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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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Zamani N, Buckley NA, Hassanian-Moghaddam H. Buprenorphine to reverse respiratory depression from methadone overdose in opioid-dependent patients: a prospective randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:44. [PMID: 32033582 PMCID: PMC7006192 DOI: 10.1186/s13054-020-2740-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/14/2020] [Indexed: 12/12/2022]
Abstract
Background Naloxone is the usual drug used in opioid-induced respiratory depression but it has a short half-life, precipitates withdrawal in dependent patients, and thus for persistent reversal of long-acting opioids has to be given by titrated doses and infusions. The partial agonist buprenorphine has a much longer duration of action and causes less severe withdrawal, but still should largely reverse respiratory depression induced by full agonist opioids. We aimed to compare the efficacy/safety of buprenorphine and naloxone in reversing respiratory depression in methadone-poisoned opioid-dependent patients. Methods Patients with methadone-induced respiratory depression were randomized to receive naloxone (titrated doses), or lower or higher doses of buprenorphine (10 μg/kg or 15 μg/kg). The primary outcome was immediate reversal of respiratory depression. We also recorded acute opioid withdrawal, need for intubation/recurrent apnea, repeated doses of opioid antagonists, length of hospital stay, other morbidity, and mortality. The study was registered with the Iranian Registry of Clinical Trials (Trial ID: 18265; Approval code: IRCT2015011020624N1). Results Eighty-five patients were randomized; 55/56 patients who received buprenorphine had rapid reversal of respiratory depression, which persisted for at least 12 h. Naloxone was effective in 28/29 patients, but often required very high titrated doses (thus delaying time to respond) and prolonged infusions. Intubation (8/29 vs 5/56) and opioid withdrawal (15/29 vs 7/56) were less common with buprenorphine. There were no serious complications or deaths in those receiving buprenorphine. The 15-μg/kg buprenorphine dose appeared to provide a longer duration of action, but precipitated withdrawal more frequently than the 10-μg/kg dose. Conclusion Buprenorphine appears to be a safe and effective substitute for naloxone in overdosed opioid-dependent patients. Further studies are warranted to explore the optimal dosing strategy for buprenorphine to consistently maintain reversal of respiratory depression but not precipitate withdrawal. Trial registration number IRCT2015011020624N1. Registered 30 September 2015. Electronic supplementary material The online version of this article (10.1186/s13054-020-2740-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nasim Zamani
- Social Determinant of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, South Karegar Street, Tehran, Iran.,Toxicological Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nicholas A Buckley
- Pharmacology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hossein Hassanian-Moghaddam
- Social Determinant of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, South Karegar Street, Tehran, Iran.
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Smith KE, Bunting AM, Walker R, Hall MT, Grundmann O, Castillo O. Non-Prescribed Buprenorphine Use Mediates the Relationship between Heroin Use and Kratom Use among a Sample of Polysubstance Users. J Psychoactive Drugs 2019; 51:311-322. [PMID: 30961450 PMCID: PMC10083077 DOI: 10.1080/02791072.2019.1597224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Abstract
In Asia, Mitragyna speciosa (e.g., "kratom") has been used to mitigate alcohol and drug dependence. Some preliminary findings suggest kratom's potential use as an informal harm-reduction method in the United States, such as an opioid substitute or as a means of lessening opioid withdrawal symptoms. To determine correlates of past-year kratom use among a sample of polysubstance users enrolled in residential recovery programs in Kentucky, an anonymous survey was completed by clients in April 2017. Logistic regression was used to identify significant associations with past-year kratom use. Of the final sample (N = 478), 10.4% reported past-year kratom use. Past-year heroin use, but not past-year prescription opioid (e.g., oxycodone, hydrocodone) use, was significantly associated with kratom use, such that individuals who reported past-year heroin use were 2.5 times more likely to also report past-year kratom use. Non-prescribed buprenorphine (i.e., Suboxone) use partially mediated the relationship between past-year heroin and kratom use by explaining 36% of the association between the two drugs. Though amphetamines were highly preferred, past-year use was negatively correlated with past-year kratom use. Rates of past-year kratom use were lower than rates of alcohol and illicit drug use. Kratom was not preferred over heroin or prescription opioids.
