 13:1052113. [PMID: 36467036 PMCID: PMC9715596 DOI: 10.3389/fphar.2022.1052113] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2023] Open
Abstract
The severity of the ongoing opioid crisis, recently exacerbated by the COVID-19 pandemic, emphasizes the importance for individuals suffering from opioid use disorder (OUD) to have access to and receive efficacious, evidence-based treatments. Optimal treatment of OUD should aim at blocking the effects of illicit opioids while controlling opioid craving and withdrawal to facilitate abstinence from opioid use and promote recovery. The present work analyses the relationship between buprenorphine plasma exposure and clinical efficacy in participants with moderate to severe OUD using data from two clinical studies (39 and 504 participants). Leveraging data from placebo-controlled measures assessing opioid blockade, craving, withdrawal and abstinence, we found that buprenorphine plasma concentrations sustained at 2-3 ng/ml (corresponding to ≥70% brain mu-opioid receptor occupancy) optimized treatment outcomes in the majority of participants, while some individuals (e.g., injecting opioid users) needed higher concentrations. Our work also included non-linear mixed effects modeling and survival analysis, which identified a number of demographic, genetic and social factors modulating treatment response and retention. Altogether, these findings provide key information on buprenorphine plasma levels that optimize clinical outcomes and increase the likelihood of individual treatment success. NLM identifiers: NCT02044094, NCT02357901.
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Affiliation(s)
| | - Eliford Ngaimisi
- Center for Translational Medicine, University of Maryland, Baltimore, MD, United States
| | | | - Vijay Ivaturi
- Center for Translational Medicine, University of Maryland, Baltimore, MD, United States
| | - Malcolm Young
- Indivior Inc., North Chesterfield, VA, United States
| | - Mark K. Greenwald
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, United States
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