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Affiliation(s)
- Kirsten E. Smith
- Kent School of Social Work, University of Louisville, Louisville, KY, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | | | - Robert Walker
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA
| | - Martin T. Hall
- Kent School of Social Work, University of Louisville, Louisville, KY, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Olivia Castillo
- University of Miami School of Law, University of Miami, Coral Gables, FL, USA
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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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Koo CH, Yoon S, Kim BR, Cho Y, Kim T, Jeon Y, Seo JH. Intraoperative naloxone reduces remifentanil-induced postoperative hyperalgesia but not pain: a randomized controlled trial. Br J Anaesth 2017; 119:1161-1168. [DOI: 10.1093/bja/aex253] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2017] [Indexed: 11/13/2022] Open
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Carroll JJ, Marshall BDL, Rich JD, Green TC. Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:136-145. [PMID: 28578864 DOI: 10.1016/j.drugpo.2017.05.023] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/27/2017] [Accepted: 05/05/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Illicit fentanyl use has become wide spread in the US, causing high rates of overdose deaths among people who use drugs. This study describes patterns and perceptions of fentanyl exposure among opioid users in Rhode Island. METHODS A mixed methods study was conducted via questionnaire with a convenience sample of 149 individuals using illicit opioids or misusing prescription opioids in Rhode Island between January and November 2016. Of these, 121 knew of fentanyl and reported known or suspected exposure to fentanyl in the past year. Semi-structured interviews were conducted with the first 47 participants. RESULTS Study participants were predominantly male (64%) and white (61%). Demographic variables were similar across sample strata. Heroin was the most frequently reported drug of choice (72%). Self-reported exposure to illicit fentanyl in the past year was common (50.4%, n=61). In multivariate models, regular (at least weekly) heroin use was independently associated with known or suspected fentanyl exposure in the past year (adjusted prevalence ratio (APR)=4.07, 95% CI: 1.24-13.3, p=0.020). In interviews, users described fentanyl as unpleasant, potentially deadly, and to be avoided. Participants reporting fentanyl exposure routinely experienced or encountered non-fatal overdose. Heroin users reported limited ability to identify fentanyl in their drugs. Harm reduction strategies used to protect themselves from fentanyl exposure and overdose, included test hits, seeking prescription opioids in lieu of heroin, and seeking treatment with combination buprenorphine/naloxone. Participants were often unsuccessful in accessing structured treatment programs. CONCLUSION Among illicit opioid users in Rhode Island, known or suspected fentanyl exposure is common, yet demand for fentanyl is low. Fentanyl-contaminated drugs are generating user interest in effective risk mitigation strategies, including treatment. Responses to the fentanyl epidemic should be informed by the perceptions and experiences of local users. The rapid scale-up of buprenorphine/naloxone provision may slow the rate of fentanyl-involved overdose deaths.
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Affiliation(s)
- Jennifer J Carroll
- The Warren Alpert School of Medicine of Brown University, 222 Richmond St., Providence, RI 02903, USA; Division of Infectious Diseases, The Miriam Hospital, 164 Summit Ave, Providence, RI 02906, USA.
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main St., Box G-S-121-2, Providence, RI 02912, USA
| | - Josiah D Rich
- The Warren Alpert School of Medicine of Brown University, 222 Richmond St., Providence, RI 02903, USA; Division of Infectious Diseases, The Miriam Hospital, 164 Summit Ave, Providence, RI 02906, USA; Department of Epidemiology, Brown University School of Public Health, 121 South Main St., Box G-S-121-2, Providence, RI 02912, USA
| | - Traci C Green
- The Warren Alpert School of Medicine of Brown University, 222 Richmond St., Providence, RI 02903, USA; Department of Epidemiology, Brown University School of Public Health, 121 South Main St., Box G-S-121-2, Providence, RI 02912, USA; Department of Emergency Medicine, Boston University School of Medicine, 771 Albany St., Room 1208, Boston, MA 02118, USA
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Zamani N, Hassanian-Moghaddam H. Intravenous Buprenorphine: A Substitute for Naloxone in Methadone-Overdosed Patients? Ann Emerg Med 2017; 69:737-739. [DOI: 10.1016/j.annemergmed.2016.12.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Indexed: 10/20/2022]
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Howland RH. A Question About the Safety of Buprenorphine/Naloxone and Benzodiazepine Drugs. J Psychosoc Nurs Ment Health Serv 2015; 53:11-4. [PMID: 26653090 DOI: 10.3928/02793695-20151117-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Drug overdose is the leading cause of injury death in the United States, and most deaths are related to prescription drugs. A substantial proportion of these deaths involve opioid or benzodiazepine drugs, and many overdoses include a combination of both drug classes. Buprenorphine/naloxone has an unusual pharmacology that distinguishes it from other opioid drugs. Animal and human studies have found that buprenorphine is associated with a ceiling to its cardio-respiratory depressant effect at higher doses, such that it may have a wider safety margin compared to other opioid drugs. Compared to buprenorphine alone, buprenorphine/naloxone is associated with less cardiorespiratory depression. Drug safety data from the National Poison Data System, Drug Abuse Warning Network, and other sources suggest that the safety of buprenorphine/naloxone is favorable compared to the morbidity and mortality associated with other opioid drugs and other classes of psychotropic drugs.
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Wagner KD, Liu L, Davidson PJ, Cuevas-Mota J, Armenta RF, Garfein RS. Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention. Drug Alcohol Depend 2015; 153:215-20. [PMID: 26091751 PMCID: PMC4512661 DOI: 10.1016/j.drugalcdep.2015.05.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 05/11/2015] [Accepted: 05/12/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Accidental overdose, driven largely by opioids, is a leading cause of death among people who inject drugs (PWIDs). We conducted secondary analysis of data from a cohort of PWIDs to identify venues where high-risk PWID could be targeted by overdose education/naloxone distribution (OEND) programs. METHODS 573 PWIDs completed a quantitative survey between June, 2012 and January, 2014, which was analyzed using multivariable logistic regression. The dependent variable was a dichotomous indicator of experiencing a heroin/opioid-related overdose in the past six months. Independent variables included: demographics, drug use behavior, and encounters with two venues - the health care and criminal justice systems - that could serve as potential venues for OEND programs. RESULTS Almost half (41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. In the final multivariable model, receiving care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07, 8.04, p<0.001) and being arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37, 11.24, p<0.001) were associated with experiencing an opioid overdose in the past six months. CONCLUSIONS Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings, such as hospitals, and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs.
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Affiliation(s)
- Karla D. Wagner
- School of Community Health Sciences, University of Nevada, Reno; 1664 N. Virginia St. MC 0274; Reno, NV 89557
| | - Lin Liu
- Division of Biostatistics & Bioinformatics, Department of Family Medicine and Public Health, University of California School of Medicine; 9500 Gilman Drive MC 0717; La Jolla, CA 92093
| | - Peter J. Davidson
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
| | - Jazmine Cuevas-Mota
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
| | - Richard F. Armenta
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
| | - Richard S. Garfein
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
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Fareed A, Buchanan-Cummings AM, Crampton K, Grant A, Drexler K. Reversal of overdose on fentanyl being illicitly sold as heroin with naloxone nasal spray: A case report. Am J Addict 2015; 24:388-90. [DOI: 10.1111/ajad.12230] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/24/2015] [Accepted: 03/28/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ayman Fareed
- Atlanta VA Medical Center; Decatur Georgia
- Department of Psychiatry; Emory University; Atlanta Georgia
| | | | | | | | - Karen Drexler
- Atlanta VA Medical Center; Decatur Georgia
- Department of Psychiatry; Emory University; Atlanta Georgia
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Reversal of opioid overdose syndrome in morphine-dependent rats using buprenorphine. Toxicol Lett 2015; 232:590-4. [DOI: 10.1016/j.toxlet.2014.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/09/2014] [Accepted: 12/10/2014] [Indexed: 11/19/2022]
